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

Nadinda A.M. Van Der Ende*, Femke C.C. Kremers, Wouter Van Der Steen, Esmee Venema, Manon Kappelhof, Charles B.L.M. Majoie, Alida A. Postma, Jelis Boiten, Ido R. Van Den Wijngaard, Aad Van Der Lugt, Diederik W.J. Dippel, Bob Roozenbeek

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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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.

Original languageEnglish
Pages (from-to)476-487
Number of pages12
Issue number2
Publication statusPublished - Feb 2023

Bibliographical note

Funding Information:
Drs Dippel and van der Lugt report unrestricted grants from Stryker, Penumbra, Medtronic, Cerenovus, Thrombolytic Science, LLC, Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organization for Health Research and Development, and Health Holland Top Sector Life Sciences & Health for research, paid to institution. Dr Majoie received funds from TWIN Foundation (related to this project, paid to institution), CVON/Dutch Heart Foundation, Stryker, European Commission, Health Evaluation Netherlands (unrelated to this project; all paid to institution) and is shareholder of Nicolab. Dr Postma received an institutional grant from Siemens Healthineers. The other authors report no conflicts.

Funding Information:
The MR CLEAN Registry was partly funded by Stichting Toegepast Wetenschappelijk Instituut voor Neuromodulatie (TWIN), Erasmus MC University Medical Center, Maastricht University Medical Center, and Amsterdam University Medical Center.

Publisher Copyright:
© 2023 Lippincott Williams and Wilkins. All rights reserved.


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