Relationship of White Matter Lesions with Intracerebral Hemorrhage Expansion and Functional Outcome: MISTIE II and CLEAR III

Clinical Trial Protocol for BEACH: A Phase 2a Study of MW189 in Patients with Acute Nontraumatic Intracerebral Hemorrhage

Patients with acute spontaneous intracerebral hemorrhage (ICH) develop secondary neuroinflammation and cerebral edema that can further damage the brain and lead to increased risk of neurologic complications. Preclinical studies in animal models of acute brain injury have shown that a novel small-molecule drug candidate, MW01-6-189WH (MW189), decreases neuroinflammation and cerebral edema and improves functional outcomes. MW189 was also safe and well tolerated in phase 1 studies in healthy adults. The proof-of-concept phase 2a Biomarker and Edema Attenuation in IntraCerebral Hemorrhage (BEACH) clinical trial is a first-in-patient, multicenter, randomized, double-blind, placebo-controlled trial. It is designed to determine the safety and tolerability of MW189 in patients with acute ICH, identify trends in potential mitigation of neuroinflammation and cerebral edema, and assess effects on functional outcomes. A total of 120 participants with nontraumatic ICH will be randomly assigned 1:1 to receive intravenous MW189 (0.25 mg/kg) or placebo (saline) within 24 h of symptom onset and every 12 h for up to 5 days or until hospital discharge. The 120-participant sample size (60 per group) will allow testing of the null hypothesis of noninferiority with a tolerance limit of 12% and assuming a "worst-case" safety assumption of 10% rate of death in each arm with 10% significance and 80% power. The primary outcome is all-cause mortality at 7 days post randomization between treatment arms. Secondary end points include all-cause mortality at 30 days, perihematomal edema volume after symptom onset, adverse events, vital signs, pharmacokinetics of MW189, and inflammatory cytokine concentrations in plasma (and cerebrospinal fluid if available). Other exploratory end points are functional outcomes collected on days 30, 90, and 180. BEACH will provide important information about the utility of targeting neuroinflammation in ICH and will inform the design of future larger trials of acute central nervous system injury.

Cerebral small vessel disease modifies outcomes after minimally invasive surgery for intracerebral haemorrhage

BACKGROUND

Minimally invasive surgery (MIS) for spontaneous supratentorial intracerebral haemorrhage (ICH) is controversial but may be beneficial if end-of-treatment (EOT) haematoma volume is reduced to ≤15 mL. We explored whether MRI findings of cerebral small vessel disease (CSVD) modify the effect of MIS on long-term outcomes.

METHODS

Prespecified blinded subgroup analysis of 288 subjects with qualified imaging sequences from the phase 3 Minimally Invasive Surgery Plus Alteplase for Intracerebral Haemorrhage Evacuation (MISTIE) trial. We tested for heterogeneity in the effects of MIS and MIS+EOT volume ≤15 mL on the trial's primary outcome of good versus poor function at 1 year by the presence of single CSVD features and CSVD scores using multivariable models.

RESULTS

Of 499 patients enrolled in MISTIE III, 288 patients had MRI, 149 (51.7%) randomised to MIS and 139 (48.3%) to standard medical care (SMC). Median (IQR) ICH volume was 42 (30-53) mL. In the full MRI cohort, there was no statistically significant heterogeneity in the effects of MIS versus SMC on 1-year outcomes by any specific CSVD feature or by CSVD scores (all Pinteraction >0.05). In 94 MIS patients with EOT ICH volume ≤15 mL, significant reduction in odds of poor outcome was found with cerebral amyloid angiopathy score <2 (OR, 0.14 (0.05-0.42); Pinteraction=0.006), absence of lacunes (OR, 0.37 (0.18-0.80); Pinteraction=0.02) and absence of severe white matter hyperintensities (WMHs) (OR, 0.22 (0.08-0.58); Pinteraction=0.03).

CONCLUSIONS

Following successful haematoma reduction by MIS, we found significantly lower odds of poor functional outcome with lower total burden of CSVD in addition to absence of lacunes and severe WMHs. CSVD features may have utility for prognostication and patient selection in clinical trials of MIS.

Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury

Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.

Clinical and paraclinical predictors of early neurological deterioration and poor outcome in spontaneous intracerebral hemorrhage

Background

Spontaneous intracerebral hemorrhage (sICH) is the second most common form of stroke. It is a major cause of morbidity and mortality. Several clinical and radiological parameters are related to its poor outcome. The aim of this study is to elucidate the clinical, laboratory, and radiological factors associated with early neurological deterioration and poor outcome in patients with ICH.

Results

seventy patients diagnosed with sICH were evaluated within the first 72 h from the onset of symptoms by Clinical, radiological, and laboratory parameters. Patients were assessed for early neurological deterioration (END) during the hospital stay (up to 7 days from admission) using Glasgow coma scale (GSC), and the National Institutes of Health Stroke Scale (NIHSS), and within 3 months from stroke onset using modified Rankin scale (mRS). ICH score and Functional Outcome in Patients with Primary Intracerebral Hemorrhage (FUNC) Score were calculated for prognostication. 27.1% and 71.42% of patients had END and showed unfavorable outcome, respectively. Clinical indices, as NIHSS > 7 on admission and age > 51 years, radiological characteristics, as large hematoma size, leukoaraiosis, and mass effect detected on CT scan, as well as serum biomarkers; serum urea level > 50 mg/dL, high neutrophil:lymphocyte ratio on admission, high ALT and AST, as well as low total, LDL, and HDL cholesterol levels, all were significantly associated with poor outcome in the patients. Stepwise multivariate logistic regression analysis found the presence of aspiration to be an independent predictor of END, and the scores of NIHSS > 7 on admission, age > 51 years, and urea level > 50 mg/dL were independent predictors of poor outcome.

Conclusions

There are several predictors for END as well as poor outcome in ICH. Some are clinical, others are radiological and laboratory. Aspiration was an independent predictor of END during hospital stay (3-7 days) in patients with ICH, while older age, high NIHSS and urea level on admission were independent predictors of poor outcome.

Moderate-Severe White Matter Lesion Predicts Delayed Intraventricular Hemorrhage in Intracerebral Hemorrhage

BACKGROUND

Most existing studies have focused on the correlation between white matter lesion (WML) and baseline intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH), whereas few studies have investigated the relationship between WML severity and delayed IVH after admission. This study aimed to investigate the correlation between WML severity and delayed IVH and to verify the association between WML and baseline IVH.

METHODS

A total of 480 patients with spontaneous ICH from February 2018 to October 2020 were selected. WML was scored using the Van Swieten Scale, with scores of 0-2 representing nonslight WML and scores of 3-4 representing moderate-severe WML. We determined the presence of IVH on baseline (< 6 h) and follow-up computed tomography (< 72 h) images. Univariate analysis and multiple logistic regression were used to analyze the influencing factors of baseline and delayed IVH.

RESULTS

Among 480 patients with ICH, 172 (35.8%) had baseline IVH, and there was a higher proportion of moderate-severe WML in patients with baseline IVH (20.3%) than in those without baseline IVH (12.7%) (P = 0.025). Among 308 patients without baseline IVH, delayed IVH was found in 40 patients (12.9%), whose proportion of moderate-severe WML (25.0%) was higher than that in patients without delayed IVH (10.8%) (P = 0.012). Multiple logistic regression results showed that moderate-severe WML was independently correlated with baseline IVH (P = 0.006, odds ratio = 2.266, 95% confidence interval = 1.270-4.042) and delayed IVH (P = 0.002, odds ratio = 7.009, 95% confidence interval = 12.086-23.552).

CONCLUSIONS

Moderate-severe WML was an independent risk factor for delayed IVH as well as baseline IVH.

Higher Cerebral Small Vessel Disease Burden in Patients With Small Intracerebral Hemorrhage

Objective

To investigate the association between cerebral small vessel disease (SVD) and hematoma volume in primary intracerebral hemorrhage (ICH).

Methods

Patients from a prospective ICH cohort were enrolled. Admission and follow-up CT scan within 72 h after onset were reviewed to calculate the final hematoma volume. We evaluated cortical superficial siderosis and the global SVD score, including white matter hyperintensities, lacunes, enlarged perivascular space, and cerebral microbleeds on MRI. We conducted the multivariate logistic regression analyses to explore the association between SVD markers and small ICH, as well as hematoma volume. Hematoma location was stratified into lobar and non-lobar for subgroup analysis.

Results

A total of 187 patients with primary ICH (mean age 62.4 ± 13.4 years, 67.9% male) were enrolled. 94 (50.2%) patients had small ICH. The multivariate logistic regression analysis showed an association between global SVD score and small ICH [adjusted odds ratio (aOR) 1.27, 95% CI 1.03–1.57, p = 0.027] and a trend of higher global SVD score towards non-lobar small ICH (aOR 1.23, 95% CI 0.95–1.58, p = 0.122). In the multivariate linear regression analysis, global SVD score was inversely related to hematoma volume of all ICH (β = −0.084, 95% CI −0.142 to −0.025, p = 0.005) and non-lobar ICH (β = −0.112, 95% CI −0.186 to −0.037, p = 0.004). Lacune (β = −0.245, 95% CI −0.487 to −0.004, p = 0.046) was associated with lower non-lobar ICH volume.

Conclusion

Global SVD score is associated with small ICH and inversely correlated with hematoma volume. This finding predominantly exists in non-lobar ICH.

Cerebral Small Vessel Disease and Prognosis in Intracerebral Hemorrhage: A Systematic Review and Meta-analysis of Cohort Studies

BACKGROUND

To investigate whether cerebral small vessel disease (CSVD) markers and the total CSVD burden are associated with functional outcome, mortality, stroke recurrence, and hematoma expansion in patients with spontaneous intracerebral hemorrhage (ICH).

METHODS

Following a previously registered protocol (PROSPERO protocol: CRD42021287743), we systematically searched PubMed, Web of Science, and EMBASE to identify relevant literature up to November 2021. Cohort studies that examined the association between CSVD markers (white matter hyperintensity [WMH], lacune, enlarged perivascular space [EPVS], cerebral microbleed [CMB], and brain atrophy) or CSVD burden and prognosis in patients with ICH were included. The pooled estimates were calculated using random effects models.

RESULTS

Forty-one studies with 19,752 ICH patients were pooled in the meta-analysis. WMH (OR=1.50, 95% CI=1.32 to 1.70), lacune (OR=1.32, 95% CI=1.18 to 1.49), CMB (OR=2.60, 95% CI=1.13 to 5.97) and brain atrophy (OR=2.22, 95% CI=1.48 to 3.31) were associated with worse functional outcome. CSVD markers concerning increased risk of mortality were WMH (OR=1.57, 95% CI=1.38 to 1.79) and brain atrophy (OR=1.84, 95% CI=1.11 to 3.04), while concerning increased risk of stroke recurrence were WMH (OR=1.62, 95% CI=1.28 to 2.04) and lacune (OR=3.00, 95% CI=1.68 to 5.37). EPVS was not related to prognosis. There was a lack of association between CSVD markers and hematoma expansion. CSVD burden increased the risk of worse functional outcome, mortality, and stroke recurrence by 57%, 150%, and 44%, respectively.

CONCLUSIONS

In patients with spontaneous ICH, WMH, lacune, CMB, brain atrophy, and the total CSVD burden are associated with substantially increased risk of worse functional outcome, mortality, or stroke recurrence.

Clinical efficacy and safety of neuroendoscopic surgery for severe thalamic hemorrhage with ventricle encroachment

To summarize and analyze the clinical efficacy and safety of neuroendoscopic surgery (NES) in the treatment of patients for severe thalamic hemorrhage with ventricle encroachment (THVE). Eighty-three patients with severe THVE were treated in the Neurosurgery Department of Anqing Hospital Affiliated to Anhui Medical University from July 2019 to August 2021. Our study was approved by the ethics committee. The patients were randomly divided into NES group and extraventricular drainage (EVD) group. The hospital stay, Glasgow coma scale (GCS) scores on the 1st and 14th days postoperatively, the incidence of intracranial infections, and the clearance of postoperative hematomas were compared and analyzed between the two groups. The patients had follow-up evaluations 6 months postoperatively. The prognosis was evaluated based on the activity of daily living (ADL) score. A head CT or MRI was obtained to determine whether there was hydrocephalus, cerebral infarction, or other related complications. Eighty-three patients were randomly divided into 41 cases of NES group and 42 cases of EVD group. The length of postoperative hospital stay was 17.42 ± 1.53 days, the GCS scores were 6.56 ± 0.21, and 10.83 ± 0.36 on days 1 and 14, respectively; intracranial infections occurred in 3 patients (7.31%) and the hematoma clearance rate was 83.6 ± 5.18% in the NES group, all of which were significantly better than the EVD group (P < 0.05). After 6 months of follow-up, 28 patients (68.29%) had a good prognosis, 5 patients (12.19%) died, and 4 patients (9.75%) had hydrocephalus in the NES group. In the EVD group, the prognosis was good in 15 patients (35.71%), 12 patients (28.57%) died, and 17 patients (40.47%) had hydrocephalus. The prognosis, mortality rate, and incidence of hydrocephalus in the NES group were significantly better than the EVD group (P < 0.05). Compared to traditional EVD, NES for severe THVE had a higher hematoma clearance rate, and fewer intracranial infections and patients with hydrocephalus, which together improve the clinical prognosis and is thus recommended for clinical use.

White Matter Hyperintensities and Functional Outcomes in Patients With Cerebral Hemorrhage: A Systematic Review and Meta-Analysis

Background and Objectives

There are controversies about white matter hyperintensities (WMH) and the prognosis of spontaneous intracerebral hemorrhage. Our objective is to investigate the relationship between WMH and functional outcomes after intracerebral hemorrhage (ICH).

Methods

We systematically searched PubMed, EMBASE, and Cochrane Library databases from inception through August 10, 2021 without any restriction of countries. Articles investigating the relationship of WMH and functional outcomes as well as mortality of patients with spontaneous ICH were included. We extracted relevant data and evaluated the study quality with the Newcastle-Ottawa Scale. We pooled odds ratio (OR) for the presence and different severities of WMH with random effects models using STATA.

Results

A total of 10,584 patients with ICH in 18 studies were included in the analysis. Moderate/severe WMH were related to poor functional outcome [OR, 1.805, 95% confidence interval (CI), 1.320–2.469] and all-cause mortality (OR, 3.27, 95% CI, 2.07–5.18) after ICH. Besides, the increasing severity of WMH was also related to poor functional outcome (OR, 1.34, 95% CI, 1.17–1.53) and all-cause mortality (OR, 1.62, 95% CI, 1.39–1.90). The pooled data did not find the relationship between the presence of WMH and poor functional outcome (OR, 2.54, 95% CI, 0.91–7.05) after ICH. The results remained stable after adjusting for age, hematoma volume, stroke, and intraventricular hemorrhage.

Conclusion

We found moderate and severe WMH were related to poor functional outcomes and all-cause mortality after ICH. High-quality prospective studies are still needed.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021278409.

Hematoma Evacuation via Image-Guided Para-Corticospinal Tract Approach in Patients with Spontaneous Intracerebral Hemorrhage

Introduction

Corticospinal tract injury caused by direct hematoma compression and secondary damage induced from blood toxic substances might influence the outcomes in patients with intracerebral hemorrhage (ICH). This study aimed to evaluate the safety and efficacy of hematoma evacuation via image-guided para-corticospinal tract approach based on the protection of compressed or residual corticospinal tract.

Methods

Seventy-five patients with ICH who underwent the image-guided para-corticospinal tract approach were retrospectively collected into the surgery group. Diffusion tensor imaging or computed tomography angiography was performed to identify the relationship between important white matter tracts and hematoma. The neuronavigation system for the preoperative imaging data loaded was used to identify the location of the burr hole, insertion trajectory, and depth of insertion. Cortical entry points and insertion trajectories were kept parallel to the corticospinal tract route into the hematoma based on the protection of compressed or residual corticospinal tract. Hematoma was removed under the image-guided para-corticospinal tract approach. Seventy-five age-, sex-, hematoma site-, and volume-matched patients with ICH who underwent conservative treatment were selected as controls. Demographical, clinical, radiological, and treatment-related data were retrospectively analyzed. Functional outcome was evaluated by modified Rankin scale on day 90.

Results

A total of 150 patients with ICH were retrospectively enrolled. The median Glasgow coma scale (GCS) score on admission was 11 (IQR 8–13). Deep hematoma (thalamus and basal ganglion) was present in 86.7% (130 patients). The mean hematoma volume on admission was 47 ± 19 mL, and the postoperative hematoma volume was 11 ± 10 mL. A higher proportion of favorable outcome was observed in the surgery group than in conservative treatment group (32.0% versus 17.4%; p = 0.037).

Conclusion

Hematoma evacuation via image-guided para-corticospinal tract approach based on the protection of compressed or residual corticospinal tract seems to be safer in patients with ICH with a relatively higher functional independence.

Intracerebral hematoma expansion and intracranial internal carotid artery calcifications

BACKGROUND AND AIMS

Prediction of intracerebral hematoma expansion (IHE) is of critical importance during intracerebral hemorrhage (ICH) management. Given its suggested positive connection with cerebral microvascular disease status, intracranial internal carotid artery wall calcifications (ICAC) on admission computed tomography (CT) studies may contribute to prediction of IHE.

METHOD

Presence, burden and type [as per Kockelkoren's score] of ICAC were defined in admission CT and CT-angiography of 201 ICH patients [mean age: 70 ± 13 years, 44 % female]. A Kockelkoren's score of <7 indicated intimal calcification [iICAC], while ≥7 indicated non-intimal [or medial] ones [mICAC]. IHE criteria were absolute volume increase of ≥12.5cc or ≥6cc, and relative increase ≥33 % or ≥26 %.

RESULT

ICAC was diagnosed in 79.6 % of ICH patients. ICAC status was not independent indicator of milder IHE (≥6cc and ≥26 % IHE, both in 27 %). Presence of contralateral mICAC was found to be an independent predictor for higher grade IHE (expβ = 3.44, 95 %CI: 1.47-8.04, for IHE ≥ 12.5cc, diagnosed in 14.4 %; and expβ = 2.67, 95 %CI: 1.29-5.55, for IHE ≥ 33 %, diagnosed in 24 %). Mortality (31 %) was higher in those with ipsilateral any type ICAC (36 % in mICAC, 38 % in iICAC, 17 % in no ICAC, p = 0.017), but this was not independent predictor in logistic regression. Similarly, medial ICAC in both ipsilateral (47 % vs. 31 %, p = 0.037) and contralateral (47 % vs. 30 %, p = 0.017) sides was associated with poorer prognosis (42 %) on univariate, but not multivariate analysis.

CONCLUSION

Intracranial ICA calcification is highly prevalent in ICH. mICAC may be associated with risk of "high amount" acute hematoma expansion, hospital mortality and poor prognosis.