Baseline blood pressure but not early computed tomography changes predicts major hemorrhage after streptokinase in acute ischemic stroke.
OBJECTIVE
Intracerebral hemorrhage is the most serious complication of thrombolytic therapy for stroke. We explored factors associated with this complication in the Australian Streptokinase Trial.


METHODS
The initial CT scans (< or =4 hours after stroke) of 270 patients were reviewed retrospectively by an expert panel for early signs of ischemia and classified into the following 3 categories: no signs or < or =1/3 or >1/3 of the vascular territory. Hemorrhage on late CT scans was categorized as major or minor on the basis of location and mass effect. Stepwise, backward elimination, multivariate logistic regression analysis was used to identify risk factors for each hemorrhage category.


RESULTS
Major hemorrhage occurred in 21% of streptokinase (SK) and 4% of placebo patients. Predictors of major hemorrhage were SK treatment (odds ratio [OR], 6.40; 95% CI, 2.50 to 16.36) and elevated systolic blood pressure before therapy (OR, 1.03; 95% CI, 1.01 to 1.05). Baseline systolic blood pressure >165 mm Hg in SK-treated patients resulted in a >25% risk of major secondary hemorrhage. Early ischemic CT changes, either < or =1/3 or >1/3, were not associated with major hemorrhage (OR, 1.58; 95% CI, 0.65 to 3.83; and OR, 1.11; 95% CI, 0.45 to 2.76, respectively). Minor hemorrhage occurred in 30% of the SK and 26% of the placebo group. Predictors of minor hemorrhage were male sex, severe stroke, early CT changes, and SK treatment. Ninety-one percent of patients with major hemorrhage deteriorated clinically compared with 23% with minor hemorrhage.


CONCLUSIONS
SK increased the risk of both minor and major hemorrhage. Major hemorrhage was also more likely in patients with elevated baseline systolic blood pressure. However, early CT changes did not predict major hemorrhage. Results from this study highlight the importance of baseline systolic blood pressure as a potential cause of hemorrhage in patients undergoing thrombolysis.
Gilligan
A K
AK
National Stroke Research Institute and University of Melbourne Department of Medicine, Austin and Repatriation Medical Centre, Heidelberg West, Victoria, Australia. gilligan@austin.unimelb.edu.au
Markus
R
R
Read
S
S
Srikanth
V
V
Hirano
T
T
Fitt
G
G
Arends
M
M
Chambers
B R
BR
Davis
S M
SM
Donnan
G A
GA
D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure; D002545:Brain Ischemia / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D002543:Cerebral Hemorrhage / Q000139:chemically induced* / Q000000981:diagnostic imaging; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011237:Predictive Value of Tests; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D013300:Streptokinase / Q000009:adverse effects* / Q000627:therapeutic use; D020521:Stroke / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D013300:Streptokinase