Cognitive outcome after acute spontaneous intracerebral hemorrhage: analysis of the iDEF randomized trial

Introduction The impact of intracerebral hemorrhage (ICH) on cognition and the determinants of cognitive recovery early after ICH remain elusive. In this post-hoc analysis of the Intracerebral Hemorrhage Deferoxamine (iDEF) trial, we examined the trajectories of cognitive impairment and the determinants of early cognitive recovery after ICH. Methods We examined baseline factors associated with 90-day cognitive outcome and constructed generalized linear mixed models to examine the trajectory of cognitive function over time among iDEF participants. Cognition was measured by the Montreal Cognitive Assessment (MoCA) scores at days 7, 30 and 90. Results 291 were available for analysis under the trial's modified intention-to-treat definition (38% female, mean age 60.3 +/- 12.0 years, median NIHSS 13, IQR 8-18). The median baseline ICH volume was12.9 IQR (6.4-26.0) ml; 59 (20%) of the ICH cases were lobar, 120 (41%) had intraventricular extension. There was an overall significant increase in total MOCA score with time (p<0.0001). Total MOCA score increased by an estimated 3.9 points (95% CI 3.1, 4.7) between the Day 7 and Day 30 assessments and by an additional 2.9 points (95% CI 2.2, 3.6) between the Day 30 and Day 90 assessments. Despite the overall improvement, 134 of 205 (65%) patients with patients with available 90-day MoCA score remained cognitively impaired with a score <26 at 90 days. Older age, higher NIHSS score, baseline ICH volume, intraventricular hemorrhage and perihematoma edema had an adjusted negative impact on cognitive recovery. Conclusions Although ICH survivors exhibit significant improvement of cognitive status over the first 3 months, cognitive performance remains impaired in the majority of patients. Among factors independently associated with worse cognitive recovery, higher baseline ICH, intraventricular blood and perihematomal edema volumes, are potential therapeutic targets that merit further exploration.