Prevalence and Risk Factors for Hemorrhagic Transformation in Patients with Posterior Circulation Ischemic Stroke: A Systematic Review and Meta-Analysis
Karlos Acurio1, Fritz Vascones Roman1, Carlos Rodrigo Vicuña2, Luis Aguilar Alvarez3, Demy Vascones Roman4, Gerardo Luna-Peralta5, Meiling Carbajal Galarza1, Andy Vascones Aldazabal6, Jack Vascones Roman7, Brigith Avila Lucas1, Irving Calisaya-Madariaga1, Niels Pacheco8
1Universidad Peruana Cayetano Heredia, 2Universidad Científica del Sur, 3Universidad Nacional de Cajamarca, 4Universidad Andina de Cusco, 5Universidad Nacional Mayor de San Marcos, 6Universidad San Ignacio de Loyola, 7Universidad Nacional San Antonio Abad del Cusco, 8Harvard University
Objective:
To determine the prevalence of hemorrhagic transformation (HT) and identify associated risk factors in patients with posterior circulation ischemic stroke (PCIS).
Background:
PCIS constitutes approximately 20% of all ischemic stroke cases. HT is a recognized complication of ischemic stroke, leading to worsened outcomes. While extensive research has focused on HT in anterior circulation strokes, data on HT prevalence and risk factors in PCIS remains limited.
Design/Methods:
A systematic search of three databases was conducted up to August 2024.. Case-control, cohort and cross-sectional studies reporting the prevalence of HT and symptomatic intracranial hemorrhage (sICH) and associated risk factors were selected. A meta-analysis using a random-effects model was planned for pooled effect estimates where applicable, and a narrative synthesis was provided when meta-analysis was not feasible. The risk of bias was assessed using the Joanna Briggs Institute (JBI) tool for prevalence studies, and the certainty of evidence (CoE) was evaluated with GRADE criteria.
Results:
Twelve studies were included in the final analysis, with a predominance of female patients (55.9%) and a mean age of 66.8 years. All studies demonstrated a low risk of bias. The pooled prevalence of HT was 12.0% (1,359 participants; 95% CI: 8.0%-18.0%; I² = 85%; CoE: very low), while the prevalence of symptomatic HT was 34.0% (7 studies; 147 participants; 95% CI: 17.0%-53.0%; I² = 78%; CoE: very low). A higher National Institutes of Health Stroke Scale (NIHSS) score was identified as an independent risk factor for HT, and an eTICI score of 0-2a was a predictor of sICH.
Conclusions:
Our analysis shows a significant prevalence of HT in PCIS patients, with higher NIHSS scores consistently linked to increased risk. However, the very low certainty of evidence and limited studies highlight the need for more robust research.
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