Intracerebral Hemorrhage Score Research Articles

African Americans and Women Have Lower Functional Gains During Acute Inpatient Rehabilitation After Hemorrhagic Stroke.

Intracerebral hemorrhage can lead to significant long-term disability. While research in stroke rehabilitation has focused primarily on ischemic strokes, identifying factors that impact recovery in patients with intracerebral hemorrhage is necessary. Our purpose is to identify factors, including racial and sex disparities, associated with functional outcomes in intracerebral hemorrhage patients after inpatient rehabilitation. This was a retrospective analysis of consecutive patients with intracerebral hemorrhage admitted to an inpatient rehabilitation facility at an academic tertiary facility in the Southeastern United States from 2016 to 2019. Clinical characteristics, demographics, admission, and discharge Functional Independence Measure scores were collected. We evaluated 59 patients (54.4 ± 14.1 yrs, 39% females, 48.2% African American) with a median intracerebral hemorrhage volume of 13.4 (4.2-33.0) and a mean (SD) Functional Independence Measure efficiency of 1.8 ± 1.3. In multiple regression, being female was negatively associated with Functional Independence Measure efficiency (β = -1.13, P = 0.0037) when adjusting for race and intracerebral hemorrhage score. The Functional Independence Measure efficiency was lower in African Americans (β = -0.97, P = 0.0119) when adjusting for sex and intracerebral hemorrhage volume. The results of our study indicate that Functional Independence Measure efficiency was worse for African Americans and female patients with intracerebral hemorrhage. Future research should consider these racial and sex disparities and focus on providing targeted rehabilitation therapy.

Early Minimally Invasive Parafascicular Surgery for Evacuation of Spontaneous Intracerebral Hemorrhage in the Setting of Computed Tomography Angiography Spot Sign: A Case Series.

Spontaneous intracerebral hemorrhage (sICH) is associated with high morbidity and mortality, and the role of surgery is uncertain. Spot sign on computed tomography angiography (CTA) has previously been seen as a contraindication for minimally invasive techniques. To demonstrate the use of minimally invasive parafascicular surgery (MIPS) for early evacuation of sICH in patients with spot sign on CTA. Retrospective review of patients presenting to a US tertiary academic medical center from 2018 to 2020 with sICH and CTA spot sign who were treated with MIPS within 6 h of arrival. Seven patients (6 men and 1 woman, mean age 54.4 yr) were included in this study. There was a significant decrease between preoperative and postoperative intracerebral hemorrhage volumes (75.03 ± 39.00 cm3 vs 19.48 ± 17.81 cm3, P = .005) and intracerebral hemorrhage score (3.1 ± 0.9 vs 1.9 ± 0.9, P = .020). The mean time from arrival to surgery was 3.72 h (±1.22 h). The mean percentage of hematoma evacuation was 73.78% (±21.11%). The in-hospital mortality was 14.29%, and the mean modified Rankin score at discharge was 4.6 (±1.3). No complications related to the surgery were encountered in any of the cases, with no abnormal intraoperative bleeding and no pathology demonstrating occult vascular lesion. Early intervention with MIPS appears to be a safe and effective means of hematoma evacuation despite the presence of CTA spot sign, and this finding should not delay early intervention when indicated. Intraoperative hemostasis may be facilitated by the direct visualization provided by a tubular retractor system.

Machine Learning-Based Approaches for Prediction of Patients' Functional Outcome and Mortality after Spontaneous Intracerebral Hemorrhage.

Spontaneous intracerebral hemorrhage (SICH) has been common in China with high morbidity and mortality rates. This study aims to develop a machine learning (ML)-based predictive model for the 90-day evaluation after SICH. We retrospectively reviewed 751 patients with SICH diagnosis and analyzed clinical, radiographic, and laboratory data. A modified Rankin scale (mRS) of 0–2 was defined as a favorable functional outcome, while an mRS of 3–6 was defined as an unfavorable functional outcome. We evaluated 90-day functional outcome and mortality to develop six ML-based predictive models and compared their efficacy with a traditional risk stratification scale, the intracerebral hemorrhage (ICH) score. The predictive performance was evaluated by the areas under the receiver operating characteristic curves (AUC). A total of 553 patients (73.6%) reached the functional outcome at the 3rd month, with the 90-day mortality rate of 10.2%. Logistic regression (LR) and logistic regression CV (LRCV) showed the best predictive performance for functional outcome (AUC = 0.890 and 0.887, respectively), and category boosting presented the best predictive performance for the mortality (AUC = 0.841). Therefore, ML might be of potential assistance in the prediction of the prognosis of SICH.

Enhancing Robustness of Machine Learning Integration With Routine Laboratory Blood Tests to Predict Inpatient Mortality After Intracerebral Hemorrhage.

Objective: The accurate evaluation of outcomes at a personalized level in patients with intracerebral hemorrhage (ICH) is critical clinical implications. This study aims to evaluate how machine learning integrates with routine laboratory tests and electronic health records (EHRs) data to predict inpatient mortality after ICH.Methods: In this machine learning-based prognostic study, we included 1,835 consecutive patients with acute ICH between October 2010 and December 2018. The model building process incorporated five pre-implant ICH score variables (clinical features) and 13 out of 59 available routine laboratory parameters. We assessed model performance according to a range of learning metrics, such as the mean area under the receiver operating characteristic curve [AUROC]. We also used the Shapley additive explanation algorithm to explain the prediction model.Results: Machine learning models using laboratory data achieved AUROCs of 0.71–0.82 in a split-by-year development/testing scheme. The non-linear eXtreme Gradient Boosting model yielded the highest prediction accuracy. In the held-out validation set of development cohort, the predictive model using comprehensive clinical and laboratory parameters outperformed those using clinical alone in predicting in-hospital mortality (AUROC [95% bootstrap confidence interval], 0.899 [0.897–0.901] vs. 0.875 [0.872–0.877]; P <0.001), with over 81% accuracy, sensitivity, and specificity. We observed similar performance in the testing set.Conclusions: Machine learning integrated with routine laboratory tests and EHRs could significantly promote the accuracy of inpatient ICH mortality prediction. This multidimensional composite prediction strategy might become an intelligent assistive prediction for ICH risk reclassification and offer an example for precision medicine.

Predictors of Mortality in Spontaneous Intracerebral Haemorrhage: A Prospective Interventional Study from a Tertiary Care Centre, Kerala, India

Introduction: Spontaneous Intracerebral Haemorrhage (SICH) is a potentially life-threatening condition associated with a high mortality and morbidity. Early assessment of outcome is important to optimise the therapeutic efforts. This study helps in the prediction of outcomes in SICH based on clinical and radiological predictors, so as to effectively utilise the treatment resources. Aim: To assess clinical and radiological predictors of mortality and morbidity in patients with SICH at a Tertiary Care Centre, Kerala, India. Materials and Methods: This prospective interventional study included 100 patients admitted with SICH at Government Medical college, Kozhikode, Kerala, India, from 1st May 2019 to 30th January 2020. The assessed variables include age, sex, mean Glasgow Coma Scale (GCS) score on admission, Intracerebral Haemorrhage (ICH) volume, ICH site, ICH score and treatment provided (conservative/surgery). The dependent variable was 30 day mortality. Univariate analysis was performed to determine the association between the mortality and independent variables. A binary logistic regression was also performed. Statistical analysis performed using Statistical Package for the Social Sciences (SPSS) software version 22.0. The p-value &lt;0.05 was considered significant. Results: Among the total of 100 SICH patients, males were 52% and females were 48%; the mean age was 67±11 years. The medical history of SICH patients predominantly showed hypertension (90%), diabetes (45%) and alcohol abuse (33%). Out of total, 70% cases were managed conservatively, and 30% cases were managed surgically. The short-term outcome of 30 day mortality was 40% and the survival rate was 60%. Univariate analysis inferred that the location of bleed (p-value=0.0002), volume of ICH (p-value &lt;0.001), ICH score (p-value 0.003) and type of management (p-value &lt;0.001) were statistically significant predictors for 30 day mortality in SICH patients. Conclusion: The 30 day mortality in patients with SICH was 40%. The location of bleed, volume of ICH, ICH score and type of management were statistically significant predictors for 30 day mortality in SICH patients

Serum homocysteine in intracerebral hemorrhage: A savior or a destroyer?

Objectives: Intracerebral hemorrhage (ICH) is more common in the Indian subcontinent compared to the Western world and associated with significant morbidity and mortality. Hence, all possible modifiable factors should be searched and steps taken so that a single opportunity is not missed in preventing such a catastrophe. The aim of the study is to find out whether homocysteine and Vitamin B12 are related to ICH. Materials and Methods: We included acute ICH patients of 18 years and above who came to our institute and got admitted in 5 months (September 2021–January 2022). Our team noted the demographics, National Institutes of Health Stroke Scale (at admission and discharge) and other clinical parameters. Volume and site of the intracerebral hematoma (from the initial computed tomography [CT] scan of the brain) were noted. The outcome and prognostic markers like Modified Rankin Scale (mRS) at discharge, MRS at 3 months (also MRS at admission) and ICH score were calculated. The blood parameters, including serum homocysteine and Vitamin B12 level, were noted post admission in hospital. Results: We found out of 44 ICH patients; ten patients had hyperhomocysteinemia (HHcy): 22.72%. We detected significant correlation between HHCy with ICH score (inverse relationship) and dyslipidemia (direct relationship). Conclusion: We found an inverse correlation between serum homocysteine level and ICH score, which shows a short-term (1 month) prognosis. This might hint that homocysteine might have a protective role to play in ICH. However, we probably need larger study population to find a correlation strong enough so that we can make a stronger conclusion.

Predictors of Mortality in Spontaneous Intracerebral Hemorrhage Cases

Aim and objectives: This study was done with the aim of finding clinical and radiological correlation of patients with spontaneous intracerebral hemorrhage (SICH) and its correlation with 90-day mortality. The primary objective was to study the clinical, laboratory and radiological predictors of mortality in patients of intracerebral hemorrhage. The secondary objective was to compare 90-day mortality in patients with spontaneous intracerebral hemorrhage with that to coagulopathy related intra cerebral hemorrhage. Methods: This was a longitudinal, observational study carried out from June 2020 to June 2022 at Govt hospital situated in North India. The relevant history and clinical examination was done according to pre designed and pretested protocol. All patients underwent non-contrast computerized tomography imaging, their Glasgow coma scale score and intracerebral hemorrhage score were noted. For the sake of coagulopathy related intracerebral hemorrhage, the patients were classified as taking single antiplatelet, dual antiplatelet agents and oral anti-coagulant drugs. These patients were followed up daily during the hospital stay and regularly thereafter until 90 days. Functional outcome of patients was determined by modified Rankin's scale at 30 days and 90 days. The statistical analysis was done using SPSS software. Results: A total of 235 cases were studied. 202 patients were detected to have hypertension, out of which 25 (12.37%) deaths were recorded within 48hrs of admission, 77 (38.1%) and 85 (42%) of patients with hypertension had died at 30 days and 90 days respectively. Similarly, out of 40 diabetics in this cohort, 15 (37.5%) and 18 (45%) deaths occurred at 30 and 90 days. 97 out of 235 cases who consumed alcohol, 56 (57.7%) and 61 (62.9%) died at 30 and 90 days. Among 52 smokers in this study, 21 (40.4%) and 24 (46.2%) died at 30 and 90 days. Death at 30 and 90 days was significantly more among subjects with intracerebral hemorrhage score of 3 or more with P value of 0.001 and also in patients with GCS score less than 8. Higher mortality rates were seen among subjects with modified Rankin's scale (mRS) score 6 with P value of 0.001 at 30 days. Total number of coagulopathy related intracerebral hemorrhage cases were 99/235. On radiological correlation between spontaneous intracerebral hemorrhage and coagulopathy related intracerebral hemorrhage, this study did not find any strong correlation. The P value was 0.913 at 30 days and 0.961 at 90 days. Conclusion: This study found that comorbidities like hypertension and type 2 Diabetes mellitus were significant predictors of mortality in spontaneous intracerebral hemorrhage cases. The significant correlation was also found between consumption of alcohol and smoking with mortality in intracerebral hemorrhage cases. The 30 and 90-day mortality was significantly among subjects with ICH score 3 or more and also in patients with GCS score less than 8. Similarly, higher mortality is seen with higher modified Rankin score at 30 days. On radiological examination, the Intra cerebral bleed volume greater than 30 ml was greatest predictor of death. This study did not find coagulopathy as a strong predictor of mortality when compared with spontaneous modified Rankin score. Similarly, the location of intra cerebral bleed was not associated with higher mortality in this study.

Clinical and Radiological Profile in Non Hypertensive Intracerebral HaemorrhageA Prospective Observational Study

Introduction: Intracerebral Haemorrhage (ICH) is less frequent than ischemic stroke, but has higher mortality and morbidity, it being one of the first causes of severe disability. Hypertension is the most common cause of ICH but Non Hypertensive Intracerebral Haemorrhages (NHICH) are not rare. Hence, the importance of recognizing these conditions and need for urgent specific therapy which may play a vital role in therapeutic planning and prevention of ICH. Hence this study was performed to study. Aim: To study the clinical and radiological profile in NHICH, to identify risk factors, and to determine whether clinical/neuronradiological parameters would predict the prognosis of ICH. Materials and Methods: The present prospective observational study was conducted in the Department of General Medicine Mahadevappa Rampure Medical College Gulbarga, Karnataka, India, from January 2016-January 2017. It involved 50 subjects with NHICH. Demographic details, clinical and radiological data were collected in patients presenting with signs and symptoms of stroke and confirmed by Computed Tomography (CT) scan/ Magnetic Resonance Imaging (MRI) brain as ICH, who were non hypertensive and with age more than 18 years. Clinical outcome of the patients was measured based on Glasgow Coma Scale (GCS), site and volume of haemorrhage. Descriptive statistics of the explanatory and outcome variables were calculated by mean, Standard Deviation (SD) and Chi-square test was applied for qualitative variables. Results: In the present study 31 (62%) were males, and 19 (38%) were females. The age of patients ranged from 18-85 years. The most common risk factor associated with intracerebral haemorrhage was alcohol consumption 16 (32.0%), followed by smoking 13 (26%), and anticoagulant intake 13 (26%). Most common clinical presentation were hemiplegia/hemiparesis, speech defect, vomiting, convulsion, pupillary defect and cranial nerve involvement, in decreasing frequency. High ICH score and low GCS were poor prognostic factors for outcome of intracerebral haemorrhage patient in the present study. In hospital mortality rate was 28%. During 30 days follow-up, there was 22.2% mortality among the discharged patient. Conclusion: Although hypertension remains as a most common risk factor for intracerebral bleed, other risk factors such as significant alcohol consumption, coagulopathy should also be kept in mind especially in young. Non hypertensive haemorrhage usually occurs at sites not typical for hypertensive bleed. All efforts should be directed to establish the aetiological factors for intracerebral bleed, so that appropriate timely therapy can be provided to prevent further morbidity and mortality

Clostridium difficile Infection Does Not Impact Outcomes in Stroke Patients.

Data are limited for Clostridium difficile infection (CDI) in stroke patients. This study investigates incidence, patient characteristics, clinical features, and outcomes of CDI following stroke, including ischemic stroke (IS), intracerebral hemorrhage (ICH), and aneurysmal subarachnoid hemorrhage (SAH). The hospital database was queried for all patients with IS, ICH, or SAH from 2010 through 2014. Patients who underwent testing for C. difficile testing (CDT) through polymerase chain reaction were assessed. Demographics, risk factors, clinical features, and outcomes were recorded. Fever was defined as temperature >101°F. CDT was obtained in 555/4004 patients and was positive in 99, for CDI incidence of 2.5% [SAH 6.5% (26/402) vs. 2.9% in ICH (21/730) and 1.8% in IS (52/2872)]. There were no differences in demographics, severity [ICH score, National Institutes for Health Stroke Scale (NIHSS), Hunt Hess (HH), Glasgow coma scale (GCS)], mechanical ventilation, neurosurgical procedures, stress ulcer prophlyaxis or antibiotic use. Steroid use (P=0.0273) and male sex (P=0.0112) were associated with a positive CDT. On the day of diagnosis, 61% of CDT-positive patients had white blood cell <12, and 71% were afebrile. Length of stay, discharge disposition, mortality, and 3-month and 12-month modified Rankin, were not impacted by CDT results. Two patients with CDI required bowel resection. CDI incidence following stroke was low and most common with SAH. Male sex and steroid use were associated with a positive result. Leukocytosis and fever occurred in under half of infected patients. Outcome measures were not impacted by CDI.

Mortality prediction of patients with spontaneous intracerebral hemorrhage by serum soluble Fas ligand concentrations

ABSTRACT Background A study of patients with spontaneous intracerebral hemorrhage (SIH) found a higher content of Fas ligand in the perihematomic brain area compared to healthy brain areas. The objective of this study was to analyze whether blood soluble Fas ligand (sFasL) concentrations could be used to estimate the prognosis of SIH patients. Methods Observational and prospective study performed in five Spanish Intensive Care Units. Patients with severe supratentorial SIH, defined as Glasgow Coma Scale (GCS) <9, were included. Serum sFasL levels were determined at the time of diagnosis of severe SIH. Mortality at 30 days was the end-point study. Results Surviving SIH patients (n = 41) compared to nonsurvivors (n = 38) showed lower serum sFasL levels (p < 0.001). The area under curve of mortality prediction for serum sFasL levels was 0.79 (95% CI = 0.70–0.89; p < 0.001). Multiple logistic regression analysis found an association of serum sFasL concentrations with 30-day mortality (ORo = 1,034; 95% CI = 1,010–1,058; p = 0,006) after controlling for midline shift, early hematoma evacuation, and intracerebral hemorrhage score. Conclusions The capability of serum sFasL to predict SIH patient mortality is the main novel finding of our study. Abbreviations APACHE II: Acute Physiology and Chronic Health Evaluation; aPTT: activated partial thromboplastin time; FIO2: fraction of inspired oxygen; GCS: Glasgow Coma Scale; ICU: Intensive Care Unit; INR: international normalized ratio; PaO2: pressure of arterial oxygen

Admission Dehydration Status Portends Adverse Short-Term Mortality in Patients with Spontaneous Intracerebral Hemorrhage.

The impact of dehydration at admission of patients with spontaneous intracerebral hemorrhage (ICH) on short-term mortality remains ambiguous due to scarce data. All of the consecutive patients with spontaneous ICH, who were referred to our neurovascular center in 2018/19, were assessed for hydration status on admission. Dehydration was defined by a blood urea-to-creatinine ratio > 80. In a cohort of 249 patients, 76 patients (31%) were dehydrated at the time of admission. The following factors were significantly and independently associated with increased 30-day mortality in multivariate analysis: “signs of cerebral herniation” (p = 0.008), “initial midline shift > 5 mm” (p < 0.001), “ICH score > 3” (p = 0.007), and “admission dehydration status” (p = 0.007). The results of the present study suggest that an admission dehydration status might constitute a significant and independent predictor of short-term mortality in patients with spontaneous ICH.

Elevated Red Cell Distribution Width to Platelet Ratio Is Associated With Poor Prognosis in Patients With Spontaneous, Deep-Seated Intracerebral Hemorrhage.

Object: Inflammatory response is an important determinant of subsequent brain injury after deep-seated intracerebral hemorrhage (ICH). The ratio of red blood cell (RBC) distribution width to platelet count (RPR) has been established as a new index to reflect the severity of inflammation. To the best of our knowledge, no association between RPR and prognosis after spontaneous ICH has yet been reported.Methods: In all patients with deep-seated ICH treated at our Neurovascular Center from 2014 to 2020, initial laboratory values were obtained to determine RPR in addition to patient characteristics and known risk factors. Subsequent multivariate analysis was performed to identify independent risk factors for 90-day mortality after deep-seated ICH.Results: Hundred and two patients with deep-seated ICH were identified and further analyzed. Patients with an initial RPR < 0.06 exhibited significantly lower mortality rate after 90 days than those with an initial RPR ≥ 0.06 (27 vs. 57%; p = 0.003). Multivariate analysis identified “ICH score ≥ 3” (p = 0.001), “anemia on admission” (p = 0.01), and “elevated RPR ≥ 0.06” (p = 0.03) as independent predictors of 90-day mortality.Conclusions: The present study constitutes the first attempt to demonstrate that the ratio of RBC distribution width to platelets—as an independent inflammatory marker—might serve for prognostic assessment in deep-seated ICH.

Mortality of spontaneous intracerebral haemorrhage patients and high serum caspase-8 concentrations

PurposeApoptotic changes in brain samples have been found in haematoma areas of patients with spontaneous intracerebral haemorrhage (SIH) undergoing surgical haematoma evacuation. However, circulating caspase-8 concentrations in SIH patients have not been described. Thus, we carried out this study with the aim to explore whether there is an association of circulating caspase-8 concentrations and mortality in patients with SIH. MethodsWe included patients with severe and supratentorial SIH. We established that the SIH was severe if Glasgow Coma Scale (GCS) was lower than 9. Intensive Care Units from 5 Spanish hospitals carried out the recruitment of patients of this observational and prospective study. We registered serum caspase-8 levels at moment of severe SIH diagnosis and 30-day mortality. ResultsSurviving (n = 41) in respect to non-surviving SIH patients (n = 38) showed lower serum caspase-8 levels (p < 0.001). The area under the curve to estimate 30-day mortality ability by serum caspase-8 levels was 0.75 (95% CI = 0.64–86; p < 0.001). Kaplan-Meier analysis found that patients with serum caspase-8 levels > 17.8 ng/mL showed higher death risk (Hazard ratio = 3.9; 95% CI = 1.99–7.63; p < 0.001). Multiple logistic regression analysis revealed the association of serum caspase-8 concentrations (controlling for intracerebral haemorrhage score, midline shift and early haematoma evacuation) with mortality at 30 days (Odds Ratio = 1.048; 95% CI = 1.018−1.079; p = 0.002). ConclusionsThe association of serum caspase-8 concentrations with mortality of SIH patient mortality is the main of novel findings that have been revealed in our study.

The coronal plane maximum diameter of deep intracerebral hemorrhage predicts functional outcome more accurately than hematoma volume.

Among prognostic imaging variables, the hematoma volume on admission computed tomography (CT) has long been considered the strongest predictor of outcome and mortality in intracerebral hemorrhage. To examine whether different features of hematoma shape are associated with functional outcome in deep intracerebral hemorrhage. We analyzed 790 patients from the ATACH-2 trial, and 14 shape features were quantified. We calculated Spearman's Rho to assess the correlation between shape features and three-month modified Rankin scale (mRS) score, and the area under the receiver operating characteristic curve (AUC) to quantify the association between shape features and poor outcome defined as mRS>2 as well as mRS > 3. Among 14 shape features, the maximum intracerebral hemorrhage diameter in the coronal plane was the strongest predictor of functional outcome, with a maximum coronal diameter >∼3.5 cm indicating higher three-month mRS scores. The maximum coronal diameter versus hematoma volume yielded a Rho of 0.40 versus 0.35 (p = 0.006), an AUC[mRS>2] of 0.71 versus 0.68 (p = 0.004), and an AUC[mRS>3] of 0.71 versus 0.69 (p = 0.029). In multiple regression analysis adjusted for known outcome predictors, the maximum coronal diameter was independently associated with three-month mRS (p < 0.001). A coronal-plane maximum diameter measurement offers greater prognostic value in deep intracerebral hemorrhage than hematoma volume. This simple shape metric may expedite assessment of admission head CTs, offer a potential biomarker for hematoma size eligibility criteria in clinical trials, and may substitute volume in prognostic intracerebral hemorrhage scoring systems.

POCUS OBTAINED OPTIC NERVE SHEATH DIAMETER IN PATIENTS PRESENTING WITH INTRACEREBRAL HEMORRHAGE

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Intracerebral hemorrhage (ICH) results in spontaneous bleeding into the brain. This accounts for 10-15% of all strokes in the United States and has poor outcomes due to death or disability. An ICH can result in increased intracranial pressure due to blood occupying extra space. Optic nerve ultrasonography has emerged as a quick noninvasive procedure to detect increased intracranial pressure. A question that has not been answered is whether there is a specific correlation between the size of hematoma in the brain and the optic nerve sheath diameter (ONSD). The optic nerve is wrapped by a sheath derived from the meninges. Cerebrospinal fluid (CSF) can transfer freely between the intracranial and intraorbital spaces. METHODS: 23 patients were recruited into this study. Each of these patient’s received the diagnosis of ICH and admitted to the neuro intensive care unit (NICU). Ultrasound of the optic nerve was performed using a Sonosite machine and the high frequency probe. The exam was performed upon admission to the NICU. Both eyes were scanned in two planes, longitudinal and transverse. Once the ONSD measurements were recorded, the volume of the ICH was noted on initial head CT. RESULTS: The average ICH score was 1.35 and the average APACHE IV score was 27.35. In addition, the average GCS on admission was 13. The most common cause of ICH was hypertension. The most common location for the ICH was lobar hemorrhage. 8 out of 23 patients had midline shift on their initial head CT. 4 out of 23 patients underwent some sort of surgical intervention. The smallest average combined ONSD was 4.43cm. The longest average combined ONSD was 8.03cm. The minimum hemorrhage volume was 0.20cm3. The maximum was 60.0cm3. A moderate, positive correlation was detected between average optic nerve size and hemorrhage volume (correlation=0.5262; p-value=0.0099). A weak positive correlation was detected between APACHE IV and average ONSD (correlation=0.2052; p-value=0.3476). A weak-moderate positive correlation was detected between ICH score and average ONSD. (correlation=0.3622; p-value=0.0895). Those who experienced a midline shift had significantly higher averaged ONSD compared to those who did not. CONCLUSIONS: This study determined there was a moderate positive correlation between the ONSD and volume of hematoma. From a pathophysiological standpoint, conditions like ICH lead to cerebral parenchyma swelling which is transmitted to the optic nerves through the meninges. Additionally, our study revealed a significant difference in average ONSD and midline shift observed on CT scan. In settings where no invasive monitoring is available, ONSD enlargement may be a useful technique for monitoring midline shift. CLINICAL IMPLICATIONS: There are already established prognostic indicators for ICH including an ICH volume of 60cm3or greater on initial CT along with a GCS of 9 or less which predict a 30 day mortality of 19%. ONSD has a role in prognostication. Growth of the hematoma in the first 24 hours is an independent predictor of mortality and poor outcome. Serial exams of a patients ONSD can be applied to indirectly monitor any expanding hematoma. Given the positive correlation between ONSD and hematoma volume, I would be interested in ONSD and the degree of disability scores such as the modified rankin scale. DISCLOSURES: No relevant relationships by Braden Anderson, source=Web Response No relevant relationships by Shekhar Ghamande, source=Web Response No relevant relationships by Sarita Kambhampati, source=Web Response No relevant relationships by Matthew Lohse, source=Web Response No relevant relationships by Alireza Nathani, source=Web Response

Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness.

Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1-4.3], P<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4], P<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229], P<0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate. In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.

The benefit and outcome prediction of acute surgery for hemorrhagic brainstem cavernous malformation with impending respiratory failure

ObjectivesImpending respiratory failure is catastrophic neurological deterioration caused by repeated c of a brainstem cavernous malformation (BSCM). The benefit and outcome prediction of acute surgery for this fatal condition is rarely reported. In this study, the authors reported a case series of acute surgical treatment (≤3 weeks after the last hemorrhagic episode) for the BSCM with impending respiratory failure and reviewed literature over the past 20 years. Materials and MethodsClinical and outcome data from 6 consecutive acute surgically-treated BSCM patients were analyzed. Intracerebral hemorrhage (ICH) scores, primary pontine hemorrhage (PPH) scores, and Lawton's BSCM grading were applied for surgical outcome prediction. Ten related articles were included for the literature review. ResultsThere were three men and three women, with a mean age of 32.2 ± 9.3 years (range 15–45 years). The BSCMs were located at the pons in 5 cases and the medulla in 1 case. The ICH score was 1–2 in all cases, while the PPH score was 0 in all pontine BSCMs. For Lawton's BSCM grading, 3 cases were grade 2, 2 cases were grade 3, and 1 case was grade 1. All patients achieved spontaneous respiratory dysfunction relief postoperatively and significantly improved at follow-up (mean 4.47 ± 0.24 years;range4.0–5.6 years). ConclusionsRepeated hemorrhagic BSCM with impending respiratory failure can benefit from acute surgical treatment. The ICH score, PPH score, and Lawton's BSCM grading are promisingly useful tools for fast and efficient surgical outcome prediction.

Anticoagulation after intracerebral hemorrhage in patients with atrial fibrillation: between Scylla and Charybdis.

Oral anticoagulants (OAC) are indicated in patients with atrial fibrillation (AF) and high risk of ischemic stroke. However, the introduction of anticoagulation in patients with AF and previous intracerebral hemorrhage (ICH) is controversial. We aimed to better understand the efficacy and safety of OAC in this context and to assess the factors that may influence this decision. In a single-center retrospective observational study, patients with AF and ICH who survived hospitalization at a level A Stroke Unit between 2009 and 2018 were included. Patients were followed for two years after discharge. Data were collected regarding the introduction or not of OAC and the occurrence of major thrombotic/hemorrhagic events and death. Ninety-five patients (75.2 ± 9.9years) were included and 40 patients (42.1%) started OAC. Patients were more likely to initiate anticoagulation if they had: mechanical prosthetic valves, previous AF (p = 0.005) and previous OAC therapy (p < 0001); and less if they had previous hemorrhagic stroke (p < 0.005). During follow-up, 10.5% had at least one major hemorrhagic event (60% anticoagulated), 20% had at least one major thrombotic event (all non-anticoagulated) and 20% died. The only factor associated with the risk of bleeding was ICH score (OR:2.49 per 1-point increase; 95%CI:1.14-5.46). Patients who initiated anticoagulation had lower mortality than non-anticoagulated (OR:0.296; 95%CI:0.090-0-975). Previous ICH and higher CHA2DS2-VASc were associated with higher mortality. In this retrospective series, anticoagulation reduced thrombotic events and overall mortality in patients admitted for ICH and AF, without a significant increase in bleeding risk.

Admission Lymphocytopenia is Associated with Urinary Tract Infection and Nosocomial Infections in Hemorrhagic Stroke

ObjectiveGrowing evidence suggests that lymphocytopenia on admission (LOA) is associated with infectious complications and poor outcomes in intracerebral hemorrhage (ICH). Whether LOA preferentially increases the risk for community acquired infections or nosocomial infections is unknown. This study investigates the relationship between LOA and nosocomial infections in a cohort of patients with ICH in a safety-net hospital. Material and methodsThis is a single center, observational, retrospective study of 213 patients with non-traumatic ICH admitted to the neurocritical care unit between 2008 and 2014. Patients’ clinical, demographic, lab and radiologic data were retrieved from institutional electronic medical records. Nosocomial infection was defined as clinical onset 48 h after admission. ResultsPrevalence of LOA was 24.8%. Patients with LOA showed significant associations with mechanical ventilation (67.9% versus 49.4%; p= 0.019), higher median ICH score (2 versus 1; p=0.006), nosocomial infection (43.4% versus 28.0%; p=0.038), nosocomial UTI (24.5% versus 8.9%; p=0.003). Adjusting for baseline covariates in a multivariate logistic regression, we observed an association of LOA with nosocomial UTI (OR, 3.66 [95% CI, 1.36-9.88], p=0.010). From the Cox proportional model, patients with LOA had 1.76 times the hazard of developing of nosocomial infection, compared to those without LOA ([95% CI: 1.01, 3.07], p=0.046) and had 3.27 times the hazard of developing nosocomial UTI, compared to those without LOA ([95% CI: 1.39, 7.67], p=0.007). ConclusionsThis study is the first to show that LOA is associated with nosocomial urinary tract infections and significantly shorter times to develop nosocomial infections.

Abstract P150: Sex Differences In Augmentation Index And Aortic Pulse Pressure Among Patients Diagnosed With Acute Primary Intracerebral Hemorrhage

Introduction: Intracerebral hemorrhage (ICH) is the second most common subtype of stroke. Hypertension is a major cause of primary spontaneous ICH. However, sex difference in blood pressure (BP) and arterial stiffness among ICH patients is not well characterized. Methods: A prospective pilot study to investigate the feasibility of measuring arterial stiffness in acute primary ICH patients was approved by the institutional research board at Wake Forest Baptist Health. Eligible subjects with primary ICH were enrolled in the study within 7 days of onset. Non-invasive measurements of brachial BP, aortic BP, augmentation index at heart rate of 75 beats per minute (AIx75), and carotid-femoral pulse wave velocity (cf-PWV) were measured at the patient’s bedside, using the SphygmoCor XCEL System v1 (AtCor Medical Pty Ltd., Sydney, Australia). Results: A total of 20 patients have been enrolled in the study over 5 months. Over half the patients enrolled were female (55%, n = 11), including 82% (n = 9) White, 9% (n = 1) Asian and 9% (n = 1) Hispanic. There was increased diversity in the male patients (45%, n = 9) including 44% (n = 4) Black, 22% (n = 2) White, 22% (n = 2) Hispanic, and 11% (n = 1) Asian. Men were significantly younger than women (57 ± 5 years vs 74 ± 3 years, respectively, P = 0.009). There were no significant differences in BMI or ICH score. At the time of measurement, there were no significant sex differences in brachial or aortic blood pressures (systolic and diastolic), however, females had significantly higher AIx75 (35 ± 4 vs 20 ± 6, P = 0.036) and aortic PP (53 ± 2 mm Hg vs 42 ± 4 mm Hg, P = 0.020) than males. Sex difference in cf-PWV was not statistically significant (p = 0.054). Conclusion: In the current feasibility pilot study, preliminary data show that females had higher arterial stiffness measured as AIx75 and aortic PP than males in the acute setting of ICH. Further study will be required to ascertain whether this is related to higher age at presentation in females. Whether sex differences in arterial stiffness predict differences in the outcome among ICH patients is not well characterized; thus, assessment of 30-day functional and neurological outcomes will be performed with NIHSS and modified Rankin Scores.