Intracerebral Hemorrhage Post-thrombolytic Therapy In Acute Ischemic Stroke

Background:Cerebral hemorrhage after thrombolytic therapy is the most feared complication. Tissue plasminogen activator (tPA) or recombinant tissue plasminogen activator (rt-PA) is a standard agent therapy for acute ischemic stroke (AIS) approved by the US Food and Drug Administration (FDA) but urokinase (UK) has been widely used for thrombolytic therapy in China for acute ischemic stroke. Because it’s expensive and did not have significantly good clinical outcomes, FDA stopped the fabrication of UK, and it is no longer available for use in the United States.Purpose:The purpose of this study is to investigate the factors that contribute to hemorrhagic transformation (HT) on an ischemic stroke brain or intracerebral hemorrhage post thrombolysis in our hospital setting, to assess the safety, feasibility, and efficacy of the treatment. The knowledge of different factors associated with cerebral hemorrhage is important for the selection of the patients, to minimize the rate of hemorrhage complications to achieve good clinical outcome and desired benefit.Methods:We retrospectively reviewed the medical records of all patients who had received thrombolytic therapy from 2008 to 2015 in ZhongDa Hospital Affiliated to Southeast University. We evaluated and analyzed the clinical outcomes of the patients enrolled in the thrombolysis, compared the characteristics, factors contributing for symptomatic intracerebral hemorrhage (SICH) or hemorrhagic transformation (HT), outcomes, and violations of treatment protocol with those of patients in the National Institute of Neurological Disorders and Stroke (NINDS) trial and Chia-Yi Christian Hospital Study (CYCH study) to establish what may have cause brain hemorrhage in our study group.Results:In this past 7 years forty-five patients (17 women,28 men) were admitted to ZhongDa Hospital Affiliated to Southeast University and received thrombolysis as treatment for acute ischemic stroke. Eight patients (17.8%) out of forty-five patients, had cerebral hemorrhage, five patients died including one patient with cerebral hemorrhage and five patients were discharged against medical advice.All patients were treated with rt-PA or UK. The mean age was 67 years and with higher male proportion (62%). The median pretreatment National Institutes of Health Stroke Scale score was 12. The mean time from stroke onset to treatment was 3 hours, it was not possible to access the door-to-computed tomography or door-to-needle time. According to the risk factors of hemorrhage, thirty four patients (76%) were diagnosed as having hypertension, seven patients had diabetes (16%), and eleven patients had history of smoking (24%) and eighteen patients with atrial fibrillation (40%). Intracerebral hemorrhage occurred during the first 72 hours. Large-vessel occlusive (76%) was the leading cause of ischemic stroke in our study group, higher NIHSS scores after the treatment (17 vs 11, p=0.03). Logistic regression analysis showed that NIHSS scores after the treatment (OR=1.15,95% CI=1.008～1.31, p=0.04) was associate with intracerebral hemorrhage after the treatment.Conclusion:NIHSS scores after the treatment is a factor associated with early intracerebral hemorrhage after thrombolysis in patients with acute ischemic infarction.