‘Room for improvement’ in post-thrombolysis haemorrhage management

By Eleanor McDermid, Senior medwireNews Reporter

Real-world data on the management of post-thrombolysis symptomatic intracerebral haemorrhage (sICH) highlight delays in diagnosis and treatment.

In an editorial accompanying the study in JAMA Neurology, Tiffany Cossey and Nicole Gonzales (University of Texas Health Sciences Center, Houston, USA) say that the researchers “have begun to unravel a complex topic that is fraught with confounding factors”, noting that post-thrombolysis care “has remained essentially unchanged for 2 decades”.

The findings come from 3894 stroke patients given intravenous recombinant tissue plasminogen activator at 10 US stroke centres. Of these, 3.3% developed sICH, defined by the SITS-MOST criteria of a parenchymal hematoma type 2 and at least a 4-point increase in National Institutes of Health Stroke Scale (NIHSS) score.

Shadi Yaghi (Brown University, Providence, Rhode Island, USA) and team report a median time of 470 minutes between thrombolysis and sICH diagnosis. Patients with higher NIHSS scores had longer times to diagnosis, which the team says suggests a ceiling effect, with sICH making little difference to an already high NIHSS score.

“Our results support the use of sICH prediction scores to screen patients with a high NIHSS score, which may help reduce the time to diagnosis and treatment”, they say.

In addition, the researchers note that current recommendations advise reducing the frequency of neurological assessment from 2 hours after thrombolysis, yet 85.9% of their patients developed sICH after this time. They therefore urge frequent assessment for up to 12 hours after thrombolysis.

Treatment of sICH was also delayed, with a median of 112 minutes elapsing after diagnosis. Yaghi et al note that haematoma expansion, which occurred in 26.8% of the 82 patients with follow-up brain imaging, is assumed to occur soon after haemorrhage onset, implying that prompt treatment could prevent this.

The patients in the study received treatments including vitamin K, fresh frozen plasma, cryoprecipitate, prothrombin complex concentrate and recombinant factor VIIa. Treatment was not significantly associated with reduced in-hospital mortality, although the team says that the wide variety of interventions used might have obscured an effect.

Of note, a code status change to comfort measures in the first 24 hours after sICH diagnosis was the only variable independently associated with increased in-hospital mortality, raising the odds 3.6-fold.

The editorialists say: “While it is intuitive that the rapid reversal of thrombolysis-related coagulopathy could limit the damage due to sICH, there may be other factors that weigh heavily against treatment of sICH for clinicians.

“It is important to identify these factors and determine whether they are justified. In addition, the variability in treatment for sICH is guided by each individual clinical situation. An attempt to standardize treatment may be warranted and, ultimately, would help in determining whether treatment for sICH is actually beneficial.”

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