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

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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.

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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 information

Authors and Affiliations

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

    Lucia Rivera-Lara, Saman Nekoovaght-Tak, Hasan Ali, Nichol McBee, Rachel Dlugash, Malathi Ram, Daniel F. Hanley & Wendy C. Ziai

  2. Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Lucia Rivera-Lara, Daniel F. Hanley & Wendy C. Ziai

  3. Department of Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Daniel F. Hanley & Wendy C. Ziai

  4. Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Daniel F. Hanley & Wendy C. Ziai

  5. Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Daniel F. Hanley

  6. Department of Neurology, Weill Cornell Medicine, New York, NY, USA

    Santosh B. Murthy

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

    Santosh B. Murthy

  8. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Richard Thompson

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

    Issam A. Awad

Authors
  1. Lucia Rivera-Lara
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  2. Santosh B. Murthy
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  3. Saman Nekoovaght-Tak
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  4. Hasan Ali
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  5. Nichol McBee
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  6. Rachel Dlugash
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  7. Malathi Ram
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  8. Richard Thompson
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  9. Issam A. Awad
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  10. Daniel F. Hanley
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  11. Wendy C. Ziai
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For the CLEAR Investigators

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.

Corresponding author

Correspondence to Lucia Rivera-Lara.

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The authors declare that they have no competing interests.

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Rivera-Lara, L., Murthy, S.B., Nekoovaght-Tak, S. et al. Influence of Bleeding Pattern on Ischemic Lesions After Spontaneous Hypertensive Intracerebral Hemorrhage with Intraventricular Hemorrhage. Neurocrit Care 29, 180–188 (2018). https://doi.org/10.1007/s12028-018-0516-x

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  • DOI: https://doi.org/10.1007/s12028-018-0516-x

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