Treatment of brain haemorrhage after thrombolysis for stroke not associated with reduced chance of in-hospital mortality or haematoma expansion

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According to an article published by the Journal of the American Medicine Association (JAMA) Neurology, treating symptomatic intracerebral haemorrhage (sICH) after clot-busting thrombolysis for stroke was not associated with a reduced likelihood of in-hospital death or expansion of the haematoma. Shortening time to diagnosis and treatment, however, may be key to improving outcomes.

Shadi Yaghi, Brown University, Providence, USA, et al examined data from 10 US stroke centres to understand the natural history of thrombolysis-related sICH, and to focus on the efficacy of various treatments used. The authors looked at outcomes for in-hospital death and haematoma expansion.

There were 3,894 patients treated with rtPA between January 2009 and April 2014; among them 128 patients (3.3%) had sICH. Of those 128 patients, 38.2% (49 patients) received any treatment for sICH and 28.9% (37 patients) had their code status changed to comfort measures within the first 24 hours after sICH diagnosis.

 The authors report the most commonly used treatment was the frozen blood product cryoprecipitate (31.3% [40 of 128]). The median time from initiation of rtPA therapy to sICH diagnosis was 470 minutes and the median time from sICH diagnosis to treatment of sICH was 112 minutes.


The in-hospital mortality rate was 52.3% (67 of 128 patients) and 26.8% of patients (22 of 82) had haematoma expansion. A change in code status to comfort measures after sICH diagnosis was the only factor associated with increased in-hospital death, according to the results.

The authors note the effects of therapy may be underestimated because few patients received each of the sICH treatments.

“In this study, treatment of post-thrombolysis sICH did not significantly reduce the likelihood of in-hospital mortality or haematoma expansion. Shortening the time to diagnosis and treatment may be a key variable in improving outcomes of patients with sICH,” the study concludes.

In a related JAMA Neurology editorial, Tiffany Cossey, and Nicole R Gonzales, University of Texas Health Science Center,  Houston, USA, write “Although sICH may be an uncommon occurrence, the known risk weighs heavily on the decision of clinicians to administer tPA [intravenous tissue plasminogen activator], as well as on the decisions of patients and families regarding treatment. It is worthwhile to dedicate efforts to minimising the risk of this complication for both the direct and indirect benefits.”

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