Leukoaraiosis and intracerebral hemorrhage after thrombolysis in acute stroke

Palumbo, Vanessa; Boulanger, J M; Hill, Michael D.; Inzitari, Domenico; Buchan, Alastair

doi:10.1212/01.wnl.0000257817.29883.48

Cited by 122 publications

(122 citation statements)

References 18 publications

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“…The presence of severe leukoariosis was recently established as an independent risk factor for sICH, whereas the role of old microbleeds remains elusive. 22,[25][26][27] Our data indicate that both leukoariosis and DWI lesion volume are independent predictors of sICH. In addition, our data demonstrate a trend toward increased sICH risk associated with greater baseline NIHSS scores.…”

Section: Discussionmentioning

confidence: 57%

Risk for symptomatic intracerebral hemorrhage after thrombolysis assessed by diffusion‐weighted magnetic resonance imaging

Singer

Humpich²,

Fiehler

et al. 2007

Annals of Neurology

172

112

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Objective:The risk for symptomatic intracerebral hemorrhage (sICH) associated with thrombolytic treatment has not been evaluated in large studies using diffusion-weighted imaging (DWI). Here, we investigated the relation between pretreatment DWI lesion size and the risk for sICH after thrombolysis. Methods: In this retrospective multicenter study, prospectively collected data from 645 patients with anterior circulation stroke treated with intravenous or intraarterial thrombolysis within 6 hours (Ͻ3 hours: n ϭ 320) after symptom onset were pooled. Patients were categorized according to the pretreatment DWI lesion size into three prespecified groups: small (Յ10ml; n ϭ 218), moderate (10 -100ml; n ϭ 371), and large (Ͼ100ml; n ϭ 56) DWI lesions. Results: In total, 44 (6.8%) patients experienced development of sICH. The sICH rate was significantly different between subgroups: 2.8, 7.8, and 16.1% in patients with small, moderate, and large DWI lesions, respectively (p Ͻ 0.05). This translates to a 5.8 (2.8)-fold greater sICH risk for patients with large DWI lesions as compared with patients with small (or moderate) DWI lesions. The results were similar in the large subgroup (n ϭ 536) of patients treated with intravenous tissue plasminogen activator. DWI lesion size remained an independent risk factor when including National Institutes of Health Stroke Scale, age, time to thrombolysis, and leukoariosis in a logistic regression analysis. Interpretation: This multicenter study provides estimates of sICH risk in potential candidates for thrombolysis. The sICH risk increases gradually with increasing DWI lesion size, indicating that the potential benefit of therapy needs to be balanced carefully against the risk for sICH, especially in patients with large DWI lesions.

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Section: Discussionmentioning

confidence: 57%

Risk for symptomatic intracerebral hemorrhage after thrombolysis assessed by diffusion‐weighted magnetic resonance imaging

Singer

Humpich²,

Fiehler

et al. 2007

Annals of Neurology

172

112

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“…29 Leukoaraiosis, which is also believed to be more common in the lipohyalinotic subtype of lacunar infarction, has already been associated with an increased risk of intracranial bleeding following the use of anticoagulants 30 and thrombolytics. 31 Future studies might address the prognostic implications of our findings. 3,22,23 Due to the cross-sectional nature of this investigation, we cannot determine the temporality of the observed associations.…”

Section: Statistical Analysis Since Lipohyalinotic Lesions Are Assumedmentioning

confidence: 90%

Risk factors for lacune subtypes in the Atherosclerosis Risk in Communities (ARIC) Study

Bezerra¹,

Sharrett²,

Matsushita³

et al. 2012

Neurology

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Objective: Lacunar infarctions are mainly due to 2 microvascular pathologies: lipohyalinosis and microatheroma. Little is known about risk factor differences for these subtypes. We hypothesized that diabetes and glycated hemoglobin (HbA 1 c) would be related preferentially to the lipohyalinotic subtype.Methods: We performed a cross-section analysis of the brain MRI data from 1,827 participants in the Atherosclerosis Risk in Communities study. We divided subcortical lesions Յ20 mm in diameter into those Յ7 mm (of probable lipohyalinotic etiology) and 8-20 mm (probably due to microatheroma) and used Poisson regression to investigate associations with the number of each type of lesion. Unlike previous studies, we also fitted a model involving lesions Ͻ3 mm.Results: Age (prevalence ratio [PR] 1.11 per year; 95% confidence interval [CI] 1.08-1.14), black ethnicity (vs white, PR 1.66; 95% CI 1.27-2.16), hypertension (PR 2.12; 95% CI 1.61-2.79), diabetes (PR 1.42; 95% CI 1.08-1.87), and ever-smoking (PR 1.34; 95% CI 1.04-1.74) were significantly associated with lesions Յ7 mm. Findings were similar for lesions Ͻ3 mm. HbA 1 c, substituted for diabetes, was also associated with smaller lesions. Significantly associated with 8-20 mm lesions were age (PR 1.14; 95% CI 1.09-1.20), hypertension (PR 1.79; 95% CI 1.14-2.83), ever-smoking (PR 2.66; 95% CI 1.63-4.34), and low-density lipoprotein (LDL) cholesterol (PR 1.27 per SD; 95% CI 1.06-1.52). When we analyzed only participants with lesions, history of smoking (PR 1.99; 95% CI 1.23-3.20) and LDL (PR 1.33 per SD; 95% CI 1.08-1.65) were associated with lesions 8-20 mm. Conclusions:Smaller lacunes (even those Ͻ3 mm) were associated with diabetes and HbA 1 c, and larger lacunes associated with LDL cholesterol, differences which support long-held theories relating to their underlying pathology. The findings may contribute to broader understanding of cerebral microvascular disease. Neurology Lacunar infarcts are small CSF-filled cavities caused by the occlusion of small arteries in the brain. When symptomatic, they may be evident as lacunar strokes. The pathogenesis of lacunes has not been fully clarified, and there is pathologic and clinical evidence of distinct types of lacunar entities. 2-4 Fisher described 2 main vascular culprit lesions: 1) lipohyalinosis, usually with 1 or more small lacunar infarcts (up to 7 mm) and rare symptoms; and 2) microatheromata, usually linked to larger (5-20 mm), more often symptomatic lacunes. 4,5 This pathologic distinction remains unchallenged. Although contemporary authors describe several types of small-vessel disease associated with lacunes, 5-7 we will, for convenience,

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“…Although leukoaraiosis has been associated with an increase risk of bleeding post-thrombolysis, most of the intracranial hemorrhages are limited to the ischemic area. 6 In the absence of coagulopathies, defibrinogenemia, arteriovenous malformations and cerebral amyloid angiopathy (CAA) have been described. 7 Although hypertension appears to be a cofactor in the genesis of ICH, it is unclear as to the possible additive effect of arterial hypertension during the acute phase on angiopathy linked to gradient echo positive microbleeds and CAA.…”

Section: Discussionmentioning

confidence: 99%

Multifocal Simultaneous Remote Intracerebral Hemorrhage After t-PA for Ischemic Stroke

Saposnik

Schneiderman

Bayer

2008

Can. j. neurol. sci.

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Intracranial hemorrhage is the most feared complication of thrombolytic therapy for acute ischemic stroke. Its frequency in large trials varies from 6.6% to 8.8%, 1,2 but has been decreased by following the current guidelines for the management of thrombolysis for acute stroke in prospective community studies. Multifocal intracerebral hemorrhage is a rare complication after thrombolysis. We herein describe two cases of multifocal simultaneous intracerebral hemorrhage (MSE-ICH) after receiving thrombolytic therapy for acute stroke.

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Leukoaraiosis and intracerebral hemorrhage after thrombolysis in acute stroke

Abstract: The presence of small vessel disease on CT scan does not affect overall clinical outcome at 3 months in routine community use of tPA for ischemic stroke. A significant increase in the risk of symptomatic ICH is observed.

Cited by 122 publications

References 18 publications

Risk for symptomatic intracerebral hemorrhage after thrombolysis assessed by diffusion‐weighted magnetic resonance imaging

Risk for symptomatic intracerebral hemorrhage after thrombolysis assessed by diffusion‐weighted magnetic resonance imaging

Risk factors for lacune subtypes in the Atherosclerosis Risk in Communities (ARIC) Study

Multifocal Simultaneous Remote Intracerebral Hemorrhage After t-PA for Ischemic Stroke

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