Hyperacute prediction of functional outcome in spontaneous intracerebral haemorrhage: systematic review and meta-analysis

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.

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.

Association Between Prior Antiplatelet Therapy and Prognosis in Patients With Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

PURPOSE

Approximately 20% to 30% of intracerebral hemorrhage (ICH) patients were reported to be on antiplatelet therapy (APT), and association between prior APT and prognosis was unclear. We aimed to clarify the impact of APT on the prognosis of ICH through an updated systematic review and meta-analysis, and to further compare the risk of single APT (SAPT) or dual APT (DAPT) prior to ICH as well as the risk associated with various antiplatelet drugs.

METHODS

EMBASE, MEDLINE via Ovid SP and Web of Science were searched from inception of each database to November 4, 2023. Included studies reported prognosis in both patients with prior APT and those without.

FINDINGS

A total of 433,103 patients from 43 studies were included in the meta-analysis. Both univariate and multivariate analyses demonstrated a significant association between prior-APT and an increased mortality risk (odd ratio [OR] 1.43, 95% confidence interval [CI] 1.28-1.59; OR 1.20, 95%CI 1.10-1.30, respectively). The risk was higher in short term follow-up (Univariate OR 1.73, 95%CI 1.22-2.46; Multivariate OR 1.94, 95%CI 1.48-2.55). A notably increased risk of hematoma expansion was also observed in patients previously treated with APT (Univariate OR 1.47, 95%CI 1.12-1.94; Multivariate OR 1.88, 95%CI 1.30-2.71), which were mainly attributed to events within 24 hours. The impact of prior-APT on poor functional outcome was inconsistent between univariate and multivariate analyses. Both direct and indirect comparisons showed that SAPT significantly reduced the risk of mortality (OR 0.67, 95%CI 0.64-0.70; OR 0.84, 95%CI 0.71-0.99) and poor functional outcome (OR 0.84, 95%CI 0.72-0.98; OR 0.81, 95%CI 0.72-0.91) compared to DAPT.

IMPLICATIONS

Prior-APT increased the risk of mortality and hematoma expansion in patients with ICH. The increased risk of mortality and hematoma expansion was more obvious in the short term follow-up and within 24 hours, respectively. The effect of APT on poor functional outcome exhibited inconsistency between univariate and multivariate analyses, suggesting that further investigation is warranted to clarify this relationship. In comparison with DAPT, SAPT could decrease the risk of mortality and poor functional outcome. Further studies focusing on antiplatelet drug response, racial differences, and specific APT regimens may help verify the influence.

Whole-brain diffusion tensor imaging predicts 6-month functional outcome in acute intracerebral haemorrhage

INTRODUCTION

Small vessel disease (SVD) causes most spontaneous intracerebral haemorrhage (ICH) and is associated with widespread microstructural brain tissue disruption, which can be quantified via diffusion tensor imaging (DTI) metrics: mean diffusivity (MD) and fractional anisotropy (FA). Little is known about the impact of whole-brain microstructural alterations after SVD-related ICH. We aimed to investigate: (1) association between whole-brain DTI metrics and functional outcome after ICH; and (2) predictive ability of these metrics compared to the pre-existing ICH score.

METHODS

Sixty-eight patients (38.2% lobar) were retrospectively included. We assessed whole-brain DTI metrics (obtained within 5 days after ICH) in cortical and deep grey matter and white matter. We used univariable logistic regression to assess the associations between DTI and clinical-radiological variables and poor outcome (modified Rankin Scale > 2). We determined the optimal predictive variables (via LASSO estimation) in: model 1 (DTI variables only), model 2 (DTI plus non-DTI variables), model 3 (DTI plus ICH score). Optimism-adjusted C-statistics were calculated for each model and compared (likelihood ratio test) against the ICH score.

RESULTS

Deep grey matter MD (OR 1.04 [95% CI 1.01-1.07], p = 0.010) and white matter MD (OR 1.11 [95% CI 1.01-1.23], p = 0.044) were associated (univariate analysis) with poor outcome. Discrimination values for model 1 (0.67 [95% CI 0.52-0.83]), model 2 (0.71 [95% CI 0.57-0.85) and model 3 (0.66 [95% CI 0.52-0.82]) were all significantly higher than the ICH score (0.62 [95% CI 0.49-0.75]).

CONCLUSION

Our exploratory study suggests that whole-brain microstructural disruption measured by DTI is associated with poor 6-month functional outcome after SVD-related ICH. Whole-brain DTI metrics performed better at predicting recovery than the existing ICH score.