Ischemic lesions signal preventive needs in ICH patients

By Eleanor McDermid, Senior MedWire Reporter

The finding of new ischemic lesions in patients with hypertensive intracerebral hemorrhage (ICH) identifies patients at the greatest need of preventive therapy, research published in Neurology suggests.

"Proof of ischemia in the setting of acute ICH has real implications and may lead to a new therapeutic paradigm: modifying the risk of secondary ischemia following ICH in order to reduce recurrent stroke risk and improve long-term outcomes," say Shyam Prabhakaran (Rush University Medical Center, Chicago, Illinois, USA) and Kevin Sheth (University of Maryland School of Medicine, Baltimore, Maryland, USA), authors of an accompanying editorial.

They add: "While routine antithrombotic therapy after ICH is controversial, the authors' findings suggest that, using [magnetic resonance imaging], we may be able to identify those ICH patients who may most benefit from secondary prevention strategies."

Ischemic lesions ‑ those that were remote from the ICH and the area of perihematomal edema ‑ were relatively common in this study, appearing in 26.8% of the 97 patients who underwent diffusion-weighted magnetic resonance imaging (DWI) 5 days after onset. About three-quarters were found in the subcortical white matter or brainstem.

All the lesions were smaller than 3 mm and bore no relation to patients' symptoms or condition. Yet study author Dong-Wha Kang (University of Ulsan College of Medicine, Seoul, South Korea) and colleagues found that patients with these lesions had a significantly increased risk for the composite outcome of ischemic or hemorrhagic stroke or vascular death over a median follow up of 42 months.

In multivariate analysis, the risk was elevated 5.69- or 9.33-fold, depending on the statistical method used (inverse-probability-of-treatment weighting and bootstrap resampling, respectively).

Prabhakaran and Sheth remark that the findings "strengthen the notion that a small vessel microangiopathy, due to chronic hypertension or cerebral amyloid angiopathy, may contribute to ischemic and hemorrhagic presentations in rapid sequence in a minority of patients."

Of note, new ischemic lesions did not predict patients' 3-month outcomes, contrary to previous study findings.

The editorialists say that several patient- and treatment-related factors could account for this discrepancy. "Clarifying the complex interactions between lowering of blood pressure, hematoma expansion, and DWI lesions will be important and might alter our current approach to blood pressure management in ICH."

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