Influence of moderate to severe leukoaraiosis on hemorrhagic transformation and prognosis of acute ischemic stroke patients after intravenous thrombolysis

Objective To investigate the influence of moderate to severe leukoaraiosis (LA) on hemorrhagic transformation and prognosis of patients after intravenous recombinant tissue plasminogen activator thrombolysis for acute ischemic stroke and analyze influencing factors of the clinical prognosis. Methods We consecutively collected patients with acute infarct on anterior circulation (n=78) in Department of Neurology or Emergency of our hospital between January 2014 and March 2017, and all patients received intravenous thrombolysis therapy within the 4.5-hour time window. All patients processed brain MRI after intravenous thrombolysis therapy. According to the degree of LA, all subjects were classified into two groups; LA group (moderate to severe) vs no LA group (absent to mild). Clinical data were obtained and compared among patients with different grades of LA. Logistic regression analysis was used to confirm the relevant factors of prognosis 90 days after stroke. Results Among 78 enrolled patients, 24 (30.8%) were classified as LA and 54 (69.2%) as no LA. In the group of LA, 33.3% (8/24) patients conducted hemorrhagic transformation, whereas 11.1% (6/54) patients also underwent hemorrhagic transformation in the group of no LA. There was a significant difference between the two groups (χ2=5.571, P=0.018). But symptomatic intracranial hemorrhage accounted for 16.7% (4/24) and 5.6% (3/54) respectively in the two groups without significant difference (χ2=2.304, P=0.129). Three-month recurrence of stroke in the groups of LA and no LA was 20.8% (5/24) and 5.6% (3/54) respectively, also without significant difference between the two groups (χ2 =3.850, P=0.050). Age ((73.7±6.7) years vs (61.3±10.6) years, t=6.567, P=0.012), 90 d Fugl-Meyer Scale (FMS) score (92.3±3.4 vs 72.9±7.8, t=22.345, P<0.01) and proportion of 90 d modified Rankin Scale score 0-2 (83.3% (45/54) vs 50.0% (12/24), χ2=9.383, P=0.002) were significantly different between the two groups. Follow-up 90-day after onset showed that the good outcome was found in 57 cases (73.1%), poor outcome in 21 patients (26.9%) and death in six cases (7.7%). The grade of LA (57.1% (12/21) vs 21.1% (12/57), χ2=9.383, P=0.002), silent lacunar infarction (66.7% (14/21) vs 35.1% (20/57), χ2=6.224, P=0.013), age ((72.8±7.9) vs (61.5±11.7) years, t=4.423, P=0.039), proportion of thrombolysis within 3.0-4.5 hours (71.4% (15/21) vs 38.6% (22/57), χ2=6.634, P=0.010), vascular occlusion size (66.7% (14/21) vs 38.6% (22/57), χ2=4.865, P=0.027), infarction size (52.4% (11/21) vs 12.3% (7/57), χ2=14.053, P=0.001) and baseline NIHSS score (16.9±6.7 vs 9.5±4.5, t=5.426, P=0.022) were significantly different between the two groups. After adjusting for age, thrombolysis time, baseline NIHSS score, infarction size, vascular occlusion size and silent lacunar infarction, multivariate analysis revealed that moderate to severe LA (OR=4.564, 95% CI 1.199-67.724, P=0.033) was risk factor for worse outcome of patients after intravenous thrombolysis. Conclusions Acute ischemic stroke patients with moderate to severe LA have high hemorrhagic transformation after intravenous thrombolysis and may have poor 90-day FMS score. And moderate to severe LA was found to be an independent risk factor for prognosis in cerebral infarction patients with intravenous thrombolysis. Key words: Cerebral infarction; Tissue plasminogen activator; Thrombolytic therapy; Leukoaraiosis; Prognosis