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Samarasekera N, Rodrigues MA, Toh PS, Salman RAS. Imaging features of intracerebral hemorrhage with cerebral amyloid angiopathy: Systematic review and meta-analysis. PLoS One 2017; 12:e0180923. [PMID: 28700676 PMCID: PMC5507310 DOI: 10.1371/journal.pone.0180923] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 06/23/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We sought to summarize Computed Tomography (CT)/Magnetic Resonance Imaging (MRI) features of intracerebral hemorrhage (ICH) associated with cerebral amyloid angiopathy (CAA) in published observational radio-pathological studies. METHODS In November 2016, two authors searched OVID Medline (1946-), Embase (1974-) and relevant bibliographies for studies of imaging features of lobar or cerebellar ICH with pathologically proven CAA ("CAA-associated ICH"). Two authors assessed studies' diagnostic test accuracy methodology and independently extracted data. RESULTS We identified 22 studies (21 cases series and one cross-sectional study with controls) of CT features in 297 adults, two cross-sectional studies of MRI features in 81 adults and one study which reported both CT and MRI features in 22 adults. Methods of CAA assessment varied, and rating of imaging features was not masked to pathology. The most frequently reported CT features of CAA-associated ICH in 21 case series were: subarachnoid extension (pooled proportion 82%, 95% CI 69-93%, I2 = 51%, 12 studies) and an irregular ICH border (64%, 95% CI 32-91%, I2 = 85%, five studies). CAA-associated ICH was more likely to be multiple on CT than non-CAA ICH in one cross-sectional study (CAA-associated ICH 7/41 vs. non-CAA ICH 0/42; χ2 = 7.8, p = 0.005). Superficial siderosis on MRI was present in 52% of CAA-associated ICH (95% CI 39-65%, I2 = 35%, 3 studies). CONCLUSIONS Subarachnoid extension and an irregular ICH border are common imaging features of CAA-associated ICH, but methodologically rigorous diagnostic test accuracy studies are required to determine the sensitivity and specificity of these features.
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Affiliation(s)
- Neshika Samarasekera
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Pheng Shiew Toh
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
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Block F, Dafotakis M. Cerebral Amyloid Angiopathy in Stroke Medicine. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:37-42. [PMID: 28179050 DOI: 10.3238/arztebl.2017.0037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 02/09/2016] [Accepted: 09/02/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Cerebral amyloid angiopathy (CAA) is a degenerative vasculopathy that is classically associated with lobar intracerebral or sulcal hemorrhage. Its prevalence is estimated at 30% in the seventh decade and 50% in the eighth and ninth decades. In this review, we summarize the risks linked to CAA with respect to the treatment and prevention of stroke. METHODS This review is based on pertinent publications retrieved by a selective search employing the terms "amyloid cerebral angiopathy," "stroke," "intra - cerebral bleeding," and "acute stroke therapy." RESULTS Among patients given systemic lytic treatment for stroke, those who have microhemorrhages tend to have a higher risk of treatment-associated brain hemorrhage. In a meta-analysis, 70% of patients who sustained a hemorrhage after thrombolytic therapy were found to have CAA, compared to only 22% in a control population. Patients with cerebral hemorrhages have microhemorrhages more commonly than patients with transient ischemic attacks (TIA) or infarcts. This was observed among persons under treatment with vitamin K antagonists (odds ratio, 2.7) or platelet aggregation inhibitors (odds ratio, 1.7). Moreover, the apolipoprotein E2 allele is associated with a higher incidence of intracerebral hemorrhage (ICH) under oral anticoagulation. Strict treatment of arterial hypertension can lower the risk of ICH in persons with probable CAA by 77%. On the other hand, the use of statins after a lobar ICH increases the risk for a clinically manifest recurrent hemorrhage from 14% to 22%. CONCLUSION In patients with CAA, arterial hypertension should be tightly controlled. On the other hand, caution should be exercised in prescribing oral anticoagulants or platelet aggregation inhibitors for patients with CAA, or statins for patients who have already sustained a lobar ICH.
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Mattila OS, Sairanen T, Laakso E, Paetau A, Tanskanen M, Lindsberg PJ. Cerebral amyloid angiopathy related hemorrhage after stroke thrombolysis: case report and literature review. Neuropathology 2014; 35:70-4. [PMID: 25377279 DOI: 10.1111/neup.12152] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 08/01/2014] [Indexed: 11/29/2022]
Abstract
Cerebral amyloid angiopathy (CAA) predisposes to symptomatic intracerebral hemorrhage (sICH) after combined thrombolytic and anticoagulant treatment of acute myocardial infarction. However, the role of CAA in stroke thrombolysis has not been established. Here, we describe a confirmed case of CAA-related hemorrhage in a patient receiving thrombolysis for acute ischemic stroke. On autopsy, immunohistochemistry revealed amyloid-β positive staining in thickened cortical and meningeal arteries at sites of hemorrhage. Further research is urgently needed to determine the hemorrhage risk related to CAA in stroke thrombolysis and develop better diagnostic tools to identify CAA in the emergency room.
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Affiliation(s)
- Olli S Mattila
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland; Research Program of Molecular Neurology, Research Programs Unit, University of Helsinki, Helsinki, Finland; Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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Block HS, Biller J. Commonly asked questions: thrombolytic therapy in the management of acute stroke. Expert Rev Neurother 2014; 13:157-65. [DOI: 10.1586/ern.12.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Fiehler J, Siemonsen S, Thomalla G, Illies T, Kucinski T. Combination of T2*W and FLAIR Abnormalities for the Prediction of Parenchymal Hematoma Following Thrombolytic Therapy in 100 Stroke Patients. J Neuroimaging 2009; 19:311-6. [DOI: 10.1111/j.1552-6569.2008.00240.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Black dots in the brain parenchyma diagnosed in T2(*)-weighted magnetic resonance imaging should be interpreted in light of the patient's history as well as the location, number and distribution of the lesions and associated imaging findings. These dots will correspond to haemoglobin degradation products in most of the cases referred to as cerebral microbleeds in patients with small vessel disease. Cerebral microbleeds have a prevalence of 5.7% (range 3.7-7.7%) and are observed more frequently with increasing age. cerebral microbleeds have been observed in 47-80% of the primary intracerebral haemorrhage patients and in 0-78% of the patients with ischaemic cerebrovascular disease and appear to be a general marker of various types of bleeding-prone, small vessel disease and a predictor of recurrent vascular events. The occurrence and the number of cerebral microbleeds are associated with the degree of cerebral white matter abnormalities. Current data does not support the hypothesis that cerebral microbleeds are associated with a higher risk for a clinically relevant intracerebral haemorrhage, after anticoagulation/antiaggregation therapy, or after thrombolytic therapy in stroke patients. Therefore, the current data do not support the general exclusion of patients from therapy based on the presence of cerebral microbleeds. In the future, cerebral microbleeds may be incorporated into the design of clinical trials of anticoagulation/antiaggregation drugs in stroke patients for potential individual stratification for both the risk of recurrent ischaemic stroke and for the risk of intracerebral haemorrhage.
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Affiliation(s)
- Jens Fiehler
- Department of Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
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Trouillas P, von Kummer R. Classification and pathogenesis of cerebral hemorrhages after thrombolysis in ischemic stroke. Stroke 2006; 37:556-61. [PMID: 16397182 DOI: 10.1161/01.str.0000196942.84707.71] [Citation(s) in RCA: 188] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Brain hemorrhage after ischemic stroke is a serious complication of treatment; however, its pathology is poorly understood. A classification based on brain imaging may help to better understand and avoid causal factors. METHODS Review of the results of controlled randomized trials and the available literature. RESULTS Hemorrhagic infarctions have no impact on clinical outcome and are probably not associated with the thrombolytic itself and the type of reperfusion strategy. They are associated with the extent of ischemic damage and most probably to an ischemic vasculopathy. Parenchymal hematomas are often clinically relevant. Their incidence is affected by the thrombolytic itself, the type, and probably the time point of reperfusion strategy. The loss of hemostatic control seems important in their pathogenesis. Extraischemic hematomas (remote from the infarct), unique or multiple, suggest pre-existing brain pathology, especially cerebral amyloid angiopathy. CONCLUSIONS The radiological description of 3 different types of brain hemorrhage is useful to better understand the specific pathology and the impact on clinical outcome. It may help to avoid clinically relevant brain hemorrhages.
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Affiliation(s)
- Paul Trouillas
- Cerebrovascular Unit, Hôpital Neurologique, Lyon, France.
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Zhan RY, Tong Y, Shen JF, Lang E, Preul C, Hempelmann RG, Hugo HH, Buhl R, Barth H, Klinge H, Mehdorn HM. Study of clinical features of amyloid angiopathy hemorrhage and hypertensive intracerebral hemorrhage. JOURNAL OF ZHEJIANG UNIVERSITY. SCIENCE 2004; 5:1262-1269. [PMID: 15362199 PMCID: PMC1388732 DOI: 10.1631/jzus.2004.1262] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2004] [Accepted: 03/24/2004] [Indexed: 05/24/2023]
Abstract
OBJECTIVE The purpose of this study was to differentiate between cerebral amyloid angiopathy (CAA) and hypertension (HTN) based on hemorrhage pattern interpretation. METHODS From June 1994 to Oct., 2000, 83 patients admitted to our service with acute intracerebral hemorrhage (ICH) were investigated retrospectively; 41 patients with histologically proven diagnosis of cerebral amyloid angiography and 42 patients with clear history of hypertension were investigated. RESULTS Patients with a CAA-related ICH were significantly older than patients with a HTN-related ICH (74.0 years vs 66.5 years, P < 0.05). There was a significantly higher number of hematomas > or = 30 ml in CAA (85.3%) when compared with HTN (59.5%). No basal ganglional hemorrhage was seen in CAA, but in 40.5% in HTN. In CAA-related ICH, subarachnoid hemorrhage (SAH) was seen in 26 patients (63.4%) compared to only 11 patients (26.2%) in HTN-related ICH. Intraventricular hemorrhage was seen in 24.4% in CAA, and in 26.2% in HTN. Typical features of CAA-related ICH included lobar distribution affecting mainly the lobar superficial areas, lobulated appearance, rupture into the subarachnoid space, and secondary IVH from the lobar hemorrhage. More specifically, multiplicity of hemorrhage, bilaterality, and repeated episodes also strongly suggest the diagnosis of CAA. Multiple hemorrhages, defined as 2 or more separate hematomas in multiple lobes, accounted for 17.1% in CAA-related ICH. CONCLUSION There are certain features in CAA on CT and MRI and in clinical settings. To some extent, these features may contribute to distinguishing CAA from HTN related ICH.
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Affiliation(s)
- Ren-ya Zhan
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China.
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McCarron MO, Nicoll JAR. Cerebral amyloid angiopathy and thrombolysis-related intracerebral haemorrhage. Lancet Neurol 2004; 3:484-92. [PMID: 15261609 DOI: 10.1016/s1474-4422(04)00825-7] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Intracerebral haemorrhage is a complication of thrombolytic therapy for acute myocardial infarction, pulmonary embolism, and ischaemic stroke. There is increasing evidence that cerebral amyloid angiopathy (CAA), which itself can cause haemorrhage (CAAH), may be a risk factor for thrombolysis-related intracerebral haemorrhage. CAAH and thrombolysis-related intracerebral haemorrhage share some clinical features, such as predisposition to lobar or superficial regions of the brain, multiple haemorrhages, increasing frequency with age, and an association with dementia. In vitro work showed that accumulation of amyloid-beta peptide causes degeneration of cells in the walls of blood vessels, affects vasoactivity, and improves proteolytic mechanisms, such as fibrinolysis, anticoagulation, and degradation of the extracellular matrix. In a mouse model of CAA there is a low haemorrhagic threshold after thrombolytic therapy compared with that in wild-type mice. To date only a small number of anecdotal clinicopathological relations have been reported; neuroimaging advances and further study of the frequency and role of CAA in patients with thrombolysis-related intracerebral haemorrhage are required.
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Affiliation(s)
- Mark O McCarron
- Department of Neurology, Altnagelvin Hospital, Londonderry, BT47 6SB, UK.
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Wong KS, Mok V, Lam WW, Kay R, Tang A, Chan YL, Woo J. Aspirin-associated intracerebral hemorrhage: clinical and radiologic features. Neurology 2000; 54:2298-301. [PMID: 10881256 DOI: 10.1212/wnl.54.12.2298] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To identify the clinical and radiologic features of intracerebral hemorrhage (ICH) in aspirin users. BACKGROUND Although the benefits of aspirin outweigh its hemorrhagic risks for patients at high risk of vascular diseases, prolonged use of aspirin is associated with an increased risk of ICH. METHODS The authors enrolled consecutive patients with acute stroke who were admitted to a regional hospital from 1993 to 1998 into a stroke registry. From this registry, they identified all stroke patients who had ICH confirmed by CT scan and then selected those taking regular aspirin before ICH as the study group. For each study patient, they selected the immediate next two patients with ICH but not taking aspirin as controls. RESULTS The authors identified 58 aspirin users and 1193 nonusers among all patients hospitalized for ICH. From the group of nonusers, they selected 116 patients as controls. The locations of the hematoma were different (p = 0.002), with more lobar hematoma in the aspirin group (32.8%) than in the control group (10.3%). Prior cerebrovascular disease was the reason for taking aspirin in 37 (64%) patients but five patients had prior ICH. CONCLUSIONS The propensity for lobar hematoma in aspirin-associated ICH suggests its pathology may be somewhat different from spontaneous ICH among nonaspirin users. Further research to examine the risks and benefits of aspirin use in certain subgroups at risk of both thrombotic and hemorrhagic events is needed.
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Affiliation(s)
- K S Wong
- Departments of Medicine & Therapeutics, the Chinese University of Hong Kong, Shatin
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Miller JH, Wardlaw JM, Lammie GA. Intracerebral haemorrhage and cerebral amyloid angiopathy: CT features with pathological correlation. Clin Radiol 1999; 54:422-9. [PMID: 10437691 DOI: 10.1016/s0009-9260(99)90825-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
AIMS To review the computed tomography (CT) features of intracerebral haemorrhage pathologically proven to be associated with cerebral amyloid angiopathy in order to facilitate recognition of the presence of cerebral amyloid angiopathy in life. METHODS We prospectively collected the clinical and brain imaging records of patients dying following an intracerebral haemorrhage who underwent a post-mortem examination and were found to have cerebral amyloid angiopathy. We reviewed the brain imaging to highlight features of the haemorrhage and of the rest of the brain common to these cases. RESULTS Seven patients aged 60-86 years were examined over a 30-month period. On CT, the notable features were that the haemorrhages appeared large, lobar, often extended through the cortex to the subarachnoid space or into the ventricles, and were multiple and recurrent in patients who survived the initial bleed. The high density (blood) within the haematoma tended to sediment posteriorly. CONCLUSIONS There are features on CT of cerebral amyloid angiopathy associated with spontaneous intracerebral haemorrhage which should raise the possibility of this underlying diagnosis. We suspect this condition is under-recognized in life, and should perhaps be considered more widely.
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Affiliation(s)
- J H Miller
- Department of Radiology, University of Edinburgh, Western General Hospital, Scotland, UK
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Gebel JM, Sila CA, Sloan MA, Granger CB, Mahaffey KW, Weisenberger J, Green CL, White HD, Gore JM, Weaver WD, Califf RM, Topol EJ. Thrombolysis-related intracranial hemorrhage: a radiographic analysis of 244 cases from the GUSTO-1 trial with clinical correlation. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. Stroke 1998; 29:563-9. [PMID: 9506593 DOI: 10.1161/01.str.29.3.563] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Intracranial hemorrhage (ICH) is a serious complication of thrombolytic therapy. We systematically reviewed the radiographic features of 244 cases of symptomatic ICH complicating thrombolysis for acute myocardial infarction in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial, correlated these observations with clinical data, and speculated on hemorrhage pathogenesis. METHODS CT scans from 244 patients suffering symptomatic ICH were systematically reviewed for selected radiographic features, including ICH type, location, hematoma characteristics, mass effect features, hydrocephalus, and preexisting lesions. Hematoma volume was estimated by computer-assisted volumetric analysis. Data from this analysis were correlated with clinical data including hypertension, anticoagulation, age, thrombolytic regimen, and ICH timing. RESULTS Most hemorrhages were large (median [25th, 75th percentile] volume, 72 mL [39, 118]), solitary (66%), lobar (77%), confluent (80%), and intraparenchymal (82%) with a blood/fluid level (82%) and little edema (median [25th, 75th percentile] volume, 9 mL [5, 16]). Hydrocephalus (P<.001), any one mass effect feature (P<.001), intraventricular hemorrhage (P=.022), mottled hematoma appearance (P=.050), and hematoma blood/fluid level (P<.001) were associated with higher hemorrhage volume in the radiographic analysis, as were older age (P=.005), treatment with combined streptokinase and tissue plasminogen activator (P=.034), and hemorrhage onset 8 to 13 hours after treatment (P=.008) in the clinical analysis. Subdural hemorrhage was a high-volume subgroup whose risk increased with antecedent trauma (P=.026) or syncope (P=.006). Deep intraparenchymal hemorrhage was associated with hypertension (P=.016), and multifocal ICH occurred significantly earlier after treatment (P=.002). CONCLUSIONS Although the majority of postthrombolytic ICH are large, solitary, and supratentorial, the spectrum is diverse. Features of mass effect reflected the large volumes, and hematoma characteristics of mottling and blood/fluid levels were frequent. Thrombolysis-related coagulopathy and age appear to be the most important identifiable factors in the genesis of postthrombolytic ICH, but the hemorrhage subtype seen may reflect an interaction with other factors such as hypertension, ICH timing, antecedent head trauma, and syncope.
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Affiliation(s)
- J M Gebel
- Cleveland Clinic Foundation, Ohio 44195, USA
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Leblanc R, Carpenter S, Stewart J, Pokrupa R. Subacute enlarging cerebral hematoma from amyloid angiopathy: case report. Neurosurgery 1995; 36:403-6. [PMID: 7731523 DOI: 10.1227/00006123-199502000-00024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
We report the case of a 74-year-old woman who, during a 36-hour period, developed progressive, focal neurological deficits and eventual coma associated with a spontaneously enlarging intraparenchymal hematoma resulting from cerebral amyloid angiopathy. The subacute, progressive enlargement of the hematoma, confirmed by serial computed tomographic scans, supports the hypothesis that hematomas enlarge in amyloid angiopathy as a result of the replacement of the contractile elements of the arterial wall by noncontractile amyloid protein. This interference with vasoconstriction, the first phase of hemostasis, may be supplemented by local endothelial dysfunction causing alterations in the chemical mediators of hemostasis, thereby promoting hemorrhage and hematoma enlargement.
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Affiliation(s)
- R Leblanc
- Montreal Neurological Hospital and Institute, McGill University, Quebec, Canada
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Levy DE, Brott TG, Haley EC, Marler JR, Sheppard GL, Barsan W, Broderick JP. Factors related to intracranial hematoma formation in patients receiving tissue-type plasminogen activator for acute ischemic stroke. Stroke 1994; 25:291-7. [PMID: 8303734 DOI: 10.1161/01.str.25.2.291] [Citation(s) in RCA: 131] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Several studies are currently evaluating tissue-type plasminogen activator (TPA) as a potential therapy in acute ischemic stroke. The possibility of inducing intracranial hematomas, however, introduces an important concern into ultimate evaluation of risk and benefit. This retrospective analysis sought to identify factors associated with intracranial hematoma formation in a pilot phase 1 study of TPA for stroke. METHODS Ninety-four patients received TPA within 3 hours of the onset of an acute ischemic stroke. Five of these patients developed a symptomatic intracerebral hematoma: 3 of 74 (4%) among patients treated within 90 minutes of stroke onset and 2 of 20 (10%) among those treated at 91 to 180 minutes. Three of the 5 died within 2 weeks. The analysis investigated associations between clinical factors and intracerebral hematomas. RESULTS Factors significantly related to the development of an intracerebral hematoma were TPA dose and diastolic hypertension. Intracerebral hematomas developed in 4 (18%) of 22 patients given a TPA dose of at least 0.90 mg/kg versus only 1 hematoma in the remaining 72 patients (1%; P < .02, Fisher's exact test). Four (18%) of 22 patients who had initial diastolic blood pressures of at least 100 mm Hg suffered an intracerebral hematoma versus only 1 (1%) of 72 patients (P < .02) with lower initial diastolic pressures. CONCLUSIONS Since the study was not designed to test specific safety hypotheses, results must not be overinterpreted. Nonetheless, these data emphasize the need for caution in both patient and dose selection for further studies of thrombolytic agents in stroke.
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Affiliation(s)
- D E Levy
- Department of Neurology, Cornell University Medical College, New York, NY
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Intracerebral Hematoma Related to Thrombolysis for Myocardial Infarction. Neurosurgery 1993. [DOI: 10.1097/00006123-199311000-00019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kaufman HH, McAllister P, Taylor H, Schmidt S. Intracerebral hematoma related to thrombolysis for myocardial infarction. Neurosurgery 1993; 33:898-900; discussion 900-1. [PMID: 8264890 DOI: 10.1227/00006123-199311000-00019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The incidence of intracerebral hematomas after myocardial infarction increases after thrombolysis. As noted in the case described, clots formed after the administration of thrombolytic agents may remain liquid, and this blood can be drained by a catheter. However, in this case, the patient continued to bleed locally. This problem requires the development of methods to stop such ongoing local bleeding. It may be prevented in the future by improved thrombolytic drugs.
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Affiliation(s)
- H H Kaufman
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown
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Wijdicks EF, Jack CR. Intracerebral hemorrhage after fibrinolytic therapy for acute myocardial infarction. Stroke 1993; 24:554-7. [PMID: 8465362 DOI: 10.1161/01.str.24.4.554] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE Intracerebral hematoma may complicate treatment of acute myocardial infarction in patients treated with fibrinolytic agents. We studied the clinical presentation and computed tomographic characteristics. METHODS We studied eight patients with lobar intracerebral hematomas after fibrinolytic treatment of acute coronary occlusion. All patients had electrocardiographic and laboratory evidence of acute myocardial infarction and were treated with tissue plasminogen activator or streptokinase followed by heparin infusion to prevent reocclusion. Computed tomography scans of 17 patients with cerebral hemorrhage from other causes were used for comparison. RESULTS For most patients, outcome was fatal within hours of the ictus. Computed tomography scans showed superficially large lobar hematomas in six patients. One patient had a putaminal hemorrhage, and one had a vermis hemorrhage. Multiple sites of intracerebral hemorrhage were noted in three patients. Fluid levels inside the hematoma suggesting continuing hemorrhage into multiple compartments were common. Radiologically, fluid levels in hematomas, multiple hematomas, and blood in multiple compartments served to differentiate fibrinolysis-induced hemorrhage from hemorrhage of other causes. Severe amyloid angiopathy was found in one patient who was operated on. CONCLUSIONS Hemorrhages in multiple compartments and the presence of fluid levels inside the hematoma suggest fibrinolysis-associated cerebral hematomas. Severe amyloid angiopathy may be a crucial factor in this clinical entity. Outcome is poor, and a high proportion of patients have rapid progression to brain death. Therefore, emergency neurosurgical evacuation will probably be unsuccessful.
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Affiliation(s)
- E F Wijdicks
- Department of Neurology, Mayo Clinic, Rochester, MN 55905
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Leblanc R, Haddad G, Robitaille Y. Cerebral hemorrhage from amyloid angiopathy and coronary thrombolysis. Neurosurgery 1992; 31:586-90. [PMID: 1407440 DOI: 10.1227/00006123-199209000-00025] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Coronary thrombolysis with streptokinase or tissue plasminogen activator is useful for the treatment of acute myocardial infarction in selected patients. This treatment is associated with local hemorrhagic complications and age-related cerebral hemorrhage. Coronary thrombolysis is contraindicated in patients with transient cerebral ischemia and stroke, arterial hypertension, cerebral trauma, cerebral aneurysms, and arteriovenous malformations, because of the risk of cerebral hemorrhage. We report the occurrence of a cerebral hemorrhage related to cerebral amyloid angiopathy in a patient who underwent thrombolysis and treatment with heparin for acute myocardial infarction. Despite normal coagulation parameters, the cerebral hematoma enlarged over 36 hours, as documented by sequential computed tomographic scans, to produce significant mass effect, which prompted surgical evacuation. Histological examination of the resected specimen demonstrated the strong affinity for Congo red and yellow-green birefringence that are characteristic of cerebral amyloid angiopathy. Hemostasis was difficult to achieve, as the divided or disrupted amyloid-laden cortical vessels failed to vasoconstrict, their contractile elements replaced by amyloid beta protein. The patient died of recurrent myocardial ischemia 3 days postoperatively. The incidence of cerebral amyloid angiopathy increases with advancing age. It must be considered as a potential source of cerebral hemorrhage in elderly patients undergoing thrombolysis for cardiac ischemia. Such an occurrence presents a difficult challenge because cardiac function is compromised, the coagulation profile may be altered, the cerebral hematoma is life threatening, and intracranial hemostasis is difficult to achieve.
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Affiliation(s)
- R Leblanc
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Canada
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Abstract
The knowledge obtained from the ongoing investigational trials of tPA for acute ischemic stroke will not only help establish the appropriate dose range and complication rates but will also further develop the clearly mandatory rapid, aggressive team approach needed to truly treat acute ischemic strokes successfully. Experimental cerebral ischemia data have pointed to the need to treat acute clinical stroke within only a few hours or less to effectively reduce stroke morbidity and mortality. Specifically, with reversible MCA occlusion models of focal cerebral ischemia (dogs and cats), the animals uniformly survive without neurological deficit if the occlusion is for less than 2 to 3 hours. Similarly in primates, MCA occlusion for 3 hours or less will lead to clinical improvement and a decrease in infarct size, with complete recovery generally associated with less than 2 hours of MCA occlusion. Therefore, it appears unlikely that ischemic brain can be salvaged if vascular occlusion persists longer than 4 to 6 hours (similar to the pathophysiology of myocardial ischemia). Further, at least one third of ischemic stroke patients reperfuse spontaneously (and obviously too late) within 48 hours of stroke onset. Several factors believed to be related to successful outcome after thrombolytic therapy are summarized in Table 16. A schematic approach to determining the response to thrombolytic agents in acute ischemic stroke is outlined in Table 17. Zivin succinctly reviews thrombolysis for stroke, both experimental and clinical, and summarizes some of the difficulties of the early clinical stroke trials with thrombolytic agents and speculates about future prospects. He believes tPA may prove valuable in the treatment of some forms of thromboembolic stroke. Its usefulness may depend in part on how quickly the drug can be initiated and the risk of side effects; factors that will require further study. The currently used doses of tPA may be too low to lyse large cerebral arterial clots and, therefore, if current trials do not show a positive treatment response, further trials with higher doses may be indicated. The implications of a potentially effective treatment for truly acute stroke are enormous: stroke will need to be considered by all (lay public through to caregivers) as a true medical emergency, analogous to MI and trauma.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- S R Levine
- Department of Neurology, Henry Ford Hospital, Detroit, MI 48202
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Ball MJ. Iatrogenic amyloidotic apoplexy. Ann Neurol 1991; 30:229. [PMID: 1910276 DOI: 10.1002/ana.410300229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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