Thrombolysis in Postoperative Stroke

Nicolas Voelkel, MD; Nikolai Dominik Hubert, MSc; Roland Backhaus, MD; Roman Ludwig Haberl, MD; Gordian Jan Hubert, MD


Stroke. 2017;48(11):3034-3039. 

In This Article


From February 2003 to October 2014, 4848 patients received tPA for stroke in the TEMPiS network. Among those, 134 were identified as having had surgical interventions within 90 days before IVT (Figure 1). Patients had a median age of 75 years (interquartile range, 66–79), had a median NIHSS of 11 (interquartile range, 7–17), and were more often men (56%; Table 1; Table I in the online-only Data Supplement). Four of those patients had 2 surgical procedures within the time period (Table II in the online-only Data Supplement). Surgery was performed within 1 to 10 days before stroke in 49 patients (37%) and 11 to 90 days before stroke in 85 (63%). Surgery was classified as major in 86 cases (63%) and minor in 48 (36%). Types of surgery are shown in Table 2.

Figure 1.

Days between surgery and thrombolysis therapy. All columns, patients with preceding surgery; black columns, patients with surgical site hemorrhage (SSH) after thrombolysis.

In 9 patients (7%), SSH developed after IVT (Table 3), of whom 4 (3%) were categorized as life-threatening or disabling according to Valve Academic Research Consortium and required additional intervention (transfusion of red cell concentrate, acute colonoscopy, and removal of subcutaneous hematoma). All 4 serious bleeding events occurred in patients with major surgery, none of these were fatal. One of these patients also had an eventually fatal bleeding remote from the surgical area (Table 4).

Rate of ICH was 9.7% (13/134), all asymptomatic. Other bleeding complications occurred in 5.2% (7/134), and in-hospital mortality was 8.2% (11/134). Ten patients died because of severity of index ischemic stroke, 1 patient died from non-SSH gastric bleeding. Overall non-ICHs (including those in surgical areas) were found in 15 patients (11.2%).

The chance of SSH was significantly higher in patients with recent than in those with nonrecent surgeries (14.3% versus 2.4%; ORadj, 10.73; 95% confidence interval, 1.88–61.27). In patients with major surgery, the rate of SSH was nonsignificantly higher than in patients with minor operations (8.1% versus 4.2%; ORadj, 4.03; 95% confidence interval, 0.65–25.04). Rate of major versus minor surgery was unequally distributed in recent and nonrecent subgroups, and statistical analysis was adjusted accordingly. There was no significant difference in intracerebral hemorrhage, other bleeding, and in-hospital mortality regarding the subgroups. Highest bleeding risk was seen in patients who had surgeries that were both recent and major (21.7%; Figure 2). Comparing this high-risk group with all other patients showed an 8-fold higher chance of SSH development (ORadj, 8.36; 95% confidence interval, 1.82–38.48).

Figure 2.

Rate of surgical site hemorrhage after intravenous thrombolysis (IVT) in combined subgroups. Major indicates surgery with major bleeding risk; minor, surgery with minor bleeding risk; nonrecent, surgery between 11 and 90 days before IVT; and recent, surgery within 10 days before IVT.