Early and late mortality of spontaneous hemorrhagic transformation of ischemic stroke

J Stroke Cerebrovasc Dis. 2014 Apr;23(4):649-54. doi: 10.1016/j.jstrokecerebrovasdis.2013.06.005. Epub 2013 Jul 5.


Background: Hemorrhagic transformation (HT), a complication of ischemic stroke (IS), might influence patient's prognosis. Our aim is to evaluate, in a hospital-based series of patients not treated with thrombolysis, the relationship between HT and mortality.

Methods: We compared mortality of individuals with spontaneous HT with that of individuals without. Medical records of patients diagnosed with anterior IS were retrospectively reviewed. Outcome measures were 30- and 90-day survival after IS onset. Kaplan-Meier estimates were used to construct survival curves. Cox proportional hazards model was used to estimate hazard ratio (HR) for the main outcome measure (death). HT was stratified in hemorrhagic infarction and parenchymal hematoma (PH). We also evaluated the relationship between HT and the main mortality risk factors (gender, age, premorbid status, severity of stroke, and radiological features).

Results: Thirty days from stroke onset, 8.1% (19 of 233) of patients died. At multivariate analysis, PH (HR: 7.7, 95% confidence interval [CI]: 2.1, 27.8) and low level of consciousness at admission (HR: 5.0, 95% CI: 1.3, 18.6) were significantly associated with death. At 3-month follow-up, mortality rate was 12.1% (28 of 232). At multivariate analysis, large infarct size (HR: 2.7, 95% CI: 1.2, 6.0) and HT (HR: 2.3, 95% CI: 1.0, 5.4) were independent risk factors for mortality. Parenchymal hematoma was, however, the strongest predictor of late mortality (HR: 7.9, 95% CI: 2.9, 21.4).

Conclusions: Neurological status and infarct size play a significant role, respectively, in early and late mortality after IS. Parenchymal hematoma independently predicts both early and late mortality.

Keywords: Ischemic stroke; epidemiology; hemorrhagic transformation; prognosis; survival.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Anticoagulants / therapeutic use
  • Aspirin / therapeutic use
  • Brain Ischemia / complications
  • Brain Ischemia / drug therapy
  • Brain Ischemia / mortality*
  • Cohort Studies
  • Disease Progression
  • Female
  • Follow-Up Studies
  • Heparin / therapeutic use
  • Humans
  • Intracranial Hemorrhages / complications
  • Intracranial Hemorrhages / drug therapy
  • Intracranial Hemorrhages / mortality*
  • Male
  • Middle Aged
  • Platelet Aggregation Inhibitors / therapeutic use
  • Retrospective Studies
  • Risk Factors
  • Stroke / drug therapy
  • Stroke / etiology
  • Stroke / mortality*
  • Survival Rate


  • Anticoagulants
  • Platelet Aggregation Inhibitors
  • Heparin
  • Aspirin