Recurrence of bleeding in patients with hypertensive intracerebral hemorrhage

Ipsilateral simultaneous multiple hypertensive intracerebral hemorrhages: Analysis of hematoma formation and comparison with distribution of hypertensive mixed-type hematoma

A 55-year-old Japanese woman with a history of hypertension and right putaminal hemorrhage developed simultaneous hemorrhages in the left thalamus and putamen and died 24 h later. There were no vascular anomalies in the brain. Synaptophysin immunostaining combined with eosin azure 50 (EA50) staining clearly identified the hematoma and the surrounding brain structures. In the right cerebral hemisphere, a cystic lesion as a sequela of the usual type of hypertensive putaminal hematoma was evident. In the left cerebral hemisphere, two fresh hematomas were evident. One was a thalamic hematoma, which had destroyed the dorsal and medial structures of the thalamus, and the other was an unusual putaminal hematoma, which had destroyed the entire putamen and crossed the internal capsule and caudate nucleus. α-Smooth muscle actin immunostaining combined with EA50 and Victoria bleu staining demonstrated three ruptured arteries associated with fibrin aggregates in the anterior thalamic nucleus and anterior putamen. Some circular structures composed of fibrin, suggesting the presence of ruptured arteries in the neighborhood, were evident in the thalamus and putamen. In the putamen, ruptured arteries and circular structures were present in the lateral to medial areas. Fibrin aggregates in the anterior thalamic nucleus were more numerous than those in the putamen. On the basis of these findings, we concluded that: (i) the artery with numerous fibrin aggregates in the anterior thalamic nucleus had ruptured first, followed by the arteries distributed in other parts of the thalamus and putamen; (ii) the unusual putaminal hematoma was attributable to rupture of the arteries around the center of the putamen, which are not responsible for the usual type of hypertensive putaminal hematoma; and (iii) it is suggested that even if hypertensive hemorrhage occurs simultaneously in the ipsilateral putamen and thalamus, the usual type of hypertensive mixed-type hematoma does not form.

Impact of Uncontrolled Hypertension at 3 Months After Intracerebral Hemorrhage

Background

Survivors of intracerebral hemorrhage (ICH) are at high risk for recurrent stroke, which is associated with blood pressure control. Because most recurrent stroke events occur within 12 to 18 months of the index ICH, rapid blood pressure control is likely to be crucial. We investigated the frequency and prognostic impact of uncontrolled short‐term hypertension after ICH.

Methods and Results

We analyzed data from Massachusetts General Hospital (n=1305) and the University of Hong Kong (n=523). We classified hypertension as controlled, undertreated, or treatment resistant at 3 months after ICH and determined the following: (1) the risk factors for uncontrolled hypertension and (2) whether hypertension control at 3 months is associated with stroke recurrence and mortality. We followed 1828 survivors of ICH for a median of 46.2 months. Only 9 of 234 (4%) recurrent strokes occurred before 3 months after ICH. At 3 months, 713 participants (39%) had controlled hypertension, 755 (41%) had undertreated hypertension, and 360 (20%) had treatment‐resistant hypertension. Black, Hispanic, and Asian race/ethnicity and higher blood pressure at time of ICH increased the risk of uncontrolled hypertension at 3 months (all P<0.05). Uncontrolled hypertension at 3 months was associated with recurrent stroke and mortality during long‐term follow‐up (all P<0.05).

Conclusions

Among survivors of ICH, >60% had uncontrolled hypertension at 3 months, with undertreatment accounting for the majority of cases. The 3‐month blood pressure measurements were associated with higher recurrent stroke risk and mortality. Black, Hispanic, and Asian survivors of ICH and those presenting with severe acute hypertensive response were at highest risk for uncontrolled hypertension.

Contribution of Racial and Ethnic Differences in Cerebral Small Vessel Disease Subtype and Burden to Risk of Cerebral Hemorrhage Recurrence

OBJECTIVE

Black and Hispanic survivors of intracerebral hemorrhage (ICH) are at higher risk of recurrent intracranial bleeding. MRI-based markers of chronic cerebral small vessel disease (CSVD) are consistently associated with recurrent ICH. We therefore sought to investigate whether racial/ethnic differences in MRI-defined CSVD subtype and severity contribute to disparities in ICH recurrence risk.

METHODS

We analyzed data from the Massachusetts General Hospital ICH study (n = 593) and the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study (n = 329). Using CSVD markers derived from MRIs obtained within 90 days of index ICH, we classified ICH cases as cerebral amyloid angiopathy (CAA)-related, hypertensive arteriopathy (HTNA)-related, and mixed etiology. We quantified CSVD burden using validated global, CAA-specific, and HTNA-specific scores. We compared CSVD subtype and severity among White, Black, and Hispanic ICH survivors and investigated its association with ICH recurrence risk.

RESULTS

We analyzed data for 922 ICH survivors (655 White, 130 Black, 137 Hispanic). Minority ICH survivors had greater global CSVD (p = 0.011) and HTNA burden (p = 0.021) on MRI. Furthermore, minority survivors of HTNA-related and mixed-etiology ICH demonstrated higher HTNA burden, resulting in increased ICH recurrence risk (all p < 0.05).

CONCLUSIONS

We uncovered significant differences in CSVD subtypes and severity among White and minority survivors of primary ICH, with direct implication for known disparities in ICH recurrence risk. Future studies of racial/ethnic disparities in ICH outcomes will benefit from including detailed MRI-based assessment of CSVD subtypes and severity and investigating social determinants of health.

Long-term prognosis after intracerebral haemorrhage

Introduction

The aim of this study was to determine the risk of recurrent intracerebral haemorrhage (ICH), ischaemic stroke, all stroke, any vascular event and all-cause mortality in 30-day survivors of ICH, according to age and sex.

Patients and methods

We linked national hospital discharge, population and cause of death registers to obtain a cohort of Dutch 30-day survivors of ICH from 1998 to 2010. We calculated cumulative incidences of recurrent ICH, ischaemic stroke, all stroke and composite vascular outcome, adjusted for competing risk of death and all-cause mortality. Additionally, we compared survival with the general population.

Results

We included 19,444 ICH-survivors (52% male; median age 72 years, interquartile range 61–79; 78,654 patient-years of follow-up). First-year cumulative incidence of recurrent ICH ranged from 1.5% (95% confidence interval 0.9–2.3; men 35–54 years) to 2.4% (2.0–2.9; women 75–94 years). Depending on age and sex, 10-year risk of recurrent ICH ranged from 3.7% (2.6–5.1; men 35–54 years) to 8.1% (6.9–9.4; women 55–74 years); ischaemic stroke 2.6% to 7.0%, of all stroke 9.9% to 26.2% and of any vascular event 15.0% to 40.4%. Ten-year mortality ranged from 16.7% (35–54 years) to 90.0% (75–94 years). Relative survival was lower in all age-groups of both sexes, ranging from 0.83 (0.80–0.87) in 35- to 54-year-old men to 0.28 (0.24–0.32) in 75- to 94-year-old women.

Discussion

ICH-survivors are at high risk of recurrent ICH, of ischaemic stroke and other vascular events, and have a sustained reduced survival rate compared to the general population.

Conclusion

The high risk of recurrent ICH, other vascular events and prolonged reduced survival-rates warrant clinical trials to determine optimal secondary prevention treatment after ICH.

Intracerebral haemorrhage, microbleeds and antithrombotic drugs

Antithrombotic therapy is a cornerstone for secondary prevention of ischaemic events, cerebral and extra-cerebral. A number of clinical questions remain unanswered concerning the impact of antithrombotic drugs on the risk of first-ever and recurrent macro or micro cerebral haemorrhages, raising the clinical dilemma on the risk/benefit balance of giving antiplatelets and anticoagulants in patients with potential high risk of brain bleeds. High field magnetic resonance imaging (MRI) blood-weighted sequences, including susceptibility weighted imaging (SWI), have expanded the spectrum of these clinical questions, because of their increasing sensitivity in detecting radiological markers of small vessel disease. This review will summarise the literature, focusing on four main clinical questions: how do cerebral microbleeds impact the risk of cerebrovascular events in healthy patients, in patients with previous ischaemic stroke or transient ischaemic attack, and in patients with intracerebral haemorrhage? Is the risk/benefit balance of oral anticoagulants shifted by the presence of microbleeds in patients with atrial fibrillation after recent ischaemic stroke or transient ischaemic attack? Should we restart antiplatelet drugs after symptomatic intracerebral haemorrhage or not? Are oral anticoagulants allowed in patients with a history of atrial fibrillation and previous intracerebral haemorrhage?

Antithrombotics in intracerebral hemorrhage in the era of novel agents and antidotes: A review

BACKGROUND

Intracerebral hemorrhage (ICH)1 is characterized by the pathological accumulation of blood within the brain parenchyma, most commonly associated with hypertension, arteriovenous malformations, or trauma. However, it can also present in patients receiving antithrombotic drugs, either anticoagulants such as acenocoumarol/warfarin-novel oral anticoagulants or antiplatelets, for the prevention and treatment of thromboembolic disease.

OBJECTIVE

The purpose of this review is to present current bibliographic data regarding ICH irrespective of the cause, as well as post-hemorrhage use of antithrombotic agents. Moreover, this review attempts to provide guidelines concerning the termination, inversion, and of course resumption of antithrombotic therapy.

METHODS AND MATERIALS

We reviewed the most recently presented available data for patients who dealt with intracerebral hemorrhagic events while on antithrombotic agents (due to atrial fibrillation, prosthetic mechanical valves or recent/recurrent deep vein thrombosis). Furthermore, we examined and compared the thromboembolic risk, the bleeding risk, as well as the re-bleeding risk in two groups: patients receiving antithrombotic therapy versus patients not on antithrombotic therapy.

CONCLUSION

Antithrombotic therapy is of great importance when indicated, though it does not come without crucial side-effects, such as ICH. Optimal timing of withdrawal, reversal, and resumption of antithrombotic treatment should be determined by a multidisciplinary team consisting of a stroke specialist, a cardiologist, and a neurosurgeon, who will individually approach the needs and risks of each patient.

Racial/ethnic disparities in the risk of intracerebral hemorrhage recurrence

OBJECTIVE

To estimate the risk of intracerebral hemorrhage (ICH) recurrence in a large, diverse, US-based population and to identify racial/ethnic and socioeconomic subgroups at higher risk.

METHODS

We performed a longitudinal analysis of prospectively collected claims data from all hospitalizations in nonfederal California hospitals between 2005 and 2011. We used validated diagnosis codes to identify nontraumatic ICH and our primary outcome of recurrent ICH. California residents who survived to discharge were included. We used log-rank tests for unadjusted analyses of survival across racial/ethnic groups and multivariable Cox proportional hazards regression to determine factors associated with risk of recurrence after adjusting for potential confounders.

RESULTS

We identified 31,355 California residents with first-recorded ICH who survived to discharge, of whom 15,548 (50%) were white, 6,174 (20%) were Hispanic, 4,205 (14%) were Asian, and 2,772 (9%) were black. There were 1,330 recurrences (4.1%) over a median follow-up of 2.9 years (interquartile range 3.8). The 1-year recurrence rate was 3.0% (95% confidence interval [CI] 2.8%-3.2%). In multivariable analysis, black participants (hazard ratio [HR] 1.22; 95% CI 1.01-1.48; p = 0.04) and Asian participants (HR 1.29; 95% CI 1.10-1.50; p = 0.001) had a higher risk of recurrence than white participants. Private insurance was associated with a significant reduction in risk compared to patients with Medicare (HR 0.60; 95% CI 0.50-0.73; p < 0.001), with consistent estimates across racial/ethnic groups.

CONCLUSIONS

Black and Asian patients had a higher risk of ICH recurrence than white patients, whereas private insurance was associated with reduced risk compared to those with Medicare. Further research is needed to determine the drivers of these disparities.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Hypertension and intracerebral hemorrhage recurrence among white, black, and Hispanic individuals

OBJECTIVE

To clarify whether recurrence risk for intracerebral hemorrhage (ICH) is higher among black and Hispanic individuals and whether this disparity is attributable to differences in blood pressure (BP) measurements and their variability.

METHODS

We analyzed data from survivors of primary ICH enrolled in 2 separate studies: (1) the longitudinal study conducted at Massachusetts General Hospital (n = 759), and (2) the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) study (n = 1,532). Participants underwent structured interview at enrollment (including self-report of race/ethnicity) and were followed longitudinally via phone calls and review of medical records. We captured systolic BP (SBP) and diastolic BP measurements, and quantified variability as SBP and diastolic BP variation coefficients. We used multivariable (Cox regression) survival analysis to identify risk factors for ICH recurrence.

RESULTS

We followed 2,291 ICH survivors (1,121 white, 529 black, 605 Hispanic, and 36 of other race/ethnicity). Both black and Hispanic patients displayed higher SBP during follow-up (p < 0.05). Black participants also displayed greater SBP variability during follow-up (p = 0.032). In univariable analyses, black and Hispanic patients were at higher ICH recurrence risk (p < 0.05). After adjusting for BP measurements and their variability, both Hispanic (hazard ratio = 1.51, 95% confidence interval 1.14-2.00, p = 0.004) and black (hazard ratio = 1.98, 95% confidence interval 1.36-2.86, p < 0.001) patients remained at higher risk of ICH recurrence.

CONCLUSION

Black and Hispanic patients are at higher risk of ICH recurrence; hypertension severity (average BP and its variability) does not fully account for this finding. Additional studies will be required to further elucidate determinants for this health disparity.

Use of aspirin in Chinese after recovery from primary intracranial haemorrhage

Intracranial haemorrhage (ICH) accounts for ~35% of all strokes in Chinese. Anti-platelet agent is often avoided after an index event due to the possibility of recurrent ICH. This single-centered observational study included 440 consecutive Chinese patients with a first spontaneous ICH surviving the first month performed during 1996–2010. The subjects were identified, and their clinical characteristics, anti-platelet therapy after ICH, and outcomes including recurrent ICH, ischaemic stroke, and acute coronary syndrome were checked from hospital records. Of these 440 patients, 56 patients (12.7%) were prescribed aspirin (312 patient-aspirin years). After a follow-up of 62.2 ± 1.8 months, 47 patients had recurrent ICH (10.7%, 20.6 per 1,000 patient years). Patients prescribed aspirin did not have a higher risk of recurrent ICH compared with those not prescribed aspirin (22.7 per 1,000 patient-aspirin years vs. 22.4 per 1,000 patient years, p=0.70). Multivariate analysis identified age > 60 years (hazard ratio [HR]: 2.0, 95% confidence interval [CI]: 1.07–3.85, p=0.03) and hypertension (HR: 2.0, 95% CI: 1.06–3.75, p=0.03) as independent predictors for recurrent ICH. In a subgroup analysis including 127 patients with standard indications for aspirin of whom 56 were prescribed aspirin, the incidence of combined vascular events including recurrent ICH, ischaemic stroke, and acute coronary syndrome was statistically lower in patients prescribed aspirin than those not prescribed aspirin (52.4 per 1,000 patient-aspirin years, vs. 112.8 per 1,000 patient-years, p=0.04). In conclusion, we observed in a cohort of Chinese post-ICH patients that aspirin use was not associated with an increased risk for a recurrent ICH.

Current Practice Trends for Use of Early Venous Thromboembolism Prophylaxis After Intracerebral Hemorrhage

BACKGROUND

Venous thromboembolism (VTE) is common after intracerebral hemorrhage (ICH). Guidelines recommend early VTE prophylaxis.

OBJECTIVE

To determine characteristics associated with early chemoprophylaxis (CP) after ICH in the Get With The Guidelines-Stroke registry.

METHODS

In this observational cohort study, we identified patients with ICH between January 1, 2009 and September 30, 2013, who (1) were non-ambulatory and/or not comfort care measures by hospital day 2; (2) were not transferred to another acute care facility; and (3) had known VTE prophylaxis status at end of hospital day 2. Categories for VTE prophylaxis were as follows: (1) mechanical non-CP or (2) CP with or without mechanical prophylaxis. Early prophylaxis was defined as occurring by hospital day 2. Using multivariable logistic regression, we assessed patient, hospital, and geographic factors independently associated with early CP use.

RESULTS

Among 74 283 patients with ICH from 1358 hospitals, 5929 (7.9%) received early CP, 66 444 (89.4%) received early mechanical/non-CP, and 1910 (2.6%) had no prophylaxis, mechanical or CP, within the first 2 days. There was no increase in early CP use over the study period; 60% of hospitals provided early CP to &lt;9% of patients. In multivariable analysis, female sex, atrial fibrillation, diabetes, coronary, carotid, and peripheral artery disease, prior ischemic stroke or transient ischemic attack, hospital size &gt;500 beds, and geographic region were independently associated with early vs no early CP use.

CONCLUSION

Nationwide, the large majority of ICH patients receive early mechanical VTE prophylaxis only, without CP. Patient comorbidities and hospital characteristics such as geographic location are determinants of higher use of early CP.

Novel oral anticoagulant management issues for the stroke clinician

BACKGROUND

Four nonvitamin K antagonist oral anticoagulants (NOACs) are approved for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF).

AIMS

In this review, we assemble available evidence for the best management of ischemic and hemorrhagic stroke patients in the context of NOAC use.

SUMMARY OF REVIEW

NOACs provide predictable anticoagulation with fixed dosages. The direct thrombin inhibitor dabigatran and direct factor Xa inhibitors apixaban, edoxaban, and rivaroxaban are all noninferior to warfarin for the prevention of ischemic stroke and systemic embolism and are associated with reduced incidence of intracranial hemorrhage. While these agents offer treatment options for NVAF patients, they also present challenges specific to the clinician managing cerebrovascular disease patients.

CONCLUSIONS

We summarize available evidence and current approaches to the initiation, dosing, monitoring and potential reversal of NOACs in stroke patients.

Delayed Consecutive Contralateral Thalamic Hemorrhage after Spontaneous Thalamic Hemorrhage

Simultaneous or subsequent bilateral thalamic hemorrhagic events have ranged from 12 to 19 in prior reports, with a time lag between bilateral thalamic hemorrhage of up to two days. Herein, we report the first case of delayed (17 days) consecutive contralateral thalamic hemorrhage after spontaneous first thalamic hemorrhage. A 65-year-old female initially presented with a drowsy mentality with a left-side motor weakness (grade II/III). Brain computed tomography (CT) demonstrated right side thalamic and intraventricular hemorrhage. She regained alertness with mild residual motor weakness (grade III/IV) under medical management. Seventeen days later, a sudden and generalized tonic-clonic seizure developed. Brain CT scans revealed a new contralateral thalamic hemorrhage coincident with microbleeds. Neurologic status remained unchanged, consisting of a stuporous mentality with quadriparesis of grade II/II. We report the first case of delayed consecutive contralateral thalamic hemorrhage up to 17 days after first thalamic hemorrhage. The case highlights the need for close monitoring of patients with thalamic hemorrhage who experience microbleeds on the contralateral side, due to the possibility of delayed hemorrhage.

Multiple Spontaneous Intracerebral Hematoma without Presenting Risk Factors

The incidence of intracerebral hemorrhage in those aged 45–84 years is 0.3-0.5%. In people over 80 years of age, this incidence increases 25-fold compared with that of the total population. The most common causes of spontaneous intracerebral hemorrhage in the younger population are vascular malformation, aneurysm, and overuse of drugs. In contrast, common causes in the elderly include hypertension, tumors, and coagulation disorders. Here, we present a case involving a 72-year-old male patient who, without any of these predisposing conditions, was admitted to the hospital with spontaneous intracerebral hemorrhage and showed signs of multifocal intracerebral hemorrhage during his stay. We conclude that spontaneous intracerebral hemorrhage can occur without any predisposing factors, and can lead to a patient's death. Therefore, the possibility of recurrent spontaneous intracerebral hemorrhage must be considered in patients with primary spontaneous intracerebral hemorrhage.

Blood Pressure Management After Intracerebral Hemorrhage

OPINION STATEMENT

Elevated blood pressure (BP), which presents in approximately 80 % of patients with acute intracerebral hemorrhage (ICH), is associated with increased risk of poor outcome. The Second Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT2) study, a multinational, multicenter, randomized controlled trial published in 2013, demonstrated better functional outcomes with no harm for patients with acute spontaneous ICH within 6 h of onset who received target-driven, early intensive BP lowering (systolic BP target <140 mmHg within 1 h, continued for 7 days) and suggested that greater and faster reduction in BP might enhance the treatment effect by limiting hematoma growth. The trial resulted in revisions of guidelines for acute management of ICH, in which intensive BP lowering in patients with acute ICH is recommended as safe and effective treatment for improving functional outcome. BP lowering is also the only intervention that is proven to reduce the risk of recurrent ICH. Current evidences from several randomized trials, including PROGRESS and SPS3, indicate that long-term strict BP control in patients with ICH is safe and could offer additional benefits in major reduction in risk of recurrent ICH. The latest American Heart Association/American Stroke Association (AHA/ASA) guidelines recommended a target BP of <130/80 mmHg after ICH, but supporting evidence is limited. Randomized controlled trials are needed that focus on strict BP control, initiated early after onset of the disease and continued long-term, to demonstrate effective prevention of recurrent stroke and other major vascular events without additional harms in the ICH population.

Long-term prognosis after intracerebral haemorrhage: systematic review and meta-analysis

BACKGROUND AND AIM

There is uncertainty about the long-term prognosis after spontaneous intracerebral haemorrhage (ICH). Therefore, we systematically reviewed the literature for studies reporting long-term survival and ICH recurrence, and their predictors.

METHODS

We searched Ovid Medline 1946-2011 inclusive for cohort studies of ≥50 patients reporting long-term (>30 days) outcome after ICH. Two reviewers independently extracted data from each study. We meta-analysed 1-year and 5-year survival data from population-based studies using a random effects model (and quantified inconsistency using the I2 statistic).

RESULTS

We identified 122 eligible studies. The pooled estimate of 1-year survival was 46% (95% CI 43% to 49%; nine population-based studies (n=2408); I2=27%) and 5-year survival was 29% (95% CI 26% to 33%; three population-based studies (n=699); I2=6%). In 27 cohort studies, predictors most consistently associated with death were increasing age, decreasing Glasgow Coma Scale score, increasing ICH volume, presence of intraventricular haemorrhage, and deep/infratentorial ICH location. The annual risk of recurrent ICH varied from 1.3% to 7.4% in nine studies and this risk was higher after lobar ICH than non-lobar ICH in two of three hospital-based studies. Four studies reporting the risks of recurrent ICH and ischaemic stroke after ICH found no significant differences between these risks.

CONCLUSIONS

Less than a half of patients with ICH survive 1 year and less than a third survive 5 years. Risks of recurrent ICH and ischaemic stroke after ICH appear similar after ICH, provoking uncertainties about the use of antithrombotic drugs.

Simultaneous multiple Basal Ganglia and cerebellar hemorrhage: case report

A 35-year-old man presented with simultaneous multiple intracranial hematomas in the right cerebellar dentate nucleus and left basal ganglia. The hematomas were visible by computed tomography performed within two hours of the patient's arrival. The initial computed tomography showed acute hemorrhage in the left basal ganglia and dentate nucleus in cerebellum. The patient then experienced a change of consciousness due to newly developed hydrocephalus, and emergent extra-ventricular drainage was performed. By discharge, fortunately, the patient was fully recovered.

Update in intracerebral hemorrhage

Spontaneous, nontraumatic intracerebral hemorrhage (ICH) is defined as bleeding within the brain parenchyma. Intracranial hemorrhage includes bleeding within the cranial vault and encompasses ICH, subdural hematoma, epidural bleeds, and subarachnoid hemorrhage (SAH). This review will focus only on ICH. This stroke subtype accounts for about 10% of all strokes. The hematoma locations are deep or ganglionic, lobar, cerebellar, and brain stem in descending order of frequency. Intracerebral hemorrhage occurs twice as common as SAH and is equally as deadly. Risk factors for ICH include hypertension, cerebral amyloid angiopathy, advanced age, antithrombotic therapy and history of cerebrovascular disease. The clinical presentation is "stroke like" with sudden onset of focal neurological deficits. Noncontrast head computerized tomography (CT) scan is the standard diagnostic tool. However, newer neuroimaging techniques have improved the diagnostic yield in terms of underlying pathophysiology and may aid in prognosis. Intracerebral hemorrhage is a neurological emergency. Medical care begins with stabilization of airway, breathing function, and circulation (ABCs), followed by specific measures aimed to decrease secondary neurological damage and to prevent both medical and neurological complications. Reversal of coagulopathy when present is of the essence. Blood pressure management can be key and continues as an area of debate and ongoing research. Surgical evacuation of ICH is of unproven benefit though a subset of well-selected patients may have improved outcomes. Ventriculostomy and intracranial pressure (ICP) monitoring are interventions also used in this patient population. To date, hemostatic medications and neuroprotectants have failed to result in clinical improvement. A multidisciplinary approach is recommended, with participation of vascular neurology, vascular neurosurgery, critical care, and rehabilitation medicine as the main players.

Risk of recurrent intracerebral hemorrhages

Intracerebral hemorrhage (ICH) occurs in about 10%-15% of all strokes, and hypertension and cerebral amyloid angiopathy (CAA) are the main underlying causes. There is often controversy regarding surgical evacuation especially in elderly patients. Follow-up of these patients and regulation of hypertension is important to prevent re-bleeding. The number of recurrent hematomas will increase with time of follow-up. We reviewed 968 patients with an ICH treated in our Department and 48 patients with recurrent hemorrhages (4.9%). The mean interval between the first and the second hemorrhage was three years (one month to 10 years). Clinical outcome after a second hemorrhage was severe and only 50% of patients were operated on the second hemorrhage compared to 77% (37/48) of patients who were operated on the first hemorrhage.

Predictive value of the HAS-BLED score for the risk of recurrent intracranial hemorrhage after first spontaneous intracranial hemorrhage

BACKGROUND

Patients who survive intracranial hemorrhage (ICH) are at high risk of recurrence. The Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly (Age >65 years), Drugs/Alcohol Concomitantly (HAS-BLED) score has recently been developed to assess bleeding risk.

METHODS

This observational study was aimed to investigate the prognostic performance of the HAS-BLED score in predicting recurrent ICH. Consecutive patients (434) with a first spontaneous ICH who were not prescribed antiplatelet or anticoagulation therapy (59.8 ± 15.3 years; men, 62.3%) were recruited.

RESULTS

Most patients (71.6%) had a HAS-BLED score of >1. After a follow-up of 52.7 months, there were 42 ICH recurrences (2.25 per 100 patient-years). The risk of ICH recurrence increased with HAS-BLED score. Specifically, the risk of ICH recurrence with HAS-BLED score of 1, 2, 3, and 4 were 1.37, 2.38, 3.39, and 2.90 per 100 patient-years, respectively. The sensitivity and specificity of HAS-BLED was 79.1% and 29.2%, respectively, with C-statistic of 0.54 (0.50-0.59).

CONCLUSION

This study provided data on the risk of ICH recurrence stratified using the HAS-BLED score in patients after an ICH.

Prevention of intracerebral hemorrhage recurrence

PURPOSE OF REVIEW

: Limited data are available on the prevention of intracerebral hemorrhage (ICH) recurrence, which is substantial, especially in the case of lobar ICH related to cerebral amyloid angiopathy. In view of the relative paucity of prospectively generated data, current strategies for the secondary prevention of ICH involve the extrapolation of data on primary prevention of ICH to its secondary prevention and the avoidance of certain agents that have been shown in clinical series to be associated with increased risk of ICH recurrence. This review analyzes ways to approach the secondary prevention of ICH in the setting of a paucity of adequate prospectively generated data on the subject.

RECENT FINDINGS

: Risk factors for ICH recurrence identified through data extrapolation include hypertension, diabetes, excessive alcohol consumption, cigarette smoking, and probably migraine with aura. Agents associated with increased risk of ICH recurrence include warfarin, antiplatelet agents, statins, and vitamin E.

SUMMARY

: This article reviews the prevention of ICH recurrence based on extrapolating data from primary prevention of ICH along with the clinically appropriate strategy of avoiding the use of agents that have been shown to carry an increased risk of ICH recurrence.

Comparisons of 30-day mortalities and 90-day functional recoveries after first and recurrent primary intracerebral hemorrhage attacks: a multiple-institute retrospective study

BACKGROUND

The aim of this study was to determine and compare 30-day mortalities and 90-day functional recoveries after first and recurrent primary intracerebral hemorrhage (PICH) attacks. The investigators sought to identify factors predisposing 30-day mortality and functional recovery and to compare patients after first and recurrent PICH attacks.

METHODS

The medical records of 1856 PICH patients treated in Samsung Changwon Hospital and Dong-A University Medical Center from January 2000 to December 2010 were retrospectively evaluated.

RESULTS

Of these 1856 patients, 1499 were included. Mean patient age was 66.4 ± 16.3 years, and there were 742 male patients (49.5%). Recurrent PICH occurred in 142 (9.5%) patients. Thirty-day mortality was 13.6% for first PICH patients and 14.1% for recurrent PICH patients (P = 0.824). Good functional recovery at 90 days after ictus was achieved by 52.2% of first PICH patients and by 31.0% of recurrent patients (P = 0.003). In both groups, multivariate analysis showed that unconsciousness, pupillary abnormality, surgery, and underlying disease were associated with high mortality, and that consciousness, a lobal location, a small hemorrhagic volume, and conservative treatment were associated with good functional recovery. After excluding recurrent patients with a previous moderate to severe disability due to the sequelae of PICH, no difference was found between the first (25.1%) and recurrent groups (19.0%) in terms of functional recovery (P = 0.083).

CONCLUSIONS

The factors found to predispose clinical outcome were similar in the two groups. This study shows that given optimal treatment, recurrent PICH patients can achieve the same clinical outcomes as first PICH patients.

Recurrent, sequential, bilateral deep cerebellar hemorrhages: a case report

INTRODUCTION

Hypertensive intra-cerebral hemorrhage is usually a one-time event and recurrences are rare. Most recurrences develop as part of long-term failure of blood pressure control. The site of the re-bleed is usually limited to the basal ganglia and thalami.

CASE PRESENTATION

We report the case of a 59-year-old hypertensive Caucasian woman who developed two sequential, right- and then left-sided, deep cerebellar hemorrhages. The second hemorrhage followed the first one by 57 days, at a time when her blood pressure was optimally controlled. In spite of these critical sites and short duration between the two bleeds, the patient achieved a relatively good functional recovery. Her brain magnetic resonance angiogram was unremarkable.

CONCLUSION

The development of recurrent hypertensive hemorrhage is rare and usually occurs within two years of the first bleed. To the best of our knowledge, this is the first reported case of bilateral, sequential, right- and then left-sided deep cerebellar hemorrhages. These hemorrhages were separated by eight weeks and the patient had a relatively good functional recovery. We believe that hypertension was the etiology behind these hemorrhages.

Investigational therapies for ischemic stroke: neuroprotection and neurorecovery

Stroke is one of the leading causes of death and disability worldwide. Current treatment strategies for ischemic stroke primarily focus on reducing the size of ischemic damage and rescuing dying cells early after occurrence. To date, intravenous recombinant tissue plasminogen activator is the only United States Food and Drug Administration approved therapy for acute ischemic stroke, but its use is limited by a narrow therapeutic window. The pathophysiology of stroke is complex and it involves excitotoxicity mechanisms, inflammatory pathways, oxidative damage, ionic imbalances, apoptosis, angiogenesis, neuroprotection, and neurorestoration. Regeneration of the brain after damage is still active days and even weeks after a stroke occurs, which might provide a second window for treatment. A huge number of neuroprotective agents have been designed to interrupt the ischemic cascade, but therapeutic trials of these agents have yet to show consistent benefit, despite successful preceding animal studies. Several agents of great promise are currently in the middle to late stages of the clinical trial setting and may emerge in routine practice in the near future. In this review, we highlight select pharmacologic and cell-based therapies that are currently in the clinical trial stage for stroke.

Statin use following intracerebral hemorrhage: a decision analysis

CONTEXT

Statins are widely prescribed for primary and secondary prevention of ischemic cardiac and cerebrovascular disease. Although serious adverse effects are uncommon, results from a recent clinical trial suggested increased risk of intracerebral hemorrhage (ICH) associated with statin use. For patients with baseline elevated risk of ICH, it is not known whether this potential adverse effect offsets the cardiovascular and cerebrovascular benefits.

OBJECTIVE

To address the following clinical question: Given a history of prior ICH, should statin therapy be avoided?

DESIGN

A Markov decision model was used to evaluate the risks and benefits of statin therapy in patients with prior ICH.

MAIN OUTCOME MEASURE

Life expectancy, measured as quality-adjusted life-years. We investigated how statin use affects this outcome measure while varying a range of clinical parameters, including hemorrhage location (deep vs lobar), ischemic cardiac and cerebrovascular risks, and magnitude of ICH risk associated with statins.

RESULTS

Avoiding statins was favored over a wide range of values for many clinical parameters, particularly in survivors of lobar ICH who are at highest risk of ICH recurrence. In survivors of lobar ICH without prior cardiovascular events, avoiding statins yielded a life expectancy gain of 2.2 quality-adjusted life-years compared with statin use. This net benefit persisted even at the lower 95% confidence interval of the relative risk of statin-associated ICH. In patients with lobar ICH who had prior cardiovascular events, the annual recurrence risk of myocardial infarction would have to exceed 90% to favor statin therapy. Avoiding statin therapy was also favored, although by a smaller margin, in both primary and secondary prevention settings for survivors of deep ICH.

CONCLUSIONS

Avoiding statins should be considered for patients with a history of ICH, particularly those cases with a lobar location.

Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations.

CONCLUSIONS

Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

A systematic review of clinical trials of pharmacological interventions for acute ischaemic stroke (1955-2008) that were completed, but not published in full

BACKGROUND

We assessed the prevalence, and potential impact of, trials of pharmacological agents for acute stroke that were completed but not published in full. Failure to publish trial data is to be deprecated as it sets aside the altruism of participants' consent to be exposed to the risks of experimental interventions, potentially biases the assessment of the effects of therapies, and may lead to premature discontinuation of research into promising treatments.

METHODS

We searched the Cochrane Stroke Group's Specialised Register of Trials in June 2008 for completed trials of pharmacological interventions for acute ischaemic stroke, and searched MEDLINE and EMBASE (January 2007 - March 2009) for references to recent full publications. We assessed trial completion status from trial reports, online trials registers and correspondence with experts.

RESULTS

We identified 940 trials. Of these, 125 (19.6%, 95% confidence interval 16.5-22.6) were completed but not published in full by the point prevalence date. They included 16,058 participants (16 trials had over 300 participants each) and tested 89 different interventions. Twenty-two trials with a total of 4,251 participants reported the number of deaths. In these trials, 636/4251 (15.0%) died.

CONCLUSIONS

Our data suggest that, at the point prevalence date, a substantial body of evidence that was of relevance both to clinical practice in acute stroke and future research in the field was not published in full. Over 16,000 patients had given informed consent and were exposed to the risks of therapy. Responsibility for non-publication lies with investigators, but pharmaceutical companies, research ethics committees, journals and governments can all encourage the timely publication of trial data.

Silent microbleeds and old hematomas in spontaneous cerebral hemorrhages

OBJECTIVE

The authors studied the risk factors of silent cerebral microbleeds (MBs) and old hematomas (OHs) and their association with concurrent magnetic resonance (MR) imaging findings in the patients of intracerebral hemorrhages (ICHs).

METHODS

From April 2002 to June 2007, we retrospectively studied 234 patients of primary hemorrhagic stroke. All patients were evaluated with computed tomography (CT) and 3.0-tesla MR imaging studies within the first week of admission. MBs and OHs were assessed by using T2*-weighted gradient-echo (GRE) MR imaging. The patients were divided into 2 groups, depending on whether or not they had two GRE lesions of chronic hemorrhages. A correlation between MBs and OHs lesions were also statistically tested. Lacunes and white matter and periventricular hyperintensities (WMHs, PVHs) were checked by T1- and T2-weighted spin-echo and fluid attenuated inversion recovery sequences. Variables on the clinical and laboratory data and MR imaging abnormalities were compared between both groups with or without MBs and OHs.

RESULTS

MBs were observed in 186 (79.5%) patients and a total of 46 OHs were detected in 45 (19.2%) patients. MBs (39.6%), OHs (80.4%), and ICHs (69.7%) were most commonly located in the ganglionic/thalamic region. Both MBs and OHs groups were more frequently related to chronic hypertension and advanced WMHs and PVHs. The prevalence and number of MBs were more closely associated with OHs groups than non-OH patients.

CONCLUSION

This study clearly demonstrated the presence of MBs and OHs and their correlation with hypertension and cerebral white matter microangiopathy in the ICHs patients. Topographic correlation between the three lesions (MBs, OHs, and ICHs) was also noted in the deep thalamo-basal location.

Hemorrhagic Stroke in Chronic Dialysis Patients

AIMS

This study was designed to retrospectively investigate the clinical profiles, disease course and management of hemorrhagic stroke in chronic dialysis patients. We emphasized on the factors affecting the prognosis.

PATIENTS AND METHODS

We retrospectively studied (January 1991-June 1999) the chronic dialysis patients who were admitted to our facility with a diagnosis of acute hemorrhagic stroke. The medical results were reviewed in detail and the clinical characteristics, laboratory data and management records of each individual were collected for analysis.

RESULTS

There were 16 patients analyzed in total, 9 males and 7 females. The average age was 59.4+/-13.3 years old. Before admission, 14 patients received chronic hemodialysis (HD) and two patients peritoneal dialysis (PD). The co-morbidities included hypertension (16/16), Diabetes Mellitus (DM) (9/16), previous cerebrovascular accidents (9/16) and hyperlipidemia (5/16). The locations of cerebral hemorrhage (CH) were: the putamen (6/16), brain stem (3/16), thalamus (3/16) and others (4/16). Among the 14 HD patients, 8 remained on HD after onset of CH, while 6 switched to PD. Those who received PD before their development of CH continued to perform PD. The overall mortality was 44% (7/16). One of the 8 patients who continued on HD died (mortality 12.5%). Among the 8 patients who received PD, 6 died (mortality 75%). Two patients who underwent surgical intervention also passed away. The major cause of death was neurological deterioration. The interval between the onset of CH and death was short (15+/-13 days, range 2-39 days).

CONCLUSION

The overall prognosis of CH in the chronic dialysis population is poor. Patients with lower hemoglobin levels upon presentation and those performing PD after CH may have even worse prognosis.

In Search of Clinical Neuroprotection After Brain Ischemia

Background and Purpose— Brain injury after stroke and other cerebral ischemic events is a leading cause of death and disability worldwide. Our purpose here is to argue in favor of combined mild hypothermia (35°C) and magnesium as an acute neuroprotective treatment to minimize ischemic brain injury.

Methods and Results— Drawing on our own experimental findings with mild hypothermia and magnesium, and in light of the moderate hypothermia trials in cardiac arrest/resuscitation and magnesium trials in ischemic stroke (IMAGES, FAST-Mag), we bring attention to the advantages of mild hypothermia compared with deeper levels of hypothermia, and highlight the existing evidence for its combination with magnesium to provide an effective, safe, economical, and widely applicable neuroprotective treatment after brain ischemia. With respect to effectiveness, our own laboratory has shown that combined mild hypothermia and magnesium treatment has synergistic neuroprotective effects and reduces brain injury when administered several hours after global and focal cerebral ischemia.

Conclusions— Even when delayed, combined treatment with mild hypothermia and magnesium has broad therapeutic potential as a practical neuroprotective strategy. It warrants further experimental investigation and presents a good case for assessment in clinical trials in treating human patients after brain ischemia.

Treatment and prevention of spontaneous intracerebral hemorrhage: comparison of EUSI and AHA/ASA recommendations

Stroke is a leading cause of death and the primary cause of permanent disability in adults in Western countries and has an enormous socioeconomic impact. Among all stroke subtypes, intracerebral hemorrhage is the deadliest form, especially in patients with intraventricular hemorrhage. In recent years, intracerebral hemorrhage has become a major focus within stroke research. The latest data from randomized controlled trials, however, have shown disappointing results. In 2006, the European Stroke Initiative published recommendations for the management of spontaneous intracerebral hemorrhage, followed by an updated recommendation by the American Heart Association/American Stroke Association in 2007. This review gives a comprehensive overview and comparison of the two recommendations. Finally, we provide an overview of ongoing clinical trials in intracerebral hemorrhage.

The risk of recurrent stroke after intracerebral haemorrhage

BACKGROUND AND AIM

The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0-24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed.

PATIENTS AND METHODS

All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronal post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke.

RESULTS

Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were "lobar-lobar" type.

CONCLUSION

The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.

[Recommendations of the European Stroke Initiative for the diagnosis and treatment of spontaneous intracerebral haemorrhage]

This article summarises the recommendations for the management of managing patients with intracerebral haemorrhage published in 2006 by the European Stroke Initiative (EUSI) on behalf of the European Stroke Council (ESC), the European Neurological Society (ENS), and the European Federation of Neurological Societies (EFNS).

Recommendations for the Management of Intracranial Haemorrhage – Part I: Spontaneous Intracerebral Haemorrhage

This article represents the recommendations for the management of spontaneous intracerebral haemorrhage of the European Stroke Initiative (EUSI). These recommendations are endorsed by the 3 European societies which are represented in the EUSI: the European Stroke Council, the European Neurological Society and the European Federation of Neurological Societies.

Recurrence and extension of lobar hemorrhage related to cerebral amyloid angiopathy: multivariate analysis of clinical risk factors

BACKGROUND

Many recent studies have analyzed clinical risk factors for the recurrence and extension of intracerebral hemorrhage. However, they have not been investigated in patients with lobar hemorrhage related to cerebral amyloid angiopathy (CAA).

METHODS

We studied 40 surgically treated patients with lobar hemorrhage diagnosed histologically as being related to CAA. To determine clinical factors influencing the recurrence and hematoma size their clinical data (demographics, medical history, and radiographic and laboratory data) were examined retrospectively and subjected to multivariate analysis.

RESULTS

Twelve patients (30%) had recurrent lobar hemorrhage. Twenty-one patients had a small hematoma and 19 had a large hematoma. Hypertension was the only significant clinical factor influencing the recurrence of CAA-related lobar hemorrhage. There was no significant clinical factor influencing the hematoma size of CAA-related lobar hemorrhage.

CONCLUSIONS

The history of hypertension is associated with an increase in the recurrence of CAA-related lobar hemorrhage.

Recurrent primary intracerebral hemorrhage in Izumo City, Japan

BACKGROUND

Recurrent intracerebral hemorrhage (ICH) is a devastating illness among stroke survivors. We investigated the rate and characteristics of ICH recurrence in Izumo City, Japan.

METHODS

The recurrence rate of ICH was calculated for 279 patients who suffered their first-ever ICH between 1991 and 1998 and were followed up during a mean period of 3.0 years (range, 1 month to 11 years). The characteristics of recurrent ICH were evaluated for 42 patients who were treated for it between 1991 and 1998.

RESULTS

Of the 279 patients with ICH, 19 (7%) had rebleeding; the recurrence rate was 2.3% per year. Analysis of the 42 patients with recurrent ICH showed that the most common pattern of recurrence was ganglionic-ganglionic (n = 25). The crude and the age- and sex-adjusted annual incidence rates for recurrent ICH were both 6 per 100,000 population. Of the 42 patients with recurrent ICH, 16 (38%) had a favorable outcome at discharge and 10 (24%) died. The overall 1-year survival rate for recurrent ICH was 72%. Intraventricular hemorrhage on computed tomography scans was the only significant predictor of not only ICH recurrence but also the 1-year case-fatality rate in patients with recurrent ICH.

CONCLUSIONS

Recurrence after an initial ICH is not rare, and the most common pattern of recurrence is ganglionic-ganglionic. Whereas the functional outcome of recurrent ICH is unsatisfactory, the 1-year survival rate is not necessarily low. Intraventricular hemorrhage on computed tomography scans is an important predictor of both ICH recurrence and the 1-year case-fatality rate in patients with recurrent ICH.

Anticoagulation or Inferior Vena Cava Filter Placement for Patients With Primary Intracerebral Hemorrhage Developing Venous Thromboembolism?

Background— Most patients with primary intracerebral hemorrhage developing clinically apparent proximal deep vein thrombosis (DVT) and/or pulmonary embolism (PE) require treatment with either anticoagulants or inferior vena cava filter insertion. Although the latter probably reduces the immediate risk of incident or recurrent PE and surmounts the undefined risk of recurrent intracranial bleeding with anticoagulation, the issue of preventing further thrombus propagation is not addressed, and there are associated short- and long-term risks, including a greater incidence of recurrent DVT.

Summary of Review— There are no data from randomized trials to clarify optimum treatment in these patients; indeed, the feasibility of such studies is questionable. Hence, treatment decisions continue to be made on an individualized basis and should include assimilation of information on key factors such as time elapsed post-stroke and lobar versus deep hemispheric location of the index event, natural history studies demonstrating a two-fold risk of recurrent intracerebral hemorrhage in the former subgroup.

Conclusions— In patients selected for anticoagulation, data from nonstroke patients suggest that a 5- to 10-day course of full-dose low-molecular-weight heparin followed by 3 months of lower-dose low-molecular-weight heparin is at least as effective as warfarin and may be associated with fewer hemorrhagic complications.

Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis

BACKGROUND AND PURPOSE

Warfarin increases both the likelihood and the mortality of intracerebral hemorrhage (ICH), particularly in patients with a history of prior ICH. In light of this consideration, should a patient with both a history of ICH and a clear indication for anticoagulation such as nonvalvular atrial fibrillation be anticoagulated? In the absence of data from a clinical trial, we used a decision-analysis model to compare the expected values of 2 treatment strategies-warfarin and no anticoagulation-for such patients.

METHODS

We used a Markov state transition decision model stratified by location of hemorrhage (lobar or deep hemispheric). Effectiveness was measured in quality-adjusted life years (QALYs). Data sources included English language literature identified through MEDLINE searches and bibliographies from selected articles, along with empirical data from our own institution. The base case focused on a 69-year-old man with a history of ICH and newly diagnosed nonvalvular atrial fibrillation.

RESULTS

For patients with prior lobar ICH, withholding anticoagulation therapy was strongly preferred, improving quality-adjusted life expectancy by 1.9 QALYs. For patients with prior deep hemispheric ICH, withholding anticoagulation resulted in a smaller gain of 0.3 QALYs. In sensitivity analyses for patients with deep ICH, anticoagulation could be preferred if the risk of thromboembolic stroke is particularly high.

CONCLUSIONS

Survivors of lobar ICH with atrial fibrillation should not be offered long-term anticoagulation. Similarly, most patients with deep hemispheric ICH and atrial fibrillation should not receive anticoagulant therapy. However, patients with deep hemispheric ICH at particularly high risk for thromboembolic stroke or low risk of ICH recurrence might benefit from long-term anticoagulation.

Tolerability of NXY-059 at higher target concentrations in patients with acute stroke

BACKGROUND AND PURPOSE

NXY-059 is a nitrone-based free radical-trapping agent in development for acute stroke. In patients with acute stroke, NXY-059 is well tolerated at concentrations known to be associated with neuroprotection in animal models of transient cerebral ischemia; however, higher target concentrations appear necessary on the basis of animal models of permanent ischemia.

METHODS

This was a randomized, double-blind, placebo-controlled, parallel-group, dose-escalation, multicenter study that evaluated safety, tolerability, and plasma concentrations of 2 NXY-059 dosing regimens within 24 hours of acute stroke. NXY-059 was administered as either 915 mg over 1 hour followed by 420 mg/h for 71 hours or 1820 mg for 1 hour followed by 844 mg/h for 71 hours; plasma concentrations were monitored. Neurological and functional outcomes were recorded for up to 30 days.

RESULTS

One hundred thirty-five patients were recruited, of whom 134 received study treatment and completed assessments (844 mg/h, n=39; 420 mg/h, n=48; placebo, n=47). Mean age was 69 years (range, 34 to 92 years), and baseline National Institutes of Health Stroke Scale score was 8.5 (SD, 6.6). Serious adverse events occurred in 3, 17, and 13 patients, respectively, with deaths in 0, 4, and 3 patients and treatment discontinuations because of adverse events in 0, 1, and 3 patients. Good outcome, defined by modified Rankin Scale score of 0 or 1, was seen in 53%, 29% and 40%, respectively. No safety concern was identified in analysis of body temperature, blood pressure, or other laboratory parameters. The unbound plasma concentration at steady state was 260+/-79 micromol/L, exceeding the target of 200 micromol/L in the high-dose group.

CONCLUSIONS

NXY-059 was well tolerated in patients with an acute stroke at and above concentrations shown to be neuroprotective in an animal model when initiated 4 hours after onset of permanent focal ischemia.

Magnesium in stroke treatment

Magnesium is involved in multiple physiological processes that may be relevant to cerebral ischaemia, including antagonism of glutamate release, NMDA receptor blockade, calcium channel antagonism, and maintenance of cerebral blood flow. Systemically administered magnesium at doses that double physiological serum concentration significantly reduces infarct volume in animal models of stroke, with a window of up to six hours after onset and favourable dose-response characteristics when compared with previously tested neuroprotective agents. Small clinical trials have reported benefit, but results are not statistically significant in systematic review. A large ongoing trial (IMAGES) will report in 2003-4 and further trials are planned.