Treatment and Outcome of Thrombolysis-Related Hemorrhage: A Multicenter Retrospective Study.
OBJECTIVE
Treatments for symptomatic intracerebral hemorrhage (sICH) are based on expert opinion, with limited data available on efficacy.


OBJECTIVE
To better understand the natural history of thrombolysis-related sICH, with a focus on the efficacy of various treatments used.


METHODS
Multicenter retrospective study between January 1, 2009, and April 30, 2014, at 10 primary and comprehensive stroke centers across the United States. Participants were all patients with sICH, using the definition by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST), which included a parenchymal hematoma type 2 and at least a 4-point increase in the National Institutes of Health Stroke Scale score.


METHODS
The primary outcome was in-hospital mortality, and the secondary outcome was hematoma expansion, defined as a 33% increase in the hematoma volume on follow-up imaging.


RESULTS
Of 3894 patients treated with intravenous recombinant tissue plasminogen activator (rtPA) within 4½ hours after symptom onset of ischemic stroke, 128 (3.3%) had sICH. The median time from initiation of rtPA therapy to sICH diagnosis was 470 minutes (range, 30-2572 minutes), and the median time from diagnosis to treatment of sICH was 112 minutes (range, 12-628 minutes). The in-hospital mortality rate was 52.3% (67 of 128), and 26.8% (22 of 82) had hematoma expansion. In the multivariable models, code status change to comfort measures after sICH diagnosis was the sole factor associated with increased in-hospital mortality (odds ratio, 3.6; 95% CI, 1.2-10.6). Severe hypofibrinogenemia (fibrinogen level, <150 mg/dL) was associated with hematoma expansion, occurring in 36.3% (8 of 22) of patients without hematoma expansion vs in 25.0% (15 of 60) of patients with hematoma expansion (P = .01), highlighting a role for cryoprecipitate in reversing rtPA coagulopathy.


CONCLUSIONS
In this study, treatment of postthrombolysis sICH did not significantly reduce the likelihood of in-hospital mortality or hematoma expansion. Shortening the time to diagnosis and treatment may be a key variable in improving outcomes of patients with sICH.
Department of Neurology, Columbia University Medical Center, New York, New York2currently with the Department of Neurology, Brown University, Providence, Rhode Island.
Shadi
S
Yaghi
Department of Neurology, Columbia University Medical Center, New York, New York.
Amelia K
AK
Boehme
Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio.
Jamil
J
Dibu
Department of Neurology, Washington University in St Louis, St Louis, Missouri.
Christopher R
CR
Leon Guerrero
Department of Neurology, University of Arkansas for Medical Sciences, Fayetteville.
Syed
S
Ali
Department of Neurology, Tulane University, New Orleans, Louisiana.
Sheryl
S
Martin-Schild
Department of Neurology, The University of Alabama at Birmingham, Birmingham.
Kara A
KA
Sands
Department of Neurology, UCLA (University of California, Los Angeles), for the UCLA Acute Stroke Investigators, Los Angeles.
Ali Reza
AR
Noorian
Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia.
Christina A
CA
Blum
Department of Neurology, University of Oklahoma, Norman.
Shuchi
S
Chaudhary
Department of Neurology, Massachusetts General Hospital, Boston.
Lee H
LH
Schwamm
Department of Neurology, UCLA (University of California, Los Angeles), for the UCLA Acute Stroke Investigators, Los Angeles.
David S
DS
Liebeskind
Department of Neurology, Columbia University Medical Center, New York, New York.
Randolph S
RS
Marshall
Department of Neurology, Columbia University Medical Center, New York, New York.
Joshua Z
JZ
Willey
D000293:Adolescent; D000328:Adult; D000368:Aged; D002543:Cerebral Hemorrhage / Q000209:etiology* / Q000628:therapy*; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006406:Hematoma / Q000209:etiology*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy / Q000401:mortality; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000009:adverse effects*; D015898:Tomography Scanners, X-Ray Computed; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
D010959:Tissue Plasminogen Activator