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

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 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
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, 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
 any hemorrhage + any clinical deterioration
local or remote parenchymal hemorrhage type 2 (PH2) + clinical deterioration  (NIHSS increase of ≥ 4  or death) within 24 hours
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

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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Hemorrhagic Complications in Acute Ischemic Stroke