The risk of intravenous thrombolysis-induced intracranial hemorrhage in Taiwanese patients with unruptured intracranial aneurysm

Abstract

Background: The presence of an intracranial aneurysm is contraindicated to recombinant tissue plasminogen activator (r-tPA) treatment for acute ischemic stroke. However, it is difficult to exclude asymptomatic intracranial aneurysms by using conventional, noncontrast head computed tomography (CT), which is the only neuroimaging suggested before r-tPA. Recent case reports and series have shown that administering r-tPA to patients with a pre-existing aneurysm does not increase the bleeding risk. However, Asians are known to have a relatively higher bleeding risk, and little evidence is available regarding the risk of using r-tPA on Asian patients with intracranial aneurysms.

Methods: Medical records from the Shuang Ho hospital stroke registration between July 2010 and December 2014 were retrospectively reviewed, and 144 patients received r-tPA. Unruptured intracranial aneurysms were detected using CT, or magnetic resonance or conventional angiography after r-tPA. The primary and secondary outcomes were the difference in overall intracranial hemorrhage (ICH) and symptomatic ICH after r-tPA. The differences were analyzed using Fisher's exact or Mann-Whitney U tests, and p < 0.05 was defined as the statistical significance.

Results: A total of 144 patients were reviewed, and incidental unruptured intracranial aneurysms were found in 11 of them (7.6%). No significant difference was observed in baseline demographic data between the aneurysm and nonaneurysm groups. Among patients with an unruptured aneurysm, two had giant aneurysms (7.7 and 7.4 mm, respectively). The bleeding risk was not significant different between aneurysm group (2 out of 11, 18%) with nonaneurysm group (7 out of 133, 5.3%) (p = 0.14). None of the patients with an unruptured aneurysm had symptomatic ICH, whereas one patient without an aneurysm exhibited symptomatic ICH.

Conclusions: The presence of an unruptured intracranial aneurysm did not significantly increase the risk of overall and symptomatic ICH in Taiwanese patients after they received r-tPA.

Fig 1. Representative images of patients with intracranial aneurysm with a complicated post-r-tPA intracranial hemorrhage.

(A-C) The 72-year-old man had acute ischemic stroke and had received r-tPA within 3 h after the onset of stroke. Follow-up diffusion-weighted imaging (A) (2 h after r-tPA) revealed acute ischemic stroke over the left middle cerebral artery territory. (B) Magnetic resonance angiography revealed a small (2 mm) saccular form of intracranial aneurysm (arrow) over the left internal carotid artery (Source images of magnetic resonance angiography is available in the S1 Fig). (C) Follow-up computed tomography performed 2 days after r-tPA demonstrated petechial hemorrhage in the infarcted margin. (D-F) The 77-year-old woman had acute ischemic stroke and had received r-tPA within 3 h after the onset of stroke. Follow-up diffusion-weighted imaging (D) (2 days after r-tPA) revealed acute ischemic stroke over the left middle cerebral artery territory. (E) Magnetic resonance angiography revealed a small (2.5 mm) saccular form of intracranial aneurysm (arrow) over the left internal carotid artery (Source images of magnetic resonance angiography is available in the S2 Fig). (F) T2-weighted image demonstrated petechial hemorrhage over the infarcted areas without mass effect.