We evaluated the outcomes of patients receiving intravenous thrombolysis (IVT) with a history of intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) to determine the safety of IVT in this population.

IVT is the standard of care for ischemic stroke patients presenting within 4.5 hours of symptom onset, but prior ICH/SAH is a contraindication to its administration due to the theoretical increased risk of hemorrhagic transformation. Small retrospective studies regarding its off-label use have suggested IVT may be safe in this population, necessitating further study.

Data were prospectively collected from Florida hospitals participating in Get With the Guidelines-Stroke between January 2019 and December 2022. Patients diagnosed with ischemic stroke and treated with IVT were separated into those with a history of ICH/SAH and those without this history.

Among 20,369 patients treated with IVT for acute ischemic stroke, 94 (0.5%) had prior ICH/SAH. Patients with history of ICH/SAH were older (75 vs 70) and more likely to have dyslipidemia (56.4% vs 45.8%), atrial fibrillation (30.9% vs 15.0%), prior ischemic stroke (25.5% vs 11.7%), and antiplatelet drug use (52.1% vs 37.2%), all p values <0.05. Patients with prior ICH/SAH were more likely to develop symptomatic ICH within 36h of IVT (7.5% vs 2.2%, OR 3.6 [1.6-7.8]), while in-hospital mortality was similar (4.3% vs 3.3%). Patients with prior ICH/SAH were less likely to be discharged to home or acute rehab (55.3% vs 70.9%, OR 0.5 [0.3-0.8]) or ambulate independently at discharge (34.0% vs 49.1%, OR 0.5 [0.3-0.8]).

Patients with prior ICH/SAH who received IVT had more than triple the risk of symptomatic hemorrhage compared to those without this history. Our finding underscores apprehensions regarding the safety of IVT in this specific patient population and emphasizes the need for further research and cautious clinical consideration when weighing the risks and benefits of this treatment