Bleeding Patterns and Prognostic Implications in Large-Core Ischemic Stroke: Insights from the TENSION Trial

Area of Science:

• Neurology
• Interventional Neurology
• Stroke Medicine

Background:

• Large-core infarcts pose significant risks for post-treatment intracranial hemorrhage (ICH).
• The clinical implications and predictors of ICH following stroke treatment are not well understood.
• The TENSION trial provides a dataset to investigate ICH in large-core infarcts.

Purpose of the Study:

• To characterize the frequency, patterns, and predictors of post-treatment ICH.
• To evaluate the prognostic relevance of ICH in patients with large-core infarcts.
• To analyze the impact of mechanical thrombectomy (MT) versus best medical treatment (BMT) on ICH development and outcomes.

Main Methods:

• Post hoc analysis of 253 patients from the TENSION trial with anterior circulation stroke (ASPECTS 3-5).
• Patients were randomized to MT plus BMT or BMT alone.
• Hemorrhages classified using Heidelberg Bleeding Classification; predictors of parenchymal hematoma (PH) and symptomatic ICH (sICH) identified via logistic regression; outcomes assessed using multivariable models.

Main Results:

• Any ICH occurred in 45.1% of patients, more frequent after MT (54.4%) than BMT (35.9%), mostly asymptomatic.
• Parenchymal hematoma (PH) was more common after MT (23.2%) than BMT (9.4%).
• Predictors of PH included MT, higher NIHSS, and larger core volume. Bleeding severity did not independently predict poor outcome, but age, NIHSS, and core volume did. MT remained associated with better outcomes, though PH attenuated its benefit.

Conclusions:

• Intracranial hemorrhage is frequent in large-core stroke, especially after MT, but often asymptomatic.
• Parenchymal hematoma may diminish the benefits of mechanical thrombectomy.
• Despite ICH risks, mechanical thrombectomy is associated with improved functional outcomes; distinguishing hemorrhage types is crucial for risk assessment.