Influence of Bleeding Pattern on Ischemic Lesions After Spontaneous Hypertensive Intracerebral Hemorrhage with Intraventricular Hemorrhage

  • Lucia Rivera-Lara
  • Santosh B. Murthy
  • Saman Nekoovaght-Tak
  • Hasan Ali
  • Nichol McBee
  • Rachel Dlugash
  • Malathi Ram
  • Richard Thompson
  • Issam A. Awad
  • Daniel F. Hanley
  • Wendy C. Ziai
  • For the CLEAR Investigators
Original Article

Abstract

Background

Concomitant acute ischemic lesions are detected in up to a quarter of patients with spontaneous intracerebral hemorrhage (ICH). Influence of bleeding pattern and intraventricular hemorrhage (IVH) on risk of ischemic lesions has not been investigated.

Methods

Retrospective study of all 500 patients enrolled in the CLEAR III randomized controlled trial of thrombolytic removal of obstructive IVH using external ventricular drainage. The primary outcome measure was radiologically confirmed ischemic lesions, as reported by the Safety Event Committee and confirmed by two neurologists. We assessed predictors of ischemic lesions including analysis of bleeding patterns (ICH, IVH and subarachnoid hemorrhage) on computed tomography scans (CT). Secondary outcomes were blinded assessment of mortality and modified Rankin scale (mRS) at 30 and 180 days.

Results

Ischemic lesions occurred in 23 (4.6%) during first 30 days after ICH. Independent risk factors associated with ischemic lesions in logistic regression models adjusted for confounders were higher IVH volume (p = 0.004) and persistent subarachnoid hemorrhage on CT scan (p = 0.03). Patients with initial IVH volume ≥ 15 ml had five times the odds of concomitant ischemic lesions compared to IVH volume < 15 ml. Patients with ischemic lesions had significantly higher odds of death at 1 and 6 months (but not poor outcome; mRS 4–6) compared to patients without concurrent ischemic lesions.

Conclusions

Occurrence of ischemic lesions in the acute phase of IVH is not uncommon and is significantly associated with increased early and late mortality. Extra-parenchymal blood (larger IVH and visible subarachnoid hemorrhage) is a strong predictor for development of concomitant ischemic lesions after ICH.

Keywords

Intracerebral hemorrhage Intraventricular hemorrhage Ischemic lesions Concomitant ischemic strokes CLEAR trial 

Notes

Acknowledgements

Dr. Murthy is supported by the American Academy of Neurology, American Brain Foundation, and the Leon Levy Neuroscience Foundation. Dr. Hanley was awarded significant research support through grant numbers 5U01NS062851 for Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III. Dr. Ziai is supported by Grants 5U01NS062851 and 1U01NS08082. The other authors report no disclosures.

Author’s Contributions

Drs. Rivera-Lara and Ziai had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Rivera-Lara, Hanley, and Ziai were involved in study concept and design. Rivera-Lara, Murthy, and Ziai acquired, analyzed, and interpreted the data. Rivera-Lara and Ziai drafted the manuscript. Rivera-Lara, Murthy, Dlugash, McBee, Aldrich, Caron, Awad, Hanley, and Ziai critically revised the manuscript for important intellectual content. Rivera-Lara and Ziai were involved in statistical analysis. Ziai contributed to administrative, technical, or material support. Ziai was involved in study supervision.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no competing interests.

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Lucia Rivera-Lara
    • 1
    • 2
  • Santosh B. Murthy
    • 6
    • 7
  • Saman Nekoovaght-Tak
    • 1
  • Hasan Ali
    • 1
  • Nichol McBee
    • 1
  • Rachel Dlugash
    • 1
  • Malathi Ram
    • 1
  • Richard Thompson
    • 8
  • Issam A. Awad
    • 9
  • Daniel F. Hanley
    • 1
    • 2
    • 3
    • 4
    • 5
  • Wendy C. Ziai
    • 1
    • 2
    • 3
    • 4
  • For the CLEAR Investigators
  1. 1.Division of Neurosciences Critical Care, Department of NeurologyJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Department of AnesthesiologyJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Department of Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreUSA
  4. 4.Department of NeurosurgeryJohns Hopkins University School of MedicineBaltimoreUSA
  5. 5.Department of MedicineJohns Hopkins University School of MedicineBaltimoreUSA
  6. 6.Department of NeurologyWeill Cornell MedicineNew YorkUSA
  7. 7.Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research InstituteWeill Cornell MedicineNew YorkUSA
  8. 8.Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  9. 9.Department of Neurological SurgeryUniversity of Chicago MedicineChicagoUSA

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