(Stroke. 2000;31:1785.)
© 2000 American Heart Association, Inc.
Letters to the Editor |
Extraparenchymal Bleeding Predicts an Unfavorable Outcome in Patients With Hemorrhagic Transformation
Istituto di Clinica Neurologica, Università degli Studi di Milano, IRCCS Ospedale Maggiore-Policlinico
Stroke Unit, Divisione Neurologica, Ospedale Niguarda Ca’ Granda
Divisione Neurologica, Ospedale S. Paolo, Milano, Italy
To the Editor:
We read with interest the recent article by Fiorelli et
al.1 The authors confirmed the reliability of hemorrhagic
transformation (HT) as a diagnosis which, as we have found, could be
made by either a neuroradiologist or a trained
neurologist.2 However, of greater clinical relevance was
the fact that they found that only severe HT (parenchymal hematoma 2
[PH2] in ECASS I1 ) was associated with an unfavorable
outcome. As shown in the Table
, the same
result emerged from the Multicentre Acute Stroke Trial–Italy (MAST-I)
analysis.3
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We have found that severe HT is very often associated with intraventricular or subarachnoid bleeding. This finding, together with but independent of cerebral edema, made the prognosis unfavorable in our study. The severe HT (PH2) definition of ECASS I points to a "significant space occupying effect" and includes the presence of a "clot remote from the infarct area." But the ECASS I investigators did not specifically assess the effect of the intraventricular or subarachnoid bleeding on the prognosis. This finding and not HT per se is the real adverse effect of thrombolytic treatment, and we wonder whether any results from ECASS and NIH studies have been published on this point. We need confirmation of our funding on the prognostic significance of intraventricular or subarachnoid bleeding before implementing new strategies to prevent it or to manage it as soon as it develops.
References
1.
Fiorelli M, Bastianello S, von Kummer R, del Zoppo
GJ, Larrue V, Leseffre E, Ringleb AP, Lorenzano S, Manelfe C, Bozzao L,
for the ECASS I Study Group. Hemorrhagic transformation within 36 hours
of a cerebral infarct: relationships with early clinical deterioration
and 3-month outcome in the European Cooperative Acute Stroke Study I
(ECASS I) cohort. Stroke.. 1999;30:2280–2284.
2.
Motto C, Aritzu E, Boccardi E, De Grandi C, Piana A,
Candelise L. Reliability of hemorrhagic transformation diagnosis in
acute ischemic stroke. Stroke.. 1997;28:302–306.
3.
Motto C, Ciccone A, Aritzu E, Boccardi E, De Grandi C,
Piana A, Candelise L, and the MAST-I Collaborative Group.
Hemorrhage after an acute ischemic stroke.
Stroke.. 1999;30:761–764.
Response
Department of Neurological Sciences, University La Sapienza, Rome, Italy
Department of Neuroradiology, University of Technology, Dresden, Germany
Department of Neurological Sciences, University La Sapienza, Rome, Italy
Key Words: prognosis • stroke, hemorrhagic
We are grateful for the interest shown by Candelise et al
in our article concerning the prognosis of hemorrhagic transformation
of a cerebral infarct. In the ECASS I cohort, 34 of 71 patients (48%)
with parenchymal hematoma (PH) at day 1 had an associated
extraparenchymal hemorrhage (EH+). At 3 months all these 34
patients had a poor outcome, defined as a Rankin score (RS) of 
1
(100%, 95% CI 90% to 100%), as opposed to 90% (79% to 97%) of
patients with PH but no EH (EH-). The analysis of risk
expressed in terms of odds ratio did not reveal a significant
additional risk of poor outcome associated with EH (OR 1.09, 95% CI
0.54 or 2.19). Poor outcome defined as an RS of 2 was observed in
91% (77% to 97%) of EH+ patients as opposed to 70% (54% to 83%)
of their EH- counterparts (OR 1.3, 0.65 to 2.61).
Our data are therefore not in favor of the hypothesis that the risk for
disability and death is increased in association with EH. The numbers
are too small, however, to rule out type 2 errors. In any case,
comparisons between our data and those collected in the framework of
MAST-I should be made with caution. At variance with ECASS I, the
MAST-I investigators defined unfavorable outcome as an RS of 3 at 6
months after stroke. Our opinion is that rather than EH, the mass
effect caused by PH and the resulting compression of functioning brain
tissue is the primary determinant of poor outcome. However, topics of
crucial importance like this certainly deserve further studies.
Between-cohorts analyses can help, especially if made using
individual data and after having verified the extent to which the
information drawn from different sources is comparable.
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