Predicting Symptomatic Intracerebral Hemorrhage Versus Lacunar Disease in Patients With Longstanding Hypertension

Abstract

Background and Purpose Hypertension results in a spectrum of subcortical cerebrovascular disease. It is unclear why some individuals develop ischemia and others develop hemorrhage. Risk factors may differ for each population. We identify factors that predispose an individual to subcortical symptomatic intracerebral hemorrhage (sICH) compared with ischemia. Methods Demographic and laboratory data were prospectively collected for hypertensive patients presenting with ischemic stroke or sICH during an 8.5-year period. Neuroimaging was retrospectively reviewed for acute (subcortical lacunes [<2.0 cm] versus subcortical sICH) and chronic (periventricular white matter disease and cerebral microbleeds) findings. We evaluated the impact of age, race, sex, serum creatinine, erythrocyte sedimentation rate, low-density lipoprotein, presence of periventricular white matter disease or cerebral microbleeds, and other factors on the risk of sICH versus acute lacune using multivariate logistic regression. Results Five hundred seventy-one patients had subcortical pathology. The presence of cerebral microbleeds (adjusted odds ratio [OR], 3.39; confidence interval [CI], 2.09–5.50) was a strong predictor of sICH, whereas severe periventricular white matter disease predicted ischemia (OR, 0.56 risk of sICH; CI, 0.32–0.98). This association was strengthened when the number of microbleeds was evaluated; subjects with >5 microbleeds had an increased risk of sICH (OR, 4.11; CI, 1.96–8.59). It remained significant when individuals with only cortical microbleeds were removed (OR, 1.77, CI, 1.13–2.76). An elevated erythrocyte sedimentation rate (OR, 1.19 per 10 mm/h increase; CI, 1.06–1.34) was significantly associated with sICH, whereas low-density lipoprotein was associated with ischemic infarct (OR, 0.93 risk of sICH per 10 mg/dL increase; CI, 0.86–0.99). Conclusions Subclinical pathology is the strongest predictor of the nature of subsequent symptomatic event. Low-density lipoprotein and erythrocyte sedimentation rate may also have a role in risk stratification.

Glomerular Filtration Rate is Associated with Hemorrhagic Transformation in Acute Ischemic Stroke Patients without Thrombolytic Therapy

“…In line with the previous studies,[ 17 18 37 40 49 ] our study also disclosed that large cerebral infarction, AF, and HA are associated with increased risk of HT for AIS patients. It will appear massive cerebral edema and severe BBB damage when patients exist large infarction volume, which could accelerate microvascular injury, facilitate HT rate, and expand hemorrhage size after reperfusion.…”

“…This results in the increased infarct growth, higher final infarct volume, and more frequent severe HT. [ 49 ] The upper of HT in HA patients may attributed to the absence of effect from albumin. Because albumin has been proved to be markedly neuroprotective in AIS and traumatic brain injury based on the theories of directly protecting both parenchymal and vascular elements of the brain, maintaining microvascular integrity, diminishing brain edema, inhibiting endothelial cell apoptosis, transporting fatty acids to the post-stroke brain, and exerting antioxidant effects.…”

Predicting Hemorrhagic Transformation of Acute Ischemic Stroke

“…Renal failure has also been associated with inflammation that may damage the small vessels, leading to increased permeability of the blood brain barrier over time. 22 – 26 …”

Long-Term Stroke Recurrence after Transient Ischemic Attack: Implications of Etiology

“…Although a low rate of AF detection in TIAs has been reported [21], our results suggest a subgroup of patients (cortical symptoms without a major cause) that could benefit more from prolonged cardiac monitoring strategies. The second cause of diverse etiology in the SR was hemorrhagic stroke, which occurred more frequently in patients with TIA of SAD etiology; these entities have similar pathophysiological mechanisms [22]. The Secondary Prevention of Small Subcortical Strokes (SPS3) trial study, one of the main studies of patients with SAD, reported higher hemorrhagic risk in these patients and emphasized that control of hypertension is as important as antithrombotic treatment [23].…”