Ischemia in Intracerebral Hemorrhage Is Associated With Leukoaraiosis and Hematoma Volume, Not Blood Pressure Reduction

Gioia, Laura; Kate, Mahesh; Choi, Victor; Sivakumar, Leka; Jeerakathil, Thomas; Kosior, Jayme C.; Emery, Derek; Butcher, Ken

doi:10.1161/strokeaha.114.008304

Cited by 52 publications

(67 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…[5][6][7][8][9][10] Over the last several years, a growing number of studies have characterized the presence and frequency of ischemic lesions remote from the acute hematoma visualized on diffusion-weighted imaging (DWI) in patients with primary ICH undergoing MRI. [11][12][13][14][15][16][17][18][19] Across these series, remote DWI lesions are visualized in 11%-41% of patients. There have been conflicting reports of an association between DWI lesions and large fluctuations in BP in the acute hospital setting.…”

mentioning

confidence: 87%

See 1 more Smart Citation

Ischemic lesions, blood pressure dysregulation, and poor outcomes in intracerebral hemorrhage

et al. 2017

View full text Add to dashboard Cite

Objective: To evaluate the associations among diffusion-weighted imaging (DWI) lesions, blood pressure (BP) dysregulation, MRI markers of small vessel disease, and poor outcome in a large, prospective study of primary intracerebral hemorrhage (ICH). Methods:The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a multicenter, observational study of ICH among white, black, and Hispanic patients.Results: Of 600 patients, mean (6SD) age was 60.8 6 13.6 years, median (interquartile range) ICH volume was 9.1 mL (3.5-20.8), and 79.6% had hypertension. Overall, 26.5% of cases had DWI lesions, and this frequency differed by race/ethnicity (black 33.8%, Hispanic 24.9%, white 20.2%, overall p 5 0.006). A logistic regression model of variables associated with DWI lesions included lower age (odds ratio [OR] 0.721, p 5 0.002), higher first recorded systolic BP (10-unit OR 1.12, p 5 0.002), greater change in mean arterial pressure (MAP) prior to the MRI (10-unit OR 1.10, p 5 0.037), microbleeds (OR 1.99, p 5 0.008), and higher white matter hyperintensity (WMH) score (1-unit OR 1.16, p 5 0.002) after controlling for race/ethnicity, leukocyte count, and acute in-hospital antihypertensive treatment. A second model of variables associated with poor 90-day functional outcome (modified Rankin Scale scores 4-6) included DWI lesion count (OR 1.085, p 5 0.034) as well as age, ICH volume, intraventricular hemorrhage, Glasgow Coma Scale score, WMH score, race/ethnicity, acute in-hospital antihypertensive treatment, and ICH location. Conclusions:These results support the hypotheses that acute BP dysregulation is associated with the development of DWI lesions in primary ICH and that DWI lesions are, in turn, associated with poor outcomes. Neurology ® 2017;88:782-788 GLOSSARY ADC 5 apparent diffusion coefficient; BP 5 blood pressure; CAA 5 cerebral amyloid angiopathy; DWI 5 diffusion-weighted imaging; ERICH 5 Ethnic/Racial Variations of Intracerebral Hemorrhage; FLAIR 5 fluid-attenuated inversion recovery; GCS 5 Glasgow Coma Scale; GRE 5 gradient recalled echo; ICH 5 intracerebral hemorrhage; INTERACT2 5 Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage 2; IVH 5 intraventricular hemorrhage; MAP 5 mean arterial pressure; mRS 5 modified Rankin Scale; SBP 5 systolic blood pressure; SWI 5 susceptibility-weighted imaging; WMH 5 white matter hyperintensity.Primary intracerebral hemorrhage (ICH) is the second most common cause of stroke, affecting over 1 million people worldwide each year.1,2 ICH causes significantly greater morbidity and mortality than ischemic stroke. Hypertension is the most common risk factor for ICH. Elevated blood pressure (BP), often at extreme levels, frequently occurs in the hyperacute and acute phases of primary ICH and is associated with hemorrhage expansion and poor outcome. 3,4 Several recent trials have sought to determine whether intensive lowering of BP acutely improves outcomes in patients with ICH. 5-10Over the last several years, a growing number of studies have characte...

show abstract

mentioning

confidence: 87%

“…However, the median hematoma volume in our study (9.1 mL) is comparable to the majority of prior MRI-based reports. [12][13][14][15] Of note, the median hematoma volume in the INTERACT II study was 11 mL. 7 MRIs were not all acquired at routine timepoints or with identical magnet strengths and sequence parameters.…”

mentioning

confidence: 99%

Ischemic lesions, blood pressure dysregulation, and poor outcomes in intracerebral hemorrhage

et al. 2017

View full text Add to dashboard Cite

show abstract

“…Previous studies reported PDR in 10-70% of all cases; however, most of these studies were limited by small sample sizes [9][10][11][12][13] . The temporal pattern of ADC properties of the perihematomal zone was previously shown to be highly variable.…”

Section: Discussionmentioning

confidence: 98%

“…This threshold represents a 30% reduction of ADC compared to normal white matter, which is indicative of severely restricted diffusion as reached after prolonged ischemia [16][17][18] . This threshold has previously been used to assess PDR in ICH [10,13] . The ADC of a contralateral mirror ROI was measured as well.…”

Section: Imaging Studiesmentioning

confidence: 99%

“…These studies were, however, limited by small sample sizes (n <40) and yielded contradictory results. A recent study investigated the properties of PDR in 117 patients with ICH who underwent MRI within 14 days after symptom onset [13] . This study observed PDR in 32.4% of their patients and identified hematoma volume as its sole independent predictor.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Perihematomal Diffusion Restriction in Intracerebral Hemorrhage Depends on Hematoma Volume, But Does Not Predict Outcome

et al. 2016

View full text Add to dashboard Cite

Background: Perihematomal diffusion restriction (PDR) is a frequent finding in primary intracerebral hemorrhage (ICH) on diffusion-weighted MRI. Its frequency, associated clinical and imaging findings and impact on clinical outcome are not well understood. Methods: This is a retrospective single-center analysis of 172 patients with primary ICH who received MRI within 24 h from symptom onset. PDR was defined as a reduction of apparent diffusion coefficient below 550 × 10^-6 mm²/s. Multivariate regression analyses were used to assess independent imaging and clinical predictors of PDR. Clinical outcome was assessed using the modified Rankin scale (mRS) at discharge. Results: PDR was present in 88 patients (51.2%). Median PDR volume was 1.1 ml (interquartile range 0.2-4.2). Multivariate analyses identified hematoma volume as the key independent predictor of PDR. The volume of perihematomal edema, lobar hematoma location and low diastolic blood pressure at admission were further predictors. Although the occurrence of PDR correlated with in-hospital mortality (75.0 vs. 43.4%, p < 0.001) and moderately severe to severe disability or death at discharge (mRS ≥4; 56.4 vs. 27.8%, p = 0.002), PDR was not an independent predictor of clinical outcome. In contrast, hematoma volume, ventricular extension of hemorrhage and higher age independently predicted an adverse clinical outcome. Conclusions: PDR is common after primary ICH within 24 h of symptom onset. Hematoma volume was identified as the key predictor of PDR. Although PDR was associated with mortality and severe disability, this effect was confounded by established risk factors. These results do not support a role of early PDR as prognostic factor after ICH independent of hematoma volume.

show abstract

A Pooled Analysis of Diffusion-Weighted Imaging Lesions in Patients With Acute Intracerebral Hemorrhage

et al. 2020

View full text Add to dashboard Cite

IMPORTANCE The etiology and significance of diffusion-weighted imaging (DWI) lesions in patients with acute intracerebral hemorrhage (ICH) remain unclear. OBJECTIVE To evaluate which factors are associated with DWI lesions, whether associated factors differ by ICH location, and whether DWI lesions are associated with functional outcomes. DESIGN, SETTING, AND PARTICIPANTS This analysis pooled individual patient data from 3 randomized clinical trials (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial, Antihypertensive Treatment of Acute Cerebral Hemorrhage trial, and Intracerebral Hemorrhage Deferoxamine phase 2 trial) and 1 multicenter prospective study (Ethnic/Racial Variations of Intracerebral Hemorrhage). Patients were enrolled from August 1, 2010, to September 30, 2018. Of the 4782 patients, 1788 who underwent magnetic resonance imaging scans of the brain were included. Data were analyzed from July 1 to December 31, 2019. MAIN OUTCOMES AND MEASURES The primary outcome consisted of factors associated with DWI lesions. Secondary outcomes were poor functional outcome, defined as a modified Rankin score (mRS) of 4 to 6, and mortality, both assessed at 3 months. Mixed-effects logistic regression was used to evaluate the association between exposures and outcomes. Subgroup analyses stratified by hematoma location were performed. RESULTS After exclusion of 36 patients with missing data on DWI lesions, 1752 patients were included in the analysis (1019 men [58.2%]; mean [SD] age, 60.8 [13.3] years). Diffusion-weighted imaging lesions occurred in 549 patients (31.3%). In mixed-effects regression models, factors associated with DWI lesions included younger age (odds ratio [OR] per year, 0.98; 95% CI, 0.97-0.99), black race (OR, 1.64; 95% CI, 1.17-2.30), admission systolic blood pressure (OR per 10-mm Hg increase, 1.13; 95% CI, 1.08-1.18), baseline hematoma volume (OR per 10-mL increase, 1.12; 95% CI, 1.02-1.22), cerebral microbleeds (OR, 1.85; 95% CI, 1.39-2.46), and leukoaraiosis (OR, 1.59; 95% CI, 1.67-2.17). Diffusion-weighted imaging lesions were independently associated with poor mRS (OR, 1.50; 95% CI, 1.13-2.00), but not with mortality (OR, 1.11; 95% CI, 0.72-1.71). In subgroup analyses, similar factors were associated with DWI lesions in lobar and deep ICH. Diffusion-weighted imaging lesions were associated with poor mRS in deep but not lobar ICH. CONCLUSIONS AND RELEVANCEIn a large, heterogeneous cohort of prospectively identified patients with ICH, results were consistent with the hypothesis that DWI lesions represent acute sequelae of chronic cerebral small vessel disease, particularly hypertensive vasculopathy. Diffusion-weighted imaging lesions portend a worse prognosis after ICH, mainly deep hemorrhages.

show abstract

Ischemia in Intracerebral Hemorrhage Is Associated With Leukoaraiosis and Hematoma Volume, Not Blood Pressure Reduction

Cited by 52 publications

References 26 publications

Ischemic lesions, blood pressure dysregulation, and poor outcomes in intracerebral hemorrhage

Ischemic lesions, blood pressure dysregulation, and poor outcomes in intracerebral hemorrhage

Perihematomal Diffusion Restriction in Intracerebral Hemorrhage Depends on Hematoma Volume, But Does Not Predict Outcome

A Pooled Analysis of Diffusion-Weighted Imaging Lesions in Patients With Acute Intracerebral Hemorrhage

Contact Info

Product

Resources

About