ICH Volume Research Articles

Aneurysmal intracerebral hematoma: Risk factors and surgical treatment decisions

ObjectivesIntracerebral hematoma (ICH) complicates the course of aneurysmal subarachnoid hemorrhage (SAH). To date, there are no unique guidelines for management of aneurysmal ICH. The aim of this study was to identify risk factors for and impact of aneurysmal ICH with special attention on treatment decisions derived from ICH volume. Patients and MethodsAll patients admitted with aneurysmal SAH between 2003 and 2016 were eligible for this study. Various demographic, clinical and radiographic characteristics of patients were correlated with the occurrence and volume of ICH in univariate and multivariate manner. The associations between ICH volume and the need for surgical procedures and functional outcome were also analyzed. Results991 patients were included into final analysis. ICH occurred in 301 (30.4%) cases. Location in the middle cerebral artery (MCA, p < 0.001, aOR = 7.04), WFNS grade 4–5 (p < 0.001, aOR = 4.43), rebleeding before therapy (p = 0.004, aOR = 2.45), intracranial pressure over 20 mmHg upon admission (p = 0.008, aOR = 1.60) and intraventricular bleeding (p = 0.008, aOR = 1.62) were independently associated with ICH presence. In turn, WFNS grade 4–5 (p < 0.001) and MCA aneurysms (p < 0.001) were the only independent predictors of ICH volume. According to the receiver operating characteristic curves, the clinically relevant cutoff for additional surgical interventions (decompression/hematoma evacuation) was 17 mL. ICH occurrence and ICH volume ≥17 mL independently predicted poor outcome at 6 months after SAH (defined as modified Rankin Scale>3). ConclusionOf over 30 tested variables, the location of the ruptured aneurysm in the MCA remains the major risk factor for occurrence and volume of ICH. Given the presence of brain swelling and other bleeding components of SAH, surgical intervention on aneurysmal ICH is indicated at lower volume values, than it is generally accepted for spontaneous ICH.

Comparative analysis of predictive significance of neuroimaging parameters in patients with spontaneous supratentorial intracerebral hemorrhage

The main purpose of the study was to conduct a comparative analysis of the neuroimaging parameters informative value for the determination of vital and functional outcomes prognosis of the spontaneous supratentorial intracerebral hemorrhage (SSICH) in the acute period, depending on the secondary intraventricular hemorrhage (SIVH) presence or absence at the disease onset. Materials and methods. A prospective cohort study was conducted in 154 patients (88 men and 66 women, mean age 64.4 ± 0.9 years) with SSICH on the basis of conservative treatment. This study included clinical assessment and visualization of cerebral structures. Intracerebral hemorrhage volume (ICHV), average midline shift (AMS) and intraventricular hemorrhage volume (IVHV) were detected. The modified Rankin Scale (mRS) score >3 on the 21 st day of the disease was considered as an unfavourable functional outcome of SSICH in the acute period. Results . Secondary intraventricular hemorrhage was revealed in 70 (45.5 %) patients. It was found that ICHV was less informative than IVHV in patients with SIVH for the vital outcome prognosis of disease in the acute period determination (AUC ICHV = 0.72 ± 0.09 (0.60–0.82) versus AUC IVHV = 0.94 ± 0.04 (0.86–0.98), P = 0.026), whereas the informative value of ICH volume and AMS were not significantly different in patients without SIVH for the vital outcome prognosis determination (AUC ICHV = 0.77 ± 0.11 (0.67–0.86) versus AUC AMS = 0.87 ± 0.05 (0.78–0.94), P = 0.257) in the acute period of disease. It was detected, that IVHS >24.5 mL was the predictor of SSICH lethal outcome in the acute period (Se = 84.6 %, Sp = 96.5 %). Conclusions. Predictive value of the neuroimaging parameters at SSICH onset depends on SIVH presence or absence. Intracerebral hemorrhage volume is less informative than IVHV and AMS for the vital and functional outcomes prognosis determination in the acute period of SSICH with SIVH. The informative value of neuroimaging parameters for the vital outcome prognosis of SSICH in the acute period determination is higher than the one for the functional prognosis determination.

CCL2 and CXCL10 are associated with poor outcome after intracerebral hemorrhage.

ObjectiveIntracerebral hemorrhage carries a high mortality and survivors are frequently left with significant disability. Immunological mechanisms may play an important role in hemorrhage‐induced brain injury, however, research linking these mechanisms with clinical outcome remains limited. We aim to identify serum inflammatory mediators that are associated with outcome after intracerebral hemorrhage in order to translate data from experimental models to a patient cohort and identify potential targets worthy of reverse translation.MethodsA prospective cohort study at two comprehensive stroke centers enrolled patients with spontaneous intracerebral hemorrhage. Peripheral blood was collected at 6, 24, and 72 h from onset. Functional outcome was assessed at 90 days using the modified Rankin Scale (mRS). Serum inflammatory mediators were measured using multiplex ELISA. Multivariable modeling identified serum biomarkers independently associated with functional outcome at 90 days.Results115 patients completed the study. At 6 h after onset, patients with elevated CCL2 had worse mRS score at day 90 (OR 4.07, 95% CI 1.27–13.10, P = 0.02) after adjusting for age, gender, ICH volume, IVH, infratentorial location and NIHSS score. At 24 and 72 h after onset, elevation in CXCL10 was independently associated with worse 90 days mRS score (24 h: OR 8.08, 95% CI 2.69–24.30, P < 0.001; 72 h: OR 3.89, 95% CI 1.12–13.49, P = 0.03).InterpretationAcute and subacute elevations in specific immune factors are associated with poor outcome, highlighting potential pathways that may contribute to ongoing brain injury in patients with intracerebral hemorrhage.

Unmet Needs and Challenges in Clinical Research of Intracerebral Hemorrhage.

Unmet Needs and Challenges in Clinical Research of Intracerebral Hemorrhage.

Combination of Intra-Hematomal Hypodensity on CT and BRAIN Scoring Improves Prediction of Hemorrhage Expansion in ICH.

Hematoma expansion (HE) occurs in 1/3 of ICH patients and is associated with poor outcome. Intra-hematomal hypodensity (IHH) on CT has been reported to predict HE, as has the "BRAIN" score. We sought to assess the predictive value of these markers alone and in combination. We performed a retrospective single-center study of ICH patients with CT<6h from onset. Two blinded neurologists assessed IHH on initial CT. Two HE definitions were examined:>6ml and>6ml or>33%. Multivariable logistic regression was used to determine the relationship between IHH and HE. Predictive value of the BRAIN score alone and integrated with IHH was assessed. In 122 included patients, median ICH volume was 13ml, median time to CT 2.0h; HE>6ml occurred in 31% and>6ml/>33% in 43% of subjects. IHH were identified in 61% of patients with moderate inter-rater agreement (κ=0.59). In multivariable analysis, IHH was associated with HE using>6ml definition (OR 8.3, 95% CI, 2.6-32.8, P<0.001) but not using the>6ml/>33% definition (OR 1.9, 95% CI 0.84-4.3, P=0.12). Rate of HE (>6ml) increased across increasing BRAIN score quartiles (Q1:11%, Q2:23%, Q3:43%, Q4:57%, P for trend<0.001). Rate of HE>6ml in patients with BRAIN score≥10 and IHH was 55%, with either alone was 33%, and with neither was 3%. Combining IHH on non-contrast CT and a simple clinical BRAIN score is a potentially powerful way to predict those patients at very high and very low risk of HE.

Abstract WMP108: Defining Optimal Thresholds for Achieving Clinical Benefit in Spontaneous Intraventricular Hemorrhage

Introduction: Fibrinolytic therapy for spontaneous intraventricular hemorrhage (IVH) appears to reduce mortality with uncertain benefit on long-term functional outcomes. Threshold for volume of IVH which responds to intraventricular fibrinolytic therapy with therapeutic benefit has not been determined. Methods: CLEAR III, a randomized, multi-center, double-blinded, placebo-controlled trial was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular Alteplase improved outcome, in comparison to EVD plus saline. We analyzed of IVH volume strata from study randomization: Large IVH: volume ≥50 mL; small IVH: volume&lt;20 mL. We assessed clinical variables and outcomes by IVH volume group. Outcome measures were blinded assessment of modified Rankin score (mRS) at 30, 180 and 365 days, (with mRS&gt;3 signifying poor outcome). We performed logistic regression to evaluate outcomes by IVH volume group. Results: Among the 500 patients enrolled, 55 (11%) had IVH volumes &gt;50 mL and 222 (44.4%) had IVH volume &lt;20mL. Subjects with large volume IVH were older (mean, 62.3 vs. 58.1 years; p=0.01), had smaller ICH volume (6.1 vs. 9.9 mL; p&lt;0.001), less thalamic ICH (16.4% vs. 63.6%; p&lt;0.001), more pre-admission use of anticoagulants and antiplatelet agents and greater proportion of high intracranial pressure readings during monitoring at all thresholds (&gt;20, 30, 40 mmHg), compared to those with IVH volume &lt;50mL. Day 180 mortality and poor mRS were 49.1% and 81.8% in large volume IVH compared to 13.1% and 43.3% in small volume IVH. In logistic regression models adjusted for confounders, drainage of &gt;85% IVH volume was significantly associated with higher odds of good outcome (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.3) and lower odds of mortality (OR, 0.3; 95% CI, 0.1-0.8) compared to &lt;85% drainage, in patients with baseline volumes &lt;50mL. Removal of &gt;85% IVH volume (n=3/55) was not associated with improved outcomes in patients with large IVH. Conclusions: IVH volume &gt;50mL may represent a cohort without identified benefit from fibrinolytic treatment. Defining an upper limit for IVH volume would benefit from a larger sample and other methods of achieving IVH reduction.

Abstract WMP107: Efficacy of Intraventricular Administration of Alteplase for Intraventricular Hemorrhage

Introduction: The efficacy of extraventricular drain (EVD) alone was compared to EVD with intraventricular alteplase injection for the treatment of intraventricular hemorrhage (IVH) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) cohort. Methods: ERICH study subjects with IVH and EVD placement were dichotomized by alteplase administration. Propensity score modeling was used to adjust for significant differences in baseline variables and included age, gender, race/ethnicity, initial Glasgow Coma Scale (GCS) score, ICH location, initial ICH volume, primary IVH, and initial IVH volume (Table 1). Outcome measures included 3, 6, and 12-month modified Rankin scale (mRS) as well as IVH volume change on follow-up head CT within 24 hours. Good outcome was defined as a mRS &lt;=3. Mann-Whitney U and Chi-squared tests were utilized for statistical analyses. Results: Follow-up mRS scores at 3, 6, and 12 months were not significantly different between the two groups. Compared to the initial head CT on presentation, a significant reduction of IVH volume was seen on the subsequent head CT (Table 2). Conclusion: For ERICH subjects with IVH and EVD placement, the administration of intraventricular alteplase resulted in significant IVH volume reduction. The sample size, however, was likely insufficient to detect a difference between mRS outcomes. Our findings in this non-randomized IVH cohort highlight real world clinical practice outcomes and are consistent with the results of CLEAR III.

Abstract WMP120: Does ICH Volume Affect Onset to Arrival Time?

Background: ICH is a disease of high mortality. Increased hematoma volume has been associated with increased NIHSS severity and worse outcome. The purpose of this study was to determine if hematoma volume was correlated with time from symptom onset to time of hospital arrival. Methods: We conducted a review of consecutive acute ICH patients who were treated at UC San Diego from an IRB approved, prospectively collected UC San Diego Stroke Registry (1/2003-07/2016). All patients that presented as a “code stroke” within 12 hours and had ICH as the primary diagnosis were included in the analysis. Patients were allocated to time quartiles from symptom onset to arrival and compared between those quartiles for baseline demographic variables. A correlation matrix was built to assess variables that were correlated with ICH volume (mL). Variables with a p &gt;0.10 were then included in a logistic regression to model. Results: The overall sample included 316 patients. Time from onset to arrival ranged from 25-720 minutes. The baseline demographics were significantly different amongst the time quartiles for: 1) history of atrial fibrillation (p=0.04); 2) current alcohol use (0.04); 3) and NIHSS (p=0.006). Patient in Q3 had the highest a-fib rates (20.5%). NIHSS was highest in Q1. ICH volume was significantly and positively correlated with age, history of HTN, current ETOH abuse, current SBP, and 90 day mRS (all p&lt;0.05). ICH volume was not significantly correlated with time of arrival. Conclusion: This study supports the previous data of ICH volumes relationships to outcome. Other variables may be considered in ICH outcome scales to improve prognosis.

Abstract TP332: Intracerebral Hemorrhage Volume to Edema Volume Ratio Predicts Poor Functional Outcome in Young Patients with Non-Lobar Primary Intracerebral Hemorrhage

Background and Purpose: Cerebral edema is known to contribute to clinical decline in patients with spontaneous ICH. We sought to evaluate the significance of cerebral edema on outcome in young patients with primary ICH. Methods: We performed a retrospective review of patients presenting to our CSC center from 2014-2015 with primary ICH, excluding patients with lobar ICH and age 55 and above. Patients were grouped according to functional outcome at discharge (mRS 0-3 vs. 4-6). Imaging characteristics of those with poor short-term functional outcome (mRS 4-6) were compared to those with mRS 0-3. Receiver Operating Characteristics curves were used to evaluate the discriminatory ability of imaging characteristics with regards to poor functional outcome. Results: A total of 38 patients met inclusion criteria (mean age 47, 42% black, 55% male). On presentation, patients with poor functional outcome had larger mean ICH volume (26 vs 9cc; p=0.020), higher ICH volume to edema volume ratios (2.0 vs. 0.7, p=0.010), more evidence of midline shift (38% vs. 6%, p=0.026), and IVH (52% vs. 17%, p=0.043). Groups did not differ in terms of edema volume, amount of midline shift, evidence of hydrocephalus, or herniation. ICH volume to edema volume ratio was a better discriminator of poor outcome (AUC=0.813, p=0.006) than ICH volume (AUC=0.802, p=0.008, Figure 1a). Further, ICH volume to edema volume ratio was a better discriminator of poor outcome (AUC=0.801, p=0.009) than ICH score (AUC=0.724, p=0.051, Figure 1b). Discussion: Among young patients with non-lobar primary ICH we observed that the ICH to edema ratio was a better predictor of poor functional status at discharge than ICH volume or ICH score.

Abstract WP355: Predictors and Outcome of Intubation for Patients with Primary Intracerebral Hemorrhage

Background: Patients with primary intracerebral hemorrhage (pICH) are at risk of airway compromise and commonly undergo intubation. Poor outcomes have been reported for these patients. Factors predicting intubation prior to admission (PTA), and after admission are unknown. These factors may be helpful in predicting which pICH patients require intubation, and its optimal timing. Methods: Patients with pICH directly admitted or transferred from another facility to our center were included. Patients with SAH, SDH, epidural hemorrhage, underlying lesions, or infarct with hemorrhagic transformation were excluded. Intubation note from medical chart was used to determine the timing of intubation. Demographic and clinical data were recorded. The primary outcome was a discharge mRS (dmRS) of 4-6. Results: A total of 370 patients were included. Patients intubated PTA had a lower average GCS (6 vs. 9; p=0.0003) and a higher average NIHSS (26 vs. 18; p=0.0007) than those intubated after admission. Higher incidences of hematoma expansion (30.9% vs. 16.3%; p=0.0253), tracheostomies performed (17.5% vs. 4.8%; p=0.0004), ICH volumes &gt; 30cc (40% vs. 25.5%; p=0.0352), and pneumonia (35.1% vs. 5.4%; p&lt;0.0001) were seen in patients intubation after admission, when compared to other patients. Patients requiring intubation at any time had statistically non-significant higher incidences of cortical and brainstem hemorrhage (see Table 1), compared to patients not intubated. After adjusting for pneumonia and ICH score, intubation is significantly associated with a dmRS of 4-6 (OR 4.87, 95%CI 1.27-18.7, p=0.0208). Conclusions: Lower GCS and higher NIHSS significantly predict intubation in pICH patients PTA. ICH volumes &gt; 30cc, hematoma expansion and pneumonia significantly predict intubation after admission. Intubation is significantly associated with poor functional outcomes independent of ICH score and pneumonia. Location of ICH does not predict intubation.

Abstract WP353: Bleeding Following Removal of Intracerebral Catheters in MISTIE III

Introduction: Minimally invasive surgery plus alteplase has been shown to effectively reduce the volume of intracerebral hemorrhage in patients with supratentorial bleeds. Removal of these catheters is a unique timepoint when bleeding may restart due to mechanical forces and/or the presence of alteplase/plasmin in the brain. We hypothesized that surgically-treated patients in the MISTIE III trial who had increased bleeding post catheter removal would have shorter periods of time between last dose and catheter removal and be less likely to have lobar ICH. Methods: MISTIE III is a prospective, randomized trial testing the efficacy of minimally invasive surgery plus alteplase for hematoma removal compared to medical management. We analyzed 107 surgically-treated patients. Semi-automated threshold based segmentation of the ICH volumes for all time points were performed using OsiriX. Results: Of the 107 surgical patients, 16 experienced an increase in ICH volume &gt;10% between T1, the scan taken 24 hours prior to cath removal, and T2, the scan taken 24 hours post catheter removal. Mean percent difference between T1 and T2 was 37.5% for those that expanded versus those that did not, -17.4% (p&lt;0.001) with an absolute difference in ICH volume of 3.0 cc and -2.2 cc (p&lt;0.001). The mean residual volume at T2 for both groups was similar at 12.84 cc and 12.71 cc, respectively (p=0.96). Time from last dose to catheter removal in days was 1.27 for those that expanded and 1.44 for those that did not (p=0.09). Furthermore, 14/16 (87.5%) patients with expansion had ICH’s located in deep structures compared to 55/91 (60.4%) of patients that did not expand (p&lt;0.01). Conclusion: Overall, incidence of bleeding following ICH catheter removal in MISTIE III was low. When bleeding was seen, it was more often found in patients with deep ICH locations and whose catheters were removed sooner after the last dose of alteplase.

Middle cerebral artery aneurysms with intracerebral hematoma-the impact of side and volume on final outcome.

Middle cerebral artery aneurysms (MCA aneurysms) belong to the most frequent type of intracranial aneurysms forming an intracerebral hematoma. The consequences of the hematoma-the laterality, the impact of ICH volume and size of the aneurysm with the final outcome of these patients had not been studied in detail in this location, and we focused on the analysis of these factors. Patients with MCA aneurysms and associated intracerebral hematomas with a volume ≥10ml were studied; these were treated from January 2006 to December 2015. During this period, more than 700 patients with spontaneous subarachnoid hemorrhage were admitted to the Department of Neurosurgery, University Hospital Brno. The data were collected from the subarachnoid hemorrhage database of the unit and from the local hospital registry. All consecutive patients at the treating center were involved in this retrospective study. We collected clinical data such as age, gender, aneurysm location, preoperative hematoma size, Hunt-Hess grade and type of surgical procedures. We focused on the analysis of the final outcome [Glasgow Outcome Scale (GOS) score] in relation to ICH volume, side of bleeding and finally the relationship between aneurysm size and the volume of ICH. Fifty-eight patients with an MCA aneurysm and ICH were included; the mean age of this series was 59.4years. Thirty-six patients (62%) had clinical status Hunt-Hess 4-5 on admission. The mean size of the intracerebral hematoma was 47.1ml (10-133ml). Most frequently, in 30 patients (52%), the hematoma had bled into the temporal lobe. Fifty three patients were operated on, and 5 were treated conservatively because of their poor condition. Twenty-three patients (40%) had a favorable Glasgow Outcome Scale score, and 35 (60%) had an unfavorable outcome including 20 patients (35%) who died. Of the 53 patients operated on, 20 (38%) underwent decompressive hemicraniectomy (DHC). Patients with an unfavorable outcome had significantly larger hematomas with a median size of 54ml, whereas those with a favorable outcome had a median size of 26ml (p = 0.0022). Larger hematomas were found on the right side. The cutoff volume for an unfavorable outcome in ICH was 25ml. The outcomes were not related to the side of the ICH (p = 0.42), and the aneurysm size did not predetermine the ICH volume (p = 0.3159). Our study confirms the benefit of the active treatment of patients with MCA aneurysms and associated ICH. A significant proportion of these patients achieves a favorable outcome. No association between the side of bleeding and outcome was demonstrated. Hematomas larger than 25ml have a greater tendency to lead to an unfavorable outcome. The treatment decision-making process should not differ for either side.

Glial Fibrillary Acidic Protein for Prehospital Diagnosis of Intracerebral Hemorrhage

Background: Both, acute ischemic stroke (AIS) and hemorrhage stroke (intracerebral hemorrhage, ICH) require early attention but different treatment strategies. Plasma glial fibrillary acidic protein (GFAP) levels were found to be elevated in ICH patients after they arrived in the hospital. Because treatment options differed, we sought to determine whether GFAP can be used to accurately differentiate between of AIS and ICH in the prehospital setting. Methods: We assessed acute stroke patients in the Stroke Emergency Mobile (STEMO). STEMO is a stroke ambulance staffed by a specialized team including a neurologist and equipped with a computed tomography scanner plus a point-of-care laboratory. The STEMO ambulance is integrated in the emergency medical system of Berlin, Germany. Following prehospital stroke diagnosis, blood was drawn and subsequently analysed using research assays from Roche diagnostics. The clinical accuracy of plasma GFAP was tested using a cut-off value of 0.29 ng/ml. Results: Blood samples of 74 patients were analysed. Twenty-five patients had ICH (mean age 69 ± 11 years, median National Institutes of Health Stroke Scale (NIHSS) 15) and 49 IS (mean age 75 ± 10 years, median NIHSS 6). Nine ICH (0 IS patients) had GFAP-levels above 0.29 ng/ml. The sensitivity and specificity of GFAP for differentiating between ICH and AIS were 36.0 and 100%. The sensitivity for ICH volume >15 ml was 61.5%. ICH patients without GFAP elevation had significantly smaller hemorrhage volumes (median 4.5 vs. 37.6 ml, p = 0.004) and were less likely to deteriorate (19 vs. 56%, p = 0.087). Conclusions: GFAP levels >0.29 ng/ml were seen only in ICH, thus confirming the diagnosis of ICH during prehospital care. However, sensitivity is low particularly in smaller hemorrhages.

Decompressive Hemicraniectomy in Hypertensive Basal Ganglia Hemorrhages

Objectives: The aim of this study was to analyze efficacy and safety of decompressive hemicraniectomy (DHC) in hypertensive basal ganglia hemorrhage (HBGH). Neurosurgical management of HBGH is still a controversial issue. Surgical techniques are diverse, from the open large craniotomy, to the minimally invasive techniques like stereotactic aspiration of the HBGH, endoscopic evacuation and stereotactic catheter drainage after instillation of thrombolytic agents. Decompressive hemicraniectomy lowers intracranial pressure and improves outcome in patients with HBGH.Methods: 8 patients with HBGH who underwent decompressive craniectomy in the last 2 years were analyzed. Parameters investigated included clinical presentations, radiologic profile, time interval from ictus to surgery, and modified Rankin Scale score at 6 months.Results: The patients mean age 55 years, the mean Glasgow Coma Scale (GCS) score was 7 (range 5–13), the mean ICH volume was 58 ml (range 40–70 ml), and the mean midline shift was 10.62 mm (range 6-16 mm). The outcome after 6 months was appreciated as good (modified Rankin Scale 0–4) or poor (modified Rankin Scale 5-6). Five patients had good and three had poor outcomes (including two deaths).Conclusion: We conclude, based on this small cohort, that DC can reduce mortality in some cases. Larger prospective studies are needed to assess safety and efficacy of this method.Pulse Vol.8 January-December 2015 p.38-42

Clinical characteristics and outcome of aneurysmal subarachnoid hemorrhage with intracerebral hematoma.

OBJECTIVE Intracerebral hematoma (ICH) with subarachnoid hemorrhage (SAH) indicates a unique feature of intracranial aneurysm rupture since the aneurysm is in the subarachnoid space and separated from the brain by pia mater. Broad consensus is lacking regarding the concept that ultra-early treatment improves outcome. The aim of this study is to determine the associative factors for ICH, ascertain the prognostic value of ICH, and investigate how the timing of treatment relates to the outcome of SAH with concurrent ICH. METHODS The study data were pooled from the SAH International Trialists repository. Logistic regression was applied to study the associations of clinical and aneurysm characteristics with ICH. Proportional odds models and dominance analysis were applied to study the effect of ICH on 3-month outcome (Glasgow Outcome Scale) and investigate the effect of time from ictus to treatment on outcome. RESULTS Of the 5362 SAH patients analyzed, 1120 (21%) had concurrent ICH. In order of importance, neurological status, aneurysm location, aneurysm size, and patient ethnicity were significantly associated with ICH. Patients with ICH experienced poorer outcome than those without ICH (OR 1.58; 95% CI 1.37-1.82). Treatment within 6 hours of SAH was associated with poorer outcome than treatment thereafter (adjusted OR 1.67; 95% CI 1.04-2.69). Subgroup analysis with adjustment for ICH volume, location, and midline shift resulted in no association between time from ictus to treatment and outcome (OR 0.99; 95% CI 0.94-1.07). CONCLUSIONS The most important associative factor for ICH is neurological status on admission. The finding regarding the value of ultra-early treatment suggests the need to more robustly reevaluate the concept that hematoma evacuation of an ICH and repair of a ruptured aneurysm within 6 hours of ictus is the most optimal treatment path.

Electrocorticographic(ECoG) monitoring in spontaneous intracerebral hemorrhage(sICH): Metabolic profile of cortical spreading depolarizations(CSD)

Objective Metabolic changes accompany CSDs in clinical secondary brain injury. This was investigated for the first time after sICH. Methods Patients with sICH were enrolled in COSBID (Co-operative Study on Brain Injury Depolarisations). Prolonged depressions of ECoG was used to detect CSDs. Brain tissue oxygen tension (PbtO2), cerebral blood flow (CBF), and cerebral metabolism (microdialysis) were monitored in the region of perihematomal edema (PHE). Results 18 patients (38% female, 55–67 years) had an ICH volume of 33–69 ml. Hematoma evacuation (n = 17) or craniectomy only (n = 1) was performed. During monitoring for 10 (6–14) days, a total of 129 CSDs were observed in 66.7% (n = 12) of patients. CSDs occurred in 73% (N = 11) of patients with PHE expansion. CSDs were directly associated with a significant decrease of PbtO2 (−4mmHg [−3;−7]) in 68% (52/77), CBF changes in 95% (19/20), and metabolic derangement in 80% (80/100) of events. PHE expansion was observed in all patients with spreading convulsions (N = 2) and patients with repetitive CSDs. Conclusions CSDs are associated with local PbtO2 decreases. Clusters of CSDs in particular seems to be associated with detrimental metabolic changes of the perihematomal brain tissue. Key Message ECoG reveals brain pathophysiology of sICH: CSDs are frequent and accompanied by metabolic derangement.

Abstract WP357: The Impact of Specific Neuroanatomical Location in Deep Supratentorial Intracerebral Hemorrhage (ICH): Findings From the Ethnic/Racial Variations of ICH Study

Background: Recently early phase clinical trials have targeted individual anatomical locations. However, information regarding ICH characteristics and outcomes of specific deep locations of ICH is limited. Methods: ERICH is a multi-center, prospective, case-control study of a racially mixed population with ICH. ICH locations were systematically designated by a central imaging core. Subjects with supratentorial deep ICH based on initial head CT originating in the caudate, thalamus, or putamen were included. Those with pre-morbid modified Rankin Scale (mRS) &gt; 2, positive drug screen, or missing 3-month mRS were excluded. Differences in baseline characteristics and medical interventions were examined by anatomic location, stratified by intraventricular hemorrhage (IVH) presence. Receiver operating curve analysis was performed to determine ICH volume specificity for poor outcome (mRS 4-6). Results: A total of 945 subjects met inclusion criteria for the analysis: caudate (n=62), putamen (n=394), thalamus (n=489). Significant differences were noted for presence of IVH (caudate 89%, putamen 23%, thalamus 64%, p&lt;.0001), ventriculostomy (caudate 52%, putamen 14%, thalamus 27%; p&lt;.0001), and surgery (caudate 2%, putamen 10%, thalamus 2%, p&lt;.0001). In multivariable analysis, subjects with thalamic ICH without IVH (compared with putaminal ICH without IVH) were more likely to be younger (OR 1.02; 95%CI 1.00-1.04, p=.0130, have history of hypertension (OR 2.82, 95%CI 1.24-6.39), and lower ICH volume (OR 0.28, 95%CI 0.21-0.38, p&lt;.0001). Subjects with thalamic ICH and IVH (compared with putaminal ICH and IVH) were less likely to have surgery for evacuation (OR 0.14, 95%CI 0.04-0.46, p=.0012) and have lower ICH volume (OR 0.13, 95%CI 0.08-0.22, p&lt;.0001). Receiver operating curve analysis identified 5.39 mL volume in thalamic ICH without IVH and 18.68 ml in putaminal ICH without IVH as having 95% specificity for poor outcome. Conclusion: In patients with deep supratentorial ICH, IVH is significantly more common in caudate and thalamic ICH compared with putaminal ICH. ICH volume cut-offs highly specific for poor outcome were identified. These findings may have implications for prognosis and clinical trial design.

Abstract WP292: Discharge Disposition After Intracerebral Hemorrhage and Functional Outcomes

Introduction: Data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study previously reported racial/ethnic differences in discharge disposition after ICH hospitalization to home-like environments vs. medical facilities. We sought to explore how discharge disposition affects functional outcome for ICH patients with disability at time of hospital discharge. Methods: ERICH is a multi-center, prospective case-control study of ICH among whites, blacks, and Hispanics. Patients included in this analysis had pre-stroke modified Rankin Scale (mRS) &lt; 3, available ICH volume measurements (log transformed), and mRS of 2-5 at discharge. The mRS at 3 months post onset was the primary outcome variable. Logistic regression was used to model the probability of 3-month functional disability (mRS≥3) against discharge disposition, adjusting for ICH score and dementia. Results: Between 08/2010 and 3/2015, 2964 ICH cases were enrolled, of whom 1627 qualified for analysis. Univariate analysis examined demographics, past medical history, social status (education level, marital status, employment), and type of insurance. In multivariate analysis, higher age, lower GCS, higher discharge mRS, non-lobar ICH location, higher ICH volume, presence of IVH, and history of dementia were independently associated with increased risk of mRS≥3 at 3 months. In a multivariate model that controlled for ICH score, patients who were mRS=3 at hospital discharge were more likely to be mRS ≥ 3 at 3 months if discharged to a medical facility rather than to home (p=.0153, OR 2.7, CI 1.2-6.2); additional independent predictors of 3-month mRS≥3 were presence of IVH (p=.002, OR 3.5, CI 1.8-6.6) and dementia (p=.04, OR 3.8, CI 1.1-13.7). However, patients who were mRS=4 at discharge were equally as likely to be mRS≥3 at 3 months, whether discharged home or to a medical facility (p=0.599, OR 0.9, CI 0.5-1.5). Conclusion: ICH patients with moderate disability at hospital discharge were more likely to have a favorable functional outcome at 3 months if discharged to a home environment vs. a medical facility. Future analysis is needed to look at the rate of complications for ICH patients at medical facilities vs. home-like environments that may affect 3-month outcome.

The etiologic subtype of intracerebral hemorrhage may influence the risk of significant hematoma expansion

BackgroundIntracerebral hemorrhage (ICH) growth is an important independent predictor of clinical deterioration and outcome. Little is known about the association between etiology of ICH and occurrence of hematoma expansion (HE). The aim of the present study was to assess whether ICH etiologic subtype may influence the risk of significant HE. MethodsWe conducted an analysis on retrospectively collected data of 424 consecutive patients with ICH, who were admitted to the Verona General Hospital, from March 2011 to December 2014.Using the SMASH-U (Structural vascular lesions, Medication, Amyloid angiopathy, Systemic disease, Hypertension, or Undetermined) classification, we identified the ICH etiologic subtypes. Outcome measure was significant HE (an absolute increase in ICH volume>12.5mL or >50%) within 48h. ResultsSignificant HE occurred in 11/57 (19.3%) Amyloid, 7/14 (50%) Structural, 31/57 (54.4%) Medication, 25/44 (56.8%) in Systemic, 62/139 (44.6%) Hypertensive, and 21/68 (30.9%) Undetermined ICH. Baseline ICH volume (OR 1.011 per mL, 95% CI 1.006–1.017, p<0.001) and onset-to-baseline CT time (OR 0.919 per hour, 95% CI 0.852–0.990, p=0.027) were predictors of significant HE. Compared with Amyloid ICH, ORs for significant HE were higher in patients with Structural ICH (OR 1.430, 95% CI 1.060–1.948, p=0.023), Medication ICH (OR 4.344, 95% CI 1.382–13.653, p=0.012), Systemic ICH (OR 1.796, 95% CI 1.070–3.015, p=0.027), and Hypertensive ICH (OR 3.081, 95% CI 1.426–6.655, p=0.004). ConclusionOur study shows that Structural, Medication, Systemic, and Hypertensive ICH were the etiologic subtypes associated with a higher risk of significant HE, compared with Amyloid ICH patients.

Abstract W P332: Ratio of Blood Urea Nitrogen to Serum Creatinine Predicts Primary Intracerebral Hemorrhage Volume

Background&amp;Purpose: Dehydration is associated with poor outcomes in stroke patients. A common marker of hydration status is the calculated blood urea nitrogen (BUN) to serum creatinine (SCr) ratio. Few studies in primary ICH patients have focused on intravascular volume depletion and ICH volume. We examined if dehydration (BUN/SCr &gt; 15) predicted admission ICH volume. Subjects&amp;Methods: Consecutive patients (2008 – 2013) who presented with a spontaneous ICH to our academic stroke center in the Southeast US were retrospectively analyzed. Demographics, initial lab values, ICH volumes, and ICH scores were recorded. Patients with INR &lt;= 1.5 were divided into two groups: BUN/SCr &lt;= 15 and &gt; 15. ICH volumes were compared between groups. Statistical significance was determined using linear regression adjusting for admission systolic blood pressure (SBP) and ICH score. Results: We identified 326 patients who met inclusion criteria (mean age 63; SD=15, 43% women, 45% black). Patients with ratio &gt;15 were older (68 vs.60 years, p&lt;0.001). In addition, a higher proportion were white (63% vs.40%, p &lt;0.001) and female (56% vs. 36%, p&lt;0.001). The average SBP on arrival was similar between groups (176 vs.181 mmHg, p=0.159). The average initial ICH volumes for those with BUN/SCr &gt; 15 were higher than patients with BUN/SCr &lt;= 15 (29.6 mL vs. 20.6 mL, p = 0.022). After adjusting for SBP and ICH score, patients with elevated BUN/SCr had an average of 9 mL larger ICH volumes on admission. Conclusions: Elevated BUN/SCr ratio is linked to larger initial ICH volumes even after controlling for ICH score and SBP. This simple ratio is an independent predictor of ICH volume, may reflect poor hydration status, and can potentially be used in the early evaluation and treatment of ICH patients. Future studies to determine if correction impacts functional outcomes are warranted.