Absolute risk and predictors of the growth of acute spontaneous intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data

Standards for Detecting, Interpreting, and Reporting Noncontrast Computed Tomographic Markers of Intracerebral Hemorrhage Expansion

Significant hematoma expansion (HE) affects one-fifth of people within 24 hours after acute intracerebral hemorrhage (ICH), and its prevention is an appealing treatment target. Although the computed tomography (CT)-angiography spot sign predicts HE, only a minority of ICH patients receive contrast injection. Conversely, noncontrast CT (NCCT) is used to diagnose nearly all ICH, so NCCT markers represent a widely available alternative for prediction of HE. However, different NCCT signs describe similar features, with lack of consensus on the optimal image acquisition protocol, assessment, terminology, and diagnostic criteria. In this review, we propose practical guidelines for detecting, interpreting, and reporting NCCT predictors of HE. ANN NEUROL 2019;86:480-492.

Serial Metabolic Evaluation of Perihematomal Tissues in the Intracerebral Hemorrhage Pig Model

Purpose

Perihematomal edema (PHE) occurs in patients with intracerebral hemorrhage (ICH) and is often used as surrogate of secondary brain injury. PHE resolves over time, but little is known about the functional integrity of the tissues that recover from edema. In a pig ICH model, we aimed to assess metabolic integrity of perihematoma tissues by using non-invasive magnetic resonance spectroscopy (MRS).

Materials and Methods

Fourteen male Yorkshire pigs with an average age of 8 weeks were intracerebrally injected with autologous blood to produce ICH. Proton MRS data were obtained at 1, 7, and 14 days after ICH using a whole-body 3.0T MRI system. Point-resolved spectroscopy (PRESS)-localized 2D chemical shift imaging (CSI) was acquired. The concentration of N-Acetylaspartate (NAA), Choline (Cho), and Creatine (Cr) were measured within the area of PHE, tissues adjacent to the injury with no or negligible edema (ATNE), and contralesional brain tissue. A linear mixed model was used to analyze the evolution of metabolites in perihematomal tissues, with p-value < 0.05 indicating statistical significance.

Results

The perihematoma volume gradually decreased from 2.38 ± 1.23 ml to 0.41 ± 0.780 ml (p < 0.001) over 2 weeks. Significant (p < 0.001) reductions in NAA, Cr, and Cho concentrations were found in the PHE and ATNE regions compared to the contralesional hemisphere at day 1 and 7 after ICH. All three metabolites were significantly (p < 0.001) restored in the PHE tissue on day 14, but remained persistently low in the ATNE area, and unaltered in the contralesional voxel.

Conclusion

This study highlights the potential of MRS to probe salvageable tissues within the perihematoma in the sub-acute phase of ICH. Altered metabolites within the PHE and ATNE regions in addition to edema and hematoma volumes were explored as possible markers for tissue recovery. Perihematomal tissue with PHE demonstrated a more reversible injury compared to the tissue adjacent to the injury without edema, suggesting a potentially beneficial role of edema.

Prise en charge hémostatique des hémorragies cérébrales sous anticoagulants oraux

L’hématome intracrânien spontané a un pronostic clinique sévère. Le devenir des patients dépend de l’efficacité de la prise en charge initiale. L’importance du saignement, le volume de l’hématome et son évolution sont les facteurs principaux qui contrôlent mortalité et morbidité. Les traitements anticoagulants oraux, antivitamines K (AVK) et anticoagulants oraux directs (AOD), favorisent l’expansion de l’hématome. La correction rapide de l’hémostase permet le contrôle partiel de l’hématome. Alors que la réversion des AVK par les concentrés de complexe prothrombinique (CCP) a fait l’objet de recommandations bien diffusées, l’attitude thérapeutique reste peu codifiée avec les AOD, alliant l’utilisation de l’idarucizumab pour le dabigatran et des CCP pour les anti-Xa qui n’ont, pour l’instant, pas d’antidote.

Association of Intensive Blood Pressure Reduction With Risk of Hematoma Expansion in Patients With Deep Intracerebral Hemorrhage

Importance

Hypertension is the strongest risk factor for spontaneous intracerebral hemorrhage (ICH) involving deep brain regions, but it appears to be unknown if intensive blood pressure reduction in the acute care setting decreases hematoma expansion or improves outcomes in patients with deep ICH.

Objective

To determine whether intensive blood pressure reduction is associated with decreased risk of hematoma expansion and changes in 90-day modified Rankin Scale scores and if these associations are modified by the specific deep-brain nuclei involved.

Design, Setting, and Participants

This study is an exploratory analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage-2 international, multicenter randomized clinical trial, which was conducted from May 2011 to September 2015, enrolled eligible patients with primary ICH, and followed up with them for 90 days. Patients who had ICH and complete neuroimaging data were included in the analysis. Data analysis was completed from July 2018 to December 2018.

Exposures

Participants were randomized to either intensive treatment (with a systolic blood pressure target of 110-139 mm Hg) or standard treatment (with a systolic blood pressure target of 140-179 mm Hg).

Main Outcomes and Measures

The main outcome was hematoma expansion, defined as an increase greater than 33% in hematoma volume between baseline and 24 hours. Functional outcome was evaluated 90 days after the ICH via the modified Rankin Scale.

Results

Of 1000 trial participants, 870 (87.0%) had deep ICH, of whom 780 (89.7%) had complete neuroimaging data (of 336 thalamic and 444 basal ganglia hemorrhages). The baseline characteristics of the intensive and standard treatment groups remained balanced in this subgroup of the original study. Intensive treatment was associated with a decreased risk of hematoma expansion in univariable analysis (odds ratio [OR], 0.62 [95% CI, 0.43-0.87]; P = .006) and multivariable analysis (OR, 0.61 [95% CI, 0.42-0.88]; P = .009). This association was modified by the specific deep location of the ICH (OR, 0.44 [95% CI, 0.22-0.96]; interaction P = .02), with stratified analyses showing a reduction in risk of hematoma expansion with intensive vs standard treatment among basal ganglia ICH (OR, 0.44 [95% CI, 0.27-0.72]; P = .001) but not thalamic ICH (OR, 0.91 [95% CI, 0.51-0.64]; P = .76). Intensive treatment was not associated with an improvement in the modified Rankin Scale score distribution.

Conclusions and Relevance

Compared with standard treatment, intensive blood pressure treatment was associated with reduced hematoma expansion in deep ICH, specifically among basal ganglia hemorrhages.

Intracerebral hemorrhage: an update on diagnosis and treatment

Introduction: Spontaneous non-traumatic intracerebral hemorrhage (ICH) is most often caused by small vessel diseases: deep perforator arteriopathy (hypertensive arteriopathy) or cerebral amyloid angiopathy (CAA). Although ICH accounts for only 10-15% of all strokes it causes a high proportion of stroke mortality and morbidity, with few proven effective acute or preventive treatments. Areas covered: We conducted a literature search on etiology, diagnosis, treatment, management and current clinical trials in ICH. In this review, We describe the causes, diagnosis (including new brain imaging biomarkers), classification, pathophysiological understanding, treatment (medical and surgical), and secondary prevention of ICH. Expert opinion: In recent years, significant advances have been made in deciphering causes, understanding pathophysiology, and improving acute treatment and prevention of ICH. However, the clinical outcome remains poor and many challenges remain. Acute interventions delivered rapidly (including medical therapies - targeting hematoma expansion, hemoglobin toxicity, inflammation, edema, anticoagulant reversal - and minimally invasive surgery) are likely to improve acute outcomes. Improved classification of the underlying arteriopathies (from neuroimaging and genetic studies) and prognosis should allow tailored prevention strategies (including sustained blood pressure control and optimized antithrombotic therapy) to further improve longer-term outcome in this devastating disease.

Effects of Candesartan in the Acute Phase of Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Uncertainty persists over the effects of blood pressure-lowering treatment in acute intracerebral hemorrhage (ICH). We assessed the effects of treatment with candesartan in acute ICH and according to different types of hematoma.

METHODS

Post-hoc analysis of the Scandinavian Candesartan Acute Stroke Trial, a randomized- and placebo-controlled, double-masked trial of candesartan in patients with any stroke within the acute phase (<30 hours) and high systolic blood pressure (≥140 mm Hg). We collected baseline computed tomography scans of participants with ICH, and characterized hematoma volume (planimetric approach), location (deep versus lobar or infratentorial), hemisphere side, and presence of intraventricular hemorrhage. The trial's 2 coprimary effect variables were the composite endpoint of vascular death, stroke or myocardial infarction, and functional outcome at 6 months according to the modified Rankin scale. We used Cox, ordinal, and binary logistic regression for analysis and adjusted for key, predefined prognostic variables.

RESULTS

Of 274 participants with ICH, computed tomography scans were available in 205 patients (74.8%). There were no significant differences between the candesartan and placebo groups with respect to hematoma volume (median 15.6 mL versus 13.5 mL, P = .96), deep location (77% versus 72%, P = .64), right hemisphere (49% versus 51%, P = .46), and presence of intraventricular hemorrhage (18% versus 11%, P = .22). Candesartan was associated with a significant increase in poor functional outcome in patients with deep hematoma (adjusted common odds ratio 2.27, 95% confidence interval 1.23-4.18, P = .009, P for interaction .015), but there was no differential effect on functional outcome or vascular events in any of the other imaging subgroups.

CONCLUSIONS

Candesartan was not associated with any beneficial effect when initiated in the acute phase of ICH, a possible adverse effect on functional outcome in patients with deep hematomas cannot be ruled out by this study alone.

Reversal of oral anticoagulation in patients with acute intracerebral hemorrhage

In light of an aging population with increased cardiovascular comorbidity, the use of oral anticoagulation (OAC) is steadily expanding. A variety of pharmacological alternatives to vitamin K antagonists (VKA) have emerged over recent years (direct oral anticoagulants, DOAC, i.e., dabigatran, rivaroxaban, apixaban, and edoxaban) which show a reduced risk for the occurrence of intracerebral hemorrhage (ICH). Yet, in the event of ICH under OAC (OAC-ICH), hematoma characteristics are similarly severe and clinical outcomes likewise substantially limited in both patients with VKA- and DOAC-ICH, which is why optimal acute hemostatic treatment in all OAC-ICH needs to be guaranteed. Currently, International Guidelines for the hemostatic management of patients with OAC-ICH are updated as several relevant large-sized observational studies and recent trials have established treatment approaches for both VKA- and DOAC-ICH. While the management of VKA-ICH is mainly based on the immediate reversal of elevated levels of international normalized ratio using prothrombin complex concentrates, hemostatic management of DOAC-associated ICH is challenging requiring specific antidotes, notably idarucizumab and andexanet alfa. This review will provide an overview of the latest studies and trials on hemostatic reversal agents and timing and summarizes the effects on hemorrhage progression and clinical outcomes in patients with OAC-ICH.

The REstart or STop Antithrombotics Randomised Trial (RESTART) after stroke due to intracerebral haemorrhage: statistical analysis plan for a randomised controlled trial

BACKGROUND

For adults surviving stroke due to spontaneous (non-traumatic) intracerebral haemorrhage (ICH) who had taken an antithrombotic (i.e. anticoagulant or antiplatelet) drug for the prevention of vaso-occlusive disease before the ICH, it is unclear whether starting antiplatelet therapy modifies the risks of recurrent ICH, major haemorrhagic events, major occlusive vascular events, or a composite of all major vascular events compared to avoiding antiplatelet therapy.

METHODS/DESIGN

The REstart or STop Antithrombotics Randomised Trial (RESTART) is an investigator-led, parallel group, open, assessor-blind, randomised trial comparing starting versus avoiding antiplatelet therapy for adults surviving antithrombotic-associated ICH. Recruitment began on 22 May 2013 and ended on 31 May 2018. Follow-up ended on 30 November 2018. This update to the protocol describes the statistical analysis plan (version 1.7, finalised on 25 January 2019). Database lock and un-blinding occurred on 29 January 2019, after which the un-masked trial statistician conducted the final analyses according to this statistical analysis plan.

DISCUSSION

Final results of RESTART will be analysed and disseminated in May 2019.

TRIAL REGISTRATION

ISRCTN registry 71907627 . Prospectively registered on 25 April 2013.

Recent advances in spontaneous intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a stroke subtype associated with significant morbidity and mortality. The purpose of this review is to provide an update on important research on ICH over the past three years. Topics covered include risk factors, imaging predictors of hematoma expansion, scoring schema to predict hematoma expansion, hemostatic therapies, acute blood pressure lowering, intraventricular administration of alteplase for intraventricular hemorrhage, and the current status of surgical therapies.

BAT Score Versus Spot Sign in Predicting Intracerebral Hemorrhage Expansion

OBJECTIVE

The BAT score is a novel prediction score of hematoma expansion based on noncontrast computed tomography (CT) and consists of the blend sign, hypodensities, and time interval from onset to CT. This study aimed to compare the BAT score and the spot sign on CT angiography in a cohort of patients with spontaneous intracerebral hemorrhage.

METHODS

Eligible patients with spontaneous intracerebral hemorrhage were analyzed retrospectively. The BAT score and the spot sign were assessed according to the criteria described in previous studies. Receiver operating curve analysis was used to assess the performance of the BAT score and the spot sign in hematoma expansion prediction.

RESULTS

In 225 included patients, 34 (15.1%) had a BAT score ≥3. The spot sign was shown in 68 (30.2%) patients. Hematoma expansion was identified in 56 (24.9%) patients. In multivariate analysis, both BAT score ≥3 and presence of spot sign were independently correlated with hematoma expansion. BAT score ≥3 had 0.41 sensitivity and 0.93 specificity, and spot sign had 0.64 sensitivity and 0.81 specificity. The area under the curve of BAT score ≥3 and area under the curve of spot sign were 0.673 and 0.727, respectively (P = 0.386).

CONCLUSIONS

The BAT score based on noncontrast CT is a good predictor of hematoma expansion. When CT angiography spot sign is unobtainable, the BAT score can be used to predict hematoma expansion.

Intracerebral hemorrhage outcome: A comprehensive update

Non-traumatic intracerebral hemorrhage (ICH) is associated with a significant global burden of disease, and despite being proportionally less frequent than ischemic stroke, in 2010 it was associated with greater worldwide disability-adjusted life years lost. The focus of outcome assessment after ICH has been mortality in most studies, because of the high early case fatality which reaches 40% in some population-based studies. The most robust and consistent predictors of early mortality include age, severity of neurological impairment, hemorrhage volume and antithrombotic therapy at the time of the event. Long-term outcome assessment is multifaceted and includes not only mortality and functional outcome, but also patient self-assessment of the health-related quality of life, occurrence of cognitive impairment, psychiatric disorders, epileptic seizures, recurrent ICH and subsequent thromboembolic events. Several scores which predict mortality and functional outcome after ICH have been validated and are useful in the daily clinical practice, however they must be used in combination with the clinical judgment for individualized patients. Management of patients with ICH both in the acute and chronic phases, requires health care professionals to have a comprehensive and updated perspective on outcome, which informs decisions that are needed to be taken together with the patient and next of kin.