Intracerebral Haemorrhage after Thrombolysis for Acute Ischemic Stroke. An update

Abstract

Background and Purpose: Intracerebral haemorrhage (ICH) still represents the most feared complication of thrombolysis. Our aim was to review the literature regarding clinical, biological and imaging predictors of ICH following thrombolysis for acute ischaemic stroke.

Summary of Review: Relevant studies were identified through a search in Pubmed, using the following key words: "intracerebral", "haemorrhage", "stroke" and "thrombolytic". The query was limited to studies published in the English literature. The reference list of all relevant articles was reviewed to identify additional studies. The main predictors of clinically significant ICH are age, clinical stroke severity as assessed by the NIHSS score on admission, high blood pressure, hyperglycemia, early CT changes, large baseline diffusion lesion volume and leukoaraiosis on MRI. The contribution of biomarkers in the prediction of the ICH risk is currently under evaluation. Available data on patients with limited number of microbleeds on pretreatment gradient echo MRI sequences suggest safe use of thrombolysis.

Conclusions: ICH after stroke thrombolysis is a complex and heterogeneous phenomenon, which involves numerous parameters whose knowledge remains partial. In order to minimize the risk of tPA-related symptomatic ICH, careful attention must be given to the pre-therapeutic glycaemia value and a strict protocol for the control of elevated blood pressure is needed during the first 24 hours. Future research should focus on predictors of severe intracerebral haemorrhagic complications (parenchymal haematomas type 2 [PH-2] according to the ECASS classification). The input of multimodal MRI and biological predictors of ICH deserves further investigation.