Hemorrhagic transformation of ischemic brain tissue: asymptomatic or symptomatic?
OBJECTIVE
The term symptomatic hemorrhage secondary to ischemic stroke implies a clear causal relationship between clinical deterioration and hemorrhagic transformation (HT) regardless of the type of HT. The aim of this study was to assess which type of HT independently affects clinical outcome.


METHODS
We used the data set of the European Cooperative Acute Stroke Study (ECASS) II for a post hoc analysis. All patients had a control CT scan after 24 to 96 hours or earlier in case of rapid and severe clinical deterioration. HT was categorized according to radiological criteria: hemorrhagic infarction type 1 and type 2 and parenchymal hematoma type 1 and type 2. The clinical course was prospectively documented with the National Institutes of Health Stroke Scale and the modified Rankin Scale: The independent risk of each type of HT was calculated for clinical deterioration at 24 hours and disability and death at 3 months after stroke onset and adjusted for possible confounding factors such as age, severity of stroke syndrome at baseline, and extent of the ischemic lesion on the initial CT.


RESULTS
Compared with absence of HT, only parenchymal hematoma type 2 was associated with an increased risk for deterioration at 24 hours after stroke onset (adjusted odds ratio, 18; 95% CI, 6 to 56) and for death at 3 months (adjusted odds ratio, 11; 95% CI, 3.7 to 36). All other types of HT did not independently increase the risk of late deterioration.


CONCLUSIONS
Only parenchymal hematoma type 2 independently causes clinical deterioration and impairs prognosis. It has a distinct radiological feature: it is a dense homogeneous hematoma >30% of the ischemic lesion volume with significant space-occupying effect.
Berger
C
C
Department of Neurology, University of Heidelberg, Germany. christian_berger@med.uni-heidelberg.de
Fiorelli
M
M
Steiner
T
T
Schäbitz
W R
WR
Bozzao
L
L
Bluhmki
E
E
Hacke
W
W
von Kummer
R
R
D000367:Age Factors; D002545:Brain Ischemia / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D002543:Cerebral Hemorrhage / Q000145:classification / Q000175:diagnosis* / Q000209:etiology; D003937:Diagnosis, Differential; D018450:Disease Progression; D004311:Double-Blind Method; D005060:Europe; D006406:Hematoma / Q000145:classification / Q000209:etiology / Q000473:pathology; D006801:Humans; D016017:Odds Ratio; D011237:Predictive Value of Tests; D011379:Prognosis; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018570:Risk Assessment / Q000706:statistics & numerical data; D012720:Severity of Illness Index; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014057:Tomography, X-Ray Computed
D010959:Tissue Plasminogen Activator