Doppler Pulsatility Index After Stroke Thrombectomy Flags Bleeding Risk

A simple ultrasound measurement taken shortly after emergency stroke surgery may help identify which patients are most likely to develop bleeding in the brain, according to a new study published in Frontiers in Neurology. Researchers in China found that the pulsatility index of the middle cerebral artery on the same side as the stroke, measured early after endovascular treatment, was independently associated with cerebral hemorrhage in patients treated for anterior circulation large vessel occlusion, one of the most severe forms of acute ischemic stroke. The study followed 120 patients who underwent endovascular treatment for acute ischemic stroke caused by a blockage in a large artery supplying the front of the brain.

After treatment, the patients were divided into two groups: 17 who developed cerebral hemorrhage and 103 who did not. Three variables emerged as independent associations with cerebral hemorrhage: diabetes mellitus, with an odds ratio of 4.154 (95% confidence interval 1.255 to 13.756, P = 0.020); an Alberta Stroke Programme Early CT Score, or ASPECTS, greater than 8, which was associated with lower odds of hemorrhage (odds ratio 0.115, 95% confidence interval 0.014 to 0.942, P = 0.044); and elevated ipsilateral pulsatility index, which carried an odds ratio of 11.355 (95% confidence interval 1.267 to 101.761, P = 0.030). The wide confidence interval for the pulsatility index reflects the small number of hemorrhage events in the cohort and underscores the uncertainty around the precise size of the effect.

The predictive performance of the pulsatility index on its own was moderate. Receiver operating characteristic analysis yielded an area under the curve of 0.716 (95% confidence interval 0.597 to 0.835), with an optimal cutoff value of 0.735. At that threshold, the measurement showed a sensitivity of 0.882, meaning it flagged nearly nine out of ten patients who went on to hemorrhage, but a specificity of only 0.505, meaning about half of the patients without hemorrhage would also have been flagged.

When the researchers combined the pulsatility index with diabetes status and ASPECTS, discrimination improved. The combined model achieved an area under the curve of 0.808 (95% confidence interval 0.718 to 0.899), with a sensitivity of 0.882 and a specificity of 0.650. Adding the pulsatility index to the two clinical and imaging variables was associated with a modest but statistically significant improvement in discrimination, with a change in area under the curve of 0.088 (P = 0.011) and a continuous net reclassification improvement of 0.594 (P = 0.020).

This procedure yielded a bias-corrected area under the curve of 0.810 (95% confidence interval 0.717 to 0.896) and an optimism estimate of −0.0022, indicating that the apparent performance of the combined model was not inflated by overfitting within this cohort. The authors conclude that the early postoperative ipsilateral middle cerebral artery pulsatility index is a potential prognostic marker for any radiographic intracranial hemorrhage after endovascular treatment in anterior circulation large vessel occlusion stroke, with an optimal cutoff of 0.735. They emphasize that the findings are exploratory and require validation in larger cohorts.

The hemorrhage outcome in the study was defined radiographically, meaning the analysis captured bleeding visible on imaging rather than distinguishing between asymptomatic radiographic hemorrhage and symptomatic intracranial hemorrhage with clinical consequences. Several limitations frame the results. The wide confidence interval around the pulsatility index odds ratio, spanning from near 1 to over 100, illustrates this uncertainty.

The authors also note that all claims expressed in the article are solely those of the researchers and do not necessarily represent those of their affiliated organizations or the publisher.

Subject of Research: Predictive value of early postoperative middle cerebral artery pulsatility index for cerebral hemorrhage after endovascular treatment of anterior circulation large vessel occlusion stroke

Article Title: Early postoperative ipsilateral middle cerebral artery pulsatility index is associated with cerebral hemorrhage after endovascular treatment in anterior circulation large vessel occlusion

Article References: Zhang, W., Liu, W., Zhu, J., Xing, W., Yang, G., Gu, H., Huang, Y., Zhu, M., Zi, W., Zhong, X., Zhong, G., & Jiang, Z. (2026). Early postoperative ipsilateral middle cerebral artery pulsatility index is associated with cerebral hemorrhage after endovascular treatment in anterior circulation large vessel occlusion. Frontiers in Neurology, 17, Article 1972755. https://doi.org/10.3389/fneur.2026.1972755

Image Credits: AI Generated

DOI: 10.3389/fneur.2026.1972755

Keywords: acute ischemic stroke, large vessel occlusion, endovascular treatment, cerebral hemorrhage, pulsatility index, transcranial Doppler, middle cerebral artery, ASPECTS, diabetes mellitus, predictive model, thrombectomy, Early