American Heart Association


Readmission after Subarachnoid Hemorrhage

Pouya Tahsili-Fahadan, MD

Dasenbrock HH, Angriman F, Smith TR, Gormley WB, Frerichs KU, Aziz-Sultan MA, et al. Readmission After Aneurysmal Subarachnoid Hemorrhage: A Nationwide Readmission Database Analysis. Stroke. 2017

Readmission (within a pre-defined period of time from discharge) is frequently measured and reported as a quality measure for care provided by physicians and hospitals. However, it is debatable whether this measure is an appropriate quality metric for various indications and etiologies of the index hospitalization. Dasenbrock et al. investigated this question by analyzing the Nationwide Readmission Database (NRD) for readmission after aneurysmal subarachnoid hemorrhage (SAH).

Data from this longitudinal administrative database within 21 states were extracted for 3806 non-elective adult patients admitted for treatment of aneurysmal subarachnoid or intracerebral hemorrhage and discharged alive in 2013. Mortality during the index hospitalization and readmission were 11% and 1.7%, respectively, and about two thirds of survivors were discharged home. The median cost of the index and readmission hospitalizations were $266,304 and $45,091, respectively, and readmission was associated with increased total costs. Within the next 30 days from discharge, 10.2% of patients were readmitted with 34.4%, 65.6%, and 82.4% of readmissions within 1, 2, and 3 weeks from discharge, respectively. As expected, patients who were readmitted had higher SAH severity scale, higher incidence of cerebral edema, and complications during their index hospitalization, and were more likely to undergo tracheostomy or gastrostomy, and less likely to be discharged home. Treatment modality (clipping versus coiling) was not associated with increased rate of readmission. Independent predictors for readmission, however, were identified as comorbidity score equal or more than 3, higher SAH severity, and discharge destination other than home; the more predictors, the higher chance of readmission. Of note, high-volume institutions had lower risk of readmission and mortality. The most common reasons for readmission included hydrocephalus, other neurological complications, infections, and thromboembolic events. Neurosurgical procedures and surgeries were among the most common operations performed after readmission. Importantly, hydrocephalus during index hospitalization was associated with increased risk of readmission for hydrocephalus.

Author Interview: Søren Bache, MD

Søren Bache

Søren Bache

A conversation with Søren Bache, MD, from the Neurointensive Care Unit, Department of Neuroanaesthesiology and Centre for Genomic Medicine, Rigshospitalet, University of Copenhagen, Denmark, about microRNA changes after subarachnoid hemorrhage.

Interviewed by José G. Merino, MD, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper, “MicroRNA Changes in Cerebrospinal Fluid After Subarachnoid Hemorrhage,” published in the September 2017 issue of Stroke.

​Dr. Merino: Thank you for agreeing to the interview. First, I would like you to explain some things about delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) for our readers: How common is it? How soon after SAH does it develop? How does it affect outcome after SAH?

Dr. Bache: The reported prevalence of DCI after SAH varies, but newer randomized clinical trials have found a risk of 21–38% in patients who survive the initial bleeding and aneurism-securing surgery. The variation in calculated risk may be due to discrepancies both in case definition (i.e. the numerator) and in the definition of which patients are entered into the denominator. Today, most researchers base their case definition of DCI on the criteria suggested by Vergouwen et al. (Vergouwen MD, et al. Stroke. 2010). Before this consensus work, the definition varied even more, and many used their own criteria for DCI, delayed ischemic neurological deficits (DIND) or cerebral vasospasm. However, not all patients are conscious enough to be assessed clinically for a deterioration in consciousness, and such patients may be either included or excluded in the total number of patients; hence, the variation in the denominator. Based on Vergouwen’s criteria, in our center, we found a prevalence of 23% in 450 patients admitted from 2009–12 with SAH (unpublished data). These patients all receive prophylactic nimodipine, which lowers the risk of DCI; therefore, one should expect publications from the pre-nimodipine era to report a higher prevalence of DCI (Dorhout Mees SM, et al. Cochrane Database of Systematic Reviews. 2007).

Delayed cerebral ischemia occurs a median of 6–7 days after hemorrhage, but this varies, with a typical reported range from 3 to 14 days. DCI may be reversible, but in some cases it progresses to permanent brain injury, thereby affecting outcome.

The Complex Relationship Between Statins and Intracerebral Hemorrhage Outcomes

Mark R. Etherton, MD, PhD

Siddiqui FM, Langefeld CD, Moomaw CJ, Comeau MJ, Sekar P, Rosand J, et al. Use of Statins and Outcomes in Intracerebral Hemorrhage Patients. Stroke. 2017

In this entry, I discuss a recent publication by Fazeel Siddiqui and colleagues regarding the use of statins and outcomes after intracerebral hemorrhage (ICH).

The current evidence suggests a complex relationship between serum cholesterol levels, statin use, and outcomes after ICH. Low serum cholesterol levels have been associated with increased incidence of ICH, as well as hematoma expansion. However, a prior meta-analysis demonstrated antecedent statin use was associated with decreased risk of mortality and increased likelihood of a good outcome after ICH (Jung et al. Int J Stroke. 2015). The authors, therefore, set out to investigate the relationship of statin use with ICH outcomes by evaluating 3-month disability, mortality, and hematoma size/expansion.

Hematoma Shape, but not Density, is Predictive of Clinical Outcomes in ICH from the INTERACT2 Study

Peggy Nguyen, MD

Delcourt C, Zhang S, Arima H, Sato S, Al-Shahi Salman R, Wang X, et al. Significance of Hematoma Shape and Density in Intracerebral Hemorrhage: The Intensive Blood Pressure Reduction in Acute Intracerebral Hemorrhage Trial Study. Stroke. 2016

In patients with intracerebral hemorrhage (ICH), parameters such as hematoma volume has been shown to be predictive of hematoma growth and poor clinical outcomes; other characteristics, such as shape and density have been shown to be associated with growth, but evidence demonstrating its predictive value for clinical outcomes has been limited. Here, the authors used data from the INTERACT2 study and evaluated the association of hematoma shape (irregularity) and density (heterogeneity) on 90-day death or disability.

2066 subjects were included for analysis, with 946 subjects having irregular hematomas and 781 subjects having heterogenous hematomas. Of note, there were significant differences between patients with irregular versus regular hematomas, including older age, more severe neurological status, and lobar hemorrhages in the former group, among others. Similarly, patients with heterogenous hematomas, compared to those with homogenous hematomas, were more likely to have lobar hematomas and less likely to have intraventricular extension. Larger hematomas were more likely to be irregular and heterogenous, and this is likely reflected in the differences between each group and their comparators. In addition, the decision to withdraw treatment was more likely to be made among patients with irregular hematomas and among patients with heterogenous hematomas, when compared to their counterparts.

Nevertheless, when controlled for factors such as age, systolic blood pressure, NIHSS, prior use of antithrombotics, location and volume of baseline hematoma, IVH, and decision to withdraw active treatment, irregular hematomas were found to be independently associated with the primary outcome of risk of death or major disability at 90-days (OR 1.60) and major disability at 90 days (OR 1.60) although not with death alone. Heterogenous density did not predict the primary outcome, nor individually, the outcome of death nor disability.

This study is significant in providing some evidence for imaging markers which may be predictive of clinical outcomes in the emergent period, allowing clinicians to adjust decision making and provide better informed counseling to patients and their families.   

Administration of transdermal glycerol trinitrate does not affect functional outcomes in patients with ICH

Alexander E. Merkler, MD

Krishnan K, Scutt P, Woodhouse L, Adami A, Becker JL, Berge E, et al. Glyceryl Trinitrate for Acute Intracerebral Hemorrhage: Results From the Efficacy of Nitric Oxide in Stroke (ENOS) Trial, a Subgroup Analysis. Stroke. 2016

Outcomes in patients with intracerebral hemorrhage (ICH) are poor; more than two-thirds of survivors with ICH are left disabled at three months and less than half of patients with ICH are alive at 1 year. Ongoing research continues to address ways to improve outcomes – one such approach is acute blood pressure reduction. High blood pressure is common in acute ICH and is associated with worse outcomes, at least in part through hematoma expansion. Previous trials such as INTERACT have shown a trend towards improved functional outcomes using intensive BP lowering within the first 6 hours after ICH, but management of high BP in acute ICH remains uncertain.

The current subgroup analysis of the ENOS (Efficacy of Nitric Oxide in Stroke) trial evaluates the impact of transdermal glyceryl trinitrate (GTN) in patients with ICH. ENOS was a large multicenter trial that evaluated BP reduction in patients with both ischemic stroke and ICH using GTN. When GTN was given within 48 hours of stroke onset, BP was significantly reduced at day 1; however, functional outcome at 90 days was no different. When GTN was given within six hours of stroke though, functional outcomes were improved. In this current manuscript, the authors performed a pre-specified subgroup analysis, evaluating whether use of GTN in patients with ICH improved functional outcomes both overall, and within 6 hours of having an ICH.

629 patients with ICH presenting within 48 hours and initial SBP >140mmHg were included. Patients were randomized to receive GTN transdermally for one week versus no GTN. The mean time to randomization was 25 hours. 87% of hemorrhages were deep and 26% of patients had IVH. BP was significantly lower following the first dose of GTN versus no GTN (7.5/4.2 mmHg).

Overall, at 90 days, the median mRS was the same (3) in both the GTN and no GTN groups. In addition, there were no differences between secondary outcomes such as measures of disability, cognition, mood and quality of life. No differences in serious adverse events were seen.

Of the 61 (9.7%) patients randomized within 6 hours (and in whom the average time to treatment was 4.4 hours), patients randomized to GTN had an improved functional outcome as manifested by a positive shift on the mRS, improved mood and quality of life and reduced death.

GTN is a useful transdermal agent to acutely lower BP and does not seem to have serious adverse effects. The study adds further support that early BP lowering in patients with ICH may improve functional outcomes.

By |January 15th, 2016|hemorrhage|0 Comments

High risk of growth and rupture found in vertobrobasilar, non-sacular and dolichoectatic aneurysms

Alexander E. Merkler, MD

Nasr DM, Brinjikji W, Rouchaud A, Kadirvel R, Flemming KD, and Kallmes DF. Imaging Characteristics of Growing and Ruptured Vertebrobasilar Non-Saccular and Dolichoectatic Aneurysms. Stroke. 2016

Vertebrobasilar, non-sacular and dolichoectatic aneurysms (VBDAs) often represent a therapeutic challenge to clinicians – observe, serial image, or treat? The current study by Nasr et al adds further support to the pre-existing literature that VBDAs are generally associated with a poor natural history with high growth and rupture rates.

The authors performed a retrospective study on all VBDAs seen at their hospital. VBDAs were defined to include fusiform aneurysms (aneurysms with focal dilitations without a definable neck), dolichoectasia (uniform aneurysm dilitations), and transitional aneurysms (uniform aneurysm dilitations with superimposed dilitations of a focal portion of the involved artery). Dissecting aneuryms were excluded as the authors felt these lesions have a distinct natural history. 

152 patients with VBDAs were followed for a mean of 3.6 years. 30% of the aneurysms were fusiform, 49% were dolichoectatic, and 21% were transitional. The median diameter of the aneurysms was 7.2mm. 23% of aneurysms demonstrated growth (>2mm) during the course of the study, resulting in an annual aneurysm growth rate of 6.5%. 5.3% (8) of aneurysms ruptured during follow-up, yielding a rupture rate of 1.5%/year and 13.2% of patient with VBDAs had posterior circulation infarcts.

In univariate analyses, aneurysm type, large (>10mm) aneurysms, presence of T1 signal in the aneurysm rim (representing subacute thrombus), presence of thrombus, and presence of daughter aneurysm were also associated with aneurysm rupture. However, in multivariate analyses, only aneurysm type was associated with aneurysm growth and rupture: transitional aneurysms had significantly higher odds of growth/rupture than dolichoectatic, but not fusiform aneurysms

The main limitations include the lack of standardization of imaging modality and lack of pre-specified time of imaging follow-up.

Overall, this study confirms that VBRAs, and in particular transitional vertebrobasilar aneurysms, have high rates of growth and rupture and warrant close imaging follow-up. Further research will be needed to better distinguish which aneurysms are at highest risk for rupture and may potentially benefit from treatment.

By |January 6th, 2016|hemorrhage|0 Comments

Markers on non-contrast CT head that predict later hematoma expansion

Peggy Nguyen, MD

Blacquiere D, Demchuk AM, Al-Hazzaa M, Deshpande A, Petrcich W, Aviv RI, et al. Intracerebral Hematoma Morphologic Appearance on Noncontrast Computed Tomography Predicts Significant Hematoma Expansion. Stroke. 2015 

Hematoma expansion occurs in approximately one-third of patients with intracerebral hemorrhage (ICH), but markers for predicting expansion are not well defined. The PREDICT study, aimed at prospectively validating the spot sign on CT angiography, found the spot sign had a sensitivity of 51% for predicting expansion. Markers present on non-contrast CT head previously published elsewhere as associated with hematoma expansion or larger ICH include hematoma density, shape, presence of fluid-levels, and regularity, but predictive models utilizing these markers are not widely used. Here, the authors hypothesized that these non-contrast CT head markers (irregular margins, heterogeneous density, and fluid-blood levels) would predict expansion both independently and together with the spot sign on CTA, with the aim of identifying non-contrast measures which would be reliable markers of hematoma expansion and to create a more sensitive prediction model.

Analyzing a PREDICT cohort of 311 patients, the authors found a high inter-observer agreement for fluid levels, and relatively good agreement for scoring of heterogeneity and irregularity. All 3 non-contrast CT markers were significantly associated with hematoma expansion on follow up CT scan; in addition, all 3 non-contrast CT markers were significantly associated with the spot sign on CTA and with absolute hematoma growth at 24 hours. Margin irregularity was the most sensitive and fluid levels was the most specific, but the spot sign remained the most specific predictor of hematoma expansion, with the highest positive and negative predictive values of hematoma expansion. The predictive value of the spot sign was not altered when the non-contrast markers were added to the model, confirming the spot sign as the most reliable marker for hematoma expansion. However, given the ease of scoring, the relatively good inter-observer agreement, and the ease of obtaining a non-contrast CT scan, especially in situations where contrast may be contraindicated, it does appear that heterogeneity, irregularity, and fluid-blood levels might also be appropriate surrogate markers.

By |November 6th, 2015|hemorrhage|0 Comments

Cognitive Decline Occurs in More Than 1/3 of Long-Term Survivors of ICH

Alexander E. Merkler, MD

Benedictus MR, Hochart A, Rossi C, Boulouis G, Hénon H, van der Flier WM, and  Cordonnier C. Prognostic Factors for Cognitive Decline After Intracerebral Hemorrhage. Stroke. 2015

The association between stroke and cognitive decline is complex and, as Drs. Benedictus et al point out, pre-existing dementia is often present in patients with stroke, and post-stroke dementia is also highly prevalent. Furthermore, dementia increases the risk of stroke, and as a corollary, stroke also increases the risk of dementia. Disentangling this relationship poses a challenge.

In the present article, Drs. Benedictus and her colleagues evaluate the association and potential risk factors for cognitive decline after intracerebral hemorrhage (ICH). Although ICH accounts for only 10% of all strokes, the mortality rate is over 50% within the first year. Although various scores have been created to help predict which patients will survive and regain functional independence (ICH score and FUNC score), there has been a paucity of data on cognitive outcomes after ICH. 

In order to assess risk factors for cognitive decline after ICH, the authors evaluated a cohort of adult patients with ICH. MRI was used to evaluate for cortical atrophy, white matter hyperintensities, lacunes, and microbleeds. Patients were prospectively followed for cognitive decline using MMSEs at 6 months, 12 months, and then annually after ICH.

Out of a cohort of 560 patients, 167 were included in the final analysis. During a median follow-up of 4 years, 37% of patients developed cognitive decline. Perhaps not surprisingly, pre-existing cognitive impairment was the strongest predictor of cognitive decline after ICH. In addition, both previous stroke/TIA and severity of cortical atrophy (but not presence of white matter hyperintensities, microbleeds, or lacunes) were associated with cognitive decline after ICH. In a post-hoc sensitivity analysis evaluating risk factors of cognitive decline in patients without pre-existing cognitive decline, only severity of cortical atrophy remained associated with development of cognitive decline. Finally, ICH location (lobar or non-lobar) was not associated with development of cognitive decline.

Limitations include: 1) baseline demographics (age) and radiographic risk factors such as cortical atrophy were not equally distributed between patients who had cognitive data available for analysis; 2) cognitive decline was solely based on MMSE which made it impossible to perform in patients with certain neurological sequelae of stroke such as aphasia; and 3) cognitive status was only evaluated in patients who survived for at least 1 year after ICH (since patients needed 2 MMSE performed 6 months apart), which limits generalizability of this study.

Overall, what does this study tell us? First, more than 1/3 of patients with ICH will develop cognitive decline. Second, risk factors for the development of cognitive decline after ICH are already present before ICH occurs – baseline cognitive impairment, prior stroke/TIA, and baseline cortical atrophy. Third, the interaction between neurodegenerative and vascular pathology is complex, but this study emphasizes the need for better stroke prevention, which, in turn, may lead to decreased neurodegeneration and perhaps vice versa.

By |September 23rd, 2015|hemorrhage|1 Comment

The ABC/2 score is an accurate measurement for ICH

Peggy Nguyen, MD

Webb AJS, Ullman NL, Morgan TC, Muschelli J, Kornbluth J, Awad IA, et al. Accuracy of the ABC/2 Score for Intracerebral Hemorrhage: Systematic Review and Analysis of MISTIE, CLEAR-IVH, and CLEAR III. Stroke. 2015

The ABC/2 score is a simple method used by both clinicians and researchers to assess intracranial hemorrhage (ICH) size; however, the score has only been validated in small research cohorts. In this study, Webb et al. perform an analysis and systematic review of the validity of the ABC/2 score in three large clinical trials, MISTIE, CLEAR-IVH, and CLEAR III to address whether the ABC/2 score, in both a specialized reading center (RC) as well as a local research site, is an accurate and valid score for determining ICH volume as well as eligibility and clot resolution in trials for ICH.

In their analysis of 4369 scans, the authors found that, when compared to the reference-standard of CT-based planimetry (CTP), both RC-ABC/2 scores as well as site-ABC/2 scores were valid measures of ICH volume for eligibility and clot resolution in all trials. Specifically, RC-ABC/2 scores had good accuracy in defining ICH volume, and categorizing ICH volume as mild, moderate, or severe. Site-ABC/2 scores were less accurate, but still acceptable. ABC/2 scores tended to be less accurate with lobar hemorrhages, larger ICHs, and irregular or heterogenous clots, a conclusion also supported in part by their systematic review, which, although too heterogenous for quantitative analysis, did identify ten studies, of which 2 found greater errors with larger ICHs, and 2 found greater errors with more irregular ICHs.

This study is the largest validation of the ABC/2 score, providing good evidence that the ABC/2 score, which can be performed easily, is accurate and valid. Keeping in mind its possible limitations in certain types of ICH (lobar, larger and more irregular size), this gives clinicians and researchers greater confidence in using the ABC/2 score both in clinical practice and in research, especially in smaller settings where more accurate CT based measurements may not be quickly feasible.

By |August 12th, 2015|hemorrhage|0 Comments

VASOGRADE in DCI- Does it Scale?

Abdel Kaleel, MD, MSc

de Oliveira Manoel AL, Jaja BN, Germans MR, Yan H, Qian W, Kouzmina E, et al.The VASOGRADE: A Simple Grading Scale for Prediction of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. Stroke. 2015

VASOGRADE, a grading scale mostly derived from the WFNS grade and modified Fisher scale, has been proposed for risk stratification after aneurysmal subarachnoid hemorrhage. The purpose of this study was to validate this scale, particularly its relationship with the development of Delayed Cerebral Ischemia (DCI). Consecutive patients between January 2012 and June 2013 at the St. Michael’s Hospital in Toronto, Canada were assessed, having been divided into three VASOGRADE categories: VASOGRADE-Green (modified Fisher scale 1 or 2 and World Federation of Neurosurgical Societies scale (WFNS) 1 or 2); VASOGRADE-Yellow (modified Fisher 3 or 4 and WFNS 1-3); and VASOGRADE-Red (WFNS 4 or 5, irrespective of modified Fisher grade. A total of 746 patients were included in the final analysis. The primary outcome was delayed cerebral ischemia (DCI). DCI was present in 151 patients with 15%, 9%, and 37% of VASOGRADES Green, Yellow, and Red groups having developed DCI, respectively. Patients who were identified as VASOGRADE Red had a significantly higher risk of development of DCI and patients who were classified as VASOGRADE Yellow had a tendency for a higher risk for DCI. Overall, DCI status was appropriately identified in almost 70% of patients. Multiple clinical applications of VASOGRADE’s use in DCI were proposed, including decision on disposition/length of stay and treatment aggressiveness, in addition to its ability to predict DCI risk.