Dear Editor,

I am writing to highlight the growing concern regarding a severe complication of thrombolytic therapy, intracranial hemorrhage, and the need to identify associated risk factors. Considering the frequency of comorbidities in stroke patients worldwide, it is essential to provide a global perspective on this issue.

Intracerebral hemorrhage is a severe complication associated with worse functional outcomes and greater disability¹. In 2021, in the United States, low albumin levels and elevated HbA1c levels were reported to be significantly associated with a higher risk of symptomatic intracranial hemorrhage (SIH) post-fibrinolysis². In China, smoking, prolonged activated partial thromboplastin time (aPTT), and thrombocytopenia were found to be associated with a higher risk of hemorrhagic transformation post-fibrinolysis³. In Iran, post-fibrinolysis hemorrhage in stroke was significantly related to atrial fibrillation (OR = 2.75, 95% CI: 1.24-6.09), NIHSS score 15-24 (OR = 5.22, 95% CI: 1.39-19.66), and NIHSS score >24 (OR = 7.25, 95% CI: 1.42-37.09). The National Institutes of Health Stroke Scale (NIHSS) assesses stroke severity through clinical parameters, with scores ranging from 0 to 42 points, classified as follows: <6 points: low, 6-14 points: medium-low, 15-24 points: medium-high, and ≥25 points: high⁴.

Not all studies have shown significant associations. For example, one of the largest studies during the COVID-19 pandemic, which included seven centers in Iran, one in Greece, and one in Germany, found that a history of COVID-19 was not associated with an increased risk of hemorrhagic transformation⁵. Similarly, an Italian study of 24 cases and 24 controls found no significant difference between the presence of active malignant neoplasia and the risk of intracranial hemorrhage (p-value: >0.999)⁶.

In Latin America, a study in Brazil reported that current statin treatment and high NIHSS scores were significantly related to SIH⁷. In Peru, no compatible studies were found on this topic. These results can be observed in the Table.

In conclusion, our findings highlight the importance of recognizing risk factors for intracranial hemorrhage post-fibrinolysis and the need for further studies. Identifying these risk factors would be highly useful for early neurological clinical examination and the use of imaging, such as computed tomography. It is recommended to allocate more resources for research in this field, especially in the Latin American population, as the limited evidence reported in this population hinders early recognition and timely management of patients at risk of hemorrhage post-thrombolytic therapy.