Abstract W P62: Symptomatic Intracerebral Hemorrhage after Thrombolysis in MRI Selected Patients is Rare and Unpredictable

Abstract

Background: Symptomatic intracerebral hemorrhage (sICH) is the most feared complication following intravenous tissue plasminogen activator (IV-tPA) in ischemic stroke with a mortality rate of 50%. The strictest definition of a sICH is a parenchymal hemorrhage type 2 (defined as a hemorrhage of more than 30% of the infarct with a mass effect or hemorrhage in an unrelated area) and associated with an increase in NIHSS of 4 points or more. The incidence of sICH in a stroke cohort selected by CT was nearly 3% in a recent study. Objectives: We examined the incidence of sICH in acute MRI-evaluated stroke patients treated with IV-tPA in a Danish stroke center between 2004 and 2010. We also sought to identify clinical and imaging factors related to an increased risk of sICH. Methods: MRI is the preferred imaging modality for patients presenting with symptoms of acute stroke at our hospital. Treatment with IV tPA was guided by MRI findings and patients with DWI lesions >1/3 of MCA was excluded from therapy. No higher or lower NIHSS cut off was applied and treatment was initiated within 4.5 hours from symptom onset. Results: Overall, 519 patients received IV tPA on the basis of an acute MRI scan. (Forty-six patients who received both IV tPA and intraarterial treatment were excluded.) Six patients (1.2%) had a sICH as defined above. Age, acute DWI lesion size, stroke severity and time to treatment did not differ significantly among patients with and without a sICH. The patients with sICH did not differ from the patients not suffering sICH regarding vascular risk factors (sex, hypertension, diabetes, hyperlipidemia, smokingor atrial fibrillation). However, five patients suffering an sICH (83%) were taking antiplatelet drugs prior to treatment, while only 33% of the “non-bleeders” were (p=0.03). Conclusion: MRI-based IV tPA, with exclusion of large infarct sizes from treatment, is associated with low rates of sICH. No pretreatment clinical or imaging characteristics, but antiplatelet drugs, could identify patients with an increased risk of sICH.