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Hemorrhagic Complications in Acute Ischemic Stroke

Created 25.10.2019, last update 30.10.2021

  • the efficacy of thrombolysis has been demonstrated despite an increased risk of severe hemorrhagic transformation (HT) in patients treated with tPA
  • knowledge of risk factors for severe HT may improve the selection of patients and the safety of treatment, interpretation of trial results is difficult because different classifications of HTs were used
    • the CT-based classification provides no direct information on the clinical consequences of hemorrhage
    • the clinical classification does not acknowledge the contribution of ischemic edema to clinical deterioration
    • usage of both clinical and radiological criteria is optimal

ECASS group hemorrhage classification

Radiological bleeding 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 infarcted area with some slight space-occupying effect
PH2 blood clots in > 30% of the infarcted area with a substantial space-occupying effect
Bleeding classification after Stroke and Reperfusion Therapy (ECASS II)
Bleeding classification after Stroke and Reperfusion Therapy (ECASS II)

Definitions of symptomatic hemorrhage (sICH)

Definition of a symptomatic intracranial hemorrhage (SICH) in different trials
  • an intracranial hemorrhage was defined as symptomatic (SICH) if the patient had clinical deterioration leading to an increase in the NIHSS score of ≥4 points and if the hemorrhage was likely to be the cause of the clinical deterioration
  • in doubt, an association of the hemorrhage with the deterioration was assumed
 any hemorrhage + any clinical deterioration
local or remote parenchymal hemorrhage type 2 (PH2) + clinical deterioration  (increase in the  NIHSS of ≥ 4  or death) within 24h
new intracranial hemorrhage detected by CT/MRI associated with any of the item below:

  • ≥4 points total NIHSS compared to immediately before worsening (not to the baseline)
  • ≥2 point in one NIHSS category (to capture new hemorrhages producing new symptoms, making them clearly symptomatic but not causing worsening in the original territory)
  • leading to intubation/hemicraniectomy/EVD placement or other major medical/surgical intervention
  • + absence of alternative explanation for deterioration

The Heidelberg Bleeding Classification

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
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