The critical care management of spontaneous intracranial hemorrhage: a contemporary review

Monitoring Intracranial Cerebral Hemorrhage Using Multicontrast Real-Time Magnetic Particle Imaging

Magnetic particle imaging (MPI) is an innovative radiation-free tomographic imaging method providing excellent temporal resolution, contrast, sensitivity, and safety. Mobile human MPI prototypes suitable for continuous bedside monitoring of whole-brain perfusion have been developed. However, for the clinical translation of MPI, a crucial gap in knowledge still remains: while MPI can visualize the reduction in blood flow and tissue perfusion in cerebral ischemia, it is unclear whether MPI works in intracranial hemorrhage. Our objective was to investigate the capability of MPI to detect intracranial hemorrhage in a murine model. Intracranial hemorrhage was induced through the injection of collagenase into the striatum of C57BL/6 mice. After the intravenous infusion of a long-circulating MPI-tailored tracer consisting of superparamagnetic iron oxides, we detected the intracranial hemorrhage in less than 3 min and could monitor hematoma expansion in real time. Multicontrast MPI can distinguish tracers based on their physical characteristics, core size, temperature, and viscosity. By employing in vivo multicontrast MPI, we were able to differentiate areas of liquid and coagulated blood within the hematoma, which could provide valuable information in surgical decision making. Multicontrast MPI also enabled simultaneous imaging of hemorrhage and cerebral perfusion, which is essential in the care of critically ill patients with increased intracranial pressure. We conclude that MPI can be used for real-time diagnosis of intracranial hemorrhage. This work is an essential step toward achieving the clinical translation of MPI for point-of-care monitoring of different stroke subtypes.

Clinico-radiological related to early brain death factors

OBJECTIVE

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 hours.

DESIGN

A retrospective cohort study was made covering the period 2015-2017.

SETTING

An adult Intensive Care Unit (ICU).

PATIENTS/METHODS

Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD.

RESULTS

A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD >24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD >24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD >24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups.

CONCLUSIONS

Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

The microsurgical treatment for primary hypertensive brainstem hemorrhage: Experience with 52 patients

OBJECTIVE

This study aims to investigate the effect of minimal invasive microsurgery in treating primary hypertensive brainstem hemorrhage (PHBH).

METHODS

52 patients of PHBH (≥3.5 ml) who have taken the minimal invasive microsurgery with neuronavigation guidance were included between Jan. 2011 and Dec. 2018. The volume/location/type of hematoma, preoperative Glasgow Coma Scale (GCS), postoperative Glasgow Outcome Scale (GOS) and hemorrhagic dilatation of the fourth ventricle were analyzed during the follow-up period ranged from 3 to 57 months.

RESULTS

Among all the patients, 18 achieved complete hematoma evacuation (≥95%), 31 achieved subtotal evacuation (≥90%), 3 achieved premodinantly evacuation (>75%). No rebleeding during or after surgery within 24 h were found. 45 patients survived after 3 months, the mean preoperative hematoma volume decreased from 7.1 ± 2.6 ml-0.9 ml (p < 0.05), 19 patients got GOS Grade V/Ⅳ. It is shown the volume less than 10 ml always led to better outcome while massive and bilateral hematoma were related with poor prognosis.

CONCLUSION

The microsurgical hematoma evacuation under neuronavigation assistance is a rapid, effective, and safe technique for the removal of PHBH, especially for the volume less than 10 ml.

Regular-Shaped Hematomas Predict a Favorable Outcome in Patients with Hypertensive Intracerebral Hemorrhage Following Stereotactic Minimally Invasive Surgery

BACKGROUND

Stereotactic minimally invasive surgery (sMIS) has been used in the treatment of intracerebral hemorrhage (ICH) in recent years and has obtained promising results. However, the outcomes of patients are associated with many factors. The aim of the present study was to retrospectively observe the relationship between hematoma shape features and the outcome of patients with spontaneous ICH following sMIS.

METHODS

One hundred eighty-three patients with hypertensive ICH who underwent sMIS were enrolled. Based on hematoma shape features, the patients were assigned to a regular-shaped hematoma group (RSH group, including 121 patients) or an irregular-shaped hematoma group (ISH group, including 62 patients). The Glasgow Coma Scale (GCS) score and the National Institutes of Health Stroke Scale (NIHSS) score were assessed on admission and at 1 week and 2 weeks after surgery. The rates of severe pulmonary infection, cardiac complications, and postoperative rebleeding during the hospital stay were also recorded for comparison. The functional outcome assessed by using the modified Rankin scale score was determined at discharge. A multivariate logistic regression analysis was performed for predictors of good outcome in patients with ICH who underwent sMIS. A receiver operating characteristic curve was also used to confirm the results.

RESULTS

Compared to the ISH group, the RSH group showed increased median GCS scores at one week and two weeks after surgery. The RSH group showed significantly decreased NIHSS scores at one week and two weeks after surgery compared with the ISH group at the same time point. Significant differences in the GCS score and the NIHSS score at 1 week (P < 0.05) and 2 weeks (P < 0.05) after surgery were observed between the RSH group and the ISH group. The RSH group showed lower rates of severe pulmonary infection, heart failure, and postoperative rehemorrhage than the ISH group (P < 0.05). Of the total patients with good outcomes, the RSH group accounted for 84.6%, and just 15.4% were from the ISH group. The multivariate logistic regression analysis demonstrated that regular-shaped hematoma (P < 0.0001) was an independent predictor of good outcome. The postoperative residual hematoma volume (P < 0.05) predicted a poor outcome. The sensitivity, specificity, and positive and negative predictive values of regular-shaped hematomas for the prediction of a favorable outcome in patients were 0.667, 0.846, 0.917, and 0.542, respectively. Additionally, the Youden index was 0.513.

CONCLUSIONS

Patients with regular-shaped hematomas exhibited more favorable outcomes. Irregular-shaped hematomas and postoperative residual hematoma volume predicted a poor outcome in patients with ICH following sMIS.

Intracranial Hypertension After Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis of Prevalence and Mortality Rate

The objective of this study was to determine the prevalence of intracranial hypertension (IHT) and the associated mortality rate in patients who suffered from primary intracerebral hemorrhage (ICH). A secondary objective was to assess predisposing factors to IHT development. We conducted a systematic literature search of major electronic databases (MEDLINE, EMBASE, and Cochrane Library), for studies that assessed intracranial pressure (ICP) monitoring in patients with acute ICH. Study level and outcome measures were extracted. The meta-analysis was performed using a random-effects model. A total of six studies comprising 381 patients were pooled to estimate the overall prevalence of any episode of IHT (ICP > 20 mmHg) after ICH. The pooled prevalence rate for any episode of IHT after ICH was 67% (95% CI 51-84%). Four studies comprising 239 patients were pooled in order to estimate the overall mortality rate associated with IHT. Pooled mortality rate was 50% (95% CI 24-76%). For both outcomes, heterogeneity was statistically significant, and risk of bias was nonsignificant. Reported variables correlated significantly with increased ICP were lower Glasgow Coma Scale score at admission, midline shift, hemorrhage volume, and hydrocephalus. The prevalence and mortality rates associated with IHT after ICH are high and may be underestimated. Predicting factors for the development of IHT reflect the magnitude of the primary injury. However, the results of present meta-analysis should be interpreted with caution due to methodological limitations such as selection bias of patients who had ICP monitoring, and lack of standardized IHT definition.

Potential of stem cell therapy in intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is a common disease associated with high mortality and morbidity. The treatment of patients with ICH includes medical and surgical interventions. New areas of surgical intervention have been focused on the evacuation of hematoma through minimally invasive neurosurgery. In contrast, there have been no significant advances in the development of medical interventions for functional recovery after ICH. Stem cells exert multiple therapeutic functions and have emerged as a promising treatment strategy. Herein, we summarized the pathophysiology of ICH and its treatment targets, and we introduced the therapeutic mechanisms of stem cells (e.g. neutrotrophy and neuroregeneration). Moreover, we reviewed and summarized the experimental designs of the preclinical studies, including the types of cells and the timing and routes of stem cell administration. We further listed and reviewed the completed/published and ongoing clinical trials supporting the safety and efficacy of stem cell therapy in ICH. The limitations of translating preclinical studies into clinical trials and the objectives of future studies were discussed. In conclusion, current literatures showed that stem cell therapy is a promising treatment in ICH and further translation research on judiciously selected group of patients is warranted before it can be extensively applied in clinical practice.

Stepwise stroke recognition through clinical information, vital signs, and initial labs (CIVIL): Electronic health record-based observational cohort study

BACKGROUND

Stroke recognition systems have been developed to reduce time delays, however, a comprehensive triaging score identifying stroke subtypes is needed to guide appropriate management. We aimed to develop a prehospital scoring system for rapid stroke recognition and identify stroke subtype simultaneously.

METHODS AND FINDINGS

In prospective database of regional emergency and stroke center, Clinical Information, Vital signs, and Initial Labs (CIVIL) of 1,599 patients suspected of acute stroke was analyzed from an automatically-stored electronic health record. Final confirmation was performed with neuroimaging. Using multiple regression analyses, we determined independent predictors of tier 1 (true-stroke or not), tier 2 (hemorrhagic stroke or not), and tier 3 (emergent large vessel occlusion [ELVO] or not). The diagnostic performance of the stepwise CIVIL scoring system was investigated using internal validation. A new scoring system characterized by a stepwise clinical assessment has been developed in three tiers. Tier 1: Seven CIVIL-AS3A2P items (total score from -7 to +6) were deduced for true stroke as Age (≥ 60 years); Stroke risks without Seizure or psychiatric disease, extreme Sugar; "any Asymmetry", "not Ambulating"; abnormal blood Pressure at a cut-off point ≥ 1 with diagnostic sensitivity of 82.1%, specificity of 56.4%. Tier 2: Four items for hemorrhagic stroke were identified as the CIVIL-MAPS indicating Mental change, Age below 60 years, high blood Pressure, no Stroke risks with cut-point ≥ 2 (sensitivity 47.5%, specificity 85.4%). Tier 3: For ELVO diagnosis: we applied with CIVIL-GFAST items (Gaze, Face, Arm, Speech) with cut-point ≥ 3 (sensitivity 66.5%, specificity 79.8%). The main limitation of this study is its retrospective nature and require a prospective validation of the CIVIL scoring system.

CONCLUSIONS

The CIVIL score is a comprehensive and versatile system that recognizes strokes and identifies the stroke subtype simultaneously.

The Role of Platelet Transfusions After Intracranial Hemorrhage in Patients on Antiplatelet Agents: A Systematic Review and Meta-Analysis

The evidence suggests that antiplatelet agents (APA) slightly increase the risk of death and disease progression in patients with traumatic brain injury or spontaneous intracranial hemorrhage (ICH). There is little evidence that APA reversal with platelet (PLT) transfusion may improve the outcome. In this systematic review and meta-analysis, our goal was to evaluate the differences in mortality, severe disability, and hematoma expansion related to PLT transfusion. We retrieved randomized or cohort studies comparing adult patients on APA with traumatic brain injury or ICH who were treated with PLT or not. We calculated the standardized risk difference and 95% confidence interval. A random-effects model was applied to analyze the data. The heterogeneity of the retrieved trials was evaluated through the I² statistic. Our review included 16 clinical trials. We observed a significant difference between the 2 groups only for hematoma expansion: risk difference was -0.10 (10%; 95% confidence interval, -0.14 to -0.05; P < 0.0001; I² = 0.90) in favor of PLT transfusion. Performing subgroups analyses according to the type of bleeding mechanism, we observed the same results. The use of PLT in patients on APA affected by ICH seemed to have no clear beneficial effect for the outcomes evaluated; conversely, PLT seemed to slightly increase the odds for adverse events of thromboembolic origin, even although not significantly.

Impact of Anticoagulation on Mortality and Resource Utilization Among Critically Ill Patients With Major Bleeding

OBJECTIVES

Patients with major bleeding are commonly admitted to the ICU. A growing number are on either oral or parenteral anticoagulation, but the impact of anticoagulation on patient outcomes is unknown. We sought to examine this association between anticoagulation therapy and mortality, as well as the independent effects of warfarin compared to direct oral anticoagulants.

DESIGN

Analysis of a prospectively collected registry (2011-2017) of consecutive ICU patients admitted with major bleeding (as defined by International Society on Thrombosis and Haemostasis clinical criteria).

SETTING

Two hospitals within a single tertiary care level hospital system.

PATIENTS

We analyzed 1,598 patients identified with major bleeding, of which 245 (15.3%) had been using anticoagulation at the time of ICU admission. Of patients on anticoagulation, 149 were using warfarin, and 60 were using a direct oral anticoagulant.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model. Patients with anticoagulation-associated major bleeding had higher in-hospital mortality (adjusted odds ratio, 1.49; 95% CI, 1.16-1.92). Among survivors, anticoagulation use was associated with longer median hospital length of stay, and higher mean costs. No differences in hospital mortality were seen between warfarin- and direct oral anticoagulant-associated major bleeding. Patients with warfarin-associated major bleeding had longer median length of stay (11 vs 6 d; p = 0.02), and higher total costs than patients with direct oral anticoagulant-associated major bleeding.

CONCLUSIONS

Among ICU patients admitted with major bleeding, pre-admission anticoagulation use was associated with increased hospital mortality, prolonged length of stay, and higher costs among survivors. As compared to direct oral anticoagulants, patients with warfarin-associated major bleeding had increased length of stay and costs. These findings have important implications in the care of ICU patients with major bleeding.

Surgery for spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage is a devastating disease, accounting for 10 to 15% of all types of stroke; however, it is associated with disproportionally higher rates of mortality and disability. Despite significant progress in the acute management of these patients, the ideal surgical management is still to be determined. Surgical hematoma drainage has many theoretical benefits, such as the prevention of mass effect and cerebral herniation, reduction in intracranial pressure, and the decrease of excitotoxicity and neurotoxicity of blood products.

Several surgical techniques have been considered, such as open craniotomy, decompressive craniectomy, neuroendoscopy, and minimally invasive catheter evacuation followed by thrombolysis. Open craniotomy is the most studied approach in this clinical scenario, the first randomized controlled trial dating from the early 1960s. Since then, a large number of studies have been published, which included two large, well-designed, well-powered, multicenter, multinational, randomized clinical trials. These studies, The International Surgical Trial in Intracerebral Hemorrhage (STICH), and the STICH II have shown no clinical benefit for early surgical evacuation of intraparenchymal hematoma in patients with spontaneous supratentorial hemorrhage when compared with best medical management plus delayed surgery if necessary. However, the results of STICH trials may not be generalizable, because of the high rates of patients’ crossover from medical management to the surgical group. Without these high crossover percentages, the rates of unfavorable outcome and death with conservative management would have been higher. Additionally, comatose patients and patients at risk of cerebral herniation were not included. In these cases, surgery may be lifesaving, which prevented those patients of being enrolled in such trials. This article reviews the clinical evidence of surgical hematoma evacuation, and its role to decrease mortality and improve long-term functional outcome after spontaneous intracerebral hemorrhage.

Underlying Mechanisms and Potential Therapeutic Molecular Targets in Blood-Brain Barrier Disruption after Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a subtype of hemorrhagic stroke with significant morbidity and mortality. Aneurysmal bleeding causes elevated intracranial pressure, decreased cerebral blood flow, global cerebral ischemia, brain edema, blood component extravasation, and accumulation of breakdown products. These post-SAH injuries can disrupt the integrity and function of the blood-brain barrier (BBB), and brain tissues are directly exposed to the neurotoxic blood contents and immune cells, which leads to secondary brain injuries including inflammation and oxidative stress, and other cascades. Though the exact mechanisms are not fully clarified, multiple interconnected and/or independent signaling pathways have been reported to be involved in BBB disruption after SAH. In addition, alleviation of BBB disruption through various pathways or chemicals has a neuroprotective effect on SAH. Hence, BBB permeability plays an important role in the pathological course and outcomes of SAH. This review discusses the recent understandings of the underlying mechanisms and potential therapeutic targets in BBB disruption after SAH, emphasizing the dysfunction of tight junctions and endothelial cells in the development of BBB disruption. The emerging molecular targets, including toll-like receptor 4, netrin-1, lipocalin-2, tropomyosin-related kinase receptor B, and receptor tyrosine kinase ErbB4, are also summarized in detail. Finally, we discussed the emerging treatments for BBB disruption after SAH and put forward our perspectives on future research.

Blood Biomarkers for Stroke Diagnosis and Management

Biomarkers are objective indicators used to assess normal or pathological processes, evaluate responses to treatment and predict outcomes. Many blood biomarkers already guide decision-making in clinical practice. In stroke, the number of candidate biomarkers is constantly increasing. These biomarkers include proteins, ribonucleic acids, lipids or metabolites. Although biomarkers have the potential to improve the diagnosis and the management of patients with stroke, there is currently no marker that has demonstrated sufficient sensitivity, specificity, rapidity, precision, and cost-effectiveness to be used in the routine management of stroke, thus highlighting the need for additional work. A better standardization of clinical, laboratory and statistical procedures between centers is indispensable to optimize biomarker performance. This review focuses on blood biomarkers that have shown promise for translation into clinical practice and describes some newly reported markers that could add to routine stroke care. Avenues for the discovery of new stroke biomarkers and future research are discussed. The description of the biomarkers is organized according to their expected application in clinical practice: diagnosis, treatment decision, and outcome prediction.

Neuroprotective effects of taurine and 3-hydroxypyridine derivatives in the intracerebral hemorrhage model in rats

Introduction: At present, the problem of pharmacological correction of free radical processess emerges full-blown. The aim of the study is an experimental study of the neuroprotective effect of taurine and 3-hydroxypyridine derivatives.

Materials and methods: The study was performed in Wistar rats. The neuroprotective effect of the substances was studied in the intracerebral hemorrhage model.

Results and discussion: The administration of the studied substances had a positive effect on the survival of the animals within the first day (50% of rats died in the control group, 30% – in the Mexidol- and Ethoxidol-treated groups, and 20% – in LKhT 3-17-treated group). Within the first day after the surgery, all rats with stroke had severe neurological disorders. However, by the 3rd day, the Ethoxidol- and LKhT 3-17-treated rats had a lower neurological deficit. By Day 14, all groups of animals treated with the test substances had a lower severity of post-stroke disorders than those in the control group, which was evident as a 1.5-time lower McGraw Stroke Index score. LKhT 3-17 substance showed the most pronounced neuroprotective effect.

Conclusions: The studied derivatives of taurine and 3-hydroxypyridine have a neuroprotective effect, which is manifested in the lower severity of neurological disorders,a more rapid reduction in the signs of neurodegeneration and accelerated hemorrhage processes.

Minimally invasive surgery and transsulcal parafascicular approach in the evacuation of intracerebral haemorrhage

Intracerebral haemorrhage (ICH) describes haemorrhage into the brain parenchyma that may result in a decline of the patient’s neurological function. ICH is a common cause of morbidity and mortality worldwide. Aggressive surgical treatment for ICH has remained controversial as clinical trials have failed to demonstrate substantial improvement in patient outcome and mortality. Recently, promising mechanical and pharmacological minimally invasive surgery (MIS) techniques for the treatment of ICH have been described. MIS was designed with the objective of reducing morbidity due to complications of surgical manipulation. Mechanical MIS includes the use of tubular retractors and small diameter instruments for ICH removal. Pharmacological methods consist of catheter placement inside the haematoma cavity for the passive drainage of the haematoma over the course of several days. One of the most favourable approaches for MIS is the use of natural corridors for reaching the lesion, such as the transsulcal parafascicular approach. This approach provides an anatomical dissection of the subjacent white matter tracts, causing the least amount of damage while evacuating the haematoma. A detailed description of the currently known MIS techniques and devices is presented in this review. Special attention is given to the transsulcal parafascicular approach, which has particular benefits to provide a less traumatic MIS with promising overall patient outcome.

Prise en charge hémostatique des hémorragies cérébrales sous anticoagulants oraux

L’hématome intracrânien spontané a un pronostic clinique sévère. Le devenir des patients dépend de l’efficacité de la prise en charge initiale. L’importance du saignement, le volume de l’hématome et son évolution sont les facteurs principaux qui contrôlent mortalité et morbidité. Les traitements anticoagulants oraux, antivitamines K (AVK) et anticoagulants oraux directs (AOD), favorisent l’expansion de l’hématome. La correction rapide de l’hémostase permet le contrôle partiel de l’hématome. Alors que la réversion des AVK par les concentrés de complexe prothrombinique (CCP) a fait l’objet de recommandations bien diffusées, l’attitude thérapeutique reste peu codifiée avec les AOD, alliant l’utilisation de l’idarucizumab pour le dabigatran et des CCP pour les anti-Xa qui n’ont, pour l’instant, pas d’antidote.

An update on neurocritical care for intracerebral hemorrhage

Introduction: Intracerebral hemorrhage remains one of the leading causes of death and disability worldwide with few established interventions that improve neurologic outcome. Research dedicated to better understanding and treating hemorrhagic strokes has multiplied in the past decade. Areas Covered: This review aims to discuss the current landscape of management of intracerebral hemorrhage in a critical care setting and provide updates regarding developments in therapeutic interventions and targets. PubMed was utilized to review recent literature, with a focus on large trials and meta-analyses, which have shaped current practice. Published committee guidelines were also included. A focus was placed on research published after 2015 in an effort to supplement previous reviews included in this publication. Expert Opinion: Literature pertaining to ICH management has allowed for a greater understanding of ineffective strategies as opposed to those of benefit. Despite this, mortality has improved worldwide, which may be the result of growing research efforts. Areas of future research that will impact mortality and improve neurologic outcomes include prevention of hematoma expansion, optimization of blood pressure targets, effective coagulopathy reversal, and minimally invasive surgical techniques to reduce hematoma burden.

Proposal of modification in management strategy for intracranial hemorrhage in low- and middle-income countries

This brief communication describes the challenges faced by neurosurgeons in Low- or middle-income countries to treat neurosurgical emergencies from intracranial bleeds (whether traumatic or spontaneous). The authors point out that in low- or middle-income countries and Africa in particular, resources, facilities, and personnel are lacking to follow the guidelines proposed for treating these conditions in high-income countries. The proposal offered here is to move to early surgical intervention because algorithms to monitor patients under conservative management guidelines are often not possible.

Safety and Efficacy of Intraventricular Delivery of Bone Marrow-Derived Mesenchymal Stem Cells in Hemorrhagic Stroke Model

External ventricular drain (EVD) is used clinically to relieve intracranial pressure and occasionally to deliver medications following intracerebral hemorrhage (ICH). Mesenchymal stem cell (MSC) therapy has been shown to be neuroprotective and can induce neuroregeneration in stroke models. We evaluated the safety and efficacy of delivering MSCs intraventricularly in a rat hemorrhagic stroke model. Using autologous blood, hemorrhagic stroke was induced at specific coordinates in the right basal ganglia. After 30 minutes, rats were treated with either bone marrow-derived MSCs or a phosphate-buffered saline placebo via direct intraventricular infusion. Three dosages (2 × 10⁵/kg, 5 × 10⁵/kg, and 1 × 10⁶/kg) of MSCs were administered. Forelimb use asymmetry test was employed to evaluate functional improvement after cell therapy. At the end of the experiment, peripheral blood samples and organs were harvested; biochemistry, cytokine, and growth factor analysis and histology evaluations were performed to explore cell toxicity and cell fate, and the effects of MSC therapy on injury volume, anti-inflammation, and neurogenesis. Intraventricular administration of MSCs in ICH rat model showed improved behavior and alleviated brain damage. Additionally, treated ICH rats showed significantly reduced expression of IL-1α, IL-6, and IFN-γ. No obvious cell toxicity was noticed through blood chemistry and histology evaluation. None of the infused MSCs were detected at the end of the experiment. EVD is safe and effective to use as a method of delivering MSCs to treat ICH. Intraventricularly delivered MSCs have anti-inflammatory properties and a capacity to induce neurogenesis and improve function following ICH injury.

Deep structural brain lesions associated with consciousness impairment early after hemorrhagic stroke

The purpose of this study was to determine the significance of deep structural lesions for impairment of consciousness following hemorrhagic stroke and recovery at ICU discharge. Our study focused on deep lesions that previously were implicated in studies of disorders of consciousness. We analyzed MRI measures obtained within the first week of the bleed and command following throughout the ICU stay. A machine learning approach was applied to identify MRI findings that best predicted the level consciousness. From 158 intracerebral hemorrhage patients that underwent MRI, one third was unconscious at the time of MRI and half of these patients recovered consciousness by ICU discharge. Deep structural lesions predicted both, impairment and recovery of consciousness, together with established measures of mass effect. Lesions in the midbrain peduncle and pontine tegmentum alongside the caudate nucleus were implicated as critical structures. Unconscious patients predicted to recover consciousness by ICU discharge had better long-term functional outcomes than those predicted to remain unconscious.

Macrophage stimulating protein preserves blood brain barrier integrity after intracerebral hemorrhage through recepteur d'origine nantais dependent GAB1/Src/β-catenin pathway activation in a mouse model

Blood brain barrier (BBB) disruption is an important contributor to brain edema and neurological deficits following intracerebral hemorrhage (ICH). Macrophage stimulating protein (MSP) is a hepatocyte growth factor-like protein that mediates its functions via activating receptor tyrosine kinase recepteur d'origine nantais (RON). Grb2-associated binder 1 (GAB1) is a docking protein that mediates downstream receptor signal transduction pathways. This study aimed to evaluate the role of MSP and RON activated signaling pathway in preserving BBB integrity after collagenase-induced ICH. ICH mice received recombinant human MSP (rhMSP) or rhMSP combined with siRNA knockdown of RON or GAB1. rhMSP was administered by intranasal route 1 h after ICH. Brain edema, neurobehavior, BBB tight junction protein expression, and BBB permeability were evaluated. The expression of endogenous MSP and p-RON was decreased after ICH. Exogenous rhMSP administration reduced brain edema, neurological deficits, BBB permeability, and increased the expression of tight junction proteins in ICH mice. rhMSP administration increased the expression of p-RON, p-GAB1, p-Src, nuclear β-catenin, and tight junction proteins after ICH. These effects were reversed with RON and GAB1 siRNA. We conclude that MSP activation of RON preserved BBB integrity via GAB-1/Src/β-catenin pathway, thereby reducing brain edema and neurological deficits after ICH in mice.

miR-181b regulates ER stress induced neuron death through targeting Heat Shock Protein A5 following intracerebral haemorrhage

Endoplasmic reticulum (ER) stress acts as a protein folding and contributes to neuronal damage and neurological deterioration following intracerebral hemorrhage (ICH). Heat Shock Protein A5 (HSPA5) serves as an essential regulator of the endoplasmic reticulum (ER) stress response. However, the specific mechanism has not been will identified. Primary cortical neurons from C57BL/6 mice were subjected to erythrocyte lysates. Cell viability, microRNA and HSPA5 levels, and ER stress was detected. The interaction between microRNA and the target HSPA5 was identified by dual luciferase reporter gene assay. In addition, inflammatory cytokines, brain edema, and neurological functions in ICH mice were also assessed. Erythrocyte lysates induced ER stress and neuron damage, downregulated miR-181b and upregulated HSPA5 levels. MiR-181b suppressed HSPA5 expression by directly binding its 3'-untranslated region. Correspondingly, our data demonstrated that overexpression of miR-181b attenuated erythrocyte lysates induced neuronal necrosis and apoptosis. In vivo, downregulated miR-181b increased the HSPA5 level, along with significant elevations of pro-inflammatory cytokines, brain edema, and neurological injury following ICH. HSPA5 pathway plays an important role in ER stress induced brain damage following ICH. In addition, miR-181b has neuroprotective effects that alleviates neurological injury and represents a promising therapeutic strategy in ICH.

DIFFERENTIAL DIAGNOSIS OF NON-TRAUMATIC BRAIN HEMORRHAGE WITH ETIOPATHOGENETIS ASSOSIATION

Differential diagnostics of non-traumatic intracerebral hemorrhages is a critical area of scientific research and development in neuroradiology. In modern clinical practice, diagnostics are often limited to anatomical description of pathology without taking into account its etiology and pathogenesis. This paper analyzes the ethiopathogenetic factors underlying non-traumatic intracranial hemorrhages, as well as the potential of tomography in differential diagnosis of intracerebral non-traumatic hemorrhages with regard to localization and prevalence. Additionally, the paper analyzes the most common misinterpretations in the diagnostics of non-traumatic intracerebral hemorrhages, providing examples of pathologies with different etiologic but similar hallmarks in magnetic resonance imaging (MRI) and computed tomography (CT).

Noninterventional Treatment Options for Stroke

Given the need for early restoration of blood flow and preservation of partially damaged brain cells after ischemic stroke, the noninterventional treatment of stroke relies heavily on the speedy recognition and classification of the clinical syndrome. Initiation of systemic thrombolysis with careful observation of contraindications within the 3.0 (4.5)-hour time window is the approved therapy of choice. Management of hemorrhagic complications and resumption of oral anticoagulation if indicated are also discussed in this article.

β-amyloid wall deposit of temporal artery in subjects with spontaneous intracerebral haemorrhage

Background

Cerebral Amyloid Angiopathy has been indicated as an important cause of spontaneous non-hypertensive intracerebral haemorrhage (ICH).

Aims

to analyze the presence of β-amyloid deposit in the temporal artery of consecutive patients with ICH in comparison to control subjects and its relation to APO-E haplotype frequency.

Methods

We enrolled consecutive patients admitted to Neurosurgery Ward of University Hospital “P. Giaccone” of Palermo with a diagnosis of spontaneous non hypertensive ICH and as control 12 subjects without brain haemorrhage. Biopsy of superficial temporal artery has been performed and β-amyloid deposit was quantified.

Results

Among 25 subjects with ICH, 10 (40%) had APOE epsilon 2 allele and among these subjects 7 (70%) showed amyloid accumulation on temporal artery specimens, 8 (32%) subjects had APOE epsilon 3 allele and among these subjects only 2 (25%) showed amyloid accumulation on temporal artery specimens, whereas 7 (28%) had APOE epsilon 4 allele and of these, 7 (100%) showed amyloid accumulation on temporal artery specimens. At multivariable logistic regression analysis for the presence of amyloid, predictive factors for the presence of amyloid in temporal artery biopsies were: age, hypertension, intralobar site of haemorrhage, APOE epsilon 2 and APOE epsilon 4 alleles.

Discussion

Our findings of a higher frequency of amyloid deposition in temporal artery specimens in subjects with spontaneous intracerebral haemorrhage indicate a possible role of temporal artery as a possible diagnostic site of biopsy in subjects at high risk to develop intracranial haemorrhage related to Cerebral Amyloid Angiopathy.

Fluid Management in Acute Brain Injury

PURPOSE OF THE REVIEW

The aims of fluid management in acute brain injury are to preserve or restore physiology and guarantee appropriate tissue perfusion, avoiding potential iatrogenic effects. We reviewed the literature, focusing on the clinical implications of the selected papers. Our purposes were to summarize the principles regulating the distribution of water between the intracellular, interstitial, and plasma compartments in the normal and the injured brain, and to clarify how these principles could guide fluid administration, with special reference to intracranial pressure control.

RECENT FINDINGS

Although a considerable amount of research has been published on this topic and in general on fluid management in acute illness, the quality of the evidence tends to vary. Intravascular volume management should aim for euvolemia. There is evidence of harm with aggressive administration of fluid aimed at achieving hypervolemia in cases of subarachnoid hemorrhage. Isotonic crystalloids should be the preferred agents for volume replacement, while colloids, glucose-containing hypotonic solutions, and other hypotonic solutions or albumin should be avoided. Osmotherapy seems to be effective in intracranial hypertension management; however, there is no clear evidence regarding the superiority of hypertonic saline over mannitol. Fluid therapy plays an important role in the management of acute brain injury patients. However, fluids are a double-edged weapon because of the potential risk of hyper-hydration, hypo- or hyper-osmolar conditions, which may unfavorably affect the clinical course and the outcome.

Hemorrhagic and non-hemorrhagic causes of signal loss on susceptibility-weighted imaging

Susceptibility-weighted imaging (SWI) plays a key role in an emergency setting. SWI takes the intrinsic properties of materials being scanned and creates a visual representation of their effects on the magnetic field, thereby differentiating a number of pathologies. Magnetic resonance imaging (MRI) is now more often used, especially when computed tomography (CT) is inconclusive or even negative. Often, clinicians prefer to obtain an MRI first. This article will review the various hemorrhagic and non-hemorrhagic causes of low signal on SWI. There will be a focus on the distribution patterns of low signal on SWI in pathologies such as diffuse axonal injury, cerebral amyloid angiopathy, and cerebral fat embolism. It is important to recognize these patterns of susceptibility, as the radiologist may be the first to give an accurate diagnosis and therefore, directly impact clinical management.

Primary cCT Imaging Based Clinico-Neurological Assessment-Calling for Addition of Telestroke Video Consultation in Patients With Intracerebral Hemorrhage

Background and Purpose: Intracerebral hemorrhage (ICH) requires rapid decision making to decrease morbidity and mortality although time frame and optimal therapy are still ill defined. Ideally, specialized neurologists, neurosurgeons, and (neuro-) radiologists who know the patient's clinical status and their cerebral computed tomography imaging (cCT) make a joint decision on the clinical management. However, in telestroke networks, a shift toward cCT imaging criteria used for decision making can be observed for practical reasons. Here we investigated the “reverse correlation” from cCT imaging to the actual clinical presentation as evaluated by the Glasgow Coma Scale (GCS) and the National Institutes of Health Stroke Scale (NIHSS).

Methods: CCT images and basic information (age, sex, and time of onset) of 50 patients with hypertensive and lobar ICH were presented to 14 experienced neurologists and 15 neurosurgeons. Based on this information, the NIHSS and GCS scores were estimated for each patient. The differences between the actual GCS and NIHSS scores and the cCT-imaging-based estimated scores were plotted in a bland-Altman plot.

Results: The average estimated GCS score mainly based on cCT imaging was 12. 4 ± 2.8 (actual value: 13.0 ± 2.5; p = 0.100), the estimated NIHSS score was 13.9 ± 9.1 (actual value: 10.8 ± 7.3; p < 0.001). Thus, in cCT-imaging-based evaluation, the neurological status of patients especially employing the NIHSS was estimated poorer, particularly in patients with lobar ICH. “Reverse clinical” evaluation based on cCT-imaging alone may increase the rate of intubation and secondary transferal and neurosurgical treatment. Telestroke networks should consider both, videoassessment of the actual clinical picture and cCT-imaging findings to make appropriate acute treatment decisions.

Reversal Strategies for Intracranial Hemorrhage Related to Direct Oral Anticoagulant Medications

Direct oral anticoagulants (DOACs) are a new class of anticoagulants that directly inhibit either thrombin or factor Xa in the coagulation cascade. They are being increasingly used instead of warfarin or other vitamin K antagonists (VKAs). Adverse side effects of DOACs may result in hemorrhagic complications, including life-threatening intracranial hemorrhage (ICH), though to a much lesser degree than VKAs. Currently there are relatively limited indications for DOACS but their usage is certain to expand with the availability of their respective specific reversal agents. Currently, only idarucizumab (antidote for dabigatran) has been United States Food and Drug Administration- (FDA-) approved, but others (andexanet-α and ciraparantag) may be approved in near future, and the development and availability of such reversal agents have the potential to dramatically change the current anticoagulant use by providing reversal of multiple oral anticoagulants. Until all the DOACs have FDA-approved reversal agents, the treatment of the dreaded side effects of bleeding is challenging. This article is an attempt to provide an overview of the management of hemorrhage, especially ICH, related to DOAC use.

Evaluation of Acute Kidney Injury and Mortality After Intensive Blood Pressure Control in Patients With Intracerebral Hemorrhage

Background

We sought to assess the risk of acute kidney injury (AKI) and mortality associated with intensive systolic blood pressure reduction in acute intracerebral hemorrhage.

Methods and Results

Patients with acute intracerebral hemorrhage had spontaneous cause and symptom onset within 24 hours. We excluded patients with structural causes, coagulopathy, thrombocytopenia, and preexisting end‐stage renal disease. We defined AKI using the Acute Kidney Injury Network criteria. Chronic kidney disease status was included in risk stratification and was defined by Kidney Disease Outcomes Quality Initiative staging. Maximum systolic blood pressure reduction was defined over a 12‐hour period and dichotomized using receiver operating characteristic curve analysis. Descriptive statistics were done using independent sample t tests, χ² tests, and Mann‐Whitney U tests, whereas multivariable logistic regression analysis was used to evaluate for predictors for AKI and mortality. A total of 448 patients with intracerebral hemorrhage met inclusion criteria. Maximum systolic blood pressure reduction was dichotomized to 90 mm Hg and found to increase the risk of AKI in patients with normal renal function (odds ratio, 2.1; 95% confidence interval, 1.19–3.62; P=0.010) and chronic kidney disease (odds ratio, 3.91; 95% confidence interval, 1.26–12.15; P=0.019). The risk of AKI was not significantly different in normal renal function versus chronic kidney disease groups when adjusted for demographics, presentation characteristics, and medications associated with AKI. AKI positively predicted mortality for patients with normal renal function (odds ratio, 2.41; 95% confidence interval, 1.11–5.22; P=0.026) but not for patients with chronic kidney disease (odds ratio, 3.13; 95% confidence interval, 0.65–15.01; P=0.154).

Conclusions

These results indicate that intensive systolic blood pressure reduction with a threshold >90 mm Hg in patients with acute intracerebral hemorrhage may be an independent predictor for AKI.

Remote Diffusion-Weighted Imaging Lesions in Intracerebral Hemorrhage: Characteristics, Mechanisms, Outcomes, and Therapeutic Implications

Spontaneous intracerebral hemorrhage (ICH) is one of the most fatal form of stroke, with high mortality and disability rate. Small diffusion-weighed imaging lesions are not rare to see in regions remote from the hematoma after ICH and have been generally considered as related with poor outcome. In this review, we described the characteristics of remote ischemic lesions, discussed the possible mechanisms and clinical outcomes of these lesions, and evaluated the potential therapeutic implications.

Accuracy of Shape Irregularity and Density Heterogeneity on Noncontrast Computed Tomography for Predicting Hematoma Expansion in Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis was aimed to evaluate the predictive values of shape irregularity and density heterogeneity of hematoma on noncontrast computed tomography (NCCT) for hematoma expansion (HE).

METHODS

A literature search was performed in PubMed, Embase, Scopus, Web of Science, and Cochrane Library. Studies about predictive values of shape regularity or density heterogeneity of hematoma on NCCT for HE in spontaneous intracerebral hemorrhage were included. Meta-analysis was performed to pool the data. Publication bias assessment, subgroup analysis, and univariate meta-regression were conducted.

RESULTS

A total of 7 studies with 2294 patients were included. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of shape irregularity were 67%, 47%, 1.30, and 0.71, respectively. In contrast, the pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of density irregularity were 52%, 69%, 1.70, and 0.69, respectively.

CONCLUSIONS

Considering the relatively low sensitivity and specificity, the predictive values of shape irregularity and density heterogeneity of hematoma for HE are limited. Further studies are still needed to find optimal NCCT predictors for HE in spontaneous intracerebral hemorrhage patients.

RETRACTED: Effect of microRNA-129-5p targeting HMGB1-RAGE signaling pathway on revascularization in a collagenase-induced intracerebral hemorrhage rat model

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief. An Expression of Concern for this article was previously published while an investigation was conducted (see related editorial: https://doi.org/10.1016/j.biopha.2022.113812). This retraction notice supersedes the Expression of Concern published earlier. Concern was raised about the reliability of the Western blot data in Figure 2A, which contain suspected image duplications within the β-actin blot, and appear to represent a distinct phenotype as found in many other publications, as detailed here: https://pubpeer.com/publications/83FD53A8F4C5B60E2187CBF9F29B01; and here: https://docs.google.com/spreadsheets/d/1r0MyIYpagBc58BRF9c3luWNlCX8VUvUuPyYYXzxWvgY/edit#gid=262337249. Independent analysis confirmed these findings and also identified additional suspected image duplications within Figures 3 and 4A. The journal requested the corresponding author comment on these concerns and provide the associated raw data. The authors did not respond to this request and therefore the Editor-in-Chief decided to retract the article.

Predictive Value of CTA Spot Sign on Hematoma Expansion in Intracerebral Hemorrhage Patients

Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage and leads to high rates of mortality and morbidity. Currently, contrast extravasation within hematoma, termed the spot sign on computed tomography angiography (CTA), has been identified as a strong independent predictor of early hematoma expansion. Past studies indicate that the spot sign is a dynamic entity and is indicative of active hemorrhage. Furthermore, to enhance the spot sign's accuracy of predicting HE, spot parameters observed on CTA or dynamic CTA were used for its quantification. In addition, spot signs detected on multiphase CTA and dynamic CTA are shown to have higher sensitivity and specificity when compared with simple standardized spot sign detection in recent studies. Based on the spot sign, novel methods such as leakage sign and rate of contrast extravasation were explored to redefine HE prediction in combination with clinical characteristics and spot sign on CTA to assist clinical judgment. The spot sign is an accepted independent predictor of active hemorrhage and is used in both secondary intracerebral hemorrhage and the process of surgical assessment for hemorrhagic risk in patients with ischemic stroke. Spot sign predicts patients at high risk for hematoma expansion.

Oleuropein protects intracerebral hemorrhage-induced disruption of blood-brain barrier through alleviation of oxidative stress

BACKGROUND

Intracerebral haemorrhage (ICH) as a devastating form of stroke has remained a public health threat due to lack of FDA-approved therapy. Oxidative stress originated from blood cell degradation products plays a crucial role in the ICH pathogenesis. In this study we evaluated oleuropein, a potent natural antioxidant from olive, in a well-established rat ICH model from overall symptoms to detailed molecular mechanism.

METHODS

ICH model was established by collagenase injection to the brain of rats, which were randomly divided into groups with vehicle mock treatment, followed by treatment with different doses of oleuropein via daily intraperitoneal injection post-ICH for 3days. The overall neurological deficit, brain edema level and blood-brain barrier (BBB) integrity were then measured in different treatment groups. To understand the protection mechanism of oleuropein in ICH, BBB structural components ZO-1 and occludin, oxidative stress and MAPK signalling pathways were also examined.

RESULTS

Oleuropein treatment showed overall alleviation of ICH-associated neurological deficit and brain edema in a dose dependent manner. Consistently, it could preserve the BBB structure and attenuate oxidative stress as well as ICH-induced MAPK activation in brain tissue.

CONCLUSION

Our study suggests oleuropein could be used as a promising therapeutic agent for ICH.