Should we exclude acute stroke patients with previous intracerebral hemorrhage from receiving intravenous thrombolysis?

Lee, Sang-Hwa; Kim, Beom Joon; Han, Moon-Ku; Park, Tai Hwan; Lee, Kyung Bok; Lee, Byung-Chul; Yu, Kyung-Ho; Oh, Mi Sun; Cha, Jae Kwan; Kim, Dae-Hyun; Nah, Hyun-Wook; Lee, Jun; Lee, Soo Joo; Ko, Youngchai; Kim, Jae Guk; Park, Jong-Moo; Kang, Kyusik; Cho, Yong-Jin; Hong, Keun-Sik; Choi, Jay Chol; Kim, Joon-Tae; Choi, Kangho; Kim, Dong-Eog; Ryu, Wi-Sun; Kim, Wook-Joo; Shin, Dong-Ick; Yeo, Minju; Lee, Juneyoung; Lee, Ji Sung; Gorelick, Philip B; Bae, Hee-Joon

BACKGROUND Current guidelines have contraindicated history of intracerebral hemorrhage for intravenous recombinant tissue plasminogen activator. AIM This study aimed to investigate the safety and effectiveness of intravenous recombinant tissue plasminogen activator for patients who had previous intracerebral hemorrhage on history or initial brain magnetic resonance imaging. METHODS Using a prospective multicenter stroke registry database, we identified acute ischemic stroke patients treated with intravenous recombinant tissue plasminogen activator within 4.5 h of onset. Previous intracerebral hemorrhage was defined as having a clinical history or evidence of old intracerebral hemorrhage on initial brain magnetic resonance imaging. Associations of previous intracerebral hemorrhage with symptomatic hemorrhagic transformation during hospitalization and functional outcome and mortality at discharge and three months were analyzed. RESULTS Among 1495 patients who were treated with intravenous recombinant tissue plasminogen activator, 73 (4.9%) had previous intracerebral hemorrhage; 9 on history only, 61 on magnetic resonance imaging only and 3 on both. Of those 1495 patients, 71 (4.7%) experienced symptomatic hemorrhagic transformation; 6.8% in patients with previous intracerebral hemorrhage and 4.6% in those without previous intracerebral hemorrhage. Multivariable logistic regression analysis showed that previous intracerebral hemorrhage did not significantly increase the risk of symptomatic hemorrhagic transformation (odds ratio 1.08, 95% confidence interval 0.39-2.96) mortality, and most of functional outcome measures CONCLUSIONS Previous intracerebral hemorrhage may neither increase the risk of symptomatic hemorrhagic transformation nor alter major clinical outcomes in acute ischemic stroke patients receiving intravenous recombinant tissue plasminogen activator. This study suggests reconsideration of prior history of intracerebral hemorrhage as an exclusion criterion for intravenous recombinant tissue plasminogen activator administration in acute ischemic stroke.