Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage

Development of the European Society of Hypertension guidelines for the management of arterial hypertension: comparison of the helpfulness of ESH 2013, 2018, and 2023 guidelines

OBJECTIVE

Over the last decade, the European Society of Hypertension (ESH) published several guidelines (GLs) for the Management of Arterial Hypertension (2013, 2018, and 2023). We hypothesized that the GL has been improved because of the publications of new evidence. Thus, we aimed to examine the development of ESH guidelines (ESH GLs) by comparing their helpfulness regarding the diagnosis and treatment of hypertension.

METHODS

A novel mathematical analysis was used to compare ESH GLs. Not only the frequency of Classes of Recommendations (CLASS) and the Levels of Evidence (LEVEL) were examined but a newly developed certainty index (CI) was calculated. This CI allows the CLASS and LEVEL to be assessed together, providing a less biased assessment of GLs, than examining the CLASS and LEVEL independently or related to each other.

RESULTS

The number of recommendations showed continuous and significant increases from 2013 ( N  = 110) to 2018 ( N  = 169), and 2023 ( N  = 269). Examining the frequency of CLASS and/or LEVEL led to biased results, showing both improvements and/or worsening comparing years. However, based on the new analysis, a continuous improvement was shown in the percentage of certainty from 2013 to 2023 (2013: 60.5%, 2018: 72.1%, 2023: 75.3%). Accordingly, the CI was also significantly increased from 2013 (CI: 0.21), to 2018 (CI: 0.44), and to 2023 (CI: 0.51).

CONCLUSION

The analysis shows that compared to previous GLs, the structure of the ESH 2023 GL has been rearranged and simplified. The higher number of Recommendations indicates a continuously accumulating knowledge regarding the mechanisms, clinical findings, and epidemiology of hypertension. Moreover, the ESH 2023 GL shows a higher degree of certainty and CI, corresponding to a higher level of helpfulness of the ESH 2023 GL for healthcare professionals to diagnose, prevent, and treat hypertension.

Factors Related to Nonachievement of Intensive Blood Pressure-Lowering Target in Patients with Intracerebral Hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is one of the most disabling forms of stroke. Intensive lowering of blood pressure (BP) has been postulated as one of the therapies that can improve functional outcomes. However, this intensive reduction is not always achieved. We aimed to study the differences between patients in whom intensive BP lowering was achieved during the first 24 h after admission and those in whom this BP lowering was not possible.

METHODS

We retrospectively reviewed medical charts to obtain information on BP management during the first 24 h. Our protocol establishes that intensive BP lowering below 140 mm Hg of systolic BP should be pursued.

RESULTS

In total, 210 patients were included. In 107 (51.0%), an intensive target BP was not achieved. This group of patients had higher initial National Institutes of Health Stroke Scale scores and poorer clinical evolution, with more early neurological deterioration, higher requirements for antihypertensive treatment, higher necessity for surgical evacuation, more withdrawal of life-sustaining therapies, and higher mortality at 3 months (all p < 0.05). In the multivariable analysis, high BP levels at admission remained related to the nonachievement of BP-lowering goals, despite a higher administration of antihypertensive medications.

CONCLUSIONS

In this study, the intensive BP-lowering goal was not achieved in about half of the patients with ICH, despite the high proportion of patients receiving antihypertensive medications. This group of patients had poorer outcomes and higher mortality rates at 3 months. High BP at presentation may be difficult to control in patients with high clinical severity of ICH despite aggressive management.

Exploring the impact of glycemic variability on clinical outcomes in critically ill cerebral infarction patients

BACKGROUND

Glycemic variability (GV) is a key determinant of outcomes in critically ill patients, yet its impact on cerebral infarction patients in intensive care units (ICUs) remains underexplored. This study evaluates the association between GV and clinical outcomes, including discharge outcomes, 90-day and 1-year mortality, and ICU/hospital length of stay (LOS).

METHODS

This retrospective study of 778 cerebral infarction patients from the MIMIC-IV database assessed GV, calculated as the glucose standard deviation-to-mean ratio during ICU stays. Regression models evaluated GV's impact on discharge outcomes, mortality, and ICU/hospital LOS, with adjustments for confounders. Restricted cubic spline analyses identified risk thresholds, while sensitivity and subgroup analyses validated findings. Predictive performance was assessed using AUC, NRI, and IDI, and multiple imputation methods addressed missing data.

RESULTS

Higher GV was significantly linked to adverse outcomes. Patients in the highest GV quartile had increased risks of poor discharge outcomes (adjusted OR: 1.83; 95% CI: 1.03-3.32; P = 0.042), 90-day mortality (adjusted HR: 1.51; 95% CI: 1.03-2.22; P = 0.036), and 1-year mortality (adjusted HR: 1.53; 95% CI: 1.07-2.18; P = 0.018). RCS analysis identified critical GV thresholds (≥ 11% for 90-day and ≥ 10% for 1-year mortality). Subgroup analysis revealed stronger associations between GV and poor outcomes in non-diabetic patients (adjusted OR: 1.89; 95% CI: 1.24-2.88; P = 0.003) compared to diabetic patients (adjusted OR: 0.81; 95% CI: 0.53-1.25; P = 0.337). Sensitivity analyses confirmed the robustness of findings across imputation methods.

CONCLUSIONS

GV independently predicts poor outcomes in ICU cerebral infarction patients. Integrating GV metrics into clinical workflows may improve risk stratification and guide interventions. Future research should validate these findings and explore strategies to reduce GV.

Ultra-Early Blood Pressure Control in Acute Intracerebral Hemorrhage

Acute intracerebral hemorrhage (ICH) remains one of the most devastating neurological emergencies, with blood pressure (BP) management in the early hours playing a pivotal role in determining patient outcomes. Emerging evidence suggests that ultra-early BP control-intervening within minutes to 2 hours of symptom onset-has the potential to reduce secondary brain injury and improve survival. Yet, despite this evidence, current clinical practice is often inconsistent, and there is no universally agreed-upon approach for managing BP in the acute phase of ICH. We advocate for ultra-early BP intervention as a standard of care in ICH, as it offers a clear opportunity to mitigate damage and to enhance recovery. We contend that current BP management protocols are often too conservative and fail to recognize the critical importance of acting swiftly. The first few hours represent a unique window in which targeted interventions, such as continuous infusion intravenous antihypertensives, may limit hematoma expansion and stabilize cerebral perfusion pressure. However, achieving optimal outcomes requires more than just aggressive treatment-it demands a tailored approach to BP control, accounting for individual patient factors, evolving clinical conditions, and operational aspects of care. We advocate for a paradigm shift toward prioritizing ultra-early intervention, supported by clear, evidence-based protocols and real-time decision-making.

Is the Effect of Intensive Antihypertensive Treatment in Acute Intracerebral Hemorrhage Dependent on Hematoma Volume? A Traditional Meta-analysis of the Effect of Antihypertensive Regimens, a Bayesian Network Meta-analysis of the Mortality of Antihypertensive Drugs and Systematic Review

BACKGROUND AND OBJECTIVES: Intensive or conventional antihypertensive treatment for acute intracerebral hemorrhage is still controversial. This study aimed to compare those antihypertensive regimens and analyze the efficacy of antihypertensive drugs.

METHODS

Retrieval was conducted through four databases. Meta-analysis and Bayesian network meta-analysis were performed to evaluate the safety of antihypertensive treatments and the efficacy of antihypertensive drugs.

RESULTS

A total of 9271 patients were included. Intensive strategy showed an advantage in 24-h hematoma enlargement (relative risk, RR = 0.76; 95% confidence intervals, CI = 0.67-0.87; P < 0.0001) and 90-day intracranial rebleeding (RR = 0.71, 95% CI = 0.52-0.96, P = 0.03) compared with conventional strategy. Meanwhile, the 90-day renal insufficiency (RR = 2.31, 95% CI = 1.05-5.05, P = 0.04) and renal failure (RR = 2.42, 95% CI = 1.20-4.86, P = 0.01) were increased. When cerebral hematoma volume was less than 15 ml, intensive strategy had a protective effect on 24-h hematoma enlargement (RR = 0.77, 95% CI = 0.67-0.89, P = 0.0003), but it increased 90-day renal failure (RR = 2.33, 95% CI = 1.07-5.04, P = 0.03). For the volume greater than 15 ml, it enhanced 90-day functional independence (RR = 0.78, 95% CI = 0.65-0.94, P = 0.01) and decreased intracranial rebleeding (RR = 0.68, 95% CI = 0.49-0.94, P = 0.02). Labetalol was the best, with the mortality risk probability of 0.09 and the surface under the cumulative ranking curve of 0.33.

CONCLUSIONS

This meta-analysis suggests that for intracerebral hematoma volume greater than 15 ml, intensive antihypertensive treatment can improve functional independence and reduce intracranial bleeding. Labetalol has the best effect among the four antihypertensive regimens studied.

Optimal Magnitude of Blood Pressure Reduction and Hematoma Growth and Functional Outcomes in Intracerebral Hemorrhage

BACKGROUND AND OBJECTIVES

Early intensive systolic blood pressure (SBP) reduction is a promising strategy for intracerebral hemorrhage (ICH), but the optimal magnitude of reduction in the first 2 hours remains uncertain. This study aimed to determine the optimal SBP reduction magnitude to maximize benefit in patients enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial.

METHODS

We performed a post hoc analysis of the ATACH-2 trial. Participants with baseline SBP ≥180 mm Hg were randomized within 4.5 hours from onset and assigned to the intensive or standard group. The magnitude of SBP reduction was calculated as admission SBP minus minimum SBP at 2 hours. Eligible participants were divided into 5 groups by 15 mm Hg stratum: <40, 40-55, 55-70, 70-85, and ≥85 mm Hg. Poor functional outcome was defined as the modified Rankin Scale score at 3-6 and hematoma expansion (HE) as a relative increase of >33% from baseline to 24 hours. Multivariable logistic regression assessed associations between SBP reduction and outcomes.

RESULTS

Our study included 925 patients, of whom 360 (38.9%) were female. The median age was 62 years (IQR: 53-71). The median hematoma volume was 10.2 mL (IQR: 5.1-18.4), and the median magnitude of SBP reduction was 68 mm Hg (IQR: 48-88). Of those, 209 (22.6%) experienced HE, 122 (13.2%) experienced acute kidney injury (AKI), and 516 (55.8%) had poor outcome. Hematoma expansion decreased linearly as the magnitude of blood pressure reduction increased in 5 SBP reduction groups (p < 0.001). After multivariable adjustment, patients with a greater degree of SBP reduction (≥70 mm Hg) were less likely to experience HE and a SBP reduction ≥55 mm Hg was associated with a lower risk of poor outcomes (odds ratio [OR] 0.49, 95% CI 0.28-0.85). However, a SBP reduction ≥85 mm Hg increased AKI risk compared with <40 mm Hg (OR, 2.00; 95% CI 1.01-3.94).

DISCUSSION

Targeting a SBP reduction within the range of 55-85 mm Hg during the first 2 hours seems to be associated with optimal outcomes in patients with mild-to-moderate ICH, balancing the need to limit hematoma growth while avoiding adverse effect. Further study focusing on severe ICH is warranted.

TRIAL REGISTRATION INFORMATION

Clinical trial registration number: NCT01176565.

CLASSIFICATION OF EVIDENCE

This post hoc analysis of the ATACH-2 trial provides Class III evidence that SBP reduction of 55-85 mm Hg during the initial 2 hours is associated with lower frequency of HE and better functional outcomes in patients with acute cerebral hemorrhage.

Drug delivery strategy of hemostatic drugs for intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is associated with high rates of mortality and disability, underscoring an urgent need for effective therapeutic interventions. The clinical prognosis of ICH remains limited, primarily due to the absence of targeted, precise therapeutic options. Advances in novel drug delivery platforms, including nanotechnology, gel-based systems, and exosome-mediated therapies, have shown potential in enhancing ICH management. This review delves into the pathophysiological mechanisms of ICH and provides a thorough analysis of existing treatment strategies, with an emphasis on innovative drug delivery approaches designed to address critical pathological pathways. We assess the benefits and limitations of these therapies, offering insights into future directions in ICH research and highlighting the transformative potential of next-generation drug delivery systems in improving patient outcomes.

Glycemic variability and its association with short and long term clinical outcomes in critically ill patients with cerebral hemorrhage

Cerebral hemorrhage is a major cause of mortality and disability. This study investigates the association between glycemic variability (GV) and short- and long-term clinical outcomes such as poor outcomes at discharge, mortality at 90 days and 1 year and intensive care unit (ICU) /hospital length of stay (LOS) in ICU patients with critically ill cerebral hemorrhage. This retrospective analysis examined 732 ICU patients with non-traumatic cerebral hemorrhage from the Medical Information Mart for Intensive Care (MIMIC)-IV database. GV was quantified as the ratio of standard deviation to mean glucose during ICU stay. To assess associations between GV and clinical outcomes (poor outcomes at discharge, 90-day and 1-year mortality, ICU/hospital LOS), the study employed logistic regression, Cox proportional hazards models, and linear regression. Additionally, non-linear relationships were explored through restricted cubic spline analysis. The investigation further incorporated subgroup and sensitivity analyses to ensure robustness of findings. To evaluate the incremental predictive value of GV, the study utilized receiver operating characteristic (ROC) curve analysis, net reclassification improvement, and integrated discrimination improvement, thereby providing a comprehensive assessment of GV's clinical utility. Higher GV was significantly associated with increased risk of poor outcomes at discharge and 90-day and 1-year mortality in both patient groups. GV showed a linear association with poor outcomes at discharge but a non-linear association with 90-day and 1-year mortality. GV thresholds of ≥ 0.11 for non-traumatic cerebral hemorrhage increased mortality risks. Cohort showed non-linear relationships between GV and ICU/hospital LOS. GV's impact was stronger in non-hypertensive and male patients. Adding GV to existing severity scores improved their predictive ability for adverse outcomes. In patients with non-traumatic cerebral hemorrhage admitted to the ICU, GV demonstrates an independent association with poor outcomes over both short-term and long-term time horizons. Furthermore, GV is associated with extended durations of both ICU and overall hospital stays in this patient population. These findings underscore the importance of glycemic control in this patient population and suggest that GV could be a valuable prognostic indicator and potential therapeutic target.

Predictive factors for functional and motor recovery following spontaneous intracerebral haemorrhage

OBJECTIVE

Intracerebral haemorrhage significantly impacts patients' functional and motor recovery. Identifying predictive factors is crucial for enhancing post-intracerebral haemorrhage rehabilitation strategies. This study explores the predictors of functional improvement and motor recovery in intracerebral haemorrhage survivors.

DESIGN

This retrospective cohort study was conducted at a tertiary referral hospital, encompassing patients diagnosed with acute spontaneous intracerebral haemorrhage from 1 June 2019, to 30 June 2023.

METHODS

Data on clinical characteristics, activity-based indicators like the initial ability to sit independently without physical assistance and the ability to sit independently for 2 minutes, and haematoma location were analysed to determine their association with functional and motor recovery outcomes, assessed by the modified Rankin Scale, Barthel Index, and Brunnstrom stages.

RESULTS

Among 310 patients, significant predictors for functional outcomes included hypertension, the initial ability to sit independently without physical assistance, the initial ability to sit independently for 2 min, length of hospitalization, and initial National Institute of Health Stroke Scale (NIHSS). For motor recovery, the initial ability to sit independently with-out physical assistance, the initial ability to sit independently for 2 min, 24-h NIHSS, and length of hospitalization were identified as strong predictors for Brunnstrom stage recovery of upper and lower limbs.

CONCLUSION

Predictive factors including hypertension, early NIHSS, the initial ability to sit independently without physical assistance, the initial ability to sit independently for 2 min, and length of hospitalization play a crucial role in predicting functional and motor recovery after intracerebral haemorrhage.

Pharmacotherapy adjuncts for traumatic brain injury: A narrative review of evidence and considerations in the emergency department

Traumatic Brain Injury (TBI) remains a significant global health concern with significant impact on morbidity and mortality. This narrative review explores adjunctive pharmacologic agents to be employed by emergency medicine clinicians during Advanced Trauma Life Support (ATLS) in patients presenting with a TBI. Pharmacologic agents are commonly employed for the management of rapid sequence intubation and post-intubation analgosedation, hemodynamics, intracranial pressure, coagulopathy, seizure prophylaxis, and infection. This narrative review discusses current evidence and controversies to optimize adjunct pharmacotherapies during the acute management of TBI within the emergency department.

Association between pulse pressure and risk of acute kidney injury after intracerebral hemorrhage

The aim of this study was to determine whether pulse pressure (PP), an indicator of arterial stiffness, was independently associated with the risk of acute kidney injury (AKI) following intracerebral hemorrhage (ICH). We enrolled patients with acute ICH from a multicenter stroke registry in Fukuoka, Japan, from June 2007 to September 2019. The mean PP, measured three times on the third day after admission, was categorized into three groups based on tertiles: G1 < 54 mmHg, G2 54-64 mmHg, and G3 ≥ 65 mmHg. AKI was defined as an increase of ≥0.3 mg/dL or ≥150% in serum creatinine levels above baseline during hospitalization. The associations between PP and AKI were evaluated using logistic regression analyses. Overall, 1512 patients with acute ICH (mean age: 69.8 ± 13.5 years; 56.4% men) were included in the analysis. The incidence rates of AKI were 5.6%, 11.0%, and 13.2% in groups G1, G2, and G3, respectively. The odds ratio (95% confidence interval) of AKI was significantly elevated in G2 (1.77 [1.07-2.91]) and G3 (1.82 [1.10-3.03]) compared to G1, even after adjusting for initial systolic blood pressure (SBP) values on admission and subsequent SBP reductions. This significant association was observed in patients with an initial SBP < 200 mmHg (P for heterogeneity, 0.045) and those receiving intravenous antihypertensive therapy in the acute stage (P for heterogeneity, 0.03). High PP should be recognized as a novel potential risk factor for AKI following ICH. High pulse pressure was significantly associated with an increased risk of acute kidneyinjury following intracranial hemorrhage. Pulse pressure should be recognized as anovel potential risk factor and one of the predictors of acute kidney injury afterintracranial hemorrhage.

Subacute Neurological Improvement Predicts Favorable Functional Recovery After Intracerebral Hemorrhage: INTERACT2 Study

BACKGROUND

The frequency and prognostic significance of subacute neurological improvement (SNI) on 90-day outcomes after acute intracerebral hemorrhage are unknown.

METHODS

Secondary analyses of participant data from the INTERACT2 trial (Second Intensive Blood Pressure Reduction in Acute Intracerebral Hemorrhage Trial). SNI included any, moderate, significant, and substantial neurological improvement defined as ≥1, ≥2, ≥3, and ≥4 points decrease, respectively, on the National Institutes of Health Stroke Scale from 24 hours to 7 days after intracerebral hemorrhage. Logistic regression models were used to assess associations of SNI and death or major disability (modified Rankin Scale score of 3-6), major disability (modified Rankin Scale scores, 3-5), and death alone at 90 days. Data are reported as odds ratios and 95% CIs.

RESULTS

Of 2571 patients included in analyses, 1492 (58.0%), 1057 (41.1%), 731 (28.4%), and 490 (19.1%) patients experienced any, moderate, significant, and substantial SNI (24 hours to 7 days) after intracerebral hemorrhage, respectively. After adjustment for key confounders, any SNI was associated with 49%, 25%, and 65% reduced odds of death or major disability (odds ratio, 0.51 [95% CI, 0.42-0.63]), major disability alone (odds ratio, 0.75 [95% CI, 0.63-0.90]), and death (odds ratio, 0.35 [95% CI, 0.24-0.50]), respectively. Moderate, significant, and substantial SNI were also significantly associated with decreased odds of death or major disability at 90 days. The relationship between any SNI and study outcomes was consistent in most subgroups, including age and baseline hematoma volume. Early intensive blood pressure-lowering treatment did not increase the odds of SNI.

CONCLUSIONS

SNI from 24 hours to 7 days is common after intracerebral hemorrhage and predicts a lower likelihood of death or major disability.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00716079.

A new perspective on the regulation of neuroinflammation in intracerebral hemorrhage: mechanisms of NLRP3 inflammasome activation and therapeutic strategies

Intracerebral hemorrhage (ICH), a specific subtype within the spectrum of stroke disorders, is characterized by its high mortality and significant risk of long-term disability. The initiation and progression of neuroinflammation play a central and critical role in the pathophysiology of ICH. The NOD-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome, a protein complex involved in initiating inflammation, is the central focus of this article. Microglia and astrocytes play critical roles in the inflammatory damage process associated with neuroinflammation. The NLRP3 inflammasome is expressed within both types of glial cells, and its activation drives these cells toward a pro-inflammatory phenotype, which exacerbates inflammatory damage in the brain. However, the regulatory relationship between these two cell types remains to be explored. Targeting NLRP3 inflammasomes in microglia or astrocytes may provide an effective approach to mitigate neuroinflammation following ICH. This article first provides an overview of the composition and activation mechanisms of the NLRP3 inflammasome. Subsequently, it summarizes recent research findings on novel signaling pathways that regulate NLRP3 inflammasome activity. Finally, we reviewed recent progress in NLRP3 inflammasome inhibitors, highlighting the clinical translation potential of certain candidates. These inhibitors hold promise as innovative strategies for managing inflammation following ICH.

Emergency Priorities in the Treatment of Cerebral Hemorrhage: Code-Intracerebral Hemorrhage

The focus of acute treatment of intracerebral hemorrhage (ICH) includes acute blood pressure management, prevention of secondary hematoma expansion through anticoagulation reversal, and neurosurgical interventions for select patients. Recent evidence points to ultra-early acute ICH bundles, implementing multiple therapies in parallel, as the most impactful therapy in reducing morbidity and mortality. It is time for widespread implementation of formalized care bundles in ICH, including specific metrics for time to treatment and criteria for neurosurgical therapy. No longer just "Code Stroke," it is time for "Code ICH.".

Incidence, case fatality, and functional outcome of intracerebral haemorrhage, according to age, sex, and country income level: a systematic review and meta-analysis

Background

Intracerebral haemorrhage (ICH) accounts for approximately 28% of all strokes worldwide. ICH has a high case fatality, and only few survivors recover to independent living. Over the past decades, demographic changes, and changes in prevalence and management of risk factors may have influenced incidence. Widespread implementation of stroke units and improved care in general may have affected case fatality and outcome. We aimed to update the evidence on incidence, case fatality, and functional outcome of ICH, according to age, sex, and country income level.

Methods

We systematically searched PubMed and Embase from 2008 to April 2023 for prospective population-based studies on incidence, case fatality, or functional outcome of first-ever ICH. We excluded studies in which less than 80% of cases was confirmed with imaging or autopsy. Quality of the studies was assessed based on the used case finding methods. We used inverse variance-based random-effects meta-analyses to pool the crude incidence, case fatality at 1 month, and the percentage of patients with good functional outcome after 3, 6, or 12 months, as defined by the authors of the individual studies. Time trends were assessed using weighted linear meta-regression. Funnel plots were constructed to study publication bias. The review was registered on PROSPERO (CRD42023413314).

Findings

We identified 70 eligible studies, describing 19,470 ICH patients from 26 different countries. Of these, 62 studies reported on crude incidence, 41 on case fatality, and 10 on functional outcome. Overall crude incidence was 29.2 per 100,000 person-years (95% CI 23.3-36.4; I2 = 100%). Incidence was lower in women than in men and increased with age. Incidence was highest in lower-middle income countries, followed by high and upper-middle income countries. Case fatality at 1 month was 35.5% (95% CI 32.3-38.9; I2 = 90%). The percentage of patients with good functional outcome (mRS 0-2 in nine studies, mRS 0-3 in one) after 3-12 months was 31.2% (95% CI 24.7-38.6; I2 = 76%). We found no time trends in incidence, case fatality, or functional outcome.

Interpretation

Our results demonstrate the persistently high burden and devastating consequences of ICH, stressing the need for better preventive strategies and acute treatments.

Funding

None.

Door-In-Door-Out Times at Referring Hospitals and Outcomes of Hemorrhagic Stroke

STUDY OBJECTIVE

Interhospital transfer is often required in the care of patients with hemorrhagic stroke. Guidelines recommend a door-in-door-out (DIDO) time of ≤120 minutes at the transferring emergency department (ED); however, it is unknown whether DIDO times are related to clinical outcomes of hemorrhagic stroke.

METHODS

Retrospective, observational cohort study using US registry data from Get With The Guidelines-Stroke participating hospitals. Patients include those aged ≥18 years with intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) who were transferred from the ED to a Get With The Guidelines participating receiving hospital from January 1, 2019, to July 31, 2022. The primary outcome was ordinal discharge modified Rankin scale (mRS) score and secondary outcomes included dichotomous discharge mRS, ability to ambulate independently at discharge, and inhospital mortality at the receiving hospital.

RESULTS

In all, 19,708 ICH and 7,757 patients with SAH were included. For patients with ICH, an increasing DIDO time was associated with greater odds of mRS 0 to 3 versus 4 to 6 at discharge in the unadjusted analyses (DIDO 91 to 180 minutes, odds ratio [OR] 1.15 [1.04 to 1.27]; DIDO 181 to 270 minutes, OR 1.51 [1.33, 1.71]; DIDO >270 minutes, OR 1.83 [1.58, 2.11]; versus DIDO ≤90 minutes). In the adjusted analyses, no associations were observed. Similar results were seen for mRS at discharge in patients with SAH. In both patients with ICH and SAH, longer DIDO times were associated with greater odds of independent ambulation at discharge and lower odds of inhospital mortality in the unadjusted analyses. After adjustment, the effect sizes of these associations were reduced, with some of the results based on quartiles becoming statistically nonsignificant.

CONCLUSION

These findings suggest that EDs currently expedite the transfer of the sickest patients; however, prospective studies and more granular data are needed to understand the impact of early treatment and timing of transfer for patients with hemorrhagic stroke.

Noninvasive Vagus Nerve Stimulation Protects Neurons in the Perihematomal Region and Improves the Outcomes in a Rat Model of Intracerebral Hemorrhage

BACKGROUND

Intracranial hemorrhage (ICH) is a devastating stroke subtype with a high rate of mortality and disability. Therapeutic options available are primarily limited to supportive care and blood pressure control, whereas the surgical approach remains controversial. In this study, we explored the effects of noninvasive vagus nerve stimulation (nVNS) on hematoma volume and outcome in a rat model of collagenase-induced ICH.

METHODS

Adult male Wistar rats were randomized into two study groups: (1) ICH-treated (rats treated with five 2-min nVNS) and (2) ICH-control (ICH with sham nVNS). Each group received either a 0.1-U or a 0.2-U collagenase dose. After assessing neurological function, rats were euthanized at 24 h for spectrophotometric hemoglobin assay, hematoma volume measurements, and histological studies.

RESULTS

The ICH-treated group that received the 0.1-U collagenase dose demonstrated significantly smaller hematoma volume and improved motor function compared with the ICH-control with the same dose. Furthermore, the pooled data for the ICH-treated groups (both 0.1 U and 0.2 U of collagenase) revealed a reduction in neuronal loss in the perihematomal region in the histopathological studies. This effect was not significant for the group that received a 0.2-Ucollagenase dose.

CONCLUSIONS

nVNS therapy in acute settings may provide a neuroprotective effect and limit hematoma expansion in smaller volumes, improving neurological function post-ICH.

Predicting the risk of hematoma expansion in acute intracerebral hemorrhage: the GIVE score

BACKGROUND

Numerous noncontrast computed tomography (NCCT) markers have been reported and validated as effective predictors of hematoma expansion (HE). Our objective was to develop and validate a score based on NCCT markers and clinical characteristics to predict risk of HE in acute intracerebral hemorrhage (ICH) patients.

METHODS

We prospectively collected spontaneous ICH patients at the First Affiliated Hospital of Chongqing Medical University to form the development cohort (n = 395) and at the Third Affiliated Hospital of Chongqing Medical University to establish the validation cohort (n = 139). We adopted a revised HE definition, incorporating the standard definition of HE (> 6 mL or > 33%) and intraventricular hemorrhage (IVH) expansion (any new IVH or IVH expansion ≥ 1 ml). The predictive score was formulated based on the parameter estimates derived from the multivariable logistic regression analysis.

RESULT

The Glasgow Coma Scale, island sign, ventricular hemorrhage and time elapsed from onset to NCCT scan (GIVE) score was created as a total of individual points (0-6) based on Glasgow Coma Scale (2 points for ≤ 11), island sign (1 point for presence), ventricular hemorrhage (1 point for presence), and time elapsed from onset to NCCT scan (2 points for ≤ 2.5 h). The c statistic was 0.72(95% confidence interval [CI], 0.66-0.78) and 0.73(95% CI, 0.63-0.82) in the development and validation cohorts, respectively.

CONCLUSION

A six-point scoring algorithm has been developed and validated to assess the risk of HE in patients with ICH. This scoring system facilitates the rapid and accurate identification of patients at increased risk for HE.

Human platelet lysate: a potential therapeutic for intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a major public health challenge worldwide, and is associated with elevated rates of mortality, disability, and morbidity, especially in low- and middle-income nations. However, our knowledge of the detailed molecular processes involved in ICH remains insufficient, particularly those involved in the secondary injury stage, resulting in a lack of effective treatments for ICH. Human platelet lysates (HPL) are abundant in bioactive factors, and numerous studies have demonstrated their beneficial effects on neurological diseases, including their anti-neuroinflammatory ability, anti-oxidant effects, maintenance of blood-brain barrier integrity, and promotion of neurogenesis. In this review, we thoroughly explore the potential of HPL for treating ICH from three critical perspectives: the rationale for selecting HPL as a treatment for ICH, the mechanisms through which HPL contributes to ICH management, and the additional measures necessary for HPL as a treatment for ICH. We elucidate the role of platelets in ICH pathophysiology and highlight the limitations of the current treatment options and advancements in preclinical research on the application of HPL in neurological disorders. Furthermore, historical developments and preparation methods of HPL in the field of biomedicine are discussed. Additionally, we summarize the bioactive molecules present in HPL and their potential therapeutic effects in ICH. Finally, we outline the issues that must be addressed regarding utilizing HPL as a treatment modality for ICH.

Timely delivery of care in neurological emergencies: can standardized management protocols help?

PURPOSE OF REVIEW

To review the evidence that supports the implementation of goal-directed care bundle protocols to improve outcomes from neurocritical conditions, and of the possible advantage of specific over generalized protocols.

RECENT FINDINGS

Articles from January 1, 2023 to July 31, 2024 were searched to evaluate the effectiveness of standardized management in neurological emergencies. The use of care bundles and standardized protocols with time- and target-related metrics has shown benefit in patients with acute stroke and traumatic brain injury.

SUMMARY

A goal-directed care protocol to guide standard management implemented by a multidisciplinary team can improve outcomes from neurological emergencies. However, implementation challenges need to be addressed before wide adoption of protocolized care for maximum benefit to populations.

Evaluating the effect of noise reduction strategies in CT perfusion imaging for predicting infarct core with deep learning

This study evaluates the efficacy of deep learning models in identifying infarct tissue on computed tomography perfusion (CTP) scans from patients with acute ischemic stroke due to large vessel occlusion, specifically addressing the potential influence of varying noise reduction techniques implemented by different vendors. We analyzed CTP scans from 60 patients who underwent mechanical thrombectomy achieving a modified thrombolysis in cerebral infarction (mTICI) score of 2c or 3, ensuring minimal changes in the infarct core between the initial CTP and follow-up MR imaging. Noise reduction techniques, including principal component analysis (PCA), wavelet, non-local means (NLM), and a no denoising approach, were employed to create hemodynamic parameter maps. Infarct regions identified on follow-up diffusion-weighted imaging (DWI) within 48 hours were co-registered with initial CTP scans and refined with ADC maps to serve as ground truth for training a data-augmented U-Net model. The performance of this convolutional neural network (CNN) was assessed using Dice coefficients across different denoising methods and infarct sizes, visualized through box plots for each parameter map. Our findings show no significant differences in model accuracy between PCA and other denoising methods, with minimal variation in Dice scores across techniques. This study confirms that CNNs are adaptable and capable of handling diverse processing schemas, indicating their potential to streamline diagnostic processes and effectively manage CTP input data quality variations.

Indian Trial of Tranexamic acid in Spontaneous Intracerebral Hemorrhage study protocol

RATIONALE

Early mortality in intracerebral hemorrhage (ICH) is due to hematoma volume (HV) expansion, and there are no effective treatments available other than reduction in blood pressure. Tranexamic acid (TXA) a hemostatic drug that is widely available and safe can be a cost-effective treatment for ICH, if proven efficacious.

HYPOTHESIS

Administration of TXA in ICH patients when given within 4.5 h of symptom onset will reduce early mortality at 30 days.

DESIGN

Indian Trial of Tranexamic acid in Spontaneous Intracerebral Haemorrhage (INTRINSIC trial) is a multicenter, randomized, open-label, trial enrolling patients aged more than 18 years presenting with non-traumatic ICH within 4.5 h of symptom onset or when last seen well. Study participants received 2 g of TXA administered within 45 min while control group received standard of care. Intensive blood pressure reduction as per INTERACT 2 protocol is followed is done in both groups. Study plans to recruit 3400 patients. Primary outcome is mortality at day 30. Secondary outcomes are radiological reduction in HV at 24 h from baseline, neurological impairment at day 7 or earlier (if discharged), and assessments of dependency and quality of life at day 90.

SUMMARY

If proven to be beneficial, TXA will have a major impact on medical management of ICH.

TRIAL REGISTRATION

Clinical Trial Registry India (CTRI/2023/03/050224) and Clinical Trials.gov (NCT05836831).

Andexanet alfa: trials just leave us with more questions

Andexanet Alfa in Acute Intracranial Hemorrhage in Patients Receiving an Oral Factor Xa Inhibitor (ANNEXA-I), the first ever randomized controlled trial of a reversal agent for direct oral anticoagulants, was published in 2024. The trial, which randomized patients with intracranial hemorrhage to andexanet alfa or usual care, was mandated by the United States Food and Drug Administration as part of its conditional approval in 2018. This approval was originally based on the single-arm trial, The Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors (ANNEXA-4). ANNEXA-I was stopped early for benefit and showed a reduction in the number of patients with significant hematoma expansion. However, the study was not powered for clinical endpoints such as disability or death and showed no difference in these outcomes. It did, however, show an increased risk of thrombosis, predominantly stroke with andexanet alfa. In this perspective, I reflect on some of the key criticisms of the trial and the implications for its interpretation.

Individualized autoregulation-guided arterial blood pressure management in neurocritical care

Cerebral autoregulation (CA) is the physiological process by which cerebral blood flow is maintained during fluctuations in arterial blood pressure (ABP). There are various validated methods to measure CA, either invasively, with intracranial pressure or brain tissue oxygenation monitors, or noninvasively, with transcranial Doppler ultrasound or near-infrared spectroscopy. Utilizing these monitors, researchers have been able to discern CA patterns in several pathological states, such as but not limited to acute ischemic stroke, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, sepsis, and post-cardiac arrest, and they have found CA to be altered in these patients. CA disturbances predispose patients suffering from these ailments to worse outcomes. Much focus has been placed on CA monitoring in these populations, with an emphasis on arterial blood pressure optimization. Many guidelines recommend universal static ABP targets; however, in patients with altered CA, these targets may make them susceptible to hypoperfusion and further neurological injury. Based on this observation, there has been much investigation on individualized ABP goals and their effect on clinical outcomes. The scope of this review includes (1) a summary of the physiology of CA in healthy adults; (2) a review of the evidence on CA monitoring in healthy individuals; (3) a summary of CA changes and its effect on outcomes in various diseased states including acute ischemic stroke, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, sepsis and meningitis, post-cardiac arrest, hypoxic-ischemic encephalopathy, surgery, and moyamoya disease; and (4) a review of the current evidence on individualized ABP changes in various patient populations.

Intracerebral haemorrhage in patients taking different types of oral anticoagulants: a pooled individual patient data analysis from two national stroke registries

BACKGROUND

We investigated outcomes in patients with intracerebral haemorrhage (ICH) according to prior anticoagulation treatment with Vitamin K antagonists (VKAs), direct oral anticoagulants (DOACs) or no anticoagulation.

METHODS

This is an individual patient data study combining two prospective national stroke registries from Switzerland and Norway (2013-2019). We included all consecutive patients with ICH from both registries. The main outcomes were favourable functional outcome (modified Rankin Scale 0-2) and mortality at 3 months.

RESULTS

Among 11 349 patients with ICH (mean age 73.6 years; 47.6% women), 1491 (13.1%) were taking VKAs and 1205 (10.6%) DOACs (95.2% factor Xa inhibitors). The median percentage of patients on prior anticoagulation was 23.7 (IQR 22.6-25.1) with VKAs decreasing (from 18.3% to 7.6%) and DOACs increasing (from 3.0% to 18.0%) over time. Prior VKA therapy (n=209 (22.3%); adjusted ORs (aOR), 0.64; 95% CI, 0.49 to 0.84) and prior DOAC therapy (n=184 (25.7%); aOR, 0.64; 95% CI, 0.47 to 0.87) were independently associated with lower odds of favourable outcome compared with patients without anticoagulation (n=2037 (38.8%)). Prior VKA therapy (n=720 (49.4%); aOR, 1.71; 95% CI, 1.41 to 2.08) and prior DOAC therapy (n=460 (39.7%); aOR, 1.28; 95% CI, 1.02 to 1.60) were independently associated with higher odds of mortality compared with patients without anticoagulation (n=2512 (30.2%)).

CONCLUSIONS

The spectrum of anticoagulation-associated ICH changed over time. Compared with patients without prior anticoagulation, prior VKA treatment and prior DOAC treatment were independently associated with lower odds of favourable outcome and higher odds of mortality at 3 months. Specific reversal agents unavailable during the study period might improve outcomes of DOAC-associated ICH in the future.

Bloodletting at the ear apex for acute stroke: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Stroke is a major cause of death and disability worldwide. Despite innovative developments in acute stroke treatment techniques in modern society, many stroke survivors still experience complications, leading to a demand for complementary and alternative medicines, including traditional medicine. Bloodletting at the ear apex (BLEA) is a nonpharmacological intervention used for various diseases, including acute stroke, in traditional medicine in East Asian countries, including China and Korea. This study aimed to evaluate the clinical efficacy of BLEA for acute stroke recovery.

METHODS

We searched PubMed, Embase, CENTRAL, AMED, CNKI, KoreaMed, ScienceOn, and OASIS databases for randomized controlled trials (RCTs) evaluating the effect of BLEA on acute stroke recovery. We systematically reviewed the literature published in academic journals up to September 8, 2024 and synthesized the data extracted from the final selected literature. The results of the meta-analysis are presented as mean differences (MDs) with 95% confidence intervals (CIs). The Cochrane Risk of Bias 2 tool and GRADE methodology were used for quality assessment.

RESULTS

Six RCTs with 530 participants were included in this meta-analysis. In patients with acute stroke receiving conventional Western medical treatment, the addition of BLEA significantly improved neurological deficits assessed by the National Institute of Stroke Scale (MD, -2.83; 95% CIs, -4.48 to -1.17), consciousness impairment measured by the Glasgow Coma Scale (MD, 2.75. 95% CIs, 1.72 to 3.78), and motor function assessed by the Fugl-Meyer Assessment (MD, 5.31. 95% CIs, 3.04 to 7.58). It also significantly reduced the length of hospital stay (MD, -7.39; 95% CIs. -8.85 to -5.93).

CONCLUSION

BLEA may be a promising intervention that provides additional benefits to patients with acute stroke receiving standard western medical care. However, the supporting evidence comes from a few small studies with a high risk of bias and low reporting quality. Future studies with appropriate population sizes and more rigorous methodology are warranted.

Brain health: A concern for anaesthesiologists and intensivists

Damage to the brain can have disastrous and long-lasting consequences. The European Society of Anaesthesiology and Intensive Care (ESAIC) is aware of the importance of taking good care of the brain, both of patients and of anaesthesia and intensive care unit (ICU) caregivers, and has organised a complete learning track on brain health to bring this concern to the attention of practitioners. This learning track included an online Focus Meeting on Brain Health (November 25, 2023). We here provide readers with a digest of the information that was delivered during that meeting in an opinion paper driven by the authors' own reading of the literature. It is divided according to the meeting's sessions, including how to improve the health of an injured brain, how to keep a young or old brain healthy, how to keep a healthy adult brain unimpaired, how monitoring can impact brain health in the operating room and in the intensive care unit, and how to keep the anaesthesia and ICU caregivers' brain healthy. Each part is a brief and focused summary. The main delivered messages are that the management of injured brain patients involves an adequate choice of sedation, adequate brain monitoring, and focused attention to specific points depending on the underlying pathology; that several measures can be undertaken to protect the brain of the very young needing anaesthesia; that it is possible to detect older patients at risk of postoperative neurocognitive disorders, and that dedicated perioperative management by a multidisciplinary expert team may improve their outcomes; that apparently healthy adult brains may suffer during anaesthesia; that the electroencephalogram may track peri-operative brain dysfunction, and that female patients should be given special care in this respect; that multimodal brain monitoring helps to detect pathological processes and to maintain brain homeostasis; and that burnout in anaesthesiologists can be effectively fought using personal, organisational, managerial and legal approaches.

Intracerebral haemorrhage - mechanisms, diagnosis and prospects for treatment and prevention

Intracerebral haemorrhage (ICH) is a devastating condition associated with high mortality and substantial residual disability among survivors. Effective treatments for the acute stages of ICH are limited. However, promising findings from randomized trials of therapeutic strategies, including acute care bundles that target anticoagulation therapies, blood pressure control and other physiological parameters, and trials of minimally invasive neurosurgical procedures have led to renewed optimism that patient outcomes can be improved. Currently ongoing areas of research for acute treatment include anti-inflammatory and haemostatic treatments. The implementation of effective secondary prevention strategies requires an understanding of the aetiology of ICH, which involves vascular and brain parenchymal imaging; the use of neuroimaging markers of cerebral small vessel disease improves classification with prognostic relevance. Other data underline the importance of preventing not only recurrent ICH but also ischaemic stroke and cardiovascular events in survivors of ICH. Ongoing and planned randomized controlled trials will assess the efficacy of prevention strategies, including antiplatelet agents, oral anticoagulants or left atrial appendage occlusion (in patients with concomitant atrial fibrillation), and optimal management of long-term blood pressure and statin use. Together, these advances herald a new era of improved understanding and effective interventions to reduce the burden of ICH.

Microglial mitochondrial DNA release contributes to neuroinflammation after intracerebral hemorrhage through activating AIM2 inflammasome

Intracerebral hemorrhage (ICH) is a severe disease that often leads to disability and death. Neuroinflammatory response is a key causative factor of early secondary brain injury after ICH. AIM2 is a DNA-sensing protein that recognizes cytosolic double-stranded DNA and take a significant part in neuroinflammation. Mitochondrial DNA participates in the translation of proteins such as the respiratory chain in the mitochondria. Whether mtDNA is involved in forming AIM2 inflammasome after ICH remains unclear. We used mice to construct ICH model in vivo and we used BV2 microglial cells treated with oxyhemoglobin to simulate ICH in vitro. Following lentiviral transfection to overexpress AIM2 antagonist P202, a notable decrease was observed in the levels of AIM2 inflammasome-associated proteins, leading to a reduction in dead neurons surrounding the hematoma and an enhancement in long-term and short-term behavior of neurological deficits. We further explored whether mtDNA took part in the AIM2 activation after ICH. The cytosolic mtDNA level was down-regulated by the mitochondrial division protector Mdivi-1 and up-regulated by transfection of mtDNA into cytoplasm. We found the expression level of AIM2 inflammasome-related proteins and inflammatory cytokines release were regulated by the cytosolic mtDNA level. In conclusion, after ICH, the mtDNA content in the cytoplasm of microglia around the hematoma rises, causing AIM2 inflammation leading to neuronal apoptosis, which leads to neurological deficits in mice. On the other hand, P202 was able to block inflammatory vesicle activation and improve neurological function by preventing the interaction between AIM2 protein and mitochondrial DNA.

Mobile Stroke Unit Management in Patients With Acute Ischemic Stroke Eligible for Intravenous Thrombolysis

Importance

Clinical trials have suggested that prehospital management in a mobile stroke unit (MSU) improves functional outcomes in patients with acute ischemic stroke who are potentially eligible for intravenous thrombolysis, but there is a paucity of real-world evidence from routine clinical practice on this topic.

Objective

To determine the association between prehospital management in an MSU vs standard emergency medical services (EMS) management and the level of global disability at hospital discharge.

Design, Setting, and Participants

This was a retrospective, observational, cohort study that included consecutive patients with a final diagnosis of ischemic stroke who received either prehospital management in an MSU or standard EMS management between August 1, 2018, and January 31, 2023. Follow-up ended at hospital discharge. The primary analytic cohort included those who were potentially eligible for IV thrombolysis. A separate, overlapping cohort including all patients regardless of diagnosis was also analyzed. Patient data were obtained from the American Heart Association's Get With The Guidelines-Stroke (GWTG-Stroke) Program, a nationwide, multicenter quality assurance registry. This analysis was completed in May 2024.

Exposure

Prehospital management in an MSU (vs standard EMS management).

Main Outcomes and Measures

The primary efficacy end point was the utility-weighted modified Rankin Scale (UW-mRS) score. The secondary efficacy end point was independent ambulation status. The coprimary safety end points were symptomatic intracranial hemorrhage (sICH) and in-hospital mortality.

Results

Of 19 433 patients (median [IQR] age, 73 [62-83] years; 9867 female [50.8%]) treated at 106 hospitals, 1237 (6.4%) received prehospital management in an MSU. Prehospital management in an MSU was associated with a better score on the UW-mRS at discharge (adjusted mean difference, 0.03; 95% CI, 0.01-0.05) and a higher likelihood of independent ambulation at discharge (53.3% [468 of 878 patients] vs 48.3% [5868 of 12 148 patients]; adjusted risk ratio [aRR], 1.08; 95% CI, 1.03-1.13). There was no statistically significant difference in sICH (5.2% [57 of 1094] vs 4.2% [545 of 13 014]; aRR, 1.30; 95% CI, 0.94-1.75]) or in-hospital mortality (5.7% [70 of 1237] vs 6.2% [1121 of 18 196]; aRR, 1.03; 95% CI, 0.78-1.27) between the 2 groups.

Conclusions and Relevance

Among patients with acute ischemic stroke potentially eligible for intravenous thrombolysis, prehospital management in an MSU compared with standard EMS management was associated with a significantly lower level of global disability at hospital discharge. These findings support policy efforts to expand access to prehospital MSU management.

Activation of chaperone-mediated autophagy exerting neuroprotection effect on intracerebral hemorrhage-induced neuronal injury by targeting Lamp2a

Intracerebral hemorrhage (ICH) is a common and devastating type of stroke, marked by significant morbidity and a grim prognosis. The inflammation cascade triggered by astrocytes plays a critical role in secondary brain injury (SBI) following ICH, leading to detrimental effects such as cell death. However, effective intervention strategies are currently lacking. This study aims to investigate the role of the astrocyte cascade reaction following ICH and identify potential intervention targets. Utilizing the GSE216607 and GSE206971 databases for analysis, we established a mouse autologous blood model. Firstly, our research revealed a significant activation of the autophagy pathway following intracerebral hemorrhage (ICH), with a notable upregulation of Lamp2a, a key factor in chaperone-mediated autophagy (CMA), primarily localized in astrocytes. Additionally, the downregulation of Lamp2a resulted in a significant augmentation of A1 reactive astrocytes, concomitant with a reduction in myelin coverage area, heightened neuronal injury, exacerbated motor and sensory deficits, and diminished neurological scores after ICH in mice. Conversely, CA77.1, an activator of CMA, could reverse ICH-induced augmentation of A1 reactive astrocytes, myelin damage, neuronal death, and neurobehavioral disorders. In conclusion, the activation of astrocyte CMA following ICH can exert neuroprotective effects. Lamp2a represents a promising therapeutic target for post-ICH treatment.

A Comparative Study of a Nomogram and Machine Learning Models in Predicting Early Hematoma Expansion in Hypertensive Intracerebral Hemorrhage

RATIONALE AND OBJECTIVES

Early identification for hematoma expansion can help improve patient outcomes. Presently, there are many methods to predict hematoma expansion. This study compared a variety of models to find a model suitable for clinical promotion.

MATERIALS AND METHODS

Non-contrast head CT images and clinical data were collected from 203 patients diagnosed with hypertensive intracerebral hemorrhage. Radiomics features were extracted from all CT images, and the dataset was randomly divided into training and validation sets (7:3 ratio) after applying the synthetic minority oversampling method. The radiomics score (Radscore) was calculated using least absolute shrinkage and selection operator (LASSO) regression, combined with selected clinical predictors, to develop a nomogram and four machine learning (ML) models: logistic regression, random forest, support vector machine, and extreme gradient boosting (XGBoost). Discrimination, calibration and clinical usefulness of the nomogram and ML models were assessed.

RESULTS

The nomogram and ML models were integrated with Radscore and clinical predictors. The nomogram demonstrated favorable discriminatory ability in the training set with an AUC of 0.80, which was confirmed in the validation set (AUC=0.76). Among the ML models, the XGBoost model achieved the highest AUC (training set=0.89 and validation set=0.85), surpassing that of the nomogram. The XGBoost model exhibited good clinical usefulness.

CONCLUSION

Both the nomogram and ML models constructed by non-contrast head CT image-based Radscore integrated with clinical predictors can predict early hematoma expansion of hypertensive intracerebral hemorrhage, and the XGBoost model had the highest prediction performance and best clinical usefulness.

Traditional Chinese medicine FYTF-919 (Zhongfeng Xingnao oral prescription) for the treatment of acute intracerebral haemorrhage: a multicentre, randomised, placebo-controlled, double-blind, clinical trial

BACKGROUND

There are few proven treatments for acute spontaneous intracerebral haemorrhage, and they all target reducing expansion of the haematoma. The traditional Chinese medicine FYTF-919 (Zhongfeng Xingnao) in an oral solution is comprised of several Chinese herbs that are widely used to treat patients with intracerebral haemorrhage in China on the understanding that they enhance resorption of the haematoma and reduce neuroinflammation. We aimed to provide a reliable assessment of the safety and efficacy of FYTF-919 in patients with moderate to severe acute intracerebral haemorrhage.

METHODS

We did a pragmatic, multicentre, randomised, double-blind, placebo-controlled trial at 26 hospitals in China. We enrolled adults (age ≥18 years) with a diagnosis of symptomatic spontaneous intracerebral haemorrhage (confirmed by brain imaging) within 48 h after the onset of symptoms (or last seen well), which resulted in moderate to severe neurological impairment defined by scores of at least 8 on the National Institute of Health Stroke Scale or between 7 and 14 inclusive on the Glasgow Coma Scale. Randomisation (1:1) was via a central internet-based system with a block grouping method stratified by provincial location of the hospital, severity of neurological impairment, and site of the haematoma in the brain. FYTF-919 and the placebo were masked through consistency in appearance, smell, taste, and other aspects. Participants were allocated to receive 33 mL (or 25 mL via a nasogastric tube if a participant's swallowing was impaired) of either oral liquid FYTF-919 or matching placebo administered at least 30 min after a meal every 8 h (or 6 h via nasogastric tube) over 24 h for 28 days. The primary efficacy outcome was the utility weighted modified Rankin Scale (a seven-level ordinal scale that ranges from 0 [no symptoms] to 6 [death], in which the utility weights of 0·97, 0·88, 0·74, 0·55, 0·20, -0·19, and 0·00 were assigned to the seven levels respectively, with higher scores indicating a better outcome according to the participants' perspective) at 90 days analysed in a general linear model with adjustment for baseline factors. We did several adjusted and sensitivity analyses. Primary analyses were assessed in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT05066620 and is complete.

FINDINGS

Between Nov 24, 2021, and Dec 28, 2023, of 9000 patients screened, 1648 were randomly assigned to treatment, 817 to the FYTF-919 group and 831 to the placebo group. Before receiving any treatment two patients in the FYTF-919 group and five patients in the placebo group immediately withdrew their consent leaving 1641 participants with available primary outcome data in the intention-to-treat population, 815 in the FYTF-919 group and 826 in the placebo group. 1242 (75·7%) participants consumed 80% or more of the study medication and 994 (60·6%) consumed all of it within 28 days. Mean utility weighted modified Rankin Scale scores at 90 days were 0·44 in the FYTF-919 group and 0·44 in the placebo group (difference 0·01, 95% CI -0·02 to 0·04; p=0·63). The neutral result was consistent in adjusted and sensitivity analyses. There was no significant difference in serious adverse events.

INTERPRETATION

This large, randomised, placebo-controlled, double-blind, clinical trial showed no effect of the traditional Chinese medicine herbal compound FYTF-919 on functional recovery, survival, and health-related quality of life in patients with moderate to severe intracerebral haemorrhage. The results reaffirm the need for methodologically rigorous, randomised controlled trials to evaluate the effectiveness of existing therapies, including traditional Chinese medicines that are already in widespread use throughout the world.

FUNDING

Key-Area Research and Development Program of Guangdong Province.

Postoperative Blood Pressure Goals After Craniotomy for Tumor Resection: A National Survey

BACKGROUND AND OBJECTIVES

Acute hypertension can occur in 90% of postcraniotomy patients for tumor resection, and 60% to 90% of patients require treatment with antihypertensive agents. Postoperative intracranial hemorrhage is a major driver of morbidity and mortality after craniotomy for tumor resection, and perioperative hypertension is believed to be a risk factor. Many neurosurgeons impose postoperative blood pressure (BP) goals to mitigate this risk, but there is little evidence to guide the selection of a specific target BP, leading to a wide variation in patient care. In this article, we have conducted a national survey to report the current practices regarding postoperative BP management.

METHODS

We conducted a cross-sectional survey of academic neurosurgical programs by distributing a 10-item questionnaire to neurosurgical residents of each accredited national neurosurgical residency training program (n = 117). Responses were collected over 3 months, from July 2023 to September 2023. Analysis was performed at the program level; for programs with multiple responding residents, the responses of the senior residents were retained.

RESULTS

Responses were received from 66 residents at 45 institutions. Forty-two programs set postoperative BP goals using systolic blood pressure (SBP) as a parameter, and 2 used mean arterial pressure. Among programs using an SBP goal, most programs kept a goal SBP of <140 mm Hg (41%-43% depending on the tumor type), followed by SBP <160 mm Hg (36%-39%). Most programs maintained this goal until the morning of the first postoperative day. Intravenous nicardipine (n = 12, 27%) and labetalol (n = 12, 27%) were the most frequently administered medications to maintain BP goals.

CONCLUSION

Most of the academic neurosurgical programs use a postoperative SBP goal after craniotomy for tumor resection. Programs are evenly divided between goals of SBP <140 mm Hg and SBP <160 mm Hg. The variability among programs indicates clinical equipoise between these 2 approaches in the context of a future clinical trial.

Early minimally invasive image-guided eNdoscopic evacuation of iNTracerebral hemorrhage: a phase II pilot trial

Background

Whether minimally invasive endoscopic surgery (ES) improves survival and functional outcome in people with spontaneous supratentorial intracerebral hemorrhage (SSICH) is unknown.

Methods

This is a single-center pilot study performed between July 2021 to January 2023. Any supratentorial hematoma with a volume between 20 mL and 100 mL was endoscopically evacuated within 24 h after bleeding onset. Participants were followed-up for 6 months, assessing clinical and radiological outcomes. The primary feasibility outcome was satisfactory hematoma removal (<15 mL residual volume on the first postinterventional CT study) and the primary efficacy outcome was reaching a modified Rankin Scale 0-3 (mRS) at 6 months. Secondary outcomes were mortality and morbidity rates.

Results

Ten participants (median age 72.5 years [IQR 67-81], 70% male, median baseline hematoma volume 34.1 [IQR 25.5-58.0]) were included. Satisfactory hematoma evacuation was achieved in 70% (7/10) with a median evacuation percentage of 69.5% [IQR 45.3-93.9%]. The median duration of surgery was 91 min [IQR 73-111]. Favorable outcome at 6 months was observed in 60% of the participants and improved from within 24 h before the intervention to the last follow-up (6 months). Five participants (50%) experienced a total of six complications, two recurrent bleedings, three pneumonias and one epilepsy. Mortality rate was 30%, while one participant died from pneumonia, one from a recurrent bleeding, and one participant due to a glioblastoma.

Conclusion

ES appears to be feasible, with satisfactory hematoma removal being achieved in the majority of participants. Based on the descriptive results of this pilot trial, a national multicenter RCT comparing ES to best medical treatment is currently ongoing.

Clinical trial registration

https://clinicaltrials.gov/, identifier NCT05681988.

Comparison of functional outcome after intracerebral hemorrhage in patients with or without end stage renal disease on hemodialysis: a propensity-score matched study

BACKGROUND

End stage renal disease (ESRD) requiring hemodialysis (HD) increases mortality among patients with intracerebral hemorrhage (ICH). The aim of this study is to investigate the clinical characteristics and outcome of ICH patients with ESRD on HD versus propensity-score matched controls.

METHODS

This is a single center retrospective study. Consecutive ICH admissions at the University of California, Irvine Medical Center from January 1, 2018 to July 31, 2022 were analyzed.

RESULTS

Among 347 ICH admissions that met inclusion criteria, 24 patients (6.92%) had ESRD on HD. Compared to patients without ESRD, patients with ESRD on HD had significantly higher rate of diabetes mellitus (79.2% vs. 36.8%, p < 0.01) and in-hospital mortality (25% vs. 7.43%, p < 0.01). There were no significant differences in demographics, other comorbidities, clinical characteristics, good (mRS score 0-3) or poor (mRS score 4-5) functional outcomes, rate of comfort care and the time to comfort care decision between the 2 groups. After propensity score matching, the ESRD group had a significantly higher in-hospital mortality rate (27.3% vs. 8%, p = 0.012) and a lower rate of obesity (9.1% vs. 34.1%, p = 0.02). Among patients who died during admission, ESRD on HD status did not inadvertently influence end-of-life care decisions. Univariate logistic regression and area under curve analysis showed that ICH score ≥ 3 was a predictor of increased mortality in both ESRD and non-ESRD groups.

CONCLUSIONS

ICH patients with ESRD on HD had significantly higher in-hospital mortality and lower rate of obesity than propensity score matched controls, suggesting a survival benefit from obesity. ICH score ≥ 3 is an independent predictor for poor outcomes in both ESRD and non-ESRD groups.

Reliability of ABC/2 volumetric estimation in spontaneous intracerebral hemorrhage for hematoma expansion prediction scores

INTRODUCTION

Prediction scores for hematoma expansion in spontaneous intracerebral hemorrhage (ICH), such as the 9-point and BRAIN scores, were developed predominantly using planimetry to measure hematoma volume. In this study, we aim to investigate whether the ABC/2 formula, which is known to overestimate hematoma volume, can be reliably used as a substitute for planimetry in these prediction scores.

PATIENTS AND METHODS

A total of 429 patients from four hospitals were retrospectively enrolled. CT scan and clinical data at admission and follow-up CT scan were collected. The 9-point and BRAIN scores were calculated using hematoma volume from ABC/2 and planimetry. Hematoma expansion was assessed using hematoma volume from planimetry.

RESULTS

The median hematoma volume measured by ABC/2 was 11.97 ml (interquartile range [IQR], 4.8-30.0), whereas the volume measured by planimetry was 11.70 ml (IQR, 4.9-26.6). The median measurement error between ABC/2 and planimetry was 0.30 ml (IQR, -0.72-2.87). ABC/2 overestimated hematoma volume in 244 patients (56.9%) compared to planimetry. In the 9-point score, the area under the curves (AUCs) for predicting hematoma expansion were 0.735 (95% confidence interval [CI], 0.675-0.796) with ABC/2 and 0.732 (95% CI, 0.672-0.793) with planimetry. In the BRAIN score, the AUCs were 0.753 (95% CI, 0.693-0.813) with ABC/2 and 0.745 (95% CI, 0.688-0.803) with planimetry.

DISCUSSION AND CONCLUSION

The 9-point and BRAIN scores using hematoma volume measured by ABC/2 and planimetry showed good performance in predicting hematoma expansion in ICH. ABC/2 volumetric estimation proved to be reliable for these scores.

Continuous Blood Pressure Indices During the First 72 Hours and Functional Outcome in Patients with Spontaneous Intracerebral Hemorrhage

BACKGROUND

Management of intracerebral hemorrhage (ICH) is challenged by limited therapeutic options and a complex relationship between blood pressure (BP) dynamics, especially BP variability (BPV) and ICH outcome.

METHODS

In an exploratory analysis of prospectively collected data on consecutive patients with nontraumatic ICH between 2015 and 2020, continuous BP accessed via an arterial line extracted from the Intellispace Critical Care and Anesthesia information system (Philips Healthcare) was analyzed over the first 72 h post admission. Arterial lines were used as part of standard clinical practice in the intensive care, ensuring high fidelity and real-time data essential for acute care settings. BPV was assessed through successive variation (SV), standard deviation (SD), and coefficient of variation using all available BP measurements. Multivariate regression models were applied to evaluate the association between BPV indices and functional outcome at 3 months.

RESULTS

Among 261 patients (mean age 69.6 ± 15.2 years, 47.9% female, median National Institutes of Health Stroke Scale [NIHSS] score 6 [interquartile range 2-12]) analyzed, lower systolic BP upon admission (< 140 mm Hg) and lower systolic BPV were significantly associated with favorable outcome, whereas higher diastolic BPV correlated with improved outcomes. In the multivariate analysis, diastolic BPV (SD, SV) within the first 72 h post admission emerged as an independent predictor of good functional outcome (modified Rankin Scale score < 3; odds ratio 1.123, 95% confidence interval CI 1.008-1.184, p = 0.035), whereas systolic BPV (SD) showed a negative association. Patients with better outcomes also exhibited distinct clinical characteristics, including younger age, lower median NIHSS scores, and less prevalence of anticoagulation therapy upon admission.

CONCLUSIONS

This study shows the prognostic value of BPV in the acute phase of ICH. Lower systolic BPV (SD) and higher diastolic BPV (SD, SV) were associated with better functional outcomes, challenging traditional BP management strategies. These findings might help to tailor a personalized BP management in ICH.

Anticoagulation Therapy Timing in patients with Atrial Fibrillation after Acute and Chronic Subdural Haematoma (ATTAACH): a pilot randomised controlled trial

INTRODUCTION

Subdural haematomas (SDHs), acute or chronic, are common neurosurgical diagnoses. These problems can occur among patients requiring direct oral anticoagulation (DOAC) for atrial fibrillation. There are currently no guidelines regarding the optimal timing to resume anticoagulation for these patients after SDH. The objective of this study is to evaluate the feasibility of conducting a future large randomised controlled trial (RCT) evaluating the safety and efficacy of resuming DOACs early (ie, at 30 days) vs late (ie, at 3 months) for patients with atrial fibrillation following diagnosis of SDH.

METHODS AND ANALYSIS

This is a pilot, open-label, multicentre RCT that will enrol adults with newly diagnosed acute or chronic SDH with or without other intracranial bleeding who were receiving therapeutic anticoagulation with a DOAC as stroke prophylaxis for atrial fibrillation. Patients will be randomly allocated to resume a DOAC at standard dosing starting either days 30+7 or days 90±14. The primary outcomes for the pilot RCT are recruitment rate, protocol adherence and patient compliance with the randomly allocated interventions. Secondary outcomes are patient functional outcomes and safety and effectiveness outcomes, which will comprise key endpoints for the future planned RCT. This pilot RCT will provide important data to inform the feasibility of conducting a future, large RCT of early versus late resumption of DOACs for atrial fibrillation stroke prophylaxis in patients newly diagnosed with SDH. The future RCT will help inform management of a commonly encountered clinical dilemma with high associated morbidity and mortality.

ETHICS AND DISSEMINATION

This study has been approved by the research ethics board of record. It will be conducted in accordance with the Declaration of Helsinki, Good Clinical Practice guidelines and regulatory requirements. Informed consent will be obtained from eligible patients or substitute decision-makers. Data from this study will inform the design of future, larger RCTs.

TRIAL REGISTRATION NUMBER

NCT05472766.

The relationship between the extent of posterior limb of the internal capsule damage measured by non-contrast computed tomography and clinical outcomes after basal ganglia hemorrhage

Assessing the extent of damage to the posterior limb of the internal capsule (PLIC) is important for early prediction of clinical outcomes in intracerebral hemorrhage (ICH) patients. Currently, using MRI to reconstruct the extent of damage to PLIC is not suitable for quick assessment of prognosis in emergency settings. We aimed to investigate whether the PLIC damage quantified by non-contrast computed tomography (NCCT) is associated with clinical outcomes after basal ganglia intracerebral hemorrhage (BG-ICH). This study retrospectively included 146 BG-ICH patients from the Department of Neurosurgery at the Second Affiliated Hospital of Chongqing Medical University. The damage to the PLIC was quantified using Tangency X measured by NCCT. The importance of features is determined using the Boruta algorithm and Least Absolute Shrinkage and Selection Operator (LASSO) regression. Multivariate logistic regression models were established to examine the impact of PLIC damage on outcomes. Restricted Cubic Splines (RCS) were used to explore potential nonlinear relationships, and Receiver Operating Characteristic (ROC) curves were used to compare the predictive performance of Tangency X with other scoring systems for 6-month neurological outcomes (poor outcomes [mRS: 3-6]). In the multivariate logistic regression adjusting for all covariates, Tangency X was independently associated with an increased risk of poor outcomes (OR = 1.32, 95% CI: 1.17-1.52) in BG-ICH patients. There is a nonlinear relationship between Tangency X and poor outcomes. Specifically, the risk of poor outcomes increases by 1.29 times (OR = 1.29, 95% CI: 1.09-1.67) for each additional 1 mm increase in Tangency X beyond 4 mm. We next observed that the AUC for Tangency X in predicting poor outcomes is 0.8511. The extent of PLIC damage measured by NCCT may represent a promising predictor of poor outcomes after BG-ICH.

A Narrative Review of Interhospital Transfers for Intracerebral Hemorrhage

Of the 750,000 strokes in the United States every year, 15% patients suffer from hemorrhagic stroke. Intracerebral hemorrhage (ICH) is a subtype of hemorrhagic stroke. Despite advances in acute management, patients with hemorrhagic stroke continue to suffer from high mortality and survivors suffer from multidomain impairments in the physical, cognitive, and mental health domains which could last for months to years from their index stroke. Long-term prognosis after ICH is critically dependent on the quality and efficacy of care a patient receives during the acute phase of care. With ongoing care consolidation in stroke systems of care, the number of ICH patients who need to undergo interhospital transfers (IHTs) is increasing. However, the associations between IHT and ICH outcomes have not been well described in literature. In this review, we describe the epidemiology of IHT for ICH, the relationship between IHT and ICH patient outcomes, and proposed improvements to the IHT process to ensure better long-term patient outcomes. Our review indicates that evidence regarding the safety and benefit of IHT for ICH patients is conflicting, with some studies reporting poorer outcomes for transferred patients compared to direct admissions via emergency rooms and other studies showing no effect on outcomes. The American Heart Association guidelines for ICH provide recommendations for timely blood pressure control and anticoagulation reversal to improve patient outcomes. The American Heart Association stroke systems of care guidelines provide recommendations for transfer agreements and but do not provide details on how patients should be managed while undergoing IHT. Large, prospective, and multicenter studies comparing outcomes of IHT patients to direct admissions are necessary to provide more definitive guidance to optimize IHT protocols and aid clinical decision-making.

Assessment of Blood Pressure and Heart Rate Related Variables in Acute Stroke Patients Receiving Intravenous Antihypertensive Medication Infusions

BACKGROUND

We performed an analysis of a large intensive care unit electronic database to provide preliminary estimates of various blood pressure parameters in patients with acute stroke receiving intravenous (IV) antihypertensive medication and determine the relationship with in-hospital outcomes.

METHODS

We identified the relationship between pre-treatment and post-treatment systolic blood pressure (SBP) and heart rate (HR)-related variables and in-hospital mortality and acute kidney injury in patients with acute stroke receiving IV clevidipine, nicardipine, or nitroprusside using data provided in the Medical Information Mart for Intensive Care (MIMIC) IV database.

RESULTS

A total of 1830 patients were treated with IV clevidipine (n = 64), nicardipine (n = 1623), or nitroprusside (n = 143). The standard deviations [SDs] of pre-treatment SBP (16.3 vs. 13.7, p ≤ 0.001) and post-treatment SBP (15.4 vs. 14.4, p = 0.004) were higher in patients who died compared with those who survived, particularly in patients with intracerebral hemorrhage (ICH). The mean SBP was significantly lower post treatment compared with pre-treatment values for clevidipine (130.7 mm Hg vs. 142.5 mm Hg, p = 0.006), nicardipine (132.8 mm Hg vs. 141.6 mm Hg, p ≤ 0.001), and nitroprusside (126.2 mm Hg vs. 139.6 mm Hg, p ≤ 0.001). There were no differences in mean SDs post treatment compared with pre-treatment values for clevidipine (14.5 vs. 13.5, p = 0.407), nicardipine (14.2 vs. 14.6, p = 0.142), and nitroprusside (14.8 vs. 14.8, p = 0.997). The SDs of pre-treatment and post-treatment SBP were not significantly different in patients with ischemic stroke treated with IV clevidipine, nicardipine, or nitroprusside or for patients with ICH treated with IV clevidipine or nitroprusside. However, patients with ICH treated with IV nicardipine had a significantly higher SD of post-treatment SBP (13.1 vs. 14.2, p = 0.0032).

CONCLUSIONS

We found that SBP fluctuations were associated with in-hospital mortality in patients with acute stroke. IV antihypertensive medication reduced SBP but did not reduce SBP fluctuations in this observational study. Our results highlight the need for optimizing therapeutic interventions to reduce SBP fluctuations in patients with acute stroke.

Premorbid Blood Pressure Control Modifies Risk of DWI Lesions With Acute Blood Pressure Reduction in Intracerebral Hemorrhage

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.

Process Evaluation of an Ambulance-Delivered Early Intensive Blood Pressure-Lowering Stroke Trial: Design, Rationale, and Reflection

INTRODUCTION

The fourth INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4) is a large-scale, multicenter, prospective, randomized, open-label, blinded endpoint assessment trial, initiated in an ambulance in China, aiming at evaluating the effectiveness and safety of prehospital blood pressure (BP) lowering in patients with suspected acute stroke and elevated BP. A prespecified process evaluation is intended to explore the implementation of the trial intervention, provide support to interpret the trial outcomes and put forward suggestions to scale up the intervention in broader settings in the future.

METHODS

This process evaluation is a mixed-methods design, and follows the Normalization Process Theory (NPT) and the UK Medical Research Council (UK MRC) guidance. Fidelity, reach, acceptability, appropriateness, adoption, sustainability, and relevant contextual factors and mechanisms affecting the implementation of prehospital early intensive BP-lowering treatment will be analyzed. Semi-structured interviews with ambulance staff, ward and emergency department clinicians, and nurses are undertaken to explore perceptions of the intervention, contextual factors, and potential suggestions for future implementation in practice. Data from observational records, surveys, conventional monitoring data, on-site records, and case report forms will be analyzed to understand background care and context.

CONCLUSION

The process evaluation of INTERACT4 will provide insights for the implementation of prehospital early intensive BP-lowering intervention in different health systems and help better explain the trial results for further scale up.

Intracranial Pressure Variability Associates with 3-Month Outcomes in Spontaneous Intracerebral Hemorrhage: A Retrospective Analysis of 597 Patients

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is a devastating type of stroke, and most favorable treatments to improve patients' neurologic outcomes are not clear. Invasive intracranial pressure (ICP) monitoring is a common treatment of ICH, but whether patients with ICH could benefit from ICP monitoring is controversial. ICP variability (IPV) has been shown to correlate with poor outcomes in patients with subarachnoid hemorrhage and traumatic brain injury, but this association has not been clearly elucidated in patients with ICH. We hypothesized that 72-hour IPV from time of ICP probe implantation is associated with outcomes in patients with ICH.

METHODS

A retrospective chart review analysis of adult patients with ICH who received ICP monitoring at Huashan Hospital, Fudan University between January 2008 and January 2023 was performed. We included patients with ICH within 6 hours of signs or symptoms onset. Outcomes of patients with ICH were assessed using 3-month modified Rankin Scale (mRS) score, and were dichotomized into a poor (mRS score 4-6) and good (mRS score 0-3) outcome group. ICPs were recorded from the implantation of invasive ICP probe until it was removed. ICP was analyzed in the acute period, from 0 to 72 hours after ICP implantation. IPV was analyzed by SD, coefficient of variation, and successive variation of ICP.

RESULTS

We analyzed 597 patients' charts. The first mean ICP assessment, immediately after ICP implantation, at a median 117 minutes (interquartile range, 82-231 minutes) after admission was 20.5 (SD 7.8) mm Hg. The second mean ICP assessment, on neurosurgical intensive care unit arrival after operation, was 14.6 (SD 8.3) mm Hg. Poor outcomes occurred in 213 patients (35.68%). In univariate analysis, univariate quintile analysis, or multivariate analysis, ICP SD, ICP coefficient of variation, and ICP successive variation were associated with poor outcomes.

CONCLUSIONS

IPV during the first 72 hours after ICP implantation in patients with ICH was independently associated with poor functional outcome at 3 months. Stabilization of IPV during hyperacute and acute periods may be a potential therapeutic target to improve functional outcomes of these patients.

Code-ICH: A New Paradigm for Emergency Intervention

PURPOSE OF REVIEW

Intracerebral hemorrhage (ICH) is the most devastating type of stroke, causing widespread disability and mortality. Unfortunately, the acute care of ICH has lagged behind that of ischemic stroke. There is an increasing body of evidence supporting the importance of early interventions including aggressive control of blood pressure and reversal of anticoagulation in the initial minutes to hours of presentation. This review highlights scientific evidence behind a new paradigm to care for these patients called Code-ICH.

RECENT FINDINGS

While numerous trials aimed at decreasing hematoma expansion through single interventions had failed to show statistically significant effects on primary outcomes, time-sensitive, multifaceted, bundled care approaches have recently shown substantial promise in improving functional outcomes in patients with ICH. The concept of Code-ICH can serve as a structural platform for the practice of acute care neurology to continuously measure its performance, reflect on best practices, advance care, and address disparities.