Objective: To identify and compare clinical and neuroimaging predictors of primary lobar intracerebral hemorrhage (ICH) recurrence, assessing their relative contributions to recurrent ICH.Methods: Subjects were consecutive survivors of primary ICH drawn from a single-center prospective cohort study. Baseline clinical, imaging, and laboratory data were collected. Survivors were followed prospectively for recurrent ICH and intercurrent aspirin and warfarin use, including duration of exposure. Cox proportional hazards models were used to identify predictors of recurrence stratified by ICH location, with aspirin and warfarin exposures as time-dependent variables adjusting for potential confounders.Results: A total of 104 primary lobar ICH survivors were enrolled. Recurrence of lobar ICH was associated with previous ICH before index event (hazard ratio [HR] 7.7, 95% confidence interval [CI] 1.4 -15.7), number of lobar microbleeds (HR 2.93 with 2-4 microbleeds present, 95% CI 1.3-4.0; HR ϭ 4.12 when Ն5 microbleeds present, 95% CI 1.6 -9.3), and presence of CTdefined white matter hypodensity in the posterior region (HR 4.11, 95% CI 1.01-12.2). Although aspirin after ICH was not associated with lobar ICH recurrence in univariate analyses, in multivariate analyses adjusting for baseline clinical predictors, it independently increased the risk of ICH recurrence (HR 3.95, 95% CI 1.6 -8.3, p ϭ 0.021). Conclusions:Recurrence of lobar ICH is associated with previous microbleeds or macrobleeds and posterior CT white matter hypodensity, which may be markers of severity for underlying cerebral amyloid angiopathy. Use of an antiplatelet agent following lobar ICH may also increase recurrence risk. Neurology ® 2010;75:693-698 GLOSSARY CAA ϭ cerebral amyloid angiopathy; CI ϭ confidence interval; CT-WMH ϭ CT-defined white matter hypodensity; HR ϭ hazard ratio; ICH ϭ intracerebral hemorrhage; VIF ϭ variance inflation factor.Intracerebral hemorrhage (ICH), although accounting for only 15% of acute strokes in the United States, 1 carries the worst prognosis of all acute cerebrovascular diseases. 2,3 Lobar ICH location (selective involvement of the cerebral cortex and underlying white matter) is associated with greater risk for recurrence than deep ICH location [4][5][6] and is associated with different clinical features and risk factors. 7,8 Nonfamilial cerebral amyloid angiopathy (CAA), caused by ␤-amyloid deposition in cerebral arteries and arterioles, is a major cause of lobar ICH but not deep ICH, as shown by autopsy investigations, 9 as well as studies linking lobar ICH with several hallmarks of CAA, such as the APOE ⑀2 and ⑀4 alleles, 5,9,10 asymptomatic microbleeds detected on gradient-echo MRI, 11,12 and white matter lesions. 13 Based on recent evidence, there is some suggestion that asymptomatic CAA may be highly prevalent in the elderly. 14,15 Although several predictors of lobar ICH recurrence have been described, little is known regarding the relative contribution or interaction of each of these predictors. For examp...

Background: Neuropathologic studies suggest an association between cerebral amyloid angiopa-

Background White matter hyperintensity (WMH), or leukoaraiosis, is a radiological finding generally assumed to reflect diseased small cerebral vasculature. WMH has significant functional impact through its relationship to cognitive decline and risk of ischemic and hemorrhagic stroke. Accumulating evidence suggests that some manifestations of small vessel disease such as intracerebral hemorrhage (ICH) are associated with low levels of cholesterol. We sought to determine the relationship between hyperlipidemia (HL) and WMH severity in patients with acute ischemic stroke (AIS). Methods We analyzed two independent hospital-based AIS cohorts. Demographic and clinical data were collected prospectively. WMH was measured using semi-automated volumetric image analysis and a semi-quantitative visual grading scale. Univariate and multivariable regression analyses were used to assess the relationship between WMH severity and study variables. Results A total of 631 and 504 subjects in the first and second cohorts, respectively, were included. In univariate analyses, advancing age and hypertension were associated with severity of WMH (p<0.001) in both cohorts. In the multivariable analysis, after controlling for age, gender, and those significant risk factors in the univariate and age-adjusted analyses, patients with a history of HL had less severe WMH in both cohorts (p<0.01). Conclusions Results from two independent cohorts demonstrate that AIS patients with a history of HL have less severe WMH at the time of stroke. These data support the hypothesis that HL may play a relatively protective role on cerebral small vessel disease.

Anemia develops in the majority of patients with ICH at some point during their hospitalization. PRBC transfusion was associated with improved outcome in these patients.