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Impact of Ultra-Early Perioperative Antihypertensive Therapy in Acute Intracerebral Hemorrhage
(Ovid Technologies (Wolters Kluwer Health), 2026-06)
Tao Liu
;
Linan Chen
;
Leibo Liu
;
Yang Liu
;
Lu Ma
<jats:sec> <jats:title>BACKGROUND:</jats:title> <jats:p>Early intensive blood pressure (BP) lowering improves outcomes in acute intracerebral hemorrhage, but its perioperative benefit among patients undergoing surgical hematoma evacuation is uncertain. We evaluated whether earlier achievement of intensive BP targets is associated with improved outcomes in this population.</jats:p> </jats:sec> <jats:sec> <jats:title>METHODS:</jats:title> <jats:p>Post hoc secondary analysis of the INTERACT3 (the third Intensive Care Bundle With Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial) pragmatic, international, multicenter, blinded-end point, and stepped-wedge cluster-randomized trial. Among 7036 enrolled intracerebral hemorrhage patients at 121 hospitals, those who underwent surgical hematoma evacuation were included. Patients were categorized by time from hospital arrival to achieving the target systolic BP <140 mm Hg: ≤2 hours versus >2 hours. The primary outcome was 6-month mortality. Key secondary outcomes included death or disability (modified Rankin Scale scores 4–6), modified Rankin Scale score shift, health-related quality-of-life (EuroQol 5-Dimension 3-Level [EQ-5D-3L] domains, visual analog scale, and health utility index), and serious adverse events. Adjusted associations were estimated using Cox, logistic, ordinal logistic, and linear regression models, controlling for age, sex, treatment type, and admission Glasgow Coma Scale.</jats:p> </jats:sec> <jats:sec> <jats:title>RESULTS:</jats:title> <jats:p> Of 7036 patients with acute intracerebral hemorrhage, 1506 underwent surgical hematoma evacuation (mean [SD] age, 59.7 [11.8] years; 33.9% women). Overall, there was no statistically significant difference in 6-month mortality between patients who achieved target BP within 2 hours of treatment initiation and those who achieved it after 2 hours (adjusted hazard ratio, 0.81 [95% CI, 0.63–1.04]; <jats:italic toggle="yes">P</jats:italic> =0.09). Early BP achievement was associated with a lower risk of death or disability (adjusted odds ratio [OR], 0.71 [95% CI, 0.56–0.90]; <jats:italic toggle="yes">P</jats:italic> =0.01), a favorable shift in the distribution of modified Rankin Scale scores (adjusted common OR, 0.73 [95% CI, 0.60–0.89]; <jats:italic toggle="yes">P</jats:italic> <0.01), and fewer serious adverse events (adjusted OR, 0.73 [95% CI, 0.57–0.94]; <jats:italic toggle="yes">P</jats:italic> =0.02). EuroQol 5-Dimension 3-Level outcomes also favored the early group, with significant improvements in mobility (adjusted OR, 0.76 [95% CI, 0.60–0.97]; <jats:italic toggle="yes">P</jats:italic> =0.03), pain/discomfort (adjusted OR, 0.72 [95% CI, 0.54–0.95]; <jats:italic toggle="yes">P</jats:italic> =0.02), and usual activities (adjusted OR, 0.79 [95% CI, 0.62–1.00]; <jats:italic toggle="yes">P</jats:italic> =0.05), as well as higher visual analog scale (mean difference, 0.08 [95% CI, 0.002–0.17]; <jats:italic toggle="yes">P</jats:italic> =0.04) and health utility scores (mean difference, 0.05 [95% CI, 0.02–0.09]; <jats:italic toggle="yes">P</jats:italic> <0.01). </jats:p> </jats:sec> <jats:sec> <jats:title>CONCLUSIONS:</jats:title> <jats:p>In patients with intracerebral hemorrhage undergoing surgical hematoma evacuation, perioperative intensive BP reduction appears safe. Achieving systolic BP <140 mm Hg within 2 hours was associated with better functional and quality-of-life outcomes, and fewer serious adverse events. These time-sensitive associations support prioritizing ultra-early perioperative BP control; confirmatory prospective analyses are warranted.</jats:p> </jats:sec> <jats:sec> <jats:title>REGISTRATION:</jats:title> <jats:p> URL: <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="https://www.clinicaltrials.gov">https://www.clinicaltrials.gov</jats:ext-link> ; Unique identifier: NCT03209258. </jats:p> </jats:sec>
1
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Mapping within-country disparities in Ischemic stroke burden and trends by human development index, age and sex
(Elsevier BV, 2026-05)
Marilaura Nuñez
;
DELGADO BECERRA, OROZIMBA IRIS
;
Alejandra Venegas Peña
;
LAVADOS GERMAIN, PABLO MANUEL
;
Craig S. Anderson
1
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Predisposing Factors, Pathologies, and Precipitating Factors Causing Intracerebral Hemorrhage
(Ovid Technologies (Wolters Kluwer Health), 2026-04)
Alice Hosking
;
Neshika Samarasekera
;
Tom J. Moullaali
;
William N. Whiteley
;
Vega Pratiwi Putri
<jats:sec> <jats:title/> <jats:p>Most people with spontaneous intracerebral hemorrhage (ICH) have hypertension, which is the strongest modifiable predisposing (risk) factor. However, multiple long-term medical conditions and other known predisposing factors for ICH usually coexist with hypertension, indicating that the causal pathway is multifactorial, and the term hypertensive ICH is oversimplistic. In this review, we integrate the highest quality evidence and our clinical experience in a framework to attribute multiple predisposing factors, underlying pathologies, and precipitating factors as the cause of ICH. In clinical practice, this framework supports physicians to take a holistic approach to treatment and prevention of ICH. In research, this framework shows how existing classification systems for the cause of ICH include underlying macrovascular, microvascular, and other structural pathologies but few predisposing or precipitating factors. Furthermore, this framework can inform the development of a more holistic classification system and expose knowledge gaps, including how predisposing factors lead to underlying pathologies and why only some people with these pathologies experience ICH.</jats:p> </jats:sec>
2Scopus© Citations 1
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Effects of Blood Pressure Lowering Across Hematoma Volume in Acute Intracerebral Hemorrhage: Pooled Analysis of the Four
<scp>INTERACT</scp>
and
<scp>ATACH</scp>
‐2 Trials
(Wiley, 2026-04-01)
Xinwen Ren
;
Qiang Li
;
Menglu Ouyang
;
Xiaoying Chen
;
Chen Chen
<jats:sec> <jats:title>Objective</jats:title> <jats:p>The objective of this study was to assess the heterogeneity in treatment effect of intensive blood pressure (BP)‐lowering across hematoma volume after acute intracerebral hemorrhage (ICH).</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>We undertook a pooled analysis of individual patient data from the pivotal trials of early intensive BP‐lowering in ICH (the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial 4 [INTERACT4] and Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 [ATACH‐2] studies). The primary outcome was functional recovery, defined by the distribution of scores on modified Rankin scale (mRS). Secondary outcomes were hematoma expansion (HE) over 24 hours, defined by absolute (<0, 0–6, 6–12.5, and >12.5 ml) and relative HE (<0, 0–33, 33–66, and >66%). Generalized linear mixed models with trial as a random effect were conducted. We further assessed effect modification by hematoma volume and plotted the treatment effect curve.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p> Among 6,125 individuals with available hematoma volume, intensive BP‐lowering improved functional recovery (odds ratio [OR] for unfavorable shift in mRS score = 0.90, 95% confidence interval [CI] = 0.82 to 0.99, <jats:italic>p</jats:italic> = 0.027). In 3,897 participants with available HE, intensive BP‐lowering reduced the risk of absolute (OR = 0.88, 95% CI = 0.78 to 0.99, <jats:italic>p</jats:italic> = 0.043) and relative (OR = 0.88, 95% CI = 0.78 to 0.99, <jats:italic>p</jats:italic> = 0.034) HE. We found effect modification of treatment on functional outcome and absolute HE by hematoma volume (p for interaction = 0.043 and 0.025, respectively). U‐shaped curves were observed, with benefits seen in cases with hematoma volume of 7.5 to 27.5 and 7.0 to 32.5 ml, respectively, both peaking at 20 ml. </jats:p> </jats:sec> <jats:sec> <jats:title>Interpretation</jats:title> <jats:p>Early intensive BP‐lowering improves functional outcome and reduces HE in ICH. Heterogeneity by hematoma volume indicates the importance of patient selection in future trials and clinical practice. ANN NEUROL 2026</jats:p> </jats:sec>
1
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Low-Intensity Monitoring for Mild-to-Moderate Acute Ischemic Stroke Is Cost Saving: Economic Evaluation for OPTIMISTmain
(Ovid Technologies (Wolters Kluwer Health), 2026-03)
Lizheng Xu
;
Menglu Ouyang
;
Emily R. Atkins
;
Debbie Summers
;
Yi Sui
<jats:sec> <jats:title>BACKGROUND:</jats:title> <jats:p>OPTIMISTmain (Main Optimal Post rtPA-IV Monitoring in Ischemic Stroke Trial) has shown that low-intensity monitoring is feasible and safe compared with standard monitoring in stable patients who receive thrombolysis treatment for acute ischemic stroke of mild-to-moderate neurological impairment. We aimed to estimate the economic benefits of low-intensity care compared with standard care.</jats:p> </jats:sec> <jats:sec> <jats:title>METHODS:</jats:title> <jats:p>A cost-minimization analysis based on OPTIMISTmain was conducted for Australia, China, Malaysia, the United Kingdom, the United States, and Vietnam. A decision tree model comprising 2 arms was developed from the trial design. State transition probabilities for each country were extracted from the trial, and cost data were sourced from the existing literature. Mean costs over the 90-day duration of follow-up were compared, and univariate and probabilistic sensitivity and scenario analyses were performed.</jats:p> </jats:sec> <jats:sec> <jats:title>RESULTS:</jats:title> <jats:p>Low-intensity monitoring had the highest probability of cost saving in China (100.00%) and the United Kingdom (100.00%), followed by Australia (99.94%), the United States (95.91%), and Vietnam (86.66%), as patients in this group incurred US dollars savings of 239, 133, 647, 943, and 3 in direct costs compared with patients in the standard group, respectively. In Malaysia, however, the intervention costs slightly exceeded those for standard care (US dollars 5643 versus 5378). Countries with higher proportions of patients having intensive care unit monitoring had greater cost savings. Cost-saving thresholds of monitoring costs were 1.24, 1.30, 1.26, 1.24, 1.01, and 0.91 times the base case value in Australia, China, the United Kingdom, the United States, Vietnam, and Malaysia, respectively.</jats:p> </jats:sec> <jats:sec> <jats:title>CONCLUSIONS:</jats:title> <jats:p>The low-intensity monitoring protocol was cost saving in countries with high proportions of intensive care resources for postthrombolysis treatment monitoring, such as in the United States.</jats:p> </jats:sec> <jats:sec> <jats:title>REGISTRATION:</jats:title> <jats:p> URL: <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="https://www.clinicaltrials.gov">https://www.clinicaltrials.gov</jats:ext-link> ; Unique identifier: NCT03734640. URL: <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="https://www.anzctr.org.au/">https://www.anzctr.org.au/</jats:ext-link> ; Unique identifier: ACTRN 12619001556134p. </jats:p> </jats:sec>
2
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Implementing Low-Intensity Thrombolysis Monitoring for Patients with Acute Ischemic Stroke in Latin America: Insights from the OPTIMISTmain Process Evaluation
(S. Karger AG, 2025-12-18)
MUÑOZ VENTURELLI, PAULA ANDREA
;
Francisca González
;
Craig S. Anderson
;
Carlos Delfino
;
Marilaura Nuñez
<jats:p>Introduction: The Optimal Post-rtPA-IV Monitoring in Ischemic Stroke Trial (OPTIMISTmain) was an international, pragmatic, stepped-wedge, cluster-randomized, non-inferiority trial designed to compare a low-intensity protocol to standard high-intensity monitoring in patients with mild-to-moderate acute ischemic stroke treated with thrombolysis. The results showed the safety, feasibility, and non-inferiority efficacy of the low-intensity monitoring protocol, supporting hospitals to consider adopting this approach in stroke care depending on local resources and circumstances. An embedded process evaluation was undertaken to explore factors influencing implementation and impact of the intervention in Latin America. Methods: A convergent mixed-methods design was used to combine quantitative data and qualitative interviews with implementers and patients (or family members) at participating hospitals in Chile and Mexico. Purposive sampling ensured that a diverse range of experiences and discourses were captured, and normalization process theory (NPT) guided the identification of factors facilitating or hindering the incorporation of low-intensity monitoring. The analysis focused on key implementation outcomes. Results: Low-intensity monitoring was widely accepted by clinicians who found it efficient, straightforward to implement, and potentially cost saving for hospital services. Patients and families expressed acceptance, emphasizing the protocol’s potential to support continuous improvements in healthcare. Implementation challenges included staff turnover across shifts and hospital units, reliance on external contractors, and resistance to changing established care routines. Factors enabling successful implementation included strong team communication, dedicated stroke units, and ongoing feedback. Overall, the intervention demonstrated high acceptability, adoption and appropriateness, fidelity (median of 17 assessments in both countries), and sustainability. Feasibility outcomes were more variable, reflecting organizational challenges at the healthcare system level, such as initial resistance of nursing teams and high workloads in emergency services. Conclusions: Implementation of a novel low-intensity monitoring protocol was well accepted by healthcare staff and offers potential benefits to patients with mild-to-moderate acute ischemic stroke admitted to hospitals in Latin America. Embedding a process evaluation into the main trial provided valuable insights into the challenges of implementing a complex intervention. A comprehensive understanding of the factors influencing organization change is critical to improving health outcomes.</jats:p>
1
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Influence of Multiple Long-Term Conditions on Outcome after Thrombolysis for Acute Ischaemic Stroke: Secondary Analysis of the ENCHANTED Trial
(S. Karger AG, 2025-08-06)
Xinwen Ren
;
Yang Zhao
;
Menglu Ouyang
;
Qiang Li
;
Chen Chen
Introduction: The influence of multiple long-term conditions on the outcomes from acute ischaemic stroke (AIS) is not well defined. This study aimed to determine the association of multiple long-term conditions in participants of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). Methods: ENCHANTED was an international, multicentre, 2 × 2 quasi-factorial, open, randomized controlled, blinded endpoint assessed trial that assessed the effectiveness and safety of intensive blood pressure lowering and low-dose thrombolysis against standard of care in adults with AIS. Multiple long-term condition was defined as two or more coexisting chronic conditions according to medical history. The primary outcome was function recovery (distribution of scores on the modified Rankin scale) and mortality at 90 days post-randomization. Associations were estimated in multivariate logistic regression models, and an assessment of heterogeneity was undertaken in subgroups including age, sex, baseline systolic blood pressure, and clinical features. Results: In 4,566 AIS participants (mean age 66.7 years, 37.8% female), those with multiple long-term conditions were older, more often female, and had more severe neurological impairment. Multiple long-term conditions increased the odds of poor functional outcome (adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI]: 1.03–1.30; p = 0.020) and mortality (aOR 1.35, 95% CI: 1.04–1.76; p = 0.024). The association between multiple long-term conditions and mortality/functional outcome was consistent across all subgroups. Conclusion: Individuals with multiple long-term conditions have higher odds of poor functional outcome and death after thrombolytic treatment for AIS.
9
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Surgical outcomes from haematoma evacuation for intracerebral haemorrhage in the INTERACT3 study
(Elsevier BV, 2025-09)
Xin Hu
;
Menglu Ouyang
;
Jianguo Xu
;
Yi Liu
;
Xi Li
1Scopus© Citations 4
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Patterns and Clinical Implications of Hemorrhagic Transformation After Thrombolysis in Acute Ischemic Stroke
(Ovid Technologies (Wolters Kluwer Health), 2024-12-10)
Yanan Wang
;
Toshiki Maeda
;
Shoujiang You
;
Chen Chen
;
Leibo Liu
2
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Risk and impact of stroke across 38 countries and territories of the Americas from 1990 to 2021: a population-based trends analysis from the Global Burden of Disease Study 2021
(Elsevier BV, 2025-03)
Ramón Martinez
;
MUÑOZ VENTURELLI, PAULA ANDREA
;
Pedro Ordunez
;
Felipe Fregni
;
Carlos Abanto
Scopus© Citations 22 3

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