Intensive Blood Pressure Lowering and DWI Lesions in Intracerebral Hemorrhage: Exploratory Analysis of the ATACH-2 Randomized Trial

Shoamanesh, Ashkan; Cassarly, Christy; Morotti, Andrea; Romero, Javier; Oliveira‐Filho, Jamary; Schlunk, Frieder; Jessel, Michael J.; Butcher, Ken; Gioia, Laura; Ayres, Alison; Vashkevich, Anastasia; Schwab, Kristin; Afzal, Mohammad Rauf; Martin, Renée; Qureshi, Adnan I; Greenberg, Steven M.; Rosand, Jonathan; Goldstein, Joshua N.; Atach,; investigators, Nett

doi:10.1007/s12028-021-01254-9

Cited by 9 publications

(9 citation statements)

References 25 publications

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“…Besides the primary brain injury, the parenchymal hematoma triggers a series of adverse events causing secondary injury, which plays an essential role in neurological impairment. 25 , 26 , 27 According to the body of literature to date, the presence of DWILs may indicate advanced cerebral small vessel disease burden, which suggests severe endothelial failure, 28 , 29 reduced connectivity of the brain, 30 and susceptibility to the cytokines and prothrombotic milieu generated by a hematoma, 31 , 32 , 33 all of which may affect post‐ICH recovery.…”

Section: Discussionmentioning

confidence: 99%

ANAID‐ICH nomogram for predicting unfavorable outcome after intracerebral hemorrhage

Luo

Peng

et al. 2022

CNS Neurosci Ther

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Objective Diffusion‐weighted imaging lesions (DWILs) are associated with unfavorable outcome in intracerebral hemorrhage (ICH). We proposed a novel predictive nomogram incorporating DWILs. Methods A total of 738 patients with primary ICH in a tertiary hospital were prospectively enrolled as a training cohort. DWILs were defined as remote focal hyperintensities on DWI corresponding to low intensities on apparent diffusion coefficient images and remote from the focal hematoma. The outcome of interest was modified Rankin Scale scores of 4–6 at 90 days after onset. Multivariate logistic regression was used to construct a nomogram. Model performance was tested in the training cohort and externally validated with respect to discrimination, calibration, and clinical usefulness in another institute. Additionally, the nomogram was compared with the ICH score in terms of predictive ability. Results Overall, 153 (20.73%) and 23 (15.54%) patients developed an unfavorable outcome in the training and validation cohorts, respectively. The multivariate analysis revealed that age, National Institutes of Health Stroke Scale (NIHSS) score, anemia, infratentorial location, presence of DWILs, and prior ICH were associated with unfavorable outcome. Our ANAID‐ICH nomogram was constructed according to the aforementioned variables; the area under the receiver operating characteristic curve was 0.842 and 0.831 in the training and validation sets, respectively. With regard to the 90‐day outcome, the nomogram showed a significantly higher predictive value than the ICH score in both cohorts. Conclusions The ANAID‐ICH nomogram comprising age, NIHSS score, anemia, infratentorial location, presence of DWILs, and prior ICH may facilitate the identification of patients at higher risk for an unfavorable outcome.

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Section: Discussionmentioning

confidence: 99%

ANAID‐ICH nomogram for predicting unfavorable outcome after intracerebral hemorrhage

Luo

Peng

et al. 2022

CNS Neurosci Ther

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“…Other studies have indicated that underlying chronic small vessel disease, particularly hypertensive small vessel disease, may predispose certain patients to encountering these DWI ischemic lesions, perhaps independently of acute blood pressure changes, and potentially related to microthrombosis. 1,3,5,23–26 Our results appear to provide novel evidence to suggest a plausible role of higher baseline hemoglobin concentrations as a risk factor associated with DWI lesions in patients with acute ICH. It is known that higher hemoglobin concentrations enhance hemostasis and can provoke thrombosis in settings of vascular injury 8 and have relevant associations with ischemic stroke.…”

Section: Discussionmentioning

confidence: 54%

Relationships of Hemoglobin Concentration, Ischemic Lesions, and Clinical Outcomes in Patients With Intracerebral Hemorrhage

Roh

Boehme

Mamoon

et al. 2023

Stroke

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BACKGROUND: Hemoglobin concentration and diffusion-weighted imaging (DWI) ischemic lesions are separately known to be associated with poor intracerebral hemorrhage (ICH) outcomes. While hemoglobin concentrations have known relationships with ischemic stroke, it is unclear whether hemoglobin concentration is associated with DWI ischemic lesions after ICH. We sought to investigate the hypothesis that hemoglobin concentrations would associate with DWI lesions after ICH and further investigated their relationships with clinical outcomes. METHODS: Supratentorial ICH patients enrolled between 2010 and 2016 to a prospective, multicenter, observational cohort study (ERICH study [Ethnic/Racial Variations of Intracerebral Hemorrhage]) were assessed. Patients from this study with baseline, admission hemoglobin, and hospitalization magnetic resonance imaging were analyzed. Hemoglobin was examined as the primary exposure variable defined as a continuous variable (g/dL). Magnetic resonance imaging DWI ischemic lesion presence was assessed as the primary radiographic outcome. Primary analyses assessed relationships of hemoglobin with DWI lesions. Secondary analyses assessed relationships of DWI lesions with poor 3-month outcomes (modified Rankin Scale score, 4–6). These analyses were performed using separate multivariable logistic regression models adjusting for relevant covariates. RESULTS: Of 917 patients with ICH analyzed, mean baseline hemoglobin was 13.8 g/dL (±1.9), 60% were deep ICH, and DWI lesions were identified in 27% of the cohort. In our primary analyses, increased hemoglobin, defined as a continuous variable, was associated with DWI lesions (adjusted odds ratio, 1.21 per 1 g/dL change in hemoglobin [95% CI, 1.07–1.37]) after adjusting for sex, race, ICH severity, time to magnetic resonance imaging, and acute blood pressure change. In secondary analyses, DWI lesions were associated with poor 3-month outcomes (adjusted odds ratio, 1.83 [95% CI, 1.24–2.69]) after adjusting for similar covariates. CONCLUSIONS: We identified novel relationships between higher baseline hemoglobin concentrations and DWI ischemic lesions in patients with ICH. Further studies are required to clarify the role of hemoglobin concentration on both cerebral small vessel disease pathophysiology and ICH outcomes.

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“…However, the number of patients with hypertension did not differ between groups with and without DWI+ lesions. Furthermore, a recent individual patient data meta-analyses investigated ICH-related DWI+ lesions, blood pressure control, and outcomes, and did not find any associations ( 2 ), and a recent randomized controlled trial demonstrated that intensive acute blood pressure lowering did not lower the frequency of DWI+ lesions in ICH-patients ( 13 ), Alternatively, some hemorrhages might be caused by the hemorrhagic transformation of DWI+ lesions ( 14 , 15 ).…”

Section: Discussionmentioning

confidence: 99%

Diffusion-Weighted Lesions After Intracerebral Hemorrhage: Associated MRI Findings

et al. 2022

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The current study aimed to investigate whether diffusion-weighted imaging-positive (DWI+) lesions after acute intracerebral hemorrhage (ICH) are associated with underlying small vessel disease (SVD) or linked to the acute ICH. We included patients ≥18 years with spontaneous ICH confirmed on neuroimaging and performed 3T MRIs after a median of 11 days (interquartile range [IQR] 6–43). DWI+ lesions were assessed in relation to the hematoma (perihematomal vs. distant and ipsilateral vs. contralateral). Differences in clinical characteristics, ICH characteristics, and MRI markers of SVD between participants with or without DWI+ lesions were investigated using non-parametric tests. We observed 54 DWI+ lesions in 30 (22%) of the 138 patients (median age [IQR] 65 [55–73] years; 71% men, 59 lobar ICH) with available DWI images. We found DWI+ lesions ipsilateral (54%) and contralateral (46%) to the ICH, and 5 (9%) DWI+ lesions were located in the immediate perihematomal region. DWI+ lesion presence was associated with probable CAA diagnosis (38 vs. 15%, p = 0.01) and larger ICH volumes (37 [8–47] vs. 12 [6–24] ml, p = 0.01), but not with imaging features of SVD. Our findings suggest that DWI+ lesions after ICH are a feature of both the underlying SVD and ICH-related mechanisms.

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Intensive Blood Pressure Lowering and DWI Lesions in Intracerebral Hemorrhage: Exploratory Analysis of the ATACH-2 Randomized Trial

Cited by 9 publications

References 25 publications

ANAID‐ICH nomogram for predicting unfavorable outcome after intracerebral hemorrhage

ANAID‐ICH nomogram for predicting unfavorable outcome after intracerebral hemorrhage

Relationships of Hemoglobin Concentration, Ischemic Lesions, and Clinical Outcomes in Patients With Intracerebral Hemorrhage

Diffusion-Weighted Lesions After Intracerebral Hemorrhage: Associated MRI Findings

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