Primary Intracranial Hemorrhage Research Articles

Racial and ethnic differences in restarting antiplatelet therapy in patients with primary intracranial hemorrhage: a systematic review and meta-analysis

BackgroundThere has long been clinical disagreement over the resumption of antiplatelet therapy in patients with primary intracranial hemorrhage (ICH). This meta-analysis aimed to systematically evaluate the efficacy and safety of restarting antiplatelet therapy after ICH among different races and ethnicities.MethodsAll relevant medical studies involving adults with antiplatelet-associated ICH published in PubMed, The Cochrane Library and Chinese National Knowledge Infrastructure from inception to March 2024 were sourced. Outcome measures were thromboembolic events (stroke and myocardial infarction) and recurrence of ICH. After assessing study heterogeneity and publication bias, we performed a meta-analysis using random-effects model to assess the strength of association between resumption of antiplatelet therapy and our outcomes.The review was not registered and the review protocol was not prepared.ResultsThirty-five studies were included, with 9758 ICH patients. Subgroup analysis revealed that restarting antiplatelet therapy was associated with a significantly higher risk of recurrence or aggravation of cerebral hemorrhage in Asians[OR = 1.48, 95% CI (1.13–1.94), P = 0.004]; in Caucasians, on the contrary, reinitiation of antiplatelet therapy was not associated with a significantly higher risk of recurrence or aggravation of cerebral hemorrhage [OR = 0.85, 95% CI (0.67–1.06), P = 0.149]. Reinitiation of antiplatelet therapy was associated with a significantly lower risk of cerebral infarction [OR = 0.61, 95% CI (0.39–0.96), P = 0.033]. Restarting antiplatelet therapy after cerebral hemorrhage was not associated with a higher incidence rate of mortality [OR = 0.79, 95% CI (0.57, 1.08), P = 0.138], myocardial infarction [OR = 2.40, 95%CI (0.53,10.79), P = 0.253], hemiparesis [OR = 0.38, 95%CI (0.03,4.81), P = 0.451], neurological deficit [OR = 0.86,95%CI(0.32,2.33),P = 0.766].ConclusionReinstitution of antiplatelet therapy after ICH was associated with a lower risk of thromboembolic complications.Resumption of antiplatelet therapy was not associated with a higher incidence of cerebral hemorrhage in Caucasians, but may be associated with a higher risk of cerebral hemorrhage recurrence in Asian populations.

Abstract TP168: Association of Factors With Disorders of Consciousness in Hemorrhagic Stroke Patients

Objective: Disorders of consciousness (DoC) are known to correlate with worse functional outcome after hemorrhagic stroke. Here we evaluate factors associated low Glasgow Coma Scale [GCS] score at time of admission in patients with hemorrhagic stroke. Methods: We performed a prospective cohort study of patients enrolled in the Neurological Emergencies Outcomes Study between January 2014 and June 2023 of patients with primary intracranial hemorrhage (intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH)). The primary outcome was coma (GCS ≤ 8) at time of admission. Univariable analysis with chi-squared test and Mann Whitney U test followed by adjusted logistic regression were used to assess the relationship between admission factors and DoC. We then confirmed the association with admission GCS and discharge modified Rankin score (mRS). Results: We included 314 patients admitted with intracranial hemorrhage, 51 (16%) of whom had GCS ≤ 8 at time of admission, 51% female and median [interquartile (IQR)] age of 63 [51-73]. The median [IQR] ICH volume was 9.3 ml [2.5-27.2] for ICH patients and the median [IQR] modified Fisher score was 3 [3-4] for SAH patients. Female gender, Asian race, hematoma size, hydrocephalus, peak temperature, lowest hemoglobin, and peak glucose in the first 24 hours were all associated with DoC (p<0.05 for all). Controlling for age, disease process (ICH vs SAH), and all factors with p < 0.05, we found female gender (OR 4.7, 95% CI 1.7-13.4), highest temperature (OR 3.8, 95% CI 1.9-7.3), lowest hemoglobin (OR 0.8, 95% CI 0.6-0.99), and highest glucose OR 1.01, 95% CI 1.00-1.02) remained significantly associated with coma at time of admission. Premorbid dependency as measured by Barthel Index was not a predictor of coma. However, coma at time of admission was associated with a worse discharge mRS (median discharge mRS [IQR] for patients with coma 5 [4-6] vs without 3 [2-4], p < 0.001). Conclusions: We found that female gender, low hemoglobin, high body temperature, and elevated glucose at time of admission were all associated with coma. Low admission GSC (≤ 8) was associated with higher mRS at time of discharge. These modifiable risk factors are an important therapeutic target for improving outcomes for patients with DoC.

STUDY OF “MAGNETIC RESONANCE IMAGING IN STROKE PATIENTS AT A TERTIARY HEALTH CARE CENTER”

Background: One of the main causes of mortality and disability worldwide is stroke. Cerebral infarction, non-traumatic subarachnoid hemorrhage, primary intracranial hemorrhage, and various dural sinus/cerebral vein obstruction are the different types of stroke. About 80–90% of strokes are ischemic strokes, which are the most frequent form of stroke. Aim of the Study: The aim of this study was to study “Magnetic resonance imaging in stroke patients at a tertiary health care center.” Methods: This was 18-month cross-sectional research conducted in the Department of Radiodiagnosis at the Shrisatyasai Medical College and Research Institute in Chengalpattu, Tamil Nadu, from December 2020 to June 2021. Results: In the present study, middle cerebral artery is 43.3%, posterior cerebral artery (PCA) is 16.7%, anterior cerebral artery is 13.3%, lacunar infarcts is 16.7%, multiple infarcts is 8.3%, and basilar excluding PCA is 1.7% in the present study. About 73.3% of the patients (44/60) had infarcts, 10% had hemorrhage (6/60), and 16.7% had stroke mimics (10/60). Conclusion: DWI is a better imaging method than conventional MRI in detecting early ischemic lesions in stroke patients with Sensitivity of 94% and specificity of 100% was observed among acute infarct patients.

Ischemic and hemorrhagic strokes in young adults: Comparison of functional outcomes and return to work after stroke

BackgroundFunctional recovery and return to work (RTW) after stroke are important rehabilitation goals that have significant impact on quality of life. Comparisons of functional outcomes and RTW between ischemic stroke (IS) and hemorrhagic stroke (HS), especially among young adults with stroke, have either been limited or yielded inconsistent results. We aimed to assess functional outcomes and ability to RTW in young adults with IS and HS, specifically primary spontaneous intracranial hemorrhage (SICH). MethodsYoung adults with IS or SICH aged 18–50-years-old were included. Outcome measures were modified Rankins score (mRS) on discharge and 3-months and RTW at 3-months after stroke. Good functional outcome was defined as an mRS of 0–2. ResultsWe included 459 patients (71.5% male) with a mean age of 43.3 ± 5.7 years, comprising 49.2% IS and 50.8% SICH. Patients with SICH were more likely to have unfavourable shifts in ordinal mRS on discharge (OR 7.52, CI 5.18–10.87, p < 0.001) and at 3-months (OR 6.41, CI 4.17–9.80, p < 0.001). Patients with IS more likely achieved good functional outcomes (80.2% vs. 51.8%, p < 0.001) and were able to RTW at 3-months (54.4% vs. 36.3%, p = 0.004). Among all stroke patients with good functional outcomes, one-third did not RTW at 3-months. Patients with longer length of hospitalisation and higher National Institutes of Health Stroke Scale (NIHSS) score on admission, especially in the domain categories of level of consciousness, vision, motor function, language and neglect, were less likely to RTW at 3-months. ConclusionPatients with IS were more likely to RTW when compared to SICH patients. Many young stroke patients did not RTW despite good functional outcomes. Further research should therefore address differences in prognosis and identify predictors that influence ability to RTW after stroke in the young adult population.

Primary Intracranial Hemorrhage: Characteristics, Distribution, Risk Factors, and Outcomes-A Comparative Study between Jewish and Arab Ethnic Groups in Northern Israel.

Background and purpose: This study aimed to investigate the differences in intracerebral hemorrhage (ICH) between Jews and Arabs residing in northern Israel, focusing on risk factors, hemorrhage volume, and functional outcome. Methods: A retrospective analysis was conducted utilizing a population-based registry to investigate intracerebral hemorrhage (ICH) characteristics, risk factors, and outcomes. The registry consisted of inpatients diagnosed with hemorrhagic stroke. Due to the wide variation in data on ICH characteristics and the limited availability of population-based data on predictors of ICH survival and functional outcomes, we collected retrospective data on all adult patients admitted to the Galilee Medical Center with a diagnosis of ICH. Data were obtained from the registry covering the period from 2013 to 2019. Ethnic differences and risk factors associated with intracranial hemorrhage (ICH) were examined within a diverse population of 241 patients, comprising 52.70% Jews (n = 127) and 47.30% Arabs (n = 114). Results: The results of this study revealed significant differences in age, obesity rates, and intracerebral hemorrhage (ICH) location between the two ethnic groups. Hypertension emerged as the most prevalent condition among ICH patients in both ethnic groups (76.70%), followed primarily by anticoagulant use (63.60%), dyslipidemia (60.70%), diabetes (44.60%), obesity (30.60%), smoking (24.60%), and a history of cardiovascular disease (21.80%). Furthermore, 20.90% of the patients had a history of previous cerebrovascular accidents (CVA). Arab patients with ICH were generally younger (62.90 ± 16.00 years) and exhibited higher rates of obesity (38.70%) compared to Jewish patients with ICH (70.17 ± 15.24 years, 23% obesity; p = 0.001, p = 0.013, respectively). Hemorrhage volume was identified as a crucial determinant of patient outcomes, with larger volumes associated with poorer Modified Rankin Scale (mRS) scores at discharge and higher mortality rates. Interestingly, patients without hypertension had higher hemorrhage volumes compared to those with hypertension. The extent of hemorrhage into the ventricles did not significantly correlate with mRS at discharge in our dataset. Conclusions: This study highlights significant differences in the characteristics and outcomes of intracranial hemorrhage (ICH) between Jews and Arabs in northern Israel. The findings reveal variations in age, obesity rates, and ICH location between the two groups. While hypertension was the most prevalent risk factor for both populations, other risk factors differed. Notably, hemorrhage volume emerged as a crucial prognostic factor, aligning with previously published data. These findings underscore the necessity for tailored approaches that consider ethnic-specific factors in the risk assessment, prevention, and management of ICH. Further research is warranted to elucidate the underlying mechanisms and develop interventions aimed at improving outcomes and enhancing healthcare practices in ICH management.

The accuracy of non-contrast brain CT scan in predicting the presence of a vascular etiology in patients with primary intracranial hemorrhage

Spontaneous intraparenchymal cerebral hemorrhages (SIPH) account for 10–15% of acute strokes. Sorting these patients according to the risk of harboring an underlying vascular etiology may help selecting the patients who would mostly benefit from Multidetector CT Angiography (MDCTA). The aim of this study was to evaluate the accuracy of Non-Contrast brain CT (NCCT) in predicting possible vascular etiologies in patients with SIPH. In this retrospective study, we evaluated the NCCT of 334 patients who presented with SIPH from March 2017 to March 2021 and we looked for vascular etiologies in the CTA which was performed for these patients. We used NCCT criteria to predict the presence of any vascular etiologies in SIPH patients and proposed a scoring system based on these criteria which might predict the risk of vascular ICH (VICH score). Out of 334 evaluated patients, 9.3% had an underlying vascular etiology. Independent predictors of the vascular etiology included: age < 46 years, no history of hypertension and coagulation disorders, lobar hemorrhages, and presence of significant perilesional edema. We used these criteria and NCCT classification to create a practical scoring system to predict the risk of vascular ICH (VICH). In our study, VICH score ≥ 4 had 51.6% sensitivity and 96.4% specificity for predicting a positive MDCTA as the maximum optimal cut-off point. The VICH score seemed to be successful in predicting vascular etiologies in this retrospective cohort of 334 patients. This scoring system can be used to select patients if there are limited resources to perform CT angiography.

Machine learning-based CT radiomics model to discriminate the primary and secondary intracranial hemorrhage

It is challenging to distinguish between primary and secondary intracranial hemorrhage (ICH) purely by imaging data, and the two forms of ICHs are treated differently. This study aims to evaluate the potential of CT-based machine learning to identify the etiology of ICHs and compare the effectiveness of two regions of interest (ROI) sketching methods. A total of 1702 radiomic features were extracted from the CT brain images of 238 patients with acute ICH. We used the Select K Best method, least absolute shrinkage, and selection operator logistic regression to select the most discriminable features with a support vector machine to build a classifier model. Then, a ten-fold cross-validation strategy was employed to evaluate the performance of the classifier. From all quantitative CT-based imaging features obtained by two sketch methods, eighteen features were selected respectively. The radiomics model outperformed radiologists in distinguishing between primary and secondary ICH in both the volume of interest and the three-layer ROI sketches. As a result, a machine learning-based CT radiomics model can improve the accuracy of identifying primary and secondary ICH. A three-layer ROI sketch can identify primary versus secondary ICH based on the CT radiomics method.

Abstract Number: LBA16 Does Intracranial Hemorrhage Associated with Tenecteplase Occur Exclusively Within the Stroke Burden?

Introduction As IV tenecteplase (TNK) is becoming an alternative to IV alteplase in acute ischemic stroke (AIS), establishing the incidence of intracranial hemorrhage (ICH) complications is important. Given the higher fibrin specificity of TNK as compared to alteplase, our aim was to distinguish hemorrhage within the stroke burden versus spontaneous ICH in patients with AIS with TNK‐associated ICH. Methods Retrospective chart review of patients presenting from February 2020 to January 2022 with anterior circulation AIS to our comprehensive stroke center who received TNK was performed to evaluate for associated ICH. ECASS‐3 criteria was used to define hemorrhagic transformation and ICH score was used for primary, spontaneous ICH. Fisher exact test statistic was used to evaluate for significant differences in ASPECTS score, medium versus versus large vessel occlusion, angiographic recanalization, IV eptifibatide use, pre‐morbid antiplatelet use, and association with symptomatic versus asymptomatic hemorrhage. A benchmark less than 5% symptomatic ICH incidence was set based on historical alteplase rates within our network. Social science statistics software was used for data analysis. Results Out of 77 subjects who received TNK, 20.7% (n = 16) developed ICH, 9.1% (n = 7) of which were symptomatic ICH with a temporally‐related increase in NIHSS of at least 4 or greater. Seven subjects (43.75%) were male. Mean age was 73.38 (95% CI 65.92, 80.83). Median initial NIHSS was 16, 95% CI [11.74, 21.51]. Median ASPECTS was 9, 95% CI [8.74, 9.89]. Two subjects developed spontaneous, primary ICH (n = 1 symptomatic ICH, n = 1 non‐symptomatic ICH) in the absence of hemorrhagic transformation of ischemic stroke. No significant difference between subjects with asymptomatic hemorrhage versus symptomatic hemorrhage was found when comparing ASPECTS &gt; = 7 versus &lt; 7 (Fisher value = 1), angiographic recanalization (Fisher value = 1), use of IV eptifibatide (Fisher value = 1), pre‐morbid antiplatelet use (Fisher value = 0.13), or medium vessel occlusion (Fisher value = ‐0.63). Conclusions Expected rates of hemorrhagic transformation were higher in tenecteplase than our historical benchmark rate for alteplase. Spontaneous hemorrhage unrelated to ischemic stroke area were seen in 2 subjects without known hematological disorders. Larger, prospective studies are needed to validate safety of tenecteplase in real world settings.

Abstract WP204: Real World Data On Spontaneous Cervical Artery Dissection From A Comprehensive Stroke Center

Introduction: Cervical artery dissection (CAD) is a common cause of stroke in the young and carries a high risk of early recurrence. We aim to compare the characteristics of patients from a real-world cohort to those from prior randomized controlled trials. Methods: We pooled data from consecutive patients with a diagnosis of spontaneous CAD treated at a comprehensive stroke center who were followed for at least 90 days. We excluded patients with traumatic dissection and those with primary intracranial hemorrhage in the setting of trauma or dissection. We compared the baseline characteristics and stroke recurrence rates in our cohort to the TREAT-CAD (2021) and CADISS (2019) trials. We report recurrence rates in patients treated with single antiplatelet (SAPT), dual antiplatelet (DAPT), and anticoagulation (AC). Results: 80 patients with CAD met our inclusion criteria. Our study sample characteristics differ from TREAT-CAD and CADISS, with our cohort more likely to have hypertension and diabetes but less likely to have a smoking history. The rate of recurrent stroke at 90 days was numerically higher in our patient cohort (6.3%) compared to TREAT-CAD (3.6%) and CADISS (1.6%). The rates of recurrent stroke were 8.6% (3/35) with SAPT, 4.2% (1/24) with DAPT, and 5% (1/20) with AC strategies. Conclusions: Characteristics of a real-world CAD population differ from those enrolled in clinical trials with an overall higher rate of recurrent stroke but comparable rates among patients treated with DAPT and AC. The ongoing STOP-CAD study will compare DAPT to AC with a substantially larger number of patients, with an estimated projection of at least 3000 patients in a multi-center international cohort.

A Radiologist Approach to Acute Parenchymal Hemorrhages: How to Intercept Shrouded Dragons

Primary intracranial hemorrhage (ICH) or hemorrhagic strokes etiology is unknown in the initial stage. The location, size and morphology are three important factors when reading the scan of intracranial hemorrhage. Clinical ICH score correlates with a 30 day mortality which takes into consideration admission Glasgow coma scale,&gt;80 years old, ICH volume, infratentorial and presence of intraventricular hemorrhage. Management includes finding the cause of hemorrhage or symptomatic management.

553: COMPARISON OF INTRACRANIAL HEMATOMA EXPANSION IN PATIENTS ON WARFARIN VS. DIRECT ORAL ANTICOAGULANTS

Introduction: Anticoagulation associated intracranial hemorrhage has been associated with larger initial hematoma volumes and a greater frequency of hematoma expansion. Preventing hematoma expansion is a promising treatment strategy as expansion is a predictor of poor outcomes. Limited studies have been conducted that directly compare hematoma expansion in patients taking warfarin versus direct oral anticoagulants (DOACs). Due to increased prescribing of DOACs, this study aimed to assess intracranial hematoma expansion in patients taking warfarin compared to DOACs. Methods: This was a retrospective, observational study conducted at an academic, adult level one trauma, and comprehensive stroke center between October 1, 2016 and November 30, 2021. Adult patients were included if they were diagnosed with a primary intracranial hemorrhage, prescribed warfarin or DOACs prior to admission, admitted to an intensive care unit (ICU), and had an initial and follow-up computed tomography (CT) brain within 24 hours. The primary outcome was incidence of hematoma expansion upon repeat CT brain. Secondary outcomes included hospital and ICU length of stay (LOS), incidence and duration of mechanical ventilation, in-hospital mortality, incidence and type of thrombotic complications during hospital stay, and discharge disposition. Results: Of the 56 patients included, 29 were on warfarin and 27 were on a DOAC. Hematoma expansion occurred in 8 (27.6%) warfarin and 9 (33.3%) DOAC patients (P=0.640). Patients in the DOAC group had a significantly shorter ICU LOS (2.7 ± 2.3 vs 4.7 ± 4.1 days; P=0.033) and hospital LOS (6.0 ± 4.9 vs 9.4 ± 6.1; P=0.028) compared to the warfarin group. Additionally, 7 (24.1%) warfarin patients were discharged to hospice compared to 0 (0.0%) in the DOAC group (P=0.011). No other significant differences were observed. Conclusions: There was no statistically significant difference in the incidence of hematoma expansion between groups. However, a shorter ICU and hospital LOS was demonstrated in the DOAC group.

Radiographic Predictors of Shunt Dependency in Intracranial Hemorrhage With Intraventricular Extension.

BackgroundIntracranial hemorrhage (ICH) may be complicated by intraventricular hemorrhage (IVH) and hydrocephalus, which can require the placement of a ventriculoperitoneal shunt (VPS). ICH and IVH risk scores using radiographic and clinical characteristics have been developed but utilization for assessment of future need for VPS placement is limited.MethodsThis is a single-institution retrospective review for patients with primary ICH with IVH from 2018-2020. Initial CTs and charts were analyzed to determine ICH, IVH, LeRoux and Graeb scores, Evans’ index, ICH and IVH volumes, and comorbidities. Outcomes including Glasgow coma scale (GCS), National Institute of Health Stroke Scale (NIHSS), length of stay, and shunt placement were evaluated with bivariate correlations, t-tests, chi-squared tests, and receiver operating characteristic (ROC) curves (p=0.05).ResultsA total of 130 patients were included of which 102 underwent full treatment beyond hospital day one. VPS placement was significantly associated with longer length of stay (p<0.001), discharge NIHSS (p=0.001), arrival Evans’ index (p<0.001), IVH (p=0.033), LeRoux (p=0.049), but not comorbidities, ICH score, or admission GCS. When treated beyond hospital day one, Evans’ index (p<0.001), IVH volume (p=0.029), Graeb (p=0.0029), IVH (p=0.004), Slice (p=0.015), and Leroux scores (p=0.006) were associated with shunt placement of which an Evans’ index of 0.31 or greater had highest sensitivity and specificity (area under the ROC curve (AUC) 0.81, sensitivity 81%, specificity 0.76).ConclusionsThe higher the Evans’ index, Graeb, IVH, Slice, and LeRoux scores on admission, the higher the risk of shunt dependency in patients undergoing full treatment beyond hospital day one. Admission imaging scores significantly predict the development of shunt dependence and may be considered in treatment.

High In-Hospital Mortality Incidence Rate and Its Predictors in Patients with Intracranial Hemorrhage Undergoing Endotracheal Intubation.

(1) Background: The goal of this study was to determine the incidence of in-hospital mortality and to investigate its predictors in patients with a primary intracranial hemorrhage (ICH) undergoing endotracheal intubation. (2) Methods: This retrospective study, between July 2018 to July 2019, recruited patients who were diagnosed with a primary ICH and who were intubated during treatment in our institution. The outcome variable was in-hospital mortality, known as 30-day mortality, in patients with ICH undergoing endotracheal intubation. Multivariable analyses were performed to identify the prediction of in-hospital mortality. (3) Results: A total of 180 patients with ICH undergoing endotracheal intubation were included, with a mean (SD) age of 62.64 (13.82) years. A total of 73.33% were female, and 71.11% of the patients were indicated for intubation due to neurological reasons. The in-hospital mortality rate, following endotracheal intubation, was 58.33%. In a reduced model using a stepwise backward selection strategy with p values < 0.2, independent predictors of in-hospital mortality were brain herniations on cranial CT scans (OR: 10.268, 95% CI: 2.749–38.344), lower Glasgow coma scale (CGS) scores before intubation (OR: 0.614, 95% CI: 0.482–0.782), and the loss of the vertical oculocephalic reflex before intubation (OR: 6.288, 95% CI: 2.473–15.985). Conclusions: The in-hospital mortality rate was comparable to that in the early evidence, but was significantly higher compared to recent reports. We infer that brain herniations on cranial CT imaging, lower CGS scores before intubation, and the loss of the vertical oculocephalic reflex before intubation could be used to approximately predict in-hospital mortality in patients with primary ICH undergoing endotracheal intubation. These considerations can help guide clinical decisions and community stroke discussions.

Diagnostic utility of flow cytometry based coated-platelets assay as a biomarker to predict thrombotic or hemorrhagic phenotype in acute stroke.

Coated-platelets are sub-population of platelets "coated" with highly procoagulant proteins and phosphatidylserine that sustains thrombin generation. They are produced upon dual agonist stimulation by collagen and thrombin. This study was conducted to assess if there was any difference in the levels of coated-platelets in patients with primary intracranial hemorrhage (PICH) and ischemic stroke due to large artery atherosclerosis (LAA) as compared to healthy controls, and to see if coated-platelet levels had any influence on the hemorrhagic transformation (HT) of ischemic stroke. Coated-platelet levels were determined by flow cytometry using fluorescently tagged Annexin V antibody to identify phosphatidylserine exposed on the surface of platelets activated by dual agonists (convulxin and thrombin) in cross-sectional cohort of 75 patients with stroke and 34 controls. Patients with PICH (n=35) had significantly lower coated-platelets than the controls (adjusted mean ± SE, 21.0 ± 1.9% vs. 36.1 ± 1.7%, p <0.001), while patients with LAA (n=30) had significantly higher coated-platelets than controls (adjusted mean ± SE, 51.9 ± 1.5% vs. 36.1 ± 1.7%, p <0.001). Patients with subsequent HT of ischemic stroke (n=10) had significantly lower coated-platelet levels at admission compared to those without HT (adjusted mean ± SE, 18.1 ± 2.6% vs. 51.9 ± 1.5%, p <0.001). Coated-platelet levels are significantly different in patients with hemorrhagic and ischemic stroke as compared with controls. Lower levels of coated-platelets measured by flow cytometry may be earliest predictor of subsequent HT in patients with ischemic stroke even before the radiological changes suggestive of HT are visualized.

Some evidence on Gerstmann’s syndrome: A case study on a variant of the clinical disorder

We describe the case of a bilingual patient with persistent symptoms largely, although not fully, consistent with those that are usually reported in Gerstmann’s syndrome. Twenty months after a spontaneous primary intracranial hemorrhage, the patient was evaluated with a series of neuropsychological tasks and underwent an MRI investigation based on Diffusion Tensor Imaging probabilistic tractography. The patient suffered from dysgraphia (difficulty in the access to the graphemic representation of letter forms), autotopoagnosia (difficulties in locating body parts on verbal command), right–left confusion (difficulties in localizing right and left side of symmetrical body parts), and number processing/calculation impairments (predominant difficulties on transcoding tasks). Probabilistic tractography revealed a relatively spared superior longitudinal fasciculus and severe damage to the subcortical white matter connecting the angular gyrus with other parietal regions, such as the intraparietal sulcus and the supramarginal gyrus. Within the framework of the contemporary cognitive accounts of Gerstmann’s syndrome, the case supports the assumption of an anatomical intraparietal disconnection more than a functional Grundstörung (core impairment).

Risk factors for intracerebral hemorrhage in patients with COVID-19.

Intracerebral hemorrhage (ICH) can be a devastating complication of coronavirus disease (COVID-19). We aimed to assess risk factors associated with ICH in this population. We performed a retrospective cohort study of adult patients admitted to NYU Langone Health system between March 1 and April 27 2020 with a positive nasopharyngeal swab polymerase chain reaction test result and presence of primary nontraumatic intracranial hemorrhage or hemorrhagic conversion of ischemic stroke on neuroimaging. Patients with intracranial procedures, malignancy, or vascular malformation were excluded. We used regression models to estimate odds ratios and 95% confidence intervals (OR, 95% CI) of the association between ICH and covariates. We also used regression models to determine association between ICH and mortality. Among 3824 patients admitted with COVID-19, 755 patients had neuroimaging and 416 patients were identified after exclusion criteria were applied. The mean (standard deviation) age was 69.3 (16.2), 35.8% were women, and 34.9% were on therapeutic anticoagulation. ICH occurred in 33 (7.9%) patients. Older age, non-Caucasian race, respiratory failure requiring mechanical ventilation, and therapeutic anticoagulation were associated with ICH on univariate analysis (p < 0.01 for each variable). In adjusted regression models, anticoagulation use was associated with a five-fold increased risk of ICH (OR 5.26, 95% CI 2.33–12.24, p < 0.001). ICH was associated with increased mortality (adjusted OR 2.6, 95 % CI 1.2–5.9). Anticoagulation use is associated with increased risk of ICH in patients with COVID-19. Further investigation is required to elucidate underlying mechanisms and prevention strategies in this population.Electronic supplementary materialThe online version of this article (10.1007/s11239-020-02288-0) contains supplementary material, which is available to authorized users.

Benefit of Targeting a LDL (Low-Density Lipoprotein) Cholesterol

Background and Purpose- The TST trial (Treat Stroke to Target) evaluated the benefit of targeting a LDL (low-density lipoprotein) cholesterol of <70 mg/dL to reduce the risk of cardiovascular events in 2860 patients with ischemic stroke with atherosclerotic stenosis of cerebral vasculature or aortic arch plaque >4 mm, in a French and Korean population. The follow-up lasted a median of 5.3 years in French patients (similar to the median follow-up time in the SPARCL trial [Stroke Prevention by Aggressive Reduction in Cholesterol Level]) and 2.0 years in Korean patients. Exposure duration to statin is a well-known driver for cardiovascular risk reduction. We report here the TST results in the French cohort. Methods- One thousand seventy-three French patients were assigned to <70 mg/dL (1.8 mmol/L) and 1075 to 100±10 mg/dL (90-110 mg/dL, 2.3-2.8 mmol/L). To achieve these goals, investigators used the statin and dosage of their choice and added ezetimibe on top if needed. The primary outcome was the composite of ischemic stroke, myocardial infarction, new symptoms requiring urgent coronary or carotid revascularization and vascular death. Results- After a median follow-up of 5.3 years, the achieved LDL cholesterol was 66 (1.69 mmol/L) and 96 mg/dL (2.46 mmol/L) on average, respectively. The primary end point occurred in 9.6% and 12.9% of patients, respectively (HR, 0.74 [95% CI, 0.57-0.94]; P=0.019). Cerebral infarction or urgent carotid revascularization following transient ischemic attack was reduced by 27% (P=0.046). Cerebral infarction or intracranial hemorrhage was reduced by 28% (P=0.023). The primary outcome or intracranial hemorrhage was reduced by 25% (P=0.021). Intracranial hemorrhages occurred in 13 and 11 patients, respectively (HR, 1.17 [95% CI, 0.53-2.62]; P=0.70). Conclusions- After an ischemic stroke of documented atherosclerotic origin, targeting a LDL cholesterol of <70 mg/dL during 5.3 years avoided 1 subsequent major vascular event in 4 (number needed to treat of 30) and no increase in intracranial hemorrhage. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01252875.

Factors associated with enlargement of hematoma in patients with primary intracranial hemorrhage

Factors associated with enlargement of hematoma in patients with primary intracranial hemorrhage - IJN- Print ISSN No: - 2581-8236 Online ISSN No:- 2581-916X Article DOI No:- 10.18231/j.ijn.2019.029, IP Indian Journal of Neurosciences-IP Indian J Neurosci

Randomized Controlled Trials on Intracerebral Hemorrhage: A Cross Sectional Retrospective Analysis of CONSORT Item Adherence

Object: Intracranial hemorrhage (ICH) is the second most common cause of stroke but still there is little consolidated knowledge about the optimal treatment strategies (e.g., the benefit of surgical evacuation). We evaluated the current randomized controlled trials (RCTs) on primary ICH (01.2013–03.2017) according to their fulfillment of the CONSORT statement's criteria (published in 2010) –as a marker of transparency and quality of study planning and realization.Methods: A Pubmed and a Cochrane database (including clinicaltrials.gov) search was carried out (01.2014–3.2017, respectively 01.2013–12.2013). s were screened for inclusion. Eligible full text manuscripts were assessed for the implementation of the CONSORT criteria. Citation frequencies and impact factors of the journals were related to ratio of CONSORT criteria fulfillment. Further, the risk of bias according to the Risk of bias tool 2 (RoB 2) was assessed.Results: Overall 3097 abstracts were screened for inclusion; 39 studies were suitable for final analysis. A mean fulfillment ratio of 51% (±28%) was found. A high correlation between impact factor and adherence to CONSORT criteria was shown (r = 0.7664; p < 0.0001). Citation frequency per year was related to ratio of CONSORT item fulfillment (r = 0.6747; p < 0.0001) and to the impact factor of the publishing journal (r = 0.7310; p < 0.0001). Of note, the items 10 (randomization: implementation) and 21 (generalizability) showed particularly high rates of non-fulfillment (87 and 85%). The majority of studies (95%) complied with item 2b (specific objectives or hypotheses), but strikingly objectives were mostly described vaguely. Other essential criteria such as sample size determination, definition of outcome parameters, and participant flow were only fulfilled weakly (51, 54, and 39%).Conclusions: Over 20 years after its inception there is still weak adherence to the CONSORT statement. As a consequence, conclusions are hampered by inadequate planning and/or reporting. Particularly with respect to pathologies as ICH lacking clear, evidence-based guidelines adherence to the CONSORT statement might improve research quality in order to define valuable treatment strategies.

Safety and Efficacy of Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

The antithrombotic treatment of patients with atrial fibrillation (AF) and coronary artery disease, in particular with acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI), poses a significant treatment dilemma in clinical practice. To study the safety and efficacy of different antithrombotic regimens using a network meta-analysis of randomized controlled trials in this population. PubMed, EMBASE, EBSCO, and Cochrane databases were searched to identify randomized controlled trials comparing antithrombotic regimens. Four randomized studies were included (n = 10 026; WOEST, PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this systematic review and network meta-analysis between 4 regimens using a Bayesian random-effects model. A pre hoc statistical analysis plan was written, and the review protocol was registered at PROSPERO. Data were analyzed between November 2018 and February 2019. The primary safety outcome was Thrombolysis in Myocardial Infarction (TIMI) major bleeding; secondary safety outcomes were combined TIMI major and minor bleeding, trial-defined primary bleeding events, intracranial hemorrhage, and hospitalization. The primary efficacy outcome was trial-defined major adverse cardiovascular events (MACE); secondary efficacy outcomes were individual components of MACE. The overall prevalence of ACS varied from 28% to 61%. The mean age ranged from 70 to 72 years; 20% to 29% of the trial population were women; and most patients were at high risk for thromboembolic and bleeding events. Compared with a regimen of vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT; P2Y12 inhibitor plus aspirin), the odds ratios (ORs) for TIMI major bleeding were 0.58 (95% CI, 0.31-1.08) for VKA plus P2Y12 inhibitor, 0.49 (95% CI, 0.30-0.82) for non-VKA oral anticoagulant (NOAC) plus P2Y12 inhibitor, and 0.70 (95% CI, 0.38-1.23) for NOAC plus DAPT. Compared with VKA plus DAPT, the ORs for MACE were 0.96 (95% CI, 0.60-1.46) for VKA plus P2Y12 inhibitor, 1.02 (95% CI, 0.71-1.47) for NOAC plus P2Y12 inhibitor, and 0.94 (95% CI, 0.60-1.45) for NOAC plus DAPT. A regimen of NOACs plus P2Y12 inhibitor was associated with less bleeding compared with VKAs plus DAPT. Strategies omitting aspirin caused less bleeding, including intracranial bleeding, without significant difference in MACE, compared with strategies including aspirin. Our results support the use of NOAC plus P2Y12 inhibitor as the preferred regimen post-percutaneous coronary intervention for these high-risk patients with AF. A regimen of VKA plus DAPT should generally be avoided.