Introduction: Symptomatic Intracerebral Hemorrhage (sICH) is a rare but serious complication of reperfusion therapy in ischemic stroke. Conventional radiological predictors include early CT hypodensity and leukoariaosis. We report 2 hyper-acute strokes with poor collaterals who developed sICH after reperfusion. 
Case 1. 66 year old male with AF and hypertension not on anticoagulation presented with left sided deficits (NIHSS 19) at 3 hours from onset. Initial CT Head ASPECTS was 6 and CT angiogram showed right M1 MCA occlusion and Miteff Grade 3 collaterals. He received alteplase at 201 minutes and underwent endovascular therapy with TICI 2b recanalization at 318 minutes from onset. Post-thrombectomy, his level of consciousness (GCS < 8) decreased requiring intubation. 24 hour CT Head showed PH2 type sICH. Patient expired 5 days later.
Case 2. 79 year old male with multiple comorbidities with left sided deficits (NIHSS 18) presented at one hour from onset. CT Head ASPECTS 9 and CT angiogram showed Right M2 MCA occlusion with Miteff grade 2 collaterals. CT Perfusion showed a matched defect with a core of 47ml. He received Alteplase at 110 minutes. Patient’s level of consciousness deteriorated 12 hours post-thrombolysis and CT head showed PH2 with intraventricular extension. Patient expired the following day.
Conclusion:Poor collaterals in hyper-acute stroke could be a predictor of sICH and early mortality. Mechanical thrombectomy without alteplase could be an option in this patient sub-group. Further studies assessing the correlation between collateral score and hemorrhagic transformation are needed.

Is Poor Collateral a Predictor of Symptomatic Intracerebral Hemorrhage in Hyper-acute Stroke?