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Gastrointestinal bleeding after acute ischemic stroke

From McMaster University (M.J.O., J.W.E., W.O., J.S.), Hamilton; University of Toronto (M.K.K., G.S., F.L.S.); Institute for Clinical Evaluative Sciences (M.K.K., J.F., F.L.S.), Toronto; and Hamilton Health Sciences (L.G., C.D.), Hamilton, ON, Canada.

Address correspondence and reprint requests to Dr. Martin O'Donnell, Henderson Research Centre, 70 Wing, Room 220, 711 Concession Street, Hamilton, Ontario, L8V 1C3, Canada odonnm{at}mcmaster.ca

Objective: Recent studies report that major bleeding is associated with a significant increase in mortality after acute coronary syndrome. Major bleeding has also been reported to be common after ischemic stroke, most often gastrointestinal, but its association with clinical outcome is less certain. We sought to describe the incidence, risk factors, and association with clinical outcomes of gastrointestinal bleeding following acute ischemic stroke.

Methods: Consecutive patients with acute ischemic stroke, who were admitted to 11 Ontario hospitals, were identified from the Registry of the Canadian Stroke Network (2003–2006). Stroke severity was measured using the Canadian Neurological Scale. Dependence was measured with the modified Rankin Scale (mRS), and categorized into strokes with no or mild–moderate dependency (mRS 0–3) and those with severe dependence or death (mRS 4–6). Multivariable logistic regression was used to determine the association between gastrointestinal bleeding and clinical outcome (death or severe dependence at hospital discharge and 6-month mortality), independent of comorbidities and in-hospital medical complications.

Results: In total, 6,853 patients with acute ischemic stroke were included. One hundred (1.5%) patients experienced gastrointestinal hemorrhage during hospitalization, of which 36 (0.5%) required blood transfusion. On multivariable analyses, previous history of peptic ulcer disease, cancer, and stroke severity were independent predictors of gastrointestinal bleeding. Gastrointestinal hemorrhage was independently associated with death or severe dependence at discharge (OR 3.3; 95% CI 1.9–5.8) and mortality at 6 months (HR 1.5; 95% CI 1.1–2.0).

Conclusions: Gastrointestinal hemorrhage is relatively uncommon after acute ischemic stroke but is associated with increased odds of death and severe dependence.

Abbreviations: LACI= lacunar infarct; OCSP= Oxfordshire Community Stroke Project; PACI= partial anterior circulation infarct; POCI= posterior circulation infarct; RCSN= Registry of the Canadian Stroke Network; TACI= total anterior circulation infarct.

Received October 18, 2007. Accepted in final form May 1, 2008.

e-Pub ahead of print on August 6, 2008, at www.neurology.org.

The Registry of the Canadian Stroke Network was funded by grants from the Canadian Stroke Network. Data collection was supported by the Ontario Ministry of Health and Long-term Care. Dr. Martin O'Donnell holds the William Walsh Endowed Research Chair in Internal Medicine and a Mentor-Mentee Award from the Canadian Institutes of Health Research. Dr. Moira Kapral is supported by the Canadian Stroke Network, the University Health Network Women's Health Program, and holds a New Investigator Award from the Canadian Institutes of Health Research. Dr. John Eikelboom holds a Tier II Research Chair from the Canadian Institutes of Health Research. Dr. Frank Silver is supported by the Canadian Stroke Network.

Disclosure: The authors report no disclosures.

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