ArticleFrontiers in medicine2026
Cognitive impairment as a mediator of treatment discontinuation after intracerebral hemorrhage in acute leukemia.
Article in Frontiers in medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Neurological deficits after spontaneous intracerebral hemorrhage (ICH) are linked to treatment discontinuation in acute leukemia patients, but underlying mechanisms are unknown. We tested whether cognitive impairment mediates this relationship. Methods: In this single-center retrospective cohort study (2016-2024), we included 102 acute leukemia patients who survived ≥6 months post-ICH and remained on hematologic treatment at the 6 month landmark. Neurological deficit at discharge [modified Rankin Scale (mRS), 0-2 vs. 3-5] was the exposure; MoCA score at 6 months was the mediator; time to permanent treatment discontinuation (non progression) was the outcome. We applied counterfactual mediation analysis with 1,000 bootstraps, reporting natural direct/indirect effects (NDE/NIE) as hazard ratios (HRs). We tested the proportional hazards assumption, quantified inter-rater agreement for outcome adjudication, and performed sensitivity analyses (continuous exposure, binary mediator, competing risks, and E-value). Results: Mean MoCA was 22.0 (SD 5.2); 48.0% had impairment (MoCA < 26). Over 12 month median follow up, 44.1% discontinued. Total effect of mRS 3-5 (vs. 0-2) was HR 3.42 (95% CI 2.05-5.72). Decomposition yielded NDE 2.08 (1.13-3.84) and NIE 1.64 (1.17-2.32), with 42.1% (15.4%-68.4%) mediated via cognition. Sensitivity analyses produced consistent estimates (NIE range 1.25-1.55; mediated proportion 35.8%-38.9%); E-value for NIE was 2.66 (lower CI 1.62). Conclusions: In this cohort of 6-month ICH survivors with acute leukemia, cognitive impairment was estimated to mediate 42.1% of the neurological deficit effect on hematologic treatment discontinuation. These findings are hypothesis-generating and suggest that post-ICH cognitive dysfunction may be a modifiable mechanism. Cognitive screening and early rehabilitation may warrant integration into post-ICH care; prospective trials are needed to test whether cognitive interventions improve treatment persistence.
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