Hemorrhagic Transformation After Acute Ischemic Stroke
Diagnosis and Imaging
Suspect hemorrhagic transformation immediately when any of the following occur: decreased level of consciousness, blood pressure elevation, motor examination deterioration, new headache, or nausea and vomiting. 1
Imaging Protocol
- Obtain immediate non-contrast CT or MRI when hemorrhagic transformation is suspected, regardless of timing from stroke onset 1
- Perform routine follow-up imaging at 24 hours, 7-10 days, 30 days, and 90 days after stroke onset to detect asymptomatic hemorrhagic transformation 1
- Emergency imaging is mandatory for any abrupt neurological deterioration 1
Classification on Imaging
- Hemorrhagic infarct (HI): Petechial or small confluent hemorrhages within hypodense ischemic tissue without mass effect 1
- Parenchymal hematoma (PH): Homogeneous hemorrhage with or without intraventricular extension, usually with mass effect 1
Immediate Management When Hemorrhagic Transformation is Detected
If Patient is on rtPA Infusion
Stop the rtPA infusion immediately when hemorrhagic transformation is suspected 1
Laboratory Workup
Obtain emergently: 1
- PT/INR
- aPTT
- Fibrinogen level
- Complete blood count with platelets
- Type and cross-match
Reversal of Thrombolytic Effect
Administer 6-8 units of cryoprecipitate (containing factor VIII) and 6-8 units of platelets immediately after confirming hemorrhagic transformation 1
Anticoagulation and Antiplatelet Management
For Symptomatic Hemorrhagic Transformation
Discontinue all anticoagulants and antiplatelets immediately for at least 1-2 weeks during the acute period 2, 3
- This applies regardless of the underlying indication for anticoagulation, including atrial fibrillation or mechanical heart valves 3
- Avoid heparin boluses entirely due to increased bleeding risk; if heparin must be restarted, use continuous infusion only with aPTT target 1.5-2.0 times control 3, 4
- Higher aPTT ratios directly correlate with increased symptomatic bleeding risk 3, 4
For Asymptomatic Hemorrhagic Transformation
Continue antiplatelet therapy if the patient has a compelling indication and remains asymptomatic, with close monitoring via serial neurological examinations and repeat neuroimaging 2
- Hemorrhagic transformation has a fundamentally different natural history than primary intracerebral hemorrhage—these bleeds are typically asymptomatic, rarely progress, and are relatively common 2, 3
- Monitor closely for expansion with repeat imaging 2
Blood Pressure Management
Avoid automatic aggressive blood pressure lowering, as elevated blood pressure may be a sign of hemorrhagic transformation rather than a target for treatment 1
- Blood pressure elevation is a warning sign of hemorrhagic transformation, not necessarily an independent treatment target 1
- Follow institutional protocols for blood pressure management in the context of hemorrhagic transformation 1
Timing of Anticoagulation Restart
Risk Stratification Based on Infarct Size and Hemorrhage Type
Use the following algorithm to determine timing of anticoagulation restart: 2
| Clinical Scenario | Timing to Restart |
|---|---|
| TIA or no visible infarct | Day 0-3 |
| Small infarct (<1.5 cm), asymptomatic HI | Day 3-5 |
| Medium infarct (≥1.5 cm, not full territory), asymptomatic HI | Day 7-9 |
| Large infarct (full cortical territory or >35% hemisphere) | Day 14 or later |
| Any symptomatic hemorrhagic transformation | Minimum 14 days |
Special Considerations for High Thromboembolic Risk
For patients with mechanical heart valves or CHADS₂ score ≥4, consider restarting anticoagulation at 7-10 days with graduated dosing 2
- Start with reduced dose (e.g., apixaban 2.5 mg twice daily for days 1-2), then increase to standard dose 2
- This applies only to asymptomatic or minimal hemorrhagic transformation 2
Factors Favoring Earlier Restart (7-10 days)
- High thromboembolic risk (mechanical valve, recent stroke, CHADS₂ ≥4) 2
- Small hemorrhagic transformation size 2
- Stable or improving neurological status 2
- Hemorrhagic infarction (HI) rather than parenchymal hematoma (PH) 2
Factors Requiring Delayed Restart (≥14 days)
- Large cerebral infarction (NIHSS >15 or complete arterial territory) 2
- Symptomatic hemorrhagic transformation 2, 3
- Parenchymal hematoma with mass effect 2
- Uncontrolled hypertension 2
Management of Cerebral Edema
Monitor for signs of increased intracranial pressure related to large stroke lesions, particularly in the first 24-72 hours 1
- Maintain nurse-patient ratio of 1:2 for the first 24 hours in patients at high risk 1
- Peak swelling occurs several days after stroke onset 1
- Younger patients with decreased intracranial compliance are at higher risk for brain tissue shift 1
Critical Pitfalls to Avoid
Do not automatically discontinue antiplatelet therapy in all cases of hemorrhagic transformation—this increases thromboembolic risk in high-risk patients with asymptomatic transformation 2
Never use heparin boluses in patients with hemorrhagic transformation; studies demonstrate increased bleeding risk 3, 4
Do not delay imaging when hemorrhagic transformation is suspected—immediate CT or MRI is mandatory 1
Avoid treating blood pressure elevation as an isolated finding without first ruling out hemorrhagic transformation as the cause 1
Risk Factors for Hemorrhagic Transformation
Patient-Related Factors
- NIHSS score >20 (17% symptomatic ICH risk vs. 3% for NIHSS <10) 1
- Age >80 years 1
- Severe baseline stroke (NIHSS ≥11) 1
- Blood glucose >200 mg/dL 1
- Prior head trauma 1