Abstract 1122‐000051: Isolated Diplacusis Due to Ipsilateral Temporal Lobe Infarction: A Case Report

Introduction: Double hearing or Diplacusis is a synchronous double perception of a sound and can have Binauralis or Monauralis pattern, with inner ear disorders being the main culprit [1]. Other forms of Auditory illusions have been reported as a co‐manifestation of stroke syndromes, but none as an isolated presentation [1][2]. This is a case of a 77‐year‐old male with acute onset isolated Diplacusis in a patient due to a right temporal lobe ischemic infarct. To our knowledge, this is the first case report of an isolated diplacusis due to cortical infarct. Methods: A case presentation with Pubmed search of review articles and case reports. Results: The patient had a past medical history of sensorineural deafness in his left ear. He described any sound heard as the same quality but occurring with an echo heard a fraction of a second later in his right ear. There was no decreased hearing quality or tinnitus reported in his right ear. His drug screen test was negative. His examination was only remarkable for a sensorineural hearing loss pattern on his left ear. His (NIHSS) was zero, and no other cranial nerve abnormalities were detected. His MRI was significant for a punctate restricted diffusion on the right temporal lobe, resembling an ischemic infarct (Figure). Conclusions: Isolated diplacusis can present as acute ischemic stroke in the temporal lobe. Further studies are needed to understand its pathophysiology

Sulfonylurea drug pretreatment and functional outcome in diabetic patients with acute intracerebral hemorrhage

Purpose Intracerebral hemorrhage (ICH) is associated with poor clinical outcome and high mortality. Sulfonylurea (SFU) use may be a viable therapy for inhibiting sulfonylurea receptor-1 and NCCa-ATP channels and reducing perihematomal edema and blood-brain barrier disruption. We sought to evaluate the effects of prehospital SFU use with outcomes in diabetic patients with acute ICH. Methods We retrospectively analyzed a cohort of diabetic patients presenting with acute ICH at a tertiary care center. Study inclusion criteria included spontaneous ICH etiology and age > 18 years. Baseline clinical severity was documented using ICH-score. Hematoma volumes (HV) on admission were calculated using ABC/2 formula. Unfavorable functional outcome was documented as discharge modified Rankin Scale scores 2–6. Results 230 diabetic patients with acute ICH fulfilled inclusion criteria (mean age 64 ± 13 years, men 53%). SFU pretreatment was documented in 16% of the study population. Patients with SFU pretreatment had significantly (p < 0.05) lower median ICH-scores (0, IQR: 0–2) and median admission HV (4cm3, IQR: 1–12) compared to controls [ICH-score: 1 (IQR: 0–3); HV: 9cm3 (IQR: 3–20)]. SFU pretreatment was independently (p = 0.033) and negatively associated with the cubed root of admission HV (linear regression coefficient: − 0.208; 95%CI: − 0.398 to − 0.017) in multiple linear regression analyses adjusting for potential confounders. Pretreatment with SFU was also independently (p = 0.033) associated with lower likelihood of unfavorable functional outcome (OR = 0.19; 95%CI: 0.04–0.88) in multivariable logistic regression models adjusting for potential confounders. Conclusion SFU pretreatment may be an independent predictor for improved functional outcome in diabetic patients with acute ICH. This association requires independent confirmation in a large prospective cohort study

Higher low-density lipoprotein cholesterol levels are associated with decreased mortality in patients with intracerebral hemorrhage

Background and aims: The relationship between lipoprotein levels, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and clinical outcome after intracerebral hemorrhage (ICH) remains controversial. We sought to evaluate the association of lipoprotein cholesterol levels and statin dosage with clinical and neuroimaging outcomes in patients with ICH. Methods: Data on consecutive patients hospitalized with spontaneous acute ICH was prospectively collected over a 5-year period and retrospectively analyzed. Demographic characteristics, clinical severity documented by NIHSS-score and ICH-score, neuroimaging parameters, pre-hospital statin use and doses, and LDL-C and HDL-C levels were recorded. Outcome events characterized were hematoma volume, hematoma expansion, in-hospital functional outcome, and in-hospital mortality. Results: A total of 672 patients with acute ICH [(mean age 61.6±14.0 years, 43.6% women, median ICH score 1 (IQR: 0-2)] were evaluated. Statin pretreatment was not associated with neuroimaging or clinical outcomes. Higher LDL-C levels were associated with several markers of poor clinical outcome and in-hospital mortality. LDL-C levels were independently and negatively associated with the cubed root of hematoma volume (linear regression coefficient - 0.021, 95% CI: -0.042−-0.001; p=0.049) on multiple linear regression models. Higher admission LDL-C (OR 0.88, 95% CI 0.77 – 0.99; p= 0.048) was also an independent predictor for decreased hematoma expansion. Higher admission LDL-C levels were independently (p <0.001) associated with lower likelihood of in-hospital mortality (OR per 10mg/dL increase 0.68, 95% CI: 0.57– 0.80) in multivariable logistic regression models.Conclusions: Higher LDL-C levels at hospital admission were an independent predictor for lower likelihood of hematoma expansion and decreased in-hospital mortality in patients with acute spontaneous ICH. This association requires independent confirmation

Elevated pulse pressure levels are associated with increased in-hospital mortality in acute spontaneous intracerebral hemorrhage

Objectives: Clinical outcome after intracerebral hemorrhage (ICH) remains poor. Definitive phase-3 trials in ICH have failed to demonstrate improved outcomes with intensive systolic blood pressure (SBP) lowering. We sought to determine whether other BP parameters—diastolic BP (DBP), pulse pressure (PP), and mean arterial pressure (MAP)—showed an association with clinical outcome in ICH. Methods: We retrospectively analyzed a prospective cohort of 672 patients with spontaneous ICH and documented demographic characteristics, stroke severity, and neuroimaging parameters. Consecutive hourly BP recordings allowed for computation of SBP, DBP, PP, and MAP. Threshold BP values that transitioned patients from survival to death were determined from ROC curves. Using in-hospital mortality as outcome, BP parameters were evaluated with multivariable logistic regression analysis. Results: Patients who died during hospitalization had higher mean PP compared to survivors (68.5 ± 16.4 mm Hg vs. 65.4 ± 12.4 mm Hg; P = 0.032). The following admission variables were associated with significantly higher in-hospital mortality (P < 0.001): poorer admission clinical condition, intraventricular hemorrhage, and increased admission normalized hematoma volume. ROC analysis showed that mean PP dichotomized at 72.17 mm Hg, provided a transition point that maximized sensitivity and specific for mortality. The association of this increased dichotomized PP with higher in-hospital mortality was maintained in multivariable logistic regression analysis (odds ratio, 3.0; 95% confidence interval, 1.7–5.3; P < 0.001) adjusting for potential confounders. Conclusion: Widened PP may be an independent predictor for higher mortality in ICH. This association requires further study

Clinical Outcomes and Neuroimaging Profiles in Nondisabled Patients With Anticoagulant-Related Intracerebral Hemorrhage

Background and Purpose- The aim of this study was to prospectively validate our prior findings of smaller hematoma volume and lesser neurological deficit in nonvitamin K oral anticoagulant (NOAC) compared with Vitamin K antagonist (VKA)-related intracerebral hemorrhage (ICH). Methods- Prospective 12-month observational study in 15 tertiary stroke centers in the United States, Europe, and Asia. Consecutive patients with premorbid modified Rankin Scale score ofvolume, significant hematoma expansion (absolute [12.5 mL] or relative [\u3e33%] increase), neurological severity measured by National Institutes of Health Stroke Scale score, 90-day mortality, and functional status (modified Rankin Scale score). Results- Our cohort comprised 196 patients, 62 NOAC related (mean age, 75.0±11.4 years; 54.8% men) and 134 VKA related (mean age, 72.3±10.5; 73.1% men). There were no differences in vascular comorbidities, antiplatelet, and statin use; NOAC-related ICH patients had lower median baseline hematoma volume (13.8 [2.5-37.6] versus 19.5 [6.6-52.0] mL; P=0.026) and were less likely to have severe neurological deficits (National Institutes of Health Stroke Scale score of \u3e10 points) on admission (37% versus 55.3%, P=0.025). VKA-ICH were more likely to have significant hematoma expansion (37.4% versus 17%, P=0.008). NOAC pretreatment was independently associated with smaller baseline hematoma volume (standardized linear regression coefficient:-0.415 [95% CI, -0.780 to -0.051]) resulting in lower likelihood of severe neurological deficit (odds ratio, 0.44; 95% CI, 0.22-0.85) in multivariable-adjusted models. Conclusions- Patients with NOAC-related ICH have smaller baseline hematoma volumes and lower odds of severe neurological deficit compared with VKA-related ICH. These findings are important for practicing clinicians making anticoagulation choices

Direct oral anticoagulant-vs vitamin k antagonist-related nontraumatic intracerebral hemorrhage

Objective: To compare the neuroimaging profile and clinical outcomes among patients with intracerebral hemorrhage (ICH) related to use of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF). Methods: We evaluated consecutive patients with NVAF with nontraumatic, anticoagulant-related ICH admitted at 13 tertiary stroke care centers over a 12-month period. We also performed a systematic review and meta-analysis of eligible observational studies reporting baseline characteristics and outcomes among patients with VKA- or DOAC-related ICH. Results: We prospectively evaluated 161 patients with anticoagulation-related ICH (mean age 75.6 ± 9.8 years, 57.8% men, median admission NIH Stroke Scale [NIHSSadm] score 13 points, interquartile range 6–21). DOAC-related (n = 47) and VKA-related (n = 114) ICH did not differ in demographics, vascular risk factors, HAS-BLED and CHA2DS2-VASc scores, and antiplatelet pretreatment except for a higher prevalence of chronic kidney disease in VKA-related ICH. Patients with DOAC-related ICH had lower median NIHSSadm scores (8 [3–14] vs 15 [7–25] points, p = 0.003), median baseline hematoma volume (12.8 [4–40] vs 24.3 [11–58.8] cm3, p = 0.007), and median ICH score (1 [0–2] vs 2 [1–3] points, p = 0.049). Severe ICH (>2 points) was less prevalent in DOAC-related ICH (17.0% vs 36.8%, p = 0.013). In multivariable analyses, DOAC-related ICH was independently associated with lower baseline hematoma volume (p = 0.006), lower NIHSSadm scores (p = 0.022), and lower likelihood of severe ICH (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.13–0.87, p = 0.025). In meta-analysis of eligible studies, DOAC-related ICH was associated with lower baseline hematoma volumes on admission CT (standardized mean difference = −0.57, 95% CI −1.02 to −0.12, p = 0.010) and lower in-hospital mortality rates (OR = 0.44, 95% CI 0.21–0.91, p = 0.030). Conclusions: DOAC-related ICH is associated with smaller baseline hematoma volume and lesser neurologic deficit at hospital admission compared to VKA-related ICH

Direct oral anticoagulant- vs vitamin K antagonist-related nontraumatic intracerebral hemorrhage

OBJECTIVE: To compare the neuroimaging profile and clinical outcomes among patients with intracerebral hemorrhage (ICH) related to use of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF). METHODS: We evaluated consecutive patients with NVAF with nontraumatic, anticoagulant-related ICH admitted at 13 tertiary stroke care centers over a 12-month period. We also performed a systematic review and meta-analysis of eligible observational studies reporting baseline characteristics and outcomes among patients with VKA- or DOAC-related ICH. RESULTS: We prospectively evaluated 161 patients with anticoagulation-related ICH (mean age 75.6 ± 9.8 years, 57.8% men, median admission NIH Stroke Scale [NIHSSadm] score 13 points, interquartile range 6-21). DOAC-related (n = 47) and VKA-related (n = 114) ICH did not differ in demographics, vascular risk factors, HAS-BLED and CHA2DS2-VASc scores, and antiplatelet pretreatment except for a higher prevalence of chronic kidney disease in VKA-related ICH. Patients with DOAC-related ICH had lower median NIHSSadm scores (8 [3-14] vs 15 [7-25] points, p = 0.003), median baseline hematoma volume (12.8 [4-40] vs 24.3 [11-58.8] cm3, p = 0.007), and median ICH score (1 [0-2] vs 2 [1-3] points, p = 0.049). Severe ICH (\u3e2 points) was less prevalent in DOAC-related ICH (17.0% vs 36.8%, p = 0.013). In multivariable analyses, DOAC-related ICH was independently associated with lower baseline hematoma volume (p = 0.006), lower NIHSSadm scores (p = 0.022), and lower likelihood of severe ICH (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.13-0.87, p = 0.025). In meta-analysis of eligible studies, DOAC-related ICH was associated with lower baseline hematoma volumes on admission CT (standardized mean difference = -0.57, 95% CI -1.02 to -0.12, p = 0.010) and lower in-hospital mortality rates (OR = 0.44, 95% CI 0.21-0.91, p = 0.030). CONCLUSIONS: DOAC-related ICH is associated with smaller baseline hematoma volume and lesser neurologic deficit at hospital admission compared to VKA-related ICH