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Mechanistic Evaluation of Diffusion Weighted Hyperintense Lesions After Large Spontaneous Intracerebral Hemorrhage: A Subgroup Analysis of MISTIE III

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Abstract

Background

Ischemic lesions on diffusion weighted imaging (DWI) are common after acute spontaneous intracerebral hemorrhage (ICH) but are poorly understood for large ICH volumes (> 30 mL). We hypothesized that large blood pressure drops and effect modification by cerebral small vessel disease markers on magnetic resonance imaging (MRI) are associated with DWI lesions.

Methods

This was an exploratory analysis of participants in the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial with protocolized brain MRI scans within 7 days from ICH. Multivariable logistic regression analysis was performed to assess biologically relevant factors associated with DWI lesions, and relationships between DWI lesions and favorable ICH outcomes (modified Rankin Scale 0–3).

Results

Of 499 enrolled patients, 300 had MRI at median 7.5 days (interquartile range 7–8), and 178 (59%) had DWI lesions. The incidence of DWI lesions was higher in patients with systolic blood pressure (SBP) reduction ≥ 80 mm Hg in first 24 h (76%). In adjusted models, factors associated with DWI lesions were as follows: admission intraventricular hematoma volume (p = 0.03), decrease in SBP ≥ 80 mm Hg from admission to day 1 (p = 0.03), and moderate-to-severe white matter disease (p = 0.01). Patients with DWI lesions had higher odds of severe disability at 1 month (p = 0.04), 6 months (p = 0.036), and 12 months (p < 0.01). No evidence of effect modification by cerebral small vessel disease on blood pressure was found.

Conclusions

In patients with large hypertensive ICH, white matter disease, intraventricular hemorrhage volume, and large reductions in SBP over the first 24 h were independently associated with DWI lesions. Further investigation of potential hemodynamic mechanisms of ischemic injury after large ICH is warranted.

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Funding

This study is supported by a grant from the National Institutes of Health through the following grants: K23NS105948 (Dr. Murthy), and U01-NS080824 for the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial (Drs. Hanley and Ziai).

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Author notes

  1. Santosh B. Murthy and Wendy C. Ziai contributed equally.

Authors and Affiliations

  1. Division of Stroke and Neurocritical Care, Department of Neurology, Stanford University, Palo Alto, CA, USA

    Lucia Rivera-Lara

  2. Division of Neurosciences Critical Care, Department of Neurology and Neurosurgery, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA

    Sung-Min Cho & Wendy C. Ziai

  3. Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA

    Yunke Li, Hasan Ali, Nichol McBee, Radhika Avadhani, Daniel F. Hanley & Nathan Walborn

  4. Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA

    Issam A. Awad

  5. Department of Radiology, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA

    Dheeraj Gandhi

  6. Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA

    Santosh B. Murthy

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  1. Lucia Rivera-Lara
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Contributions

LRL: Manuscript writing, data analysis. SMC: Data collection, manuscript writing. YL: Acquisition of data. HA: Acquisition of data. NB: Acquisition of data. IA: Conception and design, manuscript review. RA: Acquisition of data. DH: Conception and design, manuscript review. DG: Conception and design, manuscript review. NW: Acquisition of data. SM: Conception and design, data analysis, manuscript review. WZ: Conception and design, data analysis, manuscript review. The final manuscript was approved by all authors.

Corresponding author

Correspondence to Wendy C. Ziai.

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Rivera-Lara, L., Cho, SM., Li, Y. et al. Mechanistic Evaluation of Diffusion Weighted Hyperintense Lesions After Large Spontaneous Intracerebral Hemorrhage: A Subgroup Analysis of MISTIE III. Neurocrit Care (2023). https://doi.org/10.1007/s12028-023-01890-3

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