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 - 10/11/26
, Marjan Vaezi b, Sara Mohammad Vali Samani c, Cem Bilgin d, Waleed Brinjikji d, Ram Kadirvel d, e, David F. Kallmes dHighlights |
• | 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. |
Graphical abstract |
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 = 1887) 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.
Le texte complet de cet article est disponible en PDF.Keywords : Ischemic stroke, Large core, ASPECTS, Hemorrhagic transformation, Meta-analysis, Intracranial hemorrhage
Abbreviations : AIS, ASPECTS, EVT, HI, HI1, HI2, HT, ICH, IVH, MM, PH, PH1, PH2, RCT, SAH, sICH
Plan
Vol 53 - N° 6
Article 101601- février 2026 Retour au numéro
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