Apolipoprotein E Genotype Is Associated With CT Angiography Spot Sign in Lobar Intracerebral Hemorrhage
The “spot sign” is extravasation of contrast into the intracerebral hematoma after CT angiography. It has been shown to predict hematoma expansion and poor outcome after ICH. This study aimed to identify genetic predictors of the spot sign. Apolipoprotein E (APOE) ϵ2 and ϵ4 alleles have been shown to increase the risk of lobar ICH, with ϵ2 allele associated with vasculopathic changes leading to the rupture of diseased vessels and ϵ4 allele associated with increased severity of amyloid deposition in the vessel wall. This is a retrospective analysis of prospectively collected data. Three hundred seventy-one patients with CT angiography and genetic data were analyzed. By multivariate analysis, patients on warfarin were more likely to have a spot sign regardless of ICH location. APOE ϵ2, and not APOE ϵ4, was associated with the presence of the spot sign in lobar ICH. In deep ICH, there was no association between wither APOE ϵ2 or APOE ϵ4 and the presence of the spot sign. Their findings suggest that both hemostatic factors and vessel pathology influence the presence of the spot sign. APOE ϵ2 is a potential biomarker in acute ICH lending itself to potentially impacting the management of intracerebral hemorrhage in the acute setting.
See p 2120.
Multimodal Recanalization Therapy in Acute Basilar Artery Occlusion: Long-Term Functional Outcome and Quality of Life
Acute basilar artery occlusion has a high mortality rate and poor outcome. This retrospective analysis analyzed long-term mortality, functional outcome, and health-related quality of life in patients with acute basilar artery occlusion managed with multimodal recanalization therapy. Ninety-one patients treated at their institution over a 7-year span were identified. The mean National Institutes of Health Stroke Scale score at admission was 21.7±7.8. Overall recanalization was achieved in 81 of 91 patients (89%). Thirty-six patients (40%) died during the acute hospitalization and 2 additional patients had died within 3 months. All 10 of the patients who had failed recanalization died in the hospital. After a median observation of 4.2 years, the mortality rate was 59%. Of the 35 surviving patients, 26 (74%) had a favorable long-term outcome (modified Rankin Scale ≤3). Compared with a historical population of unselected patients with stroke from the International Stroke Trial, the surviving basilar artery patients scored higher in health-related quality of life. The majority (91%) of long-term survivors lived at home and was not dependent on professional nursing care. The likelihood of a favorable long-term outcome decreased with increasing time to treatment and none of the patients treated beyond 9 hours had a favorable outcome. Intravenous thrombolysis and female sex were predictors of favorable outcome using backward stepwise logistic regression. Coma at admission was associated with poor outcome (modified Rankin Scale ≥4). This review highlights the importance of recanalization with 100% mortality in patients who failed recanalization, but despite recanalization, mortality is still high in the acute stages of basilar artery occlusion. However, survivors had a 75% chance to reach a favorable long-term clinical outcome. Prospective clinical trials are needed to determine the best treatment for acute basilar artery occlusion.
See p 2130.
Earlier Blood Pressure-Lowering and Greater Attenuation of Hematoma Growth in Acute Intracerebral Hemorrhage: INTEnsive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT) Pilot Phase
Growth of intracerebral hemorrhage (ICH) is common and a strong predictor of death and dependency. Treatments such as hemostatic medications and blood pressure (BP)-lowering aimed at reducing growth of the hematoma may improve prognosis after ICH. The pilot phase of INTERACT (INTEnsive blood pressure Reduction in Acute Cerebral hemorrhage Trial) showed that early intensive BP-lowering reduced hematoma growth in patients with ICH. Four hundred four patients with ICH within 6 hours of onset and elevated systolic BP (150–220 mm Hg) were randomly assigned to intensive BP-lowering using intravenous medications (target systolic BP <140 mm Hg) or standard management (target systolic BP <180 mm Hg). This analysis aimed to determine the treatment effects on hematoma growth by time from ICH onset to randomization. They showed that reductions in proportional hematoma growth produced by more intensive BP-lowering over 72 hours decreased progressively with delays in initiation of study treatment (22%, 17%, 9%, and 3% for quartile groups defined by time from onset to randomization of <2.9, 2.9–3.6, 3.7–4.8, and ≥4.9 hours, respectively (P trend=0.001). There were also smaller absolute reductions in hematoma growth with delays in initiation of study treatment, but this did not reach statistical significance. Like FAST (Factor seven for Acute hemorrhagic Stroke Trial), which found greater hematoma growth reduction in patients who received recombinant activated factor VII at 3 hours compared with 3 to 4 hours, this present study showed that early and intensive BP reduction results in greater reduction of hematoma growth after ICH.
See p 2236.
- © 2012 American Heart Association, Inc.
- Apolipoprotein E Genotype Is Associated With CT Angiography Spot Sign in Lobar Intracerebral Hemorrhage
- Multimodal Recanalization Therapy in Acute Basilar Artery Occlusion: Long-Term Functional Outcome and Quality of Life
- Earlier Blood Pressure-Lowering and Greater Attenuation of Hematoma Growth in Acute Intracerebral Hemorrhage: INTEnsive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT) Pilot Phase
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