Abstract 1122‐000024: Stereotactic IntraCerebral Underwater Blood Aspiration Improves Survival Following Intracerebral Hemorrhage as Compared to Predicted Mortality

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Steven D Shapiro ◽  
Miryam Alkayyali ◽  
Alexandra Reynolds ◽  
Kaitlin Reilly ◽  
Magdy Selim ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Absolute Risk ◽  
Absolute Risk Reduction ◽  
Hospital Length Of Stay ◽  
Neurological Injury ◽  
Hematoma Expansion ◽  
Spot Sign ◽  
Continuous Irrigation ◽  
Discharge Disposition ◽  
Ich Score

Introduction : Intracerebral hemorrhage (ICH) is a devastating form of neurological injury with substantial mortality. Recent publications on minimal invasive surgery (MIS) for hematoma evacuation have suggested survival benefits in select patients. Since 2015, our center has been performing an MIS technique using continuous irrigation with aspiration through an endoscope (SCUBA). SCUBA does not require a stability scan and can be performed despite hematoma expansion, intraventricular hemorrhage or radiographic spot sign. We present the 30‐day mortality of our initial experience and compare it to predicted mortality by presenting ICH score. Methods : We performed a retrospective review of consecutively admitted patients with spontaneous non‐traumatic supratentorial ICH who underwent SCUBA between 12/2015 – 03/2019. The primary outcome was observed 30‐day mortality compared to predicted mortality by ICH score on presentation. Key secondary outcomes were operative markers, hospital length of stay, and discharge disposition. Results : One hundred and fifteen patients were identified, with mean (SD) ICH volume of 51.4mL (33.9mL) and median ICH score of 2. The median evacuation was 97% of the hematoma volume and 85% of patients had a residual clot burden of less than 15mL. Twelve patients died within one month of SCUBA for an overall mortality rate of 10.4%. This was significantly lower than the predicted mortality by ICH score of 35.1%, with an absolute risk reduction of 24.7%. When analyzed by presenting ICH score, significant mortality benefits were observed for all ICH scores > 2, with more pronounced differences at higher ICH scores (Table 1). Conclusions : This study suggests that MIS with the SCUBA technique for ICH may reduce predicted 30‐day mortality, with a number need to treat of 4 to prevent one mortality. Further evaluation of this technique in a randomized clinical trial is required.

scholarly journals Calculation of Prognostic Scores, Using Delayed Imaging, Outperforms Baseline Assessments in Acute Intracerebral Hemorrhage

Stroke ◽  
2020 ◽  
Vol 51 (4) ◽  
pp. 1107-1110 ◽  
Author(s):  
Ronda Lun ◽  
Vignan Yogendrakumar ◽  
Andrew M. Demchuk ◽  
Richard I. Aviv ◽  
David Rodriguez-Luna ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Predictive Accuracy ◽  
Area Under The Curve ◽  
Prognostic Scores ◽  
Hematoma Expansion ◽  
Imaging Data ◽  
Spot Sign ◽  
Delayed Imaging ◽  
Predictive Values ◽  
Ich Score

Background and Purpose— Patients with intracerebral hemorrhage (ICH) are often subject to rapid deterioration due to hematoma expansion. Current prognostic scores are largely based on the assessment of baseline radiographic characteristics and do not account for subsequent changes. We propose that calculation of prognostic scores using delayed imaging will have better predictive values for long-term mortality compared with baseline assessments. Methods— We analyzed prospectively collected data from the multicenter PREDICT study (Prediction of Hematoma Growth and Outcome in Patients With Intracerebral Hemorrhage Using the CT-Angiography Spot Sign). We calculated the ICH Score, Functional Outcome in Patients With Primary Intracerebral Hemorrhage (FUNC) Score, and modified ICH Score using imaging data at initial presentation and at 24 hours. The primary outcome was mortality at 90 days. We generated receiver operating characteristic curves for all 3 scores, both at baseline and at 24 hours, and assessed predictive accuracy for 90-day mortality with their respective area under the curve. Competing curves were assessed with nonparametric methods. Results— The analysis included 280 patients, with a 90-day mortality rate of 25.4%. All 3 prognostic scores calculated using 24-hour imaging were more predictive of mortality as compared with baseline: the area under the curve was 0.82 at 24 hours (95% CI, 0.76–0.87) compared with 0.78 at baseline (95% CI, 0.72–0.84) for ICH Score, 0.84 at 24 hours (95% CI, 0.79–0.89) compared with 0.76 at baseline (95% CI, 0.70–0.83) for FUNC, and 0.82 at 24 hours (95% CI, 0.76–0.88) compared with 0.74 at baseline (95% CI, 0.67–0.81) for modified ICH Score. Conclusions— Calculation of the ICH Score, FUNC Score, and modified ICH Score using 24-hour imaging demonstrated better prognostic value in predicting 90-day mortality compared with those calculated at presentation.

Abstract WP355: Intracerebral Hemorrhage Care in a Stroke Unit is Safe and Associated With Lower Costs

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Corey R Fehnel ◽  
Linda C Wendell ◽  
N. Stevenson Potter ◽  
Kimberly Glerum ◽  
Richard N Jones ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Stroke Unit ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Hospital Charges ◽  
Total Hospital ◽  
Reduced Costs ◽  
Reducing Costs ◽  
Ich Score ◽  
Median Hospital

Background: There is little data to support level of care decisions for lower risk intracerebral hemorrhage (ICH) patients. The addition of a dedicated stroke unit (SU) at our institution allowed for a comparison of such patients cared for in the intensive care unit (ICU) or SU. We hypothesized that SU care of select ICH patients would not change functional outcome, and result in reduced costs. Methods: Two retrospective cohorts of consecutive patients with small (<20 cc) supratentorial ICH and the absence of anticoagulation were enrolled. In the first study period from August 1, 2008 to February 1, 2011, patients were admitted to the neurological or medical ICU (historical control). In the second study period from August 1, 2012 to January 30, 2014, patients were admitted to a dedicated SU. Intubated patients, those requiring vasopressors, osmotic therapy, or ventriculostomy were excluded. Primary outcomes were discharge modified Rankin Score (mRS) and total hospital charges. Multivariate analyses were used for predicting mRS and early complications. Results: There were 104 patients included in the analysis (41 ICU, 63 SU). Mean age, gender and race did not differ significantly between groups. Mean ICH volume was 6cc in the SU group and 8cc in the ICU group (P>.05). Prior antiplatelet use, ICH location, and ICH score did not differ between groups. Intraventricular hemorrhage and hydrocephalus were more common in the ICU group (P<.001). Two SU patients transferred to the ICU for pneumonia and acute myocardial infarction. There were no significant differences in complications such as ICH expansion, use of osmotic therapy, seizures, or pneumonia. There was no difference in discharge mRS between groups (P>.05). Median hospital length of stay was 6 days in the ICU group and 3 days in SU group (P<.001). Median direct costs for the ICU group were $5,859 (IQR 4,782-9,733) and were $4,078 (IQR 2,861-6,865) for the SU group (P<.001). Unit of admission was not a significant predictor of early complication (P=.73) or discharge mRS (P=.43) in multivariate analysis. Conclusions: This preliminary retrospective study provides support for select low-risk ICH patients to be safely cared for in a lower intensity setting with potential for reducing costs.

Abstract TP352: Safety and Efficacy of Andexanet Alfa in Patients With Life Threatening Intracerebral Hemorrhage: A Single Center Experience

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Syed Daniyal Asad ◽  
Stephanie R Lombardi ◽  
Ilene Staff ◽  
Amre M Nouh ◽  
Mark J Alberts
Keyword(s):  
Intracerebral Hemorrhage ◽  
Factor Xa ◽  
Hospital Length ◽  
Factor Xa Inhibitors ◽  
Hematoma Expansion ◽  
Amyloid Angiopathy ◽  
Single Center ◽  
Discharge Disposition ◽  
Ischemic Complications ◽  
Andexanet Alfa

Background: Intracerebral hemorrhage (ICH) is a devastating condition with high 30- day mortality. Up to a third of patients experience hematoma expansion within the first 24 hours; anticoagulation with factor Xa inhibitors may increase the risk of expansion and poor outcomes. Objective: We assessed our experience using Andexanet alfa (Aα) by evaluating stabilization of the hematoma and ischemic complications. Methods: We conducted a single center prospective observational study on all patients receiving Aα for reversal of anticoagulation in the setting of an ICH and use of Factor Xa inhibitors. The degree of hematoma expansion within 12 hours of drug administration on non-contrast head CT was categorized as 'excellent' (<20% increase in hematoma size), ‘good' ( > 20-<35%), and 'poor' ( > 35%). Secondary outcomes included dosage, median length of stay, mortality, modified Rankin score (mRS), discharge disposition, and ischemic complications. Results: Fifteen patients received Aα (5=lobar, 5=deep, 5= multicompartment). One patient with a presumed deep hemorrhage was excluded because subsequent imaging showed chronic mineralization. The predominant etiologies were hypertension (40%), amyloid angiopathy (26.6%) and trauma (13.3%). The median age was 86 years (IQR 19) and median ICH score on arrival was 2 (IQR 2), and median hematoma size was 14.3 mL (IQR 34.5). Most patients (71.4%) received the low dose formulation. Based on hematoma expansion, 64.3%, 14.3% and 21.4% of patients achieved excellent, good and poor hemostasis, respectively. Reduction in hematoma size was seen in 20% (n=3) while 13.3% (n=2) patients had no expansion. Median ICU and hospital length of stays were 2.0 days (IQR 2.2) and 6.6 days (IQR 9.78) respectively. Mortality was 28.6% and median mRS upon discharge was 4 (IQR 2), with most patients discharged to rehabilitation facilities (60%). There were no ischemic complications. Conclusion: Our experience is consistent with the results of the ANNEXA 4 study with 78.6% of patients showing excellent or good hemostasis. These results led to improved clinical outcomes, with 60% of patients being discharged to rehabilitation. These data support the efficacy of this treatment paradigm in a real-world setting.

scholarly journals Role of 'Spot Sign' on CT Angiography to Predict Hematoma Expansion in Spontaneous Intracerebral Hemorrhage

2010 ◽  
Vol 48 (5) ◽  
pp. 399 ◽  
Author(s):  
Soo Yong Park ◽  
Min Ho Kong ◽  
Jung Hee Kim ◽  
Dong Soo Kang ◽  
Kwan Young Song ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Ct Angiography ◽  
Hematoma Expansion ◽  
Spontaneous Intracerebral Hemorrhage ◽  
Spot Sign

scholarly journals Tranexamic Acid for Prevention of Hematoma Expansion in Intracerebral Hemorrhage Patients With or Without Spot Sign

Stroke ◽  
2021 ◽  
Author(s):  
Christian Ovesen ◽  
Janus Christian Jakobsen ◽  
Christian Gluud ◽  
Thorsten Steiner ◽  
Zhe Law ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Intracerebral Hemorrhage ◽  
Tranexamic Acid ◽  
Symptom Onset ◽  
Odds Ratio ◽  
Hematoma Expansion ◽  
Spot Sign ◽  
Main Trial ◽  
Acid Versus ◽  
Acute Intracerebral Hemorrhage

Background and Purpose: The computed tomography angiography or contrast-enhanced computed tomography based spot sign has been proposed as a biomarker for identifying on-going hematoma expansion in patients with acute intracerebral hemorrhage. We investigated, if spot-sign positive participants benefit more from tranexamic acid versus placebo as compared to spot-sign negative participants. Methods: TICH-2 trial (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) was a randomized, placebo-controlled clinical trial recruiting acutely hospitalized participants with intracerebral hemorrhage within 8 hours after symptom onset. Local investigators randomized participants to 2 grams of intravenous tranexamic acid or matching placebo (1:1). All participants underwent computed tomography scan on admission and on day 2 (24±12 hours) after randomization. In this sub group analysis, we included all participants from the main trial population with imaging allowing adjudication of spot sign status. Results: Of the 2325 TICH-2 participants, 254 (10.9%) had imaging allowing for spot-sign adjudication. Of these participants, 64 (25.2%) were spot-sign positive. Median (interquartile range) time from symptom onset to administration of the intervention was 225.0 (169.0 to 310.0) minutes. The adjusted percent difference in absolute day-2 hematoma volume between participants allocated to tranexamic versus placebo was 3.7% (95% CI, −12.8% to 23.4%) for spot-sign positive and 1.7% (95% CI, −8.4% to 12.8%) for spot-sign negative participants ( P heterogenity =0.85). No difference was observed in significant hematoma progression (dichotomous composite outcome) between participants allocated to tranexamic versus placebo among spot-sign positive (odds ratio, 0.85 [95% CI, 0.29 to 2.46]) and negative (odds ratio, 0.77 [95% CI, 0.41 to 1.45]) participants ( P heterogenity =0.88). Conclusions: Data from the TICH-2 trial do not support that admission spot sign status modifies the treatment effect of tranexamic acid versus placebo in patients with acute intracerebral hemorrhage. The results might have been affected by low statistical power as well as treatment delay. REGISTRATION: URL: http://www.controlled-trials.com ; Unique identifier: ISRCTN93732214.

Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness

Stroke ◽  
2021 ◽  
Author(s):  
Ayham Alkhachroum ◽  
Antonio J. Bustillo ◽  
Negar Asdaghi ◽  
Erika Marulanda-Londono ◽  
Carolina M. Gutierrez ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Hospital Mortality ◽  
Odds Ratio ◽  
Mediation Effect ◽  
Hospital Length Of Stay ◽  
Do Not Resuscitate ◽  
Hospital Size ◽  
Stroke Registry ◽  
Discharge Disposition ◽  
Life Sustaining Treatment

Background and Purpose: Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). Methods: Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. Results: Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1–4.3], P <0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3–0.4], P <0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152–229], P <0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate. Conclusions: In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.

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