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This Article Figures Only Full Text Full Text (PDF) CME: Take the course for this article: Volume 71, Number 17, October 21, 2008 Korean Translation All Versions of this Article: 01.wnl.0000313936.15842.0dv1 71/17/1304    most recent Correspondence: Submit a response Alert me when this article is cited Alert me when Correspondence are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Saqqur, M. Search for Related Content PubMed PubMed Citation Articles by Saqqur, M. Related Collections All Cerebrovascular disease/Stroke Intracerebral hemorrhage Related Article

Symptomatic intracerebral hemorrhage and recanalization after IV rt-PA

A multicenter study

From the Department of Medicine (Neurology) (M. Saqqur, M. Siddiqui), University of Alberta, Canada; Department of Neurology (G.T.), Eginition Hospital, University of Athens, Greece; Comprehensive Stroke Center (G.T., A.V.A.), University of Alabama at Birmingham; Vall d’Hebron Hospital (C.A.M., J.A.-S.), Barcelona, Spain; Department of Clinical Neurosciences (A.M.D.), University of Calgary, Alberta, Canada; University of Pittsburgh (K.U.), PA; Hospital Universitario Central de Asturias (S.C.), Oviedo, Spain; and University of Texas-Houston Medical School (A.V.A.).

Address correspondence and reprint requests to Dr. Maher Saqqur, 2E3 Walter C Mackenzie, Health Science Centre, Edmonton, Alberta, Canada T6G 2B7 msaqqur{at}ualberta.ca

Background: Symptomatic intracerebral hemorrhage (sICH) is the most unfavorable complication after IV thrombolytic treatment. We aimed to determine the relationship between early recanalization and the risk of sICH.

Methods: Patients with acute stroke received IV tissue plasminogen activator (rt-PA) within 3 hours of symptom onset with transcranial Doppler (TCD) monitoring at four academic centers. sICH was defined as parenchymal hemorrhage on CT in relation to neurologic worsening (NIH Stroke Scale [NIHSS] 4) within 72 hours after treatment. Poor outcome was defined as modified Rankin Scale 3-6 at 3 months. Early recanalization was graded with Thrombolysis in Brain Ischemia (TIBI) system. Multiple logistic regression analyses were used to identify predictors of sICH.

Results: A total of 349 patients received rt-PA at median 134 ± 32 minutes (mean age 69 ± 13 years, 186 men [53%]). Median pretreatment NIHSS score was 16 points (interquartile range: 12-20). Median time to TCD was 130 ± 40 minutes. At the end of rt-PA infusion, 135 patients (38%) had no recanalization, 101 (29%) partial, and 113 (32%) complete recanalization. sICH occurred in 26 patients (7.4%). Of the 135 patients without early recanalization, 18 (13%) had sICH, as compared to 4 (4%) of the 109 subjects with partial recanalization and 4 (3.5%) of 113 with complete recanalization, p = 0.005. After adjustment for age, sex, baseline NIHSS score, glucose, blood pressure, and time to treatment, patients with persistent occlusion had sixfold higher risk of sICH (OR = 6, 95% CI 1.5-21.3, p = 0.01).

Conclusion: The risk of tPA-related symptomatic intracerebral hemorrhage (sICH) is low after early and complete restoration of blood flow. Arterial occlusion persistent beyond tissue plasminogen activator infusion emerges as an independent predictor of higher risk of sICH in patients treated with systemic thrombolysis.

Abbreviations: ASPECT = Alberta Stroke Program Early CT; MMP = matrix metalloproteinase; mRS = modified Rankin Scale; NIHSS = NIH Stroke Scale; rt-PA = tissue plasminogen activator; SBP = systolic blood pressure; sICH = symptomatic intracerebral hemorrhage; TCD = transcranial Doppler; TIBI = Thrombolysis in Brain Ischemia; TIMI = Thrombolysis in Myocardial Infarction.

Editorial, page 1300

e-Pub ahead of print on August 27, 2008, at www.neurology.org.

*Members of the CLOTBUST Investigators are listed in the appendix.

Dr. Tsivgoulis is the recipient of a neurosonology fellowship grant from the Neurology Department of Eginition Hospital, University of Athens School of Medicine, Athens, Greece.

Disclosure: Andrew M. Demchuk, MD, FRCPC: honoraria (<$10,000) from Astra Zeneca, BMS, Sanofi, Hoffman Laroche, Consultant for Terumo, BMS, Sanofi. Andrei V. Alexandrov, MD: research grant (>$10,000): NINDS K 23-02229. Speaker bureau for Genentech, honoraria (<$10,000) from Genentech for the CLOTBUST Investigators.

Received April 11, 2007. Accepted in final form March 4, 2008.

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