Intracerebral Hemorrhage Survivors Research Articles

Outcome Trajectories after Intracerebral Hemorrhage.

Spontaneous intracerebral hemorrhage (ICH) is the most morbid of all stroke types with a high early mortality and significant early disability burden. Traditionally, outcome assessments after ICH have mirrored those of acute ischemic stroke, with 3 months post-ICH being considered a standard time point in most clinical trials, observational studies, and clinical practice. At this time point, the majority of ICH survivors remain with moderate to severe functional disability. However, emerging data suggest that recovery after ICH occurs over a more protracted course and requires longer periods of follow-up, with more than 40% of ICH survivors with initial severe disability improving to partial or complete functional independence over 1 year. Multiple other domains of recovery impact ICH survivors including cognition, mood, and health-related quality of life, all of which remain under studied in ICH. To further complicate the picture, the most important driver of mortality after ICH is early withdrawal of life-sustaining therapies, before initiation of treatment and evaluating effects of prolonged supportive care, influenced by early pessimistic prognostication based on baseline severity factors and prognostication biases. Thus, our understanding of the true natural history of ICH recovery remains limited. This review summarizes the existing literature on outcome trajectories in functional and nonfunctional domains, describes limitations in current prognostication practices, and highlights areas of uncertainty that warrant further research.

Evaluating Sleep Apnea Risk in Survivors of Intracerebral Hemorrhage in the REDUCE Cohort (P9-9.002)

Evaluating Sleep Apnea Risk in Survivors of Intracerebral Hemorrhage in the REDUCE Cohort (P9-9.002)

Cognitive Outcome after Acute Spontaneous Intracerebral Hemorrhage: Analysis of the iDEF Randomized Trial.

The impact of intracerebral hemorrhage (ICH) on cognition and the determinants of cognitive recovery early after ICH remain elusive. In this post hoc analysis of the intracerebral hemorrhage deferoxamine (iDEF) trial, we examined the trajectories of cognitive impairment and the determinants of early cognitive recovery after ICH. We examined baseline factors associated with a 90-day cognitive outcome and constructed generalized linear mixed models to examine the trajectory of cognitive function over time among iDEF participants. Cognition was measured by the Montreal Cognitive Assessment (MoCA) scores on days 7, 30, and 90. 291 were available for analysis under the trial's modified intention-to-treat definition (38% female, mean age 60.3 ± 12.0 years, median NIHSS 13, IQR 8-18). The median baseline ICH volume was 12.9 IQR (6.4-26.0) mL; 59 (20%) of the ICH cases were lobar, 120 (41%) had intraventricular extension. There was an overall significant increase in total MOCA score with time (p < 0.0001). Total MOCA score increased by an estimated 3.9 points (95% CI: 3.1, 4.7) between the day 7 and day 30 assessments and by an additional 2.9 points (95% CI: 2.2, 3.6) between the day 30 and day 90 assessments. Despite the overall improvement, 134 of 205 (65%) patients with an available 90-day MoCA score remained cognitively impaired with a score <26 on day 90. Older age, higher NIHSS score, baseline ICH volume, intraventricular hemorrhage, and perihematoma edema had an adjusted negative impact on cognitive recovery. Although ICH survivors exhibit significant improvement of cognitive status over the first 3 months, cognitive performance remains impaired in the majority of patients. Among factors independently associated with worse cognitive recovery, higher baseline ICH, intraventricular blood and perihematomal edema volumes, are potential therapeutic targets that merit further exploration.

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.

Rationale and Design of the Statin Use in Intracerebral Hemorrhage Patients (SATURN) Trial

Introduction: The benefits and risks of HMG-CoA reductase inhibitor (statin) drugs in survivors of intracerebral hemorrhage (ICH) are unclear. Observational studies suggest an association between statin use and increased risk of lobar ICH, particularly in patients with apolipoprotein-E (APOE) ε2 and ε4 genotypes. There are no randomized controlled trials addressing the effects of statins after ICH leading to uncertainty as to whether statins should be used in patients with lobar ICH who are at high risk for ICH recurrence. The SATURN trial aims to evaluate the effects of continuation versus discontinuation of statin on the risk of ICH recurrence and ischemic major adverse cerebro-cardio-vascular events (MACCEs) in patients with lobar ICH. Secondary aims include the assessment of whether the APOE genotype modifies the effects of statins on ICH recurrence, functional and cognitive outcomes, and quality of life. Methods: The SATURN trial is a multi-center, pragmatic, prospective, randomized, open-label, phase III clinical trial with blinded end-point assessment. A planned total of 1,456 patients with lobar ICH will be recruited from 140 sites in the USA, Canada, and Spain. Patients presenting within 7 days of a spontaneous lobar ICH that occurred while taking a statin will be randomized (1:1) to continuation (control) versus discontinuation (intervention) of the same statin drug and dose that they were using at ICH onset. The primary outcome is the time to recurrent symptomatic ICH within a 2-year follow-up period. The primary safety outcome is the occurrence of ischemic MACCE. Conclusion: The results will help to determine the best strategy for statin use in survivors of lobar ICH and may help to identify if there is a subset of patients who would benefit from or be harmed by statins.

Differences in lobar microbleed topography in cerebral amyloid angiopathy and hypertensive arteriopathy

Lobar cerebral microbleeds are a characteristic neuroimaging finding in cerebral amyloid angiopathy (CAA) but can also be found in hypertensive arteriolosclerosis. We aimed to investigate whether CAA is more associated with intracortical lobar microbleeds than hypertensive arteriosclerosis. Ninety-one survivors of spontaneous intracerebral hemorrhage with at least one lobar microbleed were included and underwent brain MRI and amyloid PET. We categorized lobar microbleeds as intracortical, juxtacortical, or subcortical. We assessed the associations between the lobar microbleed categories and microangiopathy subtypes or cerebral amyloid load based on the Pittsburgh Compound-B PET standardized uptake value ratio (SUVR). Patients with CAA had a higher prevalence of intracortical lobar microbleeds (80.0% vs. 50.8%, P = 0.011) and lower prevalence of subcortical lobar microbleeds (13.3% vs. 60.1%, P < 0.001) than patients with hypertensive arteriolosclerosis. Strictly intracortical/juxtacortical lobar microbleeds were associated with CAA (OR 18.9 [1.9–191.4], P = 0.013), while the presence of subcortical lobar microbleeds was associated with hypertensive arteriolosclerosis (OR 10.9 [1.8–68.1], P = 0.010). Amyloid retention was higher in patients with strictly intracortical/juxtacortical CMBs than those without (SUVR = 1.15 [1.05–1.52] vs. 1.08 [1.02–1.19], P = 0.039). Amyloid retention positively correlated with the number of intracortical lobar microbleeds (P < 0.001) and negatively correlated with the number of subcortical lobar microbleeds (P = 0.018). CAA and cortical amyloid deposition are more strongly associated with strictly intracortical/juxtacortical microbleeds than subcortical lobar microbleeds. Categorization of lobar microbleeds based on anatomical location may help differentiate the underlying microangiopathy and potentially improve the accuracy of current neuroimaging criteria for cerebral small vessel disease.

Long-term headache after spontaneous intracerebral haemorrhage.

Though headache is commonly observed after stroke and may affect survivors' quality of life, it has rarely been studied after spontaneous intracerebral haemorrhage (ICH). In a cohort of ICH survivors, we assessed the long-term prevalence and determinants of headache. We screened consecutive ICH survivors enrolled in the prospective, single-centre Prognosis of Intracerebral Haemorrhage study for headache 1, 3, and 6 years after ICH, according to the International Headache Society's criteria. Depressive and anxiety symptoms severity was measured at 1-year follow-up. Variables associated with the presence of headache 1 year after ICH were analyzed using univariate and multivariable models. Among the 146 patients included in this study, 31 (21%), 25 (19%), and 14 (20%) patients reported headache at 1-, 3-, and 6-year follow-up, respectively. In an age-adjusted model, patients with headache at ICH onset (adjusted odds ratio [aOR] 2.75; 95% CI 1.02-7.42) and previous history of headache (aOR 4.60; 95% CI 1.74-12.1) were associated with headache at 1-year follow-up. Patients with headache were more likely to report depressive and anxiety symptoms at 1-year follow-up (both p < 0.02). One in five ICH survivors suffered from headache and patients who reported headache at ICH onset were especially at risk.

Abstract TMP78: Disparities in Experiencing Major Adverse Cardiovascular Events Among Survivors of Spontaneous Intracerebral Hemorrhage by Hematoma Location

Background: Large studies evaluating the association of hematoma location with the risk of developing major adverse cardiovascular events (MACE) among survivors of intracerebral hemorrhage (ICH) in the United States are lacking. Methods: We identified adult (&gt;=18 years) ICH survivors from the state inpatient and the state emergency department databases of Florida, New York, Maryland, Washington, and Georgia (2016 - 2019). We fit a series of multivariable Fine-Gray sub-distribution hazard models, with the competing risk of death, and report the sub-distribution hazard ratio (SHR) and 95% confidence interval (CI) of the independent associations of hematoma location (lobar vs. non-lobar) with recurrent ICH (r-ICH), acute ischemic stroke (AIS), acute myocardial infarction (AMI), and MACE (any stroke, AMI, systemic embolism, or vascular death). Results: Among 10,652 ICH patients (median age [IQR]: 70 [58 - 80] years; 47.7% female; 43.2% lobar ICH), 3.3%, 3.1%, 0.5%, and 8.1%, respectively, experienced r-ICH, AIS, AMI, and MACE. Patients with lobar ICH (vs. non-lobar ICH) had a higher risk of r-ICH (SHR, CI: 1.67, 1.35 - 2.07) and MACE (1.28, 1.14 - 1.44). Blacks (vs. Whites) have a higher risk of AIS (1.64, 1.32 - 2.03) and MACE (1.42, 1.22 - 1.65). Also, privately insured patients (vs. Medicare) have a lower risk of r-ICH (0.45, 0.31 - 0.67), AIS (0.71, 0.53 - 0.95), and MACE (0.58, 0.47 - 0.71). Patients from low-income zip codes have a higher risk of AMI (1.83, 1.23 - 2.15) and MACE (1.16, 1.02 - 1.32). Patients with atrial fibrillation had a higher risk of AIS (1.47, 1.18 - 1.84) and MACE (1.26, 1.07 - 1.49). Patients with a high risk of metabolic syndrome (&gt;= 2 of the following: hypertension, diabetes, hyperlipidemia, or obesity) have a higher risk of AIS (1.37, 1.13 - 1.65), AMI (1.81, 1.19 - 2.75), and MACE (1.28, 1.13 - 1.44). Conclusions: Developing targeted secondary prevention strategies tailored to the specific sociodemographic and clinical profiles of ICH survivors is warranted.

Abstract WMP79: Mobility Impairment is Not Associated With Long-Term Valuation of Health by Survivors of Intracerebral Hemorrhage: A Mediation Analysis

Introduction: Clinical trial outcomes such as the modified Rankin score (mRS) are heavily influenced by mobility. We examined if mobility impairment and functional disability influenced long-term overall health evaluation by survivors of intracerebral and intraventricular hemorrhage (ICH/IVH). Methods: We pooled data from MISTIE-III and CLEAR-III trials. ICH/IVH survivors performed a protocolized direct valuation of their overall health using time trade-off utility (TTO-U) at 6 months post-ictus. TTO-U asks responders to consider trading years off their current disability-stricken state in exchange for perfect health. TTO-U index ranges from 0-1, with lower scores indicating greater years traded off and poorer valuation of overall health. TTO-U scores were dichotomized as good (&gt;=0.7) and poor (&lt;0.7). Associations between functional outcomes, European quality of life 5 dimensions (EQ-5D) and poor TTO-U at 6-months were assessed in multivariable logistic regression. A mediation analysis evaluated if mobility impairment and persistent poor mRS (mRS4-5) mediated associations between significant covariates and poor TTO-U at 6-months. Results: Of 773 survivors at 6-months, 442 (57%) patients with median (IQR) mRS of 3 (3-4) reported median (IQR) TTO-U of 1 (0.7-1); 332 patients had good and 110 had poor TTO-U. In multivariable logistic regression, moderate to severe anxiety/depression and problems with selfcare (dressing/washing) were independently associated with poor valuation of overall health, but mobility impairment and poor functional outcome were not. In mediation analyses, mobility impairment and poor mRS (4-5) at 6-months did not mediate the effect of persistent anxiety/depression (controlled direct effect (CDE), 1.79 [1.10-2.89]; natural indirect effect (NIE) of mobility, 0.93 [0.58-1.49], p=0.75; NIE of mRS, 1.00 [0.91-1.10], p=0.96) and selfcare deficits (CDE, 4.85 [2.13-11.05]; NIE of mobility, 0.72 [0.42-1.26]; NIE of mRS, 1.04 [0.78-1.39]) on long-term valuation of health state. Conclusions: Long-term valuation of overall health in survivors after severe ICH/IVH was influenced by persistent dependence in caring for self and mood dysfunction. Mobility impairment and mRS did not mediate these associations.

Abstract TP37: The Relationship Between Long-Term Neuropsychiatric Symptoms and Cognitive Performances in Intracerebral Hemorrhage Survivors

Introduction: Neuropsychiatric (NP) symptoms have substantial influence on patients surviving with intracerebral hemorrhage (ICH), but their impact to cognitive impairment and life quality are poorly understood. We aim to investigate the subtypes of long-term NP symptoms, and their correlation to neurocognitive profiles and quality of life (QoL) in ICH survivors. Methods: Fifty-six patients survived with spontaneous ICH for at least 12 months were prospectively recruited to participate in this study. Each patient received comprehensive neurocognitive and NP assessment as well as a questionnaire for their QoL. We reported the prevalence and types of NP symptoms, and compared the demographic and neuroimaging findings between patients with and without NP symptoms. Multivariable linear regression models were applied to investigate the association between NP symptoms and cognitive domains after adjustment for age, sex, educational years, hematoma location and small vessel disease (SVD) scores. Results: NP symptoms were present in 24 (42.9%) of the recruited patients, in which affective symptoms were most common (35.7%), followed by apathy/vegetative symptoms (26.8%), hyperactivity (17.9%), and psychosis (1.8%). Patients with NP symptoms showed more cerebral SVD changes and they were associated with worse general cognitive abilities (p&lt;0.05). In our analysis regarding each NP subtype, the presence of apathy/vegetative symptoms was associated with slower processing speed (p=0.015) and worse category fluency (p=0.042) while the affective or hyperactivity symptoms were neither associated any domain-specific neurocognitive functions. Additionally, the presence of these NP symptoms except for psychosis independently predicts worse QoL. Conclusions: Long-term NP symptoms are frequent in ICH survivors and is independently related to cognitive dysfunction and worse life quality. The NP subtype, especially apathy/vegetative symptoms, should be well-characterized for their contribution to neurocognitive domains.

Abstract TP103: Association Between Neighborhood-Level Disadvantage and Patient-Reported Mental Health Outcomes in Intracerebral Hemorrhage Survivors

Introduction: The influence of social determinants of health (SDH) is well-documented across a range of medical conditions and health outcomes. Less clear is the impact of SDH on patient-reported outcomes, particularly mental health outcomes, in intracerebral hemorrhage (ICH). This study examines the association between the Area Deprivation Index (ADI), a measure of neighborhood-level disadvantage, and self-reported health outcomes in ICH survivors. Methods: This investigation is nested within the REDUCE clinical trial, an ongoing, randomized trial comparing standard-of-care to spironolactone-containing hypertension regimens in ICH survivors. Participants complete the PROMIS Global Health survey at baseline. Global Mental Health (GMH) and Global Physical Health (GPH) scores are standardized to t-scores (GMH 21.2-67.6; GPH 16.2-67.7) around a reference population mean (50 ± 10). ADI uses elements of income, education, employment, and housing quality to assign a composite score (1-100), with a higher score signifying greater disadvantage. Patients were grouped into tertiles based on ADI. GMH and GPH scores were analyzed against the reference mean via a one-sample t-test and across tertiles with a one-way ANOVA. Bivariable linear regression examined ADI as a continuous variable. Multivariable models adjusted for sex, age, race, ethnicity, ICH to baseline interval, and baseline mRS. Results: Fifty patients were included in the analysis. Those in the third, most disadvantaged, tertile had significantly lower GMH scores (39.5 ± 8.17) than the reference population (p&lt;0.001), the first tertile (54.10 ± 10.20, p&lt;0.001), and the second tertile (50.4 ± 8.90, p=0.003). In multivariable analysis, these differences remained significant (T3 vs. T1, B= -18.31, p&lt;0.001; T3 vs. T2, B= -14.67, p&lt;0.001). Further, ADI as a continuous variable was significantly associated with GMH scores in bivariable (B= -0.22, p&lt;0.001) and multivariable analysis (B= -0.23, p=0.005). No significant relationship was found between ADI and GPH. Conclusions: Higher ADI is associated with worse patient-reported mental health outcomes after ICH. Neighborhood disadvantage, and its constituting factors, should be considered in reporting post-ICH patient care and outcomes.

Abstract 67: Risk and Time-Course of Post-Stroke Dementia: A Population-Wide Cohort Study, 2002-2022

Background: People with acute stroke are at high risk of dementia. Population-wide data on the risk and time-course of dementia after stroke are lacking. Methods: We conducted a population-wide analysis of over 15 million people in Ontario, Canada between 2002-2022. Using linked administrative databases, we compared all 90-day survivors of first acute ischemic stroke or intracerebral hemorrhage (ICH) to controls in the general population and with acute myocardial infarction (AMI) by matching 1:1 on age, sex, rural residence, neighborhood marginalization, and vascular comorbidities, and excluded people with prior dementia. We evaluated the rate of dementia per 100 person-years using a validated definition which included hospitalization, physician claims, and medications, and calculated cause-specific hazard ratios overall and across follow-up time. Results: We identified 180,940 people with acute stroke, of which 33,765 (18.7%) developed dementia over mean follow-up of 5.5 years (max 20y). The rate of dementia per 100 person-years was highest after acute stroke compared to the general population (3.40 vs. 1.88) and compared to AMI (3.23 vs. 1.81). The overall risk of dementia was higher in those with acute stroke compared to the general population (HR 1.79, 95% CI 1.76-1.82; Figure 1A), and particularly after ICH (HR 2.43, 2.31-2.57). The results were similar when compared to AMI (HR 1.77, 1.74-1.80; Figure 1C). There was an almost 3-fold elevation of dementia risk in the first year after stroke, decreasing to 1.5-fold by 5 years and remaining elevated even 20 years after (Figure 1B/1D). Conclusion: In this large, population-wide study almost one fifth of people developed dementia after stroke, with an 80% higher risk of developing dementia compared to matched controls. The risk was highest early after stroke but remained elevated 20 years after, raising the urgency of developing interventions for dementia prevention in acute and chronic survivors of stroke.

Abstract TMP32: Race and Ethnic Differences in Rehabilitation and Functional Recovery Post-Stroke Within the Florida Stroke Registry - Transitions of Care

Introduction: Historically, non-Hispanic black (NHB) and Hispanic stroke survivors have been discharged at a poorer functional level than non-Hispanic whites (NHW). The purpose of this study was to examine race and ethnic differences in rehabilitation prescription and participation at time of discharge (DC) and in modified Rankin Scale (mRS) at 30- and 90-days post-stroke. Methods: The Transitions of Stroke Care Disparities Study is designed to reduce disparities and optimize post-stroke care in hospital-to-home transitions. Survivors of ischemic stroke and intracerebral hemorrhage from a subset of 165 hospitals in the Florida Stroke Registry were included in the Get with the Guidelines-Stroke® (GWTG-S) database. Race and ethnicity, therapy prescription and participation, and mRS were extracted from GWTG-S, and by self-report at 30- and 90-days after DC. Race and ethnic differences were assessed in therapy prescription, participation, and mRS using binary logistic regression adjusted for age, sex, stroke severity (NIHSS), and DC walking ability. Results: In 1,129 stroke survivors (mean age 64y, 45% women, 55% NHW, 23% NHB, 22% Hispanic, 76% independent walkers at DC), 29% were prescribed inpatient and 50% outpatient rehabilitation at DC. Multivariable analysis showed NHW were significantly less likely to be prescribed inpatient therapy compared to NHB [OR 0.56, 95%CI (0.35-0.88)] or Hispanics [OR 0.50, 95%CI (0.31-0.80)]. Hispanic individuals [OR 1.69, 95%CI (1.20-2.38)] were significantly less likely to be prescribed outpatient therapy compared to NHW or NHB. No differences in therapy participation were seen between NHW and NHB [OR 1.16, 95%CI (0.69-1.97)] or Hispanics [OR 1.41, 95%CI (0.82-2.43)]. No differences in mRS were seen between NHW and NHB [30-days, OR 0.85, 95% CI (0.52-1.39); 90-days, OR 0.68, 95%CI (0.42-1.11)] or Hispanics [30-days, OR 0.63, 95% CI (0.37-1.10); 90-days, OR 0.61, 95%CI (0.36-1.03)]. Conclusions: Although there were significant race and ethnic differences in therapy prescription setting, no race and ethnic differences were seen in therapy participation or in mRS at either 30- or 90-days. Further research is warranted to examine race and ethnic differences in stroke recurrence and readmission rates.

Abstract WMP76: Long-Term Effects of Intracerebral Hemorrhage on Behavior and Inflammation

Introduction: Intracerebral hemorrhage (ICH) survivors remain at high risk for progressive cognitive impairment and post-stroke depression. However, little is known about the contribution of chronic neuroinflammation and sex-specific differences to behavioral changes at late timepoints. Methods: ICH was induced in 3-month male and female C57BL/6J wild type mice by injecting 0.8μL of type VII collagenase into the right striatum. Mice were perfused on day 0 (naïve) and day 28 following ICH, and the perihematomal region harvested for microglia isolation on a FACSAria. Transcriptomics was analyzed using nCounter Digital Analyzer using a custom neuroinflammation panel. Social deficits and cognition were measured via the 3-chambered sociability test at 0, 28, and 60-days post-ICH. Results: GO Biological Processes revealed that type I interferon signaling genes comprised the top three upregulated gene sets (adjusted P value &lt; 10 -5 ) when compared to naïve microglia, suggesting a continued inflammatory response 28 days following ICH. As expected, behavioral analysis showed no sociability differences between males (N=4) and females (N=3) at day 0 (p = 0.1313). Males did not show an overall decline in sociability at day 28 or day 60 when compared to day 0 (p &gt; 0.05, N= 5, 4). However, females showed a progressive decrease in sociability that became significant at day 60 (p = 0.032, N= 3). Interestingly, females spent significantly less time with the novel mouse (p = 0.019) and more time in the nonsocial chambers when compared to males at day 60 (p = 0.030). Conclusions: Our findings suggest that there is a chronic inflammatory signature long after the initial cell response to ICH which may be promoting long-term behavioral deficits in a sex-specific manner. As type I interferons have been increasingly linked to mood disorders, understanding the relationship between chronic inflammation, mood, and sex-specific differences will be crucial.

Abstract WMP33: Translating Evidence Into Practice: Early Supported Discharge in Intracerebral Hemorrhage

Background: The 2022 guidelines from the American Heart Association/American Stroke Association underscore the significance of coordinated multidisciplinary care and early discharge planning for spontaneous intracerebral hemorrhage (ICH) patients. Early Supported Discharge (ESD) programs have been found to curtail hospital stays for ICH patients. Purpose: This Quality Improvement initiative aimed to optimize our ESD program, originally designed for acute ischemic stroke patients, by expanding eligibility to encompass mild to moderate spontaneous ICH patients. The primary objectives were to evaluate the effects on the hospital length of stay and discharge-to-home rates. Methods: In 2020, a collaboration between our acute care hospital and homecare organization led to the development of an ESD program, Homeward Stroke Recovery, for ischemic stroke survivors in local catchment areas. Eligibility criteria were broadened to include ICH patients in July 2022. Descriptive statistics were used to track the program's performance, specifically discharge-to-home rates and hospital length of stay for ICH survivors discharged with Homeward Stroke Recovery. Results: Following the expansion of Homeward Stroke Recovery Program eligibility, the discharge-to-home rate for ICH patients at the site increased by 14.2% (27.5% to 41.7%). Additionally, the median length of stay decreased by 2 days (6 days to 4 days). Conclusions: In conclusion, our Quality Improvement project has successfully enhanced the Homeward Stroke Recovery program. This was achieved by aligning eligibility criteria with evidence-based recommendations for patients with mild to moderate spontaneous ICH, leading to a substantial positive impact on patient outcomes. The outcomes of this initiative not only affirm the efficacy of broadening eligibility for ESD programs but serves as a beacon and blueprint to widen scope through evidence-guided improvements.

Abstract WP109: Framework for Evaluating Sequential Patterns in Post-Acute Transitions of Care Among Ischemic and Hemorrhagic Stroke Survivors: Analysis of Medicare Beneficiaries in the State of Texas

Background: Utilizing medical claims derived information, we evaluated temporal trends in post-acute care utilization pathways among patients with acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH). Methods: Data were retrieved from a CMS Qualified Entity housing healthcare utilization data for ≥80% of the Texas state population (100% of Medicare Fee-for-Service). Analytical sample included all Medicare enrollees with a primary discharge diagnosis (AIS or ICH) from 2016 to 2020. Episodes of care within 1 year of discharge were collated and categorized “Discharged”, “Inpatient Rehab”, “Skilled Nursing”, “Hospice”, “Readmission”, or “Death”. Sequential pattern mining was used to calculate conditional probabilities (likelihoods) of post-discharge transitions of care. Prediction rules were generated by converting care sequences into antecedent-consequent pairs. Rule based performance was evaluated by extracting 90 day sequences (antecedent) and assigning predictions of 1 year settings (consequent) based on highest likelihoods (Panel A). Results: A total of 82,829 AIS and 12,761 ICH hospitalizations were analyzed (described in Panel B). An example rulebook of care sequences and associated likelihoods of subsequent transitions for ICH is depicted in Panel C. Whereas ICH survivors entering inpatient rehab had respective likelihoods of 11.2% and 16.2% for subsequently being admitted to hospice care or death, those entering skilled nursing facilities had respective likelihoods of 21.9% and 30.5%. Using 90 day transition of care sequences, predictive accuracy of exact 1 year setting for AIS was 65.3% (1 attempt) and 84.0% (2 attempts); for ICH, the respective accuracy was 50.9% and 82.3% (Panel D). Conclusion: Post stroke transitions of care patterns may yield insights as to the long-term trajectory of outcomes. Predictive capability is expected to strengthen with planned multi-modal integration of EMR-derived clinical and imaging features.

Functional outcome improvement from 3 to 12 months after intracerebral hemorrhage.

Most intracerebral hemorrhage (ICH) trials assessed outcome at 3 months but the recovery trajectory of ICH survivors may continue up to 1 year after the index event. We aimed to describe the predictors of functional outcome improvement from 3 to 12 months after ICH. Retrospective analysis of patients admitted to six European Stroke Centers for supratentorial ICH. Functional outcome was measured with the modified Rankin Scale (mRS) at 3 and 12 months. Predictors of functional outcome improvement were explored with binary logistic regression. We included 703 patients, of whom 245 (34.9%) died within 3 months. Among survivors, 131 (28.6%) had an mRS improvement, 78 (17.0%) had a worse mRS and 249 (54.4%) had a stable functional status at 12 months. Older age and the presence of baseline disability (defined as pre-stroke mRS > 1), were associated with lower odds of functional outcome improvement (Odds Ratio (OR) 0.98 per year increase, 95% Confidence Interval (CI) 0.96-1.00, p = 0.017 and OR 0.45, 95% CI 0.25-0.81, p = 0.008 respectively). Conversely, deep ICH location increased the probability of long term mRS improvement (OR 1.67, 95% CI, 1.07-2.61, p = 0.023). Patients with mild-moderate disability at 3 months (mRS 2-3) had the highest odds of improvement at 12 months (OR 8.76, 95% CI 3.68-20.86, p < 0.001). Long term recovery is common after ICH and associated with age, baseline functional status, mRS at 3 months and hematoma location. Our findings might inform future trials and improve long-term prognostication in clinical practice.

Comparing motor recovery in ischaemic stroke and intracerebral haemorrhage: A Systematic Review.

Background The pathophysiology and medical management between ischaemic stroke and intracerebral haemorrhage differ as do their functional independence and mortality outcomes. However, whether their respective upper limb motor impairment and recovery differs is less clear. This information could inform discussions with patients about their recovery prognosis as well as identify appropriate rehabilitation settings. Methods A PROSPERO registered systematic search of three databases (MEDLINE, CINAHL, Embase) identified studies that measured upper limb motor function (Fugl-Meyer assessment scale for upper extremity) in participants with first stroke (ischaemic stroke or intracerebral haemorrhage) within 31 days post-stroke and at least one follow-up assessment. Risk of bias was assessed using the Critical Appraisal Skills Programme. Results The search identified 1108 studies of which three met inclusion criteria, with a total of 258 participants (200 ischaemic stroke, 58 intracerebral haemorrhage). All studies had low to moderate risk of bias. At baseline, participants with intracerebral haemorrhage had greater upper limb motor impairment on the Fugl-Meyer assessment scale, but at six months post-stroke, the stroke subtypes reached similar upper limb motor function. Improvements were greatest early after stroke. Conclusions Despite greater severity at baseline, intracerebral haemorrhage survivors appeared to reach the same level of arm function at six months post stroke. However, these findings need to be interpreted with caution due to limited studies and small number of participants included in this review and warrant further research. PROSPERO registration CRD42020159110 (19/02/2020).

Antithrombotic and Statin Prescription After Intracerebral Hemorrhage in the Get With The Guidelines-Stroke Registry.

Survivors of intracerebral hemorrhage (ICH) face an increased risk of ischemic cardiovascular events. Current ICH guidelines do not provide definitive recommendations regarding the use of antithrombotic and statin therapies. We, therefore, sought to study practice patterns and factors associated with the use of such medications after ICH. This was a cross-sectional study of patients with ICH in the Get With The Guidelines-Stroke registry, between 2011 and 2021. Patients transferred to another hospital, those who died during hospitalization, and those with missing information on discharge medications were excluded. The study exposure was the proportion of patients who were prescribed antithrombotic or statin medications. We first ascertained the proportion of patients prescribed antithrombotic and lipid-lowering medications at discharge overall and across strata defined by pre-ICH use and history of previous ischemic vascular disease or atrial fibrillation. We then studied factors associated with the discharge prescription of these medications after ICH, using multiple logistic regressions. In the final cohort, 50 416 (10.4%) of 486 586 patients with ICH were prescribed antiplatelet medications, 173 322 (35.1%) of 493 491 patients with ICH were prescribed statins, and 27 085 (5.4%) of 486 585 patients with ICH were prescribed anticoagulation therapy at discharge. The proportion of patients with antiplatelet therapy was 16.6% with pre-ICH use and 15.6% in those with previous ischemic vascular disease. Statins were prescribed to 41.1% and 43.7% of patients on previous lipid-lowering therapy and ischemic vascular disease, respectively. Anticoagulation therapy was restarted in 11.1% of patients. In logistic regression analysis, factors associated with higher use of antithrombotic or statin therapies after ICH were younger age, male sex, pre-ICH medication use, previous ischemic vascular disease, atrial fibrillation, lower admission National Institutes of Health Stroke Scale, longer length of stay, and favorable discharge outcome. Few patients with ICH are prescribed antithrombotic or statin therapies at hospital discharge. Given the emerging association between ICH and future major cardiovascular events, trials examining the net benefit of antiplatelet and lipid-lowering therapy after ICH are warranted.

Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage.

This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral hemorrhage (ICH) complements earlier updates about blood pressure-lowering, lipid-lowering, and oral anticoagulation or left atrial appendage occlusion for atrial fibrillation after ICH. When used for secondary prevention in people without ICH, antiplatelet agents reduce the risk of major adverse cardiovascular event (rate ratio, 0.81 [95% CI, 0.75-0.87]) and might increase the risk of ICH (rate ratio, 1.67 [95% CI, 0.97-2.90]). Before 2019, guidance for clinical decisions about antiplatelet agent use after ICH has focused on estimating patients' predicted absolute risks and severities of ischemic and hemorrhagic major adverse cardiovascular event and applying the known effects of these drugs in people without ICH to estimate whether individual ICH survivors in clinical practice might be helped or harmed by antiplatelet agents. In 2019, the main results of the RESTART (Restart or Stop Antithrombotics Randomized Trial) randomized controlled trial including 537 survivors of ICH associated with antithrombotic drug use showed, counterintuitively, that antiplatelet agents might not increase the risk of recurrent ICH compared to antiplatelet agent avoidance over 2 years of follow-up (12/268 [4%] versus 23/268 [9%]; adjusted hazard ratio, 0.51 [95% CI, 0.25-1.03]; P=0.060). Guidelines in the United States, Canada, China, and the United Kingdom and Ireland have classified the level of evidence as B and indicated that antiplatelet agents may be considered/reasonable after ICH associated with antithrombotic agent use. Three subsequent clinical trials have recruited another 174 participants with ICH, but they will not be sufficient to determine the effects of antiplatelet therapy on all major adverse cardiovascular events reliably when pooled with RESTART. Therefore, ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage) aims to recruit 4148 ICH survivors to determine the effects of antiplatelet agents after ICH definitively overall and in subgroups.