ADD-ONS

Hemorrhagic Complications in Acute Ischemic Stroke

David Goldemund M.D.
Updated on 03/03/2024, published on 26/04/2021

hemorrhagic complications are a serious concern in acute ischemic stroke; they can be divided into two main categories:
- early hemorrhagic complications – occurring within 24 hours of stroke onset
  - most commonly due to reperfusion injury when a blood clot is dissolved by thrombolytic therapy or spontaneous recanalization; SAH or remote ICH are rare
- late hemorrhagic complications
risk factors for hemorrhagic complications:
- age
  - older patients generally have a higher risk of hemorrhagic complications, possibly due to the increased prevalence of other risk factors like hypertension and the use of anticoagulants
- thrombolytic therapy
  - the overall efficacy of intravenous thrombolysis has been demonstrated despite the known increased risk of bleeding
- poorly controlled hypertension during thrombolysis
- stroke severity and presence of extensive early signs of ischemia (late recanalization)
  - larger lesions carry a higher risk of hemorrhagic transformation or complications
- comorbidities (hypertensive angiopathy, CAA, uncontrolled diabetes, etc.)
- concurrent antithrombotic medication
- prior hemorrhagic stroke
understanding the risk factors for hemorrhagic complications is crucial, especially given the delicate balance between treating the stroke and avoiding additional harm

different classifications of hemorrhagic transformation have been used:
- CT-based classification does not provide direct information on the clinical consequences of hemorrhage
- clinical classification does not acknowledge the contribution of ischemic edema to clinical deterioration
- the use of both clinical and radiologic criteria seems optimal

Radiologic hemorrhage classification (Larrue, 2001)
Hemorrhagic infarction (HI) – petechiae in the infarcted tissue without space-occupying effect
HI1	small isolated petechiae along the margins of the infarct
HI2	confluent petechiae
Parenchymal hemorrhage (PH) – hemorrhage with space-occupying effect
PH1	blood clots in ≤ 30% of the infarct area with a slight space-occupying effect
PH2	blood clots in > 30% of the infarct area with a substantial space-occupying effect

Definition of a symptomatic intracranial hemorrhage (SICH) in different trials
ECASS III	an intracranial hemorrhage was defined as symptomatic (SICH) if the patient had clinical deterioration (increase in NIHSS score ≥4 points) and if the hemorrhage was likely to have caused the clinical deterioration in case of doubt, a relationship between the hemorrhage and the deterioration was assumed
NINDS	any hemorrhage + any clinical deterioration
SITS-MOST	local or remote parenchymal hemorrhage type 2 (PH2) + clinical deterioration (NIHSS increase ≥ 4 or death) within 24 hours
Heidelberg classification	new intracranial hemorrhage detected by CT/MRI associated with any of the following: ≥4 points in total NIHSS compared to immediately before deterioration (not baseline) ≥2 points in any NIHSS category (to capture new bleeding that causes new symptoms) leading to intubation/hemicraniectomy/EVD placement or other major medical/surgical intervention + absence of an alternative explanation for the deterioration

1	Hemorrhagic transformation of infarcted brain tissue
1a	Scattered small petechiae, no mass effect (HI1)
1b	Confluent petechiae, no mass effect (HI2)
1c	Hematoma within infarcted tissue, occupying <30%, no substantive mass effect (PH1)
2	Intracerebral hemorrhage within and beyond infarcted brain tissue
	Hematoma occupying 30% or more of the infarcted tissue, with obvious mass effect (PH2)
3	Intracerebral hemorrhage outside the infarcted brain tissue or intracranial-extracerebral hemorrhage
3a	Parenchymal hematoma remote from infarcted brain tissue
3b	Intraventricular hemorrhage
3c	Subarachnoid hemorrhage
3d	Subdural hemorrhage