Spontaneous (non-traumatic) intracerebral haemorrhage (ICH) affects ~3.4 million people worldwide each year, causing ~2.8 million deaths. Many randomised controlled trials and high-quality observational studies have added to the evidence base for the management of people with ICH since the last European Stroke Organisation (ESO) guidelines for the management of spontaneous ICH were published in 2014, so we updated the ESO guideline. This guideline update was guided by the European Stroke Organisation (ESO) standard operating procedures for guidelines and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework, in collaboration with the European Association of Neurosurgical Societies (EANS). We identified 37 Population, Intervention, Comparator, Outcome (PICO) questions and prioritised clinical outcomes. We conducted systematic literature searches, tailored to each PICO, seeking randomised controlled trials (RCT) - or observational studies when RCTs were not appropriate, or not available - that investigated interventions to improve clinical outcomes. A group of co-authors allocated to each PICO screened titles, abstracts, and full texts and extracted data from included studies. A methodologist conducted study-level meta-analyses and created summaries of findings tables. The same group of co-authors graded the quality of evidence, and drafted recommendations that were reviewed, revised and approved by the entire group. When there was insufficient evidence to make a recommendation, each group of co-authors drafted an expert consensus statement, which was reviewed, revised and voted on by the entire group. The systematic literature search revealed 115,647 articles. We included 208 studies. We found strong evidence for treatment of people with ICH on organised stroke units, and secondary prevention of stroke with blood pressure lowering. We found weak evidence for scores for predicting macrovascular causes underlying ICH; acute blood pressure lowering; open surgery via craniotomy for supratentorial ICH; minimally invasive surgery for supratentorial ICH; decompressive surgery for deep supratentorial ICH; evacuation of cerebellar ICH > 15 mL; external ventricular drainage with intraventricular thrombolysis for intraventricular extension; minimally invasive surgical evacuation of intraventricular blood; intermittent pneumatic compression to prevent proximal deep vein thrombosis; antiplatelet therapy for a licensed indication for secondary prevention; and applying a care bundle. We found strong evidence against anti-inflammatory drug use outside of clinical trials. We found weak evidence against routine use of rFVIIa, platelet transfusions for antiplatelet-associated ICH, general policies that limit treatment within 24 h of ICH onset, temperature and glucose management as single measures (outside of care bundles), prophylactic anti-seizures medicines, and prophylactic use of temperature-lowering measures, prokinetic anti-emetics, and/or antibiotics. New evidence about the management of ICH has emerged since 2014, enabling this update of the ESO guideline to provide new recommendations and consensus statements. Although we made strong recommendations for and against a few interventions, we were only able to make weak recommendations for and against many others, or produce consensus statements where the evidence was insufficient to guide clinical decisions. Although progress has been made, many interventions still require definitive, high-quality evidence, underpinning the need for embedding clinical trials in routine clinical practice for ICH.

Pathophysiological mechanisms underlying hematoma expansion in spontaneous intracerebral hemorrhage (ICH) remain poorly understood, and most data are derived from postmortem studies or serial neuroimaging studies performed over hours to days from onset. Our unique case report of a hypertensive ICH serendipitously captured by serial CT provides valuable in vivo data from the very onset of hematoma formation in an aging individual. A 76-year-old hypertensive man underwent elective carotid CT angiography to evaluate a previously known asymptomatic right carotid stenosis. During scanning, he developed severe right hemispheric neurological deficit signs. Immediate rescanning and subsequent follow-up imaging revealed the hyperacute evolution of a right putaminal ICH. We co-registered four scans (from 00 h:00 min, 00 h:06 min, 00 h:21 min, and 24 h:58 min) to a common template in 3D and made volumetric measurements of the growing hematoma also assessing the spatial relationship of expansion with the sources of bleed seen as contrast extravasation ("spot signs"). We found that spot signs appeared on the periphery of the initial hematoma, and further expansion was seen in the directions determined by these spot signs. Most of the final ICH volume developed in the first 20 min post-onset, highlighting the hyperacute nature of hematoma growth. Our findings support the hypothesis that hematoma expansion in hypertensive ICH, particularly in aging individuals, results from multiple sources of bleeding due to a cascade of secondary vessel ruptures with eccentric expansion rather than a single source and continuous bleeding with concentric expansion reflecting the global fragility of the cerebral vasculature. The therapeutic time window for hematoma expansion prevention is very narrow.

To investigate the differences in blood pressure (BP) management and outcomes between intracerebral hemorrhage (ICH) patients on oral anticoagulant (OAC) therapy compared to those not on OAC therapy within the first 24 h of hospital admission.

This retrospective cohort study included 165 ICH patients admitted to a comprehensive stroke center between July 1, 2014 and June 30, 2021. Patients were divided into two groups: those on OAC therapy (n = 55) and those not on OAC therapy (n = 110). BP measurements, including systolic BP (SBP) within 24 h of post-admission, were recorded. Clinical outcomes, such as mortality, modified Rankin Scale (mRS) scores, and length of hospital stay, were assessed. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to evaluate the impact of BP management on patient outcomes.

No significant differences in overall survival were observed between the OAC and non-OAC groups. Although the mean SBP at 24 h was slightly higher in the OAC group (142 mmHg) compared to the non-OAC group (136 mmHg; p = 0.032), this did not translate into differences in mortality or functional outcomes. Higher ICH scores were associated with increased mortality risk (HR 2.01, 95% CI 1.29-3.12, p = 0.002). Higher GCS scores were associated with better functional outcomes (HR 0.92, 95% CI 0.85-0.99, p = 0.035), while BP management strategies did not show a significant impact.

BP management in the first 24 h for ICH patients on OAC may not significantly affect mortality or functional outcomes. Current BP management strategies may be applicable to both OAC and non-OAC patients, though further research is needed to explore tailored approaches.

Spontaneous intracerebral hemorrhage (ICH) accounts for up to 20% of all strokes and results in 40% mortality at 30 days. Although conservative medical management is still the standard treatment for ICH patients with small hematoma, patients with residual hematoma ≤15 mL after surgery are associated with better functional outcomes and survival rates. This study reported our clinical experience with using Robotic Stereotactic Assistance (ROSA) as a safe and effective approach for stereotactic ICH aspiration and intra-clot catheter placement.

A retrospective analysis was conducted of patients with spontaneous ICH who underwent ROSA-guided ICH aspiration surgery. ROSA-guided ICH surgical techniques, an aspiration and intra-clot catheter placement protocol, and a specific operative workflow (pre-operative protocol, intraoperative procedure and postoperative management) were employed to aspirate ICH using the ROSA One Brain, and appropriate follow-up care was provided.

From September 14, 2021 to May 4, 2022, a total of 7 patients were included in the study. Based on our workflow design, ROSA-guided stereotactic ICH aspiration effectively aspirated more than 50% of hematoma volume (or more than 30 mL for massive hematomas), thereby reducing the residual hematoma to less than 15 mL. The mean operative time of entire surgical procedure was 1.3 ± 0.3 h, with very little perioperative blood loss and no perioperative complications. No patients required catheter replacement and all patients' functional status improved.

Within our clinical practice ROSA-guided ICH aspiration, using our established protocol and workflow, was safe and effective for reducing hematoma volume, with positive functional outcomes.

Although lower hemoglobin levels associate with worse intracerebral hemorrhage (ICH) outcomes, causal drivers for this relationship remain unclear. We investigated the hypothesis that lower hemoglobin relates to increased hematoma expansion risk and poor outcomes using human observational data and assessed causal relationships using a translational murine model of anemia and ICH.

A multicenter, prospective observational cohort study of 2997 patients with ICH enrolled between 2010 and 2016 was assessed. Patients with baseline hemoglobin measurements and serial computed tomography neuroimaging were included for analyses. Patients with systemic evidence of coagulopathy were excluded. Separate regression models assessed relationships of baseline hemoglobin with hematoma expansion (≥33% and/or ≥6 mL growth) and poor long-term neurological outcomes (modified Rankin Scale score of 4-6) after adjusting for relevant covariates. Using a murine collagenase ICH model with serial neuroimaging in anemic versus nonanemic C57/BL6 mice, intergroup differences in ICH lesion volume, lesion volume changes, and early mortality were assessed.

Among 1190 ICH patients analyzed, the mean age was 61 years old, and 62% of the cohort were males. Lower baseline hemoglobin levels are associated with increased odds of hematoma expansion (adjusted odds ratio per -1 g/dL hemoglobin decrement, 1.10 [95% CI, 1.02-1.19]) and poor 3-month clinical outcomes (adjusted odds ratio per -1 g/dL hemoglobin decrement, 1.11 [95% CI, 1.03-1.21]). Similar relationships were seen with poor 6- and 12-month outcomes. In our animal model, anemic mice had significantly greater ICH lesion expansion, 24-hour lesion volumes, and greater mortality, as compared with nonanemic mice.

These results, in a human cohort and a mouse model, provide novel evidence suggesting that anemia has causal roles in hematoma expansion and poor ICH outcomes. Additional studies are required to clarify whether correcting anemia can improve these outcomes.

Hyperthermia within the first 24 h following ischemic stroke (IS) has been associated with poor outcomes. We sought to determine whether blood-brain barrier (BBB) permeability contributes to the relationship between hyperthermia and early infarct growth (EIG). A retrospective analysis was conducted on a prospective stroke biobank. EIG was defined as the percentage difference between the initial volume (mL) determined by the diffusion-weighted imaging at admission and the volume (mL) from the control CT image on the 4 th-7 th day. Hyperthermia was defined as an axillary body temperature ≥ 37.5 °C within the first 24 h. Soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK) serum levels were measured by ELISA. One-hundred and two (19.7%) patients showed EIG from a cohort of 519 patients (45.6% females). Linear correlation was observed for axillar body temperature and EIG (Pearson's r = 0.46; p < 0.001). sTWEAK serum levels showed a c-statistic of 0.74 (95% CI: 0.69-0.79), with an optimal cut-off point > 3000 pg/mL for EIG prediction. Moreover, microalbuminuria levels strongly correlated with sTWEAK levels (Pearson's r = 0.75; p < 0.001). In the multivariate analysis for EIG was observed an independent association with hyperthermia (adjusted OR 24.21; 95% CI: 12.03-39.12), sTWEAK levels > 3000 pg/mL (adjusted OR 16.43; 95% CI: 3.71-72.70), leukoaraiosis (adjusted OR 10.42; 95% CI: 2.68-39.08), and microalbuminuria (adjusted OR 1.02; 95% CI: 1.00-1.12). In our cohort, hyperthermia was independently associated with EIG after IS. The fact that microalbuminuria, leukoaraiosis, and sTWEAK were also associated with EIG suggests a relationship with increased BBB permeability.

Early prognosis of patients with spontaneous intracerebral hemorrhage (ICH) can help create individualized and optimized treatment plans for the patients.

This study evaluates short-term mortality and identifies risk factors in ICH patients at 115 People's Hospital within 30 days.

A retrospective cohort study was conducted involving 598 patients diagnosed with ICH by neurologists from December 2022 to June 2023. Diagnosis was confirmed by imaging, with symptoms appearing within 24 h of admission. Short-term mortality was defined as death within 30 days of onset.

Among the 598 patients (mean age 58.4; 40% female), 110 (18.4%) died, while 488 (81.6%) survived. The ICH score (AUC = 95.75%; p < 0.001; optimal cutoff = 1.5) was more prognostic for mortality than the NIHSS score (AUC = 94.61%; optimal cutoff = 17.5; p < 0.001). Identified risk factors included age ≥ 80 (RR = 2.2, p = 0.002), ICH score ≥ 2 (RR = 38.4, p < 0.001), NIHSS score ≥ 16 (RR = 15.1, p < 0.001), hematoma volume ≥ 30 cm3 (RR = 15.1, p < 0.001), and the presence of intraventricular (RR = 7.2, p < 0.001) or subtentorial hemorrhage (RR = 2.8, p < 0.001).

The mortality rate for ICH was significant. The ICH score, NIHSS, and hematoma volume are effective in predicting mortality in spontaneous ICH patients.

To develop and validate a nomogram based on systemic inflammation response index (SIRI) and clinical risk factors to predict short-term prognosis in very elderly patients with hypertensive intracerebral hemorrhage (HICH).

A total of 324 very elderly HICH patients from January 2017 to June 2024 were retrospectively enrolled and randomly divided into two cohorts for training (n = 227) and validation (n = 97) according to the ratio of 7:3. Independent predictors of poor prognosis were analyzed using univariate and multivariate logistic regression analyses. Furthermore, a nomogram prediction model was built. The area under the receiver operating characteristic curves (AUC), calibration plots and decision curve analysis (DCA) were used to evaluate the performance of the nomogram in predicting the prognosis of very elderly HICH.

By univariate and stepwise multivariate logistic regression analyses, GCS score (p < 0.001), hematoma expansion (p = 0.049), chronic obstructive pulmonary disease (p = 0.010), and SIRI (p = 0.005) were independent predictors for the prognosis in very elderly patients with HICH. The nomogram showed the highest predictive efficiency in the training cohort (AUC = 0.940, 95% CI: 0.909 to 0.971) and the validation cohort (AUC = 0.884, 95% CI: 0.813 to 0.954). The calibration curve indicated that the nomogram had good calibration. DCA showed that the nomogram had high applicability in clinical practice.

The nomogram incorporated with the SIRI and clinical risk factors has good potential in predicting the short-term prognosis of very elderly HICH.

The Tranexamic acid for IntraCerebral Haemorrhage-2 (TICH-2) trial reported no significant improvement in death and dependency at day 90 despite reductions in haematoma expansion, early neurological deterioration and early death. However, significant recovery after stroke, particularly intracerebral haemorrhage (ICH), may take more than 3 months. Here we report the participant outcomes at 1 year after stroke.

TICH-2 was a prospective randomised controlled trial that tested the efficacy and safety of tranexamic acid in spontaneous ICH when given within 8 h of onset. Patients with ICH on anticoagulation were excluded. Centralised blinded telephone follow up was performed for patients from the United Kingdom at 1 year. The primary outcome was modified Rankin Scale at 1 year. Secondary outcomes included Barthel index, Telephone Interview Cognitive Status-modified, EuroQoL-5D and Zung Depression Scale. This was a prespecified secondary analysis of the TICH-2 trial.

About 2325 patients were recruited into the trial (age 68.9 ± 13.8 years; 1301 male, 56%). About 1910 participants (82.2%) were eligible for day 365 follow up. 57 patients (3.0%) were lost to follow up. Tranexamic acid did not reduce the risk of poor functional outcome at 1 year (adjusted OR 0.91 95% CI 0.77-1.09; p = 0.302). However, Cox proportional hazard analysis revealed significant survival benefit in the tranexamic acid group (adjusted HR 0.83, 95% CI 0.70-0.99; p = 0.038).

There was no difference in functional outcome at 1 year after ICH. Tranexamic acid may reduce mortality at 1 year without an increase in severely dependent survivors. But this should be interpreted with caution as this is a result of secondary analysis in a neutral trial.

Andexanet Alfa in Acute Intracranial Hemorrhage in Patients Receiving an Oral Factor Xa Inhibitor (ANNEXA-I), the first ever randomized controlled trial of a reversal agent for direct oral anticoagulants, was published in 2024. The trial, which randomized patients with intracranial hemorrhage to andexanet alfa or usual care, was mandated by the United States Food and Drug Administration as part of its conditional approval in 2018. This approval was originally based on the single-arm trial, The Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors (ANNEXA-4). ANNEXA-I was stopped early for benefit and showed a reduction in the number of patients with significant hematoma expansion. However, the study was not powered for clinical endpoints such as disability or death and showed no difference in these outcomes. It did, however, show an increased risk of thrombosis, predominantly stroke with andexanet alfa. In this perspective, I reflect on some of the key criticisms of the trial and the implications for its interpretation.

Hemorrhagic strokes constitute 10-15% of all strokes and have the worst mortality and morbidity of all subtypes. Mortality and morbidity of spontaneous intracerebral hemorrhage (sICH) are often secondary to the effects of inflammation, brain edema, and swelling. Studies have shown that celecoxib, a selective cyclooxygenase 2 (COX-2) inhibitor, reduces perihematomal edema formation and inflammation. This study aimed to examine the impact of celecoxib on sICH outcomes.

TriNetX, a multi-institutional research database, was retrospectively queried to identify patients with sICH. Outcomes in patients who received celecoxib within 5 days (cohort 1) were analyzed and compared to those in patients who did not receive celecoxib (cohort 2). The primary end point was mortality within 1 year of sICH. Secondary end points included ventilator dependence, tracheostomy, percutaneous endoscopic gastrostomy tube placement, craniotomy, deep venous thrombosis, pulmonary embolism, ischemic stroke, transient ischemia attack, myocardial infarction, and seizures. Further analysis was performed to assess these outcomes for patients treated with ibuprofen, a nonselective COX inhibitor.

After propensity score matching, 833 patients were identified in each cohort based on celecoxib use. Mortality at 1 year was significantly reduced in patients with sICH receiving celecoxib compared to those who did not (13.33% vs. 17.77%; p = 0.0124). Risks of ventilator dependence, tracheostomy, percutaneous endoscopic gastrostomy tube placement, craniotomy, deep venous thrombosis, pulmonary embolism, ischemic stroke, transient ischemia attack, myocardial infarction, and seizures were not significantly increased in patients who received celecoxib within 5 days of sICH compared to those who did not receive celecoxib. There was no significant difference in mortality between patients based on ibuprofen administration.

There exists a growing interest in using COX-2 as a potential target strategy for neuroprotection in patients with sICH, with some evidence of a mortality benefit in small cohort studies. This study shows that early celecoxib use is associated with decreased mortality in patients with sICH.

Medial intracranial carotid artery calcifications (ICAC) are associated with impaired vascular physiology, increased arterial stiffness and pulse pressure. Their presence might therefore be associated with increased risk of intracerebral hemorrhage (ICH) expansion, according to the avalanche model. We explored the association between ICAC presence and pattern and hematoma expansion (HE).

Retrospective analysis of a monocentric, prospectively collected cohort of ICH patients admitted between June 2017 and October 2023. ICAC pattern was determined by Kockelkoren's rating scale on admission CT; medial ICAC were defined with a >6 points cutoff. A follow-up CT scan was performed within 72 h. HE was analyzed as a dichotomous (≥6 mL and/or ≥33%) and as a categorical (none/mild/moderate/severe) variable, and its predictors were explored with logistic and ordinal regression respectively, accounting for baseline volume, onset-to-CT time, and anticoagulation. All the analyses were stratified by ICH location (supratentorial deep vs lobar ICH).

A total of 201 patients were included (median age 78, 42% females, 59% deep ICH). Medial ICAC were significantly more common in deep ICH with HE compared with non-expanders (72% vs 49%, p = 0.03), whereas there was no association between ICAC and HE in lobar ICH (53% vs 52%, p = 0.85). This association between medial ICAC and HE in deep ICH remained significant in logistic (aOR 3.11, 95% CI [1.19-9.06], p = 0.03) and ordinal regression (acOR 2.42, 95% CI [1.19-4.99], p = 0.01).

Ipsilateral medial ICAC are associated with higher odds of HE in deep ICH. Our findings are best interpreted as hypothesis generating, requiring prospective validation and further research to characterize the underlying biological mechanisms.

The objective of this study is to investigate key prognostic factors of clinical data and prognostic factors in patients with hypertensive intracerebral hemorrhage (HICH) who have undergone neuroendoscopic hematoma evacuation, specifically focusing on those with a hemorrhage volume of 20-40 mL, to identify the determinants influencing their prognosis. In this study, a total of 113 patients were ultimately included in the analysis. Variables such as age, preoperative Glasgow Coma Scale (GCS) scores, and hemorrhage locations were assessed. LASSO logistic regression was employed to select pertinent variables, which were then incorporated into a multivariate logistic regression model. The model's performance was evaluated using ROC and calibration curves, along with clinical utility curves, and the recovery times of patients were analyzed using Kaplan-Meier curves, complemented by COX regression analysis. These three variables-Age (OR: 0.811; 95% CI 0.711-0.925), GCS score (OR: 25.923; 95% CI 4.108-163.598), and ICH location (OR: 7.345; 95% CI 1.811-29.783)-are strong predictors of intracerebral hemorrhage prognosis. Among the patients analyzed, 85.84% experienced a favorable prognosis. Younger age, higher preoperative GCS scores, and hemorrhages located in the basal ganglia and cerebral lobes were associated with better outcomes (mRS score of 0-3) . The nomogram, validated by an ROC curve analysis yielding an AUC of 0.9417 and the Hosmer-Lemeshow test, demonstrated accurate predictive and calibration capabilities for postoperative prognosis in patients with hypertensive intracerebral hemorrhage. Kaplan-Meier intervals and COX regression analysis indicated that age is a significant factor affecting the recovery time of these patients. Age, GCS score, and ICH location are significant prognostic factors for patients undergoing neuroendoscopic hematoma evacuation following hypertensive intracerebral hemorrhage, with age being a particularly important determinant of recovery time. Younger age, higher GCS scores, and lobar hemorrhage are associated with better prognosis.

Spontaneous intracerebral hemorrhage (ICH) is a type of stroke less prevalent than ischemic stroke but associated with high mortality rates. Hematoma expansion (HE) is an increase in the bleeding that affects 30%-38% of hemorrhagic stroke patients. It is observed within 24 h of onset and associated with patient worsening. Clinically it is relevant to detect the patients that will develop HE from their initial computed tomography (CT) scans which could improve patient management and treatment decisions. However, this is a significant challenge due to the predictive nature of the task and its low prevalence, which hinders the availability of large datasets with the required longitudinal information. In this work, we present an end-to-end deep learning framework capable of predicting which cases will exhibit HE using only the initial basal image. We introduce a deep learning framework based on the 2D EfficientNet B0 model to predict the occurrence of HE using initial non-contrasted CT scans and their corresponding lesion annotation as priors. We used an in-house acquired dataset of 122 ICH patients, including 35 HE cases, containing longitudinal CT scans with manual lesion annotations in both basal and follow-up (obtained within 24 h after the basal scan). Experiments were conducted using a 5-fold cross-validation strategy. We addressed the limited data problem by incorporating synthetic images into the training process. To the best of our knowledge, our approach is novel in the field of HE prediction, being the first to use image synthesis to enhance results. We studied different scenarios such as training only with the original scans, using standard image augmentation techniques, and using synthetic image generation. The best performance was achieved by adding five generated versions of each image, along with standard data augmentation, during the training process. This significantly improved (p=0.0003) the performance obtained with our baseline model using directly the original CT scans from an Accuracy of 0.56 to 0.84, F1-Score of 0.53 to 0.82, Sensitivity of 0.51 to 0.77, and Specificity of 0.60 to 0.91, respectively. The proposed approach shows promising results in predicting HE, especially with the inclusion of synthetically generated images. The obtained results highlight the significance of this research direction, which has the potential to improve the clinical management of patients with hemorrhagic stroke. The code is available at: https://github.com/NIC-VICOROB/HE-prediction-SynthCT.

The long history of treatment for intracerebral hemorrhage (ICH) includes the development of surgical procedures. However, few studies have demonstrated that surgery improved the functional outcome. The present study used the prospective Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation of the outcomes in endoscopic surgery, which is widely followed in Japan, to try to establish clinical evidence.

The Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation is a multicenter, prospective registry in Japan, and included 143 surgical cases treated by certified neurosurgeons. The etiology and the location of ICH was evaluated by univariate and multivariate analyses as follows: deep, surface, intraventricular hemorrhage, cerebellum, and surgical outcome.

Hematoma location was deep in 44.8% of cases, intraventricular hemorrhage in 19.6%, surface in 21.7%, and cerebellum in 14.0%. Most cases were treated in the ultraearly stage within 8 hours. Mean hematoma evacuation rate was 83.6% and median residual hematoma volume was 3.0 ml. Duration of surgery was median 78 minutes. Rebleeding as a complication was observed in 6.7%, but only 2.9% were symptomatic. 2 cases required reoperation. Favorable outcome at 6 months was achieved in 35.8% of cases, with a mortality rate of 5.6%.

Endoscopic surgery for spontaneous ICH is safe and comparable to conventional surgery. The time required for the procedure was significantly reduced, demonstrating the minimally invasive character of the surgical burden. However, this study did not establish whether minimally invasive surgery is superior to conservative treatment. Future randomized controlled trials should clarify the effectiveness of the treatment.

The incidence of spontaneous intracerebral hemorrhage (ICH) in young people is relatively low; however, it leads to devastating lifelong neurologic deficits. We focused on spontaneous ICH occurring in young adults between 30 and 50 years of age.

We retrospectively reviewed the records of 139 patients, aged 30-50 years, diagnosed with spontaneous ICH between 2011 and 2021. Cases of ICH attributable to discernible causative lesions were excluded. Demographic data, laboratory results, image findings, and clinical outcome were analyzed.

After exclusions, 73 patients were included in this study. Common characteristics among the study patients included male sex (83.6%), high body mass index (>25 kg/m2, 45.8%), smoking history (47.2%), heavy alcohol consumption (30.6%), previously diagnosed hypertension (41.1%), high serum triglyceride level (>150 mg/dL, 33.3%), and microbleeds or white matter changes observed on magnetic resonance images (51.3%). In the multivariate analysis, previously diagnosed hypertension was the sole significant risk factor for cerebral small vessel (OR 7.769, P=0.031). Age, brain stem location, Glasgow Coma Scale score at admission, and hematoma volume were associated with poor outcomes.

Hypertension, obesity, smoking, and cerebral small vessel disease were important factors associated with non-lesional spontaneous intracerebral hemorrhage in young patients. Radiologic changes corresponding to cerebral small vessel disease appeared in young patients (in their 30s) and they were associated with hypertension.

Our study explores the efficacy and economic benefits of neurosurgical teleconsultations in managing intracerebral hemorrhage (ICH), focusing on reducing unnecessary patient transfers and associated costs.

We conducted a cost-savings analysis at our institution of a previously published pilot study involving a cohort of patients with ICH who were potential candidates for airlift to our tertiary care center but instead received neurosurgical consultation via teleconsultation to avoid the transfer. Data on patient demographics, distances, and costs were collected and analyzed to assess the economic impact of teleconsultations.

The cohort comprised 14 patients; we noted significant cost savings from avoiding interhospital transfers, ranging from $84,346.52 to $120,495.03 per patient. Teleconsultations facilitated immediate, collaborative decision-making between healthcare providers at community hospitals and a tertiary care center, reducing the need for expensive air transportation and unnecessary hospital transfers.

Neurosurgical teleconsultations offer a cost-effective alternative to traditional patient transfer methods for ICH management, providing substantial economic benefits while maintaining high physician and patient-family satisfaction levels. This study underscores the potential of our teleneurosurgery program to significantly reduce costs by reducing unnecessary financial burdens on patients' families and healthcare systems.

Although lower hemoglobin levels associate with worse intracerebral hemorrhage (ICH) outcomes, causal drivers for this relationship remain unclear. We investigated the hypothesis that lower hemoglobin relates to increased hematoma expansion (HE) risk and poor outcomes using human observational data and assessed causal relationships using a translational murine model of anemia and ICH.

ICH patients with baseline hemoglobin measurements and serial CT neuroimaging enrolled between 2010-2016 to a multicenter, prospective observational cohort study were studied. Patients with systemic evidence of coagulopathy were excluded. Separate regression models assessed relationships of baseline hemoglobin with HE (≥33% and/or ≥6mL growth) and poor long-term neurological outcomes (modified Rankin Scale 4-6) after adjusting for relevant covariates. Using a murine collagenase ICH model with serial neuroimaging in anemic vs. non-anemic C57/BL6 mice, intergroup differences in ICH lesion volume, ICH volume changes, and early mortality were assessed.

Among 1190 ICH patients analyzed, lower baseline hemoglobin levels associated with increased odds of HE (adjusted OR per -1g/dL hemoglobin decrement: 1.10 [1.02-1.19]) and poor 3-month clinical outcomes (adjusted OR per -1g/dL hemoglobin decrement: 1.11 [1.03-1.21]). Similar relationships were seen with poor 6 and 12-month outcomes. In our animal model, anemic mice had significantly greater ICH lesion expansion, final lesion volumes, and greater mortality, as compared to non-anemic mice.

These results, in a human cohort and a mouse model, provide novel evidence suggesting that anemia has causal roles in HE and poor ICH outcomes. Additional studies are required to clarify whether correcting anemia can improve these outcomes.

A spot sign on computed tomography angiography (CTA) scan is a widely recognized radiographic indicator of primary intracerebral hemorrhage (ICH) used to predict early hematoma expansion. Nonetheless, recent multicenter studies have indicated that its predictive value for hematoma expansion is not as significant as previously stated. Therefore, identifying the reasons for the poor performance of these studies is imperative.

A 48-year-old man presented with a 9-hour history of alalia and right limb hemiplegia. Noncontrast computed tomography (CT) revealed a hematoma in the left frontal lobe, while CTA showed a spot sign within the hematoma, leading to a diagnosis of frontal lobe hemorrhage. During the surgical procedure, a blood clot was removed, revealing the presence of 3 mm of saccular tissue resembling an aneurysm. The process of exposing its complete form resulted in its rupture and bleeding. The location of this tissue at the top of the hematoma cavity corresponded to the CTA spot sign. Pathological examination confirmed that the characteristics of the tissue wall were consistent with those of a pseudoaneurysm.

This case suggests that more stringent identification criteria should be established in studies predicting ICH expansion using the spot sign on CTA to differentiate and exclude pseudoaneurysms, thereby improving the accuracy of predicting early hematoma expansion using the CTA spot sign.

Accurate prediction of hematoma expansion (HE) in spontaneous intracerebral hemorrhage (sICH) is crucial for tailoring patient-specific treatments and improving outcomes. Recent advancements have yielded numerous HE risk factors and predictive models. This study aims to evaluate the characteristics and efficacy of existing HE prediction models, offering insights for performance enhancement.

A comprehensive search was conducted in PubMed for observational studies and randomized controlled trials focusing on HE prediction, written in English. The prediction models were categorized based on their incorporated features and modeling methodology. Rigorous quality and bias assessments were performed. A meta-analysis of studies reporting C-statistics was executed to assess and compare the performance of current HE prediction models. Meta-regression was utilized to explore heterogeneity sources.

From 358 initial records, 22 studies were deemed eligible, encompassing traditional models, hematoma imaging feature models, and models based on artificial intelligence or radiomics. Meta-analysis of 11 studies, involving 12,087 sICH patients, revealed an aggregated C-statistic of 0.74 (95% CI: 0.69-0.78) across seven HE prediction models. Eight characteristics related to development cohorts were identified as key factors contributing to performance variability among these models.

The findings indicate that the current predictive capacity for HE risk remains suboptimal. Enhanced accuracy in HE prediction is vital for effectively targeting patient populations most likely to benefit from tailored treatment strategies.

The American Heart Association/American Stroke Association released a revised spontaneous intracerebral hemorrhage guideline in 2022. A working group of stroke experts reviewed this guideline and identified a subset of recommendations that were deemed suitable for creating performance measures. These 15 performance measures encompass a wide spectrum of intracerebral hemorrhage patient care, from prehospital to posthospital settings, highlighting the importance of timely interventions. The measures also include 5 quality measures and address potential challenges in data collection, with the aim of future improvements.

Hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH) is a key predictor of poor prognosis and potentially amenable to treatment. This study aimed to build a classification model to predict HE in patients with ICH using deep learning algorithms without using advanced radiological features.

Data from the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) was utilized. Variables included in the models were chosen as per literature consensus on salient variables associated with HE. HE was defined as increase in either >33% or 6 mL in hematoma volume in the first 24 h. Multiple machine learning algorithms were employed using iterative feature selection and outcome balancing methods. 70% of patients were used for training and 30% for internal validation. We compared the ML models to a logistic regression model and calculated AUC, accuracy, sensitivity and specificity for the internal validation models respective models.

Among 1000 patients included in the ATACH-2 trial, 924 had the complete parameters which were included in the analytical cohort. The median [interquartile range (IQR)] initial hematoma volume was 9.93.mm3 [5.03-18.17] and 25.2% had HE. The best performing model across all feature selection groups and sampling cohorts was using an artificial neural network (ANN) for HE in the testing cohort with AUC 0.702 [95% CI, 0.631-0.774] with 8 hidden layer nodes The traditional logistic regression yielded AUC 0.658 [95% CI, 0.641-0.675]. All other models performed with less accuracy and lower AUC. Initial hematoma volume, time to initial CT head, and initial SBP emerged as most relevant variables across all best performing models.

We developed multiple ML algorithms to predict HE with the ANN classifying the best without advanced radiographic features, although the AUC was only modestly better than other models. A larger, more heterogenous dataset is needed to further build and better generalize the models.

Stroke is the world's second-leading cause of death. Current treatments for cerebral edema following intracerebral hemorrhage (ICH) mainly involve hyperosmolar fluids, but this approach is often inadequate. Propolis, known for its various beneficial properties, especially antioxidant and anti-inflammatory properties, could potentially act as an adjunctive therapy and help alleviate stroke-associated injuries. The chemical composition of Geniotrigona thoracica propolis extract was analyzed by GC-MS after derivatization for its total phenolic and total flavonoid content. The total phenolic content and total flavonoid content of the propolis extract were 1037.31 ± 24.10 μg GAE/mL and 374.02 ± 3.36 μg QE/mL, respectively. By GC-MS analysis, its major constituents were found to be triterpenoids (22.4% of TIC). Minor compounds, such as phenolic lipids (6.7% of TIC, GC-MS) and diterpenic acids (2.3% of TIC, GC-MS), were also found. Ninety-six Sprague Dawley rats were divided into six groups; namely, the control group, the ICH group, and four ICH groups that received the following therapies: mannitol, propolis extract (daily oral propolis administration after the ICH induction), propolis-M (propolis and mannitol), and propolis-B+A (daily oral propolis administration 7 days prior to and 72 h after the ICH induction). Neurocognitive functions of the rats were analyzed using the rotarod challenge and Morris water maze. In addition, the expression of NF-κB, SUR1-TRPM4, MMP-9, and Aquaporin-4 was analyzed using immunohistochemical methods. A TUNEL assay was used to assess the percentage of apoptotic cells. Mannitol significantly improved cognitive-motor functions in the ICH group, evidenced by improved rotarod and Morris water maze completion times, and lowered SUR-1 and Aquaporin-4 levels. It also significantly decreased cerebral edema by day 3. Similarly, propolis treatments (propolis-A and propolis-B+A) showed comparable improvements in these tests and reduced edema. Moreover, combining propolis with mannitol (propolis-M) further enhanced these effects, particularly in reducing edema and the Virchow-Robin space. These findings highlight the potential of propolis from the Indonesian stingless bee, Geniotrigona thoracica, from the Central Tapanuli region as a neuroprotective, adjunctive therapy.

Disruption of the blood-central nervous system barrier (BCB) is increasingly recognized as a pathological factor in diseases and trauma of the central nervous system. Despite the neuropathological impact, current treatment modalities do not target the BCB; strategies to reconstitute the impaired BCB have been restricted to nutritional and dietary remedies. As an integral cell type in the neurovascular unit, pericytes are crucial to the development, maintenance, and repair of the BCB. As such, pericytes are well poised as cellular agents for reconstitution of the impaired BCB. Here, we summarize recent revelations regarding the role of BCB disruption in diseases and trauma of the central nervous system and highlight how pericytes are harnessed to provide targeted therapeutic effect in each case. This review will also address how recent advances in pericyte derivation strategies can serve to overcome practical hurdles in the clinical use of pericytes.

In patients with acute intracerebral haemorrhage (ICH) and elevated systolic blood pressure (BP), guidelines suggest that systolic BP reduction to <140 mmHg should be rapidly initiated. Compared with conventional care, Mobile Stroke Units (MSUs) allow for earlier ICH diagnosis through prehospital imaging and earlier BP lowering.

ICH patients were prospectively evaluated as a cohort of the controlled B_PROUD-study in which MSU availability alone determined MSU dispatch in addition to conventional ambulance. We used inverse probability of treatment weighting to adjust for confounding to estimate the effect of additional MSU dispatch in ICH patients. Outcomes of interest were 7-day mortality (primary), systolic BP (sBP) at hospital arrival, dispatch-to-imaging time, largest haematoma volume, anticoagulation reversal, length of in-hospital stay, 3-month functional outcome.

Between February 2017 and May 2019, MSUs were dispatched to 95 (mean age: 72 ± 13 years, 45% female) and only conventional ambulances to 78 ICH patients (mean age: 71 ± 12 years, 44% female). After adjusting for confounding, we found shorter dispatch-to-imaging time (mean difference: -17.75 min, 95% CI: -27.16 to -8.21 min) and lower sBP at hospital arrival (mean difference = -16.31 mmHg, 95% CI: -30.64 to -6.19 mmHg) in the MSU group. We found no statistically significant difference for the other outcomes, including 7-day mortality (adjusted odds ratio: 1.43, 95% CI: 0.68 to 3.31) or favourable outcome (adjusted odds ratio = 0.67, 95% CI: 0.27 to 1.67).

Although MSU dispatch led to sBP reduction and lower dispatch-to-imaging time compared to conventional ambulance care, we found no evidence of better outcomes in the MSU dispatch group.

The time taken to achieve blood pressure (BP) control could be pivotal in the benefits of reducing BP in acute intracerebral hemorrhage (ICH). We aimed to assess the relationship between the rapid achievement and sustained maintenance of an intensive systolic BP (SBP) target with radiologic, clinical, and functional outcomes.

Rapid, Intensive, and Sustained BP lowering in Acute ICH (RAINS) was a multicenter, prospective, observational cohort study of adult patients with ICH <6 hours and SBP ≥150 mm Hg at 4 Comprehensive Stroke Centers during a 4.5-year period. Patients underwent baseline and 24-hour CT scans and 24-hour noninvasive BP monitoring. BP was managed under a rapid (target achievement ≤60 minutes), intensive (target SBP <140 mm Hg), and sustained (target stability for 24 hours) BP protocol. SBP target achievement ≤60 minutes and 24-hour SBP variability were recorded. Outcomes included hematoma expansion (>6 mL or >33%) at 24 hours (primary outcome), early neurologic deterioration (END, 24-hour increase in NIH Stroke Scale score ≥4), and 90-day ordinal modified Rankin scale (mRS) score. Analyses were adjusted by age, sex, anticoagulation, onset-to-imaging time, ICH volume, and intraventricular extension.

We included 312 patients (mean age 70.2 ± 13.3 years, 202 [64.7%] male). Hematoma expansion occurred in 70/274 (25.6%) patients, END in 58/291 (19.9%), and the median 90-day mRS score was 4 (interquartile range, 2-5). SBP target achievement ≤60 minutes (178/312 [57.1%]) associated with a lower risk of hematoma expansion (adjusted odds ratio [aOR] 0.43, 95% confidence interval [CI] 0.23-0.77), lower END rate (aOR 0.43, 95% CI 0.23-0.80), and lower 90-day mRS scores (aOR 0.48, 95% CI 0.32-0.74). The mean 24-hour SBP variability was 21.0 ± 7.6 mm Hg. Higher 24-hour SBP variability was not related to expansion (aOR 0.99, 95% CI 0.95-1.04) but associated with higher END rate (aOR 1.15, 95% CI 1.09-1.21) and 90-day mRS scores (aOR 1.06, 95% CI 1.04-1.10).

Among patients with acute ICH, achieving an intensive SBP target within 60 minutes was associated with lower hematoma expansion risk. Rapid SBP reduction and stable sustention within 24 hours were related to improved clinical and functional outcomes. These findings warrant the design of randomized clinical trials examining the impact of effectively achieving rapid, intensive, and sustained BP control on hematoma expansion.

This study provides Class III evidence that in adults with spontaneous ICH and initial SBP ≥150 mm Hg, lowering SBP to <140 mm Hg within the first hour and maintaining this for 24 hours is associated with decreased hematoma expansion.

Prehospital identification of intracerebral haemorrhage (ICH) in suspected stroke cases may enable the initiation of appropriate treatments and facilitate better-informed transport decisions. This scoping review aims to examine the literature to identify early clinical features and portable devices for the detection of ICH in the prehospital setting.

Three databases were searched via Ovid (MEDLINE, EMBASE and CENTRAL) from inception to August 2022 using prespecified search strategies. One reviewer screened all titles, abstracts and full-text articles for eligibility, while a second reviewer independently screened 20% of the literature during each screening stage. Data extracted were tabulated to summarise the key findings.

A total of 6803 articles were screened for eligibility, of which 22 studies were included for analysis. Among them, 15 studies reported on early clinical features, while 7 considered portable devices. Associations between age, sex and comorbidities with the presence of ICH varied across studies. However, most studies reported that patients with ICH exhibited more severe neurological deficits (n=6) and higher blood pressure levels (n=11) at onset compared with other stroke and non-stroke diagnoses. Four technologies were identified for ICH detection: microwave imaging technology, volumetric impedance phase shift spectroscopy, transcranial ultrasound and electroencephalography. Microwave and ultrasound imaging techniques showed promise in distinguishing ICH from other diagnoses.

This scoping review has identified potential clinical features for the identification of ICH in suspected stroke patients. However, the considerable heterogeneity among the included studies precludes meta-analysis of available data. Moreover, we have explored portable devices to enhance ICH identification. While these devices have shown promise in detecting ICH, further technological development is required to distinguish between stroke subtypes (ICH vs ischaemic stroke) and non-stroke diagnoses.

To evaluate the impact of nurse care changes in implementing a blood pressure management protocol on achieving rapid, intensive and sustained blood pressure reduction in acute intracerebral haemorrhage patients.

Retrospective cohort study of prospectively collected data over 6 years.

Intracerebral haemorrhage patients within 6 h and systolic blood pressure ≥ 150 mmHg followed a rapid (starting treatment at computed tomography suite with a target achievement goal of ≤60 min), intensive (target systolic blood pressure < 140 mmHg) and sustained (maintaining target stability for 24 h) blood pressure management plan. We differentiated six periods: P1, stroke nurse at computed tomography suite (baseline period); P2, antihypertensive titration by stroke nurse; P3, retraining by neurologists; P4, integration of a stroke advanced practice nurse; P5, after COVID-19 impact; and P6, retraining by stroke advanced practice nurse. Outcomes included first-hour target achievement (primary outcome), tomography-to-treatment and treatment-to-target times, first-hour maximum dose of antihypertensive treatment and 6-h and 24-h systolic blood pressure variability.

Compared to P1, antihypertensive titration by stroke nurses (P2) reduced treatment-to-target time and increased the rate of first-hour target achievement, retraining of stroke nurses by neurologists (P3) maintained a higher rate of first-hour target achievement and the integration of a stroke advanced practice nurse (P4) reduced both 6-h and 24-h systolic blood pressure variability. However, 6-h systolic blood pressure variability increased from P4 to P5 following the impact of the COVID-19 pandemic. Finally, compared to P1, retraining of stroke nurses by stroke advanced practice nurse (P6) reduced tomography-to-treatment time and increased the first-hour maximum dose of antihypertensive treatment.

Changes in nursing care and continuous education can significantly enhance the time metrics and blood pressure outcomes in acute intracerebral haemorrhage patients.

STROBE guidelines.

No Patient or Public Contribution.

To predict hematoma growth in intracerebral hemorrhage patients by combining clinical findings with non-contrast CT imaging features analyzed through deep learning.

Three models were developed to predict hematoma expansion (HE) in 572 patients. We utilized multi-task learning for both hematoma segmentation and prediction of expansion: the Image-to-HE model processed hematoma slices, extracting features and computing a normalized DL score for HE prediction. The Clinical-to-HE model utilized multivariate logistic regression on clinical variables. The Integrated-to-HE model combined image-derived and clinical data. Significant clinical variables were selected using forward selection in logistic regression. The two models incorporating clinical variables were statistically validated.

For hematoma detection, the diagnostic performance of the developed multi-task model was excellent (AUC, 0.99). For expansion prediction, three models were evaluated for predicting HE. The Image-to-HE model achieved an accuracy of 67.3%, sensitivity of 81.0%, specificity of 64.0%, and an AUC of 0.76. The Clinical-to-HE model registered an accuracy of 74.8%, sensitivity of 81.0%, specificity of 73.3%, and an AUC of 0.81. The Integrated-to-HE model, merging both image and clinical data, excelled with an accuracy of 81.3%, sensitivity of 76.2%, specificity of 82.6%, and an AUC of 0.83. The Integrated-to-HE model, aligning closest to the diagonal line and indicating the highest level of calibration, showcases superior performance in predicting HE outcomes among the three models.

The integration of clinical findings with non-contrast CT imaging features analyzed through deep learning showed the potential for improving the prediction of HE in acute spontaneous intracerebral hemorrhage patients.

Previous research has found that an adaptive response to ferroptosis involving glutathione peroxidase 4 (GPX4) is triggered after intracerebral hemorrhage. However, little is known about the mechanisms underlying adaptive responses to ferroptosis. To explore the mechanisms underlying adaptive responses to ferroptosis after intracerebral hemorrhage, we used hemin-treated HT22 cells to mimic brain injury after hemorrhagic stroke in vitro to evaluate the antioxidant enzymes and performed bioinformatics analysis based on the mRNA sequencing data. Further, we determined the expression of GSTO2 in hemin-treated hippocampal neurons and in a mouse model of hippocampus-intracerebral hemorrhage (h-ICH) by using Western blot. After hemin treatment, the antioxidant enzymes GPX4, Nrf2, and glutathione (GSH) were upregulated, suggesting that an adaptive response to ferroptosis was triggered. Furthermore, we performed mRNA sequencing to explore the underlying mechanism, and the results showed that 2234 genes were differentially expressed. Among these, ten genes related to ferroptosis (Acsl1, Ftl1, Gclc, Gclm, Hmox1, Map1lc3b, Slc7a11, Slc40a1, Tfrc, and Slc39a14) were altered after hemin treatment. In addition, analysis of the data retrieved from the GO database for the ten targeted genes showed that 20 items on biological processes, 17 items on cellular components, and 19 items on molecular functions were significantly enriched. Based on the GO data, we performed GSEA and found that the glutathione metabolic process was significantly enriched in the hemin phenotype. Notably, the expression of glutathione S-transferase omega (GSTO2), which is involved in glutathione metabolism, was decreased after hemin treatment, and overexpression of Gsto2 decreased lipid reactive oxygen species level in hemin-exposed HT22 cells. In addition, the expression of GSTO2 was also decreased in a mouse model of hippocampus-intracerebral hemorrhage (h-ICH). The decreased expression of GSTO2 in the glutathione metabolic process may be involved in ferroptotic neuronal injury following hemorrhagic stroke.

Hematoma expansion (HE) is a modifiable risk factor and a potential treatment target in patients with intracerebral hemorrhage (ICH). We aimed to train and validate deep-learning models for high-confidence prediction of supratentorial ICH expansion, based on admission non-contrast head Computed Tomography (CT). Applying Monte Carlo dropout and entropy of deep-learning model predictions, we estimated the model uncertainty and identified patients at high risk of HE with high confidence. Using the receiver operating characteristics area under the curve (AUC), we compared the deep-learning model prediction performance with multivariable models based on visual markers of HE determined by expert reviewers. We randomly split a multicentric dataset of patients (4-to-1) into training/cross-validation (n = 634) versus test (n = 159) cohorts. We trained and tested separate models for prediction of ≥6 mL and ≥3 mL ICH expansion. The deep-learning models achieved an AUC = 0.81 for high-confidence prediction of HE≥6 mL and AUC = 0.80 for prediction of HE≥3 mL, which were higher than visual maker models AUC = 0.69 for HE≥6 mL (p = 0.036) and AUC = 0.68 for HE≥3 mL (p = 0.043). Our results show that fully automated deep-learning models can identify patients at risk of supratentorial ICH expansion based on admission non-contrast head CT, with high confidence, and more accurately than benchmark visual markers.

Hematoma expansion (HE) following an intracerebral hemorrhage (ICH) is a modifiable risk factor and a treatment target. We examined the association of HE with neurological deterioration (ND), functional outcome, and mortality based on the time gap from onset to baseline CT.

We included 567 consecutive patients with supratentorial ICH and baseline head CT within 24 h of onset. ND was defined as a ≥4-point increase on the NIH stroke scale (NIHSS) or a ≥2-point drop on the Glasgow coma scale. Poor outcome was defined as a modified Rankin score of 4 to 6 at 3-month follow-up.

The rate of HE was higher among those scanned within 3 h (124/304, 40.8%) versus 3 to 24 h post-ICH onset (53/263, 20.2%) (p < 0.001). However, HE was an independent predictor of ND (p < 0.001), poor outcome (p = 0.010), and mortality (p = 0.003) among those scanned within 3 h, as well as those scanned 3-24 h post-ICH (p = 0.043, p = 0.037, and p = 0.004, respectively). Also, in a subset of 180/567 (31.7%) patients presenting with mild symptoms (NIHSS ≤ 5), hematoma growth was an independent predictor of ND (p = 0.026), poor outcome (p = 0.037), and mortality (p = 0.027).

Despite decreasing rates over time after ICH onset, HE remains an independent predictor of ND, functional outcome, and mortality among those presenting >3 h after onset or with mild symptoms.

To conduct a quantitative analysis of published studies on hematoma enlargement after intracerebral hemorrhage.

Studies on hematoma enlargement after cerebral hemorrhage were retrieved from the Web of Science database on June 30, 2023. Microsoft Excel, VOSviewer, and CiteSpace software were used for bibliometric analysis and visualization, focusing on the quantitative characteristics of the literature.

A total of 444 articles were published in 161 journals, with 2161 authors from 41 countries and 717 institutions. The most published authors, countries, and institutions were Goldstein, the USA, and Massachusetts General Hospital. Stroke published the most studies, but the average citation number per year of Lancet Neurology far exceeded that of other journals. The research field of hematoma enlargement is mainly divided into 3 focuses, including mechanisms, identification (computed tomography signs, predictive models), and treatment (hemostasis, antihypertensive therapy). Most bursts in publication number have been since 2010, where the highest burst was from research on spot signs, and the latest burst focused on tranexamic acid. Treatment using tranexamic acid based on different computed tomography signs is a focus of current research, but the effectiveness still requires further exploration.

This bibliometric analysis analyzed the research framework and hotspots on hematoma enlargement after cerebral hemorrhage, which can help researchers better understand this field and provide potential suggestions for collaborations and research.