Symptomatic Intracranial Hemorrhage After Stroke Thrombolysis: Comparison of Prediction Scores

The only approved clot-busting medical treatment in ischemic stroke, intravenous thrombolysis (IVT), is not without complications. One of the major reasons for withholding the therapy remains fear of symptomatic intracranial hemorrhage (sICH), which can worsen patients’ outcomes. The number needed for IVT to cause fatal sICH is 36.5, and to cause any worsening of outcome (≥1 grade on modified Rankin Scale) ranges from 29.7 to 40.1. There are several scoring systems for predicting the risk of sICH. In an ideal situation, a prediction score could identify patients with very high risk of postthrombolysis sICH. We aimed to compare the performance of existing risk prediction scores in a large multicenter cohort. Background and Purpose—Several prognostic scores have been developed to predict the risk of symptomatic intracranial hemorrhage (sICH) after ischemic stroke thrombolysis. We compared the performance of these scores in a multicenter cohort. Methods—We merged prospectively collected data of patients with consecutive ischemic stroke who received intravenous thrombolysis in 7 stroke centers. We identified and evaluated 6 scores that can provide an estimate of the risk of sICH in hyperacute settings: MSS (Multicenter Stroke Survey); HAT (Hemorrhage After Thrombolysis); SEDAN (blood sugar, early infarct signs, [hyper]dense cerebral artery sign, age, NIH Stroke Scale); GRASPS (glucose at presentation, race [Asian], age, sex [male], systolic blood pressure at presentation, and severity of stroke at presentation [NIH Stroke Scale]); SITS (Safe Implementation of Thrombolysis in Stroke); and SPAN (stroke prognostication using age and NIH Stroke Scale)-100 positive index. We included only patients with available variables for all scores. We calculated the area under the receiver operating characteristic curve (AUC-ROC) and also performed logistic regression and the Hosmer–Lemeshow test. Results—The final cohort comprised 3012 eligible patients, of whom 221 (7.3%) had sICH per National Institute of Neurological Disorders and Stroke, 141 (4.7%) per European Cooperative Acute Stroke Study II, and 86 (2.9%) per Safe Implementation of Thrombolysis in Stroke criteria. The performance of the scores assessed with AUC-ROC for predicting European Cooperative Acute Stroke Study II sICH was: MSS, 0.63 (95% confidence interval, 0.58–0.68); HAT, 0.65 (0.60– 0.70); SEDAN, 0.70 (0.66–0.73); GRASPS, 0.67 (0.62–0.72); SITS, 0.64 (0.59–0.69); and SPAN-100 positive index, 0.56 (0.50–0.61). SEDAN had significantly higher AUC-ROC values compared with all other scores, except for GRASPS where the difference was nonsignificant. SPAN-100 performed significantly worse compared with other scores. The discriminative ranking of the scores was the same for the National Institute of Neurological Disorders and Stroke, and Safe Implementation of Thrombolysis in Stroke definitions, with SEDAN performing best, GRASPS second, and SPAN-100 worst. Conclusions—SPAN-100 had the worst predictive power, and SEDAN constantly the highest predictive power. However, none of the scores had better than moderate performance. (Stroke. 2014;45:752-758.)