PAPER

Symptomatic intracranial haemorrhage after intra-arterial thrombolysis in acute ischaemic stroke: assessment of 294 patients treated with urokinase

C Brekenfeld¹, L Remonda¹, K Nedeltchev¹, M Arnold², H P Mattle², U Fischer², L Kappeler², G Schroth¹

¹ Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Berne, Berne, Switzerland
² Department of Neurology, Inselspital, University of Berne

Correspondence to:
C Brekenfeld
Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Berne, CH-3010 Berne, Switzerland; caspar.brekenfeld{at}insel.ch

Background: The PROACT II trial showed that intra-arterial thrombolysis (IAT) is effective for treatment of acute ischaemic stroke attributable to M1 and M2 segment occlusions. Incidence of symptomatic intracranial haemorrhage (sICH) was 10%.

Objective: : To evaluate the risk and predictors of sICH after IAT by using urokinase in a large number of patients presenting with the whole spectrum of cerebral vessel occlusions.

Methods: 294 patients with stroke treated with intra-arterial urokinase were retrospectively analysed. The risk of sICH as well as bleeding characteristics were assessed. Demographic and radiological data, time to treatment, urokinase dose, recanalisation rates, stroke aetiology and severity were analysed for predictors.

Results: sICH occurred in 14 of 294 (4.8%) patients. The median National Institute of Health Stroke Scale score of all patients was 15. All but one sICH were located in the infarcted brain tissue, and no sICH occurred in patients with peripheral vessel occlusions (M3 or M4 segments of the middle cerebral artery). Poor collaterals (p = 0.001), early signs of ischaemia on computed tomography (p = 0.003), higher urokinase dose (p = 0.019), lower recanalisation rate (p = 0.02) and higher diastolic blood pressure on admission (p = 0.04) were found to be correlated with sICH on univariate analysis. On multivariate analysis, poor collaterals (p = 0.004), urokinase dose (p = 0.021) and early signs on computed tomography (p = 0.026) remained predictors of sICH.

Conclusions: With regard to the whole spectrum of cerebral vessel occlusions, an incidence of <5% sICH after IAT is distinctly low. This result underlines the important role of IAT in the treatment of acute stroke.

Abbreviations: IAT, intra-arterial thrombolysis; IQR, interquartile range; IVT, intravenous thrombolysis; MCA, middle cerebral artery; MRI, magnetic resonance imaging; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; PTA, percutaneous transluminal angioplasty; sICH, symptomatic intracranial haemorrhage; TIMI, thrombolysis in myocardial infarction; TOAST, Trial of Org 10172 in Acute Stroke Treatment

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