Abstract
BackgroundIntravenous tissue plasminogen activator (IV tPA) after acute ischemic stroke carries the risk of symptomatic intracerebral hemorrhage (sICH). Cerebral microbleeds (CMBs) may indicate increased risk of hemorrhage and can be seen on magnetic resonance imaging (MRI). In this study, we examined the association between CMBs and sICH, focusing on the predictive value of their presence, burden, and location.MethodsRecords from all patients presenting to two academic stroke centers with acute ischemic stroke treated with IV tPA over a 5-year period were retrospectively reviewed. Demographic, medical, and imaging variables were evaluated. The presence, number, and location (lobar vs nonlobar) of CMBs were noted on gradient echo MRI sequences obtained during the admission. Univariable and multivariable statistical models were used to determine the relationship between CMBs and hemorrhagic (symptomatic and asymptomatic) transformation.ResultsOf 292 patients (mean age 62.8 years (SD 15.3), 49% African-American, 52% women), 21% (n = 62) had at least one CMB, 1% (n = 3) had > 10 CMBs, and 1% (n = 3) were diagnosed with probable cerebral amyloid angiopathy. After treatment, 16% (n = 46) developed hemorrhagic transformation, of which 6 (2%) were sICH. There was no association between CMB presence (p = .135) or location (p = .325) with sICH; however, those with a high CMB burden (> 10 CMB) were more likely to develop sICH (OR 37.8; 95% CI: 2.7–539.3; p = .007).ConclusionsOur findings support prior findings that a high CMB burden (> 10) in patients with acute stroke treated with IV tPA are associated with a higher risk of sICH. However, the overall rate of sICH in the presence of CMB is very low, indicating that the presence of CMBs by itself should not dictate the decision to treat with thrombolytics.
Highlights
Intravenous tissue plasminogen activator (IV tPA) after acute ischemic stroke carries the risk of symptomatic intracerebral hemorrhage
Cerebral microbleeds (CMBs) are small areas of signal void, 2–10 mm in diameter [4,5,6] that can be seen on gradient echo magnetic resonance imaging (MRI) sequences, mostly representing blood products commonly associated with disorders such as hypertension or cerebral amyloid angiopathy (CAA)
Given the lack of consensus in the literature regarding the relationship between CMBs and symptomatic intracerebral hemorrhage (sICH) in this study, we examine the association of CMBs with hemorrhage, taking into account presence, burden, location, and the likelihood of CAA, to predict hemorrhage in patients treated with IV tPA
Summary
Intravenous tissue plasminogen activator (IV tPA) after acute ischemic stroke carries the risk of symptomatic intracerebral hemorrhage (sICH). Along with other known risk factors for hemorrhage such as age, renal disease, and stroke volume [7], CMBs may be associated with hemorrhage risk [8, 9] .The reported prevalence of CMBs on pre-IV tPA imaging ranges from 15 to 40% [10, 11]. This is clinically relevant, as it is becoming increasingly common to Chacon-Portillo et al BMC Neurology (2018) 18:33 perform an MRI as part of the acute work-up of ischemic stroke [12]. Understanding the associated risk of sICH may, be of significant clinical impact when considering the use of thrombolytics
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