MRI predicts intracranial hemorrhage in patients who receive long-term oral anticoagulation

ObjectiveWe tested the hypothesis that the risk of intracranial hemorrhage (ICH) in patients with cardioembolic ischemic stroke who are treated with oral anticoagulants (OAs) can be predicted by evaluating surrogate markers of hemorrhagic-prone cerebral angiopathies using a baseline MRI.MethodsPatients were participants in a multicenter and prospective observational study. They were older than 64 years, had a recent cardioembolic ischemic stroke, and were new users of OAs. They underwent a baseline MRI analysis to evaluate microbleeds, white matter hyperintensities, and cortical superficial siderosis. We collected demographic variables, clinical characteristics, risk scores, and therapeutic data. The primary endpoint was ICH that occurred during follow-up. We performed bivariate and multivariate Cox regression analyses.ResultsWe recruited 937 patients (aged 77.6 ± 6.5 years; 47.9% were men). Microbleeds were detected in 207 patients (22.5%), moderate/severe white matter hyperintensities in 419 (45.1%), and superficial siderosis in 28 patients (3%). After a mean follow-up of 23.1 ± 6.8 months, 18 patients (1.9%) experienced an ICH. In multivariable analysis, microbleeds (hazard ratio 2.7, 95% confidence interval [CI] 1.1–7, p = 0.034) and moderate/severe white matter hyperintensities (hazard ratio 5.7, 95% CI 1.6–20, p = 0.006) were associated with ICH (C index 0.76, 95% CI 0.66–0.85). Rate of ICH was highest in patients with both microbleed and moderate/severe WMH (3.76 per 100 patient-years, 95% CI 1.62–7.4).ConclusionPatients taking OAs who have advanced cerebral small vessel disease, evidenced by microbleeds and moderate to severe white matter hyperintensities, had an increased risk of ICH. Our results should help to determine the risk of prescribing OA for a patient with cardioembolic stroke.ClinicalTrials.gov identifierNCT02238470.

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White Matter Hyperintensities as a Risk Factor for Ischemic Stroke in Patients With Systemic Lupus Erythematosus

Frontiers in Neurology ◽

10.3389/fneur.2021.738173 ◽

2021 ◽

Vol 12 ◽

Author(s):

Eri Sano ◽

Shigeki Arawaka

Keyword(s):

Systemic Lupus Erythematosus ◽

Risk Factor ◽

Ischemic Stroke ◽

White Matter ◽

Lupus Erythematosus ◽

White Matter Hyperintensities ◽

Brain Mri ◽

Systemic Lupus ◽

Increased Risk

Objective: The occurrence of ischemic stroke in patients with systemic lupus erythematosus (SLE) can cause extended periods of reduced daily activities. However, the risk factors for ischemic stroke in SLE patients are not fully elucidated. Herein, we examined the effect of white matter hyperintensities (WMH) on the occurrence of ischemic stroke in SLE patients.Methods: We analyzed the relationship between WMH burden and ischemic stroke using follow-up brain magnetic resonance imaging (MRI) data of 79 patients with SLE. Of these patients, 16 developed stroke during the observation period. WMH on MRI were classified into periventricular hyperintensities and deep white matter hyperintensities (DWMH), while the lesion extent was graded using the Fazekas scale.Results: Kaplan–Meier curves showed that ischemic stroke events were significantly associated with age at initial brain MRI of ≥40 years (p = 0.015) and history of anti-phospholipid syndrome (p = 0.030). Additionally, ischemic stroke events were significantly associated with a one grade deterioration of periventricular hyperintensities (p = 0.003) and a one grade deterioration of DWMH (p = 0.002). Multivariate analysis using the logistic regression model showed that a one grade deterioration of DWMH was an independent risk factor for ischemic stroke (hazard ratio, 6.0; 95% confidence interval, 1.3–27.4).Conclusions: Although several factors affect the occurrence of ischemic stroke, SLE patients show increased risk of ischemic stroke via development of DWMH. An observation of DWMH deterioration on follow-up brain MRI may be useful for assessing the risk of ischemic stroke in SLE patients.

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Abstract TP135: White Matter Hyperintensities in Relation to Severity of Intracranial Atherosclerotic Stenosis

Stroke ◽

10.1161/str.44.suppl_1.atp135 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Jong-Ho Park ◽

Dong-Sun Kim ◽

Hyun Jeong Han

Keyword(s):

Ischemic Stroke ◽

White Matter ◽

White Matter Hyperintensities ◽

Small Vessel Disease ◽

Brain Mri ◽

Multivariable Analysis ◽

Cerebral Hypoperfusion ◽

Intracranial Atherosclerotic Stenosis ◽

Atherosclerotic Stenosis ◽

Increased Risk

Background & Objectives: White matter hyperintensities (WMH) is regarded as a small-vessel disease because the accompanying silent infarcts are predominantly lacunes and share the same pathological basis with WMH. Endothelial dysfunction is known to play a cardinal role in progression of WMH. Accordingly, atherosclerotic burden might be associated with the development of WMH. Because metabolic syndrome (MetS) is associated with an increased risk of WMH and with intracranial atherosclerotic stenosis (ICAS), we assessed the hypothesis that WMH might be related to ICAS in ischemic stroke patients. We compared a severity of WMH among the ICAS, extracranial (ECAS), and no cerebral atherosclerotic stenosis (NCAS) groups. Methods: We conducted a cross-sectional study in 605 Korean patients with acute ischemic stroke (mean age 67.7±12.8; 347 males), who underwent brain MRI/MRA. The severity of deep WMH (d-WMH, n=495) and periventricular WMH (pv-WMH, n=521) was rated separately. Irrespective of index stroke mechanisms, patients were classified into three groups: ICAS (n=294), extracranial (ECAS, n=63), and no cerebral atherosclerotic stenosis (NCAS, n=248). Stenosis groups and demographics, including the presence of MetS, were compared between patients with d-/pv-WMH and without. Results: The ICAS group showed a higher d-WMH / pv-WMH grade (1.61±0.85 / 1.64±0.80) than both the ECAS (1.29±0.87 / 1.21±0.77) and NCAS (1.15±0.92 / 1.21±0.82) groups ( P <0.001 for all). Patients with more severe ICAS were more likely to have higher grades of d-WMH and pv-WMH ( P <0.001 for all). Patients with higher grades of d-WMH and pv-WMH had a higher incidence of ICAS ( P <0.001 for all) but not of ECAS or NCAS. Patients with a greater number of MetS components were more likely to have higher grades of d-WMH and pv-PWMH ( P <0.001 for all). With a multivariable analysis, a dose-response relationship was observed between the presence of ICAS and the WMH: (1) for d-WMH, OR=3.25 (95% CI, 1.18-8.96) for 2 ICAS, OR=6.39 (1.84-22.14) for ≥3 ICAS, (2) for pv-WMH, OR=2.22 (95% CI, 1.25-3.95) for 2 ICAS, OR=3.40 (1.89-6.09) for ≥3 ICAS versus 1 ICAS. Conclusions: ICAS, rather than ECAS or NCAS is a predictor of d-/pv-WMH. ICAS burden might be the substrate for chronic cerebral hypoperfusion.

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Characteristics of ischemic stroke and intracranial hemorrhage in patients with nephrotic syndrome

BMC Nephrology ◽

10.1186/s12882-021-02415-w ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Wen-Yi Huang ◽

Chun-Wei Chang ◽

Chiung-Mei Chen ◽

Kuan-Hsing Chen ◽

Chien-Hung Chang ◽

...

Keyword(s):

Nephrotic Syndrome ◽

Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Cox Regression ◽

Hazard Ratio ◽

Chang Gung Memorial Hospital ◽

Cerebral Stroke ◽

Research Database ◽

Anterior Circulation ◽

Cox Regression Analysis

Abstract Background The incidence of cerebral stroke, including ischemic infarction and intracranial hemorrhage (ICH), increases in patients with nephrotic syndrome (NS). However, the clinical characteristics of patients with NS and stroke remain elusive. We aimed to investigate the clinical presentation and prognosis among patients with NS and ischemic stroke (IS) or ICH. Methods We conducted a population-based retrospective cohort study of patients with NS and acute stroke using the Chang Gung Research Database of Taiwan from January 1, 2001, to December 31, 2017. The participants were recruited from the 7 branches of Chang Gung Memorial Hospital. Results A total of 233 patients with IS and 57 patients with ICH were enrolled. The median age was 60 (52–70) years. The prevalence rates of hyperlipidemia, hyperuricemia, and smoking were higher in IS than in ICH. IS demonstrated lower white blood cell count (7.80 vs. 8.92 × 109/L) and high-sensitivity C-reactive protein level (33.42 vs. 144.10 nmol/L) and higher cholesterol (5.74 vs. 4.84 mmol/L), triglyceride (1.60 vs. 1.28 mmol/L), and albumin (24 vs. 18 g/L) levels compared with ICH. The dependent functional status and 30-day mortality were higher in ICH than in IS. The risk factors for 30-day mortality for patients with NS and stroke were coronary artery disease (CAD), ICH, and total anterior circulation syndrome. The multivariate Cox regression analysis revealed that CAD was positively associated with 30-day mortality in patients with IS (hazard ratio 24.58, 95 % CI 1.48 to 408.90). In patients with ICH, CAD and subarachnoid hemorrhage were positively associated with 30-day mortality (hazard ratio 5.49, 95 % CI 1.54 to 19.56; hazard ratio 6.32, 95 % CI 1.57 to 25.53, respectively). Conclusions ICH demonstrated a higher risk of dependence and 30-day mortality compared with IS in patients with NS. Intensive monitoring and treatment should be applied particularly in patients with NS and ICH.

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Abstract TMP83: Long-term Risk of Venous Thromboembolism After Stroke

Stroke ◽

10.1161/str.48.suppl_1.tmp83 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Santosh B Murthy ◽

Alexander E Merkler ◽

Gino Gialdini ◽

Abhinaba Chatterjee ◽

Costantino Iadecola ◽

...

Keyword(s):

Ischemic Stroke ◽

Venous Thromboembolism ◽

Proportional Hazards ◽

Cox Regression ◽

Multivariable Analysis ◽

First Year ◽

Cumulative Rate ◽

Incident Cases

Background: There are few data on the long-term risk of venous thromboembolism (VTE) among stroke survivors. We aimed to compare the incidence of VTE amongst patients with ischemic stroke versus those with intracerebral hemorrhage (ICH). Methods: We identified all adults discharged from nonfederal acute care hospitals in CA, NY, and FL between 2005 and 2012 with previously validated ICD-9-CM codes for ischemic stroke and ICH. Our primary outcome of VTE was defined as pulmonary embolism or deep vein thrombosis. To capture incident cases of VTE, we excluded patients with a VTE prior to or during the index stroke. Kaplan-Meier survival statistics were used to calculate the cumulative rate of incident VTE. Cox regression was used to compare the risk of VTE after stroke while adjusting for demographics, vascular risk factors, and Elixhauser comorbidity index. As there was a violation of the proportional-hazards assumption, we calculated separate hazard ratios (HR) for each year of follow-up. Results: We identified 834,660 patients with stroke, of whom 712,440 (85.3%) had ischemic stroke and 112,220 (14.7%) had ICH. Over a mean follow-up of 2.8 (+/-2.4) years, 19,937 (2.4%) developed VTE. After 7 years, the cumulative rate of VTE was 4.7% (95% confidence interval [CI], 4.5-4.9%) in patients with ICH and 4.4% (95% CI, 4.3-4.5%) in patients with ischemic stroke. In multivariable analysis, VTE risk was higher in the first year after ICH compared to ischemic stroke (HR 1.51; 95% CI, 1.43-1.58). However, following the first year, the hazard of VTE was higher among patients with ischemic stroke versus those with ICH (Figure). Conclusions: The risk of VTE after stroke varies by stroke type and time. Patients with ICH have a higher risk of VTE in the first year after stroke as compared to those with ischemic stroke while patients with ischemic stroke have a higher risk beyond 1 year.

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Brain Arteriovenous Malformation Recurrence After Apparent Microsurgical Cure

Stroke ◽

10.1161/strokeaha.120.030135 ◽

2020 ◽

Vol 51 (10) ◽

pp. 2990-2996

Author(s):

Alexander Copelan ◽

Gerald Drocton ◽

M. Travis Caton ◽

Eric R. Smith ◽

Daniel L. Cooke ◽

...

Keyword(s):

Arteriovenous Malformation ◽

Recurrence Rate ◽

Surgical Resection ◽

Intracranial Hemorrhage ◽

Cox Regression ◽

Initial Presentation ◽

High Rate ◽

Brain Arteriovenous Malformation ◽

Increased Risk

Background and Purpose: Do children have an increased risk for brain arteriovenous malformation (AVM) recurrence compared with adults and does this risk vary depending on initial presentation with AVM rupture? Methods: We retrospectively studied 115 patients initially presenting with brain AVM under age 25 years who underwent complete surgical resection of the AVM as documented by digital subtraction angiography (DSA) and had delayed follow-up DSA to evaluate for AVM recurrence after apparent initial cure. Results: The mean time from baseline DSA to follow-up DSA was 2.3 years, ranging from 0 to 15 years. Twelve patients (10.4% of the 115 patient cohort and 16.7% of 72 patients with hemorrhage at initial presentation) demonstrated AVM recurrence on follow-up DSA. All patients with recurrence initially presented with intracranial hemorrhage, and intracranial hemorrhage was a significant predictor of recurrence (log rank P =0.037). Among patients with initial hemorrhage, the 5-year recurrence rate was 17.8% (95% CI, 8.3%–35.7%). All recurrences occurred in patients who were children at the time of their initial presentation; the oldest was 15 years of age at the time of initial AVM surgery. The 5-year recurrence rate for children (0–18 years of age) with an initial presentation of hemorrhage was 21.4% (95% CI, 10.1%–41.9%). Using Cox regression, we found the risk of AVM recurrence decreased by 14% per each year increase in age at the time of initial surgical resection (hazard ratio=0.86 [95% CI, 0.75–0.99]; P =0.031). Conclusions: There is a high rate of recurrence of apparently cured brain AVMs in children who initially present with AVM rupture. Imaging follow-up is warranted to prevent re-rupture.

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Convexity subarachnoid hemorrhage in lobar intracerebral hemorrhage

Neurology ◽

10.1212/wnl.0000000000009036 ◽

2020 ◽

Vol 94 (9) ◽

pp. e968-e977 ◽

Cited By ~ 1

Author(s):

Nicolas Raposo ◽

Andreas Charidimou ◽

Duangnapa Roongpiboonsopit ◽

Michelle Onyekaba ◽

M. Edip Gurol ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracerebral Hemorrhage ◽

Regression Models ◽

Cox Regression ◽

Bleeding Risk ◽

Superficial Siderosis ◽

Amyloid Angiopathy ◽

Increased Risk ◽

Cortical Superficial Siderosis

ObjectiveTo investigate whether acute convexity subarachnoid hemorrhage (cSAH) associated with acute lobar intracerebral hemorrhage (ICH) increases the risk of ICH recurrence in patients with cerebral amyloid angiopathy (CAA).MethodsWe analyzed data from a prospective cohort of consecutive survivors of acute spontaneous lobar ICH fulfilling the Boston criteria for possible or probable CAA (CAA-ICH). We analyzed baseline clinical and MRI data, including cSAH (categorized as adjacent or remote from ICH on a standardized scale), cortical superficial siderosis (cSS), and other CAA MRI markers. Multivariable Cox regression models were used to assess the association between cSAH and recurrent symptomatic ICH during follow-up.ResultsWe included 261 CAA-ICH survivors (mean age 76.2 ± 8.7 years). Of them, 166 (63.6%, 95% confidence interval [CI] 57.7%–69.5%) had cSAH on baseline MRI. During a median follow-up of 28.3 (interquartile range 7.2–57.0) months, 54 (20.7%) patients experienced a recurrent lobar ICH. In Cox regression, any cSAH, adjacent cSAH, and remote cSAH were independent predictors of recurrent ICH after adjustment for other confounders, including cSS. Incidence rate of recurrent ICH in patients with cSAH was 9.9 per 100 person-years (95% CI 7.3–13.0) compared with 1.2 per 100 person-years (95% CI 0.3–3.2) in those without cSAH (adjusted hazard ratio 7.5, 95% CI 2.6–21.1).ConclusionIn patients with CAA-related acute ICH, cSAH (adjacent or remote from lobar ICH) is commonly observed and heralds an increased risk of recurrent ICH. cSAH may help stratify bleeding risk and should be assessed along with cSS for prognosis and clinical management.

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Acquired infection during neonatal and pediatric extracorporeal membrane oxygenation

Perfusion ◽

10.1177/0267659118766436 ◽

2018 ◽

Vol 33 (6) ◽

pp. 472-482 ◽

Cited By ~ 10

Author(s):

Katherine Cashen ◽

Ron Reeder ◽

Heidi J. Dalton ◽

Robert A. Berg ◽

Thomas P. Shanley ◽

...

Keyword(s):

Viral Infections ◽

Cox Regression ◽

Multivariable Analysis ◽

Secondary Analysis ◽

Hazard Ratio ◽

Research Network ◽

Factors Associated ◽

Increased Risk ◽

Neonatal Icu ◽

Pediatric Icu

Introduction: Our objectives are to (1) describe the pathogens, site, timing and risk factors for acquired infection during neonatal and pediatric ECMO and (2) explore the association between acquired infection and mortality. Methods: Secondary analysis of prospective data collected by the Collaborative Pediatric Critical Care Research Network between December 2012 and September 2014. Clinical factors associated with acquired infection were assessed with multivariable Cox regression. Factors associated with mortality were assessed with logistic regression. Results: Of 481 patients, 247 (51.3%) were neonates and 400 (83.2%) received venoarterial ECMO. Eighty (16.6%) patients acquired one or more infections during ECMO; 60 (12.5%) patients had bacterial, 21 (4.4%) had fungal and 11 (2.3%) had viral infections. The site of infection included respiratory for 53 (11.0%) patients, bloodstream for 21 (4.4%), urine for 20 (4.2%) and other for 7 (1.5%). Candida species were most common. Median time to infection was 5.2 days (IQR 2.3, 9.6). On multivariable analysis, a greater number of procedures for ECMO cannula placement was independently associated with increased risk of acquired infection during ECMO (Hazard Ratio 2.13 (95% CI 1.22, 3.72), p<0.01) and receiving ECMO in a neonatal ICU compared to a pediatric or cardiac ICU was associated with decreased risk (Hazard Ratio pediatric ICU 4.25 (95% CI 2.20, 8.20), cardiac ICU 2.91 (95% CI 1.48, 5.71), neonatal ICU as reference, p<0.001). Acquired infection was not independently associated with mortality. Conclusion: ECMO procedures and location may contribute to acquired infection risk; however, acquired infection did not predict mortality in this study.

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Association of White Matter Hyperintensity Markers on MRI and Long-term Risk of Mortality and Ischemic Stroke

Neurology ◽

10.1212/wnl.0000000000011827 ◽

2021 ◽

Vol 96 (17) ◽

pp. e2172-e2183 ◽

Cited By ~ 1

Author(s):

Rashid Ghaznawi ◽

Mirjam I. Geerlings ◽

Myriam Jaarsma-Coes ◽

Jeroen Hendrikse ◽

Jeroen de Bresser ◽

...

Keyword(s):

Ischemic Stroke ◽

White Matter ◽

Cox Regression ◽

Brain Mri ◽

Arterial Disease ◽

White Matter Hyperintensity ◽

Risk Of Mortality ◽

Mri Scans

ObjectiveTo determine whether white matter hyperintensity (WMH) markers on MRI are associated with long-term risk of mortality and ischemic stroke.MethodsWe included consecutive patients with manifest arterial disease enrolled in the Second Manifestations of Arterial Disease–Magnetic Resonance (SMART-MR) study. We obtained WMH markers (volume, type, and shape) from brain MRI scans performed at baseline using an automated algorithm. During follow-up, occurrence of death and ischemic stroke was recorded. Using Cox regression, we investigated associations of WMH markers with risk of mortality and ischemic stroke, adjusting for demographics, cardiovascular risk factors, and cerebrovascular disease.ResultsWe included 999 patients (59 ± 10 years; 79% male) with a median follow-up of 12.5 years (range 0.2–16.0 years). A greater periventricular or confluent WMH volume was independently associated with a greater risk of vascular death (hazard ratio [HR] 1.29, 95% confidence interval [CI] 1.13–1.47) for a 1-unit increase in natural log-transformed WMH volume and ischemic stroke (HR 1.53, 95% CI 1.26–1.86). A confluent WMH type was independently associated with a greater risk of vascular (HR 1.89, 95% CI 1.15-3.11) and nonvascular death (HR 1.65, 95% CI 1.01–2.73) and ischemic stroke (HR 2.83, 95% CI 1.36-5.87). A more irregular shape of periventricular or confluent WMH, as expressed by an increase in concavity index, was independently associated with a greater risk of vascular (HR 1.20, 95% CI 1.05–1.38 per SD increase) and nonvascular death (HR 1.21, 95% CI 1.03–1.42) and ischemic stroke (HR 1.28, 95% CI 1.05–1.55).ConclusionsWMH volume, type, and shape are associated with long-term risk of mortality and ischemic stroke in patients with manifest arterial disease.

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Impact of Plasma Potassium Normalization on Short‐Term Mortality in Patients With Hypertension and Hyperkalemia

Journal of the American Heart Association ◽

10.1161/jaha.120.017087 ◽

2020 ◽

Vol 9 (24) ◽

Author(s):

Maria Lukács Krogager ◽

Peter Søgaard ◽

Christian Torp‐Pedersen ◽

Henrik Bøggild ◽

Gunnar Gislason ◽

...

Keyword(s):

Cardiovascular Mortality ◽

Cox Regression ◽

Reference Group ◽

Multivariable Analysis ◽

Plasma Potassium ◽

Cardiovascular Death ◽

Risk Of Death ◽

Increased Risk ◽

Short Term Mortality

Background Hyperkalemia can be harmful, but the effect of correcting hyperkalemia is sparsely studied. We used nationwide data to examine hyperkalemia follow‐up in patients with hypertension. Methods and Results We identified 7620 patients with hypertension, who had the first plasma potassium measurement ≥4.7 mmol/L (hyperkalemia) within 100 days of combination antihypertensive therapy initiation. A second potassium was measured 6 to 100 days after the episode of hyperkalemia. All‐cause mortality within 90 days of the second potassium measurement was assessed using Cox regression. Mortality was examined for 8 predefined potassium intervals derived from the second measurement: 2.2 to 2.9 mmol/L (n=37), 3.0 to 3.4 mmol/L (n=184), 3.5 to 3.7 mmol/L (n=325), 3.8 to 4.0 mmol/L (n=791), 4.1 to 4.6 mmol/L (n=3533, reference), 4.7 to 5.0 mmol/L (n=1786), 5.1 to 5.5 mmol/L (n=720), and 5.6 to 7.8 mmol/L (n=244). Ninety‐day mortality in the 8 strata was 37.8%, 21.2%, 14.5%, 9.6%, 6.3%, 6.2%, 10.0%, and 16.4%, respectively. The multivariable analysis showed that patients with concentrations >5.5 mmol/L after an episode of hyperkalemia had increased mortality risk compared with the reference (hazard ratio [HR], 2.27; 95% CI, 1.60–3.20; P <0.001). Potassium intervals 3.5 to 3.7 mmol/L and 3.8 to 4.0 mmol/L were also associated with increased risk of death (HR, 1.71; 95% CI, 1.23–2.37; P <0.001; HR, 1.36; 95% CI, 1.04–1.76; P <0.001, respectively) compared with the reference group. We observed a trend toward increased risk of death within the interval 5.1 to 5.5 mmol/L (HR, 1.29; 95% CI, 0.98–1.69). Potassium concentrations <4.1 mmol/L and >5.0 mmol/L were associated with increased risk of cardiovascular death. Conclusions Overcorrection of hyperkalemia to levels <4.1 mmol/L was frequent and associated with increased all‐cause and cardiovascular mortality. Potassium concentrations >5.5 mmol/L were also associated with an increased all‐cause and cardiovascular mortality.

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Long Term Vascular Outcomes in Patients with Mixed Location Intracerebral Hemorrhage and Microbleeds

Neurology ◽

10.1212/wnl.0000000000011378 ◽

2020 ◽

pp. 10.1212/WNL.0000000000011378

Author(s):

Hsin-Hsi Tsai ◽

Szu-Ju Chen ◽

Li-Kai Tsai ◽

Marco Pasi ◽

Yen-Ling Lo ◽

...

Keyword(s):

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Cox Regression ◽

Vascular Event ◽

Superficial Siderosis ◽

Amyloid Angiopathy ◽

Composite Outcome ◽

Vascular Outcome ◽

Hypertensive Intracerebral Hemorrhage

ObjectiveTo determine whether mixed location intracerebral hemorrhages/microbleeds (Mixed-ICH) is a risk factor for vascular unfavorable outcome compared to cerebral amyloid angiopathy-related ICH (CAA-ICH) or strictly deep hypertensive intracerebral hemorrhage/microbleeds (HTN-ICH).Methods300 patients with spontaneous ICH were included. Clinical data, neuroimaging markers and follow-up outcomes (recurrent ICH, ischemic stroke and vascular death) were compared between Mixed-ICH (n=148), CAA-ICH (n=32) and HTN-ICH (n=120). The association between follow-up events and neuroimaging markers were explored using multivariable Cox regression models.ResultsPatients with Mixed-ICH are older (65.6±12.1 years vs 58.1±13.3 years, p<0.001) than HTN-ICH, but younger than CAA-ICH (73.3±13.8 years, p=0.001). Compared to CAA-ICH, Mixed-ICH has similar incidence of vascular event (all p>0.05). Compared to HTN-ICH, Mixed-ICH is associated with higher ICH recurrence (hazard ratio [HR]=3.0, 95% confidence interval [CI]: 1.2-7.7), more ischemic stroke (HR=8.2, 95% CI: 1.0-65.8), and vascular composite outcome (HR=3.5, 95% CI: 1.5-8.2) after adjustment for age and sex. In patients with Mixed-ICH, the presence of cortical superficial siderosis (cSS) is associated the development of ICH recurrence (HR=4.8, 95% CI 1.0-23.2), ischemic stroke (HR=8.8, 95% CI: 1.7-45.5), and vascular composite outcome (HR=6.2, 95% CI: 1.9-20.2). The association between cSS and ischemic stroke (p=0.01) or vascular composite outcome (p=0.003) remained significant after further adjustment for other radiological markers.ConclusionsMixed-ICH harbors higher risk of unfavorable vascular outcome than HTN-ICH. Presence of cSS in Mixed-ICH independently predicts vascular event, suggesting the contribution of detrimental effect due to coexisting CAA.

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