Thrombolysis-Related Hemorrhagic Infarction

Abstract

Background and Purpose-The role of early and delayed recanalization after thrombolysis in the development of hemorrhagic transformation (HT) subtypes remains uncertain. We sought to explore the association between the timing of recanalization and HT risk in patients with proximal middle cerebral artery (MCA) occlusion treated with intravenous recombinant tissue plasminogen activator (rtPA) Ͻ3 hours of stroke onset and to investigate the relationship between HT subtypes, infarct volume, and outcome. Methods-Thirty-two patients with acute stroke caused by proximal MCA occlusion treated with rtPA Ͻ3 hours of symptom onset were prospectively studied. Serial transcranial Doppler examinations were performed on admission and at 6, 12, 24, and 48 hours. Presence and type of HT were assessed on CT at 36 to 48 hours. Modified Rankin scale was used to assess outcome at 3 months. Results-Early and delayed recanalization was identified in 17 patients (53.1%) and 8 patients (25%), respectively. HT was detected in 14 patients (43.7%): 4 (12.5%) with hemorrhagic infarction (HI 1 ), 5 (15.6%) with HI 2 , 3 (9.3%) with parenchymal hematoma (PH 1 ), and 2 (6.8%) with PH 2 . Distribution of HT subtypes differed significantly (Pϭ0.025), depending on the time to artery reopening. Eight of 9 (89%), 1 of 5 (20%), and 8 of 18 (44.4%) with HI 1 -HI 2 , with PH 1 -PH 2 , and without HT, respectively, recanalized in Ͻ6 hours. Delayed recanalization was observed in 1 patient with HI 1 -HI 2 (11%), 4 with PH 1 -PH 2 (80%), and 3 without HT (16.6%). Neurological improvement was significantly (PϽ0.001) more frequent in patients with HI 1 -HI 2 (88%) than in those without HT (39%

Soluble ST2 predicts outcome and hemorrhagic transformation after acute stroke

“…The HT rate by sST2 tertile was 3%, 6% and 9%, respectively ( P = 0.049). In some studies, HI2 or greater has been proposed as a marker for poststroke injury,16 whereas HI1 may be a beneficial marker of reperfusion 17. Accordingly, sST2 tertile predicted the risk of HI2 or greater ( P = 0.003).…”

“…The latter classification was selected because hemorrhagic infarction type 2 (HI2), or parenchymal hemorrhage (PH1 and PH2) have been associated with worse long term functional outcome 16. Moreover, small petechial hemorrhagic infarction (HI1) may be benign and potentially serves as a marker of early reperfusion 17. Since symptomatic intracerebral hemorrhages (sICH), as defined by ECASS III criteria, were rare in this cohort ( n = 7), they were not separately studied.…”

Hemorrhagic Transformation of Ischemic Stroke: Prediction with CT Perfusion

“…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.…”

“…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). Because even small degrees of hemorrhage may be detrimental, it may be desirable to identify those patients who are more likely to have HT before administering TPA.…”

Intravenous Recombinant Tissue Plasminogen Activator Improves Arterial Recanalization Rates and Reduces Infarct Volumes in Patients With Hyperdense Artery Sign on Baseline Computed Tomography

“…Recanalization that occurs after tissue is already dead may be associated with increased edema and potentially poorer outcome. 19 At the same time, reperfusion may also increase the rate of both asymptomatic and symptomatic ICH, an effect that is compounded by the lytic action of rt-PA. 20 The effect of rt-PA on lesion volumes at three months was still present although did not reach statistical significance. The loss of subjects in both treatment groups between 24 hours and three months led to much more use of imputation in the lesion volume analysis.…”