ORIGINAL RESEARCH article
Front. Neurol.
Sec. Stroke
Volume 16 - 2025 | doi: 10.3389/fneur.2025.1620170
Wake-up intracerebral hemorrhage: hematoma expansion and outcomes
Provisionally accepted
- Karolinska Institutet (KI), Solna, Sweden
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Introduction: While understudied, wake-up intracerebral hemorrhage (WU-ICH) is not uncommon . Since the risk of hematoma expansion (HE) decreases as time passes, uncertain onset time in WU-ICH may influence the risk of in-hospital HE and potential effects of HE-preventive treatments. We aimed to evaluate HE and outcomes in WU-ICH compared to knownonset ICH. Methods: We included ICH patients admitted to the Karolinska University Hospital 2016-22, comparing WU-ICH versus known-onset ICH regarding baseline characteristics, HE, and outcomes. Results: Of 763 patients, 147 (19%) had WU-ICH and 616 (81%) had known onset, median (IQR) last-known-well to hospital time 9.6 h (5.9-12.2 h) vs 1.3 h (0.9-2.0 h). WU-ICH patients more often had dementia (15% vs 5%, p<0.001), oral anticoagulants (26% vs 16%, p=0.005), and pre-stroke modified Rankin Scale 3-5 (24% vs 15%, p=0.01). Baseline ICH volume was 14 ml (6-35 ml) vs 13 ml (5-34 ml). Among patients who underwent CT angiography at admission, 15% of WU-ICH vs 27% of known onset ICH had spot signs (p=0.002). Of patients with CT follow-up <72 h, HE occurred in 24/77 (31.2%) in WU-ICH, and 123/356 (34.6%) in known-onset ICH, p=0.57. Wake-up onset was not associated with HE in multivariable analysis, adjusted OR=0.79 (95% CI 0.43-1.42). Analysis of 3-month modified Rankin Scale showed no differences (median 4 vs 4), unadjusted p=0.35 and adjusted p=0.78. Conclusion: WU-ICH had similar risk of HE and similar 3month outcomes as known-onset ICH. Excluding WU-ICH from future trials targeting HE may be unwarranted.
Keywords: intracerebral hemorrhage, acute stroke, computed tomography, Mortality, Outcomes Assessment
Received: 29 Apr 2025; Accepted: 07 Jul 2025.
Copyright: © 2025 Almqvist, Falk Delgado, Sjöstrand and Mazya. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Tove Almqvist, Karolinska Institutet (KI), Solna, Sweden
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