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

Abstract

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...

Acute ischaemic lesions are associated with cortical superficial siderosis in spontaneous intracerebral hemorrhage

“…In our cohort, we observed acute ischaemic lesions among 15.5% of patients with acute ICH within 10 days after symptom onset. These results are in line with the prevalence reported in previous studies, ranging from 11% to 41% . As previously described, we found that patients with lobar ICH more frequently had DWI lesions than those with deep ICH .…”

“…The mechanisms and etiology of DWI lesions in patients with acute ICH remain uncertain. Previous studies have linked DWI lesions to underlying SVD . DWI lesions are more frequently observed in CAA‐ICH and are associated with markers of CAA including lobar CMB, WMHs and enlarged perivascular spaces in the centrum semiovale .…”

Incidence and Etiology of Microinfarcts in Patients with Ischemic Stroke

“…A recent population‐based autopsy study also showed an association between premortem BP decline over time and the occurrence of microinfarcts . Similarly, the occurrence of CMI after hemorrhagic stroke has been associated with more aggressive reduction in BP after admission . Furthermore, in a hemorrhagic stroke model in mice, both amyloid deposition and microinfarct count increased after chronic hypoperfusion due to bilateral carotid artery stenosis .…”

Early elevated neutrophil‐to‐lymphocyte ratio associated with remote diffusion‐weighted imaging lesions in acute intracerebral hemorrhage

“…Moreover, the presence of intracerebral remote diffusion‐weighted imaging lesions (R‐DWILs) has been known to worsen the stroke outcome . R‐DWILs are defined as focal hyperintensities remote from the site of the ICH or the peri‐hematoma region on diffusion‐weighted images, which are detected in about 11%‐41% of ICH patients . It is an essential complication that requires attention owing to its significant effect on the increased risk of recurrent ICH, cognitive impairment, and mortality.…”

“…Apart from the progression of microangiopathy, inflammatory response following ICH has also been implicated to exert influence on the development of R‐DWILs . However, prior studies examining the effect of inflammation, in the form of leukocytes, had failed to find a correlation with R‐DWILs . It was possible that they analyzed leukocytes as an entirety instead of a subset and neglected the respective implications of neutrophils or lymphocytes following ICH.…”