Higher low-density lipoprotein cholesterol levels are associated with decreased mortality in patients with intracerebral hemorrhage.

BACKGROUND AND AIMS: The relationship between lipoprotein levels, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and clinical outcome after intracerebral hemorrhage (ICH) remains controversial. We sought to evaluate the association of lipoprotein cholesterol levels and statin dosage with clinical and neuroimaging outcomes in patients with ICH. METHODS: Data on consecutive patients hospitalized with spontaneous acute ICH was prospectively collected over a 5-year period and retrospectively analyzed. Demographic characteristics, clinical severity documented by NIHSS-score and ICH-score, neuroimaging parameters, pre-hospital statin use and doses, and LDL-C and HDL-C levels were recorded. Outcome events characterized were hematoma volume, hematoma expansion, in-hospital functional outcome, and in-hospital mortality. RESULTS: A total of 672 patients with acute ICH [(mean age 61.6 ± 14.0 years, 43.6% women, median ICH score 1 (IQR: 0-2)] were evaluated. Statin pretreatment was not associated with neuroimaging or clinical outcomes. Higher LDL-C levels were associated with several markers of poor clinical outcome and in-hospital mortality. LDL-C levels were independently and negatively associated with the cubed root of hematoma volume (linear regression coefficient -0.021, 95% CI: -0.042--0.001; p = 0.049) on multiple linear regression models. Higher admission LDL-C (OR 0.88, 95% CI 0.77-0.99; p = 0.048) was also an independent predictor for decreased hematoma expansion. Higher admission LDL-C levels were independently (p < 0.001) associated with lower likelihood of in-hospital mortality (OR per 10 mg/dL increase 0.68, 95% CI: 0.57-0.80) in multivariable logistic regression models. CONCLUSIONS: Higher LDL-C levels at hospital admission were an independent predictor for lower likelihood of hematoma expansion and decreased in-hospital mortality in patients with acute spontaneous ICH. This association requires independent confirmation.

Serum Magnesium Levels and Outcomes in Patients With Acute Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Magnesium (Mg) has potential hemostatic properties. We sought to investigate the potential association of serum Mg levels (at baseline and at 48 hours) with outcomes in patients with acute spontaneous intracerebral hemorrhage (ICH). METHODS AND RESULTS: We reviewed data on all patients with spontaneous ICH with available Mg levels at baseline, over a 5-year period. Clinical and radiological outcome measures included initial hematoma volume, admission National Institutes of Health Stroke Scale and ICH scores, in-hospital mortality, favorable functional outcome (modified Rankin Scale scores, 0-1), and functional independence (modified Rankin Scale scores, 0-2) at discharge. Our study population consisted of 299 patients with ICH (mean age, 61±13 years; mean admission serum Mg, 1.8±0.3 mg/dL). Increasing admission Mg levels strongly correlated with lower admission National Institutes of Health Stroke Scale score (Spearman's r, -0.141; P=0.015), lower ICH score (Spearman's r, -0.153; P=0.009), and lower initial hematoma volume (Spearman's r, -0.153; P=0.012). Higher admission Mg levels were documented in patients with favorable functional outcome (1.9±0.3 versus 1.8±0.3 mg/dL; P=0.025) and functional independence (1.9±0.3 versus 1.8±0.3 mg/dL; P=0.022) at discharge. No association between serum Mg levels at 48 hours and any of the outcome variables was detected. In multiple linear regression analyses, a 0.1-mg/dL increase in admission serum Mg was independently and negatively associated with the cubed root of hematoma volume at admission (regression coefficient, -0.020; 95% confidence interval, -0.040 to -0.000; P=0.049) and admission ICH score (regression coefficient, -0.053; 95% confidence interval, -0.102 to -0.005; P=0.032). CONCLUSIONS: Higher admission Mg levels were independently related to lower admission hematoma volume and lower admission ICH score in patients with acute spontaneous ICH.

Evaluation of Acute Kidney Injury and Mortality After Intensive Blood Pressure Control in Patients With Intracerebral Hemorrhage.

BACKGROUND: We sought to assess the risk of acute kidney injury (AKI) and mortality associated with intensive systolic blood pressure reduction in acute intracerebral hemorrhage. METHODS AND RESULTS: Patients with acute intracerebral hemorrhage had spontaneous cause and symptom onset within 24 hours. We excluded patients with structural causes, coagulopathy, thrombocytopenia, and preexisting end-stage renal disease. We defined AKI using the Acute Kidney Injury Network criteria. Chronic kidney disease status was included in risk stratification and was defined by Kidney Disease Outcomes Quality Initiative staging. Maximum systolic blood pressure reduction was defined over a 12-hour period and dichotomized using receiver operating characteristic curve analysis. Descriptive statistics were done using independent sample t tests, χ2 tests, and Mann-Whitney U tests, whereas multivariable logistic regression analysis was used to evaluate for predictors for AKI and mortality. A total of 448 patients with intracerebral hemorrhage met inclusion criteria. Maximum systolic blood pressure reduction was dichotomized to 90 mm Hg and found to increase the risk of AKI in patients with normal renal function (odds ratio, 2.1; 95% confidence interval, 1.19-3.62; P=0.010) and chronic kidney disease (odds ratio, 3.91; 95% confidence interval, 1.26-12.15; P=0.019). The risk of AKI was not significantly different in normal renal function versus chronic kidney disease groups when adjusted for demographics, presentation characteristics, and medications associated with AKI. AKI positively predicted mortality for patients with normal renal function (odds ratio, 2.41; 95% confidence interval, 1.11-5.22; P=0.026) but not for patients with chronic kidney disease (odds ratio, 3.13; 95% confidence interval, 0.65-15.01; P=0.154). CONCLUSIONS: These results indicate that intensive systolic blood pressure reduction with a threshold >90 mm Hg in patients with acute intracerebral hemorrhage may be an independent predictor for AKI.

Sulfonylurea drug pretreatment and functional outcome in diabetic patients with acute intracerebral hemorrhage.

PURPOSE: Intracerebral hemorrhage (ICH) is associated with poor clinical outcome and high mortality. Sulfonylurea (SFU) use may be a viable therapy for inhibiting sulfonylurea receptor-1 and NCCa-ATP channels and reducing perihematomal edema and blood-brain barrier disruption. We sought to evaluate the effects of prehospital SFU use with outcomes in diabetic patients with acute ICH. METHODS: We retrospectively analyzed a cohort of diabetic patients presenting with acute ICH at a tertiary care center. Study inclusion criteria included spontaneous ICH etiology and age>18years. Baseline clinical severity was documented using ICH-score. Hematoma volumes (HV) on admission were calculated using ABC/2 formula. Unfavorable functional outcome was documented as discharge modified Rankin Scale scores 2-6. RESULTS: 230 diabetic patients with acute ICH fulfilled inclusion criteria (mean age 64±13years, men 53%). SFU pretreatment was documented in 16% of the study population. Patients with SFU pretreatment had significantly (p<0.05) lower median ICH-scores (0, IQR: 0-2) and median admission HV (4cm3, IQR: 1-12) compared to controls [ICH-score: 1 (IQR: 0-3); HV: 9cm3 (IQR: 3-20)]. SFU pretreatment was independently (p=0.033) and negatively associated with the cubed root of admission HV (linear regression coefficient: -0.208; 95%CI: -0.398 to -0.017) in multiple linear regression analyses adjusting for potential confounders. Pretreatment with SFU was also independently (p=0.033) associated with lower likelihood of unfavorable functional outcome (OR=0.19; 95%CI: 0.04-0.88) in multivariable logistic regression models adjusting for potential confounders. CONCLUSION: SFU pretreatment may be an independent predictor for improved functional outcome in diabetic patients with acute ICH. This association requires independent confirmation in a large prospective cohort study.

Elevated Pulse Pressure Levels Are Associated With Increased In-Hospital Mortality in Acute Spontaneous Intracerebral Hemorrhage.

OBJECTIVES: Clinical outcome after intracerebral hemorrhage (ICH) remains poor. Definitive phase-3 trials in ICH have failed to demonstrate improved outcomes with intensive systolic blood pressure (SBP) lowering. We sought to determine whether other BP parameters-diastolic BP (DBP), pulse pressure (PP), and mean arterial pressure (MAP)-showed an association with clinical outcome in ICH. METHODS: We retrospectively analyzed a prospective cohort of 672 patients with spontaneous ICH and documented demographic characteristics, stroke severity, and neuroimaging parameters. Consecutive hourly BP recordings allowed for computation of SBP, DBP, PP, and MAP. Threshold BP values that transitioned patients from survival to death were determined from ROC curves. Using in-hospital mortality as outcome, BP parameters were evaluated with multivariable logistic regression analysis. RESULTS: Patients who died during hospitalization had higher mean PP compared to survivors (68.5 ± 16.4 mm Hg vs. 65.4 ± 12.4 mm Hg; P = 0.032). The following admission variables were associated with significantly higher in-hospital mortality (P < 0.001): poorer admission clinical condition, intraventricular hemorrhage, and increased admission normalized hematoma volume. ROC analysis showed that mean PP dichotomized at 72.17 mm Hg, provided a transition point that maximized sensitivity and specific for mortality. The association of this increased dichotomized PP with higher in-hospital mortality was maintained in multivariable logistic regression analysis (odds ratio, 3.0; 95% confidence interval, 1.7-5.3; P < 0.001) adjusting for potential confounders. CONCLUSION: Widened PP may be an independent predictor for higher mortality in ICH. This association requires further study.

Admission systolic blood pressure and outcomes in large vessel occlusion strokes treated with endovascular treatment.

BACKGROUND AND PURPOSE: High admission blood pressure (BP) levels have been associated with lower recanalization rates after endovascular treatment (EVT) for patients with acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). We sought to evaluate the association of admission BP with early outcomes in patients with ELVO treated with EVT. METHODS: Consecutive patients with AIS presenting with ELVO in a tertiary stroke center during a 4-year period were prospectively evaluated. Admission systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using automated cuff recordings. A blinded neuroradiologist calculated the final infarct volume (FIV) using standardized ABC/2 methodology. A favorable functional outcome (FFO) at 3 months was defined as modified Rankin Scale score of 0-2. RESULTS: Our study population consisted of 116 patients with AIS (mean age 63±13 years, median NIH Stroke Scale score 17 points (IQR 14-21), median FIV 30 cm3 (IQR 8-94)). Higher admission SBP correlated with higher FIV (r +0.225; p=0.020). Patients with FFO had lower admission SBP (151±24 mm Hg vs 165±28 mm Hg; p=0.010), while admission SBP levels were higher in patients who died during hospitalization (169±34 mm Hg vs 156±24 mm Hg; p=0.043). A 10 mm Hg increment in admission SBP was independently (p=0.010) associated with an increase of 12 cm3 in FIV (95% CI 3 to 21) in multiple linear regression models adjusting for potential confounders. A 10 mm Hg increment in admission SBP was independently (p=0.012) associated with a lower likelihood of FFO at 3 months (OR 0.64; 95% CI 0.45 to 0.91) in multiple logistic regression models adjusting for potential confounders. CONCLUSIONS: Higher admission SBP is an independent predictor of increased FIV and lower likelihood of 3-month FFO in patients with ELVO treated with EVT.