1801
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Patients with intracranial bleeding and atrial fibrillation treated with left atrial appendage occlusion: Results from the Amplatzer Cardiac Plug registry. Int J Cardiol 2017; 236:232-236. [DOI: 10.1016/j.ijcard.2017.02.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/24/2017] [Accepted: 02/10/2017] [Indexed: 11/21/2022]
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1802
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Risk Factors for Poor Outcome in Hypertensive Intraventricular Hemorrhage Treated by External Ventricular Drainage with Intraventricular Fibrinolysis. World Neurosurg 2017; 102:240-245. [DOI: 10.1016/j.wneu.2017.03.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 03/05/2017] [Accepted: 03/07/2017] [Indexed: 11/20/2022]
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1803
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Ye Z, Ai X, Zheng J, Hu X, Lin S, You C, Li H. Antihypertensive treatments for spontaneous intracerebral hemorrhage in patients with cerebrovascular stenosis: A randomized clinical trial (ATICHST). Medicine (Baltimore) 2017; 96:e7289. [PMID: 28658126 PMCID: PMC5500048 DOI: 10.1097/md.0000000000007289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Antihypertensive treatment is associated with clinical outcomes in patients with spontaneous intracerebral hemorrhage (sICH). ADAPT showed that intensive blood pressure lowering (<140 mm Hg) does not reduce peri-hematoma regional cerebral blood flow (rCBF) in patients with sICH. However, the stenosis of main cerebral arteries that has a high presence in patients with sICH is well-known related to the brain ischemia. The effect of intensive BP lowering for sICH in patients with cerebrovascular stenosis is still unknown. AIM The aim of this study was to determine the safety and effectiveness of intensive BP lowering for sICH in patients with cerebrovascular stenosis. METHODS AND ANALYSIS A pilot trial has been conducted to calculate the sample size and 80 patients of sICH with cerebrovascular stenosis will be involved. The target of systolic blood pressure (SBP) will be maintained at from 120 to 140 mm Hg or from 140 to 180 mm Hg for 7 days. Cerebral ischemia will be assessed at 24 hours after onset by computed tomography (CT) perfusion imaging and the follow-up will be conducted at 30-day and 90-day. The primary outcome is the reduction of peri-hematoma rCBF. The other cerebral perfusion indexes and the rate of ischemic stroke are regarded as other primary outcomes. The secondary outcomes include clinical outcome at 30 days and 90 days, complications, and hospital stays. DISCUSSION The ATICHST trial has been signed as a parallel, prospective, randomized, assessor-blinded clinical trial to determine the effects of intensive BP lowering on sICH in patients with cerebrovascular stenosis, the results of which will contribute to guide the management of blood pressure in sICH. CONCLUSION The protocol will determine the safety and effectiveness of intensive BP lowering for sICH with cerebrovascular stenosis.
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1804
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Abstract
Abstract
This comprehensive review summarizes the evidence regarding use of cerebral autoregulation-directed therapy at the bedside and provides an evaluation of its impact on optimizing cerebral perfusion and associated functional outcomes. Multiple studies in adults and several in children have shown the feasibility of individualizing mean arterial blood pressure and cerebral perfusion pressure goals by using cerebral autoregulation monitoring to calculate optimal levels. Nine of these studies examined the association between cerebral perfusion pressure or mean arterial blood pressure being above or below their optimal levels and functional outcomes. Six of these nine studies (66%) showed that patients for whom median cerebral perfusion pressure or mean arterial blood pressure differed significantly from the optimum, defined by cerebral autoregulation monitoring, were more likely to have an unfavorable outcome. The evidence indicates that monitoring of continuous cerebral autoregulation at the bedside is feasible and has the potential to be used to direct blood pressure management in acutely ill patients.
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1805
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A glimmer of hope for a devastating complication. Blood 2017; 129:2952-2953. [DOI: 10.1182/blood-2017-04-777771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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1806
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Hong KS. Blood Pressure Management for Stroke Prevention and in Acute Stroke. J Stroke 2017; 19:152-165. [PMID: 28592775 PMCID: PMC5466289 DOI: 10.5853/jos.2017.00164] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/19/2017] [Accepted: 05/02/2017] [Indexed: 01/08/2023] Open
Abstract
Elevated blood pressure (BP) is the leading modifiable risk factor for stroke and the benefit of BP lowering therapy on the stroke risk reduction is well established. The optimal BP target for preventing stroke and other vascular events have been controversial, but the evidences from epidemiological studies and randomized controlled trials (RCTs) support intensive BP lowering for greater vascular protection, particularly for stroke prevention. For secondary stroke prevention, the evidence of intensive BP lowering benefit is limited since only a single RCT for patients with lacunar infarctions was conducted and most data were driven by exploratory analyses. In acute intracerebral hemorrhage, immediate BP lowering targeting systolic BP<140 mm Hg is recommended by guidelines based on the results from RCTs. In contrast, in acute ischemic stroke, early BP lowering is not usually recommended because of no benefit on functional outcome and future vascular events and potential harm of stroke progression. This review aims to summarize the updated evidence for optimal BP management for primary and secondary stroke prevention and in patients with acute stroke.
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Affiliation(s)
- Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
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1807
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Boulouis G, Morotti A, Brouwers HB, Charidimou A, Jessel MJ, Auriel E, Pontes-Neto O, Ayres A, Vashkevich A, Schwab KM, Rosand J, Viswanathan A, Gurol ME, Greenberg SM, Goldstein JN. Association Between Hypodensities Detected by Computed Tomography and Hematoma Expansion in Patients With Intracerebral Hemorrhage. JAMA Neurol 2017; 73:961-8. [PMID: 27323314 DOI: 10.1001/jamaneurol.2016.1218] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Hematoma expansion is a potentially modifiable predictor of poor outcome following an acute intracerebral hemorrhage (ICH). The ability to identify patients with ICH who are likeliest to experience hematoma expansion and therefore likeliest to benefit from expansion-targeted treatments remains an unmet need. Hypodensities within an ICH detected by noncontrast computed tomography (NCCT) have been suggested as a predictor of hematoma expansion. OBJECTIVE To determine whether hypodense regions, irrespective of their specific patterns, are associated with hematoma expansion in patients with ICH. DESIGN, SETTING, AND PARTICIPANTS We analyzed a large cohort of 784 patients with ICH (the development cohort; 55.6% female), examined NCCT findings for any hypodensity, and replicated our findings on a different cohort of patients (the replication cohort; 52.7% female). Baseline and follow-up NCCT data from consecutive patients with ICH presenting to a tertiary care hospital between 1994 and 2015 were retrospectively analyzed. Data analyses were performed between December 2015 and January 2016. MAIN OUTCOMES AND MEASURES Hypodensities were analyzed by 2 independent blinded raters. The association between hypodensities and hematoma expansion (>6 cm3 or 33% of baseline volume) was determined by multivariable logistic regression after controlling for other variables associated with hematoma expansion in univariate analyses with P ≤ .10. RESULTS A total of 1029 patients were included in the analysis. In the development and replication cohorts, 222 of 784 patients (28.3%) and 99 of 245 patients (40.4%; 321 of 1029 patients [31.2%]), respectively, had NCCT scans that demonstrated hypodensities at baseline (κ = 0.87 for interrater reliability). In univariate analyses, hypodensities were associated with hematoma expansion (86 of 163 patients with hematoma expansion had hypodensities [52.8%], whereas 136 of 621 patients without hematoma expansion had hypodensities [21.9%]; P < .001). The association between hypodensities and hematoma expansion remained significant (odds ratio, 3.42 [95% CI, 2.21-5.31]; P < .001) in a multivariable model; other independent predictors of hematoma expansion were a CT angiography spot sign, a shorter time to CT, warfarin use, and older age. The independent predictive value of hypodensities was again demonstrated in the replication cohort (odds ratio, 4.37 [95% CI, 2.05-9.62]; P < .001). CONCLUSION AND RELEVANCE Hypodensities within an acute ICH detected on an NCCT scan may predict hematoma expansion, independent of other clinical and imaging predictors. This novel marker may help clarify the mechanism of hematoma expansion and serve as a useful addition to clinical algorithms for determining the risk of and treatment stratification for hematoma expansion.
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Affiliation(s)
- Gregoire Boulouis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Andrea Morotti
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - H Bart Brouwers
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston2Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht Universi
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Michael J Jessel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Eitan Auriel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Octávio Pontes-Neto
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Alison Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Kristin M Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical Sch
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Mahmut E Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Joshua N Goldstein
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical Sch
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1808
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Morotti A, Charidimou A, Phuah CL, Jessel MJ, Schwab K, Ayres AM, Romero JM, Viswanathan A, Gurol ME, Greenberg SM, Anderson CD, Rosand J, Goldstein JN. Association Between Serum Calcium Level and Extent of Bleeding in Patients With Intracerebral Hemorrhage. JAMA Neurol 2017; 73:1285-1290. [PMID: 27598746 DOI: 10.1001/jamaneurol.2016.2252] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Calcium is a key cofactor of the coagulation cascade and may play a role in the pathophysiology of intracerebral hemorrhage (ICH). Objective To investigate whether a low serum calcium level is associated with an increase in the extent of bleeding in patients with ICH as measured by baseline hematoma volume and risk of hematoma expansion. Design, Setting, and Participants Prospective cohort study of 2103 consecutive patients with primary ICH ascertained during the period between 1994 and 2015 at an academic medical center. The statistical analysis was performed in January 2016. Main Outcomes and Measures Total calcium level was measured on admission, and hypocalcemia was defined as a serum calcium level of less than 8.4 mg/dL. Baseline and follow-up hematoma volumes, detected by noncontrast computed tomography, were measured using a computer-assisted semiautomatic analysis. Hematoma expansion was defined as an increase of more than 30% or 6 mL from baseline ICH volume. Associations between serum calcium level and baseline hematoma volume and between serum calcium level and ICH expansion were investigated in multivariable linear and logistic regression models, respectively. Results A total of 2123 patients with primary ICH were screened, and 2103 patients met the inclusion criteria (mean [SD] age, 72.7 [12.5] years; 54.3% male patients), of whom 229 (10.9%) had hypocalcemia on admission. Hypocalcemic patients had a higher median baseline hematoma volume than did normocalcemic patients (37 mL [IQR, 15-72 mL] vs 16 mL [IQR, 6-44 mL]; P < .001). Low calcium levels were independently associated with higher baseline ICH volume (β = -0.13, SE = .03, P < .001). A total of 1393 patients underwent follow-up noncontrast computed tomography and were included in the ICH expansion analysis. In this subgroup, a higher serum calcium level was associated with reduced risk of ICH expansion (odds ratio, 0.55 [95% CI, 0.35-0.86]; P = .01), after adjusting for other confounders. Conclusions and Relevance Hypocalcemia correlates with the extent of bleeding in patients with ICH. A low calcium level may be associated with a subtle coagulopathy predisposing to increased bleeding and might therefore be a promising therapeutic target for acute ICH treatment trials.
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Affiliation(s)
- Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy2Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston3J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Andreas Charidimou
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Chia-Ling Phuah
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston3J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Michael J Jessel
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Kristin Schwab
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Alison M Ayres
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Javier M Romero
- Neuroradiology Service, Department of Radiology, Massachusetts General Hospital, Boston
| | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - M Edip Gurol
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Steven M Greenberg
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Christopher D Anderson
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston3J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Jonathan Rosand
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston3J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston3J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston5Department of Emergency Medicine, Massachusetts General Hospital, Boston
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1809
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Minaeian A, Patel A, Essa B, Goddeau RP, Moonis M, Henninger N. Emergency Department Length of Stay and Outcome after Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:2167-2173. [PMID: 28551289 DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Emergency department length of stay (ED-LOS) has been associated with worse outcomes after various medical conditions. However, there is a relative paucity of data for ischemic stroke patients. We sought to determine whether a longer ED-LOS is associated with a poor 90-day outcome after ischemic stroke. METHODS This study is a retrospective analysis of a single-center cohort of consecutive ischemic stroke patients (n = 325). Multivariable linear and logistic regression models were constructed to determine factors independently associated with ED-LOS as well as a poor 90-day outcome (modified Rankin Scale [mRS] score >2), respectively. RESULTS The median ED-LOS in the cohort was 5.8 hours. For patients admitted to the inpatient stroke ward (n = 160) versus the neuroscience intensive care unit (NICU; n = 165), the median ED-LOS was 8.2 hours versus 3.7 hours, respectively. On multivariable linear regression, NICU admission (P <.001), endovascular stroke therapy (P = .001), and thrombolysis (P = .021) were inversely associated with the ED-LOS. Evening shift presentation was associated with a longer ED-LOS (P = .048). On multivariable logistic regression, a greater admission National Institutes of Health Stroke Scale score (P <.001), worse preadmission mRS score (P = .001), hemorrhagic conversion (P = .041), and a shorter ED-LOS (P = .016) were associated with a poor 90-day outcome. Early initiation of statin therapy (P = .049), endovascular stroke therapy (P = .041), NICU admission (P = .029), and evening shift presentation (P = .035) were associated with a good 90-day outcome. CONCLUSIONS In contrast to prior studies, a shorter ED-LOS was associated with a worse 90-day functional outcome, possibly reflecting prioritized admission of more severely affected patients who are at high risk of a poor functional outcome.
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Affiliation(s)
- Artin Minaeian
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Anand Patel
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Basad Essa
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Richard P Goddeau
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts; Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts.
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1810
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Teramoto S, Yamamoto T, Nakao Y, Watanabe M. Novel Anatomic Classification of Spontaneous Thalamic Hemorrhage Classified by Vascular Territory of Thalamus. World Neurosurg 2017; 104:452-458. [PMID: 28532917 DOI: 10.1016/j.wneu.2017.05.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/09/2017] [Accepted: 05/11/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Spontaneous thalamic hemorrhage has increased in incidence in recent years. Analysis of the characteristics of thalamic hemorrhage was based on the vascular territories of the thalamus. METHODS Retrospective analysis included 303 consecutive patients with spontaneous thalamic hemorrhage. Thalamic hemorrhage was classified into 4 types: anterior type (supplied mainly by the tuberothalamic artery), medial (mainly paramedian thalamic-subthalamic artery), lateral (mainly thalamogeniculate artery), and posterior (mainly posterior choroidal artery). The baseline characteristics, complications, and functional outcomes were assessed. RESULTS The anterior type was found in 10 patients (3.3%), the medial type in 47 (15.5%), the lateral type in 230 (75.9%), and the posterior type in 16 (5.3%). Intracerebral hemorrhage volume was smallest in the anterior type, and significantly smaller than in the medial (P = 0.002) and lateral types (P < 0.001). Intraventricular hemorrhage (IVH) or acute hydrocephalus was significantly associated with the medial type (P < 0.01 or P < 0.01, respectively). Non-IVH or non-acute hydrocephalus was significantly associated with the anterior (P < 0.05 or P < 0.05, respectively) and lateral (P < 0.05 or P < 0.05, respectively) types. Emergency surgery was correlated only with the medial type (P < 0.01). The independent predictors of poor outcome were age (odds ratio [OR], 1.07; P = 0.002), admission National Institutes of Health Stroke Scale score (OR, 1.32; P < 0.001), and type of thalamic hemorrhage (OR, 2.08; P = 0.038). CONCLUSIONS The present study proposed a novel anatomic classification of thalamic hemorrhage according to the major thalamic vascular territories.
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Affiliation(s)
- Shinichiro Teramoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan.
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Mitsuya Watanabe
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
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1811
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Gioia L, Klahr A, Kate M, Buck B, Dowlatshahi D, Jeerakathil T, Emery D, Butcher K. The intracerebral hemorrhage acutely decreasing arterial pressure trial II (ICH ADAPT II) protocol. BMC Neurol 2017; 17:100. [PMID: 28525977 PMCID: PMC5437568 DOI: 10.1186/s12883-017-0884-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/10/2017] [Indexed: 11/19/2022] Open
Abstract
Background Aggressively lowering blood pressure (BP) in acute intracerebral hemorrhage (ICH) may improve outcome. Although there is no evidence that BP reduction changes cerebral blood flow, retrospective magnetic resonance imaging (MRI) studies have demonstrated sub-acute ischemic lesions in ICH patients. The primary aim of this study is to assess ischemic lesion development in patients randomized to two different BP treatment strategies. We hypothesize aggressive BP reduction is not associated with ischemic injury after ICH. Methods The Intracerebral Hemorrhage Acutely Decreasing Blood Pressure Trial II (ICH ADAPT II) is a phase II multi-centre randomized open-label, blinded-endpoint trial. Acute ICH patients (N = 270) are randomized to a systolic blood pressure (SBP) target of <140 or <180 mmHg. Acute ICH patients within 6 h of onset and two SBP measurements ≥140 mmHg recorded >2 mins apart qualify. SBP is managed with a pre-defined treatment protocol. Patients undergo MRI at 48 h, Days 7 and 30, with clinical assessment at Day 30 and 90. The primary outcome is diffusion weighted imaging (DWI) lesion frequency at 48 h. Secondary outcomes include cumulative DWI lesion rate frequency within 30 days, absolute hematoma growth, prediction of DWI lesion incidence, 30-day mortality rates, day 90 functional outcome, and cognitive status. Discussion This trial will assess the impact of hypertensive therapies on physiological markers of ischemic injury. The findings of this study will provide evidence for the link, or lack thereof, between BP reduction and ischemic injury in ICH patients. Trial registration This study is registered with clinicaltrials.gov (NCT02281838, first received October 29, 2014). Electronic supplementary material The online version of this article (doi:10.1186/s12883-017-0884-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Laura Gioia
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Ana Klahr
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Mahesh Kate
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Brian Buck
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | | | - Thomas Jeerakathil
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Derek Emery
- Department of Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Kenneth Butcher
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada.
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1812
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Abstract
Clinicians make frequent treatment decisions regarding acute blood pressure reduction for the critically ill. Key to the decision making process is a balance between reducing arterial wall stress and maintaining perfusion to vital organs. In this article, we review the physiological considerations underlying acute blood pressure management, including the concept of cerebral autoregulation and its adaptations to chronic hypertension. We then discuss available pharmacological interventions suited for reducing blood pressure acutely. We also discuss specific blood pressure targets in common critical illnesses and consider future directions in this therapeutic area.
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1813
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Zheng J, Yu Z, Xu Z, Li M, Wang X, Lin S, Li H, You C. The Accuracy of the Spot Sign and the Blend Sign for Predicting Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage. Med Sci Monit 2017; 23:2250-2257. [PMID: 28498827 PMCID: PMC5437917 DOI: 10.12659/msm.901583] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hematoma expansion is associated with poor outcome in intracerebral hemorrhage (ICH) patients. The spot sign and the blend sign are reliable tools for predicting hematoma expansion in ICH patients. The aim of this study was to compare the accuracy of the two signs in the prediction of hematoma expansion. MATERIAL AND METHODS Patients with spontaneous ICH were screened for the presence of the computed tomography angiography (CTA) spot sign and the non-contrast CT (NCCT) blend sign within 6 hours after onset of symptoms. The sensitivity, specificity, and positive and negative predictive values of the spot sign and the blend sign in predicting hematoma expansion were calculated. The accuracy of the spot sign and the blend sign in predicting hematoma expansion was analyzed by receiver-operator analysis. RESULTS A total of 115 patients were enrolled in this study. The spot sign was observed in 25 (21.74%) patients, whereas the blend sign was observed in 22 (19.13%) patients. Of the 28 patients with hematoma expansion, the CTA spot sign was found on admission CT scans in 16 (57.14%) and the NCCT blend sign in 12 (42.86%), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of the spot sign for predicting hematoma expansion were 57.14%, 89.66%, 64.00%, and 86.67%, respectively. In contrast, the sensitivity, specificity, positive predictive value, and negative predictive value of the blend sign were 42.86%, 88.51%, 54.55%, and 82.80%, respectively. The area under the curve (AUC) of the spot sign was 0.734, which was higher than that of the blend sign (0.657). CONCLUSIONS Both the spot sign and the blend sign seemed to be good predictors for hematoma expansion, and the spot sign appeared to have better predictive accuracy.
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Affiliation(s)
- Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Zhao Xu
- Department of Anesthesia, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Mou Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Xiaoze Wang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Sen Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
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1814
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Lahti AM, Saloheimo P, Huhtakangas J, Salminen H, Juvela S, Bode MK, Hillbom M, Tetri S. Poststroke epilepsy in long-term survivors of primary intracerebral hemorrhage. Neurology 2017; 88:2169-2175. [PMID: 28476758 DOI: 10.1212/wnl.0000000000004009] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/20/2017] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To identify the incidence and predisposing factors for development of poststroke epilepsy (PSE) after primary intracerebral hemorrhage (PICH) during a long-term follow-up. METHODS We performed a retrospective study of patients who had had their first-ever PICH between January 1993 and January 2008 in Northern Ostrobothnia, Finland, and who survived for at least 3 months. These patients were followed up for PSE. The associations between PSE occurrence and sex, age, Glasgow Coma Scale (GCS) score on admission, hematoma location and volume, early seizures, and other possible risk factors for PSE were assessed using the Cox proportional hazards regression model. RESULTS Of the 615 PICH patients who survived for longer than 3 months, 83 (13.5%) developed PSE. The risk of new-onset PSE was highest during the first year after PICH with cumulative incidence of 6.8%. In univariable analysis, the risk factors for PSE were early seizures, subcortical hematoma location, larger hematoma volume, hematoma evacuation, and a lower GCS score on admission, whereas patients with infratentorial hematoma location or hypertension were less likely to develop PSE (all variables p < 0.05). In multivariable analysis, we found subcortical location (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.35-3.81, p < 0.01) and early seizures (HR 3.63, 95% CI 1.99-6.64, p < 0.01) to be independent risk factors, but patients with hypertension had a lower risk of PSE (HR 0.54, 0.35-0.84, p < 0.01). CONCLUSIONS Subcortical hematoma location and early seizures increased the risk of PSE after PICH in long-term survivors, while hypertension seemed to reduce the risk.
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Affiliation(s)
- Anna-Maija Lahti
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland.
| | - Pertti Saloheimo
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Juha Huhtakangas
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Henrik Salminen
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Seppo Juvela
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Michaela K Bode
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Matti Hillbom
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Sami Tetri
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland.
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1815
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Beynon C, Unterberg AW. [Oral anticoagulant-associated intracerebral haemorrhage]. Med Klin Intensivmed Notfmed 2017; 112:475-488. [PMID: 28466292 DOI: 10.1007/s00063-017-0293-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 02/06/2017] [Accepted: 02/21/2017] [Indexed: 11/26/2022]
Abstract
Intracerebral haemorrhage during treatment with oral anticoagulants is associated with high rates of morbidity and mortality. Impaired haemostasis can lead to progressive haematomas and, therefore, it should be identified early in order to initiate measures to reverse anticoagulation. Substitution of coagulation factors is essential in the treatment of these patients, but other intensive care measures such as blood pressure control are mandatory as well.
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Affiliation(s)
- C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - A W Unterberg
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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1816
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Hong D, Stradling D, Dastur CK, Akbari Y, Groysman L, Al-Khoury L, Chen J, Small SL, Yu W. Resistant Hypertension after Hypertensive Intracerebral Hemorrhage Is Associated with More Medical Interventions and Longer Hospital Stays without Affecting Outcome. Front Neurol 2017; 8:184. [PMID: 28515710 PMCID: PMC5413489 DOI: 10.3389/fneur.2017.00184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 04/18/2017] [Indexed: 01/08/2023] Open
Abstract
Background Hypertension (HTN) is the most common cause of spontaneous intracerebral hemorrhage (ICH). The aim of this study is to investigate the role of resistant HTN in patients with ICH. Methods and results We conducted a retrospective study of all consecutive ICH admissions at our medical center from November 2013 to October 2015. The clinical features of patients with resistant HTN (requiring four or more antihypertensive agents to keep systolic blood pressure <140 mm Hg) were compared with those with responsive HTN (requiring three or fewer agents). Of the 152 patients with hypertensive ICH, 48 (31.6%) had resistant HTN. Resistant HTN was independently associated with higher body mass index and proteinuria. Compared to the responsive group, patients with resistant HTN had higher initial blood pressures and greater requirement for ventilator support, hematoma evacuation, hypertonic saline therapy, and nicardipine infusion. Resistant HTN increases length of stay (LOS) in the intensive care unit (ICU) (4.2 vs 2.1 days; p = 0.007) and in the hospital (11.5 vs 7.0 days; p = 0.003). Multivariate regression analysis showed that the rate of systolic blood pressure >140 mm Hg and duration of nicardipine infusion were independently associated with LOS in the ICU. There was no significant difference in hematoma expansion and functional outcome at hospital discharge between the two groups. Conclusion Resistant HTN in patients with ICH is associated with more medical interventions and longer LOS without effecting outcome at hospital discharge.
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Affiliation(s)
- Daojun Hong
- Department of Neurology, University of California at Irvine, Irvine, CA, USA.,Department of Neurology, The First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, China
| | - Dana Stradling
- Department of Neurology, University of California at Irvine, Irvine, CA, USA
| | - Cyrus K Dastur
- Department of Neurology, University of California at Irvine, Irvine, CA, USA
| | - Yama Akbari
- Department of Neurology, University of California at Irvine, Irvine, CA, USA
| | - Leonid Groysman
- Department of Neurology, University of California at Irvine, Irvine, CA, USA
| | - Lama Al-Khoury
- Department of Neurology, University of California at Irvine, Irvine, CA, USA
| | - Jefferson Chen
- Department of Neurosurgery, University of California at Irvine, Irvine, CA, USA
| | - Steven L Small
- Department of Neurology, University of California at Irvine, Irvine, CA, USA
| | - Wengui Yu
- Department of Neurology, University of California at Irvine, Irvine, CA, USA
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1817
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Helbok R, Schiefecker AJ, Friberg C, Beer R, Kofler M, Rhomberg P, Unterberger I, Gizewski E, Hauerberg J, Möller K, Lackner P, Broessner G, Pfausler B, Ortler M, Thome C, Schmutzhard E, Fabricius M. Spreading depolarizations in patients with spontaneous intracerebral hemorrhage: Association with perihematomal edema progression. J Cereb Blood Flow Metab 2017; 37:1871-1882. [PMID: 27207168 PMCID: PMC5435285 DOI: 10.1177/0271678x16651269] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 04/05/2016] [Accepted: 04/26/2016] [Indexed: 11/16/2022]
Abstract
Pathophysiologic mechanisms of secondary brain injury after intracerebral hemorrhage and in particular mechanisms of perihematomal-edema progression remain incompletely understood. Recently, the role of spreading depolarizations in secondary brain injury was established in ischemic stroke, subarachnoid hemorrhage and traumatic brain injury patients. Its role in intracerebral hemorrhage patients and in particular the association with perihematomal-edema is not known. A total of 27 comatose intracerebral hemorrhage patients in whom hematoma evacuation and subdural electrocorticography was performed were studied prospectively. Hematoma evacuation and subdural strip electrode placement was performed within the first 24 h in 18 patients (67%). Electrocorticography recordings started 3 h after surgery (IQR, 3-5 h) and lasted 157 h (median) per patient and 4876 h in all 27 patients. In 18 patients (67%), a total of 650 spreading depolarizations were observed. Spreading depolarizations were more common in the initial days with a peak incidence on day 2. Median electrocorticography depression time was longer than previously reported (14.7 min, IQR, 9-22 min). Postoperative perihematomal-edema progression (85% of patients) was significantly associated with occurrence of isolated and clustered spreading depolarizations. Monitoring of spreading depolarizations may help to better understand pathophysiologic mechanisms of secondary insults after intracerebral hemorrhage. Whether they may serve as target in the treatment of intracerebral hemorrhage deserves further research.
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Affiliation(s)
- Raimund Helbok
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | | | - Christian Friberg
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Ronny Beer
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Mario Kofler
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Paul Rhomberg
- Department of Neuroradiology, Medical University Innsbruck, Austria
| | - Iris Unterberger
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Elke Gizewski
- Department of Neuroradiology, Medical University Innsbruck, Austria
| | - John Hauerberg
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Möller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen, Denmark
| | - Peter Lackner
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Gregor Broessner
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Bettina Pfausler
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Martin Ortler
- Department of Neurosurgery, Medical University Innsbruck, Austria
| | - Claudius Thome
- Department of Neurosurgery, Medical University Innsbruck, Austria
| | - Erich Schmutzhard
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Martin Fabricius
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
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1818
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Akers A, Al-Shahi Salman R, A. Awad I, Dahlem K, Flemming K, Hart B, Kim H, Jusue-Torres I, Kondziolka D, Lee C, Morrison L, Rigamonti D, Rebeiz T, Tournier-Lasserve E, Waggoner D, Whitehead K. Synopsis of Guidelines for the Clinical Management of Cerebral Cavernous Malformations: Consensus Recommendations Based on Systematic Literature Review by the Angioma Alliance Scientific Advisory Board Clinical Experts Panel. Neurosurgery 2017; 80:665-680. [PMID: 28387823 PMCID: PMC5808153 DOI: 10.1093/neuros/nyx091] [Citation(s) in RCA: 287] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 02/09/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite many publications about cerebral cavernous malformations (CCMs), controversy remains regarding diagnostic and management strategies. OBJECTIVE To develop guidelines for CCM management. METHODS The Angioma Alliance ( www.angioma.org ), the patient support group in the United States advocating on behalf of patients and research in CCM, convened a multidisciplinary writing group comprising expert CCM clinicians to help summarize the existing literature related to the clinical care of CCM, focusing on 5 topics: (1) epidemiology and natural history, (2) genetic testing and counseling, (3) diagnostic criteria and radiology standards, (4) neurosurgical considerations, and (5) neurological considerations. The group reviewed literature, rated evidence, developed recommendations, and established consensus, controversies, and knowledge gaps according to a prespecified protocol. RESULTS Of 1270 publications published between January 1, 1983 and September 31, 2014, we selected 98 based on methodological criteria, and identified 38 additional recent or relevant publications. Topic authors used these publications to summarize current knowledge and arrive at 23 consensus management recommendations, which we rated by class (size of effect) and level (estimate of certainty) according to the American Heart Association/American Stroke Association criteria. No recommendation was level A (because of the absence of randomized controlled trials), 11 (48%) were level B, and 12 (52%) were level C. Recommendations were class I in 8 (35%), class II in 10 (43%), and class III in 5 (22%). CONCLUSION Current evidence supports recommendations for the management of CCM, but their generally low levels and classes mandate further research to better inform clinical practice and update these recommendations. The complete recommendations document, including the criteria for selecting reference citations, a more detailed justification of the respective recommendations, and a summary of controversies and knowledge gaps, was similarly peer reviewed and is available on line www.angioma.org/CCMGuidelines .
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Affiliation(s)
| | | | - Issam A. Awad
- Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Kelly Flemming
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Blaine Hart
- Department of Radiology, University of New Mexico, Albuquerque, New Mexico
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | | | - Douglas Kondziolka
- Departments of Neurosurgery and Radiation Oncology, NYU Langone Medical Center, New York City, New York
| | | | - Leslie Morrison
- Departments of Neurology and Pediatrics, University of New Mexico, Albuquerque, New Mexico
| | - Daniele Rigamonti
- Department of Neurosurgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Tania Rebeiz
- Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Darrel Waggoner
- Department of Human Genetics and Pediatrics, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Kevin Whitehead
- Department of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
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1819
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Kyeremanteng K, Hendin A, Bhardwaj K, Thavorn K, Neilipovitz D, Kubelik D, D'Egidio G, Stotts G, Rosenberg E. Neuroscience Intermediate-Level Care Units Staffed by Intensivists: Clinical Outcomes and Cost Analysis. J Intensive Care Med 2017; 34:109-114. [PMID: 28443389 DOI: 10.1177/0885066617706651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION: With an aging population and increasing numbers of intensive care unit admissions, novel ways of providing quality care at reduced cost are required. Closed neurointensive care units improve outcomes for patients with critical neurological conditions, including decreased mortality and length of stay (LOS). Small studies have demonstrated the safety of intermediate-level units for selected patient populations. However, few studies analyze both cost and safety outcomes of these units. This retrospective study assessed clinical and cost-related outcomes in an intermediate-level neurosciences acute care unit (NACU) before and after the addition of an intensivist to the unit's care team. METHODS: Starting in October 2011, an intensivist-led model was adopted in a 16-bed NACU unit, including daytime coverage by a dedicated intensivist. Data were obtained from all patients admitted 1 year prior to and 2 years after this intervention. Primary outcomes were LOS and hospital costs. Safety outcomes included mortality and readmissions. Descriptive and analytic statistics were calculated. Individual and total patient costs were calculated based on per-day NACU and ward cost estimates and significance measured using bootstrapping. RESULTS: A total of 2931 patients were included over the study period. Patients were on average 59.5 years and 53% male. The most common reasons for admission were central nervous system (CNS) tumor (27.6%), ischemic stroke (27%), and subarachnoid hemorrhage (11%). Following the introduction of an intensivist, there was a significant reduction in NACU and hospital LOS, by 1 day and 3 days, respectively. There were no differences in readmissions or mortality. Adding an intensivist produced an individual cost savings of US$963 in NACU and US$2687 per patient total hospital stay. CONCLUSION: An intensivist-led model of intermediate-level neurointensive care staffed by intensivists is safe, decreases LOS, and produces cost savings in a system increasingly strained to provide quality neurocritical care.
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Affiliation(s)
- Kwadwo Kyeremanteng
- 1 Division of Critical Care and Palliative Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ariel Hendin
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kalpana Bhardwaj
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- 3 Department of Epidemiology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Dave Neilipovitz
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dalibour Kubelik
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Gianni D'Egidio
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Grant Stotts
- 4 Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Rosenberg
- 2 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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1820
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Neira JA, McKhann GM. Intraventricular Thrombolytics in Intraventricular Hemorrhage: Their Role is not so Clear. Neurosurgery 2017; 80:N31-N33. [DOI: 10.1093/neuros/nyx104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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1821
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Konstantinidis I, Patel S, Camargo M, Patel A, Poojary P, Coca SG, Nadkarni GN. Representation and reporting of kidney disease in cerebrovascular disease: A systematic review of randomized controlled trials. PLoS One 2017; 12:e0176145. [PMID: 28426831 PMCID: PMC5398672 DOI: 10.1371/journal.pone.0176145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/05/2017] [Indexed: 12/03/2022] Open
Abstract
Patients with kidney disease (KD) are at increased risk for cerebrovascular disease (CVD) and CVD patients with KD have worse outcomes. We aimed to determine the representation of KD patients in major randomized controlled trials (RCTs) of CVD interventions. We searched MEDLINE for reports of major CVD trials published through February 9, 2017. We excluded trials that did not report mortality outcomes, enrolled fewer than 100 participants, or were subgroup, follow-up, or post-hoc analyses. Two independent reviewers performed study selection and data extraction. We included 135 RCTs randomizing 194,977 participants. KD patients were excluded in 48 (35.6%) trials, but were less likely to be excluded from trials of class I/II recommended interventions (n = 7; 15.9%; p = 0.001) and more likely to be excluded in trials with registered protocols (45.5% vs. 22.4%; p = 0.007). Exclusion was lower in trials supported by academic or governmental grants compared to industry or combined funding (21.2% vs. 42.0% and 47.8%; p = 0.033 and 0.028, respectively). Among trials excluding KD patients, 24 (50.0%) used serum creatinine, 7 (14.6%) used estimated glomerular filtration rate or creatinine clearance, 7 (14.6%) used renal replacement therapy, and 19 (39.6%) used non-specific kidney-related criteria. Only 4 (3.0%) trials reported baseline renal function. No trials prespecified or reported subgroup analyses by baseline renal function. Although 19 (14.1%) trials reported the incidence of acute kidney injury, no trial examined adverse event rates according to renal function. In summary, more than one third of major CVD trials excluded patients with KD, primarily based on serum creatinine or non-specific criteria, and outcomes were not stratified by renal parameters. Therefore, purposeful efforts to increase inclusion of KD patients in CVD trials and evaluate the impact of renal function on efficacy and safety are needed to improve the quality of evidence for interventions in this vulnerable population.
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Affiliation(s)
- Ioannis Konstantinidis
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- * E-mail:
| | - Shanti Patel
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Marianne Camargo
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Achint Patel
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Priti Poojary
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Steven G. Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Girish N. Nadkarni
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
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1822
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Charidimou A, Morotti A, Boulouis G. Cumulative meta-analysis of intensive blood-pressure lowering in acute cerebral hemorrhage: Quo vadis? J Neurol Sci 2017; 375:179-180. [PMID: 28320125 DOI: 10.1016/j.jns.2017.01.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 01/09/2017] [Accepted: 01/13/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Andreas Charidimou
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
| | - Andrea Morotti
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Gregoire Boulouis
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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1823
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de Schipper LJ, Baharoglu MI, Roos YBWEM, de Beer F. Medical Treatment for Spontaneous Anticoagulation-Related Intracerebral Hemorrhage in the Netherlands. J Stroke Cerebrovasc Dis 2017; 26:1427-1432. [PMID: 28412317 DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 03/14/2017] [Accepted: 03/21/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Spontaneous anticoagulation-related intracerebral hemorrhage accounts for up to a quarter of spontaneous intracerebral hemorrhage cases and is associated with higher hematoma volume and a worse outcome. Guidelines recommend rapid anticoagulant reversal but mode and timing are not specified and optimal strategy is uncertain. Variability in everyday practice is unknown. METHODS An invitation to a web-based survey was sent to 85 Dutch stroke neurologists in different hospitals, with questions about importance, timing, and medical management of spontaneous anticoagulation-related intracerebral hemorrhage. RESULTS In total, 61 (72%) neurologists completed the survey. Nearly all (97%) deemed rapid anticoagulant reversal important. A local guideline for management of anticoagulant reversal was used in 80% of the hospitals. Most neurologists (56%) estimated anticoagulant reversal in anticoagulation-related intracerebral hemorrhage to start later than intravenous thrombolysis in ischemic stroke. Few (5%) thought it was quicker. A minority (28%) of the hospitals started anticoagulation reversal without waiting for laboratory test results or consulting a specialist in hemostasis. Prothrombin complex concentrate was used by all neurologists for vitamin K antagonist reversal and by most (74%) for reversal of thrombin inhibitors and factor Xa inhibitors (72%). Anticoagulation reversal was initiated at the emergency department according to 89% of the respondents. CONCLUSION Variability in logistics in acute management of spontaneous anticoagulation-related intracerebral hemorrhage was demonstrated. Anticoagulant reversal is deemed important, but is estimated to have a longer door-to-needle time than alteplase in thrombolysis for ischemic stroke by most neurologists. Several delaying factors were found. These factors might have an impact on outcome.
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Affiliation(s)
| | - M Irem Baharoglu
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Frank de Beer
- Department of Neurology, Spaarne Gasthuis, Haarlem, The Netherlands.
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1824
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Samuel S, Bajgur S, Savarraj JP, Choi HA. Impact of practice change in reducing venous thromboembolism in neurocritical overweight patients: 2008-2014. J Thromb Thrombolysis 2017; 43:98-104. [PMID: 27605371 DOI: 10.1007/s11239-016-1422-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Publications regarding early initiating venous thromboembolism (VTE) prophylaxis have been available since the early 1990s. These recommendations became available in current guidelines on and after 2012. The purpose of this study is to review the practice change in reducing the incidence of VTE in brain injury patients from 2008 to 2014. This was a single-center, retrospective, observational, cohort study. Data was extracted from our data base that included patients over 100 kg from January 2008 to August 2014. Included were all patients admitted with a primary diagnosis of acute brain and spinal injury to neurocritical care unit. Clinical endpoints examined were incidence of bleeding and VTE. A total of 509 patients who met the inclusion criteria were divided into two groups: The previous group (n = 212) included patients from 2008 to 2010, and the recent group (n = 297) included patients from 2011 to 2014. The time for initiating VTE prophylaxis from admission was (median, IQR) 73 h (37-140) vs. 34 h (20-46); p < 0.01. There were no differences in major and minor bleeding complications. Discontinuation of VTE prophylaxis for association with progressive bleeding was not documented in any of the study patients. The incidence of VTE was 10 % (22/212) vs. 5 % (15/297); p = 0.02. In hospital LOS in days was 16 (10-26) vs. 7 (4-15); P < 0.01. In multivariable logistic regression analysis, only the time of the initiation VTE prophylaxis after admission was significantly associated with the occurrence of VTE (median, IQR) 70 h (37-158) vs. 36 h (20-63); OR 1.004, 95 % CI 1.001-1.007; P < 0.01. In this 6-year review of data, early initiation of VTE prophylaxis has decreased the incidence of VTE without clinically documented bleeding complications.
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Affiliation(s)
- Sophie Samuel
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, 6411 Fannin Street, Houston, TX, 77054, USA.
| | - Suhas Bajgur
- Department of Neurosurgery and Neurology, The University of Texas Medical School at Houston, Houston, USA
| | - Jude P Savarraj
- Department of Neurosurgery and Neurology, The University of Texas Medical School at Houston, Houston, USA
| | - Huimahn A Choi
- Department of Neurosurgery and Neurology, The University of Texas Medical School at Houston, Houston, USA
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1825
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Howell ML, Schwab K, Ayres AM, Shapley D, Anderson CD, Gurol ME, Viswanathan A, Greenberg SM, Rosand J, Goldstein JN. Chaplaincy Visitation and Spiritual Care after Intracerebral Hemorrhage. J Health Care Chaplain 2017; 23:156-166. [PMID: 28394726 DOI: 10.1080/08854726.2017.1304726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
To better understand factors influencing spiritual care during critical illness, we examined the use of spiritual care in patients hospitalized with intracerebral hemorrhage (ICH), a frequently disabling and fatal disease. Specifically, the study was designed to examine which demographic and clinical characteristics were associated with chaplain visits to critically ill patients. The charts of consecutive adults (>18) with spontaneous ICH presenting to a single academic medical center between January 2014 and September 2015 were reviewed. Chaplains visited 86 (32%) of the 266 patients. Family requests initiated the majority of visits (57%). Visits were disproportionately to Catholic patients and those with more severe injury. Even among Catholics, 28% of those who died had no chaplaincy visit. Standardized chaplaincy screening methods and note templates may help maximize access to spiritual care and delineate the religious and spiritual preferences of patients and families.
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Affiliation(s)
- Melissa L Howell
- a Department of Emergency Medicine , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Kristin Schwab
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Alison M Ayres
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Dean Shapley
- c Department of Chaplaincy , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Christopher D Anderson
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - M Edip Gurol
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Anand Viswanathan
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Steven M Greenberg
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Jonathan Rosand
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Joshua N Goldstein
- a Department of Emergency Medicine , Massachusetts General Hospital , Boston , Massachusetts , USA
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1826
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Lim-Hing K, Rincon F. Secondary Hematoma Expansion and Perihemorrhagic Edema after Intracerebral Hemorrhage: From Bench Work to Practical Aspects. Front Neurol 2017; 8:74. [PMID: 28439253 PMCID: PMC5383656 DOI: 10.3389/fneur.2017.00074] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 02/20/2017] [Indexed: 01/24/2023] Open
Abstract
Intracerebral hemorrhages (ICH) represent about 10-15% of all strokes per year in the United States alone. Key variables influencing the long-term outcome after ICH are hematoma size and growth. Although death may occur at the time of the hemorrhage, delayed neurologic deterioration frequently occurs with hematoma growth and neuronal injury of the surrounding tissue. Perihematoma edema has also been implicated as a contributing factor for delayed neurologic deterioration after ICH. Cerebral edema results from both blood-brain barrier disruption and local generation of osmotically active substances. Inflammatory cellular mediators, activation of the complement, by-products of coagulation and hemolysis such as thrombin and fibrin, and hemoglobin enter the brain and induce a local and systemic inflammatory reaction. These complex cascades lead to apoptosis or neuronal injury. By identifying the major modulators of cerebral edema after ICH, a therapeutic target to counter degenerative events may be forthcoming.
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Affiliation(s)
- Krista Lim-Hing
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Fred Rincon
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
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1827
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Xu X, Chen X, Li F, Zheng X, Wang Q, Sun G, Zhang J, Xu B. Effectiveness of endoscopic surgery for supratentorial hypertensive intracerebral hemorrhage: a comparison with craniotomy. J Neurosurg 2017; 128:553-559. [PMID: 28387618 DOI: 10.3171/2016.10.jns161589] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to investigate the effectiveness and practicality of endoscopic surgery for treatment of supratentorial hypertensive intracerebral hemorrhage (HICH) compared with traditional craniotomy. METHODS The authors retrospectively analyzed 151 consecutive patients who were operated on for treatment of supratentorial HICH between January 2009 and June 2014 in the Department of Neurosurgery at Chinese PLA General Hospital. Patients were separated into an endoscopy group (82 cases) and a craniotomy group (69 cases), depending on the surgery they received. The hematoma evacuation rate was calculated using 3D Slicer software to measure the hematoma volume. Comparisons of operative time, intraoperative blood loss, Glasgow Coma Scale score 1 week after surgery, hospitalization time, and modified Rankin Scale score 6 months after surgery were also made between these groups. RESULTS There was no statistically significant difference in preoperative data between the endoscopy group and the craniotomy group (p > 0.05). The hematoma evacuation rate was 90.5% ± 6.5% in the endoscopy group and 82.3% ± 8.6% in the craniotomy group, which was statistically significant (p < 0.01). The operative time was 1.6 ± 0.7 hours in the endoscopy group and 5.2 ± 1.8 hours in the craniotomy group (p < 0.01). The intraoperative blood loss was 91.4 ± 93.1 ml in the endoscopy group and 605.6 ± 602.3 ml in the craniotomy group (p < 0.01). The 1-week postoperative Glasgow Coma Scale score was 11.5 ± 2.9 in the endoscopy group and 8.3 ± 3.8 in the craniotomy group (p < 0.01). The hospital stay was 11.6 ± 6.9 days in the endoscopy group and 13.2 ± 7.9 days in the craniotomy group (p < 0.05). The mean modified Rankin Scale score 6 months after surgery was 3.2 ± 1.5 in the endoscopy group and 4.1 ± 1.9 in the craniotomy group (p < 0.01). Patients had better recovery in the endoscopy group than in the craniotomy group. Data are expressed as the mean ± SD. CONCLUSIONS Compared with traditional craniotomy, endoscopic surgery was more effective, less invasive, and may have improved the prognoses of patients with supratentorial HICH. Endoscopic surgery is a promising method for treatment of supratentorial HICH. With the development of endoscope technology, endoscopic evacuation will become more widely used in the clinic. Prospective randomized controlled trials are needed.
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1828
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Bozzano V, Carandini T. Intensive lowering of blood pressure in the acute phase of intracranial haemorrhage. Intern Emerg Med 2017; 12:379-380. [PMID: 28280979 DOI: 10.1007/s11739-017-1646-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 02/25/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Viviana Bozzano
- Dipartimento di Medicina Interna e Specializzazioni Mediche, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Tiziana Carandini
- Unità di Neurologia, Dipartimento di Fisiopatologia dei Trapianti, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy.
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1829
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Abstract
Managing acute intracerebral haemorrhage is a challenging task for physicians. Evidence shows that outcome can be improved with admission to an acute stroke unit and active care, including urgent reversal of anticoagulant effects and, potentially, intensive blood pressure reduction. Nevertheless, many management issues remain controversial, including the use of haemostatic therapy, selection of patients for neurosurgery and neurocritical care, the extent of investigations for underlying causes and the benefit versus risk of restarting antithrombotic therapy after an episode of intracerebral haemorrhage.
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Affiliation(s)
- Zhe Kang Law
- University of Nottingham, UK
- National University of Malaysia, Kuala Lumpur, Malaysia
| | | | - Philip M Bath
- University of Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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1830
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Inoue Y, Miyashita F, Koga M, Minematsu K, Toyoda K. Unclear-onset intracerebral hemorrhage: Clinical characteristics, hematoma features, and outcomes. Int J Stroke 2017; 12:961-968. [PMID: 28361615 DOI: 10.1177/1747493017702664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and purpose Although unclear-onset ischemic stroke, including wake-up ischemic stroke, is drawing attention as a potential target for reperfusion therapy, acute unclear-onset intracerebral hemorrhage has been understudied. Clinical characteristics, hematoma features, and outcomes of patients who developed intracerebral hemorrhage during sleep or those with intracerebral hemorrhage who were unconscious when witnessed were determined. Methods Consecutive intracerebral hemorrhage patients admitted within 24 hours after onset or last-known normal time were classified into clear-onset intracerebral hemorrhage and unclear-onset intracerebral hemorrhage groups. Outcomes included initial hematoma volume, initial National Institutes of Health Stroke Scale score, hematoma growth on 24-hour follow-up computed tomography, and vital and functional prognoses at 30 days. Results Of 377 studied patients (122 women, 69 ± 11 years old), 147 (39.0%) had unclear-onset intracerebral hemorrhage. Patients with unclear-onset intracerebral hemorrhage had larger hematoma volumes (p = 0.044) and higher National Institutes of Health Stroke Scale scores (p < 0.001) than those with clear-onset intracerebral hemorrhage after multivariable adjustment for risk factors and comorbidities. Hematoma growth was similarly common between the two groups (p = 0.176). There were fewer patients with modified Rankin Scale (mRS) scores of 0-2 (p = 0.033) and more patients with mRS scores of 5-6 (p = 0.009) and with fatal outcomes (p = 0.049) in unclear-onset intracerebral hemorrhage group compared with clear-onset intracerebral hemorrhage as crude values, but not after adjustment. Conclusions Patients with unclear-onset intracerebral hemorrhage presented with larger hematomas and higher National Institutes of Health Stroke Scale scores at emergent visits than those with clear-onset intracerebral hemorrhage, independent of underlying characteristics. Unclear-onset intracerebral hemorrhage patients showed poorer 30-day vital and functional outcomes than clear-onset intracerebral hemorrhage patients; these differences seem to be mainly due to initial hematoma volumes and National Institutes of Health Stroke Scale scores.
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Affiliation(s)
- Yasuteru Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Fumio Miyashita
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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1831
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Xie Z, Huang L, Enkhjargal B, Reis C, Wan W, Tang J, Cheng Y, Zhang JH. Intranasal administration of recombinant Netrin-1 attenuates neuronal apoptosis by activating DCC/APPL-1/AKT signaling pathway after subarachnoid hemorrhage in rats. Neuropharmacology 2017; 119:123-133. [PMID: 28347836 DOI: 10.1016/j.neuropharm.2017.03.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/20/2017] [Accepted: 03/23/2017] [Indexed: 01/16/2023]
Abstract
Neuronal apoptosis is a crucial pathological process in early brain injury after subarachnoid hemorrhage (SAH). The effective therapeutic strategies to ameliorate neuronal apoptosis are still absent. We intended to determine whether intranasal administration of exogenous Netrin-1 (NTN-1) could attenuate neuronal apoptosis after experimental SAH, specifically via activating DCC-dependent APPL-1/AKT signaling cascade. Two hundred twenty-five male Sprague-Dawley rats were subjected to the endovascular perforation model of SAH. Recombinant human NTN-1 (rNTN-1) was administered intranasally. NTN-1 small interfering RNA (siRNA), APPL-1 siRNA, and AKT inhibitor MK2206 were administered through intracerebroventricular (i.c.v.) injection. SAH grade, neurological score, neuronal apoptosis assessed by cleaved caspase-3 (CC-3) expression and Fluoro-Jade C (FJC) staining, double immunofluorescence staining, and Western blot were examined. Our results revealed that endogenous NTN-1 level was increased after SAH. Administration of rNTN-1 improved neurological outcomes at 24 h and 72 h after SAH, while knockdown of endogenous NTN-1 worsened neurological impairments. Furthermore, exogenous rNTN-1 treatment promoted APPL-1 activation, increased phosphorylated-AKT and Bcl-2 expression, as well as decreased apoptotic marker CC-3 expression and the number of FJC-positive neurons, thereby alleviated neuronal apoptosis. Conversely, APPL-1 siRNA and MK2206 abolished the anti-apoptotic effect of exogenous rNTN-1 at 24 h after SAH. Collectively, intranasal administration of exogenous rNTN-1 attenuated neuronal apoptosis and improved neurological function in SAH rats, at least in apart via activating DCC/APPL-1/AKT signaling pathway.
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Affiliation(s)
- Zongyi Xie
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China; Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA 92354, United States
| | - Lei Huang
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA 92354, United States; Department of Anesthesiology, School of Medicine, Loma Linda University, Loma Linda, CA 92354, United States
| | - Budbazar Enkhjargal
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA 92354, United States
| | - Cesar Reis
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA 92354, United States
| | - Weifeng Wan
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA 92354, United States
| | - Jiping Tang
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA 92354, United States
| | - Yuan Cheng
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China.
| | - John H Zhang
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA 92354, United States; Department of Anesthesiology, School of Medicine, Loma Linda University, Loma Linda, CA 92354, United States; Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, CA 92354, United States.
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1832
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Lee SH, Park KJ, Park DH, Kang SH, Park JY, Chung YG. Factors Associated with Clinical Outcomes in Patients with Primary Intraventricular Hemorrhage. Med Sci Monit 2017; 23:1401-1412. [PMID: 28325888 PMCID: PMC5374890 DOI: 10.12659/msm.899309] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Primary intraventricular hemorrhage (PIVH) is an uncommon type of intracerebral hemorrhage. Owing to its rarity, the clinical and radiological factors affecting outcomes in patients with PIVH have not been widely studied. Material/Methods We retrospectively reviewed 112 patients (mean age 53 years) treated for PIVH at our institution from January 2004 to December 2014. Clinical and radiological parameters were analyzed 3 months after initial presentation to identify factors associated with clinical outcomes, as assessed by the Glasgow Outcome Scale (favorable ≥4, unfavorable <4). Results Of the 99 patients who underwent angiography, causative vascular abnormalities were found in 46%, and included Moyamoya disease, arteriovenous malformation, and cerebral aneurysm. At 3 months after initial presentation, 64% and 36% of patients were in the favorable and unfavorable outcome groups, respectively. The mortality rate was 19%. However, most survivors had no or mild deficits. Age, initial Glasgow Coma Scale (GCS) score, simplified acute physiology score (SAPS II), modified Graeb score, and various radiological parameters reflecting ventricular dilatation were significantly different between the groups. Specifically, a GCS score of less than 13 (p=0.015), a SAPS II score of less than 33 (p=0.039), and a dilated fourth ventricle (p=0.043) were demonstrated to be independent predictors of an unfavorable clinical outcome. Conclusions In this study we reveal independent predictors of poor outcome in primary intraventricular hemorrhage patients, and show that nearly half of the patients in our study had predisposing vascular abnormalities. Routine angiography is recommended in the evaluation of PIVH to identify potentially treatable etiologies, which may enhance long-term prognosis.
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Affiliation(s)
- Sang-Hoon Lee
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
| | - Kyung-Jae Park
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
| | - Dong-Hyuk Park
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
| | - Shin-Hyuk Kang
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
| | - Jung-Yul Park
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
| | - Yong-Gu Chung
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
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1833
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Boulouis G, Morotti A, Charidimou A, Dowlatshahi D, Goldstein JN. Noncontrast Computed Tomography Markers of Intracerebral Hemorrhage Expansion. Stroke 2017; 48:1120-1125. [PMID: 28289239 DOI: 10.1161/strokeaha.116.015062] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 11/16/2016] [Accepted: 02/08/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Neurology Department (G.B., A.M., A.C., J.N.G.) and Emergency Medicine Department (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Neuroradiology Department, Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, France (G.B.); and Ottawa Hospital Research Institute, Canada Faculty of Medicine, University of Ottawa, Ontario (D.D.).
| | - Andrea Morotti
- From the Hemorrhagic Stroke Research Program, Neurology Department (G.B., A.M., A.C., J.N.G.) and Emergency Medicine Department (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Neuroradiology Department, Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, France (G.B.); and Ottawa Hospital Research Institute, Canada Faculty of Medicine, University of Ottawa, Ontario (D.D.)
| | - Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Neurology Department (G.B., A.M., A.C., J.N.G.) and Emergency Medicine Department (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Neuroradiology Department, Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, France (G.B.); and Ottawa Hospital Research Institute, Canada Faculty of Medicine, University of Ottawa, Ontario (D.D.)
| | - Dar Dowlatshahi
- From the Hemorrhagic Stroke Research Program, Neurology Department (G.B., A.M., A.C., J.N.G.) and Emergency Medicine Department (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Neuroradiology Department, Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, France (G.B.); and Ottawa Hospital Research Institute, Canada Faculty of Medicine, University of Ottawa, Ontario (D.D.)
| | - Joshua N Goldstein
- From the Hemorrhagic Stroke Research Program, Neurology Department (G.B., A.M., A.C., J.N.G.) and Emergency Medicine Department (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Neuroradiology Department, Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, France (G.B.); and Ottawa Hospital Research Institute, Canada Faculty of Medicine, University of Ottawa, Ontario (D.D.)
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1834
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Alaraj A, Esfahani DR, Hussein AE, Darie I, Amin-Hanjani S, Slavin KV, Du X, Charbel FT. Neurosurgical Emergency Transfers: An Analysis of Deterioration and Mortality. Neurosurgery 2017; 81:240-250. [DOI: 10.1093/neuros/nyx012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 01/13/2017] [Indexed: 11/13/2022] Open
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1835
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Mastorakos P, Liu KC, Schomer A. Adverse Effects of Aggressive Blood Pressure Control in Patients with Intracerebral Hemorrhage. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.160102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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1836
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Tao C, Hu X, Wang J, You C. Effect of Admission Hyperglycemia on 6-Month Functional Outcome in Patients with Spontaneous Cerebellar Hemorrhage. Med Sci Monit 2017; 23:1200-1207. [PMID: 28273059 PMCID: PMC5353882 DOI: 10.12659/msm.900202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Cerebellar hemorrhage (CH) has a quite different treatment strategy and prognostic factors compared with supratentorial intracerebral hemorrhage (ICH). The prognostic role of hyperglycemia has been discussed mainly in cases of supratentorial hemorrhage; it remains to be elucidated following CH. We aimed to determine the association of hyperglycemia on admission with 6-month functional outcome in CH patients. Material/Methods We retrospectively analyzed 77 patients with acute CH between September 2010 and April 2015 in West China Hospital. Blood glucose level was measured when the patients were admitted. Primary outcome was 6-month functional outcome, which could comprehensively reflect the patient’s recovery of physical and social ability after stroke and was assessed by the modified Rankin scale (mRS). Association of hyperglycemia with functional outcome was identified in logistic regression models. Results There were 50 (64.9%) patients with poor functional outcomes. Patients with poor outcome were much older (P<0.001) and had a significantly higher glucose level on admission (P<0.001), a lower Glasgow Coma Scale score (P<0.001), a larger hematoma (P=0.003), and a higher incidence of intraventricular extension (P=0.002), brainstem compression (P=0.013), and hydrocephalus (P=0.023). Multivariate analysis showed that hyperglycemia (OR 1.50, 95% CI 1.07–2.08, P=0.017 when glucose level was analyzed as a continuous variable; OR 7.46, 95% CI 1.41–39.51, P=0.018 when glucose level was dichotomized by the critical threshold of 6.78 mmol/L) emerged as an independent predictor for adverse functional outcome at 6 months. Conclusions To the best of our knowledge, this is the first study focusing on the relationship between hyperglycemia and long-term functional outcome after CH. The study combined with previous pertinent reports definitely indicates the poor effect of hyperglycemia on both supra- and infratentorial ICH independent of hemorrhage site. Therefore, further controlled trials are urgently needed to evaluate the benefits of glucose-lowing treatment.
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Affiliation(s)
- Chuanyuan Tao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jiajing Wang
- Department of Critical Care Medicine, Neurosurgical Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
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1837
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Charidimou A, Tirschwell DL. Early case fatality in intracerebral hemorrhage: Sophistication of care, application globally. Neurology 2017; 88:926-927. [PMID: 28159887 DOI: 10.1212/wnl.0000000000003707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Andreas Charidimou
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; and UW Medicine/Harborview Comprehensive Stroke Center (D.L.T.), Department of Neurology, University of Washington School of Medicine, Seattle.
| | - David L Tirschwell
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; and UW Medicine/Harborview Comprehensive Stroke Center (D.L.T.), Department of Neurology, University of Washington School of Medicine, Seattle
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1838
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AlKherayf F, Xu Y, Westwick H, Moldovan ID, Wells PS. Timing of anticoagulant re-initiation following intracerebral hemorrhage in mechanical heart valves: Survey of neurosurgeons and thrombosis experts. Clin Neurol Neurosurg 2017; 154:23-27. [DOI: 10.1016/j.clineuro.2017.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 12/19/2016] [Accepted: 01/10/2017] [Indexed: 11/28/2022]
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1839
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Otite FO, Khandelwal P, Malik AM, Chaturvedi S, Sacco RL, Romano JG. Ten-Year Temporal Trends in Medical Complications After Acute Intracerebral Hemorrhage in the United States. Stroke 2017; 48:596-603. [DOI: 10.1161/strokeaha.116.015746] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/22/2017] [Accepted: 01/23/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Data on medical complications after intracerebral hemorrhage (ICH) are sparse. We assessed trends in the prevalence of urinary tract infection, pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism, acute renal failure (ARF), and acute myocardial infarction after ICH in the United States.
Methods—
A total of 575 211 adult ICH cases were identified from the 2004 to 2013 Nationwide Inpatient Sample. Weighted complication risks were computed by sex and mechanical ventilation status. Multivariate models were used to evaluate trends in complications and assess their association with in-hospital mortality, cost, and length of stay.
Results—
Overall risks of urinary tract infection, pneumonia, sepsis, DVT, pulmonary embolism, ARF, and acute myocardial infarction after ICH were 14.8%, 7.8%, 4.1%, 2.7%, 0.7%, 8.2%, and 2.0%, respectively, but risk differed by sex and mechanical ventilation status. From 2004 to 2013, odds of DVT and ARF increased, whereas odds of pneumonia, sepsis, and mortality declined over time. All complications were associated with >2.5-day increase in length of stay and >$8000 increase in cost. ARF and acute myocardial infarction were associated with increased mortality in all patients; sepsis and pneumonia were associated with increased mortality only in nonmechanical ventilation patients, whereas urinary tract infection and DVT were associated with reduced mortality in all patients.
Conclusions—
Despite significant mortality reduction, ARF and DVT risk after ICH have increased, whereas odds of sepsis and pneumonia have declined over the last decade. All complications were associated with increased cost and length of stay, but their associations with mortality were variable, likely due in part to survival bias. Innovative strategies are needed to prevent ICH-associated medical complications.
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Affiliation(s)
- Fadar Oliver Otite
- From the Department of Neurology, University of Miami Miller School of Medicine, FL
| | - Priyank Khandelwal
- From the Department of Neurology, University of Miami Miller School of Medicine, FL
| | - Amer M. Malik
- From the Department of Neurology, University of Miami Miller School of Medicine, FL
| | - Seemant Chaturvedi
- From the Department of Neurology, University of Miami Miller School of Medicine, FL
| | - Ralph L. Sacco
- From the Department of Neurology, University of Miami Miller School of Medicine, FL
| | - Jose G. Romano
- From the Department of Neurology, University of Miami Miller School of Medicine, FL
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1840
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Left Atrial Appendage Closure in Patients with Atrial Fibrillation and Previous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2017; 26:545-551. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.126] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/18/2016] [Accepted: 11/29/2016] [Indexed: 11/23/2022] Open
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1841
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Fam MD, Pang A, Zeineddine HA, Mayo S, Stadnik A, Jesselson M, Zhang L, Dlugash R, Ziai W, Hanley D, Awad IA. Demographic Risk Factors for Vascular Lesions as Etiology of Intraventricular Hemorrhage in Prospectively Screened Cases. Cerebrovasc Dis 2017; 43:223-230. [PMID: 28245439 DOI: 10.1159/000458452] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/28/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Spontaneous intraventricular hemorrhage (IVH) is associated with high rates of morbidity and mortality despite critical care and other advances. An important step in clinical management is to confirm/rule out an underlying vascular lesion, which influences further treatment, potential for further bleeding, and prognosis. Our aim is to compare demographic and clinical characteristics between IVH patients with and without an underlying vascular lesion, and among cohorts with different vascular lesions. METHODS We analyzed prospectively collected data of IVH patients screened for eligibility as part of the Clot Lysis: Evaluation Accelerated Resolution of IVH Phase III (CLEAR III) clinical trial. The trial adopted a structured screening process to systematically exclude patients with an underlying vascular lesion as the etiology of IVH. We collected age, sex, ethnicity, and primary diagnosis on these cases and vascular lesions were categorized prospectively as aneurysm, vascular malformation (arteriovenous malformation, dural arteriovenous fistula, and cavernoma), Moyamoya disease, or other vascular lesion. We excluded cases <18 or >80 years of age. Baseline characteristics were compared between the CLEAR group (IVH screened without vascular lesion) and the group of IVH patients screened and excluded from CLEAR because of an identified vascular lesion. We further analyzed the differential demographic and clinical characteristics among subcohorts with different vascular lesions. RESULTS A total of 10,538 consecutive IVH cases were prospectively screened for the trial between 2011 and 2015. Out of these, 496 cases (4.7%) screened negative for underlying vascular lesion, met the inclusion criteria, and were enrolled in the trial (no vascular etiology group); and 1,205 cases (11.4%) were concurrently screened and excluded from the trial because of a demonstrated underlying vascular lesion (vascular etiology group). Cases with vascular lesion were less likely to be >45 years of age (OR 0.28, 95% CI 0.20-0.40), African-American (OR 0.23, 95% CI 0.18-0.31), or male gender (OR 0.48, 95% CI 0.38-0.60), and more likely to present with primary IVH (OR 1.85, 95% CI 1.37-2.51) compared to those with no vascular etiology (p < 0.001). Other demographic factors were associated with specific vascular lesion etiologies. A combination of demographic features increases the association with the absence of vascular lesion, but not with absolute reliability (OR 0.1, 95% CI 0.06-0.17, p < 0.001). CONCLUSION An underlying vascular lesion as etiology of IVH cannot be excluded solely by demographic parameters in any patient. Some form of vascular imaging is necessary in screening patients before contemplating interventions like intraventricular fibrinolysis, where safety may be impacted by the presence of vascular lesion.
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Affiliation(s)
- Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, IL, USA
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1842
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Lattanzi S, Cagnetti C, Provinciali L, Silvestrini M. How Should We Lower Blood Pressure after Cerebral Hemorrhage? A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2017; 43:207-213. [DOI: 10.1159/000462986] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/09/2017] [Indexed: 11/19/2022] Open
Abstract
Background: The optimal treatment of high blood pressure (BP) after acute intra-cerebral hemorrhage (ICH) is controversial. Summary: The aim of the study was to evaluate the safety and efficacy of early intensive vs. conservative BP lowering treatment in patients with ICH. Randomized controlled trials with active and control groups receiving intensive and conservative BP lowering treatments were identified. The following outcomes were assessed: 3-month mortality and combined death or major disability, 24-h hematoma growth, early neurological deterioration, occurrence of hypotension, severe hypotension, and serious treatment-emergent adverse events. Five trials were included involving 4,350 participants, 2,162 and 2,188 for intensive and conservative treatment groups, respectively. The pooled risk ratio of 3-month death or major disability was 0.96 (0.91-1.01) and the weighted mean difference in absolute hematoma growth was -1.53 (95% CI -2.94 to -0.12) mL in the intensive compared to conservative BP-lowering. There were no differences across the treatments in the incidence rates of 3-month mortality, early neurological deterioration, hypotension, and treatment-related adverse effects other than renal events. Key Messages: The early intensive anti-hypertensive treatment was overall safe and reduced the hematoma expansion in patients presenting with acute-onset spontaneous ICH and high BP levels.
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1843
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Yin EB, Tan B, Nguyen T, Salazar M, Putney K, Gupta P, Suarez JI, Bershad EM. Safety and Effectiveness of Factor VIII Inhibitor Bypassing Activity (FEIBA) and Fresh Frozen Plasma in Oral Anticoagulant-Associated Intracranial Hemorrhage: A Retrospective Analysis. Neurocrit Care 2017; 27:51-59. [DOI: 10.1007/s12028-017-0383-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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1844
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Rasulo FA, Bertuetti R, Robba C, Lusenti F, Cantoni A, Bernini M, Girardini A, Calza S, Piva S, Fagoni N, Latronico N. The accuracy of transcranial Doppler in excluding intracranial hypertension following acute brain injury: a multicenter prospective pilot study. Crit Care 2017; 21:44. [PMID: 28241847 PMCID: PMC5329967 DOI: 10.1186/s13054-017-1632-2] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 02/13/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Untimely diagnosis of intracranial hypertension may lead to delays in therapy and worsening of outcome. Transcranial Doppler (TCD) detects variations in cerebral blood flow velocity which may correlate with intracranial pressure (ICP). We investigated if intracranial hypertension can be accurately excluded through use of TCD. METHOD This was a multicenter prospective pilot study in patients with acute brain injury requiring invasive ICP (ICPi) monitoring. ICP estimated with TCD (ICPtcd) was compared with ICPi in three separate time frames: immediately before ICPi placement, immediately after ICPi placement, and 3 hours following ICPi positioning. Sensitivity and specificity, and concordance correlation coefficient between ICPi and ICPtcd were calculated. Receiver operating curve (ROC) and the area under the curve (AUC) analyses were estimated after measurement averaging over time. RESULTS A total of 38 patients were enrolled, and of these 12 (31.6%) had at least one episode of intracranial hypertension. One hundred fourteen paired measurements of ICPi and ICPtcd were gathered for analysis. With dichotomized ICPi (≤20 mmHg vs >20 mmHg), the sensitivity of ICPtcd was 100%; all measurements with high ICPi (>20 mmHg) also had a high ICPtcd values. Bland-Altman plot showed an overestimation of 6.2 mmHg (95% CI 5.08-7.30 mmHg) for ICPtcd compared to ICPi. AUC was 96.0% (95% CI 89.8-100%) and the estimated best threshold was at ICPi of 24.8 mmHg corresponding to a sensitivity 100% and a specificity of 91.2%. CONCLUSIONS This study provides preliminary evidence that ICPtcd may accurately exclude intracranial hypertension in patients with acute brain injury. Future studies with adequate power are needed to confirm this result.
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Affiliation(s)
- Frank A. Rasulo
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Rita Bertuetti
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
| | - Chiara Robba
- Department of Neuro Critical Care, Addenbrookes NHS Trust University Hospital, Cambridge, UK
| | - Francesco Lusenti
- Department of Neuro Critical Care, A. Manzoni Hospital, Lecco, Italy
| | - Alfredo Cantoni
- Department of Anesthesia, Critical Care and Emergency, Circolo Fondazione Macchi Hospital, Varese, Italy
| | - Marta Bernini
- Department of Anesthesia, Critical Care and Emergency, Hospital of Cisanello, Pisa, Italy
| | - Alan Girardini
- Department of Anesthesia, Critical Care and Emergency, Fondazione Poliambulanza Hospital, Brescia, Italy
| | - Stefano Calza
- Unit of Biostatistics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
| | - Nazzareno Fagoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
| | - Nicola Latronico
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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1845
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Abstract
OPINION STATEMENT In the past two decades, there has been much focus on the adverse effect of fever on neurologic outcome, the benefits of hypothermia on functional outcomes, and the interplay of associated complications. Despite decades of experience regarding randomized, safety and feasibility, case-controlled, retrospective studies, there has yet to be a large, randomized, multicenter, clinical trial with the appropriate power to address the potential benefits of targeted temperature modulation compared to hypothermia alone. What remains unanswered is the appropriate timing of initiation, duration, rewarming speed, and depth of targeted temperature management. We learn from the cardiac arrest literature that there is a neuroprotective value to hypothermia and, most recently, near normothermia (36 °C) as well. We have also established that increased depths of cooling are associated with increases in shivering, which warrant more aggressive pharmacologic management. Normothermia also has the advantage of allowing for more rapid clearance of sedating medications and less confounding of neuroprognostication. More difficult to quantify is the increased nursing and patient care complexity associated with moderate hypothermia compared to normothermia. It remains crucial, for those patients who are being considered for hypothermia/normothermia, to be cared for in an experienced ICU, driven under protocol, with aggressive shivering management and an expectation and acceptance of the complications associated with targeted temperature management. If targeted temperature management is not of consideration, then aggressive fever control should be undertaken pharmacologically and non-invasively, as they have been shown to be safe.
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Affiliation(s)
- Jonathan Marehbian
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, 15 York Street, Building LLCI, 10th Floor, Suite 1003, New Haven, CT, 06520, USA.
| | - David M Greer
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, LLCI 912, 15 York Street, New Haven, CT, 06520-8018, USA
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1846
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Dastur CK, Yu W. Current management of spontaneous intracerebral haemorrhage. Stroke Vasc Neurol 2017; 2:21-29. [PMID: 28959487 PMCID: PMC5435209 DOI: 10.1136/svn-2016-000047] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 11/08/2016] [Indexed: 12/23/2022] Open
Abstract
Intracerebral haemorrhage (ICH) is the most devastating and disabling type of stroke. Uncontrolled hypertension (HTN) is the most common cause of spontaneous ICH. Recent advances in neuroimaging, organised stroke care, dedicated Neuro-ICUs, medical and surgical management have improved the management of ICH. Early airway protection, control of malignant HTN, urgent reversal of coagulopathy and surgical intervention may increase the chance of survival for patients with severe ICH. Intensive lowering of systolic blood pressure to <140 mm Hg is proven safe by two recent randomised trials. Transfusion of platelets in patients on antiplatelet therapy is not indicated unless the patient is scheduled for surgical evacuation of haematoma. In patients with small haematoma without significant mass effect, there is no indication for routine use of mannitol or hypertonic saline (HTS). However, for patients with large ICH (volume > 30 cbic centmetre) or symptomatic perihaematoma oedema, it may be beneficial to keep serum sodium level at 140–150 mEq/L for 7–10 days to minimise oedema expansion and mass effect. Mannitol and HTS can be used emergently for worsening cerebral oedema, elevated intracranial pressure (ICP) or pending herniation. HTS should be administered via central line as continuous infusion (3%) or bolus (23.4%). Ventriculostomy is indicated for patients with severe intraventricular haemorrhage, hydrocephalus or elevated ICP. Patients with large cerebellar or temporal ICH may benefit from emergent haematoma evacuation. It is important to start intermittent pneumatic compression devices at the time of admission and subcutaneous unfractionated heparin in stable patients within 48 hours of admission for prophylaxis of venous thromboembolism. There is no benefit for seizure prophylaxis or aggressive management of fever or hyperglycaemia. Early aggressive comprehensive care may improve survival and functional recovery.
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Affiliation(s)
- Cyrus K Dastur
- Department of Neurology, University of California Irvine, Irvine, California, USA
| | - Wengui Yu
- Department of Neurology, University of California Irvine, Irvine, California, USA
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1847
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Fassbender K, Grotta JC, Walter S, Grunwald IQ, Ragoschke-Schumm A, Saver JL. Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges. Lancet Neurol 2017; 16:227-237. [PMID: 28229894 DOI: 10.1016/s1474-4422(17)30008-x] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/02/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
In acute stroke management, time is brain. Bringing swift treatment to the patient, instead of the conventional approach of awaiting the patient's arrival at the hospital for treatment, is a potential strategy to improve clinical outcomes after stroke. This strategy is based on the use of an ambulance (mobile stroke unit) equipped with an imaging system, a point-of-care laboratory, a telemedicine connection to the hospital, and appropriate medication. Studies of prehospital stroke treatment consistently report a reduction in delays before thrombolysis and cause-based triage in regard to the appropriate target hospital (eg, primary vs comprehensive stroke centre). Moreover, novel medical options for the treatment of stroke patients are also under investigation, such as prehospital differential blood pressure management, reversal of warfarin effects in haemorrhagic stroke, and management of cerebral emergencies other than stroke. However, crucial concerns regarding safety, clinical efficacy, best setting, and cost-effectiveness remain to be addressed in further studies. In the future, mobile stroke units might allow the investigation of novel diagnostic (eg, biomarkers and automated imaging evaluation) and therapeutic (eg, neuroprotective drugs and treatments for haemorrhagic stroke) options in the prehospital setting, thus functioning as a tool for research on prehospital stroke management.
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Affiliation(s)
- Klaus Fassbender
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany.
| | - James C Grotta
- Department of Neurology, University of Texas Medical School at Houston, Houston, TX, USA
| | - Silke Walter
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Iris Q Grunwald
- Neuroscience and Vascular Simulation Unit, Faculty of Medical Science, PMI, Anglia Ruskin University, Chelmsford, UK; Department of Stroke Medicine, Southend University Hospital, Southend, UK
| | | | - Jeffrey L Saver
- Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
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1848
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Thorne K, McNaughton H, Weatherall M. An audit of coagulation screening in patients presenting to the emergency department for potential stroke thrombolysis. Intern Med J 2017; 47:189-193. [DOI: 10.1111/imj.13323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 10/19/2016] [Accepted: 10/27/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Katie Thorne
- Department of Medicine; Capital and Coast DHB; Wellington New Zealand
| | - Harry McNaughton
- Department of Neurology; Capital and Coast DHB; Wellington New Zealand
| | - Mark Weatherall
- Department of Medicine; Capital and Coast DHB; Wellington New Zealand
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1849
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Wang C, You C, Ma L, Liu M, Tian M, Li N. Acupuncture for acute moderate thalamic hemorrhage: randomized controlled trial study protocol. Altern Ther Health Med 2017; 17:112. [PMID: 28202067 PMCID: PMC5312440 DOI: 10.1186/s12906-017-1614-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/28/2017] [Indexed: 02/05/2023]
Abstract
Background Thalamic hemorrhage (TH) is a neurological insult with a high rate of morbidity and mortality. Moderate TH (10–30 ml) accounts for more than half of all TH. Treatment remains controversial. The role of acupuncture in patients with moderate TH is not clear. Methods We will conduct a single-center, randomized, parallel group, and assessor-blinded clinical trial. A total of 488 patients with moderate TH will be randomly assigned to one of eight groups: 10–15 cc left sided TH study group (N = 61) and a corresponding control group (N = 61), 10–15 cc right sided TH study group (N = 61) and a corresponding control group, 15–30 cc left sided TH study group (N = 61) and a corresponding control group (N = 61), and 15–30 cc right sided TH study group (N = 61) and a corresponding control group. Study groups will receive acupuncture in addition to standard treatment, while control groups will receive standard treatment alone. The primary outcome will be change in National Institutes of Health Stroke Scale scores at 30 and 90 days after TH. The secondary outcomes will be death or major disability, defined as a score of 3 to 6 on the modified Rankin scale (in which a score of 0 indicates no symptoms, a score of 5 indicates severe disability, and a score of 6 indicates death) at 90-days, need for surgery at 30-days, Glasgow Outcome Scale (GOS) score at 90-days following TH onset, and the results of several additional group specific tests. The rate of adverse events will then be compared between the groups. Discussion This study will attempt to answer the question of whether or not acupuncture can improve neurologic outcome following moderate TH. Trial registration Chinese clinical trial registry (ChiCTR-IOR-16008362)
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1850
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Abstract
PURPOSE OF REVIEW This article provides a synopsis of the immediate and delayed medical complications of stroke, with an emphasis on prevention and management of these complications. RECENT FINDINGS Meta-analysis of the trials for endovascular treatment of acute stroke shows no significant increase in hemorrhagic events. Rehabilitation guidelines published by the American Heart Association and American Stroke Association in 2016 aid in providing the best clinical practice for patients with stroke, from the time of their initial hospitalization to their return to the community. SUMMARY Medical complications from stroke are common and are associated with poor clinical outcomes, increased length of hospital stays and higher rates of readmission, increased cost of care, delayed time to rehabilitation, and increased mortality. Being cognizant of the common complications encountered, taking appropriate measures to prevent them, and knowing how to manage them when they do occur are essential to the continued care of patients with stroke.
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