A Case of Spontaneous Hemorrhagic Transformation in a patient with Cardioembolic Stroke due to Atrial Fibrillation

Raymond Pranata1, Veresa Chintya2, Emir Yonas3

1General Practitioner, Tabanan General Hospital, Tabanan, Bali, Indonesia 2General Practitioner, Sanjiwani General Hospital, Gianyar, Bali, Indonesia 3Faculty of Medicine, YARSI University, Jakarta, Indonesia

ABSTRACT

INTRODUCTION: Hemorrhagic transformation (HT) refers to aspectrum of ischemia-related brain hemorrhage and is associated with increased morbidity and mortality of acute ischemic stroke.

CASE ILLUSTRATION: An 83 years old female presented with loss of consciousness 30 minutes before admission. Her past medcal history of congestive heart failure, hypertension, atrial fibrillation (AF), and stroke. Physical examination showed GCS 7 andBP 190/100 mmHg. Electrocardiography showed Atrial Fibrillation NormoVentricular Response and Left Ventricular Hypertrophy. Laboratory examination showed thrombocytopenia, hypokalemia,and INR of 1,8. National Institutes of Health Stroke ScaleScore: 16CHA₂ DS₂ -VASc: 7, HAS-BLED: 4.Thorax Xray revealed cardiomegaly and Thorax CT Scan depicted characteristic of hemorrhagic transformation of an ischemic infarct. The patient was treated with hemorrhagic stroke protocol and mannitol.

DISCUSSION: Atrial fibrillation is associated with greater volumes of more severe baseline hypoperfusion, leading to higher infarct growth, more frequent severe HT and worse stroke outcomes. This patient has massive infarction andAFwhich were independent predictors of HT risk. In patients with AF probability of bleeding was about 95% if the volume of infarction edema >10 cm3.Hemorrhagic transformations may occur in patients with acute ischemic stroke who received thrombolytic, however, it may also occur spontaneously in 12.3 % of patients with ischemic stroke. Warfarin has been associated with increased HT riskirrespective of INR and aPTT values. Hemorrhage risk stratification score might be used to predict HT in acute ischemic stroke.Anticoagulant may be reinitiated after 4-8 weeks. Long-term anticoagulation with NOAC (similar efficacy with lower bleeding risk compared to VKA) or Left atrial appendage occlusion.

CONCLUSION: One-third of ischemic stroke patient may experience hemorrhagic transformation.Physician must strike a balance between stroke recurrence and HT.

Keywords:Atrial Fibrillation, Stroke, Anticoagulant