Hemorrhagic Transformation (HT) and Symptomatic Intracerebral Hemorrhage (sICH) Risk Prediction Models for Postthrombolytic Hemorrhage in the Stroke Belt

Background. Symptomatic intracerebral hemorrhage (sICH) remains the most feared complication of intravenous tissue plasminogen activator (IV tPA) treatment. We aimed to investigate how previously validated scoring methodologies would perform in treated patients in two US Stroke Belt states. Methods and Results. We retrospectively reviewed consecutive patients from two centers in two Stroke Belt states who received IV tPA (2008–2011). We assessed the ability of three models to predict sICH. sICH was defined as a type 2 parenchymal hemorrhage with deterioration in National Institutes of Health Stroke Scale (NIHSS) score of ≥4 points or death. Among 457 IV tPA-treated patients, 19 (4.2%) had sICH (mean age 68, 26.3% Black, 63.2% female). The Cucchiara model was most predictive of sICH in the entire cohort (AUC: 0.6528) and most predictive of sICH among Blacks (OR = 6.03, 95% CI 1.07–34.1, ) when patients were dichotomized by score. Conclusions. In our small sample from the racially heterogeneous US Stroke Belt, the Cucchiara model outperformed the other models at predicting sICH. While predictive models should not be used to justify nontreatment with thrombolytics, those interested in understanding contributors to sICH may choose to use the Cucchiara model until a Stroke Belt model is developed for this region. 1. Background Despite multiple acute stroke treatment trials, thrombolytic therapy with intravenous tissue plasminogen activator (IV tPA) remains the only FDA-approved acute treatment for ischemic stroke with proven long-term benefit [4, 5]. This treatment, while highly effective when administered in the appropriate setting, is not without risk. As many as 6% of patients treated with IV tPA for ischemic stroke were found to clinically deteriorate in the earliest randomized trial [5]; however current rates of symptomatic intracranial hemorrhage (sICH) are lower [6] and hemorrhagic transformation (HT) rates are around 9% [7]. These differences may be explained by differences in criteria used to define sICH [8]. Due to provider concern for sICH, early efforts at minimizing these adverse events focused on identifying sICH risk factors. Elevated serum glucose [9–11] or ferritin [12] on admission, history of diabetes mellitus [13], older age [10], greater baseline stroke severity [10, 14–16], and current tobacco use [14, 17] have all been identified as potential risk factors for sICH. In an effort to more accurately predict which patients are at the greatest risk of postthrombolytic hemorrhagic transformation (HT) [1, 18, 19] and/or sICH [2, 18–20],