Severe Intracerebral Hemorrhage Research Articles

Rest-activity patterns associated with delirium in patients with intracerebral hemorrhage

BackgroundDelirium is an acute cognitive disturbance frequently characterized by abnormal psychomotor activity and sleep-wake cycle disruption. However, the degree to which delirium affects activity patterns in the acute period after stroke is unclear. We aimed to examine these patterns in a cohort of patients with intracerebral hemorrhage (ICH). MethodsWe enrolled 40 patients with intracerebral hemorrhage (ICH) who had daily DSM-5-based delirium assessments. Continuous activity measurements were captured using bilateral wrist actigraphs throughout each patient's admission. Activity data were collected in 1-min intervals, with “rest” defined as periods with zero activity. We compared differences in activity based on delirium status across multiple time intervals using multivariable models adjusted for age, ICH severity, and mechanical ventilation. ResultsThere were 279 days of actigraphy monitoring, of which 199 (71%) were rated as days with delirium. In multivariable analyses, delirium was associated with 98.4 (95% CI 10.4–186.4) fewer daily minutes of rest, including 5.3% (95% CI -0.1–10.1%) fewer minutes during daytime periods (06:00–21:59) and 10.2% (95% CI 1.9–18.4%) fewer minutes during nocturnal periods (22:00–5:59), with higher levels of activity across multiple individual hourly intervals (18:00–21:00, 23:00–03:00, and 04:00–08:00). These differences were even more pronounced in hyperactive or mixed delirium, although even hypoactive delirium was associated with more activity during multiple time periods. ConclusionsPost-stroke delirium is associated with less rest and higher overall levels of activity, especially during nocturnal periods.

More severe initial manifestations and worse short-term functional outcome of intracerebral hemorrhage in the plateau than in the plain

Intracerebral hemorrhage (ICH) is one of the most devastating forms of stroke. However, studies on ICH at high altitude are insufficient. We aimed to compare the initial manifestations, imaging features and short-term functional outcomes of ICH at different altitudes, and further explore the effect of altitude on the severity and prognosis of ICH. We retrospectively recruited ICH patients from January 2018 to July 2021 from two centers at different altitudes in China. Information regarding to clinical manifestations, neuroimages, and functional outcomes at discharge were collected and analyzed. Association between altitude and initial severity, neuroimages, and short-term prognosis of ICH were also investigated. A total of 724 patients with 400 lowlanders and 324 highlanders were enrolled. Compared with patients from the plain, those at high altitude were characterized by more severe preliminary manifestations (P < 0.0001), larger hematoma volume (P < 0.001) and poorer short-term functional outcome (P < 0.0001). High altitude was independently associated with dependency at discharge (adjusted P = 0.024), in-hospital mortality (adjusted P = 0.049) and gastrointestinal hemorrhage incidence (adjusted P = 0.017). ICH patients from high altitude suffered from more serious initial manifestations and worse short-term functional outcome than lowlanders. Control of blood pressure, oxygen supplementation and inhibition of inflammation may be critical for ICH at high altitude.

Association Between Neutrophil-Lymphocyte Ratio and 30-Day Infection and Thrombotic Outcomes After Intraventricular Hemorrhage: A CLEAR III Analysis.

Serum neutrophil-lymphocyte ratio (NLR) is a surrogate marker for the inflammatory response after intracerebral hemorrhage (ICH) and is associated with perihematomal edema and long-term functional outcomes. Whether NLR is associated with short-term ICH complications is poorly understood. We hypothesized that NLR is associated with 30-day infection and thrombotic events after ICH. We performed a post hoc exploratory analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial. The study exposure was the serum NLR obtained at baseline and on days 3 and 5. The coprimary outcomes, ascertained at 30days, were any infection and a thrombotic event, defined as composite of cerebral infarction, myocardial infarction, or venous thromboembolism; both infection and thrombotic event were determined through adjudicated adverse event reporting. Binary logistic regression was used to study the relationship between NLR and outcomes, after adjustment for demographics, ICH severity and location, and treatment randomization. Among the 500 patients enrolled in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial, we included 303 (60.6%) without missing data on differential white blood cell counts at baseline. There were no differences in demographics, comorbidities, or ICH severity between patients with and without data on NLR. In adjusted logistic regression models, NLR ascertained at baseline (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.01-1.07, p = 0.03) and NLR ascertained at day 3 were associated with infection (OR 1.15; 95% CI 1.05-1.20, p = 0.001) but not with thrombotic events. Conversely, NLR at day 5 was associated with thrombotic events (OR 1.07, 95% CI 1.01-1.13, p = 0.03) but not with infection (OR 1.13; 95% CI 0.76-1.70, p = 0.56). NLR at baseline was not associated with either outcome. Serum NLR ascertained at baseline and on day 3 after randomization was associated with 30-day infection, whereas NLR obtained on day 5 was associated with thrombotic events after ICH, suggesting that NLR could be a potential early biomarker for ICH-related complications.

Determinants of First-Ever Stroke Severity in West Africans: Evidence From the SIREN Study.

Background Baseline stroke severity is probably partly responsible for poor stroke outcomes in sub-Saharan Africa. However, there is a paucity of information on determinants of stroke severity among indigenous Africans. We sought to identify the factors associated with stroke severity among West Africans in the SIREN (Stroke Investigative Research and Educational Networks) study. Methods and Results Stroke was diagnosed clinically and confirmed with brain neuroimaging. Severe stroke was defined as a Stroke Levity Scale score of ≤5. A multivariate logistic regression model was constructed to identify factors associated with stroke severity at 95% CI and a nominal cutoff of 5% type 1 error. A total of 3660 stroke cases were included. Overall, 50.7%% had severe stroke, including 47.6% of all ischemic strokes and 56.1% of intracerebral hemorrhage. Factors independently associated with severe stroke were meat consumption (adjusted odds ratio [aOR], 1.97 [95% CI, 1.43-2.73]), low vegetable consumption (aOR, 2.45 [95% CI, 1.93-3.12]), and lesion volume, with an aOR of 1.67 (95% CI, 1.03-2.72) for lesion volume of 10 to 30 cm3 and aOR of 3.88 (95% CI, 1.93-7.81) for lesion volume >30 cm3. Severe ischemic stroke was independently associated with total anterior circulation infarction (aOR, 3.1 [95% CI, 1.5-6.9]), posterior circulation infarction (aOR, 2.2 [95% CI, 1.1-4.2]), and partial anterior circulation infarction (aOR, 2.0 [95% CI, 1.2-3.3]) compared with lacunar stroke. Increasing age (aOR, 2.6 [95% CI, 1.3-5.2]) and lesion volume >30 cm3 (aOR, 6.2 [95% CI, 2.0-19.3]) were independently associated with severe intracerebral hemorrhage. Conclusions Severe stroke iscommon among indigenous West Africans, where modifiable dietary factors are independently associated with it. These factors could be targeted to reduce the burden of severe stroke.

Red Blood Cell Transfusions Are Not Associated With Incident Complications or Poor Outcomes in Patients With Intracerebral Hemorrhage.

Background Anemia is associated with poor intracerebral hemorrhage (ICH) outcomes, yet the relationship of red blood cell (RBC) transfusions to ICH complications and functional outcomes remains unclear. We investigated the impact of RBC transfusion on hospital thromboembolic and infectious complications and outcomes in patients with ICH. Methods and Results Consecutive patients with spontaneous ICH enrolled in a single-center, prospective cohort study from 2009 to 2018 were assessed. Primary analyses assessed relationships of RBC transfusions on incident thromboembolic and infectious complications occurring after the transfusion. Secondary analyses assessed relationships of RBC transfusions with mortality and poor discharge modified Rankin Scale score 4 to 6. Multivariable logistic regression models adjusted for baseline demographics and medical disease severity (Acute Physiology and Chronic Health Evaluation II), and ICH severity (ICH score).Of 587 patients with ICH analyzed, 88 (15%) received at least one RBC transfusion. Patients receiving RBC transfusions had worse medical and ICH severity. Though patients receiving RBC transfusions had more complications at any point during the hospitalization (64.8% versus 35.9%), we found no association between RBC transfusion and incident complications in our regression models (adjusted odds ratio [aOR], 0.71 [95% CI, 0.42-1.20]). After adjusting for disease severity and other relevant covariates, we found no significant association between RBC transfusion and mortality (aOR, 0.87 [95% CI, 0.45-1.66]) or poor discharge modified Rankin Scale score (aOR, 2.45 [95% CI, 0.80-7.61]). Conclusions In our cohort with ICH, RBC transfusions were expectedly given to patients with higher medical and ICH severity. Taking disease severity and timing of transfusions into account, RBC transfusion was not associated with incident hospital complications or poor clinical ICH outcomes.

Association Between Soluble Intercellular Adhesion Molecule-1 and Intracerebral Hemorrhage Outcomes in the FAST Trial.

Neutrophil-mediated inflammation in the acute phase of intracerebral hemorrhage (ICH) worsens outcome in preclinical studies. sICAM-1 (soluble intercellular adhesion molecule-1), an inducible ligand for integrins and cell-cell adhesion molecules, is critical for neutrophil extravasation. We aimed to determine whether serum levels of sICAM-1 are associated with worse outcomes after ICH. We conducted a post hoc secondary analysis of an observational cohort using data from the FAST trial (Factor-VII for Acute Hemorrhagic Stroke Treatment). The study exposure was the admission serum level of sICAM-1. The coprimary outcomes were mortality and poor outcome (modified Rankin Scale score 4-6) at 90 days. Secondary radiological outcomes were hematoma expansion at 24 hours and perihematomal edema expansion at 72 hours. We used multiple linear and logistic regression analyses to test for associations between sICAM-1 and outcomes, after adjustment for demographics, ICH severity characteristics, change in the systolic blood pressure in the first 24 hours, treatment randomization arm, and the time from symptom onset to study drug administration. Of 841 patients, we included 507 (60%) with complete data. Hematoma expansion occurred in 169 (33%), while 242 (48%) had a poor outcome. In multivariable analyses, sICAM-1 was associated with mortality (odds ratio, 1.53 per SD increase [95% CI, 1.15-2.03]) and poor outcome (odds ratio, 1.34 per SD increase [CI, 1.06-1.69]). In multivariable analyses of secondary outcomes, sICAM-1 was associated with hematoma expansion (odds ratio, 1.35 per SD increase [CI, 1.11-1.66]), but was not associated with log-transformed perihematomal edema expansion at 72 hours. In additional analyses stratified by treatment assignment, similar results were noted in the recombinant activated factor-VII arm, but not in the placebo arm. Admission serum levels of sICAM-1 were associated with mortality, poor outcome, and hematoma expansion. Given the possibility of a biological interaction between recombinant activated factor-VII and sICAM-1, these findings highlight the need to further explore the role of sICAM-1 as a potential marker of poor ICH outcomes.

Effect of COVID-19 pandemic on outcomes in intracerebral hemorrhage.

Patients with severe intracerebral hemorrhage (ICH) often suffer from impaired capacity and rely on surrogates for decision-making. Restrictions on visitors within healthcare facilities during the pandemic may have impacted care and disposition for patient with ICH. We investigated outcomes of ICH patients during the COVID-19 pandemic compared to a pre-pandemic period. We conducted a retrospective review of ICH patients from two sources: (1) University of Rochester Get With the Guidelines database and (2) the California State Inpatient Database (SID). Patients were divided into 2019-2020 pre-pandemic and 2020 pandemic groups. We compared mortality, discharge, and comfort care/hospice. Using single-center data, we compared 30-day readmissions and follow-up functional status. The single-center cohort included 230 patients (n = 122 pre-pandemic, n = 108 pandemic group), and the California SID included 17,534 patients (n = 10,537 pre-pandemic, n = 6,997 pandemic group). Inpatient mortality was no different before or during the pandemic in either cohort. Length of stay was unchanged. During the pandemic, more patients were discharged to hospice in the California SID (8.4% vs. 5.9%, p<0.001). Use of comfort care was similar before and during the pandemic in the single center data. Survivors in both datasets were more likely to be discharged home vs. facility during the pandemic. Thirty-day readmissions and follow-up functional status in the single-center cohort were similar between groups. Using a large database, we identified more ICH patients discharged to hospice during the COVID-19 pandemic and, among survivors, more patients were discharged home rather than healthcare facility discharge during the pandemic.

Antidepressant Use and Associations with Delirium in Patients with Intracerebral Hemorrhage (P5-7.003)

<h3>Objective:</h3> To explore the impact of antidepressant use on delirium and outcomes in patients with intracerebral hemorrhage (ICH). <h3>Background:</h3> Neurotransmitter dysregulation is thought to be a principal factor in the pathogenesis of delirium, but the relationship between antidepressants and delirium is unclear. <h3>Design/Methods:</h3> We performed a single-center cohort study on consecutive patients with non-traumatic ICH admitted over two years. Demographics and data related to clinical stroke care were prospectively collected, while medication data were retrospectively abstracted from patient records. Delirium was diagnosed according to DSM-5 criteria and classified as persistent or resolved at hospital discharge. We used multivariable logistic regression to determine associations between antidepressant use and incident delirium across the entire cohort, and persistent delirium and 3-month functional outcomes in patients who survived their ICH hospitalization. <h3>Results:</h3> Among 590 ICH patients in our cohort, 21.2% (n=125) had pre-morbid antidepressant use (SSRIs 63.2%, SNRIs 17.6%, trazodone 16.8%, mirtazapine 12.8%, bupropion 6.4%), while 31.4% (143/456) of ICH survivors were prescribed antidepressants at hospital discharge. Delirium occurred in 59.0% (n=348) of all patients (including 64.8% of patients with pre-morbid antidepressant use vs. 57.4% of those without antidepressant use; p=0.14), and was persistent at hospital discharge in 26.8% (59/220) of all survivors who experienced delirium (35.7% vs. 23.7%, respectively; p=0.08). In multivariable models adjusted for demographics and ICH severity, pre-morbid antidepressant use was associated with higher rates of incident delirium (OR 1.63, 95% CI 1.00–2.67; p=0.049) and similar albeit non-significantly higher rates of persistent delirium (OR 1.62, 95% CI 0.80–3.30). Among ICH survivors who developed delirium, there was no significant association between antidepressant prescription at discharge and unfavorable 3-month outcomes (OR 0.96, 95% CI 0.49–1.85). <h3>Conclusions:</h3> Pre-morbid antidepressant use may be associated with delirium in patients with stroke, potentially supporting the role of neurotransmitter dysfunction in delirium pathogenesis. Further studies are needed to confirm these findings. <b>Disclosure:</b> Ms. Zhou has received research support from The Barry Goldwater Scholarship and Excellence in Education Foundation. Seth Margolis has nothing to disclose. Lori Daiello has nothing to disclose. The institution of James Rudolph has received research support from VA. Richard Jones has received personal compensation in the range of $0-$499 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Journal of the American Geriatrics Society. Dr. Reznik has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Morrison Mahoney. The institution of Dr. Reznik has received research support from NIDUS.

Neighborhood Disadvantage and Outcomes Following Intracerebral Hemorrhage (S29.002)

<h3>Objective:</h3> We aimed to determine if neighborhood disadvantage is associated with poor outcomes following intracerebral hemorrhage (ICH). <h3>Background:</h3> Neighborhood disadvantage uniquely captures numerous social and environmental exposures. There is mounting evidence linking social determinants to various health outcomes. <h3>Design/Methods:</h3> We conducted a nested study within an ongoing longitudinal study that prospectively follows patients with brain injury within Connecticut’s largest healthcare system. The nested study included ICH survivors and evaluated neighborhood deprivation using the Area Deprivation Index (ADI), a publicly available metric that ranks neighborhoods’ disadvantage based on numerous factors. Patients were given an ADI tertile designation: low, intermediate, and high deprivation. Initial ICH severity was defined with admission GCS. Outcome was evaluated through the discharge and 6-month post-ICH Modified Rankin Scale (mRS), dichotomized as 0–3 (good outcome) and 4–6 (poor outcome). We used chi-square tests and multivariable logistic regression for unadjusted and adjusted association analyses, respectively. <h3>Results:</h3> Out of 687 enrolled ICH patients, 518 (mean age 67, 47.5% female, 19% Black, 8% Hispanic) had 9-digit zip-code and outcomes data. Neighborhood disadvantage was not associated with admission GCS (adjusted p=0.59) or discharge mRS (adjusted p=0.95). However, at 6-months post-discharge, the risk of poor outcome was 28%, 44%, and 47% for patients in neighborhoods with low, intermediate, and high disadvantage (unadjusted p=0.02). Multivariable analyses adjusting for potential confounders confirmed these results: compared to low-disadvantage neighborhoods, those living in neighborhoods with intermediate and high disadvantage had 52% (OR 1.52, 95%CI 0.76–3.08) and 89% (OR 1.89, 95%CI 0.91–3.94) higher risk of poor outcomes (test-for-trend p=0.01). <h3>Conclusions:</h3> Among ICH patients enrolled in a prospective study of acute brain injury, higher neighborhood disadvantage was associated with a higher risk of poor outcomes 6-months post-ICH but not with admission or discharge clinical status. These results suggest that the numerous factors captured by the ADI influence these subjects’ complex post-discharge evolution. <b>Disclosure:</b> Ms. Kim has nothing to disclose. Ms. Kitlen has nothing to disclose. Mr. Torres-Lopez has nothing to disclose. Dr. Rivier has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Pyxis Partners. Dr. Renedo has nothing to disclose. Ms. Schlechter has nothing to disclose. Ms. Kleinberg has nothing to disclose. Ms. Pish has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Twill Therapeutics. Mr. Kampp has nothing to disclose. Sara Jasak has nothing to disclose. Dr. Sansing has nothing to disclose. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ceribell. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Zoll. Dr. Sheth has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for NControl. Dr. Sheth has received stock or an ownership interest from Astrocyte. Dr. Sheth has received stock or an ownership interest from Alva. The institution of Dr. Sheth has received research support from Biogen. The institution of Dr. Sheth has received research support from Novartis. The institution of Dr. Sheth has received research support from Bard. The institution of Dr. Sheth has received research support from Hyperfine. Dr. Sheth has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Falcone has received research support from NIH. The institution of Dr. Falcone has received research support from AHA.

Abstract TP119: Relationships Of Female Sex With Intracerebral Hemorrhage Characteristics And Outcomes

Introduction: Biological sex is known to impact cerebrovascular disease characteristics and clinical outcomes. While in intracerebral hemorrhage (ICH) it is known that biological sex impacts ICH incidence, it is less clear whether biological sex impacts ICH outcomes. Hypothesis: Female sex will be associated with ICH characteristics and clinical outcomes. Methods: Spontaneous ICH patients enrolled into a prospective observational ICH cohort study between 2009-2020 were assessed. Patients with prior anticoagulant use and secondary etiologies of ICH were excluded from the analysis. Female sex was assessed as the primary exposure variable. Primary analyses assessed relationships of female sex with radiographic outcomes: ICH location, ICH volume, hematoma expansion (&gt;33% and/or &gt;6mL). Secondary analyses assessed relationships of female sex with clinical outcomes: poor discharge neurological outcome (modified Rankin 4-6), and poor discharge disposition (skilled nursing facility, hospice, or inpatient death). Separate multivariable regression models assessed these relationships after adjusting for relevant covariates. Results: Of 504 ICH patients analyzed, mean age was 67 (SD 14.9), 46% were female, and median baseline ICH volume was 14.6 mL (IQR 4.98-35.0). In primary analyses, female sex was not associated with ICH volume or hematoma expansion but was associated with lobar ICH location (adjusted OR 1.72, 95% CI: 1.09-2.70). In secondary analyses, female sex was not associated with poor discharge neurological outcomes (adjusted OR 1.40, 95% CI: 0.74-2.64) after adjusting for race, ICH severity, and ICH location. However, there was an association of female sex with poor discharge disposition (adjusted OR 1.91, 95% CI: 1.15-3.16) after adjusting for similar covariates. Conclusions: While there were no clear intergroup sex differences in ICH severity or neurological outcomes, female sex was associated with worse discharge disposition. Further work is required to clarify whether these disposition differences are due to disease specific complications, characteristics, or if there are other social disparities responsible for these outcome differences.

Abstract TP121: Association Between Neutrophil-lymphocyte Ratio And 30-day Infection And Thrombotic Outcomes After Intracerebral Hemorrhage: A CLEAR III Analysis

Introduction: Serum neutrophil-lymphocyte ratio (NLR) is a surrogate marker for the inflammatory response after intracerebral hemorrhage (ICH), and is associated with perihematomal edema and long-term functional outcomes. Whether NLR is associated with short-term ICH complications is poorly understood. Hypothesis: NLR is associated with 30-day infection and thrombotic events after ICH. Methods: We performed a post hoc exploratory analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. The study exposure was the serum NLR obtained at baseline, and on days 3 and 5. The co-primary outcomes, ascertained at 30 days, were any infection and a thrombotic event, defined as composite of cerebral infarction, myocardial infarction, or venous thromboembolism; both infection and thrombotic event were determined via adjudicated adverse event reporting. Binary logistic regression was used to study the relationship between NLR and outcomes, after adjustment for demographics, ICH severity and location, and treatment randomization. Results: Among the 500 patients enrolled in CLEAR III, we included 228 (45.6%) with no missing data on daily NLR in the first week. There were no differences in demographics, comorbidities, or ICH severity between patients with and without data on NLR. In adjusted logistic regression models, NLR at day 3 was associated with infection (OR, 1.2; 95% CI, 1.01-1.26), but not with thrombotic events (OR, 0.96; 95% CI, 0.85-1.10). Conversely, NLR at day 5 was associated with thrombotic events (OR, 1.2, 95% CI, 1.01-1.26), but not with infections (OR, 1.03; 95% CI, 0.94-1.14). NLR at baseline was not associated with either outcome. Conclusions: Serum NLR ascertained between days 3 and 5 was associated with 30-day infection and thrombotic events after ICH, suggesting that NLR could be a potential early biomarker for ICH-related complications.

Abstract WP125: Relationships Of Hemoglobin With Ischemic Lesions After Intracerebral Hemorrhage

Introduction: Hemoglobin concentrations and diffusion weighted imaging (DWI) lesions are separately known to be associated with poor intracerebral hemorrhage (ICH) outcomes. Though hemoglobin concentrations are related to both hypoxia and thrombosis at their extremes, it is unknown whether hemoglobin concentrations relate to DWI lesions after ICH. Methods: Spontaneous, supratentorial ICH patients with available baseline hemoglobin and hospitalized MRI data enrolled into a multicenter cohort study between 2010-2016 were analyzed. Baseline hemoglobin was assessed as both a continuous variable (g/dL) and categorical variable (&lt;11, 11 to &lt;13, 13 to &lt;15, &gt;/=15 g/dL). Primary analyses assessed relationships of baseline hemoglobin with MRI DWI lesions. Secondary analyses assessed independent relationships of hemoglobin and DWI lesions with poor 3-month outcomes (modified Rankin Scale [mRS] 4-6). Separate multivariable regression models assessed these relationships after adjusting for relevant covariates. Results: Of 917 ICH patients analyzed, the mean baseline hemoglobin was 13.8 g/dL (+/-1.9), 60% were deep ICH, and DWI lesions were identified in 27% of the cohort. In our primary analyses, increased hemoglobin, defined as a continuous variable, was associated with DWI lesions (adjusted OR 1.21, 95% CI: 1.07-1.37) after adjusting for sex, race, ICH severity, time to MRI, and blood pressure treatment change. In secondary analyses, DWI lesions were associated with poor 3-month outcomes (adjusted OR 1.83, 95% CI: 1.24-2.69) adjusting for similar covariates. We identified associations of low hemoglobin categories, when referenced to hemoglobin 13 to &lt;15 g/dL, with poor outcomes (&lt;11 g/dL: adjusted OR 1.99, 95% CI: 1.05-3.79; 11 to &lt;13 g/dL: adjusted OR 1.62, 95% CI: 1.04-2.52). Effect estimates of high hemoglobin (&gt;/=15 g/dL) with poor outcomes were smaller and imprecise (adjusted OR 1.39, 95% CI: 0.89-2.17). Conclusions: We identified novel relationships between higher baseline hemoglobin concentrations and DWI lesions in ICH patients. Further studies are required to clarify the role of hemoglobin concentrations on both cerebral small vessel disease pathophysiology and ICH outcomes.

Abstract TMP80: Sex Is Associated With Location, Severity And Outcome Of Intracerebral Hemorrhage: A Combined Analysis Of Four Landmark Studies

Background and objective: Small, single-center studies point to biological and clinical differences in women and men who sustain a spontaneous, non-traumatic intracerebral hemorrhage (ICH). Leveraging data from four landmark studies of ICH, we investigated the impact of sex on risk factors, location, severity and outcome of ICH. Design: Individual patient data meta-analysis of four studies of ICH, including three randomized clinical trials and one multi-ethnic observational study. Setting: Academic medical centers in the United States. Patients: Patients with neuroimaging confirmed ICH. Measurements: We conducted an individual patient data meta-analysis of four landmark studies of ICH: ERICH, ATACH-II, FAST and MISTIE-III. We evaluated whether sex was associated with specific risk factor profiles, hemorrhage location (deep or lobar), neuroimaging severity (hematoma volume and expansion), and poor 90-day functional outcomes (defined as a modified Rankin scale 4 to 6). Main Results: A total of 4,812 ICH patients were evaluated (mean age 62, 60% males). Men with ICH were younger, more likely to be smokers and diabetics, and less likely to be on anticoagulants (all p&lt;0.05). In multivariable analyses, male sex was associated with non-lobar location (odds ratio [OR], 1.69; 95% CI, 1.42-2.01; p&lt;0.001), larger hemorrhages (beta, 0.21; 95% CI, 0.14-0.28; p&lt;0.001) and a higher risk of hematoma expansion (OR, 1.31; 95% CI, 1.10-1.56; p=0.003). Despite the larger hemorrhage volume and higher risk of expansion, male sex was associated with a 22% lower risk of poor outcomes (OR, 0.78; 95% CI, 0.67-0.91; p=0.001). Conclusions: Men with ICH are more likely to have vascular risk factors, have larger hemorrhage volumes, and have higher risk of hemorrhage expansion. They are also more likely to have a good outcome at 90 days compared to women.

Abstract 149: Trajectories Of Patient Centred, Cognitive And Functional Outcomes In Survivors Of Severe Intracerebral And Intraventricular Hemorrhage

Objective: To describe trajectories of patient-centered, cognitive and functional outcomes and identify timepoints at which recovery plateaus after severe intracerebral and intraventricular hemorrhage (ICH/IVH). Methods: In this post-hoc analysis of CLEAR III and MISTIE III trials, all day-30 survivors were included (n=872). One-year trajectories of EuroQol 5-Dimensions (EQ5D), Visual Analog Scale (EQVAS), Mini Mental Status (MMSE), Barthel Index (BI), NIHSS and mRS were compared between patients with good (mRS0-3) vs. poor (mRS4-5) functional outcome at day-30, using mixed effects linear regression models. Results: Patients with good day-30 outcome (n=148), reported none to only moderate problems across all EQ5D dimensions. Mobility, selfcare and activity dimension mean scores improved significantly from day-30 to 180 (ß-slope, activity=-0.36, mobility=-0.25, selfcare=-0.27; all p&lt;0.001), but did not improve from day-180 to 365 (all p&gt;0.05). Contrarily, ICH/IVH survivors with poor day-30 outcome (n=724), reported extreme anxiety/depression, pain, inability to perform selfcare and usual activities at day-30, but, all mean scores improved significantly through 1-year (ß-slope for 1-year vs. day-30: mobility= -1.3; anxiety= -0.9, pain= -1.2; activities= -1.2; selfcare= -1.6; p&lt;0.001). Likewise, significant cognitive recovery occurred through 1-year in poor day-30 outcome survivors (mean day-30 MMSE,11.5; ß-slope through 1-year=8.7, p&lt;0.001), whereas good day-30 outcome survivors had peak cognitive recovery by day-180 (mean day-30 MMSE, 25; ß-slope=2.0, p&lt;0.001). Similar trajectories were noted for EQVAS and other outcomes. The gap across all domains between survivors with good versus poor day-30 outcome narrowed significantly by one-year, but mean scores remained different between the two groups. Conclusion: In addition to functional disability, severe ICH/IVH survivors have significant anxiety, depression, pain, cognitive impairment and inability to perform selfcare or usual activities in the early phase, all of which improve significantly over time. While patients with early functional recovery plateau by 6-months, those with severe disability at day-30 continue to improve across all domains through 1-year.

Abstract TMP73: Direct Valuation Of Long-Term Health State By Survivors Of Severe Intracerebral And Intraventricular Hemorrhage Using Time Trade-off Utility

Objective: To describe direct valuation of long-term health state by survivors of severe intracerebral and intraventricular hemorrhage (ICH/IVH) using time-trade off utility (TTO-U). TTO-U requires patients to choose between trading off years of their life in exchange for a hypothetical treatment that returns them to full functionality. Higher TTO-U (0-1) indicates lower desire to trade time off and thus a higher valuation of current health state. Methods: CLEAR III and MISTIE III trial survivors who recorded TTO-U at 180-days post-ictus were included. TTO-U was dichotomized into ≤0.6 versus &gt;0.6. Multivariable logistic regression assessed factors associated with TTO-U≤0.6, including clinical variables, quality of life and depression scales. Results: Among 774 CLEAR III and MISTIE III survivors at day-180, 442 (57%) reported TTO-U; 305 (69%) were self-reported, 122 (28%) by a proxy. Mean (SD) age was 58.4 (11.8) years, 41% female, 25% black, 68% white and 7% other races. Mean (SD) ICH volume was 33.5 (22.8) mL, IVH volume 9.1 (14.8) mL, 70% had deep ICH. Median (IQR) 180-day mRS was 3 (3-4) and TTO-U was 1.0 (0.7-1). TTO-U of 1.0 was reported by 269 (61%) and ≤0.6 by 110 (25%) patients. Increasing age, white race, but not sex, were associated with lower TTO-U. Proxy-based TTO-U scores were lower (mean, 0.76 vs. 0.83, p=0.03). In multivariable logistic regression, age (aOR per 10-yrs, 1.24 [1.003-1.52]), race (white vs. other races, 4.8 [1.1-21.3]), proxy-based assessment (1.81 [1.02-3.21]), new ischemic stroke (2.01 [1.1-3.7]), sepsis (6.6 [1.1-40.3]), gastrostomy (0.40 [0.21-0.77]) were associated with TTO-U≤0.6 after adjusting for ICH severity. Among EuroQol 5-dimensions, difficulty with selfcare (3.3 [1.97-5.62]), and anxiety/depression (1.72 [1.07-2.74]) were independently associated with TTO-U≤0.6. CES-Depression score (in MISTIE III only) was also associated with TTO-U≤0.6 (per 1-point, 1.05 [1.02-1.07]). Conclusion: Majority of survivors of severe ICH/IVH highly valued their long-term health state and were unwilling to trade time off despite significant disability. Race, age, hospital complications, inability to care for self and anxiety/depression at day-180 were associated with lower valuation of long-term health state.

Admission neutrophil-to-lymphocyte ratio to predict 30-day mortality in severe spontaneous basal ganglia hemorrhage.

Spontaneous intracerebral hemorrhage (ICH) usually occurs in the basal ganglia and is highly lethal and disabling. The aim of this study was to evaluate the predictors of 30-day mortality in patients with severe spontaneous basal ganglia hemorrhage. This retrospective study included patients with severe basal ganglia intracerebral hemorrhage treated in the Third Affiliated Hospital of Soochow University from 2012 to 2018. Demographic, clinical, laboratory and neuroradiological data were collected. The short-term prognosis was evaluated and divided into death within 30-days and survival over 30-days. We studied the factors affecting the prognosis of patients with severe intracerebral hemorrhage, analyzed the parameters related to neutrophil-to-lymphocyte (NLR) at admission, and evaluated the predictive effect of NLR on 30-day mortality. A total of 105 patients was included in this retrospective study. The 30-day death group had a larger hematoma, a higher probability of ventricular hemorrhage, a higher ICH score and a lower Glasgow Coma Scale (GCS) score on admission. Meanwhile, the patients in the death group had higher White blood cells (WBC) counts, neutrophil counts, NLRs and C-reactive protein (CRP) levels. The risk factors for 30-day death were related to the ICH volume, GCS score, ICH score, WBC count, neutrophil count, NLR and CRP. The univariate receiver operating characteristic (ROC) curve of the risk factors showed that the NLR had the best prediction performance. Mathematical predictive models for ICH patients showed that the model with NLR had better prediction accuracy. The NLR is expected to be a potential biomarker for predicting the prognosis of patients with severe basal ganglia hemorrhage.

Clinical Characteristics and Outcomes of Patients with Intracerebral Hemorrhage: Nonsurgical Versus Surgical Treatment.

Primary intracerebral hemorrhage (ICH) is a stroke subtype with high morbidity and mortality. Surgical treatments for ICH may be one of the beneficial modalities. There are inconsistent clinical outcomes of surgical treatments in several randomized controlled trials. This study aimed to evaluate if surgical treatment can reduce mortality in patients with ICH in a real-world setting. This was a retrospective analytical study. The inclusion criteria were consecutive adult patients aged 18 years or over admitted to neurosurgery ward due to ICH, and indicated for surgical treatment according to the 2015 guideline for the management of spontaneous ICH. The outcomes of this study included mortality, length of stay, Barthel index, Glasgow Outcome Score (GOS), and Glasgow Coma Scale (GCS). Descriptive statistics were used to execute the differences between those who underwent and did not undergo surgical treatments. Factors associated with mortality were computed by multivariate logistic regression analysis. There were 110 patients with ICH who met the study criteria. Of those, 34 (30.91%) patients underwent surgical treatment: mainly craniotomy (16 patients; 47.06%). The surgical treatment group had significantly higher proportions of large ICH of 30 mL or over (62.96% vs. 27.54%; P = 0.002) and intraventricular hemorrhage (70.59% vs. 46.05%; P = 0.023) than the nonsurgical treatment group. However, both groups had comparable outcomes in terms of mortality, length of stay, Barthel index, GOS, and GCS. The mortality rate in the surgery group was 47.06%, whereas the nonsurgery group had a mortality rate of 39.47 (P = 0.532). There were three independent factors associated with mortality, including age, GCS, and intraventricular hemorrhage. The adjusted odds ratio (95% confidence interval) of these factors was 1.06 (1.02-1.12), 5.42 (1.48-19.81), and 5.30 (1.65-17.01). Intraventricular hemorrhage was more common in the elderly than in the nonelderly group (66.00% vs. 43.33%; P = 0.022). Surgical treatment may not be beneficial in patients with severe ICH, particularly with intraventricular hemorrhage, large ICH volume, or low GCS. Elderly patients with ICH may also have high mortality if intraventricular hemorrhage is present.

A double-hit: End-stage renal disease patients suffer worse outcomes in intracerebral hemorrhage.

Intracerebral hemorrhage (ICH) carries significant morbidity and mortality. Previous single-center retrospective analysis suggests that end-stage renal disease (ESRD) is a risk factor for severe ICH and worse outcomes. This investigation aims to examine the impact of ESRD on ICH severity, complications, and outcomes using a multicenter national database. The International Classification of Disease, Ninth and Tenth Revision Clinical Modification codes were used to query the National Inpatient Sample for patients with ICH and ESRD between 2010 and 2019. Primary endpoints were the functional outcome, length of stay (LOS), and in-hospital mortality. Multivariate variable regression models and a propensity-score matched analysis were established to analyze patient outcomes associated with baseline patient characteristics. We identified 211,266 patients with ICH, and among them, 7,864 (3.77%) patients had a concurrent diagnosis of ESRD. Patients with ESRD were younger (60.85 vs. 67.64, P < 0.01) and demonstrated increased ICH severity (0.78 vs. 0.77, P < 0.01). ESRD patients experienced higher rates of sepsis (15.9% vs. 6.15%, P < 0.01), acute myocardial infarction (8.05% vs. 3.65%, P < 0.01), and cardiac arrest (5.94% vs. 2.4%, P < 0.01). In addition, ESRD predicted poor discharge disposition (odds ratio [OR]: 2.385, 95% confidence interval [CI]: 2.227-2.555, P < 0.01), longer hospital LOS (OR: 1.629, 95% CI: 1.553-1.709, P < 0.01), and in-hospital mortality (OR: 2.786, 95% CI: 2.647-2.932, P < 0.01). This study utilizes a multicenter database to analyze the effect of ESRD on ICH outcomes. ESRD is a significant predictor of poor functional outcomes, in-hospital mortality, and prolonged stay in the ICH population.

Multi-omics reveals specific host metabolism-microbiome associations in intracerebral hemorrhage.

Intracerebral hemorrhage (ICH) is the most devastating subtype of stroke, but effective prevention and treatment strategies are lacking. Recently, gut microbiome and its metabolitesis are considered to be an influencing factor of stroke. However, little is known about the effects of the gut microbiome on ICH and host metabolic activity. Therefore, we used 16S sequencing, macrogenomics sequencing and untargeted metabolomics to explore the differences in gut microbial-metabolome interactions between patients with intracerebral hemorrhage and healthy control populations. We found a significant decrease in the phylum of Firmicutes and a significant increase of Bacteroidetes in ICH patients. At the genus level, Streptococcus, Bifidobacterium, Akkermansia, and Lactobacillus were more abundant in ICH patients. Macrogenomic analysis revealed active glycosaminoglycan degradation, heme synthesis, galactose degradation, lipopolysaccharide core region synthesis, and beta-Lactam resistance in ICH patients. Serum untargeted metabolomic analysis combined with ROC curves showed that octanoylcarnitine, decanoylcarnitine, dodecanoylcarnitine, glyceric acid, pyruvic acid, aspartic acid, methylcysteine, pyroglutamic acid, 9E-tetradecenoic acid, N-Acetylneuraminic acid, and aconitic acid were the best markers for the diagnosis of ICH. Correlation analysis showed that microbiome enriched in the gut of ICH patients were significantly correlated with serum metabolites, revealing a close correlation between the gut microbiome of ICH patients and the host metabolome, and significant differences from the healthy population. microbiota-host co-metabolites including pyruvic acid and 9E-tetradecenoic acid is associated with the the National Institutes of Health Stroke Scale (NIHSS) scores. In conclusion, microbiome-related metabolites in ICH patients was associated with the severity of ICH, the microbiota-host co-metabolites may be a potential may be potential therapeutic targets.

Homocysteine and Clinical Outcomes in Intracerebral Hemorrhage Patients: Results from the China Stroke Center Alliance.

Elevated homocysteine (Hcy) levels play a detrimental role in ischemic stroke. Acute spontaneous intracerebral hemorrhage (ICH) accounts for nearly 25% of all stroke cases. However, the influence of Hcy levels and ICH severity on clinical outcomes is unclear. Data were obtained from 85,705 ICH patients enrolled in the China Stroke Center Alliance (CSCA) study, a national, hospital-based, multicenter, voluntary, quality assessment and improvement initiative performed in China. Patients were divided into high and normal Hcy groups according to their Hcy levels observed at admission. The outcome indices included severe ICH, in-hospital mortality, and a poor functional outcome at discharge. Multivariable logistic regression was used to analyze the association of different Hcy levels with outcomes. The final analysis included 55,793 ICH patients. High homocysteine (HHcy) levels had higher adjusted odds ratios for severe ICH (OR 1.09, 95% CI 1.01-1.10, P<0.0001) and a poor functional outcome at discharge (OR 1.06, 95% CI 1.01-1.10, P=0.0100) compared with normal Hcy levels. There was no significant difference between HHcy and in-hospital mortality. In the subgroup analysis, stratified by sex and history of hypertension, significant interactions were observed between HHcy and severe ICH (P for interactions was 0.0138 and 0.0120, respectively). HHcy levels exhibited greater associations for severe ICH in female patients (OR 1.07, 95% CI 1.02-1.12) and patients without hypertension (OR 1.20, 95% CI 1.09-1.33). An elevated Hcy level exhibited significant association with severe ICH on admission and a poor functional outcome at discharge. The relationship between HHcy and ICH severity on admission was more robust in female patients and patients without hypertension. Hcy might be a valuable biomarker for ICH patients to predict severity at onset and functional outcome at discharge.