Predictors of Intracranial hemorrhage after mechanical thrombectomy in distal middle cerebral artery occlusion.

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ALI GABER, TAMER BELAL, MOHAMMED SAID, WESSAM Mustafa, MOHAMMED ABBAS, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8079083/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Apr, 2026 Read the published version in Egyptian Journal of Radiology and Nuclear Medicine → Version 1 posted You are reading this latest preprint version Abstract Background: Stroke remains a major global cause of death and disability, with ischemic strokes accounting for most cases. Mechanical thrombectomy (MT) is well established for large-vessel occlusions, yet its role in distal middle cerebral artery (MCA) occlusions is less clearly defined. Intracranial hemorrhage (ICH), particularly symptomatic ICH (sICH), is a serious complication that may worsen outcomes. This study aimed to identify predictors of hemorrhagic transformation following MT for distal MCA occlusions. Methods: Between January 2016 and December 2022, 246 patients with distal MCA occlusion underwent MT. Patients were classified into three groups: no hemorrhage (n = 128), asymptomatic hemorrhage (n = 77), and symptomatic hemorrhage (n = 41). Clinical, imaging, and procedural variables were analyzed using univariate and multivariate logistic regression to determine predictors of sICH. Results: On univariate analysis, older age, higher NIHSS, lower ASPECTS, elevated systolic blood pressure, multiple thrombectomy passes, and incomplete reperfusion were associated with hemorrhagic-transformation.Multivariate regression identified elevated systolic blood pressure (aOR = 1.017, 95% CI 1.001–1.034, p = 0.032) and number of thrombectomy passes (aOR = 1.71, 95% CI 1.34–2.17, p < 0.001) as independent predictors of sICH, while successful final reperfusion (mTICI 2c/3) showed a protective trend (p = 0.053). Conclusions: Symptomatic intracranial hemorrhage after distal MCA thrombectomy is independently associated with elevated systolic blood pressure and repeated thrombectomy attempts. These results reinforce the importance of achieving the first-pass effect and maintaining systolic blood pressure below 150 mmHg to optimize safety and improve outcomes. Figures Figure 1 Figure 2 Introduction Stroke remains one of the leading global causes of mortality and disability, with acute ischemic stroke accounting for a substantial proportion of cases. Mechanical thrombectomy (MT) has been established through randomized controlled trials and meta-analyses as the standard of care for large-vessel occlusions in the anterior circulation, yielding significantly better functional outcomes when performed rapidly and with good reperfusion. ( 1 ) However, distal medium vessel occlusions (DMVOs), particularly involving distal segments of the middle cerebral artery (MCA), present distinct challenges: smaller vessels, more tortuous anatomy, and possibly different risk-benefit profiles. Recent work demonstrates that MT in DMVOs is generally safe and efficacious, with favorable outcomes often exceeding those for more proximal occlusions, but the evidence remains less definitive. ( 2 ) A critical concern in all thrombectomy-treated ischemic strokes is hemorrhagic transformation (HT), which ranges from asymptomatic bleeding to symptomatic intracranial hemorrhage (sICH), and may substantially worsen outcomes or increase mortality. Meta-analyses and large registry studies have identified several clinical and imaging predictors of HT after reperfusion therapy, including older age, high baseline NIHSS, elevated blood glucose, lower ASPECTS scores, number of thrombectomy passes, onset-to-treatment delays, and incomplete or poor recanalization. ( 3 ) Despite this, many studies have focused on large vessel occlusions, and the risk factors specifically in the context of distal MCA occlusions remain under-explored. Given this gap, further research is needed to understand which patients undergoing MT for distal MCA occlusions are at heightened risk of hemorrhagic transformation, particularly sICH, so that procedural and post-procedure management can be optimized. Identifying modifiable predictors (such as blood pressure control, number of passes) could lead to improved protocols, tailored patient selection, and better outcomes. This study, investigate data from 246 patients treated over several years, aims to fill this important gap by comparing clinical, imaging, and procedural factors in patients who do and do not develop HT after MT in distal MCA occlusions. Patient and method Study design and population This retrospective cohort study included consecutive patients presenting with distal MCA (M2 or beyond) occlusions within 24 hours of onset who underwent MT at Bicêtre Hospital, Paris-Saclay University, between January 2016 and December 2022. Among 326 screened patients, 80 were excluded (28 due to difficult access, 36 due to spontaneous recanalization after IV thrombolysis, and 16 for incomplete data), yielding 246 patients for final analysis “Figure 1” . Ethics The study was approved by the Institutional Review Board of Bicêtre Hospital. Informed consent was waived owing to the retrospective design. Description of mechanical thrombectomy Procedure According to the patients' state of consciousness and degree of cooperation, local anesthesia or general anesthesia was selected. Seldinger technique was used for puncture through the femoral artery a short or long vascular access sheath (8F) was placed. 8F BGC CELLO TM (Medtronic Neurovascular), FlowGate2™ (FG2; Stryker Neurovascular) ,Merci (Concentric Medical) OR Fargomax,was placed in the proximal segment of the internal carotid artery (ICA) or the distal segment of the ICA, and a microcatheter was placed over the microwire to the occluded area for the delivery of the stentriever within the thrombus. In some cases intermediate catheter 5F SOFIA (MicroVention; Terumo) was also used. After the stentriever was placed within the embolus the BGC was inflated to arrest the blood flow and the stent was subsequently retrieved for 5 mins Aspiration was then performed through the BGC using a 50 ml syringe. After the withdrawal of the stent, the balloon was immediately deflated to allow for re-circulation. Angiography was performed to assess angiographic outcomes. Endovascular Procedure Procedures were performed under either local or general anesthesia, depending on patient consciousness and cooperation. Access was via the femoral artery using the Seldinger technique; an 8F vascular sheath was inserted. A balloon-guided catheter (such as CELLO™, FlowGate2™, Merci, or Fargomax) was advanced into the proximal or distal internal carotid artery. A microcatheter was navigated over a microwire to the occlusion site for stent retriever deployment; in some cases, an intermediate catheter (5F SOFIA) was also used. After embedding the stent, the balloon in the proximal catheter was inflated to arrest flow; the stent was held for approximately five minutes and then retrieved, with aspiration through the balloon-guiding catheter (50 mL syringe). Balloon deflation followed retrieval, and angiography was repeated to assess final revascularization via the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Baseline Characteristics Clinical parameters : demographics; history of coronary artery disease, atrial fibrillation, hypertension, diabetes; prior medications (antiplatelets, anticoagulants, statins); admission NIHSS and ASPECTS; blood pressure; pretreatment with intravenous thrombolysis. Biological parameters : admission glucose, C-reactive protein (CRP), platelet count, creatinine, LDL-cholesterol. Procedural parameters : occlusion site, technique used, number of thrombectomy passes, time to puncture,first and final mTICI scores Angiographic & Clinical Outcomes Primary angiographic outcome : First Pass Effect (FPE), defined as achieving mTICI ≥2c after a single pass (or combination if used). Radiological outcome: non-contrast CT brain was done after 24 hours for evaluation of hemorrhagic transformation Clinical outcomes : NIHSS at discharge, change in NIHSS from admission to discharge and functional independence at 90 days using Modified Rankin scale (MRS) Safety evaluation : incidence of symptomatic intracranial hemorrhage (sICH), defined according ECASS III (4) as hemorrhagic transformation with ≥4-point worsening on the NIHSS. Statistical analysis and data interpretation : Data were analyzed using appropriate parametric and non-parametric tests. Continuous variables were compared using the t -test or One-Way ANOVA for normally distributed data, and the Mann–Whitney U or Kruskal–Wallis test for non-normally distributed data. Categorical variables were compared using the Chi-square or Fisher’s exact test. Variables with p < 0.10 in univariate analysis were entered into a multivariate logistic regression model to identify independent predictors of symptomatic intracranial hemorrhage (SICH). Results were expressed as adjusted odds ratios (aOR) with 95% confidence intervals, and a p-value < 0.05 was considered statistically significant. Receiver operating characteristic (ROC) analysis was performed to determine the optimal cutoff value of the number of thrombectomy passes for predicting symptomatic intracranial hemorrhage (sICH). The area under the curve (AUC) with 95% confidence interval (CI), sensitivity, and specificity were calculated. Results There was no significant difference among the three groups (no hemorrhage, asymptomatic hemorrhage, and symptomatic hemorrhage) regarding sex distribution, hypertension, diabetes, coronary artery disease, smoking status, atrial fibrillation, or prior use of antiplatelets, anticoagulants, or statins. However, patients who developed symptomatic hemorrhage were significantly older (mean 77.3 ± 12.8 years) compared to those without hemorrhage (68.4 ± 17.9 years, p = 0.01). In addition, a lower ASPECTS score on admission was observed in the hemorrhage groups, indicating larger baseline infarct size ( p = 0.02).table (1) Table 1: Demographic data, comorbidities of the studied groups and o Use of antiplatelets, anticoagulants, or statins prior to hospital arrival and ASPECTS at admission No-hemorrhage group N=128(%) Asymptomatic hemorrhage group N=77(%) Symptomatic hemorrhage group N=41 (%) P value Age/years 68.41±17.92 71.70±14.99 77.29±12.75 0.01* Sex Male Female 61(47.7) 67(52.3) 45(58.4) 32(41.6) 23(56.1) 18(43.9) 0.286 hypertension 82(64.1) 55(71.4) 28(68.3) 0.295 DM 21(16.4) 17(22.4) 7(17.1) 0.533 Coronary 21(16.4) 14(18.2) 10(25) 0.471 Smoking Non-smoker Cut Active Unknown 79(61.7) 21(16.4) 10(7.8) 18(14.1) 45(59.2) 12(15.8) 6(7.9) 13(17.1) 21(51.2) 8(19.5) 4(9.8) 8(19.5) 0.949 AF 17(13.3) 14(18.2) 8(19.5) 0.507 Antiplatelets 47(36.7) 22(28.6) 16(39) 0.397 Anti-coagulant 24(18.8) 13(16.9) 9(22) 0.798 Statin 36(28.1) 21(27.3) 13(31.7) 0.873 Aspect 8(3-10) 8(0-10) 7(5-10) 0.02* The NIHSS score at admission was significantly higher among patients with hemorrhagic transformation (median 14) compared to the no-hemorrhage group (median 9; p < 0.001), reflecting more severe initial neurological deficits. Similarly, systolic blood pressure was significantly elevated in patients with symptomatic hemorrhage (mean 155.5 ± 28.2 mmHg) compared to other groups ( p = 0.016). NIHSS at discharge was markedly worse in the symptomatic hemorrhage group (median 21), highlighting the negative clinical impact of post-thrombectomy bleeding ( p < 0.001).Table(2) Table 2: NIHSS scores at admission and admission systolic and diastolic blood pressure No-hemorrhage group N=128(%) Asymptomatic hemorrhage group N=77(%) Symptomatic hemorrhage group N=41 (%) P value NIHSS initial 9(0-28) 14(2-29) 14(0-29) <0.001* NIHSS at discharge 5(0-28) 6(0-26) 21(4-37) <0.001* Systolic blood pressure (mm/hg) 143.50±21.13 146.88±21.50 155.46±28.24 0.016* Diastolic blood pressure (mm/hg) 80.71±14.65 82.88±14.07 87.27±24.16 0.093 No significant differences were observed among the groups regarding glucose, LDL, CRP, platelet count, or creatinine levels. However, a significantly higher number of thrombectomy passes was required in patients who developed hemorrhagic transformation (median 2 passes) compared to those without hemorrhage (median 1 pass; p = 0.014). The use of intravenous thrombolysis prior to thrombectomy did not significantly affect the risk of hemorrhage ( p = 0.437). Table (3) Table 3 : Biological Parameters, Number of pass and IV thrombolytics among the studied groups. No-hemorrhage group N=128(%) Asymptomatic hemorrhage group N=77(%) Symptomatic hemorrhage group N=41 (%) P value Glucose 6.2(3-17.5) 6.2(1.4-20.5) 6.9(1.5-15.9) 0.180 LDL 2.35(0.6-209) 2.4(0.8-6.05) 2(0.6-4.5) 0.127 CRP 4.5(0-161) 9(0-308) 10(0-135) 0.074 Platelet 234000(29000-462000) 235000(27000-573000) 232000(34000-603000) 0.424 Creatinine 78(32-235) 79(40-226) 89.5(54-424) 0.141 Number of pass median (range) 1(1-7) 2(1-5) 2(1-6) 0.014* IV thrombolytics 74(57.8) 42(54.5) 19(46.3) 0.437 No significant difference was found regarding the type of device or use of balloon guide catheters between groups. However, successful reperfusion (mTICI 2c/3) after the first or final attempt was significantly less frequent in the hemorrhage groups ( p < 0.001 and p = 0.004, respectively), indicating a strong relationship between incomplete recanalization and hemorrhagic risk. Functionally, patients with symptomatic hemorrhage had worse 3-month outcomes , with 85.4% showing poor functional status (mRS 3–6; p = 0.003) Table 4: Procedural Parameters of the studied groups. No hemorrhage group N=128(%) Asymptomatic hemorrhage group N=77(%) Symptomatic hemorrhage group N=41 (%) P value BCG 64(50) 42(54.5) 15(36.6) 0.172 First passage stent Aspiration combined N=64 42(65.6) 3(4.7) 19(29.7) N=42 26(61.9) 1(2.4) 15(35.7) N=15 7(46.7) 0 8(53.3) P=0.396 P=0.604 P=0.220 Onset to punctuate (minutes) 250(0-907) 258(0-780) 250(0-427) 0.464 First TICI 0-2b 2c/3 71(55.5) 57(44.5) 56(72.7) 21(27.3) 36(87.8) 5(12.2) <0.001* Final TICI 0-2b 2c/3 41(32) 87(68) 32(41.6) 45(58.4) 27(65.9) 14(34.1) 0.004* TICI 1 st & final difference 0-2b 2c/3 N=53 35(66) 18(34) N=42 25(59.5) 17(40.5) N=26 17(65.4) 9(34.6) 0.789 MRS after 3 months 0-2 3-6 n=94 37(39.4) 57(60.6) N=68 32(47.1) 36(52.9) N=41 6(14.6) 35(85.4) 0.003* Multivariate logistic regression showed that a higher number of thrombectomy passes (aOR = 1.71, 95% CI 1.34–2.17, p < 0.001) and elevated systolic blood pressure (aOR = 1.017, 95% CI 1.001–1.034, p = 0.032) were independent predictors of symptomatic intracranial hemorrhage (SICH). Good final reperfusion (mTICI 2c/3) tended to reduce the risk (aOR = 0.49, p = 0.053), while age showed a borderline association ( p = 0.062). TABLE 5: Adjusted odds ratios (aOR) for SICH Variable aOR 95% CI p-value Age (per year) 1.03 0.999 – 1.055 0.062 ASPECT (per point) 0.91 0.732 – 1.121 0.363 NIHSS (initial, per point) 1.00 0.948 – 1.056 0.981 Systolic BP (per mmHg) 1.017 1.001 – 1.034 0.032 Number of passes (per pass) 1.706 1.339 – 2.174 <0.001 Final revascularization (mTICI 2c/3 vs 0–2b) 0.49 0.238 – 1.010 0.053 ROC curve analysis for the number of thrombectomy passes in differentiating no hemorrhage from symptomatic hemorrhage yielded an AUC of 0.602 (95% CI: 0.464–0.741, p = 0.142), indicating fair discrimination. The optimal cutoff point was ≥1.5 passes, with a sensitivity of 54.2% and specificity of 62.9% “Table 6”. TABLE 6 : ROC analysis of the number of thrombectomy passes in differentiating no hemorrhage from symptomatic hemorrhage AUC (95%CI) P value Cut off point Sensitivity Specificity number of passes 0.602 (0.464-0.741) 0.142 ≥1.5 54.2 62.9 AUC: Area under curve Discussion Our symptomatic intracranial hemorrhage (SICH) rate (~ 12.8%) is higher than most single-center distal-MCA (M2/DMVO) thrombectomy series, which generally report SICH rates in the range of ~ 2–7% (for example, de Castro Afonso et al. 2019 and several recent distal-occlusion cohorts) ( 5 ) However, pooled analyses and older meta-analyses of M2 thrombectomy have reported SICH rates closer to 10% (range ~ 6–16%), so our observed rate is comparable to these larger or more heterogeneous series and may reflect differences in patient selection, infarct size, age, number of passes, and definitions of SICH across studies. ( 6 ) Finally, more recent registry and multicenter reports show variable SICH rates—some distal-occlusion cohorts reporting low rates (< 5%) while others report rates up to ~ 10–12% depending on case mix and procedural factors—underscoring that bleeding risk for distal thrombectomy is heterogeneous and context dependent. ( 7 ) In this cohort of patients with acute distal MCA occlusions treated by mechanical thrombectomy (Fig. 2), the ROC analysis demonstrated that the number of thrombectomy passes had a modest yet fair ability to predict symptomatic intracranial hemorrhage (AUC = 0.602). This finding supports the observation that exceeding two thrombectomy attempts may increase endothelial injury and reperfusion-related bleeding, thereby reinforcing the importance of achieving the first-pass effect ( 8 ) ,successful recanalization on the initial attempt as a key procedural goal to minimize hemorrhagic complications. Elevated systolic blood pressure on admission was also identified as an independent predictor of symptomatic intracranial hemorrhage (sICH), while age showed a trend toward higher risk. Conversely, successful final reperfusion (mTICI 2c/3) appeared to exert a protective effect, whereas baseline ASPECTS and NIHSS did not retain significance after adjustment for other variables. Our findings are broadly consistent with existing literature. A recent meta-analysis of 25 cohort and trial studies confirmed that higher SBP , age , NIHSS , > 3 thrombectomy passes , and poor final reperfusion (mTICI < 2c) are important predictors of SICH after endovascular therapy. ( 9 ) For example, Kuang et al. found that lower ASPECTS and higher admission glucose were strongly associated with hemorrhagic transformation, although the impact of the number of passes was less emphasized in that cohort. ( 10 ) Similarly, large individual-patient data meta-analysis has revealed that higher mean SBP in the first 24 h post-EVT is tied to increased risk of SICH, poorer functional outcomes, and mortality. ( 11 ) Each addtional pass during thrombectomy may cause greater mechanical manipulation, increased endothelial injury, microvascular disruption, or thrombus fragmentation all potentially contributing to reperfusion injury and hemorrhagic conversion. Elevated systolic blood pressure might likewise exacerbate stress on vascular walls and contribute to breakdown of the blood-brain barrier during reperfusion. These pathophysiologic mechanisms have been discussed in prior reports and are consistent with norms in stroke reperfusion injury theory. From a clinical standpoint, our findings suggest that minimizing the number of thrombectomy passes, when possible, should be a procedural goal. Tight control of systolic blood pressure in the preprocedural and early postprocedural periods may also reduce the risk of symptomatic intracranial hemorrhage (sICH); however, excessively low blood pressure may jeopardize collateral perfusion. Although randomized trials have not yet established optimal SBP thresholds specifically for distal MCA thrombectomy, a pragmatic target used in many centers is SBP < 150 mmHg, which may help lower hemorrhagic risk while preserving collateral flow. Procedurally, achieving the first-pass effect (FPE) and limiting thrombectomy attempts to ≤ 2 passes when feasible may further reduce sICH risk. These recommendations, however, require confirmation in prospective studies. Limitations This study is limited by its retrospective, single-center design and potential selection bias. The absence of standardized post-procedure blood pressure control protocols may influence results. Future multicenter prospective studies are needed to validate these findings. Conclusion Symptomatic intracranial hemorrhage (sICH) remains a major complication after mechanical thrombectomy for distal MCA occlusions. In this cohort, elevated systolic blood pressure and a higher number of thrombectomy passes were identified as independent predictors of sICH, while complete reperfusion (mTICI 2c/3) showed a protective trend. ROC analysis indicated that performing more than two passes markedly increased the risk of hemorrhage. These findings underscore the importance of achieving the first-pass effect and maintaining careful periprocedural blood pressure control, with a pragmatic systolic blood pressure target below 150 mmHg to optimize safety. Incorporating these factors into procedural and post-procedural protocols may help minimize hemorrhagic complications and improve patient outcomes. Declarations Ethics declarations Not applicable Consent for publication All patients included in this study gave a written informed consent to publish the data contained in this study. Funding Not applicable (no funding received for this study). Author Contribution A.E.G. (Ali E. Gaber) conceived the study, collected clinical data, and drafted the manuscript.T.M.B. (Tamer M. Belal) contributed to study design, data interpretation, and critical manuscript revision.M.G. (Mohamed Gomaa) supervised data analysis and contributed to manuscript editing.W.M. (Wessam Mustafa) provided clinical oversight and methodological review.M.A. (Mohammed Abbas) assisted in statistical analysis and data validation.J.C. (Jonathan Cortese) and J.Ca. (Jildaz Caroff) contributed to the endovascular procedural review and interpretation of imaging data.L.S. (Laurent Spelle) supervised the overall project, ensured study accuracy, and provided senior editorial input. Data Availability The clinical datasets generated and analyzed during the current study are not publicly available due to institutional and patient privacy restrictions but are available from the corresponding author on reasonable request and with permission from Bicêtre Hospital, Paris-Saclay University. References Anadani, Mohammad, et al. "Mechanical thrombectomy for distal occlusions: efficacy, functional and safety outcomes: insight from the STAR collaboration." World neurosurgery 151 (2021): e871-e879. Berger, Marcel Cedric, et al. "Safety and efficacy of thrombectomy for distal medium vessel occlusions of the middle cerebral artery." Neurointervention 20.1 (2025): 15-23. Hao, Zilong, et al. "Risk factors for intracranial hemorrhage after mechanical thrombectomy: a systematic review and meta-analysis." Expert Review of Neurotherapeutics 19.10 (2019): 927-935. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. New England journal of medicine. 2008 Sep 25;359(13):1317-29. de Castro Afonso, Luís Henrique, et al. "Thrombectomy for M2 occlusions and the role of the dominant branch." Interventional Neuroradiology 25.6 (2019): 697-704. Saber, Hamidreza, et al. "Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis." Journal of neurointerventional surgery 10.7 (2018): 620-624. Bala, F., et al. "Outcomes with endovascular treatment of patients with M2 segment MCA occlusion in the late time window." American Journal of Neuroradiology 44.4 (2023): 447-452. Zaidat OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Dabus G, Malisch TW, Marden FA. First pass effect: a new measure for stroke thrombectomy devices. Stroke. 2018 Mar;49(3):660-6. Dong, Shuyang, et al. "Predictors of symptomatic intracranial hemorrhage after endovascular thrombectomy in acute ischemic stroke: a systematic review and meta-analysis." Cerebrovascular Diseases 52.4 (2023): 363-375. Kuang, Yongyao, et al. "Clinical and imaging predictors for hemorrhagic transformation of acute ischemic stroke after endovascular thrombectomy." Journal of Neuroimaging 34.3 (2024): 339-347. Katsanos, Aristeidis H., et al. "Blood pressure after endovascular thrombectomy and outcomes in patients with acute ischemic stroke: an individual patient data meta-analysis." Neurology 98.3 (2022): e291-e301. Additional Declarations No competing interests reported. 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23:25:52","extension":"xml","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":63832,"visible":true,"origin":"","legend":"","description":"","filename":"0dce7f315c53405ba950c220c12ecfa81structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8079083/v1/4b1be5b71e24b411ca885c43.xml"},{"id":97095844,"identity":"49e96911-a9b1-4a21-a45c-c97a6c28e675","added_by":"auto","created_at":"2025-11-30 23:25:52","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75959,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8079083/v1/968909a30ec3b0ea89958e69.html"},{"id":97095833,"identity":"7b40b64b-f7f7-41f1-8fe3-328ba0c45cfb","added_by":"auto","created_at":"2025-11-30 23:25:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":42437,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of patient exclusion.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8079083/v1/1950c6d02541f67c7088d35c.png"},{"id":97095834,"identity":"032600a3-6e43-4197-87b4-df02fbf4c77c","added_by":"auto","created_at":"2025-11-30 23:25:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":527492,"visible":true,"origin":"","legend":"\u003cp\u003ea) pre-thrombectomy cerebral angiography showing M2/M3 \u0026nbsp;MCA occlusion. b) post-thrombectomy cerebral angiography showing reperfusion of distal MCA branches. c) post-thermbectomy non-contrast CT showing hemorrhagic transformation\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8079083/v1/a191e4dd42148deeca8d1492.png"},{"id":106808808,"identity":"24d40e73-96c8-4f0d-8621-5a0350739bae","added_by":"auto","created_at":"2026-04-13 16:02:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1723201,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8079083/v1/8ac7521f-7b39-4c5f-9aa6-2070e338237f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predictors of Intracranial hemorrhage after mechanical thrombectomy in distal middle cerebral artery occlusion. ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStroke remains one of the leading global causes of mortality and disability, with acute ischemic stroke accounting for a substantial proportion of cases. Mechanical thrombectomy (MT) has been established through randomized controlled trials and meta-analyses as the standard of care for large-vessel occlusions in the anterior circulation, yielding significantly better functional outcomes when performed rapidly and with good reperfusion.\u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e However, distal medium vessel occlusions (DMVOs), particularly involving distal segments of the middle cerebral artery (MCA), present distinct challenges: smaller vessels, more tortuous anatomy, and possibly different risk-benefit profiles. Recent work demonstrates that MT in DMVOs is generally safe and efficacious, with favorable outcomes often exceeding those for more proximal occlusions, but the evidence remains less definitive.\u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eA critical concern in all thrombectomy-treated ischemic strokes is hemorrhagic transformation (HT), which ranges from asymptomatic bleeding to symptomatic intracranial hemorrhage (sICH), and may substantially worsen outcomes or increase mortality. Meta-analyses and large registry studies have identified several clinical and imaging predictors of HT after reperfusion therapy, including older age, high baseline NIHSS, elevated blood glucose, lower ASPECTS scores, number of thrombectomy passes, onset-to-treatment delays, and incomplete or poor recanalization.\u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e Despite this, many studies have focused on large vessel occlusions, and the risk factors specifically in the context of distal MCA occlusions remain under-explored.\u003c/p\u003e\u003cp\u003eGiven this gap, further research is needed to understand which patients undergoing MT for distal MCA occlusions are at heightened risk of hemorrhagic transformation, particularly sICH, so that procedural and post-procedure management can be optimized. Identifying modifiable predictors (such as blood pressure control, number of passes) could lead to improved protocols, tailored patient selection, and better outcomes. This study, investigate data from 246 patients treated over several years, aims to fill this important gap by comparing clinical, imaging, and procedural factors in patients who do and do not develop HT after MT in distal MCA occlusions.\u003c/p\u003e"},{"header":"Patient and method ","content":"\u003ch3\u003eStudy design and population\u003c/h3\u003e\n\u003cp\u003eThis retrospective cohort study included consecutive patients presenting with distal MCA (M2 or beyond) occlusions within 24 hours of onset who underwent MT at Bic\u0026ecirc;tre Hospital, Paris-Saclay University, between January 2016 and December 2022. Among 326 screened patients, 80 were excluded (28 due to difficult access, 36 due to spontaneous recanalization after IV thrombolysis, and 16 for incomplete data), yielding 246 patients for final analysis \u0026ldquo;Figure 1\u0026rdquo; .\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board of Bic\u0026ecirc;tre Hospital.\u0026nbsp;Informed consent was waived owing to the retrospective design.\u003c/p\u003e\n\u003ch3\u003eDescription of mechanical thrombectomy Procedure\u003c/h3\u003e\n\u003cp\u003eAccording to the patients\u0026apos; state of consciousness and degree of cooperation, local anesthesia or general anesthesia was selected. Seldinger technique was used for puncture through the femoral artery a short or long vascular access sheath (8F) was placed. 8F BGC CELLO\u003csup\u003eTM\u003c/sup\u003e (Medtronic Neurovascular), FlowGate2\u0026trade; (FG2; Stryker Neurovascular) ,Merci (Concentric Medical) OR Fargomax,was placed in the proximal segment of the internal carotid artery (ICA) or the distal segment of the ICA, and a microcatheter was placed over the microwire to the occluded area for the delivery of the stentriever within the thrombus. In some cases intermediate catheter 5F SOFIA (MicroVention; Terumo) was also used. After the stentriever was placed within the embolus the BGC was inflated to arrest the blood flow and the stent was subsequently retrieved for 5 mins Aspiration was then performed through the BGC using a 50 ml syringe. After the withdrawal of the stent, the balloon was immediately deflated to allow for re-circulation. Angiography was performed to assess angiographic outcomes.\u003c/p\u003e\n\u003ch3\u003eEndovascular Procedure\u003c/h3\u003e\n\u003cp\u003eProcedures were performed under either local or general anesthesia, depending on patient consciousness and cooperation. Access was via the femoral artery using the Seldinger technique; an 8F vascular sheath was inserted. A balloon-guided catheter (such as CELLO\u0026trade;, FlowGate2\u0026trade;, Merci, or Fargomax) was advanced into the proximal or distal internal carotid artery. A microcatheter was navigated over a microwire to the occlusion site for stent retriever deployment; in some cases, an intermediate catheter (5F SOFIA) was also used. After embedding the stent, the balloon in the proximal catheter was inflated to arrest flow; the stent was held for approximately five minutes and then retrieved, with aspiration through the balloon-guiding catheter (50 mL syringe). Balloon deflation followed retrieval, and angiography was repeated to assess final revascularization via the modified Thrombolysis in Cerebral Infarction (mTICI) scale.\u003c/p\u003e\n\u003ch3\u003eBaseline Characteristics\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eClinical parameters\u003c/strong\u003e: demographics; history of coronary artery disease, atrial fibrillation, hypertension, diabetes; prior medications (antiplatelets, anticoagulants, statins); admission NIHSS and ASPECTS; blood pressure; pretreatment with intravenous thrombolysis.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBiological parameters\u003c/strong\u003e: admission glucose, C-reactive protein (CRP), platelet count, creatinine, LDL-cholesterol.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eProcedural parameters\u003c/strong\u003e: occlusion site,\u0026nbsp;technique used, number of thrombectomy passes, time to puncture,first and final mTICI scores\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003eAngiographic \u0026amp; Clinical Outcomes\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003ePrimary angiographic outcome\u003c/strong\u003e: First Pass Effect (FPE), defined as achieving mTICI \u0026ge;2c after a single pass (or combination if used).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRadiological outcome:\u003c/strong\u003e non-contrast CT brain was done after 24 hours for evaluation of hemorrhagic transformation\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eClinical outcomes\u003c/strong\u003e: NIHSS at discharge, change in NIHSS from admission to discharge and functional independence at 90 days using Modified Rankin scale (MRS)\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSafety evaluation\u003c/strong\u003e: incidence of symptomatic intracranial hemorrhage (sICH), defined according ECASS III \u003csup\u003e(4)\u003c/sup\u003e \u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eas hemorrhagic transformation with \u0026ge;4-point worsening on the NIHSS.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis and data interpretation\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eData were analyzed using appropriate parametric and non-parametric tests. Continuous variables were compared using the \u003cem\u003et\u003c/em\u003e-test or One-Way ANOVA for normally distributed data, and the Mann\u0026ndash;Whitney U or Kruskal\u0026ndash;Wallis test for non-normally distributed data. Categorical variables were compared using the Chi-square or Fisher\u0026rsquo;s exact test. Variables with p \u0026lt; 0.10 in univariate analysis were entered into a multivariate logistic regression model to identify independent predictors of symptomatic intracranial hemorrhage (SICH). Results were expressed as adjusted odds ratios (aOR) with 95% confidence intervals, and a p-value \u0026lt; 0.05 was considered statistically significant. Receiver operating characteristic (ROC) analysis was performed to determine the optimal cutoff value of the number of thrombectomy passes for predicting symptomatic intracranial hemorrhage (sICH). The area under the curve (AUC) with 95% confidence interval (CI), sensitivity, and specificity were calculated.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThere was no significant difference among the three groups (no hemorrhage, asymptomatic hemorrhage, and symptomatic hemorrhage) regarding sex distribution, hypertension, diabetes, coronary artery disease, smoking status, atrial fibrillation, or prior use of antiplatelets, anticoagulants, or statins. However, \u003cstrong\u003epatients who developed symptomatic hemorrhage were significantly older\u003c/strong\u003e (mean 77.3 \u0026plusmn; 12.8 years) compared to those without hemorrhage (68.4 \u0026plusmn; 17.9 years, \u003cem\u003ep\u003c/em\u003e = 0.01). In addition, a \u003cstrong\u003elower ASPECTS score on admission\u003c/strong\u003e was observed in the hemorrhage groups, indicating larger baseline infarct size (\u003cem\u003ep\u003c/em\u003e = 0.02).table (1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographic data, comorbidities of the studied groups and o \u0026nbsp; Use of antiplatelets, anticoagulants, or statins prior to hospital arrival and ASPECTS at admission\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eNo-hemorrhage group\u003c/p\u003e\n \u003cp\u003eN=128(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eAsymptomatic hemorrhage group\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN=77(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eSymptomatic hemorrhage group\u003c/p\u003e\n \u003cp\u003eN=41 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eAge/years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e68.41\u0026plusmn;17.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e71.70\u0026plusmn;14.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e77.29\u0026plusmn;12.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e61(47.7)\u003c/p\u003e\n \u003cp\u003e67(52.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e45(58.4)\u003c/p\u003e\n \u003cp\u003e32(41.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23(56.1)\u003c/p\u003e\n \u003cp\u003e18(43.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.286\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003ehypertension\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e82(64.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e55(71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e28(68.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.295\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e21(16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e17(22.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e7(17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.533\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eCoronary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e21(16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e14(18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e10(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.471\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003cp\u003eNon-smoker\u003c/p\u003e\n \u003cp\u003eCut\u003c/p\u003e\n \u003cp\u003eActive\u003c/p\u003e\n \u003cp\u003eUnknown\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e79(61.7)\u003c/p\u003e\n \u003cp\u003e21(16.4)\u003c/p\u003e\n \u003cp\u003e10(7.8)\u003c/p\u003e\n \u003cp\u003e18(14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e45(59.2)\u003c/p\u003e\n \u003cp\u003e12(15.8)\u003c/p\u003e\n \u003cp\u003e6(7.9)\u003c/p\u003e\n \u003cp\u003e13(17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21(51.2)\u003c/p\u003e\n \u003cp\u003e8(19.5)\u003c/p\u003e\n \u003cp\u003e4(9.8)\u003c/p\u003e\n \u003cp\u003e8(19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.949\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eAF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e17(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e14(18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e8(19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.507\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eAntiplatelets\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e47(36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e22(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e16(39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.397\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eAnti-coagulant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e24(18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e13(16.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e9(22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.798\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eStatin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e36(28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e21(27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e13(31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.873\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eAspect\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e8(3-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e8(0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e7(5-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.02*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe \u003cstrong\u003eNIHSS score at admission\u003c/strong\u003e was significantly higher among patients with hemorrhagic transformation (median 14) compared to the no-hemorrhage group (median 9; \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), reflecting more severe initial neurological deficits. Similarly, \u003cstrong\u003esystolic blood pressure\u003c/strong\u003e was significantly elevated in patients with symptomatic hemorrhage (mean 155.5 \u0026plusmn; 28.2 mmHg) compared to other groups (\u003cem\u003ep\u003c/em\u003e = 0.016). \u003cstrong\u003eNIHSS at discharge\u003c/strong\u003e was markedly worse in the symptomatic hemorrhage group (median 21), highlighting the negative clinical impact of post-thrombectomy bleeding (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001).Table(2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: NIHSS scores at admission and admission systolic and diastolic blood pressure\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eNo-hemorrhage group\u003c/p\u003e\n \u003cp\u003eN=128(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eAsymptomatic hemorrhage\u003c/p\u003e\n \u003cp\u003egroup N=77(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eSymptomatic hemorrhage\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;group N=41 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eNIHSS initial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e9(0-28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e14(2-29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e14(0-29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eNIHSS at discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e5(0-28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e6(0-26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e21(4-37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eSystolic blood pressure (mm/hg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e143.50\u0026plusmn;21.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e146.88\u0026plusmn;21.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e155.46\u0026plusmn;28.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.016*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eDiastolic blood pressure (mm/hg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e80.71\u0026plusmn;14.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e82.88\u0026plusmn;14.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e87.27\u0026plusmn;24.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNo significant differences were observed among the groups regarding glucose, LDL, CRP, platelet count, or creatinine levels. However, a \u003cstrong\u003esignificantly higher number of thrombectomy passes\u003c/strong\u003e was required in patients who developed hemorrhagic transformation (median 2 passes) compared to those without hemorrhage (median 1 pass; \u003cem\u003ep\u003c/em\u003e = 0.014). The use of intravenous thrombolysis prior to thrombectomy did not significantly affect the risk of hemorrhage (\u003cem\u003ep\u003c/em\u003e = 0.437).\u003cstrong\u003e\u0026nbsp;Table\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(3)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e: \u003cstrong\u003eBiological Parameters, Number of pass and IV thrombolytics among the studied groups.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eNo-hemorrhage group\u003c/p\u003e\n \u003cp\u003eN=128(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eAsymptomatic hemorrhage\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;group N=77(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003eSymptomatic hemorrhage\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;group N=41 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eGlucose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e6.2(3-17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e6.2(1.4-20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e6.9(1.5-15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eLDL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2.35(0.6-209)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2.4(0.8-6.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e2(0.6-4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.127\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e4.5(0-161)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e9(0-308)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e10(0-135)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003ePlatelet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e234000(29000-462000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e235000(27000-573000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e232000(34000-603000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.424\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eCreatinine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e78(32-235)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e79(40-226)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e89.5(54-424)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.141\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eNumber of pass\u003c/p\u003e\n \u003cp\u003emedian (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e1(1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2(1-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e2(1-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.014*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eIV thrombolytics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e74(57.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e42(54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e19(46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.437\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNo significant difference was found regarding the type of device or use of balloon guide catheters between groups. However, \u003cstrong\u003esuccessful reperfusion (mTICI 2c/3)\u003c/strong\u003e after the first or final attempt was significantly less frequent in the hemorrhage groups (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001 and \u003cem\u003ep\u003c/em\u003e = 0.004, respectively), indicating a strong relationship between incomplete recanalization and hemorrhagic risk. Functionally, patients with symptomatic hemorrhage had \u003cstrong\u003eworse 3-month outcomes\u003c/strong\u003e, with 85.4% showing poor functional status (mRS 3\u0026ndash;6; \u003cem\u003ep\u003c/em\u003e = 0.003)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Procedural Parameters of the studied groups.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003eNo hemorrhage group\u003c/p\u003e\n \u003cp\u003eN=128(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eAsymptomatic hemorrhage\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;group N=77(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003eSymptomatic hemorrhage\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;group N=41 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eBCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e64(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e42(54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e15(36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.172\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eFirst passage\u003c/p\u003e\n \u003cp\u003estent\u003c/p\u003e\n \u003cp\u003eAspiration\u003c/p\u003e\n \u003cp\u003ecombined\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003eN=64\u003c/p\u003e\n \u003cp\u003e42(65.6)\u003c/p\u003e\n \u003cp\u003e3(4.7)\u003c/p\u003e\n \u003cp\u003e19(29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eN=42\u003c/p\u003e\n \u003cp\u003e26(61.9)\u003c/p\u003e\n \u003cp\u003e1(2.4)\u003c/p\u003e\n \u003cp\u003e15(35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003eN=15\u003c/p\u003e\n \u003cp\u003e7(46.7)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e8(53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eP=0.396\u003c/p\u003e\n \u003cp\u003eP=0.604\u003c/p\u003e\n \u003cp\u003eP=0.220\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eOnset to punctuate (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e250(0-907)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e258(0-780)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e250(0-427)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eFirst TICI\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0-2b\u003c/p\u003e\n \u003cp\u003e2c/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e71(55.5)\u003c/p\u003e\n \u003cp\u003e57(44.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e56(72.7)\u003c/p\u003e\n \u003cp\u003e21(27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36(87.8)\u003c/p\u003e\n \u003cp\u003e5(12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eFinal TICI\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0-2b\u003c/p\u003e\n \u003cp\u003e2c/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41(32)\u003c/p\u003e\n \u003cp\u003e87(68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32(41.6)\u003c/p\u003e\n \u003cp\u003e45(58.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27(65.9)\u003c/p\u003e\n \u003cp\u003e14(34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.004*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eTICI 1\u003csup\u003est\u003c/sup\u003e \u0026amp; final difference\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0-2b\u003c/p\u003e\n \u003cp\u003e2c/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN=53\u003c/p\u003e\n \u003cp\u003e35(66)\u003c/p\u003e\n \u003cp\u003e18(34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eN=42\u003c/p\u003e\n \u003cp\u003e25(59.5)\u003c/p\u003e\n \u003cp\u003e17(40.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN=26\u003c/p\u003e\n \u003cp\u003e17(65.4)\u003c/p\u003e\n \u003cp\u003e9(34.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.789\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eMRS after 3 months \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003cp\u003e3-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003en=94\u003c/p\u003e\n \u003cp\u003e37(39.4)\u003c/p\u003e\n \u003cp\u003e57(60.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eN=68\u003c/p\u003e\n \u003cp\u003e32(47.1)\u003c/p\u003e\n \u003cp\u003e36(52.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003eN=41\u003c/p\u003e\n \u003cp\u003e6(14.6)\u003c/p\u003e\n \u003cp\u003e35(85.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eMultivariate logistic regression\u003c/strong\u003e showed that a higher number of thrombectomy passes (aOR = 1.71, 95% CI 1.34\u0026ndash;2.17, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and elevated systolic blood pressure (aOR = 1.017, 95% CI 1.001\u0026ndash;1.034, \u003cem\u003ep\u003c/em\u003e = 0.032) were independent predictors of symptomatic intracranial hemorrhage (SICH). Good final reperfusion (mTICI 2c/3) tended to reduce the risk (aOR = 0.49, \u003cem\u003ep\u003c/em\u003e = 0.053), while age showed a borderline association (\u003cem\u003ep\u003c/em\u003e = 0.062).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 5:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAdjusted odds ratios (aOR) for SICH\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge (per year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.999 \u0026ndash; 1.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eASPECT (per point)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.732 \u0026ndash; 1.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.363\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNIHSS (initial, per point)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.948 \u0026ndash; 1.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.981\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSystolic BP (per mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.001 \u0026ndash; 1.034\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.032\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of passes (per pass)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.706\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.339 \u0026ndash; 2.174\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFinal revascularization (mTICI 2c/3 vs 0\u0026ndash;2b)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.238 \u0026ndash; 1.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eROC curve analysis for the number of thrombectomy passes in differentiating no hemorrhage from symptomatic hemorrhage yielded an AUC of 0.602 (95% CI: 0.464\u0026ndash;0.741, p = 0.142), indicating fair discrimination. The optimal cutoff point was \u0026ge;1.5 passes, with a sensitivity of 54.2% and specificity of 62.9% \u0026ldquo;Table 6\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 6 :\u003c/strong\u003e ROC analysis of the number of thrombectomy passes in differentiating no hemorrhage from symptomatic hemorrhage\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eAUC\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eCut off point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eSensitivity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eSpecificity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003enumber of passes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.602\u003c/p\u003e\n \u003cp\u003e(0.464-0.741)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e0.142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026ge;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e54.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e62.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAUC: Area under curve\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur symptomatic intracranial hemorrhage (SICH) rate (~\u0026thinsp;12.8%) is higher than most single-center distal-MCA (M2/DMVO) thrombectomy series, which generally report SICH rates in the range of ~\u0026thinsp;2\u0026ndash;7% (for example, de Castro Afonso et al. 2019 and several recent distal-occlusion cohorts)\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e However, pooled analyses and older meta-analyses of M2 thrombectomy have reported SICH rates closer to 10% (range\u0026thinsp;~\u0026thinsp;6\u0026ndash;16%), so our observed rate is comparable to these larger or more heterogeneous series and may reflect differences in patient selection, infarct size, age, number of passes, and definitions of SICH across studies.\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003eFinally, more recent registry and multicenter reports show variable SICH rates\u0026mdash;some distal-occlusion cohorts reporting low rates (\u0026lt;\u0026thinsp;5%) while others report rates up to ~\u0026thinsp;10\u0026ndash;12% depending on case mix and procedural factors\u0026mdash;underscoring that bleeding risk for distal thrombectomy is heterogeneous and context dependent.\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIn this cohort of patients with acute distal MCA occlusions treated by mechanical thrombectomy (Fig. 2), the ROC analysis demonstrated that the number of thrombectomy passes had a modest yet fair ability to predict symptomatic intracranial hemorrhage (AUC\u0026thinsp;=\u0026thinsp;0.602). This finding supports the observation that exceeding two thrombectomy attempts may increase endothelial injury and reperfusion-related bleeding, thereby reinforcing the importance of achieving \u003cstrong\u003ethe first-pass effect\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003e(\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/strong\u003e\u003c/sup\u003e ,successful recanalization on the initial attempt as a key procedural goal to minimize hemorrhagic complications. Elevated systolic blood pressure on admission was also identified as an independent predictor of symptomatic intracranial hemorrhage (sICH), while age showed a trend toward higher risk. Conversely, successful final reperfusion (mTICI 2c/3) appeared to exert a protective effect, whereas baseline ASPECTS and NIHSS did not retain significance after adjustment for other variables.\u003c/p\u003e\n\u003cp\u003eOur findings are broadly consistent with existing literature. A recent meta-analysis of 25 cohort and trial studies confirmed that \u003cstrong\u003ehigher SBP\u003c/strong\u003e, \u003cstrong\u003eage\u003c/strong\u003e, \u003cstrong\u003eNIHSS\u003c/strong\u003e, \u003cstrong\u003e\u0026gt;\u0026thinsp;3 thrombectomy passes\u003c/strong\u003e, and \u003cstrong\u003epoor final reperfusion\u003c/strong\u003e (mTICI\u0026thinsp;\u0026lt;\u0026thinsp;2c) are important predictors of SICH after endovascular therapy.\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e For example, \u003cem\u003eKuang et al.\u003c/em\u003e found that lower ASPECTS and higher admission glucose were strongly associated with hemorrhagic transformation, although the impact of the number of passes was less emphasized in that cohort.\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e Similarly, large individual-patient data meta-analysis has revealed that higher mean SBP in the first 24 h post-EVT is tied to increased risk of SICH, poorer functional outcomes, and mortality.\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eEach addtional pass during thrombectomy may cause greater mechanical manipulation, increased endothelial injury, microvascular disruption, or thrombus fragmentation all potentially contributing to reperfusion injury and hemorrhagic conversion. Elevated systolic blood pressure might likewise exacerbate stress on vascular walls and contribute to breakdown of the blood-brain barrier during reperfusion. These pathophysiologic mechanisms have been discussed in prior reports and are consistent with norms in stroke reperfusion injury theory.\u003c/p\u003e\n\u003cp\u003eFrom a clinical standpoint, our findings suggest that minimizing the number of thrombectomy passes, when possible, should be a procedural goal. Tight control of systolic blood pressure in the preprocedural and early postprocedural periods may also reduce the risk of symptomatic intracranial hemorrhage (sICH); however, excessively low blood pressure may jeopardize collateral perfusion. Although randomized trials have not yet established optimal SBP thresholds specifically for distal MCA thrombectomy, a pragmatic target used in many centers is SBP\u0026thinsp;\u0026lt;\u0026thinsp;150 mmHg, which may help lower hemorrhagic risk while preserving collateral flow. Procedurally, achieving the first-pass effect (FPE) and limiting thrombectomy attempts to \u0026le;\u0026thinsp;2 passes when feasible may further reduce sICH risk. These recommendations, however, require confirmation in prospective studies.\u003c/p\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eLimitations\u003c/h2\u003e\n \u003cp\u003eThis study is limited by its retrospective, single-center design and potential selection bias. The absence of standardized post-procedure blood pressure control protocols may influence results. Future multicenter prospective studies are needed to validate these findings.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSymptomatic intracranial hemorrhage (sICH) remains a major complication after mechanical thrombectomy for distal MCA occlusions. In this cohort, elevated systolic blood pressure and a higher number of thrombectomy passes were identified as independent predictors of sICH, while complete reperfusion (mTICI 2c/3) showed a protective trend. ROC analysis indicated that performing more than two passes markedly increased the risk of hemorrhage. These findings underscore the importance of achieving the first-pass effect and maintaining careful periprocedural blood pressure control, with a pragmatic systolic blood pressure target below 150 mmHg to optimize safety. Incorporating these factors into procedural and post-procedural protocols may help minimize hemorrhagic complications and improve patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics declarations\u003c/h2\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eAll patients included in this study gave a written informed consent to publish the data contained in this study.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNot applicable (no funding received for this study).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.E.G. (Ali E. Gaber) conceived the study, collected clinical data, and drafted the manuscript.T.M.B. (Tamer M. Belal) contributed to study design, data interpretation, and critical manuscript revision.M.G. (Mohamed Gomaa) supervised data analysis and contributed to manuscript editing.W.M. (Wessam Mustafa) provided clinical oversight and methodological review.M.A. (Mohammed Abbas) assisted in statistical analysis and data validation.J.C. (Jonathan Cortese) and J.Ca. (Jildaz Caroff) contributed to the endovascular procedural review and interpretation of imaging data.L.S. (Laurent Spelle) supervised the overall project, ensured study accuracy, and provided senior editorial input.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe clinical datasets generated and analyzed during the current study are not publicly available due to institutional and patient privacy restrictions but are available from the corresponding author on reasonable request and with permission from Bic\u0026ecirc;tre Hospital, Paris-Saclay University.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAnadani, Mohammad, et al. \u0026quot;Mechanical thrombectomy for distal occlusions: efficacy, functional and safety outcomes: insight from the STAR collaboration.\u0026quot; World neurosurgery 151 (2021): e871-e879.\u003c/li\u003e\n\u003cli\u003e Berger, Marcel Cedric, et al. \u0026quot;Safety and efficacy of thrombectomy for distal medium vessel occlusions of the middle cerebral artery.\u0026quot; Neurointervention 20.1 (2025): 15-23.\u003c/li\u003e\n\u003cli\u003e Hao, Zilong, et al. \u0026quot;Risk factors for intracranial hemorrhage after mechanical thrombectomy: a systematic review and meta-analysis.\u0026quot; Expert Review of Neurotherapeutics 19.10 (2019): 927-935.\u003c/li\u003e\n\u003cli\u003e Hacke W, Kaste M, Bluhmki E, Brozman M, D\u0026aacute;valos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. New England journal of medicine. 2008 Sep 25;359(13):1317-29.\u003c/li\u003e\n\u003cli\u003e de Castro Afonso, Lu\u0026iacute;s Henrique, et al. \u0026quot;Thrombectomy for M2 occlusions and the role of the dominant branch.\u0026quot; Interventional Neuroradiology 25.6 (2019): 697-704.\u003c/li\u003e\n\u003cli\u003eSaber, Hamidreza, et al. \u0026quot;Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis.\u0026quot; Journal of neurointerventional surgery 10.7 (2018): 620-624.\u003c/li\u003e\n\u003cli\u003e Bala, F., et al. \u0026quot;Outcomes with endovascular treatment of patients with M2 segment MCA occlusion in the late time window.\u0026quot; American Journal of Neuroradiology 44.4 (2023): 447-452.\u003c/li\u003e\n\u003cli\u003eZaidat OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Dabus G, Malisch TW, Marden FA. First pass effect: a new measure for stroke thrombectomy devices. Stroke. 2018 Mar;49(3):660-6.\u003c/li\u003e\n\u003cli\u003e Dong, Shuyang, et al. \u0026quot;Predictors of symptomatic intracranial hemorrhage after endovascular thrombectomy in acute ischemic stroke: a systematic review and meta-analysis.\u0026quot; Cerebrovascular Diseases 52.4 (2023): 363-375.\u003c/li\u003e\n\u003cli\u003e Kuang, Yongyao, et al. \u0026quot;Clinical and imaging predictors for hemorrhagic transformation of acute ischemic stroke after endovascular thrombectomy.\u0026quot; Journal of Neuroimaging 34.3 (2024): 339-347.\u003c/li\u003e\n\u003cli\u003e Katsanos, Aristeidis H., et al. \u0026quot;Blood pressure after endovascular thrombectomy and outcomes in patients with acute ischemic stroke: an individual patient data meta-analysis.\u0026quot; Neurology 98.3 (2022): e291-e301.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8079083/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8079083/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eStroke remains a major global cause of death and disability, with ischemic strokes accounting for most cases. Mechanical thrombectomy (MT) is well established for large-vessel occlusions, yet its role in distal middle cerebral artery (MCA) occlusions is less clearly defined. Intracranial hemorrhage (ICH), particularly symptomatic ICH (sICH), is a serious complication that may worsen outcomes. This study aimed to identify predictors of hemorrhagic transformation following MT for distal MCA occlusions.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eBetween January 2016 and December 2022, 246 patients with distal MCA occlusion underwent MT. Patients were classified into three groups: no hemorrhage (n\u0026thinsp;=\u0026thinsp;128), asymptomatic hemorrhage (n\u0026thinsp;=\u0026thinsp;77), and symptomatic hemorrhage (n\u0026thinsp;=\u0026thinsp;41). Clinical, imaging, and procedural variables were analyzed using univariate and multivariate logistic regression to determine predictors of sICH.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eOn univariate analysis, older age, higher NIHSS, lower ASPECTS, elevated systolic blood pressure, multiple thrombectomy passes, and incomplete reperfusion were associated with hemorrhagic-transformation.Multivariate regression identified \u003cb\u003eelevated systolic blood pressure\u003c/b\u003e (aOR\u0026thinsp;=\u0026thinsp;1.017, 95% CI 1.001\u0026ndash;1.034, p\u0026thinsp;=\u0026thinsp;0.032) and \u003cb\u003enumber of thrombectomy passes\u003c/b\u003e (aOR\u0026thinsp;=\u0026thinsp;1.71, 95% CI 1.34\u0026ndash;2.17, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) as independent predictors of sICH, while successful final reperfusion (mTICI 2c/3) showed a protective trend (p\u0026thinsp;=\u0026thinsp;0.053).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eSymptomatic intracranial hemorrhage after distal MCA thrombectomy is independently associated with elevated systolic blood pressure and repeated thrombectomy attempts. These results reinforce the importance of achieving the \u003cb\u003efirst-pass effect\u003c/b\u003e and maintaining systolic blood pressure below 150 mmHg to optimize safety and improve outcomes.\u003c/p\u003e","manuscriptTitle":"Predictors of Intracranial hemorrhage after mechanical thrombectomy in distal middle cerebral artery occlusion.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-30 23:25:47","doi":"10.21203/rs.3.rs-8079083/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3e3afcdf-cb98-4a8a-883d-bc72469298bb","owner":[],"postedDate":"November 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:00:18+00:00","versionOfRecord":{"articleIdentity":"rs-8079083","link":"https://doi.org/10.1186/s43055-026-01742-y","journal":{"identity":"egyptian-journal-of-radiology-and-nuclear-medicine","isVorOnly":false,"title":"Egyptian Journal of Radiology and Nuclear Medicine"},"publishedOn":"2026-04-09 15:57:03","publishedOnDateReadable":"April 9th, 2026"},"versionCreatedAt":"2025-11-30 23:25:47","video":"","vorDoi":"10.1186/s43055-026-01742-y","vorDoiUrl":"https://doi.org/10.1186/s43055-026-01742-y","workflowStages":[]},"version":"v1","identity":"rs-8079083","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8079083","identity":"rs-8079083","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}