The persisting burden of intracerebral haemorrhage: can effective treatments be found?

Association Between Admission Serum Phosphate Level and All-Cause Mortality Among Patients with Spontaneous Intracerebral Hemorrhage

Background

Hypophosphatemia was reported to frequently occur in patients with nontraumatic intracranial hemorrhage (ICH); however, the correlation between hypophosphatemia and outcomes of ICH remains unclear. This study aimed to examine the association between admission serum phosphate and all-cause mortality among patients with mild–moderate spontaneous ICH (sICH).

Methods

A total of 851 patients with sICH were enrolled. Serum phosphate was acquired within 24 hours on admission, and participants were divided according to phosphate quartiles. The primary outcome was all-cause mortality within 90 days, and univariate and multivariate models were employed to estimate the mortality risk.

Results

There were significant differences among sICH patients with different phosphate quartiles in terms of age, diastolic blood pressure (DBP), activated partial thromboplastin time (APTT), platelet count, and incidence of respiratory failure events on admission (P < 0.05). Log rank test showed a significant difference in the mortality risk among sICH patients with each phosphate quartile. Univariate Cox regression analysis revealed that age, smoking, DBP, APTT, NIH stroke scale (NIHSS) score, hematoma volume and serum phosphate might be associated with the 90-day all-cause mortality in patients with sICH (P < 0.05). Multivariable Cox regression analysis showed that the crude mortality was 4.3-fold greater in sICH patients with serum phosphate Q1 than those with Q4 (P < 0.001), and remained 3.18-fold higher after adjusting for age, smoking, DBP, APTT, NIHSS score, hematoma volume and early withdrawal of life-sustaining therapy (P = 0.011). Representative operating curve (ROC) analysis showed that admission serum phosphate was predictable for all-cause mortality within 90 days in patients with sICH (area under the ROC = 0.628, P < 0.001).

Conclusion

Low admission serum phosphate is strongly associated with a high risk of mortality in patients with mild–moderate sICH, and hypophosphatemia may be a prognostic marker for all-cause mortality in patients with mild–moderate sICH.

Eligibility for randomized trials of treatments specifically for intracerebral hemorrhage: community-based study

BACKGROUND AND PURPOSE

Acute treatments specifically for intracerebral hemorrhage (ICH) are being sought in randomized controlled trials. The treatment effect sizes in ongoing and future trials are likely to be small, necessitating large sample sizes.

METHODS

We searched online trial registries for randomized controlled trials investigating an acute treatment for ICH. For the trials whose eligibility criteria could be assessed in a prospective, community-based ICH cohort study (2010-2011), we quantified the proportions of patients who were eligible and investigated influences on these proportions.

RESULTS

We applied the eligibility criteria of 17 trials to 166 adults with ICH, of whom between 0.6% (95% confidence interval, 0.1-3.3) to 40% (95% confidence interval, 33-48) were eligible for each trial. Fewer patients were eligible for trials restricted to patients randomized within 12 hours of ICH onset (versus trials with a longer time window; P=0.03) and trials restricting eligibility according to premorbid disability (versus trials without this restriction; P=0.046). Each additional eligibility criterion reduced the portion of eligible patients by 1.3% (95% confidence interval, 0.4-2.2; adjusted R(2)=0.47; P=0.004).

CONCLUSIONS

Less than half of patients with ICH were eligible for current randomized controlled trials. Future trials could maximize enrollment by minimizing the number of eligibility criteria, maximizing the time window for recruiting patients after ICH onset, permitting premorbid disability, and using a simulator to assess the impact of other eligibility critiera (www.dcn.ed.ac.uk/ICHsimulator/).

Intracranial hemorrhage

Intracranial hemorrhage is a life-threatening condition, the outcome of which can be improved by intensive care. Intracranial hemorrhage may be spontaneous, precipitated by an underlying vascular malformation, induced by trauma, or related to therapeutic anticoagulation. The goals of critical care are to assess the proximate cause, minimize the risks of hemorrhage expansion through blood pressure control and correction of coagulopathy, and obliterate vascular lesions with a high risk of acute rebleeding. Simple bedside scales and interpretation of computed tomography scans assess the severity of neurological injury. Myocardial stunning and pulmonary edema related to neurological injury should be anticipated, and can usually be managed. Fever (often not from infection) is common and can be effectively treated, although therapeutic cooling has not been shown to improve outcomes after intracranial hemorrhage. Most functional and cognitive recovery takes place weeks to months after discharge; expected levels of functional independence (no disability, disability but independence with a device, dependence) may guide conversations with patient representatives. Goals of care impact mortality, with do-not-resuscitate status increasing the predicted mortality for any level of severity of intraparenchymal hemorrhage. Future directions include refining the use of bedside neuro-monitoring (electroencephalogram, invasive monitors), novel approaches to reduce intracranial hemorrhage expansion, minimizing vasospasm, and refining the assessment of quality of life to guide rehabilitation and therapy.

Management of intracerebral hemorrhage in 2020

Intracerebral hemorrhage (ICH) remains a common and deadly form of stroke, with virtually no greatly effective treatments aside from supportive and stroke unit care. Several surgical and medical therapies have been studied, but nothing has yet been found that greatly changes the pathophysiology. To achieve this, there will need to be substantial changes in treatment strategies. This article will focus on refinements to existing strategies and consider new approaches to the management of ICH. It will draw parallels with ischemic stroke treatments, and define the idea of ‘interventional therapy’ for ICH. It is suggested that reducing hematoma expansion could be compared with salvage of the ischemic penumbra, as a potential target for interventional ICH treatments. The concept of different time windows for the application of therapies according to the pathophysiology will be discussed. Finally, some novel treatment strategies are proposed, including an endovascular approach and ‘external, stereotactic cautery’, as future possibilities.