Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage

Inhibitors of early mobilization in the acute phase of intracerebral hemorrhage: A retrospective observational study

OBJECTIVES

The association between early mobilization and functional prognosis in the acute phase of intracerebral hemorrhage has been reported, but only a few studies have investigated the inhibitors of early mobilization in the acute phase of intracerebral hemorrhage. This study aimed to investigate the inhibitors of early mobilization.

MATERIALS AND METHODS

The study enrolled 322 patients with intracerebral hemorrhage. In the early mobilization group, mobilization was started within 72 h from onset, and in the delayed mobilization group, mobilization was started at or after 72 h from onset. The association between the start of mobilization timing and baseline characteristics was investigated using univariate and multivariate analyses to clarify the inhibitors of early mobilization in the acute phase of intracerebral hemorrhage.

RESULTS

Significant differences between the early mobilization and delayed mobilization groups were observed in the lesion site, leukocyte count at admission, neutrophil count at admission, C-reactive protein level at admission, surgery, use of mechanical ventilation, consciousness level at admission, hematoma volume, and hematoma growth. In the multiple logistic regression analysis, five items were adopted, namely, low consciousness level at admission, lesion below the tent, surgery, C-reactive protein at admission, and hematoma growth.

CONCLUSIONS

In this study, low consciousness level at admission, lesion below the tent, surgery, C-reactive protein level at admission, and hematoma growth affected delayed mobilization. Therefore, it is recommended to judge the start of mobilization timing by a systematic evidenced-based assessment for each case.

Effect of Hypertension on Efficacy and Safety of Ticagrelor-Aspirin Versus Clopidogrel-Aspirin in Minor Stroke or Transient Ischemic Attack

BACKGROUND

Hypertension is a risk factor of poor stroke outcomes and associated with antiplatelet resistance. This study aimed to explore the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in patients with different hypertension status, using randomized trial data from the CHANCE-2 trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II).

METHODS

A total of 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles were enrolled and randomized to either ticagrelor-aspirin or clopidogrel-aspirin group. Hypertension status were classified into no, newly diagnosed, and previously diagnosed hypertension according to medical history, blood pressure, and antihypertensive medications during hospitalization. The primary efficacy and safety outcomes were stroke recurrence and moderate to severe bleeding risk within 90-day follow-up.

RESULTS

Ticagrelor-aspirin was associated with reduced risk of new stroke in patients without hypertension (32 [4.8%] versus 60 [7.2%]; hazard ratio, 0.55 [95% CI, 0.35-0.86]), but not in those with a newly diagnosed hypertension (20 [5.3%] versus 36 [9.1%]; hazard ratio 0.59 [95% CI, 0.33-1.07]), or those with a previously diagnosed hypertension (139 [7.0%] versus 147 [7.4%]; hazard ratio, 0.93 [95% CI, 0.74-1.18]) compared with clopidogrel-aspirin (P=0.04 for interaction). The risk of bleeding for ticagrelor-aspirin was not associated with hypertension status (0.1% versus 0.4%; 0.3% versus 0.5%, 0.4% versus 0.3%, P=0.50 for interaction). All the efficacy and safety outcomes between treatments did not differ by blood pressure levels on admission.

CONCLUSIONS

In the CHANCE-2 trial, patients without hypertension received a significantly greater benefit from ticagrelor- aspirin than those with previous hypertension after minor stroke or transient ischemic attack, and a similar benefit trend was observed in those with newly diagnosed hypertension.

REGISTRATION

URL: http://www.

CLINICALTRIALS

gov; Unique identifier: NCT04078737.

Review of Long-Term Blood Pressure Control After Intracerebral Hemorrhage: Challenges and Opportunities

Blood pressure (BP) is the most important modifiable risk factor for intracerebral hemorrhage (ICH). Elevated BP is associated with an increased risk of ICH, worse outcome after ICH, and in survivors, higher risks of recurrent ICH, ischemic stroke, myocardial infarction, and cognitive impairment/dementia. As intensive BP control probably improves the chances of recovery from acute ICH, the early use of intravenous or oral medications to achieve a systolic BP goal of <140 mm Hg within the first few hours of presentation is reasonable for being applied in most patients. In the long-term, oral antihypertensive drugs should be titrated as soon as possible to achieve a goal BP <130/80 mm Hg and again in all ICH patients regardless of age, location, or presumed mechanism of ICH. The degree of sustained BP reduction, rather than the choice of BP-lowering agent(s), is the most important factor for optimizing risk reduction, with varying combinations of thiazide-type diuretics, long-acting calcium channel blockers, ACE (angiotensin-converting enzyme) inhibitors or angiotensin receptor blockers, being the mainstay of therapy. As most patients will require multiple BP-lowering agents, and physician inertia and poor adherence are major barriers to effective BP control, single-pill combination therapy should be considered as the choice of management where available. Increased population and clinician awareness, and innovations to solving patient, provider, and social factors, have much to offer for improving BP control after ICH and more broadly across high-risk groups. It is critical that all physicians, especially those managing ICH patients, emphasize the importance of BP control in their practice.

Temporal Trajectory of Systolic Blood Pressure and Outcomes in Acute Intracerebral Hemorrhage: ATACH-2 Trial Cohort

BACKGROUND

To highlight the heterogeneity of acute temporal blood pressure (BP) changes in the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) and associations with the outcomes of intracerebral hemorrhage.

METHODS

One thousand patients with acute intracerebral hemorrhage, who had been randomized to intensive (110-139 mm Hg) or standard (140-179 mm Hg) systolic BP (SBP) lowering with intravenous nicardipine in ATACH-2 from 2011 to 2015, were analyzed about temporal changes in hourly maximum SBP up to 24 hours after randomization using group-based trajectory modeling. Outcomes included death or disability (modified Rankin Scale score 4-6) at 3 months, neurological deterioration within 24 hours (≥2-point decrease in Glasgow Coma Scale score or ≥4-point increase in National Institutes of Health Stroke Scale score), and acute kidney injury (≥0.3 mg/dL within 48 hours or ≥1.5-fold increase in serum creatinine) within 7 days after onset.

RESULTS

Group-based trajectory modeling revealed 4 SBP trajectory groups: moderate SBP (from ≈190 mm Hg at hospital arrival to 150-160 mm Hg after randomization; n=298), moderate-to-low SBP (from ≈190 mm Hg to <140 mm Hg; n=395), high-to-low SBP (from >210 mm Hg to <140 mm Hg; n=134), and high SBP (from >210 mm Hg to 160-170 mm Hg; n=173). Patients with intensive treatment accounted for 11.1%, 88.6%, 85.1%, and 1.7% of each group, respectively. Compared with the moderate-to-low SBP group, the high-to-low SBP group showed increased risks of death or disability at 3 months (adjusted odds ratio, 2.29 [95% CI, 1.24-4.26]) and acute kidney injury (adjusted odds ratio, 3.50 [95% CI, 1.83-6.69]), while no increase in neurological deterioration was seen in this group (adjusted odds ratio, 0.48 [95% CI, 0.20-1.13]). The moderate SBP and high SBP groups showed no significant risk differences for such outcomes.

CONCLUSIONS

Data-driven observation using a group-based trajectory modeling approach may be useful to clarify the relationship between antihypertensive treatment, temporal SBP changes, and outcomes in acute intracerebral hemorrhage.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT01176565.

The Management of Hypertensive Emergencies-Is There a "Magical" Prescription for All?

Hypertensive emergencies (HE) represent high cardiovascular risk situations defined by a severe increase in blood pressure (BP) associated with acute, hypertension mediated organ damage (A-HMOD) to the heart, brain, retina, kidneys, and large arteries. Blood pressure values alone do not accurately predict the presence of HE; therefore, the search for A-HMOD should be the first step in the management of acute severe hypertension. A rapid therapeutic intervention is mandatory in order to limit and promote regression of end-organ damage, minimize the risk of complications, and improve patient outcomes. Drug therapy for HE, target BP, and the speed of BP decrease are all dictated by the type of A-HMOD, specific drug pharmacokinetics, adverse drug effects, and comorbidities. Therefore, a tailored approach is warranted. However, there is currently a lack of solid evidence for the appropriate treatment strategies for most HE. This article reviews current pharmacological strategies while providing a stepwise, evidence based approach for the management of HE.

ED BP Management for Subarachnoid Hemorrhage

PURPOSE OF REVIEW

To review most recent literature on management of blood pressure in acute aneurysmal subarachnoid hemorrhage (SAH) and provide practice recommendations for the emergency clinician.

RECENT FINDINGS

There is increased risk of aneurysmal rebleeding with systolic blood pressure (SBP) greater than 160 mmHg in the acute setting. Avoiding large degrees of blood pressure variability improves clinical outcomes in aneurysmal SAH. Acute lowering of SBP to a range of 140-160 mmHg decreases risk of rebleeding while also maintaining cerebral perfusion pressure (CPP) after aneurysmal rupture. Treatment with a short acting antihypertensive agent allows for rapid titration of blood pressure (BP) and reduces BP variability. Elevations in intracranial pressure occur commonly after SAH due to increased intracranial blood volume, cerebral edema, or development of hydrocephalus. Clinicians should be familiar with changes in cerebral autoregulation and effects on CPP when treating elevated BP, in order to mitigate the risk of secondary neurological injury.

Lateral Ventricular Volume Asymmetry and Optic Nerve Sheath Diameter Predict Intracranial Pressure in Traumatic Brain Injury Patients

Background

Various noninvasive methods of intracranial pressure (ICP) measurement have been proposed. Each has unique advantages and limitations. This study was aimed at investigating the relationships between lateral ventricular asymmetry on admission computed tomography, optic nerve sheath diameter (ONSD), and ICP in traumatic brain injury (TBI) patients.

Methods

A prospective observational study was conducted in the patients admitted to our department between October 2018 and October 2020. 20 patients with moderate-severe TBI with a Glasgow Coma Scale of 3-12 were enrolled. Lateral ventricle volume (LVV) value measurements were conducted using ITK-SNAP software. The lateral ventricular volume ratio (LVR) was quantified by dividing the larger LVV by the smaller.

Results

ONSD and LVR had a good correlation with ICP. Admission LVR of >1.735 was shown to have a sensitivity of 90.9% and a specificity of 88.9% for prediction of ICP increase (AUC = 0.879; standard error = 0.091; 95% CI = 0.701 to 1.0; significance level p < 0.004). Admission ONSD of >5.55 mm was shown to have a sensitivity of 81.8% and a specificity of 88.9% for prediction of ICP increase (AUC = 0.919; standard error = 0.062; 95% CI = 0.798 to 1.0; significance level p < 0.002). Combining the ONSD and LVR, the sensitivity could be improved to 90.9% in parallel test, and the specificity could be improved to 100% in serial test.

Conclusion

ONSD and LVR measurements can diagnose elevated ICP in traumatic brain injury patients. ONSD combining with LVR may further improve the diagnostic evaluation.

Automatic and Efficient Prediction of Hematoma Expansion in Patients with Hypertensive Intracerebral Hemorrhage Using Deep Learning Based on CT Images

Patients with hypertensive intracerebral hemorrhage (ICH) have a high hematoma expansion (HE) incidence. Noninvasive prediction HE helps doctors take effective measures to prevent accidents. This study retrospectively analyzed 253 cases of hypertensive intraparenchymal hematoma. Baseline non-contrast-enhanced CT scans (NECTs) were collected at admission and compared with subsequent CTs to determine the presence of HE. An end-to-end deep learning method based on CT was proposed to automatically segment the hematoma region, region of interest (ROI) feature extraction, and HE prediction. A variety of algorithms were employed for comparison. U-Net with attention performs best in the task of segmenting hematomas, with the mean Intersection overUnion (mIoU) of 0.9025. ResNet-34 achieves the most robust generalization capability in HE prediction, with an area under the receiver operating characteristic curve (AUC) of 0.9267, an accuracy of 0.8827, and an F1 score of 0.8644. The proposed method is superior to other mainstream models, which will facilitate accurate, efficient, and automated HE prediction.

Development and Validation of a Clinical-Based Signature to Predict the 90-Day Functional Outcome for Spontaneous Intracerebral Hemorrhage

We aimed to develop and validate an objective and easy-to-use model for identifying patients with spontaneous intracerebral hemorrhage (ICH) who have a poor 90-day prognosis. This three-center retrospective study included a large cohort of 1,122 patients with ICH who presented within 6 h of symptom onset [training cohort, n = 835; internal validation cohort, n = 201; external validation cohort (center 2 and 3), n = 86]. We collected the patients’ baseline clinical, radiological, and laboratory data as well as the 90-day functional outcomes. Independent risk factors for prognosis were identified through univariate analysis and multivariate logistic regression analysis. A nomogram was developed to visualize the model results while a calibration curve was used to verify whether the predictive performance was satisfactorily consistent with the ideal curve. Finally, we used decision curves to assess the clinical utility of the model. At 90 days, 714 (63.6%) patients had a poor prognosis. Factors associated with prognosis included age, midline shift, intraventricular hemorrhage (IVH), subarachnoid hemorrhage (SAH), hypodensities, ICH volume, perihematomal edema (PHE) volume, temperature, systolic blood pressure, Glasgow Coma Scale (GCS) score, white blood cell (WBC), neutrophil, and neutrophil-lymphocyte ratio (NLR) (p < 0.05). Moreover, age, ICH volume, and GCS were identified as independent risk factors for prognosis. For identifying patients with poor prognosis, the model showed an area under the receiver operating characteristic curve of 0.874, 0.822, and 0.868 in the training cohort, internal validation, and external validation cohorts, respectively. The calibration curve revealed that the nomogram showed satisfactory calibration in the training and validation cohorts. Decision curve analysis showed the clinical utility of the nomogram. Taken together, the nomogram developed in this study could facilitate the individualized outcome prediction in patients with ICH.

A Longitudinal Research on the Distribution and Prognosis of Intracerebral Hemorrhage During the COVID-19 Pandemic

Purpose

Globally, intracerebral hemorrhage (ICH) is a common cerebrovascular disease. At the beginning of 2020, due to the coronavirus disease 2019 (COVID-19) pandemic, the allocation of medical resources and the patient treatment and referrals were affected to varying degrees. We aimed to determine the characteristics and prognoses and associated factors of patients with ICH.

Patients and Methods

The baseline demographic characteristics and ICH outcomes were compared between patients diagnosed with ICH between January and June 2020 (the 2020 group) and between January and June 2019 (the 2019 group). COVID-19 positive patients were excluded from the study. A 30-day data from patients in the 2019 and 2020 groups were analyzed to create survival curves for these patients. We also used regression models to identify the significant determinants of poor outcomes [modified Rankin score (mRS): 3-6] and death.

Results

The number of patients diagnosed with ICH was slightly lower in the 2020 group (n = 707) than in the 2019 group (n = 719). During the lockdown period (February 2020), the admission rates for ICH decreased greatly by 35.1%. The distribution of the patients' domicile (P = 0.002) and the mRS (P < 0.001) differed significantly between the years. The survival curve revealed that the highest risk of death was in the acute stage (especially in the first 5 days) of ICH. At 30 days, mortality was 19.8% in February 2019 and 29.4% in February 2020 (P = 0.119). Multivariate analysis revealed age, baseline mRS, postoperative complications, massive brainstem hemorrhage, and creatinine as factors significantly associated with poor outcomes and death following ICH. Neurosurgery and massive supratentorial hemorrhage were only correlated with the risk of death.

Conclusion

During the lockdown period, the COVID-19 pandemic caused a decrease in the admission rates and severe conditions at admission due to strict traffic constraints for infection control. This led to high mortality and disability in patients with ICH. It is necessary to ensure an effective green channel and allocate adequate medical resources for patients to receive timely treatment and neurosurgery.

Pharmacological Management of Primary Arterial Hypertension: A Century of Expert Opinions in Cecil Textbook of Medicine

BACKGROUND

Advances in drug therapy for primary (or essential) arterial hypertension have contributed to a significant decrease in the frequency and severity of strokes, coronary artery disease and heart failure, and chronic renal insufficiency.

STUDY QUESTION

What are the milestones of the changes in the expert approach to the pharmacological management of arterial hypertension in the past century?

STUDY DESIGN

To determine the changes in the experts' approach to the management of arterial hypertension, as presented in a widely used textbook in the United States.

DATA SOURCES

The chapters presenting the management of arterial hypertension in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020.

RESULTS

The pharmacological management of arterial hypertension has had 3 overlapping eras in the timeframe subject to our investigation. In the empiric era (1927-1947), experts were recommending nonspecific interventions for sedation. The premodern era (1955-1963) relied on ganglion blockers, sympathetic blockers, and direct vasodilators. The modern era (1967-2020), which includes drugs used in current clinical practice, saw the introduction of diuretics (1967), beta-blockers (1971), alpha-blockers (1982), calcium channel blockers (1985), angiotensin-converting enzyme inhibitors (1985), angiotensin receptor blockers (2000), and direct renin inhibitors (2008).

CONCLUSIONS

The pharmacological management of arterial hypertension has been the focus of intense and successful research and development in the second half of the 20th century.

Systolic blood pressure measurements are unreliable for the management of acute spontaneous intracerebral hemorrhage

PURPOSE

Whether systolic blood pressure (SBP) is reliable in acute spontaneous intracerebral (sICH) by assessing agreement between simultaneous BP measurements obtained from cuff non-invasive blood pressure (NIBP) and radial arterial invasive blood pressure (AIBP) devices.

MATERIAL AND METHODS

Among 766 prospectively screened sICH subjects, 303 (39.5%) had NIBP and AIBP measurements. During the first 24 h, 2157 simultaneous paired measurement readings were abstracted. Paired NIBP/AIBP measurements were included in a Bland-Altman technique with 95% agreement limits and coefficients from regression analysis derived from a bootstrap procedure.

RESULTS

Variance for SBP was 66.1 mmHg, which was larger than the 44.3 mg Hg for diastolic blood pressure (DBP) or the 46.1 mmHg for mean arterial pressure (MAP). Pairwise comparison of mean biases showed a significant difference between SBP when compared to DBP (p < 0.0001) or MAP (p < 0.0001). The mean bias between DBP and MAP was not different (p = 0.68). Regression-based Bland Altman analysis found significant bias (slope -0.16, 95% CI -0.23, -0.09, p < 0.05) over the range of mean SBP. Bias over the range of mean DBP or MAP was not significant.

CONCLUSIONS

We concluded that SBP is an unreliable blood pressure measurement in patients with sICH.

Blood Pressure and Spot Sign in Spontaneous Supratentorial Subcortical Intracerebral Hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage is a potentially devastating cause of brain injury, often occurring secondary to hypertension. Contrast extravasation on computed tomography angiography (CTA), known as the spot sign, has been shown to predict hematoma expansion and worse outcomes. Although hypertension has been associated with an increased rate of the spot sign being present, the relationship between spot sign and blood pressure has not been fully explored.

METHODS

We retrospectively analyzed data from 134 patients (40 women and 94 men, mean age 62.3 ± 15.73 years) presenting to a tertiary academic medical center with spontaneous supratentorial subcortical intracerebral hemorrhage from 1/1/2018 to 1/4/2021.

RESULTS

A spot sign was demonstrated in images of 18 patients (13.43%) and correlated with a higher intracerebral hemorrhage score (2.61 ± 1.42 vs. 1.31 ± 1.25, p = 0.002), larger hematoma volume (53.49cm³ ± 32.08 vs. 23.45cm³ ± 25.65, p = 0.001), lower Glasgow Coma Scale on arrival (9.06 ± 4.56 vs. 11.74 ± 3.65, p = 0.027), increased risk of hematoma expansion (16.67% vs. 5.26%, p = 0.042), and need for surgical intervention (66.67% vs. 15.52%, p < 0.001). We did not see a correlation with age, sex, or underlying comorbidities. The presence of spot sign correlated with higher modified Rankin scores at discharge (4.94 ± 1.00 vs. 3.92 ± 1.64, p < 0.001). We saw significantly higher systolic blood pressure at the time of CTA in patients with a spot sign (184 mm Hg ± 43.11 vs. 153 mm Hg ± 36.99, p = 0.009) and the highest recorded blood pressure (p = 0.019), although not blood pressure on arrival (p = 0.081). Performing CTA early in the process of blood pressure lowering was associated with a spot sign (p < 0.001).

CONCLUSIONS

The presence of spot sign correlates with larger hematomas, worse outcomes, and increased surgical intervention. There is a significant association between spot sign and systolic blood pressure at the time of CTA, with the highest systolic blood pressure being recorded prior to CTA. Although the role of intensive blood pressure management in spontaneous intracerebral hemorrhage remains a subject of debate, patients with a spot sign may be a subgroup that could benefit from this.

Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions

Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.

Long-Term Survival, Stroke Recurrence, and Life Expectancy After an Acute Stroke in Australia and New Zealand From 2008-2017: A Population-Wide Cohort Study

BACKGROUND

Data on long-term outcomes following an acute stroke are sparse. We assessed survival, risk of recurrent stroke and loss in life expectancy following an acute stroke using population-wide data from Australia and New Zealand.

METHODS

We included all adults with the first stroke hospitalization during 2008 and 2017 at all public and most private hospitals. Patients were followed up to 10 years after the stroke by linkage to each region's Registry of Deaths and subsequent hospitalizations. Flexible parametric survival modeling was used to estimate all-cause mortality, stroke recurrence, and loss in life expectancy. Competing risk model was used when estimating the risk of stroke recurrence.

RESULTS

Three hundred thirteen thousand one hundred sixty-two patients were included (mean age 73.0±14.6 y, 52.0% males) with ischemic stroke (175 547, 56.1%) being the most common, followed by hemorrhagic stroke (77 940, 24.9%) and unspecified stroke (59 675, 19.1%). The overall survival probability was 79.4% at 3 months, 73.0% at 1 year, 52.8% at 5 years, and 36.4% at 10 years. Cumulative incidence of stroke recurrence was 7.8% at 3 months, 11.0% at 1 year, 19.8% at 5 years, and 26.8% at 10 years. Hemorrhagic stroke was associated with greater mortality (hazard ratio, 2.02 [95% CI, 1.99-2.04]) and recurrent stroke (hazard ratio, 1.63 [95% CI, 1.59-1.67]) compared with ischemic stroke. Female sex (hazard ratio, 1.10 [95% CI, 1.09-1.11]) and increasing age (≥85 years versus 18-54 years: hazard ratio, 7.36 [95% CI, 7.15-7.57]) were also associated with increased mortality. Several risk factors including atherosclerotic coronary and noncoronary vascular disease, cardiac arrhythmia, and diabetes were associated with increased risk of mortality and recurrent stroke. Compared with the general population, an acute stroke was associated with a loss of 5.5 years of life expectancy, or 32.7% of the predicted life expectancy, and was pronounced in patients with a hemorrhagic stroke (7.4 years and 38.5% of predicted life expectancy lost).

CONCLUSIONS

In this population-wide study, death and recurrence of stroke were common after an acute stroke and an acute stroke was associated with considerable loss in life expectancy. Further improvements in treatment and secondary prevention of stroke are needed to reduce these risks.

Clinical and Prognostic Characteristics of Recurrent Intracerebral Hemorrhage: A Contrast to First-Ever ICH

This study aimed to compare clinical and prognostic characteristics between recurrent and first-ever ICH. Four thousand twelve patients entered the study, and 64% of them were male. The median age is 62 years (interquartile range, 55–71). Among them, 3,750 (93.5%) patients had no experience of previous ICH, and 262 (6.5%) patients were considered as recurrent ICH. We compared demographic data, baseline clinical characteristics, imaging information, hematological parameters, and clinical outcomes between recurrent and first-ever ICH. We found that recurrent ICH was significantly associated with older age, more frequent history of ischemic heart disease, ischemic stroke, hypertension, and hyperlipidemia, while patients with recurrent ICH had previously received more antihypertensive therapy, and showed lower admission blood pressure (median, 160 vs. 167 mmHg) and higher baseline of National Institute of Health stroke scale (NIHSS) score (median, 10 vs. 9). We also demonstrated that recurrent ICH was an independent risk factor of 3-month function dependence after adjusting for many potentially competitive risk factors.

Blood Pressure Management After Intracerebral and Subarachnoid Hemorrhage: The Knowns and Known Unknowns

Blood pressure (BP) elevations often complicate the management of intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage, the most serious forms of acute stroke. Despite consensus on potential benefits of BP lowering in the acute phase of intracerebral hemorrhage, controversies persist over the timing, mechanisms, and approaches to treatment. BP control is even more complex for subarachnoid hemorrhage, where there are rationales for both BP lowering and elevation in reducing the risks of rebleeding and delayed cerebral ischemia, respectively. Efforts to disentangle the evidence has involved detailed exploration of individual patient data from clinical trials through meta-analysis to determine strength and direction of BP change in relation to key outcomes in intracerebral hemorrhage, and which likely also apply to subarachnoid hemorrhage. A wealth of hemodynamic data provides insights into pathophysiological interrelationships of BP and cerebral blood flow. This focused update provides an overview of current evidence, knowledge gaps, and emerging concepts on systemic hemodynamics, cerebral autoregulation and perfusion, to facilitate clinical practice recommendations and future research.

Intracerebral haemorrhage volume, haematoma expansion and 3-month outcomes in patients on antiplatelets. A systematic review and meta-analysis

Aims

We assessed the association of prior antiplatelet therapy (APT) at onset of intracerebral haemorrhage (ICH) with haematoma characteristics and outcome.

Methods

We performed a systematic review and meta-analysis of studies comparing ICH outcomes of patients on APT (APT-ICH) with patients not taking APT (non-APT-ICH). Primary outcomes were haematoma volume (mean difference and 95% CI), haematoma expansion (HE), in-hospital 3-month mortality rates and good functional outcome (modified Rankin Scale score 0-2). We provide odds ratios (ORs) from random effects models and subgroup analyses for haematoma expansion and short-term mortality rates.

Results

We included 23 of 1551 studies on 30,949 patients with APT-ICH and 62,018 with non-APT-ICH. Patients on APT were older (Δmean 6.27 years, 95% CI 5.44-7.10), had larger haematoma volume (Δmean 5.74 mL, 95% CI 1.93-9.54), higher short-term mortality rates (OR 1.44, 95% CI 1.14-1.82), 3-month mortality rates (OR 1.58, 95% CI 1.14-2.19) and lower probability of good functional outcome (OR 0.61, 95% CI 0.49-0.77). While there was no difference in HE in the overall analysis (OR 1.32, 95% CI 0.85-2.06), HE occurred more frequently when assessed within 24 h (OR 2.58, 95% CI 1.18-5.67). We found insufficient data for comparison of single versus dual APT-ICH. Heterogeneity was substantial amongst studies.

Discussion

APT is associated with larger baseline haematoma volume, early (<24 h) haematoma expansion, mortality rates and morbidity in patients with ICH. Data on differences in single and dual APT-ICH are scarce and warrant further investigation. New treatment options for APT-ICH are urgently needed.

Blood Pressure in Acute Stroke and Secondary Stroke Prevention

PURPOSE OF REVIEW

Hypertension is common in patients presenting with stroke and is independently associated with unfavorable outcomes. This article reviews current guidelines for early management of blood pressure (BP) and highlights the findings of recent investigative works.

RECENT FINDINGS

Intensive blood pressure reduction after receiving alteplase has not been shown to improve outcomes. Patients with large vessel occlusions may benefit from lower blood pressure targets post-intervention. Retrospective analyses of large intracerebral hemorrhage trials suggest that specific subgroups of patients may disproportionately benefit from or be harmed by intensive BP reduction. Robust data for management of blood pressure in subarachnoid hemorrhage patients is lacking and expert consensus continues to guide decision-making. Despite the impact of hypertension on outcomes, most prospective trials assessing efficacy of blood pressure reduction have yielded neutral or inconclusive results. Further trials are necessary to determine which patient populations are most likely to benefit from blood pressure control.

Blood Pressure Goals in Acute Stroke

Antihypertensive treatment is highly effective in both primary and secondary prevention of stroke. However, current guideline recommendations on the blood pressure goals in acute stroke are clinically empirical and generally conservative. Antihypertensive treatment is only recommended for severe hypertension. Several recent observational studies showed that the relationship between blood pressure and unfavorable clinical outcomes was probably positive in acute hemorrhagic stroke but J- or U-shaped in acute ischemic stroke with undetermined nadir blood pressure. The results of randomized controlled trials are promising for blood pressure management in hemorrhagic stroke but less so in ischemic stroke. A systolic blood pressure goal of 140 mm Hg is probably appropriate for acute hemorrhagic stroke. The blood pressure goal in acute ischemic stroke, however, is uncertain, and probably depends on the time window of treatment and the use of revascularization therapy. Further research is required to investigate the potential benefit of antihypertensive treatment in acute stroke, especially with regard to the possible reduction of blood pressure variability and more intensive blood pressure lowering in the acute and subacute phases of a stroke, respectively.

Increased Prognostic Yield by Combined Assessment of Non-Contrast Computed Tomography Markers of Antithrombotic-Related Spontaneous Intracerebral Hemorrhage Expansion

Background and aims: The utility of proposed non-contrast computed tomography (NCCT) markers for the prediction of hematoma expansion in patients with antithrombotic-related spontaneous intracerebral hemorrhage (ICH) is limited. Additionally, there is significant overlap between different suggested ICH shape and density markers. Methods: We assessed the prognostic yield for hematoma expansion of a combined score incorporating features of ICH shape irregularity (satellite sign and/or Barras score ≥ 3), heterogeneous ICH density (swirl sign and/or Barras score ≥ 3) on baseline NCCT and timing from ICH onset to NCCT. Results: We evaluated data from 79 patients with antithrombotic-related spontaneous ICH (32% with hematoma expansion). Swirl (84% vs. 39%) and satellite signs (20% vs. 7%) on baseline NCCT were significantly more prevalent (p < 0.001) in patients with hematoma expansion. Patients with hematoma expansion had more irregular and heterogeneous bleeds on baseline NCCT scans, as quantified by higher (p < 0.001) Barras shape (4 (4−5) vs. 3 (2−4)) and density scores (4 (3−5) vs. 2 (1−3)), respectively. The overall diagnostic yield of the combined score (area under the curve: 0.86, 95%CI: 0.78−0.94) significantly outperformed (p < 0.001) the diagnostic yield of each individual marker. Scores of 4 or 5 in the combined score were associated with a sensitivity of 60.0%, specificity of 90.7%, overall diagnostic accuracy of 81.0%, positive likelihood ratio (LR) of 6.48, negative LR of 0.44, positive predictive value (PV) of 0.76 and negative PV of 0.83. Conclusion: Combined NCCT marker assessment seems to increase the prognostic accuracy for hematoma expansion in antithrombotic-related spontaneous ICH patients.

The Novel Nrf2 Activator Omaveloxolone Regulates Microglia Phenotype and Ameliorates Secondary Brain Injury after Intracerebral Hemorrhage in Mice

The polarization of microglia is recognized as a crucial factor in reducing neuroinflammation and promoting hematoma clearance after intracerebral hemorrhage (ICH). Previous studies have revealed that redox components participate in the regulation of microglial polarization. Recently, the novel Nrf2 activator omaveloxolone (Omav) has been validated to improve neurological function in patients with neurodegenerative disorders by regulating antioxidant responses. In this study, we examined the efficacy of Omav in ICH. Omav significantly promoted Nrf2 nuclear accumulation and the expression of HO-1 and NQO1 in BV2 cells. In addition, both in vitro and in vivo experiments showed that Omav treatment inhibited M1-like activation and promoted the activation of the M2-like microglial phenotype. Omav inhibited OxyHb-induced ROS generation and preserved the function of mitochondria in BV2 cells. Intraperitoneal administration of Omav improved sensorimotor function in the ICH mouse model. Importantly, these effects were blocked by pretreatment with ML385, a selective inhibitor of Nrf2. Collectively, Omav modulated microglial polarization by activating Nrf2 and inhibiting ROS generation in ICH models, suggesting that it might be a promising drug candidate for the treatment of ICH.

Controlling blood pressure soon after intracerebral hemorrhage: The SAMURAI-ICH Study and its successors

The impact of acute therapy for intracerebral hemorrhage (ICH) lags far behind that for acute ischemic stroke. Intensive blood pressure lowering is a promising therapeutic strategy for acute ICH, especially for East Asian patients whose etiological mechanism is more commonly hypertension than that of patients in the Western population. A multicenter, prospective, observational study named the Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-IntraCerebral Hemorrhage (SAMURAI-ICH) study, involving 211 patients from ten Japanese stroke centers, was performed to elucidate the safety and feasibility of blood pressure lowering to 160 mmHg or less in acute ICH patients using intravenous nicardipine. When we started the study, intravenous nicardipine was not officially approved for hyperacute ICH patients in Japan. The SAMURAI-ICH study was also a pilot study to judge the feasibility of participation by many Japanese investigators in an international, randomized, controlled trial named the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)−2 trial. The SAMURAI-ICH study, ATACH-2 trial, and their combined individual participant data meta-analysis produced several new interesting findings on how to control blood pressure levels in acute ICH patients. Some of the findings are introduced in the present review article.

Association Between Preonset Anti-hypertensive Treatment and Intracerebral Hemorrhage Mortality: A Cohort Study From CHEERY

Introduction

Hypertension is the most prevalent risk factor for intracerebral hemorrhage (ICH). In this study, we investigated whether preonset anti-hypertensive therapy could affect the outcomes of ICH.

Methods

This was a retrospective cohort study. A total of 3,460 consecutive patients with acute first-ever ICH from 31 recruitment sites were enrolled into the Chinese cerebral hemorrhage: mechanism and intervention (CHERRY) study from December 1, 2018 to November 30, 2020, and 2,140 (61.8%) with hypertension history were entered into the analysis.

Results

Only 586 patients (27.4%) with hypertension history currently received anti-hypertensive therapy, and which was associated with lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) on admission (SBP, p = 0.008; DBP, p = 0.017), less hematoma volume (9.8 vs. 11%, p = 0.006), and lower all-cause mortality at 3 months (15.3 vs. 19.8%, OR = 0.728, p = 0.016). In multivariable analysis, adjusting for age, gender, residence, ischemic stroke history, admission SBP and DBP, and current use of antihypertension were significantly associated with lower adjusted hazard ratios (HRs) for all-cause mortality at discharge (adjusted HR, 0.497, p = 0.012), 30 days (adjusted HR, 0.712, p = 0.015), and 90 days (adjusted HR, 0.766, p = 0.030). However, after adjusting the variable of hematoma volume, the mortality between the two groups was not significantly different.

Conclusions

Preonset anti-hypertensive therapy was associated with lower mortality of ICH, which somewhat depended on hematoma volume.

Review of major trials of acute blood pressure management in stroke

Over the last two decades, there have been a number of major landmark clinical trials, classified as "major" as they sought to address clear clinical practice driven questions, in a pragmatic yet robust trial design, using a large powered sample size (n > 1000), in order to help improve patient outcome through informing guidelines. A commonality across all stroke sub-types included in these trials is the tendency to acute hypertensive crises within the acute stroke period. This phenomenon is associated with greater stroke complications and worsened overall prognosis. Multiple trials have attempted to address the issue of acute blood pressure management during the acute stroke period, with consideration for timing, magnitude of lowering, agent and relationship to other interventions. This review will consider the major clinical trials performed in ischaemic and haemorrhagic stroke that test the hypothesis that acute BP reduction improves clinical outcomes.

Integrative cerebral blood flow regulation in ischemic stroke

Optimizing cerebral perfusion is key to rescuing salvageable ischemic brain tissue. Despite being an important determinant of cerebral perfusion, there are no effective guidelines for blood pressure (BP) management in acute stroke. The control of cerebral blood flow (CBF) involves a myriad of complex pathways which are largely unaccounted for in stroke management. Due to its unique anatomy and physiology, the cerebrovascular circulation is often treated as a stand-alone system rather than an integral component of the cardiovascular system. In order to optimize the strategies for BP management in acute ischemic stroke, a critical reappraisal of the mechanisms involved in CBF control is needed. In this review, we highlight the important role of collateral circulation and re-examine the pathophysiology of CBF control, namely the determinants of cerebral perfusion pressure gradient and resistance, in the context of stroke. Finally, we summarize the state of our knowledge regarding cardiovascular and cerebrovascular interaction and explore some potential avenues for future research in ischemic stroke.

Integrative physiological assessment of cerebral hemodynamics and metabolism in acute ischemic stroke

Restoring perfusion to ischemic tissue is the primary goal of acute ischemic stroke care, yet only a small portion of patients receive reperfusion treatment. Since blood pressure (BP) is an important determinant of cerebral perfusion, effective BP management could facilitate reperfusion. But how BP should be managed in very early phase of ischemic stroke remains a contentious issue, due to the lack of clear evidence. Given the complex relationship between BP and cerebral blood flow (CBF)-termed cerebral autoregulation (CA)-bedside monitoring of cerebral perfusion and oxygenation could help guide BP management, thereby improve stroke patient outcome. The aim of INFOMATAS is to 'identify novel therapeutic targets for treatment and management in acute ischemic stroke'. In this review, we identify novel physiological parameters which could be used to guide BP management in acute stroke, and explore methodologies for monitoring them at the bedside. We outline the challenges in translating these potential prognostic markers into clinical use.

Utilization of Artificial Intelligence-based Intracranial Hemorrhage Detection on Emergent Noncontrast CT Images in Clinical Workflow

Authors implemented an artificial intelligence (AI)-based detection tool for intracranial hemorrhage (ICH) on noncontrast CT images into an emergent workflow, evaluated its diagnostic performance, and assessed clinical workflow metrics compared with pre-AI implementation. The finalized radiology report constituted the ground truth for the analysis, and CT examinations (n = 4450) before and after implementation were retrieved using various keywords for ICH. Diagnostic performance was assessed, and mean values with their respective 95% CIs were reported to compare workflow metrics (report turnaround time, communication time of a finding, consultation time of another specialty, and turnaround time in the emergency department). Although practicable diagnostic performance was observed for overall ICH detection with 93.0% diagnostic accuracy, 87.2% sensitivity, and 97.8% negative predictive value, the tool yielded lower detection rates for specific subtypes of ICH (eg, 69.2% [74 of 107] for subdural hemorrhage and 77.4% [24 of 31] for acute subarachnoid hemorrhage). Common false-positive findings included postoperative and postischemic defects (23.6%, 37 of 157), artifacts (19.7%, 31 of 157), and tumors (15.3%, 24 of 157). Although workflow metrics such as communicating a critical finding (70 minutes [95% CI: 54, 85] vs 63 minutes [95% CI: 55, 71]) were on average reduced after implementation, future efforts are necessary to streamline the workflow all along the workflow chain. It is crucial to define a clear framework and recognize limitations as AI tools are only as reliable as the environment in which they are deployed. Keywords: CT, CNS, Stroke, Diagnosis, Classification, Application Domain © RSNA, 2022.

Inpatient Management of Acute Stroke of Unknown Type in Resource-Limited Settings

Stroke is the second leading cause of death and disability worldwide, with a disproportionate burden on low- and middle-income countries. Critical elements of guideline-based stroke care developed in high-income countries are not applicable to resource-limited settings, where lack of access to neuroimaging prevents clinicians from distinguishing between ischemic stroke and intracranial hemorrhage, requiring challenging clinical decision-making, particularly in the acute setting. We discuss strategies for acute inpatient management of stroke of unknown type with a focus on blood pressure management and antiplatelet therapy when neuroimaging is unavailable, and review some of the challenges and strategies for successfully implementing stroke unit care in resource-limited health care settings.

Early-phase administration of human amnion-derived stem cells ameliorates neurobehavioral deficits of intracerebral hemorrhage by suppressing local inflammation and apoptosis

Background

Intracerebral hemorrhage (ICH) is a significant cause of death and disabilities. Recently, cell therapies using mesenchymal stem cells have been shown to improve ICH-induced neurobehavioral deficits. Based on these findings, we designed this study to evaluate the therapeutic efficacy and underlying mechanisms by which human amnion-derived stem cells (hAMSCs) would ameliorate neurobehavioral deficits of ICH-bearing hosts.

Methods

hAMSCs were induced from amnia obtained by cesarean section and administered intravenously to ICH-bearing mice during the acute phase. The mice were then subject to multitask neurobehavioral tests at the subacute phase. We attempted to optimize the dosage and timing of the hAMSC administrations. In parallel with the hAMSCs, a tenfold higher dose of human adipose-derived stem cells (ADSCs) were used as an experimental control. Specimens were obtained from the ICH lesions to conduct immunostaining, flow cytometry, and Western blotting to elucidate the underlying mechanisms of the hAMSC treatment.

Results

The intravenous administration of hAMSCs to the ICH-bearing mice effectively improved their neurobehavioral deficits, particularly when the treatment was initiated at Day 1 after the ICH induction. Of note, the hAMSCs promoted clinical efficacy equivalent to or better than that of hADSCs at 1/10 the cell number. The systemically administered hAMSCs were found in the ICH lesions along with the local accumulation of macrophages/microglia. In detail, the hAMSC treatment decreased the number of CD11b⁺CD45⁺ and Ly6G⁺ cells in the ICH lesions, while splenocytes were not affected. Moreover, the hAMSC treatment decreased the number of apoptotic cells in the ICH lesions. These results were associated with suppression of the protein expression levels of macrophage-related factors iNOS and TNFα.

Conclusions

Intravenous hAMSC administration during the acute phase would improve ICH-induced neurobehavioral disorders. The underlying mechanism was suggested to be the suppression of subacute inflammation and apoptosis by suppressing macrophage/microglia cell numbers and macrophage functions (such as TNFα and iNOS). From a clinical point of view, hAMSC-based treatment may be a novel strategy for the treatment of ICH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-022-02411-3.

The Patterns of Morphological Change During Intracerebral Hemorrhage Expansion: A Multicenter Retrospective Cohort Study

Objectives: Hemorrhage expansion (HE) is a common and serious condition in patients with intracerebral hemorrhage (ICH). In contrast to the volume changes, little is known about the morphological changes that occur during HE. We developed a novel method to explore the patterns of morphological change and investigate the clinical significance of this change in ICH patients. Methods: The morphological changes in the hematomas of ICH patients with available paired non-contrast CT data were described in quantitative terms, including the diameters of each hematoma in three dimensions, the longitudinal axis type, the surface regularity (SR) index, the length and direction changes of the diameters, and the distance and direction of movement of the center of the hematoma. The patterns were explored by descriptive analysis and difference analysis in subgroups. We also established a prognostic nomogram model for poor outcomes in ICH patients using both morphological changes and clinical parameters. Results: A total of 1,094 eligible patients from four medical centers met the inclusion criteria. In 266 (24.3%) cases, the hematomas enlarged; the median absolute increase in volume was 14.0 [interquartile range (IQR), 17.9] mL. The initial hematomas tended to have a more irregular shape, reflected by a larger surface regularity index, than the developed hematomas. In subtentorial and deep supratentorial hematomas, the center moved in the direction of gravity. The distance of center movement and the length changes of the diameters were small, with median values of less than 4 mm. The most common longitudinal axis type was anterior-posterior (64.7%), and the axis type did not change between initial and repeat imaging in most patients (95.2%). A prognostic nomogram model including lateral expansion, a parameter of morphological change, showed good performance in predicting poor clinical outcomes in ICH patients. Conclusions: The present study provides a morphological perspective on HE using a novel automatic approach. We identified certain patterns of morphological change in HE, and we believe that some morphological change parameters could help physicians predict the prognosis of ICH patients.

Comparison of intermittent versus continuous infusion antihypertensives in acute ischemic stroke

BACKGROUND

The optimal approach to blood pressure (BP) management in acute ischemic stroke remains unclear. The purpose of this study was to determine if an intermittent (labetalol or hydralazine) or continuous infusion (nicardipine or clevidipine) antihypertensive strategy facilitated timelier alteplase administration.

METHODS

Patients ≥18 years who presented to the emergency department (ED) between September 1, 2013 and August 31, 2020, received alteplase for acute ischemic stroke, and required BP management with an intravenous antihypertensive were included in this multicenter, retrospective cohort study. Exclusion criteria were initial administration of a non-study antihypertensive, initial study antihypertensive administration >2 hours prior to or any time following alteplase, or receipt of both an intermittent and continuous infusion antihypertensive prior to alteplase. The primary endpoint was the time from ED presentation to alteplase administration.

RESULTS

During the study period, 122 patients received an intermittent antihypertensive and 57 patients received a continuous infusion antihypertensive. The median door-to-needle time was 53 minutes for patients who received an intermittent antihypertensive compared to 57 minutes for those who received a continuous infusion antihypertensive (p=0.17). Secondarily, the proportion of patients who achieved the BP target <185/110 mmHg within 15 minutes of initial antihypertensive administration and the incidence of adverse events were similar between treatment groups. In cost analysis, intermittent antihypertensives were less expensive than continuous infusion antihypertensives ($2.20 vs. $71.40).

CONCLUSIONS

Among patients with acute ischemic stroke and uncontrolled BP, the initial use of an intermittent or continuous infusion antihypertensive did not significantly impact the time to alteplase administration.

Insights into a personalized management of blood pressure in acute stroke

PURPOSE OF REVIEW

Blood pressure management in acute stroke has long been a matter of debate. Epidemiological data show that high blood pressure is associated with death, disability and early stroke recurrence, whereas the pathophysiological rationale for ensuring elevated blood pressure in order maintain adequate cerebral perfusion remains a pertinent argument, especially in ischaemic stroke.

RECENT FINDINGS

The European Stroke Organisation Guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage provide recommendations for the appropriate management of blood pressure in various clinical acute stroke settings.

SUMMARY

In this narrative review, we provide specific updates on blood pressure management in ICH, blood pressure management in the setting of reperfusion therapies for ischaemic stroke, and the evidence for the use of induced hypertension in patients with acute ischaemic stroke in the light of the recent guidelines.

Zebrafish drug screening identifies candidate therapies for neuroprotection after spontaneous intracerebral haemorrhage

Despite the global health burden, treatment of spontaneous intracerebral haemorrhage (ICH) is largely supportive and translation of specific medical therapies has not been successful. Zebrafish larvae offer a unique platform for drug screening to rapidly identify neuroprotective compounds following ICH. We applied the Spectrum Library compounds to zebrafish larvae acutely after ICH to screen for decreased brain cell death and identified 150 successful drugs. Candidates were then evaluated for possible indications with other cardiovascular diseases. Six compounds were identified including two angiotensin converting enzyme inhibitors (ACE-I). Ramipril and quinapril were further assessed to confirm a significant 55% reduction in brain cell death. Proteomic analysis revealed potential mechanisms of neuroprotection. Using the INTERACT2 clinical trial dataset, we demonstrate a significant reduction in the adjusted odds of an unfavourable shift in the modified Rankin Scale at 90 days for patients receiving an ACE-I after ICH (vs. no ACE-I; odds ratio 0.80; 95% confidence interval 0.68-0.95; P=0.009). The zebrafish larval model of spontaneous ICH can be used as a reliable drug screening platform, and has identified therapeutics which may offer neuroprotection.

A predictive nomogram for intracerebral hematoma expansion based on non-contrast computed tomography and clinical features

PURPOSE

To develop and validate a new nomogram utilizing non-contrast computed tomography (NCCT) signs and clinical factors for predicting hematoma expansion (HE) in patients with spontaneous intracerebral hemorrhage (ICH).

METHODS

HE was defined as > 6 mL or 33% increase in baseline hematoma volume. Multivariable logistic regression analysis was performed to identify the predictors of HE. The discriminatory performance of the proposed model was evaluated via receiver operation characteristic (ROC) analysis, and the predictive accuracy was assessed by a calibration curve. The nomogram was established by R programming language. The decision curve analysis and clinical impact curve were drawn according to the related risk factors.

RESULTS

A total of 506 patients with spontaneous ICH were recruited in the development cohort, and 103 patients were registered as the external validation cohort. Among the development cohort, 132 (26.09%) experienced HE. Glasgow coma scale (GCS) (P < 0.001), neutrophil to lymphocyte ratio (NLR) (P < 0.001), blend sign (P < 0.001), swirl sign (P < 0.001), and hypodensities (P = 0.003) were significant predictors of HE, by which were used to establish the nomogram. The model demonstrated good performance with high area under the curve both in the development (AUC = 0.908; 95% confidence interval, 0.880-0.936) and the external validation (AUC = 0.844; 95% confidence interval, 0.760-0.908) cohort. The calibration curve illustrated a high accuracy for HE prediction.

CONCLUSION

The nomogram derived from NCCT markers and clinical factors outperformed the NCCT signs-only model in predicting HE for patients with ICH, thus providing an effective and noninvasive tool for the risk stratification of HE.

Fentanyl versus placebo with ketamine and rocuronium for patients undergoing rapid sequence intubation in the emergency department: The FAKT study-A randomized clinical trial

Objective

The objective was to determine whether the use of fentanyl with ketamine for emergency department (ED) rapid sequence intubation (RSI) results in fewer patients with systolic blood pressure (SBP) measurements outside the pre‐specified target range of 100–150 mm Hg following the induction of anesthesia.

Methods

This study was conducted in the ED of five Australian hospitals. A total of 290 participants were randomized to receive either fentanyl or 0.9% saline (placebo) in combination with ketamine and rocuronium, according to a weight‐based dosing schedule. The primary outcome was the proportion of patients in each group with at least one SBP measurement outside the prespecified range of 100–150 mm Hg (with adjustment for baseline abnormality). Secondary outcomes included first‐pass intubation success, hypotension, hypertension and hypoxia, mortality, and ventilator‐free days 30 days following enrollment.

Results

A total of 142 in the fentanyl group and 148 in the placebo group commenced the protocol. A total of 66% of patients receiving fentanyl and 65% of patients receiving placebo met the primary outcome (difference = 1%, 95% CI = −10 to 12). Hypotension (SBP ≤ 99 mm Hg) was more common with fentanyl (29% vs. 16%; difference = 13%, 95% CI = 3% to 23%), while hypertension (≥150 mm Hg) occurred more with placebo (69% vs. 55%; difference = 14%, 95% CI = 3 to 24). First‐pass success rate, 30 day mortality, and ventilator‐free days were similar.

Conclusions and Relevance

There was no difference in the primary outcome between groups, although lower blood pressures were more common with fentanyl. Clinicians should consider baseline hemodynamics and postinduction targets when deciding whether to use fentanyl as a coinduction agent with ketamine.

Early lowering of blood pressure after acute intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data

OBJECTIVE

To summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH).

METHODS

A prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults <7 days after ICH onset. The primary outcome was function (distribution of scores on the modified Rankin scale) 90 days after randomisation. Radiological outcomes were absolute (>6 mL) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect.

RESULTS

Of 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6-5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (p_interaction=0.031) and agent (p_interaction<0.0001). Active/intensive BP-lowering interventions clearly reduced absolute (>6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth.

INTERPRETATION

Overall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent.

PROSPERO REGISTRATION NUMBER

CRD42019141136.

Demographic and institutional predictors of stroke hospitalization mortality among adults in the United States

Introduction

Stroke remains a primary source of functional disability and inpatient mortality in the United States (US). Recent evidence reveals declining mortality associated with stroke hospitalizations in the US. However, data updating trends in inpatient mortality is lacking. This study aims to provide a renewed inpatient stroke mortality rate in a national sample and identify common predictors of inpatient stroke mortality.

Methods

In this cross-sectional study, we analyzed data from a nationwide database between 2010 and 2017. We included patient encounters for both ischemic (ICD9 433–434, ICD10 I630–I639) and hemorrhagic stroke (ICD9 430–432, ICD10 I600–I629). We performed an annual comparison of in-hospital stroke mortality rates, and a cross-sectional analytic approach of multiple variables identified common predictors of inpatient stroke mortality.

Results

Between 2010 and 2017, we identified 518,185 total stroke admissions (86.6% ischemic stroke and 13.4% hemorrhagic strokes). Stroke admissions steadily increased during the studied period, whereas we observed a steady decline in in-hospital mortality during the same time. The inpatient stroke mortality rate gradually declined from 4.8% in 2010 (95% CI 4.6–5.1) to 2.1% in 2017 (95% CI 2.0–2.1). Predictors of higher odds of dying from ischemic stroke were female (OR 1.059, 95% CI 1.015–1.105, p = 0.008), older age (OR 1.028, 95% CI 1.026–1.029, p < 0.001), and sicker patients (OR 1.091, 95% CI 1.089–1.093, p < 0.001). Predictors of higher odds of dying from hemorrhagic stroke were Hispanic ethnicity (OR 1.459, 95% CI 1.084–1.926, p < 0.001), older age (OR 1.021, 95% CI 1.019–1.023, p < 0.001), and sicker patients (OR 1.042, 95% CI 1.039–1.045, p < 0.001). All census regions and hospital types demonstrated improvements in in-hospital mortality.

Conclusion

This study identified a continuous declining rate in in-hospital mortality due to stroke in the United States, and it also identified demographic and hospital predictors of inpatient stroke mortality.

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Stroke remains a leading cause of morbidity and mortality in the United States

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Stroke hospitalization mortality trends are important to guide efforts in acute stroke care

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Vascular risk factors are still prevalent in the population admitted due to stroke and continue to be associated with higher odds of death

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There are important regional disparities in stroke hospitalization deaths in the United States

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Hospital characteristics influence odds of death from a stroke independent of stroke etiology

OUP accepted manuscript

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:

A: Appropriate Antithrombotic therapy.

B: Better functional and psychological status.

C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).