International epidemiology of intracerebral hemorrhage

Glibenclamide, a Sur1-Trpm4 antagonist, does not improve outcome after collagenase-induced intracerebral hemorrhage

The sulfonylurea 1 transient receptor potential melastatin 4 (Sur1-Trpm4) receptor is selectively expressed after intracerebral hemorrhage (ICH). This upregulation contributes to increases in intracellular sodium. Water follows sodium through aquaporin channels, leading to cytotoxic edema. Even after edema is thought to have resolved, ionic dyshomeostasis persists, as does blood-brain barrier (BBB) damage. Glibenclamide, a hypoglycemic agent that inhibits Sur1-Trpm4, has been shown to reduce BBB damage and edema following infusion of autologous blood into the brain (ICH) as well as after other brain injuries. In order to further assess efficacy, we used the collagenase ICH model in rats to test whether glibenclamide reduces edema, attenuates ion dyshomeostasis, improves BBB damage, and reduces lesion volume. We tested a widely-used glibenclamide dose shown effective in other studies (10 μg/kg loading dose followed by 200 ng/hr for up to 7 days). Early initiation of glibenclamide did not significantly impact edema (72 hours), BBB permeability (72 hours), or lesion volume after ICH (28 days). Recovery from neurological impairments was also not improved by glibenclamide. These results suggest that glibenclamide will not improve outcome in ICH. However, the treatment appeared to be safe as there was no effect on bleeding or other physiological variables.

Intracellular Fe2+ accumulation in endothelial cells and pericytes induces blood-brain barrier dysfunction in secondary brain injury after brain hemorrhage

After intracranial hemorrhage (ICH), iron is released from the hematoma and induces secondary brain injury. However, the detail effect of iron on blood-brain barrier (BBB) function is still unknown. We investigated whether hemoglobin (Hb), ferrous ammonium sulfate (FAS) or hemin which contains iron have the detrimental effect on both human brain microvascular endothelial cells and pericytes by cellular function analysis in vitro. We developed an iron (Fe²⁺)-detectable probe, Si-RhoNox-1, to investigate intracellular Fe²⁺ accumulation (Fe²⁺_intra). After FAS treatment, there was the correlation between Fe²⁺_intra and cell death. Moreover, Hb or hemin treatment induced cell death, increased reactive oxygen species and promoted Fe²⁺_intra in both cells. These changes were inhibited by the Fe²⁺ chelator, 2,2′-bipyridil (BP). Furthermore, hemin induced endothelial barrier dysfunction via disruption of junction integrity. Based on in vitro studies, we used a hemin-injection ICH mice model in vivo. Hemin injection (10 mM/10 µL, i.c.) induced deleterious effects including BBB hyper-permeability, neuronal deficits, neuronal damage, altered proteins expression, and Fe²⁺_intra in BBB composed cells. Lastly, BP (40 mg/kg, i.p.) administration attenuated neuronal deficits at 3 days after surgery. Collectively, Hb or hemin damaged BBB composed cells via Fe²⁺_intra. Therefore, the regulation of the Fe²⁺ movement in BBB might be effective for treatment of ICH.

Inflammatory, regulatory, and autophagy co-expression modules and hub genes underlie the peripheral immune response to human intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) has a high morbidity and mortality. The peripheral immune system and cross-talk between peripheral blood and brain have been implicated in the ICH immune response. Thus, we delineated the gene networks associated with human ICH in the peripheral blood transcriptome. We also compared the differentially expressed genes in blood following ICH to a prior human study of perihematomal brain tissue.

METHODS

We performed peripheral blood whole-transcriptome analysis of ICH and matched vascular risk factor control subjects (n = 66). Gene co-expression network analysis identified groups of co-expressed genes (modules) associated with ICH and their most interconnected genes (hubs). Mixed-effects regression identified differentially expressed genes in ICH compared to controls.

RESULTS

Of seven ICH-associated modules, six were enriched with cell-specific genes: one neutrophil module, one neutrophil plus monocyte module, one T cell module, one Natural Killer cell module, and two erythroblast modules. The neutrophil/monocyte modules were enriched in inflammatory/immune pathways; the T cell module in T cell receptor signaling genes; and the Natural Killer cell module in genes regulating alternative splicing, epigenetic, and post-translational modifications. One erythroblast module was enriched in autophagy pathways implicated in experimental ICH, and NRF2 signaling implicated in hematoma clearance. Many hub genes or module members, such as IARS, mTOR, S1PR1, LCK, FYN, SKAP1, ITK, AMBRA1, NLRC4, IL6R, IL17RA, GAB2, MXD1, PIK3CD, NUMB, MAPK14, DDX24, EVL, TDP1, ATG3, WDFY3, GSK3B, STAT3, STX3, CSF3R, PIP4K2A, ANXA3, DGAT2, LRP10, FLOT2, ANK1, CR1, SLC4A1, and DYSF, have been implicated in neuroinflammation, cell death, transcriptional regulation, and some as experimental ICH therapeutic targets. Gene-level analysis revealed 1225 genes (FDR p < 0.05, fold-change > |1.2|) have altered expression in ICH in peripheral blood. There was significant overlap of the 1225 genes with dysregulated genes in human perihematomal brain tissue (p = 7 × 10-3). Overlapping genes were enriched for neutrophil-specific genes (p = 6.4 × 10-08) involved in interleukin, neuroinflammation, apoptosis, and PPAR signaling.

CONCLUSIONS

This study delineates key processes underlying ICH pathophysiology, complements experimental ICH findings, and the hub genes significantly expand the list of novel ICH therapeutic targets. The overlap between blood and brain gene responses underscores the importance of examining blood-brain interactions in human ICH.

Failure of bumetanide to improve outcome after intracerebral hemorrhage in rat

After intracerebral hemorrhage (ICH), brain edema commonly occurs and can cause death. Along with edema, there are significant alterations in the concentrations of key ions such as sodium, potassium, and chloride, which are essential to brain function. NKCC1, a cation-chloride cotransporter, is upregulated after brain damage, such as traumatic injury and ischemic stroke. NKCC1 brings sodium and chloride into the cell, possibly worsening ion dyshomeostasis. Bumetanide, a specific NKCC1 antagonist, blocks the transport of chloride into cells, and thus should attenuate the increases in chloride, which should lessen brain edema and improve neuronal functioning post-ICH, as with other injuries. We used the collagenase model of ICH to test whether bumetanide treatment for three days (vs. vehicle) would improve outcome. We gave bumetanide beginning at two hours or seven days post-ICH and measured behavioural outcome, edema, and brain ion content after treatment. There was some evidence for a minor reduction in edema after early dosing, but this did not improve behaviour or lessen injury. Contrary to our hypothesis, bumetanide did not normalize ion concentrations after late dosing. Bumetanide did not improve behavioural outcome or affect lesion volume. After ICH, bumetanide is safe to use in rats but does not improve functional outcome in the majority of animals.

Biopsy During Minimally Invasive Intracerebral Hemorrhage Clot Evacuation

BACKGROUND

The safety and efficacy of brain parenchyma biopsy during minimally invasive (MIS) intracerebral hemorrhage (ICH) clot evacuation has not been previously reported. The objective of this study was to establish the safety and diagnostic efficacy of brain biopsy during MIS ICH clot evacuation and to validate the modified Boston criteria as a predictor of cerebral amyloid angiopathy (CAA) in this cohort.

METHODS

From October 2016 to March 2018, superficial and perihematomal biopsies were collected for 40 patients undergoing MIS ICH clot evacuation and analyzed by the pathology department to assess for various ICH etiologies. Additionally, the admission magnetic resonance imaging or computed tomography scan of each patient was analyzed and evaluated for the likelihood of a CAA etiology based on the modified Boston criteria. Student t test was used to analyze intergroup differences in continuous variables, and a 2-tailed Fisher exact test was used to determine intergroup differences of categorical variables, with significance set at P < 0.05.

RESULTS

Two of the 40 patients (5%) experienced postoperative rebleed. Four of the 40 patients (10%) had evidence of CAA on biopsy. Patients with CAA on biopsy were older (P = 0.005) and had a higher prevalence of parietal lobe (P = 0.02) and occipital lobe (P = 0.001) hemorrhage. The modified Boston criteria had a sensitivity of 100% (95% confidence interval [CI], 39.6%-100%) and a specificity of 72.2% (95% CI, 54.6%-84.2%) for predicting CAA on biopsy.

CONCLUSIONS

Brain biopsy in MIS ICH clot evacuation is safe and allows for the diagnosis of various ICH etiologies.

Biomarker and Drug Target Discovery Using Quantitative Proteomics Post-Intracerebral Hemorrhage Stroke in the Rat Brain

The pathological mechanisms of acute intracerebral hemorrhage (ICH) remain unknown and unverified. In the present study, we used quantitative proteomics to elucidate the pathological mechanisms and to identify novel biomarker and therapeutic target candidates via tissue proteome in a rat model of acute ICH. Rats were experimentally induced with ICH (n = 6) or Sham (n = 6), and their brain tissue was obtained by 24 h. The TMT-LC–MS/MS-based proteomics approach was used to quantify the differential proteomes across brain tissue, and the results were further analyzed by ingenuity pathway analysis to explore canonical pathways and the relationship involved in the uploaded data. Upon quantification, we found that 96 secreted proteins that were identified in the ICH 24-h group were significantly different those in the control group (P < 0.05); among these proteins, 57 increased and 39 decreased in abundance. Bioinformatic analyses of differentially expressed proteins demonstrated that the protein localization and ERK1 and ERK2 cascade were the top two biological processes with the highest concentrations of differentially proteins. The top protein-protein action network with high confidence levels of protein was the albumin and ERK signaling pathways. Albumin, ERK, and p-ERK were assessed in brain tissue by western blot analysis, and higher expression levels of albumin and p-ERK were observed in the ICH group. Our proteomic results highlight important change in the biological processes of ERK1 and ERK2 cascade, which are possible targets for future interventions of ICH. To our knowledge, this study provides in-depth analysis of ICH in brain tissue, and we propose 96 new biomarker candidates for ICH, including albumin and ERK.

Increased Expression of Apo-J and Omi/HtrA2 After Intracerebral Hemorrhage in Rats

OBJECTIVE

To investigate the changes of Apo-J and Omi/HtrA2 protein expression in rats with intracerebral hemorrhage.

METHODS

150 Sprague-Dawley adult rats were randomly divided into 3 groups: (1) normal control (NC) group, (2) sham group, and (3) intracerebral hemorrhage (ICH) group. The data were collected at 6 hours, 12 hours, 1 day, 2 days, 3 days, 5 days, and 7 days. Apoptosis was measured by terminal deoxynucleotidyl transferase-mediated biotinylated-dUTP nick-end labeling staining. The distributions of the Apo-J and Omi/HtrA2 proteins were determined by immunohistochemical staining. The levels of Apo-J mRNA and Omi/HtrA2 mRNA expressions were examined by real-time polymerase chain reaction.

RESULTS

Apoptosis in the ICH group was higher than in the sham and NC groups (P < 0.05). Both the Apo-J and Omi/HtrA2 expression levels were increased in the peripheral region of hemorrhage, with a peak at 3 days. The Apo-J mRNA level positively correlated with the HtrA2 mRNA level in the ICH group (r = 0.883, P < 0.001).

CONCLUSION

The expressions of Apo-J and Omi/HtrA2 increased in parallel in the peripheral region of rat cerebral hemorrhage. Local high expression of Apo-J in the peripheral regions may play a neuroprotective role by inhibiting apoptosis via the Omi/HtrA2 pathway after hemorrhage.

Chronic encapsulated intraventricular hematoma in a pediatric patient: case report

Chronic encapsulated intraventricular hematoma (CEIVH) is a rare, intraventricular, nonneoplastic mass lesion that can become symptomatic from mass effect or obstructive hydrocephalus. Only 5 cases have been reported in the literature, and only one of these occurred in a pediatric patient and dates back to the pre-modern neuroimaging and pre-microsurgical era of neurosurgery. Imaging features can mimic those of many more common intraventricular lesions, such as choroid plexus tumors or cavernous malformations. In all reported symptomatic cases, resection was safely performed and led to a cure and symptom resolution. Here, the authors present a case of CEIVH in a pediatric patient, describe the operative techniques of resection, review the available literature, and discuss current understanding of the pathophysiology, making this the most comprehensive report on this disease entity to date. The case is a 14-year-old boy who presented with headaches and emesis. Computed tomography showed a hyperdense mass in the trigone of the right lateral ventricle. Magnetic resonance imaging showed a contrast-enhancing well-circumscribed mass. Right temporal craniotomy utilizing a posterior middle temporal gyrus transcortical approach was performed, and gross-total resection was achieved. Pathology revealed a CEIVH. The boy's postoperative course was uncomplicated, and he was discharged 2 days after surgery.

The phosphodiesterase III inhibitor cilostazol protects the brain microvasculature from collagenase injury

A patient's prognosis, including mortality, after intracranial hemorrhage (ICH) is strongly related to the disruption of the blood-brain barrier caused by damage to vascular endothelial cells (ECs). We reported previously that cilostazol, a phosphodiesterase III inhibitor, ameliorated collagenase-induced ICH in a mouse model. We also reported that cilostazol protected cultured ECs in a blood-brain barrier model. However, the influence of cilostazol on vascular structure and cell morphology remains unclear. Therefore, we investigated whether cilostazol exerts protective effects on vascular structures, such as the extracellular matrix (ECM). A mouse model of collagenase-induced ICH was used to observe structures of the brain vasculature in a peri-hemorrhagic lesion using transmission electron microscopy. We then evaluated the morphology of the ECM and cytoskeleton in human brain microvasculature ECs by immunostaining. The brain vasculature was changed 24 h after induction of ICH. Cilostazol (30 mg/kg, orally) suppressed the thinning of the basement membrane, which is formed by the ECM components collagen IV and laminin. Moreover, this drug also suppressed the enlargement of ECs caused by ICH. Collagenase treatment (30 U/ml) of human brain microvasculature ECs caused a decrease in collagen IV expression and an increase in the number and size of the intercellular spaces, as indicated by β-actin immunostaining. Pretreatment of with 10 µM cilostazol suppressed these increases in the number and size of the intercellular spaces. These findings suggest that cilostazol protects the ECM of the brain microvasculature against ICH both in vivo and in vitro.

Association Between Blood Glucose and Functional Outcome in Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

BACKGROUND

Intracerebral hemorrhage (ICH) is a devastating subtype of stroke. Patients with ICH have poor functional outcomes. The association between blood glucose level and functional outcome in ICH remains unclear. This systematic review and meta-analysis aimed to investigate the association between blood glucose level and functional outcomes in patients with ICH.

METHODS

Literature was searched systemically in PubMed, EMBASE, Web of Science, and Cochrane Library. Published cohort studies evaluating the association between blood glucose and functional outcome in patients with ICH were included. This meta-analysis was performed using odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 16 studies were included in our meta-analysis. Our data show that hyperglycemia defined by cutoff values was significantly associated with unfavorable functional outcome (OR, 1.80; 95% CI, 1.36-2.39; P < 0.001). Our analysis also suggested a significant association between increased blood glucose levels and functional outcomes (OR, 1.05; 95% CI, 1.03-1.07; P < 0.001).

CONCLUSIONS

High blood glucose level is significantly associated with poor functional outcome in ICH. Further studies with larger sample sizes, more time points, and longer follow-up times are necessary to confirm this association.

Plasma homocysteine concentrations and risk of intracerebral hemorrhage: a systematic review and meta-analysis

Intracerebral hemorrhage (ICH) has the highest mortality rate in all strokes. However, controversy still exists concerning the association between plasma homocysteine (Hcy) and ICH. A systematic review and meta-analysis was conducted using Pubmed, Embase, and Web of Science up to April 18, 2017. Standard mean difference (SMD) for mean differences of plasma Hcy levels with 95% confidence intervals (CI) was calculated. Seven studies including 667 ICH patients and 1821 ischemic stroke patients were identified for meta-analysis. Our results showed that Hcy levels in ICH patients were significantly higher than those in healthy controls (SMD = 0.59, 95% CI = 0.51–0.68, P < 0.001); no statistic differences were found in the comparisons of Hcy levels between ICH and ischemic stroke (SMD = −0.03, 95% CI = −0.13–0.06, P > 0.05); further subgroup analysis of ethnicity (Asians: SMD = 0.57, 95% CI = 0.48–0.66, P < 0.001; Caucasians: SMD = 0.77, 95% CI = 0.51–1.02, P < 0.001) and sample size (small samples: SMD = 0.55, 95% CI = 0.30–0.80, P < 0.001; large samples size: SMD = 0.60, 95% CI = 0.51–0.69, P < 0.001) in relation to Hcy levels between ICH and healthy controls did not change these results. In conclusion, Hcy level may be an aggravating factor in atherosclerosis, which is positively associated with high risk of ICH. Race-specific differences between Asians and Caucasians have no impact on the risk of ICH.

Update on the Treatment of Spontaneous Intraparenchymal Hemorrhage: Medical and Interventional Management

PURPOSE OF REVIEW

Spontaneous intraparenchymal hemorrhage (IPH) is a prominent challenge faced globally by neurosurgeons, neurologists, and intensivists. Over the past few decades, basic and clinical research efforts have been undertaken with the goal of delineating biologically and evidence-based practices aimed at decreasing mortality and optimizing the likelihood of meaningful functional outcome for patients afflicted with this devastating condition. Here, the authors review the medical and surgical approaches available for the treatment of spontaneous intraparenchymal hemorrhage, identifying areas of recent progress and ongoing research to delineate the scope and scale of IPH as it is currently understood and treated.

RECENT FINDINGS

The approaches to IPH have broadly focused on arresting expansion of hemorrhage using a number of approaches. Recent trials have addressed the effectiveness of rapid blood pressure lowering in hypertensive patients with IPH, with rapid lowering demonstrated to be safe and at least partially effective in preventing hematoma expansion. Hemostatic therapy with platelet transfusion in patients on anti-platelet medications has been recently demonstrated to have no benefit and may be harmful. Hemostasis with administration of clotting complexes has not been shown to be effective in reducing hematoma expansion or improving outcomes although correcting these abnormalities as soon as possible remains good practice until further data are available. Stereotactically guided drainage of IPH with intraventricular hemorrhage (IVH) has been shown to be safe and to improve outcomes. Research on new stereotactic surgical methods has begun to show promise. Patients with IPH should have rapid and accurate diagnosis with neuroimaging with computed tomography (CT) and computed tomography angiography (CTA). Early interventions should include control of hypertension to a systolic BP in the range of 140 mmHg for small hemorrhages without intracranial hypertension with beta blockers or calcium channel blockers, correction of any coagulopathy if present, and assessment of the need for surgical intervention. IPH and FUNC (Functional Outcome in Patients with Primary Intracerebral Hemorrhage) scores should be assessed. Patients should be dispositioned to a dedicated neurologic ICU if available. Patients should be monitored for seizures and intracranial pressure issues. Select patients, particularly those with intraventricular extension, may benefit from evacuation of hematoma with a ventriculostomy or stereotactically guided catheter. Once stabilized, patients should be reassessed with CT imaging and receive ongoing management of blood pressure, cerebral edema, ICP issues, and seizures as they arise. The goal of care for most patients is to regain capacity to receive multidisciplinary rehabilitation to optimize functional outcome.

Elevated level of D-dimer increases the risk of stroke

The aim of this study was to systematically evaluate the association between D-dimer level and the risk of stroke through performing a meta-analysis. PubMed, Web of Science, EMBASE and Cochrane Library were searched for potentially eligible literature. Prospective observational studies or case-control studies were included. The study characteristics and relevant data were extracted. Hazard ratios (HRs) or odds ratios (ORs) with 95% confidence intervals (CIs) were pooled to estimate the association between D-dimer level and the risk of stroke. Seven prospective studies with 22,207 patients and three case-control studies with 2,248 patients were included. For the prospective studies, the pooled HRs of higher D-dimer level for all types of stroke, ischemic stroke and hemorrhagic stroke were 1.55 (95% CI, 1.28- 1.87), 1.62 (95% CI, 1.18-2.22) and 1.30 (95% CI, 0.63-2.68), respectively. The pooled HRs per SD increase in log D-dimer for all types of stroke, ischemic stroke and hemorrhagic stroke were 1.16 (95% CI, 1.06-1.26), 1.11 (95% CI, 1.03-1.21) and 1.11 (95% CI, 0.95-1.30), respectively. For the case-control studies, the pooled OR of higher D-dimer level for acute ischemic stroke was 2.06 (95% CI, 1.08-3.96). No significant publication bias was found in the meta-analysis. In conclusion, our results suggested that higher D-dimer level was associated with higher risk of stroke, especially ischemic stroke.

Intracerebral Hematoma Due to Aneurysm Rupture: Are There Risk Factors Beyond Aneurysm Location?

BACKGROUND

Along with subarachnoid hemorrhage (SAH), a ruptured aneurysm may also cause an intracerebral hematoma (ICH), which negatively impacts the functional outcome of SAH.

OBJECTIVE

To identify independent risk factors of aneurysmal ICH.

METHODS

Six hundred thirty-two consecutive patients with aneurysmal SAH treated at our institution from January 2005 to December 2012 were eligible for this study. Demographic parameters and preexisting comorbidities of patients, as well as various clinical and radiographic characteristics of SAH were correlated with the incidence and volume of aneurysmal ICH.

RESULTS

One hundred fifty-five patients (25%) had ICH on initial computed tomography with a mean volume of 26.7 mL (±26.8 mL). Occurrence and volume of ICH were associated with the location (distal anterior or middle cerebral artery >proximal anterior cerebral or internal carotid artery >posterior circulation, P < .001/P < .001) and size (>12 mm, P = .026/P < .001) of the ruptured aneurysm. Vascular risk factors independently increased the risk of ICH as well (arterial hypertension: odds ratio [OR] = 1.62, P = .032; diabetes mellitus: OR = 3.06, P = .009), while the use of aspirin (P = .037) correlated with the volume of ICH. The predictors of ICH were included into a risk score (0-9 points) that strongly predicted the occurrence of ICH (P = .01). Poor functional outcome after SAH was independently associated with the occurrence of ICH (P = .003, OR = 2.77) and its volume (P = .001, OR = 1.07 per-mL-increase).

CONCLUSION

Aneurysmal ICH is strongly associated with poorer functional outcome and seems to be predictable even before the bleeding event. The proposed risk factors for aneurysmal ICH require further validation and may be considered for treatment decisions regarding unruptured intracranial aneurysms.

ABBREVIATIONS

ACA, anterior cerebral arteryDHC, decompressive hemicraniectomyEVD, external ventricular drainageICA, internal carotid arteryICH, intracerebral hematomaMCA, middle cerebral arterymRS, modified Rankin scalePC, posterior circulationSAH, subarachnoid hemorrhageSIRS, systemic inflammatory response syndromeTCD, transcranial Doppler sonography.

Obstructive Sleep Apnea: An Unusual Cause of Hemorrhagic Stroke

Stroke is one of the most common causes of mortality and morbidity worldwide. Hemorrhagic stroke comprises 10-20% of strokes. Here, we present a case report of hemorrhagic stroke that may have been secondary to untreated Obstructive Sleep Apnea (OSA) in a young man with no other cardiovascular risk factors or features of metabolic syndrome. A 32-year-old man was admitted for hemorrhagic stroke. An initial thorough workup for the etiology of stroke was inconclusive. Eventually, a polysomnography was done, which demonstrated OSA suggesting that untreated OSA may have contributed to his stroke. OSA may cause hemorrhagic stroke by nocturnal blood pressure surge. So, all physicians should consider doing polysomnography for unexplained hemorrhagic stroke or in patients at risk. Diagnosing and treating OSA would be critical in preventing hemorrhagic stroke and its recurrences.

Prognostic role of neutrophil lymphocyte ratio in patients with spontaneous intracerebral hemorrhage

The aim of this study was to evaluate the prognostic role of neutrophil lymphocyte ratio (NLR) in patients with spontaneous intracerebral hemorrhage (ICH). PubMed, EMBASE, Web of Knowledge, Cochrane Library and China National Knowledge Infrastructure were searched for potentially relevant literature. The study and patient characteristics were extracted. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled to estimate the prognostic role of NLR in patients with ICH. Poor functional outcome was defined as modified Rankin Scale≥3. Four studies with 1,720 patients were included. The pooled OR of higher NLR for poor functional outcome at 3 months was 2.74 (95% CI, 1.33-5.65). The pooled OR of higher NLR for death at 3 months was 1.58 (95% CI, 0.44-5.68). Subgroup analysis and sensitivity analysis were also performed. Publication bias was not present. In conclusion, for patients with ICH, higher NLR was associated with poorer functional outcome at 3 months, while higher NLR was not associated with higher risk of death at 3 months.

Untreated hypertension as predictor of in-hospital mortality in intracerebral hemorrhage: A multi-center study

PURPOSE

Hypertension is a significant risk factor for intracerebral hemorrhage (ICH). The importance of managing blood pressure to reduce the risk of ICH has been recognized. However, few studies have focused on ICH outcomes due to untreated hypertension.

MATERIALS AND METHODS

We conducted a 5-year, retrospective, multicenter study of 490 consecutive ICH patients with histories of untreated-hypertension (n=56), treated-hypertension (n=314), and normotension (n=120). Demographics, symptom onset, vital signs, laboratory tests, and CT imaging were documented alongside in-hospital treatments, complications, and length of stay.

RESULTS

Untreated-hypertension subjects were found to be significantly younger than treated-hypertension. They were found to have lower rates of anticoagulant use (p<0.01), antiplatelet use (p<0.01), and hyperlipidemia (p<0.01) than subjects with treated-hypertension. In a multivariate model, untreated-hypertension, age ≥65years, ≥3 outpatient antihypertensive medications, and hematoma volumes ≥30ml were all associated with significantly increased in-hospital mortality. In contrast, mortality was lower in patients receiving ≥3 antihypertensive medications while in-hospital.

CONCLUSIONS

Subjects with untreated-hypertension were younger and had fewer comorbidities when compared with treated-hypertension and were similar when compared to normotensive individuals. Once demographic and in-hospital factors were accounted for, untreated-hypertension subjects demonstrated significantly increased in-hospital mortality following ICH when compared with normotensive individuals.

Mortality after primary intracerebral hemorrhage in relation to post-stroke seizures

Seizures after intracerebral hemorrhage are repeatedly seen. Whether the development of seizures after intracerebral hemorrhage affects survival in the long term is unknown. This study aims to determine the relation between seizures (i.e., with and without anti-epileptic therapy) and long-term mortality risk in a large patient population with intracerebral hemorrhage. We retrospectively included patients with a non-traumatic ICH in all three hospitals in the South Limburg region in the Netherlands between January 1st 2004 and December 31st 2009, and we assessed all-cause mortality until March 14th 2016. Patient who did not survive the first seven days after intracerebral hemorrhage were excluded from analyses. We used Cox multivariate analyses to determine independent predictors of mortality. Of 1214 patients, 783 hemorrhagic stroke patients fulfilled the inclusion criteria, amongst whom 37 (4.7%) patients developed early seizures (within 7 days after hemorrhage) and 77 (9.8%) developed late seizures (more than 7 days after hemorrhage). Seizure development was not significantly related to mortality risk after correction for conventional vascular risk factors and hemorrhage severity. However, we found a small but independent relation between the use of anti-epileptic drugs and a lower long-term mortality (HR = 0.32, 95% CI 0.11–0.91). In our large population, seizures and epilepsy did not relate independently to an increased mortality risk after hemorrhage.

The Therapeutic Value of Bone Marrow-Derived Endothelial Progenitor Cell Transplantation after Intracerebral Hemorrhage in Rats

Aims

To study the effect of endothelial progenitor cell (EPC) treatment on intracerebral hemorrhage (ICH) in rats and elucidate possible mechanisms.

Methods

The rats were randomly divided into three groups: (1) EPC group: ICH + EPC, (2) phosphate-buffered saline group: ICH + PBS, and (3) sham group. EPCs were transplanted intravenously 6 h after ICH. Modified neurological severity score was used to evaluate neurological function. Blood–brain barrier (BBB) integrity was evaluated. Dead cells, inflammatory cytokines, and neuroprotective cytokines were assessed to investigate possible mechanisms.

Results

The animals in the EPC group showed significant improvement in neurological function at 48 h, 72 h, and 7 days after ICH, compared with those in the PBS group. EPC transplantation significantly reduced brain edema and the number of dead cells in the hematoma boundary areas. The intensity of Evans Blue was decreased, and expression levels of zonula occluden-1 and claudin-5 were increased in the EPC group. Proinflammatory cytokines, including interferon-γ, IL-6, and TNF-α, were decreased, whereas anti-inflammatory cytokines, including transforming growth factor-β1 and IL-10, were increased in the EPC group. In addition, expression levels of brain-derived neurotrophic factor, vascular endothelial growth factor, and neurotrophic growth factor were increased following transplantation of EPCs.

Conclusion

EPC transplantation could improve neurological function of ICH rats. The protective effect may be mediated by promotion of neuroprotective cytokine secretion, restoration of the BBB, reduction of cell death, and the decrease in inflammation.

Inherited and Uncommon Causes of Stroke

PURPOSE OF REVIEW

This article is a practical guide to identifying uncommon causes of stroke and offers guidance for evaluation and management, even when large controlled trials are lacking in these rarer forms of stroke.

RECENT FINDINGS

Fabry disease causes early-onset stroke, particularly of the vertebrobasilar system; enzyme replacement therapy should be considered in affected patients. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), often misdiagnosed as multiple sclerosis, causes migraines, early-onset lacunar strokes, and dementia. Moyamoya disease can cause either ischemic or hemorrhagic stroke; revascularization is recommended in some patients. Cerebral amyloid angiopathy causes both microhemorrhages and macrohemorrhages, resulting in typical stroke symptoms and progressive dementia. Pregnancy raises the risk of both ischemic and hemorrhagic stroke, particularly in women with preeclampsia/eclampsia. Pregnant women are also at risk for posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis. Experts recommend that pregnant women with acute ischemic stroke not be systematically denied the potential benefits of IV recombinant tissue plasminogen activator.

SUMMARY

Neurologists should become familiar with these uncommon causes of stroke to provide future risk assessment and family counseling and to implement appropriate treatment plans to prevent recurrence.

Neuroprotective Mechanisms of Melatonin in Hemorrhagic Stroke

Hemorrhagic stroke which consists of subarachnoid hemorrhage and intracerebral hemorrhage is a dominant cause of death and disability worldwide. Although great efforts have been made, the physiological mechanisms of these diseases are not fully understood and effective pharmacological interventions are still lacking. Melatonin (N-acetyl-5-methoxytryptamine), a neurohormone produced by the pineal gland, is a broad-spectrum antioxidant and potent free radical scavenger. More importantly, there is extensive evidence demonstrating that melatonin confers neuroprotective effects in experimental models of hemorrhagic stroke. Multiple molecular mechanisms such as antioxidant, anti-apoptosis, and anti-inflammation, contribute to melatonin-mediated neuroprotection against brain injury after hemorrhagic stroke. This review article aims to summarize current knowledge regarding the beneficial effects of melatonin in experimental models of hemorrhagic stroke and explores the underlying mechanisms. We propose that melatonin is a promising neuroprotective candidate that is worthy of further evaluation for its potential therapeutic applications in hemorrhagic stroke.

Association Between Circulating Copeptin Level and Mortality Risk in Patients with Intracerebral Hemorrhage: a Systemic Review and Meta-Analysis

Copeptin has been identified as a biomarker of disease severity and is associated with mortality risk in several common diseases. This study sought to determine the association between circulating copeptin level and mortality risk in patients with intracerebral hemorrhage. PubMed, Web of Science, and Wanfang Medicine Database were searched for studies assessing the association between circulating copeptin level and mortality risk in patients with intracerebral hemorrhage. The pooled hazard ratio (HR) of mortality was calculated and presented with 95 % confidence interval (95 % CI). Data from 1332 intracerebral hemorrhage patients were derived from 9 studies. Meta-analysis showed that intracerebral hemorrhage patients with poor prognosis had much higher copeptin levels than those survivors (standardized mean difference = 1.68, 95 % CI 1.26-2.11, P < 0.00001). Meta-analysis of 8 studies with HRs showed that high circulating copeptin level was associated with higher risk of mortality in patients with intracerebral hemorrhage (HR = 2.42, 95 % CI 1.60-3.65, P < 0.0001). Meta-analysis of 6 studies with adjusted HRs showed that high circulating copeptin level was independently associated with higher risk of mortality in patients with intracerebral hemorrhage (HR = 1.67, 95 % CI 1.26-2.22, P = 0.0003). Our study suggests that there is an obvious association between circulating copeptin level and mortality in patients with intracerebral hemorrhage. High circulating copeptin level is independently associated with higher risk of mortality in patients with intracerebral hemorrhage.

Brain iron overload following intracranial haemorrhage

Intracranial haemorrhages, including intracerebral haemorrhage (ICH), intraventricular haemorrhage (IVH) and subarachnoid haemorrhage (SAH), are leading causes of morbidity and mortality worldwide. In addition, haemorrhage contributes to tissue damage in traumatic brain injury (TBI). To date, efforts to treat the long-term consequences of cerebral haemorrhage have been unsatisfactory. Incident rates and mortality have not showed significant improvement in recent years. In terms of secondary damage following haemorrhage, it is becoming increasingly apparent that blood components are of integral importance, with haemoglobin-derived iron playing a major role. However, the damage caused by iron is complex and varied, and therefore, increased investigation into the mechanisms by which iron causes brain injury is required. As ICH, IVH, SAH and TBI are related, this review will discuss the role of iron in each, so that similarities in injury pathologies can be more easily identified. It summarises important components of normal brain iron homeostasis and analyses the existing evidence on iron-related brain injury mechanisms. It further discusses treatment options of particular promise.

Targeting Secondary Hematoma Expansion in Spontaneous Intracerebral Hemorrhage - State of the Art

Spontaneous intracerebral hemorrhage (SICH), defined broadly as intracerebral hemorrhage not related to trauma, results in long-term disability or death in a large proportion of afflicted patients. Current management of this disease is predominantly supportive, including airway protection, optimization of hemodynamic parameters, and management of intracranial pressure. No active treatments that demonstrate beneficial effects on clinical outcome are currently available. Animal models of SICH have allowed for the elucidation of multiple pathways that may be attractive therapeutic targets. A minority of these, such as aggressive blood pressure management and recombinant activated factor VII administration, have led to large-scale clinical trials. There remains a critical need for further translational research in the realm of SICH.

Genetic variants in CETP increase risk of intracerebral hemorrhage

Objective

In observational epidemiologic studies, higher plasma high‐density lipoprotein cholesterol (HDL‐C) has been associated with increased risk of intracerebral hemorrhage (ICH). DNA sequence variants that decrease cholesteryl ester transfer protein (CETP) gene activity increase plasma HDL‐C; as such, medicines that inhibit CETP and raise HDL‐C are in clinical development. Here, we test the hypothesis that CETP DNA sequence variants associated with higher HDL‐C also increase risk for ICH.

Methods

We performed 2 candidate‐gene analyses of CETP. First, we tested individual CETP variants in a discovery cohort of 1,149 ICH cases and 1,238 controls from 3 studies, followed by replication in 1,625 cases and 1,845 controls from 5 studies. Second, we constructed a genetic risk score comprised of 7 independent variants at the CETP locus and tested this score for association with HDL‐C as well as ICH risk.

Results

Twelve variants within CETP demonstrated nominal association with ICH, with the strongest association at the rs173539 locus (odds ratio [OR] = 1.25, standard error [SE] = 0.06, p = 6.0 × 10⁻⁴) with no heterogeneity across studies (I² = 0%). This association was replicated in patients of European ancestry (p = 0.03). A genetic score of CETP variants found to increase HDL‐C by ∼2.85mg/dl in the Global Lipids Genetics Consortium was strongly associated with ICH risk (OR = 1.86, SE = 0.13, p = 1.39 × 10⁻⁶).

Interpretation

Genetic variants in CETP associated with increased HDL‐C raise the risk of ICH. Given ongoing therapeutic development in CETP inhibition and other HDL‐raising strategies, further exploration of potential adverse cerebrovascular outcomes may be warranted. Ann Neurol 2016;80:730–740

Florbetapir-PET to diagnose cerebral amyloid angiopathy: A prospective study

OBJECTIVE

We hypothesized that florbetapir, a Food and Drug Administration-approved PET tracer, could distinguish cerebral amyloid angiopathy (CAA)-related intracerebral hemorrhage (ICH) from hypertensive ICH (HTN-ICH).

METHODS

We prospectively enrolled survivors of primary ICH related to probable CAA (per Boston Criteria, n = 10) and HTN-ICH (n = 9) without dementia. All patients underwent florbetapir-PET and multimodal MRI, and patients with CAA had additional Pittsburgh compound B (PiB) PET. Amyloid burden was assessed quantitatively (standard uptake value ratio [SUVR]) and visually classified as positive or negative.

RESULTS

The CAA and HTN-ICH groups had similar age (66.9 vs 67.1), sex, and leukoaraiosis volumes (31 vs 30 mL, all p > 0.8). Florbetapir uptake and PiB retention strongly correlated in patients with CAA both globally within cerebral cortex (r = 0.96, p < 0.001) and regionally in lobar cortices (all r > 0.8, all p ≤ 0.01). Mean global cortical florbetapir uptake was substantially higher in CAA than HTN-ICH (SUVR: 1.41 ± 0.17 vs 1.15 ± 0.08, p = 0.001), as was mean occipital SUVR (1.44 ± 0.12 vs 1.17 ± 0.08, p < 0.001), even after correcting for global SUVR (p = 0.03). Visual rating for positive/negative florbetapir demonstrated perfect interrater agreement (k = 1) and was positive for all 10 patients with CAA vs 1 of 9 HTN-ICH patients (sensitivity 100%, specificity 89%).

CONCLUSIONS

Florbetapir appears to label vascular amyloid in patients with CAA-related ICH. The approved florbetapir binary visual reading method can have diagnostic value in appropriate clinical settings.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that florbetapir-PET provides a sensitivity of 100% (95% confidence interval [CI] 66%-100%) and specificity of 89% (95% CI 51%-99%) for determination of probable CAA among cognitively normal patients.

Diagnosis and Management of Acute Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the deadliest type of stroke and up to half of patients die in hospital. Blood pressure management, coagulopathy reversal, and intracranial pressure control are the mainstays of acute ICH treatment. Prevention of hematoma expansion and minimally invasive hematoma evacuation are promising therapeutic strategies under investigation. This article provides an updated review on ICH diagnosis and management in the emergency department.

Endoscopic treatment of hypertensive intracerebral hemorrhage: A technical review

Hypertensive intracerebral hemorrhage (ICH) is still a highlighting global issue. Endoscopic evacuation as a minimally invasive treatment became an alternative other than conventional craniotomy and catheter drainage for ICH. However, there is no unified indication or standardized procedure on endoscopic treatment of ICH. Here we explored the literature and gathered information from different studies, to review the background, technical points, and existing problems of endoscopic treatment for ICH.

Integrins AV and B8 Gene Polymorphisms and Risk for Intracerebral Hemorrhage in Greek and Polish Populations

Α limited number of genetic variants have been linked to the development of intracerebral hemorrhage (ICH). Ιntegrin AV and/or B8-deficient mice were found to develop ICH. The present candidate gene association study was designed to investigate possible influence of integrin AV (ITGAV) and integrin B8 (ITGB8) gene region polymorphisms on the risk of ICH. 1015 participants (250 Greek and 193 Polish patients with primary ICH and 250 Greek and 322 Polish controls) were included in the study. Using logistic regression analyses, 11 tag single nucleotide polymorphisms (SNPs) for ITGAV and 11 for ITGB8 gene were tested for associations with ICH risk, lobar ICH risk and non-lobar ICH after adjustment for age, gender, history of hypertension and country of origin. Linear regression models were used to test the effect of tag SNPs on the ICH age of onset. Correction for multiple comparisons was carried out. The rs7565633 tag SNP of the ITGAV gene was independently associated with the risk of lobar ICH in the codominant model of inheritance [odds ratio (95 % confidence interval (CI)) 0.56 (0.36-0.86), p = 0.0013]. Furthermore, heterozygous individuals of the rs10251386 and the rs10239099 of the ITGB8 gene had significantly lower age of ICH onset compared to the wild-type genotypes [regression coefficient (b) -3.884 (95 % CI -6.519, -1.249), p = 0.0039 and b = -4.502 (95 % CI -7.159, -1.845), p = 0.0009, respectively]. The present study provides preliminary indication for an influence of ITGAV gene tag SNP in the development of lobar ICH and of ITGB8 gene variants in the age of ICH onset.

Hemostatic Markers and Long-Term Risk of Intracerebral Hemorrhage in Postmenopausal Women

BACKGROUND

Known risk factors for intracerebral hemorrhage (ICH) include age, hypertension, smoking, alcohol intake, and anticoagulant use. Some previous reports have indicated that hemostatic factors measured many years before the onset of ICH might predict the later occurrence of ICH. The objective of this analysis was to test whether selected hemostatic factors measured years before the onset of ICH could identify patients at higher risk for future ICH.

METHODS

We performed a nested case-control study within the Women's Health Initiative (WHI) cohort. Postmenopausal women aged 50-79 years (mean 68) at baseline (1993-1998) were enrolled at 40 Clinical Centers in the United States and followed for adjudicated ICH for a mean of 11.4 years. ICH cases (N = 75) and controls (N = 75) were matched on age, ethnicity, blood pressure, anticoagulant use, and treated hypertension. Stored blood samples from the baseline WHI examination were tested for von Willebrand factor (vWF), a disintegrin-like and metalloprotease domain with thrombospondin type-1 motif, number 13 (ADAMTS13), tissue plasminogen activator (t-PA), and urokinase plasminogen activator (u-PA). Platelet count, white blood cell count, and hemoglobin concentration were also measured.

RESULTS

Mean baseline levels of vWF (1.03 and .95 U/mL), ADAMTS13 (1.0 and 1.1 µg/mL), vWF : ADAMTS13 ratio (.99 and .92), t-PA (14.75 and 14.80 IU/mL), and u-PA (.09 and .10 IU/mL) were not significantly different by case-control status. Significant differences were also not identified for platelet count, hemoglobin, white blood count, or reported alcohol use.

CONCLUSION

None of the 4 baseline hemostatic factors nor the platelet count was predictive of future ICH risk in this long-term study of older postmenopausal women.

Risk Profile of Symptomatic Lacunar Stroke Versus Nonlobar Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Although lacunar stroke (LS) and deep intracerebral hemorrhage (dICH) represent acute manifestations of the same pathological process involving cerebral small vessels (small vessel disease), it remains unclear what factors predispose to one phenotype rather than the other at individual level.

METHODS

Consecutive patients with either acute symptomatic LS or dICH were prospectively enrolled as part of a multicenter Italian study. We compared the risk factor profile of the 2 subgroups using multivariable logistic regression.

RESULTS

During a time course of 9.5 years, 1931 subjects (1434 LS and 497 dICH; mean age, 71.3±13.3 years; males, 55.5%) qualified for the analysis. Current smoking was associated with LS (odds ratio [OR], 2.17; P<0.001). Conversely, dICH cases were more likely to be hypertensive (OR, 1.87; P<0.001), excessive alcohol consumers (OR, 1.70; P=0.001), and more frequently under treatment with warfarin (OR, 2.05; P=0.010) and statins (OR, 3.10; P<0.001). Hypercholesterolemia, diabetes mellitus, and antiplatelet treatment were not associated with a specific small vessel disease manifestation.

CONCLUSIONS

The risk factor profile of dICH differs from that associated with LS. This might be used for disease risk stratification at individual level.

Leukocyte Count and Intracerebral Hemorrhage Expansion

BACKGROUND AND PURPOSE

Acute leukocytosis is a well-established response to intracerebral hemorrhage (ICH). Leukocytes, because of their interaction with platelets and coagulation factors, may in turn play a role in hemostasis. We investigated whether admission leukocytosis was associated with reduced bleeding after acute ICH.

METHODS

Consecutive patients with primary ICH were prospectively collected from 1994 to 2015 and retrospectively analyzed. We included subjects with a follow-up computed tomographic scan available and automated complete white blood cell count performed within 48 hours from onset. Baseline and follow-up hematoma volumes were calculated with semiautomated software, and hematoma expansion was defined as volume increase >30% or 6 mL. The association between white blood cell count and ICH expansion was investigated with multivariate logistic regression.

RESULTS

A total of 1302 subjects met eligibility criteria (median age, 75 years; 55.8% men), of whom 207 (15.9%) experienced hematoma expansion. Higher leukocyte count on admission was associated with reduced risk of hematoma expansion (odds ratio for 1000 cells increase, 0.91; 95% confidence interval, 0.86-0.96; P=0.001). The risk of hematoma expansion was inversely associated with neutrophil count (odds ratio, 0.90; 95% confidence interval, 0.85-0.96; P=0.001) and directly associated with monocyte count (odds ratio, 2.71; 95% confidence interval, 1.08-6.83; P=0.034). There was no association between lymphocyte count and ICH expansion (odds ratio, 0.96; 95% confidence interval, 0.79-1.17; P=0.718).

CONCLUSIONS

Higher admission white blood cell count is associated with lower risk of hematoma expansion. This highlights a potential role of the inflammatory response in modulating the coagulation cascade after acute ICH.

Trends in Incidence of Stroke and Transition of Stroke Subtypes in Rural Tianjin China: A Population-Based Study from 1992 to 2012

Objectives

The incidence of ischemic stroke has increased and that of hemorrhagic stroke has decreased in urban China; however, the trends in rural areas are unknown. We aimed to explore the secular trends in incidence and transition of stroke subtypes among rural Chinese.

Methods

This was a population-based stroke surveillance through the Tianjin Brain Study. A total of 14,538 residents in a township of Ji County in Tianjin, China participated in the study since 1985. We investigated the age-standardized stroke incidence (sex-specific, type-specific, and age-specific), the annual proportion of change in the incidence of stroke, and the proportion of intracerebral hemorrhage in the periods 1992–1998, 1999–2005, and 2006–2012, because the neuroimaging technique was available since 1992 in this area.

Results

The age-standardized incidence per 100,000 person-years increased significantly for both intracerebral hemorrhage (37.8 in 1992–1998, 46.5 in 1999–2005, and 76.5 in 2006–2012) and ischemic stroke (83.9 in 1992–1998, 135.3 in 1999–2005, and 238.0 in 2006–2012). The age-standardized incidence of first-ever stroke increased annually by 4.9% for intracerebral hemorrhage and by 7.3% for ischemic stroke. The greatest increase was observed in men aged 45–64 years for both stroke types (P < 0.001). The proportion of intracerebral hemorrhage was stable overall, increased among men aged 45–64 years, and decreased among men aged ≥65 years. The average age of intracerebral hemorrhage in men reduced by 7.5 years from 1992 to 2012.

Conclusion

The age-standardized incidence of main stroke subtypes increased significantly in rural China over the past 21 years; the overall proportion of intracerebral hemorrhage was stable, but the incidence increased significantly among middle-aged men. These findings imply that it is crucial to control stroke risk factors in middle-aged men for stroke prevention in future decades.

The Rotterdam Study: 2016 objectives and design update

The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. The findings of the Rotterdam Study have been presented in over 1200 research articles and reports (see www.erasmus-epidemiology.nl/rotterdamstudy ). This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.

Intracranial hemorrhage: frequency, location, and risk factors identified in a TeleStroke network

Intracranial hemorrhages are associated with high rates of disability and mortality. Telemedicine in general provides clinical healthcare at a distance by using videotelephony and teleradiology and is used particularly in acute stroke care medicine (TeleStroke). TeleStroke considerably improves quality of stroke care (for instance, by increasing thrombolysis) and may be valuable for the management of intracranial hemorrhages in rural hospitals and hospitals lacking neurosurgical departments, given that surgical/interventional therapy is only recommended for a subgroup of patients. The aim of this study was to analyze the frequency, anatomical locations of intracranial hemorrhage, risk factors, and the proportion of patients transferred to specialized hospitals. We evaluated teleconsultations conducted between 2008 and 2010 in a large cohort of patients consecutively enrolled in the Telemedical Project for Integrated Stroke Care (TEMPiS) network. In cases in which intracranial hemorrhage was detected, all images were re-examined and analyzed with a focus on frequency, location, risk factors, and further management. Overall, 6187 patients presented with stroke-like symptoms. Intracranial hemorrhages were identified in 631 patients (10.2%). Of these, intracerebral hemorrhages were found in 423 cases (67.0%), including 174 (41.1%) in atypical locations and 227 (53.7%) in typical sites among other locations. After 14 days of hospitalization in community facilities, the mortality rate in patients with intracranial hemorrhages was 15.1% (95/631). Two hundred and twenty-three patients (35.3%) were transferred to neurological/neurosurgical hospitals for diagnostic workup or additional treatment. Community hospitals are confronted with patients with intracranial hemorrhage, whose management requires specific neurosurgical and hematological expertise with respect to hemorrhage subtype and clinical presentation. TeleStroke networks help select patients who need advanced neurological and/or neurosurgical care. The relatively low proportion of interhospital transfers shown in this study reflects a differentiated decision process on the basis of both guidelines and standard operating procedures.

Imaging of Nontraumatic Neuroradiology Emergencies

Imaging of acute neurologic disease in the emergency department can be challenging because of the wide range of possible causes and the overlapping imaging appearance of many of these entities on nonenhanced computed tomography (CT). The key to formulating a succinct, pertinent differential diagnosis includes characterizing the pattern of abnormalities on CT and identifying key features that suggest a particular diagnosis. This article divides neurologic emergencies into 5 scenarios based on the CT findings, including subarachnoid hemorrhage, intraparenchymal hemorrhage, vasogenic edema without and with underlying mass lesion, and acute hydrocephalus. Specific common or important diagnoses in each category are discussed.

The Correlation Between Age and Bleeding Volume in Haemorrhagic Stroke Using Multi Slice CT at District Hospitals in Jakarta

Haemorrhagic Stroke is a common disease in Indonesia. The best imaging modality for this disease is Multi Slice Computed Tomography Scanning (MSCT), as it may help strengthening the diagnosis as well as determining the brain bleeding volume. This study aimed to show correlation between bleeding volume of the brain and patient’s age using cross-sectional approach. The 68 samples in this study were taken from secondary data from Head CT Scan of Haemorrhagic Stroke cases. Brain bleeding volume is the dependent variable, obtained through slice thickness of 5 mm and ABC/2 method with software measurement in MSCT Scan device. The independent variable of this study is the patient’s age. The result of the study was the average brain’s bleeding volume of 21.76 ml ± 2.48 ml (range of 1.04 ml to 94.73 ml). The slice thickness using ABC/2 method, has a significant correlation with brain’s bleeding volume in MSCT Scan examination, with correlation coefficient value r of 0.79. Brain bleeding volume in patients who have ages lower than 50 years and more or equal to 50 years were (18.93 ± 3.26) ml and (23.53 ± 3.47) ml respectively. There is no correlation between age and brain’s bleeding volume in haemorrhagic stroke cases, with p value of 0.18, r = 0.19.

Dimethyl fumarate confers neuroprotection by casein kinase 2 phosphorylation of Nrf2 in murine intracerebral hemorrhage

BACKGROUND AND PURPOSE

Edema formation, inflammation and increased blood-brain barrier permeability contribute to poor outcomes after intracerebral hemorrhage (ICH). This study examined the therapeutic effect of dimethyl fumarate (DMF), a fumaric acid ester that activates nuclear factor erythroid-2 related factor 2 (Nrf2) and Nrf2 heterodimerization effector protein musculo-aponeurotic fibrosarcoma-G (MAFG) in a murine ICH model.

METHODS

Male CD-1 mice (n=176) were subjected to intrastriatal infusion of bacterial collagenase (n=126), autologous blood (n=18) or sham surgery (n=32). Four (4) animals not subjected to ICH (naive) were also included in the study. After ICH, animals either received vehicle, dimethyl fumarate (10 mg or 100 mg/kg) or casein kinase 2 inhibitor (E)-3-(2,3,4,5-tetrabromophenyl)acrylic acid (TBCA). Thirty-two mice also received scrambled siRNA or MAFG siRNA 24h before ICH. Brain water content and neurological function were evaluated.

RESULTS

Dimethyl fumarate reduced Evans blue dye extravasation, decreased brain water content, and improved neurological deficits at 24 and 72 h after ICH. Casein kinase 2 inhibitor TBCA and MAFG siRNA prevented the effect of dimethyl fumarate on brain edema and neurological function. After ICH, ICAM-1 levels increased and casein kinase 2 levels decreased. Dimethyl fumarate reduced ICAM-1 but enhanced casein kinase 2 levels. Again, casein kinase 2 inhibitor TBCA and MAFG siRNA abolished the effect of dimethyl fumarate on ICAM-1 and casein kinase 2. Dimethyl fumarate preserved pNrf2 and MAFG expression in the nuclear lysate after ICH and the effect of dimethyl fumarate was abolished by casein kinase 2 inhibitor TBCA and MAFG siRNA. Dimethyl fumarate reduced microglia activation in peri-hematoma areas after ICH. The protective effect of dimethyl fumarate on brain edema and neurological function was also observed in a blood injection mouse model.

CONCLUSION

Dimethyl fumarate ameliorated inflammation, reduced blood-brain barrier permeability, and improved neurological outcomes by casein kinase 2 and Nrf2 signaling pathways after experimental ICH in mice.

Relationship between intracerebral hemorrhage and diabetes mellitus: a case-control study

INTRODUCTION

The role of diabetes mellitus in the pathogenesis of intracerebral hemorrhage (ICH) is controversial. Underlying comorbidities such as diabetes mellitus may increase the risk of intracerebral hemorrhage. In this study, we sought to assess the role of diabetes mellitus in the occurrence of intracerebral hemorrhage.

MATERIALS AND METHODS

In this case-control study, the prevalence of diabetes mellitus was evaluated in 120 patients presenting with intracerebral hemorrhage and in a control group of 135 patients with low back pain. All patients were treated at the Departments of Neurology and Neurosurgery, Shohadaye Tajrish University Hospital, Tehran, Iran between 2008 and 2012. T-test was applied for analysing the quantitative variables and chi-square and Fisher's exact tests were used to analyse qualitative variables.

RESULTS

The mean age was 67.5±12.7 y in patients with intracerebral hemorrhage and 70.5±12.6 y in the control group (p=0.201). Diabetes mellitus was found in 39 patients with intracerebral hemorrhage (33.1%) and 30 (22.2%) control subjects (p=0.054). The prevalence of diabetes mellitus in patients younger than 60 y was 7.4% in the control group and 27.8% in the case group (p=0.042).

CONCLUSION

In our study, no significant relationship was found between diabetes mellitus and intracerebral hemorrhage (except in patients younger than 60 years) and diabetes mellitus did not cause bleeding in certain brain areas. However, more studies are required on the correlation of diabetes mellitus and intracerebral hemorrhage in the same population to reach a definite conclusion.

Elevated homocysteine levels contribute to larger hematoma volume in patients with intracerebral hemorrhage

BACKGROUND

We investigate whether plasma homocysteine (HCY) levels are associated with hematoma volume and outcome in patients with intracerebral hemorrhage (ICH).

METHODS

A total of 69 patients admitted within 24 hours after ICH onset was divided into 2 groups based on admission plasma HCY levels (low homocysteinemia [LHCY] group, plasma HCY concentrations ≤14.62 μmol/L, versus high homocysteinemia [HHCY] group, >14.62 μmol/L).

RESULTS

Mean hematoma volumes for 2 groups (LHCY and HHCY) were 13.18 and 23.09 mL (P = .012), respectively, in patients with thalamoganglionic ICH, but hematoma volumes between 2 groups had no significant difference among patients with lobar or infratentorial ICH. On multivariate linear regression analysis, elevated HCY levels significantly correlated with larger hematoma volume in patients with thalamoganglionic ICH (B = .604, P = .004) after adjustment for confounding factors. Poor outcomes (6-month modified Rankin Scale scores ≥3) were not significantly different between 2 groups (low homocysteinemia group, 31.4%, versus high homocysteinemia group, 41.2%, P = .400).

CONCLUSIONS

Elevated plasma HCY levels were associated with larger hematoma volume only in patients with thalamoganglionic ICH. HCY levels might not be predictors of the 6-month clinical outcome in patients with ICH.

Up-regulation of Glis2 involves in neuronal apoptosis after intracerebral hemorrhage in adult rats

The novel Krüppel-like zinc finger protein Gli-similar 2 (Glis2), one member of the transcription factors, is involved in controlling the flow of genetic information and the modulation of diverse cellular activities. Accumulating evidence has demonstrated its important roles in adult development and several diseases. However, information regarding the regulation and possible function of Glis2 in the central nervous system is still limited. In this study, we explored the roles of Glis2 during the pathophysiological process of intracerebral hemorrhage (ICH). An ICH rat model was established and assessed by behavioral tests. Expression of Glis2 was significantly up-regulated in brain areas surrounding the hematoma following ICH. Immunofluorescence showed that Glis2 was strikingly increased in neurons, but not astrocytes or microglia. Up-regulation of Glis2 was found to be accompanied by the increased expression of active caspase-3 and Bax and decreased expression of Bcl-2 in vivo and vitro studies. Moreover, knocking down Glis2 by RNA-interference in PC12 cells reduced active caspase-3 and Bax expression while increased Bcl-2. Collectively, we speculated that Glis2 might exert pro-apoptotic function in neurons following ICH.