title: Management of thrombolysis-associated symptomatic intracerebral hemorrhage.
abstract: BACKGROUND
  Symptomatic intracerebral hemorrhage (sICH) is the most devastating complication of thrombolytic therapy for acute stroke. It is not clear whether patients with sICH continue to bleed after diagnosis, nor has the most appropriate treatment been determined.
  
  
  METHODS
  We performed a retrospective analysis of our prospectively collected Get With the Guidelines-Stroke database between April 1, 2003, and December 31, 2007. Radiologic images and all procoagulant agents used were reviewed. Multivariable logistic regression was performed to identify factors associated with in-hospital mortality.
  
  
  RESULTS
  Of 2362 patients with acute ischemic stroke during the study period, sICH occurred in 19 of the 311 patients (6.1%) who received intravenous tissue plasminogen activator and 2 of the 72 (2.8%) who received intra-arterial thrombolysis. In-hospital mortality was significantly higher in patients with sICH than in those without (15 of 20 [75.0]% vs 56 of 332 [16.9%], P < .001). Eleven of 20 patients (55.0%) received therapy for coagulopathy: 7 received fresh frozen plasma; 5, cryoprecipitate; 4, phytonadione (vitamin K(1)); 3, platelets; and 1, aminocaproic acid. Independent predictors of in-hospital mortality included sICH (odds ratio, 32.6; 95% confidence interval, 8.8-120.2), increasing National Institutes of Health Stroke Scale score (1.2; 1.1-1.2), older age (1.3; 1.0-1.7), and intra-arterial thrombolysis (2.9; 1.4-6.0). Treatment for coagulopathy was not associated with outcome. Continued bleeding (>33% increase in intracerebral hemorrhage volume) occurred in 4 of 10 patients with follow-up scans available (40.0%).
  
  
  CONCLUSIONS
  In many patients with sICH after thrombolysis, coagulopathy goes untreated. Our finding of continued bleeding after diagnosis in 40.0% of patients suggests a powerful opportunity for intervention. A multicenter registry to analyze management of thrombolysis-associated intracerebral hemorrhage and outcomes is warranted.
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Ste 3B, Boston, MA 02114, USA. jgoldstein@partners.org
authors.forename: Joshua N
authors.initials: JN
authors.lastname: Goldstein
authors.forename: Marisela
authors.initials: M
authors.lastname: Marrero
authors.forename: Shihab
authors.initials: S
authors.lastname: Masrur
authors.forename: Muhammad
authors.initials: M
authors.lastname: Pervez
authors.forename: Alex M
authors.initials: AM
authors.lastname: Barrocas
authors.forename: Abdul
authors.initials: A
authors.lastname: Abdullah
authors.forename: Alexandra
authors.initials: A
authors.lastname: Oleinik
authors.forename: Jonathan
authors.initials: J
authors.lastname: Rosand
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
authors.forename: Walter H
authors.initials: WH
authors.lastname: Dzik
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000933:Antifibrinolytic Agents / Q000627:therapeutic use*; D002543:Cerebral Hemorrhage / Q000139:chemically induced* / Q000175:diagnosis* / Q000378:metabolism / Q000628:therapy; D005260:Female; D005340:Fibrinogen / Q000378:metabolism; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D010959:Tissue Plasminogen Activator / Q000009:adverse effects*; D016896:Treatment Outcome
chemical_list: D000933:Antifibrinolytic Agents; D005340:Fibrinogen; D010959:Tissue Plasminogen Activator