Advertisement

Brain hemorrhage on 24h-CT and functional outcome in stroke patients with cerebral amyloid angiopathy features on pre-thrombolysis MRI treated with intravenous thrombolysis: A case series

      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

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Chacon-Portillo M.A.
        • Llinas R.H.
        • Marsh E.B.
        Cerebral microbleeds shouldn't dictate treatment of acute stroke: a retrospective cohort study evaluating risk of intracerebral hemorrhage.
        BMC Neurol. 2018; 18 (Dec): 33
        • Turc G.
        • Sallem A.
        • Moulin S.
        • Tisserand M.
        • Machet A.
        • Edjlali M.
        • et al.
        Microbleed status and 3-month outcome after intravenous thrombolysis in 717 patients with acute ischemic stroke.
        Stroke. 2015; 46 (Sep): 2458-2463
        • Schlemm L.
        • Braemswig T.B.
        • Boutitie F.
        • Vynckier J.
        • Jensen M.
        • Galinovic I.
        • et al.
        Cerebral microbleeds and treatment effect of intravenous thrombolysis in acute stroke: an analysis of the WAKE-UP randomized clinical trial.
        Neurology. 2022; 98 (Jan 18): e302-e314
        • Gratz P.P.
        • El-Koussy M.
        • Hsieh K.
        • von Arx S.
        • Mono M.L.
        • Heldner M.R.
        • et al.
        Preexisting cerebral microbleeds on susceptibility-weighted magnetic resonance imaging and post-thrombolysis bleeding risk in 392 patients.
        Stroke. 2014; 45 (Jun): 1684-1688
        • Yan S.
        • Jin X.
        • Zhang X.
        • Zhang S.
        • Liebeskind D.S.
        • Lou M.
        Extensive cerebral microbleeds predict parenchymal haemorrhage and poor outcome after intravenous thrombolysis.
        J Neurol Neurosurg Psychiatry. 2015; 86 (Nov): 1267-1272
        • Charidimou A.
        • Kakar P.
        • Fox Z.
        • Werring DJ.
        Cerebral microbleeds and recurrent stroke risk: systematic review and meta-analysis of prospective ischemic stroke and transient ischemic attack cohorts.
        Stroke. 2013; 44 (Apr): 995-1001
        • Charidimou A.
        • Kakar P.
        • Fox Z.
        • Werring DJ.
        Cerebral microbleeds and the risk of intracerebral haemorrhage after thrombolysis for acute ischaemic stroke: systematic review and meta-analysis.
        J Neurol Neurosurg Psychiatry. 2013; 84 (Mar 1): 277-280
        • Charidimou A.
        • Turc G.
        • Oppenheim C.
        • Yan S.
        • Scheitz J.F.
        • Erdur H.
        • et al.
        Microbleeds, cerebral hemorrhage, and functional outcome after stroke thrombolysis: individual patient data meta-analysis.
        Stroke. 2017; 48 (Aug): 2084-2090
        • Braemswig T.B.
        • Villringer K.
        • Turc G.
        • Erdur H.
        • Fiebach J.B.
        • Audebert H.J.
        • et al.
        Predictors of new remote cerebral microbleeds after IV thrombolysis for ischemic stroke.
        Neurology. 2019; 92 (Feb 12): e630-e638
        • Prats-Sánchez L.
        • Camps-Renom P.
        • Sotoca-Fernández J.
        • Delgado-Mederos R.
        • Martínez-Domeño A.
        • Marín R.
        • et al.
        Remote intracerebral hemorrhage after intravenous thrombolysis: results from a multicenter study.
        Stroke. 2016; 47 (Aug): 2003-2009
        • Gattringer T.
        • Eppinger S.
        • Beitzke M.
        • Wuensch G.
        • Niederkorn K.
        • Deutschmann H.
        • et al.
        Cortical superficial siderosis and risk of bleeding after thrombolysis for ischemic stroke.
        Cerebrovasc Dis. 2015; 40: 191-197
        • Linn J.
        • Halpin A.
        • Demaerel P.
        • Ruhland J.
        • Giese A.D.
        • Dichgans M.
        • et al.
        Prevalence of superficial siderosis in patients with cerebral amyloid angiopathy.
        Neurology. 2010; 74 (Apr 27): 1346-1350
        • Adams H.P.
        • Bendixen B.H.
        • Kappelle L.J.
        • Biller J.
        • Love B.B.
        • Gordon D.L.
        • et al.
        Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of org 10172 in acute stroke treatment.
        Stroke. 1993; 24 (Jan): 35-41
        • Trouillas P.
        • von Kummer R.
        Classification and pathogenesis of cerebral hemorrhages after thrombolysis in ischemic stroke.
        Stroke. 2006; 37 (Feb): 556-561
        • Henninger N.
        • Goddeau R.P.
        • Karmarkar A.
        • Helenius J.
        • McManus DD.
        Atrial fibrillation is associated with a worse 90-day outcome than other cardioembolic stroke subtypes.
        Stroke. 2016; 47 (Jun): 1486-1492
        • Freeze W.M.
        • Bacskai B.J.
        • Frosch M.P.
        • Jacobs H.I.L.
        • Backes W.H.
        • Greenberg S.M.
        • et al.
        Blood-brain barrier leakage and microvascular lesions in cerebral amyloid angiopathy.
        Stroke. 2019; 50 (Feb): 328-335