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.

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Background and Purpose— To investigate the relationship between chronic kidney disease (CKD) and MRI-defined cerebral microbleeds (CMB), a harbinger of future intracerebral hemorrhage (ICH), among patients with a recent history of primary ICH. Methods— Using data from a predominantly black cohort of patients with a recent ICH-enrolled in an observational study between September 2007 and June 2011, we evaluated the association between CKD (defined as estimated low glomerular filtration rate<60 mL/min per 1.73 m 2 ) and CMB on gradient-echo MRI. Multivariable models were generated to determine the contribution of CKD to the presence, number, and location of CMB. Results— Of 197 subjects with imaging data, mean age was 59 years, 48% were women, 73% were black, 114 (58%) had ≥1 CMBs, and 52 (26%) had CKD. Overall, CKD was associated with presence of CMB (adjusted odds ratio, 2.70; 95% confidence interval [CI], 1.10–6.59) and number of CMB (adjusted relative risk, 2.04; 95% CI, 1.27–3.27). CKD was associated with CMB presence (adjusted odds ratio, 3.44; 95% CI, 1.64–7.24) and number (adjusted relative risk, 2.46; 95% CI, 1.11–5.42) in black patients, but not CMB presence (adjusted odds ratio, 3.00; 95% CI, 0.61–14.86) or number (adjusted relative risk, 1.03; 95% CI: 0.22–4.89) in non-Hispanic white patients (interactions by race were statistically not significant). Conclusions— CKD is associated with a greater presence and number of CMB in ICH patients, particularly in patients of black race. Future studies should assess whether low estimated glomerular filtration rate may be a CMB risk marker or potential therapeutic target for mitigating the development of CMB.

BackgroundData on the implementation of prehospital large vessel occlusion (LVO) scales to identify and triage patients with acute ischemic stroke (AIS) in the field are limited, with the majority of studies occurring outside the USA.ObjectiveTo report our long-term experience of a US countywide emergency medical services (EMS) acute stroke triage protocol using the Rapid Arterial oCclusion Evaluation (RACE) score.MethodsOur prospective database was used to identify all consecutive patients triaged within Lucas County, Ohio by the EMS with (1) a RACE score ≥5, taken directly to an endovascular capable center (ECC) as RACE-alerts (RA) and (2) a RACE score <5, taken to the nearest hospital as stroke-alerts (SA). Baseline demographics, RACE score, time metrics, final diagnosis, treatments, and clinical and angiographic outcomes were captured. The sensitivity and specificity for patients with a RACE score ≥5 with LVO, eligible for mechanical thrombectomy (MT), were calculated.ResultsBetween July 2015 and June 2018, 492 RA and 1147 SA were triaged within our five-hospital network. Of the RA, 37% had AIS secondary to LVOs. Of the 492 RA and 1147 SA, 125 (25.4%) and 38 (3.3%), respectively, underwent MT (OR=9.9; 95% CI 6.8 to 14.6; p<0.0001). Median times from onset-to-ECC arrival (74 vs 167 min, p=0.03) and dispatch-to-ECC arrival (31 vs 46 min, p=0.0002) were shorter in the RA-MT than in the SA-MT cohort. A RACE cut-off point ≥5 showed a sensitivity and specificity of 0.77 and 0.75 for detection of patients with LVO eligible for MT, respectively.ConclusionsWe have demonstrated the long-term feasibility of a countywide EMS-based prehospital triage protocol using the RACE Scale within our hospital network.

Objective: The objective of the study was to characterize a previously unreported form of CNS barrier disruption in intracerebral hemorrhage (ICH): hyperacute injury marker (HARM). Methods:In this retrospective cohort analysis of patients presenting with primary ICH, precontrast and postcontrast MRI scans obtained within 5 days of symptom onset were analyzed. The presence of CNS barrier disruption was defined by 1) perihematomal or intrahematomal enhancement visualized on postcontrast T1-weighted MRI or 2) HARM: sulcal or ventricular hyperintensity visualized on postcontrast fluid-attenuated inversion recovery sequences (graded on a 5-point scale). Results:Forty-six patients were included in the analysis. Mean age was 65 years, median NIH Stroke Scale score was 7, and mean ICH volume was 12.2 mL (range 0.3-46.9 mL). HARM was visualized in 85% of patients, and this was moderate to severe in 50%. In all cases, the sulcal enhancement was noncontiguous with the hematoma. Of those patients with postcontrast T1-weighted imaging, perihematomal or intrahematomal contrast enhancement was visualized in 75% of patients. Conclusions:This study demonstrates that HARM occurs in intracerebral hemorrhage and that it likely represents a second type of CNS barrier disruption distinct from parenchymal postcontrast T1-weighted enhancement. Similar to T1 enhancement, this phenomenon may serve as a clinically useful biomarker to test therapies aimed at stabilizing acute ICH and CNS barrier disruption. Future studies are needed to further define the time course and prognostic implications of this finding. Neurology ® 2011;77:1725-1728 GLOSSARY BBB ϭ blood-brain barrier; BCSFB ϭ blood-CSF barrier; DWI ϭ diffusion-weighted imaging; GRE ϭ gradient echo; HARM ϭ hyperacute injury marker; FLAIR ϭ fluid-attenuated inversion recovery; HARM ϭ hyperintense acute injury marker; ICH ϭ intracerebral hemorrhage; IVH ϭ intraventricular hemorrhage.Intracerebral hemorrhage (ICH) is a devastating disease often associated with poor prognosis and high mortality rates.1 Tissue injury from primary ICH is due not only to the spaceoccupying effects of the initial hematoma, but also to an ongoing cascade of events resulting in toxicity from blood breakdown products, and release of thrombin and other inflammatory factors.2 These events lead to blood-brain barrier (BBB) and blood-CSF barrier (BCSFB) disruption followed by development of vasogenic edema. 3Prior imaging-based studies have described perihematomal and intrahematomal postcontrast enhancement in primary ICH and its importance as a marker of poor outcome. In the MRI literature, patterns of hematoma enhancement (representing classic BBB disruption) on postcontrast T1-weighted imaging in hyperacute primary ICH have been described, including their association with hematoma expansion and outcome. 4 Another type of contrast extravasation reported in ischemic stroke has been termed hyperintense acute injury marker (HARM), defined as the radiologic finding of hyperintense signal

These pilot data suggest that significant racial differences exist in the frequency and topography of microbleeds in patients with primary ICH. Microbleeds may be an important emerging imaging biomarker with the potential to provide insights into ICH pathophysiology, prognosis, and disease progression, as well as possible therapeutic strategies, particularly in medically underserved populations.