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Leukoaraiosis and intracerebral hemorrhage after thrombolysis in acute stroke

From the Department of Neurological and Psychiatric Sciences (V.P., D.I.), University of Florence, Italy; and Calgary Stroke Program, Department of Clinical Neurosciences (J.M.B., A.M.B.), and Calgary Stroke Program, Department of Clinical Neurosciences/Medicine/Community Health Sciences, Hotchkiss Brain Institute (M.D.H.), University of Calgary, Canada. Dr. Boulanger is currently with the Department of Neurology, Charles-Lemoyne Hospital, Sherbrooke University, Sherbrooke, Canada; Dr. Buchan is with the Acute Stroke Programme, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, UK.

Address correspondence and reprint requests to Dr. Vanessa Palumbo, Department of Neurological and Psychiatric Sciences, University of Florence, Viale Morgagni 85, 50134 Florence, Italy; e-mail: vanessa.palumbo{at}unifi.it

Objectives: To evaluate whether the presence of leukoaraiosis or multiple lacunes is associated with symptomatic intracerebral hemorrhage (ICH) and 90-day outcome after thrombolytic treatment with tissue plasminogen activator (tPA).

Methods: Data were from a Canadian national registry of thrombolyzed patients with ischemic stroke. A total of 820 scans were assessed, blind to clinical features, for the presence of severe vs no/moderate leukoaraiosis, and of multiple (>2) vs no/single lacunar infarcts. Logistic regression was used to determine if an independent interaction existed between the presence and degree of leukoaraiosis/lacunes and risk of symptomatic ICH, and to evaluate the predictive role of leukoaraiosis and lacunes in relation to 90-day outcome.

Results: An overall symptomatic ICH rate of 3.5% was observed. The rate of symptomatic ICH increased up to 10% in patients with severe leukoaraiosis and multiple lacunes. A significant association was observed between ICH risk and either severe leukoaraiosis (RR = 2.7 [95% CI 1.1 to 6.5]) or multiple lacunes (RR = 3.4 [95% CI 1.5 to 7.6]). Patients with multiple lacunes, but not leukoaraiosis, had higher mortality at 90 days compared to those with one or no lacunes (OR = 2.9, 95% CI 1.3 to 6.2, p = 0.008). No difference was observed in the good outcome rate among patients with and without leukoaraiosis or lacunes or both.

Conclusion: The presence of small vessel disease on CT scan does not affect overall clinical outcome at 3 months in routine community use of tPA for ischemic stroke. A significant increase in the risk of symptomatic ICH is observed.

*CASES Investigators are listed in the appendix.

Disclosure: The authors report no conflicts of interest.

Received July 21, 2006. Accepted in final form November 29, 2006.

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