Emerging medical and surgical management strategies in the evaluation and treatment of intracerebral hemorrhage

Predictors of 30-day mortality and 90-day functional recovery after primary intracerebral hemorrhage : hospital based multivariate analysis in 585 patients

OBJECTIVE

The purpose of this study was to identify independent predictors of mortality and functional recovery in patients with primary intracerebral hemorrhage (PICH) and to improve functional outcome in these patients.

METHODS

Data were collected retrospectively on 585 patients with supratentorial PICH admitted to the Stroke Unit at our hospital between 1st January 2004 and the 31st July 2008. Using multivariate logistic regression analysis, the associations between all selected variables and 30-day mortality and 90-day functional recoveries after PICH was evaluated.

RESULTS

Ninety-day functional recovery was achieved in 29.1% of the 585 patients and 30-day mortality in 15.9%. Age (OR=7.384, p=0.000), limb weakness (OR=6.927, p=0.000), and hematoma volume (OR=5.293, p=0.000) were found to be powerful predictors of 90-day functional recovery. Furthermore, initial consciousness (OR=3.013, p=0.014) hematoma location (lobar, OR=2.653, p=0.003), ventricular extension of blood (OR=2.077, p=0.013), leukocytosis (OR=2.048, p=0.008), alcohol intake (drinker, OR=1.927, p=0.023), and increased serum aminotransferase (OR=1.892, p=0.035) were found to be independent predictors of 90-day functional recovery after PICH. On the other hand, a pupillary abnormality (OR=4.532, p=0.000) and initial unconsciousness (OR=3.362, p=0.000) were found to be independent predictors of 30-day mortality after PICH.

CONCLUSION

The predictors of mortality and functional recovery after PICH identified during this analysis may assist during clinical decision-making, when advising patients or family members about the prognosis of PICH and when planning intervention trials.

Intranasal deferoxamine provides increased brain exposure and significant protection in rat ischemic stroke

Deferoxamine (DFO) is a high-affinity iron chelator approved by the Food and Drug Administration for treating iron overload. Preclinical research suggests that systemically administered DFO prevents and treats ischemic stroke damage and intracerebral hemorrhage. However, translation into human trials has been limited, probably because of difficulties with DFO administration. A noninvasive method of intranasal administration has emerged recently as a rapid way to bypass the blood-brain barrier and target therapeutic agents to the central nervous system. We report here that intranasal administration targets DFO to the brain and reduces systemic exposure, and that intranasal DFO prevents and treats stroke damage after middle cerebral artery occlusion (MCAO) in rats. A 6-mg dose of DFO resulted in significantly higher DFO concentrations in the brain (0.9-18.5 microM) at 30 min after intranasal administration than after intravenous administration (0.1-0.5 microM, p < 0.05). Relative to blood concentration, intranasal delivery increased targeting of DFO to the cortex approximately 200-fold compared with intravenous delivery. Intranasal administration of three 6-mg doses of DFO did not result in clinically significant changes in blood pressure or heart rate. Pretreatment with intranasal DFO (three 6-mg doses) 48 h before MCAO significantly decreased infarct volume by 55% versus control (p < 0.05). In addition, post-treatment with intranasal administration of DFO (six 6-mg doses) immediately after reperfusion significantly decreased infarct volume by 55% (p < 0.05). These experiments suggest that intranasally administered DFO may be a useful treatment for stroke, and a prophylactic for patients at high risk for stroke.

Prediction of fatal intracranial hemorrhage in patients with acute myeloid leukemia

BACKGROUND

Intracranial hemorrhage (ICH) is the second leading cause of mortality in patients with acute myeloid leukemia (AML). However, the prognostic factors for ICH in AML patients are still under investigation.

PATIENTS AND METHODS

A total of 841 AML patients admitted to the Department of Internal Medicine from January 1995 to December 2007 were enrolled in this study.

RESULTS

There were 51 patients with ICH, median age of 51 (range 17-86), including 12 patients diagnosed as acute promyelocytic leukemia. Forty-three patients were refractory/relapsed status. ICH was localized in the supratentorium (44 cases), basal ganglion (9), cerebellum (5), and brainstem (4). Twenty-one patients had multiple sites. Thirty-eight patients had intraparenchymal hemorrhage, 16 subarachnoid hemorrhage (SAH), 10 subdural hemorrhage, and one epidural hemorrhage (EDH). Hemorrhage ruptured into the ventricles in 13 patients. Thirty-four patients (67%) died of ICH within 30 days of diagnosis. Multivariate analysis revealed four independent prognostic factors, prolonged prothrombin time international normalized ratio >1.5 (P < 0.001), brainstem hemorrhage (P = 0.001), SAH (P = 0.017), and EDH (P = 0.014). Other clinico-laboratory data had no impact on 30-day survival.

CONCLUSIONS

ICH has high morbidity and mortality in AML. Early detection and aggressive correction coagulopathy may prevent the catastrophic event. Prompt image study for locations and types of ICH can predict outcomes.

Hemostatic therapy for the treatment of intracranial hemorrhage

Intracranial hemorrhage results in poor neurologic outcomes and high mortality. Current management is limited to supportive care. In addition to the initial bleeding event, rebleeding and hematoma expansion have been identified as major risk factors for poor outcomes in these patients. The antifibrinolytic agents tranexamic acid, aminocaproic acid, and recombinant activated factor VII (rFVIIa) have been studied with the hopes of achieving early hemostasis and improving outcomes. Available data suggest that tranexamic acid and aminocaproic acid are more harmful than beneficial for this indication; therefore, they have no role in the treatment of intracranial bleeding. Alternatively, rFVIIa, has shown promising results in the management of spontaneous intracerebral hemorrhage. Clinicians should be aware of the available evidence regarding the use of these hemostatic agents in the management of intracranial hemorrhage, including traumatic brain injury, intracerebral hemorrhage, and subarachnoid hemorrhage.

Management of warfarin-related intracerebral hemorrhage

Warfarin-related intracerebral hemorrhage (WICH) is a medical and neurosurgical emergency with a 1-month mortality of approximately 50%. Warfarin is commonly is used in patients with atrial fibrillation to prevent ischemic stroke and to prevent progression of deep vein thrombosis to pulmonary embolism. Owing to the ageing population, and increased incidence of atrial fibrillation with age and warfarin use, the incidence of WICH is expected to rise in the future. When WICH occurs, immediate discontinuation of warfarin with rapid warfarin reversal remains the first-line intervention, often with neurosurgical intervention. The optimal agent for rapid warfarin anticoagulation reversal remains to be defined owing to the lack of prospective randomized trials. We review current literature and prospects for future research for this devastating neurologic emergency.

Monitoring and intraoperative management of elevated intracranial pressure and decompressive craniectomy

There are numerous clinical scenarios wherein a critically ill patient may present with neurologic dysfunction. In a general sense these scenarios often involve ischemia, trauma, or neuroexcitation. Each of these may include a period of decreased cerebral perfusion pressure, usually due to elevated intracranial pressure (ICP), eventually compromising cerebral blood flow sufficiently to produce permanent neuronal loss, infarction, and possibly brain death. Elevated ICP is thus a common pathway for neural demise and it may arise from a variety of causes, many of which may result in a neurosurgical procedure intended to ameliorate the impact or etiology of elevated ICP.

Treatment of warfarin-associated intracerebral hemorrhage: literature review and expert opinion

Wider use of oral anticoagulants has led to an increasing frequency of warfarin-related intracerebral hemorrhage (ICH). The high early mortality of approximately 50% has remained stable in recent decades. In contrast to spontaneous ICH, the duration of bleeding is 12 to 24 hours in many patients, offering a longer opportunity for intervention. Treatment varies widely, and optimal therapy has yet to be defined. An OVID search was conducted from January 1996 to January 2006, combining the terms warfarin or anticoagulation with intracranial hemorrhage or intracerebral hemorrhage. Seven experts on clinical stroke, neurologic intensive care, and hematology were provided with the available information and were asked to independently address 3 clinical scenarios about acute reversal and resumption of anticoagulation in the setting of warfarin-associated ICH. No randomized trials assessing clinical outcomes were found on management of warfarin-associated ICH. All experts agreed that anticoagulation should be urgently reversed, but how to achieve it varied from use of prothrombin complex concentrates only (3 experts) to recombinant factor VIIa only (2 experts) to recombinant factor VIIa along with fresh frozen plasma (1 expert) and prothrombin complex concentrates or fresh frozen plasma (1 expert). All experts favored resumption of warfarin therapy within 3 to 10 days of ICH in stable patients in whom subsequent anticoagulation is mandatory. No general agreement occurred regarding subsequent anticoagulation of patients with atrial fibrillation who survived warfarin-associated ICH. For warfarin-associated ICH, discontinuing warfarin therapy with administration of vitamin K does not reverse the hemostatic defect for many hours and is inadequate. Reasonable management based on expert opinion includes a wide range of additional measures to reverse anticoagulation in the absence of solid evidence.

Angiopathie amyloïde cérébrale sporadique

INTRODUCTION

Sporadic cerebral amyloid angiopathy (CAA) is a microangiopathy identified by neuropathological examination in more than 30 percent of patients over 85 years of age.

STATE OF ART

Boston criteria for diagnosis of CAA--related hemorrhage are as follows: "definite CAA", "Probable CAA with supporting pathology", "Probable CAA" and "Possible CAA". Clinical manifestations of CAA are either lobar, cortical, corticosubcortical or cerebellar hemorrhages associated with progressive dementia. Dementia, corresponding either to Alzheimer disease, vascular or mixed dementia, precedes hemorrhages in 25 to 40 percent of cases. Brain MRI can demonstrate microbleeding.

PERSPECTIVES

This review compares data regarding CAA prevalence, intracranial hemorrhages, and their risk factors in old patients. Diagnosis and preventive strategies are discussed. It would be useful to identify those affected by CAA among elderly demented patients with atrial fibrillation requiring anticoagulation therapy.

CONCLUSIONS

CAA is suspected in the presence of recurrent lobar or cerebellar hemorrhages, and moreover if associated with pre-existing dementia. In elderly demented patients, MRI criteria to detect CAA should be considered in order to prevent hemorrhage risk, particularly after anticoagulation therapy.

The declaration of death and the withdrawal of care in the neurologic patient

Intensive care technologies have led to an increase in patients who are neurologically devastated and deceased. The practical, moral, and ethical situations encountered can be varied and challenging to manage. Decisions and discussions surrounding withdrawal of care, death by neurologic criteria, and organ donation require significant knowledge of the prognosis, ancillary testing, and definitions of these processes. Experience and skill are often required on the part of physicians and staff to guide families through these most difficult of circumstances.

Management of venous thromboembolism in patients with primary and metastatic brain tumors

Venous thromboembolism occurs commonly throughout the clinical course of patients with brain tumors. A number of hemostatic and clinical factors contribute to this hypercoagulable state. Concern over the possibility of intracranial bleeding has limited the use of anticoagulation in this population. However, mechanical approaches such as vena cava filters have high complication and treatment failure rates in patients with intracranial malignancies. In addition, the available data suggest that anticoagulation can be used safely and effectively in most of these patients. Patients with thrombocytopenia, recent neurosurgery, and tumor types prone to bleeding require special consideration. When intracranial hemorrhage does occur, it is often due to overanticoagulation, requiring prompt anticoagulation reversal and neurosurgical consultation.

Modern treatment options for intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is a devastating neurological event with a 30-day mortality of approximately 40%. Recent research provides new insights into the pathophysiology of ICH-associated edema, with potential molecular and cellular targets for future therapy. Neuroimaging techniques such as gradient echo MRI are yielding insights into cerebral microbleeds and the microangiopathies associated with hypertension and cerebral amyloid angiopathy. Recent literature provides new medical treatment strategies for fever, acute hypertension, and perihematomal edema, and methods of reducing intracranial pressure. Two randomized controlled trials have provided crucial evidence regarding surgical and medical intervention for acute ICH intervention. Recombinant factor VIIa appears to lessen growth of ICH when administered within 4 hours of ictus. Further study of potential efficacy and safety is underway in an international phase III trial. In addition, the Surgical Trial in Intracerebral Hemorrhage reported results from an international randomized trial of 1033 patients who did not show benefit for surgical evacuation of ICH, compared with medical therapy alone. Less invasive surgical methods for hematoma evacuation, studied previously over the past decade, continue to be investigated.

Dopamine changes in a rat model of intracerebral hemorrhage

Recent case reports suggest that dopamine (DA) replacement may reduce behavioral deficits resulting from hemorrhages along the nigrostriatal tract. In the rat model of intracerebral hemorrhage (ICH), behavioral deficits are first evident on day 1, with return to near control levels by day 28. The current study was conducted to determine if striatal dopamine alterations are correlated with behavioral deficits. Gamma-aminobutyric acid (GABA) levels were measured to determine selectivity. Striatal DA, DA metabolites, and GABA were determined at days 1, 3, 7, and 28 after ICH by high-pressure liquid chromatography with electrochemical detection. ICH resulted in significant increases above control in DA contralateral to the lesion (177 to 361% above control, days 1 to 28). There were also significant, but much less marked changes in GABA. In the ipsilateral striatum, significant DA increases also occurred (approximately 200%, at day 3 and approximately 275% day 28), while GABA alterations were not significant. These results indicate that the striatal DA system is selectively altered after ICH. Further studies will be needed to determine if regional dopamine alterations occur relative to the location of the hematoma.