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Carhuapoma L, Murthy S, Shah VA. Outcome Trajectories after Intracerebral Hemorrhage. Semin Neurol 2024. [PMID: 38788763 DOI: 10.1055/s-0044-1787104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is the most morbid of all stroke types with a high early mortality and significant early disability burden. Traditionally, outcome assessments after ICH have mirrored those of acute ischemic stroke, with 3 months post-ICH being considered a standard time point in most clinical trials, observational studies, and clinical practice. At this time point, the majority of ICH survivors remain with moderate to severe functional disability. However, emerging data suggest that recovery after ICH occurs over a more protracted course and requires longer periods of follow-up, with more than 40% of ICH survivors with initial severe disability improving to partial or complete functional independence over 1 year. Multiple other domains of recovery impact ICH survivors including cognition, mood, and health-related quality of life, all of which remain under studied in ICH. To further complicate the picture, the most important driver of mortality after ICH is early withdrawal of life-sustaining therapies, before initiation of treatment and evaluating effects of prolonged supportive care, influenced by early pessimistic prognostication based on baseline severity factors and prognostication biases. Thus, our understanding of the true natural history of ICH recovery remains limited. This review summarizes the existing literature on outcome trajectories in functional and nonfunctional domains, describes limitations in current prognostication practices, and highlights areas of uncertainty that warrant further research.
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Affiliation(s)
- Lourdes Carhuapoma
- Division of Neurosciences Critical Care, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Santosh Murthy
- Department of Neurology, Weil Cornell Medical College, New York
| | - Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Neurology, Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Sun P, Badihian S, Avadhani R, Walborn N, Yarava A, Alimoradi D, Awad I, Hanley D, Murthy S, Ziai W. Does stereotactic thrombolysis with alteplase for intracerebral haemorrhage alter intraventricular haematoma volume? A secondary analysis of the MISTIE-III trial. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-333032. [PMID: 38670789 DOI: 10.1136/jnnp-2023-333032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/09/2024] [Indexed: 04/28/2024]
Abstract
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.
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Affiliation(s)
- Philip Sun
- Departments of Neurology, Anesthesiology & Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Shervin Badihian
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neurology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Radhika Avadhani
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nathan Walborn
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anusha Yarava
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Donya Alimoradi
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Issam Awad
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Daniel Hanley
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Santosh Murthy
- Department of Neurology, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
| | - Wendy Ziai
- Departments of Neurology, Anesthesiology & Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
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Shao C, Wang Y, Gou H, Chen T. The factors associated with the deterioration of activities of daily life in stroke patients: A retrospective cohort study. Top Stroke Rehabil 2024; 31:21-28. [PMID: 36961229 DOI: 10.1080/10749357.2023.2194095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 03/19/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND The activities of daily life (ADL) of stroke patients generally improves after rehabilitation. However, some patients remain at risk of ADL deterioration in the future. So far, there have been few studies on the factors related to ADL deterioration in stroke patients. OBJECTIVE To identify the factors related to ADL deterioration in stroke patients with independent mobility after discharge. METHODS We assessed 336 stroke patients with independent mobility who were discharged from the rehabilitation center between January 2016 and December 2018. The primary outcome was ADL deterioration, defined as that ADL assessed at 2 years after discharge decreased more than 15 points compared with that assessed at discharge. Univariate and multivariate statistical analyses were conducted to screen for factors related to ADL deterioration. RESULTS Overall, 62 (18.4%) patients exhibited ADL deterioration at 2 years after discharge.Age (OR = 1.114, 95%CI = 1.045-1.188, p = 0.001), vascular risk factors>3 (OR = 3.269, 95%CI = 1.189-8.986, p = 0.022) and with post-stroke depression (OR = 2.486, 95%CI = 1.011-6.114, p = 0.047) were risk factors for ADL deterioration in stroke patients. In contrast, elevated Berg Balance Scale (BBS) scores at discharge was a protective factor for ADL deterioration (OR = 0.484, 95%CI = 0.386-0.606, p < 0.001). CONCLUSIONS Nearly 1 in 5 stroke patients with independent mobility experienced ADL deterioration at 2 years after discharge. Aging, vascular risk factors>3, BBS at discharge, and post-stroke depression (PSD) were identified as factors associated with ADL deterioration.
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Affiliation(s)
- Chenlan Shao
- The Rehabilitation Medicine Center, People's Hospital of Deyang City, Sichuan Province, China
| | - Yongzheng Wang
- The Rehabilitation Medicine Center, People's Hospital of Deyang City, Sichuan Province, China
| | - Hui Gou
- The Rehabilitation Medicine Center, People's Hospital of Deyang City, Sichuan Province, China
| | - Tingting Chen
- The Rehabilitation Medicine Center, People's Hospital of Deyang City, Sichuan Province, China
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Sanicola HW, Stewart CE, Luther P, Yabut K, Guthikonda B, Jordan JD, Alexander JS. Pathophysiology, Management, and Therapeutics in Subarachnoid Hemorrhage and Delayed Cerebral Ischemia: An Overview. PATHOPHYSIOLOGY 2023; 30:420-442. [PMID: 37755398 PMCID: PMC10536590 DOI: 10.3390/pathophysiology30030032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke resulting from the rupture of an arterial vessel within the brain. Unlike other stroke types, SAH affects both young adults (mid-40s) and the geriatric population. Patients with SAH often experience significant neurological deficits, leading to a substantial societal burden in terms of lost potential years of life. This review provides a comprehensive overview of SAH, examining its development across different stages (early, intermediate, and late) and highlighting the pathophysiological and pathohistological processes specific to each phase. The clinical management of SAH is also explored, focusing on tailored treatments and interventions to address the unique pathological changes that occur during each stage. Additionally, the paper reviews current treatment modalities and pharmacological interventions based on the evolving guidelines provided by the American Heart Association (AHA). Recent advances in our understanding of SAH will facilitate clinicians' improved management of SAH to reduce the incidence of delayed cerebral ischemia in patients.
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Affiliation(s)
- Henry W. Sanicola
- Department of Neurology, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - Caleb E. Stewart
- Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - Patrick Luther
- School of Medicine, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA; (P.L.); (K.Y.)
| | - Kevin Yabut
- School of Medicine, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA; (P.L.); (K.Y.)
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - J. Dedrick Jordan
- Department of Neurology, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - J. Steven Alexander
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA
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Ramadhan MIA, Sitanaya SN, Hakim AHW, Ramli Y. The Role of Iron-Chelating Therapy in Improving Neurological Outcome in Patients with Intracerebral Hemorrhage: Evidence-Based Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59030453. [PMID: 36984454 PMCID: PMC10058021 DOI: 10.3390/medicina59030453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/12/2023] [Accepted: 02/14/2023] [Indexed: 03/30/2023]
Abstract
Current primary intracerebral hemorrhage (ICH) treatments focus on limiting hematoma volume by lowering blood pressure, reversing anticoagulation, or hematoma evacuation. Nevertheless, there is no effective strategy to protect the brain from secondary injury due to ICH. Excess heme and iron as by-products of lysing clots in ICH might contribute to this secondary injury by triggering perihematomal edema. We present a clinical situation of an ICH case where iron-chelating therapy might be beneficial, as supported by scientific evidence. We looked through four databases (Pubmed, Cochrane, Embase, and Google Scholar) to find studies assessing the efficacy of iron-chelating therapy in ICH patients. Validity, importance, and applicability (VIA) of the included articles were appraised using worksheets from the Oxford Centre for Evidence-Based Medicine. Two out of five eligible studies were valid, important, and applicable to our patient. Both studies showed the positive effects of iron-chelating therapy on neurological outcome, as measured by National Institutes of Health Stroke Scale (NIHSS) score and modified Rankin Score (mRS). The beneficial effects of deferoxamine were demonstrated within the moderate volume (10-30 mL) subgroup, with a positive relative risk reduction (RRR) and low number needed to treat (six persons). Based on our appraisal, we considered iron-chelating therapy as an additional therapy for ICH patients, given its benefits and adverse effects. More specific studies using a larger sample size, focusing on moderate-volume ICH, and using standardized neurological outcomes are encouraged.
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Affiliation(s)
- Mochamad Iskandarsyah Agung Ramadhan
- Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia
| | - Shierly Novitawati Sitanaya
- Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia
| | - Ariadri Hafian Wulandaru Hakim
- Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia
| | - Yetty Ramli
- Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia
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Shah VA, Thompson RE, Yenokyan G, Acosta JN, Avadhani R, Dlugash R, McBee N, Li Y, Hansen BM, Ullman N, Falcone G, Awad IA, Hanley DF, Ziai WC. One-Year Outcome Trajectories and Factors Associated with Functional Recovery Among Survivors of Intracerebral and Intraventricular Hemorrhage With Initial Severe Disability. JAMA Neurol 2022; 79:856-868. [PMID: 35877105 PMCID: PMC9316056 DOI: 10.1001/jamaneurol.2022.1991] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Patients who survive severe intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) typically have poor functional outcome in the short term and understanding of future recovery is limited. Objective To describe 1-year recovery trajectories among ICH and IVH survivors with initial severe disability and assess the association of hospital events with long-term recovery. Design, Setting, and Participants This post hoc analysis pooled all individual patient data from the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage phase 3 trial (CLEAR-III) and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE-III) phase 3 trial in multiple centers across the US, Canada, Europe, and Asia. Patients were enrolled from August 1, 2010, to September 30, 2018, with a follow-up duration of 1 year. Of 999 enrolled patients, 724 survived with a day 30 modified Rankin Scale score (mRS) of 4 to 5 after excluding 13 participants with missing day 30 mRS. An additional 9 patients were excluded because of missing 1-year mRS. The final pooled cohort included 715 patients (71.6%) with day 30 mRS 4 to 5. Data were analyzed from July 2019 to January 2022. Exposures CLEAR-III participants randomized to intraventricular alteplase vs placebo. MISTIE-III participants randomized to stereotactic thrombolysis of hematoma vs standard medical care. Main Outcomes and Measures Primary outcome was 1-year mRS. Patients were dichotomized into good outcome at 1 year (mRS 0 to 3) vs poor outcome at 1 year (mRS 4 to 6). Multivariable logistic regression models assessed associations between prospectively adjudicated hospital events and 1-year good outcome after adjusting for demographic characteristics, ICH and IVH severity, and trial cohort. Results Of 715 survivors, 417 (58%) were male, and the overall mean (SD) age was 60.3 (11.7) years. Overall, 174 participants (24.3%) were Black, 491 (68.6%) were White, and 49 (6.9%) were of other races (including Asian, Native American, and Pacific Islander, consolidated owing to small numbers); 98 (13.7%) were of Hispanic ethnicity. By 1 year, 129 participants (18%) had died and 308 (43%) had achieved mRS 0 to 3. In adjusted models for the combined cohort, diabetes (adjusted odds ratio [aOR], 0.50; 95% CI, 0.26-0.96), National Institutes of Health Stroke Scale (aOR, 0.93; 95% CI, 0.90-0.96), severe leukoaraiosis (aOR, 0.30; 95% CI, 0.16-0.54), pineal gland shift (aOR, 0.87; 95% CI, 0.76-0.99]), acute ischemic stroke (aOR, 0.44; 95% CI, 0.21-0.94), gastrostomy (aOR, 0.30; 95% CI, 0.17-0.50), and persistent hydrocephalus by day 30 (aOR, 0.37; 95% CI, 0.14-0.98) were associated with lack of recovery. Resolution of ICH (aOR, 1.82; 95% CI, 1.08-3.04) and IVH (aOR, 2.19; 95% CI, 1.02-4.68) by day 30 were associated with recovery to good outcome. In the CLEAR-III model, cerebral perfusion pressure less than 60 mm Hg (aOR, 0.30; 95% CI, 0.13-0.71), sepsis (aOR, 0.05; 95% CI, 0.00-0.80), and prolonged mechanical ventilation (aOR, 0.96; 95% CI, 0.92-1.00 per day), and in MISTIE-III, need for intracranial pressure monitoring (aOR, 0.35; 95% CI, 0.12-0.98), were additional factors associated with poor outcome. Thirty-day event-based models strongly predicted 1-year outcome (area under the receiver operating characteristic curve [AUC], 0.87; 95% CI, 0.83-0.90), with significantly improved discrimination over models using baseline severity factors alone (AUC, 0.76; 95% CI, 0.71-0.80; P < .001). Conclusions and Relevance Among survivors of severe ICH and IVH with initial poor functional outcome, more than 40% recovered to good outcome by 1 year. Hospital events were strongly associated with long-term functional recovery and may be potential targets for intervention. Avoiding early pessimistic prognostication and delaying prognostication until after treatment may improve ability to predict future recovery.
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Affiliation(s)
- Vishank A. Shah
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard E. Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Julian N. Acosta
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yunke Li
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The George Institute China at Peking University Health Sciences Center, Beijing, China
| | | | - Natalie Ullman
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Guido Falcone
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Issam A. Awad
- Department of Neurosurgery, University of Chicago, Chicago, Illinois
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy C. Ziai
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Schwarz G, Kanber B, Prados F, Browning S, Simister R, Jäger R, Ambler G, Wheeler-Kingshott CAMG, Werring DJ. Acute corticospinal tract diffusion tensor imaging predicts 6-month functional outcome after intracerebral haemorrhage. J Neurol 2022; 269:6058-6066. [PMID: 35861854 PMCID: PMC9553831 DOI: 10.1007/s00415-022-11245-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/19/2022] [Accepted: 06/19/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Diffusion tensor imaging (DTI) can assess the structural integrity of the corticospinal tract (CST) in vivo. We aimed to investigate whether CST DTI metrics after intracerebral haemorrhage (ICH) are associated with 6-month functional outcome and can improve the predictive performance of the existing ICH score. METHODS We retrospectively included 42 patients with DTI performed within 5 days after deep supratentorial spontaneous ICH. Ipsilesional-to-contralesional ratios were calculated for fractional anisotropy (rFA) and mean diffusivity (rMD) in the pontine segment (PS) of the CST. We determined the most predictive variables for poor 6-month functional outcome [modified Rankin Scale (mRS) > 2] using the least absolute shrinkage and selection operator (LASSO) method. We calculated discrimination using optimism-adjusted estimation of the area under the curve (AUC). RESULTS Patients with 6-month mRS > 2 had lower rFA (0.945 [± 0.139] vs 1.045 [± 0.130]; OR 0.004 [95% CI 0.00-0.77]; p = 0.04) and higher rMD (1.233 [± 0.418] vs 0.963 [± 0.211]; OR 22.5 [95% CI 1.46-519.68]; p = 0.02). Discrimination (AUC) values were: 0.76 (95% CI 0.61-0.91) for the ICH score, 0.71 (95% CI 0.54-0.89) for rFA, and 0.72 (95% CI 0.61-0.91) for rMD. Combined models with DTI and non-DTI variables offer an improvement in discrimination: for the best model, the AUC was 0.82 ([95% CI 0.68-0.95]; p = 0.15). CONCLUSION In our exploratory study, PS-CST rFA and rMD had comparable predictive ability to the ICH score for 6-month functional outcome. Adding DTI metrics to clinical-radiological scores might improve discrimination, but this needs to be investigated in larger studies.
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Affiliation(s)
- G Schwarz
- Neurologia, Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, University College London, Queen Square, London, WC1N, UK
| | - B Kanber
- NMR Research Unit, Department of Neuroinflammation, Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, Queen Square Institute of Neurology, University College London (UCL), London, UK.,Department of Medical Physics and Biomedical Engineering, Centre for Medical Image Computing, UCL, London, UK.,National Institute for Health Research, Biomedical Research Centre, University College London Hospitals, London, UK
| | - F Prados
- NMR Research Unit, Department of Neuroinflammation, Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, Queen Square Institute of Neurology, University College London (UCL), London, UK.,Department of Medical Physics and Biomedical Engineering, Centre for Medical Image Computing, UCL, London, UK.,National Institute for Health Research, Biomedical Research Centre, University College London Hospitals, London, UK.,e-Health Center, Universitat Oberta de Catalunya, Barcelona, Spain
| | - S Browning
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, University College London, Queen Square, London, WC1N, UK
| | - R Simister
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, University College London, Queen Square, London, WC1N, UK
| | - R Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - G Ambler
- Department of Statistical Science, University College London, Gower Street, London, UK
| | - C A M Gandini Wheeler-Kingshott
- NMR Research Unit, Department of Neuroinflammation, Faculty of Brain Sciences, Queen Square Multiple Sclerosis Centre, Queen Square Institute of Neurology, University College London (UCL), London, UK.,Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy.,Brain Connectivity Center, IRCCS Mondino Foundation, Pavia, Italy
| | - David J Werring
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, University College London, Queen Square, London, WC1N, UK.
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Sheth KN, Selim M. Focused Update on Vascular Risk and Secondary Prevention in Survivors of Intracerebral Hemorrhage. Stroke 2022; 53:2128-2130. [PMID: 35759547 PMCID: PMC9754717 DOI: 10.1161/strokeaha.122.039819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Kevin N. Sheth
- Division of Neurocritical Care & Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Magdy Selim
- Division of Stroke & Cerebrovascular Disease, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
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Schreuder FHBM, Scholte M, Ulehake MJ, Sondag L, Rovers MM, Dammers R, Klijn CJM, Grutters JPC. Identifying the Conditions for Cost-Effective Minimally Invasive Neurosurgery in Spontaneous Supratentorial Intracerebral Hemorrhage. Front Neurol 2022; 13:830614. [PMID: 35720058 PMCID: PMC9200972 DOI: 10.3389/fneur.2022.830614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn patients with spontaneous supratentorial intracerebral hemorrhage (ICH), open craniotomy has failed to improve a functional outcome. Innovative minimally invasive neurosurgery (MIS) may improve a health outcome and reduce healthcare costs.AimsBefore starting phase-III trials, we aim to assess conditions that need to be met to reach the potential cost-effectiveness of MIS compared to usual care in patients with spontaneous supratentorial ICH.MethodsWe used a state-transition model to determine at what effectiveness and cost MIS would become cost-effective compared to usual care in terms of quality-adjusted life-years (QALYs) and direct healthcare costs. Threshold and two-way sensitivity analyses were used to determine the minimal effectiveness and maximal costs of MIS, and the most cost-effective strategy for each combination of cost and effectiveness. Scenario and probabilistic sensitivity analyses addressed model uncertainty.ResultsGiven €10,000 of surgical costs, MIS would become cost-effective when at least 0.7–1.3% of patients improve to a modified Rankin Scale (mRS) score of 0–3 compared to usual care. When 11% of patients improve to mRS 0–3, surgical costs may be up to €83,301–€164,382, depending on the population studied. The cost-effectiveness of MIS was mainly determined by its effectiveness. In lower mRS states, MIS needs to be more effective to be cost-effective compared to higher mRS states.ConclusionMIS has the potential to be cost-effective in patients with spontaneous supratentorial ICH, even with relatively low effectiveness. These results support phase-III trials to investigate the effectiveness of MIS.
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Affiliation(s)
- Floris H. B. M. Schreuder
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Floris H. B. M. Schreuder
| | - Mirre Scholte
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marike J. Ulehake
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Sondag
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Maroeska M. Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, Netherlands
| | - Catharina J. M. Klijn
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Janneke P. C. Grutters
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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10
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Magid-Bernstein J, Girard R, Polster S, Srinath A, Romanos S, Awad IA, Sansing LH. Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions. Circ Res 2022; 130:1204-1229. [PMID: 35420918 PMCID: PMC10032582 DOI: 10.1161/circresaha.121.319949] [Citation(s) in RCA: 112] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.
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Affiliation(s)
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sean Polster
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Issam A. Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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11
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Foster L, Robinson L, Yeatts SD, Conwit RA, Shehadah A, Lioutas V, Selim M. Effect of Deferoxamine on Trajectory of Recovery After Intracerebral Hemorrhage: A Post Hoc Analysis of the i-DEF Trial. Stroke 2022; 53:2204-2210. [PMID: 35306827 PMCID: PMC9246960 DOI: 10.1161/strokeaha.121.037298] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
There are limited data on the trajectory of recovery and long-term functional outcomes after intracerebral hemorrhage (ICH). Most ICH trials have conventionally assessed outcomes at 3 months following the footsteps of ischemic stroke. The i-DEF trial (Intracerebral Hemorrhage Deferoxamine Trial) assessed modified Rankin Scale (mRS) longitudinally at prespecified time points from day 7 through the end of the 6-month follow-up period. We evaluated the trajectory of mRS among trial participants and examined the effect of deferoxamine on this trajectory.
Methods:
We performed a post hoc analysis of the i-DEF trial, a multicenter, randomized, placebo-controlled, double-blind, futility-design, phase 2 clinical trial, based on the actual treatment received. Favorable outcome was defined as mRS score of 0–2. A generalized linear mixed model was used to evaluate the outcome trajectory over time, as well as whether the trajectory was altered by deferoxamine, after adjustments for randomization variables, presence of intraventricular hemorrhage, and ICH location.
Results:
A total of 291 subjects were included in analysis (145 placebo and 146 deferoxamine). The proportion of patients with mRS score of 0–2 continually increased from day 7 to 180 in both groups (interaction
P
<0.0001 for time in main effects model), but treatment with deferoxamine favorably altered the trajectory (interaction
P
=0.0010). Between day 90 and 180, the deferoxamine group improved (
P
=0.0001), whereas there was not significant improvement in the placebo arm (
P
=0.3005).
Conclusions:
A large proportion of patients continue to improve up to 6 months after ICH. Future ICH trials should assess outcomes past 90 days for a minimum of 6 months. In i-DEF, treatment with deferoxamine seemed to accelerate and alter the trajectory of recovery as assessed by mRS.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT02175225.
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Affiliation(s)
- Lydia Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.F., S.D.Y.)
| | - Laura Robinson
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (L.R., A.S., V.L., M.S.)
| | - Sharon D. Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.F., S.D.Y.)
| | - Robin A. Conwit
- National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.A.C.)
| | - Amjad Shehadah
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (L.R., A.S., V.L., M.S.)
| | - Vasileios Lioutas
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (L.R., A.S., V.L., M.S.)
| | - Magdy Selim
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (L.R., A.S., V.L., M.S.)
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12
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Wei C, Wang J, Foster LD, Yeatts SD, Moy C, Mocco J, Selim M. Effect of Deferoxamine on Outcome According to Baseline Hematoma Volume: A Post Hoc Analysis of the i-DEF Trial. Stroke 2021; 53:1149-1156. [PMID: 34789008 PMCID: PMC8960321 DOI: 10.1161/strokeaha.121.035421] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE Hematoma volume (HV) is a powerful determinant of outcome after intracerebral hemorrhage. We examined whether the effect of the iron chelator, deferoxamine, on functional outcome varied depending on HV in the i-DEF trial (Intracerebral Hemorrhage Deferoxamine). METHODS A post hoc analysis of the i-DEF trial; participants were classified according to baseline HV (small <10 mL, moderate 10-30 mL, and large >30 mL). Favorable outcome was defined as a modified Rankin Scale score of 0-2 at day-180; secondarily at day-90. Logistic regression was used to evaluate the differential treatment effect according to HV. RESULTS Two hundred ninety-one subjects were included in the as-treated analysis; 121 with small, 114 moderate, and 56 large HV. Day-180 modified Rankin Scale scores were available for 270/291 subjects (111 with small, 105 moderate, and 54 large HV). There was a differential effect of treatment according to HV on day-180 outcomes (P-for-interaction =0.0077); 50% (27/54) of deferoxamine-treated patients with moderate HV had favorable outcome compared with 25.5% (13/51) of placebo-treated subjects (adjusted odds ratio, 2.7 [95% CI, 1.13-6.27]; P=0.0258). Treatment effect was not significant for small (adjusted odds ratio, 1.37 [95% CI, 0.62-3.02]) or large (adjusted odds ratio, 0.12 [95% CI, 0.01-1.05]) HV. Results for day-90 outcomes were comparable (P-for-interaction =0.0617). Sensitivity analyses yielded similar results. CONCLUSIONS Among patients with moderate HV, a greater proportion of deferoxamine- than placebo-treated patients achieved modified Rankin Scale score 0-2. The treatment effect was not significant for small or large HVs. These findings have important trial design and therapeutic implications. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02175225.
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Affiliation(s)
- Chenchen Wei
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (C.W., J.W., M.S.).,Department of Neurology, The Affiliated Hospital of Qingdao University, China (C.W.).,Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (C.W.).,National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.M.)
| | - Jeffrey Wang
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (C.W., J.W., M.S.)
| | - Lydia D Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.)
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y.)
| | | | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, Icahn School of Medicine, New York (J.M.)
| | - Magdy Selim
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (C.W., J.W., M.S.)
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13
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Bottenfield KR, Bowley BGE, Pessina MA, Medalla M, Rosene DL, Moore TL. Sex differences in recovery of motor function in a rhesus monkey model of cortical injury. Biol Sex Differ 2021; 12:54. [PMID: 34627376 PMCID: PMC8502310 DOI: 10.1186/s13293-021-00398-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke disproportionately affects men and women, with women over 65 years experiencing increased severity of impairment and higher mortality rates than men. Human studies have explored risk factors that contribute to these differences, but additional research is needed to investigate how sex differences affect functional recovery and hence the severity of impairment. In the present study, we used our rhesus monkey model of cortical injury and fine motor impairment to compare sex differences in the rate and degree of motor recovery following this injury. METHODS Aged male and female rhesus monkeys were trained on a task of fine motor function of the hand before undergoing surgery to produce a cortical lesion limited to the hand area representation of the primary motor cortex. Post-operative testing began two weeks after the surgery and continued for 12 weeks. All trials were video recorded and latency to retrieve a reward was quantitatively measured to assess the trajectory of post-operative response latency and grasp pattern compared to pre-operative levels. RESULTS Postmortem analysis showed no differences in lesion volume between male and female monkeys. However, female monkeys returned to their pre-operative latency and grasp patterns significantly faster than males. CONCLUSIONS These findings demonstrate the need for additional studies to further investigate the role of estrogens and other sex hormones that may differentially affect recovery outcomes in the primate brain.
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Affiliation(s)
- Karen R Bottenfield
- Dept. of Anatomy & Neurobiology, Boston University School of Medicine, 700 Albany Street, W701, Boston, MA, 02118, USA.
| | - Bethany G E Bowley
- Dept. of Anatomy & Neurobiology, Boston University School of Medicine, 700 Albany Street, W701, Boston, MA, 02118, USA
| | - Monica A Pessina
- Dept. of Anatomy & Neurobiology, Boston University School of Medicine, 700 Albany Street, W701, Boston, MA, 02118, USA
| | - Maria Medalla
- Dept. of Anatomy & Neurobiology, Boston University School of Medicine, 700 Albany Street, W701, Boston, MA, 02118, USA.,Center for Systems Neuroscience, Boston University, Boston, MA, 02215, USA
| | - Douglas L Rosene
- Dept. of Anatomy & Neurobiology, Boston University School of Medicine, 700 Albany Street, W701, Boston, MA, 02118, USA.,Center for Systems Neuroscience, Boston University, Boston, MA, 02215, USA
| | - Tara L Moore
- Dept. of Anatomy & Neurobiology, Boston University School of Medicine, 700 Albany Street, W701, Boston, MA, 02118, USA.,Center for Systems Neuroscience, Boston University, Boston, MA, 02215, USA
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14
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Central Nervous System Tissue Regeneration after Intracerebral Hemorrhage: The Next Frontier. Cells 2021; 10:cells10102513. [PMID: 34685493 PMCID: PMC8534252 DOI: 10.3390/cells10102513] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
Despite marked advances in surgical techniques and understanding of secondary brain injury mechanisms, the prognosis of intracerebral hemorrhage (ICH) remains devastating. Harnessing and promoting the regenerative potential of the central nervous system may improve the outcomes of patients with hemorrhagic stroke, but approaches are still in their infancy. In this review, we discuss the regenerative phenomena occurring in animal models and human ICH, provide results related to cellular and molecular mechanisms of the repair process including by microglia, and review potential methods to promote tissue regeneration in ICH. We aim to stimulate research involving tissue restoration after ICH.
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15
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Abstract
Intracerebral hemorrhage is a stroke subtype with high mortality and poor functional outcome in survivors. Its main causes are hypertension, cerebral amyloid angiopathy, and anticoagulant treatment. Hematomas have a high frequency of expansion in the first hours after symptom onset, a process associated with neurologic deterioration and poor outcome. Control of severe hypertension, reversal of anticoagulant effect, and management of increased intracranial pressure are the mainstays of management of intracerebral hemorrhage in the acute phase. Surgical evacuation of the hematoma by conventional craniotomy does not improve outcomes, but minimally invasive techniques may be a valuable approach that deserves further evaluation.
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Affiliation(s)
- Carlos S Kase
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
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16
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Hostettler IC, Schwarz G, Ambler G, Wilson D, Banerjee G, Seiffge DJ, Shakeshaft C, Lunawat S, Cohen H, Yousry TA, Al-Shahi Salman R, Lip GYH, Brown MM, Muir KW, Houlden H, Jäger HR, Werring DJ. Cerebral Small Vessel Disease and Functional Outcome Prediction After Intracerebral Hemorrhage. Neurology 2021; 96:e1954-e1965. [PMID: 33627495 DOI: 10.1212/wnl.0000000000011746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 01/08/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether CT-based cerebral small vessel disease (SVD) biomarkers are associated with 6-month functional outcome after intracerebral hemorrhage (ICH) and whether these biomarkers improve the performance of the preexisting ICH prediction score. METHODS We included 864 patients with acute ICH from a multicenter, hospital-based prospective cohort study. We evaluated CT-based SVD biomarkers (white matter hypodensities [WMH], lacunes, brain atrophy, and a composite SVD burden score) and their associations with poor 6-month functional outcome (modified Rankin Scale score >2). The area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow test were used to assess discrimination and calibration of the ICH score with and without SVD biomarkers. RESULTS In multivariable models (adjusted for ICH score components), WMH presence (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.12-2.06), cortical atrophy presence (OR 1.80, 95% CI 1.19-2.73), deep atrophy presence (OR 1.66, 95% CI 1.17-2.34), and severe atrophy (either deep or cortical) (OR 1.94, 95% CI 1.36-2.74) were independently associated with poor functional outcome. For the revised ICH score, the AUROC was 0.71 (95% CI 0.68-0.74). Adding SVD markers did not significantly improve ICH score discrimination; for the best model (adding severe atrophy), the AUROC was 0.73 (95% CI 0.69-0.76). These results were confirmed when lobar and nonlobar ICH were considered separately. CONCLUSIONS The ICH score has acceptable discrimination for predicting 6-month functional outcome after ICH. CT biomarkers of SVD are associated with functional outcome, but adding them does not significantly improve ICH score discrimination. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT02513316.
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Affiliation(s)
- Isabel C Hostettler
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Ghil Schwarz
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Gareth Ambler
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Duncan Wilson
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Gargi Banerjee
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - David J Seiffge
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Clare Shakeshaft
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Surabhika Lunawat
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Hannah Cohen
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Tarek A Yousry
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Rustam Al-Shahi Salman
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Gregory Y H Lip
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Martin M Brown
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Keith W Muir
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Henry Houlden
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Hans Rolf Jäger
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - David J Werring
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London.
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17
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Shoamanesh A, Patrice Lindsay M, Castellucci LA, Cayley A, Crowther M, de Wit K, English SW, Hoosein S, Huynh T, Kelly M, O'Kelly CJ, Teitelbaum J, Yip S, Dowlatshahi D, Smith EE, Foley N, Pikula A, Mountain A, Gubitz G, Gioia LC. Canadian stroke best practice recommendations: Management of Spontaneous Intracerebral Hemorrhage, 7th Edition Update 2020. Int J Stroke 2020; 16:321-341. [PMID: 33174815 DOI: 10.1177/1747493020968424] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the Canadian Stroke Best Practice Recommendations includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The Canadian Stroke Best Practice Recommendations (CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.
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Affiliation(s)
- Ashkan Shoamanesh
- Faculty of Medicine (Neurology), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Division of Neurology, Hamilton, Canada
| | | | - Lana A Castellucci
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Medicine, Divisions of Hematology and General Internal Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Anne Cayley
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Kerstin de Wit
- Department of Medicine (Emergency Medicine), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Divisions of Emergency Medicine and Thrombosis, Hamilton, Canada
| | - Shane W English
- Ottawa Hospital Research Institute (Clinical Epidemiology Program), Ottawa, Canada.,University of Ottawa, Department of Medicine (Critical Care) and School of Epidemiology and Public Health, Ottawa, Canada
| | - Sharon Hoosein
- Trillium Health Partners Stroke Program, Mississauga, Canada
| | - Thien Huynh
- Department of Diagnostic and Interventional Neuroradiology, Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Michael Kelly
- Department of Neurosurgery, University of Saskatchewan, Saskatoon, Canada
| | - Cian J O'Kelly
- Department of Neurological Surgery, University of Alberta, Edmonton, Canada
| | - Jeanne Teitelbaum
- Department of Neurology, Universite de Montreal, Montreal, Canada.,Department of Neurocritical Care, Montreal Neurological Institute MUHC, Montreal, Canada
| | - Samuel Yip
- Faculty of Medicine (Neurology), University of British Columbia, Vancouver, Canada
| | | | - Eric E Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Aleksandra Pikula
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Anita Mountain
- Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Canada.,Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehabilitation Centre Site, Halifax, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Stroke Program, Halifax, Canada
| | - Laura C Gioia
- Department of Neurology, Universite de Montreal, Montreal, Canada.,CHUM-Centre Hospitalier de l'Université de Montréal, Stroke Program, Montréal, Canada
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18
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Madhok DY, Vitt JR, MacIsaac D, Hsia RY, Kim AS, Hemphill JC. Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage. Neurocrit Care 2020; 34:492-499. [PMID: 32661793 DOI: 10.1007/s12028-020-01014-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Do-not-resuscitate (DNR) orders are commonly used after intracerebral hemorrhage (ICH) and have been shown to be a predictor of mortality independent of disease severity. We determined the frequency of early DNR orders in ICH patients and whether a previously reported association with increased mortality still exists. METHODS We performed a retrospective analysis of patients discharged from non-federal California hospitals with a primary diagnosis of ICH from January 2013 through December 2014. Characteristics included hospital ICH volume and type and whether DNR order was placed within 24 h of admission (early DNR order). The risk of in-hospital mortality was evaluated both on the individual and hospital level using multivariable analyses. A case mix-adjusted hospital DNR index was calculated for each hospital by comparing the actual number of DNR cases with the expected number of DNR cases from a multivariate model. RESULTS A total of 9,958 patients were treated in 180 hospitals. Early DNR orders were placed in 20.1% of patients and 54.2% of these patients died during their hospitalization compared to 16.0% of patients without an early DNR order. For every 10% increase in a hospital's utilization of early DNR orders, there was a corresponding 26% increase in the likelihood of in-hospital mortality. Patients treated in hospitals within the highest quartile of adjusted DNR use had a higher relative risk of death compared to the lowest quartile (RR 3.9 vs 5.2) though the trend across quartiles was not statistically significant. CONCLUSIONS The use of early DNR orders for ICH continues to be a strong predictor of in-hospital mortality. However, patients treated at hospitals with an overall high or low use of early DNR had similar relative risks of death whether or not there was an early DNR order, suggesting that such orders may not be a proxy for less aggressive care as seen previously.
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Affiliation(s)
- Debbie Y Madhok
- Department of Emergency Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
| | - Jeffrey R Vitt
- Department of Neurology, University of California, San Francisco, USA
| | | | - Renee Y Hsia
- Department of Emergency Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, USA
| | - Anthony S Kim
- Department of Neurology, University of California, San Francisco, USA
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, USA
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19
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Abstract
OBJECTIVES To describe the sources of uncertainty in prognosticating devastating brain injury, the role of the intensivist in prognostication, and ethical considerations in prognosticating devastating brain injury in the ICU. DATA SOURCES A PubMed literature review was performed. STUDY SELECTION Articles relevant to prognosis in intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and postcardiac arrest anoxic encephalopathy were selected. DATA EXTRACTION Data regarding definition and prognosis of devastating brain injury were extracted. Themes related to how clinicians perform prognostication and their accuracy were reviewed and extracted. DATA SYNTHESIS Although there are differences in pathophysiology and therefore prognosis in the various etiologies of devastating brain injury, some common themes emerge. Physicians tend to have fairly good prognostic accuracy, especially in severe cases with poor prognosis. Full supportive care is recommended for at least 72 hours from initial presentation to maximize the potential for recovery and minimize secondary injury. However, physician approaches to the timing of and recommendations for withdrawal of life-sustaining therapy have a significant impact on mortality from devastating brain injury. CONCLUSIONS Intensivists should consider the modern literature describing prognosis for devastating brain injury and provide appropriate time for patient recovery and for discussions with the patient's surrogates. Surrogates wish to have a prognosis enumerated even when uncertainty exists. These discussions must be handled with care and include admission of uncertainty when it exists. Respect for patient autonomy remains paramount, although physicians are not required to provide inappropriate medical therapies.
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20
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Selim M, Foster LD, Moy CS, Xi G, Hill MD, Morgenstern LB, Greenberg SM, James ML, Singh V, Clark WM, Norton C, Palesch YY, Yeatts SD. Deferoxamine mesylate in patients with intracerebral haemorrhage (i-DEF): a multicentre, randomised, placebo-controlled, double-blind phase 2 trial. Lancet Neurol 2019; 18:428-438. [PMID: 30898550 DOI: 10.1016/s1474-4422(19)30069-9] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/02/2019] [Accepted: 02/06/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Iron from haemolysed blood is implicated in secondary injury after intracerebral haemorrhage. We aimed to assess the safety of the iron chelator deferoxamine mesylate in patients with intracerebral haemorrhage and to establish whether the drug merits investigation in a phase 3 trial. METHODS We did a multicentre, futility-design, randomised, placebo-controlled, double-blind, phase 2 trial at 40 hospitals in Canada and the USA. Adults aged 18-80 years with primary, spontaneous, supratentorial intracerebral haemorrhage were randomly assigned (1:1) to receive deferoxamine mesylate (32 mg/kg per day) or placebo (saline) infusions for 3 consecutive days within 24 h of haemorrhage onset. Randomisation was done via a web-based trial-management system centrally in real time, and treatment allocation was concealed from both participants and investigators. The primary outcome was good clinical outcome, which was defined as a modified Rankin Scale score of 0-2 at day 90. We did a futility analysis: if the 90% upper confidence bound of the absolute risk difference between the two groups in the proportion of participants with a good clinical outcome was less than 12% in favour of deferoxamine mesylate, then to move to a phase 3 efficacy trial would be futile. Primary outcome and safety data were analysed in the modified intention-to-treat population, comprising only participants in whom the study infusions were initiated. This trial is registered with ClinicalTrials.gov, number NCT02175225, and is completed. FINDINGS We recruited 294 participants between Nov 23, 2014, and Nov 10, 2017. The modified intention-to-treat population consisted of 144 patients assigned to the deferoxamine mesylate group and 147 assigned to the placebo group. At day 90, among patients with available data for the primary outcome, 48 (34%) of 140 participants in the deferoxamine mesylate group, and 47 (33%) of 143 patients in the placebo group, had modified Rankin Scale scores of 0-2 (adjusted absolute risk difference 0·6% [90% upper confidence bound 6·8%]). By day 90, 70 serious adverse events were reported in 39 (27%) of 144 patients in the deferoxamine mesylate group, and 78 serious adverse events were reported in 49 (33%) of 147 patients in the placebo group. Ten (7%) participants in the deferoxamine mesylate and 11 (7%) in the placebo group died. None of the deaths were judged to be treatment related. INTERPRETATION Deferoxamine mesylate was safe. However, the primary result showed that further study of the efficacy of deferoxamine mesylate with anticipation that the drug would significantly improve the chance of good clinical outcome (ie, mRS score of 0-2) at day 90 would be futile. FUNDING US National Institutes of Health and US National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Magdy Selim
- Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Lydia D Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Claudia S Moy
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael D Hill
- Health Science Center, University of Calgary, Calgary, AB, Canada
| | - Lewis B Morgenstern
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Steven M Greenberg
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA
| | - Michael L James
- Department of Anesthesiology and Neurology, Duke University, Durham, NC, USA
| | - Vineeta Singh
- San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Wayne M Clark
- Oregon Health and Science University Hospital, Portland, OR, USA
| | - Casey Norton
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yuko Y Palesch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
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21
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Seiffge DJ, Curtze S, Dequatre-Ponchelle N, Pezzini A, Tatlisumak T, Cordonnier C, Werring D. Hematoma location and morphology of anticoagulation-associated intracerebral hemorrhage. Neurology 2019; 92:e782-e791. [PMID: 30674603 DOI: 10.1212/wnl.0000000000006958] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 10/15/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To study hematoma location and morphology of intracerebral hemorrhage (ICH) associated with oral anticoagulants (OAC) and delineate causes and mechanism. METHODS We performed a systematic literature research and meta-analysis of studies comparing neuroimaging findings in patients with OAC-ICH compared to those with ICH not associated with OAC (non-OAC ICH). We calculated pooled risk ratios (RRs) for ICH location using the Mantel-Haenszel random-effects method and corresponding 95% confidence intervals (95% CI). RESULTS We identified 8 studies including 6,259 patients (OAC-ICH n = 1,107, pooled OAC-ICH population 17.7%). There was some evidence for deep ICH location (defined as ICH in the thalamus, basal ganglia, internal capsule, or brainstem) being less frequent in patients with OAC-ICH (OAC-ICH: 450 of 1,102/40.8% vs non-OAC ICH: 2,656 of 4,819/55.1%; RR 0.94, 95% CI 0.88-1.00, p = 0.05, I 2 = 0%) while cerebellar ICH location was significantly more common in OAC-ICH (OAC-ICH: 111 of 1,069/10.4% vs non-OAC ICH: 326 of 4,787/6.8%; RR 1.45, 95% CI 1.12-1.89, p = 0.005, I 2 = 21%) compared to non-OAC ICH. There was no statistically significant relationship to OAC use for lobar (OAC-ICH: 423 of 1,107/38.2% vs non-OAC ICH: 1,884 of 5,152/36.6%; RR 1.02, 95% CI 0.89-1.17, p = 0.75, I 2 = 53%, p for heterogeneity = 0.04) or brainstem ICH (OAC-ICH: 36 of 546/6.6% vs non-OAC ICH: 172 of 2,626/6.5%; RR 1.04, 95% CI 0.58-1.87, p = 0.89, I 2 = 59%, p for heterogeneity = 0.04). The risk for intraventricular extension (OAC-ICH: 436 of 840/51.9% vs non-OAC ICH: 1,429 of 3,508/40.7%; RR 1.26, 95% CI 1.16-1.36, p < 0.001, I 2 = 0%) was significantly increased in patients with OAC-ICH. We found few data on ICH morphology in OAC-ICH vs non-OAC ICH. CONCLUSION The overrepresentation of cerebellar ICH location and intraventricular extension in OAC-ICH might have mechanistic relevance for the underlying arteriopathy, pathophysiology, or bleeding pattern of OAC-ICH, and should be investigated further.
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Affiliation(s)
- David J Seiffge
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sami Curtze
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nelly Dequatre-Ponchelle
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alessandro Pezzini
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Turgut Tatlisumak
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Charlotte Cordonnier
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Werring
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden.
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Sembill JA, Huttner HB, Kuramatsu JB. Impact of Recent Studies for the Treatment of Intracerebral Hemorrhage. Curr Neurol Neurosci Rep 2018; 18:71. [DOI: 10.1007/s11910-018-0872-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Schmidt FA, Liotta EM, Prabhakaran S, Naidech AM, Maas MB. Assessment and comparison of the max-ICH score and ICH score by external validation. Neurology 2018; 91:e939-e946. [PMID: 30068631 DOI: 10.1212/wnl.0000000000006117] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 06/06/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE We tested the hypothesis that the maximally treated intracerebral hemorrhage (max-ICH) score is superior to the ICH score for characterizing mortality and functional outcome prognosis in patients with ICH, particularly those who receive maximal treatment. METHODS Patients presenting with spontaneous ICH were enrolled in a prospective observational study that collected demographic and clinical data. Mortality and functional outcomes were measured by using the modified Rankin Scale at 3 months. The ICH score and max-ICH score incorporate measures of symptom severity, age, hematoma volume, hematoma location, and intraventricular hemorrhage, with the max-ICH score also including a term for oral anticoagulation and having 16 score categories vs 11 for the ICH score. We compared the area under the receiver operating characteristic curve (AUC) for the ICH score and max-ICH score for both mortality and poor functional outcome, defined as modified Rankin Scale scores 4-6. RESULTS We analyzed outcomes for 372 patients, including 71 patients (19%) in whom care limitation/withdrawal of life support was instituted. Both the ICH score and max-ICH score showed good prognostic performance for 3-month mortality and poor functional outcomes in the full group as well as the subgroup with maximal treatment (i.e., no care limitations; AUC range 0.80-0.86), with no significant difference in AUC between the scores for either endpoint in either group. CONCLUSIONS External validation with direct comparison of the ICH score and max-ICH score shows that their prognostic performance is not meaningfully different. Alternatives to simple scores are likely needed to improve prognostic estimates for patient care decisions.
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Affiliation(s)
- Felix A Schmidt
- From the Department of Neurology (F.A.S.), Charité - Universitätsmedizin Berlin, Department of Neurology, NeuroCure Clinical Research Center, and the Berlin Institute of Health Berlin, Germany; and Division of Stroke and Critical Care (E.M.L., S.P., A.M.N., M.B.M.), Department of Neurology, Northwestern University, Chicago, IL
| | - Eric M Liotta
- From the Department of Neurology (F.A.S.), Charité - Universitätsmedizin Berlin, Department of Neurology, NeuroCure Clinical Research Center, and the Berlin Institute of Health Berlin, Germany; and Division of Stroke and Critical Care (E.M.L., S.P., A.M.N., M.B.M.), Department of Neurology, Northwestern University, Chicago, IL
| | - Shyam Prabhakaran
- From the Department of Neurology (F.A.S.), Charité - Universitätsmedizin Berlin, Department of Neurology, NeuroCure Clinical Research Center, and the Berlin Institute of Health Berlin, Germany; and Division of Stroke and Critical Care (E.M.L., S.P., A.M.N., M.B.M.), Department of Neurology, Northwestern University, Chicago, IL
| | - Andrew M Naidech
- From the Department of Neurology (F.A.S.), Charité - Universitätsmedizin Berlin, Department of Neurology, NeuroCure Clinical Research Center, and the Berlin Institute of Health Berlin, Germany; and Division of Stroke and Critical Care (E.M.L., S.P., A.M.N., M.B.M.), Department of Neurology, Northwestern University, Chicago, IL
| | - Matthew B Maas
- From the Department of Neurology (F.A.S.), Charité - Universitätsmedizin Berlin, Department of Neurology, NeuroCure Clinical Research Center, and the Berlin Institute of Health Berlin, Germany; and Division of Stroke and Critical Care (E.M.L., S.P., A.M.N., M.B.M.), Department of Neurology, Northwestern University, Chicago, IL.
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24
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Suo Y, Chen WQ, Pan YS, Peng YJ, Yan HY, Zhao XQ, Liu LP, Wang YL, Liu GF, Wang YJ. The max-intracerebral hemorrhage score predicts long-term outcome of intracerebral hemorrhage. CNS Neurosci Ther 2018. [PMID: 29529353 DOI: 10.1111/cns.12846] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
AIMS Little is known about the performance of the maximally treated intracerebral hemorrhage (max-ICH) score in predicting unfavorable long-term functional outcome and death in patients with intracerebral hemorrhage (ICH) in China. We aimed to validate the performance of the max-ICH score and compared it with other recognized scores. METHODS We derived data from the China National Stroke Registry (CNSR). Receiver-operating characteristic (ROC) analysis and Hosmer-Lemeshow test were used to measure the score performance. We compared the performance of max-ICH score with six recognized models, including the ICH score, ICH functional outcome score (ICH-FOS), Essen-ICH score, modified intracerebral hemorrhage (MICH) score, intracerebral hemorrhage grading scale (ICH-GS), and functional outcome (FUNC) score. RESULTS A total of 2581 patients with spontaneous ICH were enrolled in the study. The max-ICH score was similar or superior to the six existing scores in predicting long-term unfavorable functional outcome after ICH with good discrimination (AUC 0.83, 95% confidence interval [CI] 0.81-0.84) and calibration (Hosmer-Lemeshow P = 0.19). For predicting death, the AUC of max-ICH was 0.81 (95% CI 0.79-0.83). CONCLUSIONS The easy-to-use max-ICH score is a reliable tool to predict unfavorable long-term (12-month) functional outcome and death after intracerebral hemorrhage in the Chinese population.
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Affiliation(s)
- Yue Suo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wei-Qi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yue-Song Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Yu-Jing Peng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Hong-Yi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xing-Quan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Li-Ping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi-Long Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Gai-Fen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yong-Jun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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