Sex Differences in Incidence, Pathophysiology, and Outcome of Primary Intracerebral Hemorrhage

Sociodemographic biases in a commercial AI model for intracranial hemorrhage detection

PURPOSE

To evaluate whether a commercial AI tool for intracranial hemorrhage (ICH) detection on head CT exhibited sociodemographic biases.

METHODS

Our retrospective study reviewed 9736 consecutive, adult non-contrast head CT scans performed between November 2021 and February 2022 in a single healthcare system. Each CT scan was evaluated by a commercial ICH AI tool and a board-certified neuroradiologist; ground truth was defined as final radiologist determination of ICH presence/absence. After evaluating the AI tool's aggregate diagnostic performance, sub-analyses based on sociodemographic groups (age, sex, race, ethnicity, insurance status, and Area of Deprivation Index [ADI] scores) assessed for biases. χ2 test or Fisher's exact tests evaluated for statistical significance with p ≤ 0.05.

RESULTS

Our patient population was 50% female (mean age 60 ± 19 years). The AI tool had an aggregate accuracy of 93% [9060/9736], sensitivity of 85% [1140/1338], specificity of 94% [7920/ 8398], positive predictive value (PPV) of 71% [1140/1618] and negative predictive value (NPV) of 98% [7920/8118]. Sociodemographic biases were identified, including lower PPV for patients who were females (67.3% [62,441/656] vs. 72.7% [699/962], p = 0.02), Black (66.7% [454/681] vs. 73.2% [686/937], p = 0.005), non-Hispanic/non-Latino (69.7% [1038/1490] vs. 95.4% [417/437]), p = 0.009), and who had Medicaid/Medicare (69.9% [754/1078]) or Private (66.5% [228/343]) primary insurance (p = 0.003). Lower sensitivity was seen for patients in the third quartile of national (78.8% [241/306], p = 0.001) and state ADI scores (79.0% [22/287], p = 0.001).

CONCLUSIONS

In our healthcare system, a commercial AI tool had lower performance for ICH detection than previously reported and demonstrated several sociodemographic biases.

The impact of sex on epidemiology, management, and outcome of spontaneous intracerebral hemorrhage (sICH)

OBJECTIVE

Data on sex differences in spontaneous intracerebral hemorrhages are limited.

METHODS

An automated comprehensive scoping literature review was performed using PubMed and Scopus. Articles written in English about spontaneous intracerebral hemorrhage and sex were reviewed.

RESULTS

Males experience spontaneous intracerebral hemorrhage more frequently than females, at younger ages, and have a higher prevalence of deep bleeds compared to females. Risk factors between sexes vary and may contribute to differing incidences and locations of spontaneous intracranial hemorrhage. Globally, females receive less aggressive care than males, likely impacting survival.

CONCLUSIONS

Epidemiology, risk factors, and treatment of spontaneous intracranial hemorrhage vary by sex, with limited and oftentimes conflicting data available. Further research into the sex-based differences of spontaneous intracranial hemorrhage is necessary for clinicians to better understand how to evaluate and guide treatment in the future.

Predicting hematoma expansion using machine learning: An exploratory analysis of the ATACH 2 trial

INTRODUCTION

Hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH) is a key predictor of poor prognosis and potentially amenable to treatment. This study aimed to build a classification model to predict HE in patients with ICH using deep learning algorithms without using advanced radiological features.

METHODS

Data from the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) was utilized. Variables included in the models were chosen as per literature consensus on salient variables associated with HE. HE was defined as increase in either >33% or 6 mL in hematoma volume in the first 24 h. Multiple machine learning algorithms were employed using iterative feature selection and outcome balancing methods. 70% of patients were used for training and 30% for internal validation. We compared the ML models to a logistic regression model and calculated AUC, accuracy, sensitivity and specificity for the internal validation models respective models.

RESULTS

Among 1000 patients included in the ATACH-2 trial, 924 had the complete parameters which were included in the analytical cohort. The median [interquartile range (IQR)] initial hematoma volume was 9.93.mm3 [5.03-18.17] and 25.2% had HE. The best performing model across all feature selection groups and sampling cohorts was using an artificial neural network (ANN) for HE in the testing cohort with AUC 0.702 [95% CI, 0.631-0.774] with 8 hidden layer nodes The traditional logistic regression yielded AUC 0.658 [95% CI, 0.641-0.675]. All other models performed with less accuracy and lower AUC. Initial hematoma volume, time to initial CT head, and initial SBP emerged as most relevant variables across all best performing models.

CONCLUSION

We developed multiple ML algorithms to predict HE with the ANN classifying the best without advanced radiographic features, although the AUC was only modestly better than other models. A larger, more heterogenous dataset is needed to further build and better generalize the models.

Differences in stroke clinical presentation among sexes

INTRODUCTION

There are sex-based differences in stroke epidemiology, treatment, and outcomes. In this manuscript, we discuss the differences that exist in the clinical presentation of acute stroke among sexes.

DISCUSSION

We present the differences in stroke presentation among sexes including age at the time of presentation, severity of stroke on presentation, and stroke type and location. We discuss the atypical clinical presentations, explore the radiographic findings on presentation (including location, infarct core volume, the impact of collateral circulation, hematoma location in intracranial hemorrhage), and discuss differences in time elapsed between symptom onset and management amongst sexes.

CONCLUSION

Differences exist in stroke clinical presentation amongst sexes. These disparities have public health implications, and as they become better understood, impact awareness campaigns in both the public and healthcare communities.

Haemorrhagic stroke and brain vascular malformations in women: risk factors and clinical features

Haemorrhagic stroke is a severe condition with poor prognosis. Biological sex influences the risk factors, presentations, treatment, and patient outcomes of intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and vascular malformations. Women are usually older at onset of intracerebral haemorrhage compared with men but have an increased risk of aneurysmal subarachnoid haemorrhage as they age. Female-specific factors such as pregnancy, eclampsia or pre-eclampsia, postmenopausal status, and hormone therapy influence a woman's long-term risk of haemorrhagic stroke. The presence of intracranial aneurysms, arteriovenous malformations, or cavernous malformations poses unique clinical dilemmas during pregnancy and delivery. In the absence of evidence-based guidelines for managing the low yet uncertain risk of haemorrhagic stroke during pregnancy and delivery in women with vascular malformations, multidisciplinary teams should carefully assess the risks and benefits of delivery methods for these patients. Health-care providers should recognise and address the challenges that women might have to confront when recovering from haemorrhagic stroke.

Gender differences in risk factors for ischemic stroke: a longitudinal cohort study in East China

OBJECTIVES

Epidemiological studies of stroke and its risk factors can help develop strategies to prevent stroke. We aimed to explore the current gender-specific prevalence of stroke and associated risk factors.

METHODS

Data were collected using a structured precoded questionnaire designed by the Stroke Screening and Prevention Programme of the National Health and Wellness Commission Stroke Prevention and Control Project Committee, between June 2020 and November 2021. A total of 7394 residents took part in the study, 187 of whom had a stroke. The baseline information of each participant was obtained and included in this study. The chi-square test and Kruskal-Wallis tests were used to examine the relationship between these indicators and stroke, and then multivariate logistic regression was used to construct the prediction scale between different genders.

RESULTS

of 7394 participants,4571 (61.82%) were female. The overall prevalence of stroke patients in the study population was 2.53%, Multivariate analysis found that residence status (OR = 0.43, p = 0.002) 、HCY (OR = 0.962, p = 0.000)、Previous TIA (OR = 0.200, p = 0.002) 、Hypertension (OR = 0.33, p = 0.000) and Dyslipidemia (OR = 0.668, p = 0.028) were significant predictors of stroke. there are gender differences in the traditional risk factors for stroke, and women have more risk factors. ROC analysis confirmed the accuracy of the stroke risk model, and the AUC of the stroke risk model for the general population was 0.79 with p < 0.05. In the gender model, the female AUC was 0.796 (p < 0.05). and the male AUC was 0.786 with p < 0.05.

CONCLUSION

The prevalence of stroke in adults aged 40 years and above is high in eastern China were high. management of risk factors can effectively prevent the occurrence of most strokes. more attention should be paid to gender differences associated with stroke.

Sex Differences in Case Fatality of Aneurysmal Subarachnoid Hemorrhage: A Systematic Review

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (SAH) is more common in women than in men, contrary to most cardiovascular diseases. However, it is unclear whether the case fatality rate (CFR) of SAH also differs by sex. Thus, we performed a systematic review to address the relationship between sex and SAH CFRs.

METHODS

We conducted a systematic literature search in PubMed, Scopus, and Cochrane library databases. We focused on population-based studies that included both nonhospitalized and hospitalized SAHs and had either reported 1-month (28-31 day) SAH CFRs separately for men and women or calculated risk estimates for SAH CFR by sex. For quality classification, we used the Cochrane Collaboration Handbook and Critical Appraisal Skills Program guidelines. We pooled the study cohorts and calculated relative risk ratios (RRs) with 95% confidence intervals (CIs) for SAH death between women and men using a random-effects meta-analysis model.

RESULTS

The literature search yielded 5,592 initial publications, of which 33 study cohorts were included in the final review. Of the 33 study cohorts, only three reported significant sex differences, although the findings were contradictory. In the pooled analysis of all 53,141 SAH cases (60.3% women) from 26 countries, the 1-month CFR did not differ (RR = 0.99 [95% CI: 0.93-1.05]) between women (35.5%) and men (35.0%). According to our risk-of-bias evaluation, all 33 study cohorts were categorized as low quality. The most important sources of bias risks were related to the absence of proper confounding control (all 33 study cohorts), insufficient sample size (27 of 33 study cohorts), and poor/unclear diagnostic accuracy (27 of 33 study cohorts).

CONCLUSION

Contrary to SAH incidence rates, the SAH CFRs do not seem to differ between men and women. However, since none of the studies were specifically designed to examine the sex differences in SAH CFRs, future studies on the topic are warranted.

Association of the COL4A2 Gene Polymorphisms with Primary Intracerebral Hemorrhage Risk and Outcome in Chinese Han Population

The relationship of single nucleotide polymorphisms (SNPs) in COL4A2 gene with risk and outcome of primary intracerebral hemorrhage (ICH) in the Chinese Han population remains unclear, which was investigated in this study. Primary ICH patients and non-stroke controls of Chinese Han ethnicity were enrolled. The genotypes of 8 tag-SNPs were determined using a custom-by-design 48-Plex SNPscan Kit. Poor 3-month outcome was defined as modified Rankin Scale score 4-6. Logistic regression was employed to examine association between COL4A2 variants and risk and poor outcome of primary ICH. 323 patients with primary ICH and 376 stroke-free controls were included. Compared to controls, the rs1049931 G and rs1049906 C alleles were associated with increased ICH risk (p = 0.027 and 0.033), and these two allele counts increased this risk after adjustments respectively (additive model: adjusted OR [aOR] 1.41, 95% CI 1.03-1.94, corrected p = 0.043; aOR 1.37, 95% CI 1.01-1.86, corrected p = 0.043). The rs1049931 AG/GG and rs1049906 CT/CC genotypes showed increased susceptibility to non-lobar hemorrhage (aOR 1.63, 95% CI 1.06-2.50, p = 0.025; aOR 1.63, 95% CI 1.07-2.47, p = 0.022). Haplotype analysis revealed an association between rs1049906-rs1049931 haplotype CG and ICH risk (OR 1.36, 95% CI 1.05-1.78, p = 0.021). Regarding clinical outcome, the rs3803230 C allele (dominant model: aOR 1.94, 95% CI 1.04-3.63, p = 0.037) and haplotype AC of rs7990214-rs3803230 (OR 1.98, 95% CI 1.13-3.46, p = 0.015) contributed to 3-month poor outcome. The COL4A2 polymorphisms are associated with an increased risk of primary ICH, mainly non-lobar hemorrhage, and with long-term poor outcome after ICH in Chinese Han population.

Primary and Secondary Intracerebral Hemorrhage in Pregnant and Nonpregnant Young Adults by SMASH-UP Criteria

BACKGROUND

Intracerebral hemorrhage (ICH) is a major cause of maternal morbidity, but its pathophysiology is poorly characterized. We investigated characteristics of pregnancy-associated ICH (P-ICH), compared with ICH in similar aged nonpregnant adults of both sexes.

METHODS AND RESULTS

We performed a retrospective analysis of 134 adults aged 18 to 44 years admitted to our center with nontraumatic ICH from January 1, 2012, to December 31, 2021. We compared ICH characteristics among 3 groups: those with P-ICH (pregnant or within 12 months of end of pregnancy); nonpregnant women; and men. We categorized ICH pathogenesis according to a modified scheme, SMASH-UP (structural, medications, amyloid angiopathy, systemic, hypertension, undetermined, posterior reversible encephalopathy syndrome/reversible cerebral vasoconstriction syndrome), and calculated odds ratios and 95% CIs for primary (spontaneous small-vessel) ICH versus secondary ICH (structural lesions or coagulopathy related), using nonpregnant women as the reference. We also compared specific ICH pathogenesis by SMASH-UP criteria and functional outcomes between groups. Of 134 young adults with nontraumatic ICH, 25 (19%) had P-ICH, of which 60% occurred postpartum. Those with P-ICH had higher odds of primary ICH compared with nonpregnant women (adjusted odds ratio, 4.5 [95% CI, 1.4-14.7]). The odds of primary ICH did not differ between men and nonpregnant women. SMASH-UP pathogenesis for ICH differed significantly between groups (P<0.001). While the in-hospital mortality rate was lowest in the P-ICH group (4%) compared with nonpregnant women (13%) and men (24%), 1 in 4 patients with P-ICH were bedbound and dependent at the time of discharge.

CONCLUSIONS

In our cohort of young adults with ICH, 1 in 5 was pregnancy related. P-ICH differed in pathogenesis compared with non-pregnancy-related ICH in young adults, suggesting unique pathophysiology.

Female mice display sex-specific differences in cerebrovascular function and subarachnoid haemorrhage-induced injury

BACKGROUND

In male mice, a circadian rhythm in myogenic reactivity influences the extent of brain injury following subarachnoid haemorrhage (SAH). We hypothesized that female mice have a different cerebrovascular phenotype and consequently, a distinct SAH-induced injury phenotype.

METHODS

SAH was modelled by pre-chiasmatic blood injection. Olfactory cerebral resistance arteries were functionally assessed by pressure myography; these functional assessments were related to brain histology and neurobehavioral assessments. Cystic fibrosis transmembrane conductance regulator (CFTR) expression was assessed by PCR and Western blot. We compared non-ovariectomized and ovariectomized mice.

FINDINGS

Cerebrovascular myogenic reactivity is not rhythmic in females and no diurnal differences in SAH-induced injury are observed; ovariectomy does not unmask a rhythmic phenotype for any endpoint. CFTR expression is rhythmic, with similar expression levels compared to male mice. CFTR inhibition studies, however, indicate that CFTR activity is lower in female arteries. Pharmacologically increasing CFTR expression in vivo (3 mg/kg lumacaftor for 2 days) reduces myogenic tone at Zeitgeber time 11, but not Zeitgeber time 23. Myogenic tone is not markedly augmented following SAH in female mice and lumacaftor loses its ability to reduce myogenic tone; nevertheless, lumacaftor confers at least some injury benefit in females with SAH.

INTERPRETATION

Female mice possess a distinct cerebrovascular phenotype compared to males, putatively due to functional differences in CFTR regulation. This sex difference eliminates the CFTR-dependent cerebrovascular effects of SAH and may alter the therapeutic efficacy of lumacaftor compared to males.

FUNDING

Brain Aneurysm Foundation, Heart and Stroke Foundation and Ted Rogers Centre for Heart Research.

Sex Differences in Perihematomal Edema Volume and Outcome After Intracerebral Hemorrhage

BACKGROUND

Although larger hematoma volume is associated with worse outcome after intracerebral hemorrhage (ICH), the association between perihematomal edema (PHE) volume and outcome remains uncertain, as does the impact of sex on PHE and outcome. Here we aimed to determine whether larger PHE volume is associated with worse outcome and whether PHE volume trajectories differ by sex.

METHODS

We conducted a post hoc analysis of the Factor VIIa for Acute Hemorrhagic Stroke Treatment (FAST) trial, which randomized patients with ICH to receive recombinant activated factor VIIa or placebo. Computerized planimetry calculated PHE and ICH volumes on serial computed tomography (CT) scans (at baseline [within 3 h of onset], at 24 h, and at 72 h). Generalized estimating equations examined interactions between sex, CT time points, and FAST treatment arm on PHE and ICH volumes. Mixed and multivariable logistic models examined associations between sex, PHE, and outcomes.

RESULTS

A total of 781 patients with supratentorial ICH (mean age 65 years) were included. Compared to women (n = 296), men (n = 485) had similar median ICH (14.9 vs. 13.6 mL, p = 0.053) and PHE volumes (11.1 vs. 10.5 mL, p = 0.56) at baseline but larger ICH and PHE volumes at 24 h (19.0 vs. 14.0 mL, p < 0.001; 22.2 vs. 15.7 mL, p < 0.001) and 72 h (16.0 vs. 11.8 mL, p < 0.001; 28.7 vs. 19.9 mL, p < 0.001). Men had higher absolute early PHE expansion (p < 0.001) and more hematoma expansion (growth ≥ 33% or 6 mL at 24 h, 33% vs. 22%, p < 0.001). An interaction between sex and CT time points on PHE volume (p < 0.001), but not on ICH volume, confirmed a steeper PHE trajectory in men. PHE expansion (per 5 mL, odds radio 1.19, 95% confidence interval 1.10-1.28), but not sex, was associated with poor outcome.

CONCLUSIONS

Early PHE expansion and trajectory in men were significantly higher. PHE expansion was associated with poor outcomes independent of sex. Mechanisms leading to sex differences in PHE trajectories merit further investigation.

A comparison of the disease occurrence of cerebrovascular diseases, diabetes mellitus, hypertensive diseases, and ischaemic heart diseases among hospitalized older adults in Thailand

This observational research analyzed public hospital data from the Thailand Ministry of Public Health website to investigate gender differences in four categories of non-communicable diseases (NCDs) affecting hospitalized senior Thai populations for 12 years. This study aimed to determine the cumulative effects and analyze the odds ratio (OR) according to ICD-10 cause categories for the data from 2010 to 2021, accounting for 1,327,093 cases in 2010 and 2,275,936 cases in 2021. The findings revealed statistically significant gender differences in four categories of NCDs. Men were found to be more likely than women to have two types of NCDs, as measured by the OR (95%CI): cerebrovascular diseases (OR 1.34-1.47, 95%CI 1.32-1.48), and ischaemic heart disease (OR 1.24-1.63, 95%CI 1.23-1.64). Conversely, diabetes mellitus (OR 0.64-0.84, 95%CI 0.63-0.85) and hypertensive disorders (OR 0.82-0.95, 95%CI 0.81-0.97) were discovered to have a lower likelihood of ratios related in men compared to women. However, the trend of all four NCDs in men has significantly increased every year: cerebrovascular diseases = 0.0093 year(s) + 1.3391, (R2 0.82, p-value 0.001); diabetes mellitus = 0.0171 year(s) + 0.6143, (R2 0.97, p-value 0.001); hypertension = 0.0125 year(s) + 0.8091, (R2 0.96, p-value 0.001); and ischaemic heart disease = 0.0345 year(s) + 1.1884, (R2 0.99, p-value 0.001).Gender, a crucial biological factor, contributes to variations in the prevalence of illness. As such, it is essential to prioritize the disease risk occurrence and preventive care for men and women separately, with a focus on implementing more detailed screening and detection strategies, as well as tailored interventions.

Association between renal surface nodularity and increased adverse vascular event risk in patients with arterial hypertension

OBJECTIVE

To explore the association of renal surface nodularity (RSN) with the increased adverse vascular event (AVE) risk in patients with arterial hypertension.

METHODS

This cross-sectional study included patients with arterial hypertension aged 18-60 years who underwent contrasted computed tomography (CT) of kidney from January 2012 to December 2020. The subjects were classified into AVE or not (non-AVE) matched with age (≤5 years) and sex. Their CT images were analyzed using both qualitative (semiRSN) and quantitative RSN (qRSN) methods, respectively. Their clinical characteristics included age, sex, systolic blood pressure (SBP), diastolic blood pressure, hypertension course, diabetes history, hyperlipidemia, and estimated glomerular filtration rate (eGFR).

RESULTS

Compared with non-AVE group (n = 91), AVE (n = 91) was at lower age, higher SBP, and fewer rate of diabetes and hyperlipidemia history (all P < .01). Rate of positive semiRSN was higher in AVE than non-AVE (49.45% vs 14.29%, P < .001). qRSN was larger in AVE than non-AVE [1.03 (0.85, 1.33) vs 0.86 (0.75,1.03), P < .001]. The increased AVE was associated with semiRSN (odds ratio = 7.04, P < .001) and qRSN (odds ratio = 5.09, P = .003), respectively. For distinguishing AVE from non-AVE, the area under receiver operating characteristic was bigger in the models combining the clinical characteristics with either semiRSN or qRSN than that of semiRSN or qRSN alone (P ≤.01).

CONCLUSION

Among the patients with arterial hypertension aged 18-60 years, CT imaging-based RSN was associated with increased AVE risk.

Predictive value of admission red cell distribution width-to-platelet ratio for 30-day death in patients with spontaneous intracerebral hemorrhage: an analysis of the MIMIC database

Aim

Prognostic assessment plays an important role in the effective management of patients with spontaneous intracerebral hemorrhage (ICH). The study aimed to investigate whether elevated red cell distribution width-to-platelet ratio (RPR) at admission was related to 30-day death in patients with spontaneous intracerebral hemorrhage (ICH).

Methods

This retrospective cohort study included 2,823 adult patients with ICH from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC) III and IV databases between 2001 and 2019. The Cox proportional hazard model was utilized to evaluate the relationship between RPR levels and 30-day death risk. The area under receiver-operating characteristic curve (AUC) was used to assess the predictive ability of RPR for 30-day death in patients with ICH.

Results

At the end of the 30-day follow-up, 799 (28.30%) patients died, and the median RPR level was 0.066 (0.053, 0.087). After adjusting for confounders, the tertile 3 of RPR levels [hazard ratio (HR) = 1.37, 95% confidence interval (CI): 1.15-1.64] were associated with a higher risk of 30-day death in patients with ICH compared with tertile 1. In the stratified analyses, elevated RPR levels were found to be associated with an increased risk of 30-day death in patients aged <65 years (HR = 1.77, 95%CI: 1.29-2.43), aged ≥65 years (HR = 1.30, 95%CI: 1.05-1.61), with Glasgow Coma Score (GCS) <14 (HR = 1.65, 95%CI: 1.27-2.14), with Charlson comorbidity index (CCI) ≥4 (HR = 1.45, 95%CI: 1.17-1.80), with (HR = 1.66, 95%CI: 1.13-2.43) or without sepsis (HR = 1.32, 95%CI: 1.08-1.61), and female patients (HR = 1.75, 95%CI: 1.35-2.26) but not in male patients (P = 0.139) and patients with GCS ≥14 (P = 0.058) or CCI <4 (P = 0.188). The AUC for RPR to predict 30-day death in patients with ICH was 0.795 (95%CI: 0.763-0.828) in the testing set, indicating a good predictive ability.

Conclusion

Elevated RPR levels were correlated with an increased risk of 30-day death in patients with ICH, and RPP levels showed good predictive ability for 30-day death.

Sex Differences of Hospital and Emergency Department Presentations of Stroke in Canada

We provide an updated estimate of adult stroke event rates by age group, sex, and stroke type using Canadian administrative data. In the 2017-2018 fiscal year, there were an estimated 81,781 hospital or emergency department visits for stroke events in Canada, excluding Quebec. Our findings show that overall, the event rate of stroke is similar between women and men. There were slight differences in stroke event rate at various ages by sex and stroke type and emerging patterns warrant attention in future studies. Our findings emphasize the importance of continuous surveillance to monitor the epidemiology of stroke in Canada.

Sex differences in perihematomal edema volume and outcome after intracerebral hemorrhage

Objective

To determine whether in patients with intracerebral hemorrhage (ICH) perihematomal edema (PHE) volume trajectories differ by sex.

Methods

We conducted a post-hoc analysis of the Factor-VII-for-Acute-Hemorrhagic-Stroke-Treatment (FAST) trial that randomized patients with ICH to receive recombinant activated Factor VIIa or placebo. Computerized planimetry calculated PHE and ICH volumes on serial CT scans (at baseline [within 3 hours of onset], at 24, and at 72 hours). Generalized estimating equations examined interactions between sex, CT-timepoints, and FAST treatment-arm on PHE and ICH volumes. Mixed and multivariate logistic models examined associations between sex, PHE, and outcomes.

Results

781 with supratentorial ICH (mean age 65 years) were included. Compared to women (n=296), men (n=485) had similar median ICH (14.9 versus 13.6 ml, p=0.053), and PHE volumes (11.1 versus 10.5 ml, p=0.56) at baseline but larger ICH and PHE at 24 hours (19.0 versus 14.0, p<0.001; 22.2 versus 15.7, p<0.001) and 72 hours (16.0 versus 11.8, p<0.001; 28.7 versus 19.9, p<0.001). Men had higher absolute PHE expansion (p<0.001), and more hematoma expansion (growth ≥33% or 6 mL at 24 hours, 33% versus 22%, p<0.001). An interaction between sex and CT-timepoints on PHE (p<0.001) but not on ICH volumes confirmed a steeper PHE trajectory in men. PHE expansion (per 5mL, odds radio, 1.19, 95%-confidence interval 1.10-1.28), but not sex, was associated with poor outcome.

Conclusions

PHE expansion and trajectory in men were significantly higher. PHE expansion was associated with poor outcomes independent of sex. Mechanisms leading to sex differences in PHE trajectories merit further investigation.

What is already known on this topic

Prior research has reported sex differences in intracerebral hemorrhage (ICH) characteristics and some studies suggest worse outcome after ICH in women. However, we do not have a good understanding whether there are sex differences in perihematomal edema (PHE) volume trajectories, or whether sex, independent of confounders, is associated with poor after ICH.

What this study adds

In this post-hoc analysis of 781 patients with supratentorial ICH from the Factor-VII-for-Acute-Hemorrhagic-Stroke-Treatment (FAST) trial in which patients underwent brain CT imaging time-locked to symptom onset (within 3 hours of symptom onset, at 24 hours, and at 72 hours), men compared to women had similar ICH and PHE volumes at baseline, but larger ICH expansion and PHE expansion on follow up imaging. The PHE but not the ICH volume trajectory across scans was significantly higher in men than in women. While PHE expansion was associated with poor outcome at 90 days, outcome between the sexes was similar at 90 days, and sex was not associated with outcome.

How this study might affect research practice or policy

The finding of heightened early PHE and ICH expansion in men may inform study design, patient recruitment strategies, and pre-specification of subgroup analyses in future interventional trials. The findings of this study also suggest that focusing on sex-specific factors may allow novel mechanistic insight into PHE, a major cause of secondary injury and poor outcome after ICH.

Association between Diet Quality and Stroke among Chinese Adults: Results from China Health and Nutrition Survey 2011

The low-burden Diet Quality Questionnaire (DQQ) is a standardized tool to collect indicators of dietary adequacy as well as indicators of the protection of health against noncommunicable diseases (NCDs) within the framework of the global diet quality project. Stroke is the leading cause of the cardiovascular disease burden in China, with poor diet being one of the major risk factors. In this study, we aimed to understand the association of several indicators of diet quality derived from the DQQ with stroke among Chinese adults and, further, to examine the gender differences using the 2011 wave of the China Health and Nutrition Survey. Multivariable logistic regression was used to examine the associations of the NCD-Protect score, NCD-Risk score, and global dietary recommendations score (GDR) score with stroke. There were 192 stroke cases (121 in men and 71 in women) of 12,051 adults. The continuous NCD-Risk score was positively associated with stroke in women (odds ratio (OR) = 1.52, 95% confidence interval (CI): 1.13-2.06). When compared with women with an NCD-Risk score of 0 points, those with an NCD-Risk score ≥2 points had a higher risk of stroke (OR = 2.71, 95% CI: 1.35-5.43). In addition, compared with women with a GDR score ≤0, those with a GDR score ≥2 points had lower odds of stroke (OR = 0.42, 95% CI: 0.22-0.77). Poor diet quality, as reflected by the NCD-Risk score, was associated with an increased risk of stroke in Chinese women, but not in men. Our findings provided evidence that an optimal diet quality could be conducive to preventing stroke for Chinese women and suggested a diverse diet characterized by the limited consumption of unhealthy foods, such as red meat, processed meat, sweets, soft drinks (sodas), and packaged ultra-processed salty snacks.

Gender Differences in Intracerebral Hemorrhage

Differences exist between genders in intracerebral hemorrhage cause, epidemiology, and outcomes. These gender differences are in part attributable to physiologic differences; however, demographic, social/behavioral risk factors, along with health care system variation and potential family and/or clinician bias play a role as well. These factors vary from region to region and interact, making comprehensive and definitive conclusions regarding sex differences a challenging task. Differences between the genders in intracerebral hemorrhage epidemiology and extensive differences in underlying pathophysiology, intervention, risk factors, and outcome are all discussed.

Intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is a dramatic condition caused by the rupture of a cerebral vessel and the entry of blood into the brain parenchyma. ICH is a major contributor to stroke-related mortality and dependency: only half of patients survive for 1 year after ICH, and patients who survive have sequelae that affect their quality of life. The incidence of ICH has increased in the past few decades with shifts in the underlying vessel disease over time as vascular prevention has improved and use of antithrombotic agents has increased. The pathophysiology of ICH is complex and encompasses mechanical mass effect, haematoma expansion and secondary injury. Identifying the causes of ICH and predicting the vital and functional outcome of patients and their long-term vascular risk have improved in the past decade; however, no specific treatment is available for ICH. ICH remains a medical emergency, with prevention of haematoma expansion as the key therapeutic target. After discharge, secondary prevention and management of vascular risk factors in patients remains challenging and is based on an individual benefit-risk balance evaluation.

Sex Differences in Treatment and Prognosis of Acute Intracerebral Hemorrhage

Background: Intracerebral hemorrhage (ICH) accounts for 10%-15% of all stroke cases and is associated with a high risk of death and disability. Prior studies in ischemic stroke have demonstrated a less favorable outcome in women compared with men, but there is a paucity of data regarding differences in outcome by sex in ICH. The aim of the present study was to investigate possible sex differences in acute care and the 3-months follow-up of patients with ICH. Methods: Data were collected from the Swedish National Stroke Registry (Riksstroke). Demographic and baseline characteristics were collected, based on in-hospital data and data from 3-months follow-up. Results: Variables of interest were collected from 1,403 patients. Women (45.1%) were significantly older than men, with a mean age ± standard deviation of 77 ± 13years, versus 71 ± 14 years, p < 0.01. On admission, the ICH severity was similar in men and women. There was no significant association between sex and reception of neuroimaging or neurosurgery. Women were less likely to be treated in a stroke unit (80.8% vs. 85.3%, p = 0.03), or discharged to home (51.5% vs. 63.4%, p < 0.01). At 3-months follow-up, there were no sex-related differences regarding dependence, post-ICH self-reported depression, or case fatality. Conclusions: Women were less likely to be treated in a stroke unit, and were less often discharged to home. However, no significant differences in 3-month functional outcome or survival between men and women with ICH were found in this study.

Adiposity, Body Fat Distribution, and Risk of Major Stroke Types Among Adults in the United Kingdom

IMPORTANCE

Uncertainty persists regarding the independent association of general and central adiposity with major stroke types.

OBJECTIVE

To determine the independent associations of general and central adiposity with risk of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage.

DESIGN, SETTING, AND PARTICIPANTS

Between 2006 and 2010, adults without prior stroke at recruitment in England, Scotland, and Wales were recruited into the UK Biobank prospective cohort study and were followed up through linkage with electronic medical records. Data were analyzed from September 2021 to September 2022.

EXPOSURES

General adiposity (body mass index [BMI] calculated as weight in kilograms divided by height in meters squared) and central adiposity (waist circumference).

MAIN OUTCOMES AND MEASURES

Incident ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage as recorded through record linkage with electronic hospital records. Cox regression estimated adjusted hazard ratios (HRs) by stroke type.

RESULTS

Among 490 071 participants, the mean (SD) age was 56.5 (8.1) years, 267 579 (54.6%) were female, and 461 647 (94.2%) were White. During a median (IQR) of 12 (11.2-12.7) years follow-up, 7117 incident ischemic strokes, 1391 intracerebral hemorrhages, and 834 subarachnoid hemorrhages were identified. After mutual adjustment for waist circumference, BMI had no independent association with ischemic stroke (HR per 5-unit higher BMI, 1.04; 95% CI, 0.97-1.11), but was inversely associated with intracerebral hemorrhage (HR, 0.85; 95% CI, 0.74-0.96) and subarachnoid hemorrhage (HR, 0.82; 95% CI, 0.69-0.96). Waist circumference (adjusted for BMI) was positively associated with ischemic stroke (HR per 10-cm higher waist circumference, 1.19; 95% CI, 1.13-1.25) and intracerebral hemorrhage (HR, 1.17; 95% CI, 1.05-1.30), but was not associated with subarachnoid hemorrhage (HR, 1.07; 95% CI, 0.93-1.22).

CONCLUSIONS AND RELEVANCE

In this large-scale prospective study, the independent and contrasting associations of BMI and waist circumference with stroke types suggests the importance of considering body fat distribution to stroke risk. Waist circumference was positively associated with the risk of ischemic stroke and intracerebral hemorrhage, while BMI was inversely associated with the risk of subarachnoid hemorrhage and intracerebral hemorrhage. This study also suggests that some adverse correlate of low BMI may be associated with an increased risk of intracerebral hemorrhage and subarachnoid hemorrhage, which warrants further investigation.

Sex-related differences in spontaneous intracerebral hemorrhage outcomes: A prognostic study based on 111,112 medical records

Objective

To identify sex-related differences in the outcome of hospitalized patients with spontaneous intracerebral hemorrhage (SICH), and to identify potential causal pathways between sex and SICH outcome.

Methods

A total of 111,112 medical records of in-hospital patients with SICH were collected. Data- and expert-driven techniques were applied, such as a multivariate logistic regression model and causal mediation analysis. These analyses were used to determine the confounders and mediators, estimate the true effect of sex on the SICH outcome, and estimate the average causal mediation effect for each mediator.

Results

(1) Failure (disability or death) rates in women with SICH were significantly lower than in men with SICH. On the day of discharge, the odds ratio (OR) of failure between women and men was 0.9137 [95% confidence interval (CI), 0.8879–0.9402], while the odds ratio at 90 days post-discharge was 0.9353 (95% confidence interval, 0.9121–0.9591). (2) The sex-related difference in SICH outcome decreased with increasing age and disappeared after 75 years. (3) Deep coma, brainstem hemorrhage, and an infratentorial hemorrhage volume of >10 ml accounted for 62.76% (p < 0.001), 33.46% (p < 0.001), and 11.56% (p < 0.001) of the overall effect on the day of discharge, and for 52.28% (p < 0.001), 27.65% (p < 0.001), and 10.86% (p < 0.001) of the overall effect at the 90-day post-discharge.

Conclusion

Men have a higher failure risk than women, which may be partially mediated by a higher risk for deep coma, brainstem hemorrhage, and an infratentorial hemorrhage volume of >10 ml. Future work should explore the biological mechanisms underlying this difference.

CCL5 Levels Predict Stroke Volume Growth in Acute Ischemic Stroke and Significantly Diminish in Hemorrhagic Stroke Patients

Stroke remains an important health challenge. Here, we study whether circulating chemokine (C-C motif) ligand 5 (CCL5) levels may predict clinical outcomes for stroke patients. A total of 100 consecutive stroke patients (36 acute ischemic and 64 hemorrhagic) were admitted to the stroke unit. Clinical history data and monitoring parameters were recorded. Blood serum was collected at days 0, 1, and hospital discharge to measure CCL5 levels by ELISA. Infarct or hemorrhagic volume, neurological severity (NIHSS), and functional prognosis (mRankin scale) were measured as clinical outcomes. CCL5 levels were lower in patients with hemorrhagic stroke than in patients with acute ischemic stroke. No differences were found between females and males in both types of stroke. Ischemic stroke patients whose infarct volume grew had lower CCL5 levels at day 0. Levels of CCL5 in ischemic and hemorrhagic patients were not associated with more severe symptoms/worse prognosis (NIHSS > 3; mRankin > 2) at admission or at 3 months. CCL5 could be used as a diagnostic marker to distinguish between ischemic and hemorrhagic strokes. Furthermore, CCL5 levels could predict the infarct volume outcomes in ischemic patients.

Cerebral venous congestion exacerbates cerebral microhemorrhages in mice

Cerebral microhemorrhages (CMHs; microbleeds), which are small focal intracerebral hemorrhages, importantly contribute to the pathogenesis of cognitive decline and dementia in older adults. Although recently it has been increasingly recognized that the venous side of the cerebral circulation likely plays a fundamental role in the pathogenesis of a wide spectrum of cerebrovascular and brain disorders, its role in the pathogenesis of CMHs has never been studied. The present study was designed to experimentally test the hypothesis that venous congestion can exacerbate the genesis of CMHs. Increased cerebral venous pressure was induced by internal and external jugular vein ligation (JVL) in C57BL/6 mice in which systemic hypertension was induced by treatment with angiotensin II plus L-NAME. Histological analysis (diaminobenzidine staining) showed that mice with JVL developed multiple CMHs. CMHs in mice with JVL were often localized adjacent to veins and venules and their morphology was consistent with venous origin of the bleeds. In brains of mice with JVL, a higher total count of CMHs was observed compared to control mice. CMHs were distributed widely in the brain of mice with JVL, including the cortical gray matter, brain stem, the basal ganglia, subcortical white matter, cerebellum, and the hippocampi. In mice with JVL, there were more CMHs predominantly in cerebral cortex, brain stem, and cerebellum than in control mice. CMH burden, defined as total CMH volume, also significantly increased in mice with JVL. Thus, cerebral venous congestion can exacerbate CMHs. These observations have relevance to the pathogenesis of cognitive impairment associated with right heart failure as well as elevated cerebral venous pressure due to jugular venous reflux in older adults.

The Impact of Sex and Gender on Stroke

Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.

Hyperacute prediction of functional outcome in spontaneous intracerebral haemorrhage: systematic review and meta-analysis

Purpose

To describe the association between factors routinely available in hyperacute care of spontaneous intracerebral haemorrhage (ICH) patients and functional outcome.

Methods

We searched Medline, Embase and CINAHL in February 2020 for original studies reporting associations between markers available within six hours of arrival in hospital and modified Rankin Scale (mRS) at least 6 weeks post-ICH. A random-effects meta-analysis was performed where three or more studies were included.

Findings

Thirty studies were included describing 40 markers. Ten markers underwent meta-analysis and age (OR = 1.06; 95%CI = 1.05 to 1.06; p < 0.001), pre-morbid dependence (mRS, OR = 1.73; 95%CI = 1.52 to 1.96; p < 0.001), level of consciousness (Glasgow Coma Scale, OR = 0.82; 95%CI = 0.76 to 0.88; p < 0.001), stroke severity (National Institutes of Health Stroke Scale, OR=1.19; 95%CI = 1.13 to 1.25; p < 0.001), haematoma volume (OR = 1.12; 95%CI=1.07 to 1.16; p < 0.001), intraventricular haemorrhage (OR = 2.05; 95%CI = 1.68 to 2.51; p < 0.001) and deep (vs. lobar) location (OR = 2.64; 95%CI = 1.65 to 4.24; p < 0.001) were predictive of outcome but systolic blood pressure, CT hypodensities and infratentorial location were not. Of the remaining markers, sex, medical history (diabetes, hypertension, prior stroke), prior statin, prior antiplatelet, admission blood results (glucose, cholesterol, estimated glomerular filtration rate) and other imaging features (midline shift, spot sign, sedimentation level, irregular haematoma shape, ultraearly haematoma growth, Graeb score and onset to CT time) were associated with outcome.

Conclusion

Multiple demographic, pre-morbid, clinical, imaging and laboratory factors should all be considered when prognosticating in hyperacute ICH. Incorporating these in to accurate and precise models will help to ensure appropriate levels of care for individual patients.

Contemporary Trends in the Nationwide Incidence of Primary Intracerebral Hemorrhage

BACKGROUND

We report contemporary trends in nationwide incidence of intracerebral hemorrhage (ICH) across demographic and regional strata over a 15-year period.

METHODS

Utilizing the Nationwide Inpatient Sample (2004-2018) and US Census Bureau data, we calculated ICH incidence rates for age, race/ethnicity, sex, and hospital region sub-cohorts across 5 consecutive 3-year periods (2004-2006 to 2016-2018). We fit Poisson and log binomial regression models to evaluate demographic and regional differences in ICH incidence and trends in prevalence of hypertension and past/current anticoagulant use among hospitalized ICH patients.

RESULTS

Overall, the annual incidence rate (95% CI) of ICH per 100 000 was 23.15 (23.10-23.20). The 3-year incidence of ICH (per 100 000) increased from 62.79 in 2004 to 2006 to 78.86 in 2016 to 2018 (adjusted incidence rate ratio, CI: 1.11 [1.02-1.20]), coinciding with increased 3-year prevalence of hypertension and anticoagulant use among hospitalized ICH patients (adjusted risk ratio, CI: hypertension-1.16 [1.15-1.17]; anticoagulant use-2.30 [2.14-2.47]). We found a significant age-time interaction, whereby ICH incidence increased significantly faster among those aged 18 to 44 years (adjusted incidence rate ratio, CI: 1.10 [1.05-1.14]) and 45 to 64 years (adjusted incidence rate ratio, CI: 1.08 [1.03-1.13]), relative to those aged ≥75 years.

CONCLUSIONS

Rising ICH incidence among young and middle-aged Americans warrants ICH prevention strategies targeting these economically productive age groups.

Novel targets, treatments, and advanced models for intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is the second most common type of stroke and a major cause of mortality and disability worldwide. Despite advances in surgical interventions and acute ICH management, there is currently no effective therapy to improve functional outcomes in patients. Recently, there has been tremendous progress uncovering new pathophysiological mechanisms underlying ICH that may pave the way for the development of therapeutic interventions. Here, we highlight emerging targets, but also existing gaps in preclinical animal modelling that prevent their exploitation. We particularly focus on (1) ICH aetiology, (2) the haematoma, (3) inflammation, and (4) post-ICH pathology. It is important to recognize that beyond neurons and the brain, other cell types and organs are crucially involved in ICH pathophysiology and successful interventions likely will need to address the entire organism. This review will spur the development of successful therapeutic interventions for ICH and advanced animal models that better reflect its aetiology and pathophysiology.

Lymphocyte-Related Immunomodulatory Therapy with Siponimod (BAF-312) Improves Outcomes in Mice with Acute Intracerebral Hemorrhage

Modulators of the sphingosine-1-phosphate receptor (S1PR) have been proposed as a promising strategy for treating stroke. However, the detailed mechanisms and the potential translational value of S1PR modulators for intracerebral hemorrhage (ICH) therapy warrant exploration. Using collagenase VII-S-induced ICH in the left striatum of mice, we investigated the effects of siponimod on cellular and molecular immunoinflammatory responses in the hemorrhagic brain in the presence or absence of anti-CD3 monoclonal antibodies (Abs). We also assessed the severity of short- and long-term brain injury and evaluated the efficacy of siponimod in long-term neurologic function. Siponimod treatment significantly decreased brain lesion volume and brain water content on day 3 and the volume of the residual lesion and brain atrophy on day 28. It also inhibited neuronal degeneration on day 3 and improved long-term neurologic function. These protective effects may be associated with a reduction in the expression of lymphotactin (XCL1) and T-helper 1 (Th1)-type cytokines (interleukin 1β and interferon-γ). It may also be associated with inhibition of neutrophil and lymphocyte infiltration and alleviation of T lymphocyte activation in perihematomal tissues on day 3. However, siponimod did not affect the infiltration of natural killer cells (NK) or the activation of CD3-negative immunocytes in perihematomal tissues. Furthermore, it did not influence the activation or proliferation of microglia or astrocytes around the hematoma on day 3. Siponimod appears to have a profound impact on infiltration and activation of T lymphocytes after ICH. The effects of neutralized anti-CD3 Abs-induced T-lymphocyte tolerance on siponimod immunomodulation further confirmed that siponimod alleviated the cellular and molecular Th1 response in the hemorrhagic brain. This study provides preclinical evidence that encourages future investigation of immunomodulators, including siponimod, which target the lymphocyte-related immunoinflammatory reaction in ICH therapy.

Spontaneous intracerebral hemorrhage among hypertensive patients in Saudi Arabia: Study from a tertiary center

Background:

Objectives:

Patients and Methods:

Results:

Conclusion:

A Protective Role of Tumor Necrosis Factor Superfamily-15 in Intracerebral Hemorrhage-Induced Secondary Brain Injury

Destabilization of blood vessels by the activities of vascular endothelial growth factor (VEGF) and matrix metalloproteinases (MMPs) following intracerebral hemorrhage (ICH) has been considered the main causes of aggravated secondary brain injury. Here, we show that tumor necrosis factor superfamily-15 (TNFSF15; also known as vascular endothelial growth inhibitor), an inhibitor of VEGF-induced vascular hyper-permeability, when overexpressed in transgenic mice, exhibits a neuroprotective function post-ICH. In this study, we set-up a collagenase-induced ICH model with TNFSF15-transgenic mice and their transgene-negative littermates. We observed less lesion volume and neural function perturbations, together with less severe secondary injuries in the acute phase that are associated with brain edema and inflammation, including vascular permeability, oxidative stress, microglia/macrophage activation and neutrophil infiltration, and neuron degeneration, in the TNFSF15 group compared with the littermate group. Additionally, we show that there is an inhibition of VEGF-induced elevation of MMP-9 in the perihematomal blood vessels of the TNFSF15 mice following ICH, concomitant with enhanced pericyte coverage of the perihematomal blood vessels. These findings are consistent with the view that TNFSF15 may have a potential as a therapeutic agent for the treatment of secondary injuries in the early phase of ICH.

Association Between Alkaline Phosphatase and Clinical Outcomes in Patients With Spontaneous Intracerebral Hemorrhage

Background: Spontaneous intracerebral hemorrhage (ICH) is associated with high rates of mortality and morbidity. Alkaline phosphatase (ALP) is related to increased risk of cardiovascular events and is also closely associated with adverse outcomes after ischemic or hemorrhagic stroke. However, there are limited data about the effect of ALP on clinical outcomes after ICH. Therefore, we aimed to investigate the relationship between serum ALP level and prognosis in ICH patients. Methods: From January 2014 to September 2016, 939 patients with spontaneous ICH were enrolled in our study from 13 hospitals in Beijing. Patients were categorized into four groups based on the ALP quartiles (Q1, Q2, Q3, Q4). The main outcomes were 30-day, 90-day, and 1-year poor functional outcomes (modified Rankin Scale score of 3-6). Multivariable logistic regression and interaction analyses were performed to evaluate the relationships between ALP and clinical outcomes after ICH. Results: In the logistic regression analysis, compared with the third quartile of ALP, the adjusted odds ratios of the Q1, Q2, and Q4 for 30-day poor functional outcome were 1.31 (0.80-2.15), 1.16 (0.71-1.89), and 2.16 (1.32-3.55). In terms of 90-day and 1-year poor functional outcomes, the risks were significantly higher in the highest quartile of ALP compared with the third quartile after adjusting the confounding factors [90-day: highest quartile OR = 1.86 (1.12-3.10); 1-year: highest quartile OR = 2.26 (1.34-3.80)]. Moreover, there was no significant interaction between ALP and variables like age or sex. Conclusions: High ALP level (>94.8 U/L) was independently associated with 30-day, 90-day, and 1-year poor functional outcomes in ICH patients. Serum ALP might serve as a predictor for poor functional outcomes after ICH onset.

Incidence and Outcomes of Hemorrhagic Stroke among Adults in Spain (2016-2018) According to Sex: A Retrospective, Cohort, Observational, Propensity Score Matched Study

(1) Background: We aim to analyze sex differences in the incidence, clinical characteristics and in-hospital outcomes of hemorrhagic stroke (HS) in Spain (2016–2018) using the National Hospital Discharge Database. (2) Methods: Retrospective, cohort, observational study. We estimated the incidence of HS in men and women. We analyzed comorbidity, treatments, procedures, and hospital outcomes. We matched each woman with a man by age, type of HS and medical conditions using propensity score matching. (3) Results: HS was coded in 57,227 patients aged ≥18 years (44.3% women). Overall, men showed higher incidence rates (57.3/10⁵ vs. 43.0/10⁵; p < 0.001; IRR = 1.60; 95% CI: 1.38–1.83). Women suffered more subarachnoid hemorrhages (25.2% vs. 14.6%), whereas men more often had intracerebral hemorrhages (55.7% vs. 54.1%). In-hospital mortality (IHM) was higher for intracerebral hemorrhage in both men and women. Women underwent decompressive craniectomy less often than men (5.0% vs. 6.2%; p < 0.001). After matching, IHM among women was higher (29.0% vs. 23.7%; p < 0.001). Increments in age, comorbidity and use of anticoagulants and antiplatelet agents prior to hospitalization were associated were higher IHM, and decompressive craniectomy was associated with lower IHM in both sexes. After multivariable adjustment, women had higher IHM (OR = 1.23; 95% CI: 1.18–1.28). (4) Conclusion: Men had higher incidence rates of HS than women. Women less often underwent decompressive craniectomy. IHM was higher among women admitted for HS than among men.

Gender differences in long-term mortality after spontaneous intracerebral hemorrhage in southern Portugal

Introduction:

the prognosis of spontaneous intracerebral hemorrhage (SICH) remains poor. Understanding gender differences can clarify the clinico-epidemiological and process of care related factors that influence SICH prognosis. We analyzed the long-term gender differences of mortality after SICH in Algarve, southern Portugal.

Patients and Methods:

analysis of consecutive community representative of SICH survivors (2009–2015). Logistic regression analysis and Kaplan–Meier method was used to assess gender differences on 1-year mortality and survival. We further analyzed if differences exist between 4 age and gender based subgroups (women <75 years, women ≥75 years, men <75 years, men ≥75 years).

Results:

a total of 285 survivors were analyzed; majority men (66.3%). Women were 2 years older on average. Overall case fatality was 11.6% [CI: 8.3–15.8]. A non-statistically significant (P = .094) higher case-fatality rate was observed in women; men were more frequently admitted to stroke unit; women had more often poor functional outcome or modified Rankin scale (mRS) ≥3. Predictors of death were: being women with ≥ 75 years, in-hospital pneumonia and hospital discharge mRS ≥3. The likelihood of death was higher in women ≥75 years (OR = 2.91 [1.23–8.1], P = .035) in comparison to women <75 years and men ≥75 years. Women <75 years had the longest survivor time, whereas women ≥75 years the shortest survivor time (P < .001).

Conclusion:

gender and age interact to influence long-term mortality after SICH. Women ≥75 years are at increased risk of death and have reduced survival after SICH in southern Portugal. Further studies are needed to clarify the biological or social factors contributing for the poor prognosis in the very old women in the region.

A Comprehensive Review of Risk Factor, Mechanism, and Management of Left Ventricular Assist Device-Associated Stroke

The use of left ventricular assist devices (LVADs) has been increasing in the last decade, along with the number of patients with advanced heart failure refractory to medical therapy. Ischemic stroke and intracranial hemorrhage remain the leading causes of morbidity and mortality in LVAD patients. Despite the common occurrence and the significant outcome impact, underlying mechanisms and management strategies of stroke in LVAD patients are controversial. In this article, we review our current knowledge on pathophysiology and risk factors of LVAD-associated stroke, outline the diagnostic approach, and discuss treatment strategies.

Why Are Women Less Represented in Intracerebral Hemorrhage Trials?

BACKGROUND AND PURPOSE

Fewer women than men tend to be enrolled in clinical trials of intracerebral hemorrhage. It is unclear whether this reflects lower prevalence of intracerebral hemorrhage in women, selection bias, or poor recruitment efforts. We undertook this study to examine differences between men and women in the reasons for exclusion from the iDEF trial (Intracerebral Hemorrhage Deferoxamine).

METHODS

The screen failure log included 29 different reasons for exclusion. Chi-square statistics were used to evaluate the differences in reasons for exclusion between men and women.

RESULTS

A total of 38.2% of participants in iDEF were women. Three thousand nine hundred eighty-two women (45.7%) and 4736 men (54.3%) were screen failures (P<0.0001). Similar proportions of women (1.28%) and men (1.73%) were excluded due to inability to obtain consent (P=0.1). Patients or families declined participation in 1.26% of women versus 1.31% of men (P=0.9). More women than men failed screening because of age>80 (22.40% versus 12.61%; adjusted P=0.0007) and preexisting do-not-resuscitate/do-not-intubate (3.69% versus 2.83%; adjusted P=0.067).

CONCLUSIONS

Lower rates of women enrollment in the iDEF trial may be attributed to older age. Inability to obtain consent or declining participation was similar between women and men, arguing against selection bias. Our findings should be confirmed in other intracerebral hemorrhage trials to determine best strategies to improve women's representation in future trials.

Acute Treatment With Fingolimod Does Not Confer Long-Term Benefit in a Mouse Model of Intracerebral Haemorrhage

Intracerebral haemorrhage (ICH) has no specific treatment, but accounts for up to 15% of all strokes and has the highest mortality. Fingolimod (FTY720) is an immunomodulator approved for the management of multiple sclerosis, with abundant evidence of efficacy in experimental ischemic stroke, and more limited evidence in experimental ICH. The goal of this study was to confirm the efficacy of fingolimod in experimental ICH using rigorous and statistically well-powered studies. ICH was induced in C57BL/6JOlaHsd male and female mice by intrastriatal bacterial collagenase injection. Fingolimod (0.5 mg/kg) or saline was administered intraperitoneally after 0.5, 24 and 72 h, in a randomized and blinded manner. Functional improvement with cylinder, wire hanging, and foot fault tests was evaluated one and two weeks later. Lesion volume and hemispheric atrophy were quantified at the 14-day endpoint. There was a higher mortality in saline-treated females compared to fingolimod-treated females and saline-treated males. There was no treatment- or gender-related difference in the behavioural tests. Histological outcome measures did not differ between any of the groups. These results, contrasting with those of previous studies of fingolimod in experimental ICH, emphasize the importance of rigorous testing of this agent in models more representative of the clinical situation.

Translational Intracerebral Hemorrhage Research: Has Current Neuroprotection Research ARRIVEd at a Standard for Experimental Design and Reporting?

One major aim of preclinical intracerebral hemorrhage (ICH) research is to develop and test potential neuroprotectants. Published guidelines for experimental design and reporting stress the importance of clearly and completely reporting results and methodological details to ensure reproducibility and maximize information availability. The current review has two objectives: first, to characterize current ICH neuroprotection research and, second, to analyze aspects of translational design in preclinical ICH studies. Translational design is the adoption and reporting of experimental design characteristics that are thought to be clinically relevant and critical to reproducibility in animal studies (e.g., conducting and reporting experiments according to the STAIR and ARRIVE guidelines, respectively). Given that ICH has no current neuroprotective treatments and an ongoing reproducibility crisis in preclinical research, translational design should be considered by investigators. We conducted a systematic review of ICH research from 2015 to 2019 using the PubMed database. Our search returned 281 published manuscripts studying putative neuroprotectants in animal models. Contemporary ICH research predominantly uses young, healthy male rodents. The collagenase model is the most commonly used. Reporting of group sizes, blinding, and randomization are almost unanimous, but group size calculations, mortality and exclusion criteria, and animal model characteristics are infrequently reported. Overall, current ICH neuroprotection research somewhat aligns with experimental design and reporting guidelines. However, there are areas for improvement. Because failure to consider translational design is associated with inflation of effect sizes (and possibly hindered reproducibility), we suggest that researchers, editors, and publishers collaboratively consider enhanced adherence to published guidelines.

Sex differences in treatment, radiological features and outcome after intracerebral haemorrhage: Pooled analysis of Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials 1 and 2

Introduction

Reports vary on how sex influences the management and outcome from acute intracerebral haemorrhage. We aimed to quantify sex disparities in clinical characteristics, management, including response to blood pressure lowering treatment, and outcomes in patients with acute intracerebral haemorrhage, through interrogation of two large clinical trial databases.

Patients and Methods

Post-hoc pooled analysis of the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials 1 and 2, where patients with a hypertensive response (systolic, 150-220 mmHg) after spontaneous intracerebral haemorrhage (<6 h) were randomised to intensive (target <140 mmHg <1 h) or guideline-recommended (<180 mmHg) blood pressure lowering treatment. The interaction of sex on early haematoma growth (24 h), death or major disability (modified Rankin scale scores 3-6 at 90 days), and effect of randomised treatment were determined in multivariable logistic regression models adjusted for baseline confounding variables.

Results

In 3233 participants, 1191 (37%) were women who were significantly older, had higher baseline National Institutes of Health Stroke Scale scores and smaller haematoma volumes compared to men. Men had higher three-month mortality (odds ratio 1.48, 95% confidence interval 1.10-2.00); however, there was no difference between women and men in the combined endpoint of death or major disability. There were no significant sex differences on mean haematoma growth or effect of randomised blood pressure lowering treatment.

Discussion

Men included in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials had more comorbidities, larger baseline haematoma volumes and higher mortality after adjustment for age, as compared with women.

Conclusion

Men included in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials had a greater odds of dying after intracerebral haemorrhage than women, which could not be readily explained by differing casemix or patterns of blood pressure management.

Clinical trial registration

The Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials studies are registered with ClinicalTrials.gov (NCT00226096 and NCT00716079).

Decompressive Craniectomy in Spontaneous Intracerebral Hemorrhage: A Comparison with Standard Craniotomy Using Propensity-Matched Analysis

BACKGROUND

Spontaneous intracerebral hemorrhage carries a poor prognosis with a 30-day mortality rate of 35%-52%. There is no standardized surgical technique for treatment of spontaneous intracerebral hemorrhage. While minimally invasive techniques are popular, there has been renewed interest in decompressive craniectomy (DC). We compared surgical and functional outcomes of standard craniotomy and DC, both with hematoma evacuation, in the surgical treatment of supratentorial spontaneous intracerebral hemorrhage.

METHODS

This 4-year retrospective study compared outcomes of 2 surgical techniques: standard craniotomy in group A (n = 78) and DC in group B (n = 54). To minimize bias in case selection, propensity matching was performed to match preoperative Glasgow Coma Scale score and hematoma volume (group C).

RESULTS

Hematoma evacuation was performed in 132 patients. Mean age of patients was 53.3 years, 50.5 years, and 52.06 years in groups A, B, and C, respectively. Median preoperative Glasgow Coma Scale score was 9, 7, and 8 (P = 0.01; P = 0.45), and mean hematoma volume was 46.21 mL, 50.91 mL, and 49.90 mL. Overall mortality was 26.5%; 62.9% (n = 22) of deaths were in group A, and 37.1% (n = 13) were in group B (P = 0.69). Median modified Rankin Scale score was similar in both groups, both at discharge and at 3 months. After determining propensity scores, mortality and outcomes of matched groups remained similar.

CONCLUSIONS

DC with hematoma evacuation does not appear to provide a significant advantage over standard craniotomy with regard to functional outcomes and mortality. DC may overcome the need for subsequent surgery in accommodating postoperative mass effect in residual bleeds and rebleeds but is associated with greater blood loss and longer operative duration.

Potential therapeutic targets for intracerebral hemorrhage-associated inflammation: An update

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and disability but no specific or effective treatment. In the last two decades, much has been learned about the pathologic mechanisms of ICH. It is now known that after ICH onset, immune and inflammatory responses contribute to blood-brain barrier disruption, edema development, and cell death processes, jointly resulting in secondary brain injury. However, the translation of potential therapies from preclinical to clinical success has been disappointing. With the development of new laboratory technology, recent progress has been made in the understanding of ICH pathomechanisms, and promising therapeutic targets have been identified. This review provides an update of recent progress on ICH and describes the prospects for further preclinical studies in this field. Our goal is to discuss new therapeutic targets and directions for the treatment of ICH and promote the effective transformation from preclinical to clinical trials.

Index Admission Characteristics and All-Cause Readmissions Analysis in Younger and Older Adults with Intracerebral Hemorrhage

INTRODUCTION

Intracerebral hemorrhage (ICH) comprises 15-20% of all strokes with debilitating consequences. Data regarding characteristics and outcomes of primary ICH in the young are lacking, given its rarity, making comparisons between younger and older cohorts difficult to perform. Nationally representative administrative databases enable analysis of such rare events.

OBJECTIVE

To determine the baseline characteristics, all-cause readmission rates, and reasons for primary ICH in younger and older adults using a nationally representative database.

METHODS

A retrospective cohort analysis was performed using the Nationwide Readmissions Database 2013. Validated ICD-9-CM codes identified index ICH admissions, comorbidities, demographics, behavioral risk factors, procedures, and Elixhauser and Charlson Comorbidity indices. We compared "younger" (age ≤ 45 years) and "older" (age > 45) index ICH admissions by weighted 30-day all-cause readmission rates, primary diagnosis code for 30-day readmissions, most common comorbidities during the index hospitalization, and Kaplan-Meier cumulative risk of readmission up to 1 year.

RESULTS

Older admissions had higher comorbidity scores and mortality, but both groups had similar total comorbidities. Younger admissions exhibited longer length of stay with more procedures performed. Vascular anomalies (aneurysm 7.2 vs. 4.6% and arteriovenous malformation 5.9 vs. 0.8%) and behavioral risk factors (smoking 26.5 vs. 23.0%, alcohol abuse 6.7 vs. 4.6%, and substance use 13.5 vs. 2.9%) were more prevalent in younger admissions, while older patients had more cardiovascular comorbidities. All-cause 30-day readmission rates (13.1 vs. 13.0%) and 1-year cumulative risk of readmission (log-rank p value 0.7209) were similar. Readmissions in the younger cohort were primarily for neurological conditions, and those in the older cohort were for systemic conditions.

CONCLUSIONS

Adults <45 years with ICH had similar total comorbidities as older adults but more procedures, longer hospital stay, and more behavioral risk factors. Readmission rates were similar though reasons differed; younger patients were more for neurological reasons than for other systemic causes.

Nationwide patterns of hemorrhagic stroke among patients hospitalized with brain metastases: influence of primary cancer diagnosis and anticoagulation

Brain metastases can contribute to a decreased quality of life for patients with cancer, often leading to malaise, neurologic dysfunction, or death. Intracerebral hemorrhage (ICH) is an especially feared complication in patients with brain metastases given the potential for significant morbidity and mortality. We aim to characterize patients with cancer and brain metastases admitted to hospitals nationwide and identify factors associated with ICH. The 2016 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) was queried for all patients with cancer hospitalized with a diagnosis of brain metastases. Admissions with a primary or secondary diagnosis of ICH were further identified. Baseline differences in demographic, clinical, socioeconomic, and hospital-related characteristics between patients with and without ICH were assessed by chi-square, Mann–Whitney U, and ANOVA testing. Multivariable logistic regression was used to identify factors associated with ICH. Weighted frequencies were used to create national estimates for all data analysis. In 2016, a total 145,225 hospitalizations were associated with brain metastases, of which 4,145 (2.85%) had a concurrent diagnosis of ICH. Patients with ICH were more likely to have a longer length of stay (median 5 days vs 4 days, p < 0.001) and a higher cost of stay (median $14,241.14 vs $10,472.54, p  < 0.001). ICH was found to be positively associated with having a diagnosis of melanoma (odds ratio [OR] 5.01; 95% Confidence Interval [CI] 3.50–7.61) and kidney cancer (OR 2.50; 95% CI 1.69–3.72). Patients on long-term anticoagulation had a higher risk of ICH (OR 1.49; CI 1.15–1.91). Approximately 3% of patients hospitalized with brain metastases also had a diagnosis of ICH, which was significantly associated with longer length of stay and cost. Patients with melanoma, kidney cancer, and on long-term anticoagulation had a higher risk of ICH. Physicians should consider the risks of anticoagulation carefully for patients with brain metastases, especially those with melanoma and kidney cancer.

Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period

IMPORTANCE

Intracerebral hemorrhage (ICH) during pregnancy and the postpartum period results in catastrophic maternal outcomes. There is a paucity of population-based estimates of pregnancy-related ICH risk, including risk during the extended postpartum period.

OBJECTIVE

To evaluate ICH risk during pregnancy and an extended 24-week postpartum period in a population-level cohort and to determine fetal and maternal outcomes as well as demographic and comorbidity factors associated with ICH during pregnancy and post partum.

DESIGN, SETTING, AND PARTICIPANTS

This study used a cohort-crossover design in which patients serve as their own controls when no longer exposed (pregnant or post partum). Administrative data were obtained from all hospital admissions for New York, California, and Florida for a 7- to 10-year period. Participants included all women admitted for labor and delivery who were older than 12 years and did not have a prior diagnosis of ICH. Conditional Poisson regression models were used to evaluate ICH risk, and data were reported as rate ratios and 95% CIs. Data analysis was performed from August 2018 to February 2020.

EXPOSURES

Women were tracked using hospitalization records for the duration of pregnancy (40 weeks), for 24 weeks post partum, and for an additional 64 weeks when no longer exposed.

MAIN OUTCOMES AND MEASURES

Diagnosis of ICH during both 64-week observation periods was determined using validated International Classification of Diseases, Ninth Revision codes.

RESULTS

A total of 3 314 945 pregnant women were included (mean [SD] age, 28.17 [6.47] years; 1 451 780 white [43.79%], 474 808 black [14.32%], 246 789 Asian [7.44%], and 835 917 Hispanic [25.22%]). The risk of ICH was significantly higher during the third trimester (2.9 vs 0.7 cases per 100 000 pregnancies; rate ratio, 4.16; 95% CI, 2.52-6.86) and remained elevated during the first 12 weeks post partum (4.4 vs 0.5 cases per 100 000 pregnancies; rate ratio, 9.15; 95% CI, 5.16-16.23). Advanced maternal age (adjusted odds ratio [OR], 1.08; 95% CI, 1.05-1.10), nonwhite race (adjusted ORs, 2.44 [95% CI, 1.73-3.44] for black patients, 2.12 [95% CI, 1.34-3.35] for Asian patients, and 1.59 [95% CI, 1.12-2.26] for Hispanic patients), hypertension (adjusted OR, 2.02; 95% CI, 1.19-3.42), coagulopathy (adjusted OR, 14.17; 95% CI, 9.17-21.89), preeclampsia or eclampsia (adjusted OR, 9.23; 95% CI, 6.99-12.19), and tobacco use (adjusted OR, 2.83; 95% CI, 1.53-5.23) were independently associated with ICH during pregnancy and the postpartum period. Pregnancy-related ICH was associated with a higher risk of maternal (relative risk difference, 792.6; absolute risk difference, 0.18) and fetal (relative risk difference, 5.3; absolute risk difference, 0.03) death, compared with pregnancies without ICH.

CONCLUSIONS AND RELEVANCE

These findings suggest that the risk of ICH is significantly higher during the third trimester of pregnancy and the first 12 weeks post partum. There are age and race disparities in ICH risk that are associated with devastating maternal and fetal outcomes. These data illustrate the critical need for continuous monitoring and aggressive management of ICH-associated risk factors. These findings suggest that extended postpartum monitoring of high-risk women may be warranted.

Spleen associated immune-response mediates brain-heart interaction after intracerebral hemorrhage

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) patients frequently encounter cardiovascular complications which may contribute to increased mortality and poor long term outcome. ICH induces systemic oxidative stress and activates peripheral immune responses which are involved in the pathological cascade leading to cardiac dysfunction and heart failure after ICH. We have previously reported that ICH induces progressive cardiac dysfunction in mice without primary cardiac diseases. In this study, we have investigated the role of immune response in mediating cardiac dysfunction post ICH in mice.

METHODS

Adult male C57BL/6 J mice were randomly assigned to the following groups (n = 8/group): 1) sham control; 2) ICH; 3) splenectomy with ICH (ICH + Spx); 4) splenectomy alone (Spx). Echocardiography was performed at 7 and 28 days after ICH. A battery of neurological and cognitive tests were performed. Flow cytometry, western blot and immunostaining were used to test mechanisms of ICH induced cardiac dysfunction.

RESULTS

Compared to sham control mice, Spx alone does not induce acute (7 day) or chronic (28 day) cardiac dysfunction. ICH induces significant neurological and cognitive deficits, as well as acute and chronic cardiac dysfunction compared to sham control mice. Mice subjected to ICH + Spx exhibit significantly improved neurological and cognitive function compared to ICH mice. Mice with ICH + Spx also exhibit significantly improved acute and chronic cardiac function compared to ICH mice indicated by increased left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS), decreased cardiac fibrosis, decreased cardiomyocyte hypertrophy, decreased cardiac infiltration of immune cells and decreased expression of inflammatory factor and oxidative stress in the heart.

CONCLUSIONS

Our study demonstrates that splenectomy attenuates ICH-induced neurological and cognitive impairment as well as ICH-induced cardiac dysfunction in mice. Inflammatory cell infiltration into heart and immune responses mediated by the spleen may contribute to ICH-induce acute and chronic cardiac dysfunction and pathological cardiac remodeling.

Gender Differences in Outcomes after Non-traumatic Intracerebral Hemorrhage

Background

Nontraumatic intracranial hemorrhages (ICH) are serious cerebrovascular events with high morbidity and mortality. They occur in about two million people a year worldwide. While ICH continues to be a focus of research in the medical community, there is little data on the differences in outcomes by gender. We aimed to further investigate these differences in our study.

Methods

This analysis involves a de-identified dataset of all adult patients who presented to one of our hospital system's emergency departments with ICHs as one of the top three discharge diagnoses. This study was considered exempt by our medical school's Institutional Review Board (IRB). Our hospital system comprises over 176 hospitals in the United States with over 8.6 million emergency department visits annually. Logistic regression analyses were performed using JMP 14.1. Outcome variables included the length of stay, mortality, and disposition.

Results

The cohort (n = 8069) comprised 68% Caucasians, 17% Blacks, 5% Asians, and 1% Hispanic. Forty-eight percent of patients were females with a median age of 71 years. Fifty-two percent of patients were males with a median age of 65 years. One-fifth of the cohort (20%) died while another fifth (21%) were discharged home. Thirteen percent joined hospice. Women were significantly more likely to die or join hospice (p <0.0001, OR 1.304, 95% CI: 1.183-1.440) even after controlling for age. Women also had a significantly shorter length of stay even when controlled for age (P = 0.0002, 95% CI: -1.58 to -0.489, R² = 1.5%) with a median of four days for men and three days for women.

Conclusion

The median age for women with nontraumatic ICH is older than men, which could explain their increased rates of mortality and discharge to hospice. However, even after controlling for age, women were significantly more likely to die or be discharged to hospice. Conversely, men and younger patients had a longer hospital stay and a higher likelihood of being discharged home.

Men Experience Higher Risk of Pneumonia and Death After Intracerebral Hemorrhage

BACKGROUND

Infectious complications worsen outcome after intracerebral hemorrhage (ICH). We investigated the impact of sex on post-ICH infections and mortality.

METHODS

Consecutive ICH patients (admitted to a single hospital between 1994 and 2015) were retrospectively assessed via chart review to ascertain the following in-hospital infections: urinary tract infection (UTI), pneumonia, and sepsis. Adjusted logistic regression was performed to identify associations between sex, infection, and mortality at 90 days.

RESULTS

Two thousand and four patients were investigated, 1071 (53.7%) males. Men were more likely to develop pneumonia (21.9 vs 15.5% p < 0.001) and sepsis (3.4 vs 1.6%, p = 0.009), whereas women had higher risk of UTI (19.9 vs 11.7% p < 0.001). Multivariate analyses confirmed association between male sex and pneumonia (Odds Ratio (OR) 1.37, 95% confidence interval (CI) 1.08-1.74, p = 0.011). Male sex (OR 1.40; CI 1.07-1.85; p = 0.015) and infection (OR 1.56; CI 1.11-1.85; p = 0.011) were independently associated with higher 90-day mortality.

CONCLUSIONS

Types and rates of infection following ICH differ by sex. Male sex independently increases pneumonia risk, which subsequently increases 90-day mortality. Sex-specific preventive strategies to reduce the risk of these complications may be one strategy to improve ICH outcomes.

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

BACKGROUND

Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events.

METHODS

The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627).

FINDINGS

Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29-146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0- 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25-1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39-1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65-1·60]; p=0·92).

INTERPRETATION

These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention.

FUNDING

British Heart Foundation.