Risk of Hemorrhagic Transformation and Its Subtypes After Endovascular Therapy vs Medical Management in Large Core Ischemic Stroke: A Systematic Review and Meta Analysis of Randomized Clinical Trials - 28/08/26

Doi : 10.1016/j.neurad.2026.101601

Seyed Behnam Jazayeri ^1,^⁎ , Marjan Vaezi ², Sara Mohammad Vali Samani ³, Cem Bilgin ⁴, Waleed Brinjikji ⁴, Ram Kadirvel ^4,⁵, David F. Kallmes ⁴

¹ UCSD School of Medicine, Neuroscience Department, Comprehensive Stroke Center, University of California San Diego, San Diego, California

² Iran University of Medical Sciences, Tehran, Iran

³ Shaid Beheshti University of Medical Sciences, Tehran, Iran

⁴ Department of Radiology, Mayo Clinic, Rochester, Minnesota

⁵ Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota

^⁎ Corresponding author: Seyed Behnam Jazayeri, UCSD School of Medicine, Neuroscience Department, Comprehensive Stroke Center, University of California San Diego, San Diego, California; Phone: +989124187982 UCSD School of Medicine Neuroscience Department Comprehensive Stroke Center University of California San Diego San Diego California

Sous presse. Manuscrit accepté. Disponible en ligne depuis le Friday 28 August 2026

Highlights

•	Endovascular treatment (EVT) increases the risk of radiographic hemorrhagic transformation in large-core AIS compared with medical management.
•	The excess hemorrhagic risk is primarily driven by HI2 and PH1 subtypes.
•	EVT does not significantly increase the risk of PH2 or intraventricular hemorrhage.
•	Symptomatic intracranial hemorrhage is modestly increased after EVT.

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Abstract

Background

Endovascular therapy (EVT) improves outcomes in selected patients with large-core acute ischemic stroke (AIS), but concerns remain regarding hemorrhagic transformation (HT). We evaluated the risk of intracranial hemorrhage (ICH) and its subtypes following EVT versus medical management (MM).

Methods

PubMed, Embase, and Scopus were searched through February 2026. Randomized clinical trials (RCTs) enrolling adults with large-core AIS (ASPECTS ≤5 or ischemic core volume ≥70 mL) were included. Risk ratios (RRs) were pooled using random-effects models.

Results

Six RCTs (n=1,887) and five post hoc publications from same trials were included. EVT increased the risk of any ICH compared with MM (RR=1.80, 95% CI: 1.40–2.30; P<0.001). Risks of HI2 (RR=2.23), PH1 (RR=2.42), and subarachnoid hemorrhage (RR=2.21) were significantly higher, whereas PH2 and intraventricular hemorrhage were not. Symptomatic ICH occurred more frequently after EVT (5.0% vs. 3.1%; P=0.02), but this finding was not robust to sensitivity analyses. In ASPECTS 0–2 neither any ICH nor symptomatic ICH was significantly increased; however, limited sample size and influential studies precluded excluding clinically meaningful risk.

Conclusion

EVT increased radiographic hemorrhage, primarily HI2 and PH1, without a significant increase in PH2. The modest increase in symptomatic ICH was sensitive to the contributing trial and definition.

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