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Hemorrhagic Complications in Acute Ischemic Stroke

Created 26/04/2021, last revision 29/04/2023

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 the selection of patients and the safety of treatment; interpretation of trial results is difficult because different classifications of hemorrhagic transformation 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 seems optimal

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 a 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, resulting in an increase in the NIHSS score of ≥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 of ≥ 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, making them clearly symptomatic but does not cause worsening in the original territory) 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