Cerebral white matter lesions and post‐thrombolytic remote parenchymal hemorrhage

Curtze, Sami; Putaala, Jukka; Sibolt, Gerli; Melkas, Susanna; Mustanoja, Satu; Haapaniemi, Elena; Sairanen, Tiina; Tiainen, Marjaana; Tatlısumak, Turgut; Strbian, Daniel

doi:10.1002/ana.24760

Cited by 17 publications

(11 citation statements)

References 25 publications

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“…In an observational study of 2,485 patients treated with alteplase, severe white matter lesions on CT, defined as a Blennow rating scale score of 5 or 6, was independently associated with remote parenchymal hemorrhage (adjusted OR 6.79, 95% CI: 2.57-17.94), but not with parenchymal hemorrhage strictly within the ischemic area (adjusted OR 1.45, 95% CI: 0.83-2.53). 205 Another study, based on MRI volumetric evaluations of white matter lesions, confirmed that larger whole brain corrected white matter lesion volume was associated with remote ICH, irrespective of the deep or periventricular location of white matter lesions. 206 PICO 13.6 In patients with acute ischaemic stroke of < 4.5 h duration, who have an unruptured cerebral aneurysm, does IVT with alteplase lead to better functional outcome than no IVT?…”

Section: Recommendationmentioning

confidence: 90%

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

Berge

Whiteley

Audebert

et al. 2021

European Stroke Journal

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Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.

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Section: Recommendationmentioning

confidence: 90%

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

Berge

Whiteley

Audebert

et al. 2021

European Stroke Journal

Self Cite

765

607

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“…Our results are in accordance with previous studies. One previous study suggested that the frequency of severe WMH increased the occurrence rate of rICH [12], and others emphasized the predictive value of severe WMH on AIS prognosis [6,21]. The mechanism that links greater WMH burden to a higher risk of rICH appears complex.…”

Section: Discussionmentioning

confidence: 99%

Risk factors are different for deep and lobar remote hemorrhages after intravenous thrombolysis

et al. 2017

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Background and purposeRemote parenchymal haemorrhage (rPH) after intravenous thrombolysis is defined as hemorrhages that appear in brain regions without visible ischemic damage, remote from the area of ischemia causing the initial stroke symptom. The pathophysiology of rPH is not clear and may be explained by different underlying mechanisms. We hypothesized that rPH may have different risk factors according to the bleeding location. We report the variables that we found associated with deep and lobar rPH after intravenous thrombolysis.MethodsThis is a descriptive study of patients with ischemic stroke who were treated with intravenous thrombolysis. These patients were included in a multicenter prospective registry. We collected demographic, clinical and radiological data. We evaluated the number and distribution of cerebral microbleeds (CMB) from Magnetic Resonance Imaging. We excluded patients treated endovascularly, patients with parenchymal hemorrhage without concomitant rPH and stroke mimics. We compared the variables from patients with deep or lobar rPH with those with no intracranial hemorrhage.ResultsWe studied 934 patients (mean age 73.9±12.6 years) and 52.8% were men. We observed rPH in 34 patients (3.6%); 9 (0.9%) were deep and 25 (2.7%) lobar. No hemorrhage was observed in 900 (96.6%) patients. Deep rPH were associated with hypertensive episodes within first 24 hours after intravenous thrombolysis (77.7% vs 23.3%, p<0.001). Lobar rPH were associated with the presence of CMB (53.8% vs 7.9%, p<0.001), multiple (>1) CMB (30.7% vs 4.4%, p = 0.003), lobar CMB (53.8% vs 3.0%, p<0.001) and severe leukoaraiosis (76.9% vs 42%, p = 0.02).ConclusionsA high blood pressure within the first 24 hours after intravenous thrombolysis is associated with deep rPH, whereas lobar rPH are associated with imaging markers of amyloid deposition. Thus, our results suggest that deep and lobar rPH after intravenous thrombolysis may have different mechanisms.

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Cerebral white matter lesions and post‐thrombolytic remote parenchymal hemorrhage

Abstract: Severe cerebral WMLs were associated with post-thrombolytic rPH but not with iPH within the ischemic area. Ann Neurol 2016;80:593-599.

Cited by 17 publications

References 25 publications

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

More extensive white matter hyperintensity is linked with higher risk of remote intracerebral hemorrhage after intravenous thrombolysis

Risk factors are different for deep and lobar remote hemorrhages after intravenous thrombolysis

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