Nontraumatic Intracerebral Hemorrhage Research Articles

Endoscopic Evacuation Versus Open Craniotomy and Evacuation of Non-traumatic Intracerebral Bleed: A Comparative Study.

Objective In patients with intracerebral hemorrhage (ICH), the usage of microsurgical instrumentation and techniques can reduce traction-related injuries and enhance postoperative outcomes compared with traditional hematoma evacuation.The purpose of this study was to compare the results of endoscopic evacuation of spontaneous non-traumatic ICH with conventional open craniotomies and evacuations of ICH in terms of safety, feasibility, and neurological outcomes. Methods This was a prospective study that included 21 patients with spontaneous intracerebral hematomas managed by surgical evacuation endoscopically and another 24 patients with spontaneous supratentorial ICH who underwent hematoma evacuation by open craniotomy. Primary outcomes included operation duration, operative blood loss, hematoma evacuation rate, re-bleeding rate, and postoperative Glasgow Coma Scale (GCS) score. Results The median operation durations were 110 (90-200) and 230 (120-460) minutes in the endoscopic and open procedure groups, respectively (p = 0.00001). The median operative blood loss was 160 (80-300) and 530 (100-2000) mL in the endoscopic and open procedure groups, respectively (p < 0.00001). The median hematoma removal rates were 90% (60%-99%) and 85% (60%-100%) in the endoscopic and open procedure groups, respectively (p = 0.0348). Re-bleeding rates were higher in the endoscopic group (p = 0.46). Postoperative Glasgow Outcome Scale scores at two-month and six-month intervals were similar between the groups (p = 0.87). Conclusion Endoscopic hematoma evacuation for spontaneous supratentorial hemorrhage is becoming a standard surgical procedure, and promising clinical results can be expected. In addition, an endoscope can enhance time efficiency, hematoma evacuation rates, and reduce bleeding. Although endoscopic surgeries have higher re-bleeding rates, the difference is not significant when compared to open craniotomies with similar postoperative GCS scores. It is therefore important to be familiar with the endoscope and its associated equipment in order to achieve better results and reduce complications.

Emergent Management of Intracerebral Hemorrhage.

Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH. Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques. This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.

Hypertension control after intracerebral hemorrhage among varying small vessel disease etiologies.

Intracerebral hemorrhage (ICH) is attributable to cerebral small vessel disease (cSVD), which includes cerebral amyloid angiopathy (CAA) and hypertensive-cSVD (HTN-cSVD). HTN-cSVD includes patients with strictly deep ICH/microbleeds and mixed location ICH/microbleeds, the latter representing a more severe form of HTN-cSVD. We test the hypothesis that more severe forms of HTN-cSVD are related to worse hypertension control in long-term follow-up after ICH. From consecutive non-traumatic ICH patients admitted to a tertiary care center, we classified the ICH as CAA, strictly deep ICH/microbleeds, and mixed-location ICH/microbleeds. CSVD burden was quantified using a validated MRI-based score (range: 0-6 points). We created a multivariable (linear mixed effects) model adjusting for age, sex, race, year of inclusion, hypertension, and antihypertensive medication usage to investigate the association of average systolic blood pressure (SBP) during follow-up with cSVD etiology/severity. 796 ICH survivors were followed for a median of 48.8months (IQR 41.5-60.4). CAA-related ICH survivors (n = 373) displayed a lower median SBP (138mmHg, IQR 133-142mmHg) compared to those of strictly deep ICH (n = 222, 141mmHg, IQR 136-143mmHg, p = 0.04), and mixed location ICH/microbleeds (n = 201, 142mmHg, IQR 135-144mmHg, p = 0.02). In the multivariable analysis, mixed location ICH/microbleeds (effect: + 3.8mmHg, SE: 1.3mmHg, p = 0.01) and increasing cSVD severity (+ 1.8mmHg per score point, SE: 0.8mmHg, p = 0.03) were associated with higher SBP in follow-up. CSVD severity and subtype predicts long-term hypertension control in ICH patients.

Antithrombotic Treatment and Clinical Outcomes After Intracerebral Hemorrhage: A Retrospective Cohort Study from the Swedish Stroke Register.

A rapid shift has occurred from vitamin K antagonists toward direct oral anticoagulants, which have a lower risk of intracerebral hemorrhage (ICH). However, effects on clinical outcomes after ICH are understudied. We aimed to describe the prevalence of antithrombotic drugs and to study the prognosis among prestroke functionally independent Swedish patients with ICH. We identified all patients diagnosed with nontraumatic ICH in 2017 to 2021 from the Swedish Stroke Register (n=13 155) and assessed death and functional outcome at 3 months after ICH in prestroke functionally independent patients (n=10 014). Functional outcome was estimated among 3-month survivors on the basis of self-reported activities of daily living scores. Risks of outcomes were estimated using Poisson regression. In 13 155 patients, 14.5% used direct oral anticoagulant, 10.1% vitamin K antagonists, and 21.6% antiplatelets at ICH onset. Among 10 014 pre-stroke activities of daily living-independent patients, oral anticoagulants and antiplatelets were associated with increased mortality risk (adjusted risk ratio, 1.27 [95% CI, 1.13-1.43]; P<0.001; and adjusted risk ratio, 1.23 [95% CI, 1.13-1.34]; P<0.001 respectively). Mortality risk did not statistically differ between antiplatelets and oral anticoagulants nor between direct oral anticoagulant and vitamin K antagonists. Among 5126 patients with nonmissing functional outcome (69.1% of survivors), antiplatelets (adjusted risk ratio, 1.06 [95% CI, 0.99-1.13]; P=0.100) and oral anticoagulants (adjusted risk ratio, 1.01 [95% CI, 0.92-1.12]; P=0.768) were not statistically significantly associated with functional dependence. There was no statistically significant difference in mortality risk between direct oral anticoagulant and vitamin K antagonists in prestroke functionally independent patients (unadjusted for oral anticoagulant class indication). Furthermore, mortality risk in antiplatelet and oral anticoagulant users might differ less than previously suggested.

Mortality, Functional Status, and Quality of Life after 5 Years of Patients Admitted to Critical Care for Spontaneous Intracerebral Hemorrhage.

The objective of this study was to assess long-term outcome in patients with spontaneous intracerebral hemorrhage admitted to the intensive care unit. Mortality and Glasgow Outcome Scale, Barthel Index, and5-level EQ-5D version (EQ-5D-5L) scores were analyzed in a multicenter cohort study of three Spanish hospitals (336 patients). Mortality was also analyzed in theMedical Information Mart for Intensive Care III (MIMIC-III) database. The median(25th percentile-75th percentile) age was 62 (50-70) years, the median Glasgow Coma Score was 7 (4-11) points, and the median Acute Physiology and Chronic Health disease Classification System II(APACHE-II) score was 21 (15-26) points. Hospital mortality was 54.17%, mortality at 90days was 56%, mortality at 1year was 59.2%, and mortality at 5years was 66.4%. In the Glasgow Outcome Scale, a normal or disabled self-sufficient situation was recorded in 21.5% of patients at 6months, in 25.5% of patients after 1year, and in 22.1% of patients after 5years of follow-up (4.5% missing). The Barthel Index score of survivors improved over time: 50 (25-80) points at 6months, 70 (35-95) points at 1year, and 90 (40-100) points at 5years (p < 0.001). Quality of life evaluated with the EQ-5D-5L at 1year and 5years indicated that greater than 50% of patients had no problems or slight problems in all items (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). In the MIMIC-III study (N = 1354), hospital mortality was 31.83% and was 40.5% at 90days and 56.2% after 5years. In patients admitted to the intensive care unit with a diagnosis of nontraumatic intracerebral hemorrhage, hospital mortality up to 90days after admission is very high. Between 90days and 5years after admission, mortality is not high. A large percentage of survivors presented a significant deficit in quality of life and functional status, although with progressive improvement over time. Five years after the hemorrhagic stroke, a survival of 30% was observed, with a good functional status seen in 20% of patients who had been admitted to the hospital.

Uncommon Causes of Nontraumatic Intracerebral Hemorrhage.

Nontraumatic intracerebral hemorrhage is an important health issue. Although common causes such as hypertension and cerebral amyloid angiopathy predominantly affect the elderly, there exists a spectrum of uncommon etiologies that contribute to the overall incidence of intracerebral hemorrhage. The identification of these rare causes is essential for targeted clinical management, informed prognostication, and strategic secondary prevention where relevant. This topical review explores the uncommon intracerebral hemorrhage causes and provides practical clues for their clinical and imaging identification. By expanding the clinician's differential diagnosis, this review aims to bridge the gap between standard intracerebral hemorrhage classification systems and the nuanced reality of clinical practice.

Primary and Secondary Intracerebral Hemorrhage in Pregnant and Nonpregnant Young Adults by SMASH-UP Criteria.

Intracerebral hemorrhage (ICH) is a major cause of maternal morbidity, but its pathophysiology is poorly characterized. We investigated characteristics of pregnancy-associated ICH (P-ICH), compared with ICH in similar aged nonpregnant adults of both sexes. We performed a retrospective analysis of 134 adults aged 18 to 44 years admitted to our center with nontraumatic ICH from January 1, 2012, to December 31, 2021. We compared ICH characteristics among 3 groups: those with P-ICH (pregnant or within 12 months of end of pregnancy); nonpregnant women; and men. We categorized ICH pathogenesis according to a modified scheme, SMASH-UP (structural, medications, amyloid angiopathy, systemic, hypertension, undetermined, posterior reversible encephalopathy syndrome/reversible cerebral vasoconstriction syndrome), and calculated odds ratios and 95% CIs for primary (spontaneous small-vessel) ICH versus secondary ICH (structural lesions or coagulopathy related), using nonpregnant women as the reference. We also compared specific ICH pathogenesis by SMASH-UP criteria and functional outcomes between groups. Of 134 young adults with nontraumatic ICH, 25 (19%) had P-ICH, of which 60% occurred postpartum. Those with P-ICH had higher odds of primary ICH compared with nonpregnant women (adjusted odds ratio, 4.5 [95% CI, 1.4-14.7]). The odds of primary ICH did not differ between men and nonpregnant women. SMASH-UP pathogenesis for ICH differed significantly between groups (P<0.001). While the in-hospital mortality rate was lowest in the P-ICH group (4%) compared with nonpregnant women (13%) and men (24%), 1 in 4 patients with P-ICH were bedbound and dependent at the time of discharge. In our cohort of young adults with ICH, 1 in 5 was pregnancy related. P-ICH differed in pathogenesis compared with non-pregnancy-related ICH in young adults, suggesting unique pathophysiology.

Triglyceride-glucose index: a novel evaluation tool for all-cause mortality in critically ill hemorrhagic stroke patients-a retrospective analysis of the MIMIC-IV database

BackgroundHemorrhagic stroke (HS), including non-traumatic intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), constitutes a substantial proportion of cerebrovascular incidents, accounting for around 30% of stroke cases. The triglyceride-glucose index (TyG-i) represents a precise insulin resistance (IR) indicator, a crucial metabolic disturbance. Existing literature has demonstrated an association between TyG-i and all-cause mortality (ACM) among individuals suffering from ischemic stroke (IS). Yet, the TyG-i prognostic implications for severe HS patients necessitating intensive care unit (ICU) admission are not clearly understood. Considering the notably elevated mortality and morbidity associated with HS relative to IS, investigating this association is warranted. Our primary aim was to investigate TyG-i and ACM association among critically ill HS patients within an ICU context.MethodsHerein, patients with severe HS were identified by accessing the Medical Information Mart for Intensive Care-IV (MIMIC-IV, version 2.2) database, using the International Classification of Diseases (ICD)-9/10 as diagnostic guidelines. Subsequently, we stratified the subjects into quartiles, relying on their TyG-i scores. Moreover, we measured mortality at ICU, in-hospital, 30 days, 90 days, and 1 year as the outcomes. Cox proportional hazards regression analysis and restricted cubic splines (RCS) were deployed for elucidating the relation between the TyG-i and ACM while utilizing the Kaplan-Meier (K-M) method to estimate survival curves. The findings’ robustness was assessed by conducting subgroup analysis and interaction tests employing likelihood ratio tests.ResultsThe analysis included 1475 patients, with a male predominance of 54.4%. Observed mortality rates in the ICU, hospital, 30 days, 90 days, and 1 year were 7.3%, 10.9%, 13.8%, 19.7%, and 27.3%, respectively. Multivariate Cox regression analysis results manifested that heightened TyG-i was significantly related to ACM at 30 days (adjusted hazard ratio [aHR]: 1.32; 95% confidence interval [CI]: 1.05–1.67; P = 0.020), 90 days (aHR: 1.27; 95% CI: 1.04–1.55; P = 0.019), and 1 year (aHR: 1.22; 95% CI: 1.03–1.44; P = 0.023). The results of RCS analysis demonstrated a progressive elevation in ACM risk with rising TyG-i levels. Interaction tests found no significant effect modification in this relationship.ConclusionIn summary, TyG-i exhibits a significant correlation with ACM among patients enduring critical illness due to HS. This correlation underscores the probable utility of TyG-i as a prognostic tool for stratifying HS patients according to their risk of mortality. Applying TyG-i in clinical settings could enhance therapeutic decision-making and the management of disease trajectories. Additionally, this investigation augments existing research on the linkage between the TyG-i and IS, elucidating the TyG-i’s role in predicting mortality across diverse stroke categories.

Andexanet alfa versus non-specific treatments for intracerebral hemorrhage in patients taking factor Xa inhibitors - Individual patient data analysis of ANNEXA-4 and TICH-NOAC.

Data comparing the specific reversal agent andexanet alfa with non-specific treatments in patients with non-traumatic intracerebral hemorrhage (ICH) associated with factor-Xa inhibitor (FXaI) use are scarce. The study aimed to determine the association between the use of andexanet alfa compared with non-specific treatments with the rate of hematoma expansion and thromboembolic complications in patients with FXaI-associated ICH. We performed an individual patient data analysis combining two independent, prospective studies: ANNEXA-4 (180 patients receiving andexanet alfa, NCT02329327) and TICH-NOAC (63 patients receiving tranexamic acid or placebo ± prothrombin complex concentrate, NCT02866838). The primary efficacy outcome was hematoma expansion on follow-up imaging. The primary safety outcome was any thromboembolic complication (ischemic stroke, myocardial infarction, pulmonary embolism, or deep vein thrombosis) at 30 days. We used binary logistic regression models adjusted for baseline hematoma volume, age, calibrated anti-Xa activity, times from last intake of FXaI, and symptom onset to treatment, respectively. Among 243 participants included, the median age was 80 (IQR 75-84) years, baseline hematoma volume was 9.1 (IQR 3.4-21) mL and anti-Xa activity 118 (IQR 78-222) ng/mL. Times from last FXaI intake and symptom onset to treatment were 11 (IQR 7-16) and 4.7 (IQR 3.0-7.6) h, respectively. Overall, 50 patients (22%) experienced hematoma expansion (ANNEXA-4: n=24 (14%); TICH-NOAC: n=26 (41%)). After adjusting for pre-specified confounders (baseline hematoma volume, age, calibrated anti-Xa activity, times from last intake of FXaI, and symptom onset to treatment, respectively), treatment with andexanet alfa was independently associated with decreased odds for hematoma expansion (aOR 0.33, 95% CI 0.13-0.80, p = 0.015). Overall, 26 patients (11%) had any thromboembolic complication within 30 days (ANNEXA-4: n=20 (11%); TICH-NOAC: n=6 (10%)). There was no association between any thromboembolic complication and treatment with andexanet alfa (aOR 0.70, 95% CI 0.16-3.12, p = 0.641). The use of andexanet alfa compared to any other non-specific treatment strategy was associated with decreased odds for hematoma expansion, without increased odds for thromboembolic complications.

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 TP163: Associations Between Prior Oral Anticoagulant Use and Stroke Outcomes in a National Stroke Cohort: A Scottish Database Study

Background and aims: Recent studies suggest that oral anticoagulant (OAC) use prior to stroke is associated with better functional outcomes after ischaemic stroke, but worse outcomes after non-traumatic intracerebral haemorrhage (ICH). We aimed to assess the impact of prior OAC use on stroke subtype and outcomes (mortality and discharge to home) in a Scottish stroke cohort. Methods: Data on first-ever strokes between January 1, 2011, and December 31, 2018, were gathered from the Scottish Stroke Care Audit. The Prescribing Information System was used to identify patients with a prescription for OAC within 90-days before stroke, and further linked to hospital admission and discharge data in the Scottish Morbidity Record 01, and mortality data in the National Records of Scotland. Multivariable logistic regression models were adjusted for sociodemographic factors, atrial fibrillation, stroke severity, acute management and Charlson Comorbidity scores. Results: Among 52 988 stroke patients (50.1% women; mean age 72.8 [±13.3] years), 88.9% were ischaemic and 18.3% had a history of atrial fibrillation. OACs (warfarin [73%] and direct oral anticoagulants [28%]) were prescribed to 3533 (7.5%) patients with ischaemic stroke and 847 (14.4%) patients with ICH within 90 days prior to first-ever stroke. After model adjustments, prior OAC use was associated with a three-fold increase in the odds of experiencing an ICH (adjusted Odds Ratio [aOR], 2.92; 95% CI, 2.61 - 3.26]). In patients with ischaemic stroke or ICH, prior OAC use was not associated with better or worse outcomes in 30-day discharge to usual place of residence (aOR, 0.99; 95% CI, 0.89 - 1.09 and aOR, 0.86; 95% CI, 0.66 - 1.12 respectively) or 30-day mortality (aOR, 1.06; 95% CI, 0.94 - 1.21 and aOR, 1.20, 95% CI, 0.93 - 1.56 respectively) in comparison to those with no prior OAC use. Additionally, no statistically significant differences were observed for discharge or mortality outcomes within 90 days after stroke. Conclusions: Prior OAC use was higher in patients with ICH, which may partly reflect ischaemic stroke reduction in patients taking OAC. However, prior OAC use was not associated with better or worse outcomes in terms of mortality and discharge to home in either ischaemic or ICH populations.

Abstract 46: Minimally Invasive Surgery is Associated With Lower Mortality After Spontaneous Intracerebral Hemorrhage in the Get With the Guidelines Registry

Introduction: The efficacy of emergent minimally invasive surgery (MIS) in improving outcomes after non-traumatic intracerebral hemorrhage (ICH) is unclear, with two randomized clinical trials (MISTIE III and ENRICH) showing conflicting results. We therefore sought to evaluate the association of MIS for ICH with outcomes in a real-world, nationally representative cohort. Methods: We performed a retrospective cohort study of patients with ICH in the Get With The Guidelines-Stroke registry, between 2011 and 2021. Patients who underwent open craniotomy/craniectomy and those transferred to another hospital were excluded. The study exposure was MIS, defined as a composite of stereotactic surgical evacuation and endoscopic surgical evacuation. The primary outcome was in-hospital mortality. In the primary analysis, we matched patients who underwent MIS with medically managed patients in a 1:1 manner on age, sex, race, NIH Stroke Scale, prior antithrombotic therapy, and external ventricular drain use. Logistic regression was used while adjusting for withdrawal of care. In secondary analyses, stereotactic and endoscopic surgical approaches were analyzed separately. Results: Among 555,964 patients with ICH, MIS was performed in 703 patients (330 had stereotactic surgery; 391 had endoscopic surgery). The matched cohort included 485 patients in each group. Median time to surgery was 1 day (IQR, 1-2). In-hospital deaths occurred in 63 (13%) with MIS and 96 (20%) without surgery. Medically managed patients had more vascular comorbidities such as hypertension, diabetes, and prior stroke than those who underwent MIS. In regression analyses adjusted for withdrawal of care, MIS was associated with lower in-hospital mortality at discharge (aOR, 0.4; CI, 0.3-0.6). In secondary analyses, stereotactic surgery (aOR, 0.3; CI, 0.2-0.6) and endoscopic surgery (aOR, 0.6; CI, 0.3-0.9) were also independently associated with lower mortality. Conclusions: In a large heterogeneous US cohort of ICH patients, emergent MIS was associated with lower in-hospital mortality. Longer-term follow up data with ascertainment of functional outcomes may shed more light on the benefit of surgery after ICH.

Abstract WP175: Effect of Acute Blood Pressure Management on Outcomes in Patients With Nontraumatic Intracerebral Hemorrhage: Quality Assurance Study

Current guidelines for blood pressure (BP) management in patients with intracerebral hemorrhage (ICH) recommend acute lowering of systolic BP (SBP) to 140 mm Hg with a maintenance goal of 130 - 150 mm Hg. There remains a knowledge gap regarding frequency of BP monitoring, and level of SBP lowering in acute phase of ICH. Our study aimed to investigate effect of frequency of BP monitoring and acute SBP lowering in ICH patients within 48 hours of their admission. Methods: We conducted a retrospective review of study from our institutional SHOUT database (Stroke Health Outcomes Database) database. All ICH patients from 2018 through 2022 were included. Data involving BP measurements, maximum SBP and average BP within the first 48 hours of admission were collected. BP was categorized into 3 categories of &lt;140, 140-160 and &gt;160 mmHg. Frequency of BP measurements was obtained and was classified as &lt;25, 25-50 and &gt; 50 measurements of BP in the first 48 hours. Demographic data along with comorbidities were included in the analysis. Outcome was considered good if the patients were discharged home or had discharge mRS of 0-2. Outcome was considered poor if patient was discharged to a subacute rehabilitation facility or had mRS of 3-5. Results: 2998 patients were found to have ICH. 64.2 % of patients achieved lower mean BP &lt; 140 mm Hg and were found to have good outcome of home disposition. These results were statistically significant (P= 0.002). BP monitoring of &gt; 50 times was more likely to result in better outcomes in patients with ICH when compared to less monitoring (P&lt;0.001). Discussion: ICH patients who had higher number of BP readings during first 48 hours of their admission were more likely to have good outcome. Aggressive lowering of SBP was associated with higher likelihood of discharge to home or mrs 0-2.

Abstract TMP74: Association Between Hematoma Volume After Risk of Subsequent Ischemic Stroke: A MISTIE III and ATACH-2 Analysis

Background: Non-traumatic intracerebral hemorrhage (ICH) is independently associated with long-term increased risk of major arterial ischemic events. Whether hematoma volume influences this risk is poorly understood. Methods: We pooled individual patient data from the MISTIE III (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3) and the ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage) trials. The exposure was hematoma volume. In the primary analysis, hematoma volume was treated as a continuous measure after natural logarithmic transformation to approximate linearity, and in the secondary analysis, it was dichotomized by the median. The outcome was an ischemic stroke, adjudicated centrally within each trial. We evaluated the association between hematoma volume and the risk of an ischemic stroke using Cox regression analyses after adjustment for demographics, vascular comorbidities, and ICH characteristics. Results: Of 1,499 ICH patients, the mean age was 61.7 (SD, 12.8) years and 574 (38.3%) were female. The median hematoma volume was 17.3 mL (IQR, 7.2-35.7). During a median follow up of 107 days (IQR, 91-140), 30 ischemic strokes occurred of which 22 were in patients with median ICH volume &gt; 17.3 mL with a cumulative incidence of 4.6% (95% CI, 3.1-7.1). Among patients with median ICH volume &lt; 17.3 mL, there were 8 ischemic strokes with a cumulative incidence of 3.1% (95% CI, 1.7-6.0). Using adjusted Cox regression models, log-transformed ICH volume (continuous measure) was associated with an increased risk of ischemic stroke (HR, 1.5 per log-unit increase; 95% CI, 1.1-2.8). Similarly, ICH volume &gt; 17.3 mL was associated with an increased risk of ischemic stroke (HR, 2.5; 95% CI, 1.1-7.2), compared to those with an ICH volume &lt; 17.3 mL. Conclusions: In a heterogeneous cohort of ICH patients, initial hematoma volume was associated with a heightened risk of subsequent ischemic stroke.

Abstract 149: Different Response to Blood Pressure Reduction in Lobar and Deep Intracerebral Hemorrhage

Background: Blood pressure (BP) reduction is associated with better neuroimaging and clinical outcomes in patients with spontaneous, non-traumatic intracerebral hemorrhage (ICH). Because this evidence comes from studies that overwhelmingly enrolled deep hemorrhages, the impact of BP reduction in patients with lobar ICH remains understudied. Methods: We re-analyzed data from the pivotal Antihypertensive Treatment of Acute Cerebral Hemorrhage-2 (ATACH-2) study. We included all patients with available neuroimaging data. Participants were randomized to either intensive (systolic BP target 110-139 mmHg) or standard (systolic BP target 140-179 mmHg) acute BP lowering. The main outcome measures were hematoma expansion &gt; 6 mL in the first 24 hours (HE), poor functional outcome (3-month mRS 4-6) and renal adverse events (RAE) until day 7 or hospital discharge. We fitted multivariable logistic regression models to test for association between the intervention and our outcomes of interest. Covariates included sex, age, race and ethnicity, and baseline ICH volume. Results: Among 1,000 patients enrolled in ATACH-2, 875 (87.5%) with complete data were included (88.9% deep hemorrhages and 11.1% lobar hemorrhages). The baseline characteristics of the intensive and standard treatment groups remained balanced as in the original study (all comparisons p &gt;0.05). Multivariable logistic regression showed that intensive BP reduction decreased the risk of HE (OR 0.60, 95%CI 0.39-0.90; p=0.02) and increased the risk of RAE (OR 2.53, 95%CI 1.40-4.77; p=0.003) in patients with deep, but not lobar ICH (HE, OR: 0.89; 95% CI= 0.31 - 2.52; p=0.83 and RAE, OR: 0.46; 95% CI= 0.04 - 5.10; p=0.53). Intensive BP reduction was not associated with improved mRS in either deep (OR: 0.96; 95 % CI= 0.68 - 1.37; p= 0.82) nor lobar (OR: 0.66; 95% CI= 0.16 - 2.42; p= 0.54) ICH. Conclusion: The impact of intensive blood pressure lowering differs in deep and lobar ICH. These results emphasize the need for a better understanding about biologic differences in ICH, which may have therapeutic implications.

Abstract TMP17: Predicting Neurosurgical Intervention After Intracerebral Hemorrhage (ICH) Transfer

This is a retrospective chart review to ascertain the rates of neurosurgical intervention following transfer of patients with non-traumatic intracerebral hemorrhage (ICH) to a Comprehensive Stroke Center (CSC) and characterize predictors of need for surgical intervention. Introduction: While neurosurgical intervention is required in a minority of cases, it has become standard practice for all ICH patients to be transferred to our tertiary care center, without consideration of additional factors. This creates significant burden and stress to patients and families as well as hospital resources. Hypothesis: We hypothesize that only a minority of ICH patients require neurosurgical intervention and that we will be able to identify predictors that will assist in identifying patients who are at risk for needing neurosurgical intervention. Methods: We retrospectively reviewed the EMR from all ICH patients transferred to a 700-bed CSC from 2020-2023. We collected: age, sex, pre-stroke modified Rankin score, ICH score, BP management, anticoagulant reversal, any neurosurgical intervention performed, length of stay (LOS), and 30-day mortality. The data was stored and analyzed in a secure online database. Results: Of the 420 completed charts, 55% of patients were male with an average age of 67.7 years. Only 14.25% (61/420) of all patients underwent neurosurgical intervention. Predictors for surgery included: age (average age of patients who underwent surgery was 61.2 years); size and location of the hematoma (the majority of patients who underwent surgery (58/61) had ICH volume &gt;30cc, were subtentorial in location, or had IVH extension); higher ICH score (23.96% with ICH ≥2 vs. 6.67% with ICH 0-1); and lower GCS (41.5% GCS &lt;12 vs. 9.8% GCS ≥ 12). Average hospital length of stay was 10.5 days. Mortality rate at 30-days was 24.5% overall and higher in patients who underwent neurosurgical intervention (32.8%). Conclusion: Only a small percentage of patients with ICH transferred to our CSC require neurosurgical intervention. There are many predictive factors allowing for a more thoughtful approach to better utilize health care resources. We recommend further studies to develop better strategies to triage these patients.

Abstract TP244: Racial and Ethnic Differences in Risk Factors and Outcomes in Young Patients With Intracerebral Hemorrhage

Racial and ethnic disparities in risk factors and outcomes for young patients with ischemic stroke (AIS) are well described. Less is known about disparities in risk and outcomes for young patients presenting with intracerebral hemorrhage (ICH), which is associated with higher short-term and long-term mortality. As such, it is important to review disparities in its evaluation and management. In this study, we aimed to evaluate racial and ethnic differences in risk factors and outcomes for young patients with ICH. Methods: We identified patients aged 18-45 from our inpatient stroke registry who presented to our comprehensive stroke center with non-traumatic ICH from 10/2016 to 11/2019, with exclusion of patients with primary subarachnoid hemorrhage. We abstracted baseline characteristics and compared ICH risk and outcomes amongst different racial groups and ethnicities through examination of sociodemographic and medical risk factors and outcomes using independent samples t-test for continuous outcomes, and chi-squared test for categorical outcomes. All tests were two-tailed and the error rate was set at 5%. Results: Among 430 patients who met inclusion criteria, 22.3% were non-Hispanic White (NHW), 31.6% Non-Hispanic Black(NHB), 28.6% Hispanic (HIS), 4.9% Asian, and 5.1% other. There were significant differences in insured status, with 50.4% of HIS having insurance compared to 67.6% of NHB and 68.8% of NHW patients. NHB and HIS patients were more likely to be single (55.1% and 44.7%), compared to NHW (32.3%) and Asian (38.1%) patients. Black patients had the highest likelihood of living alone (20.6%; p=0.07), while Hispanic patients were more likely not to not have a primary care provider (64.2%; p=0.02). NHB patients were more likely to have prior hypertension (72%), and diastolic dysfunction (27.2%) compared to NHW (53.1%, 13.5%), and HIS (50.4%, 11.4%) patients). No significant differences in overall discharge disposition or mRS was noted when comparing racial and ethnic groups. Conclusion: Although we did not find significant differences in measured outcomes, our study demonstrates underlying sociodemographic and clinical risk factors which may underlie racial and ethnic disparities in long-term outcomes for patients with ICH.

Abstract TP165: Functional Outcomes at Discharge After Intracerebral Hemorrhage in Young Adults: Comparison by Sex and Pregnancy Status

Introduction: Intracerebral hemorrhage (ICH) is a major cause of maternal morbidity and mortality. While sex differences exist in clinical outcomes of ICH in young adults, it is not known if outcomes differ between pregnancy-associated ICH (PICH) and non-pregnancy-associated ICH (NPICH). Methods: We performed a cross-sectional analysis of 134 adults, aged 18-44 years, admitted to an urban academic medical center with non-traumatic acute ICH between 01/01/2012-12/31/2021. Participants were identified using an internally maintained stroke registry as well as data collected from the ICHOP (Intracerebral Hemorrhage Outcomes Project) study. We compared ICH outcomes between three exposure groups: PICH, NPICH in females, and NPICH in males. PICH was defined as ICH occurring during pregnancy or within 3 months postpartum. The primary outcome was mRS at discharge, with good outcome defined as mRS 0-2 and bad outcome as mRS 3-6. We used logistic regression models to calculate odds ratios (OR) and 95% confidence intervals (95%CI) for the association of exposure group status with bad outcome, with non-pregnant females as the reference group. Results: Characteristics of the study population are detailed in the Table. Individuals with PICH had a lower proportion of chronic hypertension (p&lt;0.0001) and smoking (p=0.02). Adjusting for age, hematoma volume, and ICH location, functional outcomes at discharge did not differ between groups (Figure). Conclusions: Functional outcomes at discharge after ICH were similar in young adults, regardless of sex or pregnancy status, despite a lower prevalence of vascular risk factors in patients with pregnancy-associated ICH.

Abstract NS3: Nurse Led Interventions Improve the Timeliness of Blood Pressure Reduction in Patients Presenting With Acute Nontraumatic Intracerebral Hemorrhage

Introduction: The 2022 AHA/ASA Guidelines for Intracerebral Hemorrhage (ICH) recommend initiating treatment and lowering blood pressure (BP) within 2 hours of ICH onset and reaching the target systolic BP of 130-150mmHg within one hour of treatment initiation. This study evaluates the effectiveness of nursing education at a Comprehensive Stroke Center (CSC) on improving the timeliness of BP medication administration and BP reduction in ICH patients. Methods: Emergency Department (ED) code stroke patients with a diagnosis of ICH were included in the analysis from 6/2022-12/2022 (pre-intervention) and 1/2023-6/2023 (post-intervention). Guideline based education regarding the importance of timely medication administration was provided in nursing huddles. Nurse to patient ratios were changed to 1:1 until goal BP achieved. BP medications were also placed in the CT scanner pyxis for immediate access. Baseline demographics, NIHSS, ICH score, and door to blood pressure reduction related time metrics were collected. Data were analyzed using R package. Results: 34 patients were analyzed, 12 (35%) pre and 22 (65%) post-intervention. Patient demographics and characteristics were not different between both groups (Table 1). Time from first BP medication order to BP in range improved: 62(46.7-80) vs 43(33-52.3) mins p=0.02. In addition, the time from door to Systolic BP 130-150mmHg improved 81 (68.5-91.3) vs 56 (37.38-73.5) mins p=0.02 (Table 2). Conclusion: Guideline based education is effective in promoting nursing-led interventions to achieve timely BP reduction of ICH patients to the target goal of 130-150 mmHg.

Abstract TP166: White Matter Hyperintensity Burden Associated With Stroke Severity, Aphasia, and Motor Deficits During Intracerebral Hemorrhage Hospitalization

Introduction: Cerebral Small Vessel Disease (CSVD) is associated with cognitive disruptions after intracerebral hemorrhage (ICH), however evidence connecting CSVD to specific neurological deficits after ICH is limited. Methods: Electronic medical record data were retrieved for adult patients (&gt;18 years) with admission for primary non-traumatic ICH, available admission NIHSS scores, and CSVD assessment. CSVD burden was graded from 0-4, with 1 point assessed for: 1) deep Fazekas white matter hyperintensity (WMH) score of 2-3 or periventricular (PV) Fazekas score of 3; 2) cerebral microbleed presence; 3) lacune presence; 4) &gt; 20 basal ganglia perivascular spaces. Severe CSVD was assessed scores ≥ 3, and individual marker severity was assessed using the same criteria. The primary outcome was moderate-severe stroke (total NIHSS score ≥5). Secondary outcomes were severe motor deficit (motor score &gt;12), complete aphasia (language score = 3), and cortical deficit (any impairment in language, extinction, and gaze). Associations between CSVD and NIHSS were determined using multivariable logistic regression, adjusting for major clinical and demographic factors. Adjusted odds ratios (aOR) and 95% confidence interval (CI) are reported. Results: The cohort included 1024 patients (median age [interquartile range]: 71 [61-79], 53% male). Patients were 22% Hispanic and had a racial distribution of 61% White, 24% Black, 8% Asian, 7% other. The median NIHSS score was 4 [1-11]; 477 (47%) showed moderate-severe NIHSS scores and 262 (26%) showed severe CSVD. Severe PV WMH burden was independently associated with moderate-severe NIHSS score (vs non-severe; aOR, 95% CI: 1.55, [1.02-2.36]). Severe deep WMH burden (vs non-severe) was independently associated with aphasia (1.97, [1.02-3.81]), and motor deficit (3.95, [1.22-12.73]) (Figure 1). Conclusion: Severe WMH burdens increase odds of neurological deficit among patients with primary ICH.