Intracerebral Hemorrhage Mortality Research Articles

Impact of process of care in the short-term mortality in non-severe intracerebral hemorrhage in southern Portugal

IntroductionPatients with spontaneous intracerebral hemorrhage (SICH) face the worse functional and vital prognosis among all stroke subtypes. In cases of severe SICH, therapeutic inertia or nihilism complicates meaningful identification of outcome predictors. Therefore, we sought to investigate clinic-radiological and process of care predictors of short-term mortality in patients with mild to moderate SICH. Patients and methodsObservational retrospective community representative consecutive case series of patients from Algarve, southern Portugal. Logistic regression was used to identify predictors of short-term (30-day) death. ResultsMortality was 23.9% (111/464). Most important predictors of death were unconsciousness at admission (OR = 12.392, 95% CI = 3.816–40.241, p < 0.001), hospital arrival ≥ 6 h after stroke onset (OR = 2.842, 95% CI = 1.380–5.852, p =.005), hematoma volume > 30 cc/cm3 (OR = 3.295, 95% CI 0 1.561–6.953, p =.002), intraventricular extension (OR = 2.885, 95% CI = 1.457–5.712, p =.002) and ≥ 24 h in the Emergency Department (OR = 19.675, 95% CI = 3.682–34.125, p =.009). Stroke Unit (SU) admission reduced the likelihood of death (OR = 0.293, 95% CI = 0.137-0.682, p =.002). ConclusionThe observed mortality is high. Apart from the traditional clinic-radiological factors, in mild to moderate SICH, process of care related factors have strong impact on mortality. These results highlight the need of continuous improvement of SICH care to improve the prognosis.

Predictors for intracerebral hemorrhage after intravenous or intraarterial recanalization in acute major cerebral artery occlusion in Korean patients

Objective To evaluate predictors for intracerebral hemorrhage (ICH) and 1-month mortality after intravenous (IV) or intraarterial (IA) recanalization therapy for major cerebral artery occlusion in Korean patients. Methods From 2011 to 2015, we prospectively gathered data from consecutive patients treated with IV/IA recanalization within 8 h of symptoms in a single center. The effects of demographic, clinical, laboratory, and radiological factors on ICH within 2 weeks were assessed, as well as 1-month mortality. Results From a total of 183 patients, symptomatic intracerebral hemorrhage (SICH) occurred in 32 patients (17.5%), and asymptomatic ICH occurred in 37 patients (20.2%). The mortality rate at 1 month in ICH patients was 37.7%. The international normalized ratio (INR) (OR, 4.9; 95% CI, 1.03–23.4; p = 0.046), glucose (OR, 1.119 per mmol/L; 95% CI, 1.015–1.233; p = 0.023), medium-volume infarct (15–69.9 mL) (OR, 2.62; 95% CI, 1.1–6.26; p = 0.03), large-volume infarct (≥70 mL) (OR, 5.54; 95% CI, 2.1–14.6; p = 0.001), and angioplasty or stenting (OR, 6.29; 95% CI, 1.71–23.22; p = 0.006) were predictors of any ICH. Hyperlipidemia or statin medication (OR, 4.17; 95% CI, 1.38–12.59; p = 0.011), INR (OR, 7.13; 95% CI, 0.94–54.22 p = 0.058), and large-volume infarct (≥70 mL) (OR, 7.96; 95% CI, 2.31–27.39; p = 0.001) were predictors of SICH. Hypertension (OR, 5.77; 95% CI, 1.43-23.3; p = 0.014), initial NIHSS score (OR, 1.09; 95% CI, 1.01–1.18; p = 0.27), and SICH (OR, 15.7; 95% CI, 4.04–61.08; p < 0.001) were predictors of 1-month mortality. Conclusion INR and glucose may be strong modifiable predictors of critical ICH leading to death after IV/IA recanalization therapy in acute cerebral artery occlusion.

Application of Integrated Emergency Care Model Based on Failure Modes and Effects Analysis in Patients With Ischemic Stroke.

PurposeTo explore the application value of an integrated emergency care model based on failure modes and effects analysis (FMEA) in patients with acute ischemic stroke (AIS).MethodsAccording to the convenience sampling method, 100 patients with AIS who visited the emergency department in our hospital from October 2018 to March 2019 were randomly selected as the control group and received routine emergency care mode intervention. Another 100 AIS patients who visited the emergency department from April to October 2019 were selected as the intervention group and received the integrated emergency care model based on FMEA. The total time spent from admission to completion of each emergency procedure [total time spent from admission to emergency physician reception (T0−1), total time spent from admission to stroke team reception (T0−2), total time spent from admission to imaging report out (T0−3), total time spent from admission to laboratory report out (T0−4), and total time spent from admission to intravenous thrombolysis (T0−5)] was recorded for both groups. The clinical outcome indicators (vascular recanalization rate, symptomatic intracerebral hemorrhage incidence, mortality rate) were observed for both groups. The National Institutes of Health Stroke Scale (NIHSS) score and Barthel score were evaluated for both groups after the intervention. The treatment satisfaction rate of the patients was investigated for both groups.ResultsThe total time of T0−1, T0−2, T0−3, T0−4, T0−5 in the intervention group (0.55 ± 0.15, 1.23 ± 0.30, 21.24 ± 3.01, 33.30 ± 5.28, 44.19 ± 7.02) min was shorter than that of the control group (1.22 ± 0.28, 4.01 ± 1.06, 34.12 ± 4.44, 72.48 ± 8.27, 80.31 ± 9.22) min (P < 0.05). The vascular recanalization rate in the intervention group (23.00%) was higher than that in the control group (12.00%) (P < 0.05). There was no statistical significance in the symptomatic intracerebral hemorrhage incidence and mortality rate in the two groups (P > 0.05). After intervention, the NIHSS score of the intervention group (2.95 ± 0.91) was lower than that of the control group (6.10 ± 2.02), and the Barthel score (77.58 ± 7.33) was higher than that of the control group (53.34 ± 5.12) (P < 0.05). The treatment satisfaction rate in the intervention group (95.00%) was higher than that of the control group (86.00%) (P < 0.05).ConclusionThrough FMEA, the failure mode that affects the emergency time of AIS patients is effectively analyzed and the targeted optimization process is proposed, which are important to enhance the efficiency and success rate of resuscitation of medical and nursing staff and improve the prognosis and life ability of patients.

CORRELATION BETWEEN SERUM LOW DENSITY LIPOPROTEIN (LDL) LEVELS AND HEMORRHAGIC STROKE SEVERITY: A RETROSPECTIVE REVIEW (PRELIMINARY FINDINGS)

<h3>Background</h3> The relationship between serum LDL level and hemorrhagic stroke is inconclusive. Several epidemiological Studies have noted that low LDL is a risk factor for ICH, however very few studies have defined the link between LDL and hemorrhagic stroke severity. <h3>Aim</h3> We hypothesized that low serum LDL levels may have association with intracerebral hemorrhage (ICH) severity at admission and worse outcomes. <h3>Methods</h3> This retrospective study reviewed data obtained from SIREN - the largest multicenter stroke study in Africa. We categorized patients with acute spontaneous ICH based on their baseline levels of LDL measured at admission, into 4 groups: <70, 70–100, 100-125 and >125 mg/dL of LDL. We evaluated initial stroke severity, using the GCS, ICH Score, NIHSS and unfavorable outcomes using modified Rankin Scale [mRS] score. Pearson's correlation analysis was used to correlate LDL levels with indices of hemorrhagic stroke severity (GCS, NIHSS, ICH score, ICH volume, age) and a linear regression analysis was then performed. <h3>Results</h3> A total of 1162 patients with ICH (mean age 54.42±13.63 years; 62.5% men) were included in this study of which nearly all subjects 1125 (96.8%) had hypertension as a risk factor. 766 (65.9%) had fatal outcomes with mean GCS, NIHSS, ICH Score and MRS of 11.12±3.90, 16.84±11.69, 1.74±1.39 and 4.11±1.11 respectively. 992 had serum LDL assessed at admission of which 565 (56.95%) of them had baseline LDL<125 mg/dL, 427 (43.04%) had LDL >125mg/dl. Patients that died had a lower mean serum LDL level than those that survived (121.19±47.60 vs 125.17±53.56), although not statistically significant (P= 0.275). The percentage of men with serum LDL levels <70mg/dl (70.6%), 70-100mg/dl (62.1%), >100mg/dl (66%) was significantly higher than that of men with LDL >125mg/dl (57.6%) - (P = 0.030). In a similar vein, patients with LDL <70 mg/dl were younger (mean age: 52.43<i>±13.06</i>) than those with LDL 70-100, 100-125, >125 who had mean age±SD 53.78<i>±13.73,</i> 56.74<i>±13.26,</i> 53.59<i>±13.00 respectively (P:</i>0.011). As expected, the cohort of patients with LDL <70 had a lower BMI (25.59<i>±4.59</i>) as compared with those with LDL >125mg/dl BMI: 27.06<i>±5.27</i> (P value 0.017). The presence of hypertension as a risk factor among the 4 different LDL sub-categories was not statistically significant (p = 0.648). Interestingly, patients with LDL <70 mg/dL presented with more severe stroke, with a mean GCS±SD of 9.46±3.77 when compared with patients with LDL of 70-100, 100-125, >125 who had a mean GCS 11.42±3.75, 10.11±4.30 and 11.79±3.73 respectively (P-value: 0.007). In the correlation analysis, there was a positive correlation between LDL levels and the GCS (P value: 0.014) and a negative correlation between LDL and the ICH score as well as the NIHSS score at baseline, although not statistically significant. <h3>Conclusion</h3> Mortality of ICH remains high in Africa. LDL<125mg/dl is more common in African subjects with ICH and those with LDL <70mg/dl happened to be much younger men with a good metabolic profile. LDL level < 70 mg/dL was associated with worse Glasgow Coma Score at presentation. A follow up study on the association between LDL levels and hematoma volume is imperative as it may explain this association.

Association Between Preonset Anti-hypertensive Treatment and Intracerebral Hemorrhage Mortality: A Cohort Study From CHEERY.

IntroductionHypertension is the most prevalent risk factor for intracerebral hemorrhage (ICH). In this study, we investigated whether preonset anti-hypertensive therapy could affect the outcomes of ICH.MethodsThis was a retrospective cohort study. A total of 3,460 consecutive patients with acute first-ever ICH from 31 recruitment sites were enrolled into the Chinese cerebral hemorrhage: mechanism and intervention (CHERRY) study from December 1, 2018 to November 30, 2020, and 2,140 (61.8%) with hypertension history were entered into the analysis.ResultsOnly 586 patients (27.4%) with hypertension history currently received anti-hypertensive therapy, and which was associated with lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) on admission (SBP, p = 0.008; DBP, p = 0.017), less hematoma volume (9.8 vs. 11%, p = 0.006), and lower all-cause mortality at 3 months (15.3 vs. 19.8%, OR = 0.728, p = 0.016). In multivariable analysis, adjusting for age, gender, residence, ischemic stroke history, admission SBP and DBP, and current use of antihypertension were significantly associated with lower adjusted hazard ratios (HRs) for all-cause mortality at discharge (adjusted HR, 0.497, p = 0.012), 30 days (adjusted HR, 0.712, p = 0.015), and 90 days (adjusted HR, 0.766, p = 0.030). However, after adjusting the variable of hematoma volume, the mortality between the two groups was not significantly different.ConclusionsPreonset anti-hypertensive therapy was associated with lower mortality of ICH, which somewhat depended on hematoma volume.

Abstract 140: Real-world Efficacy Of Left Atrial Appendage Closure Versus Anticoagulation Therapy For Long-term Prevention Of Ischemic Stroke And All-cause Mortality Among Patients With Atrial Fibrillation

Introduction: There is limited data on real-world efficacy of left atrial appendage closure (LAAC) procedures compared to anticoagulants (AC) for stroke prevention among patients with atrial fibrillation (AF). Methods: We utilized a retrospective cohort of over 63 million patients from 51 healthcare organizations across 6 countries via a harmonized electronic medical record-based research data platform. Utilizing international classification of disease version 10 and current procedural terminology codes, adult (≥ 18 years) patients with AF (I48) were identified and grouped by treatment type (LAAC (33340, 02L73DK) vs AC (1015112, Z79.0, BL110)). Patients with a history of stroke prior to AC initiation or LAAC procedure were excluded. Subjects were followed for 5 years for incident ischemic stroke (I63), intracerebral hemorrhage (I61), and all-cause mortality. Treatment groups were propensity score matched by age, sex, race, ethnicity, and comorbidities. Risk ratio(RR) and 95% confidence intervals(CI) among unmatched and matched populations are reported. Results: Among a total of 1,980,130 AF patients; 1,374,013 were flagged for AC use and 8,004 were treated via LAAC. Treatment cohorts were propensity score matched by age, race, sex, hyperlipidemia, and hypertension resulting in an exact 1:1 matched cohort of 8,004 subjects, across all co-variates. In the matched population the mean (SD) age was 75.2 (8.05) years, 63.2% were male; 86.6% were white, 4.4% black, 0.89% Asian, and 3.5% Hispanic; with 64.4% hyperlipidemic and 79.2% hypertensive. Prior to matching, AC (vs. LAAC) was significantly associated with a higher 5-year risk of ischemic stroke, intracerebral hemorrhage, and all-cause mortality. The protective effect of LAAC (vs. AC) was maintained for 5-year risk of ischemic stroke (RR, CI: 0.68, 0.58 - 0.79) and all-cause mortality (RR, CI: 0.42, 0.39 - 0.45). However, the difference in 5-year risk for intracerebral hemorrhage for LAAC (vs. AC) was not statistically lower (RR, CI: 0.72, 0.50 - 1.05). Conclusion: Notwithstanding the possibility of residual confounding in our analyses, LAAC seems to be associated with a lower long-term risk of ischemic stroke and all-cause mortality as compared to AC treated AF patients in large real-world data.

Abstract 142: Lives Lost Due To Disparities Quantified: Black-White And Rural-Urban Disparities In Cerebrovascular Mortality Among Middle-Aged Adults

Introduction: We aimed to quantify and trend excess cerebrovascular deaths among middle-aged adults that could be attributed to Black-white and rural-urban disparity in the US. Methods: Annual age-adjusted mortality rates (AAMR) for ischemic stroke (IS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) among middle aged adults (ages 35-64) were obtained from Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiological Research database from 1999 to 2019. AAMR difference between African-Americans and whites (Black-white disparity), as well as residents of Non-Metro and Large Metro counties (Rural-Urban disparity) was used to estimate excess event- and gender- specific annual deaths attributable to each disparity. Linear AAMR epochs and parallelism were assessed with Joinpoint. Results: Lives lost to Black-white disparity decreased from 3850 in 1999 to 2750 in 2013 and stagnated since. The finding was driven by decline in SAH and ICH mortality between 1999 and 2019, and recent increase in excess deaths due to IS (105 in 2014, 240 in 2019). Lives lost to Rural-urban disparity increased from 360 in 1999 to 740 in 2019, driven by excess deaths due to ICH (-30 in 1999, 100 in 2019) and recently IS (50 in 2013, 130 in 2019). Conclusion: Black-white disparity accounting for ~2750 excess deaths among blacks per year remains the leading inequity in cerebrovascular mortality. This is 3.7 times more deaths than Rural-Urban disparity in 2019.

Enhancing Robustness of Machine Learning Integration With Routine Laboratory Blood Tests to Predict Inpatient Mortality After Intracerebral Hemorrhage.

Objective: The accurate evaluation of outcomes at a personalized level in patients with intracerebral hemorrhage (ICH) is critical clinical implications. This study aims to evaluate how machine learning integrates with routine laboratory tests and electronic health records (EHRs) data to predict inpatient mortality after ICH.Methods: In this machine learning-based prognostic study, we included 1,835 consecutive patients with acute ICH between October 2010 and December 2018. The model building process incorporated five pre-implant ICH score variables (clinical features) and 13 out of 59 available routine laboratory parameters. We assessed model performance according to a range of learning metrics, such as the mean area under the receiver operating characteristic curve [AUROC]. We also used the Shapley additive explanation algorithm to explain the prediction model.Results: Machine learning models using laboratory data achieved AUROCs of 0.71–0.82 in a split-by-year development/testing scheme. The non-linear eXtreme Gradient Boosting model yielded the highest prediction accuracy. In the held-out validation set of development cohort, the predictive model using comprehensive clinical and laboratory parameters outperformed those using clinical alone in predicting in-hospital mortality (AUROC [95% bootstrap confidence interval], 0.899 [0.897–0.901] vs. 0.875 [0.872–0.877]; P <0.001), with over 81% accuracy, sensitivity, and specificity. We observed similar performance in the testing set.Conclusions: Machine learning integrated with routine laboratory tests and EHRs could significantly promote the accuracy of inpatient ICH mortality prediction. This multidimensional composite prediction strategy might become an intelligent assistive prediction for ICH risk reclassification and offer an example for precision medicine.

Baseline perihaematomal oedema and CRP are not associated with 30-day mortality in intracerebral haemorrhage

Baseline perihaematomal oedema and CRP are not associated with 30-day mortality in intracerebral haemorrhage

Predictors of Mortality in Spontaneous Intracerebral Haemorrhage: A Prospective Interventional Study from a Tertiary Care Centre, Kerala, India

Introduction: Spontaneous Intracerebral Haemorrhage (SICH) is a potentially life-threatening condition associated with a high mortality and morbidity. Early assessment of outcome is important to optimise the therapeutic efforts. This study helps in the prediction of outcomes in SICH based on clinical and radiological predictors, so as to effectively utilise the treatment resources. Aim: To assess clinical and radiological predictors of mortality and morbidity in patients with SICH at a Tertiary Care Centre, Kerala, India. Materials and Methods: This prospective interventional study included 100 patients admitted with SICH at Government Medical college, Kozhikode, Kerala, India, from 1st May 2019 to 30th January 2020. The assessed variables include age, sex, mean Glasgow Coma Scale (GCS) score on admission, Intracerebral Haemorrhage (ICH) volume, ICH site, ICH score and treatment provided (conservative/surgery). The dependent variable was 30 day mortality. Univariate analysis was performed to determine the association between the mortality and independent variables. A binary logistic regression was also performed. Statistical analysis performed using Statistical Package for the Social Sciences (SPSS) software version 22.0. The p-value &lt;0.05 was considered significant. Results: Among the total of 100 SICH patients, males were 52% and females were 48%; the mean age was 67±11 years. The medical history of SICH patients predominantly showed hypertension (90%), diabetes (45%) and alcohol abuse (33%). Out of total, 70% cases were managed conservatively, and 30% cases were managed surgically. The short-term outcome of 30 day mortality was 40% and the survival rate was 60%. Univariate analysis inferred that the location of bleed (p-value=0.0002), volume of ICH (p-value &lt;0.001), ICH score (p-value 0.003) and type of management (p-value &lt;0.001) were statistically significant predictors for 30 day mortality in SICH patients. Conclusion: The 30 day mortality in patients with SICH was 40%. The location of bleed, volume of ICH, ICH score and type of management were statistically significant predictors for 30 day mortality in SICH patients

Admission Emergency Department Point-of-care Biomarkers for Prediction of Early Mortality in Spontaneous Intracerebral Hemorrhage.

Spontaneous intracerebral hemorrhage (sICH) has a significant morbidity and mortality, despite representing a non-dominant hemorrhagic stroke. The aim of the study was to assess the impact of the emergency department (ED) point-of-care (POC) biomarkers on early mortality in sICH patients. Demographic data, medical history and admission clinical parameters from adult patients with imaging-based sICH diagnosis were collected retrospectively, upon their ED presentation over a period of 18 months. ED-based POC analyzers were used for blood biomarkers [complete blood count, C reactive protein (CRP), glycemia, hepatic and renal function, D-dimer and cardiac troponin I]. Derived inflammatory indexes were calculated. Mortality endpoints were collected (on day 7 and at discharge). Of the 219 included patients, mortality rates reached 30.14% on day 7 and 46.12% at discharge. In the univariate analysis, day 7 mortality was significantly associated with history of diabetes, atrial fibrillation, ongoing anticoagulant treatment, the need of endotracheal intubation and ED cardiopulmonary resuscitation, and the presence of intraventricular hemorrhage and mass effect on the initial CT scan. White blood cells and granulocytes (but not the neutrophil-to-lymphocytes ratio, nor the CRP) were significantly higher in the deceased groups, alongside serum glucose. Derived inflammatory indexes were not significantly correlated with mortality endpoints. Cut-off values of 9.6×109/l for granulocytes and 132 mg/dl for glucose were identified as day 7 mortality predictors. sICH is a potentially severe condition causing high early mortality. Emergency department point-of-care biomarkers could represent a readily available and simple to use prognostic tool.

Machine Learning Models Prognosticate Functional Outcomes Better than Clinical Scores in Spontaneous Intracerebral Haemorrhage

ObjectiveThis study aims to develop and compare the use of deep neural networks (DNN) and support vector machines (SVM) to clinical prognostic scores for prognosticating 30-day mortality and 90-day poor functional outcome (PFO) in spontaneous intracerebral haemorrhage (SICH). Materials and methodsWe conducted a retrospective cohort study of 297 SICH patients between December 2014 and May 2016. Clinical data was collected from electronic medical records using standardized data collection forms. The machine learning workflow included imputation of missing data, dimensionality reduction, imbalanced-class correction, and evaluation using cross-validation and comparison of accuracy against clinical prognostic scores. Results32 (11%) patients had 30-day mortality while 177 (63%) patients had 90-day PFO. For prognosticating 30-day mortality, the class-balanced accuracies for DNN (0.875; 95% CI 0.800-0.950; McNemar's p-value 1.000) and SVM (0.848; 95% CI 0.767-0.930; McNemar's p-value 0.791) were comparable to that of the original ICH score (0.833; 95% CI 0.748-0.918). The c-statistics for DNN (0.895; DeLong's p-value 0.715), and SVM (0.900; DeLong's p-value 0.619), though greater than that of the original ICH score (0.862), were not significantly different. For prognosticating 90-day PFO, the class-balanced accuracies for DNN (0.853; 95% CI 0.772-0.934; McNemar's p-value 0.003) and SVM (0.860; 95% CI 0.781-0.939; McNemar's p-value 0.004) were better than that of the ICH-Grading Scale (0.706; 95% CI 0.600-0.812). The c-statistic for SVM (0.883; DeLong's p-value 0.022) was significantly greater than that of the ICH-Grading Scale (0.778), while the c-statistic for DNN was 0.864 (DeLong's p-value 0.055). ConclusionWe showed that the SVM model performs significantly better than clinical prognostic scores in predicting 90-day PFO in SICH.

Acute Hyperglycemia and In-Hospital Mortality in Spontaneous Intracerebral Hemorrhage.

Hyperglycemia is reported to predict worse outcome in patients with stroke, including intracerebral hemorrhage (ICH). In 83 consecutive cases of ICH at a tertiary stroke center, hyperglycemia (serum glucose >7 mmol/L) compared to normoglycemia at presentation was associated with higher rates of in-hospital mortality (51.2% vs. 26.2%, OR 2.3, CI 1.2-7.6, p = 0.02). The association with in-hospital mortality withstood adjustment for age, ICH volume, intraventricular hemorrhage, and infratentorial ICH location, but not baseline Glasgow Coma Scale. Acute hyperglycemia is associated with in-hospital mortality in spontaneous ICH patients, though this may be an indirect, rather than a causal relationship.

Intracerebral hemorrhage under platelet inhibition and oral anticoagulation in patients with cerebral amyloid angiopathy

Die Durchführung einer oralen Antikoagulation ist bei Patienten mit einer zerebralen Amyloidangiopathie eine therapeutische Herausforderung. Die Assoziation der zerebralen Amyloidangiopathie mit Lobärblutungen, eine hohe Mortalität intrazerebraler Blutungen insbesondere unter oraler Antikoagulation sowie das hohe Rezidivrisiko solcher Blutungen erfordern eine strenge und interdisziplinäre Risiko-Nutzen-Abwägung. Vitamin-K-Antagonisten erhöhen das Risiko für die mit intrazerebralen Blutungen vergesellschaftete Mortalität um 60 % und sollten daher möglichst vermieden bzw. speziellen klinischen Situationen (z. B. mechanischer Aortenklappenersatz) vorbehalten sein. Auch der Einsatz von neuen oralen Antikoagulanzien und Thrombozytenaggregationshemmern bedarf einer strengen Risiko-Nutzen-Abwägung, da auch diese Substanzen das zerebrale Blutungsrisiko erhöhen. Insbesondere bei Patienten mit einer absoluten Arrhyhtmie bei Vorhofflimmern ist der interventionelle Vorhofohrverschluss eine therapeutische Alternative. Darüber hinaus sind weitere klinische Implikationen bei Patienten mit zerebraler Amyloidangiopathie Gegenstand dieser Literaturübersicht, beispielsweise Besonderheiten nach akutem ischämischem Schlaganfall und erforderlicher Sekundärprophylaxe, bei vorherigen intrazerebralen Blutungen und bei Patienten mit kognitiven Defiziten.

The coronal plane maximum diameter of deep intracerebral hemorrhage predicts functional outcome more accurately than hematoma volume.

Among prognostic imaging variables, the hematoma volume on admission computed tomography (CT) has long been considered the strongest predictor of outcome and mortality in intracerebral hemorrhage. To examine whether different features of hematoma shape are associated with functional outcome in deep intracerebral hemorrhage. We analyzed 790 patients from the ATACH-2 trial, and 14 shape features were quantified. We calculated Spearman's Rho to assess the correlation between shape features and three-month modified Rankin scale (mRS) score, and the area under the receiver operating characteristic curve (AUC) to quantify the association between shape features and poor outcome defined as mRS>2 as well as mRS > 3. Among 14 shape features, the maximum intracerebral hemorrhage diameter in the coronal plane was the strongest predictor of functional outcome, with a maximum coronal diameter >∼3.5 cm indicating higher three-month mRS scores. The maximum coronal diameter versus hematoma volume yielded a Rho of 0.40 versus 0.35 (p = 0.006), an AUC[mRS>2] of 0.71 versus 0.68 (p = 0.004), and an AUC[mRS>3] of 0.71 versus 0.69 (p = 0.029). In multiple regression analysis adjusted for known outcome predictors, the maximum coronal diameter was independently associated with three-month mRS (p < 0.001). A coronal-plane maximum diameter measurement offers greater prognostic value in deep intracerebral hemorrhage than hematoma volume. This simple shape metric may expedite assessment of admission head CTs, offer a potential biomarker for hematoma size eligibility criteria in clinical trials, and may substitute volume in prognostic intracerebral hemorrhage scoring systems.

Trends in the incidence and mortality of intracerebral hemorrhage, and the associated risk factors, in Denmark from 2004 to 2017.

The distribution of the major modifiable risk factors for intracerebral hemorrhage (ICH) changes rapidly. These changes call for contemporary data from large-scale population-based studies. The aim of the present study was to examine trends in incidence, risk factors, and mortality in ICH patients from 2004 to 2017. In a population-based cohort study, we calculated age- and sex-standardized incidence rates (SIRs), incidence rates (IRs) stratified by age and sex per 100,000 person-years, and trends in risk profiles. We estimated absolute mortality risk, and the Cox proportional hazards regression multivariable-adjusted hazard ratios for 30-day and 1-year mortality. We included 16,902 patients (53% men; median age 75years) from 2004 to 2017. The SIR of ICH decreased from 33 (95% confidence interval [CI] 32-34) in 2004/2005 to 28 (95% CI 27-29) in 2016/2017. Among patients aged ≥70years, the IR decreased from 137 (95% CI 130-144) in 2004/2005 to 112 (95% CI 106-117) in 2016/2017. The IR in patients aged <70years was unchanged. From 2004 to 2017, the proportion of patients with hypertension increased from 49% to 66%, the use of oral anticoagulants increased from 7% to 18%, and the use of platelet inhibitors decreased from 40% to 28%. The adjusted hazard ratio for 30-day mortality in 2016/2017 was 0.94 (95% CI 0.89-1.01) and 1-year mortality was 0.98 (95% CI 0.93-1.04) compared with 2004/2005. The incidence of spontaneous ICH decreased from 2004 to 2017, with no clear trend in mortality. The risk profile of ICH patients changed substantially, with increasing proportions of hypertension and anticoagulant treatment. Given the high mortality rate of ICH, further advances in prevention and treatment are urgently needed.

Modified ICH score was superior to original ICH score for assessment of 30-day mortality and good outcome of non-traumatic intracerebral hemorrhage

IntroductionIntracerebral hemorrhage (ICH) score has been widely used as a consistent and reliable clinical grading scale for predicting mortality. However, ICH score had not been used to predict good outcome or significant disability for those who were alive. We intended to address whether any modifications would increase prediction accuracy for mortality as well as the extent of morbidity for those who survived. MethodsWe conducted a retrospective cohort study, involving all non-traumatic ICH patients admitted to our hospital between September 2018 and July 2020. All non-traumatic ICH patients who were admitted to the stroke unit and registered in our stroke database had their medical records, neuroimaging, and laboratory test results reviewed. Only patients with complete medical records and available CT imaging and laboratory test results were included in our study. Independent predictors of mortality (modified Rankin scale/mRS of 6) or good outcome vs. significant disability (mRS≤2 vs. mRS 3–5, respectively) were identified by logistic regression. A modified ICH (mICH) score was compared with the original ICH (oICH) score for its diagnostic performance (DP). Overall DPs were graded and ranked according to Youden Index (YI). ResultsAs many as 311 patients were eligible with both 39.9% rate of 30-day mortality and good outcome. Factors independently associated with mortality were low GCS and high NIHSS on admission (P = 0.002, <0.001, respectively), and presence of respiratory failure (P < 0.001). Independent factors for good outcome were low NIHSS on admission and mass effect (midline shift > 5 mm) [both P < 0.001]. A modification of ICH score from the original was made by substituting GCS with NIHSS (0 –10 = 1; 11 – 20 = 2; >20 = 3), changing age cut-off point to > 55 years old (= 1), and adding respiratory failure (= 1), and mass effect (= 1). Overall, mICH scored better over oICH score with respect to sensitivity and had comparable specificity for both 30-day mortality and good outcome (sensitivity 80.6% vs. 50.8%; specificity 88.7% vs. 89.3%; YI 0.69 vs. 0.40, respectively) and good outcome (sensitivity 86.3% vs. 77.4%; specificity 74.6% vs. 77.8%; YI of 0.61 vs. 0.55, respectively). There was only one patient with oICH and none on mICH score of 0, who died and none survived with oICH and mICH score of ≥ 5 and ≥ 7, respectively. The proportion of 30-day mortality and good outcome increased in a more linear fashion with mICH score. ConclusionsThe mICH score was proven to be reliable and consistent as a risk grading assessment for non-traumatic ICH patients. The mICH was statistically superior to oICH score in predicting 30-day mortality and good outcome.

Association of early glycemic change with short-term mortality in lobar and non-lobar intracerebral hemorrhage

The association between early glycemic change and short-term mortality in non-diabetic patients with acute intracerebral hemorrhage (ICH) is unclear. We retrospectively investigated non-diabetic patients with lobar (n = 262) and non-lobar ICH (n = 370). Each patient had a random serum glucose test on hospital admission and a fasting serum glucose test within the following 48 h. Hyperglycemia was defined as serum glucose ≥ 7.8 mmol/l. Four patterns were determined: no hyperglycemia (reference category), persistent hyperglycemia, delayed hyperglycemia, and decreasing hyperglycemia. Associations with 30-day mortality were estimated using Cox models adjusted for major features of ICH severity. Persistent hyperglycemia was associated with 30-day mortality in both lobar (HR 3.00; 95% CI 1.28–7.02) and non-lobar ICH (HR 4.95; 95% CI 2.20–11.09). In lobar ICH, 30-day mortality was also associated with delayed (HR 4.10; 95% CI 1.77–9.49) and decreasing hyperglycemia (HR 2.01, 95% CI 1.09–3.70). These findings were confirmed in Cox models using glycemic change (fasting minus random serum glucose) as a continuous variable. Our study shows that, in non-diabetic patients with ICH, early persistent hyperglycemia is an independent predictor of short-term mortality regardless of hematoma location. Moreover, in non-diabetic patients with lobar ICH, both a positive and a negative glycemic change are associated with short-term mortality.

Prevalence, Characteristics, and Outcomes of Undetermined Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis.

There are scarce data regarding the prevalence, characteristics and outcomes of intracerebral hemorrhage (ICH) of undetermined (unknown or cryptogenic) etiology. We sought to determine the prevalence, radiological characteristics, and clinical outcomes of undetermined ICH. Systematic review and meta-analysis of studies involving patients with spontaneous ICH was conducted to primarily assess the prevalence and clinical-radiological characteristics of undetermined ICH. Additionally, we assessed the rates for ICH secondary to hypertensive arteriopathy and cerebral amyloid angiopathy. Subgroup analyses were performed based on the use of (1) etiology-oriented ICH classification, (2) detailed neuroimaging, and (3) Boston criteria among patients with cerebral amyloid angiopathy related ICH. We pooled the prevalence rates using random-effects models, and assessed the heterogeneity using Cochran Q and I2 statistics. We identified 24 studies comprising 15 828 spontaneous ICH patients (mean age, 64.8 years; men, 60.8%). The pooled prevalences of hypertensive arteriopathy ICH, undetermined ICH, and cerebral amyloid angiopathy ICH were 50% (95% CI, 43%–58%), 18% (95% CI, 13%–23%), and 12% (95% CI, 7%–17% [P<0.001 between subgroups]). The volume of ICH was the largest in cerebral amyloid angiopathy ICH (24.7 [95% CI, 19.7–29.8] mL), followed by hypertensive arteriopathy ICH (16.2 [95% CI, 10.9–21.5] mL) and undetermined ICH (15.4 [95% CI, 6.2–24.5] mL). Among patients with undetermined ICH, the rates of short-term mortality (within 3 months) and concomitant intraventricular hemorrhage were 33% (95% CI, 25%–42%) and 38% (95% CI, 28%–48%), respectively. Subgroup analysis demonstrated a higher rate of undetermined ICH among studies that did not use an etiology-oriented classification (22% [95% CI, 15%–29%]). No difference was observed between studies based on the completion of detailed neuroimaging to assess the rates of undetermined ICH (P=0.62). The etiology of spontaneous ICH remains unknown or cryptogenic among 1 in 7 patients in studies using etiology-oriented classification and among 1 in 4 patients in studies that avoid using etiology-oriented classification. The short-term mortality in undetermined ICH is high despite the relatively small ICH volume.

In-hospital complications affect short-term and long-term mortality in ICH: a prospective cohort study

BackgroundMedical complications strongly affected the mortality of patients with stroke. However, only limited research has studied the effect of in-hospital medical complications on the mortality of patients with spontaneous intracerebral...