Predictors of highly prevalent brain ischemia in intracerebral hemorrhage

Abstract

Objective To determine the prevalence, characteristics, risk factors and temporal profile of concurrent ischemic lesions in patients with acute primary intracerebral hemorrhage (ICH). Methods Patients were recruited within a prospective, longitudinal, magnetic resonance imaging (MRI) based study of primary ICH. Clinical, demographic, and MRI data were collected on all subjects at baseline and 1 month. Results Of the 138 patients enrolled, mean age was 59 years, 54% were male, 73% black, and 84% had a history of hypertension. At baseline, ischemic lesions on diffusion-weighted imaging (DWI) were found in 35% of patients. At 1 month, lesions were present in 27%, and of these lesions, 83% were new and not present at baseline. ICH volume (p=0.025), intraventricular hemorrhage (p=0.019), presence of microbleeds (p=0.024), and large, early reductions in mean arterial pressure (p=0.003) were independent predictors of baseline DWI lesions. A multivariate logistical model predicting the presence of 1 month DWI lesions included history of any prior stroke (p=0.012), presence of 1 or more microbleeds (p=0.04), black race (p=0.641), and presence of a DWI lesion at baseline (p=0.007) Interpretation This study demonstrates that more than 1/3 of patients with primary ICH have active cerebral ischemia at baseline remote from the index hematoma, and 1/4 of patients experience ongoing, acute ischemic events at 1 month. Multivariate analyses implicate blood pressure reductions in the setting of an active vasculopathy as a potential underlying mechanism. Further studies are needed to determine the impact of these lesions on outcome and optimal management strategies to arrest vascular damage.

Intracerebral Hemorrhage and Delirium Symptoms. Length of Stay, Function, and Quality of Life in a 114-Patient Cohort

“…Pneumonia was uncommon and not associated with delirium in this cohort. Cerebral ischemia is common after ICH (33,34), might be an underlying risk factor for delirium, and deserves future study.…”

Intracerebral Hematoma Extends via Perivascular Spaces and Perineurium

“…The impact of an ICH is not only restricted to the primary site of injury, but also identified in the remote regions (MunBryce et al 2004;Menon et al 2012). But the pathophysiological mechanisms of the remote effects of hematoma remain unknown, despite the important implications for both prognosis and treatment in the clinical practice of ICH.…”

Cerebral Perfusion Pressure is Maintained in Acute Intracerebral Hemorrhage: A CT Perfusion Study

“…5 In addition, more recent MR imaging studies have suggested that subacute ischemic injury occurs in areas remote from the hematoma, including borderzone (BZ, also known as watershed) regions. [6][7][8][9][10][11] The etiology of these ischemic injuries has been postulated to be hemodynamic compromise secondary to BP reduction. 10 Studies of CBF in the perihematoma region indicate that this region is relatively hypoperfused, but not se-verely enough to result in ischemia.…”

“…[6][7][8][9][10][11] The etiology of these ischemic injuries has been postulated to be hemodynamic compromise secondary to BP reduction. 10 Studies of CBF in the perihematoma region indicate that this region is relatively hypoperfused, but not se-verely enough to result in ischemia. [12][13][14] Previous PET studies have demonstrated that the perihematoma region is, in fact, hypometabolic, likely secondary to the primary brain injury, and that the oxygen extraction fraction is not elevated, indicating the absence of misery perfusion.…”

“…[6][7][8][9][10][11] The retrospective association shown between BP reduction in the setting of chronic hypertensive vasculopathy and these ischemic lesions raises the possibility that they are a consequence of hemodynamic compromise. Given that CPP has been shown to be more sensitive to slight variations in mean arterial pressure than individual measurements of CBF or CBV, 18 we postulated that subtle perfusion changes in the BZ regions may only become apparent by using this analysis.…”