Background: The NINDS Trial demonstrated the efficacy of intravenous (IV) recombinant tissue plasminogen activator (rtPA) in improving neurologic outcome in patients presenting with acute ischemic strokes. Patients that had a prior history of intracranial hemorrhage (ICH) were excluded from this trial, possibly due to a hypothetical increase in the subsequent bleeding risk. Thus there is little data available, whether against or in favor of, the use of IV rtPA in patients with prior ICH. We aim to aid in determining the safety of IV rtPA in such patients through a retrospective hospital based single center study.
Methods: We reviewed brain imaging (including CT, MRI T1, T2, T2* and DWI) of all the patients who received IV rtPA at our comprehensive stroke center from January 2006 to April 2014 for evidence of prior ICH at the time of IV rtPA administration. Their outcomes were determined in terms of subsequent development of symptomatic ICH as defined by the NINDS trial.
Results: Brain imaging for 640 patients was reviewed. A total of 27(4%) patients showed evidence of prior ICH at the time of IV thrombolysis, all intra-parenchymal. Of these 27 patients, 11 had prior frank macrobleeds and 16 had prior microbleeds. Only one patient (3.7%) developed subsequent symptomatic ICH after the administration of IV rtPA, and was from the microbleed group. Of the remaining 613 patients that received IV rtPA, 25 patients (4.1%) developed symptomatic ICH. There was no statistical significance in the rate of post thrombolysis symptomatic ICH between the two groups (p=0.69).
Conclusion: This retrospective study provides limited (Level C) evidence that patients with imaging evidence of prior asymptomatic intra-parenchymal hemorrhage presenting with an acute ischemic stroke do not show an increased risk of developing symptomatic ICH after IV thrombolysis.