Determinants of Early Versus Delayed Neurological Deterioration in Intracerebral Hemorrhage

Added Value of Frequency of Imaging Markers for Prediction of Outcome After Intracerebral Hemorrhage: A Secondary Analysis of Existing Data

BACKGROUND

Frequency of imaging markers (FIM) has been identified as an independent predictor of hematoma expansion in patients with intracerebral hemorrhage (ICH), but its impact on clinical outcome of ICH is yet to be determined. The aim of the present study was to investigate this association.

METHODS

This study was a secondary analysis of our prior research. The data for this study were derived from six retrospective cohorts of ICH from January 2018 to August 2022. All consecutive study participants were examined within 6 h of stroke onset on neuroimaging. FIM was defined as the ratio of the number of imaging markers on noncontrast head tomography (i.e., hypodensities, blend sign, and island sign) to onset-to-neuroimaging time. The primary poor outcome was defined as a modified Rankin Scale score of 3-6 at 3 months.

RESULTS

A total of 1253 patients with ICH were included for final analysis. Among those with available follow-up results, 713 (56.90%) exhibited a poor neurologic outcome at 3 months. In a univariate analysis, FIM was associated with poor prognosis (odds ratio 4.36; 95% confidence interval 3.31-5.74; p < 0.001). After adjustment for age, Glasgow Coma Scale score, systolic blood pressure, hematoma volume, and intraventricular hemorrhage, FIM was still an independent predictor of worse prognosis (odds ratio 3.26; 95% confidence interval 2.37-4.48; p < 0.001). Based on receiver operating characteristic curve analysis, a cutoff value of 0.28 for FIM was associated with 0.69 sensitivity, 0.66 specificity, 0.73 positive predictive value, 0.62 negative predictive value, and 0.71 area under the curve for the diagnosis of poor outcome.

CONCLUSIONS

The metric of FIM is associated with 3-month poor outcome after ICH. The novel indicator that helps identify patients who are likely within the 6-h time window at risk for worse outcome would be a valuable addition to the clinical management of ICH.

How much of the variance in functional outcome related to intracerebral hemorrhage volume is already apparent in neurological status at admission?

BACKGROUND

Hematoma volume is a major pathophysiological hallmark of acute intracerebral hemorrhage (ICH). We investigated how the variance in functional outcome induced by the ICH volume is explained by neurological deficits at admission using a mediation model.

METHODS

Patients with acute ICH treated in three tertiary stroke centers between January 2010 and April 2019 were retrospectively analyzed. Mediation analysis was performed to investigate the effect of ICH volume (0.8 ml (5% quantile) versus 130.6 ml (95% quantile)) on the risk of unfavorable functional outcome at discharge defined as modified Rankin Score (mRS) ≥ 3 with mediation through National Institutes of Health Stroke Scale (NIHSS) at admission. Multivariable regression was conducted to identify factors related to neurological improvement and deterioration.

RESULTS

Three hundred thirty-eight patients were analyzed. One hundred twenty-one patients (36%) achieved mRS ≤ 3 at discharge. Mediation analysis showed that NIHSS on admission explained 30% [13%; 58%] of the ICH volume-induced variance in functional outcome at smaller ICH volume levels, and 14% [4%; 46%] at larger ICH volume levels. Higher ICH volume at admission and brainstem or intraventricular location of ICH were associated with neurological deterioration, while younger age, normotension, lower ICH volumes, and lobar location of ICH were predictors for neurological improvement.

CONCLUSION

NIHSS at admission reflects 14% of the functional outcome at discharge for larger hematoma volumes and 30% for smaller hematoma volumes. These results underscore the importance of effects not reflected in NIHSS admission for the outcome of ICH patients such as secondary brain injury and early rehabilitation.

Predictors of Early versus Delayed Neurological Deterioration after Thrombolysis for Ischemic Stroke

INTRODUCTION

We aimed to determine predictors of early (END) and delayed neurological deterioration (DND) and their association with the functional outcome in patients with acute ischemic stroke (AIS) who participated in the international Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED).

METHODS

END and DND (without END) were defined as scores of a ≥2-point increase on the National Institutes of Health Stroke Scale (NIHSS) or a ≥1-point decrease on the Glasgow coma scale or death, from baseline to 24 h and 24-72 h, respectively. Multivariable logistic regression models were used to determine independent predictors of END and DND and their association with 90-day outcomes (dichotomous scores on the modified Rankin scale [mRS] of 2-6 vs. 0-1 and 3-6 vs. 0-2 and death).

RESULTS

Of 4,496 patients, 871 (19.4%) and 302 (8.4%) patients experienced END and DND, respectively. Higher baseline NIHSS score, older age, large-artery occlusion due to significant atheroma, cardioembolic stroke subtype, hemorrhagic infarction and parenchymatous hematoma within 24 h were all independent predictors for both END (all p ≤ 0.01) and DND (all p ≤ 0.024). Moreover, higher baseline systolic blood pressure (BP) (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.02-1.12), higher diastolic BP variability within 24 h (OR 1.07, 95% CI 1.04-1.09), patients from Asia (OR 1.25, 95% CI 1.03-1.52) were the only independent predictors for END. However, Asian ethnicity was negatively associated with DND (OR 0.64, 95% CI 0.47-0.86). Hemorrhagic infarction and parenchymatous hematoma within 24 h were the key predictors of END across all stroke subtypes. END and DND were all associated with a poor functional outcome at 90 days (all p < 0.001).

CONCLUSION

We identified overlapping and unique demographic and clinical predictors of END and DND after thrombolysis for AIS. Both END and DND predict unfavorable outcomes at 90 days.

Predicting hematoma expansion in acute spontaneous intracerebral hemorrhage: integrating clinical factors with a multitask deep learning model for non-contrast head CT

PURPOSE

To predict hematoma growth in intracerebral hemorrhage patients by combining clinical findings with non-contrast CT imaging features analyzed through deep learning.

METHODS

Three models were developed to predict hematoma expansion (HE) in 572 patients. We utilized multi-task learning for both hematoma segmentation and prediction of expansion: the Image-to-HE model processed hematoma slices, extracting features and computing a normalized DL score for HE prediction. The Clinical-to-HE model utilized multivariate logistic regression on clinical variables. The Integrated-to-HE model combined image-derived and clinical data. Significant clinical variables were selected using forward selection in logistic regression. The two models incorporating clinical variables were statistically validated.

RESULTS

For hematoma detection, the diagnostic performance of the developed multi-task model was excellent (AUC, 0.99). For expansion prediction, three models were evaluated for predicting HE. The Image-to-HE model achieved an accuracy of 67.3%, sensitivity of 81.0%, specificity of 64.0%, and an AUC of 0.76. The Clinical-to-HE model registered an accuracy of 74.8%, sensitivity of 81.0%, specificity of 73.3%, and an AUC of 0.81. The Integrated-to-HE model, merging both image and clinical data, excelled with an accuracy of 81.3%, sensitivity of 76.2%, specificity of 82.6%, and an AUC of 0.83. The Integrated-to-HE model, aligning closest to the diagonal line and indicating the highest level of calibration, showcases superior performance in predicting HE outcomes among the three models.

CONCLUSION

The integration of clinical findings with non-contrast CT imaging features analyzed through deep learning showed the potential for improving the prediction of HE in acute spontaneous intracerebral hemorrhage patients.

A Prospective Cohort Study of Elevated Serum NLRP1 Levels to Prognosticate Neurological Outcome After Acute Intracerebral Hemorrhage at a Single Academic Institution

Background

Nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 1 (NLRP1) participates in neuroinflammation. This study aimed to identify serum NLRP as a potential prognostic biomarker of acute intracerebral hemorrhage (ICH).

Methods

This prospective cohort study enrolled 145 patients with supratentorial ICH and 51 healthy controls. Serum NLRP1 levels were quantified on admission of all 145 patients, on days 1, 3, 5, 7, and 10 after stroke in 51 of 145 patients and at entry into the study of controls. Poststroke 6-month modified Rankin Scale (mRS) scores of 3-6 signified a poor prognosis.

Results

Compared to controls, patients had prominently increased serum NLRP1 levels until day 10 after ICH, with the highest levels at days 1 and 3. Serum NLRP1 levels were independently correlated with National Institutes of Health Stroke Scale (NIHSS) scores, hematoma volume and six-month mRS scores, and independently predicted six-month bad prognosis. A linear relationship was observed between serum NLRP1 levels and the risk of poor prognosis in a restricted cubic spline. Under the receiver operating characteristic (ROC) curve, serum NLRP levels efficiently discriminated poor prognosis. Serum NLRP1, NIHSS, and hematoma volume were merged into a prognosis prediction model, which was portrayed using a nomogram. Good performance of the model was verified using calibration curve, decision curve, and ROC curve.

Conclusion

Serum NLRP1 levels are elevated during the early period following ICH and are independently related to hemorrhagic severity and poor prognosis, suggesting that serum NLRP1 may represent a promising prognostic biomarker of ICH.

Predicting ICU readmission risks in intracerebral hemorrhage patients: Insights from machine learning models using MIMIC databases

BACKGROUND

Intracerebral hemorrhage (ICH) is a stroke subtype characterized by high mortality and complex post-event complications. Research has extensively covered the acute phase of ICH; however, ICU readmission determinants remain less explored. Utilizing the MIMIC-III and MIMIC-IV databases, this investigation develops machine learning (ML) models to anticipate ICU readmissions in ICH patients.

METHODS

Retrospective data from 2242 ICH patients were evaluated using ICD-9 codes. Recursive feature elimination with cross-validation (RFECV) discerned significant predictors of ICU readmissions. Four ML models-AdaBoost, RandomForest, LightGBM, and XGBoost-underwent development and rigorous validation. SHapley Additive exPlanations (SHAP) elucidated the effect of distinct features on model outcomes.

RESULTS

ICU readmission rates were 9.6% for MIMIC-III and 10.6% for MIMIC-IV. The LightGBM model, with an AUC of 0.736 (95% CI: 0.668-0.801), surpassed other models in validation datasets. SHAP analysis revealed hydrocephalus, sex, neutrophils, Glasgow Coma Scale (GCS), specific oxygen saturation (SpO2) levels, and creatinine as significant predictors of readmission.

CONCLUSION

The LightGBM model demonstrates considerable potential in predicting ICU readmissions for ICH patients, highlighting the importance of certain clinical predictors. This research contributes to optimizing patient care and ICU resource management. Further prospective studies are warranted to corroborate and enhance these predictive insights for clinical utilization.

Serum Secreted Protein Acidic and Rich in Cysteine-Like 1 as a Biochemical Predictor for Prognosticating Clinical Outcomes After Acute Supratentorial Intracerebral Hemorrhage: A Prospective Cohort Study

Background

Secreted protein acidic and rich in cysteine-like 1 (SPARCL1) regulates synaptic stability and is up-regulated during axonal regeneration. Here, serum SPARCL1 was determined for estimating severity and prognosticating early neurological deterioration (END) and functional outcomes of acute intracerebral hemorrhage (ICH).

Methods

In this prospective observational cohort study of 156 patients with supratentorial ICH, blood samples of 53 were acquired not only at admission but also ad days 1, 3, 5, 7 and 10. Another group of 53 healthy controls were recruited. The modified Rankin Scale (mRS) scores of 3-6 at poststroke six months were regarded as poor prognosis.

Results

As opposed to controls, serum SPARCL1 levels were markedly elevated during the early ten days after ICH, with the highest levels at days 1 and 3. Admission serum SPARCL1 levels were independently correlated with National Institutes of Health Stroke Scale scores and hematoma volume, were significantly increased in the order of six-month mRS scores from 0 to 6 and were independently correlated with six-month mRS scores. Serum SPARCL1 levels were linearly related to risks of poor six-month prognosis and END under restricted cubic spline, had significant efficiency under receiver operating characteristic (ROC) curve and were independently associated with END and poor prognosis. Subgroup analysis confirmed that no interactions existed for associations of serum SPARCL1 levels with other variables, such as age, gender and some specific vascular risk factors. END and poor prognosis prediction models integrating serum SPARCL1 were displayed using the two nomograms. The poor prognosis prediction model, but END prediction model not, performed well under calibration curve, decision curve and ROC curve.

Conclusion

A substantial elevation of serum SPARCL1 levels during the early period after ICH is independently related to illness severity and poor neurological outcomes, thus signifying that serum SPARCL1 may appear as a prognostic biomarker of ICH.

Ultraearly Intraventricular Hemorrhage Growth Predicts Early Neurologic Deterioration and Poor Functional Outcome After Acute Intracerebral Hemorrhage

Background The presence of intraventricular hemorrhage (IVH) was extensively investigated and was associated with poor outcome in patients with intracerebral hemorrhage (ICH). However, the effect of the speed of ventricular bleeding on outcomes is unknown. Methods and Results We prospectively included patients with ICH who had baseline computed tomography scans within 6 hours after ictus between January 2016 and October 2021. The clinical characteristics were compared between patients with and without early neurologic deterioration (END). Ultraearly IVH growth (uIVHG) was defined as baseline IVH volume by onset-to-imaging time. The association between uIVHG and outcomes was assessed by using multivariable logistic regression analysis. We established the ultraearly IVH growth (uIVH) score and compared the areas under the receiver operating characteristic curves of the existing scores for predicting END. A total of 299 patients were finally enrolled. Of those, 38 patients (12.7%) experienced END at 24 hours and 89 patients (29.8%) had poor outcomes at 90 days. After adjustment for confounding factors, uIVHG (odds ratio, 1.061 [95% CI, 1.011-1.113]; P=0.016) was independently associated with END in multivariable analysis. A prediction score was developed on the basis of the logistic model. The uIVH score was developed as a sum of individual points (0-6) based on age, hematoma volume, National Institutes of Health Stroke Scale, hematoma expansion, and uIVHG ≥2.5 mL/h. In comparison with the ICH score and modified Emergency Department ICH Scale, the uIVH score exhibited best performance in the prediction of END. Conclusions uIVHG is associated with early neurologic deterioration and poor functional outcome in patients with ICH.

A Prospective Cohort Study of Inter-Alpha-Trypsin Inhibitor Heavy Chain 4 as a Serologic Marker in Relation to Severity and Functional Outcome of Acute Intracerebral Hemorrhage

Background

The inter-alpha-trypsin inhibitor heavy chain 4 (ITIH4) may regulate immunity and inflammation. The current study was conducted to determine its role as a biomarker for reflecting the severity and predicting outcomes of intracerebral hemorrhage (ICH).

Methods

In this prospective cohort study, 185 patients with supratentorial ICH were enrolled, among whom 62 had blood obtained not only at admission but also on days 1, 3, 5, 7, 10, and 14. In addition, 62 healthy controls underwent blood collection at the start of the study. The serum ITIH4 levels were then quantified. We recorded early neurological deterioration (END) and poor prognosis (modified Rankin Scale [mRS] scores of 3-6]) six months after ICH.

Results

Serum ITIH4 levels decreased prominently in the early phase after ICH, continued to decline until day 5, then gradually increased until day 14, and were significantly lower during 14 days in patients than in controls. Serum ITIH4 levels on admission were independently associated with serum C-reactive protein levels, National Institutes of Health Stroke Scale (NIHSS) scores and hematoma volume. Admission serum ITIH4 levels were independently associated with mRS scores, END, and poor prognosis. No substantial differences existed in the areas under the receiver operating characteristic curve of END and poor prognosis prediction between the serum ITIH4 levels, NIHSS scores, and hematoma volume. Prediction models, in which serum ITIH4 levels, NIHSS scores, and hematoma volume were integrated, were relatively reliable and stable using a series of statistical methods. In addition, the prediction model of poor prognosis had a higher discriminatory ability than the NIHSS scores and hematoma volume alone.

Conclusion

A dramatic decline in serum ITIH4 levels during the early period following ICH is independently related to the inflammatory response, stroke severity, and poor neurologic outcomes, suggesting that serum ITIH4 may be a useful prognostic biomarker of ICH.

Determinants of acute and subacute case-fatality in elderly patients with hypertensive intracerebral hemorrhage

Background

Given that limited reports have described the survival and risk factors for elderly patients with hypertensive intracerebral hemorrhage (HICH), we aimed to develop a valid but simple prediction nomogram for the survival of HICH patients.

Methods

All elderly patients ≥65 years old who were diagnosed with HICH between January 2011 and December 2019 were identified. We performed the least absolute shrinkage and selection operator (Lasso) on the Cox regression model with the R package glmnet. A concordance index was performed to calculate the nomogram discrimination; and calibration curves and decision curves were graphically evaluated by depicting the observed rates against the probabilities predicted by the nomogram.

Results

A total of 204 eligible patients were analyzed, and over 20 % of the population was above the age of 80 (65-79 years old, n = 161; 80+ years old, n = 43). A hematoma volume ≥13.64 cm3 was associated with higher 7-day mortality (OR = 6.773, 95 % CI = 2.622-19.481; p < 0.001) and higher 90-day mortality (OR = 3.955, 95 % CI = 1.611-10.090, p = 0.003). A GCS score between 13 and 15 at admission was associated with a 7-day favorable outcome (OR = 0.025, 95 % CI = 0.005-0.086; p < 0.001) and a 90-day favorable outcome (OR = 0.033, 95 % CI = 0.010-0.099; p < 0.001).

Conclusions

Our nomogram models were visualized and accurate. Neurosurgeons could use them to assess the prognostic factors and provide advice to patients and their relatives.

Urokinase administration for intraventricular hemorrhage in adults: A retrospective analysis of hemorrhage volume reduction and clinical outcomes

BACKGROUND

Intraventricular hemorrhage (IVH) is a type of ventricular bleeding that results in significant morbidity and mortality. Multiple studies have investigated the use of urokinase in IVH treatment. The use of urokinase may lead to higher rates of hematoma resolution and lower mortality rates. However, further studies are required to determine efficacy of urokinase administration. This study examined the association between urokinase use, IVH volume reduction, and clinical outcomes.

METHODS

In total, 94 adult patients with hypertensive intracerebral hemorrhage with ventricular extension or primary IVH were enrolled between 2015 and 2021. Participants were categorized into two groups: "EVD combined with fibrinolysis" and "EVD only." The primary objective was to assess the reduction of IVH severity. Additionally, the study evaluated the functional outcomes and shunt dependency rate as secondary outcomes. Non-contrast computed tomography scans were obtained to measure the severity of IVH using the mGRAEB score. The main outcomes were the association among urokinase administration, reduced IVH severity, and functional outcomes.

RESULTS

There were no significant differences in the reduction rate of mGRAEB scores within a 7-day period (-50.0 [-64.4 to -32.5] % vs -44.2 [-59.3 to -7.9] %; p = 0.489). In addition, investigation of the third and fourth ventricles showed similar findings between the two groups. Urokinase treatment was not associated with significant differences in the modified Rankin Scale (5.0 (4.0-5.0) vs. 4.5 (4.0-5.0), p = 0.674) or shunt dependency rate (33.3% vs 39.3%, p = 0.58).

CONCLUSION

This study found that intraventricular urokinase use in patients with IVH was not associated with reduced IVH severity. In addition, urokinase use was not associated with better functional outcomes or minor shunt dependency rates.

Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury

Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.

Serum vascular endothelial growth factor and cortisol expression to predict prognosis of patients with hypertensive cerebral hemorrhage

BACKGROUND

Cerebral hemorrhage is a common and severe complication of hypertension in middle-aged and elderly men.

AIM

To investigate the correlation between vascular endothelial growth factor (VEGF) and cortisol (Cor) and the prognosis of patients with hypertensive cerebral hemorrhage.

METHODS

A hundred patients with hypertensive intracerebral hemorrhage were enrolled from January 2020 to December 2022 and assigned to the hypertensive intracerebral hemorrhage group. Another 100 healthy people who were examined at our hospital during the same period were selected and assigned to the healthy group. Peripheral venous blood was collected, and serum Cor and VGEF levels were measured through enzyme linked immunosorbent assay.

RESULTS

A statistically significant difference in serum Cor and VGEF levels was observed among patients with varying degrees of neurological impairment (P < 0.05). Serum Cor and VGEF levels were significantly higher in the severe group than in the mild-to-moderate group. Cor and VEGF levels were significantly higher in patients with poor prognoses than in those with good prognoses. Multiple logistic regression analysis revealed that serum Cor and VGEF levels were independent factors affecting hypertensive intracerebral hemorrhage (P < 0.05).

CONCLUSION

Cor and VGEF are associated with the occurrence and development of hypertensive cerebral hemorrhage and are significantly associated with neurological impairment and prognosis of patients.

Fever burden within 24 h after hematoma evacuation predicts early neurological deterioration in patients with intracerebral hemorrhage: a retrospective analysis

Background

Early neurological deterioration after hematoma evacuation is closely associated with a poor prognosis in patients with intracerebral hemorrhage. However, the relationship between body temperature after hematoma evacuation and early neurological deterioration remains unclear. Therefore, this study aims to explore the possible relationship between body temperature and early neurological deterioration in patients with intracerebral hemorrhage after hematoma evacuation.

Methods

We retrospectively collected data from patients with cerebral hemorrhage at our institute between January 2017 and April 2022. The Student's t-test, Mann-Whitney U-test, and χ2 Test and Fisher's exact test were used to analyze the clinical baseline data. A univariate logistic regression model was used to evaluate the association between the body temperature indices and early neurological deterioration. The predictive power was assessed using the area under the Receiver Operating Characteristic (ROC) curve. The secondary outcome was a poor functional outcome.

Results

Among 2,726 patients with intracerebral hemorrhage, 308 who underwent hematoma evacuation were included in the present analysis. A total of 82 patients (22.6%) developed early neurological deterioration. Univariate analysis showed that sex (p = 0.041); body temperature at 6 h (p = 0.005), 12 h (p = 0.01), and 24 h (p = 0.008) after surgery; duration of fever (p = 0.008); and fever burden (p < 0.001) were associated with early neurological deterioration. Multivariate logistic regression showed that fever burden was independently associated with early neurological deterioration (OR = 1.055 per °C × hour, 95%CI 1.008-1.103, p = 0.020). ROC showed that fever burden (AUC = 0.590; 95%CI: 0.514-0.666) could predict the occurrence of early neurological deterioration.

Conclusion

Fever burden is associated with early neurological deterioration in intracerebral hemorrhage patients undergoing hematoma evacuation. Our findings add to previous evidence on the relationship between the fever burden and the occurrence of early neurological deterioration in patients with intracerebral hemorrhage. Future studies with larger sample sizes are required to confirm these findings.

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

Background

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

Results

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

Conclusions

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

Constructing and Validating a Nomogram for Survival in Patients without Hypertension in Hypertensive Intracerebral Hemorrhage-Related Locations

OBJECTIVE

We aimed to evaluate the risk factors for patients, who had hypertensive intracerebral hemorrhage (ICH)-specific location hemorrhage without hypertensive history, to elucidate a novel and detailed understanding.

METHODS

We conducted a retrospective review to identify patients diagnosed with hemorrhage in hypertensive ICH-specific locations without hypertensive history between January 2011 and December 2019 from West China Hospital. A least absolute shrinkage and selector operation (LASSO) algorithm was used to select the optimal prognostic factors, and then we performed a multivariable logistic analysis. To verify the accuracy of the nomogram in predicting patient outcome, we used Harrell's statistics, area under the curve, and a calibration as well as decision curves.

RESULTS

The LASSO method, at a tenfold cross-validation for 7-day mortality, 90-day mortality, and 90-day morbidity, was applied to construct the prognosis-predicting models. Both a higher Glasgow Coma Scale (GCS) score at admission and larger hematoma volume ≥13.64 mL were independently associated with better survival at 7 days and 90 days in multivariate analysis. Lactic dehydrogenase >250 IU/L and neutrophilic granulocyte/lymphocyte ratio in 1 increase were significantly associated with poor outcome at 90 days. Only one factor (GCS score at 7 days) influencing 90-day morbidity remained in a LASSO model.

CONCLUSIONS

In this study, the GCS score, hematoma volume, and other laboratory factors (Lactic dehydrogenase and neutrophilic granulocyte/lymphocyte ratio) were related to survival. Our current findings of the specific location ICH need to be proven by a large randomized controlled trial study.

Prognostic significance of serum NLRC4 in patients with acute supratentorial intracerebral hemorrhage: A prospective longitudinal cohort study

Objective

Caspase activation and recruitment domain-containing protein 4 (NLRC4) is implicated in neuroinflammation. The aim of the study was to discern the potential ability of serum NLRC4 in assessment of prognosis after intracerebral hemorrhage (ICH).

Methods

In this prospective, observational study, serum NLRC4 levels were quantified in 148 acute supratentorial ICH patients and 148 controls. Severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) and hematoma volume, and poststroke 6-month functional outcome was estimated according to the modified Rankin Scale (mRS). Early neurologic deterioration (END) and 6-month poor outcome (mRS 3–6) were deemed as the two prognostic parameters. Multivariate models were established for investigating associations, and receiver operating characteristic (ROC) curves were configured to indicate predictive capability.

Results

Patients had substantially higher serum NLRC4 levels than controls (median, 363.2 pg/ml vs. 74.7 pg/ml). Serum NLRC4 levels had independent correlation with NIHSS scores [β, 0.308; 95% confidence interval (CI), 0.088–0.520], hematoma volume (β, 0.527; 95% CI, 0.385–0.675), serum C-reactive protein levels (β, 0.288; 95% CI, 0.109–0.341) and 6-month mRS scores (β, 0.239; 95% CI, 0.100–0.474). Serum NLRC4 levels above 363.2 pg/ml were independently predictive of END (odds ratio, 3.148; 95% CI, 1.278–7.752) and 6-month poor outcome (odds ratio, 2.468; 95% CI, 1.036–5.878). Serum NLRC4 levels significantly distinguished END risk [area under ROC curve (AUC), 0.765; 95% CI, 0.685–0.846] and 6-month poor outcome (AUC, 0.795; 95% CI, 0.721–0.870). In terms of predictive ability for 6-month poor outcome, serum NLRC4 levels combined with NIHSS scores and hematoma volume was superior to NIHSS scores combined with hematoma volume, NIHSS scores and hematoma volume (AUC, 0.913 vs. 0.870, 0.864 and 0.835; all P &lt; 0.05). Nomograms were built to reflect prognosis and END risk of combination models, where serum NLRC4, NIHSS scores and hematoma volume were enforced. Calibration curves confirmed stability of combination models.

Conclusions

Markedly raised serum NLRC4 levels following ICH, in close relation to illness severity, are independently associated with poor prognosis. Such results are indicative of the notion that determination of serum NLRC4 may aid in severity assessment and prediction of functional outcome of ICH patients.

Intracerebral haemorrhage expansion: definitions, predictors, and prevention

Haematoma expansion affects a fifth of patients within 24 h of the onset of acute intracerebral haemorrhage and is associated with death and disability, which makes it an appealing therapeutic target. The time in which active intervention can be done is short as expansion occurs mostly within the first 3 h after onset. Baseline haemorrhage volume, antithrombotic treatment, and CT angiography spot signs are each associated with increased risk of haematoma expansion. Non-contrast CT features are promising predictors of haematoma expansion, but their potential contribution to current models is under investigation. Blood pressure lowering and haemostatic treatment minimise haematoma expansion but have not led to improved functional outcomes in randomised clinical trials. Ultra-early enrolment and selection of participants on the basis of non-contrast CT imaging markers could focus future clinical trials to show clinical benefit in people at high risk of expansion or investigate heterogeneity of treatment effects in clinical trials with broad inclusion criteria.

Added value of non-contrast CT and CT perfusion markers for prediction of intracerebral hemorrhage expansion and outcome

OBJECTIVES

To test the hypothesis that the combined analysis of non-contrast CT (NCCT) and CT perfusion (CTP) imaging markers improves prediction of hematoma expansion (HE) and outcome in intracerebral hemorrhage (ICH).

METHODS

Retrospective, single-center analysis of patients with primary ICH undergoing NCCT and CTP within 6 h from onset. NCCT images were assessed for the presence of intrahematomal hypodensity and shape irregularity. Perihematomal cerebral blood volume and spot sign were assessed on CTP. The main outcomes of the analysis were HE (growth > 6 mL and/or > 33%) and poor functional prognosis (90 days modified Rankin Scale 3-6). Predictors of HE and outcome were explored with logistic regression.

RESULTS

A total of 150 subjects were included (median age 68, 47.1% males) of whom 54 (36%) had HE and 52 (34.7%) had poor outcome. The number of imaging markers on baseline imaging was independently associated with HE (odds ratio 2.66, 95% confidence interval 1.70-4.17, p < 0.001) and outcome (odds ratio 1.64, 95% CI 1.06-2.56, p = 0.027). Patients with the simultaneous presence of all the four markers had the highest risk of HE and unfavorable prognosis (mean predicted probability of 91% and 79% respectively). The combined-markers analysis outperformed the sensitivity of the single markers analyzed separately. In particular, the presence of at least one marker identified patients with HE and poor outcome with 91% and 87% sensitivity respectively.

CONCLUSION

NCCT and CTP markers provide additional yield in the prediction of HE and ICH outcome.

KEY POINTS

• Perihematomal hypoperfusion is associated with hematoma expansion and poor outcome in acute intracerebral hemorrhage. • Non-contrast CT and CT perfusion markers improve prediction of hematoma expansion and unfavorable prognosis. • A multimodal CT protocol including CT perfusion will help the identification of patients at high risk of clinical deterioration and poor outcome.

Prehospital Ultra-Early Neurological Deterioration in Intracerebral Hemorrhage: Definition, Prevalence, and Association with Outcomes

INTRODUCTION

The objective of this study was to define prehospital ultra-early neurological deterioration (UND) and to investigate the association with functional outcomes in patients with intracerebral hemorrhage (ICH).

METHODS

We conducted a prospective cohort study of consecutive acute ICH patients. The stroke severity at onset and hospital admission was assessed using the Chongqing Stroke Scale (CQSS), and prehospital UND was defined as a CQSS increase of ≥2 points between symptoms onset and admission. Early neurological deterioration (END) was defined as the increase of ≥4 points in NIHSS score within the first 24 h after admission. Poor outcome was defined as a modified Rankin Scale (mRS) of 4-6 at 3 months.

RESULTS

Prehospital UND occurred in 29 of 169 patients (17.2%). Patients with prehospital UND had a median admission NIHSS score of 17.0 as opposed to those without prehospital UND with a median NIHSS score of 8.5. There were three patterns of neurological deterioration: prehospital UND only in 21 of 169 patients (12.4%), END but without prehospital UND in 20 of 169 patients (11.8%), and continuous neurological deterioration in both phases in 8 patients (4.7%). Prehospital UND was associated with worse 3-month outcomes (median mRS score, 4.0 vs. 2.0, p = 0.002). After adjusting for age, time from onset to admission, END, and systolic blood pressure, prehospital UND was an independent predictor of poor outcome (odds ratio [OR] 3.27, 95% confidence interval [CI] 1.26-8.48, p = 0.015).

CONCLUSION

Prehospital UND occurs in approximately 1 in 7 patients between symptom onset and admission and is associated with poor functional outcome in patients with ICH. Further research is needed to investigate the prehospital UND in the prehospital phase in the triage of patients with ICH.

Effects of subarachnoid extension following intracerebral hemorrhage: A systematic review and meta-analysis

BACKGROUND

The effects of subarachnoid extension (SAHE) following intracerebral hemorrhage (ICH) have not yet been fully understood. We conducted a systematic review and meta-analysis of published literature on this topic to better understand the effects of SAHE.

METHODS

PubMed, Embase, and Cochrane databases were thoroughly searched from inception to October 16, 2022 to identify studies that evaluated the association between SAHE and mortality and worse functional outcomes in primary ICH. Crude odds ratios (cOR) and adjusted odds ratios (aOR) with 95% confidence interval (CI) were calculated to compare the endpoints.

RESULTS

Three studies with 3368 participants were eventually included in the analysis. In the short-term follow-up of the primary endpoint, no association was observed between SAHE and mortality (cOR: 0.51, 95% CI: 0.01-28.19; aOR: 2.31, 95% CI: 0.72-7.45). In the long-term follow-up of the primary endpoint, SAHE was associated with a significantly increased mortality of patients with primary ICH (cOR: 3.00, 95% CI: 2.27-3.98); however, only 1 study provided the values of aOR and 95% CI and showed that SAHE was not associated with increased mortality (aOR: 1.14, 95% CI: 0.71-1.83). For the secondary endpoint, the data of only 1 study on major disability (modified Rankin Scale = 3-5) were available, and the results revealed that SAHE increased the probability of major disability, but not after adjusting for baseline hematoma volume.

CONCLUSION

There is insufficient evidence to demonstrate the correlation between SAHE and mortality and worse functional outcomes in primary ICH. The validation of this correlation requires further studies as the potential effect and mechanisms of SAHE remain unclear.

Computed tomography in acute intracerebral hemorrhage: neuroimaging predictors of hematoma expansion and outcome

Intracerebral hemorrhage (ICH) accounts for 10–20% of all strokes worldwide and is associated with serious outcomes, including a 30-day mortality rate of up to 40%. Neuroimaging is pivotal in diagnosing ICH as early detection and determination of underlying cause, and risk for expansion/rebleeding is essential in providing the correct treatment. Non-contrast computed tomography (NCCT) is the most used modality for detection of ICH, identification of prognostic markers and measurements of hematoma volume, all of which are of major importance to predict outcome. The strongest predictors of 30-day mortality and functional outcome for ICH patients are baseline hematoma volume and hematoma expansion. Even so, exact hematoma measurement is rare in clinical routine practice, primarily due to a lack of tools available for fast, effective, and reliable volumetric tools. In this educational review, we discuss neuroimaging findings for ICH from NCCT images, and their prognostic value, as well as the use of semi-automatic and fully automated hematoma volumetric methods and assessment of hematoma expansion in prognostic studies.

Prediction of Neurological Deterioration After Intracerebral Hemorrhage: The SIGNALS Score

Background Intracerebral hemorrhage is the most disabling and lethal form of stroke. We aimed to develop a novel clinical score for neurological deterioration during hospitalization after intracerebral hemorrhage. Methods and Results We analyzed data from the CHERRY (Chinese Cerebral Hemorrhage: Mechanism and Intervention) study. Two-thirds of eligible patients were randomly allocated into the training cohort (n=1027) and one-third into the validation cohort (n=515). Multivariable logistic regression was used to identify factors associated with neurological deterioration (an increase in National Institutes of Health Stroke Scale of ≥4 or death) within 15 days after symptom onset. A prediction score was developed based on regression coefficients derived from the logistic model. The site, size, gender, National Institutes of Health Stroke Scale, age, leukocyte, sugar (SIGNALS) score was developed as a sum of individual points (0-8) based on site (1 point for infratentorial location), size (3 points for >20 mL of supratentorial hematoma volume or 2 points for >10 mL of infratentorial hematoma volume), sex (1 point for male sex), National Institutes of Health Stroke Scale score (1 point for >10), age (1 point for ≥70 years), white blood cell (1 point for>9.0×10⁹/L), and fasting blood glucose (1 point>7.0 mmol/L). The proportion of patients who suffered from neurological deterioration increased with higher SIGNALS score, showing good discrimination and good calibration in the training cohort (C statistic, 0.821; Hosmer-Lemeshow test, P=0.687) and in the validation cohort (C statistic, 0.848; Hosmer-Lemeshow test, P=0.592), respectively. Conclusions The SIGNALS score reliably predicts the risk of in-hospital neurological deterioration of patients with intracerebral hemorrhage.

Prediction of Neurological Deterioration After Intracerebral Hemorrhage: The SIGNALS Score

Background Intracerebral hemorrhage is the most disabling and lethal form of stroke. We aimed to develop a novel clinical score for neurological deterioration during hospitalization after intracerebral hemorrhage. Methods and Results We analyzed data from the CHERRY (Chinese Cerebral Hemorrhage: Mechanism and Intervention) study. Two-thirds of eligible patients were randomly allocated into the training cohort (n=1027) and one-third into the validation cohort (n=515). Multivariable logistic regression was used to identify factors associated with neurological deterioration (an increase in National Institutes of Health Stroke Scale of ≥4 or death) within 15 days after symptom onset. A prediction score was developed based on regression coefficients derived from the logistic model. The site, size, gender, National Institutes of Health Stroke Scale, age, leukocyte, sugar (SIGNALS) score was developed as a sum of individual points (0-8) based on site (1 point for infratentorial location), size (3 points for >20 mL of supratentorial hematoma volume or 2 points for >10 mL of infratentorial hematoma volume), sex (1 point for male sex), National Institutes of Health Stroke Scale score (1 point for >10), age (1 point for ≥70 years), white blood cell (1 point for>9.0×10⁹/L), and fasting blood glucose (1 point>7.0 mmol/L). The proportion of patients who suffered from neurological deterioration increased with higher SIGNALS score, showing good discrimination and good calibration in the training cohort (C statistic, 0.821; Hosmer-Lemeshow test, P=0.687) and in the validation cohort (C statistic, 0.848; Hosmer-Lemeshow test, P=0.592), respectively. Conclusions The SIGNALS score reliably predicts the risk of in-hospital neurological deterioration of patients with intracerebral hemorrhage.

A Prediction Model for Neurological Deterioration in Patients with Acute Spontaneous Intracerebral Hemorrhage

Aim

The aim of this study was to explore factors related to neurological deterioration (ND) after spontaneous intracerebral hemorrhage (sICH) and establish a prediction model based on random forest analysis in evaluating the risk of ND.

Methods

The clinical data of 411 patients with acute sICH at the Affiliated Hospital of Jining Medical University and Xuanwu Hospital of Capital Medical University between January 2018 and December 2020 were collected. After adjusting for variables, multivariate logistic regression was performed to investigate the factors related to the ND in patients with acute ICH. Then, based on the related factors in the multivariate logistic regression and four variables that have been identified as contributing to ND in the literature, we established a random forest model. The receiver operating characteristic curve was used to evaluate the prediction performance of this model.

Results

The result of multivariate logistic regression analysis indicated that time of onset to the emergency department (ED), baseline hematoma volume, serum sodium, and serum calcium were independently associated with the risk of ND. Simultaneously, the random forest model was developed and included eight predictors: serum calcium, time of onset to ED, serum sodium, baseline hematoma volume, systolic blood pressure change in 24 h, age, intraventricular hemorrhage expansion, and gender. The area under the curve value of the prediction model reached 0.795 in the training set and 0.713 in the testing set, which suggested the good predicting performance of the model.

Conclusion

Some factors related to the risk of ND were explored. Additionally, a prediction model for ND of acute sICH patients was developed based on random forest analysis, and the developed model may have a good predictive value through the internal validation.

Frequency, Risk Factors, and Outcomes of Unplanned Readmission to the Neurological Intensive Care Unit after Spontaneous Intracerebral Hemorrhage

BACKGROUND

Unplanned readmission to the neurological intensive care unit (ICU) is an underinvestigated topic in patients admitted after spontaneous intracerebral hemorrhage (ICH). The purpose of this study is to investigate the frequency, clinical risk factors, and outcome of bounce back to the neurological ICU in a cohort of patients admitted after ICH.

METHODS

This is a retrospective observational study inspecting bounce back to the neurological ICU in patients admitted with spontaneous ICH over an 8-year period. For each patient, demographics, medical history, clinical presentation, length of ICU stay, unplanned readmission to neurological ICU, cause of readmission, and mortality were reviewed. Bounce back to the neurological ICU was defined as an unplanned readmission to the neurological ICU from a general floor service during the same hospitalization. A multivariable analysis was used to define independent variables associated with bounce back to the neurological ICU as well as association between bounce back to the neurological ICU and mortality. The significance level was set at p < 0.05.

RESULTS

A total of 221 patients were included. Among those, 20 (9%) had a bounce back to the neurological ICU. Respiratory complications (n = 11) was the most common reason for bounce back to the neurological ICU, followed by neurological (n = 5) and cardiological (n = 4) complications. In a multivariable logistic regression, location of hemorrhage in the basal ganglia (odds ratio [OR]: 3.0, 95% confidence interval [CI]: 1.0-8.9, p = 0.03) and dysphagia at the time of transfer (OR: 3.9, 95% CI: 1.0-15.4, p = 0.04) were significantly associated with bounce back to the neurological ICU. After we controlled for ICH score, readmission to the ICU was also independently associated with higher mortality (OR: 14.1, 95% CI: 2.8-71.7, p < 0.01).

CONCLUSIONS

Bounce back to the neurological ICU is not an infrequent complication in patients with spontaneous ICH and is associated with higher hospital length of stay and mortality. We identified relevant and potentially modifiable risk factors associated with bounce back to the neurological ICU. Future prospective studies are necessary to develop patient-centered strategies that may improve transition from the neurological ICU to the general floor.

Clinico-radiological related to early brain death factors

OBJECTIVE

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 h.

DESIGN

A retrospective cohort study was made covering the period 2015-2017.

SETTING

An adult Intensive Care Unit (ICU).

PATIENTS/METHODS

Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD.

RESULTS

A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD > 24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD > 24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD > 24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups.

CONCLUSIONS

Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Construction of a nomogram to reveal the prognostic benefit of spontaneous intracranial hemorrhage among Chinese adults: a population-based study

BACKGROUND AND PURPOSE

We aimed to build a nomogram, based on patients with spontaneous intracerebral hemorrhage (SICH), to predict the probability of mortality and morbidity at 7 days and 90 days, respectively.

METHODS

We performed a retrospective study, with patients at less than 6 h from ictus admitted to the department of neurosurgery in a single institute, from January 2011 to December 2018. A total of 1036 patients with SICH were included, 486 patients (46.9%) were 47-66 years old at diagnosis, and 711 patients (68.6%) were male. The least absolute shrinkage and section operator method was performed to identify the key adverse factors predicting the outcomes in patients with SICH, and multivariate logistic regression analysis was built on these variables, and then the results were visualized by a nomogram. The discrimination of the prognostic models was measured and compared by means of Harrell's concordance index (C-index), calibration curve, area under the curve (AUC), and decision curve analysis (DCA).

RESULTS

Multivariate logistic regression analysis revealed that factors affecting 7-day mortality, including the following: age, therapy, Glasgow Coma Scale (GCS) admission, location, ventricle involved, hematoma volume, white blood cell (WBC), uric acid (UA), and L-lactic dehydrogenase (LDH); and factors affecting 90-day mortality, including temperature, therapy, GCS admission, ventricle involved, WBC, international normalized ratio, UA, LDH, and systolic blood pressure. The C-index for the 7-day mortality and 90-day mortality prediction nomogram was 0.9239 (95% CI = 0.9061-0.9416) and 0.9241 (95% CI = 0.9064-0.9418), respectively. The AUC of 7-day mortality was 92.4, as is true of 90-day mortality. The calibration curve and DCA indicated that nomograms in our study had a good prediction ability. For 90-day morbidity, age, marital status, and GCS at 7-day remained statistically significant in multivariate analysis. The C-index for the prediction nomogram was 0.6898 (95% CI = 0.6511-0.7285), and the calibration curve, AUC as well as DCA curve indicated that the nomogram for the prediction of good outcome demonstrated good agreement in this cohort.

CONCLUSIONS

Nomograms in this study revealed many novel prognostic demographic and laboratory factors, and the individualized quantitative risk estimation by this model would be more practical for treatment management and patient counseling.

Intracerebral Hemorrhage

PURPOSE OF REVIEW

Nontraumatic intracerebral hemorrhage (ICH) is the second most common type of stroke. This article summarizes the basic pathophysiology, classification, and management of ICH and discusses the available evidence on therapy for hematoma, hematoma expansion, and perihematomal edema.

RECENT FINDINGS

Current available data on potential therapeutic options for ICH are promising, although none of the trials have shown improvement in mortality rate. The literature available on reversal of anticoagulation and antiplatelet agents after an ICH and resumption of these medications is also increasing.

SUMMARY

ICH continues to have high morbidity and mortality. Advances in therapeutic options to target secondary brain injury from the hematoma, hematoma expansion, and perihematomal edema are increasing. Data on reversal therapy for anticoagulant-associated or antiplatelet-associated ICH and resumption of these medications are evolving.

Blood pressure control measured as "time in range" during initial 24 h for inpatients with spontaneous nontraumatic intracerebral haemorrhage

BACKGROUND AND PURPOSE

Blood pressure (BP) control is an integral part in the management of spontaneous nontraumatic intracerebral haemorrhage. The aim of this study is to propose a novel concept of blood pressure control measured as 'Time in Range'(TiR) and assess its relationship to neurological deterioration.

METHOD

Retrospective study of 120 patients with Intracerebral haemorrhage who were admitted within 6 h of the symptom onset. The hourly BP readings for initial 24 h were studied in the form of time in range (TiR). TiR was defined as the percentage of readings with 'in range' systolic BP (SBP 110-140mmHG) during a unit time period. TiR was correlated with mean SBP at 6,12,18 and 24 h. It was categorized dichotomously as controlled (more than 50%) or not controlled (equal to or less than 50%) and analyzed with the change in Glasgow coma scale (drop of ≥2 units) at 24 h.

RESULTS

Correlation of TiR with mean SBP at 6 and 24 h showed significant negative correlation [r = -0.71 (at 6 h); r = -0.88 (at 24 h); p < 0.001]. The association of TiR with neurological deterioration(ND) was measured by change in GCS; with lower TiR associated with higher chances of neurological deterioration at 12 h interval [OR 4.5(1.2-16.8); p = 0.025], but not at 24 h interval [OR 1.4 (0.34-5.44); p = 0.670].

CONCLUSION

Our novel concept of 'Time in Range'(TiR) was found to be relevant in our study. Its association with mean SBP reflect its potential to be a modality of expressing control of SBP in Spontaneous Nontraumatic Intracerebral Haemorrhage.

Prognostication after intracerebral hemorrhage: a review

Background

Approximately half of patients with spontaneous intracerebral hemorrhage (ICH) die within 1 year. Prognostication in this context is of great importance, to guide goals of care discussions, clinical decision-making, and risk stratification. However, available prognostic scores are hardly used in clinical practice. The purpose of this review article is to identify existing outcome prediction scores for spontaneous intracerebral hemorrhage (ICH) discuss their shortcomings, and to suggest how to create and validate more useful scores.

Main text

Through a literature review this article identifies existing ICH outcome prediction models. Using the Essen-ICH-score as an example, we demonstrate a complete score validation including discrimination, calibration and net benefit calculations. Score performance is illustrated in the Erlangen UKER-ICH-cohort (NCT03183167). We identified 19 prediction scores, half of which used mortality as endpoint, the remainder used disability, typically the dichotomized modified Rankin score assessed at variable time points after the index ICH. Complete score validation by our criteria was only available for the max-ICH score. Our validation of the Essen-ICH-score regarding prediction of unfavorable outcome showed good discrimination (area under the curve 0.87), fair calibration (calibration intercept 1.0, slope 0.84), and an overall net benefit of using the score as a decision tool. We discuss methodological pitfalls of prediction scores, e.g. the withdrawal of care (WOC) bias, physiological predictor variables that are often neglected by authors of clinical scores, and incomplete score validation. Future scores need to integrate new predictor variables, patient-reported outcome measures, and reduce the WOC bias. Validation needs to be standardized and thorough. Lastly, we discuss the integration of current ICH scoring systems in clinical practice with the awareness of their shortcomings.

Conclusion

Presently available prognostic scores for ICH do not fulfill essential quality standards. Novel prognostic scores need to be developed to inform the design of research studies and improve clinical care in patients with ICH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-021-00120-5.

A new surgical method of treatment spontaneous intracranial hemorrhage

Objective

This study aimed to determine the safety and effectiveness of DTI-assisted neuroendoscopy for treating intracranial hemorrhage (ICH).

Methods

This retrospective study included clinical data from 260 patients with spontaneous supratentorial ICH who received neuroendoscopic hematoma removal. Patients were separated into groups based on the surgery method they received: DTI-assisted neuroendoscopy (69 cases) and standard neuroendoscopy (191 cases). All patients were followed up for 6 months. Multivariate logistic regression analyzed the risk factors affecting the prognosis of patients. The outcomes of the two groups were compared using Kaplan-Meier survival curves.

Results

The prognostic modified Rankin Scale (mRS) score was significantly better (P = 0.027) in the DTI-assisted neuroendoscopy group than in the standard neuroendoscopy group. Logistic regression analysis showed that DTI-assisted neuroendoscopy is an independent protective factor for a favorable outcome (model 1: odds ratio [OR] = 0.42, P = 0.015; model 2: OR = 0.40, P = 0.013). Kaplan-Meier survival curves were used to show that the median time for a favorable outcome was 66 days (95% confidence interval [CI] = 48.50-83.50 days) in the DTI-assisted neuroendoscopy group and 104 days (95% CI = 75.55-132.45 days) in the standard neuroendoscopy group. Log-rank testing showed that the DTI-assisted neuroendoscopy group had a lower pulmonary infection rate (χ ² = 4.706, P = 0.030) and a better prognosis (χ ² = 5.223, P = 0.022) than the standard neuroendoscopy group. The survival rate did not differ significantly between the DTI-assisted neuroendoscopy group and the standard neuroendoscopy group (P > 0.05).

Conclusions

The use of DTI in neuroendoscopic hematoma removal can significantly improve neurological function outcomes in patients, but it does not significantly affect the mortality of patients.

Predictors and Outcomes of Neurological Deterioration in Intracerebral Hemorrhage: Results from the TICH-2 Randomized Controlled Trial

Neurological deterioration is common after intracerebral hemorrhage (ICH). We aimed to identify the predictors and effects of neurological deterioration and whether tranexamic acid reduced the risk of neurological deterioration. Data from the Tranexamic acid in IntraCerebral Hemorrhage-2 (TICH-2) randomized controlled trial were analyzed. Neurological deterioration was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) of ≥ 4 or a decline in Glasgow Coma Scale of ≥ 2. Neurological deterioration was considered to be early if it started ≤ 48 h and late if commenced between 48 h and 7 days after onset. Logistic regression was used to identify predictors and effects of neurological deterioration and the effect of tranexamic acid on neurological deterioration. Of 2325 patients, 735 (31.7%) had neurological deterioration: 590 (80.3%) occurred early and 145 (19.7%) late. Predictors of early neurological deterioration included recruitment from the UK, previous ICH, higher admission systolic blood pressure, higher NIHSS, shorter onset-to-CT time, larger baseline hematoma, intraventricular hemorrhage, subarachnoid extension and antiplatelet therapy. Older age, male sex, higher NIHSS, previous ICH and larger baseline hematoma predicted late neurological deterioration. Neurological deterioration was independently associated with a modified Rankin Scale of > 3 (aOR 4.98, 3.70-6.70; p < 0.001). Tranexamic acid reduced the risk of early (aOR 0.79, 0.63-0.99; p = 0.041) but not late neurological deterioration (aOR 0.76, 0.52-1.11; p = 0.15). Larger hematoma size, intraventricular and subarachnoid extension increased the risk of neurological deterioration. Neurological deterioration increased the risk of death and dependency at day 90. Tranexamic acid reduced the risk of early neurological deterioration and warrants further investigation in ICH. URL: https://www.isrctn.com Unique identifier: ISRCTN93732214.

Memantine protects blood-brain barrier integrity and attenuates neurological deficits through inhibiting nitric oxide synthase ser1412 phosphorylation in intracerebral hemorrhage rats: involvement of peroxynitrite-related matrix metalloproteinase-9/NLRP3 inflammasome activation

Memantine has demonstrated beneficial effects on several types of brain insults via therapeutic mechanisms mainly related to its activity as a receptor antagonist of N-methyl-d-aspartate. However, the influences of memantine on intracerebral hemorrhage (ICH) remain obscure. This research probed into the neurovascular protective mechanisms of memantine after ICH and its impacts on neuronal nitric oxide synthase (nNOS) ser1412 phosphorylation. ICH model was established by employing intrastriatal collagenase injection in rats. After modeling, rats were then allocated randomly into sham-operated (sham), vehicle-treated (ICH+V), and memantine-administrated (ICH+M) groups. Memantine (20 mg/kg/day) was intraperitoneally administered 30 min after ICH and thenceforth once daily. Rats were dedicated at 0.25, 6, 12, 24 h, 3 and 7 d post-ICH for measurement of corresponding indexes. Behavioral changes, brain edema, levels of nNOS ser1412 phosphorylation, peroxynitrite, matrix metalloproteinase (MMP)-9, NLRP3, IL-1β and numbers of dying neurons, as well as the cellular localization of gelatinolytic activity, were detected among the groups. Memantine improved the neurologic deficits and mitigated brain water content, levels of MMP-9, NLRP3, IL-1β and dying neurons. Additionally, treatment with memantine also reduced nNOS ser1412 phosphorylation and peroxynitrite formation compared with the ICH+V group at 24 h after ICH. In situ zymography simultaneously revealed that gelatinase activity was primarily colocalized with vessel walls and neurons. We concluded that memantine ameliorated blood-brain barrier disruption and neurologic dysfunction in an ICH rat model. The underlying mechanism might involve repression of nNOS ser1412 phosphorylation, as well as peroxynitrite-related MMP-9 and NLRP3 inflammasome activation.

Intracerebral Hemorrhage with Intraventricular Extension Associated with Loss of Consciousness at Symptom Onset

BACKGROUND

In patients with spontaneous intracerebral hemorrhage (ICH), pre-hospital markers of disease severity might be useful to potentially triage patients to undergo early interventions.

OBJECTIVE

Here, we tested whether loss of consciousness (LOC) at the onset of ICH is associated with intraventricular hemorrhage (IVH) on brain computed tomography (CT).

METHODS

Among 3000 ICH cases from ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage study, NS069763), we included patients with complete ICH/IVH volumetric CT measurements and excluded those with seizures at ICH onset. Trained investigators extracted data from medical charts. Mental status at symptom onset (categorized as alert/oriented, alert/confused, drowsy/somnolent, coma/unresponsive/posturing) and 3-month disability (modified Rankin score, mRS) were assessed through standardized interviews of participants or dedicated proxies. We used logistic regression and mediation analysis to assess relationships between LOC, IVH, and unfavorable outcome (mRS 4-6).

RESULTS

Two thousand seven hundred and twenty-four patients met inclusion criteria. Median admission Glasgow Coma Score was 15 (interquartile range 11-15). 46% had IVH on admission or follow-up CT. Patients with LOC (mental status: coma/unresponsive, n = 352) compared to those without LOC (all other mental status, n = 2372) were younger (60 vs. 62 years, p = 0.005) and had greater IVH frequency (77 vs. 41%, p < 0.001), greater peak ICH volumes (28 vs. 11 ml, p < 0.001), greater admission systolic blood pressure (200 vs. 184 mmHg, p < 0.001), and greater admission serum glucose (158 vs. 127 mg/dl, p < 0.001). LOC was independently associated with IVH presence (odds ratio, OR, 2.6, CI 1.9-3.5) and with unfavorable outcome (OR 3.05, CI 1.96-4.75). The association between LOC and outcome was significantly mediated by IVH (beta = 0.24, bootstrapped CI 0.17-0.32).

CONCLUSION

LOC at ICH onset may be a useful pre-hospital marker to identify patients at risk of having or developing IVH.

Factors Associated with Early versus Delayed Expansion of Acute Subdural Hematomas Initially Managed Conservatively

Acute subdural hematomas (ASDHs) are highly morbid and increasingly common. Hematoma expansion is a potentially fatal complication, and few studies have examined whether factors associated with hematoma expansion vary over time. To answer this, we performed a case-control study in a cohort of initially conservatively managed patients with ASDH. Two time periods were considered, early (<72 h from injury) and delayed (>72 h from injury). Cases were defined as patients who developed ASDH expansion in the appropriate period; controls were patients who had stable imaging. Associated factors were determined with logistic regression. We identified 68 cases and 237 controls in the early follow-up cohort. Early ASDH expansion was associated with coagulopathy (adjusted odds ratio [aOR] 2.3, 95 % CI: 1.2-4.5; p = 0.02), thicker ASDHs (aOR 1.1, 95% CI: 1.03-1.2; p = 0.006), additional intracranial lesions (aOR 3, 95% CI: 1.6-6.2; p = 0.002), no/minimal trauma history (aOR 0.4, 95% CI: 0.2-0.9; p = 0.03), and duration between injury and initial scan (aOR 0.9, 95% CI: 0.8-0.97; p = 0.04). In the delayed follow-up cohort, there were 41 cases and 126 controls. Delayed ASDH expansion was associated with older age (aOR 1.3 per 10 years, 95% CI: 1.1-1.6; p = 0.01), systolic blood pressure (SBP) >160 on hospital presentation (aOR 4.5, 95% CI: 1.8-11.3; p = 0.001), midline shift (aOR 1.5 per 1 mm, 95% CI: 1.3-1.9; p < 0.001), and convexity location (aOR 14.1, 95% CI: 2.6-265; p = 0.013). We conclude that early and delayed ASDH expansion are different processes with different associated factors, and that elevated SBP may be a modifiable risk factor of delayed expansion.

Outcomes of Intensive Systolic Blood Pressure Reduction in Patients With Intracerebral Hemorrhage and Excessively High Initial Systolic Blood Pressure: Post Hoc Analysis of a Randomized Clinical Trial

Importance

The safety and efficacy of intensive systolic blood pressure reduction in patients with intracerebral hemorrhage who present with systolic blood pressure greater than 220 mm Hg appears to be unknown.

Objective

To evaluate the differential outcomes of intensive (goal, 110-139 mm Hg) vs standard (goal, 140-179 mm Hg) systolic blood pressure reduction in patients with intracerebral hemorrhage and initial systolic blood pressure of 220 mm Hg or more vs less than 220 mm Hg.

Design, Setting, and Participants

This post hoc analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage-II trial was performed in November 2019 on data from the multicenter randomized clinical trial, which was conducted between May 2011 to September 2015. Patients with intracerebral hemorrhage and initial systolic blood pressure of 180 mm Hg or more, randomized within 4.5 hours after symptom onset, were included.

Interventions

Intravenous nicardipine infusion titrated to goals.

Main Outcomes and Measures

Neurological deterioration and hematoma expansion within 24 hours and death or severe disability at 90 days, plus kidney adverse events and serious adverse events until day 7 or hospital discharge.

Results

A total of 8532 patients were screened, and 999 individuals (mean [SD] age, 62.0 [13.1] years; 620 men [62.0%]) underwent randomization and had an initial SBP value. Among 228 participants with initial systolic blood pressures of 220 mm Hg or more, the rate of neurological deterioration within 24 hours was higher in those who underwent intensive (vs standard) systolic blood pressure reduction (15.5% vs 6.8%; relative risk, 2.28 [95% CI, 1.03-5.07]; P = .04). The rate of death and severe disability (39.0% vs 38.4%; relative risk, 1.02 [95% CI, 0.73-1.78]; P = .92) was not significantly different between the 2 groups. There was a significantly higher rate of kidney adverse events in participants randomized to intensive systolic blood pressure reduction (13.6% vs 4.2%; relative risk, 3.22 [95% CI, 1.21-8.56]; P = .01), but no difference was observed in the rate of kidney serious adverse events.

Conclusions and Relevance

The higher rate of neurological deterioration within 24 hours associated with intensive treatment in patients with intracerebral hemorrhage and initial systolic blood pressure of 220 mm Hg or more, without any benefit in reducing hematoma expansion at 24 hours or death or severe disability at 90 days, warrants caution against generalization of recommendations for intensive systolic blood pressure reduction.

Clinico-radiological related to early brain death factors

OBJECTIVE

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 hours.

DESIGN

A retrospective cohort study was made covering the period 2015-2017.

SETTING

An adult Intensive Care Unit (ICU).

PATIENTS/METHODS

Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD.

RESULTS

A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD >24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD >24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD >24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups.

CONCLUSIONS

Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

High plasma levels of trimethylamine N-oxide are associated with poor outcome in intracerebral hemorrhage patients

BACKGROUND AND AIMS

As a gut microbiota-dependent metabolite, trimethylamine N-oxide (TMAO) has been implicated in cardiovascular diseases. We aimed to investigate the relationship between the clinical outcomes and plasma TMAO concentrations in patients with acute intracerebral hemorrhage.

METHODS

From January 2019 to October 2019, we prospectively enrolled intracerebral hemorrhage patients diagnosed within 6 h of symptoms onset. Plasma TMAO levels was measured for all patients within 24 h after admission. The primary outcome was functional outcome at 3 months. Patients were dichotomized as good (modified Rankin scale 0-3) and poor (modified Rankin scale 4-6). Secondary outcome included early neurological deterioration (END) and hematoma enlargement (HE).

RESULTS

There were 307 patients (57.7% male) with a mean age of 66.8 years included in the study. The median TMAO levels was 3.2 μmol/L. END, HE, and 3-month poor outcome were detected in 59 (19.2%), 54 (17.6%), and 139 (45.3%) patients, respectively. After adjusting for potential confounders, the odds ratio for the highest quartile of TMAO compared with the lowest quartile was 3.65 (95% confidence interval, 1.43-9.30) for 3-month poor outcome. Furthermore, multiple-adjusted spline regression model showed a linear association between TMAO levels and poor outcome at 3 months (P = 0.013 for linearity). Similar significant findings were observed when functional outcome was analyzed by continuous mRS score. No association was found between TMAO levels and END and HE.

CONCLUSIONS

The present study demonstrated that increased TMAO levels were independently correlated with 3-month function outcome after intracerebral hemorrhage.

Targeted Delivery of Iron Oxide Nanoparticle-Loaded Human Embryonic Stem Cell-Derived Spherical Neural Masses for Treating Intracerebral Hemorrhage

This study evaluated the potential of iron oxide nanoparticle-loaded human embryonic stem cell (ESC)-derived spherical neural masses (SNMs) to improve the transportation of stem cells to the brain, ameliorate brain damage from intracerebral hemorrhage (ICH), and recover the functional status after ICH under an external magnetic field of a magnet attached to a helmet. At 24 h after induction of ICH, rats were randomly separated into three experimental groups: ICH with injection of phosphate-buffered saline (PBS group), ICH with intravenous injection of magnetosome-like ferrimagnetic iron oxide nanocubes (FION)-labeled SNMs (SNMs* group), and ICH with intravenous injection of FION-labeled SNMs followed by three days of external magnetic field exposure for targeted delivery by a magnet-embedded helmet (SNMs*+Helmet group). On day 3 after ICH induction, an increased Prussian blue-stained area and decreased swelling volume were observed in the SNMs*+Helmet group compared with that of the other groups. A significantly decreased recruitment of macrophages and neutrophils and a downregulation of pro-inflammatory cytokines followed by improved neurological function three days after ICH were observed in the SNMs*+Helmet group. Hemispheric atrophy at six weeks after ICH was significantly decreased in the SNMs*+Helmet group compared with that of the PBS group. In conclusion, we have developed a targeted delivery system using FION tagged to stem cells and a magnet-embedded helmet. The targeted delivery of SNMs might have the potential for developing novel therapeutic strategies for ICH.

Subarachnoid Extension Predicts Lobar Intracerebral Hemorrhage Expansion

Background and Purpose- We investigated whether subarachnoid extension (SAHE) of intracerebral hemorrhage (ICH) is associated with hematoma expansion (HE). Methods- Retrospective analysis of patients with primary spontaneous ICH admitted at 3 academic hospitals in Italy. The study population was divided into a development and a replication cohort. SAHE was rated on baseline noncontrast computed tomography by investigators blinded to clinical data. The main outcome of interest was HE, defined as ICH growth >33% mL and/or >6 mL. Predictors of HE were explored with multivariable logistic regression stratified by ICH location (lobar versus nonlobar). Results- A total of 360 and 192 patients were included in the development and replication cohort, respectively. SAHE was identified with good interrater reliability (K=0.82), and its frequency was 27.8% in the development and 24.5% in the replication cohort. In univariate analysis, HE was more common in patients with SAHE (52.0% versus 27.3%; P<0.001). When controlling for confounders in logistic regression, SAHE was an independent predictor of lobar HE (odds ratio, 6.00 [95% CI, 2.16-16.64]; P=0.001) whereas there was no association with HE in nonlobar ICH (odds ratio, 0.55 [95% CI, 0.17-1.84]; P=0.334). The increased risk of HE in lobar ICH with SAHE was confirmed in the replication cohort (odds ratio, 3.46 [95% CI, 1.07-11.20]; P=0.038). Conclusions- SAHE predicts HE in lobar ICH. This may improve the stratification of HE risk in clinical practice or future trials targeting HE. Further research is needed to confirm our findings and characterize the underlying biological mechanisms.