Intracerebral Hemorrhage Survivors Research Articles

Abstract TMP99: Neighborhood Disadvantage And Outcomes Following Intracerebral Hemorrhage

Introduction: Neighborhood disadvantage is associated with various health factors. Given the mounting evidence linking social determinants to risk of, and outcomes after, spontaneous intracerebral hemorrhage (ICH), we tested the hypothesis that higher neighborhood disadvantage leads to poorer outcomes following ICH. Methods: We conducted a nested study within an ongoing longitudinal study that prospectively follows patients with acute brain injury admitted to Connecticut’s largest healthcare system. The nested study included ICH survivors and evaluated neighborhood deprivation using the Area Deprivation Index, a publicly available metric that uses 9-digit zip codes to rank neighborhoods’ socioeconomic disadvantage based on factors such as income, employment, and education. Patients were given a tertile designation according to the Area Deprivation Index: low, intermediate, and high deprivation. Functional outcome was evaluated through the 6-month post-ICH Modified Rankin Scale, dichotomized as 0-3 (good outcome) and 4-6 (poor outcome). We used chi-square tests and multivariable logistic regression for unadjusted and adjusted association analyses, respectively. Results: Out of 687 ICH patients enrolled from 2018 to 2022, 518 (mean age 67, 47.5 % female, 19% Black, 8% Hispanic) had 9-digit zip code and outcomes data. The unadjusted risk of poor outcome was 40%, 55%, and 61% for patients living in neighborhoods with low, intermediate, and high disadvantage (unadjusted p=0.02). This association was confirmed in multivariable analyses adjusting for potential confounders: compared to patients living in low-disadvantage neighborhoods, those living in neighborhoods with intermediate and high disadvantage had 66% (OR 1.66, 95% CI 0.82-3.40) and 2.5 times (OR 2.44, 95% CI 1.17-5.19) higher risk of poor outcomes (test-for-trend p=0.01). Conclusion: Among ICH survivors enrolled in a prospective study of acute brain injury, increased neighborhood disadvantage was associated with a higher risk of poor outcomes. Our results validate the Area Deprivation Index as a useful tool to assess the numerous social determinants of health. Additionally, our findings highlight the negative role of these social determinants in patients' recoveries.

Abstract TMP73: Direct Valuation Of Long-Term Health State By Survivors Of Severe Intracerebral And Intraventricular Hemorrhage Using Time Trade-off Utility

Objective: To describe direct valuation of long-term health state by survivors of severe intracerebral and intraventricular hemorrhage (ICH/IVH) using time-trade off utility (TTO-U). TTO-U requires patients to choose between trading off years of their life in exchange for a hypothetical treatment that returns them to full functionality. Higher TTO-U (0-1) indicates lower desire to trade time off and thus a higher valuation of current health state. Methods: CLEAR III and MISTIE III trial survivors who recorded TTO-U at 180-days post-ictus were included. TTO-U was dichotomized into ≤0.6 versus >0.6. Multivariable logistic regression assessed factors associated with TTO-U≤0.6, including clinical variables, quality of life and depression scales. Results: Among 774 CLEAR III and MISTIE III survivors at day-180, 442 (57%) reported TTO-U; 305 (69%) were self-reported, 122 (28%) by a proxy. Mean (SD) age was 58.4 (11.8) years, 41% female, 25% black, 68% white and 7% other races. Mean (SD) ICH volume was 33.5 (22.8) mL, IVH volume 9.1 (14.8) mL, 70% had deep ICH. Median (IQR) 180-day mRS was 3 (3-4) and TTO-U was 1.0 (0.7-1). TTO-U of 1.0 was reported by 269 (61%) and ≤0.6 by 110 (25%) patients. Increasing age, white race, but not sex, were associated with lower TTO-U. Proxy-based TTO-U scores were lower (mean, 0.76 vs. 0.83, p=0.03). In multivariable logistic regression, age (aOR per 10-yrs, 1.24 [1.003-1.52]), race (white vs. other races, 4.8 [1.1-21.3]), proxy-based assessment (1.81 [1.02-3.21]), new ischemic stroke (2.01 [1.1-3.7]), sepsis (6.6 [1.1-40.3]), gastrostomy (0.40 [0.21-0.77]) were associated with TTO-U≤0.6 after adjusting for ICH severity. Among EuroQol 5-dimensions, difficulty with selfcare (3.3 [1.97-5.62]), and anxiety/depression (1.72 [1.07-2.74]) were independently associated with TTO-U≤0.6. CES-Depression score (in MISTIE III only) was also associated with TTO-U≤0.6 (per 1-point, 1.05 [1.02-1.07]). Conclusion: Majority of survivors of severe ICH/IVH highly valued their long-term health state and were unwilling to trade time off despite significant disability. Race, age, hospital complications, inability to care for self and anxiety/depression at day-180 were associated with lower valuation of long-term health state.

Early Antiplatelet Resumption and the Risks of Major Bleeding After Intracerebral Hemorrhage.

The appropriate timing of resuming antithrombotic therapy after intracerebral hemorrhage (ICH) remains unclear. The aim of this study was to compare the risks of major bleeding between early and late antiplatelet resumption in ICH survivors. Between 2008 and 2017, ICH patients were available in the National Health Insurance Research Database. Patients with a medication possession ratio of antiplatelet treatment ≥50% before ICH and after antiplatelet resumption were screened. We excluded patients with atrial fibrillation, heart failure, under anticoagulant or hemodialysis treatment, and developed cerebrovascular events or died before antiplatelet resumption. Finally, 1584 eligible patients were divided into EARLY (≤30 days) and LATE groups (31-365 days after the index ICH) based on the timing of antiplatelet resumption. Patients were followed until the occurrence of a clinical outcome, end of 1-year follow-up, death, or until December 31, 2018. The primary outcome was recurrent ICH. The secondary outcomes included all-cause mortality, major hemorrhagic events, major occlusive vascular events, and ischemic stroke. Cox proportional hazard model after matching was used for comparison between the 2 groups. Both the EARLY and LATE groups had a similar risk of 1-year recurrent ICH (EARLY versus LATE: 3.12% versus 3.27%; adjusted hazard ratio [AHR], 0.967 [95% CI, 0.522-1.791]) after matching. Both groups also had a similar risk of each secondary outcome at 1-year follow-up. Subgroup analyses disclosed early antiplatelet resumption in the patients without prior cerebrovascular disease were associated with lower risks of all-cause mortality (AHR, 0.199 [95% CI, 0.054-0.739]) and major hemorrhagic events (AHR, 0.090 [95% CI, 0.010-0.797]), while early antiplatelet resumption in the patients with chronic kidney disease were associated with a lower risk of ischemic stroke (AHR, 0.065 [95% CI, 0.012-0.364]). Early resumption of antiplatelet was as safe as delayed antiplatelet resumption in ICH patients. Besides, those without prior cerebrovascular disease or with chronic kidney disease may benefit more from early antiplatelet resumption.

Prevalence of Cognitive Impairment and Dementia After Intracerebral Hemorrhage.

To study the prevalence of cognitive impairment in survivors of intracerebral hemorrhage (ICH). Survivors of spontaneous ICH were followed up in the neurology outpatient department when they reported for follow-up after 6 months. Neuroimaging records at the onset and at follow-up visits are studied for the location of ICH, volume of ICH, intraventricular extension, and hydrocephalus. The volume of ICH is calculated by ABC/2 method on a CT scan. All patients underwent cognitive assessment with Addenbrooke's cognitive examination ACE III and were categorized as patients having cognitive impairment (or) no cognitive impairment. A total of 120 patients were studied, out of which 77 (64%) are males and 43 (36%) are females with age groups ranging from 26 to 75 years. In the study population, the mean age was found to be 62.3 years. Specifically, the mean age for males was 56.9 years, while for females it was 63.4 years. Cognitive impairment was noted in 34 of 120 patients (28%) during 6 to 12 months of examination, of which 11 of 19 were in lobar location, 21 of 94 were in sub-cortical location, and 2 of 7 were in infratentorial location. It was found that 28% of survivors of ICH were cognitively impaired. Hence, it is essential to assess cognition in post-ICH patients during follow-up, so that suitable adjustments can be made in their employment, and also in educating family members in providing a good quality of life.

Antithrombotic treatment after intracerebral hemorrhage: Surveys among stroke physicians in Scandinavia and the United Kingdom.

It is unclear whether patients with previous intracerebral hemorrhage (ICH) should receive antithrombotic treatment to prevent ischemic events. We assessed stroke physicians' opinions about this, and their views on randomizing patients in trials assessing this question. We conducted three web-based surveys among stroke physicians in Scandinavia and the United Kingdom. Eighty-nine of 205 stroke physicians (43%) responded to the Scandinavian survey, 161 of 180 (89%) to the UK antiplatelet survey, and 153 of 289 (53%) to the UK anticoagulant survey. In Scandinavia, 19 (21%) stroke physicians were uncertain about antiplatelet treatment after ICH for ischemic stroke or transient ischemic attack (TIA) and 21 (24%) for prior myocardial infarction. In the United Kingdom, 116 (77%) were uncertain for ischemic stroke or TIA and 115 (717%) for ischemic heart disease. In Scandinavia, 32 (36%) were uncertain about anticoagulant treatment after ICH for atrial fibrillation, and 26 (29%) for recurrent deep vein thrombosis or pulmonary embolism. In the United Kingdom, 145 (95%) were uncertain about anticoagulants after ICH in at least some cases. In both regions combined, 191 of 250 (76%) would consider randomizing ICH survivors in a trial of starting versus avoiding antiplatelets, and 176 of 242 (73%) in a trial of starting versus avoiding anticoagulants. Considerable proportions of stroke physicians in Scandinavia and the United Kingdomwere uncertain about antithrombotic treatment after ICH. A clear majority would consider randomizing patients in trials assessing this question. These findings support the need for such trials.

Association of Depression Onset and Treatment With Blood Pressure Control After Intracerebral Hemorrhage.

Blood pressure (BP) control represents a crucial intervention to improve long-term outcomes following spontaneous intracerebral hemorrhage (ICH). However, fewer than half of ICH survivors achieve target treatment goals. ICH survivors are also at very high risk for poststroke depression, which may contribute to inadequate BP control. We, therefore, sought to determine whether depressive symptoms after ICH are associated with inadequate BP control. We also investigated whether associations between depression after ICH and BP measurements were mediated by treatment with selective serotonin reuptake inhibitors or norepinephrine-serotonin reuptake inhibitors antidepressants. We leveraged data from a single-center longitudinal study of ICH conducted at Massachusetts General Hospital (Boston, MA) between 2006 and 2018. We collected data from semiautomated review of electronic health records, baseline and follow-up interviews, and computed tomography imaging. Information on BP measurements, depression diagnoses, antidepressants medication use, and medical visits were collected longitudinally and analyzed using mixed effects models. Primary outcomes included systolic and diastolic BP measurements during long-term follow-up after ICH. We included 1243 consecutive ICH patients without pre-stroke depression history. Of these, 721 (58%) were diagnosed with incident depression over a median follow-up time of 52.8 months (interquartile range, 42.1-60.5). Depression onset was associated with subsequent increase in systolic (+8.3 mm Hg, SE, 2.4 mm Hg, P=0.012) and diastolic (+4.4 mm Hg, SE, 1.2 mm Hg) BP measurements. Resolution of depressive symptoms was associated with subsequent decrease in systolic (-5.9 mm Hg, SE, 1.4 mm Hg, P=0.031) and diastolic (-3.4 mm Hg, SE, 1.1 mm Hg, P=0.041) BP measurements. We also found associations between higher systolic BP measurements and use of selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor antidepressants, independent of whether depression symptoms were active or not (all P<0.05). ICH survivors displayed increasing BP values after receiving a diagnosis of depression, followed by decreasing values among those experiencing resolution of depressive symptoms. Use of selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor antidepressants was independently associated with higher systolic BP measurements. Clinicians ought to closely monitor BP for ICH survivors being treated for depression, especially using selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor. Future studies will also be required to investigate the mechanisms underlying these associations.

Blood Pressure Control Targets and Risk of Cardiovascular and Cerebrovascular Events After Intracerebral Hemorrhage.

Intracerebral hemorrhage (ICH) survivors are at high risk for recurrent stroke and cardiovascular events. Blood pressure (BP) control represents the most potent intervention to lower these risks, but optimal treatment targets in this patient population remain unknown. We sought to determine whether survivors of ICH achieving more intensive BP control than current guideline recommendations (systolic BP <130 mmHg and diastolic BP <80 mmHg) were at lower risk of major adverse cardiovascular and cerebrovascular events and mortality. We analyzed data for 1828 survivors of spontaneous ICH from 2 cohort studies. Follow-up BP measurements were recorded 3 and 6 months after ICH, and every 6 months thereafter. Outcomes of interest were major adverse cardiovascular and cerebrovascular events (recurrent ICH, incident ischemic stroke, myocardial infarction), vascular mortality (defined as mortality attributed to recurrent ICH, ischemic stroke, or myocardial infarction), and all-cause mortality. During a median follow-up of 46.2 months, we observed 166 recurrent ICH, 68 ischemic strokes, 69 myocardial infarction, and 429 deaths. Compared with survivors of ICH with systolic BP 120 to 129 mmHg, participants who achieved systolic BP <120 mmHg displayed reduced risk of recurrent ICH (adjusted hazard ratio [AHR], 0.74 [95% CI, 0.59-0.94]) and major adverse cardiovascular and cerebrovascular events (AHR, 0.69 [95% CI, 0.53-0.92]). All-cause mortality (AHR, 0.76 [95% CI, 0.57-1.03]) and vascular mortality (AHR, 0.68 [95% CI, 0.45-1.01]) did not differ significantly. Among participants aged >75 years or with modified Rankin Scale score 4 to 5, systolic BP <120 mmHg was associated with increased all-cause mortality (AHR, 1.38 [95% CI, 1.02-1.85] and AHR, 1.36 [95% CI, 1.03-1.78], respectively), but not vascular mortality. We found no differences in outcome rates between survivors of ICH with diastolic BP <70 versus 70 to 79 mmHg. Targeting systolic BP <120 mmHg in select groups of survivors of ICH could result in decreased major adverse cardiovascular and cerebrovascular events risk without increasing mortality. Our findings warrant investigation in dedicated randomized controlled trials.

Intracerebral Hemorrhages Related to Clinical Conditions and Associated Outcomes Among Saudi and Non-Saudi Patients in a University Hospital: A Retrospective Study.

Objective: Intracerebral hemorrhage (ICH) is the second most common subtype of stroke. The objective of this study was to identify differences between Saudi and non-Saudi patients regarding demographics, clinical conditions, and associated ICH outcomes. Methods: This retrospective study included patients with ICH (ICD-10 code I61) admitted to a university hospital in Saudi Arabia from April 2014 to April 2019. ICH prevalence patterns were divided into 4 age groups: aged < 60, 60–69, 70–79, and ≥ 80 years. Patient data were collected from the hospital stroke registry. Several outcomes were investigated including death, modified Rankin Scale (mRS) score, external ventricular drain (EVD), and hemicraniectomy. The influence of various demographic and risk factors was studied for each outcome using several analytic techniques. Results: Of 148 patients, 53% were Saudi and 47% were non-Saudi. Death was reported in 28% of patients and was influenced by many factors including impaired renal function test (> 1.2 mg/dL in females and > 1.4 mg/dL in males) and hematoma size expansion. An unfavorable mRS score after ICH was influenced by impaired renal function test, Glasgow Coma Scale score, and smoking history. EVD insertion was influenced by intraventricular extension of hematoma and being non-Saudi. Hemicraniectomy procedures were associated with impaired renal function test. Conclusion: Non-Saudi ICH survivors had significant intraventricular extension of hematoma and required more neurosurgical interventions such as EVD procedures compared to Saudi patients. Both groups had associated comorbidities that may influence the incidence of ICH. Appropriate medical care to prevent stroke complications, especially for the older male population, as a strategy for secondary prevention of such neurologic sequelae is recommended.

Restarting Antiplatelet Agents After Intracerebral Haemorrhage: A Reassurance To Physicians.

Intracerebral haemorrhage (ICH) is the second most common cause of stroke (after ischemic stroke) across the world and has significantly higher morbidity and mortality as compared to ischemic stroke and subarachnoid haemorrhage.1 Spontaneous (atraumatic) ICH occurs in up to 31 people per 100,000 globally and the incidence is even higher in Asian countries like Pakistan.2 Most patients experiencing spontaneous ICH have a history of occlusive vascular diseases like myocardial infarction (MI) and are consequently taking antithrombotic therapy (antiplatelets, anticoagulants) at the time of ICH occurrence. Antithrombotic therapy is usually halted for a certain period following ICH but data on the safety of therapy resumption is sparse and physicians largely use clinical judgment to weigh the benefit of therapy resumption against the risk of ICH recurrence. A randomized controlled trial called RESTART was published in The Lancet in 2019 to assess if restarting the ‘antiplatelet therapy only’ increased the risk of recurrent ICH. The trial suggested a slightly increased, but nonsignificant, risk of recurrent ICH but the results were limited by a short duration of follow-up. In the latter half of 2021, the extended follow-up of the RESTART trial was published in one of the most reputed Neurology journals i.e., JAMA Neurology.3 The trial recruited 537 participants with radiologically confirmed ICH and randomly allocated half patients to restart antiplatelets (aspirin, clopidogrel) and half patients to avoid antiplatelets. The primary outcome was the recurrent ICH events during the follow-up time of up to 7 years (mean time = 3 years). Recurrent ICH occurred in 22/268 (8.2%) participants assigned to antiplatelet therapy compared with 25/268 (9.3%) participants assigned to avoid antiplatelet therapy (adjusted HR=0.87; 95% CI, 0.49-1.55; p-value = .64). This suggests that re-starting antiplatelet therapy indicated for other occlusive vascular diseases (e.g., MI, ischemic stroke) is safe in patients who suffer from ICH while they are on antiplatelet therapy. This conclusion is in line with some observational studies4,5 published on the same topic but RESTART remains the only clinical trial to provide credible evidence. The exact incidence of ICH is not known in Pakistan but trends from Asian countries suggest a higher occurrence as compared to the Western world.1 The primary reason for such high occurrence is the predisposition of the elderly population to cardiovascular risk factors like hypertension and obesity. Pakistan suffers from a very high burden of coronary artery disease and a significant number of elderly people are on preventive antiplatelet therapy (especially aspirin). Discontinuation of aspirin after an ICH episode in such patients may lead to an increased risk of MI and studies also suggest that survivors of ICH are more likely to suffer from MI and ischemic stroke.6 This trial provides reasonable reassurance to the medical community about the use of antiplatelet therapy after ICH if indicated for secondary prevention of major vascular events. Therefore, the dissemination of this information to physicians practising in Pakistan is of paramount importance.

August 2022 Stroke Highlights

August 2022 Stroke Highlights

One-Year Outcome Trajectories and Factors Associated with Functional Recovery Among Survivors of Intracerebral and Intraventricular Hemorrhage With Initial Severe Disability

Patients who survive severe intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) typically have poor functional outcome in the short term and understanding of future recovery is limited. To describe 1-year recovery trajectories among ICH and IVH survivors with initial severe disability and assess the association of hospital events with long-term recovery. This post hoc analysis pooled all individual patient data from the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage phase 3 trial (CLEAR-III) and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE-III) phase 3 trial in multiple centers across the US, Canada, Europe, and Asia. Patients were enrolled from August 1, 2010, to September 30, 2018, with a follow-up duration of 1 year. Of 999 enrolled patients, 724 survived with a day 30 modified Rankin Scale score (mRS) of 4 to 5 after excluding 13 participants with missing day 30 mRS. An additional 9 patients were excluded because of missing 1-year mRS. The final pooled cohort included 715 patients (71.6%) with day 30 mRS 4 to 5. Data were analyzed from July 2019 to January 2022. CLEAR-III participants randomized to intraventricular alteplase vs placebo. MISTIE-III participants randomized to stereotactic thrombolysis of hematoma vs standard medical care. Primary outcome was 1-year mRS. Patients were dichotomized into good outcome at 1 year (mRS 0 to 3) vs poor outcome at 1 year (mRS 4 to 6). Multivariable logistic regression models assessed associations between prospectively adjudicated hospital events and 1-year good outcome after adjusting for demographic characteristics, ICH and IVH severity, and trial cohort. Of 715 survivors, 417 (58%) were male, and the overall mean (SD) age was 60.3 (11.7) years. Overall, 174 participants (24.3%) were Black, 491 (68.6%) were White, and 49 (6.9%) were of other races (including Asian, Native American, and Pacific Islander, consolidated owing to small numbers); 98 (13.7%) were of Hispanic ethnicity. By 1 year, 129 participants (18%) had died and 308 (43%) had achieved mRS 0 to 3. In adjusted models for the combined cohort, diabetes (adjusted odds ratio [aOR], 0.50; 95% CI, 0.26-0.96), National Institutes of Health Stroke Scale (aOR, 0.93; 95% CI, 0.90-0.96), severe leukoaraiosis (aOR, 0.30; 95% CI, 0.16-0.54), pineal gland shift (aOR, 0.87; 95% CI, 0.76-0.99]), acute ischemic stroke (aOR, 0.44; 95% CI, 0.21-0.94), gastrostomy (aOR, 0.30; 95% CI, 0.17-0.50), and persistent hydrocephalus by day 30 (aOR, 0.37; 95% CI, 0.14-0.98) were associated with lack of recovery. Resolution of ICH (aOR, 1.82; 95% CI, 1.08-3.04) and IVH (aOR, 2.19; 95% CI, 1.02-4.68) by day 30 were associated with recovery to good outcome. In the CLEAR-III model, cerebral perfusion pressure less than 60 mm Hg (aOR, 0.30; 95% CI, 0.13-0.71), sepsis (aOR, 0.05; 95% CI, 0.00-0.80), and prolonged mechanical ventilation (aOR, 0.96; 95% CI, 0.92-1.00 per day), and in MISTIE-III, need for intracranial pressure monitoring (aOR, 0.35; 95% CI, 0.12-0.98), were additional factors associated with poor outcome. Thirty-day event-based models strongly predicted 1-year outcome (area under the receiver operating characteristic curve [AUC], 0.87; 95% CI, 0.83-0.90), with significantly improved discrimination over models using baseline severity factors alone (AUC, 0.76; 95% CI, 0.71-0.80; P < .001). Among survivors of severe ICH and IVH with initial poor functional outcome, more than 40% recovered to good outcome by 1 year. Hospital events were strongly associated with long-term functional recovery and may be potential targets for intervention. Avoiding early pessimistic prognostication and delaying prognostication until after treatment may improve ability to predict future recovery.

Clinical effects of restarting antiplatelet therapy in patients with intracerebral hemorrhage

ObjectiveAntiplatelet (APT) medications have been used to treat ischemic stroke and cardiovascular diseases. However, they involve a risk of re-bleeding, especially in patients with intracerebral hemorrhage (ICH), which limits their clinical application. This study aimed to compare the incidence of recurrent ICH and ischemic events in ICH survivors on APT, as well as to assess the clinical effect and safety of APT resumption. MethodsWe retrospectively reviewed the medical records of patients with spontaneous ICH at two tertiary medical centers between January 2011 and December 2020. We included adult patients with ICH who regularly took APT medications for various medical conditions. The patients were divided into two groups based on their APT resumption. Subsequently, we performed between-group comparisons of clinical or radiological characteristics; moreover, analyzed the incidence of re-bleeding and ischemic events, as well as the various risk factors for each event. ResultsWe included 202 patients; among them, 118 patients restarted APT after initial ICH (APT resumption group) while 84 patients did not (no-APT resumption group). Compared with patients in the no-APT resumption group, those in the APT resumption group were more likely to have hyperlipidemia (p < 0.001) and a previous ischemic stroke event (p = 0.026). Recurrent ICH and ischemic vascular events occurred in 14 and 15 patients, respectively. Univariate analysis demonstrated that the risk factors for recurrent ICH were older age, renal dysfunction, and no APT resumption; however, only renal dysfunction significantly increased the risk of re-bleeding in multivariate analysis (HR, 4.631; 95 % CI 1.432–14.977; p = 0.010). Moreover, previous cerebral ischemia and atrial fibrillation were positively associated with ischemic events in univariate analysis; however, only atrial fibrillation demonstrated a significant correlation in multivariate analysis (HR, 4.309; 95 % CI 1.383–13.426; p = 0.012). APT resumption had a significant prevention effect on recurrent ICH (HR, 0.180; 95 % CI 0.055–0.586; p = 0.004) and ischemic vascular events (HR, 0.240; 95 % CI 0.077–0.750; p = 0.014). ConclusionsOur findings indicated that restarting APT in patients with ICH was not associated with an increased risk of recurrent ICH. APT can be safely restarted to prevent major thromboembolic complications in patients on previous antithrombotic treatment.

Focused Update on Vascular Risk and Secondary Prevention in Survivors of Intracerebral Hemorrhage.

HomeStrokeVol. 53, No. 7Focused Update on Vascular Risk and Secondary Prevention in Survivors of Intracerebral Hemorrhage No AccessReview ArticleRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessReview ArticleRequest AccessFull TextFocused Update on Vascular Risk and Secondary Prevention in Survivors of Intracerebral Hemorrhage Kevin N. Sheth, MD and Magdy Selim, MD, PhD Kevin N. ShethKevin N. Sheth Correspondence to: Kevin N. Sheth, MD, 15 York St, LLCI Room 1003C, PO Box 208018, New Haven, CT 06510. Email E-mail Address: [email protected] Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT (K.N.S.). Search for more papers by this author and Magdy SelimMagdy Selim Division of Stroke and Cerebrovascular Disease, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.S.). Search for more papers by this author Originally published27 Jun 2022https://doi.org/10.1161/STROKEAHA.122.039819Stroke. 2022;53:2128–2130FootnotesFor Sources of Funding and Disclosures, see page 2130.Correspondence to: Kevin N. Sheth, MD, 15 York St, LLCI Room 1003C, PO Box 208018, New Haven, CT 06510. Email kevin.[email protected]edu

Protecting the Brain, From the Heart: Safely Mitigating the Consequences of Thrombosis in Intracerebral Hemorrhage Survivors With Atrial Fibrillation.

Optimal antithrombotic management after intracerebral hemorrhage remains one of the central unresolved issues for patients who survive, especially for those patients with atrial fibrillation. Given the observational nature of the studies regarding anticoagulation resumption after intracerebral hemorrhage, there is uncertainty regarding resumption of oral anticoagulation therapy and its timing. There is limited high-quality evidence to guide clinical practice, leading to significant practice variation and uncertainty for patients and providers. Here, we aim to provide the key elements to guide clinicians in their individual decision: whether or not to start or resume anticoagulation in patients with a history of intracerebral hemorrhage.

Intracerebral haemorrhage in bacterial meningitis

ObjectiveTo determine the incidence, clinical course, radiological patterns, and clinical outcome of intracerebral haemorrhage (ICH) complicating community-acquired bacterial meningitis. MethodsThe clinical characteristics and outcome of patients with ICH complicating bacterial meningitis were studied in a prospectively nationwide cohort in the Netherlands performed from 2006 to 2018. ResultsICH was identified in 44 of 2306 episodes of bacterial meningitis (1.9%). Nine of these patients (20%) were diagnosed with ICH on admission and 35 (80%) during clinical course after a median of 5 days (1–9). ICH occurred in 4 patients with endocarditis (9%), 9 patients on anticoagulation (vitamin K antagonists and heparin; 20%), and 10 patients with cerebral infarctions (23%). In 31 patients (70%) ICH was a lobar haematoma. ICH in bacterial meningitis was associated with high rates of death (24 of 44 [55%] vs. 346 of 2200 [16%]; P < 0.001) and unfavourable outcome compared to non-ICH patients (39 of 44 [89%] vs. 798 of 2200 [36%]; P < 0.001). Neurological sequelae on discharge occurred frequently in ICH survivors compared to non-ICH patients (15 of 20 [75%] vs. 203 of 1669 [12%]; P < 0.001). ConclusionsICH is a rare but severe complication in patients with bacterial meningitis occurring in those with endocarditis, cerebral infarction, and anticoagulant use. ICH complicating bacterial meningitis is associated with high rates of death and morbidity.

In Search of the Optimal Antithrombotic Regimen for Intracerebral Hemorrhage Survivors with Atrial Fibrillation

Spontaneous intracerebral hemorrhage (ICH) constitutes 10-15% of all strokes, and is a significant cause of mortality and morbidity. Survivors of ICH, especially those with atrial fibrillation (AF), are at risk for both recurrent hemorrhagic and ischemic cerebrovascular events. A conundrum in the field of vascular neurology, neurosurgery, and cardiology has been the decision to initiate or resume versus withhold anticoagulation in survivors of ICH with AF. To initiate anticoagulation would decrease the risk of ischemic stroke but may increase the risk of hemorrhage. To withhold anticoagulation maintains a lower risk of hemorrhage but does not decrease the risk of ischemic stroke. In this narrative review, we discuss the evidence for and against the use of antithrombotics in ICH survivors with AF, focusing on recently completed and ongoing clinical trials.

P.177 Assessing lesion severity in a mouse model of intracerebral hemorrhage

Background: Intracerebral hemorrhage (ICH) is caused by the rupture of a blood vessel, resulting in bleeding into the brain. This type of stroke accounts for 12-15% of all strokes and is the most fatal type of stroke (40% mortality rate). ICH stroke presents a greater burden to survivors as 90% of ICH survivors have some degree of disability. Because of the poor patient outcomes, there is a clear need for identifying new treatments as well as establishing the efficacy of existing treatments. Methods: Using previously described techniques we aim to establish a mouse model of ICH at the University of Saskatchewan. We observed them at a 1- 24-, 48- and 72hr mark post-stroke and scored for neurological deficits. Results: We currently have conducted 23 model trials. We have data on mice at 1-, 24, and 72 hr post-stroke. We have observed and begun to analyze a lesion area that can be seen in H&amp;E stained sections, and further assessed with FTIR, and synchrotron modalities. Conclusions: We have analyzed several of the specimens with FTIR imaging and synchrotron analysis with the Canadian Light Source. We have preliminary results of the progression of metabolites in the hematoma and peri-hematoma zone of the ICH.

Lobar intracerebral hemorrhage and risk of subsequent uncontrolled blood pressure.

Uncontrolled blood pressure (BP) in intracerebral hemorrhage (ICH) survivors is common and associated with adverse clinical outcomes. We investigated whether characteristics of the ICH itself were associated with uncontrolled BP at follow-up. Subjects were consecutive patients aged ⩾18 years with primary ICH enrolled in the prospective longitudinal ICH study at Massachusetts General Hospital between 1994 and 2015. We assessed the prevalence of uncontrolled BP (mean BP ⩾140/90 mmHg) 6 months after index event. We used multivariable logistic regression models to assess the effect of hematoma location, volume, and event year on uncontrolled BP. Among 1492 survivors, ICH was lobar in 624 (42%), deep in 749 (50%), cerebellar in 119 (8%). Lobar ICH location was associated with increased risk for uncontrolled BP after 6 months (OR 1.35; 95% CI [1.08-1.69]). On average, lobar ICH survivors were treated with fewer antihypertensive drugs compared to the rest of the cohort: 2.1 ± 1.1 vs 2.5 ± 1.2 (p < 0.001) at baseline and 1.8 ± 1.2 vs. 2.4 ± 1.2 (p < 0.001) after 6 months follow-up. After adjustment for the number of antihypertensive drugs prescribed, the association of lobar ICH location with risk of uncontrolled BP was eliminated. ICH survivors with lobar hemorrhage were more likely to have uncontrolled BP after 6 months follow-up. This appears to be a result of being prescribed fewer antihypertensive medications. Future treatment strategies should focus on aggressive BP control after ICH independent of hemorrhage location.

Risk of Cerebrovascular Events in Intracerebral Hemorrhage Survivors With Atrial Fibrillation: A Nationwide Cohort Study.

Background:In patients with intracerebral hemorrhage (ICH) and prevalent atrial fibrillation (AF), the optimal stroke prevention strategy is unclear. We sought to estimate the risk of cerebrovascular events among ICH survivors with AF.Methods:We used the Danish Stroke Registry to identify patients with incident ICH and prevalent AF between 2003 and 2018. Key inclusion/exclusion criteria of the PRESTIGE-AF (Prevention of Stroke in Intracerebral hemorrhage Survivors With Atrial Fibrillation) trial were applied. Cumulative incidence of recurrent ICH, cerebrovascular ischemic event, and all-cause death were investigated after one year.Results:A total of 1885 patients (median age 80.0 years; 47.6% females) were included in the study. We observed 191 cerebrovascular events and 650 all-cause deaths, and more cerebrovascular ischemic events (N=63) than recurrent ICH events (N=40). Risks of recurrent ICH, cerebrovascular ischemic event, and all-cause death were 1.5%, 3.2%, and 30.3%, respectively, among patients not exposed to OAC during follow-up. The cumulative incidences were 2.8% for recurrent ICH, 3.2% for cerebrovascular ischemic events, and 22.0% for all-cause death among patients initiating/resuming OAC during follow-up.Conclusions:We observed a high risk of cerebrovascular ischemic events and a very high risk of all-cause death at one year after the incident ICH. The results of ongoing clinical trials are warranted to determine optimal stroke prevention treatment among ICH survivors with concomitant AF.

Long-term anxiety in spontaneous intracerebral hemorrhage survivors.

Although anxiety is common in several neurological conditions, it has been poorly investigated after spontaneous intracerebral hemorrhage (ICH). In consecutive ICH survivors, we assessed the long-term prevalence of anxiety and its clinical and radiological determinants. Using the Hospital Anxiety and Depression Scale (HADS), we evaluated ICH survivors enrolled in the prospective, single-center Prognosis of Intracerebral Hemorrhage (PITCH) study. The prevalence of anxiety (defined as a HADS-anxiety subscale score >7) was evaluated at three time points (1-2, 3-5, and 6-8 years after ICH), along with neurological symptoms severity, functional disability, and cognitive impairment scores. Clinical and radiological characteristics associated with anxiety were evaluated in univariate and multivariable models. Of 560 patients with spontaneous ICH, 255 were alive 1 year later, 179 of whom completed the HADS questionnaire and were included in the study. Thirty-one patients (17%; 95% confidence interval (CI) = 12-23) had anxiety 1-2 years, 38 (27%; 95% CI = 19-34) 3-5 years, and 18 (21%; 95% CI = 12-30) 6-8 years after ICH. In patients with anxiety, the prevalence of associated depressive symptoms was 48% 1-2 years, 61% 3-5 years, and 56% 6-8 years after ICH. Among clinical and radiological baseline characteristics, only lobar ICH location was significantly associated with anxiety 1-2 years after ICH (odds ratio = 2.8; 95% CI = 1.2-6.5). Anxiety was not associated with concomitant neurological symptoms severity, functional disability, or cognitive impairment. Anxiety is frequent in ICH survivors, often in association with depressive symptoms, even many years after the index event.