Remote Intracerebral Hemorrhage Research Articles

Association of Atrial Fibrillation with Remote Intracerebral Hemorrhage After Intravenous Thrombolysis: Results from a Multicenter Study in China.

This study aimed to investigate the association between atrial fibrillation (AF), particularly newly diagnosed AF, and remote intracerebral hemorrhage (rICH) in patients with ischemic stroke who were treated with intravenous thrombolysis (IVT). This observational study was conducted on patients with ischemic stroke who received IVT with recombinant tissue-type plasminogen activator. The data were taken from a multicenter prospective registry of a Chinese population. rICH was defined as any extraischemic hemorrhage detected on computerized tomography (CT) 24h after intravenous thrombolysis. We collected and compared the demographic data and clinical characteristics of all the patients with rICH to those of patients without any type of hemorrhagic transformation. The association between AF and rICH was analyzed using univariate analysis and binary logistic regression. A total of 20,697 patients were included in the study, with 1566 (7.6%) experiencing intracerebral hemorrhage (ICH), 586 (2.8%) experiencing rICH, and 19,131 (92.4%) not experiencing any form of hemorrhagic transformation. Univariate analysis revealed significant differences in age, pre-thrombolysis systolic blood pressure, baseline National Institute of Health Stroke Scale score, previously known AF, newly diagnosed AF, coronary heart disease, congestive heart failure, hyperhomocysteinemia, and history of thrombolysis between the rICH and control groups (P < 0.05). Further multivariate logistic regression analysis indicated that total AF (OR 1.821, 95%CI 1.082-3.065, P < 0.05), previously known AF (OR 1.470, 95%CI 1.170-1.847), and newly diagnosed AF (OR 1.920, 95%CI 1.304-2.825) were independently associated with rICH. This study suggests that AF, regardless of whether it is newly diagnosed or previously known, may be associated with the occurrence of rICH following intravenous thrombolysis. Interestingly, our findings suggest that newly diagnosed AF may have a stronger impact on rICH than previously known AF, although confirmation from more studies is needed.

Prevalence, Risk Factors, and Clinical Outcomes of New Cerebral Microbleeds After Intravenous Thrombolysis in Acute Ischemic Stroke: aSystematic Review and Meta-analysis.

Cerebral microbleeds (CMBs) are common in the elderly population, and are associated with an increased risk of stroke and dementia. An acute ischemic stroke event can make CMBs develop rapidly. However, the progression of CMBs after intravenous thrombolysis is not well understood. Following apreviously registered protocol, PubMed, Web of Science, and Embase databases were systematically searched to identify relevant literature up to August 2022. Cohort studies that reported new CMBs in patients with acute ischemic stroke undergoing intravenous thrombolysis were included. Random effects models were used to calculate the pooled estimates. Seven studies with 1079 patients were included in the meta-analysis. The pooled new CMBs prevalence was 7.6% (95% CI 3.9-14.3%) and 63.6% new CMBs were located in the cerebral lobes. Compared with patients without new CMBs, those with new CMBs were older, had ahigher proportion of hypertension, and had higher systolic blood pressure and baseline CMBs burden. The presence of new CMBs increased the likelihood of remote intracerebral hemorrhage (OR 28.75, 95% CI 8.58-96.38) and symptomatic intracerebral hemorrhage (OR 15.49, 95% CI 3.21-74.73) but was not related to functional outcomes or hemorrhagic transformation. The prevalence of new CMBs after intravenous thrombolysis was approximately 7.6%. The presence of new CMBs is associated with remote and symptomatic intracerebral hemorrhage following intravenous thrombolysis. Considering the potential long-term adverse effects of CMBs progression, patients at ahigh risk of developing new CMBs should be identified based on potential risk factors.

Prevalence, risk factors, and clinical outcomes of remote intracerebral hemorrhage after intravenous thrombolysis in acute ischemic stroke: a systematic review and meta-analysis.

Hemorrhagic transformation (HT) is a common complication of alteplase treatment. However, the prevalence rate, risk factors, and clinical outcomes of remote intracerebral hemorrhage (rICH) after intravenous thrombolysis in acute ischemic stroke are not well understood. Following a previously registered protocol, the PubMed, Web of Science, and Embase databases were systematically searched to identify relevant literature up to June 2022. Cohort studies reporting thrombolysis-related rICH in patients with acute ischemic stroke were included. Random effects models were used to calculate pooled prevalence rate, mean difference (MD) or odds ratio (OR) with corresponding 95% confidence interval (CI). Fourteen studies with 52,610 patients were included in this meta-analysis. The pooled rICH prevalence was 3.2% (95% CI 3.1-3.4%). Compared to patients without intracerebral hemorrhage (ICH), those with rICH were older, more likely to be female, and had a higher proportion of prior stroke, chronic heart failure and cardioembolism, and higher diastolic blood pressure. Small vessel disease markers (e.g., white matter hyperintensities and cerebral microbleeds) werestrongly associated with rICH. The presence of rICH decreased the likelihood of favorable outcomes (OR 0.36, 95% CI 0.31-0.41) and increased the risk of mortality (OR 4.37, 95% CI 2.86-6.67). Although rICH is uncommon after intravenous thrombolysis, its presence can lead to worse functional outcomes and higher mortality in acute ischemic stroke. Patients at high risk of rICH must be identified based on potential risk factors.

A Review of Remote Intracerebral Hemorrhage after Chronic Subdural Hematoma Evacuation.

Remote intracerebral hemorrhage (RICH) is a severe complication following chronic subdural hematoma (cSDH) drainage, and only case reports and small case series have been reported to date. The authors present an emblematic patient affected by RICH following cSDH drainage. A systematic review of the literature on diagnosis and management of patients affected by RICH following cSDH evacuation has also been performed. A literature search according to the PRISMA statement was conducted using PubMed and Scopus databases with the following Mesh terms: [(remote) AND (intracerebral hemorrhage or cerebral hematoma or cerebral infarction or cerebellar hemorrhage or cerebellar hematoma or cerebellar infarction) AND (chronic subdural hematoma)]. The literature search yielded 35 results, and 25 articles met our inclusion criteria: 22 articles were case reports and 3 were case series including three to six patients. Overall, 37 patients were included in the study. Age was reported in all 37 patients, 26 males (70.3%) and 11 females (29.7%), with a male-to-female ratio of 2.4:1. The mean age at diagnosis was 64.6 years (range: 0.25-86 years). Only in 5 cases (13.5%) did the ICH occur contralaterally to the previously drained cSDH. The rapidity of drainage can lead to several types of intracranial hemorrhages, caused by a too rapid change in the cerebral blood flow (CBF) and/or tears of bridging veins. The average time interval between cSDH drainage and neurologic deterioration was 71.05 hours (range: 0-192 hours). RICH following cSDH represents a rare occurrence and a serious complication, associated with elevated morbidity. Careful monitoring of drain speed after cSDH evacuation surgery is recommended, and minimally invasive techniques such as twist drill craniostomy are suggested, especially for massive cSDHs.

Tricompartmental, Remote Intracerebral Hemorrhages Following Drainage of a Unilateral Chronic Subdural Hematoma: An Appraisal of the Pathogenesis

AbstractIntracerebral hemorrhage is a rare and unanticipated complication after burr hole drainage of a chronic subdural hematoma and usually occurs on the same side as the hematoma. In the absence of bleeding diathesis, iatrogenic injury or hypertension, it is commonly attributed to sudden expansion of the compressed brain, following rapid and uncontrolled removal of the subdural hematoma. Other factors like differential expansion of the various intracranial contents, abrupt changes in hemispheric balance, precipitous increase in focal cerebral blood flow, and unforeseen increase in cerebral venous pressure consequent to faulty positioning may also contribute to the pathogenesis of this complication.

Risk factors of postoperative remote intracerebral hemorrhage after craniotomy for ruptured cerebral aneurysms.

ObjectiveWe aimed to identify the relation between perioperative cerebrospinal fluid (CSF) drain through lumbar drainage (LD) and development of postoperative (POP) remote intracerebral hemorrhage (rICH) in craniotomy to treat ruptured intracranial aneurysms.MethodsWe retrospectively reviewed consecutive patients who underwent craniotomy for ruptured cerebral aneurysms at the authors’ institution between 1998 and 2004. We subsequently compared the incidence and characteristics of POP rICH between the patients who had a perioperative LD and those who did not. All statistical analyses were conducted using the software package SPSS 19.0 (SPSS Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant.ResultsWe enrolled 688 patients, of which 80 patients (11.6%) received perioperative LD, and 608 did not. LD and non-LD groups were comparable because although clinical characteristics of the two groups were significantly different considering history of hypertension, timing of surgery, and closed system negative pressure suction drain (SD) placement, none of these three variables was an independent risk factor associated with POP rICH in multivariate analysis. POP rICH incidence was significantly higher in the LD goup (12.5%) than non-LD group (0.8%) (p=0.000) in univariate analysis. LD placement was the only independent risk factor associated with the development of rICH in multivariate logistic regression analysis.ConclusionsPOP rICH incidence was significantly higher in patients who were managed with perioperative LD than in those who did not. LD insertion in craniotomy for ruptured intracranial aneurysm, should be closely monitored to address the occurrence of POP rICH.

Remote brain hemorrhage after IV thrombolysis: Role of preexisting lesions.

To test the hypothesis that remote intracerebral hemorrhages (r-ICHs) after IV thrombolysis occur in preexisting brain lesions. We prospectively collected baseline data from consecutive patients treated with IV thrombolysis for cerebral ischemia and reviewed their baseline MRI scans to identify preexisting lesions in those who developed r-ICH. We evaluated outcomes with the modified Rankin Scale (mRS) and defined good outcomes as scores of 0 to 2 or similar to the preexisting mRS score. Of 944 patients, 24 (2.5%) had r-ICH: lobar in 14, deep in 7, and both in 3. Sixteen of them (1.7% of all patients, 66.7% of those with r-ICH) were asymptomatic. Of the 41 r-ICHs found in these patients, 17 (41%) occurred within a lesion present before thrombolysis: 6 cerebral microbleeds (CMBs), 6 old and 1 recent infarct, and 4 areas of white matter hyperintensity. Patients with r-ICH were more likely to have strictly lobar CMBs (p = 0.049). They were 10 years older (p = 0.007), had a 16-mm Hg higher systolic blood pressure (p = 0.035) at baseline, and had more CMBs (p = 0.007). r-ICHs were better predicted by clinical (age, baseline systolic blood pressure) than imaging (purely lobar CMBs and having >5 CMBs) variables. r-ICHs tended to be associated with worse outcomes. We identified preexisting brain lesions in nearly half of the patients with r-ICH. All were of vascular origin, supporting the hypothesis that r-ICHs occur in preexisting brain lesions. Higher-field machines could help identifying preexisting lesions in those who developed r-ICH in an apparently normal area.

A case of remote intracerebral hemorrhage after thrombolysis

A case of remote intracerebral hemorrhage after thrombolysis

Remote Primary Intraventricular Haemorrhage in Case of a Ruptur ed MCA Aneurysm

This is the first documented case report of a simultaneous middle cerebral artery (MCA) aneurysmal subarachnoid hemorrhage (aSAH) and remote third ventricular clot. The occurrence of simultaneous subarachnoid hemorrhage and remote hypertensive intracerebral hemorrhage (ICH) is a rare occurrence and has only been reported three previous times in the literature. Intraventricular hemorrhage (IVH) post aneurysmal subarachnoid hemorrhage is common, where peri-ventricular intracerebral clot has ruptured the ependymal lining. However primary intraventricular hemorrhage (PIVH) without associated parenchymal clot is rare. Migration of blood via outlet foramina of the fourth ventricle through CSF pulsation and flow is thought to be the mechanism for this occurrence and would account for small volumes in the subacute setting. Here, we present a case of a 52-year-old woman with a CT demonstrated spontaneous middle cerebral artery (MCA) bifurcation aneurysmal subarachnoid hemorrhage and a large acute third ventricular clot spanning the foramen Monroe.

More extensive white matter hyperintensity is linked with higher risk of remote intracerebral hemorrhage after intravenous thrombolysis.

Remote intracerebral hemorrhage (rICH) is infrequent after intravenous thrombolysis (IVT) and its mechanism remains poorly understood. We aimed to assess its frequency and possible relationship with the severity of white matter hyperintensity (WMH) in patients with acute ischemic stroke. We prospectively analyzed data from consecutive patients with acute ischemic stroke with magnetic resonance imaging and IVT. WMH volume was quantitatively measured. rICH was defined as intracranial hemorrhage that appears in brain regions without visible ischemic changes on 24-h follow-up imaging. Unfavorable outcome was defined as a modified Rankin scale score of 3-6 at 3 months. Logistic regression analysis was used to determine the impact of WMH volume on hemorrhage, including rICH and local parenchymal hemorrhage, as well as clinical outcome. Of a total of 503 patients analyzed, 17 (3.4%) patients developed rICH. Logistic regression analysis indicated that patients with rICH had significantly larger whole-brain corrected WMH volume (cWMHv) than those without rICH (22.90 vs. 4.42 mL; odds ratio, 1.562/10 mL; 95% confidence interval, 1.215-2.009; P = 0.001). Not only the corrected peri-ventricular WMH volume (P = 0.001), but also the corrected deep WMH volume (P = 0.013) was associated with the occurrence of rICH. cWMHv was also independently associated with local parenchymal hemorrhage (P = 0.025). rICH was not related to unfavorable outcome (P = 0.323), whereas cWMHv (P = 0.006) was associated with unfavorable outcome. An increased occurrence rate of rICH after IVT is related to more extensive WMH, which may suggest underlying whole-brain vascular injury in patients with WMH.

Correction to: Remote Intracerebral Hemorrhage After Intravenous Thrombolysis: Results From a Multicenter Study

In the article by Prats-Sanchez et al, “Remote Intracerebral Hemorrhage After Intravenous Thrombolysis: Results From a Multicenter Study,” which published online ahead …

Incidence and Characteristics of Remote Intracerebral Hemorrhage After Endovascular Treatment of Unruptured Intracranial Aneurysms

The purpose of this study was to investigate the incidence and characteristics of remote intracerebral hemorrhage (ICH) after endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs). Between March 2007 and September 2015, 11 patients with remote ICH from a series of 2258 consecutive patients with 2597 UIAs treated via EVT were identified. Baseline demographic characteristics, medical history, radiologic imaging data, characteristics of remote ICH, and clinical outcomes were retrospectively reviewed. The characteristics of patients with remote ICH were compared with those of patients without remote ICH. All hematomas were single lesions located in the subcortical white matter as lobar-type in 9 patients (81.8%) and in the basal ganglia in 2 patients (18.2%). Events occurred mostly within 1 week and up to 3 weeks after EVT. Hematoma was located on the ipsilateral side in 8 patients (72.7%) and in the contralateral side in 3 patients (27.3%). Compared with patients without remote ICH, there were more aneurysms located on the internal carotid artery (ICA) (P=0.041), more patients treated with stents (P<0.001), more patients with hypertension (P = 0.026), and poorer clinical outcomes at discharge (P < 0.001) for patients with remote ICH. The incidence of remote ICH after EVT of UIAs was 0.46%. This event occurred mostly in patients with stents, hypertension, and UIAs on the ICA. It presented mostly as an ipsilateral lobar-type hemorrhage within 1 week after the procedure. This complication should not be neglected because of its poor clinical outcomes.

Abstract TMP37: Physicians’ Preferences in the Management of Silent Stroke: Results From a Worldwide Survey

Introduction: Patients with silent cerebral infarction (SCI) or microbleeds (MB) are at higher risk of developing a recurrent vascular event or suffering a hemorrhage as a consequence of thrombolysis or antithrombotic treatment. Additionally, the presence of occult cerebrovascular lesions on imaging may alter therapeutic or diagnostic recommendations. However, clinical guidelines are lacking. Hypothesis: We hypothesize that a wide variability in physician diagnostic and treatment preferences exist for individuals with SCI and MB. Methods: Respondents were practicing neurologists with expertise in stroke care identified from WSO, CSC, Vas-Cog and SORCan. Those who agreed to participate were sent a questionnaire which was completed online. Participants randomly received 10 cases from a pool of 20, assessing perception of risk for later stroke and treatment preferences, as well as demographic questions. Results: Among the 252 participants, 35 (13.9%) were excluded for incomplete responses. Of 217 participants included in this analysis, two thirds of participants would proceed with revascularization therapies (tPA: 40%, endovascular: 8%, combined: 22%) for a case scenario with acute global aphasia (NIHSS 6-7) and remote bilateral MB. Additionally, physicians would order an echocardiogram regardless of the location of the SCI (cortical SCI: 56%, lacunar SCI: 44%; p&gt;0.05). In a case-scenario with mild hypertension and 4 deep microbleeds presented with difficulty with balance, almost half of respondents did not recommend antiplatelet drugs or statins (40.2%), and 20% recommended both antiplatelet and statins. NOACS were the most commonly recommended antithrombotic treatment in a case-scenario with atrial fibrillation (AF), SCI, and a remote lobar intracerebral hemorrhage (46.4%), followed by aspirin (20.9%), no treatment (17.3%). Conclusion: There is a wide variability in the management of SCI and MB among stroke experts. The present study highlights the need for further research in treatment efficacy, as well as recommendations from scientific organizations to guide clinicians in the management of high risk patients with SCI and MB.

New Cerebral Microbleeds and Mechanism of Post-Thrombolysis Remote Intracerebral Hemorrhage: "Red Meets White" Revisited.

OPINION article Front. Neurol., 15 September 2015Sec. Stroke Volume 6 - 2015 | https://doi.org/10.3389/fneur.2015.00203

Abstract W P69: Remote Intracerebral Hemorrhage After Intravenous Thrombolysis in Patients With Ischemic Stroke: An Uncommon Complication With an Unfavourable Outcome

Background and purpose: Few studies have examined Remote parenchymal hemorrhage (PHr) after intravenous thrombolysis (IV-tPA). The aim of this study was to determine frequency, risk factors, associated clinical and radiological features, and prognosis in patients with PHr. Methods: This is a multicentre (n=9 hospitals) study of consecutive patients included in the SONIIA registry- monitors quality of reperfusion therapies in Catalonia-(January 2011 - August 2013). All patients were treated with IV-tPA according to the SITS-MOST criteria and had a follow-up CT within the first 36 hours. PHr, solitary or multiple (≥2), was defined as any hemorrhage detected by CT in regions without visible ischemic damage. Variables collected: Demographics; Vascular risk factors; NIHSS (admission and at 24 hours); Etiology; Previous treatments; Hypertensive episodes (≥185/105mmHg) and hyperglycemia (≥140mg/dl) during treatment and within the first 24 hours; Functional outcome (favourable when Rankin scale ≤2) and mortality at 3 months. We reviewed neuroimaging of PHr and PH, and we considered symptomatic PHr when NIHSS increased ≥4 points. Bivariate and multivariate analyses compared patients with any PHr, pure PHr (PHr without associated PH) with those without PHr/PH. Results: We studied 992 patients (age 73.7 ± 13.4 years, 52.9% of them were men). We observed 34 (3.4%) patients with PHr and 26 (2.6%) of them were pure PHr, 75 (7.5%) PH and 883 (89%) without PHr/PH. PHr distribution: 11 (32.3%) of PHr were lobar, 7 (20.5%) deep, 3 (8.8%) brainstem/cerebellum, 5 (14.7 %) multiple and 8 (23.5%) associated to a PH. PHr was symptomatic in 17 (50%) cases. We found no significant differences between groups in demographics, frequency of traditional vascular risk factors, previous treatments, baseline NIHSS and etiology. However, hypertensive episodes (p=0.031) and hyperglycemia (p=0.012) during IV-tPA were independent predictors of pure PHr. Both PHr and pure PHr had worse neurological status at 24 hours (both p&lt;0.001), worse functional outcome (p=0.003 and p=0.007) and higher mortality at 3 months (p=0.014 and p= 0.023). Conclusions: In conclusion, PHr was observed in 3.4% of patients and it was associated with a worse functional outcome and higher mortality at 3 months.

Cerebellar hemorrhage after resection of frontal meningioma. Case report

Abstract Introduction: Remote cerebellar hemorrhage is an infrequent complication, potentially harmful with an unclear etiologic mechanism. There may be incriminated multiple risk factors: arterial hypertension, use of antiplatelet medication (Aspenter), CSF aspiration or drainage associated with intracranial hypotension. Material and methods: We present a 69 year old woman with remote intracerebral hemorrhage that occurred after frontal parasagittal meningioma resection. Results: An inadequate oral hydration was responsible for decreased level of consciousness, cerebellar and parietaloccipital cortical-sub-cortical contra-lateral hemorrhages. Close monitoring of water balance and adequate hydration is related to clinical improvement and resolution of brain imaging. Conclusion: Retraction of the brain due to intracranial hypotension led to some small vessels rupture and development of remote cerebellar hemorrhage.

Remote Cerebral and Cerebellar Hemorrhage after Massive Cerebrospinal Fluid Leakage

Dural tears can occur during spinal surgery and may lead to cerebrospinal fluid (CSF) leakage which is rarely involved in remote cerebellar hemorrhage. Only a few of cases of simultaneous cerebral and cerebellar hemorrhage have been reported in the English literature. We experienced a case of multiple remote cerebral and cerebellar hemorrhages in a 63-year-old man who exhibited no significant neurologic deficits after spinal surgery. Magnetic resonance imaging (MRI) performed 4 days after the surgery showed a large amount of CSF leakage in the lumbosacral space. The patient underwent the second surgery for primary repair of the dural defect, but complained of headache after dural repair surgery. Brain MRI taken 6 days after the dural repair surgery revealed multifocal remote intracerebral and cerebellar hemorrhages in the right temporal lobe and both cerebellar hemispheres. We recommend diagnostic imaging to secure early identification and treatment of this complication in order to prevent serious neurologic deficits.

Subarachnoid Hemorrhage Due to Ruptured Posterior Cerebral Artery Aneurysm Simultaneously Associated With Multiple Remote Intracerebral Hemorrhages -Case Report-

A 61-year-old woman presented with aneurysmal subarachnoid hemorrhage (SAH) associated with multiple remote intracerebral hemorrhages (ICHs). She had undergone microsurgical neck clipping for ruptured right middle cerebral artery aneurysm and ventriculo-peritoneal shunting 16 years previously. Computed tomography revealed SAH predominantly in the basal cistern and ambient cistern, in association with multiple ICHs in the bilateral tegmentum of the brain stem and right caudate nucleus. Digital subtraction angiography revealed an aneurysm at the P(1) segment of the left posterior cerebral artery. The ruptured aneurysm was microsurgically clipped via a left subtemporal approach without complications. Simultaneous occurrence of aneurysmal SAH and multiple remote ICHs is rare. The spatial pattern of the ICHs in the present case is apparently unique.

Simultaneous Occurrence of Subarachnoid Hemorrhage Due to Ruptured Aneurysm and Remote Brainstem Hematoma -Case Report-

A 48-year-old woman presented with simultaneous aneurysmal subarachnoid hemorrhage (SAH) and remote intracerebral hemorrhage manifesting as sudden onset of severe headache, left hemiparesis, and diplopia. Emergent computed tomography revealed localized SAH in the interpeduncular cistern, and a remote brainstem hematoma in the right dorsolateral tegment. Neuroimaging found no signs of vascular anomaly in the brainstem. The aneurysm at the basilar artery and superior cerebellar artery bifurcation was successfully embolized using coils. Her postoperative neurological status was improved except for slight diplopia. The causes of this extremely rare case of simultaneous occurrence of aneurysmal SAH and remote brainstem hematoma in the dorsolateral tegment remain obscure.

Remote Postoperative Intracerebral Hemorrhage after Complex Neurosurgical Procedures. Three Case Reports and Review of the Literature

Remote Postoperative Intracerebral Hemorrhage after Complex Neurosurgical Procedures. Three Case Reports and Review of the Literature