Risk Factors for Severe Hemorrhagic Transformation in Ischemic Stroke Patients Treated With Recombinant Tissue Plasminogen Activator

Abstract

Background and Purpose-Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) improves the outcome for ischemic stroke patients who can be treated within 3 hours of symptom onset. The efficacy of thrombolysis has been demonstrated despite an increased risk of severe hemorrhagic transformation (HT) in patients treated with rtPA. We performed an analysis of risk factors for severe HT in the second European-Australasian Acute Stroke Study (ECASS II). Methods-HTs were classified by using clinical and radiological criteria as follows: hemorrhagic infarction (HI), parenchymal hemorrhage (PH), and symptomatic intracranial hemorrhage (SICH). Potential risk factors for HT were tested by stepwise logistic regression analysis, including rtPA-by-variable interactions. In addition, the distribution of bad outcome (modified Rankin score 5 to 6) at day 90 was stratified according to each category of HT. Results-PH and SICH but not HI were associated with rtPA. Also, PH and SICH but not HI were more severe in rtPA-treated patients than in those receiving placebo. Risk factors for PH were rtPA, extent of parenchymal hypoattenuation on baseline CT, congestive heart failure, increasing age, and baseline systolic blood pressure. The risk of PH on rtPA was increased in older patients and in those who were treated with aspirin before thrombolysis. Risk factors for SICH were rtPA, congestive heart failure, extent of parenchymal hypoattenuation, and increasing age. The risk of SICH on rtPA was increased in patients who were treated with aspirin before thrombolysis. Conclusions-This secondary analysis of ECASS II has confirmed the importance of the extent of hypoattenuation as a risk factor for severe HT. The findings also suggest that older patients and those who have used aspirin before stroke are at higher risk of a severe HT on rtPA. (Stroke. 2001;32:438-441.)

Endovascular Thrombectomy for Acute Basilar Artery Occlusion: A Multicenter Retrospective Observational Study

“…Procedure duration was defined as the interval between the time of femoral artery puncture and the time of final angiogram. Intracerebral hemorrhages were assessed with post‐treatment computed tomography or magnetic resonance imaging scans and classified as a subarachnoid hemorrhage, hemorrhagic infarction, or parenchymal hematoma, based on the ECASS (European Cooperative Acute Stroke Study) II criteria 14. A symptomatic intracranial hemorrhage was also defined according to the ECASS II classification.…”

Collateral state and the effect of endovascular reperfusion therapy on clinical outcome in ischemic stroke patients

“…2001; Trouillas and von Kummer 2006). Only PH2 was defined as a clinically significant hemorrhage (Berger et al.…”

Hemorrhagic Transformation after Ischemic Stroke in Animals and Humans

“…We propose that the mechanisms contributing to early BBB disruption and early HT differ from those involved in delayed BBB disruption and delayed HT (Figure 3). In early HT, ROS, bloodderived MMP-9, and brain-derived MMP-2 have emerged as Congestive heart failure 50,148 Atrial fibrillation 50,148 Renal impairment 50,148 Antiplatelet use 8,50,144,[167][168][169] Platelet count 143 Anticoagulant/international normalized ratio/partial thromboplastin time 162 Time to reperfusion 144 Blood marker MMP-9 important mediators. In delayed HT, brain-derived factors including MMP-9, MMP-3, other proteases, vascular remodeling, and neuroinflammation begin to have a more prominent role.…”

“…[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.…”

“…6 These clinical classifications are useful in that larger hemorrhages are more likely symptomatic, more likely to negatively affect stroke outcomes, and thus are important to prevent. 3,5,7,8 However, even so-called 'asymptomatic' HT can worsen stroke outcomes, particularly when cognition and neurologic function are assessed weeks to months after stroke onset. 6,9 This may relate in part to exacerbation of cerebral edema and other toxic effects of blood produced by HT.…”