Risk Score for Intracranial Hemorrhage in Patients With Acute Ischemic Stroke Treated With Intravenous Tissue-Type Plasminogen Activator

Abstract

Background and Purpose-There are few validated models for prediction of risk of symptomatic intracranial hemorrhage (sICH) after intravenous tissue-type plasminogen activator treatment for ischemic stroke. We used data from Get With The Guidelines-Stroke (GWTG-Stroke) to derive and validate a prediction tool for determining sICH risk. Methods-The population consisted of 10 242 patients from 988 hospitals who received intravenous tissue-type plasminogen activator within 3 hours of symptom onset from January 2009 to June 2010. This sample was randomly divided into derivation (70%) and validation (30%) cohorts. Multivariable logistic regression identified predictors of intravenous tissue-type plasminogen activator-related sICH in the derivation sample; model ␤ coefficients were used to assign point scores for prediction. Results-sICH within 36 hours was noted in 496 patients (4.8%). Multivariable adjusted independent predictors of sICH were increasing age (17 points), higher baseline National Institutes of Health Stroke Scale (42 points), higher systolic blood pressure (21 points), higher blood glucose (8 points), Asian race (9 points), and male sex (4 points). The C-statistic was 0.71 in the derivation sample and 0.70 in the independent internal validation sample. Plots of observed versus predicted sICH showed good model calibration in the derivation and validation cohorts. The model was externally validated in National Institute of Neurological Disorders and Stroke trial patients with a C-statistic of 0.68. Conclusions-The GWTG-Stroke sICH risk "GRASPS" score provides clinicians with a validated method to determine the risk of sICH in patients treated with intravenous tissue-type plasminogen activator within 3 hours of stroke symptom onset. (Stroke. 2012;43:2293-2299.)

Association of Acute and Chronic Hyperglycemia With Acute Ischemic Stroke Outcomes Post‐Thrombolysis: Findings From Get With The Guidelines‐Stroke

“…One study reported a linear relation between admission glucose and an increase in the odds of sICH (OR 1.75 per 100 mg/dL increase in admission glucose) 5. Admission blood glucose levels were identified as a risk factor for sICH after intravenous tPA in several risk models for sICH post‐tPA 11, 25, 26, 27, 28. Although blood glucose is one of the potential modifiable factor in these risk scores, further studies are required to evaluate whether treatment of hyperglycemia reduces risk of sICH post‐tPA.…”

“…Some studies have reported an increased risk of symptomatic intracranial hemorrhage (sICH) after tPA treatment in patients with diabetes or hyperglycemia,8, 9, 10 and admission glucose has been used in prognostic models to identify patients at risk of sICH after tPA 11. Even though studies did not find overall reduced benefit of tPA in diabetic patients,12 decreased rates of tPA administrations are observed in diabetic patients 13.…”

Hemorrhagic Transformation after Ischemic Stroke in Animals and Humans

“…[140][141][142] Clinical Factors: Age, Hypertension, Hyperglycemia, and Hemorrhagic Transformation Increasing age has frequently been associated with an increased risk of HT in patients with stroke. 8,26,50,[143][144][145][146][147][148] The mechanisms by which age may contribute to HT are unclear. Age may enhance the production of ROS which promotes BBB disruption.…”

“…151 Hypertension is also associated with an increased risk of HT in stroke patients. 8,[144][145][146]152,153 Acute elevations in blood pressure are presumed to directly affect BBB permeability and increase HT.…”

“…Clinical scores to predict HT that have been developed include the Multicenter Stroke Survey, 143 the Hemorrhage After Thrombolysis score, 170 and the Safe Implementation of Thrombolysis in Stroke Symptomatic Intracerebral Hemorrhage score, 144 the blood Sugar, Early infarct signs and hyperDense cerebral artery sign, Age, and NIHSS score, 145 the Glucose Race Age Sex Pressure Stroke Severity score, 146 the Stroke Prognostication using Age and NIHSS-100 index, 147 and the iScore 148 (Table 1). Though each score is able to identify patients at increased risk of HT, they do not achieve sufficient sensitivity or specificity to withhold tPA in otherwise tPA eligible patients.…”