Comparing Outcome In Hemorrhagic Transformation After Intravenous Thrombolysis Between In-house and Outside Hospital Treatment

Introduction: Intravenous thrombolysis (alteplase) is now standard of care in patients with acute ischemic stroke within 4.5 hours. Approximately 5-6 % of patients developed hemorrhagic transformation after alteplase; out of which 1-2 % have severe bleed resulting in death. Many factors leading to poor outcome higher NIHSS, time of symptom onset to need time, High blood glucose, elevated BP etc. Hypothesis: In this study we aim to compare the outcome between In-House alteplase vs patients receiving alteplase Outside hospital and later transferred, eventually develops hemorrhagic transformation.
Methods: We analyzed patients who received thrombolysis from June 2015 to June 2016 through Electronic Medical records. Hemorrhagic transformation grading scale used in Berger C, 2001, Stroke. BP cutoff was set at >180/100 systolic post alteplase. Two groups were compared In-House and Outside transfers.
Results: There were total 18 patients (In-House 10 and 8 Outside) who developed hemorrhagic transformation out of 154 patients who received alteplase in one year. Average symptom onset to needle time/ initial NIHSS was higher (196min/20) in In-House group vs Outside (142 min/16) respectively. However, discharge NIHSS and MRS was noted to be higher in Outside group by 11 points and 1 point respectively. Whereas, average duration of hospital stay was higher in In-House group by 4 days. Both groups noted to have similar BP elevation (60%) suggesting BP as important indicator for hemorrhagic transformation. Mortality rate was higher in Outside group at 60% (higher Hemorrhagic Scale) compared to 30 % in In-House group, although same percentage (60) of BP elevation was noted in both groups. The better outcome in In-house group could be attributed to higher percentage of successful intervention in In-House group (50%) vs Outside (12%). Conclusion: Patients who received alteplase In-House, saw a lower percentage of fatal hemorrhagic transformation and overall better morbidity rate likely from faster and timely successful intervention.