To describe the incidence, causes, management considerations and prognosis in patients presenting with simultaneous ischemic and hemorrhagic strokes

Simultaneous spontaneous ischemic and hemorrhagic strokes has rarely been reported, mostly confined to case reports in the literature. Appropriate management of such cases is unknown and challenging due to competing treatment goals e.g. antithrombotic therapy, blood pressure management.

Patients with a primary stroke ICD code of I61.XX, I62.XX and I63.XX admitted to George Washington Hospital between October 01, 2015 to June 30, 2018 were retrospectively identified using the hospital administrative database called MIDAS. Patients with primary ICD code I61 or I62 (hemorrhage) and secondary ICD code I63, and vice versa, were included. Only patients with neuroimaging evidence of acute intraparenchymal hemorrhage and acute cerebral infarction on initial neuroimaging were included. Patients with spontaneous or induced hemorrhagic transformation were excluded.

A total of 1103 unique patients were identified with primary stroke ICD codes. Of these patients, 75 had a combination of ischemic and hemorrhagic codes. A total of 11 (1.0% incidence) met all criteria after chart review. The most common presumed causes were blood pressure related (n=3), discrete hemorrhagic infarct and infarct (n=2), endocarditis (n=2), uncertain (n=4). Over half (6/11) were started on antithrombotic therapy during the hospitalization with a median start time of 10.5 days. Median length of stay was 12d and median discharge modified Rankin score was 4 with no deaths.

Simultaneous ischemic and hemorrhagic strokes is a rare entity (1%) and poses unique management challenges. Further studies using larger multicenter datasets are needed to better understand incidence, etiologies, management and prognosis.