Intracerebral Hemorrhage Volume Research Articles

Abstract TP166: Refining Deep Learning Application Diagnostic Accuracy in Intracerebral Hemorrhage (ICH): Focus on Subtle Hemorrhage Detection

Introduction: Deep-learning (DL)-based applications for Intracerebral Hemorrhage (ICH) detection on non-contrast computed tomography (NCCT) scans have demonstrated the potential to enhance diagnostic accuracy and efficiency amid the increasing radiologist workload. However, the sensitivity and specificity of these applications remain suboptimal, particularly in cases with subtle ICH (ICH volume < 5ml) and when confounding factors are present. This study aimed to enhance DL-based application, reduce false positives and improve the detection of subtle ICH. Methods: This study compared two versions of the DL-based application for ICH detection (CINA-ICH, Avicenna.AI, La Ciotat, France), both using a hybrid 2D/3D architecture. The first version, CINA-ICH, was trained on 8,994 representative CT scans (1,034 ICH+) from a cohort diverse in patient characteristics and acquisition parameters. The improved version, CINA-ICH(i), was trained on the same dataset enriched with 600 challenging cases (several confounding factors present) and included a specialised 3D network for subtle ICH detection, that underwent independent training on 2,238 CT-scans including 399 subtle ICH. The evaluation dataset included 479 NCCT scans (131 ICH+ including 24 subtle ICH) from over 200 U.S. hospitals, 4 scanner makers and 35 scanner models. Ground truth was determined by consensus among three board-certified radiologists. Sensitivity, Specificity, Accuracy and Matthews Correlation Coefficient (MCC) of CINA-ICH and CINA-ICH(i) were evaluated with a detailed analysis of false positive cases and subtle ICHs. Results: CINA-ICH(i) demonstrated a statistically significant (p<0.05) improvement in diagnostic performance compared to CINA-ICH: 88.5% vs. 83.2% for sensitivity, 94% vs. 85.6% for specificity, and 92.5% vs. 85% for accuracy. MCC for CINA-ICH(i) was improved from 0.65 to 0.81. CINA-ICH(i) reduced false positives from 50 to 21, effectively minimizing the detection of spurious findings and anatomical structures such as falx cerebri and sinuses. Additionally, CINA-ICH(i) enhanced the recognition of subtle ICH, detecting 37.5% of cases compared to only 8.3% detected by CINA-ICH. Conclusions: The implemented strategy to enhance the DL-based algorithm successfully increased ICH detection accuracy. This advancement demonstrates the potential for optimized algorithms to better support clinical decision-making by reducing false positives and improving the detection of subtle ICH cases.

Abstract TMP67: Validation and Modification of the Simplified Edinburgh CT Criteria in Asian Lobar Intracerebral Hemorrhage: The Proposal of Asian CT Criteria for Cerebral Amyloid Angiopathy

Background and Objective: The simplified Edinburgh CT criteria allowed a diagnosis of cerebral amyloid angiopathy (CAA) in spontaneous lobar intracerebral hemorrhage (ICH) for patients with limited accessibilities to MRI. However, its applicability to Asian populations remains uncertain. This study evaluated the diagnostic accuracy of the simplified Edinburgh CT criteria in Asian lobar ICH and to propose modifications if the performance is suboptimal. Methods: We analyzed patients with spontaneous lobar ICH (≥ 50 years) from 2015 to 2022 who underwent an acute CT and an MRI. The CT images were assessed according to the LINCHPIN CT RATING FORM. Demographic and imaging parameters were compared between probable CAA and non-CAA groups with modified Boston criteria as reference standards, and were selected to establish a logistic regression model. The modified version of CT criteria was evaluated by diagnostic accuracy, inter-rater reliability and decision curve analysis. Results: A total of 87 lobar ICHs were included (ICH volume 20.1 [10.0-39.9] ml, 46.0% probable CAA). The presence of subarachnoid hemorrhage (SAH, 47.5% vs 21.3%, p=0.010), but not finger-like projection (FLP, 42.5% vs 23.4%, p=0.057), showed significant difference between probable CAA and non-CAA groups. The simplified Edinburgh CT criteria yielded only moderate diagnostic accuracy for CAA (AUC 0.66). To enhance the diagnostic performance, we identified additional CT markers that are related to CAA including cortical atrophy and deep atrophy; absent old striatocapsular insult, old lacune or vascular lesions (all p<0.05). The hematoma in CAA tended to be less oval, had more irregular borders and variable density, and almost always reached the cortex (all p<0.05). Accordingly, we developed the new criteria that incorporated hematoma cortical involvement, absence of old lacune, and presence of cortical atrophy in predicting probable CAA. All three markers showed excellent inter-rater reliability. The updated criteria yielded good AUC of 0.843 (0.759-0.927) without evidence of poor calibration, and provided the rule-in specificity of 85.1% and the rule-out sensitivity of 85.0%. Decision curve analysis supported the clinical net benefit. Conclusions: The diagnostic accuracy of simplified Edinburgh CT criteria was suboptimal in Asians. We proposed the Asian version using CT markers of cortical involvement, absence of old lacune, and presence of cortical atrophy. External validation is warranted.

The REpeated ASSEssment of SurvivorS in intracerebral haemorrhage: protocol for a multicentre, prospective observational study

BackgroundThe REpeated ASSEssment of SurvivorS (REASSESS) study will conduct long-term cognitive, functional and neuropsychiatric performance assessments to determine whether evacuation of spontaneous intracerebral haemorrhage (ICH) reduces the risk of later cognitive decline in the ageing brain.Methods and analysisThis study will compare rates of cognitive decline under two treatment strategies for ICH. The first strategy is the use of minimally invasive surgery (MIS) with similar techniques as performed in (1) the Minimally Invasive Surgery plus rt-PA in the Treatment of Intracerebral haemorrhage Evacuation phase III (MISTIE III) trial, (2) the Early MiNimally-invasive Removal of IntraCerebral Haemorrhage (ENRICH) trial and (3) a single-centre cohort of consecutively treated patients with MIS. The second strategy is the current non-surgical standard of care using data from controls in MISTIE III and ENRICH and comparative data from The Ethnic/Racial Variations of ICH (ERICH) studyextended into the ERICH-Longitudinal study, which followed over 900 of ERICH cases with serial cognitive examinations. If successful, the REASSESS study could demonstrate that reduction of ICH volume is a critical target to reduce the risk of progressive cognitive decline, establish targets for residual haematoma volume reduction and determine if greater residual haematoma volume leads to a long-term inflammatory state.Ethics and disseminationApproval of this study was obtained from the Johns Hopkins University Institutional Review Board (IRB00311985). The findings of the study will be published in academic peer-reviewed journals.Trial registration numberNCT05611918; ClinicalTrials.gov; registered on 23 May 2023.

Abstract TP187: Automated Assessment of Intracerebral Hemorrhage Volumes using the VIOLA tool Performs Similarly to ABC/2 in Predictive Modelling

Abstract TP187: Automated Assessment of Intracerebral Hemorrhage Volumes using the VIOLA tool Performs Similarly to ABC/2 in Predictive Modelling

Real-world evaluation of the accuracy of the Viz.AI automated intracranial hemorrhage volume calculation tool

BackgroundAppropriate management of spontaneous intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) requires rapid, accurate volume estimation. Viz.AI has developed an artificial intelligence (AI)-powered ICH calculation tool that may improve existing...

Non-Invasive Brain Stimulation to Improve Functional Recovery and Predict Outcome After Intracerebral Hemorrhage: A Narrative Review.

Intracerebral hemorrhage (ICH) is a leading cause of stroke-related mortality and long-term disability, with initial ICH volume, age, location of the hemorrhage, and clinical severity being key predictors of outcome. While clinical scores incorporating these elements are validated and exhibit good inter-rater reliability, their accuracy in predicting long-term recovery remains suboptimal. Non-invasive brain stimulation (NIBS) has emerged as a potential adjunct for improving both prognostication and functional recovery in ICH survivors. Despite promising results, heterogeneity in stimulation protocols, patients' populations, and outcome measures have prevented NIBS implementation in clinical practice. This narrative review summarizes the available evidence on the association between NIBS, outcome prediction and functional recovery, discussing current challenges and future perspectives.

Predictors and lesion patterns of dysphagia and swallowing outcomes after acute intracerebral hemorrhage.

Dysphagia is a common complication following intracerebral hemorrhage (ICH) and is associated with an increased risk of aspiration pneumonia and poor outcomes. This study aimed to explore associated lesion patterns and contributing factors of post-ICH dysphagia, and predict dysphagia outcomes following ICH. A multicenter, prospective study. Patients with ICH from two stroke centers within 72 h of symptom onset received baseline bedside swallowing evaluations. Dysphagia-related lesion patterns were identified using support-vector regression-based lesion-symptom mapping. Predictors of swallowing impairment on the 7th and 30th day, as well as stroke-associated pneumonia (SAP), were determined through multiple logistic regression analyses, and nomograms were developed. A total of 153 patients were included in the final analysis. Of those, 28 had dysphagia. Dysphagia-related lesions predominantly affected bilateral subcortical and adjacent cortical regions. Stroke severity, hematoma expansion, and basal ganglia hemorrhage were significantly associated with initial dysphagia. Baseline aspiration risk and age were identified as independent predictors of impaired swallowing function on days 7 and 30, and SAP. Moreover, ICH volume was significantly correlated with swallowing impairment on day 7 and SAP occurrence. Midline shift and basal ganglia hematoma remained independent predictors of impaired swallowing on day 30. Predictive models for swallowing impairment on days 7 and 30, as well as SAP, demonstrated strong calibration and discriminatory ability, with C indices of 0.867, 0.895, and 0.773, respectively. Post-ICH dysphagia can be predicted based on stroke severity, hematoma expansion, and basal ganglia hemorrhage. Incorporating aspiration risk and imaging evaluation can further improve the identification of patients at high risk for swallowing impairment at both 1 week and 1 month after ICH.

Neuroimaging Markers of Brain Reserve and Associations with Delirium in Patients with Intracerebral Hemorrhage.

Delirium occurs frequently in patients with stroke, but the role of preexisting neural substrates in delirium pathogenesis remains unclear. We sought to explore associations between acute and chronic neural substrates of delirium in patients with intracerebral hemorrhage (ICH). Using data from a single-center ICH registry, we identified consecutive patients with acute nontraumatic ICH and available magnetic resonance imaging scans. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria were used to classify each patient as delirious or nondelirious during their hospitalization. Magnetic resonance imaging scans were processed and analyzed using semiautomated software, with volumetric measurement of acute ICH volume as well as white matter hyperintensity volume (WMHV) and gray and white matter volumes from the contralateral hemisphere. We tested associations between WMHV and incident delirium using multivariable regression models, and then determined the predictive accuracy of these neuroimaging models via area under the curve (AUC) analysis. Of 139 patients in our cohort (mean [standard deviation] age 67.3 [17.3] years, 53% male), 58 (42%) patients experienced delirium. In our primary analyses, WMHV was significantly associated with delirium after adjusting for ICH features (odds ratio 1.56 per 10cm3, 95% confidence interval 1.13-2.13), and this association was strengthened after further adjustment for segmented brain volume in patients with high-resolution scans (odds ratio 1.89 per 10cm3, 95% confidence interval 1.24-2.86). Neuroimaging-based models predicted delirium with high accuracy (AUC 0.81), especially in patients with Glasgow Coma Scale score > 13 (AUC 0.85) and smaller ICH (AUC 0.91). Chronic white matter disease is independently associated with delirium in patients with acute ICH, and neuroimaging biomarkers may have utility in predicting delirium occurrence.

Abstract 058: Outcomes in Patients with Spontaneous Intracranial Hemorrhage Who Underwent Thromboelastography Testing

Introduction In the U.S., intracerebral hemorrhage (ICH) accounts for 10‐15% of all strokes, yet it carries a significantly higher risk of death or long‐term disability. While the Thromboelastography Platelet (TEG PM) mapping tool is well‐established for managing coagulopathy in trauma, organ transplantation, massive transfusions, and ECMO patients, its use in spontaneous ICH is not well understood. This study aims to evaluate patient outcomes in spontaneous ICH cases that received TEG testing compared to those that did not. Method Following IRB approval, we conducted a retrospective review of 215 patients with intracerebral hemorrhage (ICH) from June 2020 to June 2023. Out of these, 160 had spontaneous ICH, with 98 undergoing TEG‐PM testing and 62 not. The primary outcome was to evaluate the frequency of platelet transfusions and complications related to external ventricular drains (EVD). The secondary outcome was to compare discharge outcomes, using discharge status as a proxy for functional recovery, with discharge to home or acute rehab considered a good outcome. Chi‐square tests were performed to analyze differences between the TEG and non‐TEG groups, with all analyses conducted using IBM SPSS Statistics. Results We performed a Mann‐Whitney U test to compare ICH volume and initial National Institutes of Health Stroke Scale (NIHSS) scores between the two groups. The results showed that ICH volume was significantly lower in the non‐TEG‐PM group, with a p‐value of 0.002. The median ICH volume of TEG‐PM group was 13 (IQR 4.0‐36.0), while in non‐TEG‐PM group was 4.35 (IQR 1.0‐19.6). There was no significant difference in the initial NIHSS scores between the groups (p=0.063). In patients who underwent TEG‐PM, 10.2% received platelet transfusion as compared to non‐TEG‐PM group where 0% patients received platelet transfusion with p‐value of 0.009. In TEG‐PM group, 26.8 % patients had EVD placement vs 9.7 % in non‐TEG‐PM group with Odds Ratio 0.29 (0.11‐0.76). There was 1% EVD associated hemorrhage seen in patients of TEG‐PM group as compared to 0% in non‐TEG‐PM. 44.9% of the patients in the TEG‐PM had good discharge outcome as compared to 64.5% in non‐TEG‐PM group with p‐value of 0.1 Conclusion The data indicates that TEG‐PM testing is not a reliable predictor of patient outcomes in spontaneous ICH. Interestingly, patients who underwent TEG‐PM testing received more platelet transfusions compared to those who did not, but this did not impact the discharge outcomes. The ICH volume in both groups were not clinically significant.

Prediction of the outcome of intracerebral hemorrhage by blood neutrophil to lymphocyte ratio: a prospective observational study.

Intracerebral haemorrhage (ICH) is defined as bleeding within the brain parenchyma. Neutrophil lymphocyte ratio (NLR) is a dynamic parameter that can be affected by an underlying condition like microangiopathy (e.g. hemorrhagic stroke). The NLR value at the time of stress (e.g. ICH) could be a predictor among various other factors on the outcome of the disease. The aim of this study is to see if NLR could be a predictor of the outcome of the ICH. This is a prospective observational study conducted in the Department of Neurosurgery and Department of Neurology, from March 2020 to February 2021. The ICH cases presented to the emergency department within 24h of symptoms were included. The baseline haematological and biochemical investigations were sent and the noncontrast computed tomography (NCCT) head was done for the diagnosis of ICH. The NLR was measured. The ICH volume was calculated by ABC/2. Follow-up of the patient to measure outcome was done with a modified Rankin scale (mRS) on 30 days. Student's t-test was used to correlate NLR-mRS. Fischer's exact test was used for a categorical association of NLR to mRS. A total of 89 patients with ICH were enrolled in this study. In this study, 62.92% of patients had good outcomes (NLR of 4.88±3.06), whereas 37.08% of patients had bad outcomes (NLR of 9.09± 4.92). Statistically, higher NLR was significantly predictive of poorer outcomes. ICH causes stress in the body, which alters the value of NLR. Components of NLR are altered after haemorrhage due to a change in homeostasis of brain parenchyma. The NLR value obtained at the time of emergency department visits may help to predict the 30 days outcome of ICH.

Fuzzy C-means clustering algorithm applied in computed tomography images of patients with intracranial hemorrhage.

In recent years, intracerebral hemorrhage (ICH) has garnered significant attention as a severe cerebrovascular disorder. To enhance the accuracy of ICH detection and segmentation, this study proposed an improved fuzzy C-means (FCM) algorithm and performed a comparative analysis with both traditional FCM and advanced convolutional neural network (CNN) algorithms. Experiments conducted on the publicly available CT-ICH dataset evaluated the performance of these three algorithms in predicting ICH volume. The results demonstrated that the improved FCM algorithm offered notable improvements in computational time and resource consumption compared to the traditional FCM algorithm, while also showing enhanced accuracy. However, it still lagged behind the CNN algorithm in areas such as feature extraction, model generalization, and the ability to handle complex image structures. The study concluded with a discussion of potential directions for further optimizing the FCM algorithm, aiming to bridge the performance gap with CNN algorithms and provide a reference for future research in medical image processing.

Neuroinflammation and blood-brain barrier breakdown in acute, clinical intracerebral hemorrhage

Neuroinflammation is a promising therapeutic target in intracerebral hemorrhage (ICH), characterized in the brain by microglial activation and blood-brain barrier (BBB) breakdown. In this study, 36 acute, spontaneous, supratentorial ICH patients underwent dynamic contrast-enhanced MRI to measure BBB permeability (Ktrans) 1–3 days post-onset and 16 returned for [11C](R)-PK11195 PET to quantify microglial activation (BPND), 2–7 days post-onset. We first tested if these markers were increased and co-localized in the perihematomal brain and found that perihematomal Ktrans and BPND were increased vs. the contralateral brain, but regions of high Ktrans and BPND only overlapped by a mean of 4.9%. We then tested for associations of perihematomal Ktrans and BPND with clinical characteristics (age, ICH volume & location, blood pressure), other markers of inflammation (edema, IL-6, and CRP), and long-term functional outcome (90-day mRS). Lower perihematomal BPND was associated with increasing age. Lobar hemorrhage was associated with greater Ktrans than deep, but Ktrans and BPND were not associated with ICH volume, or other inflammatory markers. While perihematomal Ktrans and BPND were not associated with outcome, contralateral Ktrans was significantly associated with greater 90-day mRS. Exploratory analyses demonstrated that blood pressure variability over 72 h was also associated with contralateral Ktrans.

Does stereotactic thrombolysis with alteplase for intracerebral haemorrhage alter intraventricular haematoma volume? A secondary analysis of the MISTIE-III trial

BackgroundStereotactic thrombolysis reduces intracerebral haemorrhage (ICH) volume in patients with spontaneous ICH. Whether intrahaematomal alteplase administration is associated with a change in intraventricular haemorrhage volume (deltaIVH) and functional outcomes is...

Feasibility Study of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage with Large Hematoma: a Comparison with Craniotomy Using Propensity Score Matching Analysis.

Spontaneous intracerebral hemorrhage (ICH) with large hematomas is commonly treated with craniotomy combined with decompressive craniectomy, procedures that involve huge trauma and require subsequent cranioplasty. Recently, endoscopic surgery has shown significant promise in treating ICH, but its feasibility for large hematomas remains uncertain. Therefore, this study aims to compare endoscopic surgery with craniotomy and to evaluate the efficacy and safety of endoscopic surgery in treating large hematomas ICH. A retrospective analysis was conducted on the clinical data from patients with spontaneous supratentorial ICH and hematoma volumes exceeding 50 mL who underwent either endoscopic surgery or craniotomy. Propensity score matching analysis was employed to reduce selection bias. The efficacy and safety of endoscopic surgery were evaluated by analyzing blood loss, postoperative edema, mortality rate, complications, and the Glasgow Outcome Scale (GOS) at 6-month follow-up. A total of 113 cases that met the criteria were collected, with 65 in the endoscopic surgery group and 48 in the craniotomy group. After propensity score matching, each group contained 34 cases. The mean hematoma volume was 64.84 ± 11.02 mL in the endoscopy group and 66.57 ± 12.77 mL in the craniotomy group (p = 0.554). Hematoma evacuation rates were 93.27% in the endoscopy group and 89.34% in the craniotomy group (p = 0.141). The endoscopy group exhibited lower blood loss, shorter surgical time, and reduced postoperative edema volume at 24 h compared to the craniotomy group. The rate of pulmonary infection was slightly lower in the endoscopy group compared to the craniotomy group (70.59% vs. 91.18%, p = 0.031), but there were no statistically significant differences in overall complications and mortality rate between the two groups. GOS scores were similar in both groups at the 6-month follow-up. Endoscopic surgery is safe and feasible for treating spontaneous supratentorial ICH with large hematomas, demonstrating efficacy similar to that of craniotomy with decompressive craniectomy.

Effect of post thrombolytic intracerebral hemorrhage volume on 90-day outcomes in acute ischemic stroke patients

Background and PurposePost thrombolytic intracerebral hemorrhage (ICH) is associated with higher rate of death or disability in acute ischemic stroke patients. We investigated the relationship between post thrombolytic ICH volume and change in volume and death or disability at 90 days in acute ischemic stroke patients. MethodsWe analyzed 110 patents recruited in the Safety Evaluation of 3K3A-APC in Ischemic Stroke (RHAPSODY) trial who received intravenous tissue plasminogen activator (tPA) followed by mechanical thrombectomy (if indicated) and 3K3A-APC or placebo. ICH volume was measured at Day 2 and Day 7 using susceptibility weighted sequence (SWI) on magnetic resonance imaging (MRI). We also calculated the post thrombolytic ICH volume change between Day 2 and Day 7. Outcomes were determined by using utility weighted modified Rankin scale (UW-mRs) at 90-days, Outcomes were determined by using utility weighted modified Rankin scale (UW-mRS) at 90 days. To minimize interpretation bias, outcome assessors were blinded to the treatment allocation and clinical data.We adjusted for age, gender, National Institutes of Health Stroke Scale (NIHSS) score (<10,10-19 and ≥20), location of hemorrhage (single basal ganglia hemorrhage, single lobar, single cerebellum, and multiple sites) in multivariate regression analysis. ResultsA total of 88 (80%) of 110 patients had post thrombolytic ICH (mean volume 28.3 ml ± SD 62 ml). The strata of ICH volume were not associated with UW-mRs at 90 days: <20 cc (regression coefficient (RC)-0.05, p= 0.58), 20-39 cc (RC-0.22, p=0.17), or ≥40 cc (RC-0.34, p= 0.083) compared with no ICH after adjusting for potential confounders. Change in ICH mean volume 26.78 ml ±59.68, 52 had increase in volume) between Day 2 and day 7 was not associated with UW-mRS at 90 days (RC -67.71, p= 0.06). ConclusionsWe did not observe any independent effect of post thrombolytic ICH volume on death or disability in acute ischemic stroke patients. Although further studies must be done, our data suggest that strategies to prevent ICH expansion such as antifibrinolytic medications and reduction in ICH volume such as surgical evacuation may not reduce death or disability in acute ischemic stroke patients with post thrombolytic ICH.

Low hemoglobin causes hematoma expansion and poor intracerebral hemorrhage outcomes.

Although lower hemoglobin levels associate with worse intracerebral hemorrhage (ICH) outcomes, causal drivers for this relationship remain unclear. We investigated the hypothesis that lower hemoglobin relates to increased hematoma expansion (HE) risk and poor outcomes using human observational data and assessed causal relationships using a translational murine model of anemia and ICH. ICH patients with baseline hemoglobin measurements and serial CT neuroimaging enrolled between 2010-2016 to a multicenter, prospective observational cohort study were studied. Patients with systemic evidence of coagulopathy were excluded. Separate regression models assessed relationships of baseline hemoglobin with HE (≥33% and/or ≥6mL growth) and poor long-term neurological outcomes (modified Rankin Scale 4-6) after adjusting for relevant covariates. Using a murine collagenase ICH model with serial neuroimaging in anemic vs. non-anemic C57/BL6 mice, intergroup differences in ICH lesion volume, ICH volume changes, and early mortality were assessed. Among 1190 ICH patients analyzed, lower baseline hemoglobin levels associated with increased odds of HE (adjusted OR per -1g/dL hemoglobin decrement: 1.10 [1.02-1.19]) and poor 3-month clinical outcomes (adjusted OR per -1g/dL hemoglobin decrement: 1.11 [1.03-1.21]). Similar relationships were seen with poor 6 and 12-month outcomes. In our animal model, anemic mice had significantly greater ICH lesion expansion, final lesion volumes, and greater mortality, as compared to non-anemic mice. These results, in a human cohort and a mouse model, provide novel evidence suggesting that anemia has causal roles in HE and poor ICH outcomes. Additional studies are required to clarify whether correcting anemia can improve these outcomes.

Cerebral small vessel disease modifies outcomes after minimally invasive surgery for intracerebral haemorrhage

BackgroundMinimally invasive surgery (MIS) for spontaneous supratentorial intracerebral haemorrhage (ICH) is controversial but may be beneficial if end-of-treatment (EOT) haematoma volume is reduced to ≤15 mL. We explored whether MRI...

Associations of Cerebral Small Vessel Disease and Chronic Kidney Disease in Patients With Acute Intracerebral Hemorrhage: A Cross-Sectional Study.

Chronic kidney disease (CKD) may be associated with the pathogenesis and phenotype of cerebral small vessel disease (SVD), which is the commonest cause of intracerebral hemorrhage (ICH). The purpose of this study was to investigate the associations of CKD with ICH neuroimaging phenotype, volume, and location, total burden of small vessel disease, and its individual components. In 2 cohorts of consecutive patients with ICH evaluated with MRI, we investigated the frequency and severity of CKD based on established Kidney Disease Improving Global Outcomes criteria, requiring estimated glomerular filtration rate (eGFR) measurements <60 mL/min/1.732 ≥ 3 months apart to define CKD. MRI scans were rated for ICH neuroimaging phenotype (arteriolosclerosis, cerebral amyloid angiopathy, mixed location SVD, or cryptogenic ICH) and the presence of markers of SVD (white matter hyperintensities [WMHs], cerebral microbleeds [CMBs], lacunes, and enlarged perivascular spaces, defined according to the STandards for ReportIng Vascular changes on nEuroimaging criteria). We used multinomial, binomial logistic, and ordinal logistic regression models adjusted for age, sex, hypertension, and diabetes to account for possible confounding caused by shared risk factors of CKD and SVD. Of 875 patients (mean age 66 years, 42% female), 146 (16.7%) had CKD. After adjusting for age, sex, and comorbidities, patients with CKD had higher rates of mixed SVD than those with eGFR >60 (relative risk ratio 2.39, 95% CI 1.16-4.94, p = 0.019). Severe WMHs, deep microbleeds, and lacunes were more frequent in patients with CKD, as was a higher overall SVD burden score (odds ratio 1.83 for each point on the ordinal scale, 95% CI 1.31-2.56, p < 0.001). Patients with eGFR ≤30 had more CMBs (median 7 [interquartile range 1-23] vs 2 [0-8] for those with eGFR >30, p = 0.007). In patients with ICH, CKD was associated with SVD burden, a mixed SVD phenotype, and markers of arteriolosclerosis. Our findings indicate that CKD might independently contribute to the pathogenesis of arteriolosclerosis and mixed SVD, although we could not definitively account for the severity of shared risk factors. Longitudinal and experimental studies are, therefore, needed to investigate causal associations. Nevertheless, stroke clinicians should be aware of CKD as a potentially independent and modifiable risk factor of SVD.

Admission Viscoelastic Hemostatic Assay Parameters Predict Poor Long-Term Intracerebral Hemorrhage Outcomes.

Viscoelastic hemostatic assays (VHAs) provide more comprehensive assessments of coagulation compared with conventional coagulation assays. Although VHAs have enabled guided hemorrhage control therapies, improving clinical outcomes in life-threatening hemorrhage, the role of VHAs in intracerebral hemorrhage (ICH) is unclear. If VHAs can identify coagulation abnormalities relevant for ICH outcomes, this would support the need to investigate the role of VHAs in ICH treatment paradigms. Thus, we investigated whether VHA assessments of coagulation relate to long-term ICH outcomes. Patients with spontaneous ICH enrolled into a single-center cohort study receiving admission Rotational Thromboelastometry (ROTEM) VHA testing between 2013 and 2020 were assessed. Patients with previous anticoagulant use or coagulopathy on conventional coagulation assays were excluded. Primary ROTEM exposure variables were coagulation kinetics and clot strength assessments. Poor long-term outcome was defined as modified Rankin Scale ≥ 4 at 6months. Logistic regression analyses assessed associations of ROTEM parameters with clinical outcomes after adjusting for ICH severity and hemoglobin concentration. Of 44 patients analyzed, the mean age was 64years, 57% were female, and the median ICH volume was 23mL. Poor 6-month outcome was seen in 64% of patients. In our multivariable regression models, slower, prolonged coagulation kinetics (adjusted odds ratio for every second increase in clot formation time 1.04, 95% confidence interval 1.00-1.09, p = 0.04) and weaker clot strength (adjusted odds ratio for every millimeter increase of maximum clot firmness 0.84, 95% confidence interval 0.71-0.99, p = 0.03) were separately associated with poor long-term outcomes. Slower, prolonged coagulation kinetics and weaker clot strength on admission VHA ROTEM testing, not attributable to anticoagulant use, were associated with poor long-term outcomes after ICH. Further work is needed to clarify the generalizability and the underlying mechanisms of these VHA findings to assess whether VHA-guided treatments should be incorporated into ICH care.

Intensive versus less intensive blood pressure targets after mechanical thrombectomy in acute ischemic stroke: a systematic review and network meta-analysis.

Hemodynamic management, specifically blood pressure, is essential to reduce mortality and preserve functional capacity. However, the literature is uncertain about the best blood pressure target to be adopted after performing mechanical thrombectomy in patients with acute ischemic stroke. Randomized clinical trials that compared blood pressure goals after mechanical thrombectomy were searched in the following databases: MEDLINE/PubMed, Embase, Scopus, Biomedcentral, and Cochrane Library. The last search was on September 19, 2023. The results obtained were used to construct network meta-analyses. A total of 1556 participants were enrolled from 4 randomized controlled trials (OPTIMAL-BP, ENCHANTED2/MT, BP-TARGET, BEST-II). The last article was not included in the network meta-analysis because it did not have common blood pressure targets. The outcomes compared were: mRS (modified Rankin scale), eTICI/mTICI scale scores, symptomatic and any intracerebral hemorrhage, post-intervention NIHSS, and post-intervention infarct volume. The outcomes using the mRS scale showed that better outcomes were reached with less intensive blood pressure targets when comparing < 120mmHg vs. ≤ 180mmHg, OR: 0.71 (95% CI 0.54 - 0.94), in the outcome of mRS 0-1. And for the mRS 0-2 outcome with comparisons < 120mmHg vs. ≤ 180mmHg, with OR: 0.59 (95% CI 0.44 - 0.77) and < 140mmHg vs. ≤ 180mmHg, with OR: 0.61 (95% CI 0.41 - 0.89). In patients with large vessel occlusion treated with mechanical thrombectomy and who achieved good reperfusion, intensive blood pressure lowering is not effective and might be harmful respect to non intensive blood pressure control in recanalized patients.