Hemorrhagic Transformation After Ischemic Stroke: Mechanisms and Management

Abstract

Symptomatic hemorrhagic transformation (HT) is one of the complications most likely to lead to death in patients with acute ischemic stroke. HT after acute ischemic stroke is diagnosed when certain areas of cerebral infarction appear as cerebral hemorrhage on radiological images. Its mechanisms are usually explained by disruption of the blood-brain barrier and reperfusion injury that causes leakage of peripheral blood cells. In ischemic infarction, HT may be a natural progression of acute ischemic stroke and can be facilitated or enhanced by reperfusion therapy. Therefore, to balance risks and benefits, HT occurrence in acute stroke settings is an important factor to be considered by physicians to determine whether recanalization therapy should be performed. This review aims to illustrate the pathophysiological mechanisms of HT, outline most HT-related factors after reperfusion therapy, and describe prevention strategies for the occurrence and enlargement of HT, such as blood pressure control. Finally, we propose a promising therapeutic approach based on biological research studies that would help clinicians treat such catastrophic complications.

Early neurological deterioration in acute ischemic stroke patients after intravenous thrombolysis with alteplase predicts poor 3-month functional prognosis - data from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China)

“…Concerning the risk factors of END, although some experts generally believe that elderly patients are more prone to END, it has not been confirmed in some studies [ 10 , 15 ]. Some studies also have demonstrated the predictors of END as follows: diabetes [ 17 , 18 ], neurological functional deficits on admission [ 19 ], and systolic BP [ 20 – 22 ].…”

Predictive value of magnetic resonance imaging-based texture analysis for hemorrhage transformation in large cerebral infarction

“…significant hemodynamic and metabolic imbalances led to breakdown of blood-brain barrier and eventually increased extravasation of blood (Warach and Latour, 2004;Hong et al, 2021). Accurate prediction of HT after AIS is crucial for therapeutic regimen selections on patient's prognosis to reduce the occurrence of HT.…”

Glucose to Platelet Ratio: A Potential Predictor of Hemorrhagic Transformation in Patients with Acute Ischemic Stroke

“…Hemorrhagic transformation (HT), which can be classified as hemorrhagic infarction (HI) and parenchymatous hematoma (PH), based on the European cooperative acute stroke study (ECASS II), is one of the most common and severe complications of AIS. HT may be triggered by either the normal progression of AIS or reperfusion treatment, often resulting in poor clinical outcomes [ 4 , 5 ]. Therefore, early identification of patients at high risk of HT is crucial.…”

“…Risk factors related to HT include massive cerebral infarction, cerebral cortex infarction, atrial fibrillation (AF), low cholesterol levels, higher National Institute of Health Stroke Scale (NIHSS) scores, poor collateral vessels, application of intravenous recombinant tPA, and early CT signs [ 4 , 6 ]. Previous studies have shown that glucose levels and platelet counts were also associated with HT [ 7 , 8 , 9 , 10 , 11 ].…”

“…In the first 36 h following successful endovascular recanalization treatment, time-related glycemic variability was strongly correlated with symptomatic intracerebral hemorrhage and poor functional outcomes [ 8 ]. Due to their hemostatic function and their significant participation in the inflammatory response, platelets have been regarded as a crucial factor against HT during ischemia/reperfusion [ 4 , 11 ]. A prospective multicenter intravenous thrombolysis register-based study suggested that a lower platelet count was related to an increased risk of symptomatic intracranial hemorrhage.…”