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

    • 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

ECASS group hemorrhage classification

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
Hemorrhage classification after stroke/reperfusion (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 (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
 any hemorrhage + any clinical deterioration
local or remote parenchymal hemorrhage type 2 (PH2) + clinical deterioration  (NIHSS increase ≥ 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)
  • 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