Search

Background: Seizures are a morbid complication of intracerebral hemorrhage (ICH) and increase the risk for herniation, status epilepticus, and worse patient outcomes. Prophylactic levetiracetam is administered to approximately 40% of patients with ICH. It is unclear which patients are consciously selected for treatment by physicians. We sought to determine how patients are selected for treatment with prophylactic levetiracetam after ICH., Methods: We administered an adaptive conjoint analysis using decision making software to an NIH Stroke Trials Network Working Group. The adaptive conjoint analysis determines the most influential attributes for making a decision in an iterative, algorithm-driven process. We asked respondents which would most influence a decision to administer prophylactic levetiracetam. The attributes and their levels were taken from published phenotypes associated with prophylactic seizure medications and the likelihood of seizures after ICH: hematoma location (lobar or basal ganglia), hematoma volume (<=10 mL or >10 mL), level of consciousness (Glasgow Coma Scale 5-12 or Glasgow Coma Scale 13-15), age (<65 or ≥65 years), and race (White or Caucasian or Black/African American). The algorithm terminated when the attributes were ranked from most to least influential., Results: The study sample included 27 respondents who completed the adaptive conjoint analysis out of 42 who responded to the survey with a mean age of 43.4 ± 9.4 years. The attribute with the greatest weight was hematoma location (30%), followed by reduced level of consciousness (24%), hematoma volume (19%), race (14%), and age (13%). Ranks of attributes were different (P < .001)., Conclusions: The decision to administer prophylactic levetiracetam to patients with ICH is driven by lobar hematoma location and depressed level of consciousness. Future research on prophylactic seizure medication could focus on patients most likely to receive it., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background/objective: Subarachnoid hemorrhage (SAH) is a devastating neurologic event for which markers to assess poor outcome are needed. Elevated cerebrospinal fluid (CSF) protein may result from inflammation and blood-brain barrier (BBB) disruption that occurs during SAH. We sought to determine if CSF protein level is associated with functional outcome after SAH., Methods: We prospectively collected single-center demographic and clinical data for consecutive patients admitted with spontaneous SAH. Inclusion required an external ventricular drain and daily CSF protein and cellular counts starting within 48 hours of symptom onset and extending through 7 days after onset. Seven-day average CSF protein was determined from daily measured values after correcting for contemporaneous CSF red blood cell (RBC) count. Three-month functional outcome was assessed by telephone interview with good outcome defined as modified Rankin score 0-3. Variables univariately associated with outcome at P less than .25 and measures of hemorrhage volume were included for binary logistic regression model development., Results: The study included 130 patients (88% aneurysmal SAH, 69% female, 54.8 ± 14.8 years, Glasgow Coma Scale [GCS] 14 [7-15]). Three-month outcome assessment was complete in 112 (86%) patients with good functional outcome in 74 (66%). CSF protein was lower in good outcome (35.3 [20.4-49.7] versus 80.5 [40.5-115.5] mg/dL; P < .001). CSF protein was not associated with cerebral vasospasm, but delayed radiographic infarction on 3 to 12-month neuroimaging was associated with higher CSF protein (46.3 [32.0-75.0] versus 30.2 [20.4-47.8] mg/dL; P = .023). Good 3-month outcome was independently associated with lower CSF protein (odds ratios [OR] .39 [.23-.70] for 75th versus 25th percentile of protein; P = .001) and higher admission GCS (OR 1.23 [1.10-1.37] for good outcome per GCS point increase; P < .001). Parenchymal hematoma predicted worse outcome (OR 6.31 [1.58-25.25]; P = .009). Results were similar after excluding nonaneurysmal SAH and after including CSF RBC count, CT score, and intraventricular hemorrhage volume in models., Conclusions: Elevated average CSF protein is associated with poor outcome after spontaneous SAH. Further research should investigate if elevated CSF protein identifies patients in whom mechanisms such as BBB disruption contribute to poor outcome., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Spontaneous intracerebral hemorrhage is a disabling form of stroke, and some patients will require nutritional interventions for dysphagia. We sought to determine if socioeconomic status indicators mediate whether minorities undergo gastrostomy tube placement., Materials and Methods: Patients with spontaneous intracerebral hemorrhage were enrolled in a single center, observational cohort study from 2010 to 2017. A socioeconomic index score was imputed using neighborhood characteristics by patients' ZIP code, according to an established method utilizing 6 indicators of wealth/income, education, and occupation. Multivariable logistic regression models were generated and stratified by racial/ethnic groups to determine the association of socioeconomic status with gastrostomy tube placement., Results: Among 512 patients, 93 (18.2%) underwent gastrostomy tube placement. There were 245 Whites, 220 Blacks, and 47 Hispanic. Blacks underwent the highest percentage of gastrostomy placement (22.7%), and Whites had the lowest percentage (13.5%). Among patients with gastrostomy, Blacks and Hispanics had lowest median socioeconomic index (-2.1 [IQR: -3.0, .7]; .7 [IQR: -1.6, 2.9], respectively, P < .001). Increasing intracerebral hemorrhage score was correlated with higher odds of gastrostomy across all groups (P values ≤ .01) but only Hispanics had reduced adjusted odds of gastrostomy with increasing socioeconomic index (OR .56; 95% .33-.84; P = .01)., Discussion: Racial/ethnic minorities had lower socioeconomic index and underwent more gastrostomy placement. Socioeconomic index was independently associated with gastrostomy only in Hispanics, in whom the odds of gastrostomy decreased with increasing socioeconomic index. Summary & Conclusion: Differences in utilization of gastrostomy were evident among minorities, and socioeconomic status may mediate this relationship among Hispanics., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background and Aim: Performance measures have been extensively studied for acute ischemic stroke, leading to guideline-established benchmarks. Factors influencing care efficiency for intracerebral hemorrhage (ICH) are not well delineated. We sought to identify factors associated with early recognition of ICH and to assess the association between early recognition and completion of emergency care tasks., Methods: Consecutive patients with spontaneous ICH were enrolled in an observational cohort study conducted from 2009 to 2017 at an urban comprehensive stroke center, excluding patient transferred from other hospitals. We used stroke team activation as the indicator of early recognition and measured completion times for multiple ICH-relevant performance metrics including door to computed tomography (CT) acquisition and door to hemostatic medication initiation., Results: We studied 204 cases. All stroke-related performance times were faster in patients managed with stroke team activation compared to no activation, including quicker door to CT acquisition (median 24 versus 48 minutes, P < .001) and door to hemostatic medication initiation (63 versus 99 minutes, P = .005). These associations were confirmed in adjusted models. Stroke codes were activated in 43% of cases and were more likely in patients with shorter onset-to-arrival times, higher National Institutes of Health Stroke Scale scores, and higher Glasgow Coma Scale scores., Conclusions: Stroke team activation was associated with more rapid diagnostic and therapeutic interventions for patients with ICH, but activation did not occur in the majority of cases, implying absence of early recognition. A stroke team activation process improves care performance, but leveraging the advantages of existing systems will require improved triage tools to identify ICH in the acute setting., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Gastrostomy placement after intracerebral hemorrhage indicates the need for continued medical care and predicts patient dependence. Our objective was to determine the optimal machine learning technique to predict gastrostomy., Methods: We included 531 patients in a derivation cohort and 189 patients from another institution for testing. We derived and tested predictions of the likelihood of gastrostomy placement with logistic regression using the GRAVo score (composed of Glasgow Coma Scale ≤12, age >50 years, black race, and hematoma volume >30 mL), compared to other machine learning techniques (kth nearest neighbor, support vector machines, random forests, extreme gradient boosting, gradient boosting machine, stacking). Receiver Operating Curves (Area Under the Curve, [AUC]) between logistic regression (the technique used in GRAVo score development) and other machine learning techniques were compared. Another institution provided an external test data set., Results: In the external test data set, logistic regression using the GRAVo score components predicted gastrostomy (P < 0.001), however, with a lower AUC (0.66) than kth nearest neighbors (AUC 0.73), random forests (AUC 0.74), Gradient boosting machine (AUC 0.77), extreme gradient boosting (AUC 0.77), (P < 0.01 for all compared to logistic regression). Results from the internal test set were similar., Conclusions: Machine learning techniques other than logistic regression (eg, random forests, extreme gradient boost, and kth nearest neighbors) were significantly more accurate for predicting gastrostomy using the same independent variables. Machine learning techniques may assist clinicians in identifying patients likely to need interventions., (Copyright © 2018. Published by Elsevier Inc.)

Objective: We evaluated whether reduced platelet activity detected by point-of-care (POC) testing is a better predictor of hematoma expansion and poor functional outcomes in patients with intracerebral hemorrhage (ICH) than a history of antiplatelet medication exposure., Methods: Patients presenting with spontaneous ICH were enrolled in a prospective observational cohort study that collected demographic, clinical, laboratory, and radiographic data. We measured platelet activity using the PFA-100 (Siemens AG, Germany) and VerifyNow-ASA (Accumetrics, CA) systems on admission. We performed univariate and adjusted multivariate analyses to assess the strength of association between those measures and (1) hematoma growth at 24 hours and (2) functional outcomes measured by the modified Rankin Scale (mRS) at 3 months., Results: We identified 278 patients for analysis (mean age 65 ± 15, median ICH score 1 [interquartile range 0-2]), among whom 164 underwent initial neuroimaging within 6 hours of symptom onset. Univariate association with hematoma growth was stronger for antiplatelet medication history than POC measures, which was confirmed in multivariable models (β 3.64 [95% confidence interval [CI] 1.02-6.26], P = .007), with a larger effect size measured in the under 6-hour subgroup (β 7.20 [95% CI 3.35-11.1], P < .001). Moreover, antiplatelet medication history, but not POC measures of platelet activity, was independently associated with poor outcome at 3 months (mRS 4-6) in the under 6-hour subgroup (adjusted OR 3.6 [95% CI 1.2-11], P = .023)., Conclusion: A history of antiplatelet medication use better identifies patients at risk for hematoma growth and poor functional outcomes than POC measures of platelet activity after spontaneous ICH., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Some previously identified predictors of 30-day stroke readmission, including age and stroke severity, are nonmodifiable. We assessed the hypothesis that in-hospital medical complications, which are potentially modifiable, after ischemic stroke (IS) and transient ischemic attack (TIA) predict 30-day readmission., Methods: In a single-center prospective cohort study of IS and TIA patients admitted from August 1, 2012, to July 31, 2013, we identified those who survived to 30-day follow-up or died during a readmission within 30 days. Patients readmitted within 30 days of discharge were identified by telephone assessment and review of hospital records. We evaluated the association between 12 prespecified and prospectively collected poststroke medical complications and 30-day readmission adjusting for baseline characteristics, in-hospital course and treatments, and discharge status using univariable and multivariable Cox proportional hazards models., Results: Among 505 patients, 107 (21.2%) patients had at least 1 medical complication during hospitalization. The most common complications were urinary tract infection (8.7%), venous thromboembolism (6.1%), and pneumonia (4.6%). Seventy-eight (15.4%) patients were readmitted within 30 days. On multivariable Cox proportional hazards analysis, cardioembolic or large-artery atherosclerotic subtype (adjusted hazard ratio [HR], 1.82; 95% confidence interval [CI], 1.17-2.83) and any medical complication (adjusted HR, 1.68; 95% CI, 1.04-2.73) increased the risk of 30-day readmission. Among the 24 readmitted patients who experienced an initial medical complication, 10 (41.6%) were considered potentially preventable., Conclusions: The occurrence of medical complications after IS or TIA increased the risk of 30-day all-cause readmission. Stroke patients with medical complications may be suitable for targeted interventions to prevent readmissions., (Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: We sought to determine whether a quantitative neurocheck biomarker could characterize the temporal pattern of early neurologic changes after intracerebral hemorrhage (ICH), and the impact of those changes on long-term functional outcomes., Methods: We enrolled cases of spontaneous ICH in a prospective observational study. Patients underwent a baseline Glasgow Coma Scale (GCS) assessment, then hourly neurochecks using the GCS in a neuroscience intensive care unit. We identified a period of heightened neurologic instability by analyzing the average hourly rate of GCS change over 5 days from symptom onset. We used a multivariate regression model to test whether those early GCS score changes were independently associated with 3-month outcome measured by the modified Rankin Scale (mRS)., Results: We studied 13,025 hours of monitoring from 132 cases. The average rate of neurologic change declined from 1.0 GCS points per hour initially to a stable baseline of .1 GCS points per hour beyond 12 hours from symptom onset (P < .05 for intervals before 12 hours). Change in GCS score within the initial 12 hours was an independent predictor of mRS at 3 months (odds ratio, .81 [95% confidence interval, .66-.99], P = .043) after adjustment for age, hematoma volume, hematoma location, initial GCS, and intraventricular hemorrhage., Conclusions: Neurochecks are effective at detecting clinically important neurologic changes in the intensive care unit setting that are relevant to patients' long-term outcomes. The initial 12 hours is a period of frequent and prognostically important neurologic changes in patients with ICH., (Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Seizures are common in patients with subarachnoid hemorrhage, potentially by inciting cortical irritability. Seizures are also commonly seen after intracerebral hemorrhage (ICH), although the mechanisms and risk factors within that population are not well understood. The objective of this study is to evaluate whether subarachnoid hemorrhage extension (SAHE) is associated with early seizures in patients with primary ICH., Methods: Patients with primary ICH were enrolled into a prospective registry between December 2006 and July 2012. Patients were managed per a structured protocol. SAHE was identified on imaging by expert reviewers blinded to outcomes. Electroencephalograms were routinely obtained in patients with unexplained, poor level of arousal. Seizure was determined by clinically observed convulsions or traditional electroencephalographic criteria. Early seizures were defined as occurring within 3 days of hemorrhage. A binary logistic regression model was developed to test whether the occurrence of SAHE was independently associated with seizures., Results: A total of 234 patients were studied. Of these, 93 (40%) had SAHE and 9 (4%) had early seizures. SAHE was associated with early seizures (P = .03). No additional variables were identified by regression modeling to mediate the association between SAHE and early seizures (odds ratio 5.62 [95% confidence interval 1.14-27.7], P = .034)., Conclusions: SAHE is associated with early seizures in patients with primary ICH. Further study is needed to confirm these findings and determine whether modifications to routine care based on the presence of SAHE would be of benefit., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Intraventricular hemorrhage (IVH) may be difficult to detect especially when in small amounts and may affect outcomes. The objective of this study was to compare the sensitivity of magnetic resonance imaging (MRI) vs computed tomography (CT) for the identification and quantification of IVH., Methods: Patients with primary intracerebral hemorrhage were enrolled into a prospective registry between December 2006 and June 2013. Diagnostic and surveillance neuroimaging studies were analyzed for the presence of IVH and quantified by Graeb score. In subjects who developed IVH and underwent both MRI and CT, each MRI was paired with the CT scan done at the closest time point, and Graeb scores were compared with the Wilcoxon signed rank test for related samples., Results: There were 289 subjects in the cohort with IVH found in 171. Sixty-eight pairs of MRI and CT were available for comparison. CT failed to detect IVH in 3% of cases, whereas MRI was 100% sensitive. MRI and CT yielded equal Graeb scores in 72% of the pairs, and MRI Graeb score was higher in 24% (P = .007)., Conclusions: MRI identifies small volumes of IVH in cases not detected by CT and yields higher estimates of intraventricular blood volume. These data indicate that consideration of technical differences is needed when comparing images from the 2 modalities in the evaluation for IVH., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)