• Lucia Rivera-Lara, Santosh B Murthy, Saman Nekoovaght-Tak, Hasan Ali, Nichol McBee, Rachel Dlugash, Malathi Ram, Richard Thompson, Issam A Awad, Daniel F Hanley, Wendy C Ziai, and CLEAR Investigators.
• Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA. lriver14@jhmi.edu.
• Neurocrit Care. 2018 Oct 1; 29 (2): 180-188.

BackgroundConcomitant acute ischemic lesions are detected in up to a quarter of patients with spontaneous intracerebral hemorrhage (ICH). Influence of bleeding pattern and intraventricular hemorrhage (IVH) on risk of ischemic lesions has not been investigated.MethodsRetrospective study of all 500 patients enrolled in the CLEAR III randomized controlled trial of thrombolytic removal of obstructive IVH using external ventricular drainage. The primary outcome measure was radiologically confirmed ischemic lesions, as reported by the Safety Event Committee and confirmed by two neurologists. We assessed predictors of ischemic lesions including analysis of bleeding patterns (ICH, IVH and subarachnoid hemorrhage) on computed tomography scans (CT). Secondary outcomes were blinded assessment of mortality and modified Rankin scale (mRS) at 30 and 180 days.ResultsIschemic lesions occurred in 23 (4.6%) during first 30 days after ICH. Independent risk factors associated with ischemic lesions in logistic regression models adjusted for confounders were higher IVH volume (p = 0.004) and persistent subarachnoid hemorrhage on CT scan (p = 0.03). Patients with initial IVH volume ≥ 15 ml had five times the odds of concomitant ischemic lesions compared to IVH volume < 15 ml. Patients with ischemic lesions had significantly higher odds of death at 1 and 6 months (but not poor outcome; mRS 4-6) compared to patients without concurrent ischemic lesions.ConclusionsOccurrence of ischemic lesions in the acute phase of IVH is not uncommon and is significantly associated with increased early and late mortality. Extra-parenchymal blood (larger IVH and visible subarachnoid hemorrhage) is a strong predictor for development of concomitant ischemic lesions after ICH.

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