Infratentorial Intracerebral Hemorrhage Research Articles

Predictors and Prognostic Impact of Hematoma Expansion in Infratentorial Cerebral Hemorrhage.

Hematoma expansion (HE) is common and predicts poor outcome in patients with supratentorial intracerebral hemorrhage (ICH). We investigated the predictors and prognostic impact of HE in infratentorial ICH. We conducted a retrospective analysis of patients with brainstem and cerebellar ICH admitted at seven sites. Noncontrast computed tomography images were analyzed for the presence of hypodensities according to validated criteria, defined as any hypodense region strictly encapsulated within the hemorrhage with any shape, size, and density. Occurrence of HE (defined as > 33% and/or > 6-mL growth) and mortality at 90days were the outcomes of interest. Their predictors were investigated using logistic regression with backward elimination at p < 0.1. Logistic regression models for HE were adjusted for baseline ICH volume, antiplatelet and anticoagulant treatment, onset to computed tomography time, and presence of hypodensities. The logistic regression model for mortality accounted for the ICH score and HE. A total of 175 patients were included (median age 75years, 40.0% male), of whom 38 (21.7%) had HE and 43 (24.6%) died within 90days. Study participants with HE had a higher frequency of hypodensities (44.7 vs. 24.1%, p = 0.013), presentation within 3h from onset (39.5 vs. 24.8%, p = 0.029), and 90-day mortality (44.7 vs. 19.0%, p = 0.001). Hypodensities remained independently associated with HE after adjustment for confounders (odds ratio 2.44, 95% confidence interval 1.13-5.25, p = 0.023). The association between HE and mortality remained significant in logistic regression (odds ratio 3.68, 95% confidence interval 1.65-8.23, p = 0.001). Early presentation and presence of noncontrast computed tomography hypodensities were independent predictors of HE in infratentorial ICH, and the occurrence of HE had an independent prognostic impact in this population.

External Validation and Retraining of DeepBleed: The First Open-Source 3D Deep Learning Network for the Segmentation of Spontaneous Intracerebral and Intraventricular Hemorrhage.

The objective of this study was to assess the performance of the first publicly available automated 3D segmentation for spontaneous intracerebral hemorrhage (ICH) based on a 3D neural network before and after retraining. We performed an independent validation of this model using a multicenter retrospective cohort. Performance metrics were evaluated using the dice score (DSC), sensitivity, and positive predictive values (PPV). We retrained the original model (OM) and assessed the performance via an external validation design. A multivariate linear regression model was used to identify independent variables associated with the model's performance. Agreements in volumetric measurements and segmentation were evaluated using Pearson's correlation coefficients (r) and intraclass correlation coefficients (ICC), respectively. With 1040 patients, the OM had a median DSC, sensitivity, and PPV of 0.84, 0.79, and 0.93, compared to thoseo f 0.83, 0.80, and 0.91 in the retrained model (RM). However, the median DSC for infratentorial ICH was relatively low and improved significantly after retraining, at p < 0.001. ICH volume and location were significantly associated with the DSC, at p < 0.05. The agreement between volumetric measurements (r > 0.90, p > 0.05) and segmentations (ICC ≥ 0.9, p < 0.001) was excellent. The model demonstrated good generalization in an external validation cohort. Location-specific variances improved significantly after retraining. External validation and retraining are important steps to consider before applying deep learning models in new clinical settings.

Risk Factors for Opioid Utilization in Patients with Intracerebral Hemorrhage.

Headache is a common presenting symptom of intracerebral hemorrhage (ICH) and often necessitates treatment with opioid medications. However, opioid prescribing patterns in patients with ICH are not well described. We aimed to characterize the prevalence and risk factors for short and longer-term opioid use in patients with ICH. We conducted a retrospective cohort study using data from a single-center registry of patients with nontraumatic ICH. This registry included data on demographics, ICH-related characteristics, and premorbid, inpatient, and postdischarge medications. After excluding patients who died or received end-of-life care, we used multivariable regression models adjusted for premorbid opioid use to determine demographic and ICH-related risk factors for inpatient and postdischarge opioid use. Of 468 patients with ICH in our cohort, 15% (n = 70) had premorbid opioid use, 53% (n = 248) received opioids during hospitalization, and 12% (n = 53) were prescribed opioids at discharge. The most commonly used opioids during hospitalization were fentanyl (38%), oxycodone (30%), morphine (26%), and hydromorphone (7%). Patients who received opioids during hospitalization were younger (univariate: median [interquartile range] 64 [53.5-74] vs. 76 [67-83] years, p < 0.001; multivariable: odds ratio [OR] 0.96 per year, 95% confidence interval [CI] 0.94-0.98) and had larger ICH volumes (univariate: median [interquartile range] 10.1 [2.1-28.6] vs. 2.7 [0.8-9.9] cm3, p < 0.001; multivariable: OR 1.05 per cm3, 95% CI 1.03-1.08) than those who did not receive opioids. All patients who had external ventricular drain placement and craniotomy/craniectomy received inpatient opioids. Additional risk factors for increased inpatient opioid use included infratentorial ICH location (OR 4.8, 95% CI 2.3-10.0), presence of intraventricular hemorrhage (OR 3.9, 95% CI 2.2-7.0), underlying vascular lesions (OR 3.0, 95% CI 1.1-8.1), and other secondary ICH etiologies (OR 7.5, 95% CI 1.7-32.8). Vascular lesions (OR 4.0, 95% CI 1.3-12.5), malignancy (OR 5.0, 95% CI 1.5-16.4), vasculopathy (OR 10.0, 95% CI 1.8-54.2), and other secondary etiologies (OR 7.2, 95% CI 1.8-29.9) were also risk factors for increased opioid prescriptions at discharge. Among patients who received opioid prescriptions at discharge, 43% (23 of 53) continued to refill their prescriptions at 3months post discharge. Inpatient opioid use in patients with ICH is common, with some risk factors that may be mechanistically connected to primary headache pathophysiology. However, the lower frequency of opioid prescriptions at discharge suggests that inpatient opioid use does not necessarily lead to a high rate of long-term opioid dependence in patients with ICH.

Defining Minor Intracerebral Hemorrhage

Background and Purpose: The minor stroke concept has not been analyzed in intracerebral hemorrhage (ICH) patients. Our purpose was to determine the optimal cut point on the NIH Stroke Scale (NIHSS) for defining a minor ICH (mICH) in patients with primary ICH. Methods: An ICH was considered minor if associated with a favorable 3-month outcome (modified Rankin Scale score ≤2). For supratentorial ICH, the discovery cohort consisted of 478 patients prospectively admitted at University Hospital del Mar. Association between NIHSS at admission and 3-month outcome was evaluated with area under the curve-receiver operating characteristics (AUC-ROC) and Youden’s index to identify the optimal NIHSS cutoff point to define mICH. External validation was performed in a cohort of 242 supratentorial ICH patients from University Hospital Sant Pau. For infratentorial location, patients from both hospitals (n = 85) were analyzed together. Results: The best ­NIHSS cutoff point defining supratentorial-mICH was 6 (AUC-ROC = 0.815 [0.774–0.857] in the discovery cohort and AUC-ROC = 0.819 [0.756–0.882] in the external validation cohort). For infratentorial ICH, the best cutoff point was 4 (AUC-ROC = 0.771 [0.664–0.877]). Using these cutoff points, 40.5% of all primary ICH cases were mICH. Of these, 70.2% were living independently at 3-month follow-up (72% for supratentorial ICH and 56.1% for infratentorial ICH) and 6.5% had died (5.3% for supratentorial ICH, and 14.6% for infratentorial ICH). For patients identified as non-mICH, good 3-month outcome was observed in 11.3% of cases; mortality was 51%. Conclusions: The definition of mICH using the NIHSS cutoff point of 6 for supratentorial ICH and 4 for infratentorial ICH is useful to identify good outcome in ICH patients.

Abstract P461: Contemporary National Estimates of Characteristics and Outcomes Associated With Supra and Infratentorial Intracerebral Hemorrhage

Introduction: Location specific Intracerebral Hemorrhage (ICH) characteristics and outcomes are important for risk stratification and clinical trial design. However, they have not been described at the population level. Methods: We analyzed the National Inpatient Sample (90% of US hospitalizations) from 09/2015 to 12/2017 and utilized ICD-10 codes to identify ICH patients with a primary diagnosis of either supra-tentorial (ST) or infra-tentorial (IT) hemorrhage; excluding intraventricular or unspecified location. Utilizing sampling weights, nationally representative proportions of ST and IT ICH patients across demographic, comorbidity, healthcare utilization, disease acuity and outcomes are provided. We fit survey design logistic regression models for in-hospital mortality (IHM) and home discharge (HD). Odds Ratios (OR) and 95% confidence Intervals (CI) are reported. Results: Across the analysis time period, a total of 161,395 ICH patients were identified, of whom 51,025 (31.6%) and 20,135(12.5%) had ST and IT ICH respectively. IT ICH patients (vs. ST ICH) were younger (66.9 vs. 67.9 years), with higher proportions of Black (19.1% vs. 17.6%) and un-insured (5.9% vs. 4.7%). A significantly greater proportion of IT ICH patients had prior myocardial infarction, congestive heart failure, atrial fibrillation, renal disease and hypertension. Whereas the prior cerebrovascular disease, dementia, depression and alcohol abuse was associated with ST ICH. Smaller proportion of IT ICH patients (vs. ST ICH) were treated in urban teaching hospitals (81.4% vs. 83.2%). A greater proportion of IT ICH underwent invasive mechanical ventilation (58.1% vs. 46.7%), ventriculostomy (18.2% vs. 10.2%), and tracheostomy (6.4% vs. 4.6%). The total charges and charges per day were significantly higher for IT ICH patients. The overall IHM was 22.6%. A greater proportion of IT ICH patients (vs. ST ICH) experienced IHM (28.2% vs. 17.3%) and smaller proportion had HD (16.7% vs. 20.7%). In the fully adjusted models, IT ICH was associated with a significantly higher IHM (OR, CI: 1.47, 1.26 - 1.71) and lower likelihood of HD (OR, CI: 0.56, 0.46 - 0.68). Conclusion: ST and IT ICH patients have distinctive risk factor and demographic profiles. IT ICH is associated with poor outcomes.

Natural History of Infratentorial Intracerebral Hemorrhages: Two Subgroups with Distinct Presentations and Outcomes

Background/ObjectiveInfratentorial intracerebral hemorrhage (ICH) is associated with worse prognosis than supratentorial ICH; however, infratentorial ICH is often excluded or underrepresented in clinical trials of ICH. We sought to evaluate the natural history of infratentorial ICH stratified by brainstem or cerebellar location using a prospective observational study inclusive of all spontaneous ICH. MethodsUsing a prospective, single center cohort of patients with spontaneous ICH between 2008-2019, we conducted a descriptive analysis of baseline demographics, severity of injury scores, and long-term functional outcomes of infratentorial ICH stratified by cerebellar or brainstem location. ResultsInfratentorial ICH occurred in 82 (13%) of 632 patients in our ICH cohort. Among infratentorial ICH, cerebellar ICH occurred in 45 (55%) and brainstem ICH occurred in 37 (45%). Compared to cerebellar ICH, patients with brainstem ICH had significantly worse severity of injury scores, including lower admission Glasgow Coma Scale (median 14 [7.0 – 15.0] versus 4 [3.0 – 8.0], respectively; P < 0.001) and higher ICH Score (median 2 [1.0 – 3.0] versus 3 [2.75 – 4.0], respectively; P = 0.02). Patients with cerebellar ICH were more likely to be discharged home or to acute rehabilitation (OR 4.8, 95% CI 1.8 – 12.8) but there was no difference in in-hospital mortality (OR 0.4, 95% CI 0.1 – 1.1, P = 0.08) or cause of death (P = 0.5). Modified Rankin Scale scores at 3 months were significantly better in patients with cerebellar ICH compared to brainstem ICH (median 3.5 [1.8 - 6.0] versus median 6 [5.0 - 6.0], P = 0.03). ConclusionsLocation of infratentorial ICH is an important determinant of admission severity and clinical outcome in unselected patients with ICH. Patients with cerebellar ICH have less severe symptoms at presentation and more favorable functional outcomes compared to patients with brainstem ICH.

Abstract 18: Diffusion Weighted Imaging Lesions in Patients With Acute Intracerebral Hemorrhage: A Pooled Analysis of Individual Patient Data From MISTIE-III, ATACH-II, I-DEF, and ERICH

Introduction: The etiology and significance of diffusion weighted imaging (DWI) lesions in patients with acute intracerebral hemorrhage (ICH) remain unclear. We evaluated which factors were associated with DWI lesions, whether associated factors differed by ICH location, and whether DWI lesions were associated with functional outcomes. Methods: We pooled individual patient data from the MISTIE III trial, the ATACH-II trial, the i-DEF trial, and the ERICH study. We included only patients who underwent protocolized magnetic resonance imaging (MRI) of the brain. A poor functional outcome was defined as a modified Rankin Scale (mRS) score of 4-6 at 3-6 months. We used mixed effects logistic regression with the study database as a random effect. Results: Among 1,775 ICH patients, there were 621 (35.6%) lobar, 978 (55.9%) deep, and 148 (8.5%) infratentorial ICHs. Median time to MRI scan was 1.5 days (IQR, 1-4). DWIHLs occurred in 559 (31.5%) patients, with 190 (34.3%) in lobar ICH and 320 (57.8%) in deep ICHs. In mixed effects regression models, factors associated with DWIHLs included younger age factors associated with DWIHLs after acute ICH included younger age (OR, 0.98; 95% CI, 0.97-0.99), black race (OR, 1.59; 95% CI, 1.18-2.16), admission systolic blood pressure (SBP per 10 mm Hg, OR, 1.13; 95% CI, 1.05-1.22), cerebral microbleeds (OR, 1.71, 95% CI, 1.24-2.35), and leukoaraiosis (OR, 1.60; 95% CI, 1.14-2.25). Patients with DWIHLs had higher odds of mRS 4-6 (OR, 1.57; 95% CI, 1.24-1.99) compared to those without, after adjustment for demographics and ICH severity. In subgroup analyses, similar factors influenced DWIHLs in deep ICH. However, in lobar ICH, younger age, admission SBP, and leukoaraiosis were associated with DWIHLs. Presence of DWIHLs was independently associated with poor mRS in deep ICH but not in lobar ICH. There was no relationship between acute BP lowering and DWIHLs, regardless of location. Conclusions: In a large, heterogeneous cohort of ICH patients, our results are consistent with the hypothesis that DWIHLs represent the effects of chronic hypertensive vasculopathy and acute blood pressure elevation. Furthermore, DWIHLs portend poor prognosis after ICH, particularly in deep hemorrhages.

Spontaneous Intracerebral Hemorrhage.

Background and Purpose- We compared clinical and radiological predictors of long-term mortality in patients with spontaneous intracerebral hemorrhage (ICH) needing intensive care. Methods- A retrospective multicenter study of adult ICH patients treated in Finnish tertiary hospital's intensive care units during 2003 to 2013. We created 3 multivariable models (clinical, radiological, and combined clinical-radiological) for 12-month mortality prediction and compared their areas under receiver operating characteristic curves (AUCs). We analyzed supratentorial and infratentorial ICHs separately. Results- Of 972 patients (796 supratentorial ICH, 176 infratentorial ICH) included, 43% died within 12 months (42% supratentorial ICH, 49% infratentorial ICH). For all patients, the clinical model (AUC, 0.83; 95% CI, 0.81-0.86) outperformed the radiological model (AUC, 0.73; 95% CI, 0.70-0.77; P<0.001), yet the combined model (AUC, 0.85; 95% CI, 0.83-0.88) outperformed both condensed models (P<0.001). For supratentorial ICH, the combined model outperformed both the clinical and radiological models (AUC, 0.84; 95% CI, 0.81-0.87 versus AUC, 0.82; 95% CI, 0.79-0.85 and AUC, 0.73; 95% CI, 0.69-0.77; P<0.001 for all). For infratentorial ICH patients, the combined model significantly outperformed the radiological model but not the clinical model (AUC, 0.92; 95% CI, 0.88-0.96 versus AUC, 0.76; 95% CI, 0.69-0.83 versus AUC, 0.91; 95% CI, 0.87-0.95; P<0.001 and P=0.433, respectively). Conclusions- Clinical factors were more important than objective radiological factors for 12-month mortality prediction in intensive care unit-treated ICH patients. The effect of clinical and radiological factors on outcome was different for supratentorial and infratentorial ICHs stressing that these should not be treated as one entity.

Infratentorial Intracerebral Hemorrhage.

Background and Purpose- Infratentorial intracerebral hemorrhage (ICH) has a poor outcome but is rarely analyzed by cerebellar versus brain stem location. We evaluated this relationship and clinical outcomes among participants of the INTERACT 1 and 2 (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials). Methods- Participants with brain stem and cerebellar ICH were compared. Logistic regression models were used to compare outcomes of death or major disability and quality of life. Results- Of 195 included patients, 92 (47%) and 103 (53%) had brain stem and cerebellar ICH, respectively. Patients with brain stem ICH were younger (mean [SD] age, 59±13 versus 70±11 years), less female (28.3% versus 50.5%), with higher admission National Institutes of Health Stroke Scale scores (median [interquartile range], 6 [4-10) versus 3 [2-8]), less prior ICH (3% versus 17%), smaller ICH volumes (1.6 mL [1.0-2.8 mL] versus 5.1 mL [2.6-10.7 mL]), and less intraventricular extension (3% versus 39%) than those with cerebellar ICH. Brain stem ICH had higher mortality (odds ratio, 37.1; 95% CI, 1.99-692.27) and worse scores in the European Quality of Life Scale (EQ-5D) pain domain (odds ratio, 3.36; 95% CI, 1.38-8.20). Conclusions- Cerebellar and brain stem ICH differ in their clinical characteristics and prognosis, with the latter being associated with higher case fatality and worse EQ-5D scores in the pain domain. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifiers: NCT00226096 and NCT00716079.

Predictors of Surgical Intervention in Patients with Spontaneous Intracerebral Hemorrhage

Despite no clear evidence from randomized trials, surgical intervention of spontaneous intracerebral hemorrhage (ICH) still occurs. We sought to describe the characteristics of patients undergoing surgical intervention in ICH. Data from the ERICH (ERICH Ethnic/Racial Variations of Intracerebral Hemorrhage) study were analyzed, and patients with ICH were categorized into surgical intervention or nonoperative management groups. Patients with primary intraventricular hemorrhage and those without data regarding the use of surgical intervention were excluded. The study cohort comprised 2947 patients, and surgical intervention was performed in 289 (10%). Younger age (odds ratio [OR], 0.967; P < 0.001), lower baseline modified Rankin Scale score (OR, 0.728; P < 0.001), higher admission Glasgow Coma Scale score (OR, 1.059; P=0.007), larger ICH volume (OR, 1.037; P < 0.001), infratentorial ICH location (OR, 5.966; P < 0.001), lobar ICH location (OR, 1.906; P= 0.001), lack of intraventricular hemorrhage (OR, 0.567; P= 0.001), intracranial pressure (ICP) monitoring (OR, 5.022; P < 0.001), and mannitol use (OR, 2.389; P < 0.001) were independent predictors of surgical intervention. Younger age (OR, 0.953; P < 0.001), lower baseline modified Rankin Scale score (OR, 0.713; P=0.002), larger ICH volume (OR, 1.033; P < 0.001), lobar ICH location (OR,2.467; P < 0.001), ICP monitoring (OR, 3.477; P < 0.001), and mannitol use (OR, 2.139; P < 0.001) were independent predictors of surgical interventions in supratentorial ICHs. Larger ICH volume (OR, 1.078; P <0.001), ICP monitoring (OR, 6.099; P < 0.001), and mannitol use (OR, 2.952; P= 0.005) were independent predictors of surgical interventions in infratentorial ICHs. We identified multiple factors associated with surgical intervention for patients with ICH. Younger age, good neurologic function at baseline, large ICH volume on presentation, and lobar or infratentorial hematomas were independently associated with surgical intervention in patients with ICH .

Abstract TP446: Predictors of Surgical Intervention in Patients With Spontaneous Intracerebral Hemorrhage

Objective: Despite no clear evidence from randomized trials, surgical intervention of spontaneous intracerebral hemorrhage (ICH) still occurs. We sought to describe the characteristics of patients undergoing surgical intervention in ICH. Methods: Data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study were analyzed, and ICH patients were categorized into surgical intervention or nonoperative management groups. Patients with primary intraventricular hemorrhage (IVH) and those without data regarding the use of surgical intervention data were excluded. Multivariable models were developed to identify predictors of surgical intervention. Results: The study cohort comprised 2,947 patients, and surgical intervention was performed in 289 (10%). Younger age (p&lt;0.001), lower baseline modified Rankin Scale score (mRS; p&lt;0.001), higher admission Glasgow Coma Scale (GCS; p=0.007), larger ICH volume (p&lt;0.001), infratentorial ICH location (p&lt;0.001), lobar ICH location (p&lt;0.001), lack of IVH (p=0.001), ICP monitoring (p&lt;0.001), and mannitol use (p&lt;0.001) were independent predictors of surgical intervention. Younger age (p&lt;0.001), lower baseline mRS score (p=0.002), larger ICH volume (p&lt;0.001), lobar ICH location (p&lt;0.001), ICP monitoring (p&lt;0.001), and mannitol use (p&lt;0.001) were independent predictors of surgical interventions in supratentorial ICHs. Larger ICH volume (p&lt;0.001), ICP monitoring (p&lt;0.001), and mannitol use (p=0.005) were independent predictors of surgical interventions in infratentorial ICHs. Conclusion: We identified multiple factors associated with surgical intervention for patients with ICH. Younger age, good neurological function at baseline, large ICH volume on presentation, and lobar or infratentorial hematomas were independently associated with surgical intervention in ICH patients. Additional studies are necessary to determine the risk to benefit profile of ICH surgery.

Abstract WP458: Blood Pressure at Hospital Arrival Does Not Reliably Distinguish Hypertensive Intracerebral Hemorrhage

Introduction: Hypertension is a known risk factor for intracerebral hemorrhage (ICH), but it is unclear whether blood pressure (BP) elevation at hospital arrival can reliably distinguish ICH caused by hypertensive angiopathy from other potential etiologies. Methods: We performed a retrospective single-center cohort study using data from consecutive patients admitted with ICH from February-June 2018. Presumed ICH etiology, location, and other clinical predictors were prospectively adjudicated by two attending neurologists. We compared patients’ first recorded systolic BP (SBP) and mean arterial pressure (MAP) at hospital arrival stratified by hypertensive vs. non-hypertensive primary ICH etiology, with further adjustment for demographics and initial arrival location (direct arrival vs. transfer) using linear regression models. In a sensitivity analysis, we used ICH location (deep, lobar, or infratentorial) rather than etiology in our models to account for potential subjectivity in adjudication. Results: There were 110 ICH patients in our cohort (mean age 69.1 [SD 17.7], 55% male, median ICH score 1.5 [IQR 1-2]). The most frequent ICH etiologies were hypertension (58%), cerebral amyloid angiopathy (19%), vascular lesions (6%), and malignancy (5%); 43% of hemorrhages occurred in deep subcortical locations, 37% were lobar, and 14% were infratentorial. Mean SBP and MAP for patients with hypertensive ICH was 158.8 (SD 29.7) and 109.0 (SD 18.3), respectively, compared to 157.1 (SD 33.4) and 108.2 (SD 21.2) in patients with ICH caused by other etiologies (p=0.78; p=0.82). Fully-adjusted regression models showed that, relative to hypertensive ICH, those caused by non-hypertensive etiologies had similar arrival BP (mean SBP and MAP difference [95% CI], -0.2 [-12.3-11.8] and -0.8 [-8.4-6.8], respectively). In a sensitivity analysis, we found that lobar and infratentorial ICH had similar arrival BP relative to deep ICH (mean SBP and MAP difference [95% CI] 2.1 [-11.1-15.3] and 0.2 [-8.3-8.6] for lobar ICH; 6.5 [-12.0-25.0] and 3.8 [-8.0-15.6] for infratentorial ICH). Conclusion: BP at hospital arrival should not be used as a primary determinant of likely ICH etiology, as hypertension may be implicated in various subtypes of ICH.

P 062 – Examination of postural problems in children with low vision: A pilot study

We investigate whether plasma homocysteine (HCY) levels are associated with hematoma volume and outcome in patients with intracerebral hemorrhage (ICH).A total of 69 patients admitted within 24 hours after ICH onset was divided into 2 groups based on admission plasma HCY levels (low homocysteinemia [LHCY] group, plasma HCY concentrations ≤14.62 μmol/L, versus high homocysteinemia [HHCY] group, >14.62 μmol/L).Mean hematoma volumes for 2 groups (LHCY and HHCY) were 13.18 and 23.09 mL (P = .012), respectively, in patients with thalamoganglionic ICH, but hematoma volumes between 2 groups had no significant difference among patients with lobar or infratentorial ICH. On multivariate linear regression analysis, elevated HCY levels significantly correlated with larger hematoma volume in patients with thalamoganglionic ICH (B = .604, P = .004) after adjustment for confounding factors. Poor outcomes (6-month modified Rankin Scale scores ≥3) were not significantly different between 2 groups (low homocysteinemia group, 31.4%, versus high homocysteinemia group, 41.2%, P = .400).Elevated plasma HCY levels were associated with larger hematoma volume only in patients with thalamoganglionic ICH. HCY levels might not be predictors of the 6-month clinical outcome in patients with ICH.

Effect of Admission Hyperglycemia on 6-Month Functional Outcome in Patients with Spontaneous Cerebellar Hemorrhage.

BackgroundCerebellar hemorrhage (CH) has a quite different treatment strategy and prognostic factors compared with supratentorial intracerebral hemorrhage (ICH). The prognostic role of hyperglycemia has been discussed mainly in cases of supratentorial hemorrhage; it remains to be elucidated following CH. We aimed to determine the association of hyperglycemia on admission with 6-month functional outcome in CH patients.Material/MethodsWe retrospectively analyzed 77 patients with acute CH between September 2010 and April 2015 in West China Hospital. Blood glucose level was measured when the patients were admitted. Primary outcome was 6-month functional outcome, which could comprehensively reflect the patient’s recovery of physical and social ability after stroke and was assessed by the modified Rankin scale (mRS). Association of hyperglycemia with functional outcome was identified in logistic regression models.ResultsThere were 50 (64.9%) patients with poor functional outcomes. Patients with poor outcome were much older (P<0.001) and had a significantly higher glucose level on admission (P<0.001), a lower Glasgow Coma Scale score (P<0.001), a larger hematoma (P=0.003), and a higher incidence of intraventricular extension (P=0.002), brainstem compression (P=0.013), and hydrocephalus (P=0.023). Multivariate analysis showed that hyperglycemia (OR 1.50, 95% CI 1.07–2.08, P=0.017 when glucose level was analyzed as a continuous variable; OR 7.46, 95% CI 1.41–39.51, P=0.018 when glucose level was dichotomized by the critical threshold of 6.78 mmol/L) emerged as an independent predictor for adverse functional outcome at 6 months.ConclusionsTo the best of our knowledge, this is the first study focusing on the relationship between hyperglycemia and long-term functional outcome after CH. The study combined with previous pertinent reports definitely indicates the poor effect of hyperglycemia on both supra- and infratentorial ICH independent of hemorrhage site. Therefore, further controlled trials are urgently needed to evaluate the benefits of glucose-lowing treatment.

Abstract WP364: Diabetes Mellitus and Spontaneous Intracerebral Hemorrhage: Clinical Features and Mortality

Our previous findings suggest that ischemic stroke patients with either type 1 (T1D) or type 2 diabetes mellitus (T2D) exhibit a distinct risk factor and etiologic profile, and a worse vascular prognosis than do nondiabetic patients. We also showed that nonaneurysmal subarachnoid hemorrhage is rather a microvascular than macrovascular complication in T1D. Here, we aimed to compare risk factors, hematoma characteristics, and long-term mortality between diabetic and nondiabetic patients with spontaneous intracerebral hemorrhage (ICH) to provide information for patient management, counseling, and future research in these patient groups. Furthermore, we compared theses features between T1D and T2D patients. Methods: We included patients with first-ever ICH enrolled in the Helsinki ICH Study and in the Finnish Diabetic Nephropathy Study. Patients were followed using the national death registry. A Cox proportional hazards model adjusting for age at ICH onset, sex, and known ICH prognosticators_Glasgow Coma Scale (GCS) on admission, hematoma volume, infratentorial location, intraventricular hematoma_was constructed to assess, whether diabetes stands as an independent prognosticator. Results: A total of 972 patients were included, of which 813 (83.6%) were nondiabetic, 45 (4.6%) had T1D, and 120 (12.3%) T2D. Compared with nondiabetic patients, diabetic patients more often men, and they had more frequently hypertension and coronary heart disease. No difference emerged in GCS or hematoma volume, but diabetic patients more often had infratentorial ICH than nondiabetic patients. T1D patients were younger at ICH onset and they more often had brain stem ICH, but less often lobar ICH, than did T2D patients. Cumulative mortality at 12 months for nondiabetic patients was 34.0% (95% confidence interval 30.1-37.9%), for T1D 47.0% (31.3-62.7%), and for T2D 46.0% (36.2-55.8%). In multivariate Cox regression, diabetes was independently associated with higher risk of death (hazard ratio 1.42, 95% confidence interval 1.11-1.82, P=0.005). Conclusions: ICH patients with diabetes exhibit a distinct pattern of comorbidities and ICH characteristics compared with nondiabetic patients. Diabetes independently decreases the likelihood for survival after an ICH.

Abstract W MP71: Effect of Race/Ethnicity on Oral Anticoagulant-Associated Intracerebral Hemorrhage

Background: Oral anticoagulant (OAC) use is associated with poor outcome in intracerebral hemorrhage (ICH). The aim of this study was to determine if race/ethnic differences exist in this condition. Methods: Data were obtained from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study which is a prospective multicenter study of ICH. Exclusion criteria included missing initial hematoma volume or being on heparin or LMWH. Baseline and clinical characteristics, laboratory and imaging data at presentation and 24h, and mortality at 3 months were compared by OAC use and race/ethnicity. ANOVA was used to identify factors affecting initial hematoma volume by location and OAC use. Logistic regression was performed to evaluate risk of hemorrhage based on race/ethnicity. Results: A total of 2,020 of 2,276 cases met the inclusion criteria and were included in the analysis (627 whites, 739 blacks, and 654 Hispanics) of which 214 (10.5%) were on OAC (54% white, 22% black, and 23% Hispanic). History of hypertension, diabetes, hypercholesterolemia, previous stroke, and atrial fibrillation, elevated INR at admission, infratentorial location, and dementia were associated with OAC use (p&lt;.001). There were no differences in initial hemorrhage volume by race/ethnicity. Among OAC users, median INRs were 2.10 (1.67-2.80) white, 1.89 (1.30-3.05) black, and 2.53 (1.60-3.60) Hispanic (p=0.06). Compared with whites, blacks on OAC were more likely to have deep hemorrhages (OR=1.5, 95%CI=1.2-1.9). Lobar ICH was less commonly seen in blacks (OR= 0.6, 95%CI 0.5-0.7) and Hispanics (OR 0.7, 95%CI 0.5-0.9). No differences were seen in infratentorial ICH. Use of OAC predicted higher case fatality at 3-months (OR=1.7, CI=1.1-2.6). In the subgroup analysis this association remained statistically significant for blacks only (OR=3.2, CI=1.4-7.0). Conclusion: In the largest prospective study in ICH we found that location and outcome in OAC-associated ICH differ among subjects of different racial/ethnic background. Our findings indicate that OAC-associated ICH is a heterogeneous condition and identifies blacks as a group with increased case fatality rate.

Elevated Homocysteine Levels Contribute to Larger Hematoma Volume in Patients with Intracerebral Hemorrhage

We investigate whether plasma homocysteine (HCY) levels are associated with hematoma volume and outcome in patients with intracerebral hemorrhage (ICH). A total of 69 patients admitted within 24hours after ICH onset was divided into 2 groups based on admission plasma HCY levels (low homocysteinemia [LHCY] group, plasma HCY concentrations ≤14.62μmol/L, versus high homocysteinemia [HHCY] group, >14.62μmol/L). Mean hematoma volumes for 2 groups (LHCY and HHCY) were 13.18 and 23.09mL (P=.012), respectively, in patients with thalamoganglionic ICH, but hematoma volumes between 2 groups had no significant difference among patients with lobar or infratentorial ICH. On multivariate linear regression analysis, elevated HCY levels significantly correlated with larger hematoma volume in patients with thalamoganglionic ICH(B=.604, P=.004) after adjustment for confounding factors. Poor outcomes (6-month modified Rankin Scale scores ≥3) were not significantly different between 2 groups (low homocysteinemia group, 31.4%, versus high homocysteinemia group, 41.2%, P=.400). Elevated plasma HCY levels were associated with larger hematoma volume only in patients with thalamoganglionic ICH. HCYlevels might not be predictors of the 6-month clinical outcome in patients with ICH.

Warfarin and Statins are Associated with Hematoma Volume in Primary Infratentorial Intracerebral Hemorrhage

Despite extensive studies of supratentorial intracerebral hemorrhage (ICH), limited data are available on determinants of hematoma volume in infratentorial ICH. We therefore aimed to identify predictors of infratentorial ICH volume and to evaluate whether location specificity exists when comparing cerebellar to brainstem ICH. We undertook a retrospective analysis of 139 consecutive infratentorial ICH cases (95 cerebellar and 44 brainstem ICH) prospectively enrolled in a single-center study of ICH. ICH volume was measured on the CT scan obtained upon presentation to the Emergency Department using an established computer-assisted method. We used linear regression to identify determinants of log-transformed ICH volume and logistic regression to evaluate their role in surgical evacuation. Median ICH volumes for all infratentorial, cerebellar, and brainstem ICH were nine [interquartile range (IQR), 3-23], ten (IQR, 3-25), and eight (IQR, 3-19) milliliters, respectively. Thirty-six patients were on warfarin treatment, 31 underwent surgical evacuation, and 65 died within 90 days. Warfarin was associated with an increase in ICH volume of 86 % [β = 0.86, standard error (SE) = 0.29, p = 0.003] and statin treatment with a decrease of 69 % (β = -69, SE = 0.26, p = 0.008). Among cerebellar ICH subjects, those on warfarin were five times more likely to undergo surgical evacuation (OR = 4.80, 95 % confidence interval 1.63-14.16, p = 0.005). Warfarin exposure increases ICH volume in infratentorial ICH. Further studies will be necessary to confirm the inverse relation observed between statins and ICH volume.

Intracerebral hemorrhage during anticoagulation with vitamin K antagonists: a consecutive observational study

Intracerebral hemorrhage (ICH) is the most devastating complication of oral anticoagulation (OAC). As the number of patients on long-term OAC is expected to rise, the proportion of intracerebral hemorrhage related to OAC (OAC-ICH) in relation to spontaneous ICH (spont-ICH) is expected to increase as well. We determined the proportion of OAC-ICH in consecutive stroke patients and explored differences between OAC-ICH and spont-ICH regarding initial volume, hematoma expansion and outcome. Our prospective study consecutively enrolled patients with supra- and infratentorial ICH. The National Institute of Health Stroke Scale Score and the modified Rankin Scale (mRS) score at baseline and after 3 months, medical history and demographic variables were recorded. All admission and follow-up CTs/MRIs were analysed regarding ICH volume using the ABC/2-method. Intraventricular hemorrhage (IVH) was quantified using the Graeb score. Within 19 months, 2,282 patients were admitted to our ER. 206 ICH patients were included. Overall, 24.8 % of all ICH were related to OAC. Compared to patients with spont-ICH, OAC-ICH patients were older (p = 0.001), more frequently had initial extension of ICH into the ventricles (p = 0.05) or isolated primary IVH (p = 0.03) and a higher Graeb score upon admission (p = 0.01). In contrast, initial ICH volume (p = 0.16) and ICH expansion (p = 0.9) in those receiving follow-up imaging (n = 152) did not differ between the two groups. After correction for age, there was a trend towards poorer outcome in OAC-ICH (p = 0.08). One-fourth of all ICH are related to OAC. Initial extension of ICH into the ventricles and primary IVH are more frequent in OAC-ICH. The rate of hematoma expansion in OAC-ICH patients is similar to non-anticoagulated ICH patients.

Abstract 3792: The Modified Graeb-scale Evaluates Extent Of Ventricular Hemorrhage And Independently Predicts Functional Outcome After Intracerebral Hemorrhage In A Population-based Cohort

Introduction: Presence of intraventricular hemorrhage (IVH) reduces survival probability after intracerebral hemorrhage (ICH). A new semi-quantitative method, describing the extent of IVH, the modified-Graeb-scale (mGraeb), has been developed for clinical trial use (e.g. CLEAR IVH). It ranges from 0 when no IVH is present, to 32 when all ventricles are filled and also expanded by blood. We analyzed the predictive value of mGraeb in a population-based ICH cohort. Method: We included 256 consecutive first-ever stroke patients with ICH from Lund Stroke Register. Baseline CT scans (&lt; 7 days after ICH) were analysed by two independent readers evaluating mGraeb, ICH-location (deep, lobar, mixed, infra-tentorial) and ICH-volume. Baseline Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS) at 3 months were estimated from patient files. Cox proportional hazards models were used to identify predictive factors (age, sex, GCS and ICH-volume in all models; IVH / mGraeb and supratentorial ICH / all ICH in different models) for unfavourable outcome defined as mRS&gt;3 or death at 3 months. Results: IVH was detected in 116 (45%) of 256 patients, with a mean mGraeb of 11.2 (range 1-28). At 3 months, the 161 (63%) patients who were still alive had a mean mRS of 2.7. In the primary Cox analysis of patients with supratentorial ICH (n=206), the presence of IVH more than doubled the hazard for poor outcome (HR 2.20; 95% CI 1.42-3.40; p&lt;0.001). In the secondary Cox analysis, each unit increase in mGraeb increased the hazard by 6% (HR 1.06; 95% CI 1.03-1.09; p&lt;0.001). Age (HR 1.03; 95% CI 1.02-1.05; p&lt;0.001), GCS (HR 1.42; 95% CI 1.23-1.65; p&lt;0.001) and ICH-volume (HR 1.07; 95% CI 1.03-1.11; p=0.001) were also related to poor outcome. Sex and ICH-location did not independently influence the outcome in the secondary Cox analysis. Results where similar when the endpoint was changed to death at 3 months and also when cases with infratentorial ICH (n=50) were included in a tertiary Cox analysis. Conclusion: The mGraeb, is an independent predictor for outcome after ICH. Compared with the dichotomous variable IVH (yes/no), it gives more detailed information regarding prognosis. The mGraeb can be considered for routine evaluation of ICH patient prognosis.