Initial Intracerebral Hemorrhage Research Articles

Long-Term Outcomes in Patients With Spontaneous Cerebellar Hemorrhage: An International Cohort Study.

Spontaneous intracerebral hemorrhage (ICH) in the cerebellum has a poor short-term prognosis, whereas data on the long-term case fatality and recurrent vascular events are sparse. Herewith, we aimed to assess the long-term case fatality and recurrence rate of vascular events after a first cerebellar ICH. In this international cohort study, we included patients from 10 hospitals (the United States and Europe from 1997 to 2017) aged ≥18 years with a first spontaneous cerebellar ICH who were discharged alive. Data on long-term case fatality and recurrence of vascular events (recurrent ICH [supratentoria or infratentorial], ischemic stroke, myocardial infarction, or major vascular surgery) were collected for survival analysis and absolute event rate calculation. We included 405 patients with cerebellar ICH (mean age [SD], 72 [13] years, 49% female). The median survival time was 67 months (interquartile range, 23-100 months), with a cumulative survival rate of 34% at 10-year follow-up (median follow-up time per center ranged: 15-80 months). In the 347 patients with data on vascular events 92 events occurred in 78 patients, after initial cerebellar ICH: 31 (8.9%) patients had a recurrent ICH (absolute event rate, 1.8 per 100 patient-years [95% CI, 1.2-2.6]), 39 (11%) had an ischemic stroke (absolute event rate, 2.3 [95% CI, 1.6-3.2]), 13 (3.7%) had a myocardial infarction (absolute event rate, 0.8 [95% CI, 0.4-1.3]), and 5 (1.4%) underwent major vascular surgery (absolute event rate, 0.3 [95% CI, 0.1-0.7]). The median time to a first vascular event during follow-up was 27 months (interquartile range, 8.7-50 months), with a cumulative hazard of 47% at 10 years. The long-term prognosis of patients who survive a first spontaneous cerebellar ICH is poor and comparable to that of patients who survive a first supratentorial ICH. Further identification of patients at high risk of vascular events following the initial cerebellar ICH is needed. Including patients with cerebellar ICH in randomized controlled trials on secondary prevention of patients with ICH is warranted.

Stereotactic radiosurgery for brain arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia

ObjectiveBrain arteriovenous malformations (AVMs) in patients with hereditary hemorrhagic telangiectasia (HHT) present different characteristics from sporadic AVMs, and they have lower initial bleeding rates. Conservative management is usually preferred for the treatment of these lesions. In this case study, we present the largest series of HHT patients treated with stereotactic radiosurgery to date.MethodsWe identified eight patients with HHT and 14 AVMs. We retrospectively collected clinical, radiographic, and treatment characteristics of the patients and each AVM.ResultsMost patients in our sample presented with small AVMs. The median volume of these AVMs was 0.22 cm3 (IQR 0.08–0.59). Three out of eight patients presented with initial intracerebral hemorrhage (ICH). The majority of lesions had low (12/14) Spetzler-Martin grades (I–II). Median maximum and margin doses used for treatment were 36.2 (IQR 35.25–44.4) and 20 (IQR 18–22.5) Gy, respectively. The overall obliteration rate after SRS was 11/14, and the median time to obliteration across all 11 obliterated AVMs was 35.83 months (IQR, 17–39.99). Neurological status was favorable with all patients having a mRS of 0 or 1 at the last follow-up. Symptomatic radiation-induced changes (RIC) after SRS were low (7.1%), and there were no permanent RIC.ConclusionsPatients with HHT who present with multiple brain AVMs are generally well served by SRS. Obliteration can be achieved in the majority of HHT patients and with a low complication rate. In the current study, initial hemorrhage rates prior to SRS were noticeable which supports the decision to treat these AVMs. Future studies are needed to better address the role of SRS for HHT patients harboring ruptured and unruptured AVMs.

Neighborhood Disadvantage and Outcomes Following Intracerebral Hemorrhage (S29.002)

<h3>Objective:</h3> We aimed to determine if neighborhood disadvantage is associated with poor outcomes following intracerebral hemorrhage (ICH). <h3>Background:</h3> Neighborhood disadvantage uniquely captures numerous social and environmental exposures. There is mounting evidence linking social determinants to various health outcomes. <h3>Design/Methods:</h3> We conducted a nested study within an ongoing longitudinal study that prospectively follows patients with brain injury within Connecticut’s largest healthcare system. The nested study included ICH survivors and evaluated neighborhood deprivation using the Area Deprivation Index (ADI), a publicly available metric that ranks neighborhoods’ disadvantage based on numerous factors. Patients were given an ADI tertile designation: low, intermediate, and high deprivation. Initial ICH severity was defined with admission GCS. Outcome was evaluated through the discharge and 6-month post-ICH Modified Rankin Scale (mRS), dichotomized as 0–3 (good outcome) and 4–6 (poor outcome). We used chi-square tests and multivariable logistic regression for unadjusted and adjusted association analyses, respectively. <h3>Results:</h3> Out of 687 enrolled ICH patients, 518 (mean age 67, 47.5% female, 19% Black, 8% Hispanic) had 9-digit zip-code and outcomes data. Neighborhood disadvantage was not associated with admission GCS (adjusted p=0.59) or discharge mRS (adjusted p=0.95). However, at 6-months post-discharge, the risk of poor outcome was 28%, 44%, and 47% for patients in neighborhoods with low, intermediate, and high disadvantage (unadjusted p=0.02). Multivariable analyses adjusting for potential confounders confirmed these results: compared to low-disadvantage neighborhoods, those living in neighborhoods with intermediate and high disadvantage had 52% (OR 1.52, 95%CI 0.76–3.08) and 89% (OR 1.89, 95%CI 0.91–3.94) higher risk of poor outcomes (test-for-trend p=0.01). <h3>Conclusions:</h3> Among ICH patients enrolled in a prospective study of acute brain injury, higher neighborhood disadvantage was associated with a higher risk of poor outcomes 6-months post-ICH but not with admission or discharge clinical status. These results suggest that the numerous factors captured by the ADI influence these subjects’ complex post-discharge evolution. <b>Disclosure:</b> Ms. Kim has nothing to disclose. Ms. Kitlen has nothing to disclose. Mr. Torres-Lopez has nothing to disclose. Dr. Rivier has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Pyxis Partners. Dr. Renedo has nothing to disclose. Ms. Schlechter has nothing to disclose. Ms. Kleinberg has nothing to disclose. Ms. Pish has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Twill Therapeutics. Mr. Kampp has nothing to disclose. Sara Jasak has nothing to disclose. Dr. Sansing has nothing to disclose. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ceribell. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Zoll. Dr. Sheth has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for NControl. Dr. Sheth has received stock or an ownership interest from Astrocyte. Dr. Sheth has received stock or an ownership interest from Alva. The institution of Dr. Sheth has received research support from Biogen. The institution of Dr. Sheth has received research support from Novartis. The institution of Dr. Sheth has received research support from Bard. The institution of Dr. Sheth has received research support from Hyperfine. Dr. Sheth has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Falcone has received research support from NIH. The institution of Dr. Falcone has received research support from AHA.

Functional outcome after initial and multiple intracerebral hemorrhages in children with cerebral cavernous malformations.

We aimed to assess the course and predictors of functional outcome after single and multiple intracerebral hemorrhage (ICH) in pediatric patients with cerebral cavernous malformations (CCMs) and to conduct a risk assessment of a third bleed during the first follow-up year after second ICH. We included patients aged ≤18 years with complete baseline characteristics, a magnetic resonance imaging dataset, ≥1 CCM-related ICH and ≥1 follow-up examination, who were treated between 2003 and 2021. Neurological functional status was obtained using modified Rankin Scale scores at diagnosis, before and after each ICH, and at last follow-up. Kaplan-Meier analysis was performed to determine the cumulative 1-year risk of third ICH. A total of 55 pediatric patients (median [interquartile range] age 12[11] years) were analyzed. Univariate analysis identified brainstem cavernous malformation (BSCM; p= 0.019) as a statistically significant predictor for unfavorable outcome after second ICH. Outcome after second ICH was significantly worse in 12 patients (42.9%; p= 0.030) than after first ICH and in five patients (55.6%; p= 0.038) after a third ICH compared to a second ICH. Cumulative 12-month risk of rebleeding during the first year after a second ICH was 10.7% (95% confidence interval 2.8%-29.37%). Pediatric patients with a BSCM have a higher risk of worse outcome after second ICH. Functional outcome improves over time after an ICH but worsens following each ICH compared to baseline or previous ICH. Second bleed was associated with neurological deterioration compared to initial ICH, and this deteriorated further after a third ICH.

Clinical effects of restarting antiplatelet therapy in patients with intracerebral hemorrhage

ObjectiveAntiplatelet (APT) medications have been used to treat ischemic stroke and cardiovascular diseases. However, they involve a risk of re-bleeding, especially in patients with intracerebral hemorrhage (ICH), which limits their clinical application. This study aimed to compare the incidence of recurrent ICH and ischemic events in ICH survivors on APT, as well as to assess the clinical effect and safety of APT resumption. MethodsWe retrospectively reviewed the medical records of patients with spontaneous ICH at two tertiary medical centers between January 2011 and December 2020. We included adult patients with ICH who regularly took APT medications for various medical conditions. The patients were divided into two groups based on their APT resumption. Subsequently, we performed between-group comparisons of clinical or radiological characteristics; moreover, analyzed the incidence of re-bleeding and ischemic events, as well as the various risk factors for each event. ResultsWe included 202 patients; among them, 118 patients restarted APT after initial ICH (APT resumption group) while 84 patients did not (no-APT resumption group). Compared with patients in the no-APT resumption group, those in the APT resumption group were more likely to have hyperlipidemia (p < 0.001) and a previous ischemic stroke event (p = 0.026). Recurrent ICH and ischemic vascular events occurred in 14 and 15 patients, respectively. Univariate analysis demonstrated that the risk factors for recurrent ICH were older age, renal dysfunction, and no APT resumption; however, only renal dysfunction significantly increased the risk of re-bleeding in multivariate analysis (HR, 4.631; 95 % CI 1.432–14.977; p = 0.010). Moreover, previous cerebral ischemia and atrial fibrillation were positively associated with ischemic events in univariate analysis; however, only atrial fibrillation demonstrated a significant correlation in multivariate analysis (HR, 4.309; 95 % CI 1.383–13.426; p = 0.012). APT resumption had a significant prevention effect on recurrent ICH (HR, 0.180; 95 % CI 0.055–0.586; p = 0.004) and ischemic vascular events (HR, 0.240; 95 % CI 0.077–0.750; p = 0.014). ConclusionsOur findings indicated that restarting APT in patients with ICH was not associated with an increased risk of recurrent ICH. APT can be safely restarted to prevent major thromboembolic complications in patients on previous antithrombotic treatment.

In-hospital outcomes of patients with spontaneous supratentorial intracerebral hemorrhage.

Spontaneous intracerebral hemorrhage (ICH) in the brain parenchyma accounts for 16.1% of all stroke types in Taiwan. It is responsible for high morbidity and mortality in some underlying causes. The objective of this study is to discover the predicting factors focusing on in-hospital outcomes of patients with spontaneous supratentorial ICH.Between June 2014 and October 2018, there were a total of 159 patients with spontaneous supratentorial ICH ranging from 27 to 91 years old in our institution. Twenty-three patients died during hospitalization, whereas 59 patients had an extended length of stay of >30 days. The outcomes were measured by inpatient death, length of stay, and activity of daily living (ADL). Both univariate and multivariate binary logistic regression, as well as multivariate linear regression, were used for statistical analysis.Multivariate binary linear regression analysis showed the larger hematoma in initial computed tomography scan of >30 cm3 (odds ratio [OR] = 2.505, P = .013) and concurrent in-hospital infection (OR = 4.173, P = .037) were both statistically related to higher mortality. On the other hand, in-hospital infection (≥17.41 days, P = .000) and surgery (≥11.23 days, P = .001) were correlated with a longer length of stay. Lastly, drastically poor change of ADL (ΔADL <–30) was associated with larger initial ICH (>30 cc, OR = 2.915, P = .049), in-hospital concurrent infection (OR = 4.695, P = .01), and not receiving a rehabilitation training program (OR = 3.473, P = .04).The results of this study suggest that age, prothrombin, initial Glasgow Coma Scale, computed tomography image, location of the lesion, and surgery could predict the mortality and morbidity of the spontaneous ICH, which cannot be reversed at the time of occurrence. However, effective control of international normalized ratio level, careful prevention against infection, and the aid of rehabilitation programs might be important factors toward a decrease of inpatient mortality rate, the length of stay, and ADL recovery.

2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association.

2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association.

Correlation of Immune-Inflammatory Markers with Clinical Features and Novel Location-Specific Nomograms for Short-Term Outcomes in Patients with Intracerebral Hemorrhage.

(1) Background: We investigated the association of four immune-inflammatory markers with clinical features and established location-specific nomograms to predict mortality risk in patients with intracerebral hemorrhage (ICH). (2) Methods: We retrospectively enrolled 613 inpatients with acute ICH. (3) Results: Overall mortality was 22%, which was highest in pontine hemorrhage and lowest in thalamic hemorrhage. All four immune-inflammatory markers exhibited a positive linear correlation with glucose, ICH volume, ICH score, and discharge Modified Rankin Scale (mRS) score. Significant predictors of death due to lobar/putaminal hemorrhage were age, glucose and creatinine levels, initial Glasgow Coma Scale (GCS) score, ICH volume, and presence of intraventricular hemorrhage. None of the immune-inflammatory markers were significant predictors of unfavorable outcome or death. We selected significant factors to establish nomograms for predicting death due to lobar/putaminal, thalamic, pontine, and cerebellar hemorrhages. The C-statistic for predicting death in model I (comprising factors in the establishment of the nomogram) in each type of ICH was higher than that in model II (comprising ICH score alone), except for cerebellar hemorrhage. These nomograms for predicting death had good discrimination (C-index: 0.889 to 0.975) and prediction probabilities (C-index: 0.890 to 0.965). (4) Conclusions: Higher immune-inflammatory markers were associated with larger ICH volume, worse initial GCS, and unfavorable outcomes, but were not independent prognostic predictors. The location-specific nomograms provided novel and accurate models for predicting mortality risk.

National Institutes of Health Stroke Scale Correlates Well with Initial Intracerebral Hemorrhage Volume

The US Centers for Medicare and Medicaid Services (CMS) currently publicly reports hospital-quality, risk-adjusted mortality measure for ischemic stroke but not intracerebral hemorrhage (ICH). The NIHSS, which is captured in CMS administrative claims data, is a candidate metric for use in ICH risk adjustment and has been shown to predict clinical outcome with accuracy similar to the ICH Score. Correlation between early NIHSS and initial ICH volume would further support use of the NIHSS for ICH risk adjustment. Among 372 ICH patients enrolled in a large multicenter trial (FAST-MAG), the relation between early NIHSS and early ICH volume was assessed with correlation and linear trend analysis. Overall, there was strong correlation between NIHSS and ICH volume, r=0.77 (p<0.001), and for every 10cc increase in ICH the NIHSS increased by 4.5 points. Correlation coefficients were comparable in all subgroups, but magnitude of NIHSS increase with ICH unit volume increase was greater with left than right hemispheric ICH, with presence rather than absence of IVH, with imaging done within the first hour than second hour after last known well, with men than women, and with younger than older patients. Early NIHSS neurologic deficit severity values correlate strongly with initial ICH hematoma volume. As with ischemic stroke, lesion volume increases produce greater NIHSS change in the left than right hemisphere, reflecting greater NIHSS sensitivity to left hemisphere function. These findings provide further support for the use of NIHSS in risk-adjusted mortality measures for intracerebral hemorrhage.

Stereotactic IntraCerebral Underwater Blood Aspiration (SCUBA) Improves Survival Following Intracerebral Hemorrhage as Compared with Predicted Mortality

Recent publications on minimally invasive surgery (MIS) for hematoma evacuation have suggested survival benefits in select patients. Since 2015, our center has been performing an MIS technique using continuous irrigation with aspiration through an endoscope (stereotactic intracerebral underwater blood aspiration [SCUBA]). It is unknown how these patient outcomes compare with intracerebral hemorrhage (ICH) score predictions. Our aim is to determine if SCUBA patients had better 30-day mortality than predicted by their presenting ICH score. Retrospective review of consecutively admitted patients who underwent SCUBA between December 2015 and March 2019. Operative criteria for MIS evacuation included supratentorial hematoma volume ≥15 mL, age >18, National Institutes of Health Stroke Scale score ≥6, and modified Rankin Scale (mRS) score ≤3. Demographic, radiographic, and clinical data were collected prospectively. The prespecified primary outcome was observed 30-day mortality of SCUBA patients compared with predicted mortality by ICH score on presentation. One-hundred and fifteen patients underwent SCUBA for hematoma evacuation. Initial mean ICH volume was 51.4 mL (standard deviation 33.9 mL), with a median National Institutes of Health Stroke Scale score of 17 and ICH score of 2. At 1 month, 12 of the 115 SCUBA patients had passed away (30-day mortality rate 10.4%). This was significantly lower than the predicted mortality of 35.1% when calculated using the presenting ICH score (χ2 (1, N= 115)= 9.5, P < 0.0001), equating to an absolute risk reduction of 24.7%. This study suggests that minimally invasive hematoma evacuation with the SCUBA technique for ICH may reduce predicted 30-day mortality, with a number needed to treat of 4 to prevent 1 mortality.

Abstract TP10: Inflammatory And Neurodegenerative Gene Expression Changes Occur Long-term After ICH

Objective: There is a high prevalence of progressive cognitive impairment in intracerebral hemorrhage (ICH) survivors. We sought to identify gene expression changes, in association with long-term neurodegeneration, among patients 12-24 months post-ICH. Methods: The Recovery and Outcomes from StrokE (ROSE) study prospectively recruits patients with spontaneous, supratentorial ICH, collecting baseline peripheral blood samples and MRI with diffusion tract imaging (DTI). The Recovery of StrokE-Longitudinal Assessment with Neuroimaging (ROSE-LAWN) study performs long term follow-up at 12-24 months on cases enrolled in ROSE. We report on the first five cases enrolled in the ROSE-LAWN study from December 2020 to March 2021. Controls were matched to an overall ICH population by age, sex, and race. RNA-sequencing, aligned to human genome assembly GRCh38, was tested for differential gene expression. Canonical pathway enrichment and network analyses were computed for differentially expressed genes using Ingenuity Pathway Analysis, STRING and MCODE. Results: RNA-seq analysis of 5 ICH cases [male, 80%; median age, 61 (45 - 73); black, 40%; ICH volume, 14.88cc ± 13.07] and 13 controls [male, 54%; median age, 74 (69 - 79); black, 15%] identified 554 differentially expressed genes (genomic control adjusted p &lt; 0.01), of which 24 met the false discovery rate correction for multiple comparisons (FDR &lt; 0.05). The most significant difference was observed in hypoxia up-regulated 1 ( HYOU1), a heat shock protein related gene (p = 2.64E-11). Pathway analysis identified enrichment of dopamine and serotonin receptor signaling (p = 8.74E-03, 2.23E-02), cell cycle regulation (p = 1.75E-02) and agranulocyte adhesion pathways (p = 2.18E-02). Comparison of baseline and follow-up MRI DTI demonstrated extensive cortical tract degeneration, beyond the initial injury. Conclusion: These results provide novel evidence of significant gene expression changes occurring years after the initial ICH. Despite resolution of the ICH, persistent inflammation may correlate with progressive neurodegeneration and subsequent cognitive impairment in ICH survivors. Future studies with greater sample sizes are supported by this work.

Abstract WP78: National Institutes Of Health Stroke Scale Correlates Well With Initial Intracerebral Hemorrhage Volume

Introduction: The US Centers for Medicare and Medicaid Services (CMS) currently publicly reports hospital-quality, risk-adjusted mortality measure for ischemic stroke but not intracerebral hemorrhage (ICH). The NIHSS, which is captured in CMS administrative claims data, is a candidate metric for use in ICH risk adjustment and has been shown to predict clinical outcome with accuracy similar to the ICH Score. Correlation between early NIHSS and initial ICH volume would further support use of the NIHSS for ICH risk adjustment. Methods: Among consecutive ICH patients enrolled in a large multicenter trial (FAST-MAG), the relation between early NIHSS and early ICH volume was assessed with correlation and linear trend analysis, in all patients and separately in; left vs right; IVH-positive vs IVH-negative, hyperacute (≤60min) vs acute (61-120min) imaging; men vs women; and younger (&lt;65y) vs older (≥65y). Results: Among 372 patients with ICH, age was 65y (SD 13), 67% were men, early NIHSS was 16 (IQR 9-25) and initial ICH volume was 14.9 cc (IQR 6.1-36.4). Overall, there was substantial correlation between NIHSS and ICH volume, r=0.77 (p&lt;0.001), and for every 10cc increase in ICH the NIHSS increased by 4.5 points. Correlations remained substantial and similar in all subgroups (Table), but magnitude of NIHSS change with ICH volume alteration varied, including greater NIHSS change with ICH unit volume increase in left than right hemisphere, absence of IVH, earlier (≤60min) than later presentation (61-120min), men than women, and younger than older patients (Table). Conclusion: Early NIHSS deficit severity values correlate strongly with initial ICH hematoma volume. As with ischemic stroke, lesion volume increases produce greater NIHSS changes in the left than right hemisphere, reflecting greater NIHSS sensitivity to left hemisphere function. These findings provide further support for the use of the NIHSS in risk-adjusted mortality measures for intracerebral hemorrhage.

Abstract 101: Predicting Hematoma Expansion Using An Artificial Neural Network: An Exploratory Analysis Of The Atach 2 Trial

Introduction: Hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH) is a key predictor of poor prognosis and potentially amenable to treatment. Current clinical scoring models, radiological markers, and labs have limited ability to predict HE. This study aimed to create a more robust classification model to predict HE in patients with ICH using a deep learning algorithm, an artificial neural network (ANN). Methods: Data from the ATACH 2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) was utilized. Variables included in the models were chosen as per literature consensus on salient factors associated with HE and clinical expertise. HE was defined as increase in either &gt;33% or 6mL in hematoma volume in the first 24 hours. A multi-layer feedforward ANN was trained using the back-propagation method to minimize the loss function with 5-fold cross validation. 80% of patients were used for training and 20% for testing. The ANN was compared to a logistic regression model (GLM). Given the imbalance in patients with HE, AUPRC (area under the precision-recall curve), recall and precision were calculated for the respective models. Results: Of the 963 patients in the study (mean age 62±13.0, 38.5% female), 31% had hematoma expansion. The median [interquartile range (IQR)] initial hematoma volume was 10.5mm 3 [5.16 - 20.25], median admission SBP [IQR] was 200 [184-217], median platelet count [IQR] was 213 [178-256], median INR [IQR] was 1.0 [0.9-1.0], and median admission GCS [IQR] was 15 [13-15]. The GLM model had AUPRC of 0.38 with recall of 0.60 and precision of 0.38 in the testing cohort. The ANN training model demonstrated AUPRC of 0.92 with recall of 0.72 with precision of 0.39 during testing. Initial ICH volume, platelets, INR, and GCS had the highest feature importance. Conclusion: We developed an ANN to predict HE in ICH patients performing with improved sensitivity and similar positive predictive value when compared to GLM. We support that ANN can capture complex associations between variables not attainable in classic regression models. This model may help identify patients at risk for HE who warrant careful monitoring and aggressive treatment upfront including those suitable for clinical trials for treatments.

Individualized blood pressure targets in the postoperative care of patients with intracerebral hemorrhage.

Recent guidelines recommend targeting a systolic blood pressure (SBP) < 140 mm Hg in the early management of patients with spontaneous intracerebral hemorrhage (ICH). The optimal SBP targets for ICH patients after hematoma evacuation (HE) remain unclear. Here, the authors aimed to define the optimal SBP range based on multimodal neuromonitoring data. Forty poor-grade ICH patients who had undergone HE and then monitoring of intracerebral pressure, brain tissue oxygen tension (PbtO2), and cerebral metabolism (via cerebral microdialysis [CMD]) were prospectively included. Episodes of brain tissue hypoxia (BTH) (1-hour averaged PbtO2 < 20 mm Hg) and metabolic distress (CMD-lactate/pyruvate ratio [LPR] ≥ 40) were identified and linked to corresponding parameters of hemodynamic monitoring (SBP and cerebral perfusion pressure [CPP]). Multivariable regression analysis was performed using generalized estimating equations to identify associations between SBP levels, PbtO2, and brain metabolism. The mean patient age was 60 (range 51-66) years and the median [IQR] initial ICH volume was 47 [29-60] ml. In multivariable models adjusted for Glasgow Coma Scale score, probe location, ICH volume, and age, lower SBP was independently associated with a higher risk of BTH (≤ 120 mm Hg: adjusted OR 2.9, p = 0.007; 120-130 mm Hg: adj OR 2.4, p = 0.002; 130-140 mm Hg: adj OR 1.6, p = 0.017) compared to a reference range of 140-150 mm Hg at the level of the foramen interventriculare Monroi, which corresponded to a CPP of 70-80 mm Hg and SBP levels between 150 and 160 mm Hg at the heart level. After exclusion of episodes with mitochondrial dysfunction, SBP targets < 140 mm Hg were associated with higher odds of cerebral metabolic distress (≤ 130 mm Hg: OR 2.5, p = 0.041; 130-140 mm Hg: OR 2.3, p = 0.033). Patients with a modified Rankin Scale score ≥ 5 at neurological ICU discharge more often exhibited BTH than patients with better outcomes (51% vs 10%, p = 0.003). These data suggest that lower SPB and CPP levels are associated with a higher risk for BTH. Further studies are needed to evaluate whether a higher SPB target may prevent BTH and improve outcomes.

Early Predictors of the Increase in Perihematomal Edema Volume After Intracerebral Hemorrhage: A Retrospective Analysis From the Risa-MIS-ICH Study.

Background and Purpose: Perihematomal edema (PHE) is associated with poor functional outcomes after intracerebral hemorrhage (ICH). Early identification of risk factors associated with PHE growth may allow for targeted therapeutic interventions.Methods: We used data contained in the risk stratification and minimally invasive surgery in acute intracerebral hemorrhage (Risa-MIS-ICH) patients: a prospective multicenter cohort study. Patients' clinical, laboratory, and radiological data within 24 h of admission were obtained from their medical records. The absolute increase in PHE volume from baseline to day 3 was defined as iPHE volume. Poor outcome was defined as modified Rankin Scale (mRS) of 4 to 6 at 90 days. Binary logistic regression was used to assess the relationship between iPHE volume and poor outcome. The receiver operating characteristic curve was used to find the best cutoff. Linear regression was used to identify variables associated with iPHE volume (ClinicalTrials.gov Identifier: NCT03862729).Results: One hundred ninety-seven patients were included in this study. iPHE volume was significantly associated with poor outcome [P = 0.003, odds ratio (OR) 1.049, 95% confidence interval (CI) 1.016–1.082] after adjustment for hematoma volume. The best cutoff point of iPHE volume was 7.98 mL with a specificity of 71.4% and a sensitivity of 47.5%. Diabetes mellitus (P = 0.043, β = 7.66 95% CI 0.26–15.07), black hole sign (P = 0.002, β = 18.93 95% CI 6.84–31.02), and initial ICH volume (P = 0.018, β = 0.20 95% CI 0.03–0.37) were significantly associated with iPHE volume. After adjusting for hematoma expansion, the black hole sign could still independently predict the increase of PHE (P < 0.001, β = 21.62 95% CI 10.10–33.15).Conclusions: An increase of PHE volume >7.98 mL from baseline to day 3 may lead to poor outcome. Patients with diabetes mellitus, black hole sign, and large initial hematoma volume result in more PHE growth, which should garner attention in the treatment.

Cardiovascular and cerebrovascular events in patients with intracerebral hemorrhage: Clinical characteristics and long-term predictors

Few studies have examined the long-term prognosis of Chinese patients with intracerebral hemorrhage (ICH). This study assessed the clinical characteristics and predictors of vascular events occurring within 5 years after ICH.We included consecutive patients diagnosed with first-ever ICH between June 2013 and December 2014. Based on follow-up data (collected until December 2019), we used multivariable logistic regression to examine the clinical characteristics and long-term predictors of vascular events (including recurrent ICH, ischemic stroke, and acute coronary syndrome) in patients who survived more than 30 days after ICH.Across the 307 patients in our analysis, the 5-year mortality rate was 28.01%. Within 5 years after ICH, major vascular events were observed in 62 patients (17.82%, 95% CI 13.78–21.82%). We observed high incidence of recurrent ICH (8.91%) and ischemic stroke (10.06%), but low incidence of acute coronary syndrome (1.15%). Most cases of recurrent ICH (80.65%) occurred within 3 years after ICH. Age ≥56 years and history of ischemic stroke or transient ischemic attack (TIA) were identified as predictors of cardiovascular and cerebrovascular events.ICH survivors are at high risk of both cardiovascular and cerebrovascular events, especially older patients (≥56 years) and those who experienced ischemic stroke or TIA prior to their first ICH. Recurrent ICH is more likely to occur within the first three years after first ICH than at later times. Clinicians should monitor patients closely for adverse events, particularly during the first three years after initial ICH.

Thrombolysis for Evacuation of Intracerebral and Intraventricular Hemorrhage: A Guide to Surgical Protocols With Practical Lessons Learned From the MISTIE and CLEAR Trials.

Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) procedure was recently tested in a large phase III randomized trial showing a significant probability of functional benefit in those cases that reached the goal hematoma evacuation of ≤15 mL residual (or ≥70% removal). Benefit of thrombolysis was also identified in cases with large intraventricular hemorrhage, and achieving at least 85% volume reduction in the Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. To protocolize steps in the MISTIE and CLEAR procedures in order to maximize hematoma evacuation and minimize complications. We articulate data-driven lessons and expert opinions surrounding the factors of patient selection, catheter placement, and dosing, which impacted safety and surgical performance in the MISTIE and CLEAR trials. Modifiable factors to maximize evacuation efficiency include optimizing catheter placement and pursuing aggressive dosing to achieve treatment goals, while strictly adhering to the safety steps as articulated in the respective trials. Prognostic factors that are viewed as nonmodifiable include greater initial intracerebral hemorrhage volume with irregular shape, smaller intraventricular bleeds, and the uncommon but consequential development of new bleeding during the dosing period despite strict protocol adherence. Surgeon education in this tutorial is aimed at maximizing the benefit of the MISTIE and CLEAR procedures by reviewing case selection, safety steps, treatment objectives, and technical nuances. Key lessons include stability imaging, etiology screening, and technical adherence to the protocol in order to achieve defined thresholds of evacuation.

Highlights of Selected Articles July 2020.

Highlights of Selected Articles July 2020.

Abstract TP329: Early Initiation of Oral Antihypertensives Reduces Intensive Care Unit Stay and Hospital Cost in Patients With Hypertensive Intracerebral Hemorrhage

Background and Purpose: Intravenous nicardipine infusion is effective for intensive blood pressure (BP) control in patients with hypertensive intracerebral hemorrhage (ICH). However, its use requires close hemodynamic monitoring in the intensive care unit (ICU). Prompt transition from nicardipine infusion to oral antihypertensives may reduce ICU length of stay (LOS). This study aimed to examine the effect of early verse late initiation of oral antihypertensives on hospital resource utilization in patients with hypertensive ICH. Methods: This is a retrospective study of patients with hypertensive ICH and initial systolic BP ≥ 180 mmHg from January 1, 2013 to December 31, 2017. Only patients who received nicardipine infusion were included. Based on timing of receiving oral antihypertensives within or after 24 hours of emergency department arrival, patients were divided into study or control group, respectively. Baseline characteristics, duration of nicardipine infusion, ICU and hospital LOS, functional outcome at hospital discharge, and the cost were compared between the 2 groups using univariate and multivariate analysis to adjust for dependent variables. Results: A total of 166 patients (90 in study group, 76 in control group) were identified. There was no significant difference in demographic features, past medical history or initial SBP between the 2 groups. Patients in study group had lower initial NIHSS and ICH scores but higher GCS score than those in the control group. Using multivariant regression analysisto adjust for initial SBP, NIHSS, GCS and ICH scores, early initiation of oral antihypertensives was associated with significant shorter ICU LOS (median 2 vs 5, p =0.004), decreased duration of nicardipine infusion (55.5 ±60.1 vs 121.6 ±141.3, P =0.002), less pharmaceutical cost (median $14207 vs $ 29299, p =0.007) and total hospital cost (median $ 24564 vs $ 47366, p =0.007). After adjustment of confounders, there was also no significant difference in functional independence (mRS 0-2, 42.2% vs 17.1%, p =0.112) or mortality (6.7% vs 13.2%, p = 0.789) between the 2 groups. Conclusions: Early initiation of oral antihypertensive therapy is associated with reduced resource utilization and hospital cost in patients with hypertensive ICH.

Abstract TMP19: MRI Characteristics and Predictors of Diffusion Weighted Hyperintense Lesions After Spontaneous Intracerebral Hemorrhage: A Secondary Analysis of MISTIE-III

Introduction: Mechanisms of diffusion weighted hyperintense lesions (DWIHL) after spontaneous intracerebral hemorrhage (ICH) are controversial. We evaluated mechanism and outcome of DWIHL. Methods: Protocolized MRI scans within 7 days from ICH were reviewed from MISTIE-III trial. Imaging analysis included DWIHL, leukoariosis (Fazekas score), enlarged perivascular space (EPVS), and cerebral microbleeds. Multivariable logistic regression analysis was performed to assess predictors and outcomes of having DWIHLs. Favorable outcome was defined as modified Rankin Score 0-3 at 12 months. Results: Of 499 patients, 300 underwent DWI studies (62% lobar ICH; 38% deep ICH) and 178 (59%) had acute DWIHLs (66% lobar; 34% deep). DWIHL locations were perihematomal in 140 (79%); and remote in 96 (54%). In multivariable regression analysis, DWIHLs were associated with initial mean arterial pressure [MAP] (odds ratio [OR]: 1.004; 95% confidence interval [CI]: 1.002-1.01), initial ICH volume (OR: 1.004; 95%CI: 1.001-1.01), NIHSS at randomization (OR: 1.01; 95%CI: 1.01-1.02), hypertension history (OR: 1.41; 95%CI: 1.04-1.93), and Fazekas score (OR: 1.04; 95%CI: 1.01-1.08). Patients with DWIHLs were less likely to have favorable outcome (66% vs. 50%; OR: 0.89; 95%CI: 0.81-0.99) after adjusting for ICH severity; however, the presence of DWIHLs did not confer an independent mortality risk at 12 months. In addition, perihematomal DWIHLs were associated with ICH volume (OR: 1.003; 95%CI: 1.00-1.01), NIHSS (OR: 1.01; 95%CI: 1.00-1.02), deep location (OR: 1.25; 95%CI: 1.10-1.42), and centrum semiovale EPVS score (OR: 0.99; 95% CI: 0.99-1.00). Remote DWIHLs were associated with Fazekas score (OR: 1.17; 95%CI: 1.06-1.29), centrum semiovale EPVS score (OR: 1.01; 95%CI: 1.00-1.01), atrial fibrillation (OR: 1.40; 95%CI: 1.04-1.90), and maximal ΔMAP on first 24 hours (OR: 1.004; 95%CI: 1.001-1.006). Conclusions: DWIHLs were common (59%) in patients after spontaneous ICH, predominantly in lobar locations and were associated with unfavorable neurologic outcome. While perihematomal DWIHLs were associated with ICH severity, remote DWIHLs suggested different mechanisms including acute blood pressure reduction, cardiac emboli, and white matter disease severity.