Risk of Intracerebral Hemorrhage After Thrombolysis in Patients with Asymptomatic Hemorrhage on T2*

Abstract

Background: Intravenous thrombolysis using the tissue-type plasminogen activator (t-PA) is contraindicated for patients with a history of intracerebral hemorrhage (ICH). T2*-weighted magnetic resonance imaging (MRI) is able to detect asymptomatic ICH. If there is an association between asymptomatic ICH on T2* before t-PA therapy and ICH after t-PA therapy, we may be able to take preventive measures before starting t-PA therapy in patients with MRI-proven hemorrhage. The aim of the present study was to investigate whether asymptomatic ICH seen on T2* increases the risk of new ICH after t-PA therapy. Methods: Patients who had consecutive stroke treated with t-PA between October 2005 and November 2013 were enrolled. A hypointense T2* signal with a diameter >5 mm was defined as asymptomatic ICH before t-PA therapy. The presence of new ICH at 24 h after t-PA therapy was assessed using T2*. Symptomatic ICH (sICH) was defined as new ICH combined with an increase in the National Institutes of Health Stroke Scale score ≥4. At 3 months after onset, good and poor outcomes were defined as modified Rankin Scale (mRS) scores of 0-1 and 4-6, respectively. Results: Of 300 patients (age 77 [68-83] years; 173 [58%] males), 25 (8%) had an asymptomatic ICH on T2* before t-PA therapy. Eleven (45%) patients showed an isolated asymptomatic ICH. Three (12%) patients had a round hypointense lesion similar to microbleeds. Nine (36%) patients had a hemorrhagic transformation within a prior infarcted area. Multiple asymptomatic ICHs were seen in 2 (8%) patients. The rates of good and poor outcomes at 3 months were 24 and 59% of patients with asymptomatic ICH and 38 and 41% of patients without asymptomatic ICH (p = 0.300 and 0.202, respectively). At 24 h after t-PA therapy, 11 (44%) of the 25 patients with asymptomatic ICH before t-PA therapy and 87 (32%) of 275 without asymptomatic ICH had new ICH (p = 0.265). Only 1 (4%) of 25 patients with asymptomatic ICH before t-PA therapy and 6 (2%) of 275 without asymptomatic ICH had sICH within 24 h (p = 0.460). On multivariate logistic regression analysis, neither new ICH (odds, 1.19; 95% CI, 0.40-3.54, p = 0.753) nor sICH (odds, 0.95; 95% CI, 0.08-11.90, p = 0.970) was related to asymptomatic ICH on T2* before t-PA therapy. Conclusion: The presence of T2* hypointensity as a marker of asymptomatic ICH may not be associated with new ICH and sICH after t-PA therapy.

Previous chronic symptomatic and asymptomatic cerebral hemorrhage in patients with acute ischemic stroke

“…In the present study, the frequency of PCH was 9.4%, or 4.5% for asymptomatic PCH, which was slightly lower than in previous studies [ 14 , 15 ]. The discrepancies could be due to the selection of the subjects and geographical regions, as well as to different imaging protocols.…”

Should we exclude acute stroke patients with previous intracerebral hemorrhage from receiving intravenous thrombolysis?

“…16 A recent single-center Japanese study of relatively small sample size (n = 300) showed that asymptomatic ICH on MRI was associated with neither new ICH at 24 h after IV tPA nor SyHT. 8 There has been, however, no study to focus on prior history of ICH as an eligibility criterion for IV tPA. 17 Our study may be the first report to describe in detail in a practice setting the influence of “ History of previous ICH ” on outcome after IV tPA in acute ischemic stroke.…”

“…Furthermore, the prevalence of silent ICH has been reported in up to 8% of patients who have been treated with IV tPA, 8 and magnetic resonance imaging (MRI) is more sensitive than computerized tomography head for the detection of old ICH lesions. 9 There is a paucity of evidence about the safety of IV tPA in patients with previous ICH (pvICH).…”

Intravenous thrombolysis in ischemic stroke patients with a prior intracranial hemorrhage: a meta-analysis

“…All of the seven included studies reported similar rates of sHT following IVT among patients with and without prior ICrH. 10 – 13 , 22 – 24 Four studies reported risk of in-hospital, 11 , 25 , 26 within 30-day, 22 or within 90-day 10 , 13 death. Zand et al 11 reported no in-hospital mortalities in the seven patients with prior ICrH.…”

“…In addition, four studies reported 90-day mRS scores in both groups. 10 , 12 , 13 , 23 Among these studies, Lee et al 10 reported less favorable 90-day functional outcomes in patients with prior ICrH, while others did not show any difference between groups.…”