From the Guidelines
Ischemic stroke conversion to hemorrhagic transformation is a serious complication that can occur in approximately 10-40% of ischemic strokes, with symptomatic hemorrhagic transformation occurring in about 2-7% of cases, and the risk is significantly increased by thrombolytic therapy with tissue plasminogen activator (tPA), particularly when administered outside the recommended time window of 4.5 hours from symptom onset 1.
Risk Factors
The risk of ischemic stroke conversion to hemorrhagic transformation is increased by several factors, including:
- Large infarct size
- Severe stroke
- Advanced age
- Hypertension
- Hyperglycemia
- Use of anticoagulants
Management
Management of ischemic stroke conversion to hemorrhagic transformation involves:
- Stopping anticoagulants and antiplatelets
- Controlling blood pressure (typically keeping systolic BP below 140-160 mmHg)
- Reversing anticoagulation if applicable
- Managing increased intracranial pressure
- Considering neurosurgical evacuation of the hematoma in severe cases
Prevention Strategies
Prevention strategies include:
- Strict adherence to thrombolysis protocols
- Careful patient selection for reperfusion therapies
- Tight blood pressure control during the acute phase of ischemic stroke According to the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack, patients with larger cerebral infarcts are at greater risk for hemorrhagic transformation and worse bleeding with early initiation of anticoagulation, and it is reasonable to delay initiation of oral anticoagulation for 14 days after stroke onset in that setting 1.
From the Research
Ischemic Stroke Conversion to Hemorrhagic
- Ischemic stroke conversion to hemorrhagic is a serious complication that can occur after intravenous thrombolytic therapy, with symptomatic intracranial hemorrhage (sICH) being the most feared complication 2.
- The risk of sICH is around 3% when using intravenous alteplase for acute ischemic stroke, and initiating treatment after 4.5 hours increases mortality and reverses the risk-benefit balance 3.
- Prior antiplatelet therapy is significantly associated with increased odds of symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage (ICH), mortality, and poor functional outcomes after intravenous alteplase 4.
- Treatment of sICH is based on expert opinion and small case series, with the efficacy of such treatments not well established, and further research is required to establish treatments aimed at maintaining integrity of the blood-brain barrier in acute ischemic stroke 2.
- Tenecteplase, a revised version of alteplase, is a potential alternative intravenous thrombolytic agent that has benefits over alteplase, including higher fibrin specificity, longer half-life, and reduced systemic coagulopathy 5, 6.