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Ischemic small vessel disease and stroke



Does the presence of ischemic small vessel disease decrease the effectiveness or increase the risk of intracranial hemorrhage when using thrombolytic therapy for stroke within 3 hours of onset of symptoms?


Study of the relationship between the degree of white matter disease and tPA outcomes has not been performed specifically to my knowledge. However, it is well known that the biggest risk factors for white matter disease are age and hypertension. Age is one of the most important predictors of outcome from stroke, and this is also true with regard to tPA (older patients who receive tPA are less likely to do well by 3 months than younger patients). In a similar fashion, we feel that high blood pressure is one factor that must be closely watched as high blood pressures after tPA may increase the risk for bleeding. There has been some work showing that patients with severe white matter changes are at somewhat higher risk for intracerebral hemorrhage (primary hemorrhagic stroke, this is not referring to the hemorrhage related to tPA use).

So in a sense, these three factors (white matter, age, and hypertension) all confer similar effects and it is reasonable to think that those with lots of white matter disease will be older and have hypertension, and are likely to be at slightly higher risk for bleeding and likely to have slightly worse outcome than younger patients.

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Response by:

Brett   Kissela, MD Brett Kissela, MD
Assistant Professor of Neurology
Director, Neurology Residency Program
College of Medicine
University of Cincinnati