Hemorrhagic cerebral infarction--a prospective study.

Abstract

SUMMARY In 65 cases of ischemic cerebral infarction, CT scans and quantitative assessments of the neurological disturbances were undertaken at specific intervals during the 4 week period after stroke. Forty-three patients underwent lumbar puncture to determine the serum/CSF albumin ratio. The etiology of the infarction was evaluated on the basis of angiographic, ultrasonic and cardiologic findings. A hemorrhagic transformation of the infarction occurred in 28 patients, eleven within the first week, and 15 within the second. Risks of hemorrhage were correlated with a severe neurological deficit, disturbance of consciousness, large infarction with a mass effect, enhancement of contrast medium in CT (especially if occurring early), Involvement of the cortex, and distinct blood/CSF barrier disturbances. Cardiac embolism was a frequent etiology in patients with secondary hemorrhagic infarction, especially when transformation occurred within the first week after stroke.In addition to a heterogenous pattern of hemorrhage, frank hematoma predominated in those infarcts which underwent early transformation, while those transforming late often showed less hyperdense cortical hemorrhagic changes.Deterioration evident on clinical evaluation was caused by the hemorrhagic transformation in three cases, in each instance within the first week after stroke.

Contrast Enhancement and Contrast Extravasation on Computed Tomography After Intra-Arterial Thrombolysis in Patients With Acute Ischemic Stroke

“…16 In addition, reperfusion of ischemic brain tissue after thrombolytic therapy may involve the risk of reperfusion injury through enhanced formation of reactive oxygen species and metalloproteinase activation. 18,24 In the present study, all cases of contrast enhancement and 86% of the contrast extravasation developed in the basal ganglia. Komiyama et al 8 reported 2 cases of extravasation of contrast medium that occurred in the region of the basal ganglia.…”

“…15,16 It is well known that contrast enhancement of brain tissue on CT or MR is caused by leakage of contrast medium from vessels into the extracellular spaces as a result of increased permeability of the BBB. 17,18 Contrast enhancement of brain tissue on nonenhanced CT scans taken immediately after intra-arterial thrombolysis may occur over a prolonged period, with contrast leaking through the BBB of the microvessels supplying the basal ganglia during thrombolysis. When intra-arterial thrombolysis is performed, multiple angiographic injections of contrast medium through either a guiding catheter or a microcatheter is done around the lenticulostriate arteries to assess the response of thrombolytic therapy.…”

Haemorrhagic transformation in ischaemic stroke is more frequent than clinically suspected – A neuropathological study

“…Hornig et al evaluated 65 patients' data. They detected HT with brain CT in 28 cases, 40% in the first week, and the rest 60% in the second post-stroke week [16]. These earlier reports show how difficult it is to define the most appropriate time for the diagnosis of HT.…”

“…Previous studies have focused on the possible aetiological role of the following parameters: age [8,10,11,13,14], systolic and diastolic arterial blood pressure [14,15], congestive heart failure [11], body temperature [15], serum glucose level [8,14], treatment with anticoagulants [10,15], pre-treatment with aspirin [10,11], early ischaemic signs on CT [11,13,15], mean infarct volume [10,11,15], plasma matrix metalloproteinase-9 [15]. The adequate time window for detection of haemorrhagic transformation is also disputed [16] and autopsy is the method which provides the most accurate diagnosis in stroke. Our goals were to i) analyse the correlation between clinical and neuropathological diagnosis; ii) to assess the clinically undisclosed findings revealed with the neuropathological analysis in a series of consecutive cases reflecting the routine practice of a stroke centre, iii) to emphasize the importance of the neuropathological evaluation in establishing the real frequency of haemorrhagic transformation which may warrant modifications of stroke protocols and diagnosing clinically undetected brain diseases.…”

Therapeutic interventions in acute stroke.

“…Open doseranging studies include the NIH tPA Study (Brott et al, 1990) Haemorrhagic transformation is a potential complication of thrombolytic treatment. This must be viewed in the light of the natural incidence of haemorrhagic transformation, which ranges from 10-43% depending on the circumstances and which increases as the time elapsed from stroke progresses (Fisher et al, 1984;Hornig et al, 1986;Lodder, 1984;Okada et al, 1989). The rate of intracerebral haemorrhage in 46,092 patients with myocardial infarction who were randomised in the ISIS-3 trial was only 0.3-0.7%, streptokinase causing significantly less haemorrhage than tPA or APSAC.…”