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Research paper
Predictors of symptomatic intracranial haemorrhage in patients with an ischaemic stroke with neurological deterioration after intravenous thrombolysis
  1. Brandon James1,
  2. Andrew D Chang1,
  3. Ryan A McTaggart1,2,
  4. Morgan Hemendinger1,
  5. Brian Mac Grory1,
  6. Shawna M Cutting1,
  7. Tina M Burton1,
  8. Michael E Reznik1,
  9. Bradford Thompson1,3,
  10. Linda Wendell1,3,
  11. Ali Mahta1,
  12. Matthew Siket4,
  13. Tracy E Madsen4,
  14. Kevin N Sheth5,
  15. Amre Nouh6,
  16. Karen L Furie1,
  17. Mahesh V Jayaraman1,2,3,
  18. Pooja Khatri7,
  19. Shadi Yaghi1
  1. 1Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
  2. 2Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
  3. 3Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
  4. 4Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
  5. 5Department of Neurology, Yale New Haven Medical Center, New Haven, Connecticut, USA
  6. 6Department of Neurology, Hartford Hospital, Hartford, Connecticut, USA
  7. 7Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
  1. Correspondence to Dr Shadi Yaghi, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA; shadiyaghi{at}


Objectives Early neurological deterioration prompting urgent brain imaging occurs in nearly 15% of patients with ischaemic stroke receiving intravenous tissue plasminogen activator (tPA). We aim to determine risk factors associated with symptomatic intracranial haemorrhage (sICH) in patients with ischaemic stroke undergoing emergent brain imaging for early neurological deterioration after receiving tPA.

Methods We abstracted data from our prospective stroke database and included all patients receiving tPA for ischaemic stroke between 1 March 2015 and 1 March 2017. We then identified patients with neurological deterioration who underwent urgent brain imaging prior to their per-protocol surveillance imaging and divided patients into two groups: those with and without sICH. We compared baseline demographics, clinical variables, in-hospital treatments and functional outcomes at 90 days between the two groups.

Results We identified 511 patients who received tPA, of whom 108 (21.1%) had an emergent brain CT. Of these patients, 17.5% (19/108) had sICH; 21.3% (23/108) of emergent scans occurred while tPA was infusing, though only 4.3% of these scans (1/23) revealed sICH. On multivariable analyses, the only predictor of sICH was a change in level of consciousness (OR 6.62, 95% CI 1.64 to 26.70, P=0.008).

Conclusion Change in level of consciousness is associated with sICH among patients undergoing emergent brain imaging after receiving tPA. In this group of patients, preparation of tPA reversal agents while awaiting brain imaging may reduce reversal times. Future studies are needed to study the cost-effectiveness of this approach.

  • ischemic stroke
  • thrombolytic therapy
  • tPA
  • neurological deterioration
  • hemorrhage

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  • Contributors BJ: data collection, manuscript preparation. ADC: data analysis, manuscript revision. RAMT: manuscript revision. MH: manuscript revision. BMG: manuscript revision. SMC: manuscript revision. TMB: manuscript revision. MER: manuscript revision. BT: manuscript revision. LW: manuscript revision. AM: manuscript revision. MS: manuscript revision. TEM: manuscript revision. KNS: manuscript revision. AN: manuscript revision. KLF: manuscript revision, study design. MVJ: manuscript revision. PK: manuscript revision, study design. SY: data collection, drafting of manuscript, study design.

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval The study obtained ethics approval by the Rhode Island Hospital Institution Board review.

  • Provenance and peer review Not commissioned; externally peer reviewed.