Stroke, Vol 15, 779-789, Copyright © 1984 by American Heart Association
The clinical implications of hemorrhagic transformation of embolic brain
infarction were explored by studying 30 patients with cardiogenic brain
embolism and either hemorrhagic infarct (HI) or intracerebral hematoma
(ICH) on CT. At the time of identification of hemorrhage, 19 patients were
receiving anticoagulants and 11 were not. Eight anticoagulated patients and
three nonanticoagulated patients developed late HI without attendant
worsening after an initial CT was nonhemorrhagic. Hemorrhagic
transformation without worsening most often occurred after 12 hours but
before 48 hours following stroke onset and was associated with large
infarcts (82%) but not with age, blood pressure or embolic source. Seven
anticoagulated patients, six with large infarcts, and one nonanticoagulated
patient with a small infarct abruptly worsened from eight hours to 11 days
after stroke, with CT revealing ICH or severe HI. Excessive anticoagulation
or acute hypertension potentially contributed to hemorrhagic transformation
in four of five patients who were receiving heparin. Brain hemorrhage in
embolic strokes most often occurs with large infarcts. Early CT may not
allow the identification of large embolic infarcts that are destined to
later undergo spontaneous hemorrhagic transformation. For large embolic
infarcts, a delay of several days before anticoagulation and special
efforts to avoid excessive anticoagulation and hypertension may be prudent.
The initial administration of large, bolus doses of heparin should perhaps
be avoided.
ARTICLES
Immediate anticoagulation of embolic stroke: brain hemorrhage and management options. Cerebral Embolism Study Group
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