Gebel J M, Sila C A, Sloan M A, Granger C B, Mahaffey K W, Weisenberger J, Green C L, White H D, Gore J M, Weaver W D, Califf R M, Topol E J
Cleveland Clinic Foundation, Ohio 44195, USA.
Stroke. 1998 Mar;29(3):563-9. doi: 10.1161/01.str.29.3.563.
Intracranial hemorrhage (ICH) is a serious complication of thrombolytic therapy. We systematically reviewed the radiographic features of 244 cases of symptomatic ICH complicating thrombolysis for acute myocardial infarction in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial, correlated these observations with clinical data, and speculated on hemorrhage pathogenesis.
CT scans from 244 patients suffering symptomatic ICH were systematically reviewed for selected radiographic features, including ICH type, location, hematoma characteristics, mass effect features, hydrocephalus, and preexisting lesions. Hematoma volume was estimated by computer-assisted volumetric analysis. Data from this analysis were correlated with clinical data including hypertension, anticoagulation, age, thrombolytic regimen, and ICH timing.
Most hemorrhages were large (median [25th, 75th percentile] volume, 72 mL [39, 118]), solitary (66%), lobar (77%), confluent (80%), and intraparenchymal (82%) with a blood/fluid level (82%) and little edema (median [25th, 75th percentile] volume, 9 mL [5, 16]). Hydrocephalus (P<.001), any one mass effect feature (P<.001), intraventricular hemorrhage (P=.022), mottled hematoma appearance (P=.050), and hematoma blood/fluid level (P<.001) were associated with higher hemorrhage volume in the radiographic analysis, as were older age (P=.005), treatment with combined streptokinase and tissue plasminogen activator (P=.034), and hemorrhage onset 8 to 13 hours after treatment (P=.008) in the clinical analysis. Subdural hemorrhage was a high-volume subgroup whose risk increased with antecedent trauma (P=.026) or syncope (P=.006). Deep intraparenchymal hemorrhage was associated with hypertension (P=.016), and multifocal ICH occurred significantly earlier after treatment (P=.002).
Although the majority of postthrombolytic ICH are large, solitary, and supratentorial, the spectrum is diverse. Features of mass effect reflected the large volumes, and hematoma characteristics of mottling and blood/fluid levels were frequent. Thrombolysis-related coagulopathy and age appear to be the most important identifiable factors in the genesis of postthrombolytic ICH, but the hemorrhage subtype seen may reflect an interaction with other factors such as hypertension, ICH timing, antecedent head trauma, and syncope.
颅内出血（ICH）是溶栓治疗的严重并发症。我们系统回顾了全球应用链激酶和组织型纤溶酶原激活剂治疗闭塞冠状动脉（GUSTO-1）试验中244例急性心肌梗死溶栓治疗后发生症状性ICH的影像学特征，将这些观察结果与临床数据相关联，并推测出血的发病机制。
对244例有症状性ICH患者的CT扫描进行系统回顾，以确定特定的影像学特征，包括ICH类型、位置、血肿特征、占位效应特征、脑积水和既往病变。通过计算机辅助容积分析估计血肿体积。该分析的数据与包括高血压、抗凝、年龄、溶栓方案和ICH发生时间在内的临床数据相关联。
大多数出血量大（中位数[第25、75百分位数]体积，72 mL[39，118]），单发（66%），脑叶性（77%），融合性（80%），脑实质内（82%），有血液/液平面（82%），且水肿轻微（中位数[第25、75百分位数]体积，9 mL[5，16]）。在影像学分析中，脑积水（P<0.001）、任何一种占位效应特征（P<0.001）、脑室内出血（P=0.022）、血肿呈斑点状外观（P=0.050）和血肿血液/液平面（P<0.001）与出血量较大相关；在临床分析中，年龄较大（P=0.005）、联合应用链激酶和组织型纤溶酶原激活剂治疗（P=0.034）以及治疗后8至13小时出血发作（P=0.008）也与出血量较大相关。硬膜下出血是一个高容量亚组，其风险随既往创伤（P=0.026）或晕厥（P=0.006）而增加。深部脑实质内出血与高血压相关（P=0.016），多灶性ICH在治疗后明显更早发生（P=0.002）。
尽管大多数溶栓后ICH量大、单发且位于幕上，但表现多样。占位效应特征反映了出血量较大，血肿斑点状外观和血液/液平面特征较为常见。溶栓相关凝血障碍和年龄似乎是溶栓后ICH发生中最重要的可识别因素，但所见出血亚型可能反映了与其他因素如高血压、ICH发生时间、既往头部创伤和晕厥的相互作用。
