Hemorrhage After Thrombolytic Therapy for Stroke

Abstract

Background and Purpose-A clinically relevant number needed to harm for tissue plasminogen activator (tPA)-related symptomatic intracerebral hemorrhage (SICH) would greatly assist therapeutic decision-making. Methods-A 15-variable prognostic model was derived from a placebo group enrolled in National Institute of Neurological Disorders and Stroke tPA Trials 1 and 2 and used to predict final global disability outcome for patients with tPA-related SICH had they been treated with placebo, rather than tPA, and not experienced SICH. Results-Among 312 tPA-treated patients, 20 experienced SICH. Compared with placebo patients, patients treated with tPA who experienced SICH were older, had more severe stroke deficits, had higher serum glucose levels, and more often displayed mass effect on pretreatment imaging. Observed 3-month modified Rankin Scale outcomes among the patients experiencing SICH after tPA were: 0 -5%, 1-5%, 4 -10%, 5-5%, and 6 -75%. Predicted outcomes had they been treated with placebo were: 0 -2%, 1-5%, 2-7%, 3-14%, 4 -28%, 5-12%, and 6 -32%. The number needed to harm for one more patient to have a final disabled or dead outcome (modified Rankin Scale Ն3) attributable to tPA-related SICH was 707. Number needed to harm for severely disabled or dead outcome (modified Rankin Scale Ն4) was 126; for fatal outcome 36.5, and for worsened outcome by any degree (Ն1 modified Rankin Scale grade) between 29.7 and 40.1. Conclusions-Most patients who experience SICH have severe baseline infarcts and already are destined for poor outcomes.For every 100 patients treated with tPA, approximately 1 will experience a severely disabled or fatal final outcome as a result of tPA-related SICH.

Blood-Brain Barrier Permeability Assessed by Perfusion CT Predicts Symptomatic Hemorrhagic Transformation and Malignant Edema in Acute Ischemic Stroke

“…Older age in tPA-treated patients was associated with SHT in an analysis of National Institute of Neuroloical Disorders and Stroke trial data. 7 In addition, a secondary analysis of the ECASS II trial demonstrated that age was an independent predictor of SHT 12 ; on a related note, the investigators in ECASS III went so far as to include only patients 80 years of age and younger in their study, 2 in part because of the putative association between older age and SHT. While the link between older age and ME is not documented like the link between age and SHT, our study suggests such a link, which is physiologically plausible given that the pathogenesis of SHT and ME share certain similarities regarding vascular damage.…”

“…6 Although the definition and the magnitude of the SHT problem are still under debate, 7 there is consensus that minimizing the occurrence of SHT is of paramount importance. The benefits of minimizing SHT go beyond the direct clinical benefits to affected patients.…”

Determinants of Intracranial Hemorrhage Occurrence and Outcome after Neurothrombectomy Therapy: Insights from the Solitaire FR With Intention For Thrombectomy Randomized Trial

“…However, multiple contending criteria have been advanced for defining an intracerebral hemor-rhage as symptomatic. 1,8 In addition, other aspects of ICH, including subarachnoid versus intraparenchymal, extent (petechial hemorrhage versus frank hematoma), and topographic location (deep versus superficial) have been identified in some studies as predictors of poor outcome after interventional treatment of acute ischemic stroke. [9][10][11] The Solitaire FR With Intention For Thrombectomy (SWIFT; https://clinicaltrials.gov/ct2/show/ NCT01054560) trial used a refined definition of SICH: any parenchymal hematoma (PH), subarachnoid hemorrhage, or intraventricular hemorrhage (IVH) associated with a worsening of National Institute of Health Stroke Scale score by Ն4 within 24 hours.…”

The role of imaging in acute ischemic stroke

“…Hemorrhagic transformation, a common complication of severe stroke (Fig. 3), is likely caused by a synergistic combination of reperfusion 150,191 and a disrupted blood brain barrier. 191 The clinical presentation of hemorrhagic transformation is widely variable, ranging from subtle neurological findings to sudden rapid decline and death.…”