Effect of BMI on Central Arterial Reflected Wave Augmentation Index, Toe-Brachial Index, Brachial-Ankle Pulse Wave Velocity and Ankle-Brachial Index in Chinese Elderly Hypertensive Patients with Hemorrhagic Stroke.

BACKGROUND: Hypertensive cerebral hemorrhage seriously endangers the health of the elderly. However, the relationship between obesity and arterial elasticity in hypertensive cerebral hemorrhage remains to be clarified. The purpose of our study is to explore the associations between body mass index (BMI) and central arterial reflected wave augmentation index (cAIx), toe-brachial index (TBI), brachial-ankle pulse wave velocity (baPWV), and ankle-brachial index (ABI) in the elderly hypertensive patients with hemorrhagic stroke. MATERIALS AND METHODS: A total of 502 elderly hypertensive patients with hemorrhagic stroke and 100 healthy controls were collected. According to the BMI, patients were divided into normal BMI, overweight, obesity, and obese groups. The multivariate logistic regression model was used to establish a risk model for elderly hypertensive hemorrhagic stroke. RESULTS: Compared with the normal BMI group, systolic blood pressure (SBP), diastolic blood pressure (DBP), cAIx, and baPWV in the abnormal BMI group were significantly increased (P < 0.05), while TBI and ABI were significantly decreased (P < 0.05). Logistic regression showed that BMI (OR = 1.031, 95%CI: 1.009-1.262), cAIx (OR = 1.214, 95%CI: 1.105-1.964), TBI (OR = 0.913, 95%CI: 0.885-0.967), baPWV (OR = 1.344, 95%CI: 1.142-2.147), and ABI (OR = 0.896, 95%CI: 0.811-0.989) are important factors for the occurrence of hemorrhagic stroke in the elderly hypertensive patients. ROC curve analysis showed that the AUC of cAIx, TBI, baPWV, ABI, and BMI were 0.914, 0.797, 0.934, 0.833, and 0.608, respectively. The final prediction model of hemorrhagic stroke elderly hypertensive patients was Y(P)= 65.424 + 0.307(cAIx) - 13.831(TBI) + 0.012(baPWV) - 0.110(ABI) + 0.339(BMI). CONCLUSIONS: Obesity is associated with decreased arterial elasticity. Therefore, reasonable weight management of the elderly may be of great significance for reducing the risk of hemorrhagic stroke in patients with hypertension.

Association of Hypothyroidism with Hypertensive Intracerebral Hemorrhage: A Case-Control Study.

BACKGROUND: Hypothyroidism is widely thought to cause vascular endothelial disorders and atherosclerosis. The purpose of this study was to explore whether patients with hypertension and hypothyroidism may have a higher incidence of hypertensive intracerebral hemorrhage. METHODS: Cases of hypertensive intracerebral hemorrhage collected from the neurology department and neurosurgery department of our hospital from January 1, 2018, to December 31, 2018, were retrospectively collected. A case-control study was conducted on an equal number of patients with hypertension without hypertensive intracerebral hemorrhage randomly selected through age matching in the same period. The history of hypothyroidism and other common risk factors at admission was recorded. RESULTS: A total of 231 patients with hypertensive intracerebral hemorrhage were included and 231 patients with hypertension were selected for control subjects according to the age matching and random screening principles. Hypothyroidism was present in 54 patients (23.4%) and 33 matched controls (14.3%). Multivariate logistic regression analysis showed that hypothyroidism was an independent risk factor for hypertensive intracerebral hemorrhage (odds ratio, 2.29; 95% confidence interval, 1.38-3.79; P = 0.001). CONCLUSIONS: Hypothyroidism may be independently associated with hypertensive intracerebral hemorrhage. In view of the known pathophysiologic relationship between hypothyroidism and vascular endothelial dysfunction and atherosclerosis, further research and exploration are necessary.

Predicting Recurrent Hypertensive Intracerebral Hemorrhage: Derivation and Validation of a Risk-Scoring Model Based on Clinical Characteristics.

OBJECTIVE: To develop and validate a risk-scoring model for predicting recurrent hypertensive cerebral hemorrhage (RHCH) occurring within 1 year after initial hypertensive cerebral hemorrhage and to facilitate preemptive clinical intervention for the prevention of secondary hemorrhage. METHODS: Patient gender, age, blood pressure, Glasgow Coma Scale (GCS) score, location of cerebral hemorrhage, surgery, past medical history, blood biochemical parameters, and Glasgow Outcome Scale score were analyzed using logistic regression analysis to determine independent predictors of RHCH. A risk-scoring model was constructed by assigning coefficients to each predictor and validating it in another independent cohort. The accuracy of the model was then assessed by the area under the receiver operating characteristic curve (AUC), and the calibration ability of the model was assessed by the Hosmer-Lemeshow test. RESULTS: Of 520 patients in the derivation cohort, 38 developed RHCH within 1 year after discharge. Independent risk factors of RHCH were age >60 years; stage 3 hypertension at admission; GCS score 9-12 (admission); GCS score 3-8 (discharge); history of cerebral ischemic stroke, smoking, alcoholism; and plasma homocysteine (Hcy) level ≥10 µmol/L. The recurrence rates for the low-risk (0-13 points), intermediate-risk (14-26 points), and high-risk (27-39 points) groups were 1.73%, 6.11%, and 57.14%, respectively (P < 0.001). The corresponding rates in the validation cohort, of whom 10/107 (9.35%) developed RHCH, were 3.45%, 7.14%, and 71.43%, respectively (P < 0.001). The risk-scoring model showed good discrimination in both the derivation and validation cohorts, with an AUC of 0.802 versus 0.863. The model also showed good calibration ability (the Hosmer-Lemeshow P values of the two cohorts were 0.532 vs. 0.724). CONCLUSIONS: This model will help identify high-risk groups for RHCH in order to facilitate and improve preemptive clinical intervention.

Inflammation, edema and poor outcome are associated with hyperthermia in hypertensive intracerebral hemorrhages.

BACKGROUND AND PURPOSE: The deleterious effect of hyperthermia on intracerebral hemorrhage (ICH) has been studied. However, the results are not conclusive and new studies are needed to elucidate clinical factors that influence the poor outcome. The aim of this study was to identify the clinical factors (including ICH etiology) that influence the poor outcome associated with hyperthermia and ICH. We also tried to identify potential mechanisms involved in hyperthermia during ICH. METHODS: We conducted a retrospective study enrolling patients with non-traumatic ICH from a prospective registry. We used logistic regression models to analyze the influence of hyperthermia in relation to different inflammatory and endothelial dysfunction markers, hematoma growth and edema volume in hypertensive and non-hypertensive patients with ICH. RESULTS: We included 887 patients with ICH (433 hypertensive, 50 amyloid, 117 by anticoagulants and 287 with other causes). Patients with hypertensive ICH showed the highest body temperature (37.5 ± 0.8°C) as well as the maximum increase in temperature (0.9 ± 0.1°C) within the first 24 h. Patients with ICH of hypertensive etiologic origin, who presented hyperthermia, showed a 5.3-fold higher risk of a poor outcome at 3 months. We found a positive relationship (r = 0.717, P < 0.0001) between edema volume and hyperthermia during the first 24 h but only in patients with ICH of hypertensive etiologic origin. This relationship seems to be mediated by inflammatory markers. CONCLUSION: Our data suggest that hyperthermia, together with inflammation and edema, is associated with poor outcome only in ICH of hypertensive etiology.

Common variants of ROCKs and the risk of hypertension, and stroke: Two case-control studies and a follow-up study in Chinese Han population.

The Rho kinases (ROCKs) are recognized as a critical regulator of vascular functions in cardiovascular disorders. It is crucial to illustrate the association of ROCKs genetic variation and hypertension and/or stroke events. Herein we aimed at investigating the association of ROCK1 and ROCK2 with hypertension and stroke in Chinese Han population. Seven tagSNPs at ROCK1 and ROCK2 were genotyped in a community-based case-control study consisting of 2012 hypertension cases and 2210 normotensive controls and 4128 subjects were further followed up. In stroke case-control study, 1471 ischemic stroke (IS) inpatients and 607 hemorrhagic stroke (HS) inpatients were collected, and 2443 age-matched controls were selected from the follow-up population. Risks were estimated as odds ratio (OR) and hazard ratio (HR) by logistic and Cox regression. The community-based case-control study didn't identify any significant tagSNPs associated with hypertension even after adjustment for covariates. The follow-up analysis showed that rs1481280 of ROCK1 significantly associated with incident hypertension (HR=1.130, P=0.048) after adjusting for covariates. rs7589629 and rs978906 of ROCK2 were significantly associated with incident IS (HR=1.373, P=0.004; HR=1.284, P=0.026) respectively. In stroke case-control study, rs288980, rs1481280 and rs7237677 were significantly associated with IS and the adjusted ORs (P values) of additive model were 0.879 (0.010), 0.895 (0.036) and 0.857 (0.002) respectively. Furthermore, rs288980, rs7237677 and rs978906 were significantly associated with HS and the adjusted ORs (P values) of additive model were 0.857 (0.025), 0.848 (0.018) and 0.856 (0.027) respectively. Our findings suggest that ROCK1 and ROCK2 contribute to the genetic susceptibility of hypertension and stroke.

Climatic and Seasonal Circumstances of Hypertensive Intracerebral Hemorrhage in a Worldwide Cohort.

BACKGROUND AND PURPOSE: Numerous studies have investigated the influence of meteorologic factors and seasons on the incidence of spontaneous intracerebral hemorrhage (ICH) with ambiguous results. In the present study, data from a large, international multicenter trial in patients with ICH were used to identify seasonal and meteorologic determinants for hypertensive-ICH with greater applicability. METHODS: Patients were grouped according to the presumptive ICH cause, that is, hypertensive when located in the basal ganglia brain stem as well as cerebellum and nonhypertensive when located lobar. Both groups were compared with regard to air temperature and air pressure and their occurrence during the year. A regression analysis was performed to identify independent predictors of hypertensive-ICH. RESULTS: Only hypertensive-ICH showed a seasonal pattern and occurred with higher air pressure values and at younger age. Independent predictors of hypertensive-ICH were increased air pressure on the actual day of the event and younger age as well as higher temperature. CONCLUSIONS: In the present study with an international cohort, besides age air pressure, more than temperature, had an influence on the occurrence of hypertensive-ICH, only.

Untreated Hypertension: A Powerful Risk Factor for Lobar and Nonlobar Intracerebral Hemorrhage in Whites, Blacks, and Hispanics.

BACKGROUND: Hypertension is a significant risk factor for intracerebral hemorrhage (ICH). Although ethnic/racial disparities related to hypertension and ICH have been reported, these previous studies were limited by a lack of Hispanics and inadequate power to analyze by ICH location. In the current study, while overcoming these prior limitations, we investigated whether there was variation by ethnicity/race of treated and untreated hypertension as risk factors for ICH. METHODS: The ERICH study (Ethnic/Racial Variations of Intracerebral Hemorrhage) is a prospective, multicenter, case-control study of ICH among whites, blacks, and Hispanics. Cases were enrolled from 42 recruitment sites. Controls matched to cases 1:1 by age (±5 years), sex, ethnicity/race, and metropolitan area were identified by random-digit dialing. Subjects were interviewed to determine history of hypertension and use of antihypertensive medications. Cases and controls within ethnic groups were compared by using conditional logistic regression. Multivariable conditional logistic regression models were computed for ICH as an overall group and separately for the location subcategories deep, lobar, and infratentorial (brainstem/cerebellar). RESULTS: Nine hundred fifty-eight white, 880 black, and 766 Hispanic ICH patients were enrolled. For ICH cases, untreated hypertension was higher in blacks (43.6%, P<0.0001) and Hispanics (46.9%, P<0.0001) versus whites (32.7%). In multivariable analyses adjusted for alcohol use, anticoagulation, hypercholesterolemia, education, and medical insurance status, treated hypertension was a significant risk factor across all locations of ICH in whites (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.24-1.98; P<0.0001), blacks (OR, 3.02; 95% CI, 2.16-4.22; P<0.0001), and Hispanics (OR, 2.50; 95% CI, 1.73-3.62; P<0.0001). Untreated hypertension was a substantially greater risk factor for all 3 racial/ethnic groups across all locations of ICH: whites (OR, 8.79; 95% CI, 5.66-13.66; P<0.0001), blacks (OR, 12.46; 95% CI, 8.08-19.20; P<0.0001), and Hispanics (OR, 10.95; 95% CI, 6.58-18.23; P<0.0001). There was an interaction between race/ethnicity and ICH risk (P<0.0001). CONCLUSIONS: Untreated hypertension confers a greater ICH risk in blacks and Hispanics relative to whites across all anatomic locations of ICH. Accelerated research efforts are needed to improve overall hypertension treatment rates and to monitor the impact of such efforts on racial/ethnic disparities in stroke. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01202864.

A Community-Based Study of the Correlation of Hemorrhagic Stroke Occurrence with Meteorologic Factors.

BACKGROUND: Meteorologic variations may affect hemorrhagic stroke. Thus, the aim of this study was to explore the correlation of daily meteorologic factors with increased incidence of hypertensive intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) in a community-based study. METHODS: In a span of 2 years, 735 patients suffering from hypertensive ICH or SAH were enrolled in the study in Fularji District, Heilongjiang Province, China. Daily meteorologic data were obtained from the Bureau of Meteorology of Qiqihar. Daily meteorologic parameters with and without events were compared with hypertensive ICH and SAH, respectively. Logistic regression was used to assess the correlation of meteorologic factors with hypertensive ICH and SAH. RESULTS: Daily mean ambient temperature (AT) was statistically associated with the onset of primary hypertensive ICH (odds ratio [OR], .983; P < .001) and SAH (OR, .984; P = .046). After adjustment with AT variations, the occurrence of primary hypertensive ICH was not only influenced by daily mean AT (P = .0004) but also by the interaction between the mean temperature and its variation (P = .0082). Interestingly, there was no statistical association between meteorologic factors and recurrent hypertensive ICH. CONCLUSIONS: The higher incidence of primary hypertensive ICH in the late spring and early autumn was because of the influence of daily mean AT and its variation. When temperature changed, suddenly dropping in the hot weather or rising in the cold weather, the incidence of primary hypertensive ICH was also increased. Conversely, the incidence of SAH increased during days with lower temperature.

Increased Risk of Intracranial Hemorrhage in Patients With Pregnancy-Induced Hypertension: A Nationwide Population-Based Retrospective Cohort Study.

Pregnancy-induced hypertension (PIH) may be a major predictor of pregnancy-associated intracranial hemorrhage (ICH). However, the relationship between PIH and long-term ICH risk is unknown.The objective of the study was to determine the association between PIH and ICH and to identify the predictive risk factors.Patients with newly diagnosed PIH were recruited from the Taiwan National Health Insurance Research Database. PIH patients were divided into gestational hypertension (GH) and preeclampsia groups. The 2 groups were separately compared with matched cohorts of patients without PIH based on age and date of delivery. The occurrence of ICH was evaluated in both cohorts. The overall observational period was from January 1, 2000 to December 31, 2013.Among the 23.3 million individuals registered in the National Health Insurance Research Database, 28,346 PIH patients, including 7390 with GH and 20,956 with preeclampsia, were identified. The incidences of ICH were increased in both groups (incidence rate ratio [IRR] = 3.72 in the GH group, 95% confidence interval [CI] 3.63-3.81, P < 0.0001 and IRR = 8.21 in the preeclampsia group, 95% CI 8.12-8.31, P < 0.0001, respectively). In addition, according to the results of stratification of follow-up years, both groups were associated with a highest risk of ICH at 1 to 5 years of follow-up (IRR = 11.99, 95% CI 11.16-12.88, P < 0.0001 and IRR = 21.83, 95% CI 21.24-22.44, P < 0.0001, respectively). After adjusting for age, parity, severity of PIH, number of PIH occurrences, gestational age, and comorbidities in the multivariate survival analysis using Cox regression model, age ≥30 years (hazard ratio [HR] 1.99, 95% CI 1.27-3.10, P = 0.0026), patients with preeclampsia (HR 2.18, 95% CI 1.22-3.90, P = 0.0089), multiple PIH occurrences (HR 4.08, 95% CI 1.85-9.01, P = 0.0005), hypertension (HR 4.51, 95% CI 1.89-10.74, P = 0.0007), and obesity (HR 7.21, 95% CI 1.58-32.84, P = 0.0107) were independent risk factors for the development of ICH among patients with PIH.Patients with PIH, especially those with older age, preeclampsia, and multiple PIH occurrences, may have an increased risk of developing ICH later in life.

Gastroschisis: epidemiology and mode of delivery, 2005-2013.

BACKGROUND: Gastroschisis is a severe congenital anomaly the etiology of which is unknown. Research evidence supports attempted vaginal delivery for pregnancies complicated by gastroschisis in the absence of obstetric indications for cesarean delivery. OBJECTIVE: The objectives of the study evaluating pregnancies complicated by gastroschisis were to determine the proportion of women undergoing planned cesarean vs attempted vaginal delivery and to provide up-to-date epidemiology on the risk factors associated with this anomaly. STUDY DESIGN: This population-based study of US natality records from 2005 through 2013 evaluated pregnancies complicated by gastroschisis. Women were classified based on whether they attempted vaginal delivery or underwent a planned cesarean (n = 24,836,777). Obstetrical, medical, and demographic characteristics were evaluated. Multivariable log-linear regression models were developed to determine the factors associated with the mode of delivery. Factors associated with the occurrence of the anomaly were also evaluated in log-linear models. RESULTS: Of 5985 pregnancies with gastroschisis, 63.5% (n = 3800) attempted vaginal delivery and 36.5% (n = 2185) underwent a planned cesarean delivery. The rate of attempted vaginal delivery increased from 59.7% in 2005 to 68.8% in 2013. Earlier gestational age and Hispanic ethnicity were associated with lower rates of attempted vaginal delivery. Factors associated with the occurrence of gastroschisis included young age, smoking, high educational attainment, and being married. Protective factors included chronic hypertension, black race, and obesity. The incidence of gastroschisis was 3.1 per 10,000 pregnancies and did not increase during the study period. CONCLUSION: Attempted vaginal delivery is becoming increasingly prevalent for women with a pregnancy complicated by gastroschisis. Recommendations from the research literature findings may be diffusing into clinical practice. A significant proportion of women with this anomaly still deliver by planned cesarean, suggesting further reduction of surgical delivery for this anomaly is possible.

Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people.

BACKGROUND: The associations of blood pressure with the different manifestations of incident cardiovascular disease in a contemporary population have not been compared. In this study, we aimed to analyse the associations of blood pressure with 12 different presentations of cardiovascular disease. METHODS: We used linked electronic health records from 1997 to 2010 in the CALIBER (CArdiovascular research using LInked Bespoke studies and Electronic health Records) programme to assemble a cohort of 1·25 million patients, 30 years of age or older and initially free from cardiovascular disease, a fifth of whom received blood pressure-lowering treatments. We studied the heterogeneity in the age-specific associations of clinically measured blood pressure with 12 acute and chronic cardiovascular diseases, and estimated the lifetime risks (up to 95 years of age) and cardiovascular disease-free life-years lost adjusted for other risk factors at index ages 30, 60, and 80 years. This study is registered at ClinicalTrials.gov, number NCT01164371. FINDINGS: During 5·2 years median follow-up, we recorded 83,098 initial cardiovascular disease presentations. In each age group, the lowest risk for cardiovascular disease was in people with systolic blood pressure of 90-114 mm Hg and diastolic blood pressure of 60-74 mm Hg, with no evidence of a J-shaped increased risk at lower blood pressures. The effect of high blood pressure varied by cardiovascular disease endpoint, from strongly positive to no effect. Associations with high systolic blood pressure were strongest for intracerebral haemorrhage (hazard ratio 1·44 [95% CI 1·32-1·58]), subarachnoid haemorrhage (1·43 [1·25-1·63]), and stable angina (1·41 [1·36-1·46]), and weakest for abdominal aortic aneurysm (1·08 [1·00-1·17]). Compared with diastolic blood pressure, raised systolic blood pressure had a greater effect on angina, myocardial infarction, and peripheral arterial disease, whereas raised diastolic blood pressure had a greater effect on abdominal aortic aneurysm than did raised systolic pressure. Pulse pressure associations were inverse for abdominal aortic aneurysm (HR per 10 mm Hg 0·91 [95% CI 0·86-0·98]) and strongest for peripheral arterial disease (1·23 [1·20-1·27]). People with hypertension (blood pressure ≥140/90 mm Hg or those receiving blood pressure-lowering drugs) had a lifetime risk of overall cardiovascular disease at 30 years of age of 63·3% (95% CI 62·9-63·8) compared with 46·1% (45·5-46·8) for those with normal blood pressure, and developed cardiovascular disease 5·0 years earlier (95% CI 4·8-5·2). Stable and unstable angina accounted for most (43%) of the cardiovascular disease-free years of life lost associated with hypertension from index age 30 years, whereas heart failure and stable angina accounted for the largest proportion (19% each) of years of life lost from index age 80 years. INTERPRETATION: The widely held assumptions that blood pressure has strong associations with the occurrence of all cardiovascular diseases across a wide age range, and that diastolic and systolic associations are concordant, are not supported by the findings of this high-resolution study. Despite modern treatments, the lifetime burden of hypertension is substantial. These findings emphasise the need for new blood pressure-lowering strategies, and will help to inform the design of randomised trials to assess them. FUNDING: Medical Research Council, National Institute for Health Research, and Wellcome Trust.

Quantification of Phase Values of Cerebral Microbleeds in Hypertensive Patients Using ESWAN MRI.

PURPOSE: The presence of cerebral microbleeds (CMBs) may have predictive and diagnostic value for cerebrovascular diseases. The purpose of our study was to measure the phase values (PVs) of CMBs by phase maps. METHODS: We retrospectively analyzed 75 patients with hypertension who had CMBs using enhanced T2*-weighted angiography (ESWAN). The PVs of CMBs were measured and documented. The mean PVs of CMBs were correlated with demographic features and the grade of white matter lesions for seven brain regions. RESULTS: A total of 275 CMBs were found. Their mean PV was - 1.39 ± 0.29 radians. The mean PV of CMBs in seven brain regions was significantly lower than that of red nucleus and substantia nigra of healthy controls (P < .05). The mean PV of CMBs in the basal ganglia gray matter was significantly lower than that of the brainstem, subcortical white matter, and cerebellum (P < 0.05). In subcortical white matter, the PVs were significantly lower in patients with hypertension < 10 years than for those patients with hypertension ≥ 10 years (P < 0.05). In basal ganglia gray matter, the PVs were significantly lower in men than in women (P < 0.05). There was no significant correlation between the PVs of CMBs and the demographic features addressed or the grade of white matter lesions. CONCLUSIONS: Measurement of the PV of phase maps using ESWAN sequence provides quantitative information for detection of CMBs. The measurement data reported herein will provide a reference for a longitudinal study of CMBs in the future.

Seasonal variation of stroke incidence in Japan for 35631 stroke patients in the Japanese Standard Stroke Registry, 1998-2007.

BACKGROUND: Seasonal variation of stroke incidence has been reported in many countries. The present study was designed to elucidate seasonal and monthly variations in the incidence of subtypes of acute ischemic stroke and hypertensive hemorrhagic stroke using the Japanese Standard Stroke Registry Study (JSSRS) database, which is currently the world's largest hospital-based stroke database, accumulating records from 163 Japanese institutions. METHODS: Among 47,782 patients with acute stroke registered with JSSRS between 1998 and 2007, we selected 35,631 for analysis (patients with ischemic or hemorrhagic stroke of unknown etiology were excluded). A simple moving average was used to examine monthly variation of stroke incidence. We also examined seasonal variation of ischemic stroke subtypes. RESULTS AND CONCLUSIONS: Monthly variation in incidence of all ischemic stroke was significant (P < .001). Noncardioembolic ischemic stroke was more frequent in summer than in winter (P < .001). Lacunar stroke showed higher incidence in summer than in winter (P < .001), although the increase did not reach significance for atherothrombotic stroke (P = .057). In contrast, cardioembolic stroke (P < .001) and hemorrhagic stroke (P < .001) occurred more frequently in winter than in summer. Hemorrhagic stroke showed a regional difference of incidence between northern and southern Japan. There is a temporal variation of stroke incidence in Japan, with different patterns of variation depending on stroke subtype. These findings may help in developing strategies for preventing stroke.

Systolic blood pressure lowering to 160 mmHg or less using nicardipine in acute intracerebral hemorrhage: a prospective, multicenter, observational study (the Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-Intracerebral Hemorrhage study).

OBJECTIVE: Optimal blood pressure (BP) control in acute intracerebral hemorrhage (ICH) remains controversial. We determined the effects of SBP lowering to 160 mmHg or more using intravenous nicardipine for acute ICH patients. METHODS: This is a prospective, multicenter, observational study conducted in Japan, with the lack of control groups. Patients with supratentorial ICH within 3 h of onset, admission SBP 180 mmHg or more, Glasgow Coma Scale (GCS) 5 or more, and hematoma volume less than 60 ml were initially treated with intravenous nicardipine to maintain SBP between 120 and 160 mmHg with 24-h frequent BP monitoring. The primary endpoints were neurological deterioration within 72 h [GCS decrement ≥ 2 points or National Institutes of Health Stroke Scale (NIHSS) increment ≥ 4 points; estimated 90% confidence interval (CI) on the basis of previous studies: 15.2-25.9%] and serious adverse effects (SAE) to stopping intravenous nicardipine within 24 h (1.8-8.9%). The secondary endpoints included hematoma expansion more than 33% at 24 h (17.1-28.3%), modified Rankin Scale (mRS) 4 or more (54.5-67.9%) and death at 3 months (6.0-13.5%). RESULTS: We enrolled 211 Japanese patients (81 women, 65.6 ± 12.0 years old). At baseline, BP was 201.8 ± 15.7/107.9 ± 15.0 mmHg. Median hematoma volume was 10.2 ml (interquartile range 5.6-19.2), and NIHSS score was 13 (8-17). Neurological deterioration was identified in 17 patients (8.1%), SAE in two (0.9%), hematoma expansion in 36 (17.1%), mRS 4 or more in 87 (41.2%), and death in four (1.9%). All the results were equal to or below the estimated lower 90% CI. CONCLUSION: SBP lowering to 160 mmHg or less using nicardipine appears to be well tolerated and feasible for acute ICH.

International epidemiology of intracerebral hemorrhage.

Intracerebral hemorrhage is the second most common subtype of stroke. In recent decades our understanding of intracerebral hemorrhage has improved. New risk factors have been identified; more knowledge has been obtained on previously known risk factors; and new imaging techniques allow for in vivo assessment of preclinical markers of intracerebral hemorrhage. In this review the latest developments in research on intracerebral hemorrhage are highlighted from an epidemiologic point of view. Special focus is on frequency, etiologic factors and pre-clinical markers of intracerebral hemorrhage.

Delayed intracerebral hemorrhage after uneventful embolization of brain arteriovenous malformations is related to volume of embolic agent administered: multivariate analysis of 13 predictive factors.

BACKGROUND: The mechanisms and management of delayed intracerebral hemorrhage (dICH) after treatment of brain arteriovenous malformations (AVMs) are poorly understood and widely debated. Many clinical predictive factors have been theorized for dICH after an otherwise uneventful AVM embolization, but there is an absence of data to discern their significance. OBJECTIVE: To analyze 13 proposed predictive factors and to assess their potential in guiding prevention strategies. METHODS: One hundred sixty-eight embolization procedures were performed on 67 patients with brain AVMs by a single surgeon. Patients were divided into 2 groups: those with symptomatic dICH and control subjects. Thirteen factors were analyzed: age, sex, race, previous ICH, Spetzler-Martin grade, AVM size, eloquence, embolic volume, embolic agent, percent obliteration, and timing, number, and stage of embolizations. Univariate and multivariate analyses were performed on these factors to determine significance. RESULTS: Six procedures were complicated by dICH; 5 (83%) occurred after the final planned procedure. The volume of embolic agent was significantly higher in the dICH group (4.5 ± 1.0 mL) compared with control subjects (1.7 ± 0.2 mL) in both univariate and multivariate analyses (P < .01), even after controlling for AVM size. AVM size was significant in univariate analysis but not multivariate analysis. There were no statistically significant differences between the groups for any of the other possible predictive factors. CONCLUSION: High volume of embolic agent administered per procedure is an independent predictive factor for dICH. Limiting the injected volume for each procedure may reduce this poorly understood complication.

Timing pattern of onset in hypertensive intracerebral hemorrhage patients.

The temporal pattern of onset of hypertensive intracerebral hemorrhage (ICH) has been evaluated in previous reports, but there are few published data on this pattern in Chongqing, China. The purpose of this study is to explore the temporal pattern of diurnal, weekly and monthly variations in the onset of hypertensive ICH from a hospital-based population. The study retrospectively reviewed 230 residents who suffered from hypertensive ICH between January 2008 and August 2009 in our hospital. The temporal pattern was investigated by hours, days and months. Chi-square test for goodness of fit was used for statistical analysis. Significant differences of the onset time of hypertensive ICH patients could be seen in diurnal variation (p=0.000) and in monthly variation (p=0.000), but could not be found in weekly variation (p=0.466). There was a bimodal distribution in diurnal variation, and monthly variation showed that the occurrence of hypertensive ICH mainly focuses on the period from December to May. Our study demonstrated the existence of diurnal and monthly variations and no significant weekly variation can be found in the time of onset of hypertensive ICH.

Risk factors of early death in patients with hypertensive intracerebral hemorrhage during hospitalization.

Hypertensive intracerebral hemorrhage (ICH) is the deadliest, most disabling and least treatable form of acute cerebral accident. A large number of patients die in a short time after the hemorrhage. However, the risk factors of early death in this pattern are still in debate. A case control study of 273 patients with hypertensive ICH admitted to our hospital was carried out. The patients were divided into the death group and survival group according to clinical outcome during hospitalization. Any possible risk factors were assessed using univariate and multivariate analysis. The logistic regression analysis revealed that the following four factors were independently associated with early death: age [odds ratio (OR), 0.966; 95% confidence interval (CI), 0.936-0.997; P=0.0327], GCS score (OR, 1.192; 95% CI, 1.090-1.303; P<0.001) and systolic pressure (OR, 0.939; 95% CI, 0.772-1.142; P<0.001) at admission, and hematoma volume (OR, 0.8000; 95% CI, 0.807-0.959; P=0.0037). Cranial computed tomography imaging is an important examination method to evaluate the clinical outcome. Effective prevention of hypertension and adequate reduction of blood pressure at admission are recommended as the major measures to improve the prognosis of hypertensive ICH.

[Correlation of ABO groups to hypertensive intracerebral hemorrhage].

OBJECTIVE: To study the relationship between ABO blood groups and hypertensive intracerebral hemorrhage (HICH). METHODS: The clinical data of 425 patients with HICH admitted to Nanfang Hospital were collected to analyze the relationship between the ABO blood groups and the occurrence of HICH, with normal Han Chinese subjects serving as the controls. RESULTS: Compared to the officially documented distribution of ABO groups in Chinese population (O 34.11%, B 28.98%, A 28.29%, AB 8.69%) and in Guangzhou residents (O 46.00%, B 25.00%, A 23.00%, AB 6.00%), a significant difference was noted in the blood group distribution in this cohort (O 45.10%, A 26.00%, B 24.00%, AB 4.90%). O blood type individuals with HICH showed a higher morbidity than others. Th ABO blood type distribution in this cohort showed no significant difference from that in the control group (P>0.05), but differed significantly from the Chinese norm (P<0.05). CONCLUSION: The ABO blood group is a factor contributing to the occurrence of HICH. O blood type is related to cerebral hemorrhage, and may serve as a risk factor for HICH.

[Mortality after surgical treatment of patients with hypertensive intracerebral hematomas].

Authors summarized the experience of specialized neurosurgical clinic for treatment of patients with stroke. From 1998 till 2008 1035 patients with hypertensive intracerebral hematomas were examined and treated in the clinic. 635 patients were operated, 400 received conservative treatment. Volumes of hematomas varied from 3 to 130 ml. Mean volume of hematoma in the "surgical" group was 52.9 ml (SD = 23.1), in the "conservative" group -- 37.2 ml (SD = 22.9). Two types of indications for surgery were defined: a) indications for life-saving surgery; b) indications for surgical treatment, implying achievement of good functional result. Hematomas were removed using different techniques: craniectomy or craniotomy -- 123 patients; minimally-invasive craniotomy and limited encephalotomy -- 78; puncture aspiration -- 65; puncture aspiration combined with local fibrinolysis (prourokinase) -- 291; combined procedures (including endoscopic) -- 49; external ventricular drainage -- 29. 30-days mortality in the "surgical" group was 29%, in the "conservative" group -- 38.7%. Critical volumes of hematomas of different localization with maximal effect on mortality were distinguished. Main causes of lethal outcome in the "surgical" group were the following: pulmonary artery thomboembolism -- 21.5%, pneumonia -- 29%, recurrent hemorrhage -- 19.5%. Therefore, surgical management of hypertensive intracerebral hematomas in selected groups of patients is associated with lower rate of mortality, in comparison with conservative management. Basically, it refers to the patients in severe condition, with volumes of hematoma above critical limits specific for certain localization.