Does stereotactic thrombolysis with alteplase for intracerebral haemorrhage alter intraventricular haematoma volume? A secondary analysis of the MISTIE-III trial

BACKGROUND

Stereotactic thrombolysis reduces intracerebral haemorrhage (ICH) volume in patients with spontaneous ICH. Whether intrahaematomal alteplase administration is associated with a change in intraventricular haemorrhage volume (deltaIVH) and functional outcomes is unknown.

METHODS

Post hoc secondary analysis of the Minimally Invasive Surgery plus Alteplase for Intracerebral Hemorrhage Evacuation Phase III (MISTIE-III) trial in patients with IVH on the stability CT scan. Exposure was minimally invasive surgery plus alteplase (MIS+alteplase). Primary outcome was deltaIVH defined as IVH volume on end-of-treatment CT minus IVH volume on stability CT scan. Secondary outcomes were favourable functional outcome (modified Rankin Scale 0-3) and mortality at 365 days. We assessed the relationship between MIS+alteplase and deltaIVH in the primary analysis using multivariable linear regression, and between deltaIVH and functional outcomes in secondary analyses using multiple logistic regression.

RESULTS

Of 499 patients in MISTIE-III, 310 (62.1%) had IVH on stability scans; mean age (SD) was 61.2±12.3 years. A total of 146 (47.1%) received the MISTIE procedure and 164 (52.9%) standard medical care (SMC) only. The MIS+alteplase group had a greater mean reduction in IVH volume compared with the SMC group (deltaIVH: -2.35 (5.30) mL vs -1.15 (2.96) mL, p=0.02). While IVH volume decreased significantly in both treatment groups, in the primary analysis, MIS+alteplase was associated with greater deltaIVH in multivariable linear regression analysis adjusted for potential confounders (β -0.80; 95% CI -1.37 to -0.22, p=0.007). Secondary analysis demonstrated no associations between IVH reduction and functional outcomes (adjusted OR (aOR) for poor outcome 1.02; 95% CI 0.96 to 1.08, p=0.61; aOR for mortality 0.99; 95% CI 0.92 to 1.06, p=0.77).

CONCLUSIONS

Alteplase delivered into the ICH in MISTIE-III subjects with IVH was associated with a small reduction in IVH volume. This reduction did not translate into a significant benefit in mortality or functional outcomes at 365 days.

TRIAL REGISTRATION NUMBER

NCT01827046.

Transcranial Doppler in Childhood Moyamoya: An Underutilized Tool?

BACKGROUND

Children with moyamoya are at high risk for incident and recurrent stroke. Transcranial Doppler (TCD) ultrasound is an attractive option to screen high-risk populations for moyamoya and to provide stroke risk stratification information due to its safety and cost-effectiveness. We used TCD to evaluate cerebral blood flow velocities in children with presurgical moyamoya and to determine if velocities differ between children with stable and unstable disease.

METHODS

Fourteen participants aged ≤21 years with a radiographic diagnosis of moyamoya or moyamoya-like arteriopathy underwent a research TCD at a median age of 7.2 years. TCDs were performed outside of the setting of acute stroke and before surgical revascularization. Arteriopathy was classified as unstable if the participant had a stroke or transient ischemic attack within three months preceding the TCD.

RESULTS

Middle cerebral artery and internal carotid artery (ICA) blood flow velocities were elevated. The median M1 velocity was 138 cm/s (interquartile range [IQR] 106 to 168). Individual M1 flow velocities were a median of 5.0 S.D.s above age-based normative values. The median distal ICA velocity was 146 cm/s (IQR 124 to 163). Individual ICA flow velocities were a median of 5.9 S.D.s above normative values. Participants with unstable arteriopathy had higher M1 velocities compared with those with stable arteriopathy (170 vs 119 cm/s, P = 0.0003). We did not identify velocity differences based on comorbid conditions or age.

CONCLUSIONS

These preliminary data suggest that TCD is a promising tool for screening for cerebral arteriopathies in high-risk pediatric populations and assessment for unstable disease.

Code ICH: A Call to Action

Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.

Are We Ready for Clinical Therapy based on Cerebral Autoregulation? A Pro-con Debate

Cerebral autoregulation (CA) is a physiological mechanism that maintains constant cerebral blood flow regardless of changes in cerebral perfusion pressure and prevents brain damage caused by hypoperfusion or hyperperfusion. In recent decades, researchers have investigated the range of systemic blood pressures and clinical management strategies over which cerebral vasculature modifies intracranial hemodynamics to maintain cerebral perfusion. However, proposed clinical interventions to optimize autoregulation status have not demonstrated clear clinical benefit. As future trials are designed, it is crucial to comprehend the underlying cause of our inability to produce robust clinical evidence supporting the concept of CA-targeted management. This article examines the technological advances in monitoring techniques and the accuracy of continuous assessment of autoregulation techniques used in intraoperative and intensive care settings today. It also examines how increasing knowledge of CA from recent clinical trials contributes to a greater understanding of secondary brain injury in many disease processes, despite the fact that the lack of robust evidence influencing outcomes has prevented the translation of CA-guided algorithms into clinical practice.

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.

Association of Intraventricular Fibrinolysis With Clinical Outcomes in Intracerebral Hemorrhage: An Individual Participant Data Meta-Analysis

BACKGROUND

In patients with intracerebral hemorrhage (ICH), the presence of intraventricular hemorrhage constitutes a promising therapeutic target. Intraventricular fibrinolysis (IVF) reduces mortality, yet impact on functional disability remains unclear. Thus, we aimed to determine the influence of IVF on functional outcomes.

METHODS

This individual participant data meta-analysis pooled 1501 patients from 2 randomized trials and 7 observational studies enrolled during 2004 to 2015. We compared IVF versus standard of care (including placebo) in patients treated with external ventricular drainage due to acute hydrocephalus caused by ICH with intraventricular hemorrhage. The primary outcome was functional disability evaluated by the modified Rankin Scale (mRS; range: 0-6, lower scores indicating less disability) at 6 months, dichotomized into mRS score: 0 to 3 versus mRS: 4 to 6. Secondary outcomes included ordinal-shift analysis, all-cause mortality, and intracranial adverse events. Confounding and bias were adjusted by random effects and doubly robust models to calculate odds ratios and absolute treatment effects (ATE).

RESULTS

Comparing treatment of 596 with IVF to 905 with standard of care resulted in an ATE to achieve the primary outcome of 9.3% (95% CI, 4.4-14.1). IVF treatment showed a significant shift towards improved outcome across the entire range of mRS estimates, common odds ratio, 1.75 (95% CI, 1.39-2.17), reduced mortality, odds ratio, 0.47 (95% CI, 0.35-0.64), without increased adverse events, absolute difference, 1.0% (95% CI, -2.7 to 4.8). Exploratory analyses provided that early IVF treatment (≤48 hours) after symptom onset was associated with an ATE, 15.2% (95% CI, 8.6-21.8) to achieve the primary outcome.

CONCLUSIONS

As compared to standard of care, the administration of IVF in patients with acute hydrocephalus caused by intracerebral and intraventricular hemorrhage was significantly associated with improved functional outcome at 6 months. The treatment effect was linked to an early time window <48 hours, specifying a target population for future trials.

Incidence and prevalence of coma in the UK and the USA

The epidemiology of coma is unknown because case ascertainment with traditional methods is difficult. Here, we used crowdsourcing methodology to estimate the incidence and prevalence of coma in the UK and the USA. We recruited UK and US laypeople (aged ≥18 years) who were nationally representative (i.e. matched for age, gender and ethnicity according to census data) of the UK and the USA, respectively, utilizing a crowdsourcing platform. We provided a description of coma and asked survey participants if they—‘right now’ or ‘within the last year’—had a family member in coma. These participants (UK n = 994, USA n = 977) provided data on 30 387 family members (UK n = 14 124, USA n = 16 263). We found more coma cases in the USA (n = 47) than in the UK (n = 20; P = 0.009). We identified one coma case in the UK (0.007%, 95% confidence interval 0.00–0.04%) on the day of the survey and 19 new coma cases (0.13%, 95% confidence interval 0.08–0.21%) within the preceding year, resulting in an annual incidence of 135/100 000 (95% confidence interval 81–210) and a point prevalence of 7 cases per 100 000 population (95% confidence interval 0.18–39.44) in the UK. We identified five cases in the USA (0.031%, 95% confidence interval 0.01–0.07%) on the day of the survey and 42 new cases (0.26%, 95% confidence interval 0.19–0.35%) within the preceding year, resulting in an annual incidence of 258/100 000 (95% confidence interval 186–349) and a point prevalence of 31 cases per 100 000 population (95% confidence interval 9.98–71.73) in the USA. The five most common causes were stroke, medically induced coma, COVID-19, traumatic brain injury and cardiac arrest. To summarize, for the first time, we report incidence and prevalence estimates for coma across diagnosis types and settings in the UK and the USA using crowdsourcing methods. Coma may be more prevalent in the USA than in the UK, which requires further investigation. These data are urgently needed to expand the public health perspective on coma and disorders of consciousness.

COVID-19 and telehealth in the intensive care unit setting: a survey

Background

Coronavirus disease (COVID-19) has led to changes in how healthcare is delivered. Here, through the administration of surveys, we evaluated telehealth use and views in US intensive care units (ICUs) during the pandemic.

Methods

From June 2020 to July 2021, voluntary, electronic surveys were provided to ICU leaders of Johns Hopkins Medical Institution (JHMI) hospitals, members of the Neurocritical Care Society (NCS) who practice in the US, and Society of Critical Care Medicine (SCCM) members practicing adult medicine.

Results

Response rates to our survey were as follows: 18 of 22 (81.8%) JHMI-based ICU leaders, 22 of 2218 (1.0%) NCS members practicing in the US, and 136 of 13,047 (1.0%) SCCM members. COVID-19 patients were among those cared for in the ICUs of 77.7, 86.4, and 93.4% of respondents, respectively, in April 2020 (defined as the peak of the pandemic). Telehealth technologies were used by 88.9, 77.3, and 75.6% of respondents, respectively, following the start of COVID-19 while only 22.2, 31.8, and 43.7% utilized them prior. The most common telehealth technologies were virtual meeting software and telephone (with no video component). Provider, nurse, and patient communications with the patient’s family constituted the most frequent types of interactions utilizing telehealth. Most common reasons for telehealth use included providing an update on a patient’s condition and conducting a goals of care discussion. 93.8–100.0% of respondents found telehealth technologies valuable in managing patients. Technical issues were noted by 66.7, 50.0, and 63.4% of respondents, respectively.

Conclusions

Telehealth use increased greatly among respondents following the start of COVID-19. In US ICUs, telehealth technologies found diverse uses during the pandemic. Future studies are needed to confirm our findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08197-7.

Intracranial Pressure and Cerebral Perfusion Pressure in Large Spontaneous Intracranial Hemorrhage and Impact of Minimally Invasive Surgery

Introduction: We investigated the effect of hematoma volume reduction with minimally invasive surgery (MIS) on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with large spontaneous intracerebral hemorrhage (ICH).

Methods:Post-hoc analysis of the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE III) study, a clinical trial with blinded outcome assessments. The primary outcome was the proportion of ICP readings ≥20 and 30 mmHg, and CPP readings <70 and 60 mm Hg. Secondary outcomes included major disability (modified Rankin scale >3) and mortality at 30 and 365 days. We assessed the relationship between proportion of high ICP and low CPP events and MIS using binomial generalized linear models, and outcomes using multiple logistic regression.

Results: Of 499 patients enrolled in MISTIE III, 72 patients had guideline based ICP monitors placed, 34 in the MIS group and 38 in control (no surgery) group. Threshold ICP and CPP events ≥20/ <70 mmHg occurred in 31 (43.1%) and 52 (72.2%) patients respectively. On adjusted analyses, proportion of ICP readings ≥20 and 30 mmHg were significantly lower in the MIS group vs. control group [Odds Ratio (OR) 0.27, 95% Confidence Interval [CI] 0.11–0.63 (p = 0.002); OR = 0.18, 0.04–0.75, p = 0.02], respectively. Proportion of CPP readings <70 and 60 mm Hg were also significantly lower in MIS patients [OR 0.31, 95% CI 0.15–0.63 (p = 0.001); OR 0.30, 95% CI 0.11–0.83 (p = 0.02)], respectively. Higher proportions of CPP readings <70 and 60 mm were significantly associated with short term mortality (p = 0.04), and (p = 0.006), respectively. Long term mortality was significantly associated with higher proportion of time with ICP ≥ 20 (p = 0.04), ICP ≥ 30 (p = 0.04), and CPP <70 mmHg (p = 0.01).

Conclusion: Our results are consistent with the hypothesis that surgical reduction of ICH volume decreases proportion of high ICP and low CPP events and that these variables are associated with short- and long-term mortality.

Proceedings of the First Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness

Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified.

Intracerebral Hemorrhage Volume Reduction and Timing of Intervention Versus Functional Benefit and Survival in the MISTIE III and STICH Trials

BACKGROUND

The extent of intracerebral hemorrhage (ICH) removal conferred survival and functional benefits in the minimally invasive surgery with thrombolysis in intracerebral hemorrhage evacuation (MISTIE) III trial. It is unclear whether this similarly impacts outcome with craniotomy (open surgery) or whether timing from ictus to intervention influences outcome with either procedure.

OBJECTIVE

To compare volume evacuation and timing of surgery in relation to outcomes in the MISTIE III and STICH (Surgical Trial in Intracerebral Hemorrhage) trials.

METHODS

Postoperative scans were performed in STICH II, but not in STICH I; therefore, surgical MISTIE III cases with lobar hemorrhages (n = 84) were compared to STICH II all lobar cases (n = 259) for volumetric analyses. All MISTIE III surgical patients (n = 240) were compared to both STICH I and II (n = 722) surgical patients for timing analyses. These were investigated using cubic spline modeling and multivariate risk adjustment.

RESULTS

End-of-treatment ICH volume ≤28.8 mL in MISTIE III and ≤30.0 mL in STICH II had increased probability of modified Rankin Scale (mRS) 0 to 3 at 180 d (P = .01 and P = .003, respectively). The effect in the MISTIE cohort remained significant after multivariate risk adjustments. Earlier surgery within 62 h of ictus had a lower probability of achieving an mRS 0 to 3 at 180 d with STICH I and II (P = .0004), but not with MISTIE III. This remained significant with multivariate risk adjustments. There was no impact of timing until intervention on mortality up to 47 h with either procedure.

CONCLUSION

Thresholds of ICH removal influenced outcome with both procedures to a similar extent. There was a similar likelihood of achieving a good outcome with both procedures within a broad therapeutic time window.

Thrombolysis for Evacuation of Intracerebral and Intraventricular Hemorrhage: A Guide to Surgical Protocols With Practical Lessons Learned From the MISTIE and CLEAR Trials

BACKGROUND

Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) procedure was recently tested in a large phase III randomized trial showing a significant probability of functional benefit in those cases that reached the goal hematoma evacuation of ≤15 mL residual (or ≥70% removal). Benefit of thrombolysis was also identified in cases with large intraventricular hemorrhage, and achieving at least 85% volume reduction in the Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial.

OBJECTIVE

To protocolize steps in the MISTIE and CLEAR procedures in order to maximize hematoma evacuation and minimize complications.

METHODS

We articulate data-driven lessons and expert opinions surrounding the factors of patient selection, catheter placement, and dosing, which impacted safety and surgical performance in the MISTIE and CLEAR trials.

RESULTS

Modifiable factors to maximize evacuation efficiency include optimizing catheter placement and pursuing aggressive dosing to achieve treatment goals, while strictly adhering to the safety steps as articulated in the respective trials. Prognostic factors that are viewed as nonmodifiable include greater initial intracerebral hemorrhage volume with irregular shape, smaller intraventricular bleeds, and the uncommon but consequential development of new bleeding during the dosing period despite strict protocol adherence.

CONCLUSIONS

Surgeon education in this tutorial is aimed at maximizing the benefit of the MISTIE and CLEAR procedures by reviewing case selection, safety steps, treatment objectives, and technical nuances. Key lessons include stability imaging, etiology screening, and technical adherence to the protocol in order to achieve defined thresholds of evacuation.

Intrathecal chemotherapy-associated cerebral vasospasm in children with hematologic malignancies

BACKGROUND

Mechanisms of chemotherapy-associated neurotoxicity are poorly understood, and therefore, prevention strategies have not been developed. We hypothesized that a subgroup of children receiving intrathecal cytarabine develops subclinical vasospasm, which may contribute to long-term neurocognitive sequelae of cancer.

METHODS

We used transcranial Doppler ultrasound to serially evaluate cerebral blood flow velocities in participants ≤25 years old receiving intrathecal cytarabine for hematologic malignancies.

RESULTS

Four of 18 participants (22%) met the criteria for subclinical vasospasm within 4 days of intrathecal cytarabine administration. The distribution of oncologic diagnoses differed between the vasospasm and non-vasospasm groups (p = 0.02). Acute myeloid leukemia was identified as a potential risk factor for vasospasm. Children with vasospasm were more likely to have received intravenous cytarabine (75% versus 0%, p = 0.01) and less likely to have received steroids (25% versus 100%, p = 0.01).

CONCLUSIONS

A subpopulation of children with hematologic malignancies develops subclinical vasospasm after intrathecal cytarabine treatment. Future research is needed to determine the long-term clinical consequences of cerebral vasospasm in this population.

IMPACT

A subset of children with hematologic malignancies who receive intrathecal cytarabine experience subclinical cerebral vasospasm, as measured by transcranial Doppler ultrasound. Of children receiving intrathecal cytarabine, those who develop cerebral vasospasm are more likely to have diagnosis of acute myeloid leukemia, more likely to receive concurrent intravenous cytarabine, and less likely to receive steroids as part of their chemotherapy regimen, as compared with children without vasospasm. Future research is needed to determine if vasospasm during chemotherapy is associated with higher rates of neurocognitive dysfunction, and if so, to focus on prevention of these long-term sequelae of childhood cancer.

A Prospective Study of Neurologic Disorders in Hospitalized Patients With COVID-19 in New York City

OBJECTIVE

To determine the prevalence and associated mortality of well-defined neurologic diagnoses among patients with coronavirus disease 2019 (COVID-19), we prospectively followed hospitalized severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients and recorded new neurologic disorders and hospital outcomes.

METHODS

We conducted a prospective, multicenter, observational study of consecutive hospitalized adults in the New York City metropolitan area with laboratory-confirmed SARS-CoV-2 infection. The prevalence of new neurologic disorders (as diagnosed by a neurologist) was recorded and in-hospital mortality and discharge disposition were compared between patients with COVID-19 with and without neurologic disorders.

RESULTS

Of 4,491 patients with COVID-19 hospitalized during the study timeframe, 606 (13.5%) developed a new neurologic disorder in a median of 2 days from COVID-19 symptom onset. The most common diagnoses were toxic/metabolic encephalopathy (6.8%), seizure (1.6%), stroke (1.9%), and hypoxic/ischemic injury (1.4%). No patient had meningitis/encephalitis or myelopathy/myelitis referable to SARS-CoV-2 infection and 18/18 CSF specimens were reverse transcriptase PCR negative for SARS-CoV-2. Patients with neurologic disorders were more often older, male, white, hypertensive, diabetic, intubated, and had higher sequential organ failure assessment (SOFA) scores (all p < 0.05). After adjusting for age, sex, SOFA scores, intubation, history, medical complications, medications, and comfort care status, patients with COVID-19 with neurologic disorders had increased risk of in-hospital mortality (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.17-1.62, p < 0.001) and decreased likelihood of discharge home (HR 0.72, 95% CI 0.63-0.85, p < 0.001).

CONCLUSIONS

Neurologic disorders were detected in 13.5% of patients with COVID-19 and were associated with increased risk of in-hospital mortality and decreased likelihood of discharge home. Many observed neurologic disorders may be sequelae of severe systemic illness.

Risk Factors of Ischemic and Hemorrhagic Strokes During Venovenous Extracorporeal Membrane Oxygenation: Analysis of Data From the Extracorporeal Life Support Organization Registry

OBJECTIVES

Stroke is commonly reported in patients receiving venovenous extracorporeal membrane oxygenation, but risk factors are not well described. We sought to determine preextracorporeal membrane oxygenation and on-extracorporeal membrane oxygenation risk factors for both ischemic and hemorrhagic strokes in patients with venovenous extracorporeal membrane oxygenation support.

DESIGN

Retrospective analysis.

SETTING

Data reported to the Extracorporeal Life Support Organization by 366 extracorporeal membrane oxygenation centers from 2013 to 2019.

PATIENTS

Patients older than 18 years supported with a single run of venovenous extracorporeal membrane oxygenation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 15,872 venovenous extracorporeal membrane oxygenation patients, 812 (5.1%) had at least one type of acute brain injury, defined as ischemic stroke, hemorrhagic stroke, or brain death. Overall, 215 (1.4%) experienced ischemic stroke and 484 (3.1%) experienced hemorrhagic stroke. Overall inhospital mortality was 36%, but rates were higher in those with ischemic or hemorrhagic stroke (68% and 73%, respectively). In multivariable analysis, preextracorporeal membrane oxygenation pH (adjusted odds ratio = 0.10; 95% CI, 0.03-0.35; p < 0.001), hemolysis (adjusted odds ratio = 2.27; 95% CI, 1.22-4.24; p = 0.010), gastrointestinal hemorrhage (adjusted odds ratio = 2.01; 95% CI 1.12-3.59; p = 0.019), and disseminated intravascular coagulation (adjusted odds ratio = 3.61; 95% CI, 1.51-8.66; p = 0.004) were independently associated with ischemic stroke. Pre-extracorporeal membrane oxygenation pH (adjusted odds ratio = 0.28; 95% CI, 0.12-0.65; p = 0.003), preextracorporeal membrane oxygenation Po2 (adjusted odds ratio = 0.96; 95% CI, 0.93-0.99; p = 0.021), gastrointestinal hemorrhage (adjusted odds ratio = 1.70; 95% CI, 1.15-2.51; p = 0.008), and renal replacement therapy (adjusted odds ratio=1.57; 95% CI, 1.22-2.02; p < 0.001) were independently associated with hemorrhagic stroke.

CONCLUSIONS

Among venovenous extracorporeal membrane oxygenation patients in the Extracorporeal Life Support Organization registry, approximately 5% had acute brain injury. Mortality rates increased two-fold when ischemic or hemorrhagic strokes occurred. Risk factors such as lower pH and hypoxemia during the pericannulation period and markers of coagulation disturbances were associated with acute brain injury. Further research on understanding preextracorporeal membrane oxygenation and on-extracorporeal membrane oxygenation risk factors and the timing of acute brain injury is necessary to develop appropriate prevention and management strategies.

Advances in Therapeutic Approaches for Spontaneous Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) results in high rates of morbidity and mortality, with intraventricular hemorrhage (IVH) being associated with even worse outcomes. Therapeutic interventions in acute ICH have continued to emerge with focus on arresting hemorrhage expansion, clot volume reduction of both intraventricular and parenchymal hematomas, and targeting perihematomal edema and inflammation. Large randomized controlled trials addressing the effectiveness of rapid blood pressure lowering, hemostatic therapy with platelet transfusion, and other clotting complexes and hematoma volume reduction using minimally invasive techniques have impacted clinical guidelines. We review the recent evolution in the management of acute spontaneous ICH, discussing which interventions have been shown to be safe and which may potentially improve outcomes.

Global Consortium Study of Neurological Dysfunction in COVID-19 (GCS-NeuroCOVID): Study Design and Rationale

BACKGROUND

As the COVID-19 pandemic developed, reports of neurological dysfunctions spanning the central and peripheral nervous systems have emerged. The spectrum of acute neurological dysfunctions may implicate direct viral invasion, para-infectious complications, neurological manifestations of systemic diseases, or co-incident neurological dysfunction in the context of high SARS-CoV-2 prevalence. A rapid and pragmatic approach to understanding the prevalence, phenotypes, pathophysiology and prognostic implications of COVID-19 neurological syndromes is urgently needed.

METHODS

The Global Consortium to Study Neurological dysfunction in COVID-19 (GCS-NeuroCOVID), endorsed by the Neurocritical Care Society (NCS), was rapidly established to address this need in a tiered approach. Tier-1 consists of focused, pragmatic, low-cost, observational common data element (CDE) collection, which can be launched immediately at many sites in the first phase of this pandemic and is designed for expedited ethical board review with waiver-of-consent. Tier 2 consists of prospective functional and cognitive outcomes assessments with more detailed clinical, laboratory and radiographic data collection that would require informed consent. Tier 3 overlays Tiers 1 and 2 with experimental molecular, electrophysiology, pathology and imaging studies with longitudinal outcomes assessment and would require centers with specific resources. A multicenter pediatrics core has developed and launched a parallel study focusing on patients ages <18 years. Study sites are eligible for participation if they provide clinical care to COVID-19 patients and are able to conduct patient-oriented research under approval of an internal or global ethics committee. Hospitalized pediatric and adult patients with SARS-CoV-2 and with acute neurological signs or symptoms are eligible to participate. The primary study outcome is the overall prevalence of neurological complications among hospitalized COVID-19 patients, which will be calculated by pooled estimates of each neurological finding divided by the average census of COVID-19 positive patients over the study period. Secondary outcomes include: in-hospital, 30 and 90-day morality, discharge modified Rankin score, ventilator-free survival, ventilator days, discharge disposition, and hospital length of stay.

RESULTS

In a one-month period (3/27/20-4/27/20) the GCS-NeuroCOVID consortium was able to recruit 71 adult study sites, representing 17 countries and 5 continents and 34 pediatrics study sites.

CONCLUSIONS

This is one of the first large-scale global research collaboratives urgently assembled to evaluate acute neurological events in the context of a pandemic. The innovative and pragmatic tiered study approach has allowed for rapid recruitment and activation of numerous sites across the world-an approach essential to capture real-time critical neurological data to inform treatment strategies in this pandemic crisis.

Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure

BACKGROUND

Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr).

OBJECTIVE

To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes.

METHODS

Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial.

RESULTS

Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation.

CONCLUSION

This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.

Primary intraventricular hemorrhage outcomes in the CLEAR III trial

BACKGROUND

Intraventricular hemorrhage occurs due to intracerebral hemorrhage with intraventricular extension or without apparent parenchymal involvement, known as primary intraventricular hemorrhage.

AIMS

We evaluated the prognosis of primary intraventricular hemorrhage patients in the CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage).

METHODS

In patients with primary intraventricular hemorrhage versus those with secondary intraventricular hemorrhage, we compared intraventricular alteplase response and outcomes including modified Rankin Scale, Barthel Index, National Institutes of Health Stroke Scale (NIHSS), and extended Glasgow Outcome Scale (eGOS) at 30, 180, and 365 days. Outcomes were also compared in primary intraventricular hemorrhage patients who received intraventricular alteplase versus placebo (normal saline) and in matched primary and secondary intraventricular hemorrhage patients using inverse-probability-weighted regression adjustment.

RESULTS

Of 500 patients enrolled in CLEAR III, 46 (9.2%) had primary intraventricular hemorrhage. Combining both treatment groups, primary intraventricular hemorrhage patients had larger intraventricular hemorrhage volumes (median: 34.2 mL vs. 20.8 mL, p < 0.01) but similar intraventricular hemorrhage removal (51.0% vs. 59.0%, p = 0.24) compared to secondary intraventricular hemorrhage patients, respectively. Confirming previous studies, primary intraventricular hemorrhage patients achieved better NIHSS, modified Rankin Scale, Barthel Index, and eGOS scores at days 30, 180, and 365, respectively (all p < 0.01), although mortality was similar to secondary intraventricular hemorrhage patients; matching analysis yielded similar results. Primary intraventricular hemorrhage patients who received intraventricular alteplase (n = 19) and saline (n = 27) achieved similar outcomes.

CONCLUSIONS

In CLEAR III, primary intraventricular hemorrhage patients who survived achieved better long-term outcomes than surviving secondary intraventricular hemorrhage patients with similar mortality. Outcomes and safety were similar between primary intraventricular hemorrhage patients receiving alteplase and those receiving saline.

Abstract 76: Non-Contrast CT Markers and Pre- and Post-Surgical Hematoma Expansion in the MISTIE III Trial Surgical Cohort

Introduction: A range of findings on non-contrast CT (NCCT) have been found to predict hematoma expansion after spontaneous ICH, but it is unclear whether these findings predict peri-procedural bleeding. We explored whether any specific NCCT marker(s) predict pre- or post-surgical hematoma expansion events.

Methods: NCCTs were reviewed for presence of black hole sign, blend sign, swirl sign, and island sign in the surgical cohort from the MISTIE-III trial which evaluated minimally invasive surgery plus alteplase in ICH >30 mL. Hematoma expansion was defined as any expansion ≥6 mL or 33% ICH volume increase during pre-surgical period (Model 1) from diagnostic CT (DiagCT) to 24 hours post DiagCT and from stability CT (StabCT) to 24 hours post last dose of alteplase (Model 2). Blend sign was removed from analysis due to small sample size. Multivariable logistic regression analysis was performed to identify independent predictors of pre-op and post-op hematoma expansion.

Results: Of 250 surgical subjects, 5 were excluded due to poor image quality. Expansion events occurred in 82 of 234 (35.0%) subjects in the pre-op interval and in 15 of 226 (7%) in the post-op interval. None of the markers were significant for pre-op expansion, but ICH volume and time from ictus to DiagCT were statistically significant predictors. Swirl sign, ICH volume, and posterior trajectory compared to lateral trajectory were independent predictors of post-op expansion events. Expansion volume pre-op and post-op were weakly associated with presence of swirl sign; Spearmans rho=0.3 p=0.065 and rho=0.60 p=0.047, respectively.

Conclusion: This is the first analysis of impact of NCCT markers on re-bleeding post minimally invasive surgery from a large clinical trial. Despite an absence of association between NCCT markers and hematoma expansion in the pre-surgical period perhaps reflecting inclusion criteria for hemorrhage stability, swirl sign was associated with post-surgical rebleeding.

Abstract WMP103: Comparative Impact of Extent of Lobar Intracerebral Hemorrhage Removal on Outcome in the MISTIE III and STICH II Trials

Introduction: The Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation Phase III trial (MISTIE III) concluded that the extent of hematoma reduction confers a mortality and functional benefit. It is unclear if a minimum extent of evacuation is needed for mortality and functional outcome benefit in lobar cases with MISTIE and with open surgical interventions.

Objective: We analyzed the effect of extent of lobar ICH evacuation on clinical outcome at 180 days after undergoing the MISTIE procedure and open craniotomy, in the context of the MISTIE III and STICH II clinical trials, respectively.

Methods: Patients randomized to the surgical arm with lobar ICH, who underwent the procedure in the MISTIE III trial (n=84) and the STICH II trial (n=266) were analyzed, excluding cases crossing over to surgery. We assessed end of treatment ICH volume on post procedure CT scans and % hematoma evacuation, in relation to survival and likelihood of mRS 0-3. Cubic spline modeling with dichotomized outcome was used to compare the extent of hematoma evacuation on clinical outcome.

Results: End of treatment volume of < 28 mL in lobar ICH MISTIE III patients and < 30 mL in STICH II trial patients showed a significantly increased probability of achieving an mRS of 0-3 at 180 days (p<0.03, p<0.006, respectively). This threshold was achieved in 83.1% of lobar cases undergoing MISTIE and in 92.1% of surgical cases in STICH II. Achieving survival benefit at 180 days trended towards improved probability with further hematoma volume reduction without a threshold value in MISTIE III, and was significant per mL reduction in STICH II (p<0.001). Analysis by percent of hematoma evacuation trended toward better probabilities of survival and improved functional outcome but were not significant.

Conclusion: This analysis confirms that extent of hematoma evacuation is important in attaining the benefits of both minimally invasive and open surgical interventions in non-herniating lobar ICH patients randomized in clinical trials. Extent of ICH evacuation must be considered in the analysis of comparative effectiveness of various techniques and in the design of future trials.

Abstract 17: An Evaluation of Patient Disposition and Long-term Health-related Quality of Life In MISTIE III: Opportunities to Improve Decision Making for Critically Ill Intracerebral Hemorrhage Patients

Introduction: Recovery in intracerebral hemorrhage (ICH) is prolonged and unpredictable, resulting in challenges in estimating health-related quality of life (HRQoL). We describe HRQoL and patient disposition for ICH survivors with similar clinical characteristics to ICH patients who had withdrawal of life-sustaining treatment (WoLST).

Methods: Using MISTIE III trial data (N = 499), we performed a matched cohort analysis using a published modified severity index (mSI) to compare ICH survivors (N = 379) with WoLST patients (N = 61). We used multivariable logistic regression adjusting for age, Glasgow Coma Score, deep ICH location, stability ICH and intraventricular hemorrhage volume and ≥ 3 comorbidities to create the mSI. After matching survivors with equal mSI to WoLST patients, we compared EuroQoL (EQ) visual analog scale (VAS) scores (US norm 69-76; range 0-100) by mSI quartile and patient disposition.

Results: We matched 224 survivors to WoLST patients by mSI (range 0-6.5), with data at all timepoints. Given the large mSI range, EQ VAS scores and patient disposition were evaluated by mSI quartile groups. The median (interquartile range [IQR]) EQ VAS score increase for all mSI groups from day 30 (D30) to 180 (D180) was 20 (0-35.5, p < 0.0001), and 23.5 (5-40, p < 0.0001) for D30 to 365 (D365). The highest percentage of survivors for all mSI groups were home by D365 (G1 55%, G2 88%, G3 84.5%, G4 90%). Median (IQR) EQ VAS scores by mSI quartile, patient disposition and timepoint are reported below.

Conclusion: ICH survivors, matching WoLST individuals, in all mSI groups demonstrated improvement in HRQoL over time, and the majority were home by D365. This study challenges current practice of identifying poor outcomes in concert with decision making employing WoLST in ICH. If goals of care are to include return to home and HRQoL, these results strongly suggest that prognostication can be improved. Prospective studies of ICH prognostication and decision making are needed.

Abstract 12: An Evaluation of Functional Outcome at 1 Year of Poor Prognosis Patients in Mistie-III

Introduction: Clinical factors impacting prognosis following Intracerebral Hemorrhage (ICH) have been well described in the literature, with “poor” prognosis often leading to withdrawing life sustaining treatments (WoLST). The MISTIE-III trial data provides an opportunity to review 12 month outcome of “poor" prognosis subjects.

Methods: In order to evaluate functional recovery of ICH survivors compared with patients who had WoLST we used a severity index (SI) score for predicting good functional recovery 1 year following ICH. The SI used 6 clinical univariate variables from the MISTIE-III analysis (age > 67, Glasgow Coma Score [GCS] < 8, deep ICH location, stability ICH volume > 45mL, stability intraventricular hemorrhage (IVH) volume>0.4mL) and > 3 comorbidities (hypertension, hyperlipidemia, cardiovascular disease, and end-stage renal disease). Based on the SI scores for subjects who had WoLST, a matched cohort of survivors with “poor" prognosis (mRS 4-5) were tracked for functional recovery for 12 months.

Results: Of the participants enrolled in MSITIE-III, 61 had WoLST. Of the non-WoLST ICH survivors, 16 progressed to death during the acute period. Another 48 had died prior to the 1 year (D365) follow up. At the 30 Day (D30) evaluation, there were 263 ICH survivors with “poor" prognosis SI scores having a mRS of 4 or 5 and 94% were still in a treatment facility. By D365, 47% of the “poor prognosis” patients had improved to mRS 0-3 (good outcome) with 98% living at home. Of the remaining, 36% had a mRS of 4 (moderately severe disability) with 64% living at home, and 17% had a mRS of 5 (severe disability) with 31% living at home.

Conclusion: For family members of patients sustaining an ICH where clinical factors indicate a “poor" prognosis, the decision to continue or withdraw life sustaining treatment is difficult. Our data shows that ICH patients with clinical factors that are assumed to indicate “poor" prognosis for recovery can, when given time, achieve a favorable outcome.

Abstract TP335: Comparative Impact of Timing From Ictus to Intracerebral Hemorrhage Evacuation on Outcome in MISTIE III, STICH I & II Trials

Introduction: Completion of the MISTIE procedure requires a period of hematoma stability before and during hematoma removal and, if necessary, dosing of rtPA which can take days to complete. Early surgery was intended in the STICH I and II trials, yet was performed after varying delays. No previous analysis has evaluated the timing for hematoma removal on outcomes in these trials.

Objective: Determine if time from ictus to completion of hematoma removal may have affected patient outcome in three large surgical clinical trials of ICH evacuation.

Methods: Patients randomized to surgery in the MISTIE III (n=242), STICH I (n=464) and STICH II (n=266) trials who received the procedure were analyzed, excluding cases crossing over to surgery. Time from ictus to end of treatment, defined as 24 hours after last dose in (MISTIE III) or time to craniotomy (STICH I and II), was analyzed in relation to likelihood of survival and functional outcome at 180 days. Cubic spline models with dichotomized outcomes were used.

Results: The probability of achieving an mRS 0-3 increased significantly with longer time until completion of the procedure, up to 83 hours post-ictus, and worsened with longer delays thereafter (p=0.05). Better mRS was also achieved in STICH I patients with longer time until surgical removal, up to 60 hours post-ictus (p=0.0002), but not with longer delays (p=0.49). In STICH II (lobar cases), there was greater likelihood of mRS 0-3 with longer delay after 22 hours post-ictus (p=0.004), but not with earlier surgery (p=0.19). There was no significant benefit in survival, with earlier intervention across modalities and trials. Adjustment by initial hematoma volume further validated that early procedures do not favor survival or achieving a mRS 0-3.

Conclusion: Early hematoma evacuation up to 60-80 hours post-ictus does not increase the probability of survival nor a good functional outcome in non-herniating ICH patients included in clinical trials, likely in view of bleeding instability. This was true in minimally invasive intervention as well as open surgeries.

Enhancing the Informed Consent Process Using Shared Decision Making and Consent Refusal Data from the CLEAR III Trial

BACKGROUND

The process of informed consent in National Institutes of Health randomized, placebo-controlled trials is poorly studied. There are several issues regarding informed consent in emergency neurologic trials, including a shared decision-making process with the patient or a legally authorized representative about overall risks, benefits, and alternative treatments.

METHODS

To evaluate the informed consent process, we collected best and worst informed consent practice information from a National Institutes of Health trial and used this in medical simulation videos to educate investigators at multiple sites to improve the consent process. Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) (clinicaltrials.gov, NCT00784134) studied the effect of intraventricular alteplase (n = 251) versus saline (placebo) injections (n = 249) for intraventricular hemorrhage reduction. Reasons for ineligibility (including refusing to consent) for all screen failures were analyzed. The broadcasted presentation outlined best practices for doctor-patient interactions during the consenting process, as well as anecdotal, study-specific reasons for consent refusal. Best and worst consent elements were then incorporated into a simulation video to enhance the informed consent process. This video was disseminated to trial sites as a webinar around the midpoint of the trial to improve the consent process. Pre- and post-intervention consent refusals were compared.

RESULTS

During the trial, 10,538 patients were screened for eligibility, of which only three were excluded due to trial timing. Pre-intervention, 77 of 5686 (1.40%) screen eligible patients or their proxies refused consent. Post-intervention, 55 of 4849 (1.10%) refused consent, which was not significantly different from pre-intervention (P = 0.312). The incidence of screen failures was significantly lower post-intervention (P = 0.006), possibly due to several factors for patient exclusion.

CONCLUSION

The informed consent process for prospective randomized trials may be enhanced by studying and refining best practices based on trial-specific plans and patient concerns particular to a study.

Abstract TMP19: MRI Characteristics and Predictors of Diffusion Weighted Hyperintense Lesions After Spontaneous Intracerebral Hemorrhage: A Secondary Analysis of MISTIE-III

Introduction: Mechanisms of diffusion weighted hyperintense lesions (DWIHL) after spontaneous intracerebral hemorrhage (ICH) are controversial. We evaluated mechanism and outcome of DWIHL.

Methods: Protocolized MRI scans within 7 days from ICH were reviewed from MISTIE-III trial. Imaging analysis included DWIHL, leukoariosis (Fazekas score), enlarged perivascular space (EPVS), and cerebral microbleeds. Multivariable logistic regression analysis was performed to assess predictors and outcomes of having DWIHLs. Favorable outcome was defined as modified Rankin Score 0-3 at 12 months.

Results: Of 499 patients, 300 underwent DWI studies (62% lobar ICH; 38% deep ICH) and 178 (59%) had acute DWIHLs (66% lobar; 34% deep). DWIHL locations were perihematomal in 140 (79%); and remote in 96 (54%). In multivariable regression analysis, DWIHLs were associated with initial mean arterial pressure [MAP] (odds ratio [OR]: 1.004; 95% confidence interval [CI]: 1.002-1.01), initial ICH volume (OR: 1.004; 95%CI: 1.001-1.01), NIHSS at randomization (OR: 1.01; 95%CI: 1.01-1.02), hypertension history (OR: 1.41; 95%CI: 1.04-1.93), and Fazekas score (OR: 1.04; 95%CI: 1.01-1.08). Patients with DWIHLs were less likely to have favorable outcome (66% vs. 50%; OR: 0.89; 95%CI: 0.81-0.99) after adjusting for ICH severity; however, the presence of DWIHLs did not confer an independent mortality risk at 12 months. In addition, perihematomal DWIHLs were associated with ICH volume (OR: 1.003; 95%CI: 1.00-1.01), NIHSS (OR: 1.01; 95%CI: 1.00-1.02), deep location (OR: 1.25; 95%CI: 1.10-1.42), and centrum semiovale EPVS score (OR: 0.99; 95% CI: 0.99-1.00). Remote DWIHLs were associated with Fazekas score (OR: 1.17; 95%CI: 1.06-1.29), centrum semiovale EPVS score (OR: 1.01; 95%CI: 1.00-1.01), atrial fibrillation (OR: 1.40; 95%CI: 1.04-1.90), and maximal ΔMAP on first 24 hours (OR: 1.004; 95%CI: 1.001-1.006).

Conclusions: DWIHLs were common (59%) in patients after spontaneous ICH, predominantly in lobar locations and were associated with unfavorable neurologic outcome. While perihematomal DWIHLs were associated with ICH severity, remote DWIHLs suggested different mechanisms including acute blood pressure reduction, cardiac emboli, and white matter disease severity.

Abstract TP354: Risk Stratification by Hemorrhage Location for Intracerebral Hemorrhage Patients in Large Administrative Databases

Background: The Nationwide Inpatient Sample (NIS) represents 90% of US hospitalizations. Beginning fourth quarter (Q4) 2015, NIS transitioned to ICD 10. ICD 10 codes for Intracerebral Hemorrhage (ICH) are hemorrhage location specific, which may predict outcomes. We examine the utilization of ICD 10 codes for ICH patients across various demographic, hospital, and disease severity factors in Q4 2015 and 2016 NIS. We report factors associated with use of non-specific codes (NSC) and assess potential coding validation based on expectations of in-hospital mortality (IHM).

Methods: We used ICD 10 codes (i610-16, i618-19) to identify non-traumatic ICH discharges. We categorized hemorrhage locations as (1) Hemispheric (cortical or subcortical) [i610-12], (2) Brain Stem or Cerebellar [i613-14], (3) Intraventricular Hemorrhage (IVH) [i615], (4) Multiple Localized [i616], and (5) Other and Not Specified [i618-19]. We considered ‘Other and Not Specified’ category as NSC and fit survey design logistic regression models for factors associated with NSC.

Results: We identified 79, 290 ICH discharges of which 38.9% were NSC. Proportion of discharges by lCH location and corresponding IHM is shown in Figure 1. Highest IHM was observed for IVH. In the fully adjusted model advanced age and white race (vs. African American) were independently associated with higher NSC use. ICH discharges from urban teaching hospitals were less likely to be NSC as compared to rural hospitals (OR, 95% CI: 0.7, 0.6 - 0.8). Patients discharged from large and medium size hospitals were 28% and 17% more likely to be provided a specific code as compared to smaller hospitals. Hospitals in Northeast US were more likely to use NSC.

Conclusion: ICD 10 codes provide an opportunity for risk adjustment in administrative data for ICH, we demonstrate that up to 40% of discharges had NSC which is more prevalent in smaller/rural/Northeast hospitals. Our work sets a foundation for examining bias caused by NSC in future studies.

From systemic to selective brain cooling - Methods in review

Therapeutic hypothermia (TH) remains one of the few proven neuroprotective modalities available in clinical practice today. Although targeting lower temperatures during TH seems to benefit ischemic brain cells, systemic side effects associated with global hypothermia limit its clinical applicability. Therefore, the ability to selectively reduce the temperature of the brain while minimally impacting core temperature allows for maximizing neurological benefit over systemic complications. In that scenario, selective brain cooling (SBC) has emerged as a promising modality of TH. In this report, we reviewed the general concepts of TH, from systemic to selective brain hypothermia, and explored the different cooling strategies and respective evidence, including preclinical and clinical data. SBC has been investigated in different animal models with promising results, wherein organ-specific, rapid, and deep target brain temperature managements stand out as major advantages over systemic TH. Nevertheless, procedure-related complications and adverse events still remain a concern, limiting clinical translation. Different invasive and noninvasive methods for SBC have been clinically investigated with variable results, and although adverse effects were still reported in some studies, therapies rendered overall safe profiles. Further study is needed to define the optimal technique, timing of initiation, rate and length of cooling as well as target temperature and rewarming protocols for different indications.

Symptomatic Hemorrhagic Complications in Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III Clinical Trial (CLEAR III): A Posthoc Root-Cause Analysis

BACKGROUND

As intraventricular thrombolysis for intraventricular hemorrhage (IVH) has developed over the last 2 decades, hemorrhagic complications have remained a concern despite general validation of its safety in controlled trials in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-IVH) program.

OBJECTIVE

To analyze factors associated with symptomatic bleeding following IVH with and without thrombolysis in conjunction with the recently completed CLEAR III trial.

METHODS

We reviewed safety reports on symptomatic bleeding events reported during the first year after randomization among subjects enrolled in the CLEAR III trial. Clinical and imaging data were retrieved through the trial database as part of ongoing quality and safety monitoring. A posthoc root-cause analysis was performed to identify potential factors predisposing to rebleeding in each case. Cases were classified according to onset of rebleeding (during dosing, early after dosing and delayed), the pattern of bleeding, and treatment rendered (alteplase vs saline).

RESULTS

Twenty subjects developed a secondary symptomatic intracranial hemorrhage constituting 4% of subjects. Symptomatic rebleeding events occurred during the dosing protocol (n = 9, 67% alteplase), early after the protocol (n = 5, 40% alteplase), and late (n = 6, 0% alteplase). Catheter-related hemorrhages were the most common (n = 7, 35%) followed by expansion or new intraventricular (n = 6, 30%) and intracerebral (n = 5, 25%) hemorrhages. Symptomatic hemorrhages during therapy resulted from a combination of treatment- and patient-related factors and were at most partially attributable to alteplase. Rebleeding after the dosing protocol primarily reflected patients' risk factors.

CONCLUSION

Intraventricular thrombolysis marginally increases the overall risk of symptomatic hemorrhagic complications after IVH, and only during the treatment phase.

Blood Pressure Variability Predicts Poor In-Hospital Outcome in Spontaneous Intracerebral Hemorrhage

Background and Purpose- There is increasing evidence that higher systolic blood pressure variability (SBPV) may be associated with poor outcome in patients with intracerebral hemorrhage (ICH). We explored the association between SBPV and in-hospital ICH outcome. Methods- We collected 10-years of consecutive data of spontaneous ICH patients at 2 healthcare systems. Demographics, medical history, laboratory tests, computed tomography scan data, in-hospital treatments, and neurological and functional assessments were recorded. Blood pressure recordings were extracted up to 24 hours postadmission. SBPV was measured using SD, coefficient of variation, successive variation (SV), range and 1 novel index termed functional SV. The effects of SBPV on the functional outcome at discharge were evaluated by multivariate logistic and ordinal regression analyses for dichotomous and trichotomous modified Rankin Scale categorizations, respectively. In secondary analyses, associations between SBPV, history of hypertension, and hematoma expansion were explored. Results- The analysis included 762 subjects. All 5 SBPV indices were significantly associated with the probability of unfavorable outcome (modified Rankin Scale score, 4-6) in logistic models. In ordinal models, SD, coefficient of variation, range, and functional SV were found to have a significant effect on the probabilities of poor (modified Rankin Scale score, 3-4) and severe/death (modified Rankin Scale score, 5-6) outcomes. Normotensive patients had significantly lower mean SBPV compared with the untreated-hypertension cohort for all SBPV indices and compared with treated-hypertension patients for 3 out of 5 SBPV indices. Lower mean SBPV of treated-hypertension subjects compared with untreated-hypertension subjects was only detected in the SV and functional SV indices (P=0.045). None of the SBPV indices were significantly associated with the probability of hematoma expansion. Conclusions- Higher SBPV in the first 24 hours of admission was associated with unfavorable in-hospital outcome among ICH patients. Further prospective studies are warranted to understand any cause-effect relationship and whether controlling for SBPV may improve the ICH outcome.

Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial

BACKGROUND

Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage.

METHODS

MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0-3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number NCT01827046.

FINDINGS

Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0-3 at 365 days (adjusted risk difference 4% [95% CI -4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012).

INTERPRETATION

For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons.

FUNDING

National Institute of Neurological Disorders and Stroke and Genentech.

Abstract WMP97: Racial/Ethnic Disparities in the Risk of Intracerebral Hemorrhage Recurrence

Background: Race/ethnicity is associated with risk of first-ever spontaneous intracerebral hemorrhage (ICH), but the influence of race/ethnicity on risk of ICH recurrence has not been well studied in a large, diverse population.

Methods: We used claims data on all discharges from community hospital inpatient stays in California between January 1, 2005 and December 31, 2011 to identify patients who were hospitalized for ICH. California residents who survived to discharge were included. We used validated diagnosis codes to identify a primary outcome of recurrent ICH. We then used survival curves and log-rank tests for unadjusted analyses of survival across race/ethnic groups and multivariable Cox proportional-hazards regression to determine factors associated with risk of ICH recurrence after adjusting for potential confounders.

Results: Between 2005-2011, we identified 31,554 first-ever ICH patients who survived to discharge, of which 15,828 (50%) were white, 6,254 (20%) Hispanic, 4,268 (14%) Asian, and 2,820 (9%) black. There were 1339 recurrences (4.2%) over a median follow-up time of 2.9 years (IQR 3.8). The 1-year recurrence rate was 3.0% (95% CI 2.8%-3.2%). In univariable and multivariable analysis, blacks (HR 1.22, 95% CI 1.01-1.48; p=0.035) and Asians (HR 1.29, 95% CI 1.10-1.50; p=0.001) had a higher risk of ICH recurrence than whites (reference categories). Private insurance was associated with a significant reduction in the risk of ICH recurrence compared to subjects with Medicare (HR 0.60, 95% CI 0.50-0.73, p<0.001), with consistent estimates across race/ethnic groups.

Conclusions: Black and Asian subjects had a higher risk of ICH recurrence than white or Hispanic subjects. Further research is needed to determine drivers of these disparities.

Abstract TP546: Association of Near-Infrared Spectroscopy Defined Regional Cerebral Oxygen Saturation with Progression of Cerebral White Matter Hyperintensity Lesions in Comatose Patients

Background: Real-time regional cerebral oxygen saturation (rScO 2 ) measurement using near-infrared spectroscopy (NIRS) may aid in the identification of intracerebral ischemia in critically ill patients. Ischemia to the cerebral white matter results in injury detectable by brain MRI as white matter hyperintensities (WMH). We hypothesized that rScO 2 as assessed by NIRS correlates with the degree of WMH progression in patients admitted to a neurocritical care unit (NCCU).

Materials and Methods: Retrospective study of eight comatose patients (Glasgow Coma Scale ≤8) in the NCCU who were continuously monitored for three days after their coma onset with NIRS to assess rScO 2, and who had a brain MRI upon admission and before their hospital discharge. Semi-automated volumetry based on intensity thresholding was used to quantify the WMH volume on FLAIR sequences. The degree of WMH progression was calculated by subtracting the WMH volume of the admission MRI from discharge MRI. Spearman rank correlation was used to determine the strength of association between the rScO 2 (averaged over the monitoring period) and the degree of WMH progression.

Results: The median averaged rScO 2 was 61 (IQR (48-73) and the lowest 45. Overall, rScO 2 inversely correlated with WMH progression (rho -.738, p= 0.037); i.e., a lower rScO 2 was associated with greater WMH progression (Figure 1). Patients with greater WMH progression had a worse modified Rankin Scale on discharge (rho .769, p= 0.026).

Interpretation: Our study provides proof of principle that rScO 2 as assessed by non-invasive NIRS monitoring may aid detection of cerebral white matter injury.

Abstract WMP100: Prior Antiplatelet Use and Outcomes After Lobar, Deep, and Intraventricular Hemorrhage

Introduction: We examined the association between prior antiplatelet therapy and outcomes in patients with lobar versus deep intracerebral hemorrhage (ICH) versus intraventricular hemorrhage (IVH).

Methods: We performed a retrospective cohort study using data from patients with lobar and deep ICH registered in the Virtual International Stroke Trials Archive (VISTA-ICH), and patients with IVH enrolled in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. We excluded patients in the intervention arms of the trials, and those on prior anticoagulation therapy. The exposure was antiplatelet therapy prior to ICH/IVH. Primary outcomes were hematoma expansion and death/major disability in the VISTA-ICH cohort, and ventriculostomy tract hemorrhage, hematoma expansion, and death/major disability in the CLEAR III cohort. We used separate sets of logistic regression models in each group—lobar ICH, deep ICH, and IVH—to examine the association between antiplatelet therapy and our outcomes.

Results: Among 548 ICH patients in the VISTA-ICH cohort, there were 416 (75.9%) lobar and 121 (22.1%) deep hematomas. Median baseline ICH volumes were 19 ml (IQR, 11-26) in lobar and 8 ml (IQR, 4-13) in deep bleeds. Prior antiplatelet therapy was reported in 92 patients with lobar (22.1%) and 26 patients (20.8%) patients with deep ICH. After adjustment for demographics, comorbidities, and hematoma characteristics, antiplatelet therapy was not associated with hematoma expansion or poor functional outcomes after lobar (OR, 0.8; 95% CI, 0.5-1.8) or deep (OR, 1.3; 95% CI, 0.4-3.8) ICH. In the CLEAR cohort, the 62 of 222 IVH patients (27.9%) with prior antiplatelet therapy had similar odds of hematoma expansion (OR, 0.6; 95% CI, 0.2-1.7) or poor functional outcomes (OR, 0.9; 95% CI, 0.4-2.1), but higher odds of ventriculostomy tract hemorrhage (OR, 3.2; 95% CI, 1.3-7.7).

Conclusions: Prior antiplatelet therapy was not associated with hematoma expansion or functional outcomes after lobar or deep ICH or IVH, but was associated with ventriculostomy tract hemorrhage.

Abstract WMP107: Cerebrospinal Fluid Leukocyte Subtypes After Intraventricular Hemorrhage: An Analysis of the CLEAR-III Trial

Background: Intracerebral hemorrhage (ICH) results in significant mortality and morbidity and initiates a cascade of inflammatory cell activation. Leukocyte subtypes have different effects, with monocytes contributing to increased hematoma expansion and mortality and neutrophils decreasing hematoma expansion. However, the response of cerebrospinal fluid (CSF) leukocytes to ICH with IVH has not been investigated.

Methods: We retrospectively analyzed CSF and serum leukocyte counts from patients enrolled in CLEAR-III. After correction for CSF red blood cell (RBC) counts, data were plotted chronologically. Linear mixed-effects models were used to assess the differences in leukocyte subtypes after intraventricular saline or alteplase. Generalized linear models are being created to assess the relationship between CSF leukocyte subtypes and IVH volumes and 30, 60, 90, and 180-day outcomes.

Results: Data were available for 237 and 228 patients in the saline and alteplase groups, respectively. Serum total white blood cell (WBC) and neutrophil counts increased after ICH, peaking at two days. Significant increases occurred in serum monocyte and lymphocyte counts, peaking at 6 and 10 days, respectively. Intraventricular alteplase had no effect on serum leukocyte counts. Peak CSF leukocyte counts occurred on day 1 after IVH (pretreatment) in the saline group. However, intraventricular alteplase resulted in a significant increase in WBC ( P =0.0001), neutrophil ( P =0.0003), monocyte ( P =0.0064), and lymphocyte counts ( P= 0.0339), peaking two days after starting treatment. No significant associations between peak serum or CSF cell counts and 30, 180, and 365 day modified Rankin Scale were found.

Conclusions: ICH drives an increase in serum leukocyte counts. Intraventricular alteplase results in an increase in all CSF leukocyte subtypes. Further work will be presented on the complex interactions between leukocyte counts, ICH severity, and outcomes.

Abstract TMP85: Optimizing Mean Arterial Pressure in Acutely Comatose Patients Using Cerebral Autoregulation Multimodal Monitoring With Near-Infrared Spectroscopy

Introduction: The cerebral oximetry index (COx) is a validated marker of cerebral autoregulation derived from near-infrared spectroscopy (NIRS) in comatose patients with acute neurological injury. The utility of this non-invasive technique to determine the optimal arterial blood pressure (MAP OPT ) at the bedside in this population is not known. This study investigated whether comatose patients with greater duration and magnitude of clinically observed MAP outside MAP OPT have worse functional outcomes and increase mortality than those with MAP closer to MAP OPT calculated by bedside multimodal monitoring using NIRS.

Methods: In this prospective observational study COx was continuously monitored with NIRS for up to three days in acutely comatose patients secondary to brain injury admitted to a neurocritical care unit. MAP OPT was defined as that MAP at the lowest COx (nadir index) for each 24 hour period of monitoring. Kaplan-Meier analysis and proportional hazard regression models were used to determine if survival at 3 months was associated with a shorter duration of MAP outside MAP OPT and the absolute difference between clinically observed MAP and MAP OPT (

Intracerebral haemorrhage: current approaches to acute management

Acute spontaneous intracerebral haemorrhage is a life-threatening illness of global importance, with a poor prognosis and few proven treatments. As a heterogeneous disease, certain clinical and imaging features help identify the cause, prognosis, and how to manage the disease. Survival and recovery from intracerebral haemorrhage are related to the site, mass effect, and intracranial pressure from the underlying haematoma, and by subsequent cerebral oedema from perihaematomal neurotoxicity or inflammation and complications from prolonged neurological dysfunction. A moderate level of evidence supports there being beneficial effects of active management goals with avoidance of early palliative care orders, well-coordinated specialist stroke unit care, targeted neurointensive and surgical interventions, early control of elevated blood pressure, and rapid reversal of abnormal coagulation.

African American Screening and Enrollment in (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III) CLEAR III

BACKGROUND

Under-enrolling minority patients in clinical trials reduces generalizability. CLEAR III, a randomized controlled trial, presented an opportunity to assess African American (AA) participation.

METHODS

AA enrollment was compared to U.S. population and NINDS trial data then stratified by region; census data for 42 recruitment cities were compared to screening and randomization percentages, using simple linear regression.

RESULTS

AAs were 25% of screens and 45.1% of enrollments (n=370), more than twice the 19.8% participation rate reported by the 2011 NINDS Advisory Panel on Health Disparities Research and triple the projected 13.9% 2014 U.S. population. Conversion rates were (AA vs. non-AA): overall (8.7% vs. 3.4%, p<0.001); Northeast (7.7% vs. 2.9%, p<0.001); South (8.2% vs. 4.0%, p<0.001); Midwest (10.3% vs. 3.6%, p<0.01); and West (8.9% vs. 3.8%, p=0.02). AA enrollments ranged from 0% to 100% (mean: 40.4%). AA screening ranged from 0% to 63.7% (mean: 23.2%). AA city census ranged from 1.3% to 82.7% (mean: 28.0%); higher census was associated with higher screening (p<0.0001) and enrollment (p=0.004).

CONCLUSIONS

AAs were willing to enroll in an acute stroke trial. AA city census rates should be considered when selecting enrollment centers and setting recruitment goals. Factors leading to successful AA recruitment should be further investigated, as population-based participation is a goal in all trials.

Changes in the cellular immune system and circulating inflammatory markers of stroke patients

This study was designed to investigate dynamic changes in the cellular immune system and circulating inflammatory markers after ischemic stroke. Blood was collected from 96 patients and 99 age-matched control subjects for detection of lymphocyte subpopulations and inflammatory markers. We observed decreases in B cells, Th cells, cytotoxic T cells, and NK cells and an increase in regulatory T (Treg) cells in stroke patients on days 1, 3, and 7. Serum levels of TNF-α, C-reactive protein (CRP), IL-4, IL-6, IL-10, IL-17, IL-23, and TGF-β increased, whereas serum level of IFN-γ decreased at all time points after stroke. Stroke patients with infection exhibited a similar tendency toward changes in some lymphocyte subpopulations and inflammatory markers as stroke patients without infection. After controlling for NIH Stroke Scale (NIHSS), we observed no differences in lymphocyte subpopulations between patients with anterior circulation stroke and those with posterior circulation stroke at any time point. The splenic volume correlated positively with the percentages of B cells, Th cells, and cytotoxic T cells, but negatively with Treg cells on day 3 after stroke. Infections were associated with splenic volume, leukocyte counts, percentage of Treg cells, and serum levels of CRP, IL-10, and IFN-γ on day 3. Lesion volume correlated positively with CRP, IL-6, and IL-23, but negatively with IFN-γ on day 3. The NIHSS showed a positive relation with IL-6 and IL-10 on day 3. Ischemic stroke has a profound effect on the systemic immune system that might explain the increased susceptibility of stroke patients to infection.

Changes in motor function, cognition, and emotion-related behavior after right hemispheric intracerebral hemorrhage in various brain regions of mouse

Intracerebral hemorrhage (ICH) is a detrimental type of stroke. Mouse models of ICH, induced by collagenase or blood infusion, commonly target striatum, but not other brain sites such as ventricular system, cortex, and hippocampus. Few studies have systemically investigated brain damage and neurobehavioral deficits that develop in animal models of ICH in these areas of the right hemisphere. Therefore, we evaluated the brain damage and neurobehavioral dysfunction associated with right hemispheric ICH in ventricle, cortex, hippocampus, and striatum. The ICH model was induced by autologous whole blood or collagenase VII-S (0.075 units in 0.5 µl saline) injection. At different time points after ICH induction, mice were assessed for brain tissue damage and neurobehavioral deficits. Sham control mice were used for comparison. We found that ICH location influenced features of brain damage, microglia/macrophage activation, and behavioral deficits. Furthermore, the 24-point neurologic deficit scoring system was most sensitive for evaluating locomotor abnormalities in all four models, especially on days 1, 3, and 7 post-ICH. The wire-hanging test was useful for evaluating locomotor abnormalities in models of striatal, intraventricular, and cortical ICH. The cylinder test identified locomotor abnormalities only in the striatal ICH model. The novel object recognition test was effective for evaluating recognition memory dysfunction in all models except for striatal ICH. The tail suspension test, forced swim test, and sucrose preference test were effective for evaluating emotional abnormality in all four models but did not correlate with severity of brain damage. These results will help to inform future preclinical studies of ICH outcomes.

Abstract TP192: Change in Cerebral Blood Flow Velocities Before and After Diuresis in an Outpatient Heart Failure Clinic

Background: Cognitive deficits have been described in individuals with heart failure (HF), with worsening at the time of acute decompensation and volume overload. We evaluated transcranial doppler cerebral blood flow velocities (CBFVs), as an index of cerebral perfusion, before and after IV diuresis, in an outpatient HF clinic, to explore mechanisms of cognitive dysfunction during HF decompensation, and to test if velocities improved after diuresis.

Methods: In an ongoing study of cognitive evaluation in an outpatient HF diuresis clinic, patients had CBFVs measured before diuresis, and again after completion of daily dosing of IV diuresis (1-7 days later, whenever they were considered to be euvolemic and no longer needing diuresis). Clinical signs and symptoms of volume overload including pulmonary edema, peripheral edema, and ascites were tracked by clinic staff. CBFVs (cm/sec) in several intracranial vessels were compared within individuals, with paired t-tests, before and after completion of the IV diuresis treatment. In linear regression models, we evaluated improvement in volume status in association with change in CBFVs.

Results: A total of 21 individuals completed CBFVs before and after diuresis. In all vessels tested (table), CBFVs decreased after diuresis, and in many cases, went from a high to a normal value. Although numbers were small, those individuals with the most improvement in their volume status had more improvement in CBFVs in several but not all vessels. For several vessels, improvement in CBFV was significantly associated with improvement on some cognitive tests.

Conclusions: CBFVs are frequently elevated in individuals with decompensated heart failure, with return to a normal range after diuresis. Further evaluation of CBFV as a potential mediator of cognitive dysfunction in HF is warranted.