Recanalization between 1 and 24 hours after t-PA therapy is a strong predictor of cerebral hemorrhage in acute ischemic stroke patients.
OBJECTIVE
Intravenous administration of tissue plasminogen activator (t-PA) can improve clinical outcomes in patients with acute ischemic stroke. The most important complication of t-PA therapy is intracerebral hemorrhage (ICH). The aim of this study was to use serial MRI studies to identify independent predictors of symptomatic and asymptomatic ICH after t-PA therapy.


METHODS
Consecutive anterior-circulation ischemic stroke patients treated with t-PA within 3 h of stroke onset were studied prospectively. To identify the presence of recanalization in the occluded arteries and the presence of ICH, MRI, including diffusion weighted imaging (DWI), T2*, and magnetic resonance angiography (MRA), was performed before and 1 h, 24 h, and 5-7 days after t-PA thrombolysis. The independent predictors of ICH were determined using multivariate logistic regression analysis.


RESULTS
41 patients (21 males, 20 females; mean age, 73.2+/-10.7 years) were enrolled, and 19 ICHs (1 symptomatic, 18 asymptomatic) were observed on T2*. The initial MRA demonstrated occluded brain arteries in 31 patients (75.6%), of which follow-up MRA at 1 h, 24 h, and 5-7 days after t-PA therapy revealed recanalization in 48.4%, 80.0%, and 90.0% of patients, respectively. The frequency of recanalization within 1 h after t-PA therapy did not differ between ICH and No-ICH groups, but the ICH group had more frequent recanalization between 1 h and 24 h after t-PA than the No-ICH group (50.0% vs. 4.5%, P=0.001). The ICH group had arterial fibrillation (AF) more frequently than the No-ICH group (78.9% vs. 27.3%, P=0.001). Compared to the No-ICH group, the NIHSS score was higher (16.4+/-5.7 vs. 11.5+/-6.5, P=0.011) and the ASPECTS-DWI value (a normal DWI has an ASPECTS-DWI value of 11 points) was lower (7.3+/-2.4 vs. 8.9+/-1.9, P=0.019) in the ICH group. Multivariate logistic regression analysis demonstrated that the presence of recanalization between 1 and 24 h after the end of t-PA infusion (OR: 20.2; CI: 1.0-340.9; P=0.037) was the only independent predictor of ICH.


CONCLUSIONS
Recanalization of occluded arteries between 1 and 24 h but not within 1 h after t-PA infusion should be independently associated with symptomatic and asymptomatic ICH after t-PA therapy.
Kimura
Kazumi
K
Department of Stroke Medicine, Kawasaki Medical School, Japan. kimurak@med.kawasaki-m.ac.jp
Iguchi
Yasuyuki
Y
Shibazaki
Kensaku
K
Kobayashi
Kazuto
K
Uemura
Junichi
J
Aoki
Junya
J
Yamashita
Shinji
S
Terasawa
Yuka
Y
Matsumoto
Noriko
N
D000368:Aged; D000369:Aged, 80 and over; D002543:Cerebral Hemorrhage / Q000139:chemically induced*; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D007275:Injections, Intravenous; D016015:Logistic Models; D018810:Magnetic Resonance Angiography / Q000379:methods; D008297:Male; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy* / Q000503:physiopathology; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects*
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator