Hemorrhagic Transformation in Acute Ischemic Stroke: A Quantitative Systematic Review.

Asaf Honig,Oscar R Benavente,Thalia S Field,Alejandra G Gomez,Jennifer Percy,Amir A Sepehry

doi:10.3390/jcm11051162

Asaf Honig, Oscar R Benavente + Show 4 more

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https://doi.org/10.3390/jcm11051162

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Abstract

The prevalence and risk factors of hemorrhagic transformation (HT) after acute ischemic stroke HT have not been adequately delineated. We performed a systematic review and meta-analysis to identify English-language prospective observational MEDLINE and EMBASE-listed reports of acute ischemic stroke with HT published from 1985–2017. Studies that used the ECASS-2 definitions of hemorrhagic transformation subtypes, hemorrhagic infarction (HI), and parenchymal hematoma (PH) were included. Patients treated with intravenous thrombolysis with tissue plasminogen activator (IV-tPA) were compared with those who did not receive thrombolysis. A total of 65 studies with 17,259 patients met inclusion criteria. Overall, HT prevalence was 27%; 32% in patients receiving IV-tPA vs. 20% in those without. Overall PH prevalence was 9%; 12% in IV-tPA treated patients vs. 5% in those without. HT was associated with a history of atrial fibrillation (OR 2.94) and use of anticoagulants (OR 2.47). HT patients had higher NIHSS (Hedge’s-G 0.96) and larger infarct volume (diffusion-weighted MRI, Hedge’s-G 0.8). In IV-tPA treated patients, PH correlated with antiplatelet (OR 3) and statin treatment (OR 4). HT (OR 3) and PH (OR 8) were associated with a poor outcome at 90-day (mRS 5–6). Hemorrhagic transformation is a frequent complication of acute ischemic stroke and is associated with poor outcome. Recognition of risk factors for HT and PH may reduce their incidence and severity.

Highlights

Hemorrhagic transformation (HT) occurs frequently in patients with acute ischemic stroke
There are two accepted classification schemes for HT assessment; one is based strictly on radiological criteria, while the second combines both clinical and radiological variables. The former was used as a safety end point for intravenous thrombolysis with tissue plasminogen activator (IV-tPA)-related HT in the European Cooperative Acute Stroke Trials (ECASS) [3–5]
As rates of HT are higher in patients treated with IV-tPA [9], we investigated interactions between possible predictors of HT in IV-tPA treated and untreated subpopulations

Summary

Introduction

Hemorrhagic transformation (HT) occurs frequently in patients with acute ischemic stroke. There are two accepted classification schemes for HT assessment; one is based strictly on radiological criteria, while the second combines both clinical and radiological variables. The former was used as a safety end point for intravenous thrombolysis with tissue plasminogen activator (IV-tPA)-related HT in the European Cooperative Acute Stroke Trials (ECASS) [3–5]. HI and PH are subdivided into type 1 and 2 for the milder and more severe forms, respectively (without HT, HI, PH, and PH2). PH2, the most severe form of HT, is classified as blood clots exceeding 30% of the infarct area with significant space-occupying effect. In cases of HT classed as ECASS-I, PH2 was associated with both neurological deterioration (OR 32.3) and increased 3-month mortality (OR 18) [4] compared with patients without PH2

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