Thrombolysis and the Aging Brain

The bleeding complications of thrombolysis are well-described, but frequently under-appreciated in the acute setting. Stroke patients often disappear upstairs after treatment in the Emergency Department quickly enough that we rarely see the neurologic worsening associated with post-thrombolysis hemorrhage.

Risk factors for post-tPA ICH are well-known, but often difficult to precisely pin down for an individual patient. This study pools patients from up to 15 studies to evaluate the effect of leukoariosis on post-tPA hemorrhage. Leukoariosis, essentially, is a cerebral small vessel disease likely related to chronic ischemic damage. It has been long-recognized as a risk factor for increased hemorrhage and poor outcome, independent of age at treatment.

In this study, authors pooled approximately 5,500 patients, half of which were identified to have leukoariosis. The unadjusted absolute risk of symptomatic ICH in those without leukoariosis was 4.1%, while the risk of those with was 6.6%. Then, looking at the 2,700 patients with leukoariosis, those with mild disease had an unadjusted absolute risk of 4.0%, compared with 10.2% for those with moderate or severe. Similar trends towards worse functional outcomes were also seen with regards to worsening leukoariosis.

The moral of the story: the baseline health of the brain matters. When discussing the risks, benefits, and alternatives for informed consent with a family, these substantial risks in those patients with leukoariosis should be clearly conveyed with regards to appropriateness of tPA when otherwise potentially indicated.

“Leukoaraiosis, intracerebral hemorrhage, and functional outcome after acute stroke thrombolysis”

http://www.neurology.org/content/early/2017/01/27/WNL.0000000000003605.abstract

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