Extraparenchymal bleeding predicts an unfavorable outcome in patients with hemorrhagic transformation.

Extraparenchymal Bleeding Predicts an Unfavorable Outcome in Patients With Hemorrhagic Transformation To the Editor: We read with interest the recent article by Fiorelli et al.1 The authors confirmed the reliability of hemorrhagic transformation (HT) as a diagnosis which, as we have found, could be made by either a neuroradiologist or a trained neurologist.2 However, of greater clinical relevance was the fact that they found that only severe HT (parenchymal hematoma 2 [PH2] in ECASS I1) was associated with an unfavorable outcome. As shown in the Table, the same result emerged from the Multicentre Acute Stroke Trial–Italy (MAST-I) analysis.3 We have found that severe HT is very often associated with intraventricular or subarachnoid bleeding. This finding, together with but independent of cerebral edema, made the prognosis unfavorable in our study. The severe HT (PH2) definition of ECASS I points to a “significant space occupying effect” and includes the presence of a “clot remote from the infarct area.”