Hypertension Intracerebral Hemorrhage Research Articles

Association of LDL-cholesterol

Recent intensive low-density lipoprotein cholesterol (LDL-C) lowering trials, including FOURIER, ODYSSEY OUTCOMES, and Treat Stroke to Target (TST) trials, have mostly refuted the concern surrounding statin use, LDL-C lowering, and intracerebral hemorrhage (ICH) risk. However, the results from these trials may not be fully applied to ICH survivors, as the populations studied were mainly patients without prior ICH, in whom the inherent ICH risk is more than 10 times lower than that of ICH survivors. Although available literature on statin use after ICH has demonstrated no excess risk of recurrent ICH, other potential factors that may modify ICH risk, especially hypertension control and ICH etiology, have not generally been considered. Notably, data on LDL-C levels following ICH are lacking. We aim to investigate the association between LDL-C levels and statin use with ICH risk among ICH survivors, and to determine whether the risk differed with patients' characteristics, especially ICH etiology. Follow-up data of consecutive spontaneous ICH survivors enrolled in the University of Hong Kong prospective stroke registry from 2011 to 2019 were retrospectively analyzed. ICH etiology was classified as cerebral amyloid angiopathy (CAA) using the modified Boston criteria or hypertensive arteriopathy, while the mean follow-up LDL-C value was categorized as <1.8 or ⩾1.8 mmol/L. The primary endpoint was recurrent ICH. The association of LDL-C level and statin use with recurrent ICH was determined using multivariable Cox regression. Pre-specified subgroup analyses were performed, including based on ICH etiology and statin prescription. Follow-up blood pressure was included in all the regression models. In 502 ICH survivors (mean age = 64.2 ± 13.5 years, mean follow-up LDL-C = 2.2 ± 0.6 mmol/L, 28% with LDL-C <1.8 mmol/L), 44 had ICH recurrence during a mean follow-up of 5.9 ± 2.8 years. Statin use after ICH was not associated with recurrent ICH (adjusted hazard ratio (AHR) = 1.07, 95% confidence interval (CI) = 0.57-2.00). The risk of ICH recurrence was increased for follow-up LDL-C <1.8 mmol/L (AHR = 1.99, 95% CI = 1.06-3.73). This association was predominantly observed in ICH attributable to CAA (AHR = 2.52, 95% CI = 1.06-5.99) and non-statin users (AHR = 2.91, 95% CI = 1.08-7.86). The association between post-ICH LDL-C <1.8 mmol/L and recurrent ICH was predominantly observed in CAA patients and those with intrinsically low LDL-C (non-statin users). While statins can be safely prescribed in ICH survivors, LDL-C targets should be individualized and caution must be exercised in CAA patients.

Abstract WMP77: In-Hospital Mortality Sex Differences in Young Adults With Intracerebral Hemorrhage

Introduction: Intracerebral hemorrhage (ICH) accounts for 10-20% of strokes and is associated with severe disability and high mortality. While males are reported to have worse outcomes in older patients with ICH, data are limited regarding sex differences in mortality risk after ICH for younger patients. Methods: We conducted a cross-sectional study of 134 adults aged 18-44 admitted to our academic medical center with ICH from 01/01/2012-12/31/2021, using data from an internal stroke registry and the Intracerebral Hemorrhage Outcomes Project (ICHOP). All vascular and non-vascular causes were included other than trauma. We used logistic regression models to calculate odds ratios (OR) and 95% confidence intervals (CI) for the association between sex and in-hospital mortality, adjusting for comorbidities and presence of multicompartmental hemorrhage (including intraventricular extension). Results: Characteristics of the study sample are summarized in the Table. Males had higher proportion of chronic hypertension and subcortical ICH location. Adjusting for hypertension, ICH location, multicompartmental extension, and use of antiplatelet medication, males had higher odds of death (OR 4.0, 95% CI 1.1-15.4) than females. Functional outcomes at discharge are shown in the Figure. Conclusion: In our cohort of young adults with ICH, males had 4-fold higher odds of in-hospital death than females. Future research should investigate the social and biological mechanisms that may underlie sex differences in mortality for young adults with ICH, including differences in ICH etiology, and potentially differential withdrawal of life sustaining treatment.

Abstract TP157: Utility of CT Angiography in Patients With Intracerebral Hemorrhage

Introduction: Patients with intracerebral hemorrhage (ICH) often undergo CT and CT angiography with the latter being done to identify vascular abnormalities for ICH etiology. It is unclear whether CTA yields are high enough to warrant routine use particularly for subcortical ICH, however. Methods: Retrospective chart review was done on the Loyola Stroke Database of ICH patients over the last 10 years. Data from CT, CTA (and other imaging modalities) regarding ICH size and location, as well as vascular abnormalities, were collected. Demographics, comorbidities, and clinical outcomes were also recorded. Frequencies and percentages are reported to describe overall sample and bivariate associations. Univariate logistic regression estimated unadjusted effects of ICH type, age, hypertension (HTN), and other predictors on the logit of vascular abnormalities. Chi square values are reported for overall interaction effects. Stratified odds ratios (OR) are reported with 95% confidence intervals and p-values. Multivariable binary logistic regression estimated adjusted effects of ICH type on the logit of vascular abnormalities, after adjusting for covariates; OR are reported for adjusted effects. Results: Of 744 ICH cases analyzed, 376 were subcortical (50.54%) and 368 cortical (49.46%). Eighty-one had vascular abnormalities (10.89%); 46 of those being lesion-related (6.18%). Unadjusted odds of lesion-related vascular abnormalities were higher for cortical versus subcortical ICH (OR: 7.04; 95% CI: 3.09, 16.04; p &lt; 0.01). Two-way interaction was non-significant for effects of ICH type and age (p = 0.76), ICH type and HTN (p = 0.68), age and hypertension (p = 0.09), and ICH type and ICH size (p = 0.93) on the logit of lesion-related vascular abnormalities. Thus, these effects did not co-vary significantly with respect to lesion-related vascular abnormalities. Odds of lesion-related vascular abnormalities are significantly higher for cortical versus subcortical ICH, after adjusting for age, HTN ICH size, and CTA (OR: 6.91; 95% CI: 2.93, 16.30; p &lt; 0.01). Conclusion: Our analysis suggests there is decreased utility for CTA in subcortical compared to cortical ICH and CTA should probably not be performed routinely on subcortical ICH.

An elderly patient with 17α-hydroxylase deficiency misdiagnosed as primary aldosteronism: a case report

Background17α-hydroxylase deficiency (17OHD) is a rare autosomal recessive disorder. Aldosterone levels are usually low in patients with 17OHD. However, among the approximately 150 cases of 17OHD reported to date, aldosterone levels were not low in all cases. Therefore, some 17OHD cases may have been misdiagnosed as primary aldosteronism (PA) cases. Often before puberty, 17OHD is diagnosed because of abnormal genital morphology and menstrual irregularities. However, we report a very rare case of 17OHD in an elderly patient with a high aldosterone/renin ratio (ARR) similar to that in PA.Case presentationA 63-year-old Japanese woman was transferred to our medical facility for the evaluation of bilateral adrenal hypertrophy, which was incidentally discovered during an abdominal examination after cholecystectomy. The patient had hypokalemia and a high aldosterone/renin ratio. Her medical history included hypertension and right intracerebral capsular hemorrhage at the age of 30 years. Additional testing revealed low cortisol, high adrenocorticotropic hormone, and low testosterone and dehydroepiandrosterone sulfate, indicating congenital adrenal hyperplasia. Genetic analysis revealed a mutation in the CYP17A1 gene and a karyotype of 46, XY; hence, she was diagnosed with 17OHD.Conclusion17OHD can resemble PA. The combination of a high ARR and low cortisol level should trigger the consideration of 17OHD.

Abstract WP164: Prediction Of 90 Day Home Time Among Patients With Low Baseline Aspects Score Undergoing Endovascular Thrombectomy

Background: The outcome in stroke patients with ASPECTS of ≤5 who undergo Endovascular Thrombectomy(EVT) in Large Vessel Occlusion (LVO) is uncertain. We used machine learning models to predict 90-day home-time in these patients. Methods: We used the QuICR provincial stroke registry and administrative data from Southern Alberta to identify patients who underwent EVT from Jan 2015-Dec 2019. Imaging data were scored by 2-physician consensus. The primary outcome was the predicted 90-day home-time(number of days a patient is back at their premorbid living situation without an increase in level of care within 90 days of the stroke) using generalized boosting machine model with Gaussian distribution. Covariate contribution to hometime was determined using partial dependence plots. Results: Of 659 EVT patients, 82(12%) had baseline ASPECTS ≤5(mean age 69.8y, 44.6% females, 93% good-moderate collaterals, M1 occlusion(64.1%). Overall, patients with low ASPECTS had lower median predicted home-time by 2.8d. Holding other covariates constant, factors predicting lower 90d-home-time were diabetes mellitus(-14d), hypertension(-7d), and symptomatic intracerebral hemorrhage (sICH) on follow up scan(-14d). Home-time decreased with increasing age in both low and non-low ASPECTS groups, but the difference was larger in older age groups (Figure). There was no meaningful difference in predicted 90d-home-time by sex, atrial fibrillation, baseline NIHSS, occlusion site, tandem lesion, thrombolysis, or successful reperfusion. Conclusions: Among patients with low ASPECTS who underwent EVT, hypertension, diabetes and sICH predicted lower 90-d home-time. .

Endoscopy can do more for Removal of Hypertension Intracerebral Hemorrhage

Being most severe morbidity of hypertension, Intracerebral Hemorrhage (HICH) was called a disease of “disability or death” due to high disability rate, high mortality rate, and also high economic burden for patient’s family [1,2].

Abstract 41: Cerebral Microbleeds and the Effect of Anticoagulation on Outcomes in 3699 Patients With Embolic Strokes of Undetermined Source: An Exploratory Analysis of the NAVIGATE ESUS Trial

Background: Cerebral microbleeds (CMBs) are reported to predict recurrent stroke and antithrombotic-related intracerebral hemorrhage (ICH). We characterize CMBs in a well-defined population of embolic strokes of undetermined source (ESUS). Notably, we report for the first time interactions between CMBs and effects of random assignment to anticoagulant therapy. Methods: Subgroup analyses of the NAVIGATE ESUS randomized trial comparing rivaroxaban 15 mg vs. aspirin 100 mg daily were performed. CMBs were rated on T2*-GRE sequences obtained at baseline MRI in 3699 participants (mean age 67y). Multivariable regression analyses were used to identify variables independently associated with CMBs. Cox proportional hazards models were used to estimate the contribution of CMBs to risk of recurrent stroke, ischemic stroke, ICH and all-cause mortality. Analyses followed the intent-to-treat paradigm. Results: CMBs were present in 11% of participants. CMBs were strictly deep in 55%, lobar in 26%, and mixed in 19% of cases. Most (68%) had 1-2 CMBs, 27% had 3-10, and 5% &gt;10. Advancing age (OR per yr 1.0, 95% CI 1.01-1.04), East Asian ethnicity (1.6, 1.0-2.4), hypertension (2.2, 1.5-3.2), multi-territorial ESUS (2.0, 1.4-2.7), chronic infarcts (1.8, 1.4-2.2), and occult ICH (5.2, 2.8-9.9) were independently associated with CMBs. During a median follow-up of 11 months, 5.1% of participants had recurrent stroke (4.8% ischemic stroke; 0.3% ICH) and 1.3% died. The presence of CMBs was associated with a 50% increased risk of recurrent stroke (HR 1.5, 95% CI 1.0-2.3), four-fold risk of ICH (4.2, 1.3-13.9), and two-fold risk of all-cause mortality (2.1, 1.1-4.3), and strictly lobar CMBs with a ~2.5-fold risk of ischemic stroke (2.3, 1.3-4.3). There were no interactions between CMBs and treatment assignments for recurrent stroke (p-value for interaction=0.2), ischemic stroke (p=0.3), or all-cause mortality (p=0.6). The hazard ratio (HR) of ICH on rivaroxaban was similar between persons with CMBs (HR 3.1, 95% CI 0.3 - 30.0) and persons without CMBs (HR 3.0, 95% CI 0.6 - 14.7; interaction p=1.0). Conclusions: CMBs mark an increased risk of recurrent ischemic stroke, ICH and mortality in ESUS, but do not appear to influence effects of rivaroxaban, particularly on the outcome of ICH.

To explore the efficiency of neuroendoscopy combined with Endport for hypertension intracerebral hemorrhage

Objective To explore the value of neuroendoscopy combined with Endport for the surgery of hypertensive intracerebral hemorrhage. Methods We retrospectively analyzed 92 cases of hypertensive intracerebral hemorrhage in our department from January 2016 to February 2018. According to the different surgical methods, they were divided into small bone window group and neuroendoscopic group, 47 cases in small bone window group and 45 cases in neuroendoscope group.The amount of intraoperative bleeding, operative time, postoperative hematoma clearance, postoperative rebleeding, hospitalization time, postoperative complications and Glasgow prognosis expansion score (GOS-E) were recorded for statistical analysis. Results Compared with neuroendoscopy group, small bone window group had more bleeding loss [(182.6±34.5)ml vs (103.3±25.7)ml] and longer operation time [(168.7±26.3)min vs (115.7±18.7)min], with significant statistically difference (P 0.05); Postoperative rebleeding occured in 3 cases (6.4%) in small bone window group and 2 cases (4.4%) in the neuroendoscopic group, with no statistically significant difference between the two groups (P>0.05). Compared with neuroendoscopy group, small bone window group had longer hospitalization time [(18.5±4.3)days vs (13.5±3.8)days], higher tracheotomy rate [15(31.9%) vs 8(17.8%) ], with significant statistically difference (P 4 in small bone window group 2 months after operation was less than that in neuroendoscopy group [42.6%(20/47) vs 62.2%(28/45)], with significant statistically difference (P<0.05). Conclusions Endoscopic treatment of intracerebral hemorrhage has the advantages of minimally invasive, short operation time, less intraoperative hemorrhage, low incidence of complications and fast recovery of postoperative function. Key words: Intracranial hemorrhage, hypertensive/SU; Neuroendoscopy

Primary Intracerebral Hemorrhage: A Closer Look at Hypertension and Cerebral Amyloid Angiopathy.

Primary intracerebral hemorrhage (ICH) studies often use hematoma location rather than ICH etiologies when assessing outcome. Characterizing ICH using hematoma location is effective/reproducible, but may miss heterogeneity among these ICH locations, particularly lobar ICH where competing primary ICH etiologies are possible. We subsequently investigated baseline characteristics/outcome differences of spontaneous, primary ICH by their etiologies: cerebral amyloid angiopathy (CAA) and hypertension. Primary ICH clinical/outcomes data were prospectively collected between 2009 and 2015. Modified Boston criteria were used to identify "probable/definite" and "possible" CAA-ICH, which were evaluated separately. SMASH-U criteria were used to identify hypertension ICH. Medication and systemic disease coagulopathy ICH were excluded. Baseline characteristics/outcomes among "probable/definite" CAA-ICH, "possible" CAA-ICH, and hypertension ICH were compared using logistic regression. Mortality models using ICH etiologies compared to hematoma location as predictor variables were assessed. Two hundred and four hypertension ICHs, 55 "probable/definite" CAA-ICHs, and 46 "possible" CAA-ICHs were identified. Despite older age and larger ICH volumes, lower hospital mortality was seen in "probable/definite" CAA-ICH versus hypertension ICH (OR 0.2; 95% CI 0.05-0.8; p=0.02) after adjusting for female gender, components of ICH score, and EVD placement. There were no mortality differences between "possible" CAA-ICH and hypertension ICH. However, lower hospital mortality was seen in "probable/definite" versus "possible" CAA-ICH (OR 0.2; 95% CI 0.04-0.7; p=0.02). When using ICH etiology rather than hematoma location, hospital mortality models significantly improved (χ2: [df=2, N=305]=6.2; p=0.01). Further investigation is required to confirm the mortality heterogeneity seen within our primary ICH cohort. Hematoma location may play a role for these findings, but the mortality differences seen among lobar ICH using CAA-ICH subtypes and a failure to identify mortality differences between "possible" CAA-ICH and hypertension ICH suggest the limitations of accounting for hematoma location alone.

Serum Copper Homeostasis in Hypertensive Intracerebral Hemorrhage and its Clinical Significance.

This study was to investigate the alterations of serum copper homeostasis after hypertensive intracerebral hemorrhage (ICH), which is not yet clear. We recruited 85 hypertensive ICH patients and determined their serum levels of total copper (TCu), small molecule copper (SMC), and ceruloplasmin (Cp). Sera from 32 healthy persons and 12 primary hypertension patients were collected and analyzed as well. Serum TCu levels in ICH patients were tested at three time points (on admission, day 3, and day 7) and found to be higher than that in hypertension patients (p < 0.05). The serum SMC levels in hypertension patients and ICH patients at three time points were higher than that in healthy controls (p < 0.05). Higher serum SMC levels on days 3 and 7 were associated with death in the hospital. Additionally, higher serum SMC levels on the seventh day were associated with poor outcome at discharge. High serum Cp levels on admission, as well as low serum Cp levels on the seventh day, were associated with death in the hospital (p = 0.002 and p = 0.034, respectively). Our findings indicated that declines in serum Cp and increases in serum SMC are correlated with lethal or poor outcome in hypertensive ICH patients, possibly as a result of contributions to secondary injury of brain after hemorrhage due to impairment of iron transport and enhanced oxidative stress.

Curative effect comparison of endoscopic surgery and craniotomic hematoma evacuation in management of hypertensive intracerebral hemorrhage

Objective To investigate and compare the curative effect of endoscopic management and craniotomic hematoma evacuation in hypertensive intracerebral hemorrhage (HICH). Methods Seventy cases of HICH were randomly divided into 2 groups: endoscopy group (30 cases) and craniotomy group (40 cases). In the patients with intracerebral hematoma volume of 30-40 ml, the therapeutic effect was compared between two groups: incision of scalp, bone window, cortical incision, blood loss, operating duration, rate of hematoma evacuation, rate of rehemorrhage, rate of intracranial infection, mortality and Barthel index. Results The length of scalp incision in endoscopy group and craniotomy group was (5.40±0.97) cm and (24.50±3.88) cm, comparison between the two groups was statistically significant (t=26.310, P=0.000). The area of bone window in endoscopy group and craniotomy group was (12.5±2.2) cm2 and (63.3±12.3) cm2 respectively, comparison between the two groups was statistically significant (t=22.320, P=0.000). The length of cortical incision in endoscopy group and craniotomy group was (1.05±0.45) cm and (2.40±0.52) cm respectively, comparison between the two groups was statistically significant (t=11.385, P=0.000). The blood loss in endoscopy group and craniotomy group was (80.0±18.3) ml and (339.0±90.3) ml respectively, comparison between the two groups was statistically significant (t=15.450, P=0.000). The time of operating duration in endoscopy group and craniotomy group was (0.96±0.31) h and (4.35±0.57) h respectively, comparison between the two groups was statistically significant (t=24.440, P=0.001). The rates of hematoma evacuation in endoscopy group and craniotomy group was (81.00±7.93)% and (92.40±6.15)% respectively, comparison between the two groups was not statistically significant (χ2=6.777, P=0.138). Rates of rehemorrhage in endoscopy group and craniotomy group was 7.5% and 6.7% respectively, comparison between the two groups was not statistically significant (χ2=0.018, P=1.000). The rates of intracranial infection in endoscopy group and craniotomy group was 10% and 15%, comparison between the two groups was not statistically significant (χ2=1.350, P=0.723). Death rates in endoscopy group and craniotomy group was 5% and 6% respectively, comparison between the two groups was not statistically significant (χ2=0.088, P=1.000). Barthel index in endoscopy group (75.34±20.51) was higher compared with craniotomy group (55.30±10.20). Comparison between the two groups was statistically significant (t=1.350, P=0.000). Conclusion For the patients with intracerebral hematoma volume 30-40 ml, endoscopic surgery has the advantages including minimally invasive、short operating duration and good prognosis, but it has lower hematoma evacuation than craniotomic hematoma evacuation. Key words: Hypertension intracerebral hemorrhage; Endoscope; Craniotomic hematoma evacuation; The rate of hematoma evacuation

English

INTRODUCTION: Normal pregnancy is characterized by unique physiological changes. It is mandatory for an anesthesiologist to understand these changes and their anesthetic implications. Pregnancy induced hypertension (PIH) is a disorder of unknown etiology affecting 5-10% of all pregnancies characterized by the development of hypertension with proteinuria after 20 weeks of gestation. Hypertension-Sustained systolic pressure of at least 140mmHg or a sustained diastolic pressure of at least 90 mmHg that occurs after 20 weeks of gestation in a woman with previously normal blood pressure. Maternal complications of severe pregnancy induced hypertension include pulmonary edema, intracerebral hemorrhage and renal failure. Fetal complications include intra uterine growth retardation (IUGR), perinatal mortality. Management of severe pregnancy induced hypertension requires multidisciplinary approach. Definitive treatment consists of termination of pregnancy along with prevention of seizures and control of blood pressure. The drugs used in the control of blood pressure are oral antihypertensives like Alphamethyldopa and intravenous agents like Hydralazine, Labetalol, Nitroglycerin etc. Intravenous Labetalol injection is a unique drug with both alpha and beta adrenergic receptor blocking properties. It has both blood pressure and heart rate reducing properties. This makes it a good choice in treating high blood pressure in severe pregnancy induced hypertension patients. Our study is to find out the efficacy of intravenous Labetalol injection in the acute preoperative control of high blood pressure in severe pregnancy induced hypertension (PIH) patients. AIM OF STUDY: The aim of this study is to find out and compare the efficacy of intravenous Labetalol injection with the routinely used regimen of oral antihypertensives tablet Alphamethyldopa and tablet Nifedipine in the acute preoperative control of high blood pressure in severe pregnancy induced hypertension patients. MATERIALS AND METHODS: After obtaining the necessary institutional and ethical committee clearance following study was conducted in the Institute of obstetrics and gynecology, (IOG), Madras Medical College & Research Institute, Chennai . All antenatal mothers were screened for severe pregnancy induced hypertension (PIH) in the casualty department and 40 patients with severe PIH were selected. Informed consent was obtained from them and randomly divided into 2 groups namely group A and group L of 20 each. Inclusion criteria: (any one of the following): 1. Systolic blood pressure> 160mmHg, 2. Diastolic blood pressure>110mmHg, 3. Proteinuria (dipsticks)>+3or+4, 4. History of oliguria or urine output < 500ml in 24 hours, 5. Presenting with imminent features– blurring of vision, epigastric pain, hyperreflexia, HELLP. Exclusion criteria: 1. Secondary hypertension, 2. Cardiac arrhythmia, 3. Bronchial asthma, 4. Diabetes mellitus, 5. Complications due to severe Pregnancy induced hypertension like intracerebral hemorrhage, acute left ventricular failure, coagulopathy, bleeding disorders, 6. Patients already on oral antihypertensives are not included in-group L. SUMMARY: Comparative clinical study of acute preoperative management of high blood pressure in severe pregnancy induced hypertension patients using two methods: one by (Group A) an oral combination of tablets Alphamethyldopa and Nifedepine and other by (Group L) intravenous Labetalol was undertaken at the Institute of Obstetrics and Gynaecology, Madras medical college & research institute, Chennai during the year 2006-2008. Summarizing the findings in the study: 1. Oral antihypertensive combination of tablets Alphamethyldopa and Nifedepine achieved blood pressure control that often necessitated intravenous Nitroglycerin as rescue drug. 2. Intravenous Labetalol achieves adequate and faster blood pressure control with better heart rate maintenance than the routinely used oral antihypertensive combination. CONCLUSION: In conclusion, intravenous Labetalol achieves adequete and faster blood pressure control with better heart rate maintenance than the routinely used oral antihypertensive combination of tablets Alphamethyldopa and Nifedipine in the control of blood pressure in preoperative severe pregnancy induced hypertension patients.

Abstract W MP110: INR reversal of Oral Anticoagulant-Associated Intracerebral Hemorrhage

Background: The use of oral anticoagulants (OAC) is associated with poor outcome in intracerebral hemorrhage (ICH). In this study we investigated the effect of delayed INR reversal and the factors influencing it in patients with OAC-associated ICH (OAC-ICH). Methods: Data were obtained from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study which is a prospective, multi-ethnic multicenter study of ICH. Exclusion criteria included missing initial hematoma volume, INR or ED arrival time and being on heparin. Baseline characteristics, INR at baseline and 12h, hematoma location and volume, treatment received, hematoma expansion at 24h, and mortality at 3 months were recorded. INR reversal was defined as INR&lt;1.4 at 12h post admission. Variables associated with INR reversal and case fatality at 3 months in non-OAC users and OAC users with and without INR &lt;1.4 were compared. Results: A total of 1,746 of 2,276 subjects were included in the analysis. A higher proportion of OAC users (n=185) were white and had hypertension, diabetes, hypercholesterolemia, and lobar ICH than non-users (P&lt;0.05). Baseline INRs for the OAC group were 3.1 (28.7%). Subjects on OAC received fresh frozen plasma (FFP, 44%) monotherapy, either recombinant factor VII or prothrombin complex (FVII/PCC, 7%), or a combination of FFP/FVII/PCC (11%). Increasing age (OR=0.96, 95% CI 0.94-0.98), elevated baseline INR (OR=0.34, 95% CI 0.26-0.43), and use of FFP only (OR=0.07, 95% CI 0.04-0.13) was associated with lack of INR reversal at 12h. Median INR at 12h (IQR) were 1.4 (1.3-1.6), 1.1 (0.9-1.1), and 1.0 (1.0-1.3) for the FFP, PCC/FVII, and FFP/FVII/PCC groups, respectively (p1.4 did not influence the rate of hematoma expansion at 24h. Case fatality at 3 months was 22% for non-OAC-ICH, 34% for OAC-ICH with INR&lt;1.4, and 44% for OAC-ICH with INR&gt;1.4 (p=.0005). Conclusion: In the ERICH study, patients treated with FFP monotherapy were less likely to have a normalized INR at 12h and this was associated with increased case fatality at 3 months. The use of FVII/PCC may shorten time to INR correction and improve outcome in OAC-ICH.

Radiological investigation of spontaneous intracerebral hemorrhage: systematic review and trinational survey.

It is not always clear whether, how, and when to undertake further radiological investigation of spontaneous (nontraumatic) intracerebral hemorrhage (ICH). We systematically reviewed Ovid MEDLINE and EMBASE databases for studies of the diagnostic utility of radiological investigations of the cause(s) of ICH. We sent a structured survey to neurologists, stroke specialists, neurosurgeons, and neuroradiologists in the United Kingdom, the Netherlands, and France to assess whether, how, and when they would investigate supratentorial ICH. This systematic review detected 20 relevant studies (including 1933 patients), which either quantified the yield of a radiological investigation/imaging strategy (n=15) or compared 2 imaging techniques (n=5). Six hundred ninety-two (49%) physicians responded to the survey. Further investigation would have been undertaken by the following: 99% of respondents, for younger (38 to 43 years), normotensive adults with lobar or deep ICH; 76%, for older (age 72 to 83 years), normotensive adults with deep ICH; and 31%, for older adults with deep ICH and prestroke hypertension. Younger patient age was the strongest influence on the decision to further investigate ICH (odds ratio=16; 95% confidence interval, 13 to 20), followed by the absence of prestroke hypertension (odds ratio=5; 95% confidence interval, 4 to 6) and lobar ICH location (odds ratio=2; 95% confidence interval, 1 to 2). The paucity of studies on the diagnostic utility of imaging investigations of the cause(s) of ICH may contribute to the variation observed in when and how and which patients are investigated in current clinical practice. Studies comparing different types of diagnostic strategies are required.

Changes of TXA2 and PGI2 during postoperative hypertensive crisis in patients with hypertensive intracerebral hemorrhage

In order to explore the changes and the roles of TXA2 and PGI2 during postoperative hypertensive crisis in patients with hypertensive intracerebral hemorrhage, 31 cases subject to craniotomy were divided into three groups: group A, 9 patients with postoperative hypertensive crisis; group B, 13 patients without postoperative hypertensive crisis; and group C, 9 patients without history of hypertension and hypertensive intracerebral hemorrhage. TXA2, TXB2, 6-keto-PGF1 alpha and PGI2 were measured after operation in the three groups respectively. The postoperative blood pressure in group A, including SBP and DBP, was elevated more obviously than that in the other two groups. TXA2 and PGI2 in group A were significantly higher than those in other two groups (P<0.01). Moreover, the ratio of TXB2 to 6-keto-PGF1 alpha in group A was significantly higher than that in other two groups (P<0.05). The increase of TXA2 and the relative inadequacy of prostacyclin, especially 6-keto-PGF1 alpha, may play roles in the postoperative hypertensive crisis. And the increased value of TXB2 to 6-keto-PGF1 alpha could provide the basis for diagnosis of postoperative hypertensive crisis.

Familial hypertensive intracerebral hemorrhage and autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is a generalized disease known to be associated with intracranial aneurysms. Non-aneurysmal intracerebral hemorrhage (ICH) has also been reported in ADPKD. We report a familial clustering of ICH and symptomatic ADPKD. This pedigree had at least six affected family members who suffered from ADPKD, hypertension and non-aneurysmal ICH. The proband demonstrated ADPKD, hypertension and cerebral hemorrhage. To our knowledge, this is the first report of familial ICH in ADPKD, which may have underlying genetic and environmental etiologies.

Alpha-adducin gene G/W460 polymorphism is associated with intracerebral hemorrhage in Chinese

To explore the association between alpha-adducin (ADD1) G/W460 and intracerebral hemorrhage (ICH) in Chinese. Samples of peripheral blood were collected from 456 patients with ICH diagnosed by CT or MRI from 7 clinical centers in China and 454 age, sex, and geographically matched subjects as controls. The ADD1 G/W460 polymorphism was detected by PCR. Information about prior exposure to various potential risk factors was collected by questionnaire survey. The distribution of ADD1gene G460W polymorphisms in the ICH patients and controls were in agreement with the Hardy-Weinberg proportion. The prevalence of 460W allele among ICH cases was 82.2%, higher than that in the controls (76.0%, crude odds ratio, 1.46; 95% CI, 1.05 to 2.05). The ADD1 460W allele was still significantly associated with ICH after adjustment for hypertension and other ICH putative risk factors (adjusted odds ratio, 1.38; 95% CI, 1.01 to 1.88). Alpha-adducin gene G/W 460 polymorphism is significantly associated with the risk of ICH. This association does not appear to be mediated by established ICH risk factors, specifically hypertension status.