ADD-ONS
Hemorrhagic Complications in Acute Ischemic Stroke
Created 26/04/2021, last revision 03/09/2023
- the efficacy of intravenous thrombolysis has been demonstrated despite an increased risk of bleeding in patients treated with tPA
- knowledge of risk factors for significant bleeding may improve patient selection and treatment safety; interpretation of trial results is difficult because 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
ECASS group hemorrhage classification
Radiologic hemorrhage classification (Larrue, 2001) | |
Hemorrhagic infarction (HI) – petechiae in the infarcted tissue without space-occupying effect |
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HI1 | small isolated petechiae along the margins of the infarct |
HI2 | confluent petechiae |
Parenchymal hemorrhage (PH) – hemorrhage with space-occupying effect |
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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 |
Definitions of symptomatic hemorrhage (sICH)
Definition of a symptomatic intracranial hemorrhage (SICH) in different trials |
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any hemorrhage + any clinical deterioration | |
local or remote parenchymal hemorrhage type 2 (PH2) + clinical deterioration (NIHSS increase ≥ 4 or death) within 24 hours |
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new intracranial hemorrhage detected by CT/MRI associated with any of the following:
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The Heidelberg Bleeding Classification
1 | Hemorrhagic transformation of infarcted brain tissue | |
1a | Scattered small petechiae, no mass effect (HI1) |
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1b | Confluent petechiae, no mass effect (HI2) |
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1c | Hematoma within infarcted tissue, occupying <30%, no substantive mass effect (PH1) |
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2 | Intracerebral hemorrhage within and beyond infarcted brain tissue | |
Hematoma occupying 30% or more of the infarcted tissue, with obvious mass effect (PH2) |
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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 |