1
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Ng Y, Qi W, King NKK, Christianson T, Krishnamoorthy V, Shah S, Divani A, Bettin M, Coleman ER, Flaherty ML, Walsh KB, Testai FD, McCauley JL, Gilkerson LA, Langefeld CD, Behymer TP, Woo D, James ML. Initial antihypertensive agent effects on acute blood pressure after intracerebral haemorrhage. Stroke Vasc Neurol 2022; 7:367-374. [PMID: 35443984 PMCID: PMC9614130 DOI: 10.1136/svn-2021-001101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 03/08/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Current guidelines recommend blood pressure (BP) lowering in patients after acute intracerebral haemorrhage (ICH) without guidance on initial choice of antihypertensive class. This study sought to determine if initial antihypertensive class differentially effects acute BP lowering in a large multiethnic ICH cohort. Methods Subjects enrolled in the Ethnic/Racial Variations in ICH study between August 2010 and August 2017 with elevated admission BP and who received labetalol, nicardipine or hydralazine monotherapy as initial antihypertensive were analysed. Primary outcomes were systolic and diastolic BP changes from baseline to first BP measurement after initial antihypertensive treatment. Secondary outcomes included haematoma expansion (HE), hospital length of stay (LOS) and modified Rankin Score (mRS) up to 12 months after ICH. Exploratory outcomes assessed effects of race/ethnicity. Linear and logistic regression analyses, adjusted for relevant covariates, were performed to determine associations of antihypertensive class with outcomes. Results In total, 1156 cases were used in analyses. Antihypertensive class was associated with diastolic BP change (p=0.003), but not systolic BP change (p=0.419). Initial dosing with nicardipine lowered acute diastolic BP than labetalol (least square mean difference (labetalol-nicardipine)=5.47 (2.37, 8.57), p<0.001). Initial antihypertensive class was also found to be associated with LOS (p=0.028), but not with HE (p=0.406), mortality (p=0.118), discharge disposition (p=0.083) or mRS score at discharge, 3, 6 and 12 months follow-up (p=0.262, 0.276, 0.152 and 0.36, respectively). Race/ethnicity variably affected multivariable models. Conclusion In this large acute ICH cohort, initial antihypertensive class was associated with acute diastolic, but not systolic, BP-lowering suggesting differential effects of antihypertensive agents. Trial registration number NCT01202864.
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Affiliation(s)
- Yisi Ng
- Duke-NUS Medical School, SG, Singapore
| | - Wenjing Qi
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Nicolas Kon Kam King
- Duke-NUS Medical School, SG, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Thomas Christianson
- Department of Anesthesiology, University of Tennessee, Knoxville, Tennessee, USA
| | | | - Shreyansh Shah
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Afshin Divani
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Margaret Bettin
- Department of Neurology, University of Virginia, Charlottesville, Virginia, USA
| | - Elisheva R Coleman
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew L Flaherty
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kyle B Walsh
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Fernando D Testai
- Department of Neurology, University of Illinois, Chicago, Illinois, USA
| | - Jacob L McCauley
- Hussman Institute for Human Genomics, University of Miami, Miami, Florida, USA
| | - Lee A Gilkerson
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Carl D Langefeld
- Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Tyler Paul Behymer
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Daniel Woo
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael L James
- Duke-NUS Medical School, SG, Singapore .,Department of Anesthesiology, Duke University, Durham, North Carolina, USA.,Department of Neurology, Duke University, Durham, North Carolina, USA
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Hooper D, Howard TD, Williamson BJ, BEHYMER TP, Comeau ME, Zimmerman K, Khandwala V, Gilkerson LA, Kittner SJ, Roh DJ, James ML, Testai FD, Vahidy FS, Bagga RS, Thornton JB, Maloney T, Sawyer RPP, Shatz RS, Boyne P, Dunning K, Vagal A, Langefeld CDD, Woo D. Abstract TP10: Inflammatory And Neurodegenerative Gene Expression Changes Occur Long-term After ICH. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tp10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
There is a high prevalence of progressive cognitive impairment in intracerebral hemorrhage (ICH) survivors. We sought to identify gene expression changes, in association with long-term neurodegeneration, among patients 12-24 months post-ICH.
Methods:
The
Recovery and Outcomes from StrokE (ROSE)
study prospectively recruits patients with spontaneous, supratentorial ICH, collecting baseline peripheral blood samples and MRI with diffusion tract imaging (DTI). The
Recovery of StrokE-Longitudinal Assessment with Neuroimaging (ROSE-LAWN)
study performs long term follow-up at 12-24 months on cases enrolled in ROSE. We report on the first five cases enrolled in the ROSE-LAWN study from December 2020 to March 2021. Controls were matched to an overall ICH population by age, sex, and race. RNA-sequencing, aligned to human genome assembly GRCh38, was tested for differential gene expression. Canonical pathway enrichment and network analyses were computed for differentially expressed genes using Ingenuity Pathway Analysis, STRING and MCODE.
Results:
RNA-seq analysis of 5 ICH cases [male, 80%; median age, 61 (45 - 73); black, 40%; ICH volume, 14.88cc ± 13.07] and 13 controls [male, 54%; median age, 74 (69 - 79); black, 15%] identified 554 differentially expressed genes (genomic control adjusted p < 0.01), of which 24 met the false discovery rate correction for multiple comparisons (FDR < 0.05). The most significant difference was observed in hypoxia up-regulated 1 (
HYOU1),
a heat shock protein related gene (p = 2.64E-11). Pathway analysis identified enrichment of dopamine and serotonin receptor signaling (p = 8.74E-03, 2.23E-02), cell cycle regulation (p = 1.75E-02) and agranulocyte adhesion pathways (p = 2.18E-02). Comparison of baseline and follow-up MRI DTI demonstrated extensive cortical tract degeneration, beyond the initial injury.
Conclusion:
These results provide novel evidence of significant gene expression changes occurring years after the initial ICH. Despite resolution of the ICH, persistent inflammation may correlate with progressive neurodegeneration and subsequent cognitive impairment in ICH survivors. Future studies with greater sample sizes are supported by this work.
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Affiliation(s)
- Destiny Hooper
- Neurology and Rehabilitation, Univ of Cincinnati, Cincinnati, OH
| | - Timothy D Howard
- Biostatistics and Data Science, Wake Forest Univ, Winston-Salem, NC
| | | | - Tyler P BEHYMER
- Neurology and Rehabilitation, Univ of Cincinnati, Cincinnati, OH
| | - Mary E Comeau
- Biostatistics and Data Science and Cntr for Precision Medicine, Wake Forest Univ, Winston-Salem, NC
| | - Kip Zimmerman
- Biostatistics and Data Science and Cntr for Precision Medicine, Wake Forest Univ, Winston-Salem, NC
| | - Vivek Khandwala
- Neurology and Rehabilitation, Univ of Cincinnati, Cincinnati, OH
| | - Lee A Gilkerson
- Neurology and Rehabilitation, Univ of Cincinnati, Cincinnati, OH
| | | | | | | | - Fernando D Testai
- Neurology and Rehabilitation Medicine, Univ of Illinois, Chicago, IL
| | - Farhaan S Vahidy
- Cntrs for Outcomes Rsch, Houston Methodist Rsch Institute, Houston, TX
| | | | | | | | | | - Rhonna S Shatz
- Neurology and Rehabilitation, Univ of Cincinnati, Cincinnati, OH
| | - Pierce Boyne
- Neurology and Rehabilitation, Univ of Cincinnati, Cincinnati, OH
| | - Kari Dunning
- Neurology and Rehabilitation, Univ of Cincinnati, Cincinnati, OH
| | | | - Carl D. D Langefeld
- Biostatistics and Data Science and Cntr for Precision Medicine, Wake Forest Univ, Winston-Salem, NC
| | - Daniel Woo
- Neurology and Rehabilitation, Univ of Cincinnati, Cincinnati, OH
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Kittner SJ, Sekar P, Comeau ME, Anderson CD, Parikh GY, Tavarez T, Flaherty ML, Testai FD, Frankel MR, James ML, Sung G, Elkind MSV, Worrall BB, Kidwell CS, Gonzales NR, Koch S, Hall CE, Birnbaum L, Mayson D, Coull B, Malkoff MD, Sheth KN, McCauley JL, Osborne J, Morgan M, Gilkerson LA, Behymer TP, Demel SL, Moomaw CJ, Rosand J, Langefeld CD, Woo D. Ethnic and Racial Variation in Intracerebral Hemorrhage Risk Factors and Risk Factor Burden. JAMA Netw Open 2021; 4:e2121921. [PMID: 34424302 PMCID: PMC8383133 DOI: 10.1001/jamanetworkopen.2021.21921] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/15/2021] [Indexed: 12/19/2022] Open
Abstract
Importance Black and Hispanic individuals have an increased risk of intracerebral hemorrhage (ICH) compared with their White counterparts, but no large studies of ICH have been conducted in these disproportionately affected populations. Objective To examine the prevalence, odds, and population attributable risk (PAR) percentage for established and novel risk factors for ICH, stratified by ICH location and racial/ethnic group. Design, Setting, and Participants The Ethnic/Racial Variations of Intracerebral Hemorrhage Study was a case-control study of ICH among 3000 Black, Hispanic, and White individuals who experienced spontaneous ICH (1000 cases in each group). Recruitment was conducted between September 2009 and July 2016 at 19 US sites comprising 42 hospitals. Control participants were identified through random digit dialing and were matched to case participants by age (±5 years), sex, race/ethnicity, and geographic area. Data analyses were conducted from January 2019 to May 2020. Main Outcomes and Measures Case and control participants underwent a standardized interview, physical measurement for body mass index, and genotyping for the ɛ2 and ɛ4 alleles of APOE, the gene encoding apolipoprotein E. Prevalence, multivariable adjusted odds ratio (OR), and PAR percentage were calculated for each risk factor in the entire ICH population and stratified by racial/ethnic group and by lobar or nonlobar location. Results There were 1000 Black patients (median [interquartile range (IQR)] age, 57 [50-65] years, 425 [42.5%] women), 1000 Hispanic patients (median [IQR] age, 58 [49-69] years; 373 [37.3%] women), and 1000 White patients (median [IQR] age, 71 [59-80] years; 437 [43.7%] women). The mean (SD) age of patients with ICH was significantly lower among Black and Hispanic patients compared with White patients (eg, lobar ICH: Black, 62.2 [15.2] years; Hispanic, 62.5 [15.7] years; White, 71.0 [13.3] years). More than half of all ICH in Black and Hispanic patients was associated with treated or untreated hypertension (PAR for treated hypertension, Black patients: 53.6%; 95% CI, 46.4%-59.8%; Hispanic patients: 46.5%; 95% CI, 40.6%-51.8%; untreated hypertension, Black patients: 45.5%; 95% CI, 39.%-51.1%; Hispanic patients: 42.7%; 95% CI, 37.6%-47.3%). Lack of health insurance also had a disproportionate association with the PAR percentage for ICH in Black and Hispanic patients (Black patients: 21.7%; 95% CI, 17.5%-25.7%; Hispanic patients: 30.2%; 95% CI, 26.1%-34.1%; White patients: 5.8%; 95% CI, 3.3%-8.2%). A high sleep apnea risk score was associated with both lobar (OR, 1.68; 95% CI, 1.36-2.06) and nonlobar (OR, 1.62; 95% CI, 1.37-1.91) ICH, and high cholesterol was inversely associated only with nonlobar ICH (OR, 0.60; 95% CI, 0.52-0.70); both had no interactions with race and ethnicity. In contrast to the association between the ɛ2 and ɛ4 alleles of APOE and ICH in White individuals (eg, presence of APOE ɛ2 allele: OR, 1.84; 95% CI, 1.34-2.52), APOE alleles were not associated with lobar ICH among Black or Hispanic individuals. Conclusions and Relevance This study found sleep apnea as a novel risk factor for ICH. The results suggest a strong contribution from inadequately treated hypertension and lack of health insurance to the disproportionate burden and earlier onset of ICH in Black and Hispanic populations. These findings emphasize the importance of addressing modifiable risk factors and the social determinants of health to reduce health disparities.
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Affiliation(s)
- Steven J. Kittner
- Geriatric Research and Education Clinical Center, Department of Neurology, Baltimore Veterans Administration Medical Center, University of Maryland School of Medicine, Baltimore
| | - Padmini Sekar
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mary E. Comeau
- Department of Biostatistics and Data Science, Wake Forest University, Winston-Salem, North Carolina
| | - Christopher D. Anderson
- Henry and Allison McCance Center for Brain Health and Center for Genomic Medicine, Massachusetts General Hospital, Boston
| | - Gunjan Y. Parikh
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Tachira Tavarez
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
| | - Matthew L. Flaherty
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Fernando D. Testai
- Department of Neurology and Rehabilitation Medicine, University of Illinois College of Medicine, Chicago, Illinois
| | - Michael R. Frankel
- Department of Neurology, Emory University, Grady Memorial Hospital, Atlanta, Georgia
| | - Michael L. James
- Departments of Anesthesiology and Neurology, Duke University, Durham, North Carolina
| | - Gene Sung
- Neurocritical Care and Stroke Division, University of Southern California, Los Angeles
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Bradford B. Worrall
- Departments of Neurology and Public Health Sciences, University of Virginia, Charlottesville
| | | | - Nicole R. Gonzales
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Christiana E. Hall
- Department of Neurology and Neurotherapeutics, University of Texas–Southwestern, Dallas
| | - Lee Birnbaum
- Department of Neurology, University of Texas–San Antonio
| | - Douglas Mayson
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC
| | - Bruce Coull
- Department of Neurology, University of Arizona–Tucson
| | - Marc D. Malkoff
- Department of Neurology and Neurosurgery, University of Tennessee Health Sciences, Memphis
| | - Kevin N. Sheth
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Jacob L. McCauley
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida
| | - Jennifer Osborne
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Misty Morgan
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lee A. Gilkerson
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tyler P. Behymer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stacie L. Demel
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Charles J. Moomaw
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan Rosand
- Henry and Allison McCance Center for Brain Health and Center for Genomic Medicine, Massachusetts General Hospital, Boston
| | - Carl D. Langefeld
- Department of Biostatistics and Data Science, Wake Forest University, Winston-Salem, North Carolina
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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4
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Stanton R, Demel SL, Flaherty ML, Antzoulatos E, Gilkerson LA, Osborne J, Behymer TP, Moomaw CJ, Sekar P, Langefeld C, Woo D. Risk of intracerebral haemorrhage from hypertension is greatest at an early age. Eur Stroke J 2021; 6:28-35. [PMID: 33817332 DOI: 10.1177/2396987321994296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 01/17/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction The risk of intracerebral haemorrhage (ICH) associated with hypertension (HTN) is well documented. While the prevalence of HTN increases with age, the greatest odds ratio (OR) for HTN as a risk for ischemic stroke is at an early age. We sought to evaluate if the risk for ICH from HTN was higher in the youngest patients of each race. Patients and methods The Ethnic/Racial Variations of ICH (ERICH) study is a prospective multicenter case-control study of ICH among whites, blacks, and Hispanics. Participants were divided into age groups based on race-specific quartiles. Cases in each race/age group were compared to controls using logistic regression (i.e., cases and controls unmatched). The probability of ICH among cases and controls for each race were compared against independent variables of HTN, quartile of age and interaction of quartile and age also using logistic regression. Results Overall, 2033 non-lobar ICH cases and 2060 controls, and 913 lobar ICH cases with 927 controls were included. ORs were highest in the youngest age quartile for non-lobar haemorrhage for blacks and Hispanics and highest in the youngest quartile for lobar haemorrhage for all races. The formal test of interaction between age and HTN was significant in all races for all locations with the exception of lobar ICH in whites (p = 0.2935). Discussion Hypertension is a strong independent risk factor for ICH irrespective of location among persons of younger age, consistent with the hypothesis that first exposure to HTN is a particularly sensitive time for all locations of ICH.
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Affiliation(s)
- Robert Stanton
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Stacie L Demel
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Matthew L Flaherty
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Eleni Antzoulatos
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Lee A Gilkerson
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Jennifer Osborne
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Tyler P Behymer
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Charles J Moomaw
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Padmini Sekar
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Carl Langefeld
- Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC, USA
| | - Daniel Woo
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, OH, USA
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5
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Ades LM, Sekar P, Behymer TP, Haverbusch MA, Gilkerson LA, Murphy R, Kwon SY, Van Sanford CD, Antzoulatos E, Aziz YN, Ridha M, Flaherty ML, Woo D, Demel SL. Abstract P448: Axial versus Vertical Area of Intracerebral Hemorrhage and Outcome. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Intracerebral hemorrhage (ICH) has the highest morbidity and mortality rate of the major stroke subtypes. Volume is a well-established predictor of outcome. Theoretically, ICH should expand more in areas of less resistance. We hypothesize that 1) expansion perpendicular to neural tracts (axially) will be less great than expansion parallel to tracts (vertically) and 2) differing effect on outcome will occur based on axial and vertical areas of hemorrhage.
Methods:
The Genetic and Environmental Risk Factors of Hemorrhagic Stroke (GERFHS) study is a population-based case-control study. Each case of ICH within the 5 county region of Greater Cincinnati was evaluated for volume of hemorrhage with a subset completing 3 month telephone follow-up to obtain data including modified Rankin Scale (mRS). Baseline variables were assessed for poor outcome, defined as mRS greater than or equal to 3 at 90 days.
Results:
From July 2009 to December 2012, 1205 cases of ICH were identified, of which 304 had 3-month follow up. The table presents univariate association with outcome. More than 86% of hemorrhages had greater vertical area than axial area. On multivariable analysis controlling for ICH score variables, vertical area showed a trend toward worse outcome (OR 1.09, p= 0.06) vs axial area (OR 0.97, p=0.69) which was not found to have a significant effect on outcome independent of total volume.
Conclusion:
Most patients have greater vertical expansion of ICH than axial expansion. This pattern of hemorrhage growth is consistent with neural tracts having less resistance vertically. If the greater impact on outcome is confirmed, improved outcome and trial inclusion criteria may be determined.
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6
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Gilkerson LA, Behymer TP, Sekar P, Moomaw CJ, Kourkoulis C, Coleman ER, Sawyer R, Woo D, Flaherty ML, Biffi A, Rosand J. Abstract WP442: Cause of Death After Intracerebral Hemorrhage in the Longitudinal Follow-up of ICH Survivors in ERICH (ERICH-L) Study. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Anticoagulant therapy after intracerebral hemorrhage (ICH) in patients with atrial fibrillation or deep vein thrombosis has been associated with a marked reduction of death. Prevention of ischemic stroke could explain this reduction. We sought to describe the causes of death after discharge and beyond 30 days in a longitudinal follow-up of a multi-racial/ethnic cohort of ICH. We hypothesized that recurrent ICH and ischemic stroke are the most common cause of death after ICH.
Methods:
The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study was a prospective, multi-center, case-control study of ICH among whites, blacks, and Hispanics. Subjects previously in the ERICH study were approached for enrollment in the Longitudinal Follow-up of ICH Survivors (ERICH-L) study. A standardized research interview was completed over the phone and 959 contacts were made with participants and surrogates to capture outcomes of interest at 6-month intervals, including information on ICH recurrence, ischemic stroke, cognitive performance, and cause of death. The median follow-up was 4.3 years with an IQR of 3.2-5.4. The cause of death categories were ICH, cardiac, ischemic CVA, other, cancer, pulmonary, renal, endocrine, accidents, infection, dementia and unknown.
Results:
There were 180 deaths (18.8%) reported by surrogates contacted in the ERICH-L study. Of those, 63 causes of death were unknown or considered unverifiable. The most common cause of death reported was decline from the index ICH (32.7%). The next most common cause of death was cardiac (14%), other (12.1%), infection (11.2%), cancer (10.3%) and ischemic stroke (1.9%). Some examples reported as other are liver failure, old age, myelodysplastic syndrome, suicide and Parkinson’s Disease. Recurrent ICH occurred in 4 out of 107 known causes of death. By year 5, cardiac causes surpassed ICH as the cause of death.
Conclusion:
Cardiac causes of death were more common than either recurrent ICH or ischemic stroke, surpassed only by decline from the index ICH. Future efforts to prevent causes of death after ICH should address cardiac disease and risk factors. This finding may explain the effect of restarting anticoagulant or antiplatelet therapy and improved mortality.
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Affiliation(s)
| | | | | | | | | | | | | | - Daniel Woo
- Neurology, Univ of Cincinnati, Cincinnati, OH
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7
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Woo D, Comeau M, Venema SU, Anderson C, Flaherty ML, Testai FD, Kittner S, Frankel MR, James ML, Sung G, Elkind MS, Worrall BB, Kidwell CS, Gonzales NR, Koch S, Hall C, Birnbaum L, Mayson D, Coull BM, Malkoff M, Sheth KN, Chong JY, McCauley JL, Osborne J, Wethington M, Gilkerson LA, Behymer TP, Coleman ER, Sekar P, Moomaw CJ, Rosand J, Langefeld CD. Abstract 75: Predictors of Poor Outcome After Intracerebral Hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Intracerebral hemorrhage (ICH) is the most severe subtype of stroke with a high mortality rate and majority of survivors suffering significant disability. The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study prospectively recruited 1000 white, 1000 black and 1000 Hispanic spontaneous ICH cases. Herein, we report the main results of the predictors of 3 month outcome after ICH.
Hypothesis:
We hypothesized that ICH Score variables of age, ICH volume, ICH location, presence of intraventricular hemorrhage (IVH), and presenting Glasgow Coma Scale would predict long-term disability in addition to prior validation of mortality.
Methods:
Between 2010-2015, cases were prospectively recruited with uniform phenotype definitions, centralized neuroimaging review and with telephone follow-up at 3 months. Apolipoprotein E genotyping was performed centrally. Individual characteristics were screened for association under a logistic regression model, 90-day mRS ≥ 4 versus 0-3, and those meeting P<0.2 were entered into multivariate model building where the final model was determined by minimum AIC score. Analyses were repeated removing subjects with withdrawal of care.
Results:
The Table presents the prevalence/average of each variable entering the final multivariate model for association with poor (mRS 4-6) compared to good (mRS 0-3) outcome at 3 months. When analyses were repeated excluding withdrawal of care, overall Graeb (IVH) score fell out of the model (with presence of IVH replacing it) but the remaining variables were retained and in the same direction of effect. C-statistic for the multivariate model = 0.884 compared to 0.763 for ICH score alone (p=1.7E-22).
Conclusion:
ICH score elements were validated as predictive of 3 month outcome. Novel baseline characteristics such as white matter hyperintensity as well as subsequent clinical events that may affect outcomes were identified. Location specific results to be presented.
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Affiliation(s)
- Daniel Woo
- Dept of Neurology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Mary Comeau
- Dept of Biostatistics, Wake Forest Sch of Medicine, Winston-Salem, NC
| | - Simone U Venema
- Cntr for Genomic Medicine, Massachusetts General Hosp, Boston, MA
| | | | - Matthew L Flaherty
- Dept of Neurology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Fernando D Testai
- Dept of Neurology, Univ of Illinois College of Medicine, Chicago, IL
| | - Steven Kittner
- Dept of Neurology, Univ of Maryland Sch of Medicine, Baltimore, MD
| | | | - Micahel L James
- Dept of Anesthesiology, Duke Univ Sch of Medicine, Durham, NC
| | - Gene Sung
- Dept of Neurology, Univ of Southern California, Los Angeles, CA
| | | | | | | | - Nicole R Gonzales
- Dept of Neurology, Univ of Texas Health Science Cntr Houston, Houston, TX
| | - Sebastian Koch
- Dept of Neurology, Univ of Miami Miller Sch of Medicine, Miami, FL
| | - Christiana Hall
- Dept of Neurology, Univ of Texas Southwestern Med Cntr, Dallas, TX
| | - Lee Birnbaum
- Dept of Neurology, Univ of Texas Health Science Cntr San Antonio, San Antonio, TX
| | | | - Bruce M Coull
- Dept of Neurology, The Univ of Arizona Health Sciences, Tucson, AZ
| | - Marc Malkoff
- Dept of Neurology, The Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Kevin N Sheth
- Dept of Neurology, Yale Sch of Medicine, New Haven, CT
| | - Ji Y Chong
- Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Jacob L McCauley
- Dept of Human Genetics, Univ of Miami Miller Sch of Medicine, Miami, FL
| | - Jennifer Osborne
- Dept of Neurology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Misty Wethington
- Dept of Neurology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Lee A Gilkerson
- Dept of Neurology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Tyler P Behymer
- Dept of Neurology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Elisheva R Coleman
- Dept of Neurology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Padmini Sekar
- Dept of Neurology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Charles J Moomaw
- Dept of Neurology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Carl D Langefeld
- Dept of Biostatistics, Wake Forest Sch of Medicine, Winston-Salem, NC
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