Influence of clinical characteristics on prognosis and treatment options

Background: Stroke is a leading causes of death and disability globally and 10-15% of all strokes are caused by intracerebral hemorrhage (ICH). An increased knowledge of factors affecting prognosis after ICH is needed to guide the development of possible interventions to improve outcome. Aim: To investigate how clinical andimaging factors affect survival and functional outcome after ICH and how these factors influence therapeutic options after ICH. Methods: Paper I: A 13-year prospective follow-up of 323 ICH patients from a population based cohort was performed to assess factors influencing long-term survival, excess mortality and causes of death. Paper II: The semi quantitative scale modified Graeb Scale (mGraeb), for estimation of intraventricular hemorrhage (IVH) severity, was evaluated for outcome prognostication after ICH in a cohort of 198 supratentorial ICH patients from Lund Stroke Register (LSR). Paper III: 635 ICH patients were included from the clinical ICH treatment trials MISTIE-II and CLEAR-III. White matter lesions (WML) at baseline CT was evaluated as a prognostic marker for hematoma expansion and 180-day functional outcome after ICH. Paper IV: Eligibility criteria from 11 large interventional trials on ICH were applied to 253 consecutive first-ever ICH patients from LSR to assess eligibility rates in an unselected ICH cohort. Prognostic differences between eligible and non-eligible patients were evaluated. Results: Paper I: One-year survivors after ICH had persisting and continuing excess mortality compared to the general population (27% 13 years after ictus). Major causes of death were stroke and ischemic heart disease. Diabetes mellitus, age, and oral anticoagulant therapy at ICH-onset negatively affected long-term mortality. Paper II: The mGraeb predicted 30-day mortality (OR 1.16; CI 95% 1.06-1.27; p=0.002) and poor functional outcome (OR 1.11; CI 95% 1.02-1.20; p=0.011) after ICH. The mGraeb improved outcome prediction beyond previously established factors. Paper III: The 349 (55%) patients with WML did not have increased odds for hematoma expansion in median 39 hours after ictus (IQR, 22.5-54.5). However, increasing WML severity was associated with worse 180-day functional outcome in univariate and multivariate analyses. Paper IV: Estimated eligibility proportions ranged between 2-36% for 11 identified clinical trials. Patients not eligible for any trial (n=96) had more severe baseline ICH characteristics, higher 30-day case fatality and worse functional outcome compared to trial eligible patients (n=157). Conclusions: ICH patients have a high short-term and long-term mortality. IVH and WML are important risk factors for poor outcome. However, the patient group is diverse and good prognostic estimations are therefore essential to develop optimal treatment for ICH patients in general clinical practice and in clinical trials