The Association Between Leukoaraiosis and Poor Outcome in Intracerebral Hemorrhage Is Not Mediated by Hematoma Growth

Research Advancements on the Correlation Between Spontaneous Intracerebral Hemorrhage of Different Etiologies and Imaging Markers of Cerebral Small Vessel Disease

Objective

The purpose of this review is to identify the correlation between ICH and CSVD imaging markers under SMASH-U classification by searching and analyzing a large number of literatures in recent years, laying a theoretical foundation for future clinical research. At the same time, by collecting clinical data to evaluate patient prognosis, analyzing whether there are differences or supplements between clinical trial conclusions and previous theories, and ultimately guiding clinical diagnosis and treatment through the analysis of imaging biomarkers.

Methods

In this review, by searching CNKI, Web of Science, PubMed, FMRS and other databases, the use of "spontaneous intracerebral hemorrhage", "hypertensive hemorrhagic cerebral small vessel disease", "cerebral small vessel disease imaging", "Based cerebral small vessel diseases", "SMASH the -u classification" and their Chinese equivalents for the main search term. We focused on reading and analyzing hundreds of relevant literatures in the last decade from August 2011 to April 2020, and also included some earlier literatures with conceptual data sources. After screening and ranking the degree of relevance to this study, sixty of them were cited for analysis and elaboration.

Results

In patients with ICH, the number of cerebral microbleeds in lobes, basal ganglia, and the deep brain is positively correlated with ICH volume and independently correlated with neurological functional outcomes; white matter hyperintensity severity is positively correlated with ICH recurrence risk; multiple lacunar infarction independently predict the risk of ICH; severe brain atrophy is an independent risk factor for a poor prognosis in the long term in patients diagnosed with ICH; and the number of enlarged perivascular spaces is correlated with ICH recurrence. However, small subcortical infarct and ICH are the subject of few studies. Higher CSVD scores are independently associated with functional outcomes at 90 days in patients diagnosed with ICH.

Clinical and paraclinical predictors of early neurological deterioration and poor outcome in spontaneous intracerebral hemorrhage

Background

Spontaneous intracerebral hemorrhage (sICH) is the second most common form of stroke. It is a major cause of morbidity and mortality. Several clinical and radiological parameters are related to its poor outcome. The aim of this study is to elucidate the clinical, laboratory, and radiological factors associated with early neurological deterioration and poor outcome in patients with ICH.

Results

seventy patients diagnosed with sICH were evaluated within the first 72 h from the onset of symptoms by Clinical, radiological, and laboratory parameters. Patients were assessed for early neurological deterioration (END) during the hospital stay (up to 7 days from admission) using Glasgow coma scale (GSC), and the National Institutes of Health Stroke Scale (NIHSS), and within 3 months from stroke onset using modified Rankin scale (mRS). ICH score and Functional Outcome in Patients with Primary Intracerebral Hemorrhage (FUNC) Score were calculated for prognostication. 27.1% and 71.42% of patients had END and showed unfavorable outcome, respectively. Clinical indices, as NIHSS > 7 on admission and age > 51 years, radiological characteristics, as large hematoma size, leukoaraiosis, and mass effect detected on CT scan, as well as serum biomarkers; serum urea level > 50 mg/dL, high neutrophil:lymphocyte ratio on admission, high ALT and AST, as well as low total, LDL, and HDL cholesterol levels, all were significantly associated with poor outcome in the patients. Stepwise multivariate logistic regression analysis found the presence of aspiration to be an independent predictor of END, and the scores of NIHSS > 7 on admission, age > 51 years, and urea level > 50 mg/dL were independent predictors of poor outcome.

Conclusions

There are several predictors for END as well as poor outcome in ICH. Some are clinical, others are radiological and laboratory. Aspiration was an independent predictor of END during hospital stay (3-7 days) in patients with ICH, while older age, high NIHSS and urea level on admission were independent predictors of poor outcome.

Impact of white matter hypodensities on outcome after intracerebral hemorrhage

OBJECTIVES

White matter hypodensities (WMH), a surrogate of small vessel disease, associate with cognitive decline and stroke risk. The impact of WMH on functional outcome after intracerebral hemorrhage (ICH) has differed between studies. We aimed to examine factors associated with the severity of WMH in ICH, and whether there is an independent association between the extent of WMH and outcome.

MATERIALS AND METHODS

This was a prospective study of consented patients with non-traumatic primary ICH, admitted to the Helsinki University Hospital between May 2014 and December 2018. To evaluate the extent of the WMH, modified van Swieten score of the side contralateral to the ICH was obtained. Patients were grouped into 3 categories of the scores. We performed univariate and multivariable analyses to find out factors associated with the severity of WMH, and whether WMH associate with functional outcome and mortality up to 12 months, adjusted for the known major outcome predictors.

RESULTS

In our cohort of 417 ICH patients, WMH severity associated with older age, female sex, admission National Institutes of Health Stroke Scale (NIHSS) points, and signs of previous ischemic stroke on CT. We found an independent association between WMH severity and poor functional outcome at 3 months (OR 1.72, 95% CI 1.27-2.33), and 1 year (OR 2.16, 95% CI 1.57-2.95), and mortality at 1 year (OR 1.91, 95% CI 1.29-2.85).

CONCLUSIONS

In our ICH patients, vascular comorbidities and older age associated with the presence of WMH, which, in turn, strongly associated with poor functional outcome.

Old thalamic lacunes contralateral to a supratentorial intracerebral hemorrhage are associated with an unfavorable outcome

OBJECTIVE

To determine the impact of old lacunes and their sites on the prognosis of one-sided supratentorial intracerebral hemorrhage (ICH) by classifying lacunes sites in relation to anatomical structures using MRI.

METHODS

Consecutive patients with one-sided supratentorial ICH ≤72 h from onset to door who underwent MRI were retrospectively included. The sites of old lacunes were categorized as follows: deep subcortical white matter, caudate head, lentiform, posterior limb and genu of the internal capsule, thalamus, and brainstem. We also evaluated all other cerebral small vessel disease markers. An unfavorable outcome was defined as a modified Rankin Scale score of 3 to 6 at 3 months after onset. We investigated whether old lacunes in particular locations were related to unfavorable outcomes.

RESULTS

We included 186 patients with one-sided supratentorial ICH (126 [68%] males, median age 62 years). Of 186 patients, 65 (35%) patients had unfavorable outcomes. Factors associated with unfavorable outcomes were age (OR 2.261, 95% CI 1.332-3.839, p = 0.003), National Institutes of Health Stroke Scale [NIHSS] score at admission (OR 1.175, 95% CI 1.090-1.267, p < 0.001), and old thalamic lacunes contralateral to the hematoma (OR 3.805, 95% CI 1.009-14.340, p = 0.048). Patients with old thalamic lacunes contralateral to the hematoma tended to have arm (p = 0.006) and leg (p = 0.011) motor impairment on the paralyzed side at discharge as estimated by the NIHSS score.

CONCLUSIONS

Old thalamic lacunes contralateral to the hematoma may be related to unfavorable outcomes in ICH.

Moderate-Severe White Matter Lesion Predicts Delayed Intraventricular Hemorrhage in Intracerebral Hemorrhage

BACKGROUND

Most existing studies have focused on the correlation between white matter lesion (WML) and baseline intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH), whereas few studies have investigated the relationship between WML severity and delayed IVH after admission. This study aimed to investigate the correlation between WML severity and delayed IVH and to verify the association between WML and baseline IVH.

METHODS

A total of 480 patients with spontaneous ICH from February 2018 to October 2020 were selected. WML was scored using the Van Swieten Scale, with scores of 0-2 representing nonslight WML and scores of 3-4 representing moderate-severe WML. We determined the presence of IVH on baseline (< 6 h) and follow-up computed tomography (< 72 h) images. Univariate analysis and multiple logistic regression were used to analyze the influencing factors of baseline and delayed IVH.

RESULTS

Among 480 patients with ICH, 172 (35.8%) had baseline IVH, and there was a higher proportion of moderate-severe WML in patients with baseline IVH (20.3%) than in those without baseline IVH (12.7%) (P = 0.025). Among 308 patients without baseline IVH, delayed IVH was found in 40 patients (12.9%), whose proportion of moderate-severe WML (25.0%) was higher than that in patients without delayed IVH (10.8%) (P = 0.012). Multiple logistic regression results showed that moderate-severe WML was independently correlated with baseline IVH (P = 0.006, odds ratio = 2.266, 95% confidence interval = 1.270-4.042) and delayed IVH (P = 0.002, odds ratio = 7.009, 95% confidence interval = 12.086-23.552).

CONCLUSIONS

Moderate-severe WML was an independent risk factor for delayed IVH as well as baseline IVH.

Higher Cerebral Small Vessel Disease Burden in Patients With Small Intracerebral Hemorrhage

Objective

To investigate the association between cerebral small vessel disease (SVD) and hematoma volume in primary intracerebral hemorrhage (ICH).

Methods

Patients from a prospective ICH cohort were enrolled. Admission and follow-up CT scan within 72 h after onset were reviewed to calculate the final hematoma volume. We evaluated cortical superficial siderosis and the global SVD score, including white matter hyperintensities, lacunes, enlarged perivascular space, and cerebral microbleeds on MRI. We conducted the multivariate logistic regression analyses to explore the association between SVD markers and small ICH, as well as hematoma volume. Hematoma location was stratified into lobar and non-lobar for subgroup analysis.

Results

A total of 187 patients with primary ICH (mean age 62.4 ± 13.4 years, 67.9% male) were enrolled. 94 (50.2%) patients had small ICH. The multivariate logistic regression analysis showed an association between global SVD score and small ICH [adjusted odds ratio (aOR) 1.27, 95% CI 1.03–1.57, p = 0.027] and a trend of higher global SVD score towards non-lobar small ICH (aOR 1.23, 95% CI 0.95–1.58, p = 0.122). In the multivariate linear regression analysis, global SVD score was inversely related to hematoma volume of all ICH (β = −0.084, 95% CI −0.142 to −0.025, p = 0.005) and non-lobar ICH (β = −0.112, 95% CI −0.186 to −0.037, p = 0.004). Lacune (β = −0.245, 95% CI −0.487 to −0.004, p = 0.046) was associated with lower non-lobar ICH volume.

Conclusion

Global SVD score is associated with small ICH and inversely correlated with hematoma volume. This finding predominantly exists in non-lobar ICH.

Cerebral Small Vessel Disease and Prognosis in Intracerebral Hemorrhage: A Systematic Review and Meta-analysis of Cohort Studies

BACKGROUND

To investigate whether cerebral small vessel disease (CSVD) markers and the total CSVD burden are associated with functional outcome, mortality, stroke recurrence, and hematoma expansion in patients with spontaneous intracerebral hemorrhage (ICH).

METHODS

Following a previously registered protocol (PROSPERO protocol: CRD42021287743), we systematically searched PubMed, Web of Science, and EMBASE to identify relevant literature up to November 2021. Cohort studies that examined the association between CSVD markers (white matter hyperintensity [WMH], lacune, enlarged perivascular space [EPVS], cerebral microbleed [CMB], and brain atrophy) or CSVD burden and prognosis in patients with ICH were included. The pooled estimates were calculated using random effects models.

RESULTS

Forty-one studies with 19,752 ICH patients were pooled in the meta-analysis. WMH (OR=1.50, 95% CI=1.32 to 1.70), lacune (OR=1.32, 95% CI=1.18 to 1.49), CMB (OR=2.60, 95% CI=1.13 to 5.97) and brain atrophy (OR=2.22, 95% CI=1.48 to 3.31) were associated with worse functional outcome. CSVD markers concerning increased risk of mortality were WMH (OR=1.57, 95% CI=1.38 to 1.79) and brain atrophy (OR=1.84, 95% CI=1.11 to 3.04), while concerning increased risk of stroke recurrence were WMH (OR=1.62, 95% CI=1.28 to 2.04) and lacune (OR=3.00, 95% CI=1.68 to 5.37). EPVS was not related to prognosis. There was a lack of association between CSVD markers and hematoma expansion. CSVD burden increased the risk of worse functional outcome, mortality, and stroke recurrence by 57%, 150%, and 44%, respectively.

CONCLUSIONS

In patients with spontaneous ICH, WMH, lacune, CMB, brain atrophy, and the total CSVD burden are associated with substantially increased risk of worse functional outcome, mortality, or stroke recurrence.

White Matter Hyperintensities and Functional Outcomes in Patients With Cerebral Hemorrhage: A Systematic Review and Meta-Analysis

Background and Objectives

There are controversies about white matter hyperintensities (WMH) and the prognosis of spontaneous intracerebral hemorrhage. Our objective is to investigate the relationship between WMH and functional outcomes after intracerebral hemorrhage (ICH).

Methods

We systematically searched PubMed, EMBASE, and Cochrane Library databases from inception through August 10, 2021 without any restriction of countries. Articles investigating the relationship of WMH and functional outcomes as well as mortality of patients with spontaneous ICH were included. We extracted relevant data and evaluated the study quality with the Newcastle-Ottawa Scale. We pooled odds ratio (OR) for the presence and different severities of WMH with random effects models using STATA.

Results

A total of 10,584 patients with ICH in 18 studies were included in the analysis. Moderate/severe WMH were related to poor functional outcome [OR, 1.805, 95% confidence interval (CI), 1.320–2.469] and all-cause mortality (OR, 3.27, 95% CI, 2.07–5.18) after ICH. Besides, the increasing severity of WMH was also related to poor functional outcome (OR, 1.34, 95% CI, 1.17–1.53) and all-cause mortality (OR, 1.62, 95% CI, 1.39–1.90). The pooled data did not find the relationship between the presence of WMH and poor functional outcome (OR, 2.54, 95% CI, 0.91–7.05) after ICH. The results remained stable after adjusting for age, hematoma volume, stroke, and intraventricular hemorrhage.

Conclusion

We found moderate and severe WMH were related to poor functional outcomes and all-cause mortality after ICH. High-quality prospective studies are still needed.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021278409.

sTWEAK is a leukoaraiosis biomarker associated with neurovascular angiopathy

Objective

Leukoaraiosis (LA) refers to white matter lesions of undetermined etiology associated with the appearance and worsening of vascular pathologies. The aim is to confirm an increased frequency and intensity of LA in symptomatic patients with neurovascular pathology compared with asymptomatic subjects, and its association with circulating serum levels of soluble tumor necrosis factor‐like weak inducer of apoptosis (sTWEAK).

Methods

An observational study was conducted in which two groups of patients were compared. Group I (N = 242) comprised of asymptomatic subjects with arterial hypertension and/or diabetes or with a history of transient ischemic attacks, and Group II (N = 382) comprised patients with lacunar stroke or deep hemispheric intracerebral hemorrhage (ICH) of hypertensive origin. Serum levels of sTWEAK were analyzed and correlated with prevalence and intensity of LA according to the Fazekas scale.

Results

The prevalence of LA was higher in symptomatic (85.1%) versus asymptomatic patients (62.0%). Logistic regression model showed a significant relation of LA with neurovascular pathologies (OR: 2.69, IC 95%: 1.10–6.59, p = 0.003). When stratified according to the Fazekas scale, LA of grade II (OR: 3.53, IC 95%: 1.10–6.59, p = 0.003) and specially grade III (OR: 4.66, 95% CI: 1.09–19.84, p = 0.037) showed correlation with neurovascular pathologies. Increased sTWEAK levels were found in the symptomatic group in all LA grades (p < 0.0001), and associated with 5.06 times more risk of presenting clinical symptoms (OR: 5.06, 95% CI: 2.66–9.75, p < 0.0001).

Interpretation

LA showed a higher prevalence in patients with symptomatic lacunar stroke or deep hemispheric ICH. There is an association between sTWEAK levels and LA degree.

Higher cerebral small vessel disease burden is associated with smaller hematoma volume in mixed-location intracerebral hemorrhage

OBJECTIVE

To study the relationship between cerebral small vessel disease (CSVD) and hematoma volume in mixed-location intracerebral hemorrhage (ICH), and non-mixed ICH (hypertensive arteriopathy/cerebral amyloid angiopathy-related ICH).

METHODS

We consecutively collected patients with primary ICH with MRI. Mixed-location ICH was defined as having ICH or cerebral microbleeds (CMBs) in both lobar and deep regions. CSVD markers including lacunes, white matter hyperintensities (WMH), CMBs, and enlarged perivascular spaces (EPVS) were assessed on brain MRI during hospitalization. Multivariable binary logistic regression (≥30 ml vs. <30 ml) and linear regression analyses (log-transformed hematoma volume as dependent variable) were implemented to explore the association between CSVD and hematoma volume.

RESULTS

Of the 167 included patients, 69 (41.3%) had mixed-location ICH, with higher prevalence of lacune, more CMB count, higher WMH score and total CSVD score than those with non-mixed ICH (all p < .001). Higher WMH score was associated with lower risk of hematoma volume ≥30 ml (adjusted OR 0.521, 95% CI 0.299-0.908, p = .021) in patients with mixed-location ICH. Also, multivariable linear regression showed the association of smaller hematoma volume with higher CSVD burden, especially in mixed-location ICH (β = -0.349, p = .019 for CMB ≥ 5; β = -0.183, p < .001 for WMH score; β = -0.456, p = .002 for EPVS>20 in basal ganglia and/or centrum semiovale; β = -0.256, p = .002 for CSVD score), while these relationships were not observed in non-mixed ICH.

CONCLUSIONS

Higher CSVD burden is associated with smaller hematoma volume in mixed-location ICH, but not in non-mixed ICH, which is novel and needs further studies with larger sample size to confirm our results and explore the underlying mechanisms.

sTWEAK is a marker of early haematoma growth and leukoaraiosis in intracerebral haemorrhage

Objective

To study the association between early growth of haematoma with biomarkers of endothelial dysfunction such as leukoaraiosis (LA) and the soluble tumour necrosis factor-like weak inducer of apoptosis (sTWEAK) in patients with intracerebral haemorrhage (ICH).

Methods

This is a retrospective observational study of patients with nontraumatic ICH. Clinical and biochemical parameters were analysed. sTWEAK levels were measured by ELISA. LA was analysed in the hemisphere without haemorrhage to avoid interference with the acute injury. The main endpoint was the haematoma growth evaluated by the difference in volume between the second and the initial neuroimage. Poor functional outcome, defined as a modified Rankin Scale >2 at 3 months, was considered as secondary endpoint. Receiver operating characteristic curve analysis was performed to stablish the best cut-off for sTWEAK levels associated with haematoma growth.

Results

We included 653 patients with ICH in our analysis (71.1±11.9 years, 44% women). Haematoma growth was observed in 188 patients (28.8%). sTWEAK levels ≥5600 pg/mL predicted ICH growth with a sensitivity of 84% and a specificity of 87%. sTWEAK levels ≥5600 pg/mL and the presence of LA were associated with haematoma growth (OR: 42.46; (CI 95% 22.67 to 79.52) and OR: 2.73 (CI 95% 1.39 to 5.34), respectively). Also, the presence of LA (OR: 4.31 (CI 95% 2.89 to 6.42)) and the interaction between ICH growth and sTWEAK (OR: 2.23 (CI 95% 1.40 to 3.55)) were associated with poor functional outcome at 3 months.

Conclusion

sTWEAKs, together with the presence and grade of LA, are biomarkers able to predict ICH growth and poor functional outcome in patients with ICH.

Do Imaging Markers of Cerebral Small Vessel Disease Predict Hematoma Volume and Outcome in Acute Intracerebral Hemorrhage?

BACKGROUND AND PURPOSE

Cerebral small vessel disease (CSVD) markers have not been widely studied in relation to hematoma volume and growth in hypertensive intracerebral hemorrhage (ICH). The objectives to assess the relationship of white matter hyperintense lesions (WMHL), microbleeds (MBs), and cortical siderosis (CSS) with hematoma volume, hematoma expansion (HE), and 3 months outcome in patients with hypertensive ICH.

METHODS

All consecutive acute hypertensive supratentorial ICH presenting to the emergency were prospectively recruited. Baseline and 24 hours computed tomography (CT) to assess hematoma volume and magnetic resonance imaging (MRI) for CSVD markers were performed in all subjects. WMHL (graded using Fazekas's scale), MBs, and CSS were assessed and compared with baseline variables and outcomes. All the images were assessed by an experienced stroke neurologist/neuroradiologist.

RESULTS

One hundred and fifty-seven patients were screened and 60 were included. Mean age was 54.08 ± 11.57 years and 47 (78%) were males. Of 60, 19 (28.1%) had HE, 31 (51.6%) had major bleed (>30 ml), and 28 (47.46%) had poor 3 month outcome (mRS 4-6). On univariate analysis, high grade WMHL was associated with greater HE [odds ratio (OR): 2.65, confidence interval (CI) 1.48-4.72, P = 0.001), greater proportion with volume >30 ml (OR: 7.16, CI: 1.09-47.13, P = 0.001) and poor outcome (OR: 2.1, CI: 0.05-3.27, P = 0.001). MBs were associated with poor outcome (P = 0.029) but not with HE/volume. CSS was related to HE (P = 0.031), a large volume bleed (P = 0.023), and poor outcome (P = 0.021). On multivariate model, only WMHL independently predicted HE (P = 0.034), greater proportion with bleed volume >30 ml (P = 0.041), and poor outcome (P = 0.042).

CONCLUSIONS

WMHL in MRI serves as a predictor of hematoma expansion, a large volume bleed, and poor outcome in hypertensive ICH and may be incorporated into existing prediction models.

Cerebral Small Vessel Disease Load Predicts Functional Outcome and Stroke Recurrence After Intracerebral Hemorrhage: A Median Follow-Up of 5 Years

Background: Uncertainty exists over the long-term prognostic significance of cerebral small vessel disease (CSVD) in primary intracerebral hemorrhage (ICH).

Methods: We performed a longitudinal analysis of CSVD and clinical outcomes in consecutive patients with primary ICH who had MRI. Baseline CSVD load (including white matter hyperintensities [WMH], cerebral microbleeds [CMBs], lacunes, and enlarged perivascular spaces [EPVS]) was evaluated. The cumulative CSVD score was calculated by combining the presence of each CSVD marker (range 0–4). We followed participants for poor functional outcome [modified Rankin scale [mRS] ≥ 4], stroke recurrence, and time-varying survival during a median follow-up of 4.9 [interquartile range [IQR] 3.1–6.0] years. Parsimonious and fuller multivariable logistic regression analysis and Cox-regression analysis were performed to estimate the association of CSVD markers, individually and collectively, with each outcome.

Results: A total of 153 patients were included in the analyses. CMBs ≥ 10 [adjusted OR [adOR] 3.252, 95% CI 1.181–8.956, p = 0.023] and periventricular WMH (PWMH) (adOR 2.053, 95% CI 1.220–3.456, p = 0.007) were significantly associated with poor functional outcome. PWMH (adOR 2.908, 95% CI 1.230–6.878, p = 0.015) and lobar CMB severity (adOR 1.811, 95% CI 1.039–3.157, p = 0.036) were associated with stroke recurrence. The cumulative CSVD score was associated with poor functional outcome (adOR 1.460, 95% CI 1.017–2.096) and stroke recurrence (adOR 2.258, 95% CI 1.080–4.723). Death occurred in 36.1% (13/36) of patients with CMBs ≥ 10 compared with 18.8% (22/117) in those with CMB < 10 (adjusted HR 2.669, 95% CI 1.248–5.707, p = 0.011). In addition, the cumulative CSVD score ≥ 2 was associated with a decreased survival rate (adjusted HR 3.140, 95% CI 1.066–9.250, p = 0.038).

Conclusions: Severe PWMH, CMB, or cumulative CSVD burden exert important influences on the long-term outcome of ICH.

Associations of Radiographic Cerebral Small Vessel Disease with Acute Intracerebral Hemorrhage Volume, Hematoma Expansion, and Intraventricular Hemorrhage

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate the impact of radiographic cerebral small vessel disease (CSVD) on the severity of acute intracerebral hemorrhage (ICH) as measured by: ICH volume, hematoma expansion, and extension of intraventricular hemorrhage (IVH).

METHODS

CSVD was determined on baseline computed tomography (CT) scans of patients from the Ethnic and Racial Variations of Intracerebral Hemorrhage study through the extent of leukoaraiosis and cerebral atrophy using visual rating scales. The associations of leukoaraiosis and atrophy with ICH volume, hematoma expansion, IVH presence, and severity of IVH were tested using multivariable regression models. Secondary analyses were stratified by hemorrhage location. Bonferroni correction was applied to correct for multiple testing.

RESULTS

A total of 2579 patients (mean age 61.7 years, 59% male) met inclusion criteria. Median ICH volume was 10.5 (Interquartile range [IQR] 4.0-25.3) mL. IVH was detected in 971 patients (38%). Neither leukoaraiosis nor atrophy was associated with hematoma expansion. Increasing grades of leukoaraiosis were associated with increased risk of IVH in a dose-dependent manner, while cerebral atrophy was inversely associated with IVH (both P for trend < 0.001). Increasing grades of global atrophy were dose-dependently associated with lower ICH volumes (ß (95% Confidence Interval [CI]) - 0.30[- 0.46, - 0.14], - 0.33[- 0.49, - 0.17], - 0.40[- 0.60, - 0.20], and - 0.54[- 0.76, - 0.32], for grades 1, 2, 3 and 4 compared to 0; all P < 0.001). The associations of leukoaraiosis with ICH volume were consistent with those of atrophy, albeit not meeting statistical significance.

CONCLUSIONS

Leukoaraiosis and cerebral atrophy appear to have opposing associations with ICH severity. Cerebral atrophy correlates with smaller ICH volume and decreased risk and severity of IVH, while leukoaraiosis is associated with increased risk of IVH. Whether these observations reflect overlapping or divergent underlying mechanisms requires further study.

Intracerebral hematoma expansion and intracranial internal carotid artery calcifications

BACKGROUND AND AIMS

Prediction of intracerebral hematoma expansion (IHE) is of critical importance during intracerebral hemorrhage (ICH) management. Given its suggested positive connection with cerebral microvascular disease status, intracranial internal carotid artery wall calcifications (ICAC) on admission computed tomography (CT) studies may contribute to prediction of IHE.

METHOD

Presence, burden and type [as per Kockelkoren's score] of ICAC were defined in admission CT and CT-angiography of 201 ICH patients [mean age: 70 ± 13 years, 44 % female]. A Kockelkoren's score of <7 indicated intimal calcification [iICAC], while ≥7 indicated non-intimal [or medial] ones [mICAC]. IHE criteria were absolute volume increase of ≥12.5cc or ≥6cc, and relative increase ≥33 % or ≥26 %.

RESULT

ICAC was diagnosed in 79.6 % of ICH patients. ICAC status was not independent indicator of milder IHE (≥6cc and ≥26 % IHE, both in 27 %). Presence of contralateral mICAC was found to be an independent predictor for higher grade IHE (expβ = 3.44, 95 %CI: 1.47-8.04, for IHE ≥ 12.5cc, diagnosed in 14.4 %; and expβ = 2.67, 95 %CI: 1.29-5.55, for IHE ≥ 33 %, diagnosed in 24 %). Mortality (31 %) was higher in those with ipsilateral any type ICAC (36 % in mICAC, 38 % in iICAC, 17 % in no ICAC, p = 0.017), but this was not independent predictor in logistic regression. Similarly, medial ICAC in both ipsilateral (47 % vs. 31 %, p = 0.037) and contralateral (47 % vs. 30 %, p = 0.017) sides was associated with poorer prognosis (42 %) on univariate, but not multivariate analysis.

CONCLUSION

Intracranial ICA calcification is highly prevalent in ICH. mICAC may be associated with risk of "high amount" acute hematoma expansion, hospital mortality and poor prognosis.

White Matter Lesion Severity is Associated with Intraventricular Hemorrhage in Spontaneous Intracerebral Hemorrhage

BACKGROUND

Intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability in intracerebral hemorrhage (ICH). A prior report identified an increased risk of IVH with greater WML burden but did not control for location of ICH. We sought to determine whether a higher degree of WML is associated with a higher risk of IVH after controlling for ICH location.

METHODS

Utilizing the patient population from 2 large ICH studies; the Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study and the Ethnic/Racial Variations of Intracerebral Hemorrhage study, we graded WML using the Van Swieten Scale (0-1 for mild, 2 for moderate, and 3-4 for severe WML) and presence or absence of IVH in baseline CT scans. We used multivariable regression models to adjust for relevant covariates.

RESULTS

Among 3023 ICH patients, 1260 (41.7%) had presence of IVH. In patients with IVH, the proportion of severe WML (28.6%) was higher compared with patients without IVH (21.8%) (P < .0001). Multivariable analysis demonstrated that moderate-severe WML, deep ICH, and increasing ICH volume were independently associated with presence of IVH. We found an increased risk of IVH with moderate-severe WML (OR = 1.38; 95%Cl 1.03-1.86, P = .0328) in the subset of lobar hemorrhages.

CONCLUSIONS

Moderate to severe WML is a risk for IVH. Even in lobar ICH hemorrhages, severe WML leads to an independent increased risk for ventricular rupture.

Relationship of White Matter Lesions with Intracerebral Hemorrhage Expansion and Functional Outcome: MISTIE II and CLEAR III

BACKGROUND/OBJECTIVE

Intracerebral hemorrhage (ICH) patients commonly have concomitant white matter lesions (WML) which may be associated with poor outcome. We studied if WML affects hematoma expansion (HE) and post-stroke functional outcome in a post hoc analysis of patients from randomized controlled trials.

METHODS

In ICH patients from the clinical trials MISTIE II and CLEAR III, WML grade on diagnostic computed tomography (dCT) scan (dCT, < 24 h after ictus) was assessed using the van Swieten scale (vSS, range 0-4). The primary outcome for HE was > 33% or > 6 mL ICH volume increase from dCT to the last pre-randomization CT (< 72 h of dCT). Secondary HE outcomes were: absolute ICH expansion, > 10.4 mL total clot volume increase, and a subgroup analysis including patients with dCT < 6 h after ictus using the primary HE definition of > 33% or > 6 mL ICH volume increase. Poor functional outcome was assessed at 180 days and defined as modified Rankin Scale (mRS) ≥ 4, with ordinal mRS as a secondary endpoint.

RESULTS

Of 635 patients, 55% had WML grade 1-4 at dCT (median 2.2 h from ictus) and 13% had subsequent HE. WML at dCT did not increase the odds for primary or secondary HE endpoints (P ≥ 0.05) after adjustment for ICH volume, intraventricular hemorrhage volume, warfarin/INR > 1.5, ictus to dCT time in hours, age, diabetes mellitus, and thalamic ICH location. WML increased the odds for having poor functional outcome (mRS ≥ 4) in univariate analyses (vSS 4; OR 4.16; 95% CI 2.54-6.83; P < 0.001) which persisted in multivariable analyses after adjustment for HE and other outcome risk factors.

CONCLUSIONS

Concomitant WML does not increase the odds for HE in patients with ICH but increases the odds for poor functional outcome.

CLINICAL TRIAL REGISTRATION

http://www.clinicaltrials.gov trial-identifiers: NCT00224770 and NCT00784134.

White Matter Hyperintensities and Blood Pressure Lowering in Acute Intracerebral Hemorrhage: A Secondary Analysis of the ATACH-2 Trial

BACKGROUND

It is not clear whether subsets of patients with intracerebral hemorrhage (ICH) benefit from intensive blood pressure (BP) lowering. We evaluated whether white matter hyperintensities (WMH) burden influences response to this therapy.

METHODS

Retrospective secondary analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial. Patients were randomized to intensive (systolic BP target: 110-139 mmHg) versus standard (systolic BP target: 140-179 mmHg) BP treatment with intravenous nicardipine within 4.5 h from onset between May 2011 and September 2015. WMH were rated on magnetic resonance images (fluid-attenuated inversion recovery sequences), defining moderate-severe WMH as total Fazekas scale score ≥ 3 (range 0-6). The main outcome was death or major disability at 90 days (modified Rankin scale ≥ 3). The secondary outcome was ICH expansion, defined as hematoma growth > 33% from baseline to follow-up CT scan. Predictors of the outcomes of interest were explored with multivariable logistic regression.

RESULTS

A total of 195/1000 patients had MRI images available for analysis, of whom 161 (82.6%) had moderate-severe WMH. When compared to patients with none-mild WMH, those with moderate-severe WMH did not have an increased risk of death or major disability (adjusted relative risk: 1.83, 95% CI 0.71-4.69) or ICH expansion (adjusted relative risk: 1.14, 95% CI 0.38-3.37). WMH burden did not modify the effect of intensive BP treatment on outcome (all p for interaction ≥ 0.2).

CONCLUSION

The majority of acute ICH patients have moderate-severe WMH, but advanced small vessel disease burden marked by WMH does not influence ICH-related outcomes or response to intensive BP reduction.

Impact of Cerebral Small Vessel Disease on Functional Recovery After Intracerebral Hemorrhage

Background and Purpose- In this study, we aim to investigate the association of computed tomography-based markers of cerebral small vessel disease with functional outcome and recovery after intracerebral hemorrhage. Methods- Computed tomographic scans of patients in the ERICH study (Ethnic and Racial Variations of Intracerebral Hemorrhage) were evaluated for the extent of leukoaraiosis and cerebral atrophy using visual rating scales. Poor functional outcome was defined as a modified Rankin Scale (mRS) of ≥3. Multivariable logistic and linear regression models were used to explore the associations of cerebral small vessel disease imaging markers with poor functional outcome at discharge and, as a measure of recovery, change in mRS from discharge to 90 days poststroke. Results- After excluding in-hospital deaths, data from 2344 patients, 583 (24.9%) with good functional outcome (mRS of 0-2) at discharge and 1761 (75.1%) with poor functional outcome (mRS of 3-5) at discharge, were included. Increasing extent of leukoaraiosis (P for trend, 0.01) and only severe (grade 4) global atrophy (odds ratio, 2.02; 95% CI, 1.22-3.39, P=0.007) were independently associated with poor functional outcome at discharge. Mean (SD) mRS change from discharge to 90-day follow-up was 0.57 (1.18). Increasing extent of leukoaraiosis (P for trend, 0.002) and severe global atrophy (β [SE], -0.23 [0.115]; P=0.045) were independently associated with less improvement in mRS from discharge to 90 days poststroke. Conclusions- In intracerebral hemorrhage survivors, the extent of cerebral small vessel disease at the time of intracerebral hemorrhage is associated with poor functional outcome at hospital discharge and impaired functional recovery from discharge to 90 days poststroke.

Progression of White Matter Injury After Intracerebral Hemorrhage: A Magnetic Resonance Imaging Study

BACKGROUND

White matter injury (WMI) has been observed after experimental intracerebral hemorrhage (ICH). The supporting clinical data have been sparse. We assessed the presence, extent, and progression of WMI in patients with ICH.

METHODS

We performed a retrospective review of data from 65 consecutive patients with spontaneous supratentorial ICH who had undergone baseline brain magnetic resonance imaging (MRI) within 7 days of ICH onset and repeat MRI afterward. We used the Fazekas scale (FZKS) to grade the severity of WMI. The clinical and imaging characteristics of the patients with and without WMI progression (WMIP) were compared using uni- and multivariate logistic regression analyses.

RESULTS

We observed WMIP in 23 patients (35.4%). WMIP was noted in both hemispheres but more commonly ipsilateral to the ICH (33% vs. 21%). The mean total FZKS score had increased from 3 (interquartile range [IQR], 1-4) at baseline to 4 (IQR, 2-5) on repeat MRI (P < 0.0001). Patients with lobar ICH had a greater median FZKS score than those with deep ICH (median, 3; IQR, 2-4; vs. 1.5, IQR, 1-3.25; P = 0.027). The baseline parenchymal ICH volume (odds ratio [OR], 1.067; 95% confidence interval [CI], 1.018-1.119; P = 0.007) and ventricular volume on baseline MRI (OR, 1.073; 95% CI, 1.019-1.130; P = 0.007) were predictors of WMIP after adjustment. Multivariate analyses showed an independent association between WMIP and unfavorable 3-month outcomes (OR, 5.196; 95% CI, 1.059-25.483; P = 0.042).

CONCLUSIONS

WMI will progress over time in patients with ICH, and WMIP has been associated with worse outcomes. This novel finding could represent a potential therapeutic target. Future prospective larger studies are needed to confirm our findings.

Prognostic significance of leukoaraiosis in intracerebral hemorrhage: A meta-analysis

BACKGROUND

Patients with intracerebral hemorrhage (ICH) have high disability and mortality. Leukoaraiosis refers to the diffuse abnormalities of white matter on neuroimaging, which has been suggested to be with poor outcome in patients with ICH. This meta-analysis was performed to summarize the current evidence on the prognostic significance of leukoaraiosis in ICH patients.

METHODS

Databases were searched for published studies about leukoaraiosis and prognosis in patients with ICH. Data from eligible studies were extracted. Odds ratios (ORs) and their 95% confidence intervals (CIs) from each study were combined with DerSimonian-Laird method and random effect model for quantitative analysis. Begg's funnel plot was adopted to assess the publication bias.

RESULTS

A total of nine studies with 4948 patients were finally included in this meta-analysis. Six studies reported functional outcome, two studies reported mortality, and another study reported both functional outcome and mortality. The meta-analysis showed that leukoaraiosis was significantly associated with worse functional outcome in patients with ICH (OR = 1.40, 95%CI 1.17-1.68, P < .001). In addition, leukoaraiosis was also significantly associated with higher mortality in patients with ICH (OR = 1.59, 95%CI 1.21-2.08, P = .001).

CONCLUSIONS

Leukoaraiosis is significantly associated with both worse functional outcome and higher mortality in patients with ICH. Leukoaraiosis can be a useful imaging marker for predicting outcome in patients with ICH.

Relationship between White Matter Hyperintensities and Hematoma Volume in Patients with Intracerebral Hematoma

The relationship of white-matter hyperintensity (WMH) to intracerebral hemorrhage (ICH) remains unclear. In this retrospective study, we investigated whether the severity and progression of WMH could be related to the hematoma volume and absorption in ICH. 2338 WMH patients with ICH aged≥40 years receiving brain computed tomography (CT) imaging within 12 hours of ICH symptom onset were screened, and 227 patients were included in the final study. The severity and progression of WMH were assessed using the software programs MRICRON and ITK-SNAP on brain magnetic resonance imaging (MRI) and the hematoma volumes and absorption with ITK-SNAP software on CT. We assessed the association of WMH severity with ICH volume in 227 patients at baseline. Totally 183 of 227 patients underwent repeated CT within 14 days of ICH onset. The relationship of WMH severity to ICH absorption was analyzed in 183 patients. Additionally, among all 227 patients, 37 subjected to another MRI before ICH onset were divided into two groups according to WMH progression: non-progression and progression groups. The link between WMH progression and hematoma volume was examined. The ICH volume was significantly larger in patients with the highest WMH scores than in those with the lowest WMH scores. Larger WMH volume was independently associated with larger ICH volume (odds ratio 1.00; 95% CI, 1.00 to 1.00; P = 0.049). There was a trend towards WMH progression being related to ICH volume (P =0.049). Contrastingly, the WMH volume was not linked with hematoma absorption (P = 0.79). In conclusion, we found that greater severity and progression of WMH were associated with larger ICH volume. Our findings suggest that WMH might provide important prognostic information about patients with ICH and may have implications for treatment stratification.