Leukoaraiosis Is a Risk Factor for Symptomatic Intracerebral Hemorrhage After Thrombolysis for Acute Stroke

Neumann‐Haefelin, Tobias; Hoelig, Silke; Berkefeld, Joachim; Fiehler, Jens; Gass, Achim; Humpich, Marek; Kastrup, Andreas; Kucinski, Thomas; Lecei, Olivera; Liebeskind, David S; Röther, Joachim; Rosso, Charlotte; Samson, Yves; Saver, Jeffrey L.; Yan, Bernard

doi:10.1161/01.str.0000239321.53203.ea

Cited by 182 publications

(141 citation statements)

References 28 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

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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

Self Cite

172

112

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“…The median NIHSS score at presentation was 15 (interquartile range, [7][8][9][10][11][12][13][14][15][16][17][18][19][20]. The mean time from stroke symptom onset to CT scanning was 125 minutes Ϯ 46.…”

Section: Resultsmentioning

confidence: 99%

“…Several radiologic and clinical parameters, including baseline stroke severity (6,7), time to reperfusion (8), thrombolytic protocol violations (2,9), tissue plasminogen activator (TPA) treatment (3,6,10), white matter disease burden (11), aspirin use (3), and heparin use (12), are associated with HT. Although more severe hemorrhage is undisputedly associated with worse outcome (10,13,14), there is controversy with regard to whether less severe forms of hemorrhage are important (8,(15)(16)(17).…”

Section: H Emorrhagic Transformation (Ht)mentioning

confidence: 99%

Hemorrhagic Transformation of Ischemic Stroke: Prediction with CT Perfusion

Aviv

d’Esterre²,

Murphy³

et al. 2009

Radiology

153

112

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Purpose:To determine whether admission computed tomography (CT) perfusion-derived permeability-surface area product (PS) maps differ between patients with hemorrhagic acute stroke and those with nonhemorrhagic acute stroke. Materials and Methods:This prospective study was institutional review board approved, and all participants gave written informed consent. Forty-one patients who presented with acute stroke within 3 hours after stroke symptom onset underwent two-phase CT perfusion imaging, which enabled PS measurement. Patients were assigned to groups according to whether they had hemorrhage transformation (HT) at follow-up magnetic resonance (MR) imaging and CT and/or whether they received tissue plasminogen activator (TPA) treatment. Clinical, demographic, and CT perfusion variables were compared between the HT and non-HT patient groups. Associations between PS and HT were tested at univariate and multivariate logistic regression analyses and receiver operating characteristic (ROC) analysis. Results:HT developed in 23 (56%) patients. Patients with HT had higher National Institutes of Health Stroke Scale (NIHSS) scores (P ϭ .005), poorer outcomes (P ϭ .001), and a higher likelihood of having received TPA (P ϭ .005) compared with patients without HT. Baseline blood flow (P ϭ .17) and blood volume (P ϭ .11) defects and extent of flow reduction (P ϭ .27) were comparable between the two groups. The mean PS for the HT group, 0.49 mL ⅐ min Ϫ1 ⅐ (100 g) Ϫ1 , was significantly higher than that for the non-HT group, 0.09 mL ⅐ min Ϫ1 ⅐ (100 g) Ϫ1 (P Ͻ .0001). PS (odds ratio, 3.5; 95% confidence interval [CI]: 1.69, 7.06; P ϭ .0007) and size of hypoattenuating area at nonenhanced admission CT (odds ratio, 0.4; 95% CI: 0.2, 0.7; P ϭ .002) were the only independent variables associated with HT at stepwise multivariate analysis. The mean area under the ROC curve was 0.918 (95% CI: 0.828, 1.00). The PS threshold of 0.23 mL ⅐ min Ϫ1 ⅐ (100 g) Ϫ1 had 77% sensitivity and 94% specificity for detection of HT. Conclusion:Admission PS measurement appears promising for distinguishing patients with acute stroke who are likely from those who are not likely to develop HT.

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“…Hypertension, smoking, diabetes, hyperhomocysteinemia, and heart disease are all risk factors for leukoaraiosis. Leukoaraiosis was proved to be a risk factor for symptomatic HT after rtPA administration [69,132].…”

Section: Neuroimagingmentioning

confidence: 99%

Hemorrhagic transformation of ischemic stroke

J¹,

Hortobágyi²

2017

Vascul Dis Ther

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The better understanding of the diverse mechanisms leading to the hemorrhagic transformation of an ischemic stroke is the crucial point in the prevention of this altogether common phenomenon. The different individual risk factors include the anatomical variability of collateral blood supply, age, genetics, body weight, etiology of the occlusion, side of the occluded vessel, renal status, stroke severity, history of high serum glucose or hypertension and hypertension or hyperglycemia at the onset of the stroke, ferritin level, INR, antiplatelet usage or the platelet count etc. All these might contribute to the process of hemorrhagic transformation. These risk factors have been identified by retrospective epidemiological studies and are useful to identify patients who are at high risk for hemorrhagic conversion and help the decision between conservative, thrombolytic or more advanced treatments such as thrombectomy. The modulations of potential molecular targets participating in the process seem to be promising in animal models, but human trials are lacking the breakthrough success so far, both in extending the time frame of the thrombolysis and in replacing the recombinant tissue plasminogen activator (rtPA) as thrombolytic agent.So far, the careful preselection of patients eligible for thrombolytic therapy is the best way to prevent hemorrhagic transformation. The intensive research in the field revealing small but important molecular details are continuously contributing to the better understanding of hemorrhagic transformation with the intention of finding new agents that co-administrated to the rtPA or completely replacing that could decrease the risk of secondary bleeding.The aim of this review is to give comprehensive insight into the process of hemorrhagic transformation of ischemic stroke, starting with basic overview of the penumbra concept and the collateral supply followed by discussion of the recanalisation-reperfusion-hemorrhagic transformation process after vessel occlusion also highlighting the importance of timing and ratio of recanalisation spontaneously and in case of thrombolytic agent administration. We overview the risk factors of hemorrhagic transformation, which may be helpful to physicians to identify high risk patients before rtPA administration. The last part of the work is dealing with future therapeutic possibilities based on the so far revealed molecular mechanisms of hemorrhagic transformation. With the aim to assess the rate and influencing factors on the recanalisation and reperfusion rate 381 patients with large-vessel occlusion was investigated. The patient group involved ones treated with rtPA or treated conservatively. Partial or complete recanalisation was achieved in 121 out of 210 (58%) patients after intravenous rtPA administration. The recanalisation success was more likely if the patient had atrial fibrillation [4] -maybe because cardioembolic clots consists more fibrin and are more likely to reopen by plasmin proteolysis than thrombosis of an atherosclerotic plaq...

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Leukoaraiosis Is a Risk Factor for Symptomatic Intracerebral Hemorrhage After Thrombolysis for Acute Stroke

Cited by 182 publications

References 28 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

Hemorrhagic Transformation of Ischemic Stroke: Prediction with CT Perfusion

Hemorrhagic transformation of ischemic stroke

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