Risk Factors and Outcomes of Hemorrhagic Transformation in Acute Ischemic Stroke Following Thrombolysis: Analysis of a Single-Center Experience and Review of the Literature

Abstract

Background and Objectives: This is a retrospective study conducted at the Clinical County Hospital of Craiova, Romania, providing valuable insights into hemorrhagic transformation (HT) in thrombolyzed patients with acute ischemic stroke (AIS). Hemorrhagic complications remain a significant concern after intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA). This study aims to analyze clinical and biological factors associated with HT following thrombolysis. Materials and Methods: A retrospective analysis was conducted on 356 patients who received rt-PA at the Clinical County Hospital of Craiova between January 2020 and December 2024. Patients were divided into three groups based on CT findings at 24 h post-thrombolysis: no HT, minimal HT, and massive HT. Baseline characteristics were analyzed, including demographics, medical history, NIHSS scores, imaging findings, and laboratory parameters. Statistical analysis was performed using ANOVA and chi-square tests, with a significance threshold of p < 0.05. Results: HT occurred in 12.08% of patients (minimal HT: 8.15%, massive HT: 3.93%). Mortality was significantly higher in the massive HT group (71.43%) compared to minimal HT (41.38%) and non-HT (13.42%) (p < 0.001). Lower platelet count (p = 0.003), elevated blood glucose (p = 0.004), prolonged QT interval (p = 0.004), and reduced fibrinogen levels (p = 0.005) were significantly associated with HT. Other risk factors included atrial fibrillation (p = 0.001), hypertension (p = 0.005), delayed door-to-needle time (p < 0.001), diabetes mellitus (p = 0.007), dense ACM sign on CT (p = 0.003), older age (p < 0.001), obesity (p = 0.001), early neurological deterioration at 2 h/24 h (p < 0.001), elevated GOT (p < 0.001), elevated GPT (p = 0.002), lower LDL cholesterol (p < 0.001), lower total cholesterol (p = 0.001), and lower triglycerides (p < 0.001). Conclusions: Patients with HT had worse clinical outcomes, with massive HT associated with the highest mortality. Risk factors include age, nutritional status, hyperglycemia, and low platelet and fibrinogen levels, among others.

Keywords: acute ischemic stroke; hemorrhagic transformation; intravenous thrombolysis; risk factors.

Figure 1

The hemorrhagic transformation of thrombolyzed ischemic stroke.

Figure 2

Age distribution and comorbidities (HTN—hypertension, DM—diabetes mellitus, AFib—atrial fibrillation).

Figure 3

Nutritional status and smoking.

Figure 4

Imaging findings. (MCA = middle cerebral artery, ASPECT = Alberta stroke program early CT score).

Figure 5

Timing of symptom onset and treatment ((DTN = door-to-needle time).

Figure 6

Interval QT.

Figure 7

Metabolic and hematological changes.

Figure 8

Hepaticchanges.

Figure 9

Lipid Profile.

Figure 10

Kidney function and blood pressure.