Intracerebral Hemorrhage Characteristics Research Articles

Antiplatelet Therapy in Primary Spontaneous and Oral Anticoagulation-Associated Intracerebral Hemorrhage.

Background and Purpose- This study determined the influence of concomitant antiplatelet therapy (APT) on hematoma characteristics and outcome in primary spontaneous intracerebral hemorrhage (ICH), vitamin K antagonist (VKA)- and non-VKA oral anticoagulant-associated ICH. Methods- Data of retrospective cohort studies and a prospective single-center study were pooled. Functional outcome, mortality, and radiological characteristics were defined as primary and secondary outcomes. Propensity score matching and logistic regression analyses were performed to determine the association between single or dual APT and hematoma volume. Results- A total of 3580 patients with ICH were screened, of whom 3545 with information on APT were analyzed. Three hundred forty-six (32.4%) patients in primary spontaneous ICH, 260 (11.4%) in VKA-ICH, and 30 (16.0%) in non-VKA oral anticoagulant-associated ICH were on APT, and these patients had more severe comorbidities. After propensity score matching VKA-ICH patients on APT presented with less favorable functional outcome (modified Rankin Scale score, 0-3; APT, 48/202 [23.8%] versus no APT, 187/587 [31.9%]; P=0.030) and higher mortality (APT, 103/202 [51.0%] versus no APT, 237/587 [40.4%]; P=0.009), whereas no significant differences were present in primary spontaneous ICH and non-VKA oral anticoagulant-associated ICH. In VKA-ICH, hematoma volume was significantly larger in patients with APT (21.9 [7.4-61.4] versus 15.7 [5.7-44.5] mL; P=0.005). Multivariable regression analysis revealed an association of APT and larger ICH volumes (odds ratio, 1.80 [1.20-2.70]; P=0.005), which was more pronounced in dual APT and supratherapeutically anticoagulated patients. Conclusions- APT does not affect ICH characteristics and outcome in primary spontaneous ICH patients; however, it is associated with larger ICH volume and worse functional outcome in VKA-ICH, presumably by additive antihemostatic effects. Combination of anticoagulation and APT should, therefore, be diligently evaluated and restricted to the shortest possible time frame.

Diabetes and intracerebral hemorrhage: baseline characteristics and mortality

Acknowledging the conflicting evidence for diabetes as a predictor of short- and long-term mortality following an intracerebral hemorrhage (ICH), we compared baseline characteristics and 30-day and long-term mortality between patients with and without diabetes after an ICH, paying special attention to differences between type 1 (T1D) and type 2 (T2D) diabetes. Patients with a first-ever ICH were followed for a median of 2.3years. Adjusting for demographics, comorbidities and documented ICH characteristics increasing mortality after ICH, logistic regression analysis assessed factors associated with case fatality and 1-year survival among the 30-day survivors. Diabetes was compared with patients without diabetes in separate models as (i) any diabetes and (ii) T1D or T2D. Of our 969 patients, 813 (83.9%) had no diabetes, 41 (4.2%) had T1D and 115 (11.9%) had T2D. Compared with patients without diabetes, those with diabetes were younger, more often men and more frequently had hypertension, coronary heart disease and chronic kidney disease, with similar ICH characteristics. Patients with T1D were younger, more often had chronic kidney disease and brainstem ICH, and less often had atrial fibrillation and lobar ICH, than did patients with T2D. Diabetes had no impact on case fatality. Any diabetes (odds ratio, 2.57; 1.19-5.52), T1D (odds ratio, 7.04; 1.14-43.48) and T2D (odds ratio, 2.32; 1.04-5.17) were independently associated with 1-year mortality. Patients with ICH with diabetes exhibited a distinct pattern of comorbidities and disease characteristics with specific differences between T1D and T2D. Despite their younger age, T1D seems to carry a substantially higher likelihood of long-term mortality after an ICH than does T2D.

Cancer is an independent predictor of poor outcomes in patients following intracerebral hemorrhage.

Patients with cancer have been reported to have poorer outcomes following intracerebral hemorrhage (ICH) than those without cancer, but the findings were not consistent between studies. The aim of this study was to test the hypothesis that cancer is associated with poor outcomes following ICH. In all, 3137 consecutive patients admitted to the stroke unit of Osaka University Hospital were reviewed. Patients diagnosed with ICH were extracted and divided into two groups according to the presence of cancer. ICH characteristics were compared between the groups. The outcomes were measured using the 30-day and 90-day modified Rankin Scale (mRS). Amongst the 399 ICH patients (37.1% women; median age 66 years), the frequency of cancer was 15.3%. Of these, 70.5% of patients had distant metastatic cancers. Compared to controls, cancer patients were comparable in the Glasgow Coma Scale, hematoma volume and the frequency of infratentorial location and intraventricular hemorrhage extension, but had poorer outcomes following ICH. Ordinal logistic regression analysis revealed that cancer was independently associated with poor outcomes following ICH (odds ratio 5.14; 95% confidence interval 2.63-10.06). Adjustment was made for the covariates age, sex, time from onset to admission, prior use of antithrombotic agents, pre-stroke mRS, Glasgow Coma Scale, hematoma volume, infratentorial location and intraventricular hemorrhage extension. When the analysis was performed using data from individuals with localized cancer, the effect remained significant after assessment with 90-day mRS but not after that with 30-day mRS. The results suggest that cancer, especially distant metastatic cancer, is an independent predictor of poorer outcomes following ICH.

Neutrophil-Lymphocyte Ratio and Perihematomal Edema Growth in Intracerebral Hemorrhage.

Although preclinical studies have shown inflammation to mediate perihematomal edema (PHE) after intracerebral hemorrhage, clinical data are lacking. Leukocyte count, often used to gauge serum inflammation, has been correlated with poor outcome but its relationship with PHE remains unknown. Our aim was to test the hypothesis that leukocyte count is associated with PHE growth. We included patients with intracerebral hemorrhage admitted to a tertiary-care stroke center between 2011 and 2015. The primary outcome was absolute PHE growth during 24 hours, calculated using semiautomated planimetry. Linear regression models were constructed to study the relationship between absolute and differential leukocyte counts (monocyte count and neutrophil-lymphocyte ratio) and 24-hour PHE growth. A total of 153 patients were included. Median hematoma and PHE volumes at baseline were 14.4 (interquartile range, 6.3-36.3) and 14.0 (interquartile range, 5.9-27.8), respectively. In linear regression analysis adjusted for demographics and intracerebral hemorrhage characteristics, absolute leukocyte count was not associated with PHE growth (β, 0.07; standard error, 0.15; P=0.09). In secondary analyses, neutrophil-lymphocyte ratio was correlated with PHE growth (β, 0.22; standard error, 0.08; P=0.005). Higher neutrophil-lymphocyte ratio is independently associated with PHE growth. This suggests that PHE growth can be predicted using differential leukocyte counts on admission.

The Effect of Age on Characteristics and Mortality of Intracerebral Hemorrhage in the Oldest-Old

Background: Incidence of acute intracerebral hemorrhage (ICH) increases with age, but there is a lack of information about ICH characteristics in the oldest-old (age ≥85 years). In particular, there is a need for information about hematoma volume, which is included in most clinical scales for prediction of mortality in ICH patients. Many of these scales also assume that, independent of ICH characteristics, the oldest-old have a higher mortality than younger elderly patients (age 65-74 years). However, supporting evidence from cohort studies is limited. We investigated ICH characteristics of oldest-old subjects compared to young (<65 years), young-old (65-74 years) and old-old (75-84 years) subjects. We also investigated whether age is an independent mortality predictor in elderly (age ≥65 years) subjects with acute ICH. Methods: We retrospectively collected clinical and neuroimaging data of 383 subjects (age 34-104 years) with acute supratentorial primary ICH who were admitted to an Italian Stroke Unit (SU) between October 2007 and December 2014. Measured ICH characteristics included hematoma location, volume and intraventricular extension of hemorrhage on admission CT scan; admission Glasgow Coma Scale ≤8 and hematoma expansion (HE) measured on follow-up CT-scans obtained after 24 h. General linear models and logistic models were used to investigate the association of age with ICH characteristics. These models were adjusted for pre-admission characteristics, hematoma location and time from symptom onset to admission CT scan. Limited to elderly subjects, Cox models were used to investigate the association of age with in-SU and 1-year mortality: the model for in-SU mortality adjusted for pre-admission and ICH admission characteristics and the model for 1-year mortality additionally adjusted for functional status and disposition at SU discharge. Results: Independent of pre-admission characteristics, hematoma location and time from symptom onset to admission CT-scan, oldest-old subjects had the highest admission hematoma volume (p < 0.01). Age was unrelated to all other ICH characteristics including HE. In elderly patients, multivariable adjusted risk of in-SU and 1-year mortality did not vary across age categories. Conclusions: Oldest-old subjects with acute supratentorial ICH have higher admission hematoma volume than young and young-old subjects but do not differ for other ICH characteristics. When taking into account confounding from ICH characteristics, risk of in-SU and 1-year mortality in elderly subjects with acute supratentorial ICH does not differ across age categories. Our findings question use of age as an independent criterion for stratification of mortality risk in elderly subjects with acute ICH.

Abstract 121: Mechanisms of Cortical Superficial Siderosis in Cerebral Amyloid Angiopathy

Introduction: Mechanisms of cortical superficial siderosis (cSS) in cerebral amyloid angiopathy (CAA) are unknown, but might include in situ bleeding from amyloid laden superficial vessels or blood products redistribution from acute lobar intracerebral hemorrhage (ICH). Hypothesis: We aimed to identify factors related to the extent and multifocality of cSS. Methods: We analyzed consecutive CAA-related ICH patients diagnosed with Boston criteria from a prospective cohort. cSS multifocality, was rated for spatially distinct foci involvement and bi-hemispheric distribution on a 0-4 scale (1 point: 1 sulcus or focal immediately adjacent sulci, 2 points: 2 or more non-adjacent sulci OR more than 3 adjacent sulci, in each hemisphere) with excellent interrater reliability (k=0.87). Radiological markers of CAA and ICH characteristics were assessed using quantitative methods or validated visual scales, and their association with cSS multifocality was investigated in multivariable regression. Results: The cohort included 312 CAA patients (53% male; mean age 71.7). cSS was found in 34.6%: unifocal in 42 patients (13.5%), multifocal in 66 (23.1%). Presence and multifocality of cSS were not related with characteristics of the acute ICH such as ICH volume, ICH side or areas of acute subarachnoid blood on initial CT. ICH side did not predict cSS side or multifocality at that side. cSS multifocality was related to the presence of IVH in patients who had a single ICH without microbleeds (MB), but not in patients with multiple hemorrhagic lesions (ICH and/or MBs). In ordinal logistic regression, cSS multifocality was related to lobar microbleeds burden (OR: 1.57; 95%CI: 1.27-1.94; p&lt;0.0001) and MRI centrum semiovale perivascular spaces (PVS, OR: 2.05; 95%CI: 1.26-3.33; p=0.004) but not basal ganglia PVS or leukoaraiosis volume. A secondary analysis using Cox regression showed that cSS multifocality was an independent risk factor for recurrent ICH (HR: 2.21; 95%CI: 1.09-4.52 and 3.91; 95%CI: 1.40-10.9 for multifocality presence and severity) after adjusting for other confounders. Conclusion: Extent and multifocality of cSS appear to be markers of CAA severity and independent predictors of ICH recurrence, and can provide insights potential into pathomechanisms.

Abstract TMP113: Long-term Cognitive Decline After Intracerebral Hemorrhage

Introduction: Cerebral small vessel disease (CSVD) is the leading cause of Vascular Cognitive Impairment (VCI). Although Intracerebral Hemorrhage (ICH) is the most severe manifestation of CSVD, VCI among ICH survivors has been the subject of limited investigations. Hypothesis: We sought to test these hypotheses: 1) long-term cognitive decline rates are substantial even among initially non-demented ICH survivors; 2) underlying CSVD plays a substantial role in determining post-ICH long-term cognitive decline. Methods: We enrolled survivors of primary ICH, with no evidence of dementia 6 months post-hemorrhage, in a single-center longitudinal observational study. Presence and severity of CSVD was assessed at enrollment using two established markers of CSVD on CT (CT-defined white hatter hypodensity [CT-WMH]) and MRI (cerebral microbleeds [CMBs]). We captured blood pressure measurements during follow-up via review of medical records. Cognitive performance was assessed using the Modified Telephone Interview for Cognitive Status (TICS-m), a standardized validated telephone-based cognitive battery. We constructed multivariate models of cognitive decline rate, defined as slope of TICS-m scores over time. Results: A total of 275 ICH survivors qualified for inclusion in our analyses; of these 83 (30%) developed incident dementia and 33 (12%) developed incident Mild Cognitive Impairment (MCI) at 5 years (Figure). CSVD imaging markers were associated with cognitive decline rate (CT-WMH: p=0.001, CMBs: p=0.003), as were pulse pressure (p=0.003) and systolic blood pressure variation coefficient (p=0.034). Conclusions: Long-term cognitive decline is frequent and substantial among ICH survivors not demented at time of ICH, and strongly associates with severity of underlying CSVD. Our findings suggest that it is the extent of CSVD and not particular ICH characteristics that are most associated with long-term cognitive decline in survivors of ICH.

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

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

Abstract WP372: Preeclampsia and Intracerebral Hemorrhage Risk in Later Life

Background: Preeclampsia is an under recognized risk factor for vascular disease. Women with preeclampsia are at higher risk for ischemic cardiovascular and cerebrovascular events later in life. It is currently unknown if this risk also applies to hemorrhagic stroke. We here investigate the risk of non-pregnancy related intracerebral hemorrhage (ICH) in women with a history of preeclampsia. Our hypothesis was that a history of preeclampsia confers an increased risk of ICH in later life. Method: ERICH is a multi-center, prospective, case-control study of a racial-ethnically mixed population with ICH. Controls were identified through random digit dialing to match cases by age (+/- 5 years), sex, race/ethnicity (non-Hispanic white, non-Hispanic black and Hispanic) and geographic area. An obstetric history was obtained in all women with ICH and their controls. Pre-eclampsia was defined as: 1) Having been told to have had toxemia, pre-eclampsia or eclampsia or 2) having had high blood pressure and protein in the urine during any pregnancy. Odds ratios (OR) for preeclampsia were calculated in cases and controls. We also compared baseline demographics and ICH characteristics of women with and without a history of preeclampsia. Results: A total of 685 cases were matched to controls. Mean age was 65 years and hypertension was more prevalent in cases (76% vs. 47%, p &lt;.0001). A history of preeclampsia was noted in 6% of controls and 7% of cases with an OR of 1.20 (0.77-1.88, p=0.425). In a case-case comparison, women with ICH and a history or preeclampsia were more likely to be younger (55±14 vs. 66±14 years, p&lt;.0001) and hypertensive (93% vs. 83%, p=.0387). After adjusting for other baseline differences women with ICH and preeclampsia history remained significantly younger than those with no history of preeclampsia. Conclusion: Despite associations of pre-eclampsia with ischemic cardiovascular and cerebrovascular events later in life, we found no association of an increased risk of spontaneous ICH. Women with ICH and a history of pre-eclampsia, however, were more likely to have an ICH at a younger age, by nearly a decade, after controlling for all other variables. Women with preeclampsia may be a suitable target for interventions to prevent early life ICH.

Prior Cannabis Use Is Associated with Outcome after Intracerebral Hemorrhage

Objective: Recent evidence suggests that a potential harmful relationship exists between cannabis use and ischemic stroke. The purpose of this study was to determine the implications of cannabis use in intracerebral hemorrhage (ICH) patients. Methods: An analysis of an international, multicenter, observational database of consecutive patients with spontaneous ICH was conducted. We extracted the following characteristics on presentation: demographics, risk factors, antiplatelet or anticoagulant use, Glasgow Coma Scale, ICH score, neuroimaging parameters, and urine toxicology screen (UTS) results. Modified Rankin Scale (mRS) score was utilized for determination of outcome at discharge. Adjusted logistic ordinal regression was used as shift analysis to assess the impact of cannabis use on mRS score at discharge. The adjusted common OR measured the likelihood that cannabis use would lead to lower mRS scores. Results: Within a cohort of 725 spontaneous ICH patients, UTS was positive for cannabinoids in 8.6%. Cannabinoids-positive (CB⁺) patients were more frequently Caucasian (p < 0.001), younger (p < 0.001), and had lower median ICH scores on admission (p = 0.017) than those who were cannabinoids-negative. CB⁺ patients also showed a shift toward better outcome in the distribution of mRS categories, with an adjusted common OR of 0.544 (95% CI 0.330-0.895, p = 0.017). Conclusion: In this multinational cohort, cannabis use was discovered in nearly 10% of patients with spontaneous ICH. Although there was no relationship between cannabis use and specific ICH characteristics, CB⁺ patients had milder ICH presentation and less disability at discharge.

Abstract W P326: Comparison of Spontaneous Intracerebral Hemorrhage Outcomes in Patients with Warfarin and Antiplatelet Medication Use

Background: Use of antiplatelet medications and warfarin has been associated with poor clinical outcomes in spontaneous intracerebral hemorrhage (ICH). However, a head to head comparison between these groups has not been performed. We compared ICH outcomes among patients on these medications. Methods: In this cohort study, we analyzed 987 patients with ICH from the Virtual International Stroke Trials Archive. Patients with ICH presented within six-hours of symptom onset had baseline clinical, radiological data, and computed tomographic scan at 72 hours. Hematoma expansion was defined as interval increase in size by &gt;33%. Main outcome variables were 90-day mortality, and modified Rankin Score (mRS) at 90 days dichotomized into 0-3 vs 4-6. Results: Of 987 ICH patients 154 had prior antiplatelet use, 30 had warfarin, and 803 had neither of the two medications. The warfarin group had significantly higher age (p&lt;0.001) and higher prevalence of atrial fibrillation (p&lt;0.001). Of the ICH characteristics, comparing warfarin, antiplatelet and no warfarin/antiplatelet cohorts, the warfarin group had lower Glasgow coma scale (GCS) scores (p=0.049), higher intraventricular hemorrhage (IVH) rate (p=0.010), and more hydrocephalus (p&lt;0.001). Hematoma expansion at 72 hours was significantly higher with warfarin use (p=0.003), while the ratio of perihematomal edema volume to hematoma volume at 72 hours was lowest with warfarin use (p&lt;0.001). In the logistic regression model adjusted for age, sex, race, hematoma volume, perihematomal edema, GCS, IVH and hydrocephalus; warfarin patients had significantly lower odds of achieving mRS 0-3 (OR: 0.23, 95% CI: 0.06-0.83, p=0.025), while the antiplatelet group had similar functional outcomes compared to no warfarin/antiplatelet use (OR: 0.75, 95% CI: 0.46-1.23, p=0.260). The 90-day mortality outcomes were not significantly different across the three groups (18.7% to 40.3%, p=0.520). Conclusion: Warfarin use is associated with a higher incidence of hydrocephalus, intraventricular hemorrhage and hematoma expansion, but lesser perihematomal edema relative to the hematoma volume. Warfarin associated ICH appears to be independently associated with worse functional outcomes but not with 90-day mortality in ICH.

Clinical characteristics and outcome of intracerebral hemorrhage in young adults.

Data on determinants of prognosis after intracerebral hemorrhage (ICH) in young adults are scarce. Our aim was to identify clinical determinants of prognosis after ICH in adults aged 18-50. We investigated 98 consecutive patients with an ICH, aged 18-50 years, admitted to our hospital between 1980 and 2010. Collected ICH characteristics included presenting symptoms, etiology, location, severity and Glasgow Coma Scale (GCS). Outcomes were case-fatality (death within 30 days), poor functional outcome (modified Rankin Scale >2), long-term mortality and recurrent ICH. We assessed discriminatory power of factors associated with case-fatality [area under receiver operating curve (AUC)]. Case-fatality was 20.4 % (n = 20) and well predicted by the GCS (AUC 0.83). Among 30-day survivors, a poor functional outcome at discharge was present in 51.3 %. During a mean follow-up of 11.3 years mortality was only increased in patients aged 40-50 years [standardized mortality ratio 4.8 (95 % CI 2.3-8.6)], but not in patients aged 18-40 years. Recurrent ICH occurred in 6 patients [10-year cumulative incidence 12.2 % (95 % CI 1.5-22.9 %)], all with the index ICH attributable to structural vascular malformations. Prognosis after ICH in young adults is poor, mainly due to high case-fatality, that is well predicted by the GCS. An exception is 30-day survivors <40 years, who have a similar risk of dying as the general population. Recurrence risk is especially present in patients with structural vascular malformations, whereas risk seems to be very low in other patients.

Low-Density Lipoprotein and Intracerebral Hematoma Expansion in Daily Alcohol Users

Background: Epidemiological studies suggest that the intracerebral hemorrhage (ICH) rate correlates with alcohol consumption. Alcohol leads to elevated blood pressure (BP) and inhibition of platelet aggregation. These factors could promote excessive bleeding. To our knowledge, in the setting of normal liver function tests, there are no studies that have systematically evaluated the relationship between daily alcohol use and hematoma expansion. The aim of this study is to compare the baseline ICH characteristics, frequency of hematoma expansion, and outcomes in patients with ICH who are daily alcohol users with those who are not daily alcohol users. Methods: A retrospective chart review was performed on consecutive patients who presented from July 2008 to July 2013 to the Tulane University Hospital in New Orleans, La., USA, with a spontaneous ICH. Ninety-nine patients who met these criteria were admitted. Patients who underwent hematoma evacuation were excluded. Hemorrhage volumes were calculated based on the ABC/2 method. Low-density lipoprotein (LDL) was dichotomized into low (<100 mg/dl) and high (≥100 mg/dl) values. Comparisons were made using t tests, χ² and nonparametric equivalents where appropriate. ICH growth in 24 h and LDL were evaluated using linear regression. Results: Of the 226 patients who met inclusion criteria, 20.4% had a history of daily alcohol use. The average age was 61 years (range 19-94), 55.6% of the patients were males, and 67.1% were of African American origin. Daily alcohol use was associated with male gender, lower rate of home antihypertensive, higher presenting BP, and lower platelet counts, but there was no difference in ICH characteristics, ICH growth, or clinical outcome. Daily alcohol use in patients with a low LDL level was associated with supratentorial location and trends for lower baseline Glasgow Coma Scale score, higher ICH score, and follow-up ICH volume, but no significant difference in significant hematoma expansion or clinical outcome except for a trend for higher mortality was found (25 vs. 9.5%, p = 0.1311) compared to patients with high LDL values. Conclusions: Our data suggest that neither chronic daily alcohol use nor a low LDL level in combination with daily alcohol use can be used to predict ICH growth. Daily alcohol use was associated with untreated hypertension and higher BP on presentation. A low LDL level in combination with daily alcohol use may be linked with larger and more severe ICH, but we were unable to demonstrate a relationship with hematoma expansion or poor clinical outcome. The role of LDL in vessel fragility and clot stabilization needs to be further explored before concluding that a low LDL level confers risk of bleeding.

Chronic Kidney Disease in Patients with Acute Intracerebral Hemorrhage: Association with Large Hematoma Volume and Poor Outcome

Background: Chronic kidney disease (CKD) is associated with both a risk of adverse vascular outcome and a risk of bleeding. We have tested the hypothesis that in the setting of an acute intracerebral hemorrhage (ICH), CKD is associated with poor outcome and with larger hematoma volume. Methods: We examined the association between CKD and ICH characteristics and outcome within a prospective cohort study of consecutive patients hospitalized with an acute stroke and followed for 1 year. CKD was categorized by the estimated baseline glomerular filtration rate into moderate/severe impairment (<45), mild impairment (45–60) and no impairment (>60 ml/min/1.73 m²). Results: Among 128 patients with an ICH (mean age = 71.7 ± 12.3 years, 41.4% women) 46.1% had CKD (23.4% mild and 22.7% moderate/severe). Patients with moderate/severe impairment had >4-fold adjusted hazard ratio for mortality over 1 year (4.29; 95% CI = 1.69–10.90) compared to patients with no impairment. The hematoma volumes [median (25–75%)] were 15.3 ml (5.4–37.5) in patients with no impairment, 16.6 (6.8–36.9) in mild impairment and 50.2 (10.4–109.1) in moderate/severe impairment (p = 0.009). The location of the hematoma was lobar in 12% with no impairment, 17% with mild impairment and 39% with moderate/severe impairment (p = 0.02). Patients with moderate/severe impairment exhibited a 2.3-fold higher hematoma volume (p = 0.04) and a >6-fold higher odds of lobar location (95% CI = 1.59–24.02) as compared to no impairment. Further adjustment for antiplatelet use and for presence of leukoaraiosis attenuated the association with hematoma volume (p = 0.15), while moderate/severe impairment was associated with an adjusted OR of 5.35 (95% CI = 1.18–24.14) for lobar location. Conclusions: Presence of moderate/severe CKD among patients with ICH is associated with larger, lobar hematomas and with poor outcome.

Leukoaraiosis Predicts Poor Outcome after Spontaneous Supratentorial Intracerebral Hemorrhage

Background and Aims: Leukoaraiosis (LA) is associated with aging and vascular risk factors, and is a risk factor of intracerebral hemorrhage (ICH) after treatment with warfarin or thrombolytic treatment for ischemic stroke. In this study, we sought to examine whether LA is a predictor of outcome after spontaneous ICH. Methods: We retrospectively analyzed 238 consecutive patients with spontaneous supratentorial ICH identified by a database search. Patients were divided into two groups according to neurological outcome at 90 days: patients with good outcomes (Glasgow Outcome Scale ≧4) and patients with poor outcomes. Demographic features, ICH characteristics, and LA severity as assessed by van Swieten score on brain CT were compared between the two groups. Results: Overall, 105 (44.1%) of the patients analyzed had poor outcomes. In univariate analysis, LA severity, ICH volume on initial brain CT, initial Glasgow Coma Scale (GCS), presence of intraventricular hemorrhage (IVH), old age, surgical treatment, and higher admission serum glucose level were associated with poor outcome. Multiple logistic regression analysis showed that severity of LA, initial GCS score, hematoma volume, presence of IVH, and surgical treatment were independent predictors of poor outcome. Conclusion: LA is an independent predictor of poor neurological outcome in patients with spontaneous supratentorial ICH.

Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage.

To determine whether mortality rate after intracerebral hemorrhage (ICH) is lower in patients admitted to a neurologic or neurosurgical (neuro) intensive care unit (ICU) compared to those admitted to general ICUs. The utility of specialty ICUs is debated. From a cost perspective, having fewer larger ICUs is preferred. Alternatively, the impact of specialty ICUs on patient outcome is unknown. Patients with ICH are admitted routinely to both general and neuro ICUs and provide an opportunity to address this question. Forty-two neuro, medical, surgical, and medical-surgical ICUs. The study was an analysis of data prospectively collected by Project Impact over 3 yrs from 42 participating ICUs (including one neuro ICU) across the country. The records of 36,986 patients were merged with records of 3,298 patients from a second neuro ICU that collected the same data over the same period. The impact of clinical (age, race, gender, Glasgow Coma Scale score, reason for admission, insurance), ICU (size, number of ICH patients, full-time intensivist, clinical service, American College for Graduate Medical Education or Critical Care Medicine fellowship), and institutional (size, location, medical school affiliation) characteristics on hospital mortality rate of ICH patients was assessed by using a forward-enter multivariate analysis. Data from 1,038 patients were included. The 13 ICUs that admitted >20 patients accounted for 83% of the admissions with a mortality rate that ranged from 25% to 64%. Multivariate analysis adjusted for patient demographics, severity of ICH, and ICU and institutional characteristics indicated that not being in a neuro ICU was associated with an increase in hospital mortality rate (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.65-7.6). Other factors associated with higher mortality rate were greater age (OR, 1.03/year; 95% CI, 1.01-1.04), lower Glasgow Coma Scale score (OR, 0.6/point; 95% CI, 0.58-0.65), fewer ICH patients (OR, 1.01/patient; 95% CI, 1.00-1.01), and smaller ICU (OR, 1.1/bed; 95% CI, 1.02-1.13). Having a full time intensivist was associated with lower mortality rate (OR, 0.388; 95% CI, 0.22-0.67). For patients with acute ICH, admission to a neuro vs. general ICU is associated with reduced mortality rate.