Research Article| Volume 324, ISSUE 1-2, P65-69, January 15, 2013

Oxfordshire Community Stroke Project classification but not NIHSS predicts symptomatic intracerebral hemorrhage following thrombolysis

Published:October 24, 2012DOI:



      The Oxfordshire Community Stroke Project (OCSP) classification is a simple tool to categorize clinical stroke syndromes. We compared the outcomes of stroke patients after intravenous thrombolysis stratified by the baseline National Institutes of Health Stroke Scale (NIHSS) score or by the OCSP classification.


      We assessed the safety of thrombolysis in consecutive stroke patients who received intravenous thrombolysis within 3 h after onset. The patients were grouped by the NIHSS score into mild to moderate stroke (≤20) and severe stroke (>20), and also by the OCSP classification as having total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), posterior circulation infarcts (POCI), or lacunar infarcts (LACI). Symptomatic intracerebral hemorrhage (SICH) was used as the primary outcome.


      Of the 145 patients included in the study, 45 had a baseline NIHSS score>20. Their stroke syndromes were as follows: 78 with TACI, 29 with PACI, 16 with POCI, and 22 with LACI. The proportion of SICH was comparable between patients with high or low NIHSS score (11.1% vs. 9.0%, P=0.690). The chance of SICH was highest in patients with TACI (15.4%), followed by LACI (4.5%), PACI (3.4%), and POCI (0%). After adjustment for age, baseline glucose, and use of antiplatelet agents before admission, SICH was significantly increased in patients with TACI relative to those with non-TACI (odds ratio 5.92; 95% confidence interval 1.24–28.33, P=0.026).


      The OCSP clinical classification may help clinicians evaluate the risk of SICH following intravenous thrombolysis.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Neurological Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group
        Tissue plasminogen activator for acute ischemic stroke.
        N Engl J Med. 1995; 333: 1581-1587
      1. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. The NINDS t-PA stroke study group.
        Stroke. 1997; 28: 2109-2118
        • Adams H.P.
        • del Zoppo G.
        • Alberts M.J.
        • Bhatt D.L.
        • Brass L.
        • Furlan A.
        • et al.
        Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists.
        Stroke. 2007; 38: 1655-1711
      2. Generalized efficacy of t-PA for acute stroke. Subgroup analysis of the NINDS t-PA stroke trial.
        Stroke. 1997; 28: 2119-2125
        • Dzialowski I.
        • Hill M.D.
        • Coutts S.B.
        • Demchuk A.M.
        • Kent D.M.
        • Wunderlich O.
        • et al.
        Extent of early ischemic changes on computed tomography (CT) before thrombolysis: prognostic value of the Alberta Stroke Program Early CT Score in ECASS II.
        Stroke. 2006; 37: 973-978
        • Selim M.
        • Fink J.N.
        • Kumar S.
        • Caplan L.R.
        • Horkan C.
        • Chen Y.
        • et al.
        Predictors of hemorrhagic transformation after intravenous recombinant tissue plasminogen activator: prognostic value of the initial apparent diffusion coefficient and diffusion-weighted lesion volume.
        Stroke. 2002; 33: 2047-2052
        • Woo D.
        • Broderick J.P.
        • Kothari R.U.
        • Lu M.
        • Brott T.
        • Lyden P.D.
        • et al.
        Does the National Institutes of Health Stroke Scale favor left hemisphere strokes? NINDS t-PA Stroke Study Group.
        Stroke. 1999; 30: 2355-2359
        • Fink J.N.
        • Selim M.H.
        • Kumar S.
        • Silver B.
        • Linfante I.
        • Caplan L.R.
        • et al.
        Is the association of National Institutes of Health Stroke Scale scores and acute magnetic resonance imaging stroke volume equal for patients with right- and left-hemisphere ischemic stroke?.
        Stroke. 2002; 33: 954-958
        • Linfante I.
        • Llinas R.H.
        • Schlaug G.
        • Chaves C.
        • Warach S.
        • Caplan L.R.
        Diffusion-weighted imaging and National Institutes of Health Stroke Scale in the acute phase of posterior-circulation stroke.
        Arch Neurol. 2001; 58: 621-628
        • Bamford J.
        • Sandercock P.
        • Dennis M.
        • Burn J.
        • Warlow C.
        Classification and natural history of clinically identifiable subtypes of cerebral infarction.
        Lancet. 1991; 337: 1521-1526
        • Pittock S.J.
        • Meldrum D.
        • Hardiman O.
        • Thornton J.
        • Brennan P.
        • Moroney J.T.
        The Oxfordshire Community Stroke Project classification: correlation with imaging, associated complications, and prediction of outcome in acute ischemic stroke.
        J Stroke Cerebrovasc Dis. 2003; 12: 1-7
        • Dewey H.
        • Macdonell R.
        • Donnan G.
        • Freeman E.
        • Thrift A.
        • Sharples C.
        Inter-rater reliability of stroke sub-type classification by neurologists and nurses within a community-based stroke incidence study.
        J Clin Neurosci. 2001; 8: 14-17
        • Mead G.E.
        • Lewis S.C.
        • Wardlaw J.M.
        • Dennis M.S.
        • Warlow C.P.
        How well does the Oxfordshire community stroke project classification predict the site and size of the infarct on brain imaging?.
        J Neurol Neurosurg Psychiatry. 2000; 68: 558-562
        • Kobayashi A.
        • Wardlaw J.M.
        • Lindley R.I.
        • Lewis S.C.
        • Sandercock P.A.G.
        • Czlonkowska A.
        • et al.
        Oxfordshire community stroke project clinical stroke syndrome and appearances of tissue and vascular lesions on pretreatment CT in hyperacute ischemic stroke among the first 510 patients in the Third International Stroke Trial (IST-3).
        Stroke. 2009; 40: 743-748
        • Hsu Y.C.
        • Sung S.F.
        • Ong C.T.
        • Wu C.S.
        • Su Y.H.
        Intravenous thrombolytic therapy for acute ischemic stroke: the experience of a community hospital.
        Acta Neurol Taiwan. 2009; 18: 14-20
        • Hsieh F.I.
        • Lien L.M.
        • Chen S.T.
        • Bai C.H.
        • Sun M.C.
        • Tseng H.P.
        • et al.
        Get with the guidelines-stroke performance indicators: surveillance of stroke care in the Taiwan Stroke Registry: get with the guidelines-stroke in Taiwan.
        Circulation. 2010; 122: 1116-1123
        • Hacke W.
        • Kaste M.
        • Fieschi C.
        • Kummer von R.
        • Davalos A.
        • Meier D.
        • et al.
        Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European–Australasian Acute Stroke Study Investigators.
        Lancet. 1998; 352: 1245-1251
        • Kimura K.
        • Iguchi Y.
        • Yamashita S.
        • Shibazaki K.
        • Kobayashi K.
        • Inoue T.
        Atrial fibrillation as an independent predictor for no early recanalization after IV-t-PA in acute ischemic stroke.
        J Neurol Sci. 2008; 267: 57-61
        • Kimura K.
        • Iguchi Y.
        • Shibazaki K.
        • Iwanaga T.
        • Yamashita S.
        • Aoki J.
        IV t-PA therapy in acute stroke patients with atrial fibrillation.
        J Neurol Sci. 2009; 276: 6-8
        • Vittinghoff E.
        • McCulloch C.E.
        Relaxing the rule of ten events per variable in logistic and Cox regression.
        Am J Epidemiol. 2007; 165: 710-718
        • Actilyse
        European Agency for the Evaluation of Medicinal Products.
        (Available from:) (Accessed June 22, 2012)
        • Chang Y.J.
        • Ryu S.J.
        • Chen J.R.
        • Hu H.H.
        • Yip P.K.
        • Chiu T.F.
        • et al.
        Guidelines for the general management of patients with acute ischemic stroke.
        Acta Neurol Taiwan. 2008; 17: 275-294
        • Lansberg M.G.
        • Albers G.W.
        • Wijman C.A.C.
        Symptomatic intracerebral hemorrhage following thrombolytic therapy for acute ischemic stroke: a review of the risk factors.
        Cerebrovasc Dis. 2007; 24: 1-10
        • Dubey N.
        • Bakshi R.
        • Wasay M.
        • Dmochowski J.
        Early computed tomography hypodensity predicts hemorrhage after intravenous tissue plasminogen activator in acute ischemic stroke.
        J Neuroimaging. 2001; 11: 184-188
        • Cocho D.
        • Borrell M.
        • Martí-Fàbregas J.
        • Montaner J.
        • Castellanos M.
        • Bravo Y.
        • et al.
        Pretreatment hemostatic markers of symptomatic intracerebral hemorrhage in patients treated with tissue plasminogen activator.
        Stroke. 2006; 37: 996-999
        • Mazya M.
        • Egido J.A.
        • Ford G.A.
        • Lees K.R.
        • Mikulik R.
        • Toni D.
        • et al.
        Predicting the risk of symptomatic intracerebral hemorrhage in ischemic stroke treated with intravenous alteplase: safe implementation of treatments in stroke (SITS) symptomatic intracerebral hemorrhage risk score.
        Stroke. 2012; 43: 1524-1531
        • Menon B.K.
        • Saver J.L.
        • Prabhakaran S.
        • Reeves M.
        • Liang L.
        • Olson D.M.
        • et al.
        Risk score for intracranial hemorrhage in patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator.
        Stroke. 2012; 43: 2293-2299
        • Sarikaya H.
        • Arnold M.
        • Engelter S.T.
        • Lyrer P.A.
        • Mattle H.P.
        • Georgiadis D.
        • et al.
        Outcomes of intravenous thrombolysis in posterior versus anterior circulation stroke.
        Stroke. 2011; 42: 2498-2502
        • Pagola J.
        • Ribo M.
        • Alvarez-Sabín J.
        • Rubiera M.
        • Santamarina E.
        • Maisterra O.
        • et al.
        Thrombolysis in anterior versus posterior circulation strokes: timing of recanalization, ischemic tolerance, and other differences.
        J Neuroimaging. 2011; 21: 108-112
        • Wardlaw J.M.
        • Dorman P.J.
        • Lewis S.C.
        • Sandercock P.A.
        Can stroke physicians and neuroradiologists identify signs of early cerebral infarction on CT?.
        J Neurol Neurosurg Psychiatry. 1999; 67: 651-653
        • Grotta J.C.
        • Chiu D.
        • Lu M.
        • Patel S.
        • Levine S.R.
        • Tilley B.C.
        • et al.
        Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy.
        Stroke. 1999; 30: 1528-1533
        • Al-Buhairi A.R.
        • Phillips S.J.
        • Llewellyn G.
        • Jan M.M.
        Prediction of infarct topography using the Oxfordshire Community Stroke Project classification of stroke subtypes.
        J Stroke Cerebrovasc Dis. 1998; 7: 339-343
        • Smith C.J.
        • Emsley H.C.
        • Libetta C.M.
        • Hughes D.G.
        • Drennan R.F.
        • Vail A.
        • et al.
        The Oxfordshire Community Stroke Project classification in the early hours of ischemic stroke and relation to infarct site and size on cranial computed tomography.
        J Stroke Cerebrovasc Dis. 2001; 10: 205-209
        • Naess H.
        • Brogger J.C.
        • Idicula T.
        • Waje-Andreassen U.
        • Moen G.
        • Thomassen L.
        Clinical presentation and diffusion weighted MRI of acute cerebral infarction. The Bergen stroke study.
        BMC Neurol. 2009; 9: 44