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Apostolaki-Hansson T, Ullberg T, Pihlsgård M, Norrving B, Petersson J. Prognosis of Intracerebral Hemorrhage Related to Antithrombotic Use: An Observational Study From the Swedish Stroke Register (Riksstroke). Stroke 2021; 52:966-974. [PMID: 33563019 DOI: 10.1161/strokeaha.120.030930] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To date, large studies comparing mortality and functional outcome of intracerebral hemorrhage (ICH) during oral anticoagulant (OAC), antiplatelet, and nonantithrombotic use are few and show discrepant results. METHODS We used data on 13 291 patients with ICH registered in Riksstroke between 2012 and 2016 to compare 90-day mortality and functional outcome following OAC-related ICH (n=2300), antiplatelet-related ICH (n=3637), and nonantithrombotic ICH (n=7354). Univariable and multivariable Cox regression analyses, with adjustment for relevant confounders, were used to compare 90-day mortality. Early (≤24 hours and 1-7 days) and late (8-90 days) mortality was also studied in subgroup analyses. Univariable and multivariable 90-day functional outcome, based on self-reported modified Rankin Scale, was determined using logistic regression. RESULTS Patients with antithrombotic treatment were more often prestroke dependent, older, and had a larger comorbidity burden compared with patients without antithrombotic treatment. At 90 days, antiplatelet and OAC were associated with an increased death rate in multivariable analysis (antiplatelet ICH: hazard ratio, 1.23 [95% CI, 1.14-1.33]; OAC ICH: hazard ratio, 1.40 [95% CI, 1.26-1.57]) compared with nonantithrombotic ICH (reference). OAC ICH and antiplatelet ICH were associated with higher risk of early mortality (≤24 hours: OAC ICH: hazard ratio, 1.93 [95% CI, 1.57-2.38]; antiplatelet ICH: hazard ratio, 1.32 [95% CI, 1.13-1.54]). In multivariable analysis, the odds ratios for the association of antiplatelet and OAC treatment on functional dependency (modified Rankin Scale score, 3-5) at 90 days were nonsignificant (antiplatelet: odds ratio, 1.07 [95% CI, 0.92-1.24]; OAC: odds ratio, 0.96 [95% CI, 0.76-1.22]). CONCLUSIONS In this large observational study, we found that 90-day mortality outcome was worse not only in OAC ICH but also in antiplatelet ICH, compared with patients with nonantithrombotic ICH. Antiplatelet ICH is common and is a serious condition with poor clinical outcome. Further studies are, therefore, warranted in determining the appropriate clinical management of these patients.
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Affiliation(s)
- Trine Apostolaki-Hansson
- Department of Neurology, Lund University, Skåne University Hospital, Sweden (T.A.-H., T.U., B.N., J.P.)
| | - Teresa Ullberg
- Department of Neurology, Lund University, Skåne University Hospital, Sweden (T.A.-H., T.U., B.N., J.P.)
| | - Mats Pihlsgård
- Department of Geriatrics, Lund University, Skåne University Hospital, Malmö, Sweden (M.P.)
| | - Bo Norrving
- Department of Neurology, Lund University, Skåne University Hospital, Sweden (T.A.-H., T.U., B.N., J.P.)
| | - Jesper Petersson
- Department of Neurology, Lund University, Skåne University Hospital, Sweden (T.A.-H., T.U., B.N., J.P.)
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Exploration of Multiparameter Hematoma 3D Image Analysis for Predicting Outcome After Intracerebral Hemorrhage. Neurocrit Care 2021; 32:539-549. [PMID: 31359310 DOI: 10.1007/s12028-019-00783-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Rapid diagnosis and proper management of intracerebral hemorrhage (ICH) play a crucial role in the outcome. Prediction of the outcome with a high degree of accuracy based on admission data including imaging information can potentially influence clinical decision-making practice. METHODS We conducted a retrospective multicenter study of consecutive ICH patients admitted between 2012-2017. Medical history, admission data, and initial head computed tomography (CT) scan were collected. CT scans were semiautomatically segmented for hematoma volume, hematoma density histograms, and sphericity index (SI). Discharge unfavorable outcomes were defined as death or severe disability (modified Rankin Scores 4-6). We compared (1) hematoma volume alone; (2) multiparameter imaging data including hematoma volume, location, density heterogeneity, SI, and midline shift; and (3) multiparameter imaging data with clinical information available on admission for ICH outcome prediction. Multivariate analysis and predictive modeling were used to determine the significance of hematoma characteristics on the outcome. RESULTS We included 430 subjects in this analysis. Models using automated hematoma segmentation showed incremental predictive accuracies for in-hospital mortality using hematoma volume only: area under the curve (AUC): 0.85 [0.76-0.93], multiparameter imaging data (hematoma volume, location, CT density, SI, and midline shift): AUC: 0.91 [0.86-0.97], and multiparameter imaging data plus clinical information on admission (Glasgow Coma Scale (GCS) score and age): AUC: 0.94 [0.89-0.99]. Similarly, severe disability predictive accuracy varied from AUC: 0.84 [0.76-0.93] for volume-only model to AUC: 0.88 [0.80-0.95] for imaging data models and AUC: 0.92 [0.86-0.98] for imaging plus clinical predictors. CONCLUSIONS Multiparameter models combining imaging and admission clinical data show high accuracy for predicting discharge unfavorable outcome after ICH.
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Associations of Radiographic Cerebral Small Vessel Disease with Acute Intracerebral Hemorrhage Volume, Hematoma Expansion, and Intraventricular Hemorrhage. Neurocrit Care 2021; 32:383-391. [PMID: 31845173 PMCID: PMC7082383 DOI: 10.1007/s12028-019-00876-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVE The aim of this study was to evaluate the impact of radiographic cerebral small vessel disease (CSVD) on the severity of acute intracerebral hemorrhage (ICH) as measured by: ICH volume, hematoma expansion, and extension of intraventricular hemorrhage (IVH). METHODS CSVD was determined on baseline computed tomography (CT) scans of patients from the Ethnic and Racial Variations of Intracerebral Hemorrhage study through the extent of leukoaraiosis and cerebral atrophy using visual rating scales. The associations of leukoaraiosis and atrophy with ICH volume, hematoma expansion, IVH presence, and severity of IVH were tested using multivariable regression models. Secondary analyses were stratified by hemorrhage location. Bonferroni correction was applied to correct for multiple testing. RESULTS A total of 2579 patients (mean age 61.7 years, 59% male) met inclusion criteria. Median ICH volume was 10.5 (Interquartile range [IQR] 4.0-25.3) mL. IVH was detected in 971 patients (38%). Neither leukoaraiosis nor atrophy was associated with hematoma expansion. Increasing grades of leukoaraiosis were associated with increased risk of IVH in a dose-dependent manner, while cerebral atrophy was inversely associated with IVH (both P for trend < 0.001). Increasing grades of global atrophy were dose-dependently associated with lower ICH volumes (ß (95% Confidence Interval [CI]) - 0.30[- 0.46, - 0.14], - 0.33[- 0.49, - 0.17], - 0.40[- 0.60, - 0.20], and - 0.54[- 0.76, - 0.32], for grades 1, 2, 3 and 4 compared to 0; all P < 0.001). The associations of leukoaraiosis with ICH volume were consistent with those of atrophy, albeit not meeting statistical significance. CONCLUSIONS Leukoaraiosis and cerebral atrophy appear to have opposing associations with ICH severity. Cerebral atrophy correlates with smaller ICH volume and decreased risk and severity of IVH, while leukoaraiosis is associated with increased risk of IVH. Whether these observations reflect overlapping or divergent underlying mechanisms requires further study.
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154
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Chen Q, Xia T, Zhang M, Xia N, Liu J, Yang Y. Radiomics in Stroke Neuroimaging: Techniques, Applications, and Challenges. Aging Dis 2021; 12:143-154. [PMID: 33532134 PMCID: PMC7801280 DOI: 10.14336/ad.2020.0421] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/21/2020] [Indexed: 12/11/2022] Open
Abstract
Stroke is a leading cause of disability and mortality worldwide, resulting in substantial economic costs for post-stroke care each year. Neuroimaging, such as cranial computed tomography or magnetic resonance imaging, is the backbone of stroke management strategies, which can guide treatment decision-making (thrombolysis or hemostasis) at an early stage. With advances in computational technologies, particularly in machine learning, visual image information can now be converted into numerous quantitative features in an objective, repeatable, and high-throughput manner, in a process known as radiomics. Radiomics is mainly used in the field of oncology, which remains an area of active research. Over the past few years, investigators have attempted to apply radiomics to stroke in the hope of gaining benefits similar to those obtained in cancer management, i.e., in promoting the development of personalized precision medicine. Currently, radiomic analysis has shown promise for a variety of applications in stroke, including the diagnosis of stroke lesions, early prediction of outcomes, and evaluation for long-term prognosis. In this article, we elaborate the contributions of radiomics to stroke, as well as the subprocesses and techniques involved in radiomics studies. We also discuss the potential challenges facing its widespread implementation in routine practice and the directions for future research.
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Affiliation(s)
- Qian Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Tianyi Xia
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Mingyue Zhang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Nengzhi Xia
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Jinjin Liu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
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Shiga Y, Aoki S, Hosomi N, Nomura R, Nakamori M, Nezu T, Tachiyama K, Kamimura T, Kinoshita N, Shimomura R, Hayashi Y, Matsushima H, Imamura E, Ueno H, Wakabayashi S, Nakano K, Kohriyama T, Maruyama H. cnm-Positive Streptococcus mutans and diffusion-weighted imaging hyperintensities in acute intracerebral hemorrhage. Eur J Neurol 2021; 28:1581-1589. [PMID: 33426742 DOI: 10.1111/ene.14725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Strains of Streptococcus mutans expressing the cell surface collagen-binding protein, Cnm, encoded by cnm (cnm-positive S. mutans), are associated with hypertensive intracerebral hemorrhage (ICH) and the occurrence of cerebral microbleeds (CMBs). Small diffusion-weighted imaging (DWI) hyperintensities in patients with acute ICH are also associated with CMBs. However, the association between cnm-positive S. mutans and DWI hyperintensities is unclear. Hence, this study aimed to investigate the association between cnm-positive S. mutans and DWI hyperintensities in patients with acute ICH. METHODS Patients with acute ICH were prospectively registered at three hospitals. Dental plaque specimens were collected within 4 days after admission, and cnm-positive S. mutans was detected using the polymerase chain reaction. Magnetic resonance imaging at 14 ± 5 days after admission was used to evaluate DWI hyperintensities and CMBs. RESULTS A total of 197 patients were enrolled in this study. cnm-positive S. mutans was detected in 30 patients (15.2%), and DWI hyperintensities were observed in 56 patients (28.4%). Patients with cnm-positive S. mutans had a higher frequency of DWI hyperintensities (50.0% vs 24.6%; p = 0.008) and a higher number of CMBs (5.5 vs 1.5; p < 0.001) than those without cnm-positive S. mutans. Multivariable logistic analysis revealed that the presence of cnm-positive S. mutans was independently associated with DWI hyperintensities (OR 2.38; 95% CI 1.01-5.61; p = 0.047) after adjusting for several confounding factors. CONCLUSION This study found an association between the presence of cnm-positive S. mutans and DWI hyperintensities in patients with acute ICH.
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Affiliation(s)
- Yuji Shiga
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Shiro Aoki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Naohisa Hosomi
- Department of Neurology, Chikamori Hospital, Kochi, Japan.,Department of Disease Model, Research Institute of Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Ryota Nomura
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Osaka, Japan
| | - Masahiro Nakamori
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan.,Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Tomohisa Nezu
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Keisuke Tachiyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan.,Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Teppei Kamimura
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan.,Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Naoto Kinoshita
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan.,Department of Neurology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Ryo Shimomura
- Department of Neurology, Brain Attack Center Ota Memorial Hospital, Fukuyama, Hiroshima, Japan
| | - Yuki Hayashi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan.,Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Hayato Matsushima
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Eiji Imamura
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Hiroki Ueno
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | | | - Kazuhiko Nakano
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Osaka, Japan
| | - Tatsuo Kohriyama
- Department of Neurology, Brain Attack Center Ota Memorial Hospital, Fukuyama, Hiroshima, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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Deep learning shows good reliability for automatic segmentation and volume measurement of brain hemorrhage, intraventricular extension, and peripheral edema. Eur Radiol 2021; 31:5012-5020. [PMID: 33409788 DOI: 10.1007/s00330-020-07558-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/25/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To evaluate for the first time the performance of a deep learning method based on no-new-Net for fully automated segmentation and volumetric measurements of intracerebral hemorrhage (ICH), intraventricular extension of intracerebral hemorrhage (IVH), and perihematomal edema (PHE) in primary ICH on CT. METHODS Three hundred and eighty primary ICH patients who underwent CT at hospital arrival were divided into a training cohort (n = 300) and a validation cohort (n = 80). An independent cohort with 80 patients was used for testing. Ground truth (segmentation masks) was manually generated by radiologists. Model performance on lesion segmentation and volumetric measurement of ICH, IVH, and PHE were evaluated by comparing the model results with the segmentations performed by radiologists. RESULTS In the test cohort, the Dice scores of lesion segmentation were 0.92, 0.79, and 0.71 for ICH, IVH, and PHE, respectively. The sensitivities were 0.93 for ICH, 0.88 for IVH, and 0.81 for PHE. The positive predictive values were 0.92, 0.76, and 0.69 for ICH, IVH, and PHE, respectively. Excellent concordance (concordance correlation coefficients [CCCs] ≥ 0.98) of ICH and IVH and good concordance of PHE (CCCs ≥ 0.92) were demonstrated between manually and automatically measured volumes. The model took approximately 15 s to provide automatic segmentation and volume analysis for each patient. CONCLUSION Our model demonstrates good reliability for automatic segmentation and volume measurement of ICH, IVH, and PHE in primary ICH, which can be useful to reduce the effort and time of doctors to calculate volumes of ICH, IVH, and PHE. KEY POINTS • Deep learning algorithms can provide automatic and reliable assessment of intracerebral hemorrhage, intraventricular hemorrhage, and perihematomal edema on CT. • Non-contrast CT-based deep learning method can be helpful to provide efficient and accurate measurements of ICH, IVH, and PHE in primary ICH patients, thereby reducing the effort and time of doctors to segment and calculate volumes of ICH, IVH, and PHE in primary ICH patients.
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Management of Intracerebral Hemorrhage: JACC Focus Seminar. J Am Coll Cardiol 2020; 75:1819-1831. [PMID: 32299594 DOI: 10.1016/j.jacc.2019.10.066] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 10/27/2019] [Indexed: 01/12/2023]
Abstract
Intracerebral hemorrhage (ICH) accounts for a disproportionate amount of stroke-related morbidity and mortality. Although chronic hypertension and cerebral amyloid angiopathy are the underlying cerebral vasculopathies accounting for the majority of ICH, there are a broad range of potential causes, and effective management requires accurate identification and treatment of the underlying mechanism of hemorrhage. Magnetic resonance imaging and vascular imaging techniques play a critical role in identifying disease mechanisms. Modern treatment of ICH focuses on rapid stabilization, often requiring urgent treatment of mass effect, aggressive blood pressure reduction and correction of contributing coagulopathies to achieve hemostasis. We discuss management of patients with ICH who continue to require long-term anticoagulation, the interaction of ICH with neurodegenerative diseases, and our approach to prognostication after ICH. We close this review with a discussion of novel medical and surgical approaches to ICH treatment that are being tested in clinical trials.
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158
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McGurgan IJ, Ziai WC, Werring DJ, Al-Shahi Salman R, Parry-Jones AR. Acute intracerebral haemorrhage: diagnosis and management. Pract Neurol 2020; 21:practneurol-2020-002763. [PMID: 33288539 PMCID: PMC7982923 DOI: 10.1136/practneurol-2020-002763] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2020] [Indexed: 12/11/2022]
Abstract
Intracerebral haemorrhage (ICH) accounts for half of the disability-adjusted life years lost due to stroke worldwide. Care pathways for acute stroke result in the rapid identification of ICH, but its acute management can prove challenging because no individual treatment has been shown definitively to improve its outcome. Nonetheless, acute stroke unit care improves outcome after ICH, patients benefit from interventions to prevent complications, acute blood pressure lowering appears safe and might have a modest benefit, and implementing a bundle of high-quality acute care is associated with a greater chance of survival. In this article, we address the important questions that neurologists face in the diagnosis and acute management of ICH, and focus on the supporting evidence and practical delivery for the main acute interventions.
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Affiliation(s)
- Iain J McGurgan
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Wendy C Ziai
- Division of Brain Injury Outcomes, Department of Neurology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, UCL, London, UK
| | | | - Adrian R Parry-Jones
- Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
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159
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Silva Blas Y, Diringer MN, Lo B, Masjuan J, Pérez de la Ossa N, Cardinal M, Yong F, Zhu T, Li G, Arkin S. Phase 1b Study to Evaluate Safety, Tolerability, and Maximum Tolerated Dose of PF-05230907 for Intracerebral Hemorrhage. Stroke 2020; 52:294-298. [PMID: 33272131 DOI: 10.1161/strokeaha.120.029789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE This study aimed to determine the maximum tolerated dose and to evaluate the overall safety and tolerability of single doses of PF-05230907 in subjects with acute intracerebral hemorrhage. METHODS Individuals presenting with intracerebral hemorrhage were enrolled in a phase 1, multicenter, open-label clinical trial. A Bayesian modified continual reassessment method design based on treatment-emergent thromboembolic or ischemic events was adopted. Sequential dosing, an external data monitoring committee, and prespecified stopping rules were incorporated as safeguards. RESULTS Twenty-one subjects received PF-05230907. The mean (±SD) age in years and intracerebral hemorrhage volume in mL at baseline were 62 (±9) and 18 (±11), respectively. Two treatment-emergent thromboembolic or ischemic events occurred (deep vein thrombosis and cerebral ischemia), in the 30 μg/kg dose group. There were no other clear drug-related toxicities at dose levels ranging from 5 to 30 μg/kg. At the time of study termination, the maximum tolerated dose was estimated to be 24 μg/kg, with a mean fitted dose-toxicity estimate of 11.9% (95% CI, 1.2%-27.4%). CONCLUSIONS Single doses of PF-05230907 appeared to be tolerated across a range of doses in the intracerebral hemorrhage population, with thrombotic events observed only at the highest dose level tested. Recruitment within the recommended therapeutic window of opportunity remains a challenge. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02687191.
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Affiliation(s)
| | | | - Benjamin Lo
- Montreal Neurological Institute, Quebec, Canada (B.L.)
| | - Jaime Masjuan
- Hospital Universitario Ramón y Cajal, Madrid, Spain (J.M.)
| | | | | | | | - Tong Zhu
- Pfizer Inc, Cambridge, MA (M.C., F.Y., T.Z., S.A.)
| | - Gang Li
- Pfizer Inc, Collegeville, PA (G.L.)
| | - Steven Arkin
- Pfizer Inc, Cambridge, MA (M.C., F.Y., T.Z., S.A.)
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160
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Toyoda K, Palesch YY, Koga M, Foster L, Yamamoto H, Yoshimura S, Ihara M, Fukuda-Doi M, Okazaki S, Tanaka K, Miwa K, Hasegawa Y, Shiokawa Y, Iwama T, Kamiyama K, Hoshino H, Steiner T, Yoon BW, Wang Y, Hsu CY, Qureshi AI. Regional Differences in the Response to Acute Blood Pressure Lowering After Cerebral Hemorrhage. Neurology 2020; 96:e740-e751. [PMID: 33219136 PMCID: PMC7884997 DOI: 10.1212/wnl.0000000000011229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/25/2020] [Indexed: 01/10/2023] Open
Abstract
Objective To compare the impact of intensive blood pressure (BP) lowering right after intracerebral hemorrhage (ICH) on clinical and hematoma outcomes among patients from different geographic locations, we performed a prespecified subanalysis of a randomized, multinational, 2-group, open-label trial to determine the efficacy of rapidly lowering BP in hyperacute ICH (Antihypertensive Treatment of Acute Cerebral Hemorrhage [ATACH]-2), involving 537 patients from East Asia and 463 recruited outside of Asia. Methods Eligible patients were randomly assigned to a systolic BP target of 110 to 139 mm Hg (intensive treatment) or 140 to 179 mm Hg (standard treatment). Predefined outcomes were poor functional outcome (modified Rankin Scale score 4–6 at 90 days), death within 90 days, hematoma expansion at 24 hours, and cardiorenal adverse events within 7 days. Results Poor functional outcomes (32.0% vs 45.9%), death (1.9% vs 13.3%), and cardiorenal adverse events (3.9% vs 11.2%) occurred significantly less frequently in patients from Asia than those outside of Asia. The treatment-by-cohort interaction was not significant for any outcomes. Only patients from Asia showed a lower incidence of hematoma expansion with intensive treatment (adjusted relative risk [RR] 0.56, 95% confidence interval [CI] 0.38–0.83). Both Asian (RR 3.53, 95% CI 1.28–9.64) and non-Asian (RR 1.71, 95% CI 1.00–2.93) cohorts showed a higher incidence of cardiorenal adverse events with intensive treatment. Conclusions Poor functional outcomes and death 90 days after ICH were less common in patients from East Asia than those outside of Asia. Hematoma expansion, a potential predictor for poor clinical outcome, was attenuated by intensive BP lowering only in the Asian cohort. ClinicalTrials.gov Identifier NCT01176565. Classification of Evidence This study provides Class II evidence that, for patients from East Asia with ICH, intensive blood pressure lowering significantly reduces the risk of hematoma expansion.
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Affiliation(s)
- Kazunori Toyoda
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis.
| | - Yuko Y Palesch
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Masatoshi Koga
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Lydia Foster
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Haruko Yamamoto
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Sohei Yoshimura
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Masafumi Ihara
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Mayumi Fukuda-Doi
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Shuhei Okazaki
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Kanta Tanaka
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Kaori Miwa
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Yasuhiro Hasegawa
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Yoshiaki Shiokawa
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Toru Iwama
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Kenji Kamiyama
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Haruhiko Hoshino
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Thorsten Steiner
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Byung-Woo Yoon
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Yongjun Wang
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Chung Y Hsu
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Adnan I Qureshi
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
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Shoamanesh A, Patrice Lindsay M, Castellucci LA, Cayley A, Crowther M, de Wit K, English SW, Hoosein S, Huynh T, Kelly M, O'Kelly CJ, Teitelbaum J, Yip S, Dowlatshahi D, Smith EE, Foley N, Pikula A, Mountain A, Gubitz G, Gioia LC. Canadian stroke best practice recommendations: Management of Spontaneous Intracerebral Hemorrhage, 7th Edition Update 2020. Int J Stroke 2020; 16:321-341. [PMID: 33174815 DOI: 10.1177/1747493020968424] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the Canadian Stroke Best Practice Recommendations includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The Canadian Stroke Best Practice Recommendations (CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.
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Affiliation(s)
- Ashkan Shoamanesh
- Faculty of Medicine (Neurology), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Division of Neurology, Hamilton, Canada
| | | | - Lana A Castellucci
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Medicine, Divisions of Hematology and General Internal Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Anne Cayley
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Kerstin de Wit
- Department of Medicine (Emergency Medicine), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Divisions of Emergency Medicine and Thrombosis, Hamilton, Canada
| | - Shane W English
- Ottawa Hospital Research Institute (Clinical Epidemiology Program), Ottawa, Canada.,University of Ottawa, Department of Medicine (Critical Care) and School of Epidemiology and Public Health, Ottawa, Canada
| | - Sharon Hoosein
- Trillium Health Partners Stroke Program, Mississauga, Canada
| | - Thien Huynh
- Department of Diagnostic and Interventional Neuroradiology, Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Michael Kelly
- Department of Neurosurgery, University of Saskatchewan, Saskatoon, Canada
| | - Cian J O'Kelly
- Department of Neurological Surgery, University of Alberta, Edmonton, Canada
| | - Jeanne Teitelbaum
- Department of Neurology, Universite de Montreal, Montreal, Canada.,Department of Neurocritical Care, Montreal Neurological Institute MUHC, Montreal, Canada
| | - Samuel Yip
- Faculty of Medicine (Neurology), University of British Columbia, Vancouver, Canada
| | | | - Eric E Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Aleksandra Pikula
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Anita Mountain
- Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Canada.,Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehabilitation Centre Site, Halifax, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Stroke Program, Halifax, Canada
| | - Laura C Gioia
- Department of Neurology, Universite de Montreal, Montreal, Canada.,CHUM-Centre Hospitalier de l'Université de Montréal, Stroke Program, Montréal, Canada
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162
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Desborough MJR, Al-Shahi Salman R, Stanworth SJ, Havard D, Brennan PM, Dineen RA, Coats TJ, Hepburn T, Bath PM, Sprigg N. Desmopressin for reversal of Antiplatelet drugs in Stroke due to Haemorrhage (DASH): protocol for a phase II double-blind randomised controlled feasibility trial. BMJ Open 2020; 10:e037555. [PMID: 33172941 PMCID: PMC7656949 DOI: 10.1136/bmjopen-2020-037555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/09/2020] [Accepted: 07/30/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Intracerebral haemorrhage (ICH) can be devastating and is a common cause of death and disability worldwide. Pre-ICH antiplatelet drug use is associated with a 27% relative increase in 1 month case fatality compared with patients not using antithrombotic drugs. We aim to assess the feasibility of conducting a randomised controlled testing the safety and efficacy of desmopressin for patients with antiplatelet-associated ICH. METHODS AND ANALYSIS We aim to include 50 patients within 24 hours of spontaneous ICH onset, associated with oral antiplatelet drug(s) use in at least the preceding 7 days. Patients will be randomised (1:1) to receive intravenous desmopressin 20 µg in 50 mL sodium chloride 0.9% infused over 20 min or matching placebo. We will mask participants, relatives and outcome assessors to treatment allocation. Feasibility outcomes include proportion of patients approached being randomised, number of patients receiving allocated treatment, rate of recruitment and adherence to treatment and follow-up. Secondary outcomes include change in ICH volume at 24 hours; hyponatraemia at 24 hours, length of hospital stay, discharge destination, early death less than 28 days, death or dependency at day 90, death up to day 90, serious adverse events (including thromboembolic events) up to day 90; disability (Barthel index, day 90), quality of life (EuroQol 5D (EQ-5D), day 90), cognition (telephone mini-mental state examination day 90) and health economic assessment (EQ-5D). ETHICS AND DISSEMINATION The Desmopressin for reversal of Antiplatelet drugs in Stroke due to Haemorrhage (DASH) trial received ethical approval from the East Midlands-Nottingham 2 research ethics committee (18/EM/0184). The DASH trial is funded by National Institute for Health and Care Research RfPB grant: PB-PG-0816-20011. Trial results will be published in a peer reviewed academic journal and disseminated through academic conferences and through patient stroke support groups. Reporting will be in compliance with Consolidated Standards of Reporting Trials recommendations. TRIAL REGISTRATION NUMBERS NCT03696121; ISRCTN67038373; EudraCT 2018-001904-12.
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Affiliation(s)
| | | | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Diane Havard
- Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Nottignham University Hospitals NHS Trust, Nottingham, UK
| | - Paul M Brennan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Robert A Dineen
- Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Nottignham University Hospitals NHS Trust, Nottingham, UK
| | - Timothy J Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Trish Hepburn
- Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Nottignham University Hospitals NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Nottignham University Hospitals NHS Trust, Nottingham, UK
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The STOP-AUST trial: a test for the spot sign in intracerebral haemorrhage. Lancet Neurol 2020; 19:964-965. [PMID: 33128911 DOI: 10.1016/s1474-4422(20)30398-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/23/2022]
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Clinical and radiological characteristics and outcome of wake-up intracerebral hemorrhage. Sci Rep 2020; 10:18749. [PMID: 33127937 PMCID: PMC7603492 DOI: 10.1038/s41598-020-75750-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/16/2020] [Indexed: 12/12/2022] Open
Abstract
There is little information on the characteristics of patients with wake-up intracerebral hemorrhage (WU-ICH). We aimed to evaluate frequency and relevant differences between WU-ICH and while-awake (WA) ICH patients. This is a retrospective study of a prospective database of consecutive patients with spontaneous ICH, who were classified as WU-ICH, WA-ICH or UO-ICH (unclear onset). We collected demographic, clinical and radiological data, prognostic and therapeutic variables, and outcome [(neurological deterioration, mortality, functional outcome (favorable when modified Rankin scale score 0-2)]. From a total of 466 patients, 98 (25.8%) were classified as UO-ICH according to the type of onset and therefore excluded. We studied 368 patients (mean age 73.9 ± 13.8, 51.4% men), and compared 95 (25.8%) WU-ICH with 273 (74.2%) WA-ICH. Patients from the WU-ICH group were significantly older than WA-ICH (76.9 ± 14.3 vs 72.8 ± 13.6, p = 0.01) but the vascular risk factors were similar. Compared to the WA-ICH group, patients from the WU-ICH group had a lower GCS score or a higher NIHSS score and a higher ICH score, and were less often admitted to a stroke unit or intensive care unit. There were no differences between groups in location, volume, rate of hematoma growth, frequency of intraventricular hemorrhage and outcome. One in five patients with spontaneous ICH are WU-ICH patients. Other than age, there are no relevant differences between WU and WA groups. Although WU-ICH is associated with worse prognostic markers vital and functional outcome is similar to WA-ICH patients.
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165
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Yu H, Cao X, Li W, Liu P, Zhao Y, Song L, Chen J, Chen B, Yu W, Xu Y. Targeting connexin 43 provides anti-inflammatory effects after intracerebral hemorrhage injury by regulating YAP signaling. J Neuroinflammation 2020; 17:322. [PMID: 33115476 PMCID: PMC7594305 DOI: 10.1186/s12974-020-01978-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/01/2020] [Indexed: 12/17/2022] Open
Abstract
Background In the central nervous system (CNS), connexin 43 (Cx43) is mainly expressed in astrocytes and regulates astrocytic network homeostasis. Similar to Cx43 overexpression, abnormal excessive opening of Cx43 hemichannels (Cx43Hcs) on reactive astrocytes aggravates the inflammatory response and cell death in CNS pathologies. However, the role of excessive Cx43Hc opening in intracerebral hemorrhage (ICH) injury is not clear. Methods Hemin stimulation in primary cells and collagenase IV injection in C57BL/6J (B6) mice were used as ICH models in vitro and in vivo. After ICH injury, the Cx43 mimetic peptide Gap19 was used for treatment. Ethidium bromide (EtBr) uptake assays were used to measure the opening of Cx43Hcs. Western blotting and immunofluorescence were used to measure protein expression. qRT-PCR and ELISA were used to determine the levels of cytokines. Coimmunoprecipitation (Co-IP) and the Duolink in situ proximity ligation assay (PLA) were applied to measure the association between proteins. Results In this study, Cx43 expression upregulation and excessive Cx43Hc opening was observed in mice after ICH injury. Delayed treatment with Gap19 significantly alleviated hematoma volume and neurological deficits after ICH injury. In addition, Gap19 decreased inflammatory cytokine levels in the tissue surrounding the hematoma and decreased reactive astrogliosis after ICH injury in vitro and in vivo. Intriguingly, Cx43 transcriptional activity and expression in astrocytes were significantly increased after hemin stimulation in culture. However, Gap19 treatment downregulated astrocytic Cx43 expression through the ubiquitin-proteasome pathway without affecting Cx43 transcription. Additionally, our data showed that Gap19 increased Yes-associated protein (YAP) nuclear translocation. This subsequently upregulated SOCS1 and SOCS3 expression and then inhibited the TLR4-NFκB and JAK2-STAT3 pathways in hemin-stimulated astrocytes. Finally, the YAP inhibitor, verteporfin (VP), reversed the anti-inflammatory effect of Gap19 in vitro and almost completely blocked its protective effects in vivo after ICH injury. Conclusions This study provides new insight into potential treatment strategies for ICH injury involving astroglial Cx43 and Cx43Hcs. Suppression of abnormal astroglial Cx43 expression and Cx43Hc opening by Gap19 has anti-inflammatory and neuroprotective effects after ICH injury.
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Affiliation(s)
- Hailong Yu
- Affiliated of Drum Tower Hospital, Medical school of Nanjing University, Nanjing, Jiangsu, People's Republic of China.,Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu, People's Republic of China.,Department of Neurology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, People's Republic of China
| | - Xiang Cao
- Affiliated of Drum Tower Hospital, Medical school of Nanjing University, Nanjing, Jiangsu, People's Republic of China
| | - Wei Li
- Department of Neurology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, People's Republic of China.,Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Pinyi Liu
- Affiliated of Drum Tower Hospital, Medical school of Nanjing University, Nanjing, Jiangsu, People's Republic of China
| | - Yuanyuan Zhao
- Department of Neurology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, People's Republic of China.,Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Lilong Song
- Department of Neurology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, People's Republic of China.,Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Jian Chen
- Affiliated of Drum Tower Hospital, Medical school of Nanjing University, Nanjing, Jiangsu, People's Republic of China
| | - Beilei Chen
- Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu, People's Republic of China.,Department of Neurology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, People's Republic of China.,Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Wenkui Yu
- Affiliated of Drum Tower Hospital, Medical school of Nanjing University, Nanjing, Jiangsu, People's Republic of China.
| | - Yun Xu
- Affiliated of Drum Tower Hospital, Medical school of Nanjing University, Nanjing, Jiangsu, People's Republic of China.
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166
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Meretoja A, Yassi N, Wu TY, Churilov L, Sibolt G, Jeng JS, Kleinig T, Spratt NJ, Thijs V, Wijeratne T, Cho DY, Shah D, Cloud GC, Phan T, Bladin C, Moey A, Aviv RI, Barras CD, Sharma G, Hsu CY, Ma H, Campbell BCV, Mitchell P, Yan B, Parsons MW, Tiainen M, Curtze S, Strbian D, Tang SC, Harvey J, Levi C, Donnan GA, Davis SM. Tranexamic acid in patients with intracerebral haemorrhage (STOP-AUST): a multicentre, randomised, placebo-controlled, phase 2 trial. Lancet Neurol 2020; 19:980-987. [PMID: 33128912 DOI: 10.1016/s1474-4422(20)30369-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/08/2020] [Accepted: 09/22/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Despite intracerebral haemorrhage causing 5% of deaths worldwide, few evidence-based therapeutic strategies other than stroke unit care exist. Tranexamic acid decreases haemorrhage in conditions such as acute trauma and menorrhoea. We aimed to assess whether tranexamic acid reduces intracerebral haemorrhage growth in patients with acute intracerebral haemorrhage. METHODS We did a prospective, double-blind, randomised, placebo-controlled, investigator-led, phase 2 trial at 13 stroke centres in Australia, Finland, and Taiwan. Patients were eligible if they were aged 18 years or older, had an acute intracerebral haemorrhage fulfilling clinical criteria (eg, Glasgow Coma Scale score of >7, intracerebral haemorrhage volume <70 mL, no identified or suspected secondary cause of intracerebral haemorrhage, no thrombotic events within the previous 12 months, no planned surgery in the next 24 h, and no use of anticoagulation), had contrast extravasation on CT angiography (the so-called spot sign), and were treatable within 4·5 h of symptom onset and within 1 h of CT angiography. Patients were randomly assigned (1:1) to receive either 1 g of intravenous tranexamic acid over 10 min followed by 1 g over 8 h or matching placebo, started within 4·5 h of symptom onset. Randomisation was done using a centralised web-based procedure with randomly permuted blocks of varying size. All patients, investigators, and staff involved in patient management were masked to treatment. The primary outcome was intracerebral haemorrhage growth (>33% relative or >6 mL absolute) at 24 h. The primary and safety analyses were done in the intention-to-treat population. The trial is registered at ClinicalTrials.gov (NCT01702636). FINDINGS Between March 1, 2013, and Aug 13, 2019, we enrolled and randomly assigned 100 participants to the tranexamic acid group (n=50) or the placebo group (n=50). Median age was 71 years (IQR 57-79) and median intracerebral haemorrhage volume was 14·6 mL (7·9-32·7) at baseline. The primary outcome was not different between the two groups: 26 (52%) patients in the placebo group and 22 (44%) in the tranexamic acid group had intracerebral haemorrhage growth (odds ratio [OR] 0·72 [95% CI 0·32-1·59], p=0·41). There was no evidence of a difference in the proportions of patients who died or had thromboembolic complications between the groups: eight (16%) in the placebo group vs 13 (26%) in the tranexamic acid group died and two (4%) vs one (2%) had thromboembolic complications. None of the deaths was considered related to study medication. INTERPRETATION Our study does not provide evidence that tranexamic acid prevents intracerebral haemorrhage growth, although the treatment was safe with no increase in thromboembolic complications. Larger trials of tranexamic acid, with simpler recruitment methods and an earlier treatment window, are justified. FUNDING National Health and Medical Research Council, Royal Melbourne Hospital Foundation.
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Affiliation(s)
- Atte Meretoja
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Helsinki University Hospital, Helsinki, Finland.
| | - Nawaf Yassi
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Teddy Y Wu
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Leonid Churilov
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Mathematics and Statistics, University of Melbourne, Melbourne, VIC, Australia
| | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Neil J Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Vincent Thijs
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Department of Neurology, Austin Hospital, Heidelberg, VIC, Australia
| | - Tissa Wijeratne
- Department of Neurology, Western Hospital, Melbourne, VIC, Australia
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Darshan Shah
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Monash University, Melbourne, VIC, Australia; Department of Clinical Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Thanh Phan
- Department of Neurology, Monash Medical Centre, Monash University, Melbourne, VIC, Australia; School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Christopher Bladin
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Department of Neurosciences, Eastern Health Medical School, Monash University, Melbourne, VIC, Australia; Ambulance Victoria, Melbourne, VIC, Australia
| | - Andrew Moey
- Department of Neurology, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Richard I Aviv
- Department of Radiology, Neuroradiology Section, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Christen D Barras
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; South Australian Health and Medical Research Institute, The University of Adelaide, Adelaide, SA, Australia
| | - Gagan Sharma
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Chung Y Hsu
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Henry Ma
- Department of Neurology, Monash Medical Centre, Monash University, Melbourne, VIC, Australia; School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Bruce C V Campbell
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Bernard Yan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Mark W Parsons
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Marjaana Tiainen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Sami Curtze
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jackson Harvey
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia; Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
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167
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Murthy S, Roh DJ, Chatterjee A, McBee N, Parikh NS, Merkler AE, Navi BB, Falcone GJ, Sheth KN, Awad I, Hanley D, Kamel H, Ziai WC. Prior antiplatelet therapy and haematoma expansion after primary intracerebral haemorrhage: an individual patient-level analysis of CLEAR III, MISTIE III and VISTA-ICH. J Neurol Neurosurg Psychiatry 2020; 92:jnnp-2020-323458. [PMID: 33106367 PMCID: PMC8071838 DOI: 10.1136/jnnp-2020-323458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/22/2020] [Accepted: 06/04/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the relationship between prior antiplatelet therapy (APT) and outcomes after primary intracerebral haemorrhage (ICH), and assess if it varies by haematoma location. METHODS We pooled individual patient data from the Virtual International Stroke Trials Archive-ICH trials dataset, Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase III trial. The exposure was APT preceding ICH diagnosis. The primary outcome was haematoma expansion at 72 hours. Secondary outcomes were admission haematoma volume, all-cause mortality, death or major disability (modified Rankin Scale (mRS) score ≥4) and shift in mRS distribution. Mixed-effects models were used to assess the relationship between APT and outcomes. Secondary analyses were stratified by ICH location and study cohort. RESULTS Among 1420 patients with ICH, there were 782 (55.1%) lobar and 596 (42.0%) deep haemorrhages. APT was reported in 284 (20.0%) patients. In adjusted regression models, prior APT was not associated with haematoma expansion (OR, 0.97; 95% CI 0.60 to 1.57), major disability or death (OR, 1.05; 95% CI 0.61 to 1.63), all-cause mortality (OR, 0.89; 95% CI 0.47 to 1.85), admission haematoma volume (beta, -0.17; SE, 0.09; p=0.07) and shift in mRS (p=0.43). In secondary analyses, APT was associated with admission haematoma volume in lobar ICH (beta, 0.25; SE, 0.12; p=0.03), but there was no relationship with other ICH outcomes when stratified by haematoma location or study cohort. CONCLUSIONS In a large heterogeneous cohort of patients with ICH, prior APT was not associated with haematoma expansion or functional outcomes after ICH, regardless of haematoma location. APT was associated with admission haematoma volumes in lobar ICH.
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Affiliation(s)
- Santosh Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - David J Roh
- Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Abhinaba Chatterjee
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - Nichol McBee
- Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - Guido J Falcone
- Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Issam Awad
- Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Daniel Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - Wendy C Ziai
- Departments of Neurology, Neurosurgery, and Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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168
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Sprigg N, Flaherty K, Appleton JP, Al-Shahi Salman R, Bereczki D, Beridze M, Ciccone A, Collins R, Dineen RA, Duley L, Egea-Guerrero JJ, England TJ, Karlinski M, Krishnan K, Laska AC, Law ZK, Ovesen C, Ozturk S, Pocock SJ, Roberts I, Robinson TG, Roffe C, Peters N, Scutt P, Thanabalan J, Werring D, Whynes D, Woodhouse L, Bath PM. Tranexamic acid to improve functional status in adults with spontaneous intracerebral haemorrhage: the TICH-2 RCT. Health Technol Assess 2020; 23:1-48. [PMID: 31322116 DOI: 10.3310/hta23350] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Tranexamic acid reduces death due to bleeding after trauma and postpartum haemorrhage. OBJECTIVE The aim of the study was to assess if tranexamic acid is safe, reduces haematoma expansion and improves outcomes in adults with spontaneous intracerebral haemorrhage (ICH). DESIGN The TICH-2 (Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage) study was a pragmatic, Phase III, prospective, double-blind, randomised placebo-controlled trial. SETTING Acute stroke services at 124 hospitals in 12 countries (Denmark, Georgia, Hungary, Ireland, Italy, Malaysia, Poland, Spain, Sweden, Switzerland, Turkey and the UK). PARTICIPANTS Adult patients (aged ≥ 18 years) with ICH within 8 hours of onset. EXCLUSION CRITERIA Exclusion criteria were ICH secondary to anticoagulation, thrombolysis, trauma or a known underlying structural abnormality; patients for whom tranexamic acid was thought to be contraindicated; prestroke dependence (i.e. patients with a modified Rankin Scale [mRS] score > 4); life expectancy < 3 months; and a Glasgow Coma Scale score of < 5. INTERVENTIONS Participants, allocated by randomisation, received 1 g of an intravenous tranexamic acid bolus followed by an 8-hour 1-g infusion or matching placebo (i.e. 0.9% saline). MAIN OUTCOME MEASURE The primary outcome was functional status (death or dependency) at day 90, which was measured by the shift in the mRS score, using ordinal logistic regression, with adjustment for stratification and minimisation criteria. RESULTS A total of 2325 participants (tranexamic acid, n = 1161; placebo, n = 1164) were recruited from 124 hospitals in 12 countries between 2013 and 2017. Treatment groups were well balanced at baseline. The primary outcome was determined for 2307 participants (tranexamic acid, n = 1152; placebo, n = 1155). There was no statistically significant difference between the treatment groups for the primary outcome of functional status at day 90 [adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.76 to 1.03; p = 0.11]. Although there were fewer deaths by day 7 in the tranexamic acid group (aOR 0.73, 95% CI 0.53 to 0.99; p = 0.041), there was no difference in case fatality at 90 days (adjusted hazard ratio 0.92, 95% CI 0.77 to 1.10; p = 0.37). Fewer patients experienced serious adverse events (SAEs) after treatment with tranexamic acid than with placebo by days 2 (p = 0.027), 7 (p = 0.020) and 90 (p = 0.039). There was no increase in thromboembolic events or seizures. LIMITATIONS Despite attempts to enrol patients rapidly, the majority of participants were enrolled and treated > 4.5 hours after stroke onset. Pragmatic inclusion criteria led to a heterogeneous population of participants, some of whom had very large strokes. Although 12 countries enrolled participants, the majority (82.1%) were from the UK. CONCLUSIONS Tranexamic acid did not affect a patient's functional status at 90 days after ICH, despite there being significant modest reductions in early death (by 7 days), haematoma expansion and SAEs, which is consistent with an antifibrinolytic effect. Tranexamic acid was safe, with no increase in thromboembolic events. FUTURE WORK Future work should focus on enrolling and treating patients early after stroke and identify which participants are most likely to benefit from haemostatic therapy. Large randomised trials are needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN93732214. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 35. See the NIHR Journals Library website for further project information. The project was also funded by the Pragmatic Trials, UK, funding call and the Swiss Heart Foundation in Switzerland.
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Affiliation(s)
- Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Maia Beridze
- The First University Clinic of Tbilisi State Medical University, Tbilisi, Georgia
| | - Alfonso Ciccone
- Neurology Unit, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy
| | - Ronan Collins
- Stroke Service, Adelaide and Meath Hospital, Tallaght, Ireland
| | - Robert A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Juan José Egea-Guerrero
- UGC de Medicina Intensiva, Hospital Universitario Virgen del Rocío, IBiS/CSIC/Universidad de Sevilla, Seville, Spain
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences & GEM, University of Nottingham, Derby, UK
| | - Michal Karlinski
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Zhe Kang Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Christian Ovesen
- Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Department of Neurology, Copenhagen, Denmark
| | - Serefnur Ozturk
- Department of Neurology, Selcuk University Medical Faculty, Konya, Turkey
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Christine Roffe
- Stroke Research, Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jegan Thanabalan
- Division of Neurosurgery, Department of Surgery, National University of Malaysia, Kuala Lumpur, Malaysia
| | - David Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, Faculty of Brain Sciences of University College London, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Whynes
- School of Economics, University of Nottingham, Nottingham, UK
| | - Lisa Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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169
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Radu RA, Terecoasa EO, Tiu C, Ghita C, Purcaru LI, Marinescu AN, Bajenaru OA. Clinical Characteristics and Outcomes of Patients with Intracerebral Hemorrhage - A Feasibility Study on Romanian Patients. J Med Life 2020; 13:125-131. [PMID: 32742502 PMCID: PMC7378341 DOI: 10.25122/jml-2020-0042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Intracerebral hemorrhage is a significant public health problem, as it is a disease associated with overwhelming mortality and disability. We performed a retrospective feasibility study of patients admitted with acute intracerebral hemorrhage in our department for four months. Our aims were to identify peculiarities of the risk factors, demographic and clinical characteristics of intracerebral hemorrhage patients from our population, to estimate a feasible recruitment rate for a larger prospective study of patients with intracerebral hemorrhage and to analyze and correct potential drawbacks in the methodology of a more extensive prospective study of patients with intracerebral hemorrhage hospitalized in our department. During the study period, we admitted 53 patients with intracerebral hemorrhage in our department. The mean age of the patients was 69.1 years, and 53% were men. Arterial hypertension was the most common etiologic factor leading to intracerebral hemorrhage. 50.01% of patients died during hospitalization, 31.19% were discharged with significant disability, and 18.8% had a favorable short-term outcome. Higher hematoma volumes, male sex, deep location of the hemorrhage, and age between 51 and 60 years were factors associated with an unfavorable short-term outcome.
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Affiliation(s)
- Razvan Alexandru Radu
- Department of Neurology, University Emergency Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Elena Oana Terecoasa
- Department of Neurology, University Emergency Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Tiu
- Department of Neurology, University Emergency Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Ghita
- Department of Neurology, University Emergency Hospital, Bucharest, Romania
| | | | - Andreea Nicoleta Marinescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Radiology and Medical Imaging, University Emergency Hospital, Bucharest, Romania
| | - Ovidiu Alexandru Bajenaru
- Department of Neurology, University Emergency Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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Morotti A, Arba F, Boulouis G, Charidimou A. Noncontrast CT markers of intracerebral hemorrhage expansion and poor outcome: A meta-analysis. Neurology 2020; 95:632-643. [PMID: 32847959 DOI: 10.1212/wnl.0000000000010660] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/22/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To provide precise estimates of the association between noncontrast CT (NCCT) markers, hematoma expansion (HE), and functional outcome in patients presenting with intracerebral hemorrhage (ICH) through a systematic review and meta-analysis. METHODS We searched PubMed for English-written observational studies or randomized controlled trials reporting data on NCCT markers of HE and outcome in spontaneous ICH including at least 50 subjects. The outcomes of interest were HE (hematoma growth >33%, >33% and/or >6 mL, >33% and/or >12.5 mL), poor functional outcome (modified Rankin Scale 3-6 or 4-6) at discharge or at 90 days, and mortality. We pooled data in random-effects models and extracted cumulative odds ratio (OR) for each NCCT marker. RESULTS We included 25 eligible studies (n = 10,650). The following markers were associated with increased risk of HE and poor outcome, respectively: black hole sign (OR = 3.70, 95% confidence interval [CI] = 1.42-9.64 and OR = 5.26, 95% CI = 1.75-15.76), swirl sign (OR = 3.33, 95% CI = 2.42-4.60 and OR = 3.70; 95% CI = 2.47-5.55), heterogeneous density (OR = 2.74; 95% CI = 1.71-4.39 and OR = 2.80; 95% CI = 1.78-4.39), blend sign (OR = 3.49; 95% CI = 2.20-5.55 and OR = 2.21; 95% CI 1.16-4.18), hypodensities (OR = 3.47; 95% CI = 2.18-5.50 and OR = 2.94; 95% CI = 2.28-3.78), irregular shape (OR = 2.01, 95% CI = 1.27-3.19 and OR = 3.43; 95% CI = 2.33-5.03), and island sign (OR = 7.87, 95% CI = 2.17-28.47 and OR = 6.05, 95% CI = 4.44-8.24). CONCLUSION Our results suggest that multiple NCCT ICH shape and density features, with different effect size, are important markers for HE and clinical outcome and may provide useful information for future randomized controlled trials.
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Affiliation(s)
- Andrea Morotti
- Neurology Unit (A.M.), ASST Valcamonica, Esine, Brescia; Stroke Unit (F.A.), Careggi University Hospital, Florence, Italy; Neuroradiology Department (G.B.), Centre Hospitalier Sainte-Anne, Paris, France; and Hemorrhagic Stroke Research Program (A.C.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston.
| | - Francesco Arba
- Neurology Unit (A.M.), ASST Valcamonica, Esine, Brescia; Stroke Unit (F.A.), Careggi University Hospital, Florence, Italy; Neuroradiology Department (G.B.), Centre Hospitalier Sainte-Anne, Paris, France; and Hemorrhagic Stroke Research Program (A.C.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Gregoire Boulouis
- Neurology Unit (A.M.), ASST Valcamonica, Esine, Brescia; Stroke Unit (F.A.), Careggi University Hospital, Florence, Italy; Neuroradiology Department (G.B.), Centre Hospitalier Sainte-Anne, Paris, France; and Hemorrhagic Stroke Research Program (A.C.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Andreas Charidimou
- Neurology Unit (A.M.), ASST Valcamonica, Esine, Brescia; Stroke Unit (F.A.), Careggi University Hospital, Florence, Italy; Neuroradiology Department (G.B.), Centre Hospitalier Sainte-Anne, Paris, France; and Hemorrhagic Stroke Research Program (A.C.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
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Wang N, Ji J, Yu S, Chang J, Chen Y, Yu B. In reply to the letter to the editor regarding "The Relationship Between Serum Vitamin D and Fracture Risk in the Elderly: A Meta-Analysis". J Orthop Surg Res 2020; 15:324. [PMID: 32795312 PMCID: PMC7427934 DOI: 10.1186/s13018-020-01820-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/27/2020] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ning Wang
- Shandong University of Traditional Chinese Medicine, Jinan, 250014, China
| | - Jindou Ji
- Shandong University of Traditional Chinese Medicine, Jinan, 250014, China
| | - Shengwen Yu
- Shandong University of Traditional Chinese Medicine, Jinan, 250014, China
| | - Jinlei Chang
- Shandong University of Traditional Chinese Medicine, Jinan, 250014, China
| | - Yungang Chen
- Department of Orthopaedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250014, China
| | - Bo Yu
- Department of Orthopaedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250014, China.
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Morotti A, Fainardi E. Response by Morotti and Fainardi to Letter Regarding Article, “Subarachnoid Extension Predicts Lobar Intracerebral Hemorrhage Expansion”. Stroke 2020; 51:e162. [DOI: 10.1161/strokeaha.120.030415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrea Morotti
- UOSD Neurologia, ASST Valcamonica, Esine (BS), Italia (A.M.)
| | - Enrico Fainardi
- Dipartimento di Dipartimento di Scienze Biomediche, Sperimentali e Cliniche, Neuroradiologia, Università degli Studi di Firenze, Ospedale Universitario Careggi, Italia (E.F.)
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Giovino A, Shomo E, Busey KV, Case D, Brockhurst A, Concha M. An 18-month single-center observational study of real-world use of andexanet alfa in patients with factor Xa inhibitor associated intracranial hemorrhage. Clin Neurol Neurosurg 2020; 195:106070. [DOI: 10.1016/j.clineuro.2020.106070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/03/2020] [Accepted: 07/04/2020] [Indexed: 10/23/2022]
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174
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Li Z, You M, Long C, Bi R, Xu H, He Q, Hu B. Hematoma Expansion in Intracerebral Hemorrhage: An Update on Prediction and Treatment. Front Neurol 2020; 11:702. [PMID: 32765408 PMCID: PMC7380105 DOI: 10.3389/fneur.2020.00702] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the most lethal type of stroke, but there is no specific treatment. After years of effort, neurologists have found that hematoma expansion (HE) is a vital predictor of poor prognosis in ICH patients, with a not uncommon incidence ranging widely from 13 to 38%. Herein, the progress of studies on HE after ICH in recent years is updated, and the topics of definition, prevalence, risk factors, prediction score models, mechanisms, treatment, and prospects of HE are covered in this review. The risk factors and prediction score models, including clinical, imaging, and laboratory characteristics, are elaborated in detail, but limited by sensitivity, specificity, and inconvenience to clinical practice. The management of HE is also discussed from bench work to bed practice. However, the upmost problem at present is that there is no treatment for HE proven to definitely improve clinical outcomes. Further studies are needed to identify more accurate predictors and effective treatment to reduce HE.
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Affiliation(s)
- Zhifang Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mingfeng You
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunnan Long
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rentang Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haoqiang Xu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Quanwei He
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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175
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The NAG scale can screen for hematoma expansion in acute intracerebral hemorrhage-a multi-institutional validation. J Neurol Sci 2020; 414:116834. [PMID: 32325359 DOI: 10.1016/j.jns.2020.116834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/08/2020] [Accepted: 04/10/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Early hematoma expansion (HE) is seen in approximately 30% of patients with intracerebral hemorrhage (ICH), but detecting patients with a high HE risk is challenging. AIMS The NAG scale is a simple predictive scale for HE in acute ICH patients. Multi-institutional validation of the usefulness of this scale was the aim of this study. METHODS We retrospectively reviewed 142 consecutive primary ICH patients admitted to our hospital between September 2016 and December 2018. The NAG scale consists of three factors: National Institutes of Health Stroke Scale (NIHSS) score ≥ 10, anticoagulant use, and glucose ≥133 mg/dl (1 point each). Patients underwent non-contrast computed tomography (CT) within 24 h of symptom onset and follow-up CT 6 h, 24 h, and 7 days after admission. We defined HE as increased hemorrhage volume > 33% or an absolute increase of >6 mL on follow-up CT. Poor prognosis was defined as a modified Rankin scale score of 4-6 at discharge. We performed logistic regression analysis and created receiver operating characteristic curves to determine the discrimination ability of the NAG score. RESULTS Patients constituted 96 men and 46 women (median age: 64 years; median NIHSS: 11), and HE was observed in 38/142 patients (27%). Higher NAG sores were associated with HE (P < .001), poor prognosis (P < .001), and in-hospital death (P < .001). The C statistic was 0.72 (95% confidence interval [CI]: 0.63-0.82) for HE, 0.67 (95% CI: 0.58-0.76) for poor prognosis, and 0.85 (95% CI: 0.74-0.95) for in-hospital death. Multivariate logistic regression analysis with known risk factors showed that NAG scale score was an independent risk factor for HE (odds ratio: 2.95; 95% CI: 1.57-5.52; P = .001). CONCLUSION The NAG scale showed good discrimination in our multi-institutional validation.
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176
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Zhao W, Wu C, Stone C, Ding Y, Ji X. Treatment of intracerebral hemorrhage: Current approaches and future directions. J Neurol Sci 2020; 416:117020. [PMID: 32711191 DOI: 10.1016/j.jns.2020.117020] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/25/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) stands out among strokes, both for the severely morbid outcomes it routinely produces, and for the striking deficiency of defenses possessed against the same. The brain damage caused by ICH proceeds through multiple pathophysiological mechanisms, broadly differentiated into those considered primary, arising from the hematoma itself, and the secondary consequences of hematoma presence and expansion thereof. A number of interventions against ICH and its sequelae have been investigated (e.g., hemostatic therapies, blood pressure control, hematoma evacuation, and a variety of neuroprotective strategies), but conclusive demonstrations of clinical benefit have remained largely elusive. In this review, we begin with a description of these interventions and the trials in which they have been implemented, coupled with an attempt to account for their failure. Possible causes discussed include iatrogenic injury during hematoma evacuation, secondary injury initiated by hematoma persistence after evacuation, and inadequate therapeutic power arising from an excessively narrow focus on a single component of the complex pathophysiology of ICH injury. To conclude, we propose several strategies, such as enhancing endogenous hematoma resolution, hematoma evacuation-based neuroprotection, and multi-targeted therapy, that hold promise as prospects for the extension of anti-ICH therapy into the domain of clinical significance.
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Affiliation(s)
- Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Christopher Stone
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Municipal Geriatric Medical Research Center, Beijing, China.
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177
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Prats-Sánchez L, Guasch-Jiménez M, Gich I, Pascual-Goñi E, Flores N, Camps-Renom P, Guisado-Alonso D, Martínez-Domeño A, Delgado-Mederos R, Rodríguez-Campello A, Ois A, Gómez-Gonzalez A, Cuadrado-Godia E, Roquer J, Martí-Fàbregas J. Influence of time to admission to a comprehensive stroke centre on the outcome of patients with intracerebral haemorrhage. Eur Stroke J 2020; 5:115-122. [PMID: 32637644 DOI: 10.1177/2396987320901616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 12/28/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction In patients with spontaneous intracerebral haemorrhage, it is uncertain if diagnostic and therapeutic measures are time-sensitive on their impact on the outcome. We sought to determine the influence of the time to admission to a comprehensive stroke centre on the outcome of patients with acute intracerebral haemorrhage. Patients and methods We studied a prospective database of consecutive patients with intracerebral haemorrhage attended at two comprehensive stroke centres (2005-2017). We excluded patients with an unwitnessed time of onset of the intracerebral haemorrhage, or previous modified Rankin Scale >3 or in those in whom withdrawal of life-sustaining interventions were decided <24 h from admission. We recorded the time from the intracerebral haemorrhage onset to admission, demographic, clinical, radiological data, the functional outcome (favourable when modified Rankin Scale ≤3) and mortality at 90 days. We conducted a propensity score-matching analysis to evaluate functional outcome and mortality. Results We included 487 patients (mean age 72.3 ± 13.9 years), and 53.2% were men. Compared to patients with an admission >110 min, patients who were admitted ≤110 min were significantly younger, and had higher National Institutes of Health Stroke Scale scores. Moreover, patients admitted ≤110 min were more likely to have basal ganglia intracerebral haemorrhage, and to show neurological deterioration. The propensity score groups were well matched. We did not find an association between time to admission and the favourable outcome (OR: 1.42 (95% CI: 0.93-2.16)) or mortality (OR: 0.64 (0.41-0.99)) at 90 days. Conclusions Our results suggest that in patients with intracerebral haemorrhage and known symptom onset who are admitted to a comprehensive stroke centre, an early admission (≤110 min) does not influence the outcome at 90 days.
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Affiliation(s)
- Luis Prats-Sánchez
- Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Ignasi Gich
- Department of Epidemiology and Public Health, Biomedical Research Institute, Barcelona, Spain
| | - Elba Pascual-Goñi
- Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Noelia Flores
- Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pol Camps-Renom
- Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | | | - Ana Rodríguez-Campello
- Department of Neurology, Universitat Pompeu Fabra-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Angel Ois
- Department of Neurology, Universitat Pompeu Fabra-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandra Gómez-Gonzalez
- Department of Neurology, Universitat Pompeu Fabra-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Department of Neurology, Universitat Pompeu Fabra-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Roquer
- Department of Neurology, Universitat Pompeu Fabra-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Martí-Fàbregas
- Department of Neurology, Universitat Autònoma de Barcelona, Barcelona, Spain
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178
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Li Q, Warren AD, Qureshi AI, Morotti A, Falcone GJ, Sheth KN, Shoamanesh A, Dowlatshahi D, Viswanathan A, Goldstein JN. Ultra-Early Blood Pressure Reduction Attenuates Hematoma Growth and Improves Outcome in Intracerebral Hemorrhage. Ann Neurol 2020; 88:388-395. [PMID: 32453453 DOI: 10.1002/ana.25793] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/13/2020] [Accepted: 05/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim was to investigate whether intensive blood pressure treatment is associated with less hematoma growth and better outcome in intracerebral hemorrhage (ICH) patients who received intravenous nicardipine treatment ≤2 hours after onset of symptoms. METHODS A post-hoc exploratory analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial was performed. This was a multicenter, international, open-label, randomized clinical trial, in which patients with primary ICH were allocated to intensive versus standard blood pressure treatment with nicardipine ≤4.5 hours after onset of symptoms. We have included 913 patients with complete imaging and follow-up data in the present analysis. RESULTS Among the 913 included patients, 354 (38.7%) had intravenous nicardipine treatment initiated within 2 hours. In this subgroup of patients treated within 2 hours, the frequency of ICH expansion was significantly lower in the intensive blood pressure reduction group compared with the standard treatment group (p = 0.02). Multivariable analysis showed that ultra-early intensive blood pressure treatment was associated with a decreased risk of hematoma growth (odds ratio, 0.56; 95% confidence interval [CI], 0.34-0.92; p = 0.02), higher rate of functional independence (odds ratio, 2.17; 95% CI, 1.28-3.68; p = 0.004), and good outcome (odds ratio, 1.68; 95% CI, 1.01-2.83; p = 0.048) at 90 days. Ultra-early intensive blood pressure reduction was associated with a favorable shift in modified Rankin Scale score distribution at 3 months (p = 0.04). INTERPRETATION In a subgroup of ICH patients with elevated blood pressure given intravenous nicardipine ≤2 hours after onset of symptoms, intensive blood pressure reduction was associated with reduced hematoma growth and improved functional outcome. ANN NEUROL 2020;88:388-395.
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Affiliation(s)
- Qi Li
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Andrew D Warren
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Andrea Morotti
- Department of Neurology and Neurorehabilitation, IRCCS Mondino Foundation, Pavia, Italy
| | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Anand Viswanathan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Navarro-Oviedo M, Muñoz-Arrondo R, Zandio B, Marta-Enguita J, Bonaterra-Pastra A, Rodríguez JA, Roncal C, Páramo JA, Toledo E, Montaner J, Hernández-Guillamon M, Orbe J. Circulating TIMP-1 is associated with hematoma volume in patients with spontaneous intracranial hemorrhage. Sci Rep 2020; 10:10329. [PMID: 32587306 PMCID: PMC7316718 DOI: 10.1038/s41598-020-67250-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/02/2020] [Indexed: 01/15/2023] Open
Abstract
Matrix metalloproteinases (MMPs) are proteolytic zinc-endopeptidases regulated by tissue Inhibitors of matrix metalloproteinases (TIMPs). We evaluated the potential of MMPs and TIMPs as clinical tools for Intracranial Haemorrhage (ICH). Spontaneous non-traumatic ICH patients were recruited from two hospitals: Complejo Hospitalario de Navarra (CHN = 29) and Vall d´Hebron (VdH = 76). Plasmatic levels of MMP-1, -2, -7, -9, -10 and TIMP-1 and their relationship with clinical, radiological and functional variables were evaluated. We further studied the effect of TIMP-1 (0.05-0.2 mg/Kg) in an experimental tail-bleeding model. In CHN, TIMP-1 was associated with admission-hematoma volume and MMP-7 was elevated in patients with deep when compared to lobar hematoma. In VdH, admission-hematoma volume was associated with TIMP-1 and MMP-7. When data from both hospitals were combined, we observed that an increase in 1 ng/ml in TIMP-1 was associated with an increase of 0.14 ml in haemorrhage (combined β = 0.14, 95% CI = 0.08-0.21). Likewise, mice receiving TIMP-1 (0.2 mg/Kg) showed a shorter bleeding time (p < 0.01). Therefore, the association of TIMP-1 with hematoma volume in two independent ICH cohorts suggests its potential as ICH biomarker. Moreover, increased TIMP-1 might not be sufficient to counterbalance MMPs upregulation indicating that TIMP-1 administration might be a beneficial strategy for ICH.
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Affiliation(s)
- Manuel Navarro-Oviedo
- Laboratory of Atherothrombosis, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain
| | | | - Beatriz Zandio
- Neurology Service, Complejo Hospitalario de Navarra, IdisNA, Pamplona, Spain
| | - Juan Marta-Enguita
- Laboratory of Atherothrombosis, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain
- Neurology Service, Complejo Hospitalario de Navarra, IdisNA, Pamplona, Spain
| | - Anna Bonaterra-Pastra
- Neurovascular Research Laboratory, Vall d´Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jose Antonio Rodríguez
- Laboratory of Atherothrombosis, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Roncal
- Laboratory of Atherothrombosis, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Jose A Páramo
- Laboratory of Atherothrombosis, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
- Haematology Service, Clínica Universidad de Navarra, Pamplona, Spain
| | - Estefania Toledo
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad de Navarra, IdiSNA, Pamplona, Spain
- Centro de Investigación Biomédica en Red en Fisiopatología de la Obesidad y Nutrición (CIBEROBN), ISCIII, Madrid, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d´Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mar Hernández-Guillamon
- Neurovascular Research Laboratory, Vall d´Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josune Orbe
- Laboratory of Atherothrombosis, CIMA, Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, IdisNA, Pamplona, Spain.
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.
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180
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Qureshi AI, Foster LD, Lobanova I, Huang W, Suarez JI. Intensive Blood Pressure Lowering in Patients with Moderate to Severe Grade Acute Cerebral Hemorrhage: Post Hoc Analysis of Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)-2 Trial. Cerebrovasc Dis 2020; 49:244-252. [PMID: 32585668 DOI: 10.1159/000506358] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/04/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To study the effect of intensive blood pressure reduction in patients with moderate to severe intracerebral hemorrhage (ICH) within the subjects recruited in Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial. DESIGN Randomized, multicenter, 2 group, open-label clinical trial. SETTING A total of 110 sites in the USA, Japan, China, Taiwan, South Korea, and Germany. PATIENTS A total of 1,000 patients underwent randomization from May 2011 till September 2015. INTERVENTIONS We analyzed the effect of intensive (goal 110-139 mm Hg) over standard (goal 140-179 mm Hg) systolic blood pressure (SBP) reduction using intravenous nicardipine within 4.5 h of symptom onset in moderate to severe grade subjects with ICH in a non-prespecified analysis. Moderate to severe grade was defined by Glasgow Coma Scale score <13 or baseline National Institutes of Health Stroke Scale score ≥10 or baseline intraparenchymal hemorrhage volume ≥30 mL or presence of intraventricular hemorrhage. The primary outcome was death or disability (score 4-6 on the modified Rankin scale) at 3 months after randomization ascertained by a blinded investigator. MEASUREMENTS AND MAIN RESULTS Of a total of 682 subjects who met the definition of moderate to severe grade (mean age 61.9 ± 13.1 years, 62.5% men) with a mean baseline SBP of 174.7 ± 24.8 mm Hg, the frequency of hematoma expansion was significantly lower among subjects randomized to intensive SBP reduction than among subjects randomized to standard SBP reduction (20.4 vs. 27.9%, relative risk [RR]: 0.7; 95% confidence interval [CI]: 0.55-0.96). The primary endpoint of death or disability was observed in 52.5% (170/324) of subjects receiving intensive SBP reduction and 48.9% (163/333) of subjects receiving standard SBP reduction (RR: 1.1; 95% CI: 0.9-1.2). CONCLUSIONS Intensive SBP lowering reduced the frequency of hematoma expansion but did not reduce the rate of death or disability in patients with moderate to severe grade ICH.
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Affiliation(s)
- Adnan I Qureshi
- Zeenet Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA,
| | - Lydia D Foster
- Division of Biostatistics and Epidemiology, Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Iryna Lobanova
- Zeenet Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Wei Huang
- Zeenet Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Jose I Suarez
- Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine Baltimore, Baltimore, Maryland, USA
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181
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Zeng Z, Gong X, Hu Z. L-3-n-butylphthalide attenuates inflammation response and brain edema in rat intracerebral hemorrhage model. Aging (Albany NY) 2020; 12:11768-11780. [PMID: 32564011 PMCID: PMC7343495 DOI: 10.18632/aging.103342] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/18/2020] [Indexed: 02/07/2023]
Abstract
L-3-n-butylphthalide(NBP), a compound found in Apium graveolens Linn seed extracts, has a therapeutic effect on acute ischemic stroke. The pathological inflammatory pathways and consequent brain edema in intracerebral hemorrhage (ICH) share some similar characteristics with ischemic stroke. We hypothesized that NBP has anti-inflammatory and therapeutic effects on rats with ICH. ICH was induced by an infusion of bacterial collagenase type IV into the unilateral striatum of anesthetized rats. The therapeutic effect of NBP was measured by assessing neurological function, brain water content, blood-brain barrier permeability, and expression of tumor necrosis factor-alpha (TNF-α) and matrix metalloproteinase-9 (MMP-9) around the hematoma 48 hours after surgery. Magnetic resonance imaging was performed 4 and 48 hours after ICH induction, and ICH-induced injured area volumes were measured using T2-weighted images. The NBP treatment group performed better in the neurological function test than the vehicle group. Moreover, in comparison with the vehicle group, NBP group showed a lower expanded hematoma volume, brain water content, blood-brain barrier permeability, and TNF-α/ MMP-9 expression level. Our results indicate that NBP attenuates inflammation and brain edema in rat ICH model. Therefore, our findings also provide a potential therapeutic strategy for the treatment of ICH with NBP.
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Affiliation(s)
- Zhou Zeng
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Xiyu Gong
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Zhiping Hu
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
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182
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Acrolein Aggravates Secondary Brain Injury After Intracerebral Hemorrhage Through Drp1-Mediated Mitochondrial Oxidative Damage in Mice. Neurosci Bull 2020; 36:1158-1170. [PMID: 32436179 PMCID: PMC7532238 DOI: 10.1007/s12264-020-00505-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 01/21/2020] [Indexed: 12/16/2022] Open
Abstract
Clinical advances in the treatment of intracranial hemorrhage (ICH) are restricted by the incomplete understanding of the molecular mechanisms contributing to secondary brain injury. Acrolein is a highly active unsaturated aldehyde which has been implicated in many nervous system diseases. Our results indicated a significant increase in the level of acrolein after ICH in mouse brain. In primary neurons, acrolein induced an increase in mitochondrial fragmentation, loss of mitochondrial membrane potential, generation of reactive oxidative species, and release of mitochondrial cytochrome c. Mechanistically, acrolein facilitated the translocation of dynamin-related protein1 (Drp1) from the cytoplasm onto the mitochondrial membrane and led to excessive mitochondrial fission. Further studies found that treatment with hydralazine (an acrolein scavenger) significantly reversed Drp1 translocation and the morphological damage of mitochondria after ICH. In parallel, the neural apoptosis, brain edema, and neurological functional deficits induced by ICH were also remarkably alleviated. In conclusion, our results identify acrolein as an important contributor to the secondary brain injury following ICH. Meanwhile, we uncovered a novel mechanism by which Drp1-mediated mitochondrial oxidative damage is involved in acrolein-induced brain injury.
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183
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Zhang M, Chen J, Zhan C, Liu J, Chen Q, Xia T, Zhang T, Zhu D, Chen C, Yang Y. Blend Sign Is a Strong Predictor of the Extent of Early Hematoma Expansion in Spontaneous Intracerebral Hemorrhage. Front Neurol 2020; 11:334. [PMID: 32508731 PMCID: PMC7248383 DOI: 10.3389/fneur.2020.00334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/07/2020] [Indexed: 01/18/2023] Open
Abstract
Background and Purpose: It is unclear which imaging marker is optimal for predicting the extent of hematoma expansion (EHE). We aimed to compare the usefulness of the blend sign (BS) with that of other non-contrast computed tomography (NCCT) markers for predicting the EHE in patients with spontaneous intracerebral hemorrhage (sICH). Methods: Patients with sICH admitted to our Neurology Emergency Department between September 2013 and January 2019 were enrolled. The EHE was calculated as the absolute increase in hematoma volume between baseline and follow-up CT (within 72 h). The EHE was categorized into four groups: "no growth," "minimal change" (≤5.1 ml), "moderate change" (5.1-12.5 ml), and "massive change" (>12.5 ml). Univariate and multivariate analyses were performed to investigate the relationship between the NCCT markers [BS, black hole sign (BHS), satellite sign, and island sign] and the EHE. Results: A total of 1,111 sICH patients were included (median age: 60 years; 66.5% males). Multiple linear regression analysis showed that the presence of the BS and BHS was independently associated with the EHE, after adjusting for confounders (P < 0.001 and P = 0.003, respectively). The presence of the BS and BHS was positively correlated with growth category (r = 0.285 and r = 0.199, both Ps < 0.001). The BS demonstrated a better predictive performance for the EHE than did the BHS [area under the curve (AUC): 0.67 vs. 0.57; both Ps < 0.001]. Conclusions: In patients with acute sICH, the BS showed a better performance in predicting the EHE compared with other NCCT markers. This imaging marker may help identify patients at a high risk of significant hematoma expansion and may facilitate its early management.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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184
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Franco L, Paciaroni M, Enrico ML, Scoditti U, Guideri F, Chiti A, De Vito A, Terruso V, Consoli D, Vanni S, Giossi A, Manina G, Nitti C, Re R, Sacco S, Cappelli R, Beyer-Westendorf J, Pomero F, Agnelli G, Becattini C. Mortality in patients with intracerebral hemorrhage associated with antiplatelet agents, oral anticoagulants or no antithrombotic therapy. Eur J Intern Med 2020; 75:35-43. [PMID: 31955918 DOI: 10.1016/j.ejim.2019.12.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/16/2019] [Accepted: 12/21/2019] [Indexed: 01/24/2023]
Abstract
The association between preceding treatment with antiplatelet agents (APs), vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) and mortality after intracerebral hemorrhage (ICH) remains unclear. The aim of this multicenter, prospective cohort study was to assess the risk for death after ICH in consecutive patients who were on treatment with APs, VKAs, DOACs, or no antithrombotic agent. The primary outcome was in-hospital death by day 30. ICH volume at admission and volume expansion were centrally assessed. Out of 598 study patients, in-hospital death occurred in 21% of patients who were on treatment with APs, 25% with VKAs, 30% with DOACs, and 13% with no antithrombotics. Crude death rate was higher in patients on antithrombotics as compared to patients receiving no antithrombotic agent. At multivariate analysis, age (HR 1.07; 95% CI 1.04-1.10), previous stroke (HR 1.83; 95% CI 1.14-2.93), GCS ≤8 at admission (HR 6.06; 95% CI 3.16-9.74) and GCS 9-12 (HR 3.38; 95% CI 1.81-6.33) were independent predictors of death. Treatment with APs (HR 1.29; 95% CI 0.61-2.76), VKAs (HR 1.42; 95% CI 0.70-2.88) or DOACs (HR 1.28; 95% CI 0.61-2.73) were not predictors of death in the overall study population, in non-trauma associated ICH as well as when GCS was not included in the model. ICH volume and volume expansion were independent predictors of death. In conclusion, preceding treatment with antithrombotic is associated with the severity of ICH. Age, previous stroke and clinical severity at presentation were independent predictors of in-hospital death in patients with ICH.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Roberta Re
- Ospedale Maggiore della Carità, Novara, Italy
| | | | | | - Jan Beyer-Westendorf
- University Hospital, Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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185
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Sondag L, Schreuder FHBM, Boogaarts HD, Rovers MM, Vandertop WP, Dammers R, Klijn CJM. Neurosurgical Intervention for Supratentorial Intracerebral Hemorrhage. Ann Neurol 2020; 88:239-250. [PMID: 32239722 PMCID: PMC7497162 DOI: 10.1002/ana.25732] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 03/11/2020] [Accepted: 03/22/2020] [Indexed: 11/30/2022]
Abstract
Objective The effect of surgical treatment for supratentorial spontaneous intracerebral hemorrhage (ICH) and whether it is modified by key baseline characteristics and timing remains uncertain. Methods We performed a systematic review and meta‐analysis of randomized controlled trials of surgical treatment of supratentorial spontaneous ICH aimed at clot removal. We searched MEDLINE, Embase, and Cochrane databases up to February 21, 2019. Primary outcome was good functional outcome at follow‐up; secondary outcomes were death and serious adverse events. We analyzed all types of surgery combined and minimally invasive approaches separately. We pooled risk ratios with 95% confidence intervals and assessed the modifying effect of age, Glasgow Coma Scale, hematoma volume, and timing of surgery with meta‐regression analysis. Results We included 21 studies with 4,145 patients; 4 (19%) were of the highest quality. Risk ratio of good functional outcome after any type of surgery was 1.40 (95% confidence interval [CI] = 1.22–1.60, I2 = 46%, 20 studies), and after minimally invasive surgery it was 1.47 (95% CI = 1.26–1.72, I2 = 47%, 12 studies). For death, the risk ratio for any type of surgery was 0.77 (95% CI = 0.68–0.85, I2 = 23%, 21 studies), and for minimally invasive surgery it was 0.68 (95% CI = 0.56–0.83, I2 = 14%, 13 studies). Serious adverse events were reported infrequently. Surgery seemed more effective when performed sooner after symptom onset (p = 0.04, 12 studies). Age, Glasgow Coma Scale, and hematoma volume did not modify the effect of surgery. Interpretation Surgical treatment of supratentorial spontaneous ICH may be beneficial, in particular with minimally invasive procedures and when performed soon after symptom onset. Further well‐designed randomized trials are needed to demonstrate whether (minimally invasive) surgery improves functional outcome after ICH and to determine the optimal time window of the treatment after symptom onset. ANN NEUROL 2020;88:239–250.
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Affiliation(s)
- Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Maroeska M Rovers
- Departments of Operating Rooms and Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, VU University Medical Center, Amsterdam, the Netherlands.,Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, the Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
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186
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Hervella P, Rodríguez-Yáñez M, Pumar JM, Ávila-Gómez P, da Silva-Candal A, López-Loureiro I, Rodríguez-Maqueda E, Correa-Paz C, Castillo J, Sobrino T, Campos F, Iglesias-Rey R. Antihyperthermic treatment decreases perihematomal hypodensity. Neurology 2020; 94:e1738-e1748. [PMID: 32221027 PMCID: PMC7282877 DOI: 10.1212/wnl.0000000000009288] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 11/21/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the effect on perihematomal hypodensity and outcome of a decrease in body temperature in the first 24 hours in patients with intracerebral hemorrhage (ICH). METHODS In this retrospective study on a prospectively registered database, among the 1,100 patients, 795 met all the inclusion criteria. Temperature variations in the first 24 hours and perihematomal hypodensity (PHHD) were recorded. Patients ≥37.5°C were treated with antihyperthermic drugs for at least 48 hours. The main objective was to determine the association among temperature variation, PHHD, and outcome at 3 months. RESULTS The decrease in temperature in the first 24 hours increased the possibility of good outcome 11-fold. Temperature decrease, lower PHHD volume, and a good outcome were observed in 31.8% of the patients who received antihyperthermic treatment. CONCLUSION The administration of early antihyperthermic treatment in patients with spontaneous ICH with a basal axillary temperature ≥37.5°C resulted in good outcome in a third of the treated patients.
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Affiliation(s)
- Pablo Hervella
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain.
| | - Manuel Rodríguez-Yáñez
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - José Manuel Pumar
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Paulo Ávila-Gómez
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Andrés da Silva-Candal
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Ignacio López-Loureiro
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Elena Rodríguez-Maqueda
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Clara Correa-Paz
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - José Castillo
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Tomás Sobrino
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Francisco Campos
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Ramón Iglesias-Rey
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain.
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Inter- and Intrarater Agreement of Spot Sign and Noncontrast CT Markers for Early Intracerebral Hemorrhage Expansion. J Clin Med 2020; 9:jcm9041020. [PMID: 32260409 PMCID: PMC7231301 DOI: 10.3390/jcm9041020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 02/07/2023] Open
Abstract
Background: The aim of this study was to assess the inter- and intrarater reliability of noncontrast CT (NCCT) markers [Black Hole Sign (BH), Blend Sign (BS), Island Sign (IS), and Hypodensities (HD)] and Spot Sign (SS) on CTA in patients with spontaneous intracerebral hemorrhage (ICH). Methods: Patients with spontaneous ICH at three German tertiary stroke centers were retrospectively included. Each CT scan was rated for four NCCT markers and SS on CTA by two radiology residents. Raters were blind to all demographic and outcome data. Inter- and intrarater agreement was determined by Cohen’s kappa (κ) coefficient and percentage of agreement. Results: Interrater agreement was excellent in 473 included patients, ranging from 96% to 99%. Interrater κ ranged from 0.85 (95% CI [0.78–0.91]) to 0.97 (95% CI [0.94–0.99]) for NCCT markers and 0.93 (95% CI [0.88–0.98]) for SS, all p-values < 0.001. Intrarrater agreement ranged from 96% to 100%, with κ ranging from 0.85 (95% CI [0.78–0.91]) to 1.00 (95% CI [0.10–0.85]) for NCCT markers and 0.96 (95% CI [0.92–1.00]) for SS, all p-values < 0.001. Conclusions: NCCT imaging findings and SS on CTA have good-to-excellent inter- and intrarater reliabilities, with the highest agreement for BH and SS.
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Yogendrakumar V, Moores M, Sikora L, Shamy M, Ramsay T, Fergusson D, Dowlatshahi D. Evaluating Hematoma Expansion Scores in Acute Spontaneous Intracerebral Hemorrhage. Stroke 2020; 51:1305-1308. [DOI: 10.1161/strokeaha.119.028574] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In acute spontaneous intracerebral hemorrhage, multiple hematoma expansion scores have been proposed for use in clinical trial environments. We performed a systematic scoping review to identify all existing hematoma expansion scores and describe their development, validation, and relative performance.
Methods—
Two reviewers searched MEDLINE, PUBMED, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) for studies that derived or validated a hematoma expansion prediction score in adults presenting with spontaneous intracerebral hemorrhage. A descriptive analysis of the extracted data was performed, focusing on score development techniques and predictive capabilities.
Results—
Of the 14 434 records retrieved, 15 studies met inclusion criteria and 10 prediction scores were identified. Validation analysis using independent samples was performed in 9 studies on 5 scores. All derivation studies reported high performance with C statistics ranging from 0.72 to 0.93. In validation, the C-statistic range was broader with studies reporting 0.62 to 0.77. For every score, the risk of expansion increased with each point increase, although patients with high scores were rare.
Conclusions—
At present, 10 hematoma expansion scores have been developed, of which 5 have been externally validated. Real-world performance in validation studies was lower than performance in derivation studies. Data from the current literature are insufficient to support a meaningful meta-analysis.
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Affiliation(s)
- Vignan Yogendrakumar
- From the Division of Neurology (V.Y., M.M., M.S., D.D.), University of Ottawa, Ontario, Canada
| | - Margaret Moores
- From the Division of Neurology (V.Y., M.M., M.S., D.D.), University of Ottawa, Ontario, Canada
| | - Lindsey Sikora
- Health Sciences Library (L.S.), University of Ottawa, Ontario, Canada
| | - Michel Shamy
- From the Division of Neurology (V.Y., M.M., M.S., D.D.), University of Ottawa, Ontario, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute (T.R., D.F.), University of Ottawa, Ontario, Canada
| | - Dean Fergusson
- Ottawa Hospital Research Institute (T.R., D.F.), University of Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- From the Division of Neurology (V.Y., M.M., M.S., D.D.), University of Ottawa, Ontario, Canada
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190
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Acute hematoma expansion after spontaneous intracerebral hemorrhage: risk factors and impact on long-term prognosis. Neurol Sci 2020; 41:2503-2509. [DOI: 10.1007/s10072-020-04356-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/16/2020] [Indexed: 02/07/2023]
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191
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Morotti A, Poli L, Leuci E, Mazzacane F, Costa P, De Giuli V, Candeloro E, Busto G, Casetta I, Micieli G, Cavallini A, Gamba M, Magoni M, Padovani A, Pezzini A, Fainardi E. Subarachnoid Extension Predicts Lobar Intracerebral Hemorrhage Expansion. Stroke 2020; 51:1470-1476. [PMID: 32200757 DOI: 10.1161/strokeaha.119.028338] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- We investigated whether subarachnoid extension (SAHE) of intracerebral hemorrhage (ICH) is associated with hematoma expansion (HE). Methods- Retrospective analysis of patients with primary spontaneous ICH admitted at 3 academic hospitals in Italy. The study population was divided into a development and a replication cohort. SAHE was rated on baseline noncontrast computed tomography by investigators blinded to clinical data. The main outcome of interest was HE, defined as ICH growth >33% mL and/or >6 mL. Predictors of HE were explored with multivariable logistic regression stratified by ICH location (lobar versus nonlobar). Results- A total of 360 and 192 patients were included in the development and replication cohort, respectively. SAHE was identified with good interrater reliability (K=0.82), and its frequency was 27.8% in the development and 24.5% in the replication cohort. In univariate analysis, HE was more common in patients with SAHE (52.0% versus 27.3%; P<0.001). When controlling for confounders in logistic regression, SAHE was an independent predictor of lobar HE (odds ratio, 6.00 [95% CI, 2.16-16.64]; P=0.001) whereas there was no association with HE in nonlobar ICH (odds ratio, 0.55 [95% CI, 0.17-1.84]; P=0.334). The increased risk of HE in lobar ICH with SAHE was confirmed in the replication cohort (odds ratio, 3.46 [95% CI, 1.07-11.20]; P=0.038). Conclusions- SAHE predicts HE in lobar ICH. This may improve the stratification of HE risk in clinical practice or future trials targeting HE. Further research is needed to confirm our findings and characterize the underlying biological mechanisms.
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Affiliation(s)
- Andrea Morotti
- From the Dipartimento di Neurologia e Neuroriabilitazione (A.M.), IRCCS Fondazione Mondino, Pavia, Italia
| | - Loris Poli
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Italia (L.P., V.D.G., A.P., A.P.)
| | - Eleonora Leuci
- U.C. Malattie Cerebrovascolari e Stroke Unit (E.L., F.M., A.C.), IRCCS Fondazione Mondino, Pavia, Italia
| | - Federico Mazzacane
- U.C. Malattie Cerebrovascolari e Stroke Unit (E.L., F.M., A.C.), IRCCS Fondazione Mondino, Pavia, Italia
| | - Paolo Costa
- U.O. di Neurologia, Istituto Clinico Fondazione Poliambulanza, Brescia, Italia (P.C.)
| | - Valeria De Giuli
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Italia (L.P., V.D.G., A.P., A.P.)
| | - Elisa Candeloro
- Neurologia e Stroke Unit, Ospedale di Circolo, ASST Settelaghi, Varese, Italia (E.C.)
| | - Giorgio Busto
- Dipartimento di Dipartimento di Scienze Biomediche, Sperimentali e Cliniche, Neuroradiologia, Università degli Studi di Firenze, Ospedale Universitario Careggi, Firenze, Italia (G.B., E.F.)
| | - Ilaria Casetta
- Clinica Neurologica, Dipartimento di Scienze Biomediche e Chirurgico Specialistiche, Università degli studi di Ferrara, Ospedale Universitario S. Anna, Ferrara, Italia (I.C.)
| | - Giuseppe Micieli
- Dipartimento di Neurologia d'Urgenza (G.M.), IRCCS Fondazione Mondino, Pavia, Italia
| | - Anna Cavallini
- U.C. Malattie Cerebrovascolari e Stroke Unit (E.L., F.M., A.C.), IRCCS Fondazione Mondino, Pavia, Italia
| | - Massimo Gamba
- Stroke Unit, Neurologia Vascolare, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili, Brescia, Italia (M.G., M.M.)
| | - Mauro Magoni
- Stroke Unit, Neurologia Vascolare, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili, Brescia, Italia (M.G., M.M.)
| | - Alessandro Padovani
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Italia (L.P., V.D.G., A.P., A.P.)
| | - Alessandro Pezzini
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Italia (L.P., V.D.G., A.P., A.P.)
| | - Enrico Fainardi
- Dipartimento di Dipartimento di Scienze Biomediche, Sperimentali e Cliniche, Neuroradiologia, Università degli Studi di Firenze, Ospedale Universitario Careggi, Firenze, Italia (G.B., E.F.)
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192
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Lun R, Yogendrakumar V, Demchuk AM, Aviv RI, Rodriguez-Luna D, Molina CA, Silva Y, Dzialowski I, Kobayashi A, Boulanger JM, Gubitz G, Srivastava P, Roy J, Kase CS, Bhatia R, Hill MD, Dowlatshahi D. Calculation of Prognostic Scores, Using Delayed Imaging, Outperforms Baseline Assessments in Acute Intracerebral Hemorrhage. Stroke 2020; 51:1107-1110. [PMID: 32151235 DOI: 10.1161/strokeaha.119.027119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Patients with intracerebral hemorrhage (ICH) are often subject to rapid deterioration due to hematoma expansion. Current prognostic scores are largely based on the assessment of baseline radiographic characteristics and do not account for subsequent changes. We propose that calculation of prognostic scores using delayed imaging will have better predictive values for long-term mortality compared with baseline assessments. Methods- We analyzed prospectively collected data from the multicenter PREDICT study (Prediction of Hematoma Growth and Outcome in Patients With Intracerebral Hemorrhage Using the CT-Angiography Spot Sign). We calculated the ICH Score, Functional Outcome in Patients With Primary Intracerebral Hemorrhage (FUNC) Score, and modified ICH Score using imaging data at initial presentation and at 24 hours. The primary outcome was mortality at 90 days. We generated receiver operating characteristic curves for all 3 scores, both at baseline and at 24 hours, and assessed predictive accuracy for 90-day mortality with their respective area under the curve. Competing curves were assessed with nonparametric methods. Results- The analysis included 280 patients, with a 90-day mortality rate of 25.4%. All 3 prognostic scores calculated using 24-hour imaging were more predictive of mortality as compared with baseline: the area under the curve was 0.82 at 24 hours (95% CI, 0.76-0.87) compared with 0.78 at baseline (95% CI, 0.72-0.84) for ICH Score, 0.84 at 24 hours (95% CI, 0.79-0.89) compared with 0.76 at baseline (95% CI, 0.70-0.83) for FUNC, and 0.82 at 24 hours (95% CI, 0.76-0.88) compared with 0.74 at baseline (95% CI, 0.67-0.81) for modified ICH Score. Conclusions- Calculation of the ICH Score, FUNC Score, and modified ICH Score using 24-hour imaging demonstrated better prognostic value in predicting 90-day mortality compared with those calculated at presentation.
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Affiliation(s)
- Ronda Lun
- From the Ottawa Stroke Program, Department of Medicine (Neurology), University of Ottawa, Canada (R.L., V.Y., D.D.)
| | - Vignan Yogendrakumar
- From the Ottawa Stroke Program, Department of Medicine (Neurology), University of Ottawa, Canada (R.L., V.Y., D.D.)
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Canada.,Department of Radiology (A.M.D., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Canada
| | - Richard I Aviv
- Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada.,Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - David Rodriguez-Luna
- Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.)
| | - Carlos A Molina
- Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.)
| | - Yolanda Silva
- Department of Neurology, Dr. Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Girona, Spain (Y.S.)
| | - Imanuel Dzialowski
- Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.)
| | - Adam Kobayashi
- Interventional Stroke and Cerebrovascular Treatment Center, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.).,2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.).,Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.)
| | - Jean-Martin Boulanger
- Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Longueuil, Canada (J.-M.B.)
| | - Gordon Gubitz
- Department of Neurology, Dalhousie University, Halifax, Canada (G.G.)
| | - Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi (P.S., R.B.)
| | - Jayanta Roy
- Apollo Gleneagles Hospitals, Kolkata, India (J.R.)
| | - Carlos S Kase
- Department of Neurology, Boston Medical Center, MA (C.S.K.)
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi (P.S., R.B.)
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Canada.,Department of Radiology (A.M.D., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Canada
| | - Dar Dowlatshahi
- From the Ottawa Stroke Program, Department of Medicine (Neurology), University of Ottawa, Canada (R.L., V.Y., D.D.)
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193
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Sembill JA, Kuramatsu JB, Gerner ST, Sprügel MI, Roeder SS, Madžar D, Hagen M, Hoelter P, Lücking H, Dörfler A, Schwab S, Huttner HB. Hematoma enlargement characteristics in deep versus lobar intracerebral hemorrhage. Ann Clin Transl Neurol 2020; 7:363-374. [PMID: 32133793 PMCID: PMC7086015 DOI: 10.1002/acn3.51001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/10/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Hematoma enlargement (HE) is associated with clinical outcomes after supratentorial intracerebral hemorrhage (ICH). This study evaluates whether HE characteristics and association with functional outcome differ in deep versus lobar ICH. METHODS Pooled analysis of individual patient data between January 2006 and December 2015 from a German-wide cohort study (RETRACE, I + II) investigating ICH related to oral anticoagulants (OAC) at 22 participating centers, and from one single-center registry (UKER-ICH) investigating non-OAC-ICH patients. Altogether, 1954 supratentorial ICH patients were eligible for outcome analyses, which were separately conducted or controlled for OAC, that is, vitamin-K-antagonists (VKA, n = 1186) and non-vitamin-K-antagonist-oral-anticoagulants (NOAC, n = 107). Confounding was addressed using propensity score matching, cox regression modeling and multivariate modeling. Main outcomes were occurrence, extent, and timing of HE (>33%/>6 mL) and its association with 3-month functional outcome. RESULTS Occurrence of HE was not different after deep versus lobar ICH in patients with non-OAC-ICH (39/356 [11.0%] vs. 36/305 [11.8%], P = 0.73), VKA-ICH (249/681 [36.6%] vs. 183/505 [36.2%], P = 0.91), and NOAC-ICH (21/69 [30.4%] vs. 12/38 [31.6%], P = 0.90). HE extent did not differ after non-OAC-ICH (deep:+59% [40-122] vs. lobar:+74% [37-124], P = 0.65), but both patients with VKA-ICH and NOAC-ICH showed greater HE extent after deep ICH [VKA-ICH, deep: +94% [54-199] vs. lobar: +56% [35-116], P < 0.001; NOAC-ICH, deep: +74% [56-123] vs. lobar: +40% [21-49], P = 0.001). Deep compared to lobar ICH patients had higher HE hazard during first 13.5 h after onset (Hazard ratio [HR]: 1.85 [1.03-3.31], P = 0.04), followed by lower hazard (13.5-26.5 h, HR: 0.46 [0.23-0.89], P = 0.02), and equal hazard thereafter (HR: 0.96 [0.56-1.65], P = 0.89). Odds ratio for unfavorable outcome was higher after HE in deep (4.31 [2.71-6.86], P < 0.001) versus lobar ICH (2.82 [1.71-4.66], P < 0.001), and only significant after small-medium (1st volume-quarter, deep: 3.09 [1.52-6.29], P < 0.01; lobar: 3.86 [1.35-11.04], P = 0.01) as opposed to large-sized ICH (4th volume-quarter, deep: 1.09 [0.13-9.20], P = 0.94; lobar: 2.24 [0.72-7.04], P = 0.17). INTERPRETATION HE occurrence does not differ among deep and lobar ICH. However, compared to lobar ICH, HE after deep ICH is of greater extent in OAC-ICH, occurs earlier and may be of greater clinical relevance. Overall, clinical significance is more apparent after small-medium compared to large-sized bleedings.
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Affiliation(s)
- Jochen A Sembill
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Stefan T Gerner
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Maximilian I Sprügel
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Sebastian S Roeder
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Dominik Madžar
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Manuel Hagen
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Philip Hoelter
- Department of Neuroradiology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
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195
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Michalski D, Jungk C, Brenner T, Dietrich M, Nusshag C, Weigand MA, Reuß CJ, Beynon C, Bernhard M. Neurologische Intensivmedizin. Anaesthesist 2020; 69:129-136. [DOI: 10.1007/s00101-019-00643-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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196
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Jeong HG, Bang JS, Kim BJ, Bae HJ, Han MK. Hematoma Hounsfield units and expansion of intracerebral hemorrhage: A potential marker of hemostatic clot contraction. Int J Stroke 2020; 16:163-171. [PMID: 31992155 DOI: 10.1177/1747493019895703] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Clot contraction reinforces hemostasis by providing an impermeable barrier and contractile force. Since computed tomography attenuation of intracerebral hemorrhage is largely determined by the density of red blood cells, clot contraction can be reflected in an increase of Hounsfield unit (HU) of hematoma. AIMS We hypothesized that hematoma expansion is inversely associated with mean HU of intracerebral hemorrhage at presentation. METHODS Eighty-nine consecutive spontaneous intracerebral hemorrhage patients with onset to first computed tomography within 24 h were included. Hematomas were segmented using semiautomated planimetry to measure the volume and mean HU. Hematoma expansion was defined as an increase in hematoma volume by over 33% or 6 mL. Multivariable logistic regression was performed for hematoma expansion. The discrimination power of mean HU for hematoma expansion was assessed using C-statistic. RESULTS The computed tomography attenuation of hematoma at presentation was 57.5 ± 3.3 HU and the volume was 16.9 ± 23.2 mL. Hematoma expansion occurred in 37.1% of patients. The computed tomography attenuation of hematoma was lower in patients with hematoma expansion than with no expansion (55.7 ± 2.9 HU vs. 58.6 ± 3.1 HU, p-value < 0.01). Multivariable logistic regression revealed that the mean HU of hematoma was inversely associated with hematoma expansion (adjusted odds ratio, 0.64; 95% confidence interval, 0.51-0.80). The C-statistic of the model with four known predictors increased from 0.66 to 0.84 after incorporating mean HU (p-value < 0.01). CONCLUSIONS Intracerebral hemorrhage with lower mean HU of hematoma at presentation is more likely to undergo hematoma expansion. This finding suggests the potential presence of clot contraction process that reinforces hemostasis in intracerebral hemorrhage.
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Affiliation(s)
- Han-Gil Jeong
- Department of Neurology, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Neurosurgery, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Seung Bang
- Department of Neurosurgery, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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197
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Sorimachi T, Atsumi H, Yonemochi T, Hirayama A, Shigematsu H, Srivatanakul K, Takizawa S, Matsumae M. Benefits and Risks of CT Angiography Immediately after Emergency Arrival for Patients with Intracerebral Hematoma. Neurol Med Chir (Tokyo) 2020; 60:45-52. [PMID: 31708512 PMCID: PMC6970072 DOI: 10.2176/nmc.oa.2019-0152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Computed tomography angiography (CTA) immediately after diagnosis of intracerebral hematoma (ICH) on noncontrast CT in the emergency room has benefits, which consist of early diagnosis of secondary ICH and prediction of hematoma growth using the spot sign in primary ICH, but CTA also involves possible risks of acute kidney injury (AKI) and adverse reactions. The purpose of this study was to evaluate the benefits and risks of CTA. A total of 1423 consecutive adult patients diagnosed with ICH who were admitted within 3 days of onset between 2010 and 2017 were retrospectively analyzed. Of 1082 patients undergoing CTA, 162 patients (15.0%) showed secondary ICH, and the sensitivity of CTA for secondary ICH was 95.7%. Of 920 patients with primary ICH, a logistic regression model using the spot sign and four other previously reported risk factors (antiplatelet agents, anticoagulants, interval from onset to arrival, hematoma volume) with an area under the curve (AUC) of 0.787 significantly improved model performance to predict hematoma growth compared with a model using the same four factors without the spot sign (AUC: 0.697) (DeLong’s test: P = 0.0002). Rates of AKI occurrence were 9.0% and 9.8% in patients with and without CTA, respectively. The odds ratio of AKI in patients with CTA adjusted by reported risk factors was 1.16 (95% confidence interval: 0.72–1.95, P = 0.5548). Emergency CTA following noncontrast CT in patients with ICH could be useful for early diagnosis of secondary ICH and prediction of hematoma growth using the spot sign in primary ICH with little risk.
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Affiliation(s)
| | - Hideki Atsumi
- Department of Neurosurgery, School of Medicine, Tokai University
| | - Takuya Yonemochi
- Department of Neurosurgery, School of Medicine, Tokai University
| | - Akihiro Hirayama
- Department of Neurosurgery, School of Medicine, Tokai University
| | | | | | - Shunya Takizawa
- Department of Neurology, School of Medicine, Tokai University
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198
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Dowlatshahi D, Morotti A, Al-Ajlan FS, Boulouis G, Warren AD, Petrcich W, Aviv RI, Demchuk AM, Goldstein JN. Interrater and Intrarater Measurement Reliability of Noncontrast Computed Tomography Predictors of Intracerebral Hemorrhage Expansion. Stroke 2020; 50:1260-1262. [PMID: 30909839 DOI: 10.1161/strokeaha.118.024050] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Early hematoma expansion after intracerebral hemorrhage is a potentially modifiable predictor of outcome and a promising therapeutic target. Radiological markers seen on noncontrast computed tomography can help predict hematoma expansion and risk stratify patients presenting with intracerebral hemorrhage. Our objective was to assess the interrater and intrarater reliability of 5 commonly reported noncontrast computed tomographic markers of hematoma expansion. Methods- Four readers independently reviewed images from 40 patients from 2 intracerebral hemorrhage imaging databases (PREDICT Collaboration [Predicting Haematoma Growth and Outcome in Intracerebral Haemorrhage Using Contrast Bolus CT] and Massachusetts General Hospital). Readers were blind to all demographic and outcome data and used accepted definitions to establish the presence or absence of intrahematoma hypodensities, blend sign, fluid level, irregular hematoma morphology, and heterogeneous hematoma density. We calculated interrater and intrarater agreement and stratified kappas for the 5 imaging markers. Results- Interrater agreement was excellent for all 5 markers, ranging from 94% to 98%. Interrater kappas ranged from 0.67 to 0.91 (the lowest for fluid level). Interrater agreement had a similar pattern, ranging from 89% to 93%, with Kappas ranging from 0.60 to 0.89. Conclusions- We show that 5 commonly used noncontrast computed tomographic imaging findings all have good-to-excellent interrater and intrarater reliabilities, with the best kappa for blend sign, hypodensities, and heterogeneity.
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Affiliation(s)
- Dar Dowlatshahi
- From the Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Canada (D.D., W.P.)
| | - Andrea Morotti
- Stroke Unit, IRCCS Mondino Foundation, Pavia, Italy (A.M.)
| | - Fahad S Al-Ajlan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia (F.S.A.-A.)
| | - Gregoire Boulouis
- Department of Neuroradiology, Université Paris Descartes, Centre Hospitalier Sainte-Anne, France (G.B.)
| | - Andrew D Warren
- Massachusetts General Hospital, Harvard Medical School, Boston (A.D.W.)
| | - William Petrcich
- From the Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Canada (D.D., W.P.)
| | - Richard I Aviv
- Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada.,Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (A.M.D.), Hotchkiss Brain Institute, University of Calgary, Canada.,Department of Radiology (A.M.D.), Hotchkiss Brain Institute, University of Calgary, Canada
| | - Joshua N Goldstein
- Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston.,J.P. Kistler Stroke Research Center (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
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199
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Wu X, Luo J, Liu H, Cui W, Guo K, Zhao L, Bai H, Guo W, Guo H, Feng D, Qu Y. Recombinant Adiponectin Peptide Ameliorates Brain Injury Following Intracerebral Hemorrhage by Suppressing Astrocyte-Derived Inflammation via the Inhibition of Drp1-Mediated Mitochondrial Fission. Transl Stroke Res 2020; 11:924-939. [DOI: 10.1007/s12975-019-00768-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/03/2019] [Accepted: 12/05/2019] [Indexed: 12/21/2022]
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200
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Helal HHAE, Bahnasy WS, Ghali AA, Rabie MO. Early hematoma expansion in primary intracerebral hemorrhage: incidence and predictors. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0108-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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