scholarly journals Hemorrhagic Transformation After Ischemic Stroke: Mechanisms and Management

2021 ◽  
Vol 12 ◽  
Author(s):  
Ji Man Hong ◽  
Da Sol Kim ◽  
Min Kim
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Pressure Control ◽  
Reperfusion Therapy ◽  
Hemorrhagic Transformation ◽  
Biological Research ◽  
Related Factors ◽  
Natural Progression ◽  
Promising Therapeutic Approach ◽  
Radiological Images

Symptomatic hemorrhagic transformation (HT) is one of the complications most likely to lead to death in patients with acute ischemic stroke. HT after acute ischemic stroke is diagnosed when certain areas of cerebral infarction appear as cerebral hemorrhage on radiological images. Its mechanisms are usually explained by disruption of the blood-brain barrier and reperfusion injury that causes leakage of peripheral blood cells. In ischemic infarction, HT may be a natural progression of acute ischemic stroke and can be facilitated or enhanced by reperfusion therapy. Therefore, to balance risks and benefits, HT occurrence in acute stroke settings is an important factor to be considered by physicians to determine whether recanalization therapy should be performed. This review aims to illustrate the pathophysiological mechanisms of HT, outline most HT-related factors after reperfusion therapy, and describe prevention strategies for the occurrence and enlargement of HT, such as blood pressure control. Finally, we propose a promising therapeutic approach based on biological research studies that would help clinicians treat such catastrophic complications.

Neuroimaging Prediction of Hemorrhagic Transformation for Acute Ischemic Stroke

2022 ◽  
pp. 1-11
Author(s):  
Lan Hong ◽  
Tzu-Ming Hsu ◽  
Yiran Zhang ◽  
Xin Cheng
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Treatment Strategies ◽  
Onset Time ◽  
Intravenous Thrombolysis ◽  
Reperfusion Therapy ◽  
Hemorrhagic Transformation ◽  
Advanced Technology ◽  
Future Research

<b><i>Background:</i></b> Hemorrhagic transformation (HT) is a common complication of acute ischemic stroke, often resulting from reperfusion therapy. Early prediction of HT can enable stroke neurologists to undertake measures to avoid clinical deterioration and make optimal treatment strategies. Moreover, the trend of extending the time window for reperfusion therapy (both for intravenous thrombolysis and endovascular treatment) further requires more precise detection of HT tendency. <b><i>Summary:</i></b> In this review, we summarized and discussed the neuroimaging markers of HT prediction of acute ischemic stroke patients, mainly focusing on neuroimaging markers of ischemic degree and neuroimaging markers of blood-brain barrier permeability. This review is aimed to provide a concise introduction of HT prediction and to elicit possibilities of future research combining advanced technology to improve the accessibility and accuracy of HT prediction under emergent clinical settings. <b><i>Key Messages:</i></b> Substantial studies have utilized neuroimaging, blood biomarkers, and clinical variables to predict HT occurrence. Although huge progress has been made, more individualized and precise HT prediction using simple and robust imaging predictors combining stroke onset time should be the future goal of development.

scholarly journals Influence of Estimated Glomerular Filtration Rate on Clinical Outcomes in Patients with Acute Ischemic Stroke Not Receiving Reperfusion Therapies

2021 ◽  
Vol 10 (20) ◽  
pp. 4719
Author(s):  
Mi-Yeon Eun ◽  
Jin-Woo Park ◽  
Bang-Hoon Cho ◽  
Kyung-Hee Cho ◽  
Sungwook Yu
Keyword(s):  
Ischemic Stroke ◽  
Glomerular Filtration Rate ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Filtration Rate ◽  
Estimated Glomerular Filtration Rate ◽  
Independent Predictor ◽  
Reperfusion Therapy ◽  
Hemorrhagic Transformation

Background: We aimed to determine whether estimated glomerular filtration rate (eGFR) is an independent predictor of clinical outcomes in patients with acute ischemic stroke not treated with reperfusion therapy. Methods: A total of 1420 patients with acute ischemic stroke from a hospital-based stroke registry were included in this study. Patients managed with intravenous thrombolysis or endovascular reperfusion therapy were excluded. The included patients were categorized into five groups according to eGFR, as follows: ≥90, 60–89, 45–59, 30–44, and <30 mL/min/1.73 m2. The effects of eGFR on functional outcome at discharge, in-hospital mortality, neurologic deterioration, and hemorrhagic transformation were evaluated using logistic regression analyses. Results: In univariable logistic regression analysis, reduced eGFR was associated with poor functional outcome at discharge (p < 0.001) and in-hospital mortality (p = 0.001), but not with neurologic deterioration and hemorrhagic transformation. However, no significant associations were observed between eGFR and any clinical outcomes in multivariable analysis after adjusting for clinical and laboratory variables. Conclusions: Reduced eGFR was associated with poor functional outcomes at discharge and in-hospital mortality but was not an independent predictor of short-term clinical outcomes in patients with acute ischemic stroke who did not undergo reperfusion therapy.

Abstract TMP20: Extraischemic Hematomas Following Intravenous rt-PA For Acute Ischemic Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Masato Osaki ◽  
Masatoshi Koga ◽  
Mayumi Fukuda ◽  
Yuya shigehatake ◽  
Kazuyuki Nagatsuka ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Hemorrhagic Transformation ◽  
Tissue Type ◽  
Stroke Patients ◽  
Related Factors ◽  
Subarachnoidal Space ◽  
Type Plasminogen Activator ◽  
The Brain

Background and purpose: Extraischemic hematoma (EIH) is defined as hemorrhage that appears in regions of the brain without visible ischemic damage. The frequency, clinical features, disease-related factors, and prognosis of patients with EIH after IV recombinant tissue-type plasminogen activator (rt-PA) are not well known. We aimed to elucidate EIH and associated factors after IV rt-PA for acute ischemic stroke. Methods: We studied consecutive stroke patients who received IV rt-PA from 2005 through 2011. EIH was defined as any extra-ischemic hemorrhages identified on the follow-up CT within the initial 36 h after rt-PA. Results: Of the total 266 patients (177 men, 73±13 years old) studied, EIH was identified in 11 (4%, 5 men, 77±7 yo, 1 multiple EIH); 8 patients in the parenchyma (5 subcortex, 1 thalamus, 1 corona radiate, 1 cerebellum), 2 in the intraventricule, 1 in the subdural space, and 1 in the subarachnoidal space. As compared with 47 patients with hemorrhagic transformation (HT) from the index infarct (30 men, 73±10 yo) and 208 with “no hemorrhage” (NH, 142 men, 73±14 yo), Fazekas grade of periventricular hyperintensity (PVH) was higher [median 2 in EIH, 1 in HT, 1 in NH; P<0.001), DWI-ASPECTS was lower [7, 7.5, 9; P<0.001), and reduced eGFR (<60 ml/min/1.73 m2) was more common in patients with EIH (82%, 32%, 38%; P=0.007). On multivariate analysis, higher grade of PVH (OR 5.06, 95%CI 1.92-16.09 per 1 point; P<0.001) and reduced eGFR (OR 6.94, 95%CI 1.40-54.69; P=0.02) were associated with EIH. Percentages of the mRS 5-6 at 3 months were 46% in EIH, 36% in HT, and 16% in NH (P=0.001). EIH was an independent predictor of the mRS 5-6 (OR 4.90, 95%CI 1.11-22.35; P=0.036), along with older age, lower DWI-ASPECTS, higher NIHSS score, and prior antithrombotic use. Of 132 patients undergoing T2*-WI before or within several days after thrombolysis, microbleeds were more common in patients with EIH (86%) than the others (19% in HT, 24% in NH, P<0.001). Conclusions: EIH developed in 4% of the stroke patients after IV rt-PA. Severe PVH and renal dysfunction were associated with the occurrence of EIH. Severe PVH might indicate prevalent existence of microbleeds. EIH was predictive of unfavorable outcome following IV rt-PA.

Abstract 75: Hemorrhagic Transformation After Acute Ischemic Stroke Due to a Large Vessel Occlusion is Associated With Less Treatment Benefit

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Katinka R van Kranendonk ◽  
Manon Kappelhof ◽  
Vicky Chalos ◽  
Kilian M Treurniet ◽  
Wim van Zwam ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Infarct Volume ◽  
Hemorrhagic Transformation ◽  
Vessel Occlusion ◽  
Treatment Benefit ◽  
Natural Progression ◽  
Before And After

Introduction: Intracranial hemorrhage after acute ischemic stroke patients manifests as natural progression or as a complication of treatment with potential subsequent neurological deterioration. Currently it is unclear whether these hemorrhagic transformations (HT) contribute to the poorer functional outcomes observed in patients with large infarcts. The purpose of this study is to assess the association of HT with follow-up infarct volume (FIV) and functional outcome at 90 days after AIS. Additionally, we determined whether the development of HT was associated with a diminished endovascular therapy (EVT) effect. Methods: All patients from the HERMES collaboration with follow-up imaging were included. HERMES is pooled data from seven randomized controlled trials that assessed the efficacy and safety of EVT compared to usual care. Patients with HT were identified according to the ECASS classification and FIV was assessed on CT or MRI. Infarct and hemorrhage were included in the FIV. We assessed functional outcome using the modified Rankin Scale 90 days after stroke onset. Ordinal logistic regression with adjustment for potential confounders was used to determine the association of HT and FIV with functional outcome. Results: Of all included patients with follow-up imaging (n=1665), 42% had HT (n=698). Before and after adjustment for confounders HT and FIV were associated with a shift in the direction of poorer functional outcome (aOR:0.71,95%CI:0.58-0.86 and aOR:0.99,95%CI:0.99-0.99). EVT was beneficial in patients with and without HT, but effect was greater in patients without (aOR:1.70,95%CI:1.27-2.28 vs. aOR:2.51,95%CI:1.97-3.20)(figure 1.) Conclusions: In this analysis, patients with HT after AIS were less likely to have good functional outcome compared to those without HT, independent of the FIV. While the EVT effect was slightly diminished in patients who developed HT, EVT was always of significant benefit.

scholarly journals Serum Occludin Level Combined With NIHSS Score Predicts Hemorrhage Transformation in Ischemic Stroke Patients With Reperfusion

2021 ◽  
Vol 15 ◽  
Author(s):  
Shuhua Yuan ◽  
Weili Li ◽  
Chengbei Hou ◽  
Huining Kang ◽  
Qingfeng Ma ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Characteristic Curve ◽  
Multivariate Logistic Regression Analysis ◽  
Clinical Information ◽  
Reperfusion Therapy ◽  
Hemorrhagic Transformation ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Nihss Score

Hemorrhagic transformation (HT) is a severe complication following acute ischemic stroke, particularly with reperfusion interventions, leading to poor prognosis. Serum occludin level is related with blood brain barrier disruption, and the National Institute of Health stroke scale (NIHSS) score reflects stroke severity. We investigated whether the two covariates are independently associated with HT and their combination can improve the accuracy of HT prediction in ischemic stroke patients with reperfusion therapy. Seventy-six patients were screened from the established database of acute ischemic stroke in our previous study, which contains all clinical information, including serum occludin levels, baseline NIHSS score, and hemorrhagic events. Multivariate logistic regression analysis showed that serum occludin level (OR = 4.969, 95% CI: 2.069–11.935, p &lt; 0.001) and baseline NIHSS score (OR = 1.293, 95% CI 1.079–1.550, p = 0.005) were independent risk factors of HT after adjusting for potential confounders. Compared with non-HT patients, HT patients had higher baseline NIHSS score [12 (10.5–18.0) versus 6 (4–12), p = 0.003] and serum occludin level (5.47 ± 1.25 versus 3.81 ± 1.19, p &lt; 0.001). Moreover, receiver operating characteristic curve based on leave-one-out cross-validation showed that the combination of serum occludin level and NIHSS score significantly improved the accuracy of predicting HT (0.919, 95% CI 0.857–0.982, p &lt; 0.001). These findings suggest that the combination of two methods may provide a better tool for HT prediction in acute ischemic stroke patients with reperfusion therapy.

scholarly journals Stress hyperglycemia as a prognostic factor in acute ischemic stroke patients: a prospective observational cohort study

2021 ◽  
Vol 13 (1) ◽  
Author(s):  
Hanaa A. El-Gendy ◽  
Mahmoud A. Mohamed ◽  
Amr E. Abd-Elhamid ◽  
Mohammed A. Nosseir
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Prognostic Value ◽  
Area Under The Curve ◽  
Hemorrhagic Transformation ◽  
Diabetic Patients ◽  
Stroke Patients ◽  
Stress Hyperglycemia ◽  
Discrimination Power ◽  
Observational Cohort

Abstract Background Hyperglycemia is a risk factor for infarct expansion and poor outcome for both diabetic and non-diabetic patients. We aimed to study the prognostic value of stress hyperglycemia on the outcome of acute ischemic stroke patients as regards National Institutes of Health Stroke Scale (NIHSS) as a primary outcome. Results Patients with high random blood sugar (RBS) on admission showed significantly higher values of both median NIHSS score and median duration of hospital stay. There were significant associations between stress hyperglycemia and the risk of 30-day mortality (p < 0.001), the need for mechanical ventilation (p < 0.001) and vasopressors (p < 0.001), and the occurrence of hemorrhagic transformation (p = 0.001). The 24-h RBS levels at a cut off > 145 mg/dl showed a significantly good discrimination power for 30-day mortality (area under the curve = 0.809). Conclusions Stress hyperglycemia had a prognostic value and was associated with less-favorable outcomes of acute stroke patients. Therefore, early glycemic control is recommended for those patients.

CKD is associated with recurrent ischemia but not with hemorrhagic transformation in acute ischemic stroke patients

Renal Failure ◽  
2013 ◽  
Vol 36 (2) ◽  
pp. 217-221 ◽  
Author(s):  
Hasan Micozkadioglu ◽  
Ruya Ozelsancak ◽  
Semih Giray ◽  
Zulfikar Arlier
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Hemorrhagic Transformation ◽  
Stroke Patients ◽  
Recurrent Ischemia

Abstract 3681: Early Anticoagulation Is Not Associated With Hemorrhagic Transformation Of Ischemic Stroke In Patients With Atrial Fibrillation

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
H. B Brouwers ◽  
Svetlana Lorenzano ◽  
Lyndsey H Starks ◽  
David M Greer ◽  
Steven K Feske ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Data ◽  
Infarct Volume ◽  
Hemorrhagic Transformation ◽  
P Value ◽  
Long Term Outcome ◽  
Nihss Score

Purpose: Hemorrhagic transformation (HT) is a common and potentially devastating complication of ischemic stroke, however its prevalence, predictors, and outcome remain unclear. Early anticoagulation is thought to be a risk factor for HT which raises the clinical question when to (re)start anticoagulation in ischemic stroke patients who have a compelling indication, such as atrial fibrillation. We conducted a prospective cohort study to address this question and to identify association of hemorrhagic transformation with outcome measures in patients with atrial fibrillation in the setting of acute ischemic stroke. Materials and Methods: We performed a prospective study which enrolled consecutive patients admitted with acute ischemic stroke presenting to a single center over a three-year period. As part of the observational study, baseline clinical data and stroke characteristics as well as 3 month functional outcome were collected. For this sub-study, we restricted the analysis to subjects diagnosed with atrial fibrillation. CT and MRI scans were reviewed by experienced readers, blinded to clinical data, to assess for hemorrhagic transformation (using ECASS 2 criteria), microbleeds and infarct volumes in both admission and follow-up scans. Clinical and outcome data were analyzed for association with hemorrhagic transformation. Results: Of 94 patients, 63 had a history of atrial fibrillation (67.0%) and 31 had newly discovered atrial fibrillation (33.0%). We identified HT in 3 of 94 baseline scans (3.2%) and 22 of 48 follow-up scans (45.8%) obtained a median of 3 days post-stroke. In-hospital initiation of either anti-platelet (n = 36; OR 0.34 [95% CI 0.10-1.16], p-value = 0.09) or anticoagulation with unfractionated intravenous heparin or low molecular weight heparin (n = 72; OR 0.25 [95% CI 0.06-1.15], p-value = 0.08) was not associated with HT. Initial NIH Stroke Scale (NIHSS) score (median 13.0 [IQR 15.0] vs. 7.0 [IQR 10.0], p-value = 0.029) and baseline infarct volume (median 17 [IQR 42.03] vs. 5 [IQR 10.95], p-value = 0.011) were significantly higher in patients with HT compared to those without. Hemorrhagic transformation was associated with a significantly higher 48-hour median NIHSS score (20 [IQR 3.0] vs. 2 [IQR 3.25], p-value = 0.007) and larger final infarct volume (81.40 [IQR 82.75] vs. 9.95 [IQR 19.73], p-value < 0.001). Finally, we found a trend towards poorer 3-month modified Rankin Scale scores in subjects with HT (OR 11.25 [95% CI 0.97-130.22], p-value = 0.05). Conclusion: In patients with atrial fibrillation, initial NIHSS score and baseline infarct volume are associated with hemorrhagic transformation in acute ischemic stroke. Early initiation of antithrombotic therapy was not associated with hemorrhagic transformation. Patients with hemorrhagic transformation were found to have a poorer short and long term outcome and larger final infarct volumes.

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