Acute Regional Infarct Topography and Hemorrhagic Transformation Risk After Endovascular Thrombectomy: A Multicenter Bayesian Analysis
Anna Bonkhoff1, Markus Schirmer1, Christopher Favilla2, Alvin Das3, Adam Dmytriw1, Rajiv Gupta1, James Rabinov1, Christopher Stapleton1, Thabele Leslie-Mazwi4, Claus Simonsen5, Aman Patel1, Eng Lo1, Natalia Rost1, Robert Regenhardt1
1Massachusetts General Hospital, 2University of Pennsylvania, 3Beth Israel Deaconess Medical Center, 4University of Washington, 5Aarhus University
Objective:
To identify associations between pre-treatment infarct location and hemorrhagic transformation (HT) after endovascular thrombectomy (EVT).
Background:
As more patients with stroke are treated with EVT, including those with larger cores, understanding the pathophysiology of HT is becoming increasingly important. Pre-EVT infarct topography may have implications for acute decisions (e.g. stenting) and for post-EVT care (e.g. antithrombotics, blood pressure goals).
Design/Methods:
Consecutive large vessel occlusion patients with pre-EVT MRI were identified from two centers (2011-2019). Acute infarcts were extracted through a deep learning-enabled pipeline from DWI and spatially normalized. Brains were parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and reduced to ten principal lesion patterns using unsupervised dimensionality reduction techniques (non-negative matrix factorization). Binary HT, defined as ECASS PH1 or PH2, was modeled via Bayesian regression, using lesion patterns as inputs, and controlling for total lesion volume, age, sex, initial NIH Stroke Scale (NIHSS), thrombolysis, good reperfusion (TICI 2b-3), acute stenting, last known well-to-puncture time, and other risk factors.
Results:
567 patients (mean age 69 ±15 years; 45% female) had pre-EVT DWI without significant artifacts that underwent lesion segmentation and registration, with median NIHSS 16 (IQR 11-20) and mean total infarct volume was 22.5 ±36.7mL. Thrombolysis was administered in 51%, good reperfusion was achieved in 83%, and HT occurred in 10% of patients. Lesion locations significantly related to HT involved bilateral caudate, putamen, pallidum, and anterior thalamic radiation; and, right more than left thalamus, corticospinal tract, and inferior fronto-occipital fasciculus (area under the curve: 0.73).
Conclusions:
These data from a large, multicenter cohort with precise MRI-defined infarcts underscore the risk of specific brain regions infarcted for HT after EVT. Understanding this pathophysiology can inform not only current clinical practice but also the development of future novel therapeutics to prevent HT as more patients with large cores undergo EVT.
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