Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage

The profile of blunt traumatic supratentorial cranial bleed types

The characteristics of blunt traumatic supratentorial cranial bleed (STCB) types have not been directly compared. The National Trauma Data Bank (NTDB) 2014 was queried for adults with an isolated single STCB n = 57,278. Patients were grouped by STCB categories: subdural (SDH), subarachnoid (SAH), epidural (EDH), intraparenchymal (IPH), and intraventricular hemorrhage (IVH). Frequency, demographics, clinical characteristics, procedures, and outcomes were compared among groups. SDH was the most common STCB (53%) and occurred mostly in elderly patients after a fall (78%), 30% underwent craniotomy and their mortality was 7%. SAH occurred in 32% of patients and carried the lowest mortality (3%). SAH were least likely to have a severe brain injury (7%), and had the lowest Injury Severity Score (ISS, median 8) and complication rate (1%), as well as the shortest hospital length of stay (HLOS, 4.6 ± 6.4 days). EDH was uncommon (2%), occurred in younger patients (median 35 years), and had the highest percentage of traffic related injuries (28%). While EDH patients presented with the poorest neurological status (16% Glasgow Coma Scale ≤ 8, ISS median 18) and were operated on more than any other STCB type (51%), their mortality was lower (4%) and they had the highest discharge to home rate (71%). IVH was the least common (2%), but most lethal (9%) STCB type. These patients had the highest HLOS and intensive care unit LOS, and the lowest craniotomy rate (21%). STCB types have different clinical course, and outcomes. Understanding these differences can be useful in managing patients with STB.

A Uniaxial Testing Approach for Consistent Failure in Vascular Tissues

Although uniaxial tensile testing is commonly used to evaluate failure properties of vascular tissue, there is no established protocol for specimen shape or gripping method. Large percentages of specimens are reported to fail near the clamp and can potentially confound the studies, or, if discarded will result in sample waste. The objective of this study is to identify sample geometry and clamping conditions that can achieve consistent failure in the midregion of small arterial specimens, even for vessels from older individuals. Failure location was assessed in 17 dogbone specimens from human cerebral and sheep carotid arteries using soft inserts. For comparison with commonly used protocols, an additional 22 rectangular samples were tested using either sandpaper or foam tape inserts. Midsample failure was achieved in 94% of the dogbone specimens, while only 14% of the rectangular samples failed in the midregion, the other 86% failing close to the clamps. Additionally, we found midregion failure was more likely to be abrupt, caused by cracking or necking. In contrast, clamp failure was more likely to be gradual and included a delamination mode not seen in midregion failure. Hence, this work provides an approach that can be used to obtain consistent midspecimen failure, avoiding confounding clamp-related artifacts. Furthermore, with consistent midregion failure, studies can be designed to image the failure process in small vascular samples providing valuable quantitative information about changes to collagen and elastin structure during the failure process.

Packing of metalized polymer nanofibers for aneurysm embolization

Aneurysmal subarachnoid hemorrhage (SAH) is the extravasation of blood into the subarachnoid space and is fatal in most cases. Platinum coils have been used to fill the hemorrhage site and prevent the extravasation of blood. Here we explored the use of Pt-coated polymer nanofibers (NF) to prevent blood extravasation and were able to achieve improved results in vitro. The polymer nanofibers were produced via electrospinning and were subsequently electroplated with Pt, resulting in metalized nanofibers. These nanofibers were installed within a microfluidic channel, and the resulting reduction in the permeability was evaluated using a fluid similar to blood. Based on the obtained results, these newly developed nanofibers are expected to decrease the operation cost for SAH, owing to their reduced size and low material cost. Furthermore, it is expected that these nanofibers will be used in a smaller amount during SAH operation while having the same preventive effect. This should reduce the operational risk associated with the multiple steps required to place the Pt coils at the SAH site. Finally, the underlying hydrodynamic mechanism responsible for the reduced permeability of the synthesized nanofibers is described.

Effect of Hyperosmolar Therapy on Outcome Following Spontaneous Intracerebral Hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

PURPOSE

We aimed to identify the effect of hyperosmolar therapy (mannitol and hypertonic saline) on outcomes after intracerebral hemorrhage (ICH) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study.

METHODS

Comparison of ICH cases treated with hyperosmolar therapy versus untreated cases was performed using a propensity score based on age, initial Glasgow Coma Scale, location of ICH (lobar, deep, brainstem, and cerebellar), log-transformed initial ICH volume, presence of intraventricular hemorrhage, and surgical interventions. ERICH subjects with a pre-ICH modified Rankin Scale (mRS) score of 3 or lower were included. Treated cases were matched 1:1 to untreated cases by the closest propensity score (difference ≤.15), gender, and race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic). The McNemar and the Wilcoxon signed-rank tests were used to compare 3-month mRS outcomes between the 2 groups. Good outcome was defined as a 3-month mRS score of 3 or lower.

RESULTS

As of December 31, 2013, the ERICH study enrolled 2279 cases, of which 304 hyperosmolar-treated cases were matched to 304 untreated cases. Treated cases had worse outcome at 3 months compared with untreated cases (McNemar, P = .0326), and the mean 3-month mRS score was lower in the untreated group (Wilcoxon, P = .0174). Post hoc analysis revealed more brain edema, herniation, and death at discharge for treated cases.

CONCLUSIONS

Hyperosmolar therapy was not associated with better 3-month mRS outcomes for ICH cases in the ERICH study. This finding likely resulted from greater hyperosmolar therapy use in patients with edema and herniation rather than those agents leading to worse outcomes. Further studies should be performed to determine if hyperosmolar agents are effective in preventing poor outcomes.

Pannexin-1 is involved in neuronal apoptosis and degeneration in experimental intracerebral hemorrhage in rats

Pannexins serve an important role in the regulation of extracellular neuronal regenerative currents and cellular signal transduction of glial cells; however, the effects of pannexins in various cerebrovascular diseases have not been reported. The present study focused on the expression and influence of pannexins in a rat model of intracerebral hemorrhage (ICH), and confirmed that pannexins (including Pannexin‑1, Pannexin‑2 and Pannexin‑3) are expressed in rat brain tissues. However, only the expression of Pannexin‑1 was significantly increased and peaked 48 h post‑ICH. Following treatment with carbenoxolone (CBX), which is an inhibitor of Pannexin‑1, apoptosis and neuronal degeneration in the brain tissues around the ICH hematoma decreased. The extent of secondary brain injury due to ICH was also alleviated. Compared with rats in the ICH‑only group, recovery of neurocognitive functions improved significantly in the CBX‑treated groups. Results from the present study suggested that the upregulation of Pannexin‑1 expression may be involved in apoptosis and degeneration of neurons in the rat brain following ICH, and may contribute to subsequent cognitive dysfunction.

Compare the Intracranial Pressure Trend after the Decompressive Craniectomy between Massive Intracerebral Hemorrhagic and Major Ischemic Stroke Patients

Objective

Massive intracerebral hemorrhage (ICH) and major infarction (MI) are devastating cerebral vascular diseases. Decompression craniectomy (DC) is a common treatment approach for these diseases and acceptable clinical results have been reported. Author experienced the postoperative intracranaial pressure (ICP) trend is somewhat different between the ICH and MI patients. In this study, we compare the ICP trend following DC and evaluate the clinical significance.

Methods

One hundred forty-three patients who underwent DC following massive ICH (81 cases) or MI (62 cases) were analyzed retrospectively. The mean age was 56.3±14.3 (median=57, male : female=89 : 54). DC was applied using consistent criteria in both diseases patients; Glasgow coma scale (GCS) score less than 8 and a midline shift more than 6 mm on brain computed tomography. In all patients, ventricular puncture was done before the DC and ICP trends were monitored during and after the surgery. Outcome comparisons included the ictus to operation time (OP-time), postoperative ICP trend, favorable outcomes and mortality.

Results

Initial GCS (p=0.364) and initial ventricular ICP (p=0.783) were similar among the ICH and MI patients. The postoperative ICP of ICH patients were drop rapidly and maintained within physiological range if greater than 80% of the hematoma was removed. While in MI patients, the postoperative ICP were not drop rapidly and maintained above the physiologic range (MI=18.8 vs. ICH=13.6 mmHg, p=0.000). The OP-times were faster in ICH patients (ICH=7.3 vs. MI=40.9 hours, p=0.000) and the mortality rate was higher in MI patients (MI=37.1% vs. ICH=17.3%, p=0.007).

Conclusion

The results of this study suggest that if greater than 80% of the hematoma was removed in ICH patients, the postoperative ICP rarely over the physiologic range. But in MI patients, the postoperative ICP was above the physiologic range for several days after the DC. Authors propose that DC is no need for the massive ICH patient if a significant portion of their hematoma is removed. But DC might be essential to improve the MI patients’ outcome and timely treatment decision.

Risk Factors of Rehemorrhage in Postoperative Patients with Spontaneous Intracerebral Hemorrhage : A Case-Control Study

Objective

Rehemorrhage is the most severe complication of postoperative patients with spontaneous intracerebral hemorrhage. The aim of the present study was to assess independent predictors of rehemorrhage and find the possibility of preventing rehemorrhage in postoperative patients with spontaneous intracerebral hemorrhage (sICH).

Methods

Medical records of 263 postoperative patients with sICH from our Hospital were reviewed. The relationships between rehemorrhage and parameters were examined by univariate and multivariate analyses. The parameters include time from onset to surgery, hematologic paremeters, neuroimaging characteristics, level and variability of systolic blood pressure, medical histories, operation duration, and blood loss. In addition, relationship between rehemorrhage and clinical outcome were analyzed by using multivariate analyses.

Results

Thirty-five (13.31%) patients experienced rehemorrhage after operation. Multivariate analyses indicated that the following factors were independently associated with rehemorrhage : history of diabetes mellitus (odds ratio [OR], 2.717; 95% confidence interval [CI], 1.005–7.346; p=0.049), and midline shift (for every 1 mm increase, OR, 1.117; 95% CI, 1.029–1.214; p=0.009). Rehemorrhage was an independent risk factor of poor functional outcome (OR, 3.334; 95% CI, 1.094–10.155; p=0.034).

Conclusion

Our finding revealed that history of diabetes mellitus and admission midline shift were possibly associated with rehemorrhage in postoperative patients with sICH.

Spontaneous Intracerebral Hemorrhage

Although commonly arising from poorly controlled hypertension, spontaneous intracerebral hemorrhage may occur secondary to several other etiologies. Clinical presentation to the emergency department ranges from headache with vomiting to coma. In addition to managing the ABCs, the crux of emergency management lies in stopping hematoma expansion and other complications to prevent clinical deterioration. This may be achieved primarily through anticoagulation reversal, blood pressure, empiric management of intracranial pressure, and early neurosurgical consultation for posterior fossa hemorrhage. Patients must be admitted to intensive care. The effects of intracerebral hemorrhage are potentially devastating with very poor prognoses for functional outcome and mortality.

Stem cell therapy for abrogating stroke-induced neuroinflammation and relevant secondary cell death mechanisms

Ischemic stroke is a leading cause of death worldwide. A key secondary cell death mechanism mediating neurological damage following the initial episode of ischemic stroke is the upregulation of endogenous neuroinflammatory processes to levels that destroy hypoxic tissue local to the area of insult, induce apoptosis, and initiate a feedback loop of inflammatory cascades that can expand the region of damage. Stem cell therapy has emerged as an experimental treatment for stroke, and accumulating evidence supports the therapeutic efficacy of stem cells to abrogate stroke-induced inflammation. In this review, we investigate clinically relevant stem cell types, such as hematopoietic stem cells (HSCs), mesenchymal stem cells (MSCs), endothelial progenitor cells (EPCs), very small embryonic-like stem cells (VSELs), neural stem cells (NSCs), extraembryonic stem cells, adipose tissue-derived stem cells, breast milk-derived stem cells, menstrual blood-derived stem cells, dental tissue-derived stem cells, induced pluripotent stem cells (iPSCs), teratocarcinoma-derived Ntera2/D1 neuron-like cells (NT2N), c-mycER(TAM) modified NSCs (CTX0E03), and notch-transfected mesenchymal stromal cells (SB623), comparing their potential efficacy to sequester stroke-induced neuroinflammation and their feasibility as translational clinical cell sources. To this end, we highlight that MSCs, with a proven track record of safety and efficacy as a transplantable cell for hematologic diseases, stand as an attractive cell type that confers superior anti-inflammatory effects in stroke both in vitro and in vivo. That stem cells can mount a robust anti-inflammatory action against stroke complements the regenerative processes of cell replacement and neurotrophic factor secretion conventionally ascribed to cell-based therapy in neurological disorders.

Inflammatory Biomarkers and Their Value in Predicting Survival and Outcome among Patients with Spontaneous Intracerebral Haemorrhage

BACKGROUND

Spontaneous intracerebral haemorrhage (SICH) has emerged as one of the most devastating forms of stroke in recent decades. This disease is noted to carry a 30-day mortality rate of approximately 45%. An increasing number of studies have implicated a complex immune-mediated and inflammation-mediated cascade of responses in the pathophysiology of SICH and the resultant neurologic outcome. Several clinical studies have demonstrated an association between inflammatory markers and outcome in patients with SICH. However, the exact relationship between serum biomarkers and functional outcomes amongst survivors has not been clearly elucidated. This study aimed to evaluate the changes in peripheral leukocyte count (WBC count) and C-reactive protein (CRP) levels in patients with SICH and to correlate these findings with survival and functional outcome.

METHODOLOGY

A prospective, descriptive and correlational study was conducted at Sarawak General Hospital (SGH) over the span of two years (April 2013-April 2015). Patients aged between 30 years and 75 years with supratentorial intracerebral bleed secondary to uncontrolled hypertension were recruited in this study. Data pertaining to the demography, clinical and radiological parameters, peripheral WBC count and CRP levels were obtained. Mortality and functional outcomes were determined at 6 months post ictus. Patients were recruited following the fulfilment of exclusion and inclusion criteria, and all obtained data were analysed with the Statistical Package for Social Sciences (SPSS) for Windows version 21.0.

RESULTS

A total of 60 patients with a mean age of 56 years were recruited in this study. We found that approximately 16 patients were less than or equal to 50 years old (26.7%) and that 44 patients belonged to the older age group of above 50 years (73.3%). The Glasgow Coma Scale (GCS) score on admission ranged from 9 to 14/15 with a median value of 11/15. The mean clot volume was 20.1 cm³. The GCS score on admission and clot volume were significantly associated with the Glasgow Outcome Scale (GOS) at 6 months and overall survival (P < 0.05). The elevated WBC count and CRP level on admission and at 72 hours post admission were significantly associated with GOS at 6 months and overall survival (P < 0.05). Thus, the GCS score, clot volume, WBC count and CRP levels on admission and at 72 hours post admission can be used to predict functional outcome at 6 months and overall survival in patients with SICH.

CONCLUSION

We could conclude via this study that for patients with SICH, the main determinants or predictors of functional outcome at 6 months and overall survival were noted to be the GCS score on admission, clot size, WBC count and CRP levels on admission and at 72 hours post admission.

Vascular Causes of Syncope: An Emergency Medicine Review

BACKGROUND

Syncope is a common emergency department (ED) complaint, accounting for 2% of visits annually. A wide variety of etiologies can result in syncope, and vascular causes may be deadly.

OBJECTIVE

This review evaluates vascular causes of syncope and their evaluation and management in the ED.

DISCUSSION

Syncope is defined by a brief loss of consciousness with loss of postural tone and complete, spontaneous recovery without medical intervention. Causes include cardiac, vasovagal, orthostatic, neurologic, medication-related, and idiopathic, and most cases of syncope will not receive a specific diagnosis pertaining to the cause. Emergency physicians are most concerned with life-threatening causes such as dysrhythmia and obstruction, and electrocardiogram is a primary means of evaluation. However, vascular etiologies can result in patient morbidity and mortality. These conditions include pulmonary embolism, subclavian steal, aortic dissection, cerebrovascular disease, intracerebral hemorrhage, carotid/vertebral dissection, and abdominal aortic aneurysm. A focused history and physical examination can assist emergency physicians in determining the need for further testing and management.

CONCLUSIONS

Syncope is common and may be the result of a deadly condition. The emergency physician, through history and physical examination, can determine the need for further evaluation and resuscitation of these patients, with consideration of vascular etiologies of syncope.

Diabetic aggravation of stroke and animal models

Cerebral ischemia in diabetics results in severe brain damage. Different animal models of cerebral ischemia have been used to study the aggravation of ischemic brain damage in the diabetic condition. Since different disease conditions such as diabetes differently affect outcome following cerebral ischemia, the Stroke Therapy Academic Industry Roundtable (STAIR) guidelines recommends use of diseased animals for evaluating neuroprotective therapies targeted to reduce cerebral ischemic damage. The goal of this review is to discuss the technicalities and pros/cons of various animal models of cerebral ischemia currently being employed to study diabetes-related ischemic brain damage. The rational use of such animal systems in studying the disease condition may better help evaluate novel therapeutic approaches for diabetes related exacerbation of ischemic brain damage.

Does suboccipital decompression and evacuation of intraparenchymal hematoma improve neurological outcome in patients with spontaneous cerebellar hemorrhage?

OBJECTIVE

Spontaneous cerebellar hemorrhages (SCH) can lead to life-threatening complications with high mortality rates of 20-50%. Although complications of SCH can be prevented by surgical therapy, there is a lack of consensus concerning the optimal surgical technique for evacuating SCH.

METHODS

In this retrospective study 85 patients with SCH were divided into four treatment groups: (1) Decompression and Hematoma Evacuation via suboccipital craniectomy and removal of the posterior arch of C1 (DHE). (2) Hematoma Evacuation Only via craniotomy (HEO). (3) External Ventricular Drainage (EVD). (4) Conservative treatment (C). To ascertain the level of consciousness, Glasgow Coma Scale (GCS) was calculated. To evaluate the clinical and neurological outcome, modified Rankin Score, Glasgow Outcome Scale and mortality rate were recorded after 6months.

RESULTS

The mean volume of hematoma was significant larger in the DHE- and HEO-group compared to the EVD- and C-group before treatment. DHE and HEO could significantly reduce the volume comparing pre- and postoperative measurements. Larger preoperative volume was a strong predictor of worse neurological outcome and high mortality. Overall mortality was 25.9%. After subdivision into the treatment groups, a comparison of the DHE- and HEO-groups showed a trend towards lower mortality and better neurological outcome in the DHE-group. Patients with the worst preoperative GCS scores profited significantly from DHE with respect to regaining consciousness.

CONCLUSIONS

Patients with SCH should receive surgical therapy when hemorrhages are space-occupying and when the patient's neurological condition deteriorates. With regards to surgical technique, and limited by the retrospective design of the study, our results indicate that patients might benefit most from DHE.

Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update

Intracerebral hemorrhage (ICH) is the second most common subtype of stroke and a critical disease usually leading to severe disability or death. ICH is more common in Asians, advanced age, male sex, and low- and middle-income countries. The case fatality rate of ICH is high (40% at 1 month and 54% at 1 year), and only 12% to 39% of survivors can achieve long-term functional independence. Risk factors of ICH are hypertension, current smoking, excessive alcohol consumption, hypocholesterolemia, and drugs. Old age, male sex, Asian ethnicity, chronic kidney disease, cerebral amyloid angiopathy (CAA), and cerebral microbleeds (CMBs) increase the risk of ICH. Clinical presentation varies according to the size and location of hematoma, and intraventricular extension of hemorrhage. Patients with CAA-related ICH frequently have concomitant cognitive impairment. Anticoagulation related ICH is increasing recently as the elderly population who have atrial fibrillation is increasing. As non-vitamin K antagonist oral anticoagulants (NOACs) are currently replacing warfarin, management of NOAC-associated ICH has become an emerging issue.

MIS Score: Prediction Model for Minimally Invasive Surgery

BACKGROUND

Reports suggest that patients with spontaneous intracerebral hemorrhage (ICH) can benefit from minimally invasive surgery, but the inclusion criterion for operation is controversial. This article analyzes factors affecting the 30-day prognoses of patients who have received minimally invasive surgery and proposes a simple grading scale that represents clinical operation effectiveness.

METHODS

The records of 101 patients with spontaneous ICH presenting to Qianfoshan Hospital were reviewed. Factors affecting their 30-day prognosis were identified by logistic regression. A clinical grading scale, the MIS score, was developed by weighting the independent predictors based on these factors.

RESULTS

Univariate analysis revealed that the factors that affect 30-day prognosis include Glasgow coma scale score (P < 0.01), age ≥80 years (P < 0.05), blood glucose (P < 0.01), ICH volume (P < 0.01), operation time (P < 0.05), and presence of intraventricular hemorrhage (P < 0.001). Logistic regression revealed that the factors that affect 30-day prognosis include Glasgow coma scale score (P < 0.05), age (P < 0.05), ICH volume (P < 0.01), and presence of intraventricular hemorrhage (P < 0.05). The MIS score was developed accordingly; 39 patients with 0-1 MIS scores had favorable prognoses, whereas only 9 patients with 2-5 MIS scores had poor prognoses.

CONCLUSIONS

The MIS score is a simple grading scale that can be used to select patients who are suited for minimal invasive drainage surgery. When MIS score is 0-1, minimal invasive surgery is strongly recommended for patients with spontaneous cerebral hemorrhage. The scale merits further prospective studies to fully determine its efficacy.

Clinical study to assess the outcome in surgically managed patients of spontaneous intracerebral hemorrhage

Introduction

Spontaneous intracerebral hemorrhage (SICH) subtype of stroke is characterized by bleeding into brain parenchyma which is not accompanied by trauma. Emergency surgical evacuation of large size SICH increases the chances of survival but does not help in functional recovery of the patients. The present study was conducted to assess the outcome of surgical management in patients with SICH.

Materials and Methods

All patients who were diagnosed with SICH and underwent surgical evacuation of the hematoma included in the study. The outcome at 1 month was obtained through follow-up visits/telephonic interview when the former is not available. The primary outcome measure was in hospital mortality/condition at the time of discharge/neurological deficit/modified Rankin Scale (mRS) at 1 month follow-up.

Results

Out of 87 patients, 49 patients (63%) were male and 38 patients (37%) were females, male to female ratio was 1.2:0.8. Nearly 42% patient had systolic blood pressure with in normal range; however, in almost 50% of the cases, the systolic blood pressure at the time of admission was more than 140 mmHg. mRS was assessed for the patients at the time of admission, 39% patients had slight disability, 15% patients had moderate disability, 11% patients had moderately severe disability, and 33% patients had severe disability. Mortality was relatively higher in patients who had admission systolic blood pressure more than 140 mmHg (51% vs. 43%). mRS was assessed for the patients at the time of discharge after completion surgery and the severity of scale.

Conclusions

Hypertension was found to be most common comorbid illness followed by smoking, alcohol intake, and diabetes mellitus. Hematoma was evacuated in 58% of the cases; it was supplement with decompressive craniectomy in 12% of the cases. Morality was relatively higher in patients who had admission systolic blood pressure more than 140 mmHg. Mortality was highest in <40 years age group in age group of 40-65 years, the mortality was 30.6%, and in >65 years age group, mortality was 15.4%; however, this was not statistically significant. Only 10% of patients can recover and live independently at 1 month, and only 20% of the survivors were independent at 6 months.

External Ventricular Drain-Related Infection in Spontaneous Intracerebral Hemorrhage

OBJECTIVE

We aimed to analyze infection rates in patients with spontaneous intracranial hemorrhage who underwent surgical external ventricular drain (EVD) placement.

METHODS

This prospective study included 94 consecutive patients who required an EVD for spontaneous intracranial hemorrhage at the Neurosurgery Department of Hospital Cristo Redentor, Porto Alegre, Rio Grande do Sul, Brazil.

RESULTS

The mean duration of EVD use was 7 days. Overall sample mortality was 45%, and overall infection rate was 36%. Patients who had an EVD in place >10 days had higher odds of infection than patients who had an EVD in place ≤10 days (odds ratio = 3.1, 95% confidence interval, 1.1-8.7). Culture positivity rate was 5.3%.

CONCLUSIONS

Our findings suggest that EVD infection is a very common complication, occurring in 36.2% of cases. We adopted ventriculitis as the standard diagnosis, as advocated by the U.S. Centers for Disease Control and Prevention. Considering the high lethality associated with intracranial hemorrhage, use of a more aggressive treatment protocol for this patient population might improve morbidity and mortality rates.

Alcohol consumption and risk of subarachnoid hemorrhage: A meta-analysis of 14 observational studies

The association between alcohol consumption and the risk of subarachnoid hemorrhage (SAH) is inconsistent. Thus, meta- and a dose-response analyses are presented with the purpose of assessing their associations. A systematic literature search was performed using Pubmed and Embase electronic databases for pertinent observational studies. Random-effects or fixed-effect models were employed to combine the estimates of the relative risks (RRs) with corresponding 95% confidence intervals (CIs). A dose-response pattern was conducted for further analysis. The current meta-analysis includes 14 observational studies reporting data on 483,553 individuals and 2,556 patients. The combined RRs of light alcohol consumption (<15 g/day) and moderate alcohol consumption (15–30 g/day) compared with teetotal individuals were 1.27 (95% CI: 0.95, 1.68) and 1.33 (95% CI: 0.84, 2.09), respectively, which indicated no significant association between light-to-moderate alcohol consumption and SAH. An increased risk of SAH was noted in heavy alcohol consumption (>30 g/day) when compared with no alcohol consumption, as demonstrated by a result of 1.78 (95% CI: 1.46, 2.17). Dose-response analysis showed evidence of a linear association (P=0.0125) between alcohol consumption and SAH. The risk of SAH increased by 12.1% when alcohol consumption was increased by 10 g/day. Therefore, heavy alcohol consumption was found to be associated with an increased risk of SAH. Furthermore, the association between SAH and alcohol consumption has clinical relevance with regard to risk factor modification and the primary and secondary prevention of SAH.

Palliative Care Utilization in Nontraumatic Intracerebral Hemorrhage in the United States

OBJECTIVES

Palliative care is now recognized as an essential component of comprehensive care in serious illness that interferes with quality of life. We explored utilization of palliative care in spontaneous intracerebral hemorrhage at a population level using a large national database.

DESIGN

Population based cross-sectional study.

SETTING

Inpatient hospital admissions from the Nationwide Inpatient Sample.

PATIENTS

A total of 311,217 patients with intracerebral hemorrhage.

INTERVENTIONS

Palliative care use.

MEASUREMENTS AND MAIN RESULTS

Intracerebral hemorrhage patients with and without palliative care were identified from the 2007-2011 Nationwide Inpatient Sample using International Classification of Diseases, 9th Revision, codes. Demographics, comorbidities, surgical procedures, and hospital characteristics were compared between patients receiving and not receiving palliative care (code V66.7). Resource utilization measures were inflation-adjusted cost of care and length of stay. Pearson chi square and Wilcoxon-Mann-Whitney tests were used for categorical and continuous variables respectively. Logistic regression was used to construct a predictive model of palliative care. Of the 311,217 intracerebral hemorrhage patients, 32,159 (10.3%) received palliative care. Utilization of palliative care increased from 4.3% in 2007 to 16.2% in 2011 (trend p < 0.001). Patients receiving palliative care had higher Charlson comorbidity scores (p < 0.001), higher all-patient refined diagnosis-related group mortality risk (p < 0.001), and lower resource utilization measures compared with those without palliative care. Independent predictors of palliative care use were older age (odds ratio, 4.06; 95% CI, 3.87-4.23; p < 0.001), female sex (odds ratio, 1.17; 95% CI, 1.14-1.20; p < 0.001), Caucasian race (p < 0.001), Medicare insurance (p < 0.001), hospitals in the west and mid-west (p < 0.001), hospital transfer (odds ratio, 1.23; 95% CI, 1.18-1.30; p < 0.001), high intracerebral hemorrhage case volume (p < 0.001), anticoagulant use (odds ratio, 1.24; 95% CI, 1.19-1.31; p < 0.001), higher Charlson comorbidity score, ventriculostomy placement (odds ratio, 1.18; 95% CI, 1.13-1.29; p < 0.001), and mechanical ventilation (odds ratio, 1.44; 95% CI, 1.39-1.49; p < 0.001). Cerebral angiogram, craniotomy, and gastrostomy were independently associated with absence of palliative care use.

CONCLUSIONS

An apparent increasing trend of palliative care utilization in intracerebral hemorrhage has occurred over the last decade. After clinical severity adjustment, gender and racial differences and hospital characteristics appear to influence palliative care use among intracerebral hemorrhage patients in the United States.

"Cool" Topic: Feeding During Moderate Hypothermia After Intracranial Hemorrhage

BACKGROUND

Therapeutic moderate hypothermia (MH; T _core 33°C-34°C) is being studied for treatment of spontaneous intracerebral hemorrhage (ICH). Nutrition assessment begins with accurate basal metabolic rate (BMR) determination. Although early enteral nutrition (EN) is associated with improved outcomes, it is often deferred until rewarming. We sought to determine the accuracy of predictive BMR equations and the safety and tolerance of EN during MH after ICH.

MATERIALS AND METHODS

Patients were randomized to 72 hours of MH or normothermia (NT; T _core 36°C-37°C). Harris-Benedict (BMR-HB) and Penn-State equation (BMR-PS) calculations were compared with indirect calorimetry (IC) at day (D) 0 and D1-3. Patients with MH received trophic semi-elemental gastric EN. Occurrences of feeding intolerance, gastrointestinal (GI)-related adverse events, and ventilator-associated pneumonia (VAP) were analyzed with a double-sided matched pairs t test.

RESULTS

Thirteen patients with ICH participated (6 MH, 7 NT). Mean time to initiate EN: 29.9 (MH) vs 18.4 (NT) hours ( P = .046). Average daily EN calories received D0-3: 398 (MH) vs 1006 (NT) ( P < .01). Three patients with MH experienced high gastric residuals prior to prokinetic agents, 1 had mild ileus, and 1 patient with NT vomited. No GI-related adverse events were reported. One patient with MH and 1 patient with NT had VAP. Two patients with MH received IC, and from D0 to D1-3, BMR-HB remained stable (1331 kcal), BMR-PS decreased (1511 vs 1145 kcal, P = .5), and IC decreased (1413 vs 985 kcal, P = .2).

CONCLUSIONS

In patients with ICH undergoing MH, resting energy expenditure is decreased and predictive equations overestimate BMR. EN is feasible, although delayed EN initiation, high gastric residuals, and less EN provision are common. Future studies should focus on EN initiation within 24 hours, advanced EN rates, and postpyloric feeds during hypothermia.

Predictors of aneurysmal rebleed before definitive surgical or endovascular management

BACKGROUND

Aneurysmal rebleed is the most dreaded complication following subarachnoid hemorrhage. Being a cause of devastating outcome, the stratification of risk factors can be used to prioritize patients, especially at high volume centers.

METHOD

A total of 99 patients with aneurysmal rebleed were analyzed in this study both prospectively and retrospectively from August 2010 to July 2014. In the control group, 100 patients were selected randomly from the patient registry. A total of 25 variables from the demographic, historical, clinical and radiological data were compared and analyzed by univariate and multivariate logistic regression analysis.

RESULTS

Significant independent predictors of aneurysm rebleed were the presence of known hypertension (p = 0.023), diastolic blood pressure of >90 mmHg on admission (p = 0.008); presence of loss of consciousness (p = 0.013) or seizures (p = 0.002) at first ictus; history of warning headaches (p = 0.005); higher Fisher grade (p < 0.001); presence of multiple aneurysms (p = 0.021); irregular aneurysm surface (0.002).

CONCLUSIONS

Identification of high risk factors can help in stratifying patients in the high risk group. The risk stratification strategy with early intervention can prevent rebleeds. This in turn may translate into better outcomes of patients with intracranial aneurysms.

Animal models of spontaneous intracerebral hemorrhage

OBJECTIVES

Intracerebral hemorrhage (ICH) is a type of stroke that results in significant mortality and morbidity. Currently there is no definitive treatment for this disease. The paucity of animal models that reflect the heterogeneity of this spontaneous human disease could be the reason.

METHODS

In this review, we searched the literature for animal models of spontaneous ICH and found eight relevant papers.

RESULTS

Two were related to hypertension and six were related to cerebral amyloid angiopathy (CAA). One model used double transgenic mice overexpressing human renin and angiotensinogen which caused the mice to be hypertensive. Induction of ICH, however required addition of a high salt diet and nitric oxide synthase inhibition. Another mouse model of hypertension employed subcutaneous angiotensin II infusion and nitric oxide synthase inhibition plus acute injections of angiotensin to further elevate blood pressure. Five CAA models were in transgenic mice overexpressing amyloid precursor protein. One relied on the natural development of CAA in squirrel monkeys.

CONCLUSIONS

While all of the spontaneous ICH models have some advantages, the disadvantages include the sporadic time of onset of ICH and variability in size and location of ICH. Since there are no known efficacious treatments for ICH, it is not known if findings in the animal models will find treatments that are effective in humans.

Dynamic evolution of D-dimer level in cerebrospinal fluid predicts poor outcome in patients with spontaneous intracerebral hemorrhage combined with intraventricular hemorrhage

The risk of mortality in patients with intracerebral hemorrhage (ICH) significantly increases when complicated by intraventricular hemorrhage (IVH). We hypothesize that serial measurement of cerebrospinal fluid (CSF) D-dimer levels in patients with both ICH and IVH may serve as an early marker of IVH severity. We performed a prospective study of 43 consecutive ICH patients combined with IVH and external ventricular drainage placement admitted in our institution from 2005-2006. IVH severity (Graeb score) and fibrinolytic activity were evaluated continuously for 7days using CT scans and CSF D-dimer levels. The primary outcome was 30day mortality. Overall 30day mortality was 26% (n=11), with eight deaths (72.7%) after 3days (D3). Graeb score and CSF D-dimer on admission (D0) were not significantly different between survivors and non-survivors. The temporal profiles of both parameters were distinctly different, with a downward trend in survivors and an upward trend in non-survivors. A mortality rate of 54% was observed between D0-D3 when both scores increased during this interval. In contrast, the mortality was only 4% when both measures decreased during this interval. Early phase (D0-D3) CSF D-dimer or Graeb score change demonstrated high sensitivity of 88% and specificity of 81% when predicting 30day mortality. Early phase CSF D-dimer change in patients with both ICH and IVH is accurate in predicting mortality and may be utilized as a cost-effective surrogate indicator of IVH severity. Serial monitoring of CSF D-dimer dynamic changes is useful for early identification of patients with hematoma progression and poor outcome.

Surgery for Patients With Spontaneous Deep Supratentorial Intracerebral Hemorrhage: A Retrospective Case-Control Study Using Propensity Score Matching

Spontaneous intracerebral hemorrhage (sICH) is one of the most dangerous cerebrovascular diseases, especially when in deep brain. The treatment of spontaneous deep supratentorial intracerebral hemorrhage is still controversial. We conducted a retrospective case-control study using propensity score matching to compare the efficacy of surgery and conservative treatment for patients with deep surpatentorial hemorrhage. We observed the outcomes of consecutive patients with spontaneous deep supratentorial hemorrhage retrospectively from December 2008 to July 2013. Clinical outcomes of surgery and conservative treatments were compared in patients with deep sICH using propensity score matching method. The primary outcome was neurological function status at 6 months post ictus. The second outcomes included mortality at 30 days and 6 months, and the incidence of complications. Subgroup analyses of 6-month outcome were conducted. Sixty-three (22.66%) of the 278 patients who received surgery had a favorable neurological function status at 6 months, whereas in the conservative group, 66 of 278 (23.74%) had the same result (P = 0.763). The 30-day mortality in the surgical group was 19.06%, whereas 30.58% in the conservative group (P = 0.002). There was significant difference in the mortality at 6 months after ictus as well (23.38% vs 36.33%, P = 0.001). The subgroup analyses showed significantly better outcomes for the surgical group when hematoma was >40 mL (13.33% vs 0%, P = 0.005) or complicated with intraventricular hemorrhage (16.67% vs 7.27%, P = 0.034). For complications, the risk of pulmonary infection, gastrointestinal hemorrhage, urinary infection, pulmonary embolus, and need for tracheostomy/long term ventilation in the surgical group was higher than the conservative group (31.29% vs 15.47%, P < 0.001; 6.83% vs 3.96%, P = 0.133; 2.88% vs 1.80%, P = 0.400; 1.80% vs 1.08%, P = 0.476; 32.73% vs 23.38%, P = 0.014). Surgery could reduce the short-term mortality as well as long-term mortality in patients with spontaneous deep supratentorial hemorrhage. Moreover, surgery might improve the functional outcome in patients with large hematoma or with IVH compared with conservative treatment. Surgery might be a beneficial choice for part of the patients with spontaneous deep supratentorial hemorrhage, but further detailed research is still needed.

Indicators of external ventricular drainage-related infections--a retrospective observational study

BACKGROUND

External ventricular drainage (EVD) is frequently used in different groups of patients in neurocritical care. Despite the frequent use of EVD, no consensus regarding the diagnosis of EVD-related infection currently exists, and diagnosis is commonly based on criteria for the diagnosis of non-EVD-related CNS infections. This study evaluates the diagnostic accuracy of clinical and laboratory parameters for the prediction of EVD-related infection in patients with proven EVD-related infection.

METHODS

In two tertiary care centers, data on EVD insertions were matched with a microbiologic database of cultured microorganisms and positive Gram stains of cerebrospinal fluid (CSF) to identify patients with EVD-related infections. Available clinical data and results of blood tests and CSF analysis were retrospectively collected. Predefined potential clinical and laboratory predictors of EVD-related infection were compared between three time points: at the time EVD insertion and 48 h before and at the time of occurrence of EVD-related infection.

RESULTS

Thirty-nine patients with EVD-associated infection defined by positive CSF culture or positive CSF Gram stains and concomitant clinical signs of infection were identified. At the time of infection, a significantly higher incidence of abnormal temperature, high respiratory rate, and a slightly but significantly higher incidence of decreased mental state were observed. The assessed blood and CSF parameters did not significantly differ between the different assessment time points.

CONCLUSIONS

Our analysis of 39 patients with culture positive EVD-related infection showed that commonly used clinical and laboratory parameters are not reliable infection predictors.

Intracranial hemorrhage alters scalp potential distribution in bioimpedance cerebral monitoring: Preliminary results from FEM simulation on a realistic head model and human subjects

PURPOSE

Current diagnostic neuroimaging for detection of intracranial hemorrhage (ICH) is limited to fixed scanners requiring patient transport and extensive infrastructure support. ICH diagnosis would therefore benefit from a portable diagnostic technology, such as electrical bioimpedance (EBI). Through simulations and patient observation, the authors assessed the influence of unilateral ICH hematomas on quasisymmetric scalp potential distributions in order to establish the feasibility of EBI technology as a potential tool for early diagnosis.

METHODS

Finite element method (FEM) simulations and experimental left-right hemispheric scalp potential differences of healthy and damaged brains were compared with respect to the asymmetry caused by ICH lesions on quasisymmetric scalp potential distributions. In numerical simulations, this asymmetry was measured at 25 kHz and visualized on the scalp as the normalized potential difference between the healthy and ICH damaged models. Proof-of-concept simulations were extended in a pilot study of experimental scalp potential measurements recorded between 0 and 50 kHz with the authors' custom-made bioimpedance spectrometer. Mean left-right scalp potential differences recorded from the frontal, central, and parietal brain regions of ten healthy control and six patients suffering from acute/subacute ICH were compared. The observed differences were measured at the 5% level of significance using the two-sample Welch t-test.

RESULTS

The 3D-anatomically accurate FEM simulations showed that the normalized scalp potential difference between the damaged and healthy brain models is zero everywhere on the head surface, except in the vicinity of the lesion, where it can vary up to 5%. The authors' preliminary experimental results also confirmed that the left-right scalp potential difference in patients with ICH (e.g., 64 mV) is significantly larger than in healthy subjects (e.g., 20.8 mV; P < 0.05).

CONCLUSIONS

Realistic, proof-of-concept simulations confirmed that ICH affects quasisymmetric scalp potential distributions. Pilot clinical observations with the authors' custom-made bioimpedance spectrometer also showed higher left-right potential differences in the presence of ICH, similar to those of their simulations, that may help to distinguish healthy subjects from ICH patients. Although these pilot clinical observations are in agreement with the computer simulations, the small sample size of this study lacks statistical power to exclude the influence of other possible confounders such as age, sex, and electrode positioning. The agreement with previously published simulation-based and clinical results, however, suggests that EBI technology may be potentially useful for ICH detection.

Intracerebral hemorrhage and cognitive impairment

Vascular cognitive impairment and vascular dementia are composed of cognitive deficits resulted from a range of vascular lesions and pathologies, including both ischemic and hemorrhagic. However the contribution of spontaneous intracerebral hemorrhage presumed due to small vessel diseases on cognitive impairment is underestimated, in contrast to the numerous studies about the role of ischemic vascular disorders on cognition. In this review we summarize recent findings from clinical studies and appropriate basic science research to better elucidate the role and possible mechanisms of intracerebral hemorrhage in cognitive impairment and dementia. This article is part of a Special Issue entitled: Vascular Contributions to Cognitive Impairment and Dementia edited by M. Paul Murphy, Roderick A. Corriveau and Donna M. Wilcock.

Stereotactic Hematoma Removal of Spontaneous Intracerebral Hemorrhage through Parietal Approach

OBJECTIVE

To determine the advantages of parietal approach compared to Kocher's point approach for spontaneous, oval-shaped intracerebral hemorrhage (ICH) with expansion to the parietal region.

METHODS

We divided patients into two groups : group A had burr holes in the parietal bone and group B had burr holes at Kocher's point. The hematoma volume, Glasgow coma scale (GCS) score, and modified Barthel Index (mBI) score were calculated. At discharge, we evaluated the patients' Glasgow outcome scale (GOS) score, modified Rankin Scale (mRS) score, motor grade, and hospitalization duration. We evaluated the patients' mBI scores and motor grades at 6 months after surgery.

RESULTS

The hematoma volume in group A was significantly less than that in group B on postoperative days 1, 3, 5, 7, 14, and 21. Group A had significantly higher GCS scores than did group B on postoperative days 1 and 3. Group A had higher mBI scores postoperatively than did group B, but the scores were not significantly different. No differences were observed for the GOS score, mRS score, motor grade at discharge, or duration of hospitalization. The mBI score of group A at 6 months after surgery was significantly higher, and more patients in group A showed muscle strength improvement.

CONCLUSION

In oval-shaped ICH with expansion to the parietal region, the parietal approach is considered to improve the clinical symptoms at the acute phase by removing the hematoma more effectively in the early stages. The parietal approach might help promote the long-term recovery of motor power.

Intracerebral Hematoma Morphologic Appearance on Noncontrast Computed Tomography Predicts Significant Hematoma Expansion

Background and Purpose—

Hematoma expansion in intracerebral hemorrhage is associated with higher morbidity and mortality. The computed tomography (CT) angiographic spot sign is highly predictive of expansion, but other morphological features of intracerebral hemorrhage such as fluid levels, density heterogeneity, and margin irregularity may also predict expansion, particularly in centres where CT angiography is not readily available.

Methods—

Baseline noncontrast CT scans from patients enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) study were assessed for the presence of fluid levels and degree of density heterogeneity and margin irregularity using previously validated scales. Presence and grade of these metrics were correlated with the presence of hematoma expansion as defined by the PREDICT study on 24-hour follow-up scan.

Results—

Three hundred eleven patients were included in the analysis. The presence of fluid levels and increasing heterogeneity and irregularity were associated with 24-hour hematoma expansion ( P =0.021, 0.003 and 0.049, respectively) as well as increases in absolute hematoma size. Fluid levels had the highest positive predictive value (50%; 28%–71%), whereas margin irregularity had the highest negative predictive value (78%; 71%–85). Noncontrast metrics had comparable predictive values as spot sign for expansion when controlled for vitamin K, antiplatelet use, and baseline National Institutes of Health Stroke Scale, although in a combined area under the receiver-operating characteristic curve model, spot sign remained the most predictive.

Conclusions—

Fluid levels, density heterogeneity, and margin irregularity on noncontrast CT are associated with hematoma expansion at 24 hours. These markers may assist in prediction of outcomes in scenarios where CT angiography is not readily available and may be of future help in refining the predictive value of the CT angiography spot sign.

Potential role of statins in the intracerebral hemorrhage and subarachnoid hemorrhage

Statins are used in primary and secondary prevention of cardiovascular episodes. Most of recent studies regard ischemic stroke. There are more emerging results of studies suggesting usefulness of these drugs in the other types of stroke e.g. intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Searching for new methods of treatment is important, because both ICH and SAH lead to poor prognosis and severe psychomotor disability. The unquestionable role of inflammatory factors in the pathogenesis of these disorders justifies considering statin treatment. Previous results are contradictory, thus in present study we review results of studies and try to explain the potential pathomechanism of statin use in hemorrhagic strokes.

Neuronal tumour necrosis factor-α and interleukin-1β expression in a porcine model of intracerebral haemorrhage: Modulation by U-74389G

Tumour necrosis factor α (TNF-α) and interleukin 1β (IL-1β) are important mediators of intracerebral haemorrhage (ICH) inflammatory response. Lazaroids, established antioxidants and neuroprotectants, have been studied in several brain pathologies. The present study was designed to investigate: a) TNF-α and IL-1β changes, in neurons and b) U-74389G effects, 4 and 24h after haematoma induction in a porcine model of intracerebral haemorrhage. In twenty male landrace pigs (swines) aged 135-150 days old, autologous whole blood was injected around the right basal ganglia territory; in ten of the pigs the lazaroid compound U-74389G was administered. Brain TNF-α and IL-1β immunopositive neurons were determined by immunoarray techniques at 4 and 24h timepoints. After the haematoma induction the number of TNF-α immunopositive neurons ipsilateral to the haematoma was significantly higher compared to the contralateral site at 4h (p<0.0005), while U-74389G significantly reduced the number of TNF-α immunopositive neurons, ipsilateral to the haematoma, at 4h (p=0.002); at 24h, TNF-α immunopositive neurons were found significantly lower in the control group ipsilateral to the haematoma in comparison to 4h timepoint(p<0.0005). The number of IL-1β immunopositive neurons at 4h after the hematoma induction was significantly higher ipsilateral to the haematoma site (p<0.0005). U-74389G had no statistical significant effect. TNF-α and IL-1β, increase in neurons, 4h after the haematoma induction, ipsilateral to the haematoma site. The administration of the antioxidant compound U-74389G, results in early (at 4h) decrease of TNF-α immunopositive neurons but shows no statistical significant effect to IL-1β immunopossitive neurons.

Central fever in patients with spontaneous intracerebral hemorrhage: predicting factors and impact on outcome

BACKGROUND

Central fever (CF) is defined as elevated temperature with no identifiable cause. We aimed to identify risk factors for developing CF among patients with spontaneous intracerebral hemorrhage (ICH) and to evaluate the impact of CF on outcome.

METHODS

Patients included in our prospective stroke registry between 1/1/09 and 1/10/10 were studied. We identified patients with CF as those with a temperature ≥38.3°C without evidence for infection or drug fever. Patients with CF were compared to those without fever and those with infectious fever. Demographics, risk factors and imaging data as well as outcome parameters were reviewed.

RESULTS

We identified 95 patients with spontaneous ICH (median age 76, median admission NIHSS 9). CF was identified in 30 patients (32%), infectious etiology was found in 9 patients (9%) and the remaining patients did not develop fever. Baseline variables were similar between the groups except for intra-ventricular extension of the ICH (IVH) and larger ICH volumes that were more common in the CF group (OR = 4.667, 95% CI 1.658-13.135 and OR = 1.013/ml, 95% CI 1.004-1.021). Outcome analysis showed higher mortality rates (80% vs. 36%, p < 0.001) and lower rates of favorable functional outcome defined as a modified Rankin score ≤ 2 at 90 days (0% vs. 53%, p < 0.001) in the CF group.

CONCLUSIONS

The risk of CF is increased in patients with larger ICH and in those with IVH. CF negatively impacts outcome in patients with ICH.

Efficacy and safety of intravenous nimodipine administration for treatment of hypertension in patients with intracerebral hemorrhage

BACKGROUND

Nicardipine (NC) is the most commonly used antihypertensive drug in neurological patients with hypertension. Although nimodipine (NM) is widely used to treat cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage, trials exploring its antihypertensive effect after intravenous administration in subjects with intracerebral hemorrhage (ICH) are scarce.

METHODS

A retrospective study was carried out to compare the safety and efficacy of NC and NM administered intravenously in patients with ICH. Therapeutic responses were assessed by achievement of goal blood pressure (BP); use of additional medications for BP control; proportion of time spent within goal; variability in BP; time to goal BP; number of dose adjustments; variability in ICH volume, Glasgow Coma Scale score, and intracranial pressure; and drug-related complications.

RESULTS

A total of 87 patients were eligible for analysis (n=46 [NC]; n=41 [NM]), and baseline characteristics between groups were similar. Both agents were effective in achieving goal BP during infusion, with 93.5% and 87.8% patients in the NC and NM groups achieving goal, respectively. Fewer additional medications were needed to control BP in the NC group. BP variability was similar and no differences were observed in the mean time to goal BP and mean numbers of dose adjustments between both groups. Interestingly, intracranial pressure declined (P=0.048) during NC administration but increased (P=0.066) after NM treatment. Finally, the incidences of hematoma expansion, neurological deterioration, and adverse drug events were similar in both groups.

CONCLUSION

NM is effective and safe for BP control in patients with ICH.

3D contrast enhancement-MR angiography for imaging of unruptured cerebral aneurysms: a hospital-based prevalence study

Background and Purpose

Contrast enhanced MRA (CE-MRA) can help to overcome the limitations of other techniques to clearly display the details of cerebral aneurysms at 1.5-T MR system. We investigated the prevalence of unruptured cerebral aneurysms (UCAs) using three dimensional (3D) CE-MRA in a tertiary comprehensive hospital in China.

Materials and Methods

The cases were prospectively recorded at our hospital between February 2009 and October 2010. 3D CE-MRA, interpreted by 2 observers blinded to the participants’ information, was used to identify the location and size of UCAs and to estimate the overall, age-specific, and sex-specific prevalence.

Results

Of the 3993 patients (men: women = 2159∶1834), 408 UCAs were found in 350 patients (men: women = 151∶199). The prevalence was 8.8% overall (95% CI, 8.0–10.0%), with 7.0% for men (CI, 6.0–8.0%) and 10.9% for women (CI, 9.0–12.0%). The overall prevalence of UCAs was higher in women than in men (P<0.001) and increased with age both in men and women. Prevalence peaked at age group 75–80 years. Forty-two patients (11.7%) had multiple aneurysms, including 10 (2.9%) male patients and 32 (9.1%) female patients. The most common site of aneurysm was the carotid siphon, and most lesions (71.3%) had a maximum diameter of 3−5 mm.

Conclusion

This hospital-based prevalence study suggested a high prevalence (8.8%) of UCAs and most lesions (71.3%) had a maximum diameter of 3–5 mm observed by 3D CE-MRA. Because the rupture of small cerebral aneurysms was not uncommon, an appropriate follow-up care strategy must be formulated.

Mild hypothermia in combination with minimally invasive evacuation of hematoma reduces inflammatory damage in patients via the nuclear factor-κB pathway

The aim of this study was to investigate the effects of mild hypothermia and minimally invasive evacuation of hematoma on the brain function of patients with cerebral hemorrhage. Seventy-six patients with acute cerebral hemorrhage were divided into the minimally invasive evacuation of hematoma (MIHE) and mild hypothermia and minimally invasive evacuation of hematoma (MHMIHE) groups. National Institutes of Health Stroke Scale (NIHSS) scores on the day of admission of the patient and one, three and seven days after the procedure were recorded. Perihematoma brain tissue morphology was observed using hematoxylin and eosin staining. Nuclear factor-κB (NF-κB) expression was determined by immunohistochemistry. The tumor necrosis factor-α (TNF-α) level was detected by ELISA. NIHSS scores in the MHMIHE group were significantly lower than those in the MIHE group on days three and seven. TNF-α and NF-κB levels peaked on day three, and the MHMIHE group had significantly lower levels of TNF-α and NF-κB than the MIHE group. In conclusion, the present study demonstrated that mild hypothermia and minimally invasive evacuation of hematoma can effectively reduce inflammation and improve the brain function of patients.

Cleaning up after ICH: the role of Nrf2 in modulating microglia function and hematoma clearance

As a consequence of intracerebral hemorrhage (ICH), blood components enter brain parenchyma causing progressive damage to the surrounding brain. Unless hematoma is cleared, the reservoirs of blood continue to inflict injury to neurovascular structures and blunt the brain repair processes. Microglia/macrophages (MMΦ) represent the primary phagocytic system that mediates the cleanup of hematoma. Thus, the efficacy of phagocytic function by MMΦ is an essential step in limiting ICH-mediated damage. Using primary microglia to model red blood cell (main component of hematoma) clearance, we studied the role of transcription factor nuclear factor-erythroid 2 p45-related factor 2 (Nrf2), a master-regulator of antioxidative defense, in the hematoma clearance process. We showed that in cultured microglia, activators of Nrf2 (i) induce antioxidative defense components, (ii) reduce peroxide formation, (iii) up-regulate phagocytosis-mediating scavenger receptor CD36, and (iv) enhance red blood cells (RBC) phagocytosis. Through inhibiting Nrf2 or CD36 in microglia, by DNA decoy or neutralizing antibody, we documented the important role of Nrf2 and CD36 in RBC phagocytosis. Using autologous blood injection ICH model to measure hematoma resolution, we showed that Nrf2 activator, sulforaphane, injected to animals after the onset of ICH, induced CD36 expression in ICH-affected brain and improved hematoma clearance in rats and wild-type mice, but expectedly not in Nrf2 knockout (KO) mice. Normal hematoma clearance was impaired in Nrf2-KO mice. Our experiments suggest that Nrf2 in microglia play an important role in augmenting the antioxidative capacity, phagocytosis, and hematoma clearance after ICH.

Glycemia in Spontaneous Intracerebral Hemorrhage: Clinical Implications

Spontaneous cerebral hemorrhage or intracranial hemorrhage accounts for 10-15% of all strokes. Intracranial hemorrhage is much less common than ischemic stroke, but has higher mortality and morbidity, one of the leading causes of severe disability. Various alterations, among these the endocrine were identified when an intracerebral hemorrhage, these stress-mediated mechanisms exacerbate secondary injury. Deep knowledge of the injuries which are directly involved alterations of glucose, offers insight as cytotoxicity, neuronal death and metabolic dysregulations alter the prognosis of patients with spontaneous intracerebral hemorrhage.

Minimally invasive surgery treatment for the patients with spontaneous supratentorial intracerebral hemorrhage (MISTICH): protocol of a multi-center randomized controlled trial

Background

The choice of surgical or conservative treatment for patients with spontaneous intracerebral hemorrhage is controversial. Some minimally invasive treatments have been applied to hematoma evacuation and could improve prognosis to some extent. Up to now, studies on minimally invasive surgery for patients with spontaneous intracerebral hemorrhage are still insufficient.

Design

The MISTICH is a multi-center, prospective, randomized, assessor-blinded, parallel group, controlled clinical trial. 2448 eligible patients will be assigned to neuroendoscopy group, stereotactic aspiration group and craniotomy group randomly. Patients will receive the corresponding surgery based on the result of randomization. Surgeries will be performed by well-trained surgeons and standard medical treatment will be given to all patients. Patients will be followed up at 7 days, 30 days, and 6 months. The primary outcome of this study is unfavorable outcome at 6 months. Secondary outcomes include: mortality at 30 days and 6 months after surgery; neurological functional status of 6 months after surgery; complications including rebleeding, ischemic stroke and intracranial infection; days of hospitalization.

Discussion

The MISTICH trial is a randomized controlled trial designed to determine whether minimally invasive surgeries could improve the prognosis for patients with spontaneous intracerebral hemorrhage compared with craniotomy. (ChiCTR-TRC-12002026. Registered 23 March 2012).