Risk for symptomatic intracerebral hemorrhage after thrombolysis assessed by diffusion-weighted magnetic resonance imaging

Ann Neurol. 2008 Jan;63(1):52-60. doi: 10.1002/ana.21222.


Objective: The risk for symptomatic intracerebral hemorrhage (sICH) associated with thrombolytic treatment has not been evaluated in large studies using diffusion-weighted imaging (DWI). Here, we investigated the relation between pretreatment DWI lesion size and the risk for sICH after thrombolysis.

Methods: In this retrospective multicenter study, prospectively collected data from 645 patients with anterior circulation stroke treated with intravenous or intraarterial thrombolysis within 6 hours (<3 hours: n = 320) after symptom onset were pooled. Patients were categorized according to the pretreatment DWI lesion size into three prespecified groups: small (< or =10 ml; n = 218), moderate (10-100 ml; n = 371), and large (>100 ml; n = 56) DWI lesions.

Results: In total, 44 (6.8%) patients experienced development of sICH. The sICH rate was significantly different between subgroups: 2.8, 7.8, and 16.1% in patients with small, moderate, and large DWI lesions, respectively (p < 0.05). This translates to a 5.8 (2.8)-fold greater sICH risk for patients with large DWI lesions as compared with patients with small (or moderate) DWI lesions. The results were similar in the large subgroup (n = 536) of patients treated with intravenous tissue plasminogen activator. DWI lesion size remained an independent risk factor when including National Institutes of Health Stroke Scale, age, time to thrombolysis, and leukoariosis in a logistic regression analysis.

Interpretation: This multicenter study provides estimates of sICH risk in potential candidates for thrombolysis. The sICH risk increases gradually with increasing DWI lesion size, indicating that the potential benefit of therapy needs to be balanced carefully against the risk for sICH, especially in patients with large DWI lesions.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Brain Infarction / drug therapy
  • Brain Ischemia / complications
  • Brain Ischemia / pathology
  • Brain Ischemia / physiopathology
  • Cerebral Arteries / drug effects*
  • Cerebral Arteries / pathology*
  • Cerebral Arteries / physiopathology
  • Cerebral Hemorrhage / chemically induced*
  • Cerebral Hemorrhage / pathology*
  • Cerebral Hemorrhage / physiopathology
  • Cerebrovascular Circulation / drug effects
  • Cerebrovascular Circulation / physiology
  • Diffusion Magnetic Resonance Imaging
  • Female
  • Fibrinolytic Agents / adverse effects
  • Humans
  • Intracranial Thrombosis / drug therapy*
  • Leukoaraiosis / chemically induced
  • Leukoaraiosis / pathology
  • Leukoaraiosis / physiopathology
  • Male
  • Middle Aged
  • Nerve Fibers, Myelinated / drug effects
  • Nerve Fibers, Myelinated / pathology
  • Predictive Value of Tests
  • Prospective Studies
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Thrombolytic Therapy / adverse effects*


  • Fibrinolytic Agents