Intracranial Hemorrhage After Reperfusion Therapies in Acute Ischemic Stroke Patients

Abstract

Reperfusion therapies are the mainstay of acute ischemic stroke (AIS) treatments and overall improve functional outcome. Among the established complications of intravenous (IV) tissue-type plasminogen activator (tPA), intracranial hemorrhage (ICH) is by far the most feared and has been extensively described by seminal works over the last two decades. Indeed, IV tPA is associated with increased odds of any ICH and symptomatic ICH responsible for increased mortality rate during the first week after an AIS. Despite these results, IV tPA has been found beneficial in several pioneering randomized trials and improves functional outcome at 3 months. Endovascular therapy (EVT) combined with IV tPA for AIS patients consecutive to an anterior circulation large-vessel occlusion does not increase ICH occurrence. Of note, EVT following IV tPA leads to significantly higher rates of early reperfusion than with IV tPA alone, with no difference in ICH, which challenges the paradigm of reperfusion as a major prognostic factor for ICH complications. However, several blood biomarkers (glycemia, platelet and neutrophil count), clinical factors (age, AIS severity, blood pressure management, diabetes mellitus), and neuroradiological factors (cerebral microbleeds, infarct size) have been identified as risk factors for ICH after reperfusion therapy. In the years to come, the ultimate goal will be to further improve either reperfusion rates and functional outcome, while reducing hemorrhagic complications. To this end, various approaches being investigated are discussed in this review, such as blood-pressure control after reperfusion or the use of new antiplatelet agents as an adjunct to IV tPA and exhibit reduced hemorrhagic potential during the early phase of AIS.

Hemorrhagic Transformation After Ischemic Stroke: Mechanisms and Management

“…Definite mass effect Hematoma in more than 30% of the infarcted area randomized controlled trials (RCTs) of reperfusion therapies (12), the mechanisms underlying cerebral hemorrhage or hematoma after stroke in individual patients remain poorly understood. Intracranial bleeding after acute ischemic stroke has a significant impact on patient outcomes (13,14), and controlling the risk of bleeding plays an important role in determining whether to proceed with recanalization (15).…”

“…With recent advances in intravenous ( 9 ) or endovascular ( 10 ) reperfusion therapies for acute ischemic stroke ( 11 ), stroke physicians need to deepen their understanding of cerebral hemorrhagic complications. Although the overall risks of complications have been well-documented in various randomized controlled trials (RCTs) of reperfusion therapies ( 12 ), the mechanisms underlying cerebral hemorrhage or hematoma after stroke in individual patients remain poorly understood. Intracranial bleeding after acute ischemic stroke has a significant impact on patient outcomes ( 13 , 14 ), and controlling the risk of bleeding plays an important role in determining whether to proceed with recanalization ( 15 ).…”

Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

“…Pre-procedural, procedural and post-procedural risk factors for sICH have been described post-EVT in early time windows. 87 Antiplatelet therapy, high C-reactive protein, elevated mean arterial blood pressure, hyperglycemia and low ASPECTS were found to be independent predictive factors of sICH after EVT. 88 In the Endovascular Treatment for Ischemic Stroke (ETIS) registry, increasing age and ASPECTS, smoking, general anesthesia, angiographic poor collaterals and embolization in a new territory independently predicted parenchymal hemorrhage.…”

Transcranial Doppler to evaluate postreperfusion therapy following acute ischemic stroke: A literature review

“…One of the most feared complications following mechanical thrombectomy is hemorrhagic transformation. In the 1990s, before the use of tPA in acute stroke, hemorrhagic transformation was reported in about 50% of patients with large vessel occlusion 22 . According to the NINDS trial, 6% of patients receiving tPA had symptomatic intracranial hemorrhage (ICH) during the first 36 h, with about 50% mortality 1 .…”