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(Stroke. 2000;31:1785.)
© 2000 American Heart Association, Inc.

Letters to the Editor

Extraparenchymal Bleeding Predicts an Unfavorable Outcome in Patients With Hemorrhagic Transformation

Livia Candelise, MD

Istituto di Clinica Neurologica, Università degli Studi di Milano, IRCCS Ospedale Maggiore-Policlinico

Alfonso Ciccone, MD

Stroke Unit, Divisione Neurologica, Ospedale Niguarda Ca’ Granda

Cristina Motto, MD

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

View this table: [in this window] [in a new window]   Table 1. Clinical Course of Different Types of Hemorrhagic Transformation in ECASS I and MAST-I

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.[Abstract/Free Full Text]

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.[Abstract/Free Full Text]

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.[Abstract/Free Full Text]

Response

Marco Fiorelli, MD

Department of Neurological Sciences, University La Sapienza, Rome, Italy

Rüdiger von Kummer, MD

Department of Neuroradiology, University of Technology, Dresden, Germany

Stefano Bastianello, MD Luigl Bozzao, MD

Department of Neurological Sciences, University La Sapienza, Rome, Italy

Key Words: prognosis • stroke, hemorrhagic

We are grateful for the interest shown . . . [Full Text of this Article]