Purpose The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage (ICH). Methods A formal literature search of Medline was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data derived recommendations. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time. Results Evidence-based guidelines are presented for the care of patients presenting with ICH. The focus was sub-divided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations. Conclusions ICH is a serious medical condition where outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal directed treatment of the ICH patient.

No abstract

Background and Purpose-To explore relationships among gender, body size, neck size, and the diameters of the common carotid artery (CCA) and internal carotid artery (ICA). Methods-Using multivariate regression, the best predictors of sonographic diameters of CCA and ICA were determined based on age, height, weight, body mass index, body surface area, neck circumference, neck length, and blood pressure. Results-Measurements were obtained in 500 consecutive patients (age 52Ϯ15 years; 61% women). Mean diameters of ICA (4.66Ϯ0.78 mm) and CCA (6.10Ϯ0.80 mm) in women were significantly smaller than in men: 5.11Ϯ0.87 mm and 6.52Ϯ0.98 mm, respectively. Sex significantly influenced the diameters after controlling for body size, neck size, age, and blood pressure. Conclusions-Carotid arteries are smaller in women even after adjusting for body and neck size, age, and blood pressure.

No abstract

No abstract

MD; for the CHANT InvestigatorsBackground and Purpose-Limited data suggest that intracerebral hemorrhage related to oral anticoagulant therapy (OAT ICH) is associated with more hemorrhage expansion and a worse prognosis than spontaneous ICH (SICH). Methods-We examined patients enrolled in the placebo arm of the CHANT study, a prospective randomized trial of a putative neuroprotectant in patients with ICH. All patients had neuroimaging within 6 hours of symptom onset and at 72 hours. Initial ICH volume and hemorrhage expansion were determined by a central reader. Multivariable logistic regression was used to determine factors associated with ICH expansion and mortality at 90 days. Results-Of 303 patients included, 21 (6.9%) had OAT ICH. Baseline median ICH volume was greater in patients with OAT ICH compared to SICH (30.6 versus 14.4 mL, Pϭ0.03). Hemorrhage expansion (defined as Ͼ33% increase in ICH volume) occurred in 56% of patients with OAT ICH compared to 26% of SICH (Pϭ0.006). Mortality was substantially higher in OAT ICH (62% versus 17%, PϽ0.001). In multivariable analysis, time to neuroimaging and oral anticoagulant use were independently associated with hemorrhage expansion, and age, gender, and oral anticoagulant use were independently associated with mortality. Conclusions-These findings confirm that OAT ICH is associated with more hemorrhage expansion and greater mortality than SICH.

ContributionsMagdy Selim --organized the trial hypotheses, designed the trial, provided guidance about the data analysis and interpretation and presentation of the data, and drafted most of the sections of the manuscript. Lydia Foster --involved in the statistical analysis and data interpretation, and Contributed to the development and revisions to the manuscript. Claudia Moy --involved in the oversight of the trial conduct and progress Guohua Xi --organized the trial hypotheses, and provided critical revisions to the manuscript. MH, MJ, VS, and WC contributed to recruitment and randomization of trial participants, and provided critical revisions to the manuscript. LM and SG were involved in the design of the trial and provided critical revisions to the manuscript. Casey Norton --provided volumetric measurements of imaging data. Yuko Palesch --involved in the design of the study, statistical analysis and data interpretation, and provided critical revisions to the manuscript. Sharon yeatts --involved in the design of the study, statistical analysis and data interpretation, and contributed to the development and revisions to the manuscript. The idef investigators (see appendix) --contributed to the identification and, when eligible, randomization of trial participants. DECLARATION OF INTERESTSThis was an investigator-initiated study, funded by the NINDS (U01 NS074425). Deferoxamine Mesylate is a generic drug, and there was no commercial or industrial support for the trial. None of the authors has any competing interests related to the submitted work. MS reports grants from the NIH/NINDS (i-DEF) and the American Heart Association (outside the submitted work), and personal fees for serving on the advisory board of CSL Behring (outside the submitted work) during the conduct of the trial. SDY reports grant support from the NINDS, personal fees from Genentech and other fees from CR Bard Inc. (outside the submitted work) during the conduct of the study. SG, LDF, YP, and GX report grants from the NIH/NINDS. MDH reports personal fees from Merck, nonfinancial support from Hoffmann-La Roche Canada Ltd, grants from Covidien (Medtronic), grants from Boehringer-Ingleheim, grants from Stryker Inc., grants from Medtronic LLC, grants from NoNO Inc., (outside the submitted work); In addition, MDH has a patent Systems and Methods for Assisting in Decision-Making and Triaging for Acute Stroke Patients pending to US Patent office Number: 62/086,077 and owns stock in Calgary Scientific Incorporated, a company that focuses on medical imaging software, is a director of the Canadian Federation of Neurological Sciences, a not-for-profit group and has received grant support from Alberta Innovates Health Solutions, CIHR, Heart & Stroke Foundation of Canada, and NINDS. LM, VS, WC, MJ, CM, and CN have nothing to disclose.

Objective: To determine patient and hospital characteristics associated with not providing IV tissue plasminogen activator (tPA) to eligible patients with acute ischemic stroke (AIS) in clinical practice.Methods: We performed a retrospective cohort study of patients with AIS arriving within 2 hours of onset to hospitals participating in Get With The Guidelines-Stroke without documented contraindications to IV tPA from April 2003 through December 2011, comparing those who received tPA to those who did not. Multivariable generalized estimating equation logistic regression modeling identified factors associated with not receiving tPA.Results: Of 61,698 eligible patients with AIS presenting within 2 hours of onset (median age 73 years, 51% female, 74% non-Hispanic white, median NIH Stroke Scale score 11, interquartile range 6-18), 15,282 (25%) were not treated with tPA within 3 hours. Failure to give tPA decreased over time from 55% in 2003 to 2005 to 18% in 2010 to 2011 (p , 0.0001). After adjustment for all covariates, including stroke severity, factors associated with failure to treat included older age, female sex, nonwhite race, diabetes mellitus, prior stroke, atrial fibrillation, prosthetic heart valve, NIH Stroke Scale score ,5, arrival off-hours and not via emergency medical services, longer onset-to-arrival and door-to-CT times, earlier calendar year, and arrival at rural, nonteaching, non-stroke center hospitals located in the South or Midwest.Conclusions: Overall, about one-quarter of eligible patients with AIS presenting within 2 hours of stroke onset failed to receive tPA treatment. Thrombolysis has improved dramatically over time and is strongly associated with stroke center certification. Additionally, some groups, including older patients, milder strokes, women, and minorities, may be undertreated.