Stress hyperglycemia is associated with longer ICU length of stay after endoscopic intracerebral hemorrhage evacuation.

BACKGROUND: Stress hyperglycemia has been linked to poor outcomes in intracerebral hemorrhage (ICH). Recent studies using the ratio of blood glucose to glycated hemoglobin (HbA1c) as a marker for stress hyperglycemia have demonstrated greater discriminative power in predicting poor outcomes for stroke inpatients compared to blood glucose alone. Therefore, we aimed to investigate whether the preoperative glucose-to-HbA1c ratio is a predictor of postoperative outcomes in patients who have undergone minimally invasive ICH evacuation. METHODS: Retrospective chart review was performed on ICH patients treated with minimally invasive surgery (MIS) in a single health system from 2015 to 2022. Stress hyperglycemia was defined as preoperative glucose-to-HbA1c ratio > calculated-median. Postoperative outcomes including modified Rankin Score (mRS) and length of stay (LOS) were collected. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. RESULTS: Of 192 patients who underwent minimally invasive ICH evacuation and had available glucose data, 96 demonstrated stress hyperglycemia (glucose-to-HbA1c ratio > 1.23). Patients with stress hyperglycemia were more likely to have a history of diabetes (43 % vs. 27 %, p=0.034), IVH (54 % vs. 33 %, p=0.007), higher preoperative hematoma volumes (46.8 ml vs. 38.6 mL, p=0.02), higher postoperative hematoma volumes (6 ml vs. 2.9 mL, p=0.008), smaller evacuation percentages (86.7 % vs. 92.7 %, p=0.048), longer procedure lengths (2.78 hrs vs. 2.23 hrs, p=0.015), and prolonged ICU LOS (9.44 days vs. 5.68 days, p=0.003). In a multivariate analysis, stress hyperglycemia remained predictive of prolonged ICU LOS (OR=2.44; p=0.026) when controlling for initial NIHSS, IVH, time to evacuation, procedure time, and diabetes. CONCLUSIONS: Stress hyperglycemia was strongly associated with prolonged ICU LOS after MIS for ICH. Understanding factors associated with LOS may provide predictive value for a patient's hospital course after minimally invasive ICH evacuation and further guide clinician expectations of recovery.

Antithrombotics alter intracerebral hemorrhage presentation without affecting minimally invasive endoscopic evacuation.

OBJECTIVES: Intracerebral hemorrhages are associated with significant morbidity and mortality. While the ENRICH trial supports the efficacy of surgical evacuation for lobar hemorrhages, the impact of antithrombotic therapies on minimally invasive surgery outcomes remains unexplored. This study evaluates the effects of chronic anticoagulants and antiplatelets on the technical and longterm outcomes of minimally invasive intracerebral hemorrhage evacuation. MATERIALS AND METHODS: A prospectively collected registry of patients undergoing minimally invasive surgery for intracerebral hemorrhage from a single institution was analyzed (December 2015-September 2022). Data included key demographics, comorbidities, antithrombotic/reversal status, presenting clinical/radiographic characteristics, procedural metrics, and clinical outcomes. Patients were divided into control (neither therapy), antiplatelet-only, and anticoagulant-only groups, with antiplatelet/anticoagulant reversals conducted per current American Heart Association/American Stroke Association guidelines. Variables significant in univariate analyses (p<0.05) were advanced to multivariable regression models. RESULTS: Among 226 intracerebral hemorrhage patients treated with minimally invasive surgery, 41% (N=93) had antithrombotic medication history; 28% (N=64) received antiplatelets, and 9% (N=21) received anticoagulants. Patients on both therapies (N=6) were excluded. The antiplatelet group presented more frequently with lobar hemorrhages (56% vs. 37%; p=0.022), while patients on anticoagulants showed increased rates of intraventricular hemorrhage co-presentation (62% vs. 46%; p=0.011) compared to controls. Despite univariate analyses showing a higher postoperative hematoma volume (3.9 vs. 2.9 milliliters; p=0.020) and lower evacuation percentage (88% vs. 92%; p=0.019) for the antiplatelet group, and longer procedures for patients on anticoagulants (2.3 vs. 1.7 hours; p=0.042) compared to control, multivariable analyses indicated that antiplatelets and anticoagulants had no significant impact on these technical outcomes. Longitudinally, antithrombotics were not associated with increased rebleeding, less frequent discharge to home, lower 30-day mortality, or worse, 6-month Modified Rankin Scale scores. CONCLUSIONS: Patients on chronic antiplatelets and anticoagulants exhibited characteristic intracerebral hemorrhage phenotypes without worse technical or long-term outcomes after minimally invasive intracerebral hemorrhage evacuation, suggesting the procedure's safety for these patients.

Anesthesia modality in endovascular treatment for distal medium vessel occlusion stroke: intention-to-treat propensity score-matched analysis.

BACKGROUND: The optimal anesthesia modality during endovascular treatment (EVT) for distal medium vessel occlusion (DMVO) stroke is uncertain. We aimed to evaluate the association of the anesthesia modality with procedural and clinical outcomes following EVT for DMVO stroke. METHODS: This is a multicenter retrospective analysis of a prospectively collected database. Patients were included if they had DMVO involving the middle cerebral artery-M3/4, anterior cerebral artery-A2/3, or posterior cerebral artery-P1/P2-3, and underwent EVT. The cohort was divided into two groups, general anesthesia (GA) and non-general anesthesia (non-GA), and compared based on the intention-to-treat principle as primary analysis. We used propensity scores to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the 90-day modified Rankin Scale (mRS). Secondary outcomes included successful reperfusion, as well as excellent (mRS 0-1) and good (mRS 0-2) clinical outcomes at 90 days. Safety measures included procedural complications, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. RESULTS: Among 366 DMVO thrombectomies, 61 matched pairs were eligible for analysis. Median age and National Institutes of Health Stroke Scale score as well as other baseline demographic and clinical characteristics were balanced between both groups. The GA group had no difference in the overall degree of disability (common OR 1.19, 95% CI 0.52 to 2.86, P=0.67) compared with the non-GA arm. Likewise, the GA group had comparable rates of successful reperfusion (OR 2.38, 95% CI 0.80 to 7.07, P=0.12), good/excellent clinical outcomes (OR 1.14, 95% CI 0.44 to 2.96, P=0.79/(OR 0.65, 95% CI 0.24 to 1.81, P=0.41), procedural complications (OR 1.00, 95% CI 0.19 to 5.16, P>0.99), sICH (OR 3.24, 95% CI 0.83 to 12.68, P=0.09), and 90-day mortality (OR 1.43, 95% CI 0.48 to 4.27, P=0.52) compared with the non-GA group. CONCLUSIONS: In patients with DMVO, our study showed that GA and non-GA groups had similar procedural and clinical outcomes, as well as safety measures. Further larger controlled studies are warranted.