Haemorrhagic Transformation of Infarction
💡 About
Haemorrhagic transformation (HT) is a common complication after ischemic stroke, especially following thrombolysis (tPA) or anticoagulation.
It represents bleeding into the infarcted area and is classified into haemorrhagic infarctions (HI) and parenchymal haematomas (PH), each with prognostic implications.
🔎 Classification
- 🩸 Haemorrhagic Infarction (HI) – petechial bleeding without mass effect:
- HI1: Small petechiae at margins.
- HI2: Confluent petechiae within infarct, no space-occupying effect.
- 🧠 Parenchymal Haematoma (PH) – dense bleed with mass effect:
- PH1: <30% of infarcted area, mild mass effect.
- PH2: >30% or remote clot, significant mass effect.
🩺 Clinical Significance
- ✅ HI: Often asymptomatic, treatment usually unchanged, better prognosis.
- ⚠️ PH: Risk of neurological deterioration & ↑ mortality. May require urgent reversal of anticoagulation or surgery.
🖥️ Imaging
- CT: HI = patchy hyperdensities without mass effect; PH = homogeneous hyperdensity + mass effect.
- MRI (SWI): very sensitive for haemorrhagic components.
⚡ Risk Factors
- tPA use 💉
- Anticoagulants / antiplatelets
- Large infarcts 🧠
- Hypertension, age, hyperglycaemia
- Blood–brain barrier disruption
💊 Management
- 👀 Monitoring: close neuro obs + repeat imaging.
- 📉 BP control: avoid extremes; optimise perfusion.
- 💊 Medications: stop/reverse anticoagulants if PH.
- 🔪 Surgery: consider decompression or evacuation if large PH with mass effect.
- 🏥 Supportive: ICU care for severe cases.
📈 Prognosis
- 🙂 HI: Favourable, minimal clinical impact.
- ☠️ PH: High morbidity & mortality due to mass effect and ↑ ICP.
📚 References
- Fiorelli M, Bastianello S, von Kummer R, et al. Stroke. 1999;30(11):2280-2284.
- Berger C, Fiorelli M, Steiner T, et al. Stroke. 2001;32(6):1330-1335.
- Lansberg MG, Thijs VN, Bammer R, et al. Stroke. 2007;38(8):2275-2278.
