Impact of Extraischemic Hemorrhage After Thrombolysis with Intravenous Recombinant Tissue Plasminogen Activator

Background: Thrombolysis is efficacious for acute ischemic stroke; however it might increase the risk of following hemorrhage. Generally, hemorrhage may occur within the ischemic region because of ischemiareperfusion injury. However, hemorrhage of extraischemic lesion called extraischemic hemorrhage (EH) may sometimes observed. The risks and outcome of EH have been still controversial. Therefore, this study aimed to reveal the clinical characteristics of EH in recent cases. Methods: Acute ischemic stroke patients who were treated with intravenous recombinant tissue plasminogen activator administration within 4.5 hrs following onset were consecutively screened (n=112). All cases were classified into no-bleeding (NB), cerebral hemorrhage within infarct lesion (HI) and EH groups. The MRI findings, patient’s background and outcome were assessed between EH and other groups. Results: Incidence rate of NB, HI and EH were 62.5%, 31.2% and 6.3%, respectively. There was no significant difference of patients’ background between EH and other groups. While, patients of EH group showed significantly higher frequency of microbleeds in subcortical region compared with NB group (p=0.01: 71.4% and 21.4%, respectively). Leukoaraiosis in deep white matter region was significantly severer in EH compared with NB group (p=0.03). Although neurologic severity at onset was the same among three groups, the outcome was significantly worse in EH group compared with other groups (p=0.04). Conclusion: Our results confirmed that extraischemic hemorrhage after thrombolysis could cause worse outcome. Moreover, it was revealed the underlying small vessel disease, represented by microbleeds and leukoaraiosis in subcortical area, might be associated with extraischemic hemorrhage. Introduction Thrombolytic therapy with intravenous recombinant tissue plasminogen activator (IV rt-PA) administration is efficacious treatment for acute ischemic stroke within 4.5 hours of the onset, and also is recommended as best therapy in clinical guideline for stroke in Japan [1]. However, hemorrhagic complication is sometimes observed following the thrombolysis, and it might affect disease state and prognosis. Trouillas reported that cerebral hemorrhage after thrombolysis could be classified into three types, i.e., hemorrhagic infarction (HI), parenchymal hemorrhage and extraischemic hematoma (EH) [2]. Particularly, the incidence rate of EH is very low, and it’s pathogenesis and prognosis has not been fully understood. In this study, we evaluated the possible association between the incidences of EH and the pathology of cerebral small vessels by acquired imaging findings. Furthermore, we explored the premorbid clinical settings and outcome of the patients who suffered from EH after thrombolysis. Patients and Methods Following the approval of the ethical committee of the Research Institute for Brain and Blood Vessels –Akita, consecutive acute ischemic stroke patients who were admitted to our hospital and treated with IV rt-PA within 4.5 hours of onset were retrospectively screened between April 1, 2007 and March 31, 2015. We excluded patients who were not performed magnetic resonance imaging (MRI) scan because of implantation of a pacemaker, joint replacement and old intracranial clips. Moreover, we excluded patients who underwent intra-arterial thrombolysis and mechanical thrombectomy following IV rt-PA administration (Figure 1). The Japanese guideline was adopted for the indication of IV rt-PA administration [1]. Blood pressure was controlled by IV Ca channel blocker and maintained systolic blood pressure (sBP) <185 mmHg and diastolic blood pressure <110 mmHg before Research Article iMedPub Journals http://www.imedpub.com/ DOI: 10.21767/2171-6625.1000130 JOURNAL OF NEUROLOGY AND NEUROSCIENCE ISSN 2171-6625 Vol.7 No.S3:13