A Score for Risk of Thrombolysis-Associated Hemorrhage Including Pretreatment with Statins

Risk prediction models for intracranial hemorrhage in acute ischemic stroke patients receiving intravenous alteplase treatment: a systematic review

Objectives

To identify and compare published models that use related factors to predict the risk of intracranial hemorrhage (ICH) in acute ischemic stroke patients receiving intravenous alteplase treatment.

Methods

Risk prediction models for ICH in acute ischemic stroke patients receiving intravenous alteplase treatment were collected from PubMed, Embase, Web of Science, and the Cochrane Library up to April 7, 2023. A meta-analysis was performed using Stata 13.0, and the included models were evaluated using the Prediction Model Risk of Bias Assessment Tool (PROBAST).

Results

A total of 656 references were screened, resulting in 13 studies being included. Among these, one was a prospective cohort study. Ten studies used internal validation; five studies used external validation, with two of them using both. The area under the receiver operating characteristic (ROC) curve for subjects reported in the models ranged from 0.68 to 0.985. Common predictors in the prediction models include National Institutes of Health Stroke Scale (NIHSS) (OR = 1.17, 95% CI 1.09-1.25, p < 0.0001), glucose (OR = 1.54, 95% CI 1.09-2.17, p < 0.05), and advanced age (OR = 1.50, 95% CI 1.15-1.94, p < 0.05), and the meta-analysis shows that these are independent risk factors. After PROBAST evaluation, all studies were assessed as having a high risk of bias but a low risk of applicability concerns.

Conclusion

This study systematically reviews available evidence on risk prediction models for ICH in acute ischemic stroke patients receiving intravenous alteplase treatment. Few models have been externally validated, while the majority demonstrate significant discriminative power.

Validation and comparison of multiple risk scores for prediction of symptomatic intracerebral hemorrhage after intravenous thrombolysis in VISTA

BACKGROUND AND AIMS

Prediction models/scores may help to identify patients at high risk of symptomatic intracerebral hemorrhage (sICH) after intravenous thrombolysis. We aimed to validate and compare the performance of different prediction models for sICH after thrombolysis using direct model estimation in the Virtual International Stroke Trials Archive (VISTA).

METHODS

We searched PubMed for potentially eligible prediction models from inception to 1 June 2019. Simple and practical models/scores were validated in VISTA. The primary outcome was sICH based on two criteria (National Institute of Neurological Diseases and Stroke, NINDS; Safe Implementation of Thrombolysis in Stroke-Monitoring Study, SITS-MOST) and the secondary outcome was parenchymal hematoma (PH). The discrimination performance of each model was evaluated using area under the curve (AUC) and calibration was evaluated by Hosmer-Lemeshow goodness-of-fit tests.

RESULTS

We found 13 prediction models and five models (HAT, MSS, SPAN-100, GRASPS and THRIVE) were finally validated in VISTA. A total of 1884 participants were eligible for our study, of whom the proportion with sICH was 4.6% (87/1884) per NINDS and 3.9% (73/1884) per SITS-MOST, and with PH was 11.3% (213/1884). MSS and GRASPS had the greatest predictive ability for sICH (NINDS criteria: MSS AUC 0.7, 95% CI 0.63-0.77, p < 0.001; GRASPS AUC 0.69, 95% CI 0.63-0.76, p < 0.001; SITS-MOST criteria: MSS, AUC 0.76, 95% CI 0.68-0.85, p < 0.001; GRASPS, AUC 0.79, 95% CI 0.71-0.87, p < 0.001). Similar results were found for PH (MSS AUC 0.68, 95% CI 0.64-0.73, p = 0.017; GRASPS AUC 0.68, 95% CI 0.63-0.72, p = 0.017). The calibration of each model was almost good.

CONCLUSION

MSS and GRASPS had good discrimination and calibration for sICH and PH after thrombolysis as assessed in VISTA. These two models could be used in clinical practice and clinical trials to identity individuals with high risk of sICH.

Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: External Validation of Prediction Models

BACKGROUND

Symptomatic intracranial hemorrhage (sICH) is a severe complication of reperfusion therapy for ischemic stroke. Multiple models have been developed to predict sICH or intracranial hemorrhage (ICH) after reperfusion therapy. We provide an overview of published models and validate their ability to predict sICH in patients treated with endovascular treatment in daily clinical practice.

METHODS

We conducted a systematic search to identify models either developed or validated to predict sICH or ICH after reperfusion therapy (intravenous thrombolysis and/or endovascular treatment) for ischemic stroke. Models were externally validated in the MR CLEAN Registry (n=3180; Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). The primary outcome was sICH according to the Heidelberg Bleeding Classification. Model performance was evaluated with discrimination (c-statistic, ideally 1; a c-statistic below 0.7 is considered poor in discrimination) and calibration (slope, ideally 1, and intercept, ideally 0).

RESULTS

We included 39 studies describing 40 models. The most frequently used predictors were baseline National Institutes of Health Stroke Scale (NIHSS; n=35), age (n=22), and glucose level (n=22). In the MR CLEAN Registry, sICH occurred in 188/3180 (5.9%) patients. Discrimination ranged from 0.51 (SPAN-100 [Stroke Prognostication Using Age and National Institutes of Health Stroke Scale]) to 0.61 (SITS-SICH [Safe Implementation of Treatments in Stroke Symptomatic Intracerebral Hemorrhage] and STARTING-SICH [STARTING Symptomatic Intracerebral Hemorrhage]). Best calibrated models were IST-3 (intercept, -0.15 [95% CI, -0.01 to -0.31]; slope, 0.80 [95% CI, 0.50-1.09]), SITS-SICH (intercept, 0.15 [95% CI, -0.01 to 0.30]; slope, 0.62 [95% CI, 0.38-0.87]), and STARTING-SICH (intercept, -0.03 [95% CI, -0.19 to 0.12]; slope, 0.56 [95% CI, 0.35-0.76]).

CONCLUSIONS

The investigated models to predict sICH or ICH discriminate poorly between patients with a low and high risk of sICH after endovascular treatment in daily clinical practice and are, therefore, not clinically useful for this patient population.

Statin pretreatment combined with intravenous thrombolysis for ischemic stroke patients: A meta-analysis

PURPOSE

For ischemic stroke patients, thrombolysis therapy combined statins might have a better benefit. But difference studies had a debate. The meta-analysis wants to make clear about whether statins could increase effect of therapy or decrease side effect for these patients.

METHODS OBJECTIVES

To evaluate the effect and safety about using statins in ischemic stroke patients receiving thrombolysis.

DATA SOURCES

Databases including PubMed, Web of Science, Embase and Cochrane Library. Eligibility criteria: original observational cohort studies.

PARTICIPANTS

ischemic stroke patients receiving thrombolysis.

INTERVENTIONS

pretreatment statins. Appraisal and synthesis methods: forest plot to show pooled results; I-squared test to evaluate the heterogeneity.

RESULTS

Of 87 selected, 8 were eligible. The 8 studies included 10,344 patients (with statins: 2048; without statins: 8296). For clinical recovery at 24 h, pooled OR (odds ratios) was 1.82 (95% CI: 1.49-2.21). For excellent outcome, pooled OR was 1.03 (95% CI: 0.80-1.12). For favorable outcome, pooled OR was 0.99 (95% CI: 0.85-1.16). For ICH (intracranial hemorrhage), pooled OR was 1.16 (95% CI: 0.97-1.40). For sICH (symptomatic intracranial hemorrhage), pooled OR was 1.40 (95% CI: 1.02-1.91). For mortality, overall pooled OR was 0.96 (95% CI: 0.74-1.25).

CONCLUSION

In conclusion, the meta-analysis found that for ischemic stroke patients receiving thrombolysis, pretreatment statins were related to a better clinical recovery and a lower short-term mortality. Pretreatment statins had no significant relationship with mRS at 90 days and ICH. Pretreatment high dose statins may be related to the occurrence of sICH.

Premorbid Use of Statin and Outcome of Acute Ischemic Stroke After Intravenous Thrombolysis: A Meta-Analysis

Background: The association between the premorbid use of statin and the early outcomes of acute ischemic stroke (AIS) after intravenous thrombolysis (IVT) remains uncertain. We performed a meta-analysis of observational studies to evaluate the influence of the premorbid use of statin on functional outcome and symptomatic intracranial hemorrhage (SIH) in AIS after IVT. Methods: Relevant studies were identified by search of PubMed, Embase, and Cochrane's Library databases. Only studies with multivariate analyses were included. A random-effect model, incorporating inter-study heterogeneity, was used to pool the results. Results: Twenty observational studies with 20,752 AIS patients who were treated with IVT were included. The pooled results showed that the premorbid use of statin was not associated with improved 3-month favorable functional outcome [odds ratio (OR): 1.05, 95% confidence interval (CI): 0.87-1.26, p = 0.60, I ² = 52%), 3-month functional independence (OR: 1.13, 95% CI: 0.96-1.33, p = 0.15, I ² = 52%), or 3-month mortality (OR: 1.12, 95% CI: 0.94-1.34, p = 0.20, I ² = 20%). Moreover, the premorbid use of statin was associated with an increased risk of SIH in AIS after IVT (OR: 1.48, 95% CI: 1.12-1.95, p = 0.006, I ² = 60%). Subgroup analyses according to study design, adjustment of baseline low-density lipoprotein cholesterol, and definitions of SIH showed consistent results (p-values for subgroup difference all >0.05). Conclusions: The premorbid use of statin is not associated with improved functional outcomes or mortality but is associated with a higher risk of SIH in AIS patients after IVT.

Neutrophil extracellular traps increased by hyperglycemia exacerbate ischemic brain damage

Hyperglycemia is common and associated with poor outcome in acute ischemic stroke patients. Neutrophil extracellular traps (NETs) are increased either in diabetes or ischemic stroke. We aimed to determine the role of NETs in acute ischemic stroke with hyperglycemia as it has not been clarified. NETs were observed in thrombi retrieved from ischemic stroke patients undergoing endovascular treatment. Citrullinated histone H3 was much more abundant in thrombi from hyperglycemic patients than in those from normoglycemic patients. BKS-db/db and wild-type mice injected with glucose were used to establish the permanent middle cerebral artery occlusion model with hyperglycemia. NETs induced by hyperglycemia were detected in the peri-ischemic brain tissue. Inhibition of NET formation decreased the infarction volume both in db/db and wild-type mice with hyperglycemia. Neurological function deficits were alleviated by blocking NET formation. These findings suggest that NETs increased by hyperglycemia play a role in exacerbation of ischemic brain damage.

The Effect of Exosomes Derived from Bone Marrow Stem Cells in Combination with Rosuvastatin on Functional Recovery and Neuroprotection in Rats After Ischemic Stroke

Rosuvastatin, known as a cholesterol-lowering agent, has been used as an alternative therapy after the onset of stroke. In this study, neuroprotection and functional recovery of exosomes in combination with rosuvastatin have been investigated. Sixty adult male Wistar rats were subjected to middle cerebral artery occlusion (MCAO). Exosome at the dose of 100 μg and/or rosuvastatin at the dose of 20 mg/kg/day for 7 days were administered to rats as a therapeutic strategy. The elevated body swing test (EBST) and Garcia score were conducted as behavioral tests for the measurement of functional recovery. The histopathological and immunohistochemical analyses were also performed for the assessment of infarcted volume and neuroprotection in the brain of rats. The real-time PCR method was carried out to determine the relative expressions of the NLRP-3 and NLRP1 genes. After 7 days of treatment with exosome and rosuvastatin in rats which underwent MCAO, the decrease in infarct volume of the animals treated with exosome was more pronounced compared with those treated only with exosome. The combination therapy remarkably lowered the size of infarct volume. Our observation was confirmed by the downregulation of the NLRP1 and NLRP3 genes in response to combinatory treatment of rats induced by MCOA, denoting a lower rate of cell death. The number of GFAP-positive cells were reduced in the exosome-treated group compared with the MCAO group. The rate of lipid peroxidation was measured by malondialdehyde (MDA) levels which demonstrated a significant reduction of MDA in the exosome- and rotuvastatin-treated groups when compared with the MCAO group. However, the levels of the SOD enzyme did not significantly alter when the treatment groups were compared with the MCAO group. According to our findings, it seems that the use of exosomes and rosuvastatin, as a novel treatment regimen, might promote neurological recovery after the onset of stroke.

The effect of HMG-CoA reductase inhibitors on thrombolysis-induced haemorrhagic transformation

Thrombolysis-induced haemorrhagic transformation is the most challenging preventable complication in thrombolytic therapy. This condition is often associated with poor functional outcome and long-term disease burden. Statins, or 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, are controversially suggested to either increase or decrease the odds of better primary outcomes compared to treatment without statins after thrombolysis in patients or animals; statins are thought to act by influencing lipid levels, the inflammatory response, blood brain barrier permeability and cell apoptosis. Statins are the cornerstone of secondary prevention of cardiovascular and cerebrovascular diseases. However, the role of statins in acute phase stroke, and the necessity of their use, remains unclear. Currently, whether statins can increase the risk of haemorrhagic transformation is of great concern for patients treated with tissue plasminogen activator (t-PA). Herein, we thoroughly summarize the recent advances that address whether the administration of statins in ischaemic stroke increases haemorrhagic transformation in patients or animals who received thrombolysis at an early stage and the related mechanisms. This review will provide more clinical and preclinical evidence to address questions regarding the exercise of caution in the use of high dose statins in patients who received thrombolysis and if low dose statins may be beneficial in decreasing thrombolysis-induced haemorrhagic transformation.

Statin, cholesterol, and sICH after acute ischemic stroke: systematic review and meta-analysis

BACKGROUND AND PURPOSE

Conflicts exist regarding relationship between prior/new statin use, cholesterol, and early poststroke intracranial hemorrhage (ICH) in acute ischemic stroke (AIS) patients. This meta-analysis is aimed at evaluating the safety of prior/new statin use, cholesterol level and risk of ICH in AIS patients.

METHODS

We searched PubMed and Embase for studies examining relation between statin use, cholesterol level, and early poststroke ICH in AIS. Included studies should report risk of early poststroke symptomatic ICH (sICH) or overall ICH. A random-effects model was used to pool the data.

RESULTS

Twenty-five articles involving 26,327 participants were included, among whom 925 had sICH. Prior statin use was not associated with overall ICH (adjusted odds ratio (OR), 1.478; 95% confidence interval (CI), 0.924-2.362; p = 0.103) and sICH in patients who received thrombolysis (adjusted OR, 1.567; 95% CI, 0.994-2.471; p = 0.053) or overall ICH in patients, most of whom had not received recanalization therapy (crude OR, 1.342; 95% CI, 0.872-2.065; p = 0.181). New statin use was associated with decreased sICH after recanalization therapy (crude OR, 0.292; 95% CI, 0.168-0.507; p < 0.001).Cholesterol level was not associated with overall ICH.

CONCLUSION

Prior/new statin use and lower cholesterol level are not risk factors for sICH and overall ICH in AIS patients, whether or not the patient has received recanalization therapy. New statin use is likely associated with decreased sICH.

The Risk of Symptomatic Intracranial Hemorrhage after Thrombolysis for Acute Stroke: Current Concepts and Perspectives

Background

Thrombolysis is the standard of treatment for acute ischemic stroke, with a time window of up to 4½ h from stroke onset. Despite the long experience with the use of recombinant tissue plasminogen activator and the adherence to protocols symptomatic intracranial hemorrhage (SICH) may occur in around 6% of cases, with high-mortality rate and poor-functional outcomes. Many patients are excluded from thrombolysis on the basis of an evaluation of known risk factors, but there are other less known factors involved.

Objective

The purpose of this work is to analyze the less known risk factors for SICH after thrombolysis. A search of articles related with this field has been undertaken in PubMed with the keywords (brain hemorrhage, thrombolysis, and acute ischemic stroke). Some risk factors for SICH have emerged such as previous microbleeds on brain magnetic resonance imaging, leukoaraiosis, and previous antiplatelet drug use or statin use. Serum matrix metalloproteinases have emerged as a promising biomarker for better selection of patients, but further research is needed.

Conclusions

In addition to the already known risk factors considered in the standard protocols, an individualized evaluation of risks is needed to minimize the risk of brain hemorrhage after thrombolysis for ischemic stroke.

Beneficial Role of Rosuvastatin in Blood-Brain Barrier Damage Following Experimental Ischemic Stroke

Hemorrhage transformation is the most challenging preventable complication in thrombolytic therapy and is related to recombinant tissue plasminogen activator (rt-PA)-induced blood–brain barrier (BBB) damage. Intraperitoneal injections of normal or high doses of rosuvastatin were administered to Balb/c mice 20 min prior to middle cerebral artery occlusion (MCAO) surgery for 3 h followed by reperfusion with rt-PA thrombolytic therapy and cerebral blood flow monitoring to investigate whether a high or normal dose of rosuvastatin reduces BBB damage after brain ischemia and rt-PA reperfusion. The integrity of the BBB was ameliorated by normal and high doses of rosuvastatin as determined from Evans blue staining, ultrastructure assessments and immunochemistry at 24 h after reperfusion. The levels of TJ proteins were preserved, potentially by targeting platelet-derived growth factor receptor α (PDGFR-α) and low-density lipoprotein receptor-related protein 1 (LRP1) to inhibit the expression of matrix metalloproteinase proteins (MMPs) by reducing the levels of phosphorylated c-jun-N-terminal kinase (pJNK), phosphorylated mitogen-activated protein kinase (MAPK) p38 (pP38) and increasing the levels of phosphorylated extracellular regulated protein kinases (pERK), and tissue inhibitor of metalloproteinases (TIMPs), as inferred from Western blotting and molecular docking analyses. In summary, rosuvastatin reduced rt-PA therapy-associated BBB permeability by PDGFR-α- and LRP1-associated MAPK pathways to reduce the mortality of mice, and a normal dose of rosuvastatin exerted greater preventative effects on reducing BBB damage than did a high dose in the time window of thrombolytic therapy.