Poor Outcome In Intracerebral Hemorrhage Research Articles

Stress hyperglycemia is associated with longer ICU length of stay after endoscopic intracerebral hemorrhage evacuation

BackgroundStress hyperglycemia has been linked to poor outcomes in intracerebral hemorrhage (ICH). Recent studies using the ratio of blood glucose to glycated hemoglobin (HbA1c) as a marker for stress hyperglycemia have demonstrated greater discriminative power in predicting poor outcomes for stroke inpatients compared to blood glucose alone. Therefore, we aimed to investigate whether the preoperative glucose-to-HbA1c ratio is a predictor of postoperative outcomes in patients who have undergone minimally invasive ICH evacuation. MethodsRetrospective chart review was performed on ICH patients treated with minimally invasive surgery (MIS) in a single health system from 2015 to 2022. Stress hyperglycemia was defined as preoperative glucose-to-HbA1c ratio > calculated-median. Postoperative outcomes including modified Rankin Score (mRS) and length of stay (LOS) were collected. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. ResultsOf 192 patients who underwent minimally invasive ICH evacuation and had available glucose data, 96 demonstrated stress hyperglycemia (glucose-to-HbA1c ratio > 1.23). Patients with stress hyperglycemia were more likely to have a history of diabetes (43 % vs. 27 %, p=0.034), IVH (54 % vs. 33 %, p=0.007), higher preoperative hematoma volumes (46.8 ml vs. 38.6 mL, p=0.02), higher postoperative hematoma volumes (6 ml vs. 2.9 mL, p=0.008), smaller evacuation percentages (86.7 % vs. 92.7 %, p=0.048), longer procedure lengths (2.78 hrs vs. 2.23 hrs, p=0.015), and prolonged ICU LOS (9.44 days vs. 5.68 days, p=0.003). In a multivariate analysis, stress hyperglycemia remained predictive of prolonged ICU LOS (OR=2.44; p=0.026) when controlling for initial NIHSS, IVH, time to evacuation, procedure time, and diabetes. ConclusionsStress hyperglycemia was strongly associated with prolonged ICU LOS after MIS for ICH. Understanding factors associated with LOS may provide predictive value for a patient's hospital course after minimally invasive ICH evacuation and further guide clinician expectations of recovery.

Glibenclamide pretreatment attenuates early hematoma expansion of warfarin-associated intracerebral hemorrhage in rats by alleviating perihematomal blood–brain barrier dysfunction

BackgroundHematoma expansion is a determinant of poor outcome of intracerebral hemorrhage but occurs frequently, especially in warfarin-associated intracerebral hemorrhage (W-ICH). In the present study, we employ the warfarin-associated intracerebral hemorrhage (W-ICH) rat model, to explore the efficacy and potential mechanism of glibenclamide pretreatment on hematoma expansion after intracerebral hemorrhage, hoping to provide proof of concept that glibenclamide in stroke primary and secondary prevention is also potentially beneficial for intracerebral hemorrhage patients at early stage.MethodsIn the present study, we tested whether glibenclamide, a common hypoglycemic drug, could attenuate hematoma expansion in a rat model of W-ICH. Hematoma expansion was evaluated using magnetic resonance imaging; brain injury was evaluated by brain edema and neuronal death; and functional outcome was evaluated by neurological scores. Then blood–brain barrier integrity was assessed using Evans blue extravasation and tight junction-related protein.ResultsThe data indicated that glibenclamide pretreatment significantly attenuated hematoma expansion at 24 h after W-ICH, thus mitigating brain edema and neuronal death and promoting neurological function recovery, which may benefit from alleviating blood–brain barrier disruption by suppressing matrix metallopeptidase-9.ConclusionsThe results indicate that glibenclamide pretreatment in stroke primary and secondary prevention might be a promising therapy for hematoma expansion at the early stage of W-ICH.

Association Between Hematoma Expansion Severity and Outcome and Its Interaction With Baseline Intracerebral Hemorrhage Volume.

Hematoma expansion (HE) is a major determinant of neurologic deterioration and poor outcome in intracerebral hemorrhage (ICH) and represents an appealing therapeutic target. We analyzed the prognostic effect of different degrees of HE. This was a retrospective analysis of patients with ICH admitted at 8 academic institutions in Italy, Germany, Canada, China, and the United States. All patients underwent baseline and follow-up imaging for HE assessment. Relative HE (rHE) was classified as follows: none (<0%), mild (0%-33%), moderate (33.1%-66%), and severe (>66%). Absolute HE (aHE) was classified as none (<0 mL), mild (0-6.0 mL), moderate (6.1-12.5 mL), and severe (>12.5 mL). Predictors of poor functional outcome (90 days modified Rankin Scale 4-6) were explored with logistic regression. We included 2,163 patients, of whom 1,211 (56.0%) had poor outcome. The occurrence of severe aHE or rHE was more common in patients with unfavorable outcome (13.9% vs 6.5%, p < 0.001 and 18.3% vs 7.2%, p < 0.001 respectively). This association was confirmed in logistic regression (rHE odds ratio [OR] 1.98, 95% CI 1.38-2.82, p < 0.001; aHE OR 1.73, 95% CI 1.23-2.45, p = 0.002) while there was no association between mild or moderate HE and poor outcome. The association between severe HE and poor outcome was significant only in patients with baseline ICH volume below 30 mL. The strongest association between HE and outcome was observed in patients with smaller initial volume experiencing severe HE. These findings may inform clinical trial design and guide clinicians in selecting patients for antiexpansion therapies.

Neutrophil percentage to albumin ratio is associated with stroke-associated pneumonia and poor outcome in patients with spontaneous intracerebral hemorrhage.

The purpose of this study was to investigate the diagnostic performance of the neutrophil percentage-to-albumin ratio (NPAR) for predicting stroke-associated pneumonia (SAP) and functional outcome in patients with intracerebral hemorrhage (ICH). We analyzed our prospective database of consecutive ICH patients who were admitted to the First Affiliated Hospital of Chongqing Medical University from January 2016 to September 2021. We included subjects with a baseline computed tomography available and a complete NPAR count performed within 6h of onset. The patients' demographic and radiological characteristics were analyzed. Good outcome was defined as a modifed Rankin Scale score of 0-3 at 90 days. Poor outcome was defined as a modifed Rankin Scale score of 4-6 at 90 days. Multivariable logistic regression models were used to investigate the association between NPAR, SAP, and functional outcome. Receiver operating characteristic (ROC) curve analysis was conducted to identify the optimal cutoff of NPAR to discriminate between good and poor outcomes in ICH patients. A total of 918 patients with ICH confirmed by non-contrast computed tomography were included. Of those, 316 (34.4%) had SAP, and 258 (28.1%) had poor outcomes. Multivariate regression analysis showed that higher NPAR on admission was an independent predictor of SAP (adjusted odds ratio: 2.45; 95% confidence interval, 1.56-3.84; P<0.001) and was associated with increased risk of poor outcome (adjusted odd ratio:1.72; 95% confidence interval, 1.03-2.90; P=0.040) in patients with ICH. In ROC analysis, an NPAR of 2 was identified as the optimal cutoff value to discriminate between good and poor functional outcomes. Higher NPAR is independently associated with SAP and poor functional outcome in patients with ICH. Our findings suggest that early prediction of SAP is feasible by using a simple biomarker NPAR.

Abstract WP130: Intracerebral Hemorrhage Outcomes And Trends During The Covid-19 Pandemic. An Observational Study Of 61,417 Cases.

Background: Patients with ischemic stroke have worse outcome if there is concomitant coronavirus 2019 (COVID-19) infection. We hypothesize that patients with intracerebral hemorrhage (ICH) during the pandemic era had worse outcomes than ICH patients during the pre-pandemic period, and that concomitant COVID-19 in ICH patients is associated with worse outcome. Methods: We analyzed data from Get With The Guidelines® Stroke. We implemented a two-stage design: first, we compared outcomes for ICH patients pre-pandemic (admitted between March 2019 and February 2020) with outcomes for ICH patients admitted during the pandemic (from March 2020 to February 2021); second, we compared outcomes of ICH patients with and without COVID-19 infection admitted during the pandemic (from March 2020 to February 2021). We used multivariable logistic regression adjusted by age, sex, race/ethnicity, and clinical covariates for in-hospital mortality and poor functional outcome using the modified Rankin Scale (mRS) at discharge (mRS &gt;= 4) and a for length of stay (LOS). Results: The first stage included 62,743 pre-pandemic and 64,681 intra-pandemic ICH cases 64,681. ICH patients during the pandemic had worse outcomes, including higher modified rankin scale (mRS) (OR 1.10, CI 1.06-1.14) and higher mortality (OR 1.04, CI 1.01-1.07). The second stage included 60,091 COVID-19-negative and 1,326 COVID-19-positive ICH patients. Patients with concomitant COVID-19 infection had worse outcomes, including higher LOS (RR 1.32, CI 1.25-1.39), high mRS (OR 1.68, CI 1.40-2.01), and increased mortality (OR 1.50, CI 1.33-1.71). (Table). Conclusion: When comparing pre- and intra-pandemic cases of ICH, critically ill stroke patients admitted during the pandemic had worse outcomes. When comparing COVID-19 positive and negative ICH cases that happened during the pandemic, those with the infection had worse clinical outcomes. COVID-19 infection is an independent risk factor for poor outcomes in ICH.

Elevated inflammatory biomarkers and poor outcomes in intracerebral hemorrhage

BackgroundAccumulating evidence suggests that spontaneous intracerebral hemorrhage (ICH) is associated with a reactive neuroinflammatory response. However, it remains unclear if circulating inflammatory biomarkers are associated with adverse outcomes in ICH. To address this knowledge gap, we conducted a cohort study using a prospectively maintained stroke register in the United Kingdom to assess the prognostic value of admission inflammatory biomarkers in ICH.MethodsThe Norfolk and Norwich Stroke and TIA Register recorded consecutive ICH cases. The primary exposures of interest were elevation of white cell count (WCC; > 10 × 109/L), elevation of c-reactive protein (CRP; > 10 mg/L), and co-elevation of both biomarkers, at the time of admission. Modified Poisson and Cox regressions were conducted to investigate the relationship between co-elevation of WCC and CRP at admission and outcomes following ICH. Functional outcome, multiple mortality timepoints, and length of stay were assessed.ResultsIn total, 1714 ICH cases were identified from the register. After adjusting for covariates, including stroke-associated pneumonia, co-elevation of WCC and CRP at admission was independently associated with significantly increased risk of poor functional outcome (RR 1.08 [95% CI 1.01–1.15]) and inpatient mortality (RR 1.21 [95% CI 1.06–1.39]); and increased 90-day (HR 1.22 [95% CI 1.03–1.45]), and 1-year mortality (HR 1.20 [95% CI 1.02–1.41]). Individual elevation of WCC or CRP was also associated with poor outcomes.ConclusionsElevated inflammatory biomarkers were associated with poor outcomes in ICH. This study indicates that these readily available biomarkers may be valuable for prognostication and underscore the importance of inflammation in ICH.

The Patterns of Morphological Change During Intracerebral Hemorrhage Expansion: A Multicenter Retrospective Cohort Study.

Objectives: Hemorrhage expansion (HE) is a common and serious condition in patients with intracerebral hemorrhage (ICH). In contrast to the volume changes, little is known about the morphological changes that occur during HE. We developed a novel method to explore the patterns of morphological change and investigate the clinical significance of this change in ICH patients.Methods: The morphological changes in the hematomas of ICH patients with available paired non-contrast CT data were described in quantitative terms, including the diameters of each hematoma in three dimensions, the longitudinal axis type, the surface regularity (SR) index, the length and direction changes of the diameters, and the distance and direction of movement of the center of the hematoma. The patterns were explored by descriptive analysis and difference analysis in subgroups. We also established a prognostic nomogram model for poor outcomes in ICH patients using both morphological changes and clinical parameters.Results: A total of 1,094 eligible patients from four medical centers met the inclusion criteria. In 266 (24.3%) cases, the hematomas enlarged; the median absolute increase in volume was 14.0 [interquartile range (IQR), 17.9] mL. The initial hematomas tended to have a more irregular shape, reflected by a larger surface regularity index, than the developed hematomas. In subtentorial and deep supratentorial hematomas, the center moved in the direction of gravity. The distance of center movement and the length changes of the diameters were small, with median values of less than 4 mm. The most common longitudinal axis type was anterior–posterior (64.7%), and the axis type did not change between initial and repeat imaging in most patients (95.2%). A prognostic nomogram model including lateral expansion, a parameter of morphological change, showed good performance in predicting poor clinical outcomes in ICH patients.Conclusions: The present study provides a morphological perspective on HE using a novel automatic approach. We identified certain patterns of morphological change in HE, and we believe that some morphological change parameters could help physicians predict the prognosis of ICH patients.

Imaging markers of intracerebral hemorrhage expansion in patients with unclear symptom onset.

Hematoma expansion (HE) is common and associated with poor outcome in intracerebral hemorrhage (ICH) with unclear symptom onset (USO). We tested the association between non-contrast computed tomography (NCCT) markers and HE in this population. Retrospective analysis of patients with primary spontaneous ICH admitted at five centers in the United States and Italy. Baseline NCCT was analyzed for presence of the following markers: intrahematoma hypodensities, heterogeneous density, blend sign, and irregular shape. Variables associated with HE (hematoma growth > 6 mL and/or > 33% from baseline to follow-up imaging) were explored with multivariable logistic regression. Of 2074 patients screened, we included 646 subjects (median age = 75, 53.9% males), of whom 178 (27.6%) had HE. Hypodensities (odds ratio (OR) = 2.67, 95% confidence interval (CI) = 1.79-3.98), heterogeneous density (OR = 2.16, 95% CI = 1.46-3.21), blend sign (OR = 2.28, 95% CI = 1.38-3.75) and irregular shape (OR = 1.82, 95% CI = 1.21-2.75) were independently associated with a higher risk of HE, after adjustment for confounders (ICH volume, anticoagulation, and time from last seen well (LSW) to NCCT). Hypodensities had the highest sensitivity for HE (0.69), whereas blend sign was the most specific marker (0.90). All NCCT markers were more frequent in early presenters (time from LSW to NCCT ⩽ 6 h, n = 189, 29.3%), and more sensitive in this population as well (hypodensities had 0.77 sensitivity). NCCT markers are associated with HE in ICH with USO. These findings require prospective replication and suggest that NCCT features may help the stratification of HE in future studies on USO patients.

Admission Lymphocytopenia is Associated with Urinary Tract Infection and Nosocomial Infections in Hemorrhagic Stroke

ObjectiveGrowing evidence suggests that lymphocytopenia on admission (LOA) is associated with infectious complications and poor outcomes in intracerebral hemorrhage (ICH). Whether LOA preferentially increases the risk for community acquired infections or nosocomial infections is unknown. This study investigates the relationship between LOA and nosocomial infections in a cohort of patients with ICH in a safety-net hospital. Material and methodsThis is a single center, observational, retrospective study of 213 patients with non-traumatic ICH admitted to the neurocritical care unit between 2008 and 2014. Patients’ clinical, demographic, lab and radiologic data were retrieved from institutional electronic medical records. Nosocomial infection was defined as clinical onset 48 h after admission. ResultsPrevalence of LOA was 24.8%. Patients with LOA showed significant associations with mechanical ventilation (67.9% versus 49.4%; p= 0.019), higher median ICH score (2 versus 1; p=0.006), nosocomial infection (43.4% versus 28.0%; p=0.038), nosocomial UTI (24.5% versus 8.9%; p=0.003). Adjusting for baseline covariates in a multivariate logistic regression, we observed an association of LOA with nosocomial UTI (OR, 3.66 [95% CI, 1.36-9.88], p=0.010). From the Cox proportional model, patients with LOA had 1.76 times the hazard of developing of nosocomial infection, compared to those without LOA ([95% CI: 1.01, 3.07], p=0.046) and had 3.27 times the hazard of developing nosocomial UTI, compared to those without LOA ([95% CI: 1.39, 7.67], p=0.007). ConclusionsThis study is the first to show that LOA is associated with nosocomial urinary tract infections and significantly shorter times to develop nosocomial infections.

Associations of an Abnormal Physiological Score With Outcomes in Acute Intracerebral Hemorrhage: INTERACT2 Study.

We determined associations of physiological abnormalities (systolic blood pressure, glucose, and body temperature) and warfarin use with outcomes in spontaneous intracerebral hemorrhage. Post hoc analyses of INTERACT2 (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial) comparing systolic blood pressure control (<140 versus <180 mm Hg) in 2839 hypertensive patients with intracerebral hemorrhage (onset <6 hours). Multivariable logistic regression defined associations of baseline scores assigned as 0 to 6 per 10 mm Hg systolic blood pressure increase (range, 150-220 mm Hg) and 0 or 1 for serum glucose (≤6.5 versus >6.5 mmol/L), body temperature (≤37.5 °C versus >37.5 °C), and warfarin use (no versus yes) and death or major disability (modified Rankin Scale scores 3-6 at 90 days). Baseline score distribution was 0 (7.7%), 1 (15.6%), 2 (19.0%), 3 (19.1%), 4 (15.2%), 5 (11.6%), 6 (8.9%), and 7 (2.9%). After adjustment for baseline neurological severity and potential confounders, significant linear associations were evident for increasing (per point) score and death or major disability (odds ratio, 1.12 [95% CI, 1.07-1.17]), death (odds ratio, 1.15 [95% CI, 1.07-1.23]), and major disability (odds ratio, 1.10 [95% CI, 1.05-1.15]). Combination of abnormal physiological parameters and warfarin use is associated with poor outcomes in intracerebral hemorrhage. Effects of their early control is under investigation in INTERACT3 (Intensive Care Bundle With Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial). Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00716079.

A Network Pharmacology-Based Analysis of the Protective Mechanism of Miao Medicine Xuemaitong Capsule Against Secondary Brain Damage in the Ischemic Area Surrounding Intracerebral Hemorrhage.

Intracerebral hemorrhage (ICH) is a devastating disease with the high mortality. The poor outcome of ICH is partially due to a combination of various secondary insults, including in the ischemic area. Xuemaitong capsule (XMT), a kind of traditional Chinese medicine, has been applied to clinic practice. The purpose of this study is to explore the mechanism of XMT in alleviating secondary damage in the ischemic area after ICH. We screened XMT target, compound components, and ICH-related targets using network pharmacology, cluster analysis, and enrichment analysis. We found that the tumor necrosis factor (TNF) signaling pathway might be the key signaling pathway for XMT treatment of ICH. An ICH rat model was established, as demonstrated by poor neurologic score. In the ICH rats, Western blot analysis and immunofluorescence indicated the upregulated expression of TNF receptor 1 (TNFR1), mitogen-activated protein kinase (MAPK), nuclear factor-κB (NF-κB), and caspase-3 (CASP3). Importantly, administration of XMT alleviated inflammation, edema, and increased perfusion in the ischemic area, whereas the expression of TNFR1, MAPK, NF-κB, and CASP3 was decreased. Furthermore, Fluoro-Jade B and terminal deoxynucleotidyl transferase-mediated digoxigenin-deoxyuridine nick-end labeling staining revealed that XMT application also inhibited apoptosis and degradation of ischemic area neurons. In conclusion, this evidence elucidates that XMT alleviates neuron apoptosis, ischemic area inflammation, edema, and perfusion through the TNFR1-mediated CASP3/NF-κB/MAPK axis. SIGNIFICANCE STATEMENT: Tumor necrosis factor (TNF) is the key signaling pathway of Xuemaitong (XMT) to intervention during intracerebral hemorrhage. Fourteen key targets [intercellular adhesion molecule 1, interleukin (IL) 6, TNF, C-C motif chemokine ligand 2, prostaglandin-endoperoxide synthase 2, v-rel reticuloendotheliosis viral oncogene homolog A, matrix metalloproteinase 9, endothelin-1 (EDN1), mitogen-activated protein kinase (MAPK) 1, fos proto-oncogene protein, caspase-3 (CASP3), jun proto-oncogene, IL1B, MAPK8] are retrieved from the data base. XMT can inhibit neuron apoptosis in the ischemic area via regulating TNF receptor 1 (TNFR1)/CASP3. XMT alleviates inflammation and edema through regulating TNFR1/nuclear factor-κB and TNFR1/MAPK signaling pathways. XMT alleviates hypoperfusion in the cerebral ischemic area through mediating TNFR1/MAPK/EDN1.

Hematoma Ventricle Distance on Computed Tomography Predicts Poor Outcome in Intracerebral Hemorrhage.

ObjectiveTo investigate the relationship between hematoma ventricle distance (HVD) and clinical outcome in patients with intracerebral hemorrhage (ICH).MethodsWe prospectively enrolled consecutive patients with ICH in a tertiary academic hospital between July 2011 and April 2018. We retrospectively reviewed images for all patients receiving a computed tomography (CT) within 6 h after onset of symptoms and at least one follow-up CT scan within 36 h. The minimum distance of hematoma border to nearest ventricle was measured as HVD. Youden index was used to evaluate the cutoff of HVD predicting functional outcome. Logistic regression model was used to assess the HVD data and clinical poor outcome (modified Rankin Scale 4–6) at 90 days.ResultsA total of 325 patients were included in our final analysis. The median HVD was 2.4 mm (interquartile range, 0–5.7 mm), and 119 (36.6%) patients had poor functional outcome at 3 months. After adjusting for age, admission Glasgow coma scale, intraventricular hemorrhage, baseline ICH volume, admission systolic blood pressure, blood glucose, hematoma expansion, withdrawal of care, and hypertension, HVD ≤ 2.5 mm was associated with increased odds of clinical poor outcome [odd ratio, 3.59, (95%CI = 1.72–7.50); p = 0.001] in multivariable logistic regression analysis.ConclusionHematoma ventricle distance allows physicians to quickly select and stratify patients in clinical trials and thereby serve as a novel and useful addition to predict ICH prognosis.

18F]-FMISO PET/MRI Imaging Shows Ischemic Tissue around Hematoma in Intracerebral Hemorrhage.

Intracerebral hemorrhage (ICH), being the most severe cerebrovascular disease, accounts for 10-15% of all strokes. Hematoma expansion is one of the most important factors associated with poor outcome in intracerebral hemorrhage (ICH). Several studies have suggested that an "ischemic penumbra" might arise when the hematoma has a large expansion, but clinical studies are inconclusive. We performed a preclinical study to demonstrate the presence of hypoxic-ischemic tissue around the hematoma by means of longitudinal [18F]-fluoromisonidazole ([18F]-FMISO) PET/MRI studies over time in an experimental ICH model. Our results showed that all [18F]-FMISO PET/MRI images exhibited hypoxic-ischemic tissue around the hematoma area. A significant increase of [18F]-FMISO uptake was found at 18-24 h post-ICH when the maximum of hematoma volume is achieved and this increase disappeared before 42 h. These results demonstrate the presence of hypoxic tissue around the hematoma and open the possibility of new therapies aimed to reduce ischemic damage associated with ICH.

Prediction of Poor Outcome in Intracerebral Hemorrhage Based on Computed Tomography Markers

Introduction: Intracerebral hemorrhage (ICH) is the most fatal type of stroke worldwide. Herein, we aim to develop a predictive model based on computed tomography (CT) markers in an ICH cohort and validate it in another cohort. Methods: This retrospective observational cohort study was conducted in 3 medical centers in China. The values of CT markers, including hypodensities, hematoma density, blend sign, black hole sign, island sign, midline shift, baseline hematoma volume, and satellite sign, in predicting poor outcome were analyzed by logistic regression analysis. A nomogram was developed based on the results of multivariate logistic regression analysis in development cohort. Area under curve (AUC) and calibration plot were used to assess the accuracy of nomogram in this development cohort and validate in another cohort. Results: A total of 1,498 patients were included in this study. Multivariate logistic regression analysis indicated that hypodensities, black hole sign, island sign, midline shift, and baseline hematoma volume were independently associated with poor outcome in development cohort. The AUC was 0.75 (95% confidence interval [CI]: 0.73–0.76) in the internal validation with development cohort and 0.74 (95% CI: 0.72–0.75) in the external validation with validation cohort. The calibration plot in development and validation cohort indicated that the nomogram was well calibrated. Conclusions: CT markers of hypodensities, black hole sign, and island sign might predict poor outcome of ICH patients within 90 days.

Higher Monocyte Count is Associated with 30-Day Case Fatality in Intracerebral Hemorrhage.

Previous studies have suggested that elevated neutrophils, monocytes, and neutrophil-to-lymphocyte ratio (NLR) may be associated with poor outcomes in intracerebral hemorrhage (ICH). We sought to determine whether white blood cell (WBC) types were independently associated with poor outcome in ICH in a large cohort. We performed a retrospective study of primary ICH at two academic centers. Cases were identified via ICD-9 code and verified via physician review. We included only those patients with WBC types obtained within 24h of ICH onset. We identified 593 patients with primary ICH and WBC differentials in the first 24h. Independent factors (OR, 95% CI) associated with 30-day case fatality were age > 80 (2.4 (1.4, 4.2)), p = 0.0023; NIHSS greater than median (3.9 (2.4, 6.3)), p < 0.0001; ICH volume quartiles (Q1: ref, Q2: 1.5 (0.7, 3.0), Q3: 3.2 (1.6, 6.6), Q4: 11.9 (5.3, 26.4)), p < 0.0001; non-lobar location (3.3 (1.9, 5.9)), p ≤ 0.0001; IVH (2.3 (1.4, 3.6)), p = 0.0005, monocytes greater than median (1.6 (1.0, 2.4)), p = 0.0457, and anticoagulant use (3.2 (1.8, 5.6)), p < 0.0001. Elevated NLR was not associated with higher case fatality. We found that elevated monocytes were independently associated with 30-day case fatality. Future studies will investigate whether there are subgroups of ICH patients, including those with particular blood or imaging biomarkers, in which WBC types might help predict poor outcome and provide targets for intervention.

Abstract WP410: Hemoglobin Levels and Poor Outcome in Intracerebral Hemorrhage: An Exploratory Analysis of Individual Patient Data Across Multiple Studies

Introduction: Observational evidence from single center studies indicates that lower admission hemoglobin (Hb) levels are associated with poor outcome after spontaneous intracerebral hemorrhage (ICH). We combined data from three multicenter studies to test the hypothesis that Hb levels inversely correlate with functional outcome in ICH. Methods: We conducted a meta-analysis of individual patient data from the clinical trials ATACH-II and FAST and the multi-ethnic study ERICH. We included participants with available Hb and outcome data. We used multivariable logistic regression to test for association between admission Hb levels and 3-month dichotomized (0-3 versus 4-6) modified Rankin Scale (mRS), adjusting for the variables contained in the ICH score. We pooled study-specific estimates using inverse-variance weighted, fixed effects meta-analysis. Results: A total of 4106 ICH patients were included in the analysis. Each additional g/dL of admission Hb was associated with a 12% (OR 0.88, 95%CI 0.85-0.91; p&lt;0.001) and 8% (OR 0.92, 95%CI 0.88-0.96; p&lt;0.001) reduction in the odds of poor outcome in unadjusted and adjusted analyses, respectively (Table 1). Dose-response analyses indicated a linear relationship between Hb levels and poor outcome across the entire evaluated range (Figure 1, test-for-trend p&lt;0.001). In metanalysis, there were not significant associations between Hb and ICH volume or expansion (both p&gt;0.05). Conclusion: Lower hemoglobin levels are associated with poor outcome in ICH. Further studies of the underlying biological mechanisms are warranted. If replicated, this pathway could become an appealing target to be tested in clinical trials.

Risk factors and clinical features of paroxysmal sympathetic hyperactivity after spontaneous intracerebral hemorrhage.

Paroxysmal sympathetic hyperactivity (PSH) is a rare complication of spontaneous intracerebral hemorrhage (ICH).We aimed to evaluate the risk factors and clinical features for PSH after ICH. From January 1, 2013 to April 1, 2018, patients with ICH were consecutively included in this observational study. Baseline characteristics were compared in patients with and without PSH. Multivariate logistic regression analysis was used to determine the risk factors associated with PSH development. Clinical features of patients with PSH were also analyzed. There were 548 patients with ICH included and a total of 15 (2.7%) patients were identified with PSH. In univariate analysis, PSH development was associated with the following: previous hemorrhagic stroke, pupils abnormity, admission Glasgow Coma Scale (GCS) score, hematoma volume, liver function abnormity, neutrophil count and early tracheostomy. Multivariate logistic regression analysis showed that a significantly increased risk of PSH was found in patients with previous hemorrhagic stroke (odds ratio [OR], 4.176; 95% confidence interval [CI], 1.111-15.698), admission GCS score (OR, 0.703; 95% CI, 0.548-0.902) and early tracheostomy (OR, 8.317; 95%CI, 1.755-39.412).The most common symptoms of PSH were hyperthermia (80%) and hyperhidrosis (80%).The median Intensive Care Unit stays and Glasgow Outcome Scale at discharge were 34 (19-46) and 2 (1.5-3), respectively. PSH is characterized by a cluster of symptoms and abnormal vital signs, which may lead to poor outcomes in ICH. The present study suggests that previous hemorrhagic stroke, admission GCS score and early tracheostomy may be the significant risk factors for PSH after ICH.

Prognostic value of elevated cardiac troponin I in patients with intracerebral hemorrhage.

BackgroundAlthough cardiac troponin has been well established as diagnostic and prognostic makers for acute coronary heart disease, the prognostic value of elevated cardiac troponin in patients with intracerebral hemorrhage (ICH) was inconsistent and not systematically evaluated.HypothesisWe proposed the hypothesis that the practical utility of cardiac troponin levels for prediction of mortality and poor outcome in ICH patients.MethodsA total of 1004 patients with ICH were retrospectively reviewed and qualified for further analysis from June 2012 to December 2015. The patients were divided into different groups based on measurements of cardiac troponin I (cTnI) at the time of admission and the following day. Multivariate Cox proportional hazards analysis were performed to determine the independent prognostic value of the cTnI for patients in‐hospital mortality and poor outcomes, the receiver operator characteristic (ROC) analysis was performed to assess the predictive value of cTnI, ICH score, and combination of them.ResultsSerum cTnI level was an independent predictor in‐hospital mortality (positive vs negative, HR (hazard ratios) = 3.44, 95% CI (confidence interval) 1.66‐7.13, P < .001) and poor outcomes in patients with ICH (positive vs negative, HR = 6.69, 95% CI 4.25‐10.52, P < .001). Addition of cTnI to ICH score significantly improved the prognostic discrimination for both in‐hospital mortality and poor outcomes.ConclusionSerum cTnI levels may be valuable as predictor for in hospital mortality and poor outcomes and may be useful in the risk stratification of ICH during hospitalization.

Association of glycosylated hemoglobin level at admission with outcomes of intracerebral hemorrhage patients

Objective: To explore the association of the glycosylated hemoglobin (HbA1c) level at admission with 90 days functional outcome in patients with spontaneous intracerebral hemorrhage (ICH). Methods: Patients admitted to the Department of Neurology, Tongji Hospital from January to December 2017 were prospectively and continuously enrolled in this study. Clinical data were collected at admission and functional outcomes 90 days after ICH were assessed by using the modified RANKIN scale. Univariate and multivariate conditional logistic regression models were constructed. Patients were divided into four groups according to the quartile of HbA1c values. The median value of HbA1c in each group was taken as the substitute value and P for trend was calculated. The logistic regression model was fitted by restricted cubic splines to investigate the association between HbA1c level and outcome of ICH. Results: A total of 345 patients with ICH were enrolled, including 214 with favorable outcomes and 131 with poor outcomes (99 severe disability cases and 32 deaths). The risk of poor 90 days outcomes was significantly associated with HbA1c level at admission indicated by multivariate logistic regression analysis, and the P for trend test was <0.001 (middle-level group vs. low-level group: OR=2.33, 95%CI: 1.07-5.07; high-level group vs. low-level group: OR=2.52, 95%CI: 1.12-5.64; extremely high-level group vs. low-level group: OR=6.80, 95%CI: 3.01-15.34). Results from the restricted cubic spline showed that there was a linear correlation between HbA1c level at admission and poor 90 days outcomes of ICH (χ(2)=14.81, P<0.001; non- linear test: P=0.118). Compared with patients with HbA1c level of 6.5%, the risk of poor outcomes in patients with HbA1c level of <6.5% decreased linearly with the decrease in HbA1c level at admission, and the risk in patients with HbA1c level >6.5% was higher but not significantly. Conclusion: There was correlation between high HbA1c level at admission and 90 days poor outcome of ICH. High HbA1c level is an independent prediction indicator for ICH.

Higher Hemoglobin A1c Level Is Associated With Poor Outcome of Intracerebral Hemorrhage.

Background: Pre-morbid chronic hyperglycemia is associated with the poor outcome of ischemic stroke, but the association between chronic hyperglycemia, and the long-term outcome of acute intracerebral hemorrhage is still poor understood.Methods: Data on patients with acute intracerebral hemorrhage in the ACROSS-China registry (Abnormal Glucose Regulation in Patients With Acute Stroke Across China) were reviewed. Elevated hemoglobin A1c (HbA1c) level on admission was indicative of chronic hyperglycemia. According to the clinical categories of HbA1c, patients were divided into three groups. Multivariable logistic regression or Cox method was performed to analyze the association of HbA1c and the prognosis of patients with acute intracerebral hemorrhage (poor functional outcome [modified Rankin scale score 3–6] and mortality) at 1 year.Results: A total of 416 patients were included in this study. Fifty-two (12.5%) patients died and 130 (31.8%) had poor functional outcome at 1-year follow-up. The higher levels of HbA1c (≥6.5%) was associated with a poor functional outcome (OR 2.35, 95% CI, 1.28–4.29) and increased mortality (OR 2.63, 95% CI 1.34–5.15), compared with the lowest category. When further stratified by diabetic or non-diabetic medical history, higher HbA1c (≥6.5%) still increased the risk of poor functional outcome (OR 3.42, 95% CI 1.39–8.44) and mortality (OR 4.48, 95% CI 1.64–12.24) in patients with non-diabetic medical history. However, higher HbA1c didn't have the association with the increased risk of poor functional outcome (OR 1.06, 95% CI 0.37–3.03) and mortality (OR 1.20, 95% CI 0.39–3.72) in patients with diabetic medical history.Conclusions: Higher HbA1c was associated with a higher risk of death and poor functional outcome 1 year after intracerebral hemorrhage, especially in patients without a diabetic history.