Intracerebral hemorrhage due to thrombolytic therapy

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By Kathleen Burger DO

Treatment of acute ischemic stroke with recombinant tissue plasminogen activator (rtPA or t-PA) leads to improved outcome, as seen in several randomized clinical trials. However, a small percentage of stroke patients treated with thrombolysis experience symptomatic hemorrhagic conversion of their ischemic stroke, with some cases resulting in further disability or death. In this clinical summary, Dr. Burger, Assistant Professor in Neurology and Director of the Stroke Program at the George Washington University Hospital and Medical Faculty Associates in Washington, D.C., reviews the clinical presentation, risk factors, and management of thrombolysis-induced hemorrhagic transformation of cerebral ischemic stroke, the most dreaded complication of rtPA.

Key Points

  • Thrombolytic therapies provide an effective treatment for select patients with acute ischemic stroke; however, these therapies have a risk of intracerebral hemorrhage.
  • The myriad definitions of symptomatic intracerebral hemorrhage have caused variability in the reported risk of hemorrhage and associated risk factors.
  • The 1995 NINDS rtPA Stroke Study reported a 6.4% rate of symptomatic intracerebral hemorrhage after intravenous rtPA for stroke within 3 hours of symptom onset, and a rate of 5% to 6% has been reported in subsequent series of patients treated in clinical practice.
  • As of 2008, the American Stroke Association recommends intravenous rtPA for patients presenting within 4.5 hours of stroke symptom onset with a few additional accepted exclusion criteria resulting in improved clinical outcomes and a 2.4% risk of symptomatic hemorrhagic complications.
  • Endovascular thrombolytic therapy in ischemic stroke (ie, intra-arterial t-PA, clot retrieval devices, stentreivers) carries similar or higher rates of hemorrhagic conversion of ischemic infarcts, with no obvious benefit over intravenous rtPA.
  • Severe stroke, early CT changes, hyperglycemia, or a history of diabetes have consistently been reported to be independent risk factors for post-thrombolysis intracerebral hemorrhage.

In This Article

Historical note and nomenclature
Clinical manifestations
Clinical vignette
Pathogenesis and pathophysiology
Differential diagnosis
Diagnostic workup
Prognosis and complications
References cited