前循环大血管闭塞性急性缺血性卒中行血管内治疗血管成功再通后术中DSA静脉早显及毛细血管充血与术后出血转化及其亚型的关系OA

Objective To investigate the association between intraprocedural DSA signs-specifically early venous drainage(EVD)and capillary blush(CB)-observed following successful endovascular treatment(EVT)recanalization,with hemorrhagic transformation(HT)and its severe subtypes,parenchymal hematoma type 2(PH2)and symptomatic intracranial hemorrhage(sICH),in patients with anterior circulation large vessel occlusion acute ischemic stroke(LVO-AIS).Methods This study retrospectively and consecutively enrolled patients with anterior circulation LVO-AIS who underwent EVT within 24 hours of symptom onset and achieved successful recanalization(defined as a post-procedural modified thrombolysis in cerebral infarction[mTICI]grade≥2b)at the Department of Cerebrovascular Diseases,Henan Provincial People's Hospital between October 2022 and July 2024.Patient demographics and clinical data were collected,including gender,age,history of hypertension,diabetes,hyperlipidemia,coronary heart disease,atrial fibrillation,smoking,alcohol consumption,and prior stroke.Clinical assessments included the admission National Institutes of Health stroke scale(NIHSS)score,Glasgow coma scale(GCS)score,and Alberta stroke program early CT score(ASPECTS).Etiology was classified using the trial of Org 10172 in acute stroke treatment(TOAST)criteria(atherosclerotic,cardioembolic,other determined etiology,undetermined etiology).Treatment details encompassed the time window from onset to puncture(OPT;≤6h,＞6-＜12h,12-24h),occlusion site(internal carotid artery,M1 or M2 segment of the middle cerebral artery,A1 segment of the anterior cerebral artery,tandem occlusion),pre-procedural intravenous thrombolysis,revascularization technique(mechanical thrombectomy,direct angioplasty,or mechanical thrombectomy plus rescue angioplasty)and procedural time metrics(OPT,puncture-to-recanalization time,and onset-to-recanalization time)were recorded.Admission laboratory values included neutrophil count,lymphocyte count,platelet count,fibrinogen,glucose,neutrophil-to-lymphocyte ratio(NLR),and systemic immune-inflammation index(SII).On post-recanalization DSA,the presence of EVD was denoted as EVD+,and its absence as EVD-.The presence of CB was denoted as CB+,and its absence as CB-.EVD+CB-standed for the presence of EVD with the absence of CB,while EVD-CB+standed for the absence of EVD with the presence of CB.A composite sign of EVD+CB+was defined as the presence of both,while EVD+/CB+as either(EVD and/or CB).Patients were evaluated for the occurrence of HT,PH2,and sICH within 72 hours post-procedure.Patients with any type of intracranial hemorrhage were assigned to the HT group,while those had no intracranial hemorrhage assigned to the non-HT group.PH2 group was consisted of patients with a hematoma exceeding 30%of the infarct area with significant mass effect,or hemorrhage remote from the infarct zone.While patients with any intracranial hemorrhage associated with neurological deterioration(an increase in the NIHSS total score by≥4 points or an increase in any single NIHSS item score by≥2 points from baseline)were signed to the sICH group.Variables showing statistically significant differences(between the HT group and the three other groups)in univariate comparisons were selected via stepwise forward regression for inclusion in multivariate Logistic regression analyses to identify independent factors associated with the occurrence of HT,PH2,and sICH within 72 hours after EVT.Receiver operating characteristic(ROC)curves were plotted,and the area under the curve(AUC)was calculated to assess the predictive performance of the EVD+CB+and EVD+/CB+signs for HT,PH2,and sICH.Results A total of 190 patients with anterior circulation LVO-AIS who achieved successful recanalization after EVT were included.There were 112 males and 78 females,aged 25-84 years with a mean age of 63±14 years.There were 39 patients(20.5%)in HT group,18 patients(9.5%)in PH2 group,and 18 patients(9.5%)in the sICH group;among these,13patients(6.8%)had both PH2 and sICH.Immediate post-procedural DSA revealed EVD+in 20 patients(10.5%),CB+in 45 patients(23.7%),EVD+CB-in 5 patients(2.6%),EVD-CB+in 30 patients(15.8%),and EVD+CB+in 15 patients(7.9%).(1)Compared to patients without HT,those in the HT group had significantly higher admission NIHSS scores,blood glucose,NLR,and SII,and significantly lower admission GCS scores,ASPECTS,lymphocyte counts,and platelet counts(all P＜0.05).The proportions of patients with EVD-CB+,EVD+CB+,and EVD+/CB+were also significantly higher in the HT group(all P＜0.05).No significant differences were found in other baseline and clinical characteristics(all P＞0.05).Compared to patients without HT,those in the PH2 group had significantly lower admission ASPECTS and a higher proportion of diabetes,as well as higher blood glucose,NLR and SII(all P＜0.05).The proportions of patients with EVD+CB+and EVD+/CB+were also significantly higher(both P＜0.05).No significant differences were found in other characteristics(all P＞0.05).Compared to patients without HT,those in the sICH group had significantly lower admission ASPECTS,lymphocyte counts,and platelet counts,and significantly higher NLR and SII(all P＜0.01).The proportions of patients with EVD+CB+and EVD+/CB+were also significantly higher(both P＜0.01).No significant differences were found in other characteristics(all P＞0.05).(2)Multivariate Logistic regression analysis revealed that higher platelet count(OR,0.992,95%CI 0.985-0.999,P=0.022)and higher admission ASPECTS(OR,0.607,95%CI 0.424-0.871,P=0.007)were independent protective factors for HT after successful EVT recanalization.Both EVD+CB+(OR,8.664,95%CI 1.533-48.953,P=0.015)and EVD+/CB+(OR,5.866,95%CI 2.261-15.217,P＜0.01)were independent risk factors for HT.Higher admission ASPECTS(OR,0.595,95%CI 0.362-0.975,P=0.039)was an independent protective factor for PH2 after successful EVT recanalization,while EVD+CB+(OR,25.450,95%CI 3.719-174.158,P＜0.01)and EVD+/CB+(OR,7.747,95%CI 1.664-36.066,P=0.009)were independent risk factors for PH2.Higher admission ASPECTS(OR,0.563,95%CI 0.357-0.888,P=0.014)was an independent protective factor for sICH after successful EVT recanalization,while EVD+CB+(OR,52.576,95%CI 7.866-351.432,P＜0.01)was an independent risk factor for sICH.(3)ROCcurve analysis showed that the AUC of EVD+CB+for predicting HT,PH2,and sICH after successful EVT recanalization was 0.660,0.771,and 0.716,respectively.The AUC of EVD+/CB+for predicting HT,PH2,and sICH after successful EVT recanalization was 0.754,0.837,and 0.726,respectively.Conclusions The combined evaluation of EVD and CB signs during EVT demonstrates predictive utility for HT,PH2,and sICH following successful recanalization in patients with anterior circulation LVO-AIS.It may serve as a real-time intraoperative imaging marker for identifying patients at high risk of hemorrhage.