Spontaneous Intracerebral Hemorrhage Research Articles

Remote Ischemic Conditioning to Reduce Perihematoma Edema in Patients with Intracerebral Hemorrhage (RICOCHET): A Randomized Control Trial

Background: Early perihematomal edema (PHE) growth is associated with worse functional outcomes at 90 days. Remote Ischemic conditioning (RIC) may reduce perihematomal inflammation if applied early to patients with intracerebral hemorrhage (ICH). We hypothesize that early RIC, delivered for seven days in patients with spontaneous ICH, may reduce PHE growth. Methods: ICH patients presenting within 6 h of symptom onset and hematoma volume < 60 milliliters (mL) were randomized to an RIC + standard care or standard care (SC) group. The primary outcome measure was calculated edema extension distance (EED), with the cm assessed on day seven. Results: Sixty patients were randomized with a mean  ±  SD age of 57.5  ±  10.8 years, and twenty-two (36.7%) were female. The relative baseline median PHE were similar (RIC group 0.75 (0.5–0.9) mL vs. SC group 0.91 (0.5–1.2) mL, p  =  0.30). The median EEDs at baseline were similar (RIC group 0.58 (0.3–0.8) cm vs. SC group 0.51 (0.3–0.8) cm, p  =  0.76). There was no difference in the median day 7 EED (RIC group 1.1 (0.6–1.2) cm vs. SC group 1 (0.9–1.2) cm, p  =  0.75). Conclusions: Early RIC therapy delivered daily for seven days was feasible. However, no decrease in EED was noted with the intervention.

Letter to the Editor "A decision tree model to help treatment decision-making for severe spontaneous intracerebral hemorrhage".

Letter to the Editor "A decision tree model to help treatment decision-making for severe spontaneous intracerebral hemorrhage".

2024 AHA/ASA Performance and Quality Measures for Spontaneous Intracerebral Hemorrhage: A Report From the American Heart Association/American Stroke Association.

The American Heart Association/American Stroke Association released a revised spontaneous intracerebral hemorrhage guideline in 2022. A working group of stroke experts reviewed this guideline and identified a subset of recommendations that were deemed suitable for creating performance measures. These 15 performance measures encompass a wide spectrum of intracerebral hemorrhage patient care, from prehospital to posthospital settings, highlighting the importance of timely interventions. The measures also include 5 quality measures and address potential challenges in data collection, with the aim of future improvements.

The impact of sex on epidemiology, management, and outcome of spontaneous intracerebral hemorrhage (sICH).

Data on sex differences in spontaneous intracerebral hemorrhages are limited. An automated comprehensive scoping literature review was performed using PubMed and Scopus. Articles written in English about spontaneous intracerebral hemorrhage and sex were reviewed. Males experience spontaneous intracerebral hemorrhage more frequently than females, at younger ages, and have a higher prevalence of deep bleeds compared to females. Risk factors between sexes vary and may contribute to differing incidences and locations of spontaneous intracranial hemorrhage. Globally, females receive less aggressive care than males, likely impacting survival. Epidemiology, risk factors, and treatment of spontaneous intracranial hemorrhage vary by sex, with limited and oftentimes conflicting data available. Further research into the sex-based differences of spontaneous intracranial hemorrhage is necessary for clinicians to better understand how to evaluate and guide treatment in the future.

Incident Dementia After Spontaneous Intracerebral Hemorrhage.

Post-stroke cognitive impairment and dementia (PSCID) is a complication that affects long-term functional outcomes after stroke. Studies on dementia after long-term follow-up in stroke have focused predominantly on ischemic stroke, which may be different from the development of dementia after spontaneous intracerebral hemorrhage (ICH). In this review, we summarize the existing data and hypotheses on the development of dementia after spontaneous ICH, review the management of post-ICH dementia, and suggest areas for future research. Dementia after spontaneous ICH has a cumulative incidence of up to 32.0-37.4% at 5 years post-ICH. Although the pathophysiology of post-ICH dementia has not been fully understood, two main theoretical frameworks can be considered: 1) the triggering role of ICH (both primary and secondary brain injury) in precipitating cognitive decline and dementia; and 2) the contributory role of pre-existing brain pathology (including small vessel disease and neurodegenerative pathology), reduced cognitive reserve, and genetic factors predisposing to cognitive dysfunction. These pathophysiological pathways may have synergistic effects that converge on dysfunction of the neurovascular unit and disruptions in functional connectivity leading to dementia post-ICH. Management of post-ICH dementia may include screening and monitoring, cognitive therapy, and pharmacotherapy. Non-invasive brain stimulation is an emerging therapeutic modality under investigation for safety and efficacy. Our review highlights that there remains a paucity of data and standardized reporting on incident dementia after spontaneous ICH. Further research is imperative for determining the incidence, risk factors, and pathophysiology of post-ICH dementia, in order to identify new therapies for the treatment of this debilitating condition.

Do Deep Learning Algorithms Accurately Segment Intracerebral Hemorrhages on Noncontrast Computed Tomography? A Systematic Review and Meta‐Analysis

BACKGROUND Stroke, a major global health issue, is broadly categorized into ischemic and hemorrhagic types. The volume of hemorrhage on noncontrast computed tomography guides the treatment options and hints at prognosis. Conventional approaches to calculate intracerebral hemorrhage (ICH) volume, like the ABC/2 method, typically rely on an assumed standard shape and might be inaccurate. Advances in deep learning have significantly improved noncontrast computed tomography's capabilities in ICH volume estimation. This study conducts a comprehensive systematic review and meta‐analysis to evaluate the precision of deep learning algorithms in delineating ICH on noncontrast computed tomography. METHODS A systematic review and meta‐analysis, adhering to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines, was conducted on literature from 2000 to October 2023. Studies were selected on the basis of strict inclusion and exclusion criteria. Performance evaluation was done using the Dice Similarity Coefficient, and the Prediction Model Risk of Bias Assessment Tool was used for quality assessment. Statistical analysis was carried out using Stata 17.0. RESULTS The review included 28 studies, mainly retrospective cohorts, with a focus on convolutional neural network architectures, particularly U‐Net variants. A meta‐analysis of 14 studies revealed a combined Dice Similarity Coefficient of 0.85 (95% CI, 0.82–0.88). Performance was consistent across various methodologies but varied on the basis of ICH pathogenesis, with spontaneous ICH having higher accuracy. CONCLUSION Deep learning models are highly effective in segmenting ICH on noncontrast computed tomography, demonstrating potential improvements in clinical neuroimaging. Despite their efficacy, challenges in segmenting smaller hemorrhages remain. The findings suggest that deep learning could reduce health care professional workloads and enhance patient care, although further research is needed to address limitations and extend clinical utility.

The relationship between perihematomal edema and hematoma expansion in acute spontaneous intracerebral hemorrhage: an exploratory radiomics analysis study

BackgroundThe relationship between early perihematomal edema (PHE) and hematoma expansion (HE) is unclear. We investigated this relationship in patients with acute spontaneous intracerebral hemorrhage (ICH), using radiomics.MethodsIn this multicenter retrospective study, we analyzed 490 patients with spontaneous ICH who underwent non-contrast computed tomography within 6 h of symptom onset, with follow-up imaging at 24 h. We performed HE and PHE image segmentation, and feature extraction and selection to identify HE-associated optimal radiomics features. We calculated radiomics scores of hematoma (Radscores_HEA) and PHE (Radscores_PHE) and constructed a combined model (Radscore_HEA_PHE). Relationships of the PHE radiomics features or Radscores_PHE with clinical variables, hematoma imaging signs, Radscores_HEA, and HE were assessed by univariate, correlation, and multivariate analyses. We compared predictive performances in the training (n = 296) and validation (n = 194) cohorts.ResultsShape_VoxelVolume and Shape_MinorAxisLength of PHE were identified as optimal radiomics features associated with HE. Radscore_PHE (odds ratio = 1.039, p = 0.032) was an independent HE risk factor after adjusting for the ICH onset time, Glasgow Coma Scale score, baseline hematoma volume, hematoma shape, hematoma density, midline shift, and Radscore_HEA. The areas under the receiver operating characteristic curve of Radscore_PHE in the training and validation cohorts were 0.808 and 0.739, respectively. After incorporating Radscore_PHE, the integrated discrimination improvements of Radscore_HEA_PHE in the training and validation cohorts were 0.009 (p = 0.086) and −0.011 (p < 0.001), respectively.ConclusionRadscore_PHE, based on Shape_VoxelVolume and Shape_MinorAxisLength of PHE, independently predicts HE, while Radscore_PHE did not add significant incremental value to Radscore_HEA.

Comparison of Open Craniotomy vs Conservative Treatment in Minor Spontaneous Intracerebral Hemorrhage (ICH)

Introduction: Intracerebral hemorrhage (ICH) accounts for 10–15% of all strokes in the USA, Europe, and Australia, and 20–30% of Asian cases, with a30-day mortality rate of 35% to 52%; half of the related deaths occur in the first 2 days. Its overall incidence is 24.6 per 100,000 person-years, indicating that it represents the most fatal type of stroke around the world. Methods: The aim of study of this study is to investigate the comparison of open craniotomy vs conservative treatment in minor spontaneous intracerebral hemorrhage (ICH). This study used the systematic review method by discovering articles using the search engines PubMed, SagePub, and Science Direct, and 5 articles met the inclusion criteria in this study. Results: Five publications were found to be directly related to our ongoing systematic examination after a rigorous three-level screening approach. Subsequently, a comprehensive analysis of the complete text was conducted, and additional scrutiny was given to these articles. Conclusion: Surgical management of intracerebral hemorrhage has unique advantages as it can remove the hematoma effectively and decrease intracranial pressure and the incidence of complications. Keywords: Intracerebral hemorrhage (ICH); surgical; treatment; craniotomy;  conservative.

Intracerebral Hemorrhage in a Child with Renal Artery Stenosis and COVID-19

Pediatric intracerebral hemorrhage is a rare condition among children. We discuss the case of a 7-year-old Filipino male with generalized tonic seizures and diagnosed to have both SARS-CoV-2 infection and hypertension secondary to renal arterial stenosis. The occurrence of intracerebral hemorrhage in children, though commonly caused by arteriovenous malformations, may be secondary to an acute hypertensive episode. In this case, the presence of COVID-19 in the patient may have been contributory to the development of spontaneous intracerebral hemorrhage due to its direct endothelial effects, as well as its dysregulatory action on the renin-angiotensin-aldosterone system.

Association of Imaging-based Predictors with Outcome in Different Treatment Options for Intracerebral Hemorrhage.

Intracerebral hemorrhage is the deadliest form of stroke. This study aimed to enhance the prediction of 30-day mortality in intracerebral hemorrhage patients by integrating computational parameters. This study retrospectively analyzed 435 patients with spontaneous intracerebral hemorrhage (ICH). Utilizing the acquired computed tomography (CT) images, we extracted the contour and visual representation of ICH. For the extracted contour, the analysis encompassed factors including compactness, fractal dimension, Fourier factor, and circle factor. For the images depicting ICH, we calculated various factors related to density distribution including mean, coefficient of variance, skewness and kurtosis, as well as texture parameters, such as energy, entropy, contrast and homogeneity. To assess the impact of surgical treatment on 30-day mortality, logistic regression analysis was used. Atotal of 126 patients (29.09%) died within 30days. Atotal of 62 (14.25%) patients underwent surgical treatment. Multivariate logistic regression analysis revealed that surgical treatment was independently associated with alower risk of 30-day mortality (odds ratio, OR 0.226, 95% confidence interval, CI 0.049-0.85; p = 0.039). Based on the moderated analysis, we found that the volume of ICH (OR 0.905, 95% CI 0.902-0.908; p < 0.001) and ICH energy (OR 1.389, 95%CI 0.884-0.988; p = 0.010) had positive moderating effect on such associations while the presence of intraventricular blood had negative moderating effect (OR 1.154, 95% CI 1.034-1.628; p = 0.010). Patients exhibiting ahigher volume and energy of ICH might benefit from surgical treatment; however, this efficacy was found to be diminished in cases involving the presence of intraventricular blood.

Does stereotactic thrombolysis with alteplase for intracerebral haemorrhage alter intraventricular haematoma volume? A secondary analysis of the MISTIE-III trial

BackgroundStereotactic thrombolysis reduces intracerebral haemorrhage (ICH) volume in patients with spontaneous ICH. Whether intrahaematomal alteplase administration is associated with a change in intraventricular haemorrhage volume (deltaIVH) and functional outcomes is...

Hemorrhage Expansion Rates Before and After Minimally Invasive Surgery for Intracerebral Hemorrhage: Post Hoc Analysis of MISTIE II/III

BACKGROUND Stereotactic thrombolysis for evacuation of large spontaneous intracerebral (ICH) and intraventricular hemorrhage (IVH) typically requires stabilizing the hemorrhage preoperatively. We investigated intracranial hemorrhage expansion (HE) in the pre‐ and postrandomization phase of 2 clinical trials of surgical candidates with protocolized computed tomography (CT) imaging up to 10 days after presentation. METHODS Prospective assessment of sequential pre‐ and post‐randomization CT scans of 141 patients enrolled in MISTIE (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation) II/ICES (Intraoperative CT‐guided Endoscopic Surgery for ICH) and 499 patients enrolled in MISTIE III. Primary outcomes were prerandomization HE of ICH &gt;6 mL and IVH &gt;5 mL. Secondary outcome was postrandomization HE. Stability was defined as CT time after which no further HE was observed. We evaluated risk factors for ICH/IVH expansion using multivariable logistic regression analyses after adjustment for demographics, ICH characteristics and treatment. RESULTS Median (interquartile range) diagnostic ICH volume was 40.4 (29.5–54.1) mL. Prerandomization HE &gt;6 mL was detected in 216 (33.8%) subjects. Median time to hematoma stability from diagnostic CT was 7 (4.7–13.6) hours. Median diagnostic IVH volume was 0 (0–1.9) mL. IVH expansion &gt;5 mL occurred in 40 (6.3%) with stability at 6.9 (4.7–11.2) hours. Of subjects with HE, final expansion events were not yet detected at 12 hours from diagnostic CT in 36% (ICH expansion) and 33% (IVH expansion), respectively, with 91% detected by 24 hours. Independent associations with ICH expansion included age, male sex, White race, anticoagulation, ICH volume, deep ICH location, IVH, and time from symptom onset to diagnostic CT. Postsurgical ICH expansion occurred in 24 patients (6.9%) and was associated with delay in achieving stability, number of alteplase doses, and fewer CT hypodensities on diagnostic CT but not with functional outcome. CONCLUSION In patients with a large ICH eligible for surgical evacuation, about two thirds of HE events stabilize within 12 hours and most within 24 hours. An earlier time window for stereotactic thrombolysis may be feasible.

Early Cardiac Evaluation, Abnormal Test Results, and Associations with Outcomes in Patients with Acute Brain Injury Admitted to a Neurocritical Care Unit

Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF &lt; 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p &lt; 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th–50th quartile (aOR 1.65 [1.10–2.47]), troponin 50th–75th quartile (aOR 1.79 [1.22–2.63]), troponin &gt;75th quartile (aOR 2.18 [1.49–3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28–6.40]), BNP &gt;75th quartile (aOR 4.54 [2.09–9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF &lt; 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th–75th quartile (aOR 1.77 [1.14–2.73]), troponin &gt;75th quartile (aOR 1.81 [1.18–2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort.

Application of deep learning and radiomics in the prediction of hematoma expansion in intracerebral hemorrhage: a fully automated hybrid approach.

Spontaneous intracerebral hemorrhage (ICH) is the most severe form of stroke. The timely assessment of early hematoma enlargement and its proper treatment are of great significance in curbing the deterioration and improving the prognosis of patients with ICH. This study aimed to develop an automated hybrid approach to predict hematoma expansion in ICH. The transfer learning method was applied to build a hybrid model based on a convolutional neural network (CNN) to predict the expansion of hematoma. The model integrated (1) a CNN for automated hematoma segmentation and (2) a CNN-based classifier for hematoma expansion prediction that incorporated both 2-dimensional images and the radiomics features of the 3-dimensional hematoma shape. The radiomics feature module had the highest area under the receiver operating characteristic curve (AUC) of 0.58, a precision of 0, a recall of 0, and an average precision (AP) of 0.26. The ResNet50 and Inception_v3 modules had AUCs of 0.79 and 0.93, a precision of 0.56 and 0.86, a recall of 0.42 and 0.75, and an AP of 0.51 and 0.85, respectively. Radiomic with Inception_v3 and Radiomic with ResNet50 had AUCs of 0.95 and 0.81, a precision of 0.90 and 0.57, a recall of 0.79 and 0.17, and an AP of 0.87 and 0.69, respectively. A model using deep learning and radiomics was successfully developed. This model can reliably predict the hematoma expansion of ICH with a fully automated process based on non-contrast computed tomography imaging. Furthermore, the radiomics fusion with the Inception_v3 model had the highest accuracy.

Tranexamic acid versus placebo in individuals with intracerebral haemorrhage treated within 2 h of symptom onset (STOP-MSU): an international, double-blind, randomised, phase 2 trial

Tranexamic acid, an antifibrinolytic agent, might attenuate haematoma growth after an intracerebral haemorrhage. We aimed to determine whether treatment with intravenous tranexamic acid within 2 h of an intracerebral haemorrhage would reduce haematoma growth compared with placebo. STOP-MSU was an investigator-led, double-blind, randomised, phase 2 trial conducted at 24 hospitals and one mobile stroke unit in Australia, Finland, New Zealand, Taiwan, and Viet Nam. Eligible participants had acute spontaneous intracerebral haemorrhage confirmed on non-contrast CT, were aged 18 years or older, and could be treated with the investigational product within 2 h of stroke onset. Using randomly permuted blocks (block size of 4) and a concealed pre-randomised assignment procedure, participants were randomly assigned (1:1) to receive intravenous tranexamic acid (1 g over 10 min followed by 1 g over 8 h) or placebo (saline; matched dosing regimen) commencing within 2 h of symptom onset. Participants, investigators, and treating teams were masked to group assignment. The primary outcome was haematoma growth, defined as either at least 33% relative growth or at least 6 mL absolute growth on CT at 24 h (target range 18-30 h) from the baseline CT. The analysis was conducted within the estimand framework with primary analyses adhering to the intention-to-treat principle. The primary endpoint and secondary safety endpoints (mortality at days 7 and 90 and major thromboembolic events at day 90) were assessed in all participants randomly assigned to treatment groups who did not withdraw consent to use any data. This study was registered with ClinicalTrials.gov, NCT03385928, and the trial is now complete. Between March 19, 2018, and Feb 27, 2023, 202 participants were recruited, of whom one withdrew consent for any data use. The remaining 201 participants were randomly assigned to either placebo (n=98) or tranexamic acid (n=103; intention-to-treat population). Median age was 66 years (IQR 55-77), and 82 (41%) were female and 119 (59%) were male; no data on race or ethnicity were collected. CT scans at baseline or follow-up were missing or of inadequate quality in three participants (one in the placebo group and two in the tranexamic acid group), and were considered missing at random. Haematoma growth occurred in 37 (38%) of 97 assessable participants in the placebo group and 43 (43%) of 101 assessable participants in the tranexamic acid group (adjusted odds ratio [aOR] 1·31 [95% CI 0·72 to 2·40], p=0·37). Major thromboembolic events occurred in one (1%) of 98 participants in the placebo group and three (3%) of 103 in the tranexamic acid group (risk difference 0·02 [95% CI -0·02 to 0·06]). By 7 days, eight (8%) participants in the placebo group and eight (8%) in the tranexamic acid group had died (aOR 1·08 [95% CI 0·35 to 3·35]) and by 90 days, 15 (15%) participants in the placebo group and 19 (18%) in the tranexamic acid group had died (aOR 1·61 [95% CI 0·65 to 3·98]). Intravenous tranexamic acid did not reduce haematoma growth when administered within 2 h of intracerebral haemorrhage symptom onset. There were no observed effects on other imaging endpoints, functional outcome, or safety. Based on our results, tranexamic acid should not be used routinely in primary intracerebral haemorrhage, although results of ongoing phase 3 trials will add further context to these findings. Australian Government Medical Research Future Fund.

Primary spontaneous intracerebral hemorrhage in COVID-19 patients: differences among presentation patterns Ó? A systematic review

Primary spontaneous intracerebral hemorrhage in COVID-19 patients: differences among presentation patterns Ó? A systematic review

Association of Anticoagulant Use with Hemorrhage Location and Etiology in Spontaneous Intracerebral Hemorrhage (S41.004)

Association of Anticoagulant Use with Hemorrhage Location and Etiology in Spontaneous Intracerebral Hemorrhage (S41.004)

Acute Seizures After Spontaneous Intracerebral Hemorrhage in Young Individuals: 11-year Trends and Association with Mortality (S19.009)

Acute Seizures After Spontaneous Intracerebral Hemorrhage in Young Individuals: 11-year Trends and Association with Mortality (S19.009)

INdian trial of TRanexamic Acid IN Spontaneous IntraCerebral haemorrhage (INTRINSIC) Trial—Study Protocol (P10-2.003)

INdian trial of TRanexamic Acid IN Spontaneous IntraCerebral haemorrhage (INTRINSIC) Trial—Study Protocol (P10-2.003)

Oral Health as a Risk Factor for Spontaneous Intracerebral Hemorrhage: A Mendelian Randomization Analysis (S34.001)

Oral Health as a Risk Factor for Spontaneous Intracerebral Hemorrhage: A Mendelian Randomization Analysis (S34.001)