Etiology Of Intracerebral Hemorrhage Research Articles

Neuro-imaging in intracerebral hemorrhage: updates and knowledge gaps.

Intracerebral hemorrhage (ICH) is characterized by hematoma development within the brain's parenchyma, contributing significantly to the burden of stroke. While non-contrast head computed tomography (CT) remains the gold standard for initial diagnosis, this review underscores the pivotal role of magnetic resonance imaging (MRI) in ICH management. Beyond diagnosis, MRI offers invaluable insights into ICH etiology, prognosis, and treatment. Utilizing echo-planar gradient-echo or susceptibility-weighted sequences, MRI demonstrates exceptional sensitivity and specificity in identifying ICH, aiding in differentiation of primary and secondary causes. Moreover, MRI facilitates assessment of hemorrhage age, recognition of secondary lesions, and evaluation of perihematomal edema progression, thus guiding tailored therapeutic strategies. This comprehensive review discusses the multifaceted utility of MRI in ICH management, highlighting its indispensable role in enhancing diagnostic accuracy as well as aiding in prognostication. As MRI continues to evolve as a cornerstone of ICH assessment, future research should explore its nuanced applications in personalized care paradigms.

Association of LDL-cholesterol

Recent intensive low-density lipoprotein cholesterol (LDL-C) lowering trials, including FOURIER, ODYSSEY OUTCOMES, and Treat Stroke to Target (TST) trials, have mostly refuted the concern surrounding statin use, LDL-C lowering, and intracerebral hemorrhage (ICH) risk. However, the results from these trials may not be fully applied to ICH survivors, as the populations studied were mainly patients without prior ICH, in whom the inherent ICH risk is more than 10 times lower than that of ICH survivors. Although available literature on statin use after ICH has demonstrated no excess risk of recurrent ICH, other potential factors that may modify ICH risk, especially hypertension control and ICH etiology, have not generally been considered. Notably, data on LDL-C levels following ICH are lacking. We aim to investigate the association between LDL-C levels and statin use with ICH risk among ICH survivors, and to determine whether the risk differed with patients' characteristics, especially ICH etiology. Follow-up data of consecutive spontaneous ICH survivors enrolled in the University of Hong Kong prospective stroke registry from 2011 to 2019 were retrospectively analyzed. ICH etiology was classified as cerebral amyloid angiopathy (CAA) using the modified Boston criteria or hypertensive arteriopathy, while the mean follow-up LDL-C value was categorized as <1.8 or ⩾1.8 mmol/L. The primary endpoint was recurrent ICH. The association of LDL-C level and statin use with recurrent ICH was determined using multivariable Cox regression. Pre-specified subgroup analyses were performed, including based on ICH etiology and statin prescription. Follow-up blood pressure was included in all the regression models. In 502 ICH survivors (mean age = 64.2 ± 13.5 years, mean follow-up LDL-C = 2.2 ± 0.6 mmol/L, 28% with LDL-C <1.8 mmol/L), 44 had ICH recurrence during a mean follow-up of 5.9 ± 2.8 years. Statin use after ICH was not associated with recurrent ICH (adjusted hazard ratio (AHR) = 1.07, 95% confidence interval (CI) = 0.57-2.00). The risk of ICH recurrence was increased for follow-up LDL-C <1.8 mmol/L (AHR = 1.99, 95% CI = 1.06-3.73). This association was predominantly observed in ICH attributable to CAA (AHR = 2.52, 95% CI = 1.06-5.99) and non-statin users (AHR = 2.91, 95% CI = 1.08-7.86). The association between post-ICH LDL-C <1.8 mmol/L and recurrent ICH was predominantly observed in CAA patients and those with intrinsically low LDL-C (non-statin users). While statins can be safely prescribed in ICH survivors, LDL-C targets should be individualized and caution must be exercised in CAA patients.

Risk factors for intracerebral hemorrhage in small-vessel disease and non-small-vessel disease etiologies-an observational proof-of-concept study.

Sporadic cerebral small-vessel disease (CSVD), i.e., hypertensive arteriopathy (HA) and cerebral amyloid angiopathy (CAA), is the main cause of spontaneous intracerebral hemorrhage (ICH). Nevertheless, a substantial portion of ICH cases arises from non-CSVD etiologies, such as trauma, vascular malformations, and brain tumors. While studies compared HA- and CAA-related ICH, non-CSVD etiologies were excluded from these comparisons and are consequently underexamined with regard to additional factors contributing to increased bleeding risk beyond their main pathology. As a proof of concept, we conducted a retrospective observational study in 922 patients to compare HA, CAA, and non-CSVD-related ICH with regard to factors that are known to contribute to spontaneous ICH onset. Medical records (available for n = 861) were screened for demographics, antithrombotic medication, and vascular risk profile, and CSVD pathology was rated on magnetic resonance imaging (MRI) in a subgroup of 185 patients. The severity of CSVD was assessed with a sum score ranging from 0 to 6, where a score of ≥2 was defined as advanced pathology. In 922 patients with ICH (median age of 71 years), HA and CAA caused the majority of cases (n = 670, 73%); non-CSVD etiologies made up the remaining quarter (n = 252, 27%). Individuals with HA- and CAA-related ICH exhibited a higher prevalence of predisposing factors than those with non-CSVD etiologies. This includes advanced age (median age: 71 vs. 75 vs. 63 years, p < 0.001), antithrombotic medication usage (33 vs. 37 vs. 19%, p < 0.001), prevalence of vascular risk factors (70 vs. 67 vs. 50%, p < 0.001), and advanced CSVD pathology on MRI (80 vs. 89 vs. 51%, p > 0.001). However, in particular, half of non-CSVD ICH patients were either aged over 60 years, presented with vascular risk factors, or had advanced CSVD on MRI. Risk factors for spontaneous ICH are less common in non-CSVD ICH etiologies than in HA- and CAA-related ICH, but are still frequent. Future studies should incorporate these factors, in addition to the main pathology, to stratify an individual's risk of bleeding.

The Hemorrhagic Side of Primary Angiitis of the Central Nervous System (PACNS).

Primary Angiitis of the Central Nervous System (PACNS) is a rare cerebrovascular disease involving the arteries of the leptomeninges, brain and spinal cord. Its diagnosis can be challenging, and the current diagnostic criteria show several limitations. Among the clinical and neuroimaging manifestations of PACNS, intracranial bleeding, particularly intracerebral hemorrhage (ICH), is poorly described in the available literature, and it is considered infrequent. This review aims to summarize the available data addressing this issue with a dedicated focus on the clinical, neuroradiological and neuropathological perspectives. Moreover, the limitations of the actual data and the unanswered questions about hemorrhagic PACNS are addressed from a double point of view (PACNS subtyping and ICH etiology). Fewer than 20% of patients diagnosed as PACNS had an ICH during the course of the disease, and in cases where ICH was reported, it usually did not occur at presentation. As trigger factors, both sympathomimetic drugs and illicit drugs have been proposed, under the hypothesis of an inflammatory response due to vasoconstriction in the distal cerebral arteries. Most neuroradiological descriptions documented a lobar location, and both the large-vessel PACNS (LV-PACNS) and small-vessel PACNS (SV-PACNS) subtypes might be the underlying associated phenotypes. Surprisingly, amyloid beta deposition was not associated with ICH when histopathology was available. Moreover, PACNS is not explicitly included in the etiological classification of spontaneous ICH. This issue has received little attention in the past, and it could be addressed in future prospective studies.

Abstract TP153: Etiology and Radiological Features of Pregnancy-Associated and Non-Pregnancy Associated Intracerebral Hemorrhage in Young Adults

Introduction: Intracerebral hemorrhage (ICH) is a major cause of maternal mortality, but its pathophysiology is not well characterized. We investigated characteristics of pregnancy-associated ICH (PICH), compared with ICH in non-pregnant young adults of both sexes. Methods: We performed a cross-sectional analysis of 134 adults aged 18-44 years admitted with non-traumatic ICH from 1/01/2012 - 12/31/2021. Participants were identified from an internal stroke registry and through the ICHOP (Intracerebral Hemorrhage Outcomes Project) study. We compared ICH etiology between three exposure groups: PICH (ICH occurring in pregnancy or within 3 months postpartum), NPICH in females, and NPICH in males. We categorized ICH etiology as primary (hypertension, amyloid angiopathy, or unknown by SMASH-U criteria) vs secondary (structural, medication, or systemic disease-related). We calculated odds ratios (OR) and 95% confidence intervals (95%CI) for the association of exposure group status with primary vs. secondary ICH, using non-pregnant females as the reference group. Results: Of 134 young adults with non-traumatic ICH, 25 (19%) were pregnant or postpartum. More than half of PICH were in lobar locations (Table) and 40% had unknown etiology (Figure). Adjusting for age, chronic hypertension, and ICH location, pregnant/postpartum patients had highest odds of primary (vs. secondary) ICH (adjusted OR 4.9, 95% CI 1.5-15.9 compared with female NPICH reference group). Conclusion: Almost 1 in 5 young adults with ICH were pregnant or postpartum. PICH differed in location and underlying etiology compared with ICH in non-pregnant young adults, suggesting unique pathophysiology

Abstract WMP77: In-Hospital Mortality Sex Differences in Young Adults With Intracerebral Hemorrhage

Introduction: Intracerebral hemorrhage (ICH) accounts for 10-20% of strokes and is associated with severe disability and high mortality. While males are reported to have worse outcomes in older patients with ICH, data are limited regarding sex differences in mortality risk after ICH for younger patients. Methods: We conducted a cross-sectional study of 134 adults aged 18-44 admitted to our academic medical center with ICH from 01/01/2012-12/31/2021, using data from an internal stroke registry and the Intracerebral Hemorrhage Outcomes Project (ICHOP). All vascular and non-vascular causes were included other than trauma. We used logistic regression models to calculate odds ratios (OR) and 95% confidence intervals (CI) for the association between sex and in-hospital mortality, adjusting for comorbidities and presence of multicompartmental hemorrhage (including intraventricular extension). Results: Characteristics of the study sample are summarized in the Table. Males had higher proportion of chronic hypertension and subcortical ICH location. Adjusting for hypertension, ICH location, multicompartmental extension, and use of antiplatelet medication, males had higher odds of death (OR 4.0, 95% CI 1.1-15.4) than females. Functional outcomes at discharge are shown in the Figure. Conclusion: In our cohort of young adults with ICH, males had 4-fold higher odds of in-hospital death than females. Future research should investigate the social and biological mechanisms that may underlie sex differences in mortality for young adults with ICH, including differences in ICH etiology, and potentially differential withdrawal of life sustaining treatment.

Abstract TP157: Utility of CT Angiography in Patients With Intracerebral Hemorrhage

Introduction: Patients with intracerebral hemorrhage (ICH) often undergo CT and CT angiography with the latter being done to identify vascular abnormalities for ICH etiology. It is unclear whether CTA yields are high enough to warrant routine use particularly for subcortical ICH, however. Methods: Retrospective chart review was done on the Loyola Stroke Database of ICH patients over the last 10 years. Data from CT, CTA (and other imaging modalities) regarding ICH size and location, as well as vascular abnormalities, were collected. Demographics, comorbidities, and clinical outcomes were also recorded. Frequencies and percentages are reported to describe overall sample and bivariate associations. Univariate logistic regression estimated unadjusted effects of ICH type, age, hypertension (HTN), and other predictors on the logit of vascular abnormalities. Chi square values are reported for overall interaction effects. Stratified odds ratios (OR) are reported with 95% confidence intervals and p-values. Multivariable binary logistic regression estimated adjusted effects of ICH type on the logit of vascular abnormalities, after adjusting for covariates; OR are reported for adjusted effects. Results: Of 744 ICH cases analyzed, 376 were subcortical (50.54%) and 368 cortical (49.46%). Eighty-one had vascular abnormalities (10.89%); 46 of those being lesion-related (6.18%). Unadjusted odds of lesion-related vascular abnormalities were higher for cortical versus subcortical ICH (OR: 7.04; 95% CI: 3.09, 16.04; p &lt; 0.01). Two-way interaction was non-significant for effects of ICH type and age (p = 0.76), ICH type and HTN (p = 0.68), age and hypertension (p = 0.09), and ICH type and ICH size (p = 0.93) on the logit of lesion-related vascular abnormalities. Thus, these effects did not co-vary significantly with respect to lesion-related vascular abnormalities. Odds of lesion-related vascular abnormalities are significantly higher for cortical versus subcortical ICH, after adjusting for age, HTN ICH size, and CTA (OR: 6.91; 95% CI: 2.93, 16.30; p &lt; 0.01). Conclusion: Our analysis suggests there is decreased utility for CTA in subcortical compared to cortical ICH and CTA should probably not be performed routinely on subcortical ICH.

Intracerebral hemorrhage in young adults: Analysis of etiology, clinical characteristics and discharge outcome

Objective: This study evaluated the etiology, clinical characteristics and discharge outcomes of intracerebral hemorrhage (ICH) without trauma in young adults admitted to a comprehensive stroke center. Subject and method: This was a retrospective study of patients aged under 46 years with nontraumatic ICH admitted from October 2022 to April 2023. Data was collected on demographics, clinical history, hemorrhage location, possible etiology, and discharge outcome. Categorical data was reported as percentage. Chi-squared test was performed to evaluate association of location of ICH, etiology of ICH with the discharge outcome. Result: Forty-five patients met the study criteria, with mean age 35.6 ± 8.1 years including 16 (35.6%) female, 29 (64.4%) male. Headache (86.7%) and hemiparalysis (77.8%) were the most common symptoms. Hematoma was most commonly seen in the deep structures in 21 (46.6%) patients followed by lobar ICH in 17 (37.8%) patients. The most common etiology of ICH was hypertension, which seen in 23 (51.1%) patients, followed by vascular abnormalities in 13 (28.8%) patients. Twenty-two patients (48.9%) had good outcome defined as mRS 0-2. Twenty-three patients (51.1%) had poor outcome with mRS 3-6 at discharge. Location and etiology of hemorrhage were not associated with discharge outcome. Conclusion: Hypertension, a modifiable risk factor, is a major cause of nontraumatic ICH in young adults. In primary care settings, hypertension and life styles were important modifiable risk factors for all subtypes of strokes. Considering that hypertension is an independent risk factor for morbidity and mortality in patients with ICH, this comorbidity should be managed aggressively in young patients as part of a primary prevention strategy related to ICH.

The association between hypertensive angiopathy and cerebral amyloid angiopathy in primary intracerebral hemorrhage

ObjectiveTo determine the association between the burden of cerebral small vessel disease (CSVD) due to hypertensive angiopathy (HA) and cerebral amyloid angiopathy (CAA) on MRI in patients with primary intracerebral hemorrhage (ICH).MethodsPatients with primary ICH admitted to our center from March 2012 to November 2021 were consecutively enrolled. We used multivariate binary and ordinal regression analyses to assess the association between HA-CSVD burden and CAA-CSVD burden. Lobar cerebral microbleeds (CMBs) were categorized into three level of severity: 0–1, 2–4, and ≥ 5 lobar CMBs. A high CAA-CSVD score was defined as a CAA-CSVD score of ≥3.ResultsOverall, 222 participants (mean age 59.88 ± 13.56) were included into analysis. Age and ICH etiology differed among different lobar CMB severity and between the presence and absence of high CAA-CSVD score (all p &amp;lt; 0.05). Positive associations between HA-related markers and both lobar CMB severity and high CAA-CSVD score (p &amp;lt; 0.05 for the presence of lacune, deep CMBs ≥5, the presence of WMH, and HA-CSVD score) were observed in univariate analysis. These associations remained significant after adjusting for age, sex, ICH etiology, and potential vascular risk factors. The distribution of CAA-CSVD score was significantly different between patients with and without CMBs ≥5 (adjusted OR 2.351, 95% CI 1.242–4.455, p = 0.009) after correcting for age, sex, ICH etiology, and vascular risk factors.ConclusionOur study provides evidence of an association between HA-CSVD and CAA-CSVD in patients with primary ICH, which needs to be verified in future studies.

Etiology of intracerebral hemorrhage during pregnancy or puerperium: A nationwide study.

Intracerebral hemorrhage during pregnancy or puerperium (pICH) is one of the leading causes of maternal death worldwide. However, limited epidemiological data exist on the etiology and outcomes of pICH, which is required to guide prevention and treatment. A retrospective nationwide cohort study and a nested case-control study was performed in Finland 1987-2016. We identified women with incident pICH by linking the Medical Birth Register (MBR) and the Hospital Discharge Register (HDR). The clinical details were collected from patient records. Three matched controls with a pregnancy without ICH were selected for each case from the MBR. In total, 49 pICH cases were identified. Half of these cases occurred during pregnancy, and the other half during peripartum and puerperium. Based on the SMASH-U (structural vascular lesion, medication, amyloid angiopathy, systemic disease, hypertension, undetermined) classification, 35.4% of the patients had a systemic disease, most commonly preeclampsia, eclampsia, or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome; 31.3% had a structural vascular lesion; 31.3% had an undetermined etiology; and one patient (2.1%) had hypertension. The most important risk factor was hypertensive disorders of pregnancy (HDP; odds ratio = 3.83, 95% confidence interval = 1.60-9.15), occurring in 31% of the cases. Maternal mortality was 12.5%, and 20.9% of the surviving women had significant disability (modified Rankin Scale = 3-5) 3 months after the pICH. Women with systemic disease had the worst outcomes. Even in a country with a comprehensive pregnancy surveillance system, the maternal mortality rate for pICH is high, and the sequelae are severe. Early recognition and treatment of the key risk factor, HDP, is crucial to help prevent this serious pregnancy complication.

Pathological Changes of Small Vessel Disease in Intracerebral Hemorrhage: a Systematic Review and Meta-analysis

In intracerebral hemorrhage (ICH) with pathology-proven etiology, we performed a systematic review and meta-analysis to elucidate the association between cerebral amyloid angiopathy (CAA) and arteriolosclerosis, and directly compared MRI and pathological changes of markers of cerebral small vessel disease (CSVD). Studies enrolling primary ICH who had received an etiological diagnosis through biopsy or autopsy were searched using Ovid MEDLINE, PubMed, and Web of Science from inception to June 8, 2022. We extracted pathological changes of CSVD for each patient whenever available. Patients were grouped into CAA + arteriolosclerosis, strict CAA, and strict arteriolosclerosis subgroups. Of 4155 studies identified, 28 studies with 456 ICH patients were included. The frequency of lobar ICH (p<0.001) and total microbleed number (p=0.015) differed among patients with CAA + arteriolosclerosis, strict CAA, and strict arteriolosclerosis. Concerning pathology, severe CAA was associated with arteriolosclerosis (OR 6.067, 95% CI 1.107–33.238, p=0.038), although this association was not statistically significant after adjusting for age and sex. Additionally, the total microbleed number (median 15 vs. 0, p=0.006) was higher in ICH patients with CAA evidence than those without CAA. The pathology of CSVD imaging markers was mostly investigated in CAA-ICH. There was inconsistency concerning CAA severity surrounding microbleeds. Small diffusion-weighted imaging lesions could be matched to acute microinfarct histopathologically. Studies that directly correlated MRI and pathology of lacunes, enlarged perivascular spaces, and atrophy were scarce. Arteriolosclerosis might be associated with severe CAA. The pathological changes of CSVD markers by ICH etiology are needed to be investigated further.

Abstract 160: Etiologies Of Intracerebral Hemorrhage In Patients With Atrial Fibrillation On Or Off Oral Anticoagulants: The Neuro-Afib Study

Background: Intracerebral hemorrhage (ICH) is the most feared complication of oral anticoagulants (OAC) used to prevent ischemic strokes (IS) in patients with atrial fibrillation (AF). As different ICH etiologic factors correspond to different ICH risks, we aimed to present the causes of ICH in AF patients who were or were not using OAC, based on data from a multicenter contemporary cohort. Methods: The Neuro-AFib study is a multicenter effort to elucidate the current causes and consequences of IS and ICH in AF patients. Detailed clinical, laboratory and multimodal imaging data were collected from consecutive patients with AF admitted to 15 US stroke centers with an IS or ICH between 1/2018-12/2019. Etiologic factors of AF patients who were admitted with ICH on OAC (OAC-ICH) and off OAC (nonOAC-ICH) will be compared. Results: A total of 868 patients presented with ICH and had a diagnosis of AF, either previously known (88%) or diagnosed during admission (12%). 571 patients (66%) were on OAC at the time of their ICH of whom 58% were on direct OAC (DOAC), 40% on warfarin and 2% on heparin. OAC-ICH patients were older than nonOAC-ICH (76.6±10 vs 74.4±13, p=0.006) while sex distribution was the same in both groups (43% female). CHA 2 DS 2 -VASC was higher in OAC-ICH (4.3±1.6 vs 3.9±1.9, p=0.001) but HAS-BLED score was the same in both groups (2.7±1.1). Cerebral amyloid angiopathy (CAA) was diagnosed in 42.5% of the ICH patients based on modified Boston criteria while hypertensive cerebral small vessel disease (HTN-cSVD) in 57.5%. HTN-cSVD was the more common ICH etiology among OAC-ICH (65%) compared to nonOAC-ICH (49%). Among OAC-ICHs, DOAC-related ICHs tended to be more commonly of hypertensive etiology when compared to warfarin-ICH (p=0.09). Conclusions: Our study is the first to report the etiologic mechanisms of ICH in AF patients on or off OAC. CAA is known to be a major cause of OAC-ICH with exceedingly high recurrence rates. Despite this fact, HTN-cSVD was more common among OAC-ICH (especially DOAC-ICH) patients, supporting the view that the presence/absence of HTN-cSVD risk markers such as deep microbleeds are as important as CAA-markers in determining the optimal stroke prevention method in AF patients (left atrial appendage closure vs lifelong OAC).

Abstract TP119: Relationships Of Female Sex With Intracerebral Hemorrhage Characteristics And Outcomes

Introduction: Biological sex is known to impact cerebrovascular disease characteristics and clinical outcomes. While in intracerebral hemorrhage (ICH) it is known that biological sex impacts ICH incidence, it is less clear whether biological sex impacts ICH outcomes. Hypothesis: Female sex will be associated with ICH characteristics and clinical outcomes. Methods: Spontaneous ICH patients enrolled into a prospective observational ICH cohort study between 2009-2020 were assessed. Patients with prior anticoagulant use and secondary etiologies of ICH were excluded from the analysis. Female sex was assessed as the primary exposure variable. Primary analyses assessed relationships of female sex with radiographic outcomes: ICH location, ICH volume, hematoma expansion (&gt;33% and/or &gt;6mL). Secondary analyses assessed relationships of female sex with clinical outcomes: poor discharge neurological outcome (modified Rankin 4-6), and poor discharge disposition (skilled nursing facility, hospice, or inpatient death). Separate multivariable regression models assessed these relationships after adjusting for relevant covariates. Results: Of 504 ICH patients analyzed, mean age was 67 (SD 14.9), 46% were female, and median baseline ICH volume was 14.6 mL (IQR 4.98-35.0). In primary analyses, female sex was not associated with ICH volume or hematoma expansion but was associated with lobar ICH location (adjusted OR 1.72, 95% CI: 1.09-2.70). In secondary analyses, female sex was not associated with poor discharge neurological outcomes (adjusted OR 1.40, 95% CI: 0.74-2.64) after adjusting for race, ICH severity, and ICH location. However, there was an association of female sex with poor discharge disposition (adjusted OR 1.91, 95% CI: 1.15-3.16) after adjusting for similar covariates. Conclusions: While there were no clear intergroup sex differences in ICH severity or neurological outcomes, female sex was associated with worse discharge disposition. Further work is required to clarify whether these disposition differences are due to disease specific complications, characteristics, or if there are other social disparities responsible for these outcome differences.

Abstract TP125: Relationships Of Female Sex With Viscoelastic Hemostatic Assay Coagulation Characteristics After Intracerebral Hemorrhage

Introduction: There are described differences in coagulation between females and males. Specifically, female sex is associated with greater platelet activation and stronger clotting characteristics. It is unclear whether there are relevant coagulation differences identifiable between female and male patients suffering from intracerebral hemorrhage (ICH). Hypothesis: Female sex will be associated with stronger clotting characteristics on whole blood viscoelastic hemostatic assay testing. Methods: Spontaneous ICH patients admitted and enrolled into a prospective observational ICH cohort study between 2009-2020 and who received baseline viscoelastic hemostatic assay testing (Rotational Thromboelastometry: ROTEM) were assessed. Patients with prior anticoagulant use, patients receiving hemorrhage control therapies prior to ROTEM, and secondary etiologies of ICH were excluded from the analysis. Female sex was assessed as the primary exposure variable. The following ROTEM clotting parameters were assessed as the outcome: Coagulation Time (CT) and Maximum Clot Firmness (MCF). We assessed relationships of female sex with these separate ROTEM parameters using multivariable linear regression analyses after adjusting for relevant covariates. Results: Of 57 ICH patients included for analyses, mean age was 65 (SD 14.1), 47% were female, and the median ICH volume was 20.6 mL (IQR 10.1-43.3). There were no baseline intergroup sex differences in demographics, age, or ICH characteristics. Female sex was associated with increased EXTEM MCF (ß 0.323, p&lt;0.05), signifying greater clotting strength, after adjusting for age, race, baseline hematoma volume, and ICH location. Female sex was not associated with other ROTEM parameters. Conclusions: We identified that female sex was associated with stronger clotting characteristics on ROTEM viscoelastic testing. Further work is required to clarify the clinical significance of these findings and their potential specific impacts on radiographic, complication, and clinical outcomes after ICH.

Etiology, 3-Month Functional Outcome and Recurrent Events in Non-Traumatic Intracerebral Hemorrhage.

Background and Purpose Knowledge about different etiologies of non-traumatic intracerebral hemorrhage (ICH) and their outcomes is scarce. Methods We assessed prevalence of pre-specified ICH etiologies and their association with outcomes in consecutive ICH patients enrolled in the prospective Swiss Stroke Registry (2014 to 2019). Results We included 2,650 patients (mean±standard deviation age 72±14 years, 46.5% female, median National Institutes of Health Stroke Scale 8 [interquartile range, 3 to 15]). Etiology was as follows: hypertension, 1,238 (46.7%); unknown, 566 (21.4%); antithrombotic therapy, 227 (8.6%); cerebral amyloid angiopathy (CAA), 217 (8.2%); macrovascular cause, 128 (4.8%); other determined etiology, 274 patients (10.3%). At 3 months, 880 patients (33.2%) were functionally independent and 664 had died (25.1%). ICH due to hypertension had a higher odds of functional independence (adjusted odds ratio [aOR], 1.33; 95% confidence interval [CI], 1.00 to 1.77; P=0.05) and lower mortality (aOR, 0.64; 95% CI, 0.47 to 0.86; P=0.003). ICH due to antithrombotic therapy had higher mortality (aOR, 1.62; 95% CI, 1.01 to 2.61; P=0.045). Within 3 months, 4.2% of patients had cerebrovascular events. The rate of ischemic stroke was higher than that of recurrent ICH in all etiologies but CAA and unknown etiology. CAA had high odds of recurrent ICH (aOR, 3.38; 95% CI, 1.48 to 7.69; P=0.004) while the odds was lower in ICH due to hypertension (aOR, 0.42; 95% CI, 0.19 to 0.93; P=0.031). Conclusions Although hypertension is the leading etiology of ICH, other etiologies are frequent. One-third of ICH patients are functionally independent at 3 months. Except for patients with presumed CAA, the risk of ischemic stroke within 3 months of ICH was higher than the risk of recurrent hemorrhage.

Ganglioglioma revealed by spontaneous intracerebral hematoma: A cohort study

BackgroundGangliogliomas are rare tumors of the central nervous system. Intracerebral hemorrhage (ICH) is a frequent pathological event, rarely related to intracranial tumor. Here we report a cohort of 14 gangliogliomas, 3 of which were revealed by ICH. We also performed a systematic review of the literature on gangliogliomas revealed by ICH. Patients and methodsWe retrospectively collected data for all gangliogliomas operated on in our department between January 2015 and December 2019: clinical history, radiological data and outcome, with a special focus on gangliogliomas revealed by spontaneous ICH. All cases had pathological validation. For the systematic review, relevant studies were identified by systematic search of the scientific literature in PubMed. ResultsFifteen patients underwent surgery for ganglioglioma during the study period. Six cases were revealed by seizures, 3 by headache, 1 by hydrocephaly and 1 by developmental disorder. Three patients (21%) had hemorrhagic presentation. All patients were male, aged 30 to 48 years, diagnosed with atypical ICH without vascular abnormality on cerebral angiogram. Conservative management was first decided. Diagnosis of ganglioglioma was made within 3 months for 2 patients and 9 years later for 1, after surgical removal and histological analysis. All hemorrhagic gangliogliomas were BRAF wild type. The systematic review of the literature identified 8 other cases of ganglioglioma revealed by ICH. ConclusionICH may be a mode of revelation of ganglioglioma, and ganglioglioma is a possible etiology of atypical ICH in young patients. Long-term imaging follow-up is mandatory in patients with unexplained ICH.

Comparing hematoma characteristics in primary intracerebral hemorrhage versus intracerebral hemorrhage caused by structural vascular lesions

Intracerebral hemorrhage (ICH) caused by structural vascular lesions is associated with better outcomes than primary ICH, but this relationship is poorly understood. We tested the hypothesis that ICH from a vascular lesion has more benign hematoma characteristics compared to primary ICH. We performed a retrospective study using data from our medical center. The SMASH-U criteria were used to adjudicate the etiology of ICH. The co-primary outcomes were admission parenchymal hematoma volume and hematoma expansion at 24 h. Linear and logistic regression analyses were performed to test associations. A total of 231 patients were included of whom 42 (18%) had a vascular lesion. Compared to primary ICH patients, those with structural vascular lesions were younger (49 vs. 68 years, p < 0.001), less likely to have hypertension (29% vs. 74%, p < 0.001), had lower mean admission systolic blood pressure (140 ± 23 vs. 164 ± 35, p < 0.001), less frequently had IVH (26% vs. 44%, p = 0.03), and had mostly lobar or infratentorial hemorrhages. The median admission hematoma volume was smaller with vascular lesions (5.9 vs. 9.7 mL, p = 0.01). In regression models, ICH from a vascular lesion was associated with smaller admission hematoma volume (beta, −0.67, 95% CI, −1.29 to −0.05, p = 0.03), but no association with hematoma expansion was detected when assessed as a continuous (OR, 0.93; 95% CI, −4.46 to 6.30, p = 0.73) or dichotomous exposure (OR, 1.86; 95% CI, 0.40 to 8.51, p = 0.42). In a single-center cohort, patients with ICH from vascular lesions had smaller hematoma volumes than patients with primary ICH.

Circle of Willis Morphology in Primary Intracerebral Hemorrhage

We aimed to study the distribution of Circle of Willis (CoW) morphology and its association with intracerebral hemorrhage (ICH) etiology and cerebral small vessel disease (CSVD) burden. Patients with primary ICH who had brain MRIs were consecutively enrolled between March 2012 and January 2021. CoW morphology, CSVD features and the combined CSVD burden (including global CSVD burden, total hypertensive arteriopathy [HA] burden, and total cerebral amyloid angiopathy [CAA] burden) were assessed. CoW morphology included poor CoW (defined as CoW score 0–2), incomplete CoW, and complete fetal-variant of the posterior communicating artery (CFPcoA). Among 296 patients enrolled, 215 were included in the analysis. There was no significant difference among HA-, CAA-, and mixed-ICH in each CoW morphology. Exploratory subgroup analyses suggested that poor CoW was associated with a greater incidence of HA-ICH and low incidence of mixed ICH in patients aged < 60 years, while mixed ICH occurred more frequently in patients with CFPcoA, especially in those without hypertension history (all p < 0.050). Additionally, incomplete CoW was correlated with a larger incidence of lacunes (adjusted OR [adOR] 2.114, 95% CI 1.062–4.207), microbleeds ≥ 5 (adOR 2.437, 95% CI 1.187–5.002), and therefore the combined CSVD burden (adOR 1.194, 95% CI 1.004–1.419 for global CSVD burden, adOR 1.343, 95% CI 1.056–1.707 for total CAA burden), independent of modifiable vascular risk factors, but not age and sex. The CoW might therefore have a potential impact on ICH etiology and is associated with a greater CSVD burden. Our findings are novel, and need to be verified in future studies.

Abstract TP99: Hemorrhagic Conversion Of Ischemic Stroke Is Associated With Hematoma Expansion

Objectives: Hemorrhagic conversion of ischemic stroke (HCIS) is a common complication of cerebral ischemia and is associated with worse stroke outcomes. Differentiation between HCIS and other causes of intracerebral hemorrhage (ICH) can be challenging in practice. We sought to determine whether imaging features of hematoma expansion (HE) can be used to discriminate HCIS from other etiologies of ICH. Materials and Methods: We performed a retrospective review of patients admitted to two large urban hospitals between 2015-2020 with non-traumatic ICH and at least two head CTs within the initial 24 hours and brain MRI prior to discharge to assist with etiology identification. ICH etiology was determined by expert consensus. HE was defined as ≥6 mL and/or ≥33% growth between the first and second scan. Clinical and imaging covariates were studied using univariable and multivariable regression to assess the relationship between cause of intracerebral hemorrhage and HE. We evaluated whether HE was associated with functional status on discharge. Results: 258 patients (median age 66 [51-76], 43% female) met our inclusion criteria including 37 (14%) with HCIS as the presumed cause of hemorrhage. Etiology for ICH was hypertensive in 29%, vascular in 27%, and cerebral amyloid angiopathy in 13%. HE occurred in 11/37 (30%) patients with HCIS, and in 33/221(15%) patients with other causes (p= 0.04). History of anticoagulation use was more frequent in patients with HCIS (24% vs 11%, p= 0.04), although there was no significant difference in admission INR or platelet count. There was no difference in age, admission systolic blood pressure, admission hematoma size or ICH score between groups. HCIS was significantly associated with HE (OR 2.4, CI 1.08-5.34, p=0.03) on univariable analysis. When controlling for hematoma size and anticoagulant use, the relationship between HCIS and HE remained significant (aOR 2.68, CI 1.17-6.13, p=0.02). Patients with HCIS had a higher modified Rankin scale on discharge when compared to those with ICH due to other causes ((mRS 5 [4-5.5] vs. mRS 4 [2-4], p&lt;0.001). Conclusion: HE within the first 24 hours is more common in HCIS than in other etiologies of ICH. Imaging signatures of HE may be contributory towards determining ICH etiology.

Magnetic resonance imaging-based scores of small vessel diseases: Associations with intracerebral haemorrhage location

IntroductionTotal small vessel disease (SVD) score and cerebral amyloid angiopathy (CAA) score are magnetic resonance imaging-based composite scores built to preferentially capture deep perforator arteriopathy-related and CAA-related SVD burden, respectively. Non-lobar intracerebral haemorrhage (ICH) is related to deep perforator arteriopathy, while lobar ICH can be associated with deep perforator arteriopathy or CAA; however, the associations between ICH location and these scores are not established. MethodsIn this post-hoc analysis from a prospective cohort study, we included 153 spontaneous non-cerebellar ICH patients. Wald test, univariable and multivariable logistic regression analysis were performed to investigate the association between each score (and individual score components) and ICH location. ResultsTotal SVD score was associated with non-lobar ICH location (Wald test: unadjusted, p = 0.017; adjusted, p = 0.003); however, no individual component of total SVD score was significantly associated with non-lobar ICH. CAA score was not significantly associated with lobar location (Wald test: unadjusted, p = 0.056; adjusted, p = 0.126); cortical superficial siderosis (OR 8.85 [95%CI 1.23–63.65], p = 0.030) and ≥ 2 strictly lobar microbleeds (OR 1.63 [95%CI 1.04–2.55], p = 0.035) were related with lobar ICH location, while white matter hyperintensities showed an inverse relation (OR 0.53 [95%CI 0.26–1.08; p = 0.081]). ConclusionsTotal SVD score was associated with non-lobar ICH location. The lack of significant association between CAA score and lobar ICH may in part be due to the mixed aetiology of lobar ICH, and to the inclusion of white matter hyperintensities, a non-specific marker of SVD type, in the CAA score.