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Can we TAG acute ischemic stroke patients with increased risk for symptomatic intracerebral haemorrhage following mechanical thrombectomy?
In the pivotal randomised clinical trials, patients with acute ischaemic stroke (AIS) with large-vessel occlusion (LVO) undergoing treatment with mechanical thrombectomy (MT), and preceding intravenous alteplase in 83% of the cases, had a total of 4.4% risk of postprocedural symptomatic intracerebral haemorrhages (sICH).1 Despite its relatively small incidence, sICH after MT has been highlighted as an independent predictor of long-term unfavourable functional outcomes and mortality, with a 10-fold increase in the risk of all-cause 3-month mortality with rates up to 72%.2
In the current issue of the Journal of Neurolog y, Neurosurgery and Psychiatry, Montalvo et al present the first stratification score on the risk of sICH in patients with AIS with LVO treated with MT.3 The score was derived from a retrospective cohort of 578 patients with LVO (mean age 73 years, 52.2% women) treated with MT in a single-centre institution during a 3.5-year period (1 July 2014–31 December 2017).3 LVO was defined as an occlusion of the intracranial internal carotid artery, the middle cerebral artery (M1 or proximal M2 segments) and the basilar artery.3
The thrombolysis in cerebral ischaemia–Alberta Stroke Program Early CT Score (ASPECTS)–glucose (TAG) score was derived after multivariable logistic regression analysis of available baseline characteristics and was independently associated with the likelihood for sICH following MT with a ‘fair’ total predictive ability (area under the curve (AUC) 0.79).3 The score was externally validated in an independent cohort of 399 patients (mean age 68 years, 49.9% women) who underwent MT and were enrolled in a multicentre prospective cohort study.3 In the validation cohort, the TAG score was associated with an almost 50% per-point increase likelihood of post-MT sICH and a ‘moderate’ total prognostic ability (AUC 0.69).3
Although ASPECTS has been previously reported to be associated with an increased risk of sICH, a very recent individual patient data meta-analysis by the highly effective reperfusion evaluated in multiple endovascular stroke trials (HERMES) collaboration suggests that there is a potential clinical benefit of MT in the whole spectrum of the ASPECTS score in spite of the increased sICH risk.4 Interestingly and in accordance to previously published studies, Montalvo et al uncovered no difference in the sICH risk according to the history of intarvenous alteplase pretreatment.3
The TAG score constitutes the first published to date prediction score for post-MT sICH risk. This score could be used for the purpose of communication between the physician and the patient/family and not for guidance in therapeutic decisions in any way. Moreover, clinicians implementing this score should first assess the applicability to their patients and compare each case with the inclusion criteria and characteristics of the cohorts analysed by Montalvo et al.3 Finally, it should be taken into consideration that advancement of MT devices and accumulative procedural experience have been associated with significant longitudinal improvements in both clinical outcomes and sICH risk assessment, and this parameter should always be taken into consideration for the longitudinal validity assessment of this score.
Contributors GT and AHK drafted the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.
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