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. 2025 Jul 25:16:1620170.
doi: 10.3389/fneur.2025.1620170. eCollection 2025.

Wake-up intracerebral hemorrhage: hematoma expansion and outcomes

Tove Almqvist  1   2 , Anna Falk Delgado  1   3 , Christina Sjöstrand  1   4 , Michael V Mazya  1   2
Affiliations

Wake-up intracerebral hemorrhage: hematoma expansion and outcomes

Tove Almqvist et al. Front Neurol. .

Abstract

Introduction: While understudied, wake-up intracerebral hemorrhage (WU-ICH) is not uncommon (8.8-20.3% of ICH patients). Since the risk of hematoma expansion (HE) decreases as time passes, an uncertain onset time in WU-ICH may influence the risk of in-hospital HE and the potential effects of HE-preventive treatments. We aimed to evaluate HE and outcomes in WU-ICH compared to known-onset ICH.

Methods: We included ICH patients admitted to the Karolinska University Hospital from 2016 to 2022, comparing WU-ICH vs. 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 the 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 a similar risk of HE and similar 3-month outcomes as known-onset ICH. Excluding WU-ICH from future trials targeting HE may be unwarranted.

Keywords: acute stroke; computed tomography; intracerebral hemorrhage; mortality; outcomes assessment.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Flow chart of patient inclusion. CT, computed tomography; HE, hematoma expansion; ICH, intracerebral hemorrhage.
Figure 2
Figure 2
Multivariate analysis of hematoma expansion and modified Rankin Scale scores at 3 months. Increased odds ratio of hematoma expansion and worse functional outcome to the right. Adjusted odds ratio: adjusted common odds ratio for higher mRS at 3 months. GCS, Glasgow Coma Scale; ICH, intracerebral hemorrhage. ***p < 0.001, **p < 0.01, *p < 0.05.
Figure 3
Figure 3
Functional outcomes at 3 months. mRS: modified Rankin Scale.
See this image and copyright information in PMC

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