Management of Symptomatic Post tPA Hemorrhage in Acute Ischemic Strokes: An Expert Consensus Guideline
Gurmeen Kaur, MBBS
Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales NR, Khatri P, et al. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2017
The American Heart Association/American Stroke Association recently published a consensus statement on treatment guidelines for management of symptomatic intracranial hemorrhage (sICH), chaired by Dr. Yaghi. After extensive review of the existing literature, the consensus committee devised this guideline based on the current available evidence.
Different authors and trials have used varying definitions of what is classified as symptomatic ICH. Based on the definitions, there was a 2.5-5-fold variation in the rates of ICH noted. The incidence of sICH after alteplase in the modern era at the standard dose of 0.9 mg/kg administered over 1 hour with a 10% bolus varies from 2% to 7% in clinical trials and prospective stroke registries.
To standardize and make the various trials comparable, the group suggested that stroke centers should classify the appearance of hemorrhagic transformation according to radiographic criteria as described in ECASS II (hemorrhagic infarction [HI] type 1, HI-2, parenchymal hematoma [PH] type 1, PH-2, or remote ICH), assess the degree of neurological worsening by National Institutes of Health Stroke Scale (NIHSS) point change, and provide an attribution of causality for the worsening. The natural history of patients with sICH, particularly the PH-2 radiological subtype, is very poor, approaching 50% mortality and significant morbidity with survival.