Abstract
Background and objectives
In stroke patients treated with intravenous thrombolysis (IVT), presence and high
number of strictly lobar cerebral microbleeds (compatible with cerebral amyloid angiopathy,
CAA) seems to be associated with increased risk of hemorrhagic transformation, symptomatic
hemorrhagic transformation, remote hemorrhage, and poor functional outcome. Some of
these CAA patients with cerebral microbleeds also have chronic lobar intracerebral
hemorrhage. Few data are available on IVT-treated CAA patients showing cortical superficial
siderosis. There are no reports studying factors associated with brain hemorrhagic
complication or functional outcome in IVT-treated CAA patients. We present a case
series study of IVT-treated stroke patients with CAA features on pre-IVT MRI in whom
we have evaluated brain hemorrhagic complications on 24 h-CT and functional outcome
after IVT.
Material and methods
In our stroke center, IVT decision in patients with CAA MRI features is at the physician's
discretion. We retrospectively screened our stroke database between January 2015 and
July 2022 for pre-IVT imaging of 959 consecutive IVT-treated stroke patients without
ongoing anticoagulation therapy for probable CAA MRI features defined by modified
Boston criteria. After exclusion of 119 patients with missing MRI (n = 47), MRI showing motion artefacts (n = 49) or with alternative chronic brain hemorrhage cause on MRI (n = 23), 15 IVT-treated patients with probable CAA on pre-IVT MRI were identified.
In these 15 patients, clinical, biological and MRI characteristics were compared between
patients with vs. without post-IVT hemorrhage and between patients with poor (MRS
3–6) vs. good (MRS 0-2) functional outcome at discharge.
Results
Two patients showed brain hemorrhage on 24 h-CT and both died after 40 and 31 days
respectively. The remaining patients had no brain hemorrhage and showed very good
outcome except one. Atrial fibrillation (p = 0.029) and Fazekas scale (p = 0.029) were associated with brain hemorrhage whereas atrial fibrillation (p = 0.0022), NIHSS (p = 0.027), blood glucose level (p = 0.024), CRP (p = 0.022) and DWI ASPECT (p = 0.016) were associated with poor outcome.
Discussion
Consequences of IVT in CAA patients can be dramatic. Larger studies are needed to
compare IVT risks and outcome between CAA and non-CAA patients, also including CAA
patients with chronic intracerebral hemorrhage or cortical superficial siderosis.
In addition, future studies should try to identify clinical, biological and radiological
features at high risk for brain hemorrhage and poor outcome in order to assess the
risk-benefit ratio for IVT in CAA.
Clinical trial registration-URL
:http://www.clinicaltrials.gov. Unique identifier: NCT05565144
Key Words
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Article info
Publication history
Published online: November 25, 2022
Accepted:
November 20,
2022
Received in revised form:
November 15,
2022
Received:
October 6,
2022
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106907
Copyright
© 2022 Elsevier Inc. All rights reserved.
