title: Predicting Hemorrhagic Transformation of Acute Ischemic Stroke: Prospective Validation of the HeRS Score.
abstract: Hemorrhagic transformation (HT) increases the morbidity and mortality of ischemic stroke. Anticoagulation is often indicated in patients with atrial fibrillation, low ejection fraction, or mechanical valves who are hospitalized with acute stroke, but increases the risk of HT. Risk quantification would be useful. Prior studies have investigated risk of systemic hemorrhage in anticoagulated patients, but none looked specifically at HT. In our previously published work, age, infarct volume, and estimated glomerular filtration rate (eGFR) significantly predicted HT. We created the hemorrhage risk stratification (HeRS) score based on regression coefficients in multivariable modeling and now determine its validity in a prospectively followed inpatient cohort.A total of 241 consecutive patients presenting to 2 academic stroke centers with acute ischemic stroke and an indication for anticoagulation over a 2.75-year period were included. Neuroimaging was evaluated for infarct volume and HT. Hemorrhages were classified as symptomatic versus asymptomatic, and by severity. HeRS scores were calculated for each patient and compared to actual hemorrhage status using receiver operating curve analysis.Area under the curve (AUC) comparing predicted odds of hemorrhage (HeRS score) to actual hemorrhage status was 0.701. Serum glucose (P < 0.001), white blood cell count (P < 0.001), and warfarin use prior to admission (P = 0.002) were also associated with HT in the validation cohort. With these variables, AUC improved to 0.854. Anticoagulation did not significantly increase HT; but with higher intensity anticoagulation, hemorrhages were more likely to be symptomatic and more severe.The HeRS score is a valid predictor of HT in patients with ischemic stroke and indication for anticoagulation.
authors.affiliation: From the Johns Hopkins School of Medicine, Department of Neurology (EBM, RHL, AEH, PD, RFG); Johns Hopkins Bayview Medical Center (EBM, RHL, EL, RFG); and Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA (ALCS, RFG).
authors.forename: Elisabeth B
authors.initials: EB
authors.lastname: Marsh
authors.forename: Rafael H
authors.initials: RH
authors.lastname: Llinas
authors.forename: Andrea L C
authors.initials: ALC
authors.lastname: Schneider
authors.forename: Argye E
authors.initials: AE
authors.lastname: Hillis
authors.forename: Erin
authors.initials: E
authors.lastname: Lawrence
authors.forename: Peter
authors.initials: P
authors.lastname: Dziedzic
authors.forename: Rebecca F
authors.initials: RF
authors.lastname: Gottesman
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects* / Q000627:therapeutic use; D019540:Area Under Curve; D002545:Brain Ischemia / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy*; D002423:Cause of Death; D002543:Cerebral Hemorrhage / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007902:Length of Stay; D016015:Logistic Models; D018810:Magnetic Resonance Angiography / Q000379:methods; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D015203:Reproducibility of Results; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D020521:Stroke / Q000175:diagnosis / Q000209:etiology / Q000401:mortality; D016019:Survival Analysis
chemical_list: D000925:Anticoagulants