Intracerebral Hemorrhage Research Articles

SP1-mediated SYN1 promotes hemin-induced damage in PC12 cells in vitro and exacerbates blood-barrier disruption and brain injury after intracerebral hemorrhage in vivo

SP1-mediated SYN1 promotes hemin-induced damage in PC12 cells in vitro and exacerbates blood-barrier disruption and brain injury after intracerebral hemorrhage in vivo

Rustam Al-Shahi Salman: balancing depth and breadth with intracerebral haemorrhage

Rustam Al-Shahi Salman: balancing depth and breadth with intracerebral haemorrhage

Management of intracavitary bleeding during ultra-early minimally invasive intracerebral hemorrhage evacuation.

Surgical evacuation of intracerebral hemorrhage (ICH) at early time points contributes to improved functional outcomes. However, ultra-early evacuation has been associated with postoperative rebleeding, a devastating complication that contributes to worse outcomes. Minimally invasive endoscopic techniques allow for intraoperative management of active bleeding, potentially allowing for safe and effective hemostasis at ultra-early time points. The authors proposed and prospectively assigned an intraoperative grading scale that quantified the severity of bleeding encountered intraoperatively. They hypothesized that ultra-early evacuation would correlate to increased intraoperative bleeding but not postoperative rebleeding or worse long-term clinical outcomes in a cohort of patients undergoing minimally invasive endoscopic evacuation. Patients presenting to a large healthcare system with spontaneous supratentorial ICH were triaged to a central hospital for potential surgical evacuation. Inclusion criteria for evacuation included age ≥ 18 years, premorbid mRS score ≤ 3, hematoma volume ≥ 15 mL, and presenting National Institutes of Health Stroke Scale score ≥ 6. A 5-point scale was developed and prospectively applied to grade the severity of bleeding encountered intraoperatively. A score of 1 indicated no active intraoperative bleeding. A score of 2 indicated minimal bleeding treated with irrigation alone. A score of 3 indicated bleeding that required cauterization to control. A score of 4 indicated bleeding that required irrigation or cauterization for at least 15 minutes to achieve hemostasis. A score of 5 indicated bleeding that required irrigation or cauterization for at least 1 hour. The authors evaluated 142 consecutive patients. The median bleeding score was 2 (IQR 2-4). Greater preoperative volume, concomitant intraventricular hemorrhage, and earlier time to evacuation were independently associated with increased bleeding score. Specifically, ultra-early evacuation within 5 hours was independently associated with a 2.4-point greater bleeding score as compared with evacuation thereafter (β = 2.41, 95% CI 1.44-3.38; p < 0.0001). Despite having higher intraoperative bleeding scores, patients undergoing ultra-early evacuation did not have an increased likelihood of postoperative rebleeding (14% vs 3%, p = 0.23), 30-day mortality (0% vs 6%, p = 0.99), or worse median 6-month mRS scores (4 [IQR 2-5] vs 4 [IQR 3-5], p = 0.51). Ultra-early evacuation within 5 hours of ictus is associated with increased intraoperative bleeding but not postoperative rebleeding or worse clinical outcomes. These findings suggest that the benefits of ultra-early evacuation can be explored without an increased risk of postoperative rebleeding when utilizing a minimally invasive endoscopic technique with good intraoperative visualization, active irrigation for targeted tamponade, and direct cauterization of bleeding vessels.

Clinical Characteristics and Outcomes in Patients with Ruptured Middle Cerebral Artery Aneurysms: A Multicenter Study in Northern China.

The long-term prognosis of ruptured middle cerebral artery aneurysms (MCAAs) in northern China remains unclear. The aim of this study is to analyze the epidemiological characteristics and long-term outcomes of ruptured MCAAs in northern China. We included patients who were consecutively admitted for ruptured MCAAs to 12 tertiary care centers in northern China from January 2017 to December 2020. Kaplan‒Meier curves were used to compare survival in hazard strata. The Cox proportional hazards model was used to analyze risk factors and mortality risk, whereas logistic regression was used to identify factors influencing 2-year survival. Subgroup analyses were performed to verify the robustness of the results. Data on 959 patients with ruptured MCAAs were analyzed; 16.4% of these patients had ruptured intracranial aneurysms (RIAs) and were registered in the Chinese cerebral aneurysm database. The mean follow-up duration was 3.0years (range 0-6.2years). The 3-month and 2-year mortality rates were 15.5% and 18.2%, respectively. The risk factors for mortality were identified via Cox regression and were as follows: age > 70years, previous stroke, combined intracerebral hemorrhage (ICH)/intraventricular hemorrhage (IVH), poor Hunt and Hess grade, multiple aneurysms, and conservative treatment (CT). The positive association between the risk of death and CT was consistent across subgroups. According to logistic regression, hypertension, previous stroke, combined ICH/IVH, Hunt and Hess grade, and WFNS (World Federation of Neurological Surgeons) score were identified as factors negatively influencing 2-year survival. We detail the epidemiologic characteristics and long-term outcomes of MCAAs. The risk factors for mortality included age > 70years, previous stroke, combined ICH/IVH, poor Hunt and Hess grade, and multiple aneurysms. Compared with microsurgical treatment (MST), CT is associated with an increased risk of mortality, while the risk of mortality associated with endovascular treatment (EVT) is not significantly different. Two-year survival was associated with hypertension, previous stroke, ICH/IVH, and poor grades at admission.

Comparing white and gray matter responses to lobar intracerebral hemorrhage in piglets and the effects of deferoxamine

BackgroundIntracerebral hemorrhage (ICH) often impacts patient white matter. However, preclinically, the effects of ICH are mostly studied in rodents with sparse white matter. This study used a lobar porcine ICH model to examine differences in the effects of ICH on white and gray matter as well as the role of the iron chelator deferoxamine (DFX), on attenuation of such injury. MethodsThis two-part study was performed in piglets. Firstly, piglets had a needle (Sham) or 2.5 ml blood injection (ICH) and were euthanized at day 3. Secondly, animals were treated with vehicle or DFX after ICH and were euthanized at day 3. White and gray matter edema, the number of oligodendrocytes (mature and immature) and neurons, and the number of Perls' (iron), ferritin and heme oxygenase (HO)-1 positive cells were examined. ResultsAt day 3, ICH induced greater edema formation in white than gray matter. This marked white matter edema was associated with a loss of mature, but not immature, oligodendrocytes. ICH also induced neuronal death in gray matter. There were also marked increases in Perls', ferritin and HO-1 positive cells after ICH in both white and gray matter, but significantly more in the former. DFX attenuated ICH-induced brain edema in white but not gray matter and this was associated with increased survival of mature oligodendrocytes. DFX also increased survival of neurons in the gray matter and it reduced the number of Perls', ferritin and HO-1 positive cells in both tissue types. ConclusionsWhile there were commonalities in perihematomal changes between white and gray matter after ICH, there was greater edema in white matter which may be linked to the susceptibility of mature oligodendrocytes to ICH injury. Similarly, while DFX reduced perihematomal iron overload in both white and gray matter, it only significantly reduced edema in white matter where it increased the number of mature oligodendrocytes.

Tenecteplase versus alteplase for acute stroke within 4·5 h of onset (ATTEST-2): a randomised, parallel group, open-label trial

Tenecteplase has potential benefits over alteplase, the standard agent for intravenous thrombolysis in acute ischaemic stroke, because it is administered as a single bolus and might have superior efficacy. The ATTEST-2 trial investigated whether tenecteplase was non-inferior or superior to alteplase within 4·5 h of onset. We undertook a prospective, randomised, parallel-group, open-label trial with masked endpoint evaluation in 39 UK stroke centres. Previously independent adults with acute ischaemic stroke, eligible for intravenous thrombolysis less than 4·5 h from last known well, were randomly assigned 1:1 to receive intravenous alteplase 0·9 mg/kg or tenecteplase 0·25 mg/kg, by use of a telephone-based interactive voice response system. The primary endpoint was the distribution of the day 90 modified Rankin Scale (mRS) score and was analysed using ordinal logistic regression in the modified intention-to-treat population. We tested the primary outcome for non-inferiority (odds ratio for tenecteplase vs alteplase non-inferiority limit of 0·75), and for superiority if non-inferiority was confirmed. Safety outcomes were mortality, symptomatic intracranial haemorrhage, radiological intracranial haemorrhage, and major extracranial bleeding. The trial was prospectively registered on ClinicalTrials.gov (NCT02814409). Between Jan 25, 2017, and May 30, 2023, 1858 patients were randomly assigned to a treatment group, of whom 1777 received thrombolytic treatment and were included in the modified intention-to-treat population (n=885 allocated tenecteplase and n=892 allocated alteplase). The mean age of participants was 70·4 (SD 12·9) years and median National Institutes of Health Stroke Scale was 7 (IQR 5-13) at baseline. Tenecteplase was non-inferior to alteplase for mRS score distribution at 90 days, but was not superior (odds ratio 1·07; 95% CI 0·90-1·27; p value for non-inferiority<0·0001; p=0·43 for superiority). 68 (8%) patients in the tenecteplase group compared with 75 (8%) patients in the alteplase group died, symptomatic intracerebral haemorrhage (defined by SITS-MOST criteria) occurred in 20 (2%) versus 15 (2%) patients, parenchymal haematoma type 2 occurred in 37 (4%) versus 26 (3%) patients, post-treatment intracranial bleed occurred in 94 (11%) versus 78 (9%) patients, significant extracranial haemorrhage occurred in 13 (1%) versus six (1%) patients, respectively, and angioedema occurred in six (1%) participants in both groups. Tenecteplase 0·25 mg/kg was non-inferior to 0·9 mg/kg alteplase within 4·5 h of symptom onset in acute ischaemic stroke. Easier administration of tenecteplase, especially in the context of interhospital transfers, indicates that tenecteplase should be preferred to alteplase for thrombolysis in acute ischaemic stroke. The ATTEST-2 population was large and representative of thrombolysis-eligible patients in the UK and, together with findings from other trials, provides robust evidence supporting the introduction of tenecteplase in preference to alteplase. The Stroke Association and British Heart Foundation.

Overall and linked blood pressure variabilities in the first 24 hours and mortality after spontaneous intracerebral hemorrhage: a retrospective study of 1,036 patients.

This study aims to establish the individual contributions of blood pressure variability (BPV) indexes, categorized into overall and linked variability, to mortality following intracerebral hemorrhage (ICH) by examining the risk factors. Patients with spontaneous ICH (n = 1,036) were identified with valid blood pressures (BP) from the first 24-h systolic BP records in the Medical Information Mart for Intensive Care IV version 2.2 database (MIMIC IV). Information on the baseline characteristics, including age, sex, initial Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) scores, ICH location, Charlson comorbidity index score, and presence of diabetes with or without complications, were collected. Three indexes of BPV-range, standard deviation (SD), and generalized BPV (GBPV)-were calculated using the first 24-h systolic BPs. An automated stepwise variable-selection procedure was used to develop the final logistic model for predicting in-hospital mortality. Out of 1,036 patients, 802 (77.4%) survived and were discharged after spontaneous ICH. Factors associated with mortality included age; male sex; ICH in the brainstem, ventricle, or multiple locations; low GCS score (< 9); high NIHSS score (> 20); and diabetes with complications. Mean systolic BP, SD, and GBPV were also linked to mortality. Higher GBPV notably increased the risk of in-hospital death, with an odds ratio of 3.21 (95% confidence interval, 2.10 to 4.97) for every + 10 mmHg/h change in GBPV. This study underscores the additional impact of GBPV, herein linked to BPV, on mortality following ICH, providing further insights into the management of blood pressure in the early stages of ICH treatment.

Minimally Invasive Surgery for Spontaneous Intracerebral Hemorrhage: Meta-Analysis of High-Quality Randomized Clinical Trials.

Spontaneous intracerebral hemorrhage (ICH) poses high mortality and morbidity rates with limited evidence-based therapeutic approaches. We aimed to evaluate the current evidence for the role of minimally invasive surgery (MIS) in the management of ICH. This systematic review and meta-analysis followed recommended guidelines and protocols. Medline, Embase, Scopus, and the Cochrane Library were searched from inception up to April 12, 2024. The inclusion was restricted to randomized clinical trials (RCTs) of high quality, ensuring they were not deemed to have a high risk of bias in any of the Cochrane risk of bias tool (RoB2) domains. Primary outcomes were good functional outcome (modified Rankin scale, 0-3) and mortality beyond 90 days. Secondary outcomes were early mortality within 30 days and rebleeding rates. We pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) using random-effects models. Fourteen high-quality RCTs were included. There were 3,027 patients with ICH (1,475 randomized to MIS, and 1,452 randomized to medical management or craniotomy). Of included patients, 1,899 (62.7%) were males. MIS resulted in higher odds of achieving long-term good functional outcome (OR, 1.51 [95% CI, 1.25-1.82]), lower odds of long-term mortality (OR, 0.72 [95% CI, 0.57-0.90]) and lower odds of early mortality (OR, 0.73 [95% CI, 0.56-0.95]). Rebleeding rates were similar (OR, 1.10 [95% CI, 0.55-2.19]). The treatment effect of MIS was consistent across multiple sensitivity and subgroup analyses, including individuals with deep ICH. This meta-analysis provides high-quality clinical trial evidence supporting the use of MIS as a primary treatment strategy in the management of ICH. ANN NEUROL 2024.

Pathology-Proven Cerebral Amyloid Angiopathy in a Patient with Spontaneous Intracerebral Hemorrhage

Cerebral amyloid angiopathy (CAA) related intracerebral hemorrhage (ICH) accounts for 20% of all types of spontaneous ICH. Results of brain magnetic resonance imaging (MRI) supports the clinical diagnosis of suspected CAA and can help predict the future risk of ICH. A definitive diagnosis of CAA requires brain biopsy and histopathological analysis.

026. Utilizing Pre-Existing Lacerations for Frontal Bone Fracture Management: A Case Report

Background: Patients with fractures of the frontal bone use the coronal incision approach to expose the anterior cranial vault, including the forehead. The flap allows for widespread exposure of the fractures, facilitating access for the removal of segmental fractures and hematoma evacuation. Maintaining sufficient pedicle width is crucial to reduce the risk of unintentional arterial damage and to ensure proper venous drainage. The objective of this study was to document the surgical approach for segmental fracture removal under a forehead pedicle flap. Case: This case presents a 22-year-old male with moderate traumatic brain injury, who had two lacerations on his forehead and showed an open depressed fracture of the frontal bone after a motor vehicle collision. The patient experienced loss of consciousness and a history of vomiting. Imaging revealed intracerebral hemorrhage in the frontal region and a depressed fracture of the frontal bone. Intraoperative findings revealed the fracture site through the previous laceration incision. The fracture was clearly evaluated by the surgeon using tools to lift the skin between the two incisions. Conclusion: Despite the access for segment fracture removal being conducted through a pre-existing laceration, the patient outcomes were favorable, and no complications were reported.

From the INVICTUS Trial to Current Considerations: It’s Not Time to Retire Vitamin K Inhibitors Yet!

Atrial fibrillation (AF) is a common arrhythmia in clinical practice, and oral anticoagulation is the cornerstone of stroke prevention in AF. Direct oral anticoagulants (DOAC) significantly reduce the incidence of intracerebral hemorrhage with preserved efficacy for preventing stroke compared to vitamin K antagonists (VKA). However, the pivotal randomized controlled trials (RCTs) of DOAC excluded patients with valvular heart disease, especially mitral stenosis, which remains an exclusion criterion for DOAC use. The INVICTUS study was a large multicenter global RCT aimed at evaluating the role of DOAC compared to VKA in stroke prevention among patients with rheumatic valvular AF. In this study, rivaroxaban failed to prove superiority over VKA in preventing the composite primary efficacy endpoints of stroke, systemic embolism, myocardial infarction, and death. Unfortunately, the bleeding rates were not lower with rivaroxaban either. The death and drug discontinuation rates were higher in the DOAC arm. Close to the heels of the dismal results of INVICTUS, an apixaban trial in prosthetic heart valves, PROACT-Xa, was also prematurely terminated due to futility. Hence, for AF complicating moderate-to-severe mitral stenosis or prosthetic valve VKA remains the standard of care. However, DOAC can be used in patients with surgical bioprosthetic valve implantation, TAVR, and other native valve diseases with AF, except for moderate-to-severe mitral stenosis. Factor XI inhibitors represent a breakthrough in anticoagulation as they aim to dissociate thrombosis from hemostasis, thereby indicating a potential to cut down bleeding further. Multiple agents (monoclonal antibodies—e.g., osocimab, anti-sense oligonucleotides—e.g., fesomersen, and small molecule inhibitors—e.g., milvexian) have garnered positive data from phase II studies, and many have entered the phase III studies in AF/Venous thromboembolism. Future studies on conventional DOAC and new-generation DOAC will shed further light on whether DOAC can dethrone VKA in valvular heart disease.

Intracerebral Hemorrhage: Keep It Simple.

The quotation, attributed to Confucius many centuries ago, in our opinion, applies to the evolving story of defining a primary surgical treatment for spontaneous intracerebral hemorrhage. The precise quote is: "Keep it simple and focus on what matters. Don't let yourself be overwhelmed."1 The evidence from multiple trials on intracerebral hemorrhage regarding mortality benefit and potential functional benefit directs us toward the simple task of evacuating the clot, similar to our prime focus on opening the artery in ischemic stroke. We need not be overwhelmed by questions about adjustments to patient selection, comparative techniques, and precision timing, for which we do not have conclusive data. We review the consensus results from the recent MISTIE trial (Minimally Invasive Surgery Plus Alteplase in ICH Evacuation) and ENRICH trial (Early Minimally Invasive Removal of Intracerebral Hemorrhage) and articulate remaining questions where further evidence is needed to challenge equipoise and define future practice.

Reliability of ABC/2 volumetric estimation in spontaneous intracerebral hemorrhage for hematoma expansion prediction scores.

Prediction scores for hematoma expansion in spontaneous intracerebral hemorrhage (ICH), such as the 9-point and BRAIN scores, were developed predominantly using planimetry to measure hematoma volume. In this study, we aim to investigate whether the ABC/2 formula, which is known to overestimate hematoma volume, can be reliably used as a substitute for planimetry in these prediction scores. A total of 429 patients from four hospitals were retrospectively enrolled. CT scan and clinical data at admission and follow-up CT scan were collected. The 9-point and BRAIN scores were calculated using hematoma volume from ABC/2 and planimetry. Hematoma expansion was assessed using hematoma volume from planimetry. The median hematoma volume measured by ABC/2 was 11.97 ml (interquartile range [IQR], 4.8-30.0), whereas the volume measured by planimetry was 11.70 ml (IQR, 4.9-26.6). The median measurement error between ABC/2 and planimetry was 0.30 ml (IQR, -0.72-2.87). ABC/2 overestimated hematoma volume in 244 patients (56.9%) compared to planimetry. In the 9-point score, the area under the curves (AUCs) for predicting hematoma expansion were 0.735 (95% confidence interval [CI], 0.675-0.796) with ABC/2 and 0.732 (95% CI, 0.672-0.793) with planimetry. In the BRAIN score, the AUCs were 0.753 (95% CI, 0.693-0.813) with ABC/2 and 0.745 (95% CI, 0.688-0.803) with planimetry. The 9-point and BRAIN scores using hematoma volume measured by ABC/2 and planimetry showed good performance in predicting hematoma expansion in ICH. ABC/2 volumetric estimation proved to be reliable for these scores.

Exploring the Connection Between Family History of Seizures and Post-traumatic Brain Injury Seizure Types: A Retrospective Study

Background: Traumatic brain injury (TBI) is one of the most common presentations to emergency departments and is associated with seizures carrying different significance at different stages following injury. The occurrence of seizures after head injury is a recognized complication of TBI and has been demonstrated to worsen functional outcomes significantly. Despite previous studies identifying various PTS risk factors, our understanding remains limited, particularly regarding familial seizure history. Materials and Methods: A retrospective study was conducted at King Abdullah University Hospital (KAUH), Jordan, examining 1934 TBI cases from 2017 to 2023, identifying 118 patients with confirmed post-traumatic seizures. Results: This study involved 118 TBI patients, aged between 2 and 86 years (median 21.5 years), with 74.6% male and 25.4% female. A family history of seizures was reported by 23.7% of patients. Intracerebral hemorrhage (ICH) (52.5%) and subarachnoid hemorrhage (SAH) (38.1%) were the predominant trauma types. Generalized tonicclonic (GTCs) seizures (69.5%) and focal seizures (30.5%) were observed post-TBI. Among 28 patients with a family history of seizures, no evidence of association was observed between the family history and post-traumatic seizure types (GTCs or focal seizures), this was confirmed by performing Chi-square tests (p = 0.9841) and logistic regression analysis (p = 0.79). Conclusion: Our findings suggest that there is no evidence of the association between family history and post-traumatic seizure types, implying that a specialized approach for patients with positive family histories may not be warranted. Larger studies are recommended for further validation.

Early Resolution of Abnormal Vascular Networks After Superficial Temporal Artery to Middle Cerebral Artery (STA-MCA) Bypass Surgery for Twig-Like Middle Cerebral Artery With Intracerebral Hemorrhage: A Case Report

Early Resolution of Abnormal Vascular Networks After Superficial Temporal Artery to Middle Cerebral Artery (STA-MCA) Bypass Surgery for Twig-Like Middle Cerebral Artery With Intracerebral Hemorrhage: A Case Report

Editorial: Brain injury in spontaneous intracerebral hemorrhage: from bench to bedside

Editorial: Brain injury in spontaneous intracerebral hemorrhage: from bench to bedside

Mild intracerebral bleeding does not adversely affect survival and neurological outcome of surgical therapy for left-sided infective endocarditis

Abstract Background Intracerebral bleeding (IB) is a serious condition that requires increased attention and has implications for treatment options. For patients with infective endocarditis (IE), current guidelines recommend postponing surgery if IB is present. IB can be classified into four relevant groups (following European Cooperative Acute Stroke Study and Heidelberger Bleeding classification): hemorrhagic transformation (HT) 1 and 2, and parenchymal hemorrhage (PH) 1 and 2. PH2 is the only IB with neurological deterioration. These classifications were originally introduced for stroke patients following thrombolysis but without IE. The hypothesis tested in our study is that IB may influence IE treatment and thus outcome. Method Patients were retrospectively identifyied who were operated for left-sided IE, neuroradiologists re-evaluated and classified preoperative cerebral imaging for any IB. Outcome was quantified using the modified Rankin score (mRS), and mRS were extracted from the patients’ hospital chart at admission and by follow-up telephone call (FU), also including mortality. To ensure that the influence of IB was comparable, patients with IB (IB+) were propensity matched (EuroScore 2, Charlson Comorbidity Index, C-reactive protein; nearest neighbor match) to patients without IB (IB-) who also received surgical IE therapy. All IB+ patients underwent a careful risk-benefit analysis before therapy. Results Of 286 consecutive patients (January 2015 - November 2022) operated for left-sided IE, 36 had IB (65±13 years, 26% female): 11 with HT1, 9 with HT2, 8 with PH1, and 8 with PH2. These patients were matched with 36 operated IB- patients. Survival analysis showed no overall effect of IB+ vs. IB- (p = 0.112, 95% CI of hazard ratio was 0.246-1.243 vs. 0.709-3.572). Although there was no effect of IB on survival in the mild IB subgroup (HT1/2, Figure A), there was a difference in patients with severe IB (PH1/2) with less survival in IB+ (Figure B). Neurological outcome (ΔmRS) showed an effect of IB grade in the two-way ANOVA analysis (p = 0.029). Intergroup comparison showed a significantly better outcome for IB- (vs. IB+) in the PH2 subgroup (p = 0.034), but not in other subgroups. For all groups, the mean ΔmRS for IB+ was 1.1±1.6 vs. 0.70±1.4 for IB- (p = 0.256). The mean FU time was 2.6±2.1 years. Conclusion In patients operated for left-sided IE, mild IB did not affect survival or neurological outcome. In the more severe forms of IB, i.e. PH1 and PH2, survival was less favorable compared to matched controls. Furthermore, we observed a difference in neurological outcome in patients with severe IB. Thus, surgical therapy of left-sided IE should be avoided in patients with severe IB, whereas we can add evidence to the safety of surgical therapy in mild IB. Therefore, we recommend regular assessment of the degree of IB in such patients.Figure

Cardiac troponin elevation in intracerebral hemorrhage patients may rather reflect acute myocardial damage than acute myocardial infarction

Abstract Background Patients with acute ischemic stroke (AIS) and elevated cardiac troponin (cTn) have worse functional and mortality-related outcome. While elevated cTn is also frequently observed in patients with intracerebral hemorrhage (ICH), routine invasive coronary angiography should not be performed on these patients. Existing data on correlation of cTn elevation with patient outcome and the underlying causes in this specific patient group are sparse and largely heterogeneous. Purpose To investigate the clinical variables that predict cTn elevation in patients with ICH and the impact of cTn elevation on intrahospital mortality and functional outcome. Methods Our long-term Stroke Database was screened for ICH patients with high-sensitivity (hs) cTn measurement on admission (from 2015 onwards). Baseline characteristics, intrahospital mortality and functional outcome at discharge were compared between the groups with and without cTn elevation (hs-cTnI &amp;gt; vs. ≤0.045 µg/L). In addition, clinical variables with suspected significance for cTn elevation were analyzed for their predictive value. Results A total of 93/498 patients with ICH (18.7%; mean age 73±15 years, 53.8% females) were found to have a cTn elevation. Regarding etiology, 38.7% had an ICH occurring after AIS and 31.2% had a hypertensive ICH (each p=NS between groups). Patients with cTn elevation did not have a more pronounced cardiovascular risk profile and had a comparably low prevalence of coronary artery disease (CAD; 18.5%, p=NS). However, they were significantly less likely to be on oral anticoagulation at the time of the bleeding event (7.5 vs. 18.0%, p=0.013). CTn elevation had no negative impact on intrahospital mortality (21.5 vs. 20.5%, p=NS) or functional outcome at discharge (NIHSS score 10 (2; 26) vs. 9 (2; 22) points, mRS 5 (3; 5) vs. 5 (3; 5) points, each p=NS). Increasing NIHSS score on admission (p=0.021, OR 1.084 [1.012-1.160]), mRS ≥4 on admission (p=0.005, OR 2.207 [1.180-2.826]), infratentorial bleeding localization (p=0.034, OR 4.899 [1.132-21.207]) and aortic valve stenosis ≥ intermediate (p&amp;lt;0.001, OR 8.435 [2.429-29.294]) predicted cTn elevation. In contrast, severely impaired left ventricular function, CAD, atrial fibrillation, intraventricular hemorrhage or ICH occurring after AIS had no predictive value. Conclusions Almost one fifth of patients with ICH had an elevated cTn. Unlike in AIS, in ICH cTn elevation was not associated with a worse functional or mortality-related intrahospital outcome. In particular, severe functional impairment on admission, reflecting severe ICH, or infratentorial hemorrhage localization, thought to affect the autonomic nervous system, was predictive of concomitant myocardial cell damage. CAD was rare overall. This could indicate that the cTn elevation in connection with ICH is primarily related to acute myocardial damage along the brain-heart axis and less to myocardial infarction.

The incidence and outcome of patients with early cardiovascular complications following intracerebral haemorrhage: An individual patient data pooled analysis from the VISTA database

Abstract Background Early cardiovascular (CV) complications in patients following intracerebral haemorrhage (ICH) is poorly understood. Such incident CV complications could be part of the so-called stroke-heart-syndrome occurring following ICH (SHS-ICH). We investigated the incidence and outcomes of patients with SHS-ICH. Methods Data were sought from the Virtual International Stroke Trials Archive (VISTA), an international repository of clinical trials data. We reviewed relevant adverse events and identified patients based on the incidence of cardiovascular complications within 30 days of post-ICH or ischaemic stroke (acute coronary syndrome [ACS] including acute myocardial injury, heart failure [HF]/left ventricular [LV] dysfunction, atrial fibrillation [AF]/atrial flutter [AFL], other arrhythmia/ ECG abnormalities, and cardio-respiratory arrest [CRA]). We conducted propensity score matching (PSM) to compare the incidence and outcomes of patients with SHS following ICH (SHS-ICH) with patients with SHS following acute ischaemic stroke (AIS). Poor outcome was defined as modified Rankin Scale, mRS ≥2, at 90 days. Results We pooled data from 12,438 participants recruited in acute stroke trials (mean age 68±12 years; 56% male), of which 1,171 (9.4%) were patients with ICH. Of the ICH patients, 150 patients (12.8%) had SHS-ICH. Following PSM, a total of 2,342 patients (1,171 for each of the ICH and AIS cohorts) were analysed. The incidence of SHS was not significantly different in the ICH and AIS cohorts (Table 1). The incidence of AF was significantly lower in patients with ICH compared to patients with AIS (1.5% vs. 4.5%, p&amp;lt;0.0001), despite comparable incidences of other arrhythmia/ECG abnormalities (9% vs. 9%, p=0.9). Multivariate-adjusted analysis found that SHS-ICH was associated with poor outcomes (Table 2, odds ratio, OR 1.08 [95%CI: 1.03-1.16], p=0.04, compared to ICH patients without SHS). Conclusions Stroke-heart syndrome is common and serves as a crucial prognostic marker in patient with ICH, with outcomes similar to SHS patients related to AIS. The development of SHS-ICH was associated with poorer outcomes compared to ICH patients without SHS.

A severity comparison of leukoaraiosis in ischemic and hemorrhagic stroke: a retrospective study.

Leukoaraiosis (LA) is a common neuroradiological finding in patients suffering from stroke. Cerebral small-vessel disease (SVD) is one of the primary causes of both ischemic stroke and hemorrhagic stroke (intracerebral hemorrhage, ICH) and the development of LA. Significant evidence that LA predicts the risk of functional dependency and mortality exists. However, studies examining the difference in LA severity between ischemic stroke and hemorrhagic stroke are lacking. We therefore aimed to compare the severity and abundance of LA in the two stroke subgroups. All patients admitted to the Department of Neurology, Haukeland University Hospital, with an ischemic stroke and intracerebral hemorrhagic (ICH) stroke diagnosed between 2006 and 2020 were included in the study. We collected patient data on risk factors and clinical and radiological findings and outcomes from our local stroke registry. The presence and severity of LA were assessed using the Fazekas score based on CT imaging. We evaluated the outcome using the modified Rankin Score (mRS) 7 days post-stroke. A total of 5,084 patients were included in our analyses: 4437 (87%) with ischemic stroke and 647 (13%) with ICH. LA was present in 2476 (45%) patients. In our ordinal logistic regression model, adjusting for age, sex, known hypertension, known diabetes mellitus, and smoking, LA was more severe and more abundant in ICH patients compared to ischemic stroke patients (Fazekas score: 1, OR: 1.54; Fazekas score: 2, OR: 1.88; and Fazekas score: 3, OR 2.13; p < 0.001). Increasing severity of LA was associated with worse functional outcomes in both groups (ischemic stroke, OR: 1.49; p < 0.001 and ICH, OR: 1.36; p < 0.025). In this study, LA was more severe and abundant in patients with ICH.