Patient outcomes from symptomatic intracerebral hemorrhage after stroke thrombolysis
Abstract
Objectives:
To assess the impact of symptomatic intracerebral hemorrhage (sICH) on outcome of thrombolysis-treated ischemic stroke patients, as additional to recognized prognosticators.
Methods:
The study cohort included 985 ischemic stroke patients treated with IV thrombolysis at the Helsinki University Central Hospital (1995–2008). In a multivariable model adjusted for baseline stroke severity, age, onset-to-treatment time, baseline glucose, hyperdense cerebral artery sign, and early infarct signs on baseline imaging, and prior modified Rankin Scale (mRS), we calculated risk ratios (RRs) of patients with sICH (separately per Safe Implementation of Thrombolysis in Stroke[SITS]–Monitoring Study, European Cooperative Acute Stroke Study II [ECASS-II], and National Institute of Neurological Disorders and Stroke [NINDS] definitions) for poor 3-month outcome (mRS 3–6) and mortality. Receiver operating characteristic (ROC) curve and integrated discrimination improvement (IDI) evaluated impact of sICH on outcome. Internal cross-validation of the model was done with bootstrap statistics.
Results:
The frequency of sICH was 2.1% (SITS), 7.0% (ECASS-II), and 9.4% (NINDS). RRs for poor and fatal outcome, respectively, were 1.7 and 4.8 (SITS), 1.6 and 3.8 (ECASS-II), and 1.6 and 3.4 (NINDS). In IDI analyses, sICH improved prediction model for 3-month mRS of 3–6 and 4–6, respectively, by 1.4% and 3.0% (SITS), 4.0% and 5.9% (ECASS-II), and 4.7% and 6.1% (NINDS). In case of 3-month mRS 5–6 and mortality, it was 6.1% and 5.3% (SITS), 11.3% and 9.3% (ECASS-II), and 10.3% and 8.0% (NINDS). ROC analysis revealed similar results.
Conclusions:
Patients with sICH have increased risk of poor and fatal outcome. Compared with recognized stroke prognosticators, contribution of sICH is smaller. Definition-wise, ECASS-II- and NINDS-based sICH contribute relatively more; ECASS-II has the largest contribution to worst outcomes.
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Supplementary Material
COINVESTIGATORS
The Helsinki Stroke Thrombolysis Registry Group further includes Ville Artto, MD, PhD; Sari Atula, MD, PhD; Sami Curtze, MD, PhD; Olli Häppölä, MD, PhD; Ron Liebkind, MD, PhD; Perttu J. Lindsberg, MD, PhD; Satu Mustanoja, MD, PhD; Katja Piironen, MD; Kirsi Rantanen, MD; Lauri Soinne, MD, PhD; and Marjaana Tiainen, MD, PhD. All are from the Department of Neurology, Helsinki University Central Hospital, Finland, and all participated in data collection.
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Copyright © 2011 by AAN Enterprises, Inc.
Publication History
Received: September 29, 2010
Accepted: January 6, 2011
Published online: June 29, 2011
Published in print: July 26, 2011
Disclosure
Dr. Strbian has received research support from The Finnish Medical Foundation. Dr. Sairanen has received speaker honoraria from Boehringer Ingelheim; serves on the editorial board of Experimental & Translational Stroke Medicine; and has received research support from the Finnish Medical Association and the Finnish Medical Foundation. Dr. Meretoja has received funding for travel and/or speaker honoraria from Boehringer Ingelheim, Lundbeck Inc., Orion Corporation, Abbott, and AstraZeneca; serves as a consultant for Boehringer Ingelheim; receives research support from Biomedicum Helsinki Foundation, Finnish-Norwegian Medical Foundation, Emil Aaltonen Foundation, Yrjö; Jahnsson Foundation, and Finnish Medical Foundation; and holds stock in Orion Corporation. Dr. Pitkäniemi reports no disclosures. Dr. Putaala has received funding for travel from Boehringer Ingelheim and Genzyme Corporation. Dr. Salonen and Dr. Silvennoinen report no disclosures. Dr. Kaste has served on scientific advisory boards for and received funding for travel and honoraria from Boehringer Ingelheim, Paion AG, Forest Laboratories, Inc., and Lundbeck Inc.; has received speaker honoraria from Boehringer Ingelheim; serves as a consultant to Stroke and on the editorial boards of The International Journal of Stroke and Avh-Lehti (Journal of Cerebrovascular Disorders); and has served as a consultant for Boehringer Ingelheim, Paion AG, Forest Laboratories Inc., and Lundbeck Inc. Dr. Tatlisumak serves on scientific advisory boards for Boehringer Ingelheim and Mitsubishi Tanabe Pharma Corporation; has received funding for travel from Boehringer Ingelheim; serves/has served on the editorial board of Stroke, Current Vascular Pharmacology, The Open Pharmacology Journal, Clinics of Turkey, Clinics of Turkey/Neurology, The Open Cardiovascular Medicine Journal, Recent Patents on Biotechnology, Recent Patents on CNS Drug Discovery, Experimental and Translational Stroke Medicine, Stroke Research and Treatment, BMC Journal of Experimental and Translational Stroke Medicine, and Frontiers in Stroke, and was founding Editor-in-chief of Case Reports in Neurology; has filed patents re: Stanniocalcin proteins and nucleic acids and methods based thereon, new therapeutic uses (method to prevent brain edema and reperfusion injury), and Thrombolytic compositions (method to prevent postthrombolytic hemorrhage formation); serves as a consultant for Boehringer Ingelheim, PhotoThera, Mitsubishi Tanabe Pharma Corporation BrainsGate, Schering-Plough Corp., Lundbeck Inc., sanofi-aventis, Concentric Medical, Inc.; and receives/has received research support from Boehringer Ingelheim, the Finnish Academy of Sciences, the European Union, Biocentrum Finland, Biocentrum Helsinki, Sigrid Juselius Foundation, Liv och Hälsa, and Maire Taponen Foundation.
Authors
Author Contributions
Dr. Strbian: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, acquisition of data, statistical analysis. Dr. Sairanen: drafting/revising the manuscript, study concept or design, analysis or interpretation of data. Dr. Meretoja: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, acquisition of data. Dr. Pitkäniemi: drafting/revising the manuscript, analysis or interpretation of data, statistical analysis. Dr. Putaala: drafting/revising the manuscript, study concept or design, acquisition of data. Dr. Salonen: analysis or interpretation of data. Dr. Silvennoinen: drafting/revising the manuscript, study concept or design, acquisition of data. Dr. Kaste: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, study supervision. Dr. Tatlisumak: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, contribution of vital reagents/tools/patients, acquisition of data, study supervision, obtaining funding.
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