Total Intracerebral Hemorrhage Research Articles

The potential for minimally invasive intracerebral hemorrhage evacuation in routine healthcare: applicability of the ENRICH trial criteria to an unselected cohort

ObjectiveFollowing the favorable outcomes demonstrated by the Early MiNimally-invasive Removal of IntraCerebral Hemorrhage (ENRICH) trial in supratentorial intracerebral hemorrhage (ICH) patients treated with minimally invasive surgery (MIS), and considering the increasing interest in MIS, we aimed to assess the potential eligibility rate for ICH patients in Sweden.MethodsAll patients with spontaneous ICH in the Swedish Stroke Register (RS) during 2017–2020 in Skane county (1.37 million) were assessed. Baseline imaging was used for radiological characterization. Clinical data were obtained from RS. MIS eligibility in the total ICH population meeting ENRICH criteria were estimated and extrapolated to the Swedish population (10.5 million).ResultsOf 1,314 ICH patients, 5.9% met the ENRICH criteria for MIS (ICH volume 30–80 ml). Considering the ENRICH trial results indicating the effectiveness of MIS was mainly attributable to intervention for lobar hemorrhages, we determined that 2.8% of our ICH cohort in Sweden would be eligible for MIS. The estimated rate of neurosurgery for ICH could increase from the current 1.46–1.90 patients/100,000 population/year (in absolute numbers from 154 to 200 interventions out of 2,400 ICHs in Sweden annually).ConclusionsWe show that 2.8% of the Skane ICH population would be eligible for MIS if ENRICH criteria are employed for patients with lobar ICH, corresponding to a 29% increase of current surgical rates for ICH in Sweden. As MIS for ICH is not yet standard practice in Sweden, consideration for its implementation within the neurosurgical organization becomes essential to accommodate the anticipated increase in patient demand.

High-Volume Hospital Had Lower Mortality of Severe Intracerebral Hemorrhage Patients.

Intracerebral hemorrhage (ICH) accompanies higher mortality rates than other type of stroke. This study aimed to investigate the association between hospital volume and mortality for cases of ICH. We used nationwide data from 2013 to 2018 to compare high-volume hospitals (≥32 admissions/year) and low-volume hospitals (<32 admissions/year). We tracked patients' survival at 3-month, 1-year, 2-year, and 4-year endpoints. The survival of ICH patients was analyzed at 3-month, 1-year, 2-year, and 4-year endpoints using Kaplan-Meier survival analysis. Multivariable logistic regression analysis and Cox regression analysis were performed to determine predictive factors of poor outcomes at discharge and death. Among 9,086 ICH patients who admitted to hospital during 18-month period, 6,756 (74.4%) and 2,330 (25.6%) patients were admitted to high-volume and low-volume hospitals. The mortality of total ICH patients was 18.25%, 23.87%, 27.88%, and 35.74% at the 3-month, 1-year, 2-year, and 4-year, respectively. In multivariate logistic analysis, high-volume hospitals had lower poor functional outcome at discharge than low-volume hospitals (odds ratio, 0.80; 95% confidence interval, 0.72-0.91; p < 0.001). In the Cox analysis, high-volume hospitals had significantly lower 3-month, 1-year, 2-year, and 4-year mortality than low-volume hospitals (p < 0.05). The poor outcome at discharge, short- and long-term mortality in ICH patients differed according to hospital volume. High-volume hospitals showed lower rates of mortality for ICH patients, particularly those with severe clinical status.

Lifetime Cumulative Effect of Reproductive Factors on Stroke and Its Subtypes in Postmenopausal Chinese Women: A Prospective Cohort Study.

Multiple reproductive factors are associated with stroke. Little is known about the cumulative effects of reproductive factors during a reproductive life course on stroke and its subtypes, especially among female Chinese individuals. The objective of this study was to assess the associations of lifetime cumulative estrogen exposure due to reproductive factors with stroke and its etiologic subtypes among postmenopausal Chinese women. Postmenopausal women without prior stroke at baseline (2004-2008) were selected from the China Kadoorie Biobank (CKB). Lifetime cumulative estrogen exposure due to reproductive factors was assessed using 3 composite indicators: reproductive lifespan (RLS), endogenous estrogen exposure (EEE), and total estrogen exposure (TEE). Stroke and its subtypes, ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), were identified through linkage to a disease registry system and health insurance data during follow-up (2004-2015). Multivariable-adjusted Cox proportional hazards regression models were applied to estimate the adjusted hazard ratio (aHR) and 95% CIs for the risk of stroke by quartiles of RLS, EEE, and TEE, respectively. A total of 122,939 postmenopausal participants aged 40-79 years without prior stroke at baseline were included. During a median follow-up period of 8.9 years, 15,139 cases with new-onset stroke were identified, including 12,853 cases with IS, 2,580 cases with ICH, and 269 cases with SAH. Compared with the lowest quartile (Q1) of RLS, the highest quartile (Q4) had a lower risk of total stroke (aHR: 0.95, 95% CI 0.92-0.98), IS (aHR: 0.95, 95% CI 0.92-0.98), and ICH (aHR: 0.87, 95% CI 0.81-0.94). Both EEE and TEE displayed a graded association with the subsequent descending risk of total stroke (aHR for Q4 vs Q1: EEE: 0.85, 95% CI 0.82-0.89; TEE: 0.87, 95% CI 0.84-0.90), IS (aHR for Q4 vs Q1: EEE: 0.86, 95% CI 0.83-0.90; TEE: 0.86, 95% CI 0.83-0.89), and ICH (EEE: 0.73, 95% CI 0.65-0.81; TEE: 0.83,95% CI 0.76-0.91), with a p for trend < 0.001 for all these associations. Individuals' cumulative estrogen exposure due to reproductive factors could potentially be a valuable indicator for risk stratification of stroke events after menopause.

Blood-based protein biomarkers for the diagnosis of acute stroke: A discovery-based SWATH-MS proteomic approach.

Background and purposesRecent developments in high-throughput proteomic approach have shown the potential to discover biomarkers for diagnosing acute stroke and to elucidate the pathomechanisms specific to different stroke subtypes. We aimed to determine blood-based protein biomarkers to diagnose total stroke (IS+ICH) from healthy controls, ischemic stroke (IS) from healthy controls, and intracerebral hemorrhage (ICH) from healthy control subjects within 24 h using a discovery-based SWATH-MS proteomic approach.MethodsIn this discovery phase study, serum samples were collected within 24 h from acute stroke (IS & ICH) patients and healthy controls and were subjected to SWATH-MS-based untargeted proteomics. For protein identification, a high-pH fractionated peptide library for human serum proteins (obtained from SCIEX) comprising of 465 proteins was used. Significantly differentially expressed (SDE) proteins were selected using the following criteria: >1.5-fold change for upregulated, < 0.67 for downregulated, p-value < 0.05, and confirmed/tentative selection using Boruta random forest. Protein–protein interaction network analysis and the functional enrichment analysis were conducted using STRING 11 online tool, g:Profiler tool and Cytoscape 3.9.0 software. The statistical analyses were conducted in R version 3.6.2.ResultsOur study included 40 stroke cases (20 IS, 20 ICH) within 24 h and 40 age-, sex-, hypertension-, and diabetes-matched healthy controls. We quantified 375 proteins between the stroke cases and control groups through SWATH-MS analysis. We observed 31 SDE proteins between total stroke and controls, 16 SDE proteins between IS and controls, and 41 SDE proteins between ICH and controls within 24 h. Four proteins [ceruloplasmin, alpha-1-antitrypsin (SERPINA1), von Willebrand factor (vWF), and coagulation factor XIII B chain (F13B)] commonly differentiated total stroke, IS, and ICH from healthy control subjects. The most common significant pathways in stroke cases involved complement and coagulation cascades, platelet degranulation, immune-related processes, acute phase response, lipid-related processes, and pathways related to extracellular space and matrix.ConclusionOur discovery phase study identified potential protein biomarker candidates for the diagnosis of acute stroke and highlighted significant pathways associated with different stroke subtypes. These potential biomarker candidates warrant further validation in future studies with a large cohort of stroke patients to investigate their diagnostic performance.

Evaluating the predictive ability of temperature-related indices on the stroke morbidity in Shenzhen, China: Under cross-validation methods framework

BackgroundComposite temperature-related indices have been utilized to comprehensively reflect the impact of multiple meteorological factors on health. We aimed to evaluate the predictive ability of temperature-related indices, choose the best predictor of stroke morbidity, and explore the association between them. MethodsWe built distributed lag nonlinear models to estimate the associations between temperature-related indices and stroke morbidity and then applied two types of cross-validation (CV) methods to choose the best predictor. The effects of this index on overall stroke, intracerebral hemorrhage (ICH), and ischemic stroke (IS) morbidity were explored and we explained how this index worked using heatmaps. Stratified analyses were conducted to identify vulnerable populations. ResultsAmong 12 temperature-related indices, the alternative temperature-humidity index (THIa) had the best overall performance in terms of root mean square error when combining the results from two CVs. With the median value of THIa (25.70 °C) as the reference, the relative risks (RRs) of low THIa (10th percentile) reached a maximum at lag 0–10, with RRs of 1.20 (95%CI:1.10–1.31), 1.49 (95%CI:1.29–1.73) and 1.12 (95%CI:1.03–1.23) for total stroke, ICH and IS, respectively. According to the THIa formula, we matched the effects of THIa on stroke under various combinations of temperature and relative humidity. We found that, although the low temperature (<20 °C) had the greatest adverse effect, the modification effect of humidity on it was not evident. In contrast, lower humidity could reverse the protective effect of temperature into a harmful effect at the moderate-high temperature (24 °C–27 °C). Stratification analyses showed that the female was more vulnerable to low THIa in IS. ConclusionsTHIa is the best temperature-related predictor of stroke morbidity. In addition to the most dangerous cold weather, the government should pay more attention to days with moderate-high temperature and low humidity, which have been overlooked in the past.

Description of intracerebral hemorrhage locations, in the United States, based on international classification of diseases, tenth revision

ObjectivesIntroduction of the International Classification of Diseases, Tenth Revision (ICD-10) in 2015 was aimed for a more detailed classification of mortality statistics of diseases, such as classifying the anatomical locations for intracerebral hemorrhage (ICH). We aimed to describe the demographics and in-hospital mortality of specified ICH locations based on ICD-10 classification. Materials and methodsPatients with a principal diagnosis of spontaneous ICH in the United States, extracted from the Nationwide Inpatient Sample (NIS) from 2015 to 2018. Subgroups of ICH locations were analyzed individually for age, gender, ethnicity, in-hospital mortality, hospital length of stay (LOS), hospital cost, and EVD placement. ResultsDuring the study period, there were 408,285 ICH patients with a mean age of 66.28 (17.11) years, 52.09% male, mainly Intraventricular (21.87%) and cortical hemispheres (19.83%). Total ICH in-hospital mortality was 21.07%, while brainstem was associated with the highest in-hospital mortality (40.68%) followed by intraventricular (33.08%) and multiple localized locations (30.16%). The mean hospital length of stay was 9.56(14.10) days, and the mean hospital cost was $32,453.38(56,851.59). Intraventricular Hemorrhage had the highest hospital LOS 12.39(17.44) and the highest hospital cost $47,385.25(76,187.5). ConclusionsOur results characterized the demographics of ICH in the US with in-hospital mortality of one out of five patients. Detail breakdown of ICH locations can improve the mortality statistics and provide more information about the ICH locations with higher hospital expenses.

Decrease in incidence of oral anticoagulant-related intracerebral hemorrhage over the past decade in the Netherlands.

BackgroundData on oral anticoagulant-related (OAC) intracerebral hemorrhage (ICH) incidence are scarce. Most studies on incidence time trends were performed before the introduction of Direct Oral Anticoagulants (DOACs). Between 2008 and 2018, the number of OAC-users in the Netherlands increased by 63%, with the number of DOAC-users almost equaling that of Vitamin K Antagonists (VKA)-users. We aimed to determine the recent total and OAC-related ICH incidence and assess changes over the last decade, including the effect of DOAC introduction.MethodsAll adult non-traumatic ICH patients presenting in any of three hospitals in the enclosed region of South-Limburg, the Netherlands, were retrospectively included, during two 3-year time periods: 2007–2009 and 2017–2019. OAC-related ICH was defined as ICH in patients using VKAs or DOACs. We calculated the incidence rate ratio (IRR) between the two study periods.ResultsIn the 2007–2009 period, we registered 652 ICHs of whom 168 (25.8%) were OAC-related (all VKA). In the 2017–2019 period, we registered 522 ICHs, 121 (23.2%) were OAC-related (70 VKA and 51 DOAC). In 2007–2009, the annual incidence of total ICH and OAC-related ICH was 40.9 and 10.5 per 100,000 person-years, respectively, which decreased to 32.4 and 7.5 per 100,000 person-years in 2017–2019. The IRR for total ICH and OAC-related ICH was 0.67 (95%-CI: 0.60–0.75) and 0.58 (0.46–0.73), respectively.ConclusionBoth total ICH and OAC-related ICH incidence decreased over the past decade in South-Limburg, the Netherlands, despite the aging population and increasing number of OAC-users. The introduction of DOACs, and possibly an improved cardiovascular risk management and change in OAC prescription pattern, could explain these findings.

Abstract TP137: Ethnic/racial Variations Of Intracerebral Hemorrhage Genetics (erich-gene) Study Protocol

Introduction: Epidemiologic studies of intracerebral hemorrhage (ICH) have consistently demonstrated variation in incidence, location, comorbidity burden, age-of-onset, and outcome by race and ethnicity, and genetic studies have identified differences in risk mediated by genetic risk factors such as Apolipoprotein E (APOE). We report the design and methods of the largest multi-ethnic genome-wide association study (GWAS) of ICH risk and outcome conducted to date. Methods: The Ethnic/Racial Variations of ICH Genetics (ERICH-GENE) study is an international, multi-center, genetic case-control study of ICH. Cases are individuals with confirmed primary ICH with biosample availability and consent compatible with shareable genome-wide genotyping or previous genotyping. Central neuroimaging phenotype harmonization of case status, hemorrhage location, and imaging characteristics of cerebral small vessel disease including leukoaraiosis, atrophy, microbleeds, intraventricular hemorrhage severity and volume of ICH measurements will be performed. Controls are ICH-free individuals of compatible age and race/ethnicity from existing studies and biorepositories. Results: As of August 2021, 2,002 ICH cases have been collected and genotyped, in addition to 2,558 already-genotyped ICH cases from the multi-ethnic ERICH study. 5,600 total new ICH cases will be genotyped under ERICH-GENE, with planned meta-analyses across existing ICH GWAS datasets and international biobanks totaling &gt;20,000 cases. We are on schedule to meet our genotyping goal within the study period. Non-European ancestry cases are being prioritized for genotyping and ~66% of the previously genotyped ERICH cases are black or Hispanic. From available cases, a total of 10,621 neuroimaging studies have been uploaded for central adjudication to date with 6,278 having undergone harmonization. Conclusions: ERICH-GENE is a large, multi-ethnic, international, centrally harmonized GWAS of ICH risk and outcome that will identify genetic risk factors across diverse populations for biological discovery and population-specific risk stratification.

Abstract WMP77: Anticoagulation-Associated Intracerebral Hemorrhage Incidence Rates: A Longitudinal Population-Based Assessment

Background: Anticoagulant-associated intracerebral hemorrhage (AA-ICH) quintupled in the Greater Cincinnati/Northern Kentucky (GC/NK) region from 1988 to 1999 in association with increasing warfarin use. Direct-acting oral anticoagulants (DOACs), available in 2010, have evidence of less bleeding risk, while atrial fibrillation detection rates have increased. We sought to determine if rates of AA-ICH continued to increase in the last decade within a large, bi-racial population. Methods: We identified all patients, 20 years or older, hospitalized with first-ever intracerebral hemorrhage (ICH) in GC/NK region in 1993/4, 1999, 2005, 2010 and 2015. AA-ICH was defined as ICH in patients prescribed warfarin, heparin or low molecular weight heparin, or a DOAC at the time of their ICH. Incidence rates were age-, sex- and race-adjusted to the 2010 US population. Change over time was tested using regression. All-cause case fatality was adjusted for age, sex and race and trend over time evaluated using a general linear model. Results: There was no significant change over time in the incidence rate for total ICH or AA-ICH from 1993 through 2015 (Table). As compared to ICH patients without anticoagulant use, patients with AA-ICH were more likely to be older, white, have hypertension, diabetes mellitus, hyperlipidemia, prior ischemic stroke and atrial fibrillation, but less likely to smoke. The age-, sex- and race-adjusted 30-day case fatality for ICH overall and AA-ICH also did not change significantly from 1993/4 to 2015 (Table). Warfarin utilization increased in our ICH population from 1993/4 (7.6%) to 2005 (17.7%), then decreased through 2015 (11.8%/DOAC 6.4%); p&lt;0.0001. Conclusion: Despite increased incidence rates of AA-ICH in the late 1980s to 1990s, we observed no overall change in incidence or case-fatality rate from AA-ICH over the full 20-year period despite higher rates of atrial fibrillation detection which may be explained by higher rates of DOAC (vs warfarin) use.

P-EP024. Prevalence and clinical characteristics of pediatric haemorrhagic stroke complicated with seizure in Sardjito Hospital, Yogyakarta, Indonesia

Introduction. Intracerebral haemorrhage (ICH) is a condition of brain parenchymal haemorrhage with or without intraventricular bleeding. Although rare, ICH remains the most common cause of stroke in pediatric population. Previous study showed that prognosis of ICH in pediatric population is better than elderly, however neurologic sequelae should be considered, including seizure that may progress to epilepsy. Objective of this study is to determine the incidence of seizure in pediatric patients with intracranial haemorrhage. Methods. Retrospective cross-sectional study of children with ICH in Sardjito Hospital during 5 years period (January 2014 – December 2019). Results. There was 94 total ICH patient complicated with seizure, 36 (38.29%) of them are children (aged <18 years old). Approximately half of them suffered from status epilepticus, accounted for 15 children. Mean age of children with ICH complicated by stroke was 60.58 months, while those complicated with status epilepticus were older than non-status epilepticus, 84 months and 47.8 months respectively. Mortality rate of children population (66.67%) in this study was higher than adults (48%), which mainly as a consequence of status epilepticus which has mortality rate of 50%. Children with status epilepticus also had prolonged length of stay, around 19.92 days. Eleven children had hematologic disorder with thrombocytopenia, such as ALL (6), AML (1), hemophilia (1), thalassemia (1), anemia apalastic (1), and ITP (1), while congenital malformation was only in two children. Almost half of sample had multiple ICH, and can be a combination of parenchymal, SAH, EDH, and SDH. Only two children complicated with hypertension. Conclusion. Mortality rate among pediatric ICH with seizure was high, especially when complicated with status epilepticus. Multifocal hemorrhagic lesion was prominent in this studied population, therefore further study is needed to evaluate this associations with seizure symptoms.

Dose-Response Association Between High-Density Lipoprotein Cholesterol and Stroke: A Systematic Review and Meta-Analysis of Prospective Cohort Studies.

IntroductionStudies investigating the effect of high-density lipoprotein cholesterol (HDL-C) on stroke and stroke subtypes have reached inconsistent conclusions. The purpose of our study was to clarify the dose–response association between HDL-C level and risk of total stroke and stroke subtypes by a systematic review and meta-analysis.MethodsWe performed a systematic search of PubMed, Embase, and Web of Science databases through July 30, 2020, for prospective cohort studies that reported the HDL-C–stroke association and extracted the estimate that was adjusted for the greatest number of confounding factors. Restricted cubic splines were used to evaluate the linear and nonlinear dose–response associations.ResultsWe included 29 articles, which reported on 62 prospective cohort studies including 900,501 study participants and 25,678 with stroke. The summary relative risk per 1-mmol/L increase in HDL-C level for total stroke was 0.82 (95% CI, 0.76–0.89; I 2 = 42.9%; n = 18); ischemic stroke (IS), 0.75 (95% CI, 0.69–0.82; I 2 = 50.1%; n = 22); intracerebral hemorrhage (ICH), 1.21 (95% CI, 1.04–1.42; I 2 = 33.4%; n = 10); and subarachnoid hemorrhage (SAH), 0.98 (95% CI, 0.96–1.00; I 2 = 0%; n = 7). We found a linear inverse association between HDL-C level and risk of total stroke and SAH, a nonlinear inverse association for IS risk, but a linear positive association for ICH risk. The strength and the direction of the effect size estimate for total stroke, IS, ICH, and SAH remained stable for most subgroups. We found no publication bias with Begg’s test and Egger’s test for the association of HDL-C level with risk of total stroke, IS, and ICH.ConclusionA high HDL-C level is associated with reduced risk of total stroke and IS and an increased risk of ICH.

Time Trends in Intracerebral Hemorrhage Associated with Oral Anticoagulation and Its Risks Factors in Spain from 2008 to 2015

Background: Intracerebral hemorrhage (ICH) is 7- to 10-fold higher in anticoagulated patients. Given the more extended use of oral anticoagulants, an increase in the prevalence of ICH associated with oral anticoagulation (ICH-OAC) could be expected. However, there is no previous study that assesses the time trends of ICH-OAC in Spain. Methods: We conducted a combined data analysis after creating a joint database of the 3 most important epidemiological studies on ICH-OAC of our country: the EPICES study (2008–2009), the TAC Registry (TR) study (2012–2013) and the TAC Registry 2 (TR2) study (2015). We finally included 65, 235, and 366 patients from the EPICES, TR, and TR2 studies, respectively. Results: We have observed a 3.73-fold increase in the crude annual incidence of ICH-OAC throughout the period of study, with proportion of ICH-OAC out of total ICH increasing from 8.4% in 2008 to 18.2% in 2015. Age, dyslipidemia, and prior antiplatelet treatment increased during the study, but we found no statistically significant differences in other risk factors for ICH-OAC. Conclusions: The incidence of ICH-OAC is increasing in our country. It might at least be partly explained by aging of the population, with mean age at presentation being higher in the last years.

Low-dose rescue tirofiban in mechanical thrombectomy for acute cerebral large-artery occlusion.

Tirofiban administration during mechanical thrombectomy (MT) remains controversial. The aim was to evaluate the safety and efficacy of a low-dose rescue tirofiban regimen during MT for Chinese acute ischaemic stroke (AIS) patients. Patients from the ANGEL study, a multicentric, prospective registry study that included AIS patients who underwent MT owing to proximal large-artery occlusion from June 2015 to December 2017, were collected. The patients were dichotomized into tirofiban and non-tirofiban groups according to whether rescue tirofiban was performed during MT. Safety outcomes [symptomatic intracerebral haemorrhage (sICH), total intracerebral haemorrhage (ICH) and distal embolization] and efficacy outcomes (artery recanalization and functional outcomes at 3-month follow-up) were compared between groups using logistic regression analysis. A total of 662 patients were included in this study, and 230 (34.7%) were in the tirofiban group. No significant differences in safety outcomes on sICH, total ICH and distal embolization and efficacy outcomes on artery recanalization and 3-month functional independence were observed between the tirofiban and non-tirofiban group in the entire cohort or the anterior circulation stroke or posterior circulation stroke patients (P>0.05 for all groups). However, low-dose rescue tirofiban was significantly correlated with 3-month mortality reduction for posterior circulation stroke patients [adjusted hazard ratio0.35 (0.14-0.92), P=0.03]. Low-dose rescue tirofiban during MT was not associated with increased risk of sICH, ICH and distal embolization for AIS patients, and may be correlated with 3-month mortality reduction for posterior circulation stroke.

Contrast Staining may be Associated with Intracerebral Hemorrhage but Not Functional Outcome in Acute Ischemic Stroke Patients Treated with Endovascular Thrombectomy.

To evaluate the incidence of post-interventional contrast staining (PICS) in acute ischemic stroke (AIS) Chinese patients who were treated with endovascular thrombectomy (ET) and investigate potential association of PICS with functional outcome and intracerebral hemorrhage (ICH). This observational study was based on a single-center prospective registry study. AIS patients who underwent ET from January 2013 to February 2017 were recruited into this study. All patients had dual-energy CT (DECT) scan of the head at 12 to 24 hours post-ET. The primary outcome was the incidence of PICS. Secondary outcomes were total ICH, symptomatic ICH (sICH), 3-month functional outcome, and long-term functional outcome. One hundred and eighty patients were enrolled in this study. PICS was detected in 50 patients (28%) based on the post-interventional CT scan. We first used basic statistical analyses, showing that the incidence of both total ICH (60% vs. 25%, p<0.001) and sICH (18% vs. 8%, p=0.044) were higher in patients with PICS than those without, and fewer patients achieved no disability (mRS≤1) in the PICS group compared to the control group at both 3-month and long-term follow-up (p<0.01 each). However, multivariate regression analysis further revealed that PICS only increased total (adjusted odds ratio, 7.38; 95% confidence interval 1.66 to 32.9; p=0.009) but not sICH risk. Furthermore, the logistic regression analyses did not show statistical difference in good clinical outcomes or mortality between the two groups. PICS is a common phenomenon in Chinese AIS patients. It is associated with total ICH after ET, but it seems to have no effect on functional outcome and sICH. Further large-scale studies are warranted to validate these results.

Abstract WP314: Driving Stroke Care Within a Health System: The Impact of the University Hospitals System Stroke Program Clinical Practice Guideline for the Emergency Management of Acute Stroke

Introduction: With 18 University Hospitals at 12 locations, UH Case Medical Center is second in the University HealthSystem Consortium ranking for patient transfers at 24% of total volume. In 2009, the University Hospitals System Stroke Program developed a Clinical Practice Guideline (UHSSP-CPG) with the goal of providing the same, high quality stroke care throughout the health system that included a triage and transfer algorithm. Methods: From 2011-2q2016 (annualized), 5666 hospital discharges from MS-DRGs 61-66 representing medical management of cerebral infarction (CI) and intracerebral hemorrhage (ICH) were analyzed from 6 UH Legacy hospitals- UH-Case CSC, 4 PSCs and 2 Stroke Ready Facilities (SRF). Advanced expertise (AE) was developed at 2 PSCs for medical management of CI (2014) and low risk ICH (2015, 2016). Results: From 2011 to 2016, total stroke discharges increased across the UHSSP by 22%; total CI by 14%; and total ICH by 68%. Total IV-tPA cases increased by 174%, representing an increase in IV-tPA utilization from 6% to 15% of total CI. At UH-Case CSC, total stroke discharges increased by 15%, especially for ICH which increased by 63%. At the PSC-AE hospitals, total stroke discharges increased by 133%; IV-tPA Drip and Keep by 1300%; and total ICH by 700%. Total stroke discharges decreased by 28% at the other PSC hospitals. Conclusions: Implementation of the UHSSP-CPG triage and transfer algorithm resulted in an increase in total stroke volume across the health system but shifted more patients with lower risk ischemic and hemorrhagic stroke to PSC within their community. This strategy promotes enhanced access of more complex stroke patients to UH-Case CSC. As hospitals continue to coalesce into systems, robust triage and transfer algorithms will play an increasingly important role in systems stroke care.

Cytochrome P450 and matrix metalloproteinase genetic modifiers of disease severity in Cerebral Cavernous Malformation type 1

BackgroundFamilial Cerebral Cavernous Malformation type 1 (CCM1) is an autosomal dominant disease caused by mutations in the Krev Interaction Trapped 1 (KRIT1/CCM1) gene, and characterized by multiple brain lesions. CCM lesions manifest across a range of different phenotypes, including wide differences in lesion number, size and susceptibility to intracerebral hemorrhage (ICH). Oxidative stress plays an important role in cerebrovascular disease pathogenesis, raising the possibility that inter-individual variability in genes related to oxidative stress may contribute to the phenotypic differences observed in CCM1 disease. Here, we investigated whether candidate oxidative stress-related cytochrome P450 (CYP) and matrix metalloproteinase (MMP) genetic markers grouped by superfamilies, families or genes, or analyzed individually influence the severity of CCM1 disease. MethodsClinical assessment and cerebral susceptibility-weighted magnetic resonance imaging (SWI) were performed to determine total and large (≥5mm in diameter) lesion counts as well as ICH in 188 Hispanic CCM1 patients harboring the founder KRIT1/CCM1 ‘common Hispanic mutation’ (CCM1–CHM). Samples were genotyped on the Affymetrix Axiom Genome-Wide LAT1 Human Array. We analyzed 1,122 genetic markers (both single nucleotide polymorphisms (SNPs) and insertion/deletions) grouped by CYP and MMP superfamily, family or gene for association with total or large lesion count and ICH adjusted for age at enrollment and gender. Genetic markers bearing the associations were then analyzed individually. ResultsThe CYP superfamily showed a trend toward association with total lesion count (P=0.057) and large lesion count (P=0.088) in contrast to the MMP superfamily. The CYP4 and CYP8 families were associated with either large lesion count or total lesion count (P=0.014), and two other families (CYP46 and the MMP Stromelysins) were associated with ICH (P=0.011 and 0.007, respectively). CYP4F12 rs11085971, CYP8A1 rs5628, CYP46A1 rs10151332, and MMP3 rs117153070 single SNPs, mainly bearing the above-mentioned associations, were also individually associated with CCM1 disease severity. ConclusionsOverall, our candidate oxidative stress-related genetic markers set approach outlined CYP and MMP families and identified suggestive SNPs that may impact the severity of CCM1 disease, including the development of numerous and large CCM lesions and ICH. These novel genetic risk factors of prognostic value could serve as early objective predictors of disease outcome and might ultimately provide better options for disease prevention and treatment.

Computed tomography perfusion-based thrombolysis in wake-up stroke.

Wake-up stroke (WUS) patients are typically excluded from reperfusion treatment, as the time of symptoms onset is unknown. The purpose of this study is to evaluate the clinical outcome and safety of intravenous thrombolysis with rt-PA in patients with WUS eligible for therapy using computed tomography perfusion criteria (CTP), compared to patients treated with rt-PA within 4.5 h of symptoms onset (non-WUS). This is an experimental, open-label trial, controlled against the best therapy currently in use. Primary endpoints were functional independence after 3 months [modified Rankin scale (mRS) ≤ 1] for clinical outcome and symptomatic intracerebral hemorrhage (SICH) for safety. Secondary endpoints were no or only mild disability after 3 months (mRS ≤ 2) for clinical outcome, total intracerebral hemorrhage (TICH) and contrast-induced nephropathy (CIN) for safety. 170 patients were treated, 143 non-WUS patients and 27 patients with WUS. Strokes of cardioembolic origin were most common in WUS patients (p < 0.001). Primary endpoints: mRS ≤ 1 was found in 35.8 % (non-WUS: 36.4% vs. WUS 33.3%; p = 0.62) and SICH was observed in 3.4 % of non-WUS patients and in WUS patients (p = 0.32). Secondary endpoints: mRS ≤ 2 was observed in 66.4 % of patients (non-WUS: 67.1% vs. WUS 62.9%; p = 0.67), TICH in 13.5 % of patients (13.9 % non-WUS vs. 11.1 % WUS; p = 0.69). CIN was documented in 3.7 % of WUS patients. rt-PA treatment carried out in WUS patients selected on the basis of CTP data demonstrate comparable clinical outcome and safety with respect to non-WUS patients. The study supports the hypothesis that a selected group of WUS patients may be suitable for thrombolysis.

Abstract W P325: Hematoma Volumes Are Independent of Elevated Prehospital Blood Pressure in Patients with Intracerebral Hemorrhage

INTRODUCTION: In a recent prehospital interventional trial, it was observed that high prehospital BP in intracerebral hemorrhage (ICH) patients is associated with larger ICH volumes. We tested the hypotheses that higher prehospital BP is associated with larger baseline ICH volumes outside a clinical trial setting. METHODS: We conducted a retrospective analysis of a prospectively-maintained centralized database of electronic patient health care reports (ePCR), including serial BP measurements, of all patients transported by Emergency Medical Services (EMS) to the Emergency Department (ED) of a single hospital with acute stroke symptoms during an 18-month period. All patients with an EMS dispatch code for suspected stroke were included. Hospital charts and neuroimaging were reviewed. Hematoma and intraventricular hemorrhage (IVH) volumes were measured planimetrically. RESULTS: A total of 877 patients were transported by EMS for suspected stroke. ICH was diagnosed in 50 (5.7%) patients. Median (IQR) time from symptom onset to first BP measurement was 82 (362) minutes. Mean prehospital SBP was 173 ± 32 mmHg. Median baseline hematoma volume was 31.8 (53.2) ml and median total ICH volume was 33.4 (58.1) ml. Mean prehospital BP was unrelated to hematoma volume (R=0.12, p=0.42) and total ICH volume (R=0.14, p=0.34). Mean prehospital SBP in patients with hematoma volumes &lt;33 ml (169 ± 32 mmHg) was similar to those ≥33 ml (177 ± 32 mmHg, p=0.45). Similar results were found with 15 ml (p=0.82), 45 ml (p=0.52), and 60 ml (p=0.50) hematoma volume cutoffs. Mean prehospital SBP in patients with total ICH volume &lt;33 ml was similar (168 ± 33 mmHg) to those ≥33 ml (177 ± 31 mmHg, p=0.39). IVH was present in 16 (32%) patients. The mean prehospital BP did not differ in patients with IVH (180 ± 27 mmHg) when compared to those without IVH (169 ± 34 mmHg, p=0.10). CONCLUSION: Prehospital BP is consistently high across different ICH volumes. Hematoma and total ICH volumes are independent of prehospital BP. These findings do not preclude a prehospital BP treatment effect.

Safety and feasibility of intravenous rt-PA in the Emergency Department without a neurologist-based stroke unit: an observational study.

Early intravenous thrombolysis has proven to be a safe and effective therapy for selected patients with acute ischemic stroke (AIS). Nowadays, thrombolysis is usually delivered by neurologists in "hub" referral centers. However, only a few among eligible patients actually receive treatment. Barriers to early administration of thrombolysis are represented by delays in presentation to referral centers, in-hospital and transfer delays, as well as changes in symptoms during assessment time. The aim of this study is to evaluate the safety and rate of thrombolysis provided in Emergency Department (ED) of a district hospital without neurological stroke team. Consecutive patients with AIS treated with intravenous thrombolysis were prospectively enrolled in this observational study, conducted between May 2010 and December 2013. The main outcomes evaluated were: mortality, symptomatic intracerebral hemorrhage (ICH), systemic adverse events, and neurological recovery. Secondly, all patients admitted with ischemic stroke were retrospectively screened to assess the reasons for exclusion to treatment and the rate of thrombolysis delivered. During the study period, 43 patients with AIS received intravenous rt-PA treatment. The mortality rate at three months was 9.5 % (4/43; 95 % CI 2.6-22.1) and total ICH at any-time CT scan imaging was 18.6 % (8/43; 8.4-33.4). At seven days or at discharge, 35/43 patients (81.4 %; 66.6-91.6) presented a neurological improvement and 46.5 % (20/43; 31.2-62.3) a complete neurological recovery presenting a normal NIHSS, while 9.5 % of patients remained in steady conditions and other 9.5 % worsened (4/43; 2.6-22.1). Outcomes do not appear to be very different from those reported in SITS-MOST study cohort. Among the overall 732 patients with AIS, 117 (16.0 %; 13.4-18.8) were eligible for age and arrived within the three-hour window of time, and the thrombolysis rate was 5.9 % (43/732; 4.3-7.8). Administration of rt-PA in an ED setting without neurological specialized stroke unit seems to be feasible and safe after adequate training. Thrombolysis rate found seems to be favorably comparable with the national average in specialist stroke units. If such data were confirmed by studies of greater dimension, this may imply the ability to perform thrombolysis even in smaller centers without the neurologist, thus being able to treat a greater number of patients in the times proven effective for thrombolysis.

Statins and intracerebral hemorrhage

Objective To briefly review the literature regarding the impact of statins on the prevention and treatment of stroke, especially on intracerebral hemorrhage (ICH). We described statins' effects, mechanism of ICH, serum total cholesterol and ICH, and the relationship between statins and ICH. Data sources All articles used in this review were mainly searched from the PubMed database with no limitations of language and year of publication. Study selection Randomized controlled studies, prospective cohort studies, animal experiments, and meta-analysis articles related to this topic in the past decade were selected. Results Statins play an important role in the primary and secondary prevention of cardiovascular diseases and also have an impact on the treatment of vascular diseases. There still exist controversies about the relationship between statins and ICH. More clinical and experimental trials indicate that statins do not increase the risk of ICH. Conclusion A low or a regular dose of statins would not increase the risk of ICH.