The Heidelberg Bleeding Classification
2015; Lippincott Williams & Wilkins; Volume: 46; Issue: 10 Linguagem: Inglês
10.1161/strokeaha.115.010049
ISSN1524-4628
AutoresRüdiger von Kummer, Joseph P. Broderick, Bruce Campbell, Andrew M. Demchuk, Mayank Goyal, Michael D. Hill, Kilian M. Treurniet, Charles B.L.M. Majoie, Henk A. Marquering, Michael V. Mazya, Luís San Román, Jeffrey L. Saver, Daniel Strbian, William Whiteley, Werner Hacke,
Tópico(s)Antiplatelet Therapy and Cardiovascular Diseases
ResumoHomeStrokeVol. 46, No. 10The Heidelberg Bleeding Classification Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBThe Heidelberg Bleeding ClassificationClassification of Bleeding Events After Ischemic Stroke and Reperfusion Therapy Rüdiger von Kummer, DrMed, Joseph P. Broderick, MD, Bruce C.V. Campbell, MD, Andrew Demchuk, MD, Mayank Goyal, MD, Michael D. Hill, MD, Kilian M. Treurniet, MD, Charles B.L.M. Majoie, MD, Henk A. Marquering, PhD, Michael V. Mazya, MD, Luis San Román, MD, Jeffrey L. Saver, MD, Daniel Strbian, MD, William Whiteley, MD and Werner Hacke, DrMed Rüdiger von KummerRüdiger von Kummer From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Joseph P. BroderickJoseph P. Broderick From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Bruce C.V. CampbellBruce C.V. Campbell From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Andrew DemchukAndrew Demchuk From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Mayank GoyalMayank Goyal From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Michael D. HillMichael D. Hill From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Kilian M. TreurnietKilian M. Treurniet From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Charles B.L.M. MajoieCharles B.L.M. Majoie From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Henk A. MarqueringHenk A. Marquering From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Michael V. MazyaMichael V. Mazya From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Luis San RománLuis San Román From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Jeffrey L. SaverJeffrey L. Saver From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , Daniel StrbianDaniel Strbian From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). , William WhiteleyWilliam Whiteley From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). and Werner HackeWerner Hacke From the Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany (R.v.K.); Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati, OH (J.P.B.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.D., M.G., M.D.H.); Department of Radiology (K.M.T., C.B.L.M.M.) and Department of Biomedical Engineering and Physics, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands (H.A.M.); Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.V.M.); Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.); Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine; Los Angeles, CA (J.L.S.); Department of Neurology, Helsinki University Central Hospital and Department of Neurological Sciences, University of Helsinki, Helsinki, Finland (D.S.); University of Edinburgh, Edinburgh, United Kingdom (W.W.); and Department of Neurology, University of Heidelberg, Heidelberg, Germany (W.H.). Originally published1 Sep 2015https://doi.org/10.1161/STROKEAHA.115.010049Stroke. 2015;46:2981–2986Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2015: Previous Version 1 IntroductionIntracranial hemorrhage is an important safety end point in clinical trials.1–6 Yet, not each intracranial hemorrhage detected by computed tomography (CT) or magnetic resonance imaging (MRI) worsens neurological symptoms and impairs outcomes. Consequently, intracranial hemorrhages after ischemic stroke and reperfusion therapy are classified by both imaging characteristics and the association with clinical worsening. Pure radiological classification uses the location, form, and extent of hemorrhage and its relation to ischemic injury to distinguish among hemorrhage subtypes that may differ in impairment of neurological function and prognosis. Mixed radiological–clinical classification adds clinical symptoms to the presence of radiological hemorrhage to classify intracranial hemorrhages as symptomatic or asymptomatic.Historically, modern approaches to classifying hemorrhage after reperfusion therapy began with the emphasis of Pessin et al1 on the radiographic distinction between hemorrhagic infarction (HI) and parenchymatous hematoma (PH) after embolic stroke. They stated that HI refers to the pathological condition in which petechial or more confluent hemorrhages occupy a portion of an area of ischemic infarction. PH in an area of infarction; in contrast, is a solid clot of blood with mass effect, which displaces and destroys brain tissue.1 They later proposed that HI (in contrast to PH) could be more of a CT curiosity than a dreaded complication.2 Wolpert et al5 defined HI as areas of barely visible increased density with indistinct margins within an infarct or areas of increased density with indistinct margins and a speckled or mottled appearance or multiple areas of coalescent hemorrhage. A mass effect could be present because of the either edema or hemorrhagic component and PH (later named parenchymal hematoma3) and as very dense, homogenous region(s) of circumscribed increased density usually with mass effect. Both HI and PH are presumably caused by the same postischemic pathophysiology, bleeding from damaged reperfused arteries, arterioles, capillaries, or venules.Levy et al6 first used the term symptomatic intracranial hemorrhage (SICH) and distinguished intracerebral hematoma from hemorrhagic conversion by requiring either contemporaneous neurological worsening or a new mass effect on CT for intracerebral hematoma.The European Cooperative Acute Stroke Study (ECASS) group graded each HI and PH into the CT grades 1 and 2 to evaluate with greater nuance the clinical relevance of intracranial hemorrhage as detected on CT after ischemic stroke.4 In agreement with histological findings,7,8 the ECASS protocol adapted pre-existing criteria1,4 to define HI 1 as small petechiae along the margins of the infarct, and HI 2 as more confluent petechiae within the infarcted area, but without space-occupying effect. PH 1 was defined as a clot not exceeding 30% of the infarcted area with some mild space-occupying effect. PH 2 represented dense blood clot(s) exceeding 30% of the infarct volume with significant space-occupying effect.9 Interobserver agreement on these categories was good although the justification for the 30% threshold between PH1 and PH2 was not clarified.10 Regardless, in the ECASS, only PH2, but not PH1 or HI, was associated with early deterioration and 3-month mortality.10 Consequently, the ECASS investigators did not report on SICH, but presented the bleeding categories as detected by CT in their trial populations.9 The National Institute of Neurological Disorders and Stroke (NINDS) recombinant tissue-type plasminogen activator (tPA) Stroke Study Group considered in their 2 trials an intracranial hemorrhage that occurred within 36 hours of treatment onset as symptomatic if it was not seen on a previous CT scan, and there had subsequently been either a suspicion of hemorrhage or any decline in neurological status.11 The protocol of the 2 NINDS studies required brain CT on day 1 and 7 after treatment. Without defining the type of brain hemorrhage and the severity of neurological symptoms associated with the CT finding, the NINDS investigators observed 12 of 168 patients (7%) with SICH after tPA and 2 of 165 patients (1%) after placebo. In ECASS II, the investigators categorized intracranial hemorrhages into HI1, HI2, PH1, and PH2 and defined SICH as blood at any site in the brain on the CT scan (as assessed by the CT reading panel, independently of the assessment by the investigator), documentation by the investigator of clinical deterioration, or adverse events indicating clinical worsening (eg, drowsiness and increase of hemiparesis) or causing an increase in the National Institutes of Health Stroke Scale (NIHSS) score of ≥4 points."12 A post hoc analysis of the ECASS II data confirmed PH2 as an independent variable associated with death at 3 months after ischemic stroke.13 The Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) defined symptomatic intracerebral hemorrhage as local or remote PH2 on 22– to 36-hour post-treatment imaging, combined with a neurological deterioration of ≥4 points on the NIHSS from baseline, from the lowest NIHSS value between baseline and 24 hours, or leading to death.14 The SITS-MOST investigators reported that 107 patients of 6444 treated patients (1.7%) fulfilled these criteria. The ECASS III investigators defined SICH as any hemorrhage with neurological deterioration, as indicated by an NIHSS score that was higher by ≥4 points than the value at baseline or the lowest value in the first 7 days or any hemorrhage leading to death. In addition, the hemorrhage must have been identified as the predominant cause of the neurological deterioration. They implemented for the first time a causal relationship between brain imaging findings and neurological deterioration in the definition, taking into account that other brain pathology than hemorrhage could impair neurological function.15 With this definition, the ECASS III investigators identified 10 patients with SICH among 418 alteplase-treated patients (2.4%) and 1 SICH patients among 403 placebo-treated patients (0.2%). When applying other SICH definitions for this study population, the incidences of SICH after tPA were 7.9% (NINDS), 5.3% (ECASS II), and 1.9% (SITS-MOST). Treatment with tPA increased the odds of SICH by an odds ratio of 2.4 (NINDS), 2.4 (ECASS II), 7.8 (SITS-MOST), and 9.9 (ECASS III). Subsequent studies confirmed that the NINDS definition of symptomatic hemorrhage was overly inclusive, capturing many cases in which the bleeding did not worsened final functional outcome.16,17,18 The NINDS investigators desired to select a definition that maximized the sensitivity to any risk related to bleeding associated with tPA, and the NINDS definition served this purpose well. However, as shown above, the definition of SICH used by ECASS III and SITS-MOST provided better discrimination between tPA and placebo as measured by odds ratio and better identification of bleeds associated with altered final clinical outcome.In the International Stroke Trial-3 (IST-3), SICH was defined as a clinically significant deterioration or death within the first 7 days of treatment with evidence of either significant brain parenchymal hemorrhage (local or distant from the infarct) or significant hemorrhagic transformation (HT) of an infarct on brain imaging. This inclusive definition captured a similarly large group of patients as the NINDS Study definition (with an absolute risk of SICH of 6.8% [104 of 1515] by <7 days of randomization), although after taking account of stroke severity and age, there was no evidence that the relative risk of bleeding with alteplase was higher in IST-3 than in other trials.19 The risk of poor outcome in patients who had an SICH was high: by 6 months after randomization, few patients w
Referência(s)