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Markers for Hemorrhagic Transformation in Acute Ischemic Stroke
Study Questions:
What clinical and imaging markers are associated with any hemorrhagic transformation (HT), hemorrhagic infarction (HI), parenchymal hematoma (PH), and symptomatic intracranial hemorrhage (sICH) in acute ischemic stroke patients with large vessel occlusion?
Methods:
This is a post hoc analysis of patients enrolled in MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), a prospective multicenter trial of endovascular therapy (EVT) versus usual care in patients with acute ischemic stroke caused by large vessel occlusion who could be treated within 6 hours of stroke onset. Presence of petechial hemorrhage at the margin of or within the infarcted bed defined HI. A large confluent hemorrhage within the infarct bed defined PH. Any ICH on computed tomography (CT) with a concomitant increase in ≥4 points on the National Institutes of Health Stroke Scale (NIHSS) defined sICH.
Results:
A total of 478 patients were included in this analysis, 428 (89%) of whom received intravenous (IV) alteplase and 227 (47%) of whom underwent EVT: 222 (46%) had any HT, 75 (16%) had PH, and 35 (7%) had sICH. There was no difference in the occurrence of HT or sICH among the four treatment groups: EVT + IV alteplase, IV alteplase only, EVT only, and untreated patients. Compared to patients without HT, patients with HI had a higher median NIHSS score and more ischemic burden on CT (lower median ASPECTS score). Patients with sICH were older (ages 75 vs. 65 years, p < 0.001), had a higher NIHSS, had a higher prevalence of diabetes, and had a higher admission systolic blood pressure (158 vs. 140 mm Hg, p < 0.01) than patients without sICH. PH and sICH were significantly associated with increased admission systolic blood pressure, atrial fibrillation, and antiplatelet use.
Conclusions:
In this post hoc analysis, HI, PH, and sICH were more likely in patients with higher NIHSS scores. Symptomatic ICH was also associated with older age, diabetes, admission systolic blood pressure, and antiplatelet use. Neither IV alteplase nor EVT were significantly associated with HT.
Perspective:
The association of NIHSS score with each subtype of hemorrhage is likely a manifestation of the positive association between NIHSS score and infarct size. Most of the HT markers identified in this analysis are not modifiable (age, NIHSS, atrial fibrillation), but systolic blood pressure can be addressed in the acute setting. American Heart Association/American Stroke Association guidelines suggest that blood pressure be maintained at <180/105 mm Hg for at least the first 24 hours after IV alteplase and that it is reasonable to maintain blood pressure at ≤180/105 mm Hg during and for 24 hours after EVT.
Clinical Topics: Arrhythmias and Clinical EP, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Interventions and Imaging, Nuclear Imaging
Keywords: Atrial Fibrillation, Blood Pressure, Blood Pressure Determination, Brain Ischemia, Diabetes Mellitus, Endovascular Procedures, Hematoma, Hemorrhage, Intracranial Hemorrhages, Secondary Prevention, Stroke, Tissue Plasminogen Activator, Tomography, Tomography, X-Ray, Vascular Diseases
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