Letter by Turc et al Regarding Article, “Defining Clinically Relevant Cerebral Hemorrhage After Thrombolytic Therapy for Stroke: Analysis of the National Institute of Neurological Disorders and Stroke Tissue-Type Plasminogen Activator Trials”

We read with interest the important article by Rao et al.1 Using publicly available data from the National Institute of Neurological Disorders and Stroke Tissue-Type Plasminogen Activator (NINDS-tPA) trials, the authors compared 4 definitions of intracranial hemorrhage (ICH) after thrombolysis to identify the most clinically relevant. They conclude that the European Cooperative Acute Stroke Study 2 (ECASS-2) and Modified Safe Implementation of Thrombolysis in Stroke-Monitoring Study (mSITS-MOST) definitions best identify tissue-type plasminogen activator hemorrhages that alter final outcome, but that their results favor the ECASS-2 definition, in line with previous reports.One important feature of the ECASS-2 definition is that it encompasses minor ICH, sometimes unlikely to cause neurological deterioration such as hemorrhagic infarction type 1 or 2. In relation to this, we are puzzled by the fate of the 6 patients (No. 22–27) who had a symptomatic ICH according to ECASS-2 and were all dead at 3 months, yet did not have parenchymal hemorrhage, raising the question whether these patients’ …