Predictors Of Intracerebral Hemorrhage Research Articles

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.

Abstract 77: Ongoing Leakage Revealed by Second Phase Spot Sign Volume Expansion in Multi-Phase Computed Tomography Angiography Strongly Predicts Intracranial Hemorrhage Growth

Background: CTA spot sign is a predictor of intracerebral hemorrhage (ICH) expansion. This sign can fluctuate in appearance, volume, and timing. Multiphase CTA (mCTA) can identify spot sign through 3 time-resolved images. We sought to identify a novel predictor of follow up total hematoma expansion using mCTA. Methods: This cohort study included patients with ICH between 2012-2019. Quantomo software was used to measure total hematoma volume (ml) from baseline CT &amp; follow-up CT/MRI blinded to spot sign in 3 mCTA phases. Spot sign expansion was calculated by subtracting 1 st phase spot sign volume from 2 nd phase spot sign volume measured in microliters. Results: 199 patients [63% male, mean age 69 years, median NIHSS 11, IQR 6-20] were included. Median baseline ICH volume was 16.1 ml (IQR 5-29.9 ml). Amongst all three mCTA phases, spot sign was best detected on the 2nd phase (23% vs 17.5% 1 st phase vs 22% 3 rd phase). In multivariable regression, spot sign expansion was significantly associated with follow up total hematoma expansion (OR: 1.03 per microliter of spot sign expansion, p=0.01). Figure 1 shows the predicted total hematoma expansion by spot sign expansion. mCTA spot sign had a higher sensitivity for predicting total hematoma volume expansion than single-phase CTA (reported in meta-analysis of 14 studies), 86% vs 53%, respectively, while both having similar specificity, 87% vs 88%, respectively. Conclusion: Spot sign expansion on mCTA is a novel predictor of total hematoma expansion and could be used to select patients for immediate therapeutic intervention in future clinical trials. Using mCTA improves sensitivity while preserving specificity over single-phase CTA.

Effect of hypomagnesemia on elderly patients with intracerebral hemorrhage

Objective To investigate the effects of hypomagnesemia on the initial amount of hematoma and patient's condition at hospitalization in elderly patients with intracerebral hemorrhage(ICH). The 90 consecutive hospitalized patients with primary ICH were chosen for prospective cohort study in the Second Hospital of Anhui Medical University from February 2017 to May 2018. Methods Demographic and baseline data of patients were collected, and CT scan, serum magnesium concentration and other laboratory examinations after hospital admission were tested.Ninety patients were divided into two groups: hypomagnesemia group(serum magnesium <0.75 mmol/L, n=38)and normo-magnesemia group(0.75-1.25 mmol/L, n=52). The impact of serum magnesium level on the patient's initial volume of hematoma and critical condition at admission were analyzed. Results The median value of random blood glucose(7.29 mmol/L vs.6.44 mmol/L)and fibrinogen degradation products(3.43 mg/L vs.1.98 mg/L)were higher in the patients with hypomagnesemia than in the normal magnesium group.The median volume of initial volume of hematoma at admission was larger in patients with hypomagnesemia than in the normal magnesium group(20 cm3vs.10 cm3). The median value of Glasgow coma scale at admission was lower in patients with hypomagnesemia than in the normal magnesium group(12.5 scores vs.14.0 scores). And their difference was statistically significant(U=-2.663, -2.951, -5.000 and -2.821 respectively, P=0.008, 0.003, 0.000 and 0.005). The correlation analysis showed that the initial volume of hematoma in patients with intracerebral hemorrhage was negatively correlated with the serum magnesium concentration at admission(r=-0.528, P=0.001). Conclusions Patients with hypomagnesemia has a larger hematoma volume and more serious disease condition.There is a significantly negative correlation between serum magnesium and hematoma volume of ICH.The serum magnesium level may become a predictor of ICH in the future. Key words: Cerebral hemorrhage; Magnesium deficiency; Hematoma

Risk factors for intracranial hemorrhage after mechanical thrombectomy: a systematic review and meta-analysis

ABSTRACTBackground: Intracerebral hemorrhage (ICH) is the most feared complication of mechanical thrombectomy (MT). This study aims to provide a comprehensive overview of ICH risk factors.Methods: The authors systematically searched Pubmed and Embase (from inception to November 2018) for studies evaluating independent predictors for symptomatic ICH (sICH), parenchymal hematoma (PH), hemorrhagic infarction (HI), and any ICH after MT.Results: This analysis included a total of 42 studies involving 10,001 patients. The combined rate was 8% (7–10%) for sICH, 13% (10–15%) for PH, 25% (20–29%) for HI, and 35% (31–39%) for any ICH. Meta-analysis identified the following predictors of sICH: female sex (OR 2.98, 95%CI 1.23–7.25, I2 = 26.3%), treatment interval (OR 1.01, 95%CI 1–1.03, I2 = 69.20%), tirofiban use (OR 3.16, 95%CI 2.11–4.73, I2 = 0%), and ASPECTS score on admission (OR 0.63, 95%CI 0.54–0.74, I2 = 0%). Predictors of any ICH were diabetes mellitus (OR 1.95, 95%CI 1.29–2.94, I2 = 35.7%), deep white matter on diffusion-weighted imaging (OR 3.11, 95%CI 1.56–6.20, I2 = 0%), and intravenous recombinant tissue plasminogen activator (rt-PA) (OR 2.57, 95%CI 1.28–5.17, I2 = 0%).Conclusion: Many predictors of ICH were identified, however, given the lack of robust evidence, larger cohort studies should be prioritized to confirm these predictors.

Abstract TP37: Predictors of Hemorrhage After Endovascular Therapy: Findings From the Interrsect Study

Background: While recent endovascular therapy trials have had a minimal number of adverse events, intracerebral hemorrhage (ICH) still occurs. The predictors of ICH with endovascular therapy remain unclear. We assessed predictors of hemorrhage following endovascular thrombectomy using data from the prospectively collected, multicenter INTERRSeCT study. Methods: Patients undergoing endovascular therapy +/- intravenous alteplase (tPA) were enrolled and received baseline CT/CTA, follow-up CTA/Angiogram and 24-hr CT or MRI images. Primary outcome was any ICH as per the ECASS classification of hemorrhage. Secondary outcome was PH1/PH2 hemorrhages. We assessed the relations between ICH and baseline ASPECTS scoring, thrombus location, residual flow, collateralization, tPA use, and final recanalization state. Multivariable regression with stepwise selection was used to adjust for relevant covariates. Results: Of 242 patients who met inclusion criteria, 58 (24%) had an ICH at 24 hours (HI1 53%, HI2 19%, PH1 7%, PH2 21%). Post-procedure hemorrhage was associated with lower ASPECTS scores (p&lt;0.001), ICA (p=0.004), proximal M1 (p=0.008), and mid-M1 (p=0.002) thrombus locations, and serum glucose (7.6 vs. 6.7; p=0.027). When adjusted for covariates, lower ASPECTS score (OR: 1.41 per point lost; 95% CI: 0.57-0.88; p=0.002), mid-M1 thrombus location (OR: 2.03; 95% CI: 1.03-4.01; p=0.041), and serum glucose (OR:1.15, 95% CI: 1.01-1.35, p=0.033) independently predicted the presence of post-procedure ICH. PH1/PH2 hemorrhages were associated with ICA thrombus (OR:2.96, 95% CI:1.05-8.33, p=0.04) after adjusting for relevant covariates. Conclusion: Early ischemia defined by imaging, mid-M1 thrombus location, and increased serum glucose are associated with increased risk of hemorrhage in patients undergoing combination tPA and endovascular therapy.

Abstract TP193: Epidemiology of Intracerebral Hemorrhage in Qatar

Background: Intracerebral hemorrhage (ICH) accounts for 10 to 30 % of all strokes. However, the clinical outcome is worse than ischemic stroke with 50 % mortality rate at 30 days follow up. Qatar has a unique multi-cultural demography which may make the etiology and mechanism of ICH different from the west. There are no reports on the epidemiology of ICH from Qatar. Our study thus aims to evaluate the main risk factors and etiology based on the age and race of our current population. Method: Using our stroke database a retrospective analysis of prospectively collected data of patients with suspected stroke was undertaken . Our study sample included all ICH’s based on head CT imaging and clinical presentation. The etiology of ICH was based on age, risk factors and neurovascular imaging findings. Etiology was classified as: hypertension, CAA, vascular malformation, drug related and others (eg: vasculitis). Baseline characteristics of ICH population were assessed using univariate analysis (χ 2 test, ANOVA &amp; student t test). Multiple logistic regression analysis was performed to define predictors of ICH using SPSS 23 and P value of 0.05 was considered significant. Result: Out of 2525 strokes, 518 (20.5%) were ICH. Patients with ICH were younger with a mean age of 51.72±13.1 compared to ischemic strokes 56.12±13.38. (P value 0.68) Due to the population distribution of races, ICH was more common in the South Asians 201/518 (38.8%) followed by Filipino and Far East [FFE] 96/518 (18.5%), then Nepali 76/518 (14.7%) then Qatari and Arabic population 12% and 9.8% (P &lt; 0.001). The main risk factors for ICH were FFE and Nepali race followed by hypertension, obesity and diabetes. Hypertensive ICH remained the main mechanism across the different races. In the multiple logistic regression analysis, the main predictors of ICH were the FFE race (adjOR: 2.297, CI: 1.77-2.97, P-Value: 0.00) and hypertension (adj OR: 1.85 CI: 1.46-2.36, P-Value: 0.00, NIHSS (adjOR: 1.15 CI: 1.13-1.17, P-value: 0.00) and age (adjOR: 0.9, CI: 0.96-0.98, P-value: 0.00) Conclusion: The rate of ICH in Qatar is similar to the west. It is substantially low in the Qatari’s compared to the Far Eastern and South Asian population. Across all races the main risk factor and etiology remains uncontrolled hypertension.

Predictors of Intracerebral Hemorrhage in Acute Stroke Patients Receiving Intravenous Recombinant Tissue Plasminogen Activator.

Background:Symptomatic Intracerebral hemorrhage (sICH) is a serious complication of recombinant tissue-plasminogen activator (rt-PA) therapy for acute ischemic stroke (AIS).Objective:To estimate the prevalence and predictors of sICH in patients after receiving IV rt-PA for AIS.Material and Methods:Consecutive patients of AIS thrombolysed between January 2010 and June 2016 in a University hospital in Hyderabad (India) were studied prospectively for sICH and it's various variables compared with the control group without sICH to determine any sigificantant difference.Results:Out of 113 patients , sICH was detected in 12 (10.61%) whose mean age(58±12.0 years) and gender ratio ( 2:1 ) was not statistically significant from controls. In s ICH group mean NIHSS score was 16.53± 5.81 vs 10.19± 5.06 in controls (p<0.001), gap between stroke onset and thrombolysis was 227.50±46.15 min vs 178.50± 69.20 min in controls(p=0.018). At presentation mean blood sugar was 208.75±90.97 mg/dl in sICH group vs 146.83±70.21 mg/dl in controls (p=0.002). Prior diabetes was in 7(53.30%) vs 23 (22.8%) in controls (p= 0.014)and hypertension in 11 (91.7%) vs (56(55.4%) in controls (p= 0.026) The mortality in sICH was 7 (58.30%)vs 4 (4.94%) in controls (p<.0.001). At 3 months mean mRS ofsICH patients was 5.57± 0.54 vs 2.17± 1.69 in controls (p<.05).Conclusion:High NIHSS score, increased stroke onset to thrombolysis time , high blood sugar at presentation ,prior diabetes and hypertension increase the chances of sICH. None of these contraindicate thrombolysing strokes but should caution the physician.

Abstract 215: Does the CT Angiography Spot Sign Identify Intracerebral Hemorrhage Patients More Likely to Benefit From Intensive Blood Pressure Reduction?

Background and Purpose: the computed tomography angiography (CTA) spot sign is a strong predictor of intracerebral hemorrhage (ICH) expansion, and may mark those most likely to benefit from intensive blood pressure (BP) reduction. The Spot Sign score in restricting ICH growth (SCORE-IT) study analyzed whether intensive BP reduction improved outcome in Spot Sign positive patients enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) clinical trial. Methods: In ATACH-2, patients with ICH were randomly assigned to intensive (systolic BP target: 110-139 mmHg) versus standard (systolic BP target: 140-179 mmHg) BP treatment within 4.5 h from stroke onset. This analysis included patients with a CTA performed within 8 hours from onset. The association between intensive BP lowering, ICH expansion and functional outcome was investigated with a multivariable logistic regression model. Results: 133 subjects met the inclusion criteria, of whom 53 (39.9%) had a spot sign and 24/123 (19.5%) experienced ICH expansion. A total of 56/123 patients had a 90 day modified Rankin scale (mRS) &gt;3 (45.5%). Among Spot positive patients, 74.1% of those in the intensive BP lowering group had poor outcome, compared with 50.0% of those in the standard group (p=0.31). After adjustment for potential confounders, intensive BP lowering was not associated with a significant reduction of ICH expansion (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.27 - 2.51, p = 0.74) or improved functional outcome (OR for mRS&gt;3 1.24, 95% CI 0.53 - 2.91, p = 0.62) in spot sign positive ICH patients. Conclusions: We found no evidence that ICH patients with a spot sign specifically benefit from intensive BP reduction.

STUDY OF&amp;NBSP; PRONOSTIC FACTORS AFTER 30 DAYS IN PATIENTS WITH INTRACRANIAL HEMORRAGIA

Background and purpose: Intracerebral hemorrhage (ICH) constitutes 10% to 15% of all strokes and remains without a treatment of proven benefit. Despite several existing outcome prediction models for ICH, there is no standard clinical grading scale for ICH analogous to those for traumatic brain injury, subarachnoid hemorrhage, or ischemic stroke. Methods: Records of all patients with acute ICH presenting to the Neurology Department, Binh Dinh General Hospital from July 2014-March 2015. Clinical outcome assessed by mRankin score and was compared with each item of ICH scale. ROC-AUC was realized to evaluated the value of ICH in prognostic the outcome of cerebral hemorrhage at day 30. Results: In the day 30: mortality rate was evaluated compared with mRS: In the group with ICH 0-1: no mortality, good outcome was 92.8% and 72.7%. ICH 2-3: mortlity rate increased 47.9% and 84.4%. ICH 4-5: mortality rate 100%. The prognostic predictor of ICH was high with Se 95%, Sp 59%. ROC-AUC 0.908, p&lt;0.0001. Conclusions: The ICH Score is a simple clinical grading scale that allows risk stratification on presentation with ICH. The use of a scale such as the ICH Score could improve standardization of clinical treatment protocols and clinical research studies in ICH. Key words: Intracerebral hemorrhage (ICH), ischemic stroke

Abstract 85: Small Vessel Disease and Stroke During Sleep

Introduction/Hypothesis: Stroke onset during sleep is common and sleep related pathologies have been associated with increased stroke risk. Based on available preliminary data, we tested the hypothesis that stroke during sleep is associated with small vessel disease (SVD). Methods: Prospectively collected data from patients consecutively enrolled after an intracerebral hemorrhage (ICH) related to SVD or after an ischemic stroke (IS) were analyzed. Symptom onset was recorded in relation to sleep vs. awake. Etiology of ICH was coded as cerebral amyloid angiopathy (CAA, per Boston criteria) and hypertensive deep ICH (HTN-ICH). The IS cohort was characterized based on the Causative Classification of Stroke system (5 subtype CCS). We compared frequencies of stroke onset during sleep between the SVD-related ICH and IS cohorts. Event rates, proportions of strokes during sleep and its associations (etiology, risk factors and stroke characteristics) were also analyzed within each cohort. Results: We analyzed 1,038 ICH (mean age: 72.5y +/- 13.0y, 45.4% female) and 1,812 IS patients (mean age: 67.9y +/- 15.9y, 46.4% female). Stroke while asleep was significantly more common among ICH patients (n=282, 26.6%) when compared to IS (n=363, 20.0%, p&lt;0.001). This association between SVD-related ICH and stroke during sleep remained significant after controlling for age, gender and other risk factors (p&lt;0.001). CAA-related ICH and small artery occlusion (SAA) related IS were etiologic subtypes more common among patients who had a stroke during sleep within their respective cohorts (asleep vs awake for CAA within ICH: 57.2% vs. 48.0%, p=0.008 and for SAA within IS: 19.3% vs. 9.1%, p&lt;0.001). CAA and SAA etiologic types remained independent predictors of ICH and IS during sleep in respective multivariate models including other clinical features and risk factors (p=0.019 and p=0.011). Conclusions: Stroke during sleep was strongly associated with SVD-related ICH when compared to all IS. CAA within ICH group and SAA etiology within IS cohort were related to stroke during sleep in univariate and multivariate models. Presence of SVD can interact with sleep pathologies and/or sleep related hemodynamic changes to cause ischemic and hemorrhagic stroke.

Cerebral microbleeds: different prevalence, topography, and risk factors depending on dementia diagnosis—the Karolinska Imaging Dementia Study.

Cerebral microbleeds are thought to represent cerebral amyloid angiopathy when in lobar regions of the brain and hypertensive arteriopathy when in deep and infratentorial locations. By studying cerebral microbleeds, their topography, and risk factors, we aimed to gain an insight into the vascular and amyloid pathology of dementia diagnoses and increase the understanding of cerebral microbleeds in dementia. We analyzed 1504 patients (53% women; mean age, 63 ± 10 years; 10 different dementia diagnoses) in this study. All patients underwent MR imaging as part of the dementia investigation, and all their clinical parameters were recorded. Among the 1504 patients with dementia, 22% had cerebral microbleeds. Cerebral microbleed topography was predominantly lobar (P = .01) and occipital (P = .007) in Alzheimer disease. Patients with cerebral microbleeds were significantly older (P < .001), were more frequently male (P < .001), had lower cognitive scores (P = .006), and more often had hypertension (P < .001). Risk factors for cerebral microbleeds varied depending on the dementia diagnosis. Odds ratios for having cerebral microbleeds increased with the number of risk factors (hypertension, hyperlipidemia, diabetes, male sex, and age 65 and older) in the whole patient group and increased differently in the separate dementia diagnoses. Prevalence, topography, and risk factors of cerebral microbleeds vary depending on the dementia diagnosis and reflect the inherent pathology of different dementia diagnoses. Because cerebral microbleeds are seen as possible predictors of intracerebral hemorrhage, their increasing prevalence with an increasing number of risk factors, as shown in our study, may require taking the number of risk factors into account when deciding on anticoagulant therapy in dementia.

101 Incidence and Predictors of Intracerebral Hemorrhage After Thrombolytic Therapy for Acute Ischemic Stroke

Acute ischemic stroke (AIS) is a leading cause of disability, and the fourth leading cause of death in the United States. Alteplase (tissue plasminogen activator) was FDA approved in 1996 for the treatment of AIS. Patients who receive alteplase are at a higher risk of having intracerebral hemorrhage (ICH). The purpose of our study was to determine the incidence of ICH after thrombolytic therapy at a stroke center compliant with currently endorsed guidelines for the administration of alteplase. A secondary objective was to identify predictors of ICH after alteplase administration for AIS.

Abstract 2733: The Comparative Importance of `Shared' Risk Factors for Ischemic Stroke and Intracerebral Hemorrhage in Patients with Atrial Fibrillation

Background: Optimal prescribing of oral anticoagulants, for the prevention of stroke in patients with atrial fibrillation, requires clinicians to estimate the competing risk of ischemic stroke and intracerebral hemorrhage (ICH). However, a number of risk factors increase the risk of both ischemic stroke and ICH (e.g. age, hypertension and chronic renal disease), and it is unclear how these ‘shared’ risk factors should influence decisions on antithrombotic therapy. Objective: To determine the comparative importance of risk factors for ischemic stroke and ICH in patients with atrial fibrillation, focusing primarily on risk factors included in the CHA2DS2VASC (risk of ischemic stroke) and HAS-BLED (risk of major bleeding) scores. Methods: Prospective registry of 3,197 patients admitted with acute ischemic stroke or ICH and atrial fibrillation included in the Registry of the Canadian Stroke Network (Jul 03-Mar 08; 11 Regional Stroke Centers in Ontario, Canada). Multivariable analysis was used to determine the association between baseline risk factors (age, sex, history of hypertension, previous stroke or transient ischemic attack, history of congestive heart failure, history of vascular disease, hepatic impairment, current alcohol intake, history of diabetes mellitus, history of gastro-intestinal bleeding, renal impairment, admission INR and antiplatelet therapy) and risk of ischemic stroke versus ICH. Results: Of 3,197 patients with atrial fibrillation and acute stroke, 2,806 (87.8%) presented with an ischemic stroke and 391 (12.2%) presented with an ICH. Of the ‘shared’ risk factors, age (OR 1.17; 95% CI 1.04-1.31 per decade) and previous history of stroke (OR 1.40; 95% CI 1.09-1.81) were associated with an increased risk of ischemic stroke relative to ICH, while a history of hypertension (OR 0.90; 95% CI 0.69-1.18) and renal impairment (OR 1.29; 0.96-1.72) were not associated with either stroke subtype, on multivariable analyses. Of the ‘non-shared’ risk factors, alcohol consumption of &lt;2 units/day vs. no consumption (OR 1.61; 95% CI 1.24-2.09), female sex (OR 1.53; 95% CI 1.20-1.96) and a history of vascular disease (OR 1.73; 95% CI 1.30- 2.30) were associated with an increased risk of ischemic stroke relative to ICH. Elevated INR at the time of admission was a significant predictor of ICH, relative to ischemic stroke. Conclusion: None of the ‘shared’ risk factors were stronger predictors of ICH compared to ischemic stroke, which has obvious implications for clinical practice. In particular, older age was more strongly associated with ischemic stroke than ICH in patients with atrial fibrillation, and therefore, should be considered as a factor favoring a decision to commence anticoagulant therapy.

Tissue Plasminogen Activator Thrombolytic Therapy for Acute Ischemic Stroke in 4 Hospital Groups in Japan

In October 2005 in Japan, the recombinant tissue plasminogen activator (tPA) alteplase was approved for patients with acute ischemic stroke within 3 hours of onset at a dose of 0.6 mg/kg. The present study was undertaken to assess the safety and efficacy of alteplase in Japan. Between October 2005 and December 2009, a total of 114 consecutive patients admitted to 4 hospitals received intravenous tPA within 3 hours of stroke onset. Clinical backgrounds and outcomes were investigated. The patients were divided into 2 chronological groups: an early group, comprising 45 patients treated between October 2005 and December 2007, and a later group, comprising 69 patients treated between January 2008 and December 2009. The mean time from arrival at the hospital to the initiation of treatment was significantly reduced in the later group, from 82.6 minutes to 70.9 minutes. Intracerebral hemorrhage (ICH) occurred in 26 patients (22.8%); compared with patients without ICH, these patients had a significantly higher prevalence of cardiogenic embolism (88.5% vs 58.0%); greater warfarin use (26.8% vs 6.8%); higher mean National Institutes of Health Stroke Scale (NIHSS) scores on admission (16 vs 10), at 3 days after admission (14 vs 5), and at 7 days after admission (13.5 vs 3); and a lower Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score (7.8 vs 9.1). Patients who received edaravone had a higher prevalence of cardiogenic embolism (70.9% vs 36.4%), a higher recanalization rate (77.7% vs 36.4%), and lower NIHSS scores on admission and at 3 and 7 days after admission compared with those who did not receive edaravone. Our data suggest that administration of intravenous alteplase 0.6 mg/kg within 3 hours of stroke onset is safe and effective, that the NIHSS and Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score are useful predictors of ICH after tPA administration, and that warfarin-treated patients are more likely to develop symptomatic ICH despite an International Normalized Ratio <1.7.

Elevated Serum Aminotransferase Level as a Predictor of Intracerebral Hemorrhage

Serum aminotransferase levels are known to be associated with cardiovascular risk factors, but the relation with stroke incidence is not well known. We investigated the relation between serum aminotransferase levels and the incidence of stroke. We measured serum aspartate and alanine aminotransferase levels and traditional cardiovascular risk factors in 108 464 Korean men, aged 35 to 59 years, in 1990 and 1992. Serum aminotransferase levels were classified into 3 categories (<35, 35 to 69, and > or =70 IU/L). The outcomes were hospital admissions and deaths from stroke subtypes (ischemic stroke, intracerebral hemorrhage [ICH], and subarachnoid hemorrhage [SAH]) from 1993 to 2002. During the 10 years, 1728 ischemic, 1051 hemorrhagic (718 ICH and 222 SAH), and 243 unspecified stroke events occurred. After adjustment for age and other traditional risk factors and according to Cox proportional-hazards models, serum aminotransferase level had an independent positive associations with ICH. However, ischemic stroke and SAH were not associated with aminotransferase levels. Compared with the level <35 IU/L, the adjusted relative risks (95% confidence interval) of ICH for an aspartate aminotransferase level of 35 to 69 and > or =70 IU/L were 1.49 (1.21 to 1.83) and 4.21 (3.06 to 5.77), respectively. The corresponding risks for alanine aminotransferase were 1.34 (1.09 to 1.65) and 2.89 (2.09 to 4.01), respectively. These associations were consistent regardless of the level of obesity, blood pressure, fasting glucose, alcohol intake, and follow-up length. These findings suggest that an elevated aminotransferase level is a predictor of ICH. The biologic significance of aminotransferase level for the development of ICH merits further study.

High Incidence of Microbleeds in Hemodialysis Patients Detected by T2*-Weighted Gradient-Echo Magnetic Resonance Imaging

The incidence and characteristics of microbleeds in hemodialysis (HD) patients were investigated to elucidate the clinical significance with T(2)(*)-weighted gradient-echo magnetic resonance (MR) imaging. The 57 patients with chronic renal failure maintained by HD had no previous history of stroke. The control group consisted of 53 patients without previous history of stroke or chronic renal failure. The incidence and the number of microbleeds were assessed in the HD and control groups. The findings of microbleeds with T(2)(*)-weighted gradient-echo MR imaging were compared with those of T(1)- and T(2)-weighted MR imaging in HD patients. The incidence of microbleeds was significantly greater in the HD patients compared with the control patients. T(2)(*)-weighted gradient-echo imaging revealed a total of 44 microbleeds in 11 HD patients. T(2)-weighted imaging demonstrated 13 of 44 microbleeds as hyperintensity, whereas T(1)-weighted imaging demonstrated 12 lesions as hypointensity. T(2)- and T(1)-weighted imagings did not demonstrate any findings in 31 and 32 lesions, respectively. T(2)(*)-weighted gradient-echo MR imaging is effective to detect microbleeds which may be a predictor of intracerebral hemorrhage in HD patients and should be included in the protocol for the study of cerebrovascular disease, because T(2)- and T(1)-weighted MR imaging recognizes microbleeds as lacunar infarction.

Predictors of Hemorrhagic Transformation Following Intra-Arterial Thrombolysis

18 Background: Hemorrhagic transformation is a major complication of intra-arterial (IA) thrombolytic therapy. Delineation of significant predictors of intracerebral hemorrhage (ICH) following thrombolysis would be useful to guide patient selection for IA treatment. Methods: Data were collected on consecutive patients with acute cerebral ischemia treated with IA thrombolysis over an 8 year period at UCLA Medical Center. Patients received either pure IA thrombolytics (tPA or urokinase) or combined intravenous/intra-arterial (IV/IA) tPA. Using univariate and multivariate analyses, 58 variables were examined as potential predictors of ICH. Results: A total of 89 patients were treated, 77 anterior circulation, 12 posterior circulation. Median baseline NIHSS score was 16. 26 patients received IA tPA only, 22 IV/IA tPA, and 41 IA urokinase only. Asymptomatic ICH occurred in 29 patients (33%), minor symptomatic ICH in 10 (11%), and major symptomatic ICH in 6 (7%). Of the 45 patients with M1 or M2 MCA occlusions treated with pure IA thrombolysis, 4 (9%) had major symptomatic ICH. There was no difference in the rate of any ICH with pure IA thrombolysis (39%) vs. combined IV/IA thrombolysis (41%). In pure IA cases, there was no difference in ICH rate between tPA and urokinase. 86% of patients with any ICH were dead or disabled (MRS > 2) at day 7 vs. 39% without ICH (p Conclusions: In this large series of patients treated with intra-arterial thrombolysis, higher NIHSS score, longer time to recanalization, and lower platelet count were independent predictors of hemorrhagic transformation. A model incorporating these variables identified patients who would develop ICH with 75% accuracy.