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Predicting hemorrhagic transformation after IV-tPA with CT perfusion.

A Alpernas1, H Hallevi2, U Sadeh Gonik3

  • 1Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.

Journal of the Neurological Sciences
|November 8, 2025
PubMed
Summary

CT perfusion (CTP) imaging identifies a core infarct, which predicts hemorrhagic transformation (HT) and worse outcomes in acute ischemic stroke patients receiving intravenous thrombolysis (IVT). Penumbra volume did not show this association.

Keywords:
CT-perfusionHemorrhagic transformationIschemic strokeReperfusionStroketPA

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Area of Science:

  • Neurology
  • Radiology
  • Medical Imaging

Background:

  • CT-perfusion (CTP) is crucial for treatment selection in acute ischemic stroke, primarily studied in endovascular thrombectomy.
  • The predictive value of CTP for hemorrhagic transformation (HT) after intravenous thrombolysis (IVT) remains unassessed.

Purpose of the Study:

  • To investigate the association between CTP parameters and HT in acute ischemic stroke patients treated solely with IVT.
  • To examine the relationship between CTP findings and clinical outcomes in this patient cohort.

Main Methods:

  • Retrospective analysis of consecutively enrolled acute stroke patients treated with IVT only.
  • CTP was performed on admission, with follow-up non-contrast CT at 24 hours.
  • Statistical analysis correlated CTP core and penumbra volumes with HT and clinical outcomes.

Main Results:

  • In 427 patients with adequate CTP, core volume was 6.3 ml and penumbra volume was 29.5 ml.
  • CTP core and penumbra presence correlated with HT (p < 0.001, p = 0.009).
  • Multivariate analysis confirmed CTP core presence associated with HT, worse outcomes, and mortality (p = 0.01, p = 0.025, p = 0.008).

Conclusions:

  • CTP core presence, not penumbra, predicts higher rates of HT, poor outcomes, and mortality in acute stroke patients receiving IVT.
  • Further research is needed to define CTP's role in optimizing thrombolysis patient selection and prognosis.