Subarachnoid hemorrhage and asymptomatic hemorrhagic stroke infarction may worsen stroke recovery: JAMA

A new study published in the Journal of American Medical Association showed that stroke recovery was inversely correlated with both subarachnoid hemorrhage (SAH) and asymptomatic hemorrhagic infarction (HI), indicating the necessity for proactive care and closer monitoring to enhance results.

While symptomatic Intracranial hemorrhage (ICH), which causes clinical deterioration, is widely known for its link with bad outcomes, asymptomatic ICH hemorrhages that are radiologically diagnosed but do not immediately impact neurological status have received far less attention. Although subarachnoid hemorrhage and asymptomatic hemorrhagic infarction following endovascular therapy (EVT) for acute ischemic stroke are frequently regarded as low risk, it is unknown how they may affect functional results in the long run. Thus, to ascertain whether asymptomatic HI and SAH are linked to a poorer 90-day functional recovery in patients with acute ischemic stroke receiving EVT, this study was carried out.

The DIRECT-MT randomized clinical study, which contrasted IV thrombolysis before EVT with EVT alone, is the subject of this secondary analysis. Between 2016 and 2019, the multicenter study was carried out with a 90-day follow-up at tertiary hospitals in China. The current analysis was conducted in December 2024 and comprised trial participants with asymptomatic HI, SAH, or no bleeding.

Asymptomatic HI and SAH seen on follow-up imaging were the primary exposure. The score on the 90-day modified Rankin scale (mRS) was the main result. The mRS scores were classified by secondary studies into three thresholds: 0 to 1, 0 to 2, and 0 to 3, which stand for outstanding, good, and favorable recovery, respectively.

A total of 357 (72.9%) of the 490 patients (median [IQR] age, 70 [60-76] years; 210 [42.9%] female) were in the no bleeding group, whereas 133 (27.1%) were in the asymptomatic HI and SAH group. Following propensity score matching, the odds ratio between the asymptomatic HI and SAH group and the no hemorrhage group was 2.59 for having lower mRS scores at 90 days.

In all models, asymptomatic HI and SAH were consistently linked to inferior recovery for binary outcomes across mRS score thresholds of 0 to 1 and 0 to 2. Overall, asymptomatic HI and SAH were linked to noticeably poorer long-term results in patients receiving mechanical thrombectomy for acute ischemic stroke, according to this secondary analysis of a randomized clinical study. 

Source:

Chen, R., Hua, W., Zhang, Y., Zhang, Y., Zhang, H., Zhang, Y., Liu, J., Yang, P., Zhang, X., & Zhang, L. (2025). Asymptomatic hemorrhagic events and functional outcomes in acute stroke: A secondary analysis of the DIRECT-MI randomized clinical trial: A secondary analysis of the DIRECT-MI randomized clinical trial. JAMA Network Open, 8(3), e252411. https://doi.org/10.1001/jamanetworkopen.2025.2411