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Ridha M, Hannawi Y, Murthy S, Carvalho Poyraz F, Kumar A, Park S, Roh D, Sekar P, Woo D, Burke J. Premorbid Blood Pressure Control Modifies Risk of DWI Lesions With Acute Blood Pressure Reduction in Intracerebral Hemorrhage. Hypertension 2024; 81:2113-2123. [PMID: 39069917 PMCID: PMC11410531 DOI: 10.1161/hypertensionaha.124.23271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 07/15/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Hypoperfusion due to blood pressure (BP) reduction is a potential mechanism of cerebral ischemia after intracerebral hemorrhage. However, prior evaluations of the relationship between BP reduction and ischemia have been conflicting. Untreated chronic hypertension is common in intracerebral hemorrhage and alters cerebral autoregulation. We hypothesized that the risk of diffusion-weighted imaging (DWI) hyperintensities from acute BP reduction is modified by premorbid BP control. METHODS Individuals enrolled in the ERICH study (Ethnic/Racial Variations of Intracerebral Hemorrhage) from 2010 to 2015 were categorized as untreated, treated, or nonhypertensive based on preintracerebral hemorrhage diagnosis and antihypertensive medication use. The percent reduction of systolic BP (SBP) was calculated between presentation and 24 hours from admission. The primary outcome was the presence of DWI lesions. Using logistic regression, we tested the association between chronic hypertension status, SBP reduction, and their interaction with DWI lesion presence. RESULTS From 3000 participants, 877 with available magnetic resonance imaging met inclusion (mean age, 60.5±13.3 years; 42.5% women). DWI lesions were detected in 25.9%. Untreated, treated, and no hypertension accounted for 32.6%, 47.9%, and 19.5% of cases, respectively. SBP reduction was not directly associated with DWI lesions; however, an interaction effect was observed between SBP reduction and chronic hypertension status (P=0.036). Nonhypertensive subjects demonstrated a linear risk of DWI lesion presence with greater SBP reduction, whereas untreated hypertension demonstrated a stable risk across a wide range of SBP reduction (P=0.023). CONCLUSIONS Premorbid BP control, especially untreated hypertension, may influence the relationship between DWI lesions and acute BP reduction after intracerebral hemorrhage. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01202864.
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Affiliation(s)
- Mohamed Ridha
- Department of Neurology, Ohio State University, Columbus (M.R., Y.H., J.B.)
| | - Yousef Hannawi
- Department of Neurology, Ohio State University, Columbus (M.R., Y.H., J.B.)
| | - Santosh Murthy
- Department of Neurology, Weil Cornell Medical Center, New York, NY (S.M.)
| | | | - Aditya Kumar
- Department of Neurology, Barrow Neurologic Institute, Phoenix, AZ (A.K.)
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, New York, NY (S.P., D.R.)
| | - David Roh
- Department of Neurology, Columbia University Medical Center, New York, NY (S.P., D.R.)
| | - Padmini Sekar
- Department of Neurology, University of Cincinnati, OH (P.S., D.W.)
| | - Daniel Woo
- Department of Neurology, University of Cincinnati, OH (P.S., D.W.)
| | - James Burke
- Department of Neurology, Ohio State University, Columbus (M.R., Y.H., J.B.)
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Li Y, Lei C, Wang L, Lin S, Zhao L, Jiang W, Deng Q, Yang X. Systematic Review and Meta-Analysis of the Association Between Appearance of Lesions on Diffusion-Weighted Imaging and Poor Outcomes Among Patients with Intracerebral Hemorrhage. World Neurosurg 2024; 190:323-328. [PMID: 39074579 DOI: 10.1016/j.wneu.2024.07.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE Some patients with intracerebral hemorrhage show lesions on diffusion-weighted magnetic resonance imaging, and such lesions have been associated with a greater risk of worse prognosis. Here we meta-analyzed the available evidence for such an association. METHODS Studies that reported the presence or absence of lesions on diffusion-weighted imaging (DWI) after intracerebral hemorrhage as well as clinical or radiological outcomes were systematically reviewed and meta-analyzed. Clinical outcome was defined as a score of modified Rankin scale (mRS) at admission to 90 days. RESULTS Ten studies involving 3575 patients were included in the meta-analysis, and the incidence of DWI lesions ranged from 11.1% to 49.6%. Lesions were associated with a significantly higher risk of poor outcome (mRS scores 3-6) across 6 studies (odds ratio: 2.91; 95% confidence interval: 1.62-5.23; P < 0.001). In subgroup analysis, mRS scores 4-6 were associated with the presence of lesions on DWI (odds ratio: 2.18; 95% confidence interval: 1.31-3.60; P = 0.003). We observed similar results using 3 different definitions of lesions on DWI. Some studies have reported that recurrence of intracerebral hemorrhage was also related with DWI lesions. But there was controversy on the relationship between mortality, ischemic stroke, and hematoma volume and DWI lesions. CONCLUSIONS Lesions on DWI after intracerebral hemorrhage were associated with a higher risk of poor outcome, but large longitudinal studies are needed to verify this association.
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Affiliation(s)
- Yongyu Li
- First Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Chunyan Lei
- First Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
| | - Lu Wang
- First Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Shihan Lin
- First Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Linhu Zhao
- First Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Wen Jiang
- First Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Qionghua Deng
- First Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xinglong Yang
- First Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
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Mutimer CA, Yassi N, Wu TY. Blood Pressure Management in Intracerebral Haemorrhage: when, how much, and for how long? Curr Neurol Neurosci Rep 2024; 24:181-189. [PMID: 38780706 PMCID: PMC11199276 DOI: 10.1007/s11910-024-01341-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE OF REVIEW When compared to ischaemic stroke, there have been limited advances in acute management of intracerebral haemorrhage. Blood pressure control in the acute period is an intervention commonly implemented and recommended in guidelines, as elevated systolic blood pressure is common and associated with haematoma expansion, poor functional outcomes, and mortality. This review addresses the uncertainty around the optimal blood pressure intervention, specifically timing and length of intervention, intensity of blood pressure reduction and agent used. RECENT FINDINGS Recent pivotal trials have shown that acute blood pressure intervention, to a systolic target of 140mmHg, does appear to be beneficial in ICH, particularly when bundled with other therapies such as neurosurgery in selected cases, access to critical care units, blood glucose control, temperature management and reversal of coagulopathy. Systolic blood pressure should be lowered acutely in intracerebral haemorrhage to a target of approximately 140mmHg, and that this intervention is generally safe in the ICH population.
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Affiliation(s)
- Chloe A Mutimer
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, 3050, Australia.
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, 3050, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, 3052, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
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Ridha M, Megjhani M, Nametz D, Kwon SB, Velazquez A, Ghoshal S, Agarwal S, Claassen J, Roh DJ, Sander Connolly E, Park S. Suboptimal Cerebral Perfusion is Associated with Ischemia After Intracerebral Hemorrhage. Neurocrit Care 2024; 40:996-1005. [PMID: 37957418 PMCID: PMC11089072 DOI: 10.1007/s12028-023-01863-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/12/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Remote ischemic lesions on diffusion-weighted imaging (DWI) occur in one third of patients with intracerebral hemorrhage (ICH) and are associated with worse outcomes. The etiology is unclear and not solely due to blood pressure reduction. We hypothesized that impaired cerebrovascular autoregulation and hypoperfusion below individualized lower limits of autoregulation are associated with the presence of DWI lesions. METHODS This was a retrospective, single-center study of all primary ICH with intraparenchymal pressure monitoring within 10 days from onset and subsequent magnetic resonance imaging. Pressure reactivity index was calculated as the correlation coefficient between mean arterial pressure and intracranial pressure. Optimal cerebral perfusion pressure (CPPopt) is the cerebral perfusion pressure (CPP) with the lowest corresponding pressure reactivity index. The difference between CPP and CPPopt, time spent below the lower limit of autoregulation (LLA), and time spent above the upper limit of autoregulation (ULA) were calculated by using mean hourly physiologic data. Univariate associations between physiologic parameters and DWI lesions were analyzed by using binary logistic regression. RESULTS A total of 505 h of artifact-free data from seven patients without DWI lesions and 479 h from six patients with DWI lesions were analyzed. Patients with DWI lesions had higher intracranial pressure (17.50 vs. 10.92 mm Hg; odds ratio 1.14, confidence interval 1.01-1.29) but no difference in mean arterial pressure or CPP compared with patients without DWI lesions. The presence of DWI lesions was significantly associated with a greater percentage of time spent below the LLA (49.85% vs. 14.70%, odds ratio 5.77, confidence interval 1.88-17.75). No significant association was demonstrated between CPPopt, the difference between CPP and CPPopt, ULA, LLA, or time spent above the ULA between groups. CONCLUSIONS Blood pressure reduction below the LLA is associated with ischemia after acute ICH. Individualized, autoregulation-informed targets for blood pressure reduction may provide a novel paradigm in acute management of ICH and require further study.
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Affiliation(s)
- Mohamed Ridha
- Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA.
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
| | - Murad Megjhani
- Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Daniel Nametz
- Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Soon Bin Kwon
- Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Angela Velazquez
- Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA
| | - Shivani Ghoshal
- Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Sachin Agarwal
- Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Jan Claassen
- Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - David J Roh
- Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - E Sander Connolly
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
- Department of Neurosurgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Soojin Park
- Division of Hospital and Critical Care Neurology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8GS Milstein, New York, NY, 10032, USA
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
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Schwabauer E, Piccininni M, Freitag E, Ebinger M, Geisler F, Harmel P, Hille A, Lorenz-Meyer I, Rohrpasser-Napierkowski I, Kurth T, Rohmann JL, Endres M, Schlunk F, Weber J, Wendt M, Audebert HJ. Effects of Mobile Stroke Unit dispatch on blood pressure management and outcomes in patients with intracerebral haematoma: Results from the Berlin_Prehospital Or Usual Care Delivery in acute Stroke (B_PROUD) controlled intervention study. Eur Stroke J 2024; 9:366-375. [PMID: 38014623 PMCID: PMC11318420 DOI: 10.1177/23969873231213156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/11/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION In patients with acute intracerebral haemorrhage (ICH) and elevated systolic blood pressure (BP), guidelines suggest that systolic BP reduction to <140 mmHg should be rapidly initiated. Compared with conventional care, Mobile Stroke Units (MSUs) allow for earlier ICH diagnosis through prehospital imaging and earlier BP lowering. PATIENTS AND METHODS ICH patients were prospectively evaluated as a cohort of the controlled B_PROUD-study in which MSU availability alone determined MSU dispatch in addition to conventional ambulance. We used inverse probability of treatment weighting to adjust for confounding to estimate the effect of additional MSU dispatch in ICH patients. Outcomes of interest were 7-day mortality (primary), systolic BP (sBP) at hospital arrival, dispatch-to-imaging time, largest haematoma volume, anticoagulation reversal, length of in-hospital stay, 3-month functional outcome. RESULTS Between February 2017 and May 2019, MSUs were dispatched to 95 (mean age: 72 ± 13 years, 45% female) and only conventional ambulances to 78 ICH patients (mean age: 71 ± 12 years, 44% female). After adjusting for confounding, we found shorter dispatch-to-imaging time (mean difference: -17.75 min, 95% CI: -27.16 to -8.21 min) and lower sBP at hospital arrival (mean difference = -16.31 mmHg, 95% CI: -30.64 to -6.19 mmHg) in the MSU group. We found no statistically significant difference for the other outcomes, including 7-day mortality (adjusted odds ratio: 1.43, 95% CI: 0.68 to 3.31) or favourable outcome (adjusted odds ratio = 0.67, 95% CI: 0.27 to 1.67). CONCLUSIONS Although MSU dispatch led to sBP reduction and lower dispatch-to-imaging time compared to conventional ambulance care, we found no evidence of better outcomes in the MSU dispatch group.
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Affiliation(s)
- Eugen Schwabauer
- Klinik für Neurologie mit Stroke Unit; Vivantes Klinikum Neukölln, Berlin, Germany
| | - Marco Piccininni
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Erik Freitag
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Frederik Geisler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Harmel
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Annegret Hille
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Tobias Kurth
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica L Rohmann
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | - Frieder Schlunk
- Berlin Institute of Health (BIH), Berlin, Germany
- Institut für Neuroradiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Weber
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | | | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Roh DJ, Boehme A, Mamoon R, Hooper D, Cottarelli A, Ji R, Mao E, Kumar A, Carvalho Poyraz F, Demel SL, Spektor V, Carmona J, Hod EA, Ironside N, Gutierrez J, Guo J, Konofagou E, Elkind MSV, Woo D. Relationships of Hemoglobin Concentration, Ischemic Lesions, and Clinical Outcomes in Patients With Intracerebral Hemorrhage. Stroke 2023; 54:1021-1029. [PMID: 36779340 PMCID: PMC10050127 DOI: 10.1161/strokeaha.122.041410] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/12/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Hemoglobin concentration and diffusion-weighted imaging (DWI) ischemic lesions are separately known to be associated with poor intracerebral hemorrhage (ICH) outcomes. While hemoglobin concentrations have known relationships with ischemic stroke, it is unclear whether hemoglobin concentration is associated with DWI ischemic lesions after ICH. We sought to investigate the hypothesis that hemoglobin concentrations would associate with DWI lesions after ICH and further investigated their relationships with clinical outcomes. METHODS Supratentorial ICH patients enrolled between 2010 and 2016 to a prospective, multicenter, observational cohort study (ERICH study [Ethnic/Racial Variations of Intracerebral Hemorrhage]) were assessed. Patients from this study with baseline, admission hemoglobin, and hospitalization magnetic resonance imaging were analyzed. Hemoglobin was examined as the primary exposure variable defined as a continuous variable (g/dL). Magnetic resonance imaging DWI ischemic lesion presence was assessed as the primary radiographic outcome. Primary analyses assessed relationships of hemoglobin with DWI lesions. Secondary analyses assessed relationships of DWI lesions with poor 3-month outcomes (modified Rankin Scale score, 4-6). These analyses were performed using separate multivariable logistic regression models adjusting for relevant covariates. RESULTS Of 917 patients with ICH analyzed, mean baseline hemoglobin was 13.8 g/dL (±1.9), 60% were deep ICH, and DWI lesions were identified in 27% of the cohort. In our primary analyses, increased hemoglobin, defined as a continuous variable, was associated with DWI lesions (adjusted odds ratio, 1.21 per 1 g/dL change in hemoglobin [95% CI, 1.07-1.37]) after adjusting for sex, race, ICH severity, time to magnetic resonance imaging, and acute blood pressure change. In secondary analyses, DWI lesions were associated with poor 3-month outcomes (adjusted odds ratio, 1.83 [95% CI, 1.24-2.69]) after adjusting for similar covariates. CONCLUSIONS We identified novel relationships between higher baseline hemoglobin concentrations and DWI ischemic lesions in patients with ICH. Further studies are required to clarify the role of hemoglobin concentration on both cerebral small vessel disease pathophysiology and ICH outcomes.
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Affiliation(s)
- David J Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons (D.J.R., A.B., E.M., A.K., F.C.P., J.C., J. Gutierrez, M.S.V.E.), Columbia University, New York, NY
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons (D.J.R., A.B., E.M., A.K., F.C.P., J.C., J. Gutierrez, M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.B., R.M., M.S.V.E.), Columbia University, New York, NY
| | - Rayan Mamoon
- Department of Epidemiology, Mailman School of Public Health (A.B., R.M., M.S.V.E.), Columbia University, New York, NY
| | - Destiny Hooper
- Department of Neurology, University of Cincinnati, OH (D.H., S.L.D., D.W.)
| | - Azzurra Cottarelli
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons (A.C., E.A.H.), Columbia University, New York, NY
| | - Robin Ji
- Department of Biomedical Engineering (R.J., E.K.), Columbia University, New York, NY
| | - Eric Mao
- Department of Neurology, Vagelos College of Physicians and Surgeons (D.J.R., A.B., E.M., A.K., F.C.P., J.C., J. Gutierrez, M.S.V.E.), Columbia University, New York, NY
| | - Aditya Kumar
- Department of Neurology, Vagelos College of Physicians and Surgeons (D.J.R., A.B., E.M., A.K., F.C.P., J.C., J. Gutierrez, M.S.V.E.), Columbia University, New York, NY
| | - Fernanda Carvalho Poyraz
- Department of Neurology, Vagelos College of Physicians and Surgeons (D.J.R., A.B., E.M., A.K., F.C.P., J.C., J. Gutierrez, M.S.V.E.), Columbia University, New York, NY
| | - Stacie L Demel
- Department of Neurology, University of Cincinnati, OH (D.H., S.L.D., D.W.)
| | - Vadim Spektor
- Department of Radiology, Vagelos College of Physicians and Surgeons (V.S.), Columbia University, New York, NY
| | - Jerina Carmona
- Department of Neurology, Vagelos College of Physicians and Surgeons (D.J.R., A.B., E.M., A.K., F.C.P., J.C., J. Gutierrez, M.S.V.E.), Columbia University, New York, NY
| | - Eldad A Hod
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons (A.C., E.A.H.), Columbia University, New York, NY
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville (N.I.)
| | - Jose Gutierrez
- Department of Neurology, Vagelos College of Physicians and Surgeons (D.J.R., A.B., E.M., A.K., F.C.P., J.C., J. Gutierrez, M.S.V.E.), Columbia University, New York, NY
| | - Jia Guo
- Department of Psychiatry (J. Guo), Columbia University, New York, NY
- Mortimer B. Zuckerman Mind Brain Behavior Institute (J. Guo), Columbia University, New York, NY
| | - Elisa Konofagou
- Department of Biomedical Engineering (R.J., E.K.), Columbia University, New York, NY
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons (D.J.R., A.B., E.M., A.K., F.C.P., J.C., J. Gutierrez, M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.B., R.M., M.S.V.E.), Columbia University, New York, NY
| | - Daniel Woo
- Department of Neurology, University of Cincinnati, OH (D.H., S.L.D., D.W.)
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Li J, Luo D, Peng F, Kong Q, Liu H, Chen M, Tong L, Gao F. ANAID-ICH nomogram for predicting unfavorable outcome after intracerebral hemorrhage. CNS Neurosci Ther 2022; 28:2066-2075. [PMID: 36000537 PMCID: PMC9627367 DOI: 10.1111/cns.13941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/21/2022] [Accepted: 07/31/2022] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Diffusion-weighted imaging lesions (DWILs) are associated with unfavorable outcome in intracerebral hemorrhage (ICH). We proposed a novel predictive nomogram incorporating DWILs. METHODS A total of 738 patients with primary ICH in a tertiary hospital were prospectively enrolled as a training cohort. DWILs were defined as remote focal hyperintensities on DWI corresponding to low intensities on apparent diffusion coefficient images and remote from the focal hematoma. The outcome of interest was modified Rankin Scale scores of 4-6 at 90 days after onset. Multivariate logistic regression was used to construct a nomogram. Model performance was tested in the training cohort and externally validated with respect to discrimination, calibration, and clinical usefulness in another institute. Additionally, the nomogram was compared with the ICH score in terms of predictive ability. RESULTS Overall, 153 (20.73%) and 23 (15.54%) patients developed an unfavorable outcome in the training and validation cohorts, respectively. The multivariate analysis revealed that age, National Institutes of Health Stroke Scale (NIHSS) score, anemia, infratentorial location, presence of DWILs, and prior ICH were associated with unfavorable outcome. Our ANAID-ICH nomogram was constructed according to the aforementioned variables; the area under the receiver operating characteristic curve was 0.842 and 0.831 in the training and validation sets, respectively. With regard to the 90-day outcome, the nomogram showed a significantly higher predictive value than the ICH score in both cohorts. CONCLUSIONS The ANAID-ICH nomogram comprising age, NIHSS score, anemia, infratentorial location, presence of DWILs, and prior ICH may facilitate the identification of patients at higher risk for an unfavorable outcome.
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Affiliation(s)
- Jiawen Li
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Dong Luo
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Feifei Peng
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Qi Kong
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Huawei Liu
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Meiyuan Chen
- Department of NeurologyThe Affiliated Hospital of Hangzhou Normal UniversityHangzhouChina
| | - Lusha Tong
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Feng Gao
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
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8
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Wiegertjes K, Voigt S, Jolink WMT, Koemans EA, Schreuder FHBM, van Walderveen MAA, Wermer MJH, Meijer FJA, Duering M, de Leeuw FE, Klijn CJM. Diffusion-Weighted Lesions After Intracerebral Hemorrhage: Associated MRI Findings. Front Neurol 2022; 13:882070. [PMID: 35785361 PMCID: PMC9240258 DOI: 10.3389/fneur.2022.882070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
The current study aimed to investigate whether diffusion-weighted imaging-positive (DWI+) lesions after acute intracerebral hemorrhage (ICH) are associated with underlying small vessel disease (SVD) or linked to the acute ICH. We included patients ≥18 years with spontaneous ICH confirmed on neuroimaging and performed 3T MRIs after a median of 11 days (interquartile range [IQR] 6–43). DWI+ lesions were assessed in relation to the hematoma (perihematomal vs. distant and ipsilateral vs. contralateral). Differences in clinical characteristics, ICH characteristics, and MRI markers of SVD between participants with or without DWI+ lesions were investigated using non-parametric tests. We observed 54 DWI+ lesions in 30 (22%) of the 138 patients (median age [IQR] 65 [55–73] years; 71% men, 59 lobar ICH) with available DWI images. We found DWI+ lesions ipsilateral (54%) and contralateral (46%) to the ICH, and 5 (9%) DWI+ lesions were located in the immediate perihematomal region. DWI+ lesion presence was associated with probable CAA diagnosis (38 vs. 15%, p = 0.01) and larger ICH volumes (37 [8–47] vs. 12 [6–24] ml, p = 0.01), but not with imaging features of SVD. Our findings suggest that DWI+ lesions after ICH are a feature of both the underlying SVD and ICH-related mechanisms.
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Affiliation(s)
- Kim Wiegertjes
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sabine Voigt
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Wilmar M. T. Jolink
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Emma A. Koemans
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Floris H. B. M. Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Marieke J. H. Wermer
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, Utrecht, Netherlands
| | | | - Marco Duering
- Department of Biomedical Engineering, Medical Image Analysis Center (MIAC AG) and qbig, University of Basel, Basel, Switzerland
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Catharina J. M. Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Catharina J. M. Klijn
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9
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Minhas JS, Moullaali TJ, Rinkel GJE, Anderson CS. Blood Pressure Management After Intracerebral and Subarachnoid Hemorrhage: The Knowns and Known Unknowns. Stroke 2022; 53:1065-1073. [PMID: 35255708 DOI: 10.1161/strokeaha.121.036139] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Jatinder S Minhas
- Department of Cardiovascular Sciences (J.S.M.), University of Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre (J.S.M.), University of Leicester, United Kingdom
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M.)
- Department of Clinical Neurosciences, NHS Lothian, United Kingdom (T.J.M.)
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (T.J.M., C.S.A.)
| | - Gabriel J E Rinkel
- Department of Neurology & Neurosurgery, University Medical Centre Utrecht, University of Utrecht, the Netherlands (G.J.E.R.)
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Germany (G.J.E.R.)
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (T.J.M., C.S.A.)
- The George Institute China at Peking University Health Sciences Centre, Beijing, P.R. China (C.S.A.)
- Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia (C.S.A.)
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