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Original Investigation |

Risk of Symptomatic Intracerebral Hemorrhage After Intravenous Thrombolysis in Patients With Acute Ischemic Stroke and High Cerebral Microbleed Burden A Meta-analysis

Georgios Tsivgoulis, MD1,2,3; Ramin Zand, MD1; Aristeidis H. Katsanos, MD2,4; Guillaume Turc, PhD5; Christian H. Nolte, MD6; Simon Jung, MD7,8; Charlotte Cordonnier, PhD9; Jochen B. Fiebach, MD6; Jan F. Scheitz, MD6; Pascal P. Klinger-Gratz, MD7; Catherine Oppenheim, PhD10; Nitin Goyal, MD1; Apostolos Safouris, MD2,11; Heinrich P. Mattle, MD8; Anne W. Alexandrov, PhD1,12; Peter D. Schellinger, MD13; Andrei V. Alexandrov, MD1
[+] Author Affiliations
1Department of Neurology, The University of Tennessee Health Science Center, Memphis
2Second Department of Neurology, Attikon Hospital, School of Medicine, University of Athens, Athens, Greece
3International Clinical Research Center, Department of Neurology, St Anne's University Hospital in Brno, Brno, Czech Republic
4Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
5Department of Neurology, Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, Inserm UMR S894, Départements Hospitalo-Universitaires Neurovasc, Paris, France
6Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany
7Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
8Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
9University Lille, Inserm, Centre Hospitalier Régional Universitaire de Lille, U1171, Degenerative and Vascular Cognitive Disorders, Lille, France
10Department of Radiology, Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, Inserm UMR S894, Départements Hospitalo-Universitaires Neurovasc, Paris, France
11Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
12Australian Catholic University, Sydney, Australia
13Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Minden, Germany
JAMA Neurol. 2016;73(6):675-683. doi:10.1001/jamaneurol.2016.0292.
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Importance  Cerebral microbleeds (CMBs) have been established as an independent predictor of cerebral bleeding. There are contradictory data regarding the potential association of CMB burden with the risk of symptomatic intracerebral hemorrhage (sICH) in patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT).

Objective  To investigate the association of high CMB burden (>10 CMBs on a pre-IVT magnetic image resonance [MRI] scan) with the risk of sICH following IVT for AIS.

Data Sources  Eligible studies were identified by searching Medline and Scopus databases. No language or other restrictions were imposed. The literature search was conducted on October 7, 2015. This meta-analysis has adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was written according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) proposal.

Study Selection  Eligible prospective study protocols that reported sICH rates in patients with AIS who underwent MRI for CMB screening prior to IVT.

Data Extraction and Synthesis  The reported rates of sICH complicating IVT in patients with AIS with pretreatment MRI were extracted independently for groups of patients with 0 CMBs (CMB absence), 1 or more CMBs (CMB presence), 1 to 10 CMBs (low to moderate CMB burden), and more than 10 CMBs (high CMB burden). An individual-patient data meta-analysis was also performed in the included studies that provided complete patient data sets.

Main Outcomes and Measures  Symptomatic intracerebral hemorrhage based on the European Cooperative Acute Stroke Study–II definition (any intracranial bleed with ≥4 points worsening on the National Institutes of Health Stroke Scale score).

Results  We included 9 studies comprising 2479 patients with AIS. The risk of sICH after IVT was found to be higher in patients with evidence of CMB presence, compared with patients without CMBs (risk ratio [RR], 2.36; 95% CI, 1.21-4.61; P = .01). A higher risk for sICH after IVT was detected in patients with high CMB burden (>10 CMBs) when compared with patients with 0 to 10 CMBs (RR, 12.10; 95% CI, 4.36-33.57; P < .001) or 1 to 10 CMBs (RR, 7.01; 95% CI, 3.20-15.38; P < .001) on pretreatment MRI. In the individual-patient data meta-analysis, high CMB burden was associated with increased likelihood of sICH before (unadjusted odds ratio, 31.06; 95% CI, 7.12-135.44; P < .001) and after (adjusted odds ratio, 18.17; 95% CI, 2.39-138.22; P = .005) adjusting for potential confounders.

Conclusions and Relevance  Presence of CMB and high CMB burdens on pretreatment MRI were independently associated with sICH in patients with AIS treated with IVT. High CMB burden may be included in individual risk stratification scores predicting sICH risk following IVT for AIS.

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Place holder to copy figure label and caption
Figure 1.
Forest Plot Comparing the Risk of Symptomatic Intracranial Hemorrhage Following Intravenous Thrombolysis In Patients With Acute Ischemic Stroke With and Without Cerebral Microbleeds (CMBs) on Pretreatment Magnetic Resonance Imaging

RR indicates risk ratio.

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Place holder to copy figure label and caption
Figure 2.
Forest Plots Comparing the Risk of Symptomatic Intracranial Hemorrhage Following Intravenous Thrombolysis in Patients With Acute Ischemic Stroke With Evidence of Cerebral Microbleed (CMB) Burden (>10 CMBs)

A, Compared with patients with 1 to 10 CMBs. B, Patients with 0 to 10 CMBs on pretreatment magnetic resonance imaging. RR indicates risk ratio.

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