Intracerebral Hemorrhage Location Research Articles

Spatial Correlates of Dementia and Disability After Intracerebral Hemorrhage.

Dementia and disability are highly prevalent after spontaneous intracerebral hemorrhage (ICH). Previous studies categorizing ICH by large anatomic boundaries have demonstrated that lobar ICH is associated with dementia, while ICH in the basal ganglia is associated with disability. This study aims to refine our understanding of the association between ICH location and post-ICH dementia and disability at a voxel level, which could improve the prognostic accuracy of these outcomes and provide mechanistic insights into post-ICH functional outcomes. In this cohort study, we segmented the ICH lesions from the noncontrast computed tomography scans from 882 patients from the MGH-ICH (Massachusetts General Hospital ICH Study) as the discovery data set and from 146 patients from the Yale-ICH cohort as the validation data set. Using electronic health records and follow-up telephone interviews, incident dementia (International Classification of Diseases, Ninth Revision [ICD-9] codes of dementia or modified telephone interview for cognitive status <20) and disability (modified Rankin Scale score >2) were identified. The median follow-up times of the MGH-ICH and Yale-ICH cohorts were 2.9 (interquartile range, 1.0-5.8) years and 1.0 (interquartile range, 0.6-1.0) years, respectively. Two techniques of lesion symptom mapping were applied on the ICH lesions: sparse canonical correlation analysis for neuroimaging and voxel-based lesion symptom mappings. Dementia conversion after ICH was associated with ICH in the left temporo-occipital region (mean hazard ratio [HR], 3.62 [95% CI, 2.71-4.63]) and left superior longitudinal fasciculus (mean HR, 2.91 [95% CI, 2.40-3.52]). Development of disability after ICH was linked to the right cerebral peduncle (mean HR, 3.10 [95% CI, 2.44-3.94]), right pallidum (mean HR, 2.96 [95% CI, 1.99-4.25]), and right posterior limb of the internal capsule (mean HR, 2.54 [95% CI, 1.88-3.96]). Specific distribution of ICH lesions is linked to development of dementia and disability after ICH. These insights have the potential to enhance clinical prognostic models for patients with ICH, facilitating more precise predictions of outcomes based on hemorrhage location.

Differential Risk Factors for Hematoma Expansion in Deep and Lobar Intracerebral Hemorrhage.

Understanding the risk factors for hematoma expansion (HE) in different regions of intracerebral hemorrhage (ICH) can help in the development of more accurate HE prediction tools and in implementing more effective clinical treatment interventions. This study aims to investigate the risk factors for HE in patients with lobar and deep ICH. A retrospective analysis was conducted on 558 cases of primary supratentorial ICH from Tongji Hospital Affiliated to Tongji University. Patients were categorized into lobar ICH and deep ICH groups. Differential analysis of ICH characteristics at different locations was performed, followed by subgroup analysis based on HE occurrence. Binary logistic regression was used to identify independent risk factors for HE in each group. Among the 404 patients with ICH who underwent follow-up noncontrast computed tomography (NCCT) scans, the proportion with HE was similar in the deep ICH group (23.2%) and the lobar ICH group (22.7%). Binary logistic regression analysis revealed that fluid level (odds ratio [OR] 4.77, 95% confidence interval [CI] 1.74-13.06), admission Glasgow Coma Scale score (OR 0.87, 95% CI 0.80-0.96), and time from onset to NCCT examination (OR 0.84, 95% CI 0.75-0.94) were independently associated with HE in thedeep ICHgroup. In thelobar ICHgroup, irregular shape (OR 4.96, 95% CI 1.37-18.01) and fibrinogen level (OR 0.42, 95% CI 0.21-0.86) were significant risk factors. Fluid level, low admission Glasgow Coma Scale score, and shorter time from onset to NCCT are independent predictors of HE in deep ICH, whereas irregular shape and low fibrinogen levels are independent predictors of HE in lobar ICH. These findings are of great significance for elucidating the mechanisms underlying HE in different locations of ICH and for developing precise predictive models of HE.

Functional outcome prediction in Japanese patients with non-surgical intracerebral hemorrhage: The FSR ICH Score.

There has been limited research on predicting the functional prognosis of patients with non-surgical intracerebral hemorrhage (ICH) from the acute stage. The aim of this study is to develop a risk prediction model for the natural course in patients with non-surgical ICH and to evaluate its performance using a multicenter hospital-based prospective study of stroke patients in Japan. We consecutively registered a total of 1,017 patients with acute ICH (mean age, 68 years) who underwent conservative treatment and followed them up for 3 months. The study outcome was a poor functional outcome (modified Rankin Scale score, 4-6) at 3 months after ICH onset. To develop the risk prediction model for natural course in patients with non-surgical ICH, we included the following clinical common factors assessed on admission in daily clinical practice for ICH: age, sex, medical history (hypertension, diabetes mellitus, dyslipidemia, pre-stroke dementia, previous stroke, coronary artery disease, smoking status, alcohol drinking status, oral anticoagulation, and antiplatelet medication), admission status (Time from onset to admission, systolic blood pressure, diastolic blood pressure, pulse pressure, plasma glucose levels, severity of the stroke), and neuroradiologic data (ICH location, intraventricular hemorrhage, and hematoma volume).The risk prediction model for poor functional outcome was developed using logistic regression analysis. In addition, the risk prediction model was translated into a point-based simple risk score (FSR ICH score) using the approach in the Framingham Heart Study. At 3 months after the ICH onset, 323 (31.8%) patients developed a poor functional outcome. Age, diabetes mellitus, pre-stroke dementia, NIHSS score on admission, intraventricular hemorrhage, and hematoma volume were included in the risk prediction model. This model demonstrated excellent discrimination (C statistic=0.884 [95% confidence interval, 0.863-0.905]; optimism-corrected C statistic based on 200 bootstrap samples=0.877) and calibration (Hosmer-Lemeshow goodness-of-fit test: P=0.72). The FSR ICH score, a point-based simple risk score, also showed excellent discrimination, with a C statistic of 0.882 (95% CI: 0.861-0.903). We developed a new risk prediction model for 3-month poor functional outcome in patients with non-surgical ICH using a multicenter hospital-based prospective study in Japan. The current risk prediction model has the potential to be a useful tool for estimating the natural course in patients with non-surgical ICH, aiding in making treatment decisions, including surgical options, early formulation of rehabilitation plans, and efficient utilization of medical resources.

Spectrum of Intracranial Hemorrhages in Cerebral Venous Thrombosis: A Pictorial Case Series and Review of Pathophysiology and Management.

We aim to provide a pictorial representation of the broad spectrum of intracranial hemorrhages associated with cerebral venous thrombosis (CVT), emphasizing atypical locations and rare intracerebral hemorrhage (ICH) types. We also hypothesize the pathophysiology leading to atypical locations of the ICH in CVT and the outcomes with anticoagulation therapy. ICH complicates about 40% of cases with CVT and is known to cause various types of ICH, including subarachnoid hemorrhage (SAH) and subdural hemorrhage (SDH). A combination of hemorrhages is also reported. Patients with computed tomography and magnetic resonance imaging findings consistent with CVT examined between January 2011 and June 2014 were included in this retrospective review. Demographic and clinical data and imaging findings were reviewed with particular attention to the type and location of ICH and sinus involvement. Treatment details and 3-month outcomes, assessed using the modified Rankin Scale, were analyzed. Eleven patients (9 males), ranging in age from 22 years to 58 years, were included. The most common clinical presentations were headache (n = 8) and seizures (n = 7). Intraparenchymal hemorrhages were most common (n = 7), followed by SDH and SAH (n = 4), intraventricular hemorrhage (IVH; n = 3), and juxtacortical hemorrhage (n = 1). All patients who received anticoagulation therapy (n = 11) experienced complete resolution of their symptoms, and the median modified Rankin Scale was 0. The spectrum of intracranial hemorrhages seen in association with CVT is broad, encompassing atypical locations like basal ganglia, external capsule, and cerebellar hemispheres, and involves multiple intracranial compartments-IVH, SAH, and SDH. While SAH and SDH are seen with superior sagittal sinus thrombosis, ICH is common with lateral sinus thrombosis, and IVH with deep venous thrombosis.

Acute hyperglycemia is associated with intraventricular extension among patients with spontaneous intracerebral hemorrhage

ObjectiveAcute hyperglycemia following intracerebral hemorrhage (ICH) is associated with poor functional outcomes and may result from a neuroendocrine stress response. Given the proximity of neuroendocrine structures to the cerebral ventricles, we tested the hypothesis that intraventricular hemorrhage (IVH) is associated with hyperglycemia. Materials and methodsA post-hoc analysis of the ICH Deferoxamine (i-DEF) trial was conducted to determine predictors of IVH. Variables with significant differences (p < 0.1) in univariable tests between patients with and without IVH were entered into a logistic regression model along with age, sex, diabetes, hyperglycemia (admission glucose ≥140 mg/dL), and baseline intraparenchymal hemorrhage (IPH) volume. This model was then applied to an independent cohort of consecutive non-traumatic ICH patients admitted to a single referral center (2007 to 2018). ResultsAmong 294 patients in the i-DEF cohort with mean age 60 ± 12 years (IVH in 41 %), hyperglycemia (aOR 1.90, 95 % CI [1.06–3.38]), smoking history (aOR 1.90, 95 % CI [1.11–3.27]), and non-lobar ICH location (aOR 3.38, 95 % CI [1.49–7.69]) were independently associated with IVH. In the independent cohort consisting of 856 patients with mean age 71 ± 12 years (IVH in 37 %), hyperglycemia (aOR 2.23, 95 % CI [1.55–3.20]), non-lobar ICH location (aOR 2.50, 95 % CI [1.75–3.59]), and IPH volume (aOR 1.02, 95 % CI [1.01–1.02]) were associated with IVH. ConclusionsHyperglycemia is associated with IVH and may be a peripheral marker for the inflammatory response to hemorrhage within the ventricles. Further translational studies are needed to elucidate the pathophysiological basis for this phenomenon.

Medial intracranial carotid artery calcifications and hematoma expansion in deep intracerebral hemorrhage.

Medial intracranial carotid artery calcifications (ICAC) are associated with impaired vascular physiology, increased arterial stiffness and pulse pressure. Their presence might therefore be associated with increased risk of intracerebral hemorrhage (ICH) expansion, according to the avalanche model. We explored the association between ICAC presence and pattern and hematoma expansion (HE). Retrospective analysis of a monocentric, prospectively collected cohort of ICH patients admitted between June 2017 and October 2023. ICAC pattern was determined by Kockelkoren's rating scale on admission CT; medial ICAC were defined with a >6 points cutoff. A follow-up CT scan was performed within 72 h. HE was analyzed as a dichotomous (≥6 mL and/or ≥33%) and as a categorical (none/mild/moderate/severe) variable, and its predictors were explored with logistic and ordinal regression respectively, accounting for baseline volume, onset-to-CT time, and anticoagulation. All the analyses were stratified by ICH location (supratentorial deep vs lobar ICH). A total of 201 patients were included (median age 78, 42% females, 59% deep ICH). Medial ICAC were significantly more common in deep ICH with HE compared with non-expanders (72% vs 49%, p = 0.03), whereas there was no association between ICAC and HE in lobar ICH (53% vs 52%, p = 0.85). This association between medial ICAC and HE in deep ICH remained significant in logistic (aOR 3.11, 95% CI [1.19-9.06], p = 0.03) and ordinal regression (acOR 2.42, 95% CI [1.19-4.99], p = 0.01). Ipsilateral medial ICAC are associated with higher odds of HE in deep ICH. Our findings are best interpreted as hypothesis generating, requiring prospective validation and further research to characterize the underlying biological mechanisms.

Predictive factors for shunt dependency in patients with spontaneous intraventricular hemorrhage

Intraventricular hemorrhage (IVH) occurs in approximately 30–50% patients with spontaneous intracerebral hemorrhage (ICH), with a high 30-day mortality rate. Excess accumulation of parenchymal or ventricular blood associated with the development of acute hydrocephalus leads to poor outcomes. The prediction of shunt dependency is important to identify patients susceptible to requiring permanent shunt placement and benefit from the diversion. This retrospective analytical study aimed to establish a predictive model of shunt dependency in patients with IVH. This study included 179 patients with primary IVH with supratentorial origin or spontaneous ICH with extension into the ventricles between 2015 and 2021. Patients were grouped into “shunt required” and “shunt not required” groups. Variables, including age, sex, preexisting hypertension and diabetes, initial Glasgow Coma Scale scores, ICH location and volume, urokinase administration, modified Graeb score (mGraeb score), and bicaudate index, were analyzed. The shunt required group had significantly higher mGraeb scores (12.0 (6.5–15.0) vs. 7.0 (4.0–12.0), p = 0.001) and higher bicaudate index (0.20 (0.17–0.23) vs. 0.16 (0.13–0.18), P < 0.001) than the shunt not required group. The receiver operating characteristic curve (ROC curve) analysis revealed that a cut-off value of 0.16 of the bicaudate index was significantly related to shunt dependency. The subgroup statistical analysis revealed that neither urokinase administration (p = 0.533) nor urokinase dosage (p = 0.117) showed significant relevance in shunt dependency in patients who received external ventricular drainage. In logistic regression adjusted for the confounders, thalamic ICH (odds ratio (OR) 3.55; 95% confidence interval [(95%CI), 1.13–11.18], an mGraeb score greater than 8 (OR, 3.93; 95%CI, 1.84–8.38), and a bicaudate index greater than 0.16 (OR, 9.87; 95%CI, 3.79–25.73) were factors associated with a higher tendency for shunting. The findings of this study may help identify patients at risk for a permanent shunt after IVH.

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.

Machine learning based classification of spontaneous intracranial hemorrhages using radiomics features.

To assess the efficacy of radiomics features extracted from non-contrast computed tomography (NCCT) scans in differentiating multiple etiologies of spontaneous intracerebral hemorrhage (ICH). CT images and clinical data from 141 ICH patients from 2010 to 2022 were collected. The cohort comprised primary (n = 57), tumorous (n = 46), and vascular malformation-related ICH (n = 38). Radiomics features were extracted from the initial brain NCCT scans and identified potential features using mutual information. A hierarchical classification with AdaBoost classifiers was employed to classify the multiple etiologies of ICH. Age of the patient and ICH's location were examined alongside radiomics features. The accuracy, area under the curve (AUC), sensitivity, and specificity were used to evaluate classification performance. The proposed method achieved an accuracy of 0.79. For identifying primary ICH, the model achieved a sensitivity of 0.86 and specificity of 0.87. Meanwhile, the sensitivity and specificity for identifying tumoral causes were 0.78 and 0.93, respectively. For vascular malformation, the model reached a sensitivity and specificity of 0.72 and 0.89, respectively. The AUCs for primary, tumorous, and vascular malformation were 0.86, 0.85, and 0.82, respectively. The findings further highlight the importance of texture-based variables in ICH classification. The age and location of the ICH can enhance the classification performance. The use of a machine learning model with radiomics features has the potential in classifying the three types of non-traumatic ICH. It may help the radiologist decide on an appropriate further examination plan to arrive at a correct diagnosis.

Factors associated with cognitive impairment before intracerebral haemorrhage: community-based neuropathological study.

Little is known about whether clinical, radiological or neuropathological features are associated with cognitive impairment before intracerebral haemorrhage. We conducted a community-based cohort study of 125 adults with intracerebral haemorrhage (lobar n = 71, non-lobar n = 54) with consent to brain autopsy. We compared small vessel disease biomarkers on diagnostic CT head and neuropathological findings including neurofibrillary tangles and amyloid plaques in adults without cognitive impairment versus cognitive impairment without dementia versus dementia before intracerebral haemorrhage, stratified by lobar and non-lobar intracerebral haemorrhage. In non-lobar intracerebral haemorrhage, severe cortical atrophy was less common in those without cognitive impairment (8/36, 22%) and cognitive impairment without dementia (0/9, 0%) versus dementia (5/9, 56%); P = 0.008. Irrespective of intracerebral haemorrhage location, adults without cognitive impairment had milder neurofibrillary tangle pathology measured by median Braak stage (lobar intracerebral haemorrhage: no cognitive impairment 2 [interquartile range, 2-3] versus cognitive impairment without dementia 4 [2-6] versus dementia 5.5 [4-6]; P = 0.004; non-lobar intracerebral haemorrhage: no cognitive impairment 2 [1-2] versus cognitive impairment without dementia 2 [1-2] versus dementia 5 [3-6]; P < 0.001). Irrespective of intracerebral haemorrhage location, adults without cognitive impairment had milder amyloid plaque pathology measured by median Thal stage (lobar intracerebral haemorrhage: no cognitive impairment 2 [1-2] versus cognitive impairment without dementia 2 [2-3] versus dementia 2.5 [2-3.5]; P = 0.033; non-lobar intracerebral haemorrhage: no cognitive impairment 1 [0-1] versus cognitive impairment without dementia 0 [0-2] versus dementia 3 [2-3]; P = 0.002). Our findings suggest that irrespective of intracerebral haemorrhage location, adults with cognitive impairment before an intracerebral haemorrhage have more Alzheimer's disease neuropathologic change.

Associations of Cerebral Small Vessel Disease and Chronic Kidney Disease in Patients With Acute Intracerebral Hemorrhage: A Cross-Sectional Study.

Chronic kidney disease (CKD) may be associated with the pathogenesis and phenotype of cerebral small vessel disease (SVD), which is the commonest cause of intracerebral hemorrhage (ICH). The purpose of this study was to investigate the associations of CKD with ICH neuroimaging phenotype, volume, and location, total burden of small vessel disease, and its individual components. In 2 cohorts of consecutive patients with ICH evaluated with MRI, we investigated the frequency and severity of CKD based on established Kidney Disease Improving Global Outcomes criteria, requiring estimated glomerular filtration rate (eGFR) measurements <60 mL/min/1.732 ≥ 3 months apart to define CKD. MRI scans were rated for ICH neuroimaging phenotype (arteriolosclerosis, cerebral amyloid angiopathy, mixed location SVD, or cryptogenic ICH) and the presence of markers of SVD (white matter hyperintensities [WMHs], cerebral microbleeds [CMBs], lacunes, and enlarged perivascular spaces, defined according to the STandards for ReportIng Vascular changes on nEuroimaging criteria). We used multinomial, binomial logistic, and ordinal logistic regression models adjusted for age, sex, hypertension, and diabetes to account for possible confounding caused by shared risk factors of CKD and SVD. Of 875 patients (mean age 66 years, 42% female), 146 (16.7%) had CKD. After adjusting for age, sex, and comorbidities, patients with CKD had higher rates of mixed SVD than those with eGFR >60 (relative risk ratio 2.39, 95% CI 1.16-4.94, p = 0.019). Severe WMHs, deep microbleeds, and lacunes were more frequent in patients with CKD, as was a higher overall SVD burden score (odds ratio 1.83 for each point on the ordinal scale, 95% CI 1.31-2.56, p < 0.001). Patients with eGFR ≤30 had more CMBs (median 7 [interquartile range 1-23] vs 2 [0-8] for those with eGFR >30, p = 0.007). In patients with ICH, CKD was associated with SVD burden, a mixed SVD phenotype, and markers of arteriolosclerosis. Our findings indicate that CKD might independently contribute to the pathogenesis of arteriolosclerosis and mixed SVD, although we could not definitively account for the severity of shared risk factors. Longitudinal and experimental studies are, therefore, needed to investigate causal associations. Nevertheless, stroke clinicians should be aware of CKD as a potentially independent and modifiable risk factor of SVD.

Association of Antithrombotic Drug Use With Incident Intracerebral Hemorrhage Location.

Few population-based studies have assessed associations between the use of antithrombotic (platelet antiaggregant or anticoagulant) drugs and location-specific risks of spontaneous intracerebral hemorrhage (s-ICH). In this study, we estimated associations between antithrombotic drug use and the risk of lobar vs nonlobar incident s-ICH. Using Danish nationwide registries, we identified cases in the Southern Denmark Region of first-ever s-ICH in patients aged 50 years or older between 2009 and 2018. Each verified case was classified as lobar or nonlobar s-ICH and matched to controls in the general population by age, sex, and calendar year. Prior antithrombotic use was ascertained from a nationwide prescription registry. We calculated odds ratios (aORs) for associations between the use of clopidogrel, aspirin, direct oral anticoagulants (DOACs) or vitamin K antagonists (VKA), and lobar and nonlobar ICH in conditional logistic regression analyses that were adjusted for potential confounders. A total of 1,040 cases of lobar (47.9% men, mean age [SD] 75.2 [10.7] years) and 1,263 cases of nonlobar s-ICH (54.2% men, mean age 73.6 [11.4] years) were matched to 41,651 and 50,574 controls, respectively. A stronger association with lobar s-ICH was found for clopidogrel (cases: 7.6%, controls: 3.5%; aOR 3.46 [95% CI 2.45-4.89]) vs aspirin (cases: 22.9%, controls: 20.4%; aOR 2.14 [1.74-2.63; p = 0.019). Corresponding estimates for nonlobar s-ICH were not different between clopidogrel (cases: 5.4%, controls: 3.4%; aOR 2.44 [1.71-3.49]) and aspirin (cases: 20.7%, controls: 19.2%; aOR 1.77 [1.47-2.15]; p = 0.12). VKA use was associated with higher odds of both lobar (cases: 14.3%, controls: 6.1%; aOR 3.66 [2.78-4.80]) and nonlobar (cases: 15.4%, controls: 5.5%; aOR 4.62 [3.67-5.82]) s-ICH. The association of DOAC use with lobar s-ICH (cases: 3.5%, controls: 2.7%; aOR 1.66 [1.02-2.70]) was weaker than that of VKA use (p = 0.006). Corresponding estimates for nonlobar s-ICH were not different between DOACs (cases: 5.1%, controls: 2.4%; aOR 3.44 [2.33-5.08]) and VKAs (p = 0.20). Antithrombotics were associated with higher risks of s-ICH, but the strength of the associations varied by s-ICH location and drug, which may reflect differences in the cerebral microangiopathies associated with lobar vs nonlobar hemorrhages and the mechanisms of drug action.

Safety of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage in the Registry of Intracerebral Hemorrhage Treated by Endoscopic Hematoma Evacuation in Japan

The long history of treatment for intracerebral hemorrhage (ICH) includes the development of surgical procedures. However, few studies have demonstrated that surgery improved the functional outcome. The present study used the prospective Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation of the outcomes in endoscopic surgery, which is widely followed in Japan, to try to establish clinical evidence. The Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation is a multicenter, prospective registry in Japan, and included 143 surgical cases treated by certified neurosurgeons. The etiology and the location of ICH was evaluated by univariate and multivariate analyses as follows: deep, surface, intraventricular hemorrhage, cerebellum, and surgical outcome. Hematoma location was deep in 44.8% of cases, intraventricular hemorrhage in 19.6%, surface in 21.7%, and cerebellum in 14.0%. Most cases were treated in the ultraearly stage within 8hours. Mean hematoma evacuation rate was 83.6% and median residual hematoma volume was 3.0ml. Duration of surgery was median 78minutes. Rebleeding as a complication was observed in 6.7%, but only 2.9% were symptomatic. 2 cases required reoperation. Favorable outcome at 6months was achieved in 35.8% of cases, with a mortality rate of 5.6%. Endoscopic surgery for spontaneous ICH is safe and comparable to conventional surgery. The time required for the procedure was significantly reduced, demonstrating the minimally invasive character of the surgical burden. However, this study did not establish whether minimally invasive surgery is superior to conservative treatment. Future randomized controlled trials should clarify the effectiveness of the treatment.

Etiology, Risk Factors and Outcome of Spontaneous Intracerebral Hemorrhage in Young Adults Admitted to Tertiary Care Hospital in Mogadishu, Somalia.

Spontaneous Intracerebral hemorrhage (ICH) in young patients is less common and not well studied compared to ICH in older patients. The etiology, risk factors and outcome of ICH in young patients may have regional and ethnic differences. The study aims to investigate the clinical characteristics, risk factors, etiology and outcome of spontaneous intracerebral hemorrhage in young adults in Somalia. The study enrolled 168 young patients with ICH (16-50 years) admitted to the neurology department of a tertiary hospital from 2019 to 2022. The information about the demographic details, documented ICH risk factors, etiology and patients' clinical status were retrieved. The etiology of ICH was determined based on clinical, laboratory and radiological findings. Intra-hospital survival status and associated factors were assessed. The mean age of the patients was 35±8.6 years. 99 (59%) of patients were male while 69 (41%) were females. Hypertension 48 (29%) was the most common risk factor, followed by substance abuse. Hypertensive hemorrhage was the most common etiology of ICH 60 (35.7%), followed by cerebral venous thrombosis (CVT) 5(15%), substance abuse 23 (13.7%) and arteriovenous malformation (AVM) in 10 (6%). AVM, CVT, cavernoma, eclampsia, substance abuse and cryptogenic etiology were more common in the 2nd and 3rd decades whereas hypertension was more common in the 4th and 5th decade. Intrahospital mortality was 28% in this study. Factors predicting intrahospital mortality were hematoma volume of greater than 30mL, thrombolytic etiology, brainstem ICH location, substance abuse related etiology, presence of associated mass effect, low GCS score on admission, high systolic blood pressure on admission, and the presence of chronic renal failure. In this study, hypertension, substance abuse, CVT and vascular malformation are the leading causes of ICH in young adults. Intracerebral hemorrhage in the young has different spectrum of etiologies and factors associated with short-term mortality compared to older patients.

How much of the variance in functional outcome related to intracerebral hemorrhage volume is already apparent in neurological status at admission?

BackgroundHematoma volume is a major pathophysiological hallmark of acute intracerebral hemorrhage (ICH). We investigated how the variance in functional outcome induced by the ICH volume is explained by neurological deficits at admission using a mediation model.MethodsPatients with acute ICH treated in three tertiary stroke centers between January 2010 and April 2019 were retrospectively analyzed. Mediation analysis was performed to investigate the effect of ICH volume (0.8 ml (5% quantile) versus 130.6 ml (95% quantile)) on the risk of unfavorable functional outcome at discharge defined as modified Rankin Score (mRS) ≥ 3 with mediation through National Institutes of Health Stroke Scale (NIHSS) at admission. Multivariable regression was conducted to identify factors related to neurological improvement and deterioration.ResultsThree hundred thirty-eight patients were analyzed. One hundred twenty-one patients (36%) achieved mRS ≤ 3 at discharge. Mediation analysis showed that NIHSS on admission explained 30% [13%; 58%] of the ICH volume-induced variance in functional outcome at smaller ICH volume levels, and 14% [4%; 46%] at larger ICH volume levels. Higher ICH volume at admission and brainstem or intraventricular location of ICH were associated with neurological deterioration, while younger age, normotension, lower ICH volumes, and lobar location of ICH were predictors for neurological improvement.ConclusionNIHSS at admission reflects 14% of the functional outcome at discharge for larger hematoma volumes and 30% for smaller hematoma volumes. These results underscore the importance of effects not reflected in NIHSS admission for the outcome of ICH patients such as secondary brain injury and early rehabilitation.

Baseline perihematomal edema, C-reactive protein, and 30-day mortality are not associated in intracerebral hemorrhage.

The relationship between baseline perihematomal edema (PHE) and inflammation, and their impact on survival after intracerebral hemorrhage (ICH) are not well understood. Assess the association between baseline PHE, baseline C-reactive protein (CRP), and early death after ICH. Analysis of pooled data from multicenter ICH registries. We included patients presenting within 24 h of symptom onset, using multifactorial linear regression model to assess the association between CRP and edema extension distance (EED), and a multifactorial Cox regression model to assess the association between CRP, PHE volume and 30-day mortality. We included 1,034 patients. Median age was 69 (interquartile range [IQR] 59-79), median baseline ICH volume 11.5 (IQR 4.3-28.9) mL, and median baseline CRP 2.5 (IQR 1.5-7.0) mg/L. In the multifactorial analysis [adjusting for cohort, age, sex, log-ICH volume, ICH location, intraventricular hemorrhage (IVH), statin use, glucose, and systolic blood pressure], baseline log-CRP was not associated with baseline EED: for a 50% increase in CRP the difference in expected mean EED was 0.004 cm (95%CI 0.000-0.008, p = 0.055). In a further multifactorial analysis, after adjusting for key predictors of mortality, neither a 50% increase in PHE volume nor CRP were associated with higher 30-day mortality (HR 0.97; 95%CI 0.90-1.05, p = 0.51 and HR 0.98; 95%CI 0.93-1.03, p = 0.41, respectively). Higher baseline CRP is not associated with higher baseline edema, which is also not associated with mortality. Edema at baseline might be driven by different pathophysiological processes with different effects on outcome.

Abstract WP158: Cortical Superficial Siderosis is Associated With Ischemia After Intracerebral Hemorrhage

Background: Ischemia on diffusion weighted imaging (DWI) after intracerebral hemorrhage (ICH) increases the risk of future ischemic stroke. Radiographic markers of small vessel disease, including cerebral microbleeds (CMB), are associated with DWI lesions. Though cortical superficial siderosis (cSS) is also a hemorrhagic small vessel disease subtype, it is unclear if cSS similarly relates to DWI lesions. We hypothesized that cSS would represent a more severe phenotype of small vessel disease and would associate with DWI lesions after ICH independent to other small vessel disease markers. Methods: Using the Intracerebral Hemorrhage Outcomes Project (ICHOP), we included all cases of spontaneous ICH who underwent DWI and susceptibility imaging/gradient echo. DWI hyperintensities were identified if &gt;10mm from the hematoma with decreased ADC signal. cSS were identified as subarachnoid hemosiderin deposition without acute subarachnoid hemorrhage. The relationship of cSS with DWI lesion presence as the outcome was assessed with logistic regression adjusted for ICH score, blood pressure change within 24 hours, and small vessel disease markers (CMB and white matter hyperintensity). Sensitivity analyses were performed to adjust for demographics and ICH location. A secondary analysis using linear regression assessed the association with the number of DWI lesions adjusted for similar covariates. Results: Of 198 patients analyzed, DWI lesions were observed in 31.3% and cSS in 10.6%. The presence of cSS was associated with DWI lesions (adjusted OR 3.72, CI: 1.29-10.72), independent of other small vessel disease markers. Separate sensitivity analyses adjusting for sex, race, and ICH location did not change the association of cSS with DWI lesions. In secondary analyses, cSS was not associated with greater number of DWI lesions counts (b 0.213, CI -0.53-0.63). Discussion: cSS is associated with the presence of DWI lesions, independent to other small vessel disease markers. cSS may represent a severe phenotype of small vessel disease with a risk of ICH recurrence and ischemia. Further work is required to investigate underlying mechanisms and optimal strategies to mitigate competing risks of future hemorrhage and ischemic events in these patients.

Abstract WMP75: Neurobehavioral Outcomes Following Left- and Right-Sided Intracerebral Hemorrhage in Mice

Background: Injury location is an established outcome predictor in intracerebral hemorrhage (ICH), with most studies focusing on outcomes relating to motor deficits. However, location may also affect other neurobehavioral deficits following ICH, such as mood and cognitive decline. To address this gap, we studied neurobehavioral outcomes following left and right-sided ICH in mice. Methods: Three-month-old male mice (C57BL/6) were given a left (n=5) or right-sided (n=5) ICH. In short, type VII collagenase was injected into the left or right striatum (0.0 mm anterior, +/- 2.3 mm lateral, and 3.6 mm deep from bregma). Naïve mice (n=5) were used as controls. Behavior was assessed at day 28 post-ICH using a video-recorded three-chamber sociability task in which one chamber had an enclosed male stranger mouse. Distance traveled, time in each chamber, and time exploring the stranger mouse were quantified using automated software (AnyMaze). Data were analyzed by one-way ANOVA and Tukey post-hoc tests. Results: ICH location had differential effects on behavioral outcomes. Compared to naïve and right-sided ICH mice, left-sided ICH mice traveled a greater overall distance exploring the chambers (both p&lt;0.05), spent a greater overall time immobile in the stranger mouse zone (both p&lt;0.001) and less time oriented towards the stranger mouse (both p&lt;0.05). Furthermore, when comparing naive and left-sided ICH mice, left-sided mice had a higher frequency of investigations of the empty cage (p&lt;0.05). No significant differences were found between the naïve and right-sided ICH mice. Conclusions: These results reveal differences in behavioral phenotypes associated with left- and right-sided ICH.

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

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

Abstract WMP81: Overweight Patients Had Higher Odds of Favorable Outcome After Both Deep and Lobar Intracerebral Hemorrhage

Introduction: Intracerebral Hemorrhage (ICH) leads to high rates of morbidity and mortality. Malnutrition is common in stroke patients and leads to worse outcomes. Body mass index (BMI) is a widely available marker of nutrition status, however studies on BMI and post-ICH outcomes are limited and have conflicting results. We aim to clarify this relationship by examining the relationship between BMI, nutritional lab markers, ICH severity, and functional outcome at discharge stratified by ICH location. Methods: We leveraged data from an ongoing longitudinal ICH study of adults with spontaneous primary ICH. Patients were divided into underweight, normal weight, overweight, and obese according to World Health Organization BMI criteria. Albumin, B12, total bilirubin, cholesterol, CRP, ferritin, iron, folate, hbA1c, HDL, LDL, hemoglobin, MCV, INR, ALT, triglycerides, and vitamin D were abstracted from health records. Associations between BMI, lab markers, ICH volume, and favorable outcome (mRS 0-2) were analyzed using univariate and multivariable logistic regression stratified by deep versus lobar hemorrhage location, with normal weight as the reference. Results: 1,370 patients (719 with deep hemorrhage, 651 with lobar hemorrhage) were included. There was no association between BMI and ICH volume in patients with deep or lobar hemorrhage. Multivariable analyses adjusting for age, education, diabetes mellitus, coronary artery disease, alcohol use, ICH volume, and intraventricular hemorrhage showed that overweight, but not underweight or obese, subjects had higher odds of favorable outcome on discharge in the deep (OR 3.16, 95% CI 1.36-7.34) and lobar (OR 3.15, 95% CI 1.67-5.94) groups. Albumin (OR 2.27, 95% CI 1.05-4.90) and hemoglobin (OR 1.31, 95% CI 1.09-1.59) were the only labs associated with favorable outcome in the deep hemorrhage group while no markers were associated with favorable outcome in the lobar hemorrhage group. Albumin and hemoglobin were not associated with being overweight. Conclusion: Overweight patients had three times higher odds of favorable outcome after both deep and lobar hemorrhages. This was not driven by ICH severity or explained by lab markers. Future biomarker studies are needed to better understand this relationship.