Spontaneous Intracerebral Hemorrhage Patients Research Articles

Serum substance P levels and early mortality of spontaneous intracerebral haemorrhage patients

Introduction and goalSubstance P, a neuropeptide of the tachykinin family, is involved in the neuroinflammation of different diseases of the central nervous system. To our knowledge, there is no published data on the level of circulating substance P levels in the prognosis of patients with spontaneous intracerebral hemorrhage (ICH). Therefore, the objectives of this observational and prospective study were to determine whether serum substance P levels in ICH patients were associated with early mortality and whether could be used in the mortality prognostic. Material and methodsWe included patients with severe primary supratentorial ICH (defined as Glasgow Coma Scale < 9) from 6 Intensive Care Units of Spanish hospitals. We determined serum substance P levels at the time of severe ICH diagnosis, at fourth and at eighth day. Thirty-day mortality was considered the end-point study. FindingsNon-surviving (n=53) compared to surviving ICH patients (n=64) showed higher serum substance P levels at day 1 (p<0.001), day 4 (p<0.001) and day 8 (p<0.001). The area under the curve for 30-day mortality prediction by serum substance P levels was of 79% (95% CI = 70–86%; p<0.001). Kaplan–Meier analysis showed a higher 30-day mortality in patients with serum substance P levels>503 pg/mL (Hazard ratio=14.7; 95% CI=6.88–31.55; p<0.001). Multiple logistic regression analysis showed an association between serum substance P levels and 30-day mortality (Odds Ratio=1.006; 95% CI=1.002–1.010; p=0.004) controlling for ICH score, midline shift, glycemia, early evacuation of ICH. ConclusionsThus, the novel aspects our study include that serum substance P levels in severe primary ICH patients were higher in non-surviving than in surviving patients, that serum substance P levels were associated with early mortality controlling for other variables, and that serum substance P levels could be used as biomarkers of prognosis.

Respiratory and Blood Stream Infections are Associated with Subsequent Venous Thromboembolism After Primary Intracerebral Hemorrhage.

BackgroundInfection and venous thromboembolism (VTE) are associated with worse outcomes after intracerebral hemorrhage (ICH). The relationship between infection and VTE in ICH patients is unclear. We hypothesized that infection would be associated with subsequent VTE after ICH.MethodsWe retrospectively studied consecutively admitted spontaneous primary ICH patients from 2009 to 2018 surviving beyond 24 h. The primary predictor variable was infection, diagnosed prior to VTE. The primary outcome was VTE. We used multivariable logistic regression models to estimate the odds ratios and 95% confidence intervals (OR, 95% CI) for VTE risk after infection of any type, after adjusting for ICH score, length of stay and days to deep venous thrombosis (DVT) prophylaxis. Similar analysis was done to estimate the association of infection subtypes, including respiratory and urinary and blood stream infections (BSI) with VTE.ResultsThere were 414 patients (mean age 65 years, 47% female) that met were analyzed. Infection was diagnosed in 181 (44%) patients. Incident VTE was diagnosed in 36 (9%) patients, largely comprised of DVT (n = 32; 89%). Infection overall was associated with increased risk of subsequent VTE (adjusted OR 4.5, 95% CI 1.6–12.6). Respiratory (adjusted OR 5.7, 95% CI 2.8–11.7) and BSI (adjusted OR 4.0, 95% CI 1.3–11.0) were associated with future VTE. Urinary and other infections were not associated with subsequent VTE.ConclusionsInfections are associated with subsequent risk of VTE among patients with ICH. Further investigation is required to elucidate mechanisms behind this association and to improve VTE prevention after ICH.

Outcome Comparison Between Surgically Treated Brain Arteriovenous Malformation Hemorrhage and Spontaneous Intracerebral Hemorrhage

Case fatality and poor outcome ratesare different between brain arteriovenous malformation-associated intracerebral hemorrhage (bAVM-ICH) and spontaneous intracerebral hemorrhage (SICH). These outcome rates, however, have never been compared in patients who need neurosurgical evacuation of the intracerebral hemorrhage (ICH). To compare the short- and long-term functional outcome between surgically treated patients with bAVM-ICH and SICH. We collected data from surgically treated ICH patients at the Department of Neurosurgery, University Hospital Zurich, from January 2015 to July 2018. We performed logistic regression analysis to compare the functional outcome between groups, adjusting for demographics, admission characteristics, and stroke risk factors. A total of 26 bAVM-ICH and 115 SICH patients were included in the final analysis. Patients with bAVM-ICH were younger and less likely to have hypertension without significant differences in ICH volume, hematoma location, intraventricular hemorrhage, and other stroke risk factors. A significantly better functional outcome rate was seen in bAVM-ICH patients at short- and long-term follow-up. These differences remained significant after adjusting for confounders. patients with a bAVM who need surgical evacuation of an ICH have a more favorable outcome than surgically treated patients with spontaneous ICH, even after correction for confounding factors, such as younger age and less premorbid hypertension.

Abstract WMP108: ABO Compatible Platelet Transfusion After Intracerebral Hemorrhage is Associated With Better Platelet Recovery and Outcomes Than Incompatible Transfusions

Introduction: There is conflicting evidence of the risks and benefits of platelet transfusions after intracerebral hemorrhage (ICH). Current practice does not necessitate the transfusion of ABO matched platelets despite evidence that platelet recovery is suboptimal in patients receiving ABO incompatible platelet transfusions. Hypothesis: We hypothesize that ICH patients receiving compatible platelet transfusions after ICH have better platelet recovery and outcomes compared to those receiving incompatible platelets. Methods: We conducted single-center, prospective cohort study of consecutive ICH patients admitted to a tertiary-referral academic medical center between 2009 and 2016. Spontaneous ICH patients who received 1 platelet transfusion within 24 hours after presentation were analyzed. Subjects were excluded if they had more than 1 platelet transfusion or non-medication related coagulopathy. Linear regression was used to evaluate the association of incompatible platelet transfusions with absolute count increment ([ACI], a continuous measure of platelet change after transfusion), adjusting for time between CBCs. Additional logistic regression analysis was performed to explore associations of ABO incompatible platelet transfusions with clinical outcomes: discharge mortality, poor modified Rankin Scale (mRS 4-6) at discharge and 3 months, after adjusting for ICH score, sex, and race. Results: Of the 135 patients studied, 62% received ABO compatible platelets and 38% incompatible platelet transfusions after ICH. Patients who received incompatible platelets had lower ACI than those who received compatible platelets (median -1 vs 15; standardized Beta=0.181, p=0.042). There was an association between incompatible transfusions and increased odds of discharge mortality (adjusted OR 4.208 [95%CI 1.478-11.985]; p=0.007). Conclusions: The majority of patients received ABO incompatible platelet transfusions, and these patients had worse platelet count recovery, higher mortality, and worse neurologic outcomes at discharge compared to those that received ABO compatible transfusions. Our findings warrant investigation into the impact of ABO compatibility in platelet transfusions and clinical outcomes after ICH.

Abstract TP330: Proportion of Intracerebral Haemorrhage Due to Cerebral Amyloid Angiopathy in the East and West

Objectives: We investigated whether the proportion of intracerebral haemorrhage (ICH) due to cerebral amyloid angiopathy (CAA) differs between patients of Eastern and Western origin. Methods: This is a retrospective international cross-sectional study of consecutive first-ever spontaneous ICH patients (including patients with surgical intervention) admitted to one stroke centre in the United Kingdom (Western centre origin) and one in Japan (Eastern centre origin) during the same period. We classified spontaneous ICH into “CAA-related ICH” defined by the Edinburgh CT diagnostic criteria, and “other ICH”. We used multivariable logistic regression analyses to assess the relationship between CAA-ICH and geographical location (Western or Eastern centre origin) or ethnicity (Western [reference], East Asian, or other) with adjustment for confounders. Results: Of 334 patients (median age, 71 years; male, 54%; Western centre origin, 58%), 15% were classified as CAA-ICH, and 85% were defined as other ICH. In multivariable logistic regression analysis, Eastern centre and ethnicity had a lower proportion of CAA-ICH (odds ratio [OR] vs Western centre origin 0.47, 95%CI 0.23-0.98; OR [vs. white] 0.41, 95%CI 0.20-0.97, respectively).The estimated incidence of CAA-related ICH in East Asian was similar to that in White populations, but the rate of other ICH was 2.5-fold higher in East Asian populations. Sensitivity analyses using the modified Boston criteria for diagnosis of CAA-related ICH showed similar results. Conclusions: The proportion CAA-ICH is lower in an Eastern compared to a Western population; this appears to be explained by a higher incidence of ICH due to hypertensive (deep perforator) arteriopathy in East Asian populations.

Ischemic Stroke and Bleeding: Clinical Benefit of Anticoagulation in Atrial Fibrillation After Intracerebral Hemorrhage.

Background and Purpose- Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF) are at risk for ischemic events. While risk calculators (CHA2DS2-VASc and HAS-BLED) have been validated to assess risk for ischemic stroke and major bleeding in AF patients, decisions about anticoagulation must consider the net clinical benefit of anticoagulation. Furthermore, stroke and bleeding risk are highly correlated, making decisions more difficult. Methods- We examined patients in the GERFHS III study (Genetic and Environmental Risk Factors for Hemorrhagic Stroke)-a population-based retrospective study of spontaneous ICH patients without a structural or traumatic cause in the Greater Cincinnati/Northern Kentucky region between July 2008 and December 2012. CHA2DS2-VASc and HAS-B(L)ED (minus L because labile international normalized ratio was unavailable) scores were calculated for ICH patients with AF. Using a Markov state transition model, we estimated net clinical benefit of anticoagulation relative to no treatment in quality-adjusted life years (QALYs). We defined minimal clinically relevant benefit as 0.1 QALYs. Results- Among 1186 cases of spontaneous ICH, 95 cases had AF and met our survival criteria. Within 1 year, 8 of 95 (8%) would be expected to have a major bleeding event on anticoagulation, and 5 of 95 (5%) of patients would be expected to have an ischemic stroke off anticoagulation. Sixty-eight of 95 (71%) patients would have higher risk for major bleeding than for ischemic stroke. Anticoagulation with directly acting anticoagulants would result in no clinically significant gain or loss in 73%. Roughly 12% would gain >0.1 QALYs, and 15% would lose >0.1 QALYs. Among patients receiving aspirin, most have no significant net clinical benefit or loss. Overall, anticoagulation of the entire cohort would result in an aggregate loss of 0.92 QALYs. Conclusions- Our analysis suggests that universal anticoagulation after ICH would be associated with a net loss of QALY. Additional factors should be considered before anticoagulating patients with AF after ICH. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00930280.

Hematoma Hounsfield units and expansion of intracerebral hemorrhage: A potential marker of hemostatic clot contraction.

Clot contraction reinforces hemostasis by providing an impermeable barrier and contractile force. Since computed tomography attenuation of intracerebral hemorrhage is largely determined by the density of red blood cells, clot contraction can be reflected in an increase of Hounsfield unit (HU) of hematoma. We hypothesized that hematoma expansion is inversely associated with mean HU of intracerebral hemorrhage at presentation. Eighty-nine consecutive spontaneous intracerebral hemorrhage patients with onset to first computed tomography within 24 h were included. Hematomas were segmented using semiautomated planimetry to measure the volume and mean HU. Hematoma expansion was defined as an increase in hematoma volume by over 33% or 6 mL. Multivariable logistic regression was performed for hematoma expansion. The discrimination power of mean HU for hematoma expansion was assessed using C-statistic. The computed tomography attenuation of hematoma at presentation was 57.5 ± 3.3 HU and the volume was 16.9 ± 23.2 mL. Hematoma expansion occurred in 37.1% of patients. The computed tomography attenuation of hematoma was lower in patients with hematoma expansion than with no expansion (55.7 ± 2.9 HU vs. 58.6 ± 3.1 HU, p-value < 0.01). Multivariable logistic regression revealed that the mean HU of hematoma was inversely associated with hematoma expansion (adjusted odds ratio, 0.64; 95% confidence interval, 0.51-0.80). The C-statistic of the model with four known predictors increased from 0.66 to 0.84 after incorporating mean HU (p-value < 0.01). Intracerebral hemorrhage with lower mean HU of hematoma at presentation is more likely to undergo hematoma expansion. This finding suggests the potential presence of clot contraction process that reinforces hemostasis in intracerebral hemorrhage.

Correlation of Glasgow outcome scale (GOS) and Haematoma Volume during Surgical and Conservative Management of Spontaneous Supratentorial Intracerebral Hemorrhage Patients

Background: Haematoma volume is an important issue for the management of spontaneous supratentorial intracerebral hemorrhage patients.&#x0D; Objective: The purpose of the present study was to correlate the Glasgow outcome scale (GOS) and haematoma volume during surgical and conservative management of spontaneous supratentorial intracerebral hemorrhage patients.&#x0D; Methodology: This randomized control trial which was conducted in the Department of Neurosurgery at Dhaka Medical College and Hospital from January 2010 to October 2011 for a period of one year and ten months. All hypertensive patients with spontaneous supratentorial intracerebral hemorrhage who were admitted within 48 hours of stroke in Neurosurgery Department during the study period were considered as a study population. Patients underwent surgery was considered as group I and patients those who did not give the consent for operation were treated conservatively was considered as group II. Surgery and conservative groups were matched in age, GCS, GOS, hematoma location and volume of hematoma.&#x0D; Result: A total of 31 patients were enrolled in this study of which 14 patients underwent surgical evacuation and 17 cases were selected for conservative therapy. Significant negative correlation was found between GCS on admission with hematoma volume in surgery group (r=-0.631; P=0.016) and conservative group (r=- 0.854; p=0.001). A negative but not significant correlation (r=-0.426; P=0.129) between GOS with hematoma volume in group I, where negative significant correlation (r=-0.503; P=0.039) in conservative group II.&#x0D; Conclusion: In conclusion Glasgow outcome scale (GOS) is positively correlated with the haematoma volume during surgical and conservative management of spontaneous supratentorial intracerebral hemorrhage patients&#x0D; Journal of Science Foundation 2019;17(1):9-14

Association Between Eosinophilic Leukocyte Count and Hematoma Expansion in Acute Spontaneous Intracerebral Hemorrhage.

Background/Objective: Hematoma expansion (HE) predicts poor outcome and is an appealing treatment target in spontaneous intracerebral hemorrhage (ICH). Clinical evidence has shown an association of HE with peripheral white blood cells (WBC) count, but the individual contributions of leukocyte subtypes between literatures are described inconsistently. Our aim was to determine the relationship between admission absolute and differential leukocyte counts and HE by using different growth definitions.Methods: We analyzed spontaneous ICH patients who underwent baseline cranial computed tomography and blood sampling within 6 h of stroke onset in our institution between September 2013 and August 2018. Hematoma volume was calculated using a semiautomated 3-dimensional reconstruction algorithm. According to commonly used absolute or relative growth definitions (>6 mL, >12.5 mL, or >33%), we defined 5 types of HE. A propensity score-matching analysis was performed to evaluate the influence of complete blood count components on HE across the various growth definitions. The receiver operating characteristic analysis assessed the predictive ability of leukocyte counts for HE.Results: A total of 1,066 patients were included, of whom 11–21% met the 5 HE definitions. After propensity score-matching, except using the definition of >12.5 mL growth or its combination with >33% growth, both WBC and neutrophil count were independently associated with reduced risk of HE (odds ratio [OR] for 103 cells increase; OR, 0.86–0.99; all p < 0.05) after adjusting confounders in multivariate analyses. However, monocyte count was correlated with increased risk of HE under the usage of >12.5 mL expansion definition only (OR, 1.43; p = 0.024). There was no association between lymphocyte count and HE (all p > 0.05). Regardless of the growth definition, admission eosinophil count was directly associated with the risk of HE (OR, 6.92–31.60; all p < 0.05), and was the best predictive subtype with area under the curve 0.64, sensitivity 69.5%, and specificity 58.9% at the optimal cut-off value of 45 cells/μL.Conclusions: Growth definition affects the relationship of HE with leukocyte subtypes counting. Eosinophil count robustly predicts HE, and may be a surrogate when using an inflammatory marker to help select acute ICH patients with high expansion risk for hemostasis treatment in clinical trial and practice.

High Serum Tissue Inhibitor of Matrix Metalloproteinase-1 Levels and Mortality in Patients with Spontaneous Intracerebral Hemorrhage

Matrix metalloproteinase (MMP)-9, a member of the endoproteinase family, is involved in the neuroinflammation of spontaneous intracerebral hemorrhage (SIH). High circulating MMP-9 levels have been associated with poor functional outcome in patients with SIH. The objectives of this study were to determine whether serum MMP-9 and tissue inhibitor of matrix metalloproteinases (TIMP)-1 levels in SIH patients were higher in nonsurviving than surviving patients, if they were associated with early mortality, and if they could be used as biomarkers of prognosis. This observational prospective study included patients with severe supratentorial SIH (defined as Glasgow Coma Scale <9) from 6 Spanish Intensive Care Units. Serum MMP-9 and TIMP-1 levels were determined at the time of severe SIH diagnosis. Thirty-day mortality was the endpoint study. Nonsurviving patients (n= 46) showed higher serum TIMP-1 (P < 0.001) and MMP-9 levels (P= 0.01) than surviving patients (n= 54). The area under the curve by serum TIMP-1 levels for the prediction of 30-day mortality was 74% (95% confidence interval= 64%-82%; P<0.001). Multiple logistic regression analysis showed an association between serum TIMP-1 levels >223 ng/mL and 30-day mortality (odds ratio= 13.993; 95% confidence interval= 2.864-68.356; P= 0.001) after controlling for intracerebral hemorrhage score, glycemia, midline shift, and early evacuation of SIH. There was an association between circulating levels of TIMP-1 and MMP-9 (rho=0.25; P= 0.01). The novel aspects our study include that serum TIMP-1 and MMP-9 levels in SIH patients were higher in nonsurviving than in surviving patients and that serum TIMP-1 levels were associated with early mortality and could be used as biomarkers for predicting mortality.

Early elevated neutrophil-to-lymphocyte ratio associated with remote diffusion-weighted imaging lesions in acute intracerebral hemorrhage.

AimsTo explore the relationship between the circulating neutrophil‐to‐lymphocyte ratio (NLR) and the remote diffusion‐weighted imaging lesions (R‐DWILs) after spontaneous intracerebral hemorrhage (ICH).MethodsConsecutive patients with spontaneous ICH were prospectively collected from November 2016 to May 2018 and retrospectively analyzed. We included subjects who presented within 24 hours after symptom onset and were free of detectable infections on admission or in hospital. Blood samples were obtained at 24‐48 hours after ICH ictus, while all complete MRI scans were performed at 5‐8 days. R‐DWILs were defined as focal hyperintensities remote from the site of the ICH or the peri‐hematoma regions. NLR was calculated by dividing the absolute neutrophil counts by the absolute lymphocyte counts. Multivariate binary logistic regression models were generated to evaluate the relationship between NLR and R‐DWILs.ResultsOne hundred sixty‐three subjects met eligibility criteria (age 62.3 ± 13.6 years, 60.7% males), of whom 31(19.0%) experienced R‐DWILs. Higher circulating NLR was documented in patients with R‐DWILs. With the best cutoff value of 6.01, elevated NLR was independently associated with the presence of R‐DWILs (OR = 3.170, 95% CI 1.306‐7.697, P = .011) in the bivariate logistic regression analysis with adjustment for age, sex, atrial fibrillation, previous ischemic stroke/TIA, SBP on admission, hematoma volume, and IVH.ConclusionsThis study provides significant evidence of the association between circulating NLR and R‐DWILs in spontaneous ICH patients. Patients with NLR > 6.01 at 24‐48 hours after ICH ictus should be paid more attention to when evaluating R‐DWILs.

Research progress in perioperative blood pressure management and its effect on myocardial injury in patients with spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (SICH) is the most common and life-threatening stroke. Post-stroke cardiovascular events are one of the common causes of death, which seriously affects the survival and prognosis of patients. This article summarizes the current clinical treatment of SICH patients and possible causes of perioperative myocardial injury, so as to avoid further myocardial damage during diagnosis and treatment. This article will review the research progress in SICH etiology, clinical diagnosis, causes of myocardial injury, prevention and treatment. Perioperative blood pressure management during diagnosis and treatment will be discussed, which provides new thoughts to avoid further myocardial injury and improvel prognosis. Key words: Spontaneous intracerebral hemorrhage; Perioperative; Blood pressure; Myocardial injury

The Serum Melatonin Levels and Mortality of Patients with Spontaneous Intracerebral Hemorrhage.

Objective: Providing melatonin in animal models with spontaneous intracerebral hemorrhage (SIH) has been associated with beneficial effects. However, to our knowledge, there are no published data on circulating melatonin levels regarding the prognosis of SIH patients. Therefore, the objectives of this study were to determine whether serum melatonin levels in SIH patients were associated with early mortality and whether they could be used as prognostic biomarkers. Methods: This observational and prospective study included patients with supratentorial and clinically severe SIH (defined as Glasgow Coma Scale GCS <9) admitted to the Intensive Care Units of six Spanish hospitals. Serum melatonin levels were determined at the time of severe SIH diagnosis. Mortality at 30 days was the study end-point. Results: Non-surviving patients (n = 46) showed higher serum melatonin levels (p < 0.001) than surviving (n = 54) patients. An area under the curve was found for the prediction of 30-day mortality by serum melatonin levels of 0.89 (95% CI = 0.81–0.94; p < 0.001). Multiple logistic regression analysis showed an association of serum melatonin levels with 30-day mortality (Odds Ratio = 8.16; 95% CI = 2.30–28.95; p = 0.001) after controlling for midline shift, glycemia, early evacuation of SIH, and Intracerebral hemorrhage (ICH) score. Conclusions: The novel findings by our study were the presence of higher serum melatonin levels in non-surviving patients than in surviving patients and the association of these levels with mortality.

Prior Antiplatelet Therapy, Excluding Phosphodiesterase Inhibitor Is Associated with Poor Outcome in Patients with Spontaneous Intracerebral Haemorrhage.

There is conflicting results on whether prior antiplatelet therapy (APT) is associated with poor outcome in spontaneous intracerebral haemorrhage (ICH) patients. To determine whether prior APT is associated with spontaneous ICH, and whether there is a difference between the different types of APT, including cyclooxygenase inhibitor (COX-I), adenosine diphosphate receptor inhibitor (ADP-I) and phosphodiesterase inhibitor (PDE-I). A retrospective study of patients with ICH diagnosed between 2001 and 2013 in the National Health Insurance Research Database. Baseline unbalance between APT and non-APT groups was solved by multivariable adjustment (primary analysis) and propensity score matching (sensitivity analysis). Patients with prior APT had a higher rate of in-hospital death (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.09-1.23) compared to non-APT group. Compared to non-APT group, there was a greater rate of in-hospital death with spontaneous ICH with ADP-I (OR, 1.49; 95% CI, 1.24-1.79) and COX-I (OR, 1.17; 95% CI, 1.09-1.25). PDE-I exhibited no difference in in-hospital death with spontaneous ICH (OR, 1.03; 95% CI, 0.91-1.16) compared to non-APT group. Remarkably, the in-hospital mortality rate was significantly higher in the ADP-I group than in the PDE-I group (hazard ratio, 1.45; 95% CI, 1.17-1.80). In this study, ADP-I and COX-1, but not PDE-I, are the most likely contributors to the association of APT with poor outcome with spontaneous ICH patients. These findings suggest that the complexity of the different mechanism of actions of prior APT can alter the outcome in spontaneous ICH.

Enlarged Perivascular Spaces and Cerebral Small Vessel Disease in Spontaneous Intracerebral Hemorrhage Patients.

Background: Cerebral small vessel disease (SVD) is associated with cognitive decline, depression, increased mortality, and disability in stroke patients. MRI-visible perivascular spaces (PVS) are a sensitive neuroimaging marker of SVD. We aimed to explore the risk factors and associations with other SVD markers of PVS in two topographical regions (in the basal ganglia [BG] and centrum semiovale [CS]) in a cohort of spontaneous intracerebral hemorrhage (ICH) patients.Method: We included 306 consecutive patients from a prospective spontaneous ICH cohort. We rated PVS, white matter hyperintensities (WMH), cerebral microbleeds (CMB), and lacunes with validated visual rating scale. We collected clinical information using standardized forms. We predefined severe PVS as score > 2 and examined associations between PVS in both BG and CS regions and clinical and imaging markers of SVD by logistic regression.Results: In the multivariable logistic regression, increasing age (OR = 1.075; 95% CI = 1.038–1.113, p < 0.001), high CS PVS degrees (OR = 6.906; 95% CI = 3.024–15.774, p < 0.001), extensive periventricular WMH (OR = 2.878; 95% CI = 1.298–6.379, p = 0.009), and the presence of CMB (OR = 4.073, 95% CI = 1.869–8.877, p < 0.001) were independently associated with BG PVS severity. Alcohol-drinking habit (OR = 2.805; 95% CI = 1.451–5.422, p = 0.002), hyperlipidemia history (OR = 3.782; 95% CI = 1.582–8.783, p = 0.003), high BG PVS degrees (OR = 6.293; 95% CI = 2.755–14.371, p < 0.001) and the presence of strictly lobar CMB (OR = 2.556, 95% CI = 1.285–5.085, p = 0.008) were independent predictors of increased CS PVS severity.Conclusion: MRI-visible PVS in BG and CS regions are inter-related and have different risk factors in spontaneous ICH patients. Further studies are needed to explore the mechanism and clinical importance of PVS, with possible implications for cerebrovascular disease prevention and effective treatments.

Minimal Computed Tomography Attenuation Value Within the Hematoma is Associated with Hematoma Expansion and Poor Outcome in Intracerebral Hemorrhage Patients.

Early hematoma expansion in intracerebral hemorrhage (ICH) patients is associated with poor outcome. We aimed to investigate whether the minimal computed tomography (CT) attenuation value predicted hematoma expansion and poor outcome. This study involved spontaneous ICH patients of two cohorts who underwent baseline CT scan within 6h after ICH onset and follow-up CT scan within 24h after initial CT scan. We determined the critical value of the minimal CT attenuation value via retrospective analysis of the data from a derivation cohort. Then, a prospective study on the validation cohort of three clinical centers was performed for determining the association between the minimal CT attenuation value and hematoma expansion as well as poor outcome (modified Rankin Scale scores > 3) at 90days by using univariate and multivariate logistic regression analyses. One hundred and forty eight ICH patients were included in the derivation cohort. Minimal CT attenuation value ≤ 31 Hounsfield units (HU) was demonstrated as the critical value to predict hematoma expansion by using receiver operating characteristic analysis. A total of 311 ICH patients were enrolled in the validation cohort, 86 (27.7%) and 133 (42.8%) of which were found hematoma expansion and poor outcome. Minimal CT attenuation value ≤ 31 HU was positive in 73 patients (23.5%). The multivariate logistic regression analysis demonstrated minimal CT attenuation value and minimal CT attenuation value ≤ 31 HU independently predicted hematoma expansion (p < 0.001) and poor outcome (p < 0.001). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of minimal CT attenuation value ≤ 31 HU for hematoma expansion and poor outcome prediction were 64.0, 92.0, 75.3, 87.0, 84.2 and 45.1%, 92.7%, 82.2%, 69.3%, 72.3%, respectively. The minimal CT attenuation value independently predicts early hematoma expansion and poor outcome in patients with ICH.

Blood Pressure Variability Predicts Poor In-Hospital Outcome in Spontaneous Intracerebral Hemorrhage.

Background and Purpose- There is increasing evidence that higher systolic blood pressure variability (SBPV) may be associated with poor outcome in patients with intracerebral hemorrhage (ICH). We explored the association between SBPV and in-hospital ICH outcome. Methods- We collected 10-years of consecutive data of spontaneous ICH patients at 2 healthcare systems. Demographics, medical history, laboratory tests, computed tomography scan data, in-hospital treatments, and neurological and functional assessments were recorded. Blood pressure recordings were extracted up to 24 hours postadmission. SBPV was measured using SD, coefficient of variation, successive variation (SV), range and 1 novel index termed functional SV. The effects of SBPV on the functional outcome at discharge were evaluated by multivariate logistic and ordinal regression analyses for dichotomous and trichotomous modified Rankin Scale categorizations, respectively. In secondary analyses, associations between SBPV, history of hypertension, and hematoma expansion were explored. Results- The analysis included 762 subjects. All 5 SBPV indices were significantly associated with the probability of unfavorable outcome (modified Rankin Scale score, 4-6) in logistic models. In ordinal models, SD, coefficient of variation, range, and functional SV were found to have a significant effect on the probabilities of poor (modified Rankin Scale score, 3-4) and severe/death (modified Rankin Scale score, 5-6) outcomes. Normotensive patients had significantly lower mean SBPV compared with the untreated-hypertension cohort for all SBPV indices and compared with treated-hypertension patients for 3 out of 5 SBPV indices. Lower mean SBPV of treated-hypertension subjects compared with untreated-hypertension subjects was only detected in the SV and functional SV indices (P=0.045). None of the SBPV indices were significantly associated with the probability of hematoma expansion. Conclusions- Higher SBPV in the first 24 hours of admission was associated with unfavorable in-hospital outcome among ICH patients. Further prospective studies are warranted to understand any cause-effect relationship and whether controlling for SBPV may improve the ICH outcome.

Use of the Bispectral Index to Predict Recovery of Consciousness in Patients with Spontaneous Intracerebral Hemorrhage After Surgical Hematoma Evacuation: A Prospective Cohort Study.

BackgroundOur study aimed to test the predictive value of the bispectral index (BIS) for the post-operational consciousness recovery in patients undergone hematoma evacuation due to spontaneous intracerebral hemorrhage (ICH).Material/MethodsIn this prospective cohort study, we enrolled adult spontaneous ICH patients after surgical hematoma evacuation who did not recover consciousness on the first postoperative day. After patient enrollment, the BIS was continuously monitored for 12 hours, and the motor response on the Glasgow Coma Scale (GCS-M) was evaluated. The patients were followed up for 30 days and divided into a consciousness recovery group and a nonrecovery group. Receiver operating characteristic curve analysis was performed to investigate the predictive values of the BIS, GCS-M and ICH score on the consciousness recovery. The area under the curve (AUC) and 95% confidence interval (95%CI) were calculated. During the 12-hour monitoring period, the peak BIS value after GCS-M stimulation was used for ROC analysis.ResultsOf the 55 enrolled patients, 19 patients recovered consciousness, and 36 patients did not. The BIS value of the consciousness recovery group was significantly higher than that of the nonrecovery group (P<0.001). For consciousness recovery prediction, the AUC (95%CI) of the BIS values after external stimulation was 0.97 (0.91–1.00), which was superior to the GCS-M (0.75 [0.59–0.91]) and ICH score (0.57 [0.41–0.73]).ConclusionsOur study demonstrates that BIS might be a potential tool for predicting the consciousness recovery in ICH patients undergone surgical hematoma evacuation.

Electrocardiographic Changes after Spontaneous Intracerebral Hemorrhage

Abstract Introduction Electrocardiographic (ECG) changes after ischemic stroke are well documented. However, ECG changes after spontaneous intracerebral hemorrhage (SICH) have been infrequently studied. In many cases, changes occur due to neurogenic causes and may be misinterpreted as primary cardiac events. Aims This study was undertaken to study ECG changes after SICH. Materials and Method This study included all SICH patients admitted over 1 year. Patients with intraventricular and subarachnoid hemorrhage without cerebral bleed were excluded, and those with a doubtful history of head injury were also excluded. Management was guided as per standard protocol. All patients were monitored in neurosurgical intensive care unit (ICU). ECG changes were noted and analyzed. Results Total 47 SICH patients were admitted over 1 year; 0.66% patients were found to have one or more ECG abnormalities at time of admission. A prolonged QTc interval was the most common finding (39%), followed by sinus tachycardia or bradycardia and ST-segment changes. All patients with brainstem or intraventricular bleed had changes in ECG, whereas 62% had basal ganglia (BG) bleed, 43% thalamic bleed, and 57% had cortical bleeds had ECG changes, and 0.13% of patients had concomitant echocardiographic (ECHO) changes also. The most common change in BG lesion was T inversion as well as QTc prolongation in thalamic lesions. An equal percentage of males and females had ECG changes; however, 80% of all patients were males. All patients younger than 40 years had changes on ECG, and 75% of patients in the age group of 61 to 70 were found to have changes on ECG. In one patient with intraventricular hemorrhagic, global hypokinesia was reversed after insertion of ventricular drain and normalization of intracranial pressure (ICP). Although the management of the cardiac events may remain the same, in cases in which the primary cause is neurogenic, treating this cause or lowering ICP may help in reverting ECG changes. Conclusion ECG changes occurring after SICH need to be cautiously interpreted, as the primary cause may be neurogenic and subsequent treatment would require lowering of ICP either surgically or medically.

Abstract WP448: Safety of Heparin for Prophylaxis of Venous Thromboembolism in Oral Anticoagulation-Associated Intracerebral Hemorrhage

Introduction: Patients with intracerebral hemorrhage (ICH) have a high risk of venous thromboembolism (VTE). Next to intermittent pneumatic compressions low-dose subcutaneous heparins represent the most intuitive treatment for VTE prophylaxis. However, in the specific setting of ICH their safety remains to be verified as randomized controlled trials are missing. The present study pooled individual data of patients with spontaneous primary ICH and OAC-ICH to explore the incidence of hemorrhagic complications during hospital stay among subgroups treated with heparins for VTE prophylaxis. Methods: We integrated both parts of the RETRACE-program (part-1: 2006-2010; part-2:2011-2015) and the single-center UKER-ICH registry (2006-2015). Including all patients receiving low-dose subcutaneous heparin for VTE prevention we pooled individual patient data of 1702 vitamin-K antagonist-(VKA) or non-VKA oral anticoagulants(NOAC)-related ICH patients treated at 22 tertiary-care centers across Germany and of 1022 primary spontaneous ICH patients from UKER. We defined intracranial hemorrhagic complications (IHC) during hospital stay as primary safety outcome measure. Secondary outcomes included mortality and functional outcome (modified Rankin Scale, mRS) at 3 months of patients with and without IHC. Results: IHC occurred in 1.7%(42/2416) of ICH patients. There were no differences in crude incidence rates among patients with VKA-ICH, NOAC-ICH and non-OAC-ICH (Log rank p=0.645; Breslow p=0.753; VKA-ICH: 27/1406[1.9%], NOAC-ICH 1/130[0.8%], non-OAC-ICH 14/880[1.6%];p=0.577). Detailed analysis according to days spent on heparin prophylaxis revealed no differences in rates of IHC per 1000 patient days (VKA-ICH: 1.49[1.00-2.14], NOAC-ICH 0.63[0.03-3.13], non-OAC-ICH 1.45[0.82-2.37]; p=0.687). Secondary outcomes showed differences in functional outcome (mRS=4-6: IHC: 29/37[78.4%] vs no-IHC: 1213/2048[59.2%];p=0.019) and mortality (IHC: 14/37[37.8%] vs no-IHC: 485/2048[23.7%];p=0.045) in disfavor of IHC-patients. Conclusions: Heparin administration for VTE prophylaxis in ICH patients appears to be safe without differently increased risks of IHC among non-OAC-ICH, VKA-ICH and NOAC-ICH.