Late Neurological Deterioration after Acute Intracerebral Hemorrhage: A post hoc Analysis of the ATACH-2 Trial

2020 ◽  
Vol 49 (1) ◽  
pp. 26-31 ◽  
Author(s):  
Shuhei Okazaki ◽  
Haruko Yamamoto ◽  
Lydia D. Foster ◽  
Mayumi Fukuda-Doi ◽  
Masatoshi Koga ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Significant Risk ◽  
Blood Pressure Level ◽  
Neurological Deterioration ◽  
Major Influence ◽  
Case Report Form ◽  
Hematoma Volume ◽  
Systolic Blood Pressure Level ◽  
Significant Difference

Background: Neurological deterioration (ND) has a major influence on the prognosis of intracerebral hemorrhage (ICH); however, factors associated with ND occurring after 24 h of ICH onset are unknown. Methods: We performed exploratory analyses of data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial, which compared intensive and standard blood pressure lowering treatment in ICH. NDs were captured on the adverse event case report form. Logistic regression analysis was performed to examine the independent predictors of late ND. Results: Among 1,000 participants with acute ICH, 82 patients (8.2%) developed early ND (≤24 h), and 64 (6.4%) had late ND. Baseline hematoma volume (adjusted OR [aOR] per 1-cm3 increase 1.04, 95% CI 1.02–1.06, p < 0.0001), hematoma volume increase in 24 h (aOR 2.24, 95% CI 1.23–4.07, p = 0.008), and the presence of intraventricular hemorrhage (IVH; aOR 2.38, 95% CI 1.32–4.29, p = 0.004) were independent predictors of late ND (vs. no late ND). Late ND was a significant risk factor for poor 90-day outcome (OR 3.46, 95% CI 1.82–6.56). No statistically significant difference in the incidence of late ND was noted between the 2 treatment groups. Conclusions: Initial hematoma volume, early hematoma volume expansion, and IVH are independent predictors of late ND after ICH. Intensive reduction in the systolic blood pressure level does not prevent the development of late ND.

Abstract P416: Remote Ischemic Conditioning Reduces Perihematomal Edema After Intracerebral Hemorrhage: First Proof-Of-Concept Randomized Controlled Trial

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Zhao Wenbo ◽  
Fang Jiang ◽  
Sijie Li ◽  
Yuchuan Ding ◽  
Xunming Ji
Keyword(s):  
Intracerebral Hemorrhage ◽  
Controlled Trial ◽  
Neurological Deterioration ◽  
Hematoma Expansion ◽  
Control Group ◽  
Hematoma Volume ◽  
Remote Ischemic Conditioning ◽  
Ischemic Conditioning ◽  
Significant Difference ◽  
Perihematomal Edema

Introduction: The prognosis of intracerebral hemorrhage (ICH) is poor because of the mass effect arising from the hematoma and the associated perihematomal edema (PHE). Remote ischemic conditioning (RIC) has been shown to promote hematoma clearance and reduce PHE in animal models, however it remains unknown whether RIC is safe and effective in reducing PHE in ICH patients. Objective: To evaluate the safety and efficacy of RIC in reducing PHE after ICH. Methods: In this open-label, rater-blind, randomized control trial, 40 subjects with supratentorial ICH (hematoma volume:10-30 ml) diagnosed between 24 to 48 hours of onset were assigned to the RIC group or control group. All subjects received standard background medical therapy. Subjects in the RIC group underwent repeated daily RIC (4 cycles of 5 minutes inflation [200 mmHg] /deflation [0 mmHg] of cuff on one arm) for 7 consecutive days. The primary efficacy outcome was PHE volume at 7 days, and both absolute PHE volume and relative PHE volume (defined as absolute PHE volume divided by hematoma volume) were measured. Safety outcome included death, neurological deterioration, hematoma expansion, and any other severe adverse events. Results: All 40 subjects completed this study. Mean age was 59.3±11.7 years, and 57.5% were male. At baseline, the median National Institutes of Health Stroke Scale score was 9.5 (range 1-28), median Glasgow Come Score was 15 (range 10-15), and mean ICH volume was 13.9±4.5 ml. The mean relative PHE volume was 1.11±0.26 in the control group and 1.05±0.23 in the RIC group at baseline; and 1.49±0.30 vs. 1.33 ±0.32 at Day 3 (p>0.05 each) respectively. After 7 days of treatment, RIC significantly reduced the relative PHE volume as compared to the control (1.77±0.39 vs. 2.02±0.27, p=0.02). The absolute PHE volume and hematoma volume at Day 3 and Day 7 had no significant difference between groups (p>0.05 each). No subject died or suffered from neurological deterioration or hematoma expansion and no adverse event was associated with RIC. Conclusion: RIC seemed to be safe in patients with ICH and induced a significant reduction in the relative PHE volume after 7 day of treatment. These results warrant a further study with large sample to examine the effect of RIC on functional outcome after ICH.

Early Achievement of Blood Pressure Lowering and Hematoma Growth in Acute Intracerebral Hemorrhage: Stroke Acute Management with Urgent Risk-Factor Assessment and Improvement-Intracerebral Hemorrhage Study

2018 ◽  
Vol 46 (3-4) ◽  
pp. 116-122
Author(s):  
Yoshitaka Yamaguchi ◽  
Masatoshi Koga ◽  
Shoichiro Sato ◽  
Hiroshi Yamagami ◽  
Kenichi Todo ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Risk Factor ◽  
Intracerebral Hemorrhage ◽  
Acute Management ◽  
Acute Hypertension ◽  
Risk Factor Assessment ◽  
Significant Difference ◽  
Pressure Lowering ◽  
Hematoma Growth ◽  
Multicenter Prospective Observational Study

Background: Previous studies have revealed that hematoma growth mainly occurs during the first 6 h after the onset of spontaneous intracerebral hemorrhage (ICH). Early lowering of blood pressure (BP) may be beneficial for preventing hematoma growth. However, relationships between timing of BP lowering and hematoma growth in ICH remain unclear. We investigated associations between timing of BP lowering and hematoma growth for ICH. Methods: The Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI)-ICH Study was a multicenter, prospective, observational study investigating the safety and feasibility of early (within 3 h from onset) reduction of systolic BP (SBP) to < 160 mm Hg with intravenous nicardipine for acute hypertension in cases of spontaneous ICH. The present study was a post hoc analysis of the SAMURAI-ICH study. We examined relationships between time from onset, imaging, and initiation of treatment to target SBP achievement and hematoma growth (absolute growth ≥6 mL) in ICH patients. Target SBP achievement was defined as the time at which SBP first became < 160 mm Hg. Results: Among 211 patients, hematoma growth was seen in 31 patients (14.7%). The time from imaging to target SBP and time from treatment to target SBP were significantly shorter in patients without hematoma growth than in those with (p = 0.043 and p = 0.032 respectively), whereas no significant difference was seen in time from onset to SBP < 160 mm Hg between groups (p = 0.177). Patients in the lower quartiles of time from imaging to target SBP and time from treatment to target SBP showed lower incidences of hematoma growth (p trend = 0.023 and 0.037 respectively). The lowest quartile of time from imaging to target SBP (< 38 min) was negatively associated with hematoma growth on multivariable logistic regression (OR 0.182; 95% CI 0.038–0.867; p = 0.032). Conclusions: Early achievement of target SBP < 160 mm Hg is associated with a lower risk of hematoma growth in ICH.

Abstract WP126: Association of 24-Hour Blood Pressure Parameters Post-Intravenous Alteplase With Symptomatic Intracerebral Hemorrhage

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Taha Nisar ◽  
Toluwalase Tofade ◽  
Ava Liberman ◽  
Priyank Khandelwal
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Treatment Time ◽  
Tertiary Care ◽  
Significant Risk ◽  
Binary Logistic Regression Analysis ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Intravenous Alteplase ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: Higher blood pressure (BP) at presentation is associated with a higher risk of symptomatic intracerebral hemorrhage (sICH) post-intravenous alteplase (IV-rtPA). We investigated the association of different BP parameters post-IV-rtPA with the development of sICH at a tertiary care center. Methods: We performed a retrospective chart review of adult patients with an acute ischemic stroke treated with IV-rtPA at a comprehensive stroke center from July 2014 to March 2018. We excluded patients who underwent mechanical thrombectomy. At the comprehensive stroke center, the BP values are documented according to standard post-IV-rtPA care guidelines. We recorded the BP values over a period of 24-hours post-IV-rtPA. A binary logistic regression analysis was performed, controlling for age, sex, pre-treatment NIHSS, atrial fibrillation, onset to treatment time, with the BP parameters as the predictors. The primary outcome was the development of sICH. SICH was defined as an intracerebral hemorrhage (ICH) that causes worsening of NIHSS score by ≥4 points post-IV-rtPA. Results: 84 patients met our inclusion criteria. 45 (53.57%) patients were male. The mean age was 63.50±15 years. 5 (5.95%) patients developed sICH. In our cohort, the BP parameters of higher maximum systolic blood pressure (SBP) (195.8±9 vs.172.22±17; OR, 1.14; 95% CI, 1.03-1.26; P 0.016), higher maximum diastolic blood pressure (DBP) (120.2±18 vs.104.76±15; OR, 1.08; 95% CI, 1.01-1.17; P 0.04), wider SBP range (79.4±20 vs.58.75±18; OR, 1.06; 95% CI, 1.01-1.12; P 0.033), wider DBP range (74.2±27 vs.47.27±15; OR, 1.11; 95% CI, 1.03-1.2; P 0.008), and coefficient variation (CV) DBP (17.7±6 vs.12.65±4; OR, 1.19; 95% CI, 1.01-1.42; P 0.048) were significantly associated with a risk of sICH post IV-rtPA. Conclusions: Our study demonstrates significant risk of sICH with higher maximum SBP and DBP, wider SBP and DBP ranges, and CV DBP post-IV-rtPA.

Abstract WP295: Acute Blood Pressure Reduction in Intracerebral Hemorrhage Patients Does Not Increase Hypoperfused Tissue Volume: a CT Perfusion Threshold Study

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Bronwen Gould ◽  
Rebecca McCourt ◽  
Michael D Hill ◽  
Negar Asdaghi ◽  
Dariush Dowlatshahi ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Time Domain ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Blood Pressure Reduction ◽  
Region Of Interest ◽  
Pressure Reduction ◽  
Threshold Analysis ◽  
Hematoma Volume

Background: The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial (ICH ADAPT) demonstrated that aggressive blood pressure (BP) reduction does not affect mean perihematoma cerebral blood flow (CBF). It remains unknown if portions of the perihematoma region or watershed vascular territories (borderzones, BZs) reach ischemic thresholds after BP reduction. We tested the hypothesis that aggressive BP reduction was associated with an increased volume of critically hypoperfused tissue in ICH ADAPT patients. Methods: ICH patients were randomized to a target systolic BP (SBP) of <150 or <180 mmHg and imaged with CT perfusion (CTP) 2h later. A 1cm perihematoma region, and ipsilateral and contralateral internal and external BZs were outlined. The volume of tissue below CBF thresholds for ischemia (<18ml/100g/min) and infarction (<12ml/100g/min) was calculated as a percentage of the total volume of each region of interest. Results: ICH patients (n=73) were randomized a median (IQR) of 7.8 (13.3) h from onset and imaged with CTP 2.3 (1.0) h later. Acute hematoma volume was 17.8 (27.1) ml and mean SBP was 183±22 mmHg. At the time of CTP, SBP was lower in the <150 mmHg group (n=37, 140±18 mmHg) than the <180 mmHg group (n=36, 162±12 mmHg, P<0.001). Mean CBF in the perihematoma region did not differ between groups (<150 mmHg: 38.9±13.0 vs. <180 mmHg: 38.5±10.9 ml/100g/min, P=0.86). BP treatment did not affect the percentage of perihematoma tissue with CBF <18 (17.5±15.4 (<150 group) vs. 16.5±14.3% (<180 group), P=0.82) or <12 ml/100g/min (7.0±7.2 vs. 6.6±7.6%, P=0.93). Similar results were found in all BZs. Linear regression revealed no relationship between low SBP load (the fraction of time between randomization and CTP with SBP <150mmHg) and the percentage of perihematoma tissue with CBF <18 (β=3.62, [-6.86, 14.10]) or <12 ml/100g/min (β=1.89, [-3.30, 7.08]). There was no relationship between low SBP load and percentage of hypoperfused tissue in any BZ. Perfusion threshold analysis of time domain parameters and cerebral blood volume yielded similar results. Conclusion: BP reduction does not increase the volume of hypoperfused tissue, at any threshold examined, in the perihematoma region or any BZ. These data support the safety of early BP reduction in ICH.

Abstract WP347: Early Achievement of Blood Pressure Lowering on Hematoma Growth in Hyperacute Intracerebral Hemorrhage: the SAMURAI-ICH Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Yoshitaka Yamaguchi ◽  
Masatoshi Koga ◽  
Kenichi Todo ◽  
Shoichiro Sato ◽  
Hiroshi Yamagami ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Antihypertensive Treatment ◽  
Blood Pressure Lowering ◽  
Acute Hypertension ◽  
Negatively Associated ◽  
Significant Difference ◽  
Pressure Lowering ◽  
Hematoma Growth ◽  
Multicenter Prospective Observational Study

Background: Little has been investigated about associations between timing of blood pressure lowering and clinical outcome of intracerebral hemorrhage (ICH). Methods: The Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI)-ICH Study is a multicenter, prospective, observational study investigating the safety and feasibility of early (within 3 hours from symptom onset) systolic blood pressure (SBP) reduction to less than 160 mmHg with intravenous nicardipine for acute hypertension in patients with spontaneous ICH. We retrospectively examined the relationship between time from onset, CT imaging, and initiation of antihypertensive treatment to target SBP achievement and hematoma growth in ICH patients. Hematoma growth was defined as an absolute growth of ≥ 6 ml from baseline to second imaging at 24 (±6) hours after the initiation of antihypertensive treatment. Results: Among 211 patients (81 women (38.4%), mean age 66 years), mean baseline hematoma volume was 13 ml and hematoma growth was seen in 36 (17.1%) patients. Time from image to target SBP and time from treatment to target SBP were significantly shorter in patients without hematoma growth than those with ( P = 0.043 and P = 0.032, respectively), whereas there was not significant difference in time from onset to target SBP between the two groups ( P = 0.177). Lower quartiles of time from image to target SBP and time from treatment to target SBP had lower incidences of hematoma growth (P trend = 0.023 and 0.037, respectively, Cochran-Armitage test), whereas there was not significant trend in time from onset to target SBP ( P = 0.074). The lowest quartile of time from image to target SBP was negatively associated with hematoma growth on multivariate logistic regression (odds ratio 0.182, 95% confidential interval 0.038-0.867, P = 0.032). Conclusions: Early achievement to target SBP <160 mmHg was negatively associated with hematoma growth in ICH patients.

scholarly journals Clinical Strategies Against Early Hematoma Expansion Following Intracerebral Hemorrhage

2021 ◽  
Vol 15 ◽  
Author(s):  
Kanta Tanaka ◽  
Kazunori Toyoda
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Stroke Onset ◽  
Factor Vii ◽  
Hematoma Expansion ◽  
Thrombin Inhibitor ◽  
Small Magnitude ◽  
Hematoma Enlargement ◽  
Significant Difference ◽  
Hematoma Growth

Hematoma volume is the strongest predictor of morbidity and mortality after intracerebral hemorrhage. Protection against early hematoma growth is therefore the mainstay of therapeutic intervention for acute intracerebral hemorrhage, but the current armamentarium is restricted to early blood pressure lowering and emergent reversal for anticoagulant agents. Although intensive lowering of systolic blood pressure to &lt;140 mmHg appears likely to prevent hematoma growth, two recent randomized trials, INTERACT-2 and ATACH-2, demonstrated non-significant trends of reduced hematoma enlargement by intensive blood pressure control, with only a small magnitude of benefit or no benefit for clinical outcomes. While oral anticoagulants can be immediately reversed by prothrombin complex concentrate, or the newly developed idarucizumab for direct thrombin inhibitor or andexanet for factor Xa inhibitors, the situation regarding reversal of antiplatelet agents is not yet quite as advanced. However, considering at most the approximately 10% rate of anticoagulant use among patients with intracerebral hemorrhage, what is most essential for patients with intracerebral hemorrhage in general is early hemostatic therapy. Tranexamic acid may safely reduce hematoma expansion, but its hemostatic effect was insufficient to be translated into improved functional outcomes in the TICH-2 randomized trial with 2,325 participants. In this context, recombinant activated factor VII (rFVIIa) is a candidate to be added to the armory against hematoma enlargement. The FAST, a phase 3 trial that compared doses of 80 and 20 μg/kg rFVIIa with placebo in 841 patients within 4 h after the stroke onset, showed a significant reduction in hematoma growth with rFVIIa treatment, but demonstrated no significant difference in the proportion of patients with severe disability or death. However, a post hoc analysis of the FAST trial suggested a benefit of rFVIIa in a target subgroup of younger patients without extensive bleeding at baseline when treated earlier after stroke onset. The FASTEST trial is now being prepared to determine this potential benefit of rFVIIa, reflecting the pressing need to develop therapeutic strategies against hematoma enlargement, a powerful but modifiable prognostic factor in patients with intracerebral hemorrhage.

Abstract T P315: Wake-up Intracerebral Hemorrhage Is Not Different From Intracerebral Hemorrhage With Known Onset Time

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Joan Martí-Fàbregas ◽  
Luis Prats ◽  
Alejandro Martínez-Domeño ◽  
Rebeca Marín ◽  
Francesca Casoni ◽  
...  
Keyword(s):  
Risk Factors ◽  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Scale Score ◽  
Neurological Deficit ◽  
Onset Time ◽  
Vascular Risk Factors ◽  
Neurological Deterioration ◽  
Vascular Risk ◽  
Nihss Score

Background: The frequency of wake-up Intracerebral Hemorrhage (WU-ICH) is uncertain. It is also unknown whether there are clinical, radiological and prognostic differences between WU-ICH and non-WU-ICH. We assessed the hypothesis that both types of ICH do not differ. Methods: This is a multicentre (n=6 tertiary hospitals) registry of consecutive patients with ICH. We collected the following variables: Time of onset. WU onset was defined as stroke detected on awakening, independently of the time of the day; Demographics (age, sex); Traditional vascular risk factors; Severity of the neurological deficit at admission (NIHSS score and/or Glasgow coma scale score -GCS-); Neurological deterioration (decrease in >1 point in GCS and/or increase in >3 points in NIHSS score); Etiology; Neuroimaging at admission (location, secondary intraventricular hemorrhage, hematoma volume); Blood pressure, blood glucose, platelet count and INR at admission; and Outcome (modified Rankin scale score -mRS- at discharge and at 3 months; favourable outcome when mRS ≤ 2). Patients were treated according to national guidelines of ICH. Comparison between groups was achieved with Student’s t-test, Chi-square test and Mann-Whitney’s U test. Results: We included a total of 270 patients, whose mean age was 70.2 ± 14.4 years, and 60% of them were men. WU-ICH was diagnosed in 49 (18%) patients. We found no significant differences between groups in demographics, frequency of vascular risk factors, severity of the neurological deficit, etiology, blood pressure, blood analysis and neuroradiological findings. Patients with WU-ICH had a lower frequency of neurological deterioration when assessed by the NIHSS scale (p= 0.04) but not by the GCS scale. The outcome at discharge and at 3-months was equivalent between groups. Conclusions: In conclusion, 18% of ICHs are detected on awakening. Patients with wake-up ICH do not differ from patients with known onset time either in most clinical and radiological variables or in the long-term prognosis. WU-ICH patients may have a lower likelihood of neurological worsening within the acute stage.

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