Hemorrhagic transformation in patients with acute ischaemic stroke and an indication for anticoagulation
Article first published online: 21 MAR 2013
© 2013 The Author(s) European Journal of Neurology © 2013 EFNS
European Journal of Neurology
Volume 20, Issue 6, pages 962–967, June 2013
How to Cite
Marsh, E. B., Llinas, R. H., Hillis, A. E. and Gottesman, R. F. (2013), Hemorrhagic transformation in patients with acute ischaemic stroke and an indication for anticoagulation. European Journal of Neurology, 20: 962–967. doi: 10.1111/ene.12126
- Issue published online: 12 MAY 2013
- Article first published online: 21 MAR 2013
- Manuscript Accepted: 30 JAN 2013
- Manuscript Received: 12 NOV 2012
- NIH/NINDS Research Education Program for Residents and Fellows in Neurology and Neurosurgery. Grant Number: 5 R25 NS065729-04
- cerebral hemorrhage;
- cerebral infarction;
- cerebrovascular diseases and cerebral circulation;
- renal failure;
Background and purpose
Intracerebral hemorrhage (ICH) can occur in patients following acute ischaemic stroke in the form of hemorrhagic transformation, and results in significant long-term morbidity and mortality. Anticoagulation theoretically increases risk. We evaluated stroke patients with an indication for anticoagulation to determine the factors associated with hemorrhagic transformation.
Three-hundred and forty-five patients with ICD-9 codes indicating: (i) acute ischaemic stroke; and (ii) an indication for anticoagulation were screened. One-hundred and twenty-three met inclusion criteria. Data were collected retrospectively. Neuroimaging was reviewed for infarct volume and evidence of ICH. Hemorrhages were classified as: hemorrhagic conversion (petechiae) versus intracerebral hematoma (a space occupying lesion); symptomatic versus asymptomatic. Using multivariable logistic regression, we determined the hypothesized factors associated with intracerebral bleeding.
Age [odds ratio (OR) = 1.50 per 10-year increment, 95% confidence interval (CI) 1.07–2.08], infarct volume (OR = 1.10 per 10 ccs, 95% CI 1.06–1.18) and worsening category of renal impairment by estimated glomerular filtration rate (eGFR; OR = 1.95, 95% CI 1.04–3.66) were predictors of hemorrhagic transformation. Ninety- nine out of 123 patients were anticoagulated. Hemorrhage rates of patients on and off anticoagulation did not differ (25.3% vs. 20.8%; P = 0.79); however, all intracerebral hematomas (n = 7) and symptomatic bleeds (n = 8) occurred in the anticoagulated group.
The risk of hemorrhagic transformation in patients with acute ischaemic stroke and an indication for anticoagulation is multifactorial, and most closely associated with an individual's age, infarct volume and eGFR.