Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK.
Stroke. 2012 Nov;43(11):2904-9. doi: 10.1161/STROKEAHA.112.665331. Epub 2012 Sep 20.
Recombinant tissue plasminogen activator (rtPA) is an effective treatment for acute ischemic stroke but is associated with an increased risk of intracranial hemorrhage (ICH). We sought to identify the risk factors for ICH with a systematic review of the published literature.
We searched for studies of rtPA-treated stroke patients that reported an association between a variable measured before rtPA infusion and clinically important ICH (parenchymal ICH or ICH associated with clinical deterioration). We calculated associations between baseline variables and ICH with random-effect meta-analyses.
We identified 55 studies that measured 43 baseline variables in 65 264 acute ischemic stroke patients. Post-rtPA ICH was associated with higher age (odds ratio, 1.03 per year; 95% confidence interval, 1.01-1.04), higher stroke severity (odds ratio, 1.08 per National Institutes of Health Stroke Scale point; 95% confidence interval, 1.06-1.11), and higher glucose (odds ratio, 1.10 per mmol/L; 95% confidence interval, 1.05-1.14). There was approximately a doubling of the odds of ICH with the presence of atrial fibrillation, congestive heart failure, renal impairment, previous antiplatelet agents, leukoaraiosis, and a visible acute cerebral ischemic lesion on pretreatment brain imaging. Little of the variation in the sizes of the associations among different studies was explained by the source of the cohort, definition of ICH, or degree of adjustment for confounding variables.
Individual baseline variables were modestly associated with post-rtPA ICH. Prediction of post-rtPA ICH therefore is likely to be difficult if based on single clinical or imaging factors alone. These observational data do not provide a reliable method for the individualization of treatment according to predicted ICH risk.
重组组织型纤溶酶原激活物（rtPA）是治疗急性缺血性脑卒中的有效方法，但会增加颅内出血（ICH）的风险。我们旨在通过系统综述已发表文献来确定与 rtPA 治疗相关的 ICH 风险因素。
我们检索了接受 rtPA 治疗的脑卒中患者的研究，这些研究报告了 rtPA 输注前测量的变量与临床上重要的 ICH（实质内 ICH 或与临床恶化相关的 ICH）之间的关系。我们使用随机效应荟萃分析计算了基线变量与 ICH 之间的相关性。
我们共确定了 55 项研究，这些研究共纳入了 65264 例急性缺血性脑卒中患者的 43 项基线变量。rtPA 后 ICH 与较高的年龄（优势比，每增加 1 岁增加 1.03；95%置信区间，1.01-1.04）、较高的卒中严重程度（优势比，每增加 1 个 NIHSS 评分点增加 1.08；95%置信区间，1.06-1.11）和较高的血糖（优势比，每增加 1mmol/L 增加 1.10；95%置信区间，1.05-1.14）相关。存在心房颤动、充血性心力衰竭、肾功能不全、既往抗血小板药物、脑白质疏松症和治疗前脑影像上可见急性脑缺血性病变时，ICH 的发生几率增加近一倍。不同研究之间关联大小的差异主要归因于队列来源、ICH 定义和混杂因素调整程度。
个别基线变量与 rtPA 后 ICH 有一定的相关性。如果仅基于单个临床或影像学因素，预测 rtPA 后 ICH 可能很困难。这些观察性数据并不能为根据预测的 ICH 风险进行个体化治疗提供可靠的方法。
