Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
Pediatr Neurol. 2019 Jun;95:26-33. doi: 10.1016/j.pediatrneurol.2019.01.023. Epub 2019 Feb 8.
Hemorrhagic transformation can complicate both arterial ischemic stroke and cerebral sinus venous thrombosis. Risk factors for hemorrhagic transformation after adult arterial ischemic stroke include larger infarct volume, cardioembolic stroke, and anticoagulation in the acute period. Large hemorrhagic transformation in adults is associated with poor outcome. Therefore hemorrhagic transformation is used as a safety end point for most arterial ischemic stroke acute treatment and secondary prevention trials. Up to 30% of children with arterial ischemic stroke have hemorrhagic transformation, most of which are petechial. As in adults, large infarct size is the greatest predictor of hemorrhagic transformation, but in children, acute anticoagulation is not a clear predictor of hemorrhage. As use of acute endovascular interventions for arterial ischemic stroke has expanded in adults, these therapies have also been used in some teenagers and even younger children. More information, including safety data with end points like hemorrhagic transformation, is needed in the pediatric population. In adults with cerebral sinus venous thrombosis, including those with hemorrhagic transformation, acute anticoagulation is associated with better outcomes and is the standard of care. Some hemorrhagic transformation may be evident at baseline in over half of children and neonates with cerebral sinus venous thrombosis. Anticoagulation-associated hemorrhage in pediatric cerebral sinus venous thrombosis occurs in about 10% of children but is not clearly related to outcome, whereas lack of anticoagulation may be associated with clot propagation and worse outcomes. This review provides background on hemorrhagic transformation of ischemic stroke in adults and summarizes literature regarding hemorrhagic transformation of pediatric arterial ischemic stroke and cerebral sinus venous thrombosis, with a focus on implications for acute treatment and outcome.
出血转化可并发动脉缺血性卒中和脑静脉窦血栓形成。成人动脉缺血性卒中后出血转化的危险因素包括梗死体积较大、心源性栓塞性卒中以及急性期抗凝治疗。成人大量出血转化与不良预后相关。因此，出血转化被用作大多数急性动脉缺血性卒中治疗和二级预防试验的安全终点。多达 30%的动脉缺血性卒中患儿发生出血转化，其中大多数为瘀点。与成人一样，较大的梗死面积是出血转化的最大预测因素，但在儿童中，急性抗凝治疗并不是出血的明确预测因素。随着急性血管内介入治疗在成人中的应用不断扩大，这些治疗方法也已在一些青少年甚至更年幼的儿童中使用。儿科人群需要更多信息，包括与出血转化等终点相关的安全性数据。在包括出血转化的脑静脉窦血栓形成成人患者中，急性抗凝治疗与更好的结局相关，是标准治疗方法。约一半以上的脑静脉窦血栓形成患儿和新生儿在基线时就存在明显的出血转化。在儿科脑静脉窦血栓形成中，约 10%的患儿发生抗凝相关出血，但与结局无明显关系，而缺乏抗凝治疗可能与血栓扩展和更差的结局相关。本综述提供了成人缺血性卒中出血转化的背景信息，并总结了关于儿科动脉缺血性卒中和脑静脉窦血栓形成出血转化的文献，重点关注对急性治疗和结局的影响。
