Displaying One Session

e-Poster Discussion
Session Type
e-Poster Discussion
Room
Station 5 (E-Poster Area)
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM

CONCURRENT OVERLYING SUBDURAL HEMATOMA IN PATIENTS WITH INTRACEREBRAL HEMORRHAGE

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 5 (E-Poster Area)
Lecture Time
06:30 PM - 06:35 PM

Abstract

Background And Aims

It has been reported that a proportion of non-traumatic intracerebral hemorrhage (ICH) patients can have associated subdural hematoma (SDH). However, the clinical and imaging determinants of SDH in this context has not been well characterized.

Methods

We compared clinical and radiological characteristics on admission between ICH patients with and without associated SDH hospitalized at a single institution during a 6-year period (2010-2016), and performed multivariable logistic regression analysis to identify characteristics that are independently associated with SDH presence.

Results

We included 129 ICH patients (mean age: 74±11 years, 66% males). Patients with concomitant SDH (17%) were significantly older (79±7 vs. 73±12 years, p=0.024) and had higher prevalence of dementia (23.8% vs. 8.6%, p=0.042) compared to ICH patients without concomitant SDH. ICH patients with SDH presented more frequently with lobar hemorrhages (77% vs. 26%, p<0.001), with an affinity to the parietal (41% vs. 20%, p=0.031) and occipital lobes (36% vs. 9%, p<0.001). The vast majority of SDHs were anatomically overlying the region of lobar ICH (82%), and had associated convexal subarachnoid hemorrhage (SAH) congruent to the ICH (63.6% vs. 12.4%, p<0.001). Only increasing age (OR=1.15 per year, 95%CI: 1.03-1.29) and SAH presence (OR=14.94, 95%CI: 1.60-139.25) withstood multivariate analysis.

Conclusions

Our results provide supporting evidence for cerebral amyloid angiopathy (CAA) as the underlying vascular pathology for SDH in non-traumatic ICH patients. The adjusted association between SDH with convexal SAH suggests that rupture of a single CAA-laden leptomeningeal vessel could contribute to multicompartment hemorrhages involving the underlying parenchyma, subarachnoid space and overlying subdural space.

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VALIDATION AND NET-BENEFIT ANALYSIS OF THE SIMPLIFIED EDINBURGH CT CRITERIA TO IDENTIFY CEREBRAL AMYLOID ANGIOPATHY

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 5 (E-Poster Area)
Lecture Time
06:35 PM - 06:40 PM

Abstract

Background And Aims

Etiologic characterization of patients with lobar intracerebral hemorrhage(ICH) is crucial to determine subsequent therapeutic and prophylactic management. Our aim was to evaluate applicability of the simplified Edinburgh CT-based criteria for (1) identification of patients with cerebral amyloid angiopathy(CAA) according to MRI-based modified Boston criteria and (2) utility in clinical decision-making for evaluation of underlying ICH etiology.

Methods

This retrospective analysis of patients with acute lobar ICH(2006-2016) who received both acute CT and MRI imaging, used individual patient data(n=210) from our single-center prospective observational cohort (UKER-ICH;NCT03183167). Primary outcomes corroborated the ability of the simplified Edinburgh criteria to (1) rule-in or -out probable CAA, and to (2) evaluate its clinical net-benefit using decision curve analysis to differentiate ICH etiologies.

Results

Of 210 patients, simplified Edinburgh CT criteria graded 33.3%(n=70) high-risk, 31.9%(n=67) medium-risk, and 34.8%(n=73) low-risk for CAA, overall showing acceptable inter-rater variability. Discrimination was good (AUROC:0.74, 95%CI:0.67–0.81) without evidence of poor calibration for validation of MRI-based probable CAA (n=94/210,44.8%). The rule-in criteria, i.e. high-risk, had 87.1%[95%CI(79.3-92.3)] specificity, and the rule-out criteria, i.e. low-risk, had 80.9%[95%CI(71.1-88.0)] sensitivity. Decision curve analysis, using an algorithm (i.e. high-risk patients & age ≥55 years), resulted in clinical net-benefit (threshold probability 0.2, net-benefit:54.5). This approach would spare one-third of MRIs, while detecting 100% of secondary ICH etiologies (n=26/26) and probable CAA patients (n=94/94).

Conclusions

The simplified Edinburgh CT-based criteria showed good predictive performance for ruling-in probable CAA and the proposed MRI decision algorithm may lead to meaningful clinical net-benefit without missing secondary ICH etiologies.

Trial Registration Number

UKER-ICH, NCT03183167, clinicaltrials.gov

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IS THE MANAGEMENT OF ACUTE INTRACEREBRAL HAEMORRHAGE (ICH) GETTING ANY BETTER IN THE UK?

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 5 (E-Poster Area)
Lecture Time
06:40 PM - 06:45 PM

Abstract

Group Name

on behalf of the SSNAP Collaboration

Background And Aims

Intracerebral Haemorrhage (ICH) represents 12% of all acute strokes in the UK and affects more than one million people worldwide annually. We aim to monitor its key hyperacute interventions which are blood pressure lowering and anticoagulation reversal.

Methods

Data were extracted from the Sentinel Stroke National Audit Programme (SSNAP), a national register of stroke in England, Wales and Northern Ireland. We evaluated time critical evidence-based interventions of systolic blood pressure (SBP) lowering to 140mmHg within 1h and urgent anticoagulant reversal for those using Direct Oral Acting Anticoagulants (DOACs) or a vitamin K antagonist/warfarin anticoagulation between December 2017 to September 2019.

Results

Of 20,014 ICH patients, 7,759 presented within 6h of onset with SBP above 150mmHg (eligible), 4,297 were on either a DOAC or a vitamin K antagonist/warfarin anticoagulation. Median [IQR] age was 78 [68-84], 50% females.

5,075 (65%) of eligible patients received SBP lowering treatment. Median [IQR] time from treatment to target (140mmHg) decreased from 114minutes [IQR 49-305] to 107minutes [IQR 48-272] over the study period (P=0.14).

298 (5.87%) of eligible patients had SBP of 140mmHg achieved within 1h of arrival over the study period.

2307 (54%) of eligible ICH patients received anticoagulation reversal. Median time from arrival to reversal remained unchanged 157 min [IQR 85-299] to 158min [IQR 83-293] over the study period (P=0.76).

Conclusions

A high proportion of eligible ICH patients are not receiving evidence-based treatments and timings are suboptimal. Further quality improvement in hyperacute ICH care is needed in the UK.

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OPTICAL COHERENCE TOMOGRAPHY DETECTS RETINAL NERVE FIBER LAYER THINNING IN HEREDITARY CEREBRAL AMYLOID ANGIOPATHY

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 5 (E-Poster Area)
Lecture Time
06:45 PM - 06:50 PM

Abstract

Background And Aims

Investigating mutation carriers with Dutch-type hereditary Cerebral Amyloid Angiopathy (D-CAA), offers the possibility to identify markers in pre- and symptomatic stages of CAA. Recently, imaging technique Optical Coherence Tomography (OCT) has shown potential to detect retinal changes in several neurodegenerative diseases. We investigated the thickness of retinal layers as possible (early) biomarker in D-CAA mutation carriers.

Methods

In this case-control study D-CAA mutation carriers (n=8 presymptomatic, n=13 symptomatic) and (n=9) controls were scanned using Spectral-Domain-Optical-Coherence-Tomography (SD-OCT). Symptomatic carriers were defined as having a history of ≥1 symptomatic intracerebral hemorrhage. D-CAA mutation carriers and controls were recruited from our D-CAA cohort and a healthy control cohort. Total peripapillary Retinal Nerve Fiber Layer (pRNFL) thickness, six regions of pRNFL, the total macular volume (TMV), and individual macular regions thickness were measured and analyzed adjusted for age.

Results

The overall mean thickness of pRNFL was decreased in symptomatic, but not presymptomatic, D-CAA mutation carriers compared with controls (90.6 ±8.1 vs. 99.5 ±11.8, p=0.006). Importantly, both presymptomatic (111.4 ±30.3 vs. 131.1 ±16.6, p<0.001) and symptomatic carriers (110.8 ±25.8 vs. 131.1 ±16.6, p=0.034) had a thinner temporal-superior quadrant of the pRNFL versus controls. Total macular volume or individual macular layers thickness did not differ between carriers and controls.

Conclusions

Thinning of regions of the Retinal Nerve Fiber Layer may be a new and early marker of disease in hereditary CAA. Further studies are needed to determine whether retinal thinning is also present in sporadic CAA and estimate its value as marker for disease progression.

Trial Registration Number

Not applicable

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CEREBROSPINAL FLUID PROFILES AND DIAGNOSTIC PROBABILITY FOR CEREBRAL AMYLOID ANGIOPATHY: HAGAKURE STUDY

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 5 (E-Poster Area)
Lecture Time
06:50 PM - 06:55 PM

Abstract

Group Name

On behalf of HAGAKURE Investigators

Background And Aims

Cerebrospinal fluid (CSF) findings in cerebral amyloid angiopathy (CAA) fulfilled Boston criteria were confirmed previously. We investigated CSF profiles in CAA defined by Edinburgh criteria, newly developed diagnostic tool for CAA.

Methods

We enrolled consecutive spontaneous intracerebral hemorrhage (ICH) patients admitted between September 2012 and August 2016. Using findings of the Edinburgh criteria (strictly lobar ICH, finger-like projections, or subarachnoid hemorrhage on brain CT, and APOE ε4 possession), CAA probability was classified into: no probability; low; medium or high. We performed multivariable ordinal regression analyses (adjusted for age, sex, and hypertension) to investigate association between CSF profiles (amyloid-β [Aβ] 40, Aβ42, Aβ40/Aβ42 ratio, total tau and phosphorylated tau) and diagnostic probability for CAA, separately. In sensitivity analysis, associations between CSF profilesand the individual finding composed of the Edinburgh criteria were investigated.

Results

CAA probability of included 129 patients (median age 71 years, male, 54%) was classified into: no, 104 (80.6%); low, 11 (8.5%); and medium or high, 14 (10.9%). In multivariable ordinal regression analysis, only Aβ40/Aβ42 ratio was associated with diagnostic probability for CAA (OR 1.40, 95%CI 1.00-1.93). In sensitivity analysis, association between FLPs and total tau (OR 1.00, 95%CI 1.00-1.01), and between SAHs and Aβ40/Aβ42 ratio (OR 1.04, 95%CI 1.01-1.08), as well as phosphorylated tau (OR 1.00, 95%CI 1.00-1.00), were observed, even after adjustment.

Conclusions

Cerebral amyloid angiopathy probability defined by the Edinburgh criteria was associated with increase of CSF Aβ40/Aβ42 ratio, suggesting that criteria might pathologically reflect a relative decrease in Aβ42 among insoluble CSF Aβ.

Trial Registration Number

UMIN000037894

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ROLE OF AMYLOID PET IN DIAGNOSING POSSIBLE TRANSMISSIBLE CEREBRAL AMYLOID ANGIOPATHY IN YOUNG ADULTS WITH A HISTORY OF NEUROSURGERY

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 5 (E-Poster Area)
Lecture Time
06:55 PM - 07:00 PM

Abstract

Background And Aims

According to the Boston criteria for cerebral amyloid angiopathy (CAA), histopathological proof is required below 55y. In vivo PET imaging of amyloid-beta has been validated to post-mortem histopathology, but its role in CAA is still unclear. Recently data emerged pointing towards transmissibility of amyloid-beta: through treatment with cadaveric growth hormone, dural grafts and even neurosurgical procedures. We investigated the role of amyloid PET in patients with possible transmissible CAA.

Methods

Between 2013-2019 we identified patients <55y with clinical and neuroimaging findings suggestive of CAA and a history of neurosurgery during childhood. These patients and amyloid-negative healthy volunteers underwent 11C-PiB-PET/CT imaging (40-60min post-injection). We calculated standardized uptake value ratios (SUVR) using pons as reference region (PMOD3.9) and performed voxelwise group comparisons of individual patients to controls using Statistical Parametric Mapping (SPM12; pFWE-corr,voxel<0.05; extent threshold >50 voxels (2x2x2mm)).

Results

We identified four male patients with clinical and neuroimaging characteristics of CAA (table 1) and compared 11C-PiB-PET findings to 19 healthy volunteers (71y±3.2y; 8 female/11 male). Voxelwise analysis revealed increased 11C-PiB binding, evidencing underlying amyloid pathology, in all patients (figure 1).

Case

Age at first presentation (y)

Neuroimaging

Negative genetic tests

Reason for neurosurgery during childhood

1

32

intracerebral hemorrhage

APP, PSEN1/2

meningo-encephalocoele

2

47

superficial siderosis

CADASIL, COL4A1/2, APP, PSEN1/2

head trauma

3

31

intracerebral hemorrhage

APP, PSEN1/2

meningioma

4

32

superficial siderosis

APP, PSEN1/2

meningomyelocele

figure 1.jpg

Conclusions

11C-PiB-PET may provide evidence of transmissible amyloid pathology in patients <55y who present with clinical and neuroimaging findings suggestive of this condition in the absence of histological proof.

Trial Registration Number

Not applicable

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CLINICAL AND RADIOLOGICAL FINDINGS PREDICTING 30-DAY MORTALITY AMONG INDIGENOUS WEST AFRICANS WITH INTRACEREBRAL HEMORRHAGE IN THE SIREN STUDY

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 5 (E-Poster Area)
Lecture Time
07:00 PM - 07:05 PM

Abstract

Group Name

the Stroke Investigative Research and Education Network (SIREN) Investigators

Background And Aims

Intracerebral Heamorhage (ICH) has a high mortality rate. Complex prognostic models for ICH have been reported, however all these have limitations particularly in developing countries. In this study, we determined the frequency and independent predictors of 30 day mortality in indigenous West African patients with ICH.

Methods

A multicenter Study among consecutive patients presenting with spontaneous ICH seen in the sixteen participating hospitals in the SIREN (Stroke Investigative and Educational Network) Study between 2015 and 2018 . Data collected included clinical, neuroimaging (Brain CT scan or MRI scan), Demographic data, Stroke severity, location and volume of heamatoma, ICH score and the 30day mortality were also collated.

Results

A total of 1074 patients comprising 676(62.9%) males, and 379(36.9%) recruited. Male: female ratio was 1.7:1 and mean age 54.1(13.1). The 30 day mortality rate was 31.7%

Stroke severity presence of seizures, presence of aspiration preumonitis, High systolic Blood pressure, deep location of ICH, poor renal function, infra-tentorial location of ICH, low Glasgow Coma scale score and higher ICH score were associated with mortality (P<0.01).

On multivariate analysis, increased NIHSS scores, presence of aspiration pneumonitis, increased systolic Blood pressure, Low Glasgow Coma scale score, were significantly associated with mortality (P<0.01). The ICH score, intraventricular heamorrhage, ICH volume >30mls, seizures, location of ICH and hyperglycemia were not significant.

Conclusions

The predictive factors for mortality were worsening stroke severity (NIHSS > 15), elevated systolic blood pressure, aspiration pneumonitis and a low Glasgow Coma Scale.

Trial Registration Number

Not applicable

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RELATIONSHIP BETWEEN HAEMATOMA LENGTH AND OUTCOME? DATA FROM THE TRANEXAMIC ACID FOR INTRACEREBRAL HAEMORRHAGE 2 (TICH-2) TRIAL

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 5 (E-Poster Area)
Lecture Time
07:05 PM - 07:10 PM

Abstract

Group Name

on behalf of the TICH-2 Investigators

Background And Aims

Increased haematoma volume (measured as ABC/2) is related to subsequent mortality and functional outcome. Haematoma length (the A in ABC/2) is easy to measure and dichotomisation of <5 cm vs >5 cm was prognostic in the TICH-2 ambulance trial.

Methods

TICH-2 was an international randomised controlled trial of tranexamic acid in intracerebral haemorrhage. Haematoma volume was measured by neuroimaging experts and here we compared outcome by length: <5 cm vs >5 cm. Data are number (%); comparisons are shown as odds ratio (OR) or hazard ratio (HR) with 95% confidence intervals (CI) following adjustment for baseline (including age, NIHSS, SBP, time from onset to randomisation and treatment assignment).

Results

Of 2280 participants, 476 (20.9%) had length >5cm and these were older, and more likely to be female, be on antiplatelet therapy, have a lower systolic blood pressure and have a worse NIHSS score (all p<0.05). Baseline haematoma volume was 61.4ml in participants with length >5cm, versus 14.1ml in <5cm participants. Participants with length >5cm had increased early death by day 7 (OR 3.44, 95% CI 2.48-4.77), late death by day 90 (HR 2.32, 95% CI 1.91-2.81), dependence on modified Rankin Scale at day 90 (OR 2.59, 95% CI 2.09-3.21) and worse secondary outcome scores for measures of disability, cognition, mood and quality of life (all p<0.0001).

Conclusions

Patients with a haematoma length >5cm were more likely to have worse clinical outcomes. Measuring haematoma length is easy and could be used to select patients for clinical trials and haemostatic therapy.

Trial Registration Number

ISRCTN93732214

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THROMBIN GENERATION IN PATIENTS WITH NON-TRAUMATIC INTRACEREBRAL HEMORRHAGE

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 5 (E-Poster Area)
Lecture Time
07:10 PM - 07:15 PM

Abstract

Background And Aims

Non-traumatic intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes and leads to a higher rate of mortality as compared to ischemic strokes. In the IRONHEART study, we aimed to find out whether the thrombin generation assay (TGA) could predict outcomes in ICH patients.

Methods

In this prospective, observational study 63 consecutive ICH patients (age: 67.85±11.82, male/female: 43/20) and 179 healthy controls were included. CT, detailed clinical and laboratory investigations were performed from patients on admission. TGA was performed on stored platelet poor plasma obtained on admission. Lag time, endogen thrombin potential (ETP), peak thrombin, time-to-peak, and velocity index were calculated. Clinical parameters including age, sex, BMI, smoking habit, traditional risk factors were registered. Short- and long-term outcomes of ICH were defined at 14 days and 3 months post-event according to the NIHSS and the modified Rankin Scale (mRS), respectively. All patients or their relatives provided written informed consent.

Results

As compared to controls, ETP was significantly higher in patients vs. controls (1664±655 vs. 1489±301 nM*min, respectively, p=0.0004). Peak thrombin was significantly higher, while lag time and time-to-peak parameters were significantly longer in patients. Elevated ETP was associated with worse long-term outcomes (mRS 0-1: 1586±299 vs. mRS 2-5: 1983±476 and mRS 6: 1765±288 nM*min, p=0.019). Time-to-peak showed a modest, significant negative correlation with intracerebral bleeding volume (r=-0.29, p=0.040).

Conclusions

Patients with ICH showed increased thrombin generation as compared to controls. Elevated ETP was associated with worse long-term outcomes, indicating that TGA might be useful to predict outcomes in patients with ICH.

Funding:GINOP-2.3.2-15-2016-00043

Trial Registration Number

Not applicable

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THE SURGE OF ANTIDIURETIC HORMONE ON THE ONSET OF SUBARACHNOID HEMORRHAGE MAY BE THE CAUSE OF HYPONATREMIA PRECEDING SYMPTOMATIC VASOSPASM.

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 5 (E-Poster Area)
Lecture Time
07:15 PM - 07:20 PM

Abstract

Group Name

The Kobe university SAH study collaborators

Background And Aims

The pathogenesis of hyponatremia preceding symptomatic vasospasm (SVS) of aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. To elucidate the pathogenesis of hyponatremia preceding SVS of aSAH using 14 days monitoring of laboratory data and biochemical measurement including with plasma cortisol (cortisol), brain natriuretic peptide (BNP), serum antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH).

Methods

This was a prospective cohort study with 86 aSAH patients within 24 hours onset. We monitored changes in serum sodium levels, serum osmolarity, daily sodium balance and daily water balance during 14 days after SAH. We also monitored cortisol at 0700hours, BNP, ADH, ACTH concentrations on days 1, 6-8, and 11-13.

Results

Among 86 patients, 13 (16.3%) had SVS. Serum sodium levels were significantly decreased from two days before the onset of SVS (Figure 1). There were no significant differences between SVS and non-SVS patient groups in terms of patients’ characteristics, treatment modality, WFNS grade, daily water balance and daily sodium balance during 14 days after aSAH. Regarding to biochemical measurement, mean values of ADH, ACTH and cortisol on Day 1 in patients with SVS were significantly higher than those without SVS (Figure 2). There were no findings of glucocorticoid insufficiency in SVS patients.

fig 1.png

figure 2.jpg

Conclusions

Hyponatremia occurred one day before SVS. The surge of antidiuretic hormone on the onset of aSAH suspected of hypothalamic injury may cause hyponatremia preceding symptomatic vasospasm. Accumulation of cases is mandatory to reveal fully the etiology of hyponatremia preceding SVS of aSAH patients.

Trial Registration Number

Not applicable

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