Hemorrhagic transformation of acute ischemic stroke is limited in hypertensive patients with cardiac hypertrophy
Introduction
Stroke is a major health problem, being the third leading cause of death in industrialized countries and the most frequent cause of permanent disability in adults worldwide. Hypertension, known to cause significant damage to organs such as the heart, kidney, eye and vessels, is the main risk factor for stroke [1]. Moreover, high blood pressure imposes continuous mechanical challenge on the cardiovascular system leading to hypertrophic remodelling of both cardiac and vascular tissues. It is now increasingly recognized that this architectural cardiovascular remodelling can be considered a double-faced process, being both a sign of target organ damage evoked by hypertension itself and a compensatory adaptive process to hemodynamic overload [2], [3], [4].
Previous studies demonstrated that not only hypertension, but also cardiac hypertrophy is an independent risk factor for ischemic stroke [5], [6]. Moreover, we also found that cardiac hypertrophy is associated to an asymptomatic cerebral ischemic damage in hypertensive patients [7], thus leading to hypothesize that when the hypertensive conditions are more sustained, likely to induce a hypertrophic remodelling, brain ischemic injury is favoured. However, it should also be noticed that the cerebrovascular ischemic event in hypertensive patients, is not only delimited to the acute onset of reduced supply of nutrients to the brain but can also be characterized by a series of pathophysiological changes that further affect the prognosis [8], [9], [10]. A better knowledge of how risk factors affect also the evolution of ischemic brain lesions, beyond the acute event itself, is very important for clinical management and prognosis.
Actually, in a relevant subset of hypertensive patients ischemic brain lesions can further be affected by a second wave of injury characterized by disruption of the blood brain-barrier (BBB) and hemorrhagic transformation (HT) of the primary ischemic lesion, which significantly aggravates the clinical outcome [11], [12]. Some risk factors for HT, beyond hypertension itself, like aging, large brain lesions, high levels of blood glucose and thrombolytic treatment, have already been identified [13], [14]. However, whether the presence of cardiac hypertrophy, one of the typical hallmarks of sustained hypertension, can affect the transition of ischemic brain lesions toward HT remains unknown. For this reason, we analyzed retrospectively the data of hypertensive patients admitted to our Clinical Unit for Acute Stroke, focusing our attention on the role of hypertrophic cardiac remodeling in the hemorrhagic evolution of ischemic stroke.
Section snippets
Study population
We performed a blinded retrospective analysis of 99 consecutive hypertensive patients who were admitted to the Stroke Unit of IRCCS Neuromed from February 2008, with an acute ischemic stroke. Data were collected and analyzed in accordance with the principles stated in the Declaration of Helsinki and Title 45, U.S. Code of Federal Regulations, Part 46, Protection of Human Subjects, Revised November 13, 2001, effective December 13, 2001. Demographics, clinical data, risk factors for stroke and
Clinical characteristics of patients
Among the 99 patients with acute ischemic stroke, 52 were men and 47 women. Their mean age was 69 (± 14) years. The HT of ischemic lesions was diagnosed in 18% of subjects, and such prevalence is in accordance with previously published reports [11].
The characteristics of patients with and without HT are shown in Table 1. Average age, proportion of gender, anamnestic variables, systolic and diastolic blood pressure on admission, area of ischemic lesion and neurological evaluation. Treatment
Discussion
In this study, we show that cardiac hypertrophy is an independent protective factor against the development of HT and, more important, of sHT in hypertensive patients suffering an acute ischemic stroke. HT of acute ischemic lesions is a common complication occurring in 15–20% of patients. It can be defined as an area of bleeding within the ischemic cerebral tissue and it is represented by red blood cells, enriched with leukocytes. HT can affect the clinical outcome with potential serious short
Conclusions
Our study evaluated a cohort of hypertensive patients undergoing acute ischemic stroke. We focused our interest in the HT, one of the most serious complications that may ensue in these patients. Occurring in about 20% of patients with acute ischemic stroke, the HT is often unexpected and unpredictable, making even more unfavorable the prognosis of these patients. Besides the already known risk factors for the development of HT, usually related to the clinical history of patients, we here
Conflict of interest
The authors report no relationships that could be construed as a conflict of interest.
Acknowledgments
This work was supported by “Ricerca Corrente” from Italian Ministry of Health (RC-2014/2016) to GL. We thank Dr. Valeria Berardi for editing assistance in the preparation of the manuscript and Dr. Licia Iacoviello for helpful discussion of results.
References (23)
- et al.
Hemorrhagic cerebral infarction-a prospective study
Stroke
(1986) - et al.
Early hemorrhagic transformation of brain infarction: rate, predictive factors, and influence on clinical outcome results of a prospective multicenter study
Stroke
(2008) - et al.
Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators
Lancet
(1998) - et al.
Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology
J. Am. Soc. Echocardiogr.
(2005) - et al.
Left ventricular mass and body size in normotensive children and adults: assessment of allometric relations and impact of overweight
J. Am. Coll. Cardiol.
(1992) - et al.
Left ventricular hypertrophy and clinical outcomes in hypertensive patients
Am. J. Hypertens.
(2008) - et al.
Primary prevention of stroke
N. Engl. J. Med.
(1995)et al.Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension
Ann. Intern. Med.
(1991) - et al.
Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study
N. Engl. J. Med.
(1990) - et al.
Hypertensive left ventricular hypertrophy risk: beyond adaptive cardiomyocytic hypertrophy
J. Hypertens.
(2011) - et al.
Left ventricular mass and risk of stroke in an elderly cohort: the Framingham Heart Study
JAMA
(1994)
Left ventricular hypertrophy as an independent predictor of acute cerebrovascular events in essential hypertension
Circulation
Cited by (0)
- 1
These authors equally contributed to the work