Clinical Relevance of Detecting Asymptomatic Embolic Signals in Acute Stroke

Hemorrhagic TransformationTo the Editor:We read with interest the recent article by Fiorelli et al. 1 The authors confirmed the reliability of hemorrhagic transformation (HT) as a diagnosis which, as we have found, could be made by either a neuroradiologist or a trained neurologist.2 However, of greater clinical relevance was the fact that they found that only severe HT (parenchymal hematoma 2 [PH2] in ECASS I 1 ) was associated with an unfavorable outcome.As shown in the Table, the same result emerged from the Multicentre Acute Stroke Trial-Italy (MAST-I) analysis.3 We have found that severe HT is very often associated with intraventricular or subarachnoid bleeding.This finding, together with but independent of cerebral edema, made the prognosis unfavorable in our study.The severe HT (PH2) definition of ECASS I points to a "significant space occupying effect" and includes the presence of a "clot remote from the infarct area."But the ECASS I investigators did not specifically assess the effect of the intraventricular or subarachnoid bleeding on the prognosis.This finding and not HT per se is the real adverse effect of thrombolytic treatment, and we wonder whether any results from ECASS and NIH studies have been published on this point.We need confirmation of our funding on the prognostic significance of intraventricular or subarachnoid bleeding before implementing new strategies to prevent it or to manage it as soon as it develops.