Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage

Minimally invasive surgery for non-traumatic spontaneous intracerebral Hemorrhage: A network Meta-Analysis of multiple treatment modalities

INTRODUCTION

Spontaneous Supratentorial Intracerebral Hemorrhage (SICH) is a severe condition with high mortality and morbidity, annually affecting around 2 million people globally. Current treatment guidelines emphasize medical management however, Minimally Invasive Surgery (MIS), including stereotactic and endoscopic approaches, has shown promise in improving outcomes. This network meta-analysis aims to compare the efficacy and safety of MIS with conventional craniotomy, burrhole catheter insertion, and medical treatment for the management of SICH.

METHODS

Following PRISMA guidelines, a comprehensive literature search across three databases to identify relevant studies. Data extracted included demographics, treatment outcomes, and adverse effects, while the quality of studies was assessed using the NHLBI tool. A network meta-analysis was performed using RStudio to compare the effectiveness of MIS approaches with other treatment modalities.

RESULTS

MIS for SICH was more effective than conservative medical management in reducing mortality (OR: 1.991; 95% CI, 1.364-2.907) but did not show a mortality benefit compared to conventional surgery, external ventricular drainage (EVD), or burr hole procedures. MIS had similar hematoma evacuation rates to conventional surgery and burr hole drainage but required significantly less operating time (SMD: 3.837; 95% CI, 2.851-4.823) and reduced ICU stay (SMD: 4.436; 95% CI, 2.386-6.486). Conventional surgery had higher risks of blood loss, seizures, GI bleed/ulceration, and pneumonia/RTI, while MIS showed a safer profile regarding these complications. There was no significant difference in rebleeding (OR: 1.492; 95% CI, 0.632-3.522) or reoperation rates (OR: 0.494; 95% CI, 0.120-2.039) between MIS, conventional surgery, and conservative treatment.

CONCLUSION

MIS significantly reduces mortality compared to conservative treatment while offering similar outcomes to other surgeries. MIS also has advantages like shorter operating times, reduced ICU stays, and fewer complications, making it a promising alternative for managing SICH.

Differences in subacute motor recovery after intracerebral haemorrhage and ischaemic stroke: Analysis using the VISTA database cohort

BACKGROUND

Motor impairment is a significant contributor to disability after stroke, but recovery is often incomplete. Whether motor recovery differs between intracerebral haemorrhage (ICH), a subgroup of stroke with far worse outcomes, and ischaemic stroke is not clear.

METHODS

We performed a retrospective observational longitudinal cohort study using individual patient-level data from the Virtual International Stroke Trials Archive (VISTA) database (ICH n=892, ischaemic stroke n=6912). Differences in motor recovery to 90-days were examined between ICH and ischaemic stroke patients with mixed effect regression models adjusted for a priori determined confounders. Motor weakness was measured by NIHSS face, arm and leg sum with secondary analyses of total NIHSS, and NIHSS language score.

RESULTS

Recovery was observed in all NIHSS domains for both stroke types to 30-days (NIHSSmotorb=-2.78, 95%CI -2.89,-2.68; NIHSStotalb=-5.74, 95%CI -5.92,-5.56; NIHSSlanguageb=-0.28 95%CI -0.31,-0.24) and 90-days (NIHSSmotorb=-3.62, 95%CI -3.69,-3.54; NIHSStotalb=-7.17, 95%CI -7.30,-7.05; NIHSSlanguageb=-0.74, 95%CI -0.78,-0.71). Baseline impairment between groups was well matched with only motor impairment being slightly greater in ICH; NIHSSmotor mean(SD)=13.0 (5.3) vs 12.3 (5.4). To 30-days the extent of recovery was not different between stroke types but recovery to 90-days was greater in ICH for motor and statistically significant for total NIHSS score (b=-0.35, 95%CI -0.71,-0.002). Ischaemic stroke survivors recovered more in NIHSS language domain.

CONCLUSIONS

Timing and extent of recovery is different between stroke types. Motor recovery in ICH is greater and occurs later. Therefore, the assumption that most recovery occurs within 30-days and proportionality of recovery should be revisited in this population.

Cost-Effectiveness Analysis of Early Minimally Invasive Removal of Intracerebral Hemorrhage

BACKGROUND

Supratentorial intracerebral hemorrhage (ICH) is common and often devastating. In a randomized controlled trial, ICH evacuation with minimally invasive trans-sulcal parafascicular surgery (MIPS) improved functional outcomes at 180 days compared with medical management (MM), primarily in patients with lobar hemorrhages. The cost-effectiveness of MIPS compared with MM is explored.

METHODS

A Markov model compared costs and outcomes using ENRICH trial (Early Minimally Invasive Removal of Intracerebral Hemorrhage) data for MIPS versus MM over the 6-month trial duration. Costs were $2020 and effectiveness was quality-adjusted life years. Monthly model transitions between modified Rankin Scale score health states were estimated from trial data. Costs were obtained from US databases and literature. MIPS device costs were $5705/patient. Primary outcomes were total hospital costs from the hospital perspective and the incremental cost-effectiveness ratio between MIPS and MM (ie, the 6-month cost difference between strategies divided by quality-adjusted life year difference) for the healthcare perspective for patients with lobar ICH. Sensitivity analyses were performed.

RESULTS

From the hospital perspective, MIPS costs were $2782 less per patient than MM ($74 252 versus $77 034), with MIPS having decreased the intensive care unit hospital length of stay, non-MIPS neurosurgery, mortality, and rehospitalization. From the healthcare perspective, including hospital and nonhospital costs, MIPS in lobar ICH cost $8850 less and gained 0.068 quality-adjusted life year per patient compared with MM; thus MIPS was dominant (less costly and more effective). Results were robust to individual parameter variation over plausible ranges and, with all parameters varied simultaneously in a probabilistic sensitivity analysis, MIPS was dominant in >93% of 10 000 model iterations and favored in >99% at $100 000/quality-adjusted life year gained (a common US benchmark).

CONCLUSIONS

In the ENRICH randomized controlled trial, MIPS cost less and was more effective compared with MM from both hospital and healthcare perspectives for patients with lobar ICH.

REGISTRATION

Unique identifier: NCT02880878.

Corticospinal tract damage on baseline CT predicts motor recovery and functional outcome in intracerebral haemorrhage

INTRODUCTION

Corticospinal tract (CST) integrity can predict motor outcome after stroke but requires specialist investigations not routinely performed after intracerebral haemorrhage (ICH). We investigated the feasibility of identifying the CST on routine clinical CT scans, and whether classification of CST overlap with haematoma is associated with motor recovery after ICH.

PATIENTS AND METHODS

An expert observer, blinded to outcome, manually segmented the CST at the posterior limb of the internal capsule (PLIC) and corona radiata (CR) on diagnostic CT scans from 98 randomly selected MISTIE-III trial participants and determined whether CST overlapped with the haematoma. Multivariable linear regression tested for associations between haematoma CST overlap and the motor component of the National Institutes of Health Stroke Scale (baseline & Day 180, rate of recovery), patient reported motor impairment (Stroke Impact Scale [SIS] domain 1) and activity limitation (SIS domains 6&7) at Day 180, and modified Rankin Scale (mRS) at day 180. Three further readers analysed the same scans and the interobserver variability was assessed.

RESULTS

Haematoma and CST overlap occurred exclusively in the CR in 6%, the PLIC in 14% and in both in 52% of patients. CR involvement alone was associated with activity limitation on Day 180. Involvement at the PLIC alone or both the PLIC and CR was independently associated with worse motor outcomes (except rate of recovery, where only involvement of both was associated). Although haematoma and CST overlap remained associated with outcome for other readers, the strength of the association decreased with less expertise, and interobserver kappa scores (κ = 0.47 for CR and κ = 0.45 for PLIC) demonstrated only moderate agreement.

DISCUSSION AND CONCLUSION

Haematoma and CST overlap at the level of the PLIC identified on routine CT scans is independently associated with poor motor outcomes, representing a novel prognostic factor. Given moderate interobserver agreement, a more reliable machine-learning classification would be desirable.

Hemin-induced transient senescence via DNA damage response: a neuroprotective mechanism against ferroptosis in intracerebral hemorrhage

Intracerebral hemorrhage (ICH) poses acute fatality and long-term neurological risks, in part due to hemin and iron accumulation from hemoglobin breakdown. We observed that hemin induces DNA double-strand breaks (DSBs), prompting a senescence-like phenotype in neurons, necessitating a deeper exploration of cellular responses. Using experimental ICH models and human ICH patient tissue, we elucidate hemin-mediated DNA damage response (DDR) inducing transient senescence and delayed expression of heme oxygenase (HO-1). HO-1 co-localizes with senescence-associated β-Galactosidase (SA-β-Gal) in ICH patient tissues, emphasizing the clinical relevance of inducible HO-1 expression in senescent cells. We reveal a reversible senescence state protective against acute cell death by hemin, while repeat exposure leads to long-lasting senescence. Inhibiting early senescence expression increases cell death, supporting the protective role of senescence against hemin toxicity. Hemin-induced senescence is attenuated by a pleiotropic carbon nanoparticle that is a catalytic mimic of superoxide dismutase, but this treatment increased lipid peroxidation, consistent with ferroptosis from hemin breakdown released iron. When coupled with iron chelator deferoxamine (DEF), the nanoparticle reduces hemin-induced senescence and upregulates factors protecting against ferroptosis. Our study suggests transient senescence induced by DDR as an early potential neuroprotective mechanism in ICH, but the risk of iron-related toxicity supports a multi-pronged therapeutic approach.

Functional outcomes of minimally invasive surgery treatment for patients with small supratentorial spontaneous intracerebral haematoma less than 30 mL: a propensity score matching study

BACKGROUND

This study investigated the efficacy of frameless robot-assisted stereotactic aspiration coupled with catheter thrombolysis (SA-CT) in treating supratentorial spontaneous intracerebral haemorrhage (sICH) with small haematoma volumes (<30 mL).

METHODS

We analysed the clinical and long-term outcome data for patients who had haematoma volumes <30 mL and underwent SA-CT between August 2019 and June 2023. Then, we matched the patients receiving conservative treatment during the same period from a multicentre intracerebral haemorrhage database using propensity score matching. The outcomes included the restoration of independent standing ability and mortality within 1 year after onset.

RESULTS

340 patients were included in the final analysis. A greater proportion of patients in the surgery group regained the ability to stand independently within 1 year (89.1% vs 78.1%, p=0.049). The Kaplan-Meier curve showed that the cumulative standing rate in the surgery group was higher than that in the conservative group (90.4% vs 82.0%, p=0.007) within 1 year, and the median time to regain standing was shorter in the surgery group (30 days vs 34 days). The mortality rates were lower in the surgery group (p<0.05). Multivariate Cox regression analysis revealed that frameless robot-guided SA-CT (adjusted HR 1.80; 95% CI 1.37 to 2.38; p<0.001), age, haematoma volume, the severe Glasgow Coma Scale scores and pneumonia were independent factors associated with standing recovery within 1 year after onset.

CONCLUSIONS

Frameless robot-guided SA-CT for small supratentorial haematoma with contralateral hemiplegia seems safe and potentially facilitates the recovery of independent standing ability and reduces the mortality rates.

Genomics of stroke recovery and outcome

The understanding of genomics has improved tremendously during the last decades. The concept of recovery and outcome after stroke has also progressed during this time. However, the connection between genomics and stroke recovery has only begun to emerge in a more structural and comprehensive way. Different types of outcomes and recovery occur after stroke. This depends on domain of neurological deficit, severity, resilience, receptivity for rehabilitation measures, and concomitant morbidity. Methods for assessing stroke patients' prognosis depend on these factors. Different genetic approaches are possible and there is an increasing need for linking genetic findings to other omics as well as to clinically meaningful results. This review addresses recent advances and views in clinical genomics of stroke recovery and outcome in humans with focus on current and previous studies, concepts, and future perspectives.

Spot Sign in Intracerebral Hemorrhage: Critical Reappraisal and Future Clinical Implications

Hematoma expansion (HE) is a common occurrence affecting around 10% to 30% of patients with acute intracerebral hemorrhage within the initial hours from symptom onset and is the only modifiable factor associated with poor clinical outcomes. The detection of contrast extravasation on computed tomography (CT) angiography, known as the spot sign, was initially embraced as a promising radiological marker for predicting HE that could aid patient selection for acute interventions aimed at minimizing HE. However, the initial enthusiasm waned as clinical studies failed to show clear clinical benefits of hemostatic treatments when patients were selected based on the presence of this imaging marker. In this narrative review, we provide a comprehensive summary of the pathophysiology, definitions, imaging protocols, and predictive performance of the CT angiography spot sign, along with the clinical studies that have selected and treated patients based on its presence. Finally, we delve into some nuances of the spot sign that can enhance its predictive performance and help stratify HE risk with greater precision. These features include static findings observed on single-phase CT angiography (ie, number, volume, CT density, and colocalization with hypodensities), as well as dynamic findings identified on multiphase/dynamic CT angiography (ie, timing of appearance, volume increase, volume decrease for tissue dispersion, and CT density changes). In this reappraisal of the spot sign, we aim to reinvigorate research on advanced neuroimaging in intracerebral hemorrhage that could lead to a more accurate HE prediction. This could facilitate better selection for therapies aimed at preventing HE or surgical approaches to address the bleeding source.

Stepwise improvement in intracerebral haematoma expansion prediction with advanced imaging: a comprehensive comparison of existing scores

BACKGROUND

We aim to comprehensively assess and compare the predictive performance of haematoma expansion (HE) scores in a homogeneous cohort of acute intracerebral haemorrhage (ICH) patients.

METHODS

Existing scores for predicting HE in acute ICH patients were included and categorised by imaging modality: non-contrast CT (NCCT), single-phase CT angiography (sCTA) and multiphase CTA (mCTA). The predictive performance of the scores was evaluated with the c-statistic in a population of consecutive adult patients with acute ICH admitted to a tertiary care centre in Southern Alberta, Canada, between February 2012 and May 2020, investigated with a multimodal imaging protocol (NCCT, sCTA and mCTA). The primary outcome was HE (ICH volume growth ≥6 mL or ≥33%), and the secondary outcome was severe HE (ICH volume growth ≥12.5 mL or ≥66%). The DeLong test compared the best-performing scores from each imaging category.

RESULTS

16 HE scores were assessed (NCCT=8, sCTA=6 and mCTA=2) in 217 patients with a median age of 70 years (IQR=60-80), and 86 (39.6%) were females. 51 (23.5%) patients experienced HE and 35 (16.1%) had severe HE. The c-statistic for predicting HE ranged from 0.516 to 0.674 for NCCT-based scores, 0.627 to 0.725 for sCTA-based scores and 0.800 to 0.814 for mCTA-based score. The c-statistic for predicting severe HE ranged from 0.505 to 0.666 for NCCT scores, 0.651 to 0.740 for sCTA scores and 0.813 to 0.828 for mCTA scores. A statistically significant difference favouring mCTA over other imaging modalities in predicting both HE and severe HE was observed.

CONCLUSIONS

Advanced imaging demonstrated a stepwise improvement in the predictive performance of HE scores. However, no existing score achieved excellent predictive performance (c-statistics ≥0.90) in our cohort, highlighting the need for further refinement.

Comparative analysis of stereotactic aspiration via supraorbital keyhole versus Kocher's point for basal ganglia intracerebral hematoma: computational simulation and propensity score-matched study

Catheter placement via the supraorbital keyhole (SOK) for removing spontaneous intracerebral hemorrhage (sICH) in the basal ganglia may result in improved aspiration rates and functional outcomes than those by the conventional Kocher's point (KP) route. Verification was performed using he results of computational simulations and retrospective clinical data matched by propensity scores. We retrospectively enrolled 50 patients who underwent stereotactic hematoma aspiration of 'typical' shape of basal ganglia sICH. After propensity score matching (PSM), comparative analyses between the two groups (n = 36) were performed. A computational simulation of hematoma aspiration was conducted in eight patients using 2-mm thin-sliced brain computed tomography images obtained preoperatively. After PSM, eighteen patients in each group were newly matched and the logit propensity score of the was 0.04 ± 0.0726. The aspiration rate was significantly higher in the SOK group (31.841 ± 40.131 in KP vs. 55.191 ± 25.387 in SOK, p = 0.045), and the proportion of patients who achieved good functional outcomes (mRS score, 0-2 at 6 months) was significantly higher in the SOK group (27.8% vs. 61.1%, p = 0.044). The computational simulations also demonstrated a lower residual volume rate in the SOK group than in the KP group in those with a typical ICH type (21.5% vs. 43.4%). Stereotactic hematoma aspiration via the SOK route in patients with typical basal ganglia ICH is a safe and effective method with an enhanced aspiration rate and favorable functional outcomes.

Outcomes Following Minimally Invasive Surgery for Intracerebral Hemorrhage in the AHA Get With The Guidelines Registry

BACKGROUND

The efficacy of minimally invasive surgery (MIS) in improving outcomes after nontraumatic intracerebral hemorrhage (ICH) remains uncertain, with inconsistent findings from randomized clinical trials. Our objective was to evaluate the real-world impact of MIS on ICH outcomes using a nationally representative cohort.

METHODS

We performed a retrospective cohort study of patients with a nontraumatic ICH enrolled in the American Heart Association Get With The Guidelines-Stroke Registry between January 1, 2011, and December 31, 2021. We excluded patients with a diagnosis of ischemic stroke or other intracranial hemorrhage subtypes, those who underwent open craniotomy or craniectomy, and patients transferred to another hospital. The exposure was MIS, defined as a composite of stereotactic surgical evacuation and endoscopic surgical evacuation. The primary outcome was in-hospital mortality, while secondary outcomes included functional outcomes at discharge (discharge disposition, ambulatory status, and modified Rankin Scale score). We matched patients who underwent MIS with nonsurgical patients using overlap propensity matching and used multiple logistic regression to study the association between MIS and outcomes.

RESULTS

Among 684 467 patients with ICH, 555 964 were included; the mean age was 68 (SD, 15.3) years, and 262 999 (47.3%) were female. MIS was performed in 703 patients of whom 312 had stereotactic surgery and 391 had endoscopic surgery. In the matched cohort, in-hospital deaths occurred in 60 of 446 (13.5%) with MIS and 8321 of 35 361 patients (23.5%) without surgery. In regression analyses, MIS was associated with lower in-hospital mortality (adjusted odds ratio, 0.50 [95% CI, 0.39-0.65]) and favorable discharge disposition (adjusted odds ratio, 1.93 [95% CI, 1.61-2.32]) but not with ambulatory status or functional outcomes. In additional analyses, stereotactic surgery and endoscopic surgery were independently associated with lower mortality.

CONCLUSIONS

In a large diverse cohort of patients with ICH, MIS was associated with lower in-hospital mortality and favorable discharge disposition. These findings support efforts to understand the durable impact of MIS in patients with ICH.

Voxel-Wise Map of Intracerebral Hemorrhage Locations Associated With Worse Outcomes

BACKGROUND

Prior studies on the clinical impact of intracerebral hemorrhage (ICH) location have used visual localization of hematomas to neuroanatomical structures. However, hematomas often cross neuroanatomical structure boundaries with inter-reviewer variability in visual localization. To address these limitations, we applied voxel-wise analysis to identify brain regions where ICH presence is independently predictive of worse outcomes.

METHODS

We included consecutive patients with acute spontaneous ICH from a comprehensive stroke center in a derivation cohort and validated the results in patients from the control arm of a multicenter clinical trial. Using general linear models, we created and publicly shared a voxel-wise map of brain regions where ICH presence was associated with higher 3-month modified Rankin Scale scores, independent of hematoma volume and clinical risk factors. We also determined the optimal overlap threshold between baseline hematoma and voxel-wise map to categorize ICH location into high versus low risk.

RESULTS

Excluding those with missing variables, head computed tomography processing pipeline failure and poor scan quality, 559 of 780 patients were included in derivation (mean age, 69.3±14.5 years; 311 [55.6%] males) and 345 of 500 (mean age, 62.5±12.9 years; 206 [59.7%] males) in validation cohorts. In a voxel-wise analysis, ICH presence in deep white matter, thalami, caudate, midbrain, and pons was associated with worse outcomes. At the patient level, >22% overlap of baseline hematoma with voxel-wise map optimally binarized ICH location to high- versus low-risk categories. In both the derivation and validation cohorts, a high-risk ICH location was independently associated with worse outcomes (higher 3-month modified Rankin Scale score), after adjusting for patients' age, symptom severity at admission, baseline hematoma volume, and the presence of intraventricular hemorrhage, with adjusted odds ratios of 2 ([95% CI, 1.3-3.0] P=0.001) and 1.7 ([95% CI, 1.1-2.9] P=0.027), respectively.

CONCLUSIONS

We created and publicly shared a voxel-wise map of brain regions where hematoma presence predicts worse outcomes, independent of volume and clinical risk factors.

Ultra-Early Hematoma Expansion Is Associated With Ongoing Hematoma Growth and Poor Functional Outcome

BACKGROUND

There are limited data on ultra-early hematoma growth dynamics and their clinical impact in primary intracerebral hemorrhage (ICH). We aimed to estimate the incidence of hematoma expansion within the hyperacute period of ICH, describe hematoma dynamics over time, investigate the associations between ultra-early hematoma expansion and clinical outcomes after ICH, and assess the effect of tranexamic acid on ultra-early hematoma expansion.

METHODS

We performed a preplanned secondary analysis of the STOP-MSU trial (Stopping Intracerebral Hemorrhage With Tranexamic Acid for Hyperacute Onset Presentation Including Mobile Stroke Units), which compared tranexamic acid with placebo in 201 patients with primary ICH presenting within 2 hours of symptom onset. Repeat computed tomography imaging ≈1 hour after treatment commencement was encouraged (ultra-early reimaging), and patients with this imaging were included in this descriptive study. Imaging analyses were separated into the following time epochs: baseline-the period from onset-to-baseline imaging; ultra-early-the period from baseline imaging to ultra-early reimaging; and interval-the period from ultra-early reimaging to 24-hour reimaging. Hematoma expansion was defined as a ≥33% or ≥6 mL increase from baseline, and functional outcomes were assessed at 90 days (poor functional outcome defined as modified Rankin Scale score of 3-6) using unadjusted logistic regression models.

RESULTS

We included 105 patients who had ultra-early reimaging (median age, 66 years; 40% female). Median onset-to-baseline imaging time was 74 minutes (interquartile range, 56-87 minutes), and baseline-to-ultra-early reimaging time was 95 minutes (interquartile range, 74-132 minutes). Forty-one patients (39%) had ultra-early hematoma expansion. These patients had larger baseline hematomas (15.9 mL versus 9.1 mL, P=0.03) compared with those with no early hematoma expansion. Hematoma growth rate declined over time (clustered median regression P<0.01). In 92 patients with imaging at all 3 time points, patients with ultra-early hematoma expansion were more likely to have further interval expansion (9/31 [29%] versus 4/61 [6.6%], P<0.01). Of the 61 patients without ultra-early hematoma expansion, there were 10 (16.4%) whose total growth from baseline to 24-hour imaging fulfilled the expansion definition. Ultra-early hematoma expansion was associated with poor functional outcomes (unadjusted odds ratio, 3.91 [1.22-12.49]; P<0.01) and mortality (unadjusted odds ratio, 6.19 [2.17-17.66]; P<0.01). There was no observed effect of tranexamic acid treatment on ultra-early hematoma expansion (P=0.65).

CONCLUSIONS

In patients with ICH presenting within 2 hours of symptom onset, most hematoma growth occurs in the ultra-early period. The presence of ultra-early hematoma expansion is associated with ongoing hematoma growth, poor functional outcomes, and mortality and represents a target for therapeutic intervention.

Nontraumatic Intracranial Hemorrhage and Risk of Incident Dementia in US Medicare Beneficiaries

BACKGROUND

To study the risk of incident dementia after a nontraumatic intracranial hemorrhage in a diverse US population and evaluate whether this risk is different for the subtypes of intracranial hemorrhage.

METHODS

We performed a retrospective cohort study using both inpatient and outpatient claims data on a 5% sample of Medicare beneficiaries per year between January 1, 2008 and December 31, 2018. The exposure was a new diagnosis of nontraumatic intracranial hemorrhage, defined as a composite of intracerebral hemorrhage, subarachnoid hemorrhage, and subdural hemorrhage. The outcome was a first-ever diagnosis of dementia. The exposure and outcomes were identified using validated International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification diagnosis codes. We excluded patients who had prevalent intracranial hemorrhage or dementia to ensure that only incident cases were counted in our analyses. In the primary analysis, we used Cox regression to study the risk of dementia after intracranial hemorrhage, after adjusting for demographics and comorbidities. In secondary analyses, the risks of dementia in different subtypes of intracranial hemorrhage were studied.

RESULTS

Among 2.1 million patients, 14 775 had a diagnosis of intracranial hemorrhage with an incidence rate of 1.2 (95% CI, 1.1-1.2) per 1000 person-years. Incident dementia was diagnosed in 2527 (17.1%) of the 14 775 patients with intracranial hemorrhage and in 260 691 (12.8%) of the 2 033 190 patients without intracranial hemorrhage. During a median follow-up of 5.6 (interquartile range, 3.0-9.0) years, the incidence rate of dementia was 8.6 (95% CI, 8.1-8.9) per 100 person-years among patients with intracranial hemorrhage and 2.2 (95% CI, 2.0-2.4) per 100 person-years among patients without intracranial hemorrhage. In an adjusted Cox regression analysis, intracranial hemorrhage was associated with an increased risk of incident dementia (hazard ratio, 2.0 [95% CI, 1.9-2.2]). In secondary analyses, a higher risk of incident dementia was observed with intracerebral hemorrhage (hazard ratio, 2.4 [95% CI, 2.2-2.5]), subarachnoid hemorrhage (hazard ratio, 1.99 [95% CI, 1.7-2.2]), and subdural hemorrhage (hazard ratio, 1.6 [95% CI, 1.4-1.7]).

CONCLUSIONS

In a large, heterogeneous cohort of elderly US participants, we found that intracranial hemorrhage was independently associated with a 2-fold increased risk of incident dementia. This elevated risk was consistently observed across subtypes of intracranial hemorrhage.

How far are we from bringing intensive care bundle for intracerebral hemorrhage into the real-world setting? A 5-year population based-study

INTRODUCTION

Comprehensive care bundles including rapid blood pressure management, anticoagulation reversal, neurosurgical consultation, control of blood glucose and body temperature, can improve short- and medium-term outcomes in patients with intracerebral hemorrhage (ICH). This study assessed how the acute management of ICH practices evolved in a real-world setting over five years characterized by global changes in ICH care.

METHODS

This study analysed ICH cases from a population-based stroke registry between 2018 and 2022. We collected demographic and clinical data, focusing on key parameters of ICH management, such as systolic blood pressure, anticoagulation reversal, neurosurgical referrals, blood glucose, and body temperature. We also examined yearly trends in control of parameters over time.

RESULTS

We included 460 patients with ICH (55.4% male, median age 79 years, interquartile range 69-85). At onset, 266 patients (57.8%) had high SBP (SBP ≥ 140 mmHg), 286 (70.3%) hyperglycemia (blood glucose ≥ 108 mg/dL), and 63 (17.3%) hyperpyrexia (body temperature ≥ 37.0*C). Anticoagulation was reversed in 21.4% of anticoagulated patients within 24 h. Neurosurgical referrals were made for 84.6% of patients while only 12.4% underwent surgery. From 2018 to 2022, anticoagulation reversal rates increased from 0 to 88.9% (p < 0.001), while neurosurgical referrals not followed by surgery decreased from 79.5 to 55.7% (p < 0.001).

CONCLUSIONS

This real-world study demonstrates suboptimal management of key factors associated with ICH prognosis; nevertheless, it highlights improvement over time. There is a need for structured interventions to improve the timely and consistent application of simple yet effective measures yielding the potential to improve patients' outcomes.

Ultra-Early Blood Pressure Control in Acute Intracerebral Hemorrhage

Acute intracerebral hemorrhage (ICH) remains one of the most devastating neurological emergencies, with blood pressure (BP) management in the early hours playing a pivotal role in determining patient outcomes. Emerging evidence suggests that ultra-early BP control-intervening within minutes to 2 hours of symptom onset-has the potential to reduce secondary brain injury and improve survival. Yet, despite this evidence, current clinical practice is often inconsistent, and there is no universally agreed-upon approach for managing BP in the acute phase of ICH. We advocate for ultra-early BP intervention as a standard of care in ICH, as it offers a clear opportunity to mitigate damage and to enhance recovery. We contend that current BP management protocols are often too conservative and fail to recognize the critical importance of acting swiftly. The first few hours represent a unique window in which targeted interventions, such as continuous infusion intravenous antihypertensives, may limit hematoma expansion and stabilize cerebral perfusion pressure. However, achieving optimal outcomes requires more than just aggressive treatment-it demands a tailored approach to BP control, accounting for individual patient factors, evolving clinical conditions, and operational aspects of care. We advocate for a paradigm shift toward prioritizing ultra-early intervention, supported by clear, evidence-based protocols and real-time decision-making.

Volume Tolerance and Prognostic Impact of Hematoma Expansion in Deep and Lobar Intracerebral Hemorrhage

BACKGROUND

The prognostic impact of intracerebral hemorrhage (ICH) volume varies according to location, with smaller volume tolerance in deep ICH, and hematoma expansion (HE) contributes to final ICH volume. We tested the hypothesis that HE influences outcome only when the final ICH volume achieves a critical threshold that differs according to ICH location.

METHODS

Retrospective analysis of patients with supratentorial ICH admitted at 10 centers in North America and China (development cohort) and Europe (replication cohort). HE was defined as growth >33% and >6 mL. Location-specific (lobar versus deep) volume cutoffs for the prediction of poor outcomes were derived using receiver operating characteristic curves and the Youden index. The prognostic impact of HE stratified by location and final volume was explored with logistic regression (poor outcome: 90-day modified Rankin Scale score of 4-6), accounting for age, Glasgow Coma Scale, baseline volume, intraventricular hemorrhage, and admission center.

RESULTS

We identified 1774 patients with ICH in the development cohort and 1746 in the replication cohort. A total of 1058 (mean age, 68 years; 47.8% males) and 1423 (mean age, 71 years; 44.7% males) subjects met the inclusion criteria, respectively. The optimal final ICH volume cutoff for poor outcome differed by location: ≥36 mL for lobar and ≥17 mL for deep ICH. HE with final volume below the cutoff was not associated with higher odds of poor outcome compared with patients without HE (adjusted odds ratio, 1.85 [95% CI, 0.78-4.38]; P=0.163 in lobar ICH; adjusted odds ratio, 0.85 [95% CI, 0.38-1.89]; P=0.685 in deep ICH). The combination of HE and final volume over the critical threshold was, however, significantly associated with poor prognosis, and the magnitude of this effect was substantial (adjusted odds ratio, 8.55 [95% CI, 2.87-25.48]; P<0.001 in lobar ICH; adjusted odds ratio, 10.34 [95% CI, 2.86-37.44]; P<0.001 in deep ICH). These findings were confirmed in the replication cohort.

CONCLUSIONS

HE significantly impacts severe outcomes only when the final ICH volume exceeds a critical target threshold, and this threshold is lower in deep versus lobar ICH. These findings might inform clinical practice and future trials.

Generative T2*-weighted images as a substitute for true T2*-weighted images on brain MRI in patients with acute stroke

PURPOSE

The purpose of this study was to validate a deep learning algorithm that generates T2*-weighted images from diffusion-weighted (DW) images and to compare its performance with that of true T2*-weighted images for hemorrhage detection on MRI in patients with acute stroke.

MATERIALS AND METHODS

This single-center, retrospective study included DW- and T2*-weighted images obtained less than 48 hours after symptom onset in consecutive patients admitted for acute stroke. Datasets were divided into training (60 %), validation (20 %), and test (20 %) sets, with stratification by stroke type (hemorrhagic/ischemic). A generative adversarial network was trained to produce generative T2*-weighted images using DW images. Concordance between true T2*-weighted images and generative T2*-weighted images for hemorrhage detection was independently graded by two readers into three categories (parenchymal hematoma, hemorrhagic infarct or no hemorrhage), and discordances were resolved by consensus reading. Sensitivity, specificity and accuracy of generative T2*-weighted images were estimated using true T2*-weighted images as the standard of reference.

RESULTS

A total of 1491 MRI sets from 939 patients (487 women, 452 men) with a median age of 71 years (first quartile, 57; third quartile, 81; range: 21-101) were included. In the test set (n = 300), there were no differences between true T2*-weighted images and generative T2*-weighted images for intraobserver reproducibility (κ = 0.97 [95 % CI: 0.95-0.99] vs. 0.95 [95 % CI: 0.92-0.97]; P = 0.27) and interobserver reproducibility (κ = 0.93 [95 % CI: 0.90-0.97] vs. 0.92 [95 % CI: 0.88-0.96]; P = 0.64). After consensus reading, concordance between true T2*-weighted images and generative T2*-weighted images was excellent (κ = 0.92; 95 % CI: 0.91-0.96). Generative T2*-weighted images achieved 90 % sensitivity (73/81; 95 % CI: 81-96), 97 % specificity (213/219; 95 % CI: 94-99) and 95 % accuracy (286/300; 95 % CI: 92-97) for the diagnosis of any cerebral hemorrhage (hemorrhagic infarct or parenchymal hemorrhage).

CONCLUSION

Generative T2*-weighted images and true T2*-weighted images have non-different diagnostic performances for hemorrhage detection in patients with acute stroke and may be used to shorten MRI protocols.

The hazards of chasing subgroups in neutral stroke trials

BACKGROUND

The majority of randomised controlled trials in acute stroke and many for prevention are neutral, i.e. they failed to reach statistical significance. However, many of these will find apparent benefit in a component of a subgroup, findings which may be 'chased' in a follow-up trial. The evidence to date is that these follow-on trials are very likely to be neutral.

FINDINGS

We discuss the issue of chasing subgroups in neutral trials and illustrate the challenges in five pairs of exemplar acute stroke trials. Problems in the exemplar trials include failing to define the subgroup in advance or even changing its definition, failing to show that both the interaction test and the primary outcome in the component were statistically significant, failing to publish additional information on the positive subgroup component, having too many subgroups, failing to make the follow-on trial large enough and failing to report the findings of the follow-on trial.

CONCLUSION

When chasing a positive component in a subgroup, it is vital that the subgroup: should be plausible biologically, defined a priori and have a significant interaction test. Further the number of subgroups should be limited and the component of interest should be statistically significant. Explanations should be given as to why the component is positive and other components of the subgroup are negative. Other outcomes should also show potential benefit. Unless this guidance is followed, it is highly likely that follow-on trials will be neutral as has occurred previously.

The Neuroprotective Role of Melatonin in Intracerebral Hemorrhage: Lessons from an Observational Study

Background/Objectives: Growing evidence is underscoring the neuroprotective properties of melatonin, particularly its anti-inflammatory, anti-apoptotic, and antioxidant effects. Preliminary findings suggest that it has the potential to attenuate secondary brain injury following intracerebral hemorrhage (ICH). This observational study aimed to investigate the effect of melatonin on post-ICH mortality and functional outcomes. Methods: We conducted an exploratory analysis of data from a single-center, non-randomized, prospective cohort study involving 177 non-ventilated patients with spontaneous ICH consecutively admitted to the Stroke Unit at the University Hospital of Tübingen, Germany, between December 2015 and December 2020. Patients received either the best standard of care (control group) or the best standard of care plus melatonin (2 mg nightly), initiated within 24 h of symptom onset and continued until discharge. The primary endpoint was mortality at discharge, while secondary endpoints included mortality at 90 days and favorable outcomes (modified Rankin Scale [mRS] ≤ 2) at both discharge and a 90-day follow-up. To minimize baseline differences, propensity score matching (PSM) was employed in the secondary analysis. Additionally, ordinal mRS shift analysis was performed to assess the patients' functional status at discharge. Results: In the full cohort (84 melatonin-treated patients vs. 93 controls), melatonin was not associated with any of the primary or secondary outcomes. In the PSM cohort (38 melatonin-treated patients vs. 38 controls), mortality at discharge was three times lower in the melatonin group compared to the control group (2.6% vs. 7.9%), although this trend did not reach statistical significance (ORadj: 0.372; 95% CI: 0.036-3.843; p = 0.407). Ordinal mRS analysis revealed no significant association between melatonin and functional status at discharge (common OR: 0.762; 95% CI: 0.327-1.773; p = 0.527). Similarly, the melatonin treatment was not associated with 90-day mortality (ORadj: 1.519; 95% CI: 0.295-7.826; p = 0.617) or the functional outcome at 90 days (ORadj: 0.626; 95% CI: 0.198-1.983; p = 0.426). Conclusions: Although 2 mg of melatonin daily did not significantly reduce mortality or improve functional outcomes in ICH patients, robust preclinical evidence and the favorable safety profile of melatonin warrant its further exploration in adequately powered, randomized-controlled clinical trials to evaluate optimized dosing regimens.

Pathophysiology of Intracerebral Hemorrhage: Recovery Trajectories

Recovery trajectories in intracerebral hemorrhage (ICH) are recognized as distinct from those observed in ischemic stroke. This narrative review aims to clarify the pathophysiology underlying ICH recovery patterns, highlighting the unique timeline and nature of functional improvements seen in ICH survivors. Population-based cohort studies tracking functional outcomes in a longitudinal fashion, along with randomized clinical trial data with standardized outcome assessments, have demonstrated that ICH recovery generally has a delayed onset in the first weeks, followed by a steep early subacute stage recovery (typically up to 3 months) continuing in protracted, gradual improvements beyond 3 to 6 months. Understanding these recovery patterns, and how these differ from ischemic stroke, is crucial for providing accurate prognostic information, facilitating targeted health care delivery, and optimizing therapeutic interventions and the design of ICH randomized trials. This article synthesizes current evidence on early- and late-stage functional recovery trajectories in primary, spontaneous ICH and cognitive outcomes, emphasizing the clinical and research implications of these recovery patterns.

Optimizing Intracerebral Hemorrhage Management and Interhospital Transfer With Viz ICH Plus AI Technology

This case study explores the integration of Viz ICH Plus, an AI-powered intracerebral hemorrhage (ICH) detection system, into a centralized program called the Neuroemergencies Management and Transfer (NEMAT) program of a large urban healthcare system. The study highlights how Viz ICH Plus promptly identified a right parieto-occipital hematoma in a patient presenting with a headache, resulting in a marked reduction in interhospital transfer (IHT) time. The patient underwent a successful supratentorial craniotomy for hematoma evacuation and demonstrated significant cognitive and physical improvement over the following year. Viz ICH Plus reduced IHT time from approximately 200 to 101 minutes, expediting access to definitive care and improving patient outcomes. Standard of care radiology review of the scan and communication of results could have added to additional delays in transferring this patient to receive definitive care. This case study illustrates a substantial reduction in transfer time and highlights the potential of AI to transform stroke care by optimizing response times and facilitating timely interventions.

Perihematomal oligemia is associated with progression to ischemia and poor outcome in a subset of patients with intracerebral hemorrhage

OBJECTIVES

We aimed to characterize the longitudinal evolution of perihematomal oligemia in acute intracerebral hemorrhage (ICH).

MATERIALS AND METHODS

A single center prospectively collected cohort of 150 patients with primary spontaneous ICH were imaged with computed tomography perfusion within 6 h from onset (T0), at 24 h (T1) and at 7 days (T7). Perihematomal cerebral blood flow (pCBF) was measured in the manually outlined perihematomal low-density area and categorized into ischemic (< 20 mL/100 g/min), oligemic (20-39.9 mL/100 g/min), normal (40-55 mL/100 g/min) and hyperemic (> 55 mL/100 g/min).

RESULTS

pCBF values were ischemic in 20.7%, oligemic 47.3%, normal in 17.3%, and hyperemic in 14.7% of patients at T0. All patients with T0 ischemia remained ischemic at T7, normal and hyperemic patients at T0 maintained good perfusion values at T7, whereas 46.5% of oligemic patients at T0 developed delayed perihematomal ischemia. In patients with T0 perihematomal oligemia, the risk of conversion into delayed ischemia at T7 was higher in those with pCBF < 30 mL/100 g/min (p < 0.001). A total of 42.7% patients had perihematomal ischemia at T7 and this profile correlated with poor outcome, regardless of baseline perfusion status.

CONCLUSION

Our findings suggest that perihematomal oligemia may not represent a benign entity and indicate that delayed perihematomal ischemia is common and associated with unfavorable outcome.

KEY POINTS

Question The natural history and longitudinal evolution of perihematomal oligemia over time in patients with intracerebral hemorrhage (ICH) remains to be established. Findings Conversion of baseline perihematomal oligemia into ischemia occurs in 46.5% of oligemic ICH patients at 7 days, where a total of 42.7% patients were ischemic. Clinical relevance Evolution of perihematomal oligemia into ischemia during the transition from hyperacute to subacute phases is common. ICH patients with perihemorrhagic cerebral blood flow values < 30 mL/100 g/min are at high risk of ischemic progression, which in turn contributes to poor outcome.

Endoscopic Hematoma Evacuation Under Local Anesthesia for Acute Intracerebral Hemorrhage in Older Patients: A Case Series

Intracerebral hemorrhage (ICH) is a severe neurological condition with a poor prognosis, and surgical intervention is often necessary in cases with significant hematoma volume. With the progression of a super-aging society, the incidence of ICH in older patients is increasing. However, traditional craniotomy under general anesthesia poses a high risk to older patients, thereby limiting its use. Recently, minimally invasive techniques have become widely used. Endoscopic hematoma evacuation can be performed under local anesthesia, which may minimize invasiveness and reduce the risk of complications associated with general anesthesia in older patients. However, only a few studies have specifically addressed endoscopic hematoma evacuation under local anesthesia for acute ICH in older patients, and the optimal protocol for surgical procedures and perioperative management remains unclear. The aim of this study is to highlight the technical considerations and potential benefits of endoscopic surgery for ICH in older patients. This study presents a case series of five patients aged ≥ 70 years who underwent endoscopic hematoma evacuation under local anesthesia for acute ICH. The median hematoma removal rate was 95.8%, with no postoperative re-bleeding or mortality. 3D visualization technology using preoperative computed tomography images not only facilitates the initiation of surgery but also assists with intraoperative support for accurate hematoma localization. In older patients, preoperative insertion of a nasogastric tube and the use of a transparent drape were effective in ensuring intraoperative airway management. Our findings suggest that endoscopic hematoma evacuation under local anesthesia is a safe and effective treatment option for older patients, offering reduced surgical invasiveness while maintaining high removal rates.

Mitigating mitochondrial dysfunction and neuroinflammation by hematoma aspiration in a new surgical model for severe intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is associated with a large hematoma that causes compression, increased intracranial pressure (IICP), midline shift, and brain herniation, and may ultimately lead to death. Urgent surgical removal of the large hematoma can ameliorate these injuries, which would be life-saving, but has not improved clinical outcome. A suitable animal model that mimics the clinically relevant human severe ICH injury requiring surgical hematoma evacuation is urgently needed. Here, we established a novel model of severe ICH in rats allowing aspiration of the hematoma and studying the effects of mitochondrial dysfunction in ICH.

METHODS

Severe ICH was induced by intra-striatal injection of 0.6 U of collagenase in 3 μL sterile saline over 15 min. Aspiration of approximately 75 % of the total hematoma was performed 6 h after induction of severe ICH. The effects of hematoma aspiration on hematoma volume, mortality, oxidative stress, ATP levels, mitochondrial dysfunction, and neurological function were measured in rats.

RESULTS

Severe ICH induction increased hematoma volume, neurological deficits, and mortality. Hematoma aspiration abolished mortality and significantly reduced hematoma volume, and neurological deficits. In addition, hematoma aspiration ameliorated the pronounced mitochondrial dysfunction responsible for the failure of energy production and excessive oxidative stress associated with severe hemorrhagic injury. Hematoma aspiration also modulated mitochondrial biogenesis and mitophagy, thereby promoting mitochondrial homeostasis. Markers of neuroinflammation, including iNOS, MMP9, and MPO, were elevated in severe ICH but attenuated by hematoma aspiration.

CONCLUSION

This study established an animal model of severe ICH and provides valuable insights into the complex pathogenesis of severe ICH. The results showed that hematoma aspiration effectively ameliorates mitochondrial dysfunction, oxidative stress, and neuroinflammation, highlighting its potential as a therapeutic intervention.

[In-hospital management of intracerebral hemorrhage]

BACKGROUND

Intracerebral hemorrhage (ICH) is a medical emergency with high morbidity and mortality. General and specific therapeutic approaches aim to improve the patient's outcome.

OBJECTIVES

The objective of this article is to present the current scientific state regarding the in-hospital care of patients with ICH.

MATERIALS AND METHODS

This narrative review presents and analyzes the current evidence regarding treatment options for ICH.

RESULTS

The primary focus of acute therapy is to prevent the prognostically unfavorable enlargement of the hematoma. This is associated with specific computed tomographic markers, as well as the initial hematoma volume, the use of anticoagulants, and a shorter time from symptom onset. An elevated blood pressure should be promptly and precisely lowered to a systolic value below 140 mm Hg, and the inhibition of coagulation must be immediately antagonized. This should be constituted into a treatment bundle with optimal adjustment of vital parameters and implementation of basic intensive care measures. Intraventricular hemorrhage can be effectively treated by external ventricular drainage and intraventricular fibrinolysis, with or without additional lumbar drainage. Minimally invasive procedures for hematoma removal have the potential to improve outcomes in lobar ICH. A realistic prognostic assessment forms the basis for informed treatment decisions regarding ICH.

CONCLUSIONS

In recent years, the evidence supporting aggressive therapeutic approaches in ICH has become increasingly robust, with reliable results now available regarding the efficacy of individual or combined measures.

Acute Spontaneous Intracerebral Hemorrhage Management Update: Five New Things You Should Know

Intracerebral hemorrhage (ICH) is a devastating condition responsible for millions of global deaths each year. Recent shifts in ICH management highlight a comprehensive care approach focusing on five pivotal components: prediction of hematoma expansion, blood pressure control, hemostasis, anticoagulation reversal, and surgical intervention. Radiological imaging allows clinicians to identify high-risk patients and implement approaches geared toward stabilizing hematoma volume to improve neurological outcomes. Surgical interventions and hematoma evacuation for cerebellar, intraventricular, and supratentorial ICH may also be used to reduce the mass effect from hematomas. This review will highlight the need to integrate all five strategies where appropriate into a bundle of care, with an emphasis on ongoing research in acute ICH management.

Enhancing Outcome Prediction in Intracerebral Hemorrhage Through Deep Learning: A Retrospective Multicenter Study

RATIONALE AND OBJECTIVES

This study aimed to employ deep learning techniques to analyze and validate an automatic prognostic biomarker for predicting outcomes following intracerebral hemorrhage (ICH).

MATERIALS AND METHODS

This study included patients with ICH whose onset-to-imaging time (OIT) was less than 6 h. Patients were randomly divided into training and test sets at a 7:3 ratio. Using the Resnet50 deep learning method, we extracted features from the hematoma and perihematomal edema (PHE) areas and constructed a 90-day prognosis prediction model using logistic regression. To evaluate predictive efficacy and clinical significance, we employed logistic regression to train three models: Clinical, Deep Score, and the combined Clinical-Deep Learning (Merge).

RESULTS

Our study comprised 1098 patients (652 male, 446 female), with a mean Glasgow Coma Scale (GCS) score of 10. Univariate and multivariate analyses identified age, intraventricular hemorrhage (IVH), hematoma and PHE volume, and admission GCS score as independent prognostic factors. Additionally, 15 deep learning features were retained through LASSO regression. In the training set, the AUC values for the three models were as follows: Clinical model (0.88), Deep Score (0.91), and Merge model (0.94). In the test set, the Merge model exhibited a significantly higher AUC value than the other models. Calibration curves revealed satisfactory calibration of the Merge model nomogram in both training and test sets.

CONCLUSION

Our Merge model nomogram is an objective and effective prognostic tool, offering personalized risk assessments for 90-day functional outcomes in patients with ICH.

Comparison of Long-Term Outcomes in Patients with Supratentorial Spontaneous Intracerebral Hemorrhage Treated with and without Surgical Intervention

BACKGROUND AND OBJECTIVES

Intracerebral hemorrhage (ICH) is associated with high mortality and morbidity. Uncertainty still exists regarding the benefit of surgery in the management of supratentorial spontaneous ICH (sICH), especially of the basal ganglia and thalamus. Studies have not shown the clinical benefit of early surgical management compared to best medical management plus delayed surgery, when necessary. Our aim was to compare the efficacy of different neurosurgical interventions with best medical management and best medical management alone.

METHODS

We conducted a single-center, retrospective study at a tertiary care center in India in sICH patients between January 2015 and December 2022. The primary outcome was functional disability evaluated by the modified Rankin Scale (mRS) at 3, 6, and 12 months. Time-to-event outcomes were compared using the Kaplan-Meier curve.

RESULTS

Among 2600 stroke patients screened, 661 had sICH. Median age was 55 years, and 250 patients (37.8%) underwent neurosurgical intervention. The most common intervention was craniotomy and hematoma evacuation. The median mRS at discharge and follow-up at 3, 6, and 12 months was lower in the conservatively managed group (4, 3, 3, and 3, respectively) compared to the surgical intervention group (5, 5, 5, 4, respectively). However, the ICH score at admission was lower in the conservatively managed group and after adjustment for ICH score, there was no statistically significant difference between the two. Among the interventions, patients undergoing decompression craniectomy had the best functional outcome.

CONCLUSIONS

Neurosurgical intervention was not associated with better functional outcome when compared to conservative management.

A simple CT score predicts early neurological disability and survival in supratentorial intracerebral hemorrhage - The intracerebral mass and brain edema score (IMBES)

Introduction

Treatment of spontaneous intracerebral hemorrhage (ICH) remains challenging, and intracerebral mass and brain edema (IMBE) are accused of being the main factors influencing patient course.

Research question

CT scan assessment of the space-occupying effect after initial ICH was evaluated using an IMBE-score to detect the sulcal effacement of the subarachnoid space.

Material and methods

Supratentorial ICH-patients within a 10 years observation period were identified. Two independent reviewers screened each CT scan in three defined axial planes. Where the combined mass effect of hemorrhage and edema showed sulcal effacement of more than half of the hemisphere, one point was assigned, resulting in an IMBES between 0 and 6. The primary endpoint was neurological outcome measured by the modified Rankin Scale (mRS) and mortality.

Results

We identified 762 patients, median age was 75.4 years (IQR: 64.3-81.1) and mean ICH volume was 46.1 cc. Multiple regression for mRS at discharge (mean: 12.5 days, IQR: 7.1-22.3) identified age, presence of intraventricular hemorrhage, ICH volume, renal insufficiency, intake of anticoagulants and IMBES as statistically significant variables. This was confirmed during follow-up examination, although ICH volume was not significantly associated with neurological outcome.

Discussion and conclusion

We observed a decreased neurological recovery and an increased mortality for patients with high IMBES during acute care and at early follow-up, indicating that IMBES had the strongest association in all regression analysis. We conclude that the fast and simple IMBES may be a useful tool to estimate patient risk for impaired neurological outcome and death.

Neurosurgical Breakthroughs of the Last 50 Years: A Historical Journey Through the Past and Present

This article presented the author's historical perspective on 25 of the most significant neurosurgical breakthrough events of the last 50 years. These breakthroughs have advanced neurosurgical patient care and management. They have improved the management of aneurysms, arteriovenous malformations, tumors, stroke, traumatic brain injury, movement disorders, epilepsy, hydrocephalus, and spine pathologies. Neurosurgery has evolved through research, innovation, and technology. Several neurosurgical breakthroughs were achieved using neuroendoscopy, neuronavigation, radiosurgery, endovascular techniques, and refinements in computer technology. With these breakthroughs, neurosurgery did not change; it just progressed. Neurosurgery should continue its progress through research to obtain new knowledge for the benefit of our patients.

Minimally Invasive Surgery for Spontaneous Intracerebral Hemorrhage: A Review

Background: Spontaneous intracerebral hemorrhage (ICH) accounts for approximately 20% of all strokes and is associated with high mortality and disability rates. Despite numerous trials, conventional surgical approaches have not demonstrated consistent improvements in functional outcomes. Minimally invasive surgery (MIS) for ICH evacuation has emerged as a promising alternative, with the potential to improve functional outcomes and reduce mortality. Objectives: This narrative review aims to provide a comprehensive overview of various MIS techniques and their reported impact on functional outcomes in patients with spontaneous ICH while discussing key limitations in the existing literature. Methods: We systematically searched PubMed to identify studies published from 1 January 2010 to 22 March 2024. The search strategy included the following terms: ("minimally*"[All Fields] AND "invasive*"[All Fields] AND "surgery*"[All Fields] AND "intracerebral*"[All Fields] AND "hemorrhage*"[All Fields]) AND (2010:2024[pdat]). This review focuses on randomized controlled trials (RCTs) that evaluate MIS techniques for ICH and their clinical outcomes. Results: Our search identified six RCTs conducted between January 2010 and March 2024, encompassing 2180 patients with a mean age of 58.03 ± 4.5 years. Four trials demonstrated significantly improved functional recovery (mRs ≤ 3), reduced mortality, and fewer adverse events compared with standard medical management or conventional craniotomy. All MIS techniques rely on stereotactic planning and the use of tools such as exoscopes, endoscopes, craniopuncture, or thrombolytic irrigation for precise hematoma evacuation. These approaches reduce brain tissue disruption and improve precision. However, the variability in techniques, costs, and lack of an external validation limit the generalizability of these findings. Conclusions: MIS shows potential as an alternative to conventional management strategies for ICH, offering encouraging evidence for improved functional outcomes and reduced mortality in selected studies. However, these findings remain limited by gaps in the literature, including the need for external validation, significant methodological heterogeneity, and economic challenges. Further rigorous trials are essential to confirm the generalizability and long-term impact of these approaches.

The REpeated ASSEssment of SurvivorS in intracerebral haemorrhage: protocol for a multicentre, prospective observational study

BACKGROUND

The REpeated ASSEssment of SurvivorS (REASSESS) study will conduct long-term cognitive, functional and neuropsychiatric performance assessments to determine whether evacuation of spontaneous intracerebral haemorrhage (ICH) reduces the risk of later cognitive decline in the ageing brain.

METHODS AND ANALYSIS

This study will compare rates of cognitive decline under two treatment strategies for ICH. The first strategy is the use of minimally invasive surgery (MIS) with similar techniques as performed in (1) the Minimally Invasive Surgery plus rt-PA in the Treatment of Intracerebral haemorrhage Evacuation phase III (MISTIE III) trial, (2) the Early MiNimally-invasive Removal of IntraCerebral Haemorrhage (ENRICH) trial and (3) a single-centre cohort of consecutively treated patients with MIS. The second strategy is the current non-surgical standard of care using data from controls in MISTIE III and ENRICH and comparative data from The Ethnic/Racial Variations of ICH (ERICH) studyextended into the ERICH-Longitudinal study, which followed over 900 of ERICH cases with serial cognitive examinations. If successful, the REASSESS study could demonstrate that reduction of ICH volume is a critical target to reduce the risk of progressive cognitive decline, establish targets for residual haematoma volume reduction and determine if greater residual haematoma volume leads to a long-term inflammatory state.

ETHICS AND DISSEMINATION

Approval of this study was obtained from the Johns Hopkins University Institutional Review Board (IRB00311985). The findings of the study will be published in academic peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05611918; ClinicalTrials.gov; registered on 23 May 2023.

SCUBA evacuation within 24 hours of basal ganglia hemorrhage results in promising functional outcomes

BACKGROUND

The recently completed Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) trial demonstrated a benefit for endoport-mediated evacuation within ≤24 hours for lobar hemorrhages but not for basal ganglia hemorrhages (BGH). We performed an exploratory evaluation of the Stereotactic Cerebral Underwater Blood Aspiration (SCUBA) technique for BGH evacuation.

METHODS

We reviewed data from patients presenting to an urban health system with BGH who underwent SCUBA evacuation according to institutional guidelines. Three cohorts were then created: (1) all patients with BGH evacuation using the SCUBA approach; (2) patients with BGH evacuation using SCUBA within ≤24 hours and with ENRICH-defined intraventricular hemorrhage (IVH) selection criteria; and (3) SCUBA evacuation within ≤24 hours, ENRICH-defined IVH, and intracerebral hemorrhage (ICH) volumes of ≥30 mL. Key outcomes included evacuation percentage, residual hematoma volume ≤15 mL, and 6-month modified Rankin Scale (mRS) score of 0-3.

RESULTS

Sixty-eight patients with BGH underwent SCUBA. Median preoperative ICH volume was 35 mL and median postoperative volume was 1.3 mL for a median evacuation percentage of 97%, with 90% achieving ≤15 mL residual volume. For 19 patients in cohort 2 and 12 patients in cohort 3, median evacuation percentages were 98% and 100% of patients had ≤15 mL residual volume in both groups. A good outcome was achieved in 53% and 50% of patients, respectively.

CONCLUSIONS

SCUBA evacuation for BGH in patients who otherwise meet ENRICH criteria suggests superior 6-month outcomes compared with ENRICH BGH patients (utility-weighted mRS 0.51 vs 0.34). A randomized clinical trial is warranted to prospectively evaluate SCUBA evacuation within 24 hours in patients with spontaneous BGH.

Association of ICH Score with Withdrawal of Life-Sustaining Treatment: A Decade from the Florida Stroke Registry

Background and Purpose

The intracerebral hemorrhage (ICH) score was created as a tool improve communication and consistency among providers, and authors initially cautioned against its use as a predictor of outcomes. We aimed to investigate the association of ICH score with mortality and withdrawal of life-sustaining treatment (WLST).

Methods

Patients with a diagnosis of ICH were identified using data from Florida Stroke Registry (FSR) hospitals participating in the American Heart Association (AHA) Get with the Guidelines-Stroke (GWTG-S) from 2013-2022. Outcomes of WLST and in-hospital mortality were collected. ICH score was stratified into three groups: ICH score 0-2; 3-4; 5-6. Importance plots were generated to identify the most predictive factors associated with WLST. AUC-ROC curves were generated for logistic regression (LR) and random forest (RF) models, adjusted for relevant confounders. Secondary outcome analyses were performed using stratified univariate logistic regression to assess changes between 2015-2018 and 2019-2022.

Results

A total of 12,426 (26%) patients had documented ICH scores (mean age 69, 55% male, 56% white). The most predictive factors associated with WLST were ICH score, age, state region, presenting level of consciousness, insurance status and race (RF AUC=.94, LR AUC=.82). Mortality was 6.6%, 41.5% and 66% for ICH score 0-2, 3-4 and 5-6. Decision to WLST occurred more for ICH scores 3-4 (OR 9.35, 95% CI: 8.5-10.3) and ICH scores 5-6 (15.43, 95% CI: 15.28-22.74). Early WLST (< 2 days) was more likely for ICH score 3-4 (OR 2.97, 95% CI: 2.48-3.55) and score 5-6 groups (OR 9.51, 95% CI: 7.33-12.35).

Conclusion

Among ICH patients admitted across Florida, we noted a significant association between ICH score and likelihood of mortality, decision to WLST, and specifically WLST within two days of presentation. We identified the most predictive variable associated with WLST to be the ICH score. These findings suggest a continued influence of the self-fulfilling prophecy in ICH.

Correlation Between Coagulation Parameters and Dense Fibrin Band Configuration in Tough Intracerebral Hematoma in Anticoagulated Patients

OBJECTIVE

Patients receiving anticoagulation therapy develop intracerebral hematomas, which are difficult to evacuate during endoscopic surgery. Insufficient thrombin activation results in the gradual conversion of fibrinogen to fibrin, forming dense fibrin bands (FBs) that harden the hematoma. We aimed to investigate the factors contributing to hematoma hardness.

METHODS

Eleven men and 11 women (age range: 41-84 years) with hypertensive intracerebral hematomas underwent surgery between 2016 and 2018. Hematoma hardness was measured intraoperatively as the maximum breaking point under compression (Newton [N]) using a bar-type tester. Hematoma samples were graded based on histological FB density. The relationships between hardness, FB grade, and hematological parameters were assessed in patients with and without anticoagulation therapy.

RESULTS

Hematomas were categorized as nonhard (0-3.0 N, n = 16) or hard (3.0-7.0 N, n = 6). Hardness was strongly correlated with FB grade (r = 0.76) and prothrombin time-international normalized ratio (PT-INR) (r = 0.75) and moderately correlated with activated partial thromboplastin time (APTT) (r = 0.65). Three patients with hematoma receiving warfarin and one receiving factor Xa inhibitor demonstrated significantly higher FB grade (P = 0.008) and increased hematoma hardness (6.0 ± 1.4 N) compared with those without anticoagulation treatment (1.3 ± 1.2 N, P = 0.00001). Receiver operating characteristic curve analysis indicated that a PT-INR of 1.81 and an APTT of 32.3 seconds may predict hard hematomas.

CONCLUSIONS

Tough hematomas were histologically characterized by high FB density. Preoperative PT-INR and APTT may predict the presence of tough hematomas.

Surgical Management of Intracerebral Hemorrhage: New Light on the Horizon?

After 30 years of disappointment, 2 randomized controlled trials investigating the effect of neurosurgical treatment on functional outcome in patients with intracerebral hemorrhage were published in 2024. The ENRICH trial (Early Minimally Invasive Removal of Intracerebral Hemorrhage) studied the efficacy of early minimally invasive hematoma removal in patients with lobar or anterior basal ganglia intracerebral hemorrhage, whereas the SWITCH trial investigated the effect of decompressive craniectomy without hematoma removal in severe deep intracerebral hemorrhage. In this critique article, we will discuss the main findings of these trials, their implications and future perspectives.

Neuroinflammation and blood-brain barrier breakdown in acute, clinical intracerebral hemorrhage

Neuroinflammation is a promising therapeutic target in intracerebral hemorrhage (ICH), characterized in the brain by microglial activation and blood-brain barrier (BBB) breakdown. In this study, 36 acute, spontaneous, supratentorial ICH patients underwent dynamic contrast-enhanced MRI to measure BBB permeability (Ktrans) 1-3 days post-onset and 16 returned for [11C](R)-PK11195 PET to quantify microglial activation (BPND), 2-7 days post-onset. We first tested if these markers were increased and co-localized in the perihematomal brain and found that perihematomal Ktrans and BPND were increased vs. the contralateral brain, but regions of high Ktrans and BPND only overlapped by a mean of 4.9%. We then tested for associations of perihematomal Ktrans and BPND with clinical characteristics (age, ICH volume & location, blood pressure), other markers of inflammation (edema, IL-6, and CRP), and long-term functional outcome (90-day mRS). Lower perihematomal BPND was associated with increasing age. Lobar hemorrhage was associated with greater Ktrans than deep, but Ktrans and BPND were not associated with ICH volume, or other inflammatory markers. While perihematomal Ktrans and BPNDwere not associated with outcome, contralateral Ktrans was significantly associated with greater 90-day mRS. Exploratory analyses demonstrated that blood pressure variability over 72 h was also associated with contralateral Ktrans.

New targets in spontaneous intracerebral hemorrhage

PURPOSE OF REVIEW

Intracerebral hemorrhage (ICH) is a devastating stroke with limited medical treatments; thus, timely exploration of emerging therapeutic targets is essential. This review focuses on the latest strategies to mitigate secondary brain injury post-ICH other than targeting surgery or hemostasis, addressing a significant gap in clinical practice and highlighting potential improvements in patient outcomes.

RECENT FINDINGS

Promising therapeutic targets to reduce secondary brain injury following ICH have recently been identified, including attenuation of iron toxicity and inhibition of ferroptosis, enhancement of endogenous resorption of hematoma, and modulation of perihematomal inflammatory responses and edema. Additionally, novel insights suggest the lymphatic system of the brain may potentially play a role in hematoma clearance and edema management. Various experimental and early-phase clinical trials have demonstrated these approaches may potentially offer clinical benefits, though most research remains in the preliminary stages.

SUMMARY

Continued research is essential to identify multifaceted treatment strategies for ICH. Clinical translation of these emerging targets could significantly enhance the efficacy of therapeutic interventions and potentially reduce secondary brain damage and improve neurological recovery. Future efforts should focus on large-scale clinical trials to validate these approaches, to pave the way for more effective treatment protocols for spontaneous ICH.

Online Dynamic Nomogram for Predicting 90-Day Prognosis of Patients With Primary Basal Ganglia Cerebral Hemorrhage After Microscopic Keyhole Craniotomy for Hematoma Removal

OBJECTIVE

Primary basal ganglia cerebral hemorrhage (PBGCH) is the most common type of hypertensive intracerebral hemorrhage. Microscopically removing the hematoma via keyhole or microbone window craniotomy remains the most common surgical method in many hospitals across China for treating cases of primary basal ganglia hemorrhage exceeding 30 mL. The aim of this study was to establish a new practical evaluation system based on preoperative clinical and imaging factors to predict the short-term prognosis of PBGCH after microscopic keyhole craniotomy for hematoma removal (MKCHR), providing a reference for clinicians and patients' families in deciding whether to proceed with surgery.

METHODS

A retrospective analysis was performed on 74 cases of PBGCH treated with MKCHR. Patient prognosis was assessed at 90 days postsurgery using the modified Rankin Scale. This study employed R software to conduct both univariate and multivariate logistic regression analyses aimed at identifying preoperative factors that influence short-term prognosis following MKCHR. Additionally, a web-based interactive nomogram was developed to forecast outcomes for PBGCH patients receiving MKCHR treatment. Model robustness was gauged using the concordance index (C-index) and receiver operating characteristic (ROC) curve. Internal validation involved bootstrap resampling and calibration. Clinical utility was assessed via decision curve analysis (DCA), clinical impact curve (CIC), and net reduction interventions (NRI).

RESULTS

Glasgow Coma Scale (GCS) score ≤ 6, hemorrhagic volume > 102 mL, brain herniation, age > 58 years (p < 0.05) were independent risk factors for poor prognosis after MKCHR. The online dynamic nomogram website is https://sjwkalg.shinyapps.io/DynNomapp/. The model's C-index and area under the ROC are both 0.899 (95% confidence interval [CI], 0.817-0.980). Following 1000 bootstrap resamples, the calibration curve indicates that the dynamic nomogram's predicted values closely match the observed values. The models of DCA, CIC, and NRI show good clinical application.

CONCLUSION

The online dynamic nomogram developed in this study demonstrates high predictive accuracy. This platform is characterized by its noninvasive and convenient nature, which facilitates the formulation of clinical treatment strategies. It offers a reliable data reference for preoperative surgical decision-making in patients with PBGCH, thereby aiming to achieve beneficial outcomes.

Code-ICH: time is brain

PURPOSE OF REVIEW

Intracerebral hemorrhage (ICH) is the most devastating type of stroke resulting in severe disability and mortality. This review summarizes the emerging body of evidence supporting a new paradigm for care of patients called Code-ICH. It highlights the need for the adoption of time-based care bundles based on recent evidence, akin to those used in the management of acute ischemic stroke.

RECENT FINDINGS

Numerous trials aimed at decreasing hematoma expansion through single interventions have historically failed to show significant effects on primary outcomes. Time-sensitive, multifaceted, bundled care approaches have emerged with substantial promise in improving functional outcomes in patients with ICH. These bundles include early aggressive control of blood pressure and reversal of anticoagulation, strict normalization of blood sugar and temperature, early surgical evaluation, and minimizing early withdrawal of care.

SUMMARY

The paradigm of Code-ICH empowers acute care providers to continuously measure system performance, reflect on best practices, improve outcomes, and tackle disparities for patients with ICH.

Computational modeling of basal ganglia hemorrhage morphology improves functional outcome prognostication after minimally invasive surgical evacuation

INTRODUCTION

Anatomic factors that predict outcomes following basal ganglia intracranial hemorrhage (bgICH) evacuation are poorly understood. Given the compact neuroanatomic organization of the basal ganglia, we hypothesized that bgICH spatial representation could predict postoperative functional outcomes.

METHODS

Patients undergoing minimally invasive surgical bgICH evacuation between 2013 and 2024 at one center were retrospectively reviewed. bgICH volumes were segmented and stereotactically localized using anatomic landmarks. Heat maps that identified bgICH spatial representation across functional outcome states were generated. Differential bgICH volume overlap with each heat map was calculated after subtracting out that patient's contribution to the map. Area under the receiver operating characteristic curve (AUC) was used to evaluate the diagnostic accuracy of differential volume overlap for poor functional outcome (modified Rankin Scale score of 4-6 within 1 year of surgery) and compared with that of the intracranial hemorrhage (ICH) score with a z test.

RESULTS

Forty-five patients were included (62% men, 7% Caucasian, median age 53 years). Thirty-two patients (71%) had poor functional outcome (median follow-up 4.1 months), which was associated with increased age (P=0.032), bgICH volume (P=0.005), intraventricular hemorrhage severity (P=0.032), National Institutes of Health Stroke Scale (P=0.006), and differential volume overlap (P<0.001). Anatomically, poor outcome was associated with bgICH extension into the anterior limb of the internal capsule (P=0.004), caudate (P=0.042), and temporal lobe (P=0.006). The AUC for differential volume overlap was 0.87 (95% CI: 0.76-0.97), which was higher than chance alone (P<0.001), but statistically similar to that (0.82 (0.71-0.97)) of the ICH score (P=0.545).

CONCLUSION

Stereotactic bgICH localization enabled functional outcome prognostication in patients undergoing minimally invasive surgical evacuation.

Intracerebral Hemorrhage-Associated Iron Release Leads to Pericyte-Dependent Cerebral Capillary Function Disruption

Intracerebral hemorrhage leads to immediate brain injury due to local mechanical damage, on which current treatment approaches are focused, but it also induces secondary brain injury. The purpose of this study is to characterize blood components, degradation products and their effects in secondary brain injury. Immunocyto- and immunohistochemistry, Fluorescence-Activated Cell Sorting, WST-1 assays and RNA sequencing were applied using human cell cultures and human ex vivo brain tissue slices. Brain tissue was immediately collected, cooled and sliced during neurosurgical operations to perform experiments on living tissue slices of the human brain. Among the blood degradation products, free iron (Fe2+ and Fe3+), but not hemoglobin, induced detrimental effects on pericyte function and survival (78.5% vs. 94.3%; p-value < 0.001). RNA sequencing revealed ferroptosis as the underlining cellular mechanism, mediated via GPX-4 (log2 fold change > 1.0, p-value < 1.08 × 10-30) in pathway analysis and eventually resulting in oxidative cell death. Pericytes located at cerebral capillary branching sites were specifically affected by ferroptosis, leading to capillary disruption and vasoconstriction, which were partially prevented by ferrostatin-1. Free iron induces the pericyte-dependent disruption of cerebral capillary function and represents a therapeutic target to attenuate secondary injury after intracerebral hemorrhage.

Hemoglobin Decrements are Associated with Ischemic Brain Lesions and Poor Outcomes in Patients with Intracerebral Hemorrhage

BACKGROUND

Acute ischemic lesions seen on brain magnetic resonance imaging (MRI) are associated with poor intracerebral hemorrhage (ICH) outcomes, but drivers for these lesions are unknown. Rapid hemoglobin decrements occur in the initial days after ICH and may impair brain oxygen delivery. We investigated whether acute hemoglobin decrements after ICH are associated with MRI ischemic lesions and poor long-term ICH outcomes.

METHODS

Consecutive patients with acute spontaneous ICH enrolled into a single-center prospective cohort study were assessed. Change in hemoglobin levels from admission to brain MRI was defined as the exposure variable. The presence of MRI ischemic lesions on diffusion-weighted imaging was the primary radiographic outcome. Poor 6-month modified Rankin Scale score (4-6) was assessed as our clinical outcome. Separate regression models assessed relationships between exposure and outcomes adjusting for relevant confounders. These relationships were also assessed in a separate prospective single-center cohort of patients with ICH receiving minimally invasive hematoma evacuation.

RESULTS

Of 190 patients analyzed in our primary cohort, the mean age was 66.7 years, the baseline hemoglobin level was 13.4 g/dL, and 32% had MRI ischemic lesions. Greater hemoglobin decrements were associated with MRI ischemic lesions (adjusted odds ratio [OR] 0.77 for every 1 g/dL change, 95% confidence interval [CI] 0.60-0.99) and with poor 6-month outcomes (adjusted OR 0.73, 95% CI 0.55-0.98) after adjusting for demographics, ICH and medical disease severity, and antithrombotic use. In our separate cohort of 172 surgical patients with ICH, greater hemoglobin concentration decrements similarly associated with MRI ischemic lesions (adjusted OR 0.74, 95% CI 0.56-0.97) and poor 6-month outcomes (adjusted OR 0.69, 95% CI 0.48-0.98).

CONCLUSIONS

Greater hemoglobin decrements after acute ICH are associated with ischemic lesions on brain MRI and poor long-term outcomes. Further work is required to clarify drivers for these relationships and whether anemia treatment and prevention can be used to improve ICH outcomes.