Early disruption of the blood-brain barrier after thrombolytic therapy predicts hemorrhage in patients with acute stroke.
OBJECTIVE
Leaks of the blood-brain barrier can be detected on postcontrast-enhanced T1-weighted MRIs. Although early disruptions of the blood-brain barrier appear to be an important risk factor for tissue plasminogen activator-related hemorrhages in rodents, little is known about their incidence and consequences in human stroke.


METHODS
This is a retrospective analysis of a prospectively collected stroke database over the past 6 years. In 52 patients, multimodal MRI (including diffusion-weighted, perfusion-weighted, and postcontrast-enhanced T1-weighted MRI to detect blood-brain barrier changes) had been performed immediately before systemic thrombolysis and in 48 patients within a median of 30 minutes (interquartile range: 30 to 60 minutes) after recombinant tissue plasminogen activator treatment. The incidence of symptomatic hemorrhage (SICH), defined as any parenchymal hemorrhage leading to deterioration in the patient's clinical condition, was related to several clinical and imaging variables, including early blood-brain barrier changes.


RESULTS
Overall, SICH was detected in 9 (9%) patients and among these, 2 died. Although no blood-brain barrier changes were detectable before thrombolysis, 3 of 48 patients (6.25%) had a parenchymal gadolinium enhancement in the areas of initial infarction after tissue plasminogen activator treatment. All 3 patients developed SICHs at sites corresponding to the areas of enhancement. The presence of a parenchymal enhancement was significantly associated with SICH (P<0.01), whereas other clinical and imaging variables did not predict SICH in this series.


CONCLUSIONS
Early parenchymal enhancement after intravenous tissue plasminogen activator is significantly associated with subsequent SICH and could therefore become a useful imaging sign for the rapid initiation of preventive strategies in the future.
Kastrup
Andreas
A
Gröschel
Klaus
K
Ringer
Thomas M
TM
Redecker
Christoph
C
Cordesmeyer
Robert
R
Witte
Otto W
OW
Terborg
Christoph
C
D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D001812:Blood-Brain Barrier / Q000187:drug effects*; D002543:Cerebral Hemorrhage / Q000453:epidemiology* / Q000473:pathology* / Q000517:prevention & control; D016208:Databases, Factual; D038524:Diffusion Magnetic Resonance Imaging; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects; D005682:Gadolinium; D006801:Humans; D015994:Incidence; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000188:drug therapy / Q000453:epidemiology / Q000473:pathology; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects
D005343:Fibrinolytic Agents; D005682:Gadolinium; D010959:Tissue Plasminogen Activator