Primary Intracerebral Hemorrhage Research Articles

Abstract 58: Socioeconomically Driven Reversal of Mortality Trends Among Patients With Primary Intracerebral Hemorrhage During the COVID-19 Pandemic: An Analysis of Nationally Representative Data

Background: Nationwide data demonstrating the impact of the COVID-19 pandemic on hemorrhagic stroke outcomes are lacking. Methods: We used the National Inpatient Sample (2016-2020) to identify adults (>=18 years) with primary intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH). We fit segmented logistic regression models to evaluate the differences in the rates of in-hospital mortality between the pre-pandemic (January 2016-February 2020) and pandemic periods (March 2020-December 2020). Multivariable logistic models were used to evaluate the differences in mortality between patients admitted from April to December 2020, with and without COVID-19, and those admitted during a similar period in 2019. Stratified analyses were conducted among patients residing in low and high-income zip codes and among patients with extreme loss of function (E-LoF) and those with minor to major loss of function (MM-LoF). Results: Overall, 309,965 ICH patients (mean age [SD]: 68[14.8], 47% female, 56% low-income) and 112,210 SAH patients (mean age [SD]: 60.2[15.4], 62% female, 55% low-income) were analyzed. Pre-pandemic, ICH mortality was decreasing by ≈1% per month (adjusted odds ratio, 95% confidence interval: 0.99, 0.99-1.00). However, during the pandemic, the overall ICH mortality increased by ≈2% per month (1.02, 1.00-1.02), and by ≈4% per month among low-income patients (1.04, 1.01-1.07). However, there was no change in trend among high-income patients during the pandemic (1.00, 0.97-1.03). Comorbid COVID-19 was significantly associated with higher odds of mortality, overall (ICH: 1.83, 1.33-2.51; SAH: 2.76, 1.68-4.54), and among patients with MM-LoF (ICH: 2.15, 1.12-4.16; SAH: 5.77, 1.57-21.17). Patients with E-LoF and comorbid COVID-19 had similar mortality rates with the 2019 cohort. Conclusion: Sustained efforts are needed to address socioeconomic disparities in healthcare access, quality, and outcomes during public health emergencies.

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 TP164: Predisposing Factors and Outcomes of Primary Intracerebral Hemorrhage in Patients Presenting With Hyponatremia

Background: Hyponatremia is the most common electrolyte abnormality seen in intracerebral hemorrhage (ICH) and is associated with a nearly doubled mortality rate and more severe presentations. However, the current literature has not addressed what factors might predispose ICH patients to presenting with hyponatremia or developing it during their hospital stay. The aim of this study was to evaluate the characteristics, comorbidities, and inpatient outcomes prevalent amongst ICH patients with hyponatremia. Methods: A retrospective study was performed for 814 adult patients admitted from January 2011-December 2022 with primary ICH at Stony Brook University Hospital. We recorded sodium and serum chemistry levels throughout admission, medical history, radiographic hematoma volumes, and Modified Rankin Scale (MRS) and Glasgow Coma Scale (GCS) up to 1-year follow-up. Results: Hyponatremia on admission was seen in 79 (9.8%) patients. Another 311 patients (38.3%) developed hyponatremia during their hospital stay. Pre-existing hyponatremia was correlated with a history of diabetes while hyponatremia during stay was correlated with diabetes, liver disease, heavy drinking, and prior valve replacement. Complications such as pneumonia, UTI, or a bloodstream infection were more prevalent in patients with hyponatremia. They also had a longer hospital stay and higher inpatient mortality (χ2(1)=5.176, p=0.023). Patients with hyponatremia had significantly lower GCS values on discharge. A multivariate regression analysis of age, admission MRS, diabetes, liver disease, ICH score, volume, and minimum Na was statistically significant ( R 2=0.255, F(7,704)=34.46, p<0.001). Minimum Na reliably predicted death in this model (β=0.007, p=0.023). Conclusions: Several factors can predispose ICH patients to hyponatremia on presentation or be associated with developing hyponatremia during their hospital stay. This study showed that developing hyponatremia during the hospital stay was associated with worse outcomes at discharge. In addition, hyponatremia can significantly predict inpatient mortality when controlling for ICH severity and common aggravating factors.

Abstract TP152: Systolic Blood Pressure Variability Characteristics Increase With Severity Among Intracerebral Hemorrhage Patients

Introduction: Selected studies link high systolic blood pressure variability (SBPV) to poor patient outcome after intracerebral hemorrhage (ICH). SBPV levels during real-world ICH admission remain unknown, however. We profile SBPV across ICH patient characteristics. Methods: Clinical data for adult patients (≥18) with primary non-traumatic ICH were retrieved from the electronic medical records. Patient SBPV was calculated as the Coefficient of Variation (CV; CV = (Standard Deviation/Mean)*100) during the first 24 hours of admission and across whole hospitalization. Hemorrhage characteristics and cerebral small vessel disease burden (CSVD; STRIVE 2.0 criteria) were assessed from neuroimaging during admission. Severe CSVD was assessed at summary scores ≥3. Cerebral Amyloid Angiopathy (CAA) was graded via Modified Boston Criteria. Descriptive statistics are provided for SBPV during first 24 hours of admission and whole-stay. Population differences are assessed using Mann Whitney Rank Sum and Kruskal Wallis tests of hypothesis. Results: Patient cohort included 2,020 primary ICH patients (median age: 67, IQR: [55-77]; 45.2% female), with an ethno-racial distribution of 43.6% White, 23.3% Black, 22.5% Hispanic, 8.2% Asian, and 2.5% Other. Median hemorrhage volume was 12.1 [1.9-36.3] cm 3 ; SBPVs over the first 24-hours and whole-stay were 12.6 [9.9-16.2] (Mean: 13.7; Skewness: 1.9; Kurtosis; 11.3) and 12.5 [10.7-15.0] (Mean: 13.4; Skewness: 3.05; Kurtosis; 21.3), respectively. SBPV significantly increased with female sex, worsening discharge disposition, increasing Glasgow Coma Scale severity, hemorrhage volume, intraventricular hemorrhage presence, and severe CSVD. Increasing CAA tiers showed reductions in SBPV. (Figure 1) Discussion: Levels of SBPV during ICH vary across patient characteristics and are elevated in those with more severe hemorrhage characteristics and worse hospital outcomes.

Abstract 148: Increased Systolic Blood Pressure Variability During the First 24-hours of Hospitalization Associates With Poor 90-day Outcome After Intracerebral Hemorrhage

Introduction: Prospective studies and secondary analyses from clinical trials have identified increased systolic blood pressure variability (SBPV) as a risk factor for poor outcomes. Evidence of this association in real-world intracerebral hemorrhage (ICH) hospitalization is lacking, however. Methods: Data for adult (≥18) patients with primary ICH were retrieved from the REINAH cerebrovascular research database. Systolic blood pressure measurements from the first 24 hours of admission were retrieved and SBPV was calculated as the Coefficient of Variation (CV) = (standard deviation/mean)*100. Socioeconomic deprivation was assessed using the state Area Deprivation Index (ADI), with high deprivation assessed at ADI ≥ 8. The primary outcome was severe disability or death (SDD; modified Rankin Scale ≥4) at 90-days after discharge. Differences in SBPV across SDD were assessed using the Mann-Whitney U test. Associations between SBPV and SDD were assessed using multivariable logistic regression models adjusted for patient characteristics. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) are reported. Results: Final cohort included 807 patients (median [IQR]: 66 [54-77], 45.6% female), with an ethno-racial distribution of 41.9% White, 25.9% Black, 23.9% Hispanic, 5.7% Asian, and 2.6% Other. The median CV was 12.07 [9.50-15.59] and 485 (60.1%) patients experienced SDD. Patients with SDD showed significantly higher SBPV than non-SDD patients (12.90 [10.33-17.11] vs 10.99 [8.72-13.72]; p<0.001). Patients with 24-hour SBPV in the 3 rd (1.86 [1.16-2.96]) and 4 th quartile (3.10 [1.89-5.09]) had higher independent odds of SDD (vs. 1 st quartile) (Figure 1). Discussion: Patients with high SBPV during the first 24 hours of admission have higher odds of severe disability or death at 90-days after discharge.

Abstract TP167: Hemorrhage Severity Associates With Hospital Acquired Delirium During Intracerebral Hemorrhage

Introduction: Delirium associates with poor outcome after intracerebral hemorrhage (ICH), yet its incidence and contributing factors are poorly characterized. We show delirium proportions among older ICH patients and identify factors that associate with hospital-acquired delirium (HAD). Methods: Data from older adult (≥70 years) patients with primary nontraumatic ICH were retrieved from electronic medical records. Delirium was assessed once every 12 hours or per shift using the modified Arousal, Attention, Abbreviated Mental Test-4, Acute change test. Delirium on admission (DOA) was defined as a positive screen within 48 hours of admission and HAD was defined as a positive screen among non-DOA patients. Population differences between HAD and non-HAD patients were assessed using Wilcoxon Rank Sum and Pearson’s Chi Squared tests. Factors associated with HAD were identified via multivariable logistic regression modelling. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) are reported. Results: The cohort included 647 patients (median age: 79, interquartile range: [74-85]; 55.0% female) with an ethno-racial distribution of 57.6% White, 16.4% Black, 15.9% Hispanic, 8.5% Asian, and 1.6% Other. The median hemorrhage volume was 8.0 [1.6-24.7] cm 3 . DOA was present in 327 (50.5%) patients. Among patients without DOA (n=320), 90 (28.1%) developed HAD. In univariate analyses, patients with HAD (vs non-HAD) were significantly older and had lower admission Glasgow Coma Scale scores, larger hemorrhages volumes, more frequent intraventricular hemorrhage (IVH), and longer lengths of stay. In multivariable modelling, HAD was independently associated with older age (1.05 [1.01-1.10]), top-quartile hemorrhage volume (2.89 [1.08-7.75]), length of stay (1.14 [1.08-1.19]), and IVH (2.03 [1.08-1.19]) (Figure 1). Discussion: Older patients and those with more severe hemorrhage characteristics show greater odds of developing in-hospital delirium.

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

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

Poor haemorrhagic stroke outcomes during the COVID-19 pandemic are driven by socioeconomic disparities: analysis of nationally representative data

BackgroundNationally representative studies evaluating the impact of the COVID-19 pandemic on haemorrhagic stroke outcomes are lacking.MethodsIn this pooled cross-sectional analysis, we identified adults (≥18 years) with primary intracerebral haemorrhage (ICH)...

Prognostic Accuracy of Common Mortality Prognostic Scales in Very Old Patients with Intracerebral Haemorrhage

Background Spontaneous intracerebral haemorrhage (SICH) is the most severe form of all stroke types. Stratification of SICH severity is important for group comparisons and treatment decisions. The existing prognostic scores for clinical prediction in SICH have not been specifically validated in the very old (≥75 years). Therefore, we aimed to evaluate the accuracy of different SICH vital prognostic scores in the very old. Purpose To compare the short-term accuracy of three vital prognostic scores: Functional Outcome in Patients with Primary Intracerebral Haemorrhage (FUNC), Modified Emergency Department Intracerebral Haemorrhage (mEDICH) and the Intracerebral Haemorrhage Score (‘ICH score’) in patients aged 75 or older. Methods Comparison of the discriminative performance of three SICH prognostic scores in a consecutive case series of patients ≥75 years. The prognostic discrimination was assessed using the area under the receiver operating characteristic curve (AUROC). Additionally, a binary logistic regression was conducted to determine independent prognostic factors associated with mortality. Results The case-fatality was 40.6%. The AUROC and Younden index for the three scores was as it follows: ‘ICH score’ 0.882 and 0.648; mEDICH 0.867 and 0.571; FUNC 0.802 and 0.519. The main independent risk factors of death were presence of intraventricular extension (OR = 4.000,95% CI= 1.933–8.276), INR value (OR = 2.173, 95% CI = 1.146–4.117), haemorrhage volume (OR = 1.881, 95% CI = 1.029–3.440) and GCS (OR = 0.119, 95% CI = 0.060–0.236) for mEDICH. Haemorrhage volume (OR = 3.020, 95% CI = 1.806–5.050) and GCS (OR = 0.043, 95% CI = 0.013–0.151) for FUNC. Haemorrhage volume (OR = 4.950, 95% CI = 2.249–10.897) and intraventricular haemorrhage (OR = 3.811, 95% CI = 1.833–7.924) for ‘ICH score’. Conclusion The three scores (‘ICH score’, FUNC and mEDICH) showed an excellent capability of discriminating the group of elderly patients at risk of short-term death. Age per se may not be crucial for accurate discrimination of death in the group of elderly. Instead, the inclusion of available physiological markers of fragility would be more scientifically meaningful than age.

Update on the INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4): progress and baseline features in 2053 participants

Background and aimsUncertainty persists over the effects of blood pressure (BP) lowering in acute stroke. The INTEnsive ambulance-delivered blood pressure Reduction in hyper-Acute stroke Trial (INTERACT4) aims to determine efficacy and safety of hyperacute intensive BP lowering in patients with suspected acute stroke. Given concerns over the safety of this treatment in the pre-hospital setting, particularly in relation to patients with intracerebral hemorrhage, we provide an update on progress of the study and profile of participants to date.MethodsINTERACT4 is an ongoing multicentre, ambulance-delivered, randomized, open-label, blinded endpoint trial of pre-hospital BP lowering in patients with suspected acute stroke and elevated BP in China. Patients are randomized via a mobile phone digital system to intensive (target systolic BP [SBP] <140mmHg within 30 min) or guideline-recommended BP management. Primary outcome is an ordinal analysis of the full range of scores on the modified Rankin scale scores at 90 days.ResultsBetween March 2020 and April 2023, 2053 patients (mean age 70 years, female 39%) were recruited with a mean BP 178/98 mmHg in whom 45% have a diagnosis of primary intracerebral hemorrhage upon arrival at hospital. At the time of presentation to hospital, the mean SBP was 160 and 170mmHg in the intensive and control groups (Δ10 mmHg), respectively. The independent data and safety monitoring board has not identified any safety concerns and recommended continuation of the trial. The sample size was reduced from 3116 to 2320 after meetings in August 2022 as the stroke mimic rate was persistently lower than initially estimated (6% vs 30%). The study is expected to be completed in late 2023 and the results announced in May 2024.ConclusionsINTERACT4 is on track to provide reliable evidence of the effectiveness of ambulance-delivered intensive BP lowering in patients with suspected acute stroke.Trial registrationClinicalTrials.gov NCT03790800; registered on 2 January 2019. Chinese Trial Registry ChCTR1900020534, registered on 7 January 2019.

Strokes in Critically Ill COVID-19 Patients Diagnosed After Deep Sedation: A Single-Center Case Series.

In the Philippines, acute cerebrovascular disease is a common neurologic complication in coronavirus disease 2019 (COVID-19) patients. Because of sedation and limited neurological examination, the diagnosis of stroke in critically ill patients with COVID-19 may be delayed. This retrospective analysis was done on the medical records of adult patients with critical COVID-19 in 2021-2022 who were brought to a tertiary hospital in the Philippines, placed on mechanical ventilation, and later discovered to have had an ischemic or hemorrhagic stroke while under deep sedation. The study aimed to explore the delayed diagnosis of cerebrovascular disease clinically concealed by deep sedation and emphasizes the importance of a collaborative, multi-specialty approach to managing such patients. There were nine patients with strokes discovered on imaging after deep sedation due to severe COVID-19 infection. The median age of the cases was 63 years, and 55.5% (n=5) were males. Three of the nine patients had an ischemic stroke with hemorrhagic conversion, three with ischemic infarction, and the other three had a primary intracerebral hemorrhage. This series shows a pattern of delayed diagnosis of cerebrovascular disease clinically concealed by deep sedation that was essential in managing acute respiratory distress syndrome in the background of severe COVID-19 infection before the emergence of severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) variants and the discovery of COVID-19 vaccines. The study demonstrates the significance of managing this unique population of patients in a collaborative and multi-specialty manner. With the continuing threat of SARS-CoV-2 and its variants, there is a need to strike a balance between the risks of ischemic and hemorrhagic stroke in COVID-19 infection and the care of this patient population.

The association between hypertensive angiopathy and cerebral amyloid angiopathy in primary intracerebral hemorrhage

The association between hypertensive angiopathy and cerebral amyloid angiopathy in primary intracerebral hemorrhage

Etiology of Primary Cerebellar Intracerebral Hemorrhage Based on Topographic Localization.

Cerebellar intracerebral hemorrhage (cICH) is often attributed to hypertension or cerebral amyloid angiopathy (CAA). However, deciphering the exact etiology can be challenging. A recent study reported a topographical etiologic relationship with superficial cICH secondary to CAA. We aimed to reexamine this relationship between topography and etiology in a separate cohort of patients and using the most recent Boston criteria version 2.0. We performed a retrospective analysis of consecutive patients with primary cICH admitted to a tertiary academic center between 2000 and 2022. cICH location on brain computed tomography/magnetic resonance imaging scan(s) was divided into strictly superficial (cortex, surrounding white matter, vermis) versus deep (cerebellar nuclei, deep white matter, peduncular region) or mixed (both regions). Magnetic resonance imaging was rated for markers of cerebral small vessel disease. We assigned possible/probable versus absent CAA using Boston criteria 2.0. We included 197 patients; 106 (53.8%) were females, median age was 74 (63-82) years. Fifty-six (28%) patients had superficial cICH and 141 (72%) deep/mixed cICH. Magnetic resonance imaging was available for 112 (57%) patients (30 [26.8%] with superficial and 82 [73.2%] with deep/mixed cICH). Patients with superficial cICH were more likely to have possible/probable CAA (48.3% versus 8.6%; odds ratio [OR], 11.43 [95% CI, 3.26-40.05]; P<0.001), strictly lobar cerebral microbleeds (51.7% versus 6.2%; OR, 14.18 [95% CI, 3.98-50.50]; P<0.001), and cortical superficial siderosis (13.8% versus 1.2%; OR, 7.70 [95% CI, 0.73-80.49]; P=0.08). Patients with deep/mixed cICH were more likely to have deep/mixed cerebral microbleeds (59.2% versus 3.4%; OR, 41.39 [95% CI, 5.01-341.68]; P=0.001), lacunes (54.9% versus 17.2%; OR, 6.14 [95% CI, 1.89-19.91]; P=0.002), severe basal ganglia enlarged perivascular spaces (36.6% versus 7.1%; OR, 7.63 [95% CI, 1.58-36.73]; P=0.01), hypertension (84.4% versus 62.5%; OR, 3.43 [95% CI, 1.61 to -7.30]; P=0.001), and higher admission systolic blood pressure (172 [146-200] versus 146 [124-158] mm Hg, P<0.001). Our results suggest that superficial cICH is strongly associated with CAA whereas deep/mixed cICH is strongly associated with hypertensive arteriopathy.

The role of hyperglycemia in the outcome of intracerebral hemorrhage: A causative analysis

BackgroundHyperglycemia in the acute phase of intracerebral hemorrhage (ICH) has been associated with poor functional outcomes, however all interventions to lower glucose have yielded neutral or negative results. We attempt an explanation of the causal role of hyperglycemia in ΙCH outcome using generalized structural equation modeling. Materials and methodsConsecutive primary ICH patients admitted to an academic hospital between 2007 and 2018 were identified. Patients with missing baseline or follow up CT scans and without 90 day follow up status were excluded. We constructed a causal model accounting for pre-defined markers of ICH severity to evaluate the association between mean 72 h glucose and 90 day functional outcome measured by modified Rankin Scale, dichotomized as favorable ≤2 or unfavorable >2. ResultsPrimary analyses included 410 patients (70.4 ± 13.8years, 43 % female). Mean 72 h glucose was 137.5 ± 33.4mg/dl and 102 (25 %) patients were diabetic. On univariable analysis, higher glucose levels were negatively correlated with favorable outcome (p < 0.0001). However in the structural equation model, this relationship was significantly attenuated (p = 0.06) after accounting for the causal effect of diabetes (p < 0.0001), hematoma volume (p < 0.0001), intraventricular extension (p = 0.01) and Glasgow coma scale (p = 0.001) on glucose levels. On secondary analyses stratifying by diagnosis of diabetes, higher glucose levels were negatively correlated with favorable outcome in patients without diabetes (p = 0.04), but not in patients with diabetes (p = 0.35). ConclusionsHyperglycemia may be a downstream effect of other markers of ICH severity, particularly among patients without diabetes, suggesting a possible explanation for the limited evidence of glucose lowering interventions in outcome.

The association between hypertensive angiopathy and cerebral amyloid angiopathy in primary intracerebral hemorrhage

ObjectiveTo determine the association between the burden of cerebral small vessel disease (CSVD) due to hypertensive angiopathy (HA) and cerebral amyloid angiopathy (CAA) on MRI in patients with primary intracerebral hemorrhage (ICH).MethodsPatients with primary ICH admitted to our center from March 2012 to November 2021 were consecutively enrolled. We used multivariate binary and ordinal regression analyses to assess the association between HA-CSVD burden and CAA-CSVD burden. Lobar cerebral microbleeds (CMBs) were categorized into three level of severity: 0–1, 2–4, and ≥ 5 lobar CMBs. A high CAA-CSVD score was defined as a CAA-CSVD score of ≥3.ResultsOverall, 222 participants (mean age 59.88 ± 13.56) were included into analysis. Age and ICH etiology differed among different lobar CMB severity and between the presence and absence of high CAA-CSVD score (all p &amp;lt; 0.05). Positive associations between HA-related markers and both lobar CMB severity and high CAA-CSVD score (p &amp;lt; 0.05 for the presence of lacune, deep CMBs ≥5, the presence of WMH, and HA-CSVD score) were observed in univariate analysis. These associations remained significant after adjusting for age, sex, ICH etiology, and potential vascular risk factors. The distribution of CAA-CSVD score was significantly different between patients with and without CMBs ≥5 (adjusted OR 2.351, 95% CI 1.242–4.455, p = 0.009) after correcting for age, sex, ICH etiology, and vascular risk factors.ConclusionOur study provides evidence of an association between HA-CSVD and CAA-CSVD in patients with primary ICH, which needs to be verified in future studies.

Early fever in patients with primary intracerebral hemorrhage is associated with worse long-term functional outcomes: a prospective study

BackgroundPrimary intracerebral hemorrhage (ICH) accounts for 85% of ICH cases and is associated with high morbidity and mortality rates. Fever can cause secondary injury after ICH; however, relevant studies have reported inconsistent results regarding the effects of fever on functional outcomes after ICH. This study examined the effects of early fever on the prognosis of ICH, particularly on long-term functional outcomes.MethodsThis prospective study recruited patients with primary ICH at a tertiary medical center between 2019 and 2021. Early fever was defined as a tympanic body temperature of ≥ 38 °C upon admission. Barthel Index (BI) and modified Rankin scale (mRS) were examined at 1 year after ICH. A BI of ≤ 60 or mRS of ≥ 4 was considered as indicating severe disability.ResultsWe included 100 patients, and early fever was significantly associated with less functional independence at 1 year post-ICH, as determined using the mRS (p = 0.048; odds ratio [OR] = 0.23), and with severe functional dependency at 1 year post-ICH, as determined using the BI (p = 0.043; OR = 3) and mRS (p = 0.045; OR = 3). In addition, patients with early fever had a longer length of hospital stay (p = 0.002; 95% confidence interval = 21.80–95.91).ConclusionsFever is common among patients with primary ICH. Our data indicate a significant association between early fever and worse functional outcomes in ICH survivors at 1 year after ICH. Additionally, patients with early fever had a significantly longer length of hospital stay after ICH.

Dilated optic nerve sheath by ultrasound predicts mortality among patients with acute intracerebral hemorrhage

Abstract Background Intracerebral hemorrhage (ICH) is a deadly disease and increased intracranial pressure (ICP) is associated with worse outcomes in this context. Objective We evaluated whether dilated optic nerve sheath diameter (ONSD) depicted by optic nerve ultrasound (ONUS) at hospital admission has prognostic value as a predictor of mortality at 90 days. Methods Prospective multicenter study of acute supratentorial primary ICH patients consecutively recruited from two tertiary stroke centers. Optic nerve ultrasound and cranial computed tomography (CT) scans were performed at hospital admission and blindly reviewed. The primary outcome was mortality at 90-days. Multivariate logistic regression, ROC curve, and C-statistics were used to identify independent predictors of mortality. Results Between July 2014 and July 2016, 57 patients were evaluated. Among those, 13 were excluded and 44 were recruited into the trial. Their mean age was 62.3 ± 13.1 years and 12 (27.3%) were female. On univariate analysis, ICH volume on cranial CT scan, ICH ipsilateral ONSD, Glasgow coma scale, National Institute of Health Stroke Scale (NIHSS) and glucose on admission, and also diabetes mellitus and current nonsmoking were predictors of mortality. After multivariate analysis, ipsilateral ONSD (odds ratio [OR]: 6.24; 95% confidence interval [CI]: 1.18–33.01; p = 0.03) was an independent predictor of mortality, even after adjustment for other relevant prognostic factors. The best ipsilateral ONSD cutoff was 5.6mm (sensitivity 72% and specificity 83%) with an AUC of 0.71 (p = 0.02) for predicting mortality at 90 days. Conclusion Optic nerve ultrasound is a noninvasive, bedside, low-cost technique that can be used to identify increased ICP in acute supratentorial primary ICH patients. Among these patients, dilated ONSD is an independent predictor of mortality at 90 days.

Blend Sign and Haemorrhage Location and Volume Predict Late Recurrence and Mortality in Intracerebral Haemorrhage Patients.

Studies on risk factors for primary intracerebral haemorrhage (ICH) focus on short-term predictive values of distinct clinical parameters or computed tomography (CT) markers and disregard the others. We, therefore, studied independent predictive values of demographic, clinical, and CT markers regarding ICH expansion, late ICH recurrence, and late mortality. In a retrospective study of 288 patients with primary ICH, ICH localization (158 lobar, 81 deep, and 49 cerebellar), volume, blend sign, spot sign, finger-like projections, and subarachnoid haemorrhages were evaluated. ICH localization-specific differences for demographic (age, sex), clinical parameters (vascular risk factors, antiplatelet, and anticoagulation therapy), and CT markers were evaluated using logistic regression. We applied Cox proportional hazards modelling using these parameters to predict risk factors for ICH expansion, late ICH recurrence, and late mortality. The blend sign in lobar ICH relates to increased risk of ICH expansion (HR2.3), late ICH recurrence (HR2.3), and mortality (HR1.6). Age, conditions requiring antiplatelet medication, deep ICH localization, volume, and blend sign represented the most important independent factors impacting overall mortality. Blend sign at baseline ICH is a manifestation of underlying detrimental vascular processes that signal increased ICH expansion risk, although is also indicative of long-term risks for late recurrent ICH and late mortality.

Predictive value of bleeding risk scores in elderly patients with atrial fibrillation and oral anticoagulation.

The predictive value of bleeding risk scores for atrial fibrillation in older patients is not as well known. The goal of this study was to evaluate the predictive value of HASBLED, ORBIT and ATRIA for major bleeding (MB) and intracranial hemorrhage (ICH) in patients ≥ 75 years with atrial fibrillation and oral anticoagulation (OAC). A retrospective unicenter study including patients ≥ 75 years with atrial fibrillation (AF) and OAC. A total of 7613 patients ≥ 75 years with AF and OAC included between 2014 and 2018 (registry: NCT04364516). We analyzed the discriminative value of HASBLED, ATRIA and ORBIT scores for bleeding endpoints (major bleeding as primary endpoint and intracerebral hemorrhage as secondary). Cox regression was used to predict major bleeding with each scale and also for searching other variables potentially predictor of major bleeding. Model discrimination was assessed using Harrell's C-statistic. Calibration was assessed with goodness-of-fit test proposed by Gronnesby and Borgan. During a mean follow up of 4.0 years (IQR: 2.4-5.7 years), 729 patients developed MB (2.61 per 100 patients/year) and 243 patients developed ICH (0.85 per 100 patients/year). Three scores showed a low discrimination for major bleeding, being ORBIT the best (HASBLED C statistic = 0.557; ATRIA C statistic = 0.568; ORBIT C statistic = 0.595) and also a low discrimination for ICH (HASBLED C statistic = 0.509; ATRIA C statistic = 0.522; ORBIT C statistic = 0.526). Among the variables that are part of the scores and other baseline characteristics, after multivariable adjustment only sex (male), dementia, prior admission for bleeding, anemia and liver disease were found as a predictors of MB. In older patients under oral anticoagulation with atrial fibrillation, the risk scores HASBLED, ATRIA and ORBIT showed a weak discrimination for major bleeding and intracranial hemorrhage. Therefore, other better alternatives should be evaluated for this purpose.

The effect of neutrophil-to-lymphocyte ratio and systemic inflammatory response on perihematomal edema after intracerebral hemorrhage

BackgroundPerihematomal edema (PHE) is a marker of secondary brain injury in patients with intracerebral hemorrhage (ICH) and is associated with increased inflammatory markers and neurological disability. This study aims to assess the effect of the neutrophile-to-lymphocyte ratio (NLR) and systemic inflammatory response syndrome (SIRS) on PHE measurements and functional status in patients with ICH. MethodsWe included 215 patients with primary ICH and the primary outcomes were absolute and relative PHE, and edema extension distance (EED). A favorable functional outcome was defined as a modified Rankin Scale (mRS) score 0–2 measured 3 months after ICH. ResultsMedian age was 73.0 years (interquartile range 66–80) and 54.4% patients were males. Fifty-nine patients were functionally independent at 90 days (mRS 0 to 2). NLR and SIRS were not predictors of absolute, relative PHE, and EED when adjusted for multiple confounders. However, admission NLR was independently associated with an unfavorable functional outcome at 90 days (aOR = 0.38; 95% CI 0.17–0.87; p = 0.021). ConclusionsNLR and SIRS are not independent predictors of absolute and relative PHE measurements following ICH. Nevertheless, NLR predicts long-term disability in ICH patients. Further research is needed to understand the mechanisms by which inflammation causes neurological injury in ICH.