151
|
Lei P, Li Z, Hua Q, Song P, Gao L, Zhou L, Cai Q. Ursolic Acid Alleviates Neuroinflammation after Intracerebral Hemorrhage by Mediating Microglial Pyroptosis via the NF-κB/NLRP3/GSDMD Pathway. Int J Mol Sci 2023; 24:14771. [PMID: 37834220 PMCID: PMC10572659 DOI: 10.3390/ijms241914771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 10/15/2023] Open
Abstract
The neuroinflammatory response after intracerebral hemorrhage (ICH) causes a large amount of neuronal loss, and inhibiting the inflammatory response can improve the prognosis. In previous laboratory studies and clinical trials, ursolic acid (UA) inhibited the inflammatory response, but whether it can be administered to inhibit the neuroinflammatory response after cerebral hemorrhage is unknown. The aim of this study was to investigate the effects of ursolic acid after cerebral hemorrhage. Online databases were used to obtain potential therapeutic targets of ursolic acid for the treatment of cerebral hemorrhage, and possible mechanisms were analyzed by KEGG, GO, and molecular docking. A rat model of cerebral hemorrhage was established using collagenase, and an in vitro cerebral hemorrhage model was constructed by adding hemin to BV2 cell culture medium. Enzyme-linked immunosorbent assay (ELISA), Western blotting (WB), immunofluorescence, TUNEL staining, and calcein/PI staining were used to investigate the degree of microglial M1 polarization, changes in the levels of inflammatory factors, activation of the NF-κB pathway, and changes in the indicators of cellular death after ursolic acid treatment. In addition, phorbol 12-myristate 13-acetate (PMA) was used to activate the NF-κB pathway to verify that ursolic acid exerts its anti-neuroinflammatory effects by regulating the NF-κB/NLRP3/GSDMD pathway. Network pharmacology and bioinformatics analyses revealed that ursolic acid may exert its therapeutic effects on cerebral hemorrhage through multiple pathways. Together, in vivo and in vitro experiments showed that ursolic acid inhibited microglial M1 polarization and significantly reduced the levels of p-NF-κB, GSDMD-N, cleaved caspase-1, TNF-α, IL-6, and IL-1β, which were significantly inhibited by the use of PMA. Ursolic acid inhibits microglial pyroptosis via the NF-κB/NLRP3/GSDMD pathway to alleviate neuroinflammatory responses after cerebral hemorrhage.
Collapse
Affiliation(s)
| | | | | | | | | | - Long Zhou
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, China; (P.L.); (Z.L.); (Q.H.); (P.S.); (L.G.)
| | - Qiang Cai
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, China; (P.L.); (Z.L.); (Q.H.); (P.S.); (L.G.)
| |
Collapse
|
152
|
Zhan Y, Zou X, Wu J, Fu L, Huang W, Lin J, Luo F, Wang W. Neuroendoscopy surgery for hypertensive intracerebral hemorrhage with concurrent brain herniation: a retrospective study of comparison with craniotomy. Front Neurol 2023; 14:1238283. [PMID: 37840932 PMCID: PMC10576608 DOI: 10.3389/fneur.2023.1238283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/21/2023] [Indexed: 10/17/2023] Open
Abstract
Background Hypertensive intracerebral hemorrhage combined with cerebral hernia (HIH-CH) is a serious condition. Neuroendoscopy can effectively remove intracranial hematoma, but there is no relevant research support for its utility in patients with HIH-CH. The purpose of this study is to investigate the efficacy and safety of neuroendoscopy in patients with HIH-CH. Methods Patients with HIH-CH who received craniotomy or neuroendoscopy treatment were included. The patients were divided into craniotomy (CHE) group and neuroendoscopy (NEHE) group. Clinical data and follow-up outcome of the two groups were collected. The primary outcome was hematoma clearance. Results The hematoma clearance rate (%) of patients in NEHE group was 97.65 (92.75, 100.00), and that of patients in CHE group was 95.00 (90.00, 100.00), p > 0.05. The operation time and intraoperative bleeding volume of patients in NEHE group were significantly less than those in CHE group (p < 0.05). There was no significant difference in the volume of residual hematoma and the incidence of rebleeding between the two groups (p > 0.05). The length of stay in ICU in NEHE group was significantly shorter than that in CHE group (p < 0.05). Conclusion Neuroendoscopy can safely and effectively remove the intracranial hematoma in patients with hypertensive intracerebral hemorrhage and cerebral hernia, significantly shorten the operation time, reduce the amount of intraoperative hemorrhage, shorten the ICU stay.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Fei Luo
- Department of Neurosurgery, The 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, China
| | - Wenhao Wang
- Department of Neurosurgery, The 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, China
| |
Collapse
|
153
|
Merella P, Talanas G, Lorenzoni G, Denurra C, Atzori E, Casu G. Percutaneous Left Atrial Appendage Occlusion: What the Practising Physician Should Know. Eur Cardiol 2023; 18:e57. [PMID: 37860701 PMCID: PMC10583154 DOI: 10.15420/ecr.2023.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/30/2023] [Indexed: 10/21/2023] Open
Abstract
Non-valvular AF is a common clinical condition associated with an increased risk of thromboembolic complications. As a consequence, oral anticoagulant therapy (OAT) is the cornerstone of non-valvular AF management. Despite the well-established efficacy of OAT, many patients cannot receive this preventive therapy due to bleeding or a high risk of bleeding. The fact that more than 90% of thrombi are formed in the left atrial appendage has led to the development of alternative methods to reduce the embolic risk. Left atrial appendage occlusion (LAAO) is a non-pharmacological option for preventing cardioembolic events in patients with non-valvular AF with a contraindication to OAT. The demand for LAAO procedures is growing exponentially and clinicians should consider this alternative option when managing patients with a contraindication to OAT. This review summarises the current thinking about LAAO.
Collapse
Affiliation(s)
- Pierluigi Merella
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari Sassari, Italy
| | - Giuseppe Talanas
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari Sassari, Italy
| | - Giovanni Lorenzoni
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari Sassari, Italy
| | - Cristiana Denurra
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari Sassari, Italy
| | - Enrico Atzori
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari Sassari, Italy
| | - Gavino Casu
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari Sassari, Italy
| |
Collapse
|
154
|
Essibayi MA, Ibrahim Abdallah O, Mortezaei A, Zaidi SE, Vaishnav D, Cherian J, Parikh G, Altschul D, Labib M. Natural History, Pathophysiology, and Recent Management Modalities of Intraventricular Hemorrhage. J Intensive Care Med 2023:8850666231204582. [PMID: 37769332 DOI: 10.1177/08850666231204582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Intraventricular hemorrhage (IVH) is a clinical challenge observed among 40-45% of intracerebral hemorrhage (ICH) cases. IVH can be classified according to the source of the hemorrhage into primary and secondary IVH. Primary intraventricular hemorrhage (PIVH), unlike secondary IVH, involves only the ventricles with no hemorrhagic parenchymal source. Several risk factors of PIVH were reported which include hypertension, smoking, age, and excessive alcohol consumption. IVH is associated with high mortality and morbidity and several prognostic factors were identified such as IVH volume, number of ventricles with blood, involvement of fourth ventricle, baseline Glasgow Coma Scale score, and hydrocephalus. Prompt management of patients with IVH is required to stabilize the clinical status of patients upon admission. Nevertheless, further advanced management is crucial to reduce the morbidity and mortality associated with intraventricular bleeding. Recent treatments showed promising outcomes in the management of IVH patients such as intraventricular anti-inflammatory drugs, lumbar drainage, and endoscopic evacuation of IVH, however, their safety and efficacy are still in question. This literature review presents the epidemiology, physiopathology, risk factors, and outcomes of IVH in adults with an emphasis on recent treatment options.
Collapse
Affiliation(s)
- Muhammed Amir Essibayi
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
- Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Ali Mortezaei
- School of Medicine, Gonabad University of Medical Sciences, Gonabad, Razavi Khorasan, Iran
| | - Saif Eddine Zaidi
- School of Medicine, University of Paris, Paris, France
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Dhrumil Vaishnav
- Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jacob Cherian
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| | - Gunjan Parikh
- Department of Neurology and Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David Altschul
- Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mohamed Labib
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| |
Collapse
|
155
|
Geng Y, Wang T, Liu Y, Liu X, Wang Y, Tan K, Li X, Li J. How to predict the outcome of primary brainstem hemorrhage: Six-year results of a single-center retrospective analysis. Medicine (Baltimore) 2023; 102:e35131. [PMID: 37713883 PMCID: PMC10508365 DOI: 10.1097/md.0000000000035131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/17/2023] [Indexed: 09/17/2023] Open
Abstract
Primary brainstem hemorrhage (PBH) is one of the most fatal intracranial hemorrhages, evaluating the prognosis in the early stage is vital for appropriate therapeutic planning. Our study aimed to identify risk factors for 30-day mortality and 90-day functional recovery of PBH. Data from 63 patients with PBH admitted to Beijing Chaoyang Hospital between 2016 and 2022 were retrieved for this study. We grouped the patients according to 30-day survival or 90-day functional recovery. Independent risk factors of 30-day mortality and 90-day functional recovery were identified by univariate and multivariate logistic regression analyses. 31 patients (49.2%) died within 30 days and 22 patients (34.9%) achieved better functional recovery. By multivariate analysis, Glasgow coma scale <9 on admission and tachycardia were significantly associated with 30-day mortality, while the hematoma volume >5 mL was an independent risk factor for 90-day functional recovery. Initial level of consciousness, tachycardia, massive hematoma were risk factors for prognosis, which must be seriously evaluated for therapeutic planning.
Collapse
Affiliation(s)
- Yibo Geng
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Tao Wang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yiqi Liu
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiaoli Liu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ke Tan
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiong Li
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jinping Li
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
156
|
Wang J, Wang T, Fang M, Wang Z, Xu W, Teng B, Yuan Q, Hu X. Advances of nanotechnology for intracerebral hemorrhage therapy. Front Bioeng Biotechnol 2023; 11:1265153. [PMID: 37771570 PMCID: PMC10523393 DOI: 10.3389/fbioe.2023.1265153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/01/2023] [Indexed: 09/30/2023] Open
Abstract
Intracerebral hemorrhage (ICH), the most devastating subtype of stoke, is of high mortality at 5 years and even those survivors usually would suffer permanent disabilities. Fortunately, various preclinical active drugs have been approached in ICH, meanwhile, the therapeutic effects of these pharmaceutical ingredients could be fully boosted with the assistance of nanotechnology. In this review, besides the pathology of ICH, some ICH therapeutically available active drugs and their employed nanotechnologies, material functions, and therapeutic principles were comprehensively discussed hoping to provide novel and efficient strategies for ICH therapy in the future.
Collapse
Affiliation(s)
- Jiayan Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Tianyou Wang
- State Key Laboratory of Polymer Materials Engineering, College of Polymer Science and Engineering, Sichuan University, Chengdu, China
| | - Mei Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Zexu Wang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Wei Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Bang Teng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Qijuan Yuan
- School of Materials Science and Engineering, Xihua University, Chengdu, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
157
|
Albakr A, Almatar A, AlFajri A, Zafar A, Nazish S, Shahid R, AlJaafari D, Soltan N, Alarfaj Z, Al Ghamdi O, Alfilw S, Abdelhady A, Albaker W. Important Factors to Expect the Outcome After Intracerebral Hemorrhage: An Observational Study From a University Hospital in Saudi Arabia. Neurologist 2023; 28:310-315. [PMID: 37027177 DOI: 10.1097/nrl.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) has worse clinical outcomes than other stroke types. The risk factors contributing to ICH outcomes are not entirely understood, and published literature from Saudi Arabia on ICH outcomes is limited. Our goal was to study the specific clinical and imaging determinants of ICH outcomes. METHODS We retrospectively retrieved all patients with spontaneous ICH (SICH) from a prospective King Fahd Hospital University registry between 2017 and 2019. The clinical characteristics of ICH events and data on clinical outcomes (6 to 12 mo) were recorded. Groups of patients with a favorable modified Rankin Scale of 0 to 2 and nonfavorable outcomes of a modified Rankin Scale of 3 to 6 were investigated. The relationship between the clinical characteristics of the SICH event and its outcomes was assessed using linear and logistic regression analyses. RESULTS A total of 148 patients with a mean age of 60.3 years (±15.2) and a median follow-up of 9 months were included. Unfavorable outcomes were reported in 98 patients (66.2%). The ICH event variables associated with unfavorable outcomes were impaired renal function, Glasgow Coma Score <8, hematoma volume, hematoma expansion, and intraventricular extension (IVE). CONCLUSIONS Our study demonstrated important clinical and radiologic features in patients with ICH that may affect their clinical long-term functional outcomes. A larger multicenter study is required to validate our results and evaluate the methods to improve health care in patients with SICH.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Suad Alfilw
- Department of Neurology, College of Nursing, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia
| | - Ahmed Abdelhady
- Department of critical care, College of Medicine, Alexandria University, Egypt
| | | |
Collapse
|
158
|
Zachrison KS, Goldstein JN, Jauch E, Radecki RP, Madsen TE, Adeoye O, Oostema JA, Feeser VR, Ganti L, Lo BM, Meurer W, Corral M, Rothenberg C, Chaturvedi A, Goyal P, Venkatesh AK. Clinical Performance Measures for Emergency Department Care for Adults With Intracranial Hemorrhage. Ann Emerg Med 2023; 82:258-269. [PMID: 37074253 DOI: 10.1016/j.annemergmed.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 04/20/2023]
Abstract
Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage, emergency departments lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative. To develop the measure set, we convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure: internal quality improvement, benchmarking, or accountability, and examined data from Emergency Quality Network Stroke Initiative-participating EDs to consider the validity and feasibility of proposed measures for quality measurement and improvement applications. The initially conceived set included 14 measure concepts, of which 7 were selected for inclusion in the measure set after a review of data and further deliberation. Proposed measures include 2 for quality improvement, benchmarking, and accountability (Last 2 Recorded Systolic Blood Pressure Measurements Under 150 and Platelet Avoidance), 3 for quality improvement and benchmarking (Proportion of Patients on Oral Anticoagulants Receiving Hemostatic Medications, Median ED Length of Stay for admitted patients, and Median Length of Stay for transferred patients), and 2 for quality improvement only (Severity Assessment in the ED and Computed Tomography Angiography Performance). The proposed measure set warrants further development and validation to support broader implementation and advance national health care quality goals. Ultimately, applying these measures may help identify opportunities for improvement and focus quality improvement resources on evidence-based targets.
Collapse
Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Ryan P Radecki
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University School of Medicine in St Louis, St Louis, MO
| | - John A Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, East Lansing, MI
| | - V Ramana Feeser
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA
| | - Latha Ganti
- Department of Emergency Medicine, University of Central Florida College of Medicine, Orlando, FL
| | - Bruce M Lo
- Department of Emergency Medicine, Sentara Norfolk General Hospital/Eastern Virginia Medical School, Norfolk, VA
| | - William Meurer
- Departments of Emergency Medicine and Neurology, University of Michigan Medical School, Ann Arbor, MI
| | | | - Craig Rothenberg
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | | | - Pawan Goyal
- American College of Emergency Physicians, Irving, TX
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| |
Collapse
|
159
|
Zhu X, Wang Z, Ferrari MW, Ferrari-Kuehne K, Hsi DH, Tse G, Zhou Q, Liang H, Zhang Y, Zhang J. Management of anticoagulation in patients with infective endocarditis. Thromb Res 2023; 229:15-25. [PMID: 37390524 DOI: 10.1016/j.thromres.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 07/02/2023]
Abstract
Infective endocarditis (IE) carries a high risk of vascular complications (e.g., cerebral embolism, intracerebral hemorrhage, and renal infarction), which are correlated with increased early and late mortality. Although anticoagulation is the cornerstone for management of thromboembolic complications, it remains controversial and challenging in patients with IE. An appropriate anticoagulation strategy is crucial to improving outcomes and requires a good understanding of the indication, timing, and regimen of anticoagulation in the setting of IE. Observational studies have shown that anticoagulant treatment failed to reduce the risk of ischemic stroke in patents with IE, supporting that IE alone is not an indication for anticoagulation. In the absence of randomized controlled trials and high-quality meta-analyses, however, current guidelines on IE were based largely on observational data and expert opinion, providing few specific recommendations on anticoagulation. A multidisciplinary approach and patient engagement are required to determine the timing and regimen of anticoagulation in patients with IE, especially in specific situations (e.g., receiving warfarin anticoagulation at the time of IE diagnosis, cerebral embolism or ischemic stroke, intracerebral hemorrhage, or urgent surgery). Collectively, individualized strategies on anticoagulation management of IE should be based on clinical evaluation, available evidence, and patient engagement, and ultimately be developed by the multidisciplinary team.
Collapse
Affiliation(s)
- Xiaogang Zhu
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, China
| | - Zhenhua Wang
- Department of Cardiology, Second Affiliated Hospital of Fujian Medical University, China
| | - Markus W Ferrari
- Clinic of Internal Medicine 1, HSK, Clinic of the City of Wiesbaden and the HELIOS Group, Germany
| | | | - David H Hsi
- Heart & Vascular Institute, Stamford Hospital, Stamford, CT, United States
| | - Gary Tse
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Quanzhong Zhou
- Department of Radiology, The Center for Medical Imaging of Guizhou Province, Affiliated Hospital of Zunyi Medical University, China
| | - Haifeng Liang
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, China
| | - Yuhui Zhang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China.
| | - Jian Zhang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China.
| |
Collapse
|
160
|
Zhou W, Qin C, Chang J, Liu Y, Chen Y, Feng M, Wang R, Yang W, Yao J. Standardized measurement of mid-surface shift of brain based on deep Hough transform. Comput Med Imaging Graph 2023; 108:102284. [PMID: 37567044 DOI: 10.1016/j.compmedimag.2023.102284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/29/2023] [Accepted: 07/29/2023] [Indexed: 08/13/2023]
Abstract
The measurement of mid-surface shift (MSS), the geometric displacement between the actual mid-surface and the ideal midsagittal plane (iMSP), is of great significance for accurate diagnosis, treatment and prognosis of patients with intracranial hemorrhage (ICH). Most previous studies are subject to inherent inaccuracy on account of calculating midline shift (MLS) based on 2D slices and ignoring pathological conditions. In this study, we propose a novel standardized measurement model to quantify the distance and the overall volume of mid-surface shift (MSS-D, MSS-V). Our work has four highlights. First, we develop an end-to-end network architecture with multiple sub-tasks including the actual mid-surface segmentation, hematoma segmentation and iMSP detection, which significantly improves the efficiency and accuracy of MSS measurement by taking advantage of the common properties among tasks. Second, an efficient iMSP detection scheme is proposed based on the differentiable deep Hough transform (DHT), which converts and simplifies the plane detection problem in the image space into a keypoint detection problem in the Hough space. Third, we devise a sparse DHT strategy and a weighted least square (WLS) method to increase the sparsity of features, improving inference speed and greatly reducing computation cost. Fourth, we design a joint loss function to comprehensively consider the correlation of features between multi-tasks and multi-domains. Extensive validation on our large in-house dataset (519 patients) and the public CQ500 dataset (491 patients), demonstrates the superiority of our method over the state-of-the-art methods.
Collapse
Affiliation(s)
- Wenxue Zhou
- Tencent AI Lab, Shenzhen, China; Shenzhen International Graduate School, Tsinghua University, Shenzhen, China
| | | | - Jianbo Chang
- Peking Union Medical College Hospital, Beijing, China
| | | | - Yihao Chen
- Peking Union Medical College Hospital, Beijing, China
| | - Ming Feng
- Peking Union Medical College Hospital, Beijing, China
| | - Renzhi Wang
- Peking Union Medical College Hospital, Beijing, China
| | - Wenming Yang
- Shenzhen International Graduate School, Tsinghua University, Shenzhen, China
| | | |
Collapse
|
161
|
Choi JH, Yoon WK, Kim JH, Kwon TH, Byun J. Predictor of the Postoperative Swelling After Craniotomy for Spontaneous Intracerebral Hemorrhage: Sphericity Index as a Novel Parameter. Korean J Neurotrauma 2023; 19:333-347. [PMID: 37840614 PMCID: PMC10567521 DOI: 10.13004/kjnt.2023.19.e41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 10/17/2023] Open
Abstract
Objective Spontaneous intracerebral hemorrhage is a serious type of stroke with high mortality and disability rates. Surgical treatment options vary; however, predicting edema aggravation is crucial when choosing the optimal approach. We propose using the sphericity index, a measure of roundness, to predict the aggravation of edema and guide surgical decisions. Methods We analyzed 56 cases of craniotomy and hematoma evacuation to investigate the correlation between the sphericity index and patient outcomes, including the need for salvage decompressive craniectomy (DC). Results The patients included 35 (62.5%) men and 21 (37.5%) women, with a median age of 62.5 years. The basal ganglia was the most common location of hemorrhage (50.0%). The mean hematoma volume was 86.3 cc, with 10 (17.9%) instances of hematoma expansion. Cerebral herniation was observed in 44 (78.6%) patients, intraventricular hemorrhage in 34 (60.7%), and spot signs in 9 (16.1%). Salvage DC was performed in 13 (23.6%) patients to relieve intracranial pressure. The median follow-up duration was 6 months, with a mortality rate of 12.5%. The sphericity index was significantly correlated with delayed swelling and hematoma expansion but not salvage DC. Conclusions The sphericity index is a promising predictor of delayed swelling and hematoma expansion that may aid in the development of surgical guidelines and medication strategies. Further large-scale studies are required to explore these aspects and establish comprehensive guidelines.
Collapse
Affiliation(s)
- Jae Hoon Choi
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Won Ki Yoon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong Hyun Kim
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Taek Hyun Kwon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Joonho Byun
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
162
|
Chen SJ, Tsai HH, Lo YL, Chen YF, Tang SC, Jeng JS, Tsai LK. Interaction between cerebral small vessel disease, blood pressure, and remote ischemic lesions in acute spontaneous intracerebral hemorrhage. Eur Stroke J 2023; 8:828-835. [PMID: 37641548 PMCID: PMC10472944 DOI: 10.1177/23969873231170989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 04/04/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Acute blood pressure (BP) reduction is the first-line treatment for acute spontaneous intracerebral hemorrhage (ICH); however, recent research suggests that intensive BP reduction along with cerebral small vessel disease (cSVD) is a risk factor for remote DWI lesions (RDWILs). We aimed to delineate the interplay between cSVD and BP reduction therapy on the risk of RDWILs. METHODS We enrolled 303 patients who underwent brain magnetic resonance imaging within 7 days after acute spontaneous ICH. RDWILs were categorized as occurring in borderzone (BZ) or non-BZ areas. We examined the effect of cSVD, acute BP reduction, and their interaction on RDWILs. RESULTS RDWILs were observed in 34 (11%) patients (59.8 ± 10.3-years-old, 24% male). RDWILs were associated with a larger acute weighted average mean arterial pressure (MAP) reduction in the initial 24 h after ICH onset and a higher total cerebral microbleed (CMB) count. Intensive MAP changes (odds ratio (OR) per 10 mmHg 1.76, 95% confidence interval (CI) 1.03-3.20), total CMBs burden (OR per 10 CMBs 1.21, 95% CI 1.08-1.39), and presence of lobar CMBs (OR 7.33, 95% CI 1.59-55.6) were risk factors for RDWILs at BZ, but not at non-BZ. Furthermore, a significant interaction was observed between lobar CMBs and MAP reduction on increased risk of RDWILs at BZ (p = 0.030). CONCLUSION cSVD modulates the effect of acute BP reduction on the risk of RDWILs. Patients with extensive microangiopathy have a higher risk of developing cerebral ischemic changes in BZ during unstable hemodynamic status.
Collapse
Affiliation(s)
- Szu-Ju Chen
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei
- Department of Neurology, National Taiwan University Hospital, Taipei
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei
| | - Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei
- Department of Neurology, National Taiwan University Hospital, Taipei
| | - Yen-Ling Lo
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu
| |
Collapse
|
163
|
Sonneville R, Mazighi M, Collet M, Gayat E, Degos V, Duranteau J, Grégoire C, Sharshar T, Naim G, Cortier D, Jost PH, Foucrier A, Bagate F, de Montmollin E, Papin G, Magalhaes E, Guidet B, Ben Hadj Salem O, Benghanem S, le Guennec L, Delpierre E, Legriel S, Megarbane B, Toumert K, Tran M, Geri G, Monchi M, Bodiguel E, Mariotte E, Demoule A, Zarka J, Diehl JL, Roux D, Barré E, Tanaka S, Osman D, Pasquier P, Lamara F, Crassard I, Boursin P, Ruckly S, Staiquly Q, Timsit JF, Woimant F. One-Year Outcomes in Patients With Acute Stroke Requiring Mechanical Ventilation. Stroke 2023; 54:2328-2337. [PMID: 37497675 DOI: 10.1161/strokeaha.123.042910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/22/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Long-term outcomes of patients with severe stroke remain poorly documented. We aimed to characterize one-year outcomes of patients with stroke requiring mechanical ventilation in the intensive care unit (ICU). METHODS We conducted a prospective multicenter cohort study in 33 ICUs in France (2017-2019) on patients with consecutive strokes requiring mechanical ventilation for at least 24 hours. Outcomes were collected via telephone interviews by an independent research assistant. The primary end point was poor functional outcome, defined by a modified Rankin Scale score of 4 to 6 at 1 year. Multivariable mixed models investigated variables associated with the primary end point. Secondary end points included quality of life, activities of daily living, and anxiety and depression in 1-year survivors. RESULTS Among the 364 patients included, 244 patients (66.5% [95% CI, 61.7%-71.3%]) had a poor functional outcome, including 190 deaths (52.2%). After adjustment for non-neurological organ failure, age ≥70 years (odds ratio [OR], 2.38 [95% CI, 1.26-4.49]), Charlson comorbidity index ≥2 (OR, 2.01 [95% CI, 1.16-3.49]), a score on the Glasgow Coma Scale <8 at ICU admission (OR, 3.43 [95% CI, 1.98-5.96]), stroke subtype (intracerebral hemorrhage: OR, 2.44 [95% CI, 1.29-4.63] versus ischemic stroke: OR, 2.06 [95% CI, 1.06-4.00] versus subarachnoid hemorrhage: reference) remained independently associated with poor functional outcome. In contrast, a time between stroke diagnosis and initiation of mechanical ventilation >1 day was protective (OR, 0.56 [95% CI, 0.33-0.94]). A sensitivity analysis conducted after exclusion of patients with early decisions of withholding/withdrawal of care yielded similar results. We observed persistent physical and psychological problems at 1 year in >50% of survivors. CONCLUSIONS In patients with severe stroke requiring mechanical ventilation, several ICU admission variables may inform caregivers, patients, and their families on post-ICU trajectories and functional outcomes. The burden of persistent sequelae at 1 year reinforces the need for a personalized, multi-disciplinary, prolonged follow-up of these patients after ICU discharge. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03335995.
Collapse
Affiliation(s)
- Romain Sonneville
- Université de Paris, INSERM UMR 1148, F-75018 Paris, France (R.S., M. Mazighi)
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, F75018 Paris, France (R.S., G.P., F.L., J.-F.T.)
| | - Mikael Mazighi
- Université de Paris, INSERM UMR 1148, F-75018 Paris, France (R.S., M. Mazighi)
- APHP, Department of Neurology, Lariboisière University Hospital, Paris, France (M. Mazighi)
- APHP, Department of Neuroradiology, Rothschild Hospital Foundation, Paris, France (M. Mazighi, P.B.)
| | - Magalie Collet
- APHP.Nord, Department of Anesthesiology and Critical Care, DMU Parabol, Université de Paris, France (M.C., E.G.)
- UMR-S 942 "MASCOT," Inserm, Paris, France (M.C., E.G.)
| | - Etienne Gayat
- APHP.Nord, Department of Anesthesiology and Critical Care, DMU Parabol, Université de Paris, France (M.C., E.G.)
- UMR-S 942 "MASCOT," Inserm, Paris, France (M.C., E.G.)
| | - Vincent Degos
- APHP, Department of Critical Care, Anesthesia and Perioperative Medicine, Pitié-Salpétrière University Hospital and Sorbonne Université, Paris, France (V.D.)
- GRC ARPE, Sorbonne Université, Paris, France (V.D.)
| | - Jacques Duranteau
- APHP, Department of Anesthesiology and Critical Care, Bicêtre University Hospitals, Le Kremlin Bicêtre, France (J.D.)
| | - Charles Grégoire
- Department of Intensive Care, Rothschild Hospital Foundation, Paris, France (C.G.)
| | - Tarek Sharshar
- Department of Neuroanesthesiology and Intensive Care, Saint Anne Hospital, Paris, France (T.S., G.N.)
| | - Giulia Naim
- Department of Neuroanesthesiology and Intensive Care, Saint Anne Hospital, Paris, France (T.S., G.N.)
| | - David Cortier
- Department of Intensive Care, Foch Hospital, Paris, France (D.C.)
| | - Paul-Henri Jost
- APHP, Department of Anesthesiology and Critical Care, Henri Mondor University Hospital, Créteil, France (P.-H.J.)
| | - Arnaud Foucrier
- APHP, Department of Anesthesiology and Critical Care, Beaujon University Hospital, Clichy, France (A.F.)
| | - François Bagate
- APHP, Department of Intensive Care Medicine, Henri Mondor University Hospital and Université de Paris Est Créteil, France (F.B.)
| | - Etienne de Montmollin
- Department of Intensive Care Medicine, Delafontaine Hospital, Saint-Denis, France (E.d.M.)
| | - Gregory Papin
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, F75018 Paris, France (R.S., G.P., F.L., J.-F.T.)
| | - Eric Magalhaes
- Department of Intensive Care Medicine, Sud Francilien Hospital, Corbeil, France (E.M.)
| | - Bertrand Guidet
- APHP, Department of Intensive Care Medicine, Saint Antoine University Hospital, Paris, France (B.G.)
| | - Omar Ben Hadj Salem
- Department of Intensive Care Medicine, Poissy-Saint Germain en Laye Hospital, Paris, France (O.B.H.S.)
| | - Sarah Benghanem
- APHP, Medical ICU, Cochin University Hospital and Université Paris Cité, France (S.B.)
| | - Loïc le Guennec
- APHP, Department of Intensive Care Medicine, La Pitié-Salpêtrière University Hospital and Sorbonne Université, Paris, France (L.l.G.)
| | - Eric Delpierre
- Department of Intensive Care Medicine, Meaux Hospital, France (E.D.)
| | - Stephane Legriel
- Department of Intensive Care Medicine, Versailles Hospital, Le Chesnay, and Paris-Saclay University UVSQ, INSERM, CESP, Villejuif, France (S.L.)
| | - Bruno Megarbane
- APHP, Department of Medical and Toxicological Critical Care, Lariboisière Hospital and INSERM UMRS-1144, Université Paris Cité, France (B.M.)
| | - Karim Toumert
- Department of Intensive Care Medicine, Gonesse Hospital, France (K.T.)
| | - Marc Tran
- Department of Intensive Care Medicine, Paris Saint-Joseph Hospital, Paris, France (M.T.)
| | - Guillaume Geri
- APHP, Department of Intensive Care Medicine, Ambroise Paré University Hospital, Boulogne, France (G.G.)
| | - Mehran Monchi
- Department of Intensive Care Medicine, Melun-Senart Hospital, France (M. Monchi)
| | - Eric Bodiguel
- APHP, Emergency Department, Georges Pompidou University Hospital, Paris, France (E. Bodiguel)
| | - Eric Mariotte
- APHP, Department of Intensive Care Medicine, Saint Louis University Hospital, Paris, France (E.M.)
| | - Alexandre Demoule
- APHP, Department of Intensive Care Medicine (R3S) and Sorbonne Université, INSERM, UMRS1158, Pitié-Salpétrière University Hospital, Paris, France (A.D.)
| | - Jonathan Zarka
- Department of Intensive Care Medicine, Lagny Hospital, France (J.Z.)
| | - Jean-Luc Diehl
- APHP, Department of Intensive Care Medicine, Georges Pompidou University Hospital and INSERM UMR_S 1140 Paris, France (J.-L.D.)
| | - Damien Roux
- APHP, Medico-Surgical ICU, Louis Mourier University Hospital, Colombes and Université Paris Cité, IAME, INSERM, UMR1137, France (D.R.)
| | - Eric Barré
- Department of Intensive Care Medicine, Mantes-la-Jolie Hospital, France (E. Barré)
| | - Sebastien Tanaka
- APHP, Department of Anesthesia and Critical Care Medicine, Bichat-Claude Bernard University Hospital and INSERM UMR 1188 DéTROI, Université de la Réunion, Saint-Denis de la Réunion, France (S.T.)
| | - David Osman
- APHP, Department of Intensive Care Medicine, Bicêtre University Hospital, Le Kremlin Bicêtre, France (D.O.)
| | - Pierre Pasquier
- Department of Anesthesiology and Critical Care, Percy Military Training Hospital, Clamart, France (P.P.)
| | - Fariza Lamara
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, F75018 Paris, France (R.S., G.P., F.L., J.-F.T.)
| | | | - Perrine Boursin
- APHP, Department of Neuroradiology, Rothschild Hospital Foundation, Paris, France (M. Mazighi, P.B.)
| | - Stéphane Ruckly
- Department of Biostatistics, ICUREsearch, Paris, France (S.R., Q.S.)
| | - Quentin Staiquly
- Department of Biostatistics, ICUREsearch, Paris, France (S.R., Q.S.)
| | - Jean-François Timsit
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, F75018 Paris, France (R.S., G.P., F.L., J.-F.T.)
| | - France Woimant
- Agence Régionale de Santé Ile-de-France, Paris, France (I.C., F.W.)
| |
Collapse
|
164
|
Sattari SA, Shahbandi A, Kim JE, Lee RP, Feghali J, Hung A, Yang W, Rincon-Torroella J, Xu R, Caplan JM, Gonzalez LF, Tamargo RJ, Huang J. Microsurgery Versus Stereotactic Radiosurgery for Treatment of Patients With Brain Arteriovenous Malformation: A Systematic Review and Meta-Analysis. Neurosurgery 2023; 93:510-523. [PMID: 36999929 DOI: 10.1227/neu.0000000000002460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/23/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Treatment decision-making for brain arteriovenous malformations (bAVMs) with microsurgery or stereotactic radiosurgery (SRS) is controversial. OBJECTIVE To conduct a systematic review and meta-analysis to compare microsurgery vs SRS for bAVMs. METHOD Medline and PubMed were searched from inception to June 21, 2022. The primary outcomes were obliteration and follow-up hemorrhage, and secondary outcomes were permanent neurological deficit, worsened modified Rankin scale (mRS), follow-up mRS > 2, and mortality. The GRADE approach was used for grading the level of evidence. RESULTS Eight studies were included, which yielded 817 patients, of which 432 (52.8%) and 385 (47.1%) patients underwent microsurgery and SRS, respectively. Two cohorts were comparable in age, sex, Spetzler-Martin grade, nidus size, location, deep venous drainage, eloquence, and follow-up. In the microsurgery group, the odds ratio (OR) of obliteration was higher (OR = 18.51 [11.05, 31.01], P < .000001, evidence: high) and the hazard ratio of follow-up hemorrhage was lower (hazard ratio = 0.47 [0.23, 0.97], P = .04, evidence: moderate). The OR of permanent neurological deficit was higher with microsurgery (OR = 2.85 [1.63, 4.97], P = .0002, evidence: low), whereas the OR of worsened mRS (OR = 1.24 [0.65, 2.38], P = .52, evidence: moderate), follow-up mRS > 2 (OR = 0.78 [0.36, 1.7], P = .53, evidence: moderate), and mortality (OR = 1.17 [0.41, 3.3], P = .77, evidence: moderate) were comparable between the groups. CONCLUSION Microsurgery was superior at obliterating bAVMs and preventing further hemorrhage. Despite a higher rate of postoperative neurological deficit with microsurgery, functional status and mortality were comparable with patients who underwent SRS. Microsurgery should remain a first-line consideration for bAVMs, with SRS reserved for inaccessible locations, highly eloquent areas, and medically high-risk or unwilling patients.
Collapse
Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Ataollah Shahbandi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
- Tehran School of Medicine, Tehran University of Medical Science, Tehran , Iran
| | - Jennifer E Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Alice Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| |
Collapse
|
165
|
Zhang L, Zhang W, Shi J, Zhang S, Xu X, Yu H, Zhang Y. Application of 3D Slicer Combined With Simple Coordinate Method in Operation of Cerebral Arteriovenous Malformations in Functional Areas. J Craniofac Surg 2023; 34:1851-1854. [PMID: 37463297 PMCID: PMC10445628 DOI: 10.1097/scs.0000000000009545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/21/2023] [Indexed: 07/20/2023] Open
Abstract
The authors report a case of intracranial arteriovenous malformation in functional areas, initially presenting with symptomatic epilepsy was surgically excised by the Neurosurgery Department of our hospital. The patient's head computed tomography, magnetic resonance imaging, and digital subtraction angiography examination suggested intracranial arteriovenous malformations in the left frontal functional area. A preoperative 3D-reconstruction technique was used to reconstruct the malformed vascular mass, supplying arteries, draining veins, and precise surgical resection was performed. Postoperative pathology indicated vascular malformation. No seizures occurred after surgery. There was no further neurological impairment. Preoperative use of image postprocessing techniques can facilitate precise surgical resection of brain arteriovenous malformations. Three-dimensional Slicer in cerebral arteriovenous malformations in functional areas not only shortened the preoperative planning time but also improved the efficiency of the surgery. Reduce the incidence of postoperative complications. It is helpful for further popularization and application.
Collapse
|
166
|
Chwał J, Kostka P, Tkacz E. Assessment of the Extent of Intracerebral Hemorrhage Using 3D Modeling Technology. Healthcare (Basel) 2023; 11:2441. [PMID: 37685475 PMCID: PMC10487057 DOI: 10.3390/healthcare11172441] [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: 07/11/2023] [Revised: 08/08/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
The second most common cause of stroke, accounting for 10% of hospital admissions, is intracerebral hemorrhage (ICH), and risk factors include diabetes, smoking, and hypertension. People with intracerebral bleeding experience symptoms that are related to the functions that are managed by the affected part of the brain. Having obtained 15 computed tomography (CT) scans from five patients with ICH, we decided to use three-dimensional (3D) modeling technology to estimate the bleeding volume. CT was performed on admission to hospital, and after one week and two weeks of treatment. We segmented the brain, ventricles, and hemorrhage using semi-automatic algorithms in Slicer 3D, then improved the obtained models in Blender. Moreover, the accuracy of the models was checked by comparing corresponding CT scans with 3D brain model cross-sections. The goal of the research was to examine the possibility of using 3D modeling technology to visualize intracerebral hemorrhage and assess its treatment.
Collapse
Affiliation(s)
- Joanna Chwał
- Department of Biosensors and Processing of Biomedical Signals, Faculty of Biomedical Engineering, Silesian University of Technology, 44-100 Gliwice, Poland; (P.K.); (E.T.)
- Joint Doctoral School, Silesian University of Technology, 44-100 Gliwice, Poland
| | - Paweł Kostka
- Department of Biosensors and Processing of Biomedical Signals, Faculty of Biomedical Engineering, Silesian University of Technology, 44-100 Gliwice, Poland; (P.K.); (E.T.)
| | - Ewaryst Tkacz
- Department of Biosensors and Processing of Biomedical Signals, Faculty of Biomedical Engineering, Silesian University of Technology, 44-100 Gliwice, Poland; (P.K.); (E.T.)
| |
Collapse
|
167
|
Burzyńska M, Uryga A, Woźniak J, Załuski R, Robba C, Goździk W. The Role of Early Serum Biomarkers and Clinical Rating Scales in the Prediction of Delayed Cerebral Ischaemia and Short-Term Outcome after Aneurysmal Subarachnoid Haemorrhage: Single Centre Experience. J Clin Med 2023; 12:5614. [PMID: 37685681 PMCID: PMC10488375 DOI: 10.3390/jcm12175614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/16/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Considering the variety of complications that arise after aneurysmal subarachnoid haemorrhage (aSAH) and the complex pathomechanism of delayed cerebral ischaemia (DCI), the task of predicting the outcome assumes a profound complexity. Therefore, there is a need to develop early predictive and decision-making models. This study explores the effect of serum biomarkers and clinical scales on patients' outcomes and their interrelationship with DCI and systemic complications in aSAH. This was a retrospective analysis including aSAH patients admitted to the Wroclaw University Hospital (Wrocław, Poland) from 2011 to 2020. A good outcome was defined as a modified Rankin Scale (mRS) score of 0-2. The prediction of the development of DCI and poor outcome was conducted using logistic regression as a standard model (SM) and random forest as a machine learning method (ML). A cohort of 174 aSAH patients were included in the analysis. DCI was diagnosed in 79 (45%) patients. Significant differences between patients with poor vs. good outcome were determined from their levels of albumin (31 ± 7 vs. 35 ± 5 (g/L); p < 0.001), D-dimer (3.0 ± 4.5 vs. 1.5 ± 2.8 (ng/mL); p < 0.001), procalcitonin (0.2 ± 0.4 vs. 0.1 ± 0.1 (ng/mL); p < 0.001), and glucose (169 ± 69 vs. 137 ± 48 (nmol/L); p < 0.001). SM for DCI prediction included the Apache II scale (odds ratio [OD] 1.05; 95% confidence interval [CI] 1.00-1.09) and albumin level (OD 0.88; CI 0.82-0.95). ML demonstrated that low albumin level, high Apache II scale, increased D-dimer and procalcitonin levels had the highest predictive values for DCI. The integration of clinical parameters and scales with a panel of biomarkers may effectively facilitate the stratification of aSAH patients, identifying those at high risk of secondary complications and poor outcome.
Collapse
Affiliation(s)
- Małgorzata Burzyńska
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, 50-370 Wroclaw, Poland
| | - Jowita Woźniak
- Department of Neurosurgery, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.W.); (R.Z.)
| | - Rafał Załuski
- Department of Neurosurgery, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.W.); (R.Z.)
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy;
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16145 Genoa, Italy
| | - Waldemar Goździk
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
| |
Collapse
|
168
|
Wang H, Zheng S, Zhang Y, Fan W, Xie B, Chen F, Lin Y, Kang D. Lower Serum Iron Level Predicts Postoperative Global Cerebral Edema Following Aneurysmal Subarachnoid Hemorrhage. Brain Sci 2023; 13:1232. [PMID: 37759833 PMCID: PMC10527267 DOI: 10.3390/brainsci13091232] [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: 07/31/2023] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Iron plays an important role in neuronal injury and edema formation after intracranial hemorrhage. However, the role of serum iron in aneurysmal subarachnoid hemorrhage (aSAH) is yet to be well-established. This study aims to identify whether serum iron could predict postoperative global cerebral edema (GCE) and poor outcome in aSAH. METHODS 847 patients' aSAH clinical data were retrospectively collected at the First Affiliated Hospital of Fujian Medical University. Data on demographics, clinical characteristics, and laboratory values were collected and analyzed through univariate and multivariate analyses. Propensity score matching (PSM) analysis was performed to balance the baseline differences between the groups. RESULTS The incidence of high-grade global cerebral edema (H-GCE) following aSAH was 12.99% (110/847). Serum iron levels [odds ratio (OR) = 1.143; 95% confidence interval (CI), (1.097-1.191); p < 0.001] were associated with the occurrence of H-GCE following aSAH in the univariate analysis. This association remained statistically significant even after adjusting for other variables in the multivariate model, with serum iron having an OR of 1.091 (95% CI, 1.043-1.141; p < 0.001) for GCE. After 1:1 PSM, serum iron levels ≤ 10.7 µmol/L remained a significant independent predictor of GCE (p = 0.002). The receiver operating characteristic (ROC) curve analysis determined that a serum iron cut-off value of ≤ 10.7 µmol/L was optimal for predicting H-GCE [Areas under the ROC curves (AUC) = 0.701, 95% CI, (0.669-0.732), p < 0.001; sensitivity, 67.27%; specificity, 63.77%] in patients with aSAH. Additionally, a trend was observed in which higher Hunt-Hess grades (HH grade) were associated with lower serum iron levels, and higher modified Fisher grades (mFisher grade) were associated with lower serum iron levels. In addition, the serum iron level was also associated with a 3-month functional neurological outcome (p < 0.001). CONCLUSIONS The results of this study indicate that a decreased serum iron level serves as a clinically significant biomarker for the prediction of postoperative GCE and a poor outcome at 3-months in patients with aSAH.
Collapse
Affiliation(s)
- Haojie Wang
- Department of Neurosurgery, Neurosurgical Research Institute, First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China; (H.W.); (S.Z.); (Y.Z.); (W.F.); (B.X.); (F.C.)
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Shufa Zheng
- Department of Neurosurgery, Neurosurgical Research Institute, First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China; (H.W.); (S.Z.); (Y.Z.); (W.F.); (B.X.); (F.C.)
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Yibin Zhang
- Department of Neurosurgery, Neurosurgical Research Institute, First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China; (H.W.); (S.Z.); (Y.Z.); (W.F.); (B.X.); (F.C.)
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Wenjian Fan
- Department of Neurosurgery, Neurosurgical Research Institute, First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China; (H.W.); (S.Z.); (Y.Z.); (W.F.); (B.X.); (F.C.)
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Bingsen Xie
- Department of Neurosurgery, Neurosurgical Research Institute, First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China; (H.W.); (S.Z.); (Y.Z.); (W.F.); (B.X.); (F.C.)
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Fuxiang Chen
- Department of Neurosurgery, Neurosurgical Research Institute, First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China; (H.W.); (S.Z.); (Y.Z.); (W.F.); (B.X.); (F.C.)
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Yuanxiang Lin
- Department of Neurosurgery, Neurosurgical Research Institute, First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China; (H.W.); (S.Z.); (Y.Z.); (W.F.); (B.X.); (F.C.)
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Dezhi Kang
- Department of Neurosurgery, Neurosurgical Research Institute, First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China; (H.W.); (S.Z.); (Y.Z.); (W.F.); (B.X.); (F.C.)
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Fujian Medical University, No. 22, Chazhong Road, Taijiang District, Fuzhou 350005, China
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, The First Affiliated Hospital, Fujian Medical University, No. 22, Chazhong Road, Taijiang District, Fuzhou 350005, China
| |
Collapse
|
169
|
Stamm B, Royan R, Giurcanu M, Messe SR, Jauch EC, Prabhakaran S. Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke. JAMA 2023; 330:636-649. [PMID: 37581671 PMCID: PMC10427946 DOI: 10.1001/jama.2023.12739] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/22/2023] [Indexed: 08/16/2023]
Abstract
Importance Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED). Objective To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times. Design, Setting, and Participants US registry-based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals. Exposure Patient- and hospital-level characteristics. Main Outcomes and Measures The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy. Results Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (-20.1 minutes; 95% CI, -22.1 to -18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (-66.7 minutes; 95% CI, -68.7 to -64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (-16.8 minutes; 95% CI, -21.0 to -12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times. Conclusions and Relevance In this US registry-based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.
Collapse
Affiliation(s)
- Brian Stamm
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Neurology, Northwestern University, Chicago, Illinois
| | - Regina Royan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois
- Assistant Editor, JAMA Network Open
| | - Mihai Giurcanu
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Steven R. Messe
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Edward C. Jauch
- Department of Research, Mountain Area Health Education Center, Asheville, North Carolina
| | | |
Collapse
|
170
|
Wagner DT, Tilmans L, Peng K, Niedermeier M, Rohl M, Ryan S, Yadav D, Takacs N, Garcia-Fraley K, Koso M, Dikici E, Prevedello LM, Nguyen XV. Artificial Intelligence in Neuroradiology: A Review of Current Topics and Competition Challenges. Diagnostics (Basel) 2023; 13:2670. [PMID: 37627929 PMCID: PMC10453240 DOI: 10.3390/diagnostics13162670] [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: 05/16/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
There is an expanding body of literature that describes the application of deep learning and other machine learning and artificial intelligence methods with potential relevance to neuroradiology practice. In this article, we performed a literature review to identify recent developments on the topics of artificial intelligence in neuroradiology, with particular emphasis on large datasets and large-scale algorithm assessments, such as those used in imaging AI competition challenges. Numerous applications relevant to ischemic stroke, intracranial hemorrhage, brain tumors, demyelinating disease, and neurodegenerative/neurocognitive disorders were discussed. The potential applications of these methods to spinal fractures, scoliosis grading, head and neck oncology, and vascular imaging were also reviewed. The AI applications examined perform a variety of tasks, including localization, segmentation, longitudinal monitoring, diagnostic classification, and prognostication. While research on this topic is ongoing, several applications have been cleared for clinical use and have the potential to augment the accuracy or efficiency of neuroradiologists.
Collapse
Affiliation(s)
- Daniel T. Wagner
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Luke Tilmans
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Kevin Peng
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | | | - Matt Rohl
- College of Arts and Sciences, The Ohio State University, Columbus, OH 43210, USA
| | - Sean Ryan
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Divya Yadav
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Noah Takacs
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Krystle Garcia-Fraley
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Mensur Koso
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Engin Dikici
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Luciano M. Prevedello
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Xuan V. Nguyen
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| |
Collapse
|
171
|
Kotovich D, Twig G, Itsekson-Hayosh Z, Klug M, Simon AB, Yaniv G, Konen E, Tau N, Raskin D, Chang PJ, Orion D. The impact on clinical outcomes after 1 year of implementation of an artificial intelligence solution for the detection of intracranial hemorrhage. Int J Emerg Med 2023; 16:50. [PMID: 37568103 PMCID: PMC10422703 DOI: 10.1186/s12245-023-00523-y] [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: 03/13/2023] [Accepted: 07/17/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND To assess the effect of a commercial artificial intelligence (AI) solution implementation in the emergency department on clinical outcomes in a single level 1 trauma center. METHODS A retrospective cohort study for two time periods-pre-AI (1.1.2017-1.1.2018) and post-AI (1.1.2019-1.1.2020)-in a level 1 trauma center was performed. The ICH algorithm was applied to 587 consecutive patients with a confirmed diagnosis of ICH on head CT upon admission to the emergency department. Study variables included demographics, patient outcomes, and imaging data. Participants admitted to the emergency department during the same time periods for other acute diagnoses (ischemic stroke (IS) and myocardial infarction (MI)) served as control groups. Primary outcomes were 30- and 120-day all-cause mortality. The secondary outcome was morbidity based on Modified Rankin Scale for Neurologic Disability (mRS) at discharge. RESULTS Five hundred eighty-seven participants (289 pre-AI-age 71 ± 1, 169 men; 298 post-AI-age 69 ± 1, 187 men) with ICH were eligible for the analyzed period. Demographics, comorbidities, Emergency Severity Score, type of ICH, and length of stay were not significantly different between the two time periods. The 30- and 120-day all-cause mortality were significantly reduced in the post-AI group when compared to the pre-AI group (27.7% vs 17.5%; p = 0.004 and 31.8% vs 21.7%; p = 0.017, respectively). Modified Rankin Scale (mRS) at discharge was significantly reduced post-AI implementation (3.2 vs 2.8; p = 0.044). CONCLUSION The added value of this study emphasizes the introduction of artificial intelligence (AI) computer-aided triage and prioritization software in an emergent care setting that demonstrated a significant reduction in a 30- and 120-day all-cause mortality and morbidity for patients diagnosed with intracranial hemorrhage (ICH). Along with mortality rates, the AI software was associated with a significant reduction in the Modified Ranking Scale (mRs).
Collapse
Affiliation(s)
- Dmitry Kotovich
- The Institute for Research in Military Medicine, The Faculty of Medicine, The Hebrew University of Jerusalem, Tel Aviv, Israel.
- The IDF Medical Corps, 9112102, Tel Aviv, Israel.
| | - Gilad Twig
- The Institute for Research in Military Medicine, The Faculty of Medicine, The Hebrew University of Jerusalem, Tel Aviv, Israel
- The IDF Medical Corps, 9112102, Tel Aviv, Israel
| | - Zeev Itsekson-Hayosh
- Center of Stroke and Neurovascular Disorders, Sheba Medical Center, Tel HaShomer, Ramat Gan, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Maximiliano Klug
- Department of Diagnostic Imaging, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Asaf Ben Simon
- Sackler School of Medicine, Faculty of Medicine, Tel Aviv University, 69978, Tel Aviv, Israel
| | - Gal Yaniv
- Department of Diagnostic Imaging, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Eli Konen
- Department of Diagnostic Imaging, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Noam Tau
- Department of Diagnostic Imaging, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Daniel Raskin
- Department of Diagnostic Imaging, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Paul J Chang
- Department of Radiology, University of Chicago Medical Center, Chicago, Illinois, 60637, USA
| | - David Orion
- Center of Stroke and Neurovascular Disorders, Sheba Medical Center, Tel HaShomer, Ramat Gan, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| |
Collapse
|
172
|
Lee SH, Sohn JH, Kim C, Kim YJ, Jeon JP, Yang J, Park SY, Choi HJ. Pre-stroke glycemic variability estimated by glycated albumin predicts hematoma expansion and poor outcomes in patients with spontaneous intracerebral hemorrhage. Sci Rep 2023; 13:12848. [PMID: 37553363 PMCID: PMC10409739 DOI: 10.1038/s41598-023-40109-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/04/2023] [Indexed: 08/10/2023] Open
Abstract
Glycemic variability has been shown to be correlated more with oxidative stress than chronic hyperglycemia. We evaluated the impact of pre-stroke glycemic variability measured using glycated albumin (GA) on hematoma expansion and clinical outcomes following spontaneous intracerebral hemorrhage (ICH). We consecutively enrolled 343 patients with ICH for 72 months using a single-center registry database. The primary outcome measure was hematoma expansion. The secondary outcome measures were early neurological deterioration (END), 1-month mortality, and 3-month poor functional outcomes (modified Rankin scale score of 4-6). The patients were divided into two groups based on pre-stroke glycemic variability: a higher GA group (GA ≥ 16.0%) and a lower GA group (GA < 16.0%). During the study period, there were 63 (18.4%) events of hematoma expansion, 61 (17.8%) of END, 45 (13.1%) of 1-month mortality, and 45 (13.1%) of 3-month poor functional outcomes after ICH. The higher GA group (36.4%) had higher rates of hematoma expansion, END, 1-month mortality, and 3-month poor functional outcomes than the lower GA group. Multivariate analysis showed that a higher GA level was significantly associated with increased hematoma expansion (adjusted odds ratio 5.83; 95% confidence interval [CI] 2.58-13.19, p < 0.001). The area under the receiver operating characteristic curve of GA (0.83; 95% CI 0.48-0.65) for predicting hematoma expansion was higher than that of glycated hemoglobin (0.57; 95% CI 0.48-0.65, p for DeLong's pairwise comparison < 0.001). Higher GA levels could be a reliable marker for predicting hematoma expansion and poor outcomes following ICH.
Collapse
Affiliation(s)
- Sang-Hwa Lee
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, South Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, South Korea
| | - Jong-Hee Sohn
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, South Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, South Korea
| | - Chulho Kim
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, South Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, South Korea
| | - Yeo Jin Kim
- Department of Neurology, Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, South Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, South Korea
| | - Jinseo Yang
- Department of Neurosurgery, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, South Korea
| | - So Young Park
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital, Seoul, South Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, South Korea.
| |
Collapse
|
173
|
Mota Telles JP, Rocha RB, Cenci GI, Nager GB, Silva GD, Figueiredo EG. Prophylactic antiseizure drugs for spontaneous intracerebral hemorrhage: An updated systematic review and meta-analysis. Int J Stroke 2023; 18:773-782. [PMID: 36337029 DOI: 10.1177/17474930221140071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND There is concern that recommendations on prophylactic antiseizure drugs (PASDs) for patients with spontaneous intracerebral hemorrhage (sICH) are biased by studies using older drugs and no electrographic monitoring. AIMS We performed a systematic review and meta-analysis to determine whether PASDs in patients with sICH reduced seizure occurrence and improved functional outcomes. We included analyses of newer trials, newer antiseizure drugs, and effectiveness in patients with consistent electrographic monitoring. METHODS Medline, Embase, and Cochrane were searched from inception until 12 August 2022, to identify studies with patients with sICH treated with PASDs, regardless of study design. The studied outcomes were functional status and occurrence of seizures. RESULTS Fourteen studies were included, including 6742 patients. Risk of bias was low overall. There was no effect of PASD on seizure occurrence overall (odds ratio (OR) 0.73, 95% confidence interval (CI) 0.47-1.15), but they were associated with reduced occurrence in studies with electrographic monitoring (OR 0.36, 95% CI 0.18-0.70). There was no effect of PASDs on functional outcomes (OR 1.15; 95% CI 0.91-1.47) or mortality (OR 0.85, 95% CI 0.65-1.11). CONCLUSION Prophylactic antiseizure medications after sICH reduce seizures in studies with electroencephalogram monitoring in high-risk patients. However, this benefit did not reflect in the improvement of functional outcomes, even in studies with newer, less toxic, antiseizure drugs.
Collapse
Affiliation(s)
| | | | | | - Gabriela Borges Nager
- School of Medicine, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | |
Collapse
|
174
|
Li R, Zhou P, Kao E, Zhu C, Mossa-Basha M, Wang Y. Unilateral cerebral arterial tortuosity: Associated with aneurysm occurrence, but potentially inversely associated with aneurysm rupture. Eur J Radiol 2023; 165:110941. [PMID: 37354772 DOI: 10.1016/j.ejrad.2023.110941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/11/2023] [Accepted: 06/17/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To investigate the association of tortuosity of the main cerebral arteries with intracranial aneurysm (IA) occurrence and rupture. To investigate the relationship between arterial tortuosity and aneurysm morphology as well as conventional risk factors of vascular diseases. METHODS Three subject groups were analyzed in this study: Patients with ruptured IAs, patients with unruptured IAs, and healthy subjects. The groups were matched by sex and age using tendency score matching. Their intracranial magnetic resonance angiography (MRA) images were collected retrospectively. The intracranial arterial structures were segmented from the MRA images. Arterial tortuosity was measured and statistically compared between the different subject groups and different vessels. Correlation analysis was conducted between arterial tortuosity and clinical risk factors as well as aneurysm morphology. RESULTS 120 patients were included in the study (average age: 67.5 years; 60% female), 40 for each group after matching. The tortuosity of the aneurysm-bearing artery was significantly greater than that of the contralateral artery in both the ruptured and unruptured IA groups (p < 0.001). There was no significant association between clinical risk factors (history of hypertension, hyperlipidemia, diabetes, smoking, and alcohol use) and arterial tortuosity. There were significant negative correlations between aneurysm-bearing artery tortuosity and aneurysm morphological features such as maximal diameter (p = 0.0011), neck diameter (p < 0.0001), maximum height (p = 0.0024), and size ratio (p = 0.0269). CONCLUSION The occurrence of cerebral aneurysms correlates to increased unilateral arterial tortuosity, but the risk of aneurysm enlargement/rupturing decreases with greater arterial tortuosity. Abnormal tortuosity may be congenital as tortuosity has no clear connection with acquired common risk factors of vascular diseases.
Collapse
Affiliation(s)
- Ran Li
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Pengyu Zhou
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Evan Kao
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Chengcheng Zhu
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Yuting Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.
| |
Collapse
|
175
|
Wu A, Yue H, Huang F, Chen J, Xie F, Wang J, Wu J, Geng Z. Serum β2-microglobulin is closely associated with 3-month outcome of acute intracerebral hemorrhage: a retrospective cohort study. Ir J Med Sci 2023; 192:1875-1881. [PMID: 36169913 DOI: 10.1007/s11845-022-03170-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 09/20/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a frequent type of hemorrhagic stroke. Numerous studies have suggested that inflammation plays an important role in the injury and recovery of ICH. β2-microglobulin (β2M) is an inflammatory indicator with an unclear association with ICH development. This study aimed to explore the role of β2M in the outcome of patients with ICH after 3 months of ICH onset. METHODS The β2M and other baseline information of 231 patients with ICH were assessed (83 females and 148 males). We followed up with all patients 3 months after ICH onset, and severe disability or a worse outcome was our main focus. We collected the serum β2M levels, National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) scores, and other relevant baseline information of each patient. We used multiple regression analysis to explore the association between β2M levels and follow-up outcomes. RESULTS Our results indicated that the β2M level of the good outcome (2.35 ± 0.84 mg/l) group was significantly lower than that of the poor outcome group (3.06 ± 1.71 mg/l) (P < 0.001). Further multiple regression analysis showed that β2M was regarded as a risk factor that was closely associated with the poor outcome 3 months after ICH onset (odds ratio = 2.26, 95% confidence interval = 1.22-4.19, P = 0.009). Further correlation analysis revealed that β2M was significantly correlated with NIHSS scores (r = 0.187, P = 0.004) and follow-up mRS scores (r = 0.25, P < 0.001). CONCLUSION β2M was a risk factor for early outcome after ICH onset, and high β2M level was associated with short-time poor prognosis of ICH patients.
Collapse
Affiliation(s)
- Aimei Wu
- Department of Neurology, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, 230011, Anhui, China
| | - Hong Yue
- Department of Neurology, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, 230011, Anhui, China
| | - Fang Huang
- Department of Neurology, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, 230011, Anhui, China
| | - Jing Chen
- Department of Neurology, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, 230011, Anhui, China
| | - Fei Xie
- Department of Neurology, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, 230011, Anhui, China
| | - Juan Wang
- Department of Neurology, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, 230011, Anhui, China
| | - Juncang Wu
- Department of Neurology, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, 230011, Anhui, China
| | - Zhi Geng
- Department of Neurology, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, 230011, Anhui, China.
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China.
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, 230022, China.
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei, 230022, China.
| |
Collapse
|
176
|
Hossain MF, Kharel M, Husna AU, Khan MA, Aziz SN, Taznin T. Prevalence of Electrolyte Imbalance in Patients With Acute Stroke: A Systematic Review. Cureus 2023; 15:e43149. [PMID: 37692728 PMCID: PMC10484326 DOI: 10.7759/cureus.43149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Electrolyte abnormalities are common in acute stroke patients and have a substantial impact on the course and prognosis of the disease. Electrolyte imbalances such as hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, and phosphate abnormalities are frequently seen in this patient population. The incidence, root causes, and medical ramifications of electrolyte abnormalities in acute stroke patients are investigated in this comprehensive study. According to our research, hyponatremia is the most prevalent electrolyte imbalance. The most common reason for hyponatremia in stroke patients is the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Higher mortality rates, longer hospital admissions, and less favorable functional outcomes are all linked to hyponatremia. Acute stroke patients also typically experience hypokalemia, which affects the severity of the stroke and the recovery of functional abilities. The review furthermore emphasizes the incidence and clinical consequences of hypercalcemia, hypomagnesemia, hypophosphatemia, and hypocalcemia in patients with acute stroke. The results highlight the significance of early electrolyte imbalance detection and treatment in acute stroke patients. To better comprehend therapeutic approaches, evaluate their influence on stroke outcomes, and analyze prognostic implications, more research is required.
Collapse
Affiliation(s)
- Md Fahad Hossain
- Hospital Medicine, Upazila Health Complex, Ministry of Health, Kishoreganj, BGD
| | - Manish Kharel
- Medicine and Surgery, Jahurul Islam Medical College, Bhagalpur, BGD
| | - Ashma Ul Husna
- Internal Medicine, Mercy Health - St. Elizabeth Boardman Hospital, Youngstown, USA
| | - Mahfuza A Khan
- Internal Medicine, Sylhet MAG (Muhammad Ataul Goni) Osmani Medical College, Sylhet, BGD
| | - Syed Nurul Aziz
- Internal Medicine, Shaheed Suhrawardy Medical College, Dhaka, BGD
| | - Tamanna Taznin
- Medical Education, Chittagong Medical College, Chittagong, BGD
| |
Collapse
|
177
|
Saad J, Ryder CH, Hasan M, Keigler G, Badarny S. Primary Intracranial Hemorrhage: Characteristics, Distribution, Risk Factors, and Outcomes-A Comparative Study between Jewish and Arab Ethnic Groups in Northern Israel. J Clin Med 2023; 12:4993. [PMID: 37568395 PMCID: PMC10419471 DOI: 10.3390/jcm12154993] [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: 06/11/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
Background and purpose: This study aimed to investigate the differences in intracerebral hemorrhage (ICH) between Jews and Arabs residing in northern Israel, focusing on risk factors, hemorrhage volume, and functional outcome. Methods: A retrospective analysis was conducted utilizing a population-based registry to investigate intracerebral hemorrhage (ICH) characteristics, risk factors, and outcomes. The registry consisted of inpatients diagnosed with hemorrhagic stroke. Due to the wide variation in data on ICH characteristics and the limited availability of population-based data on predictors of ICH survival and functional outcomes, we collected retrospective data on all adult patients admitted to the Galilee Medical Center with a diagnosis of ICH. Data were obtained from the registry covering the period from 2013 to 2019. Ethnic differences and risk factors associated with intracranial hemorrhage (ICH) were examined within a diverse population of 241 patients, comprising 52.70% Jews (n = 127) and 47.30% Arabs (n = 114). Results: The results of this study revealed significant differences in age, obesity rates, and intracerebral hemorrhage (ICH) location between the two ethnic groups. Hypertension emerged as the most prevalent condition among ICH patients in both ethnic groups (76.70%), followed primarily by anticoagulant use (63.60%), dyslipidemia (60.70%), diabetes (44.60%), obesity (30.60%), smoking (24.60%), and a history of cardiovascular disease (21.80%). Furthermore, 20.90% of the patients had a history of previous cerebrovascular accidents (CVA). Arab patients with ICH were generally younger (62.90 ± 16.00 years) and exhibited higher rates of obesity (38.70%) compared to Jewish patients with ICH (70.17 ± 15.24 years, 23% obesity; p = 0.001, p = 0.013, respectively). Hemorrhage volume was identified as a crucial determinant of patient outcomes, with larger volumes associated with poorer Modified Rankin Scale (mRS) scores at discharge and higher mortality rates. Interestingly, patients without hypertension had higher hemorrhage volumes compared to those with hypertension. The extent of hemorrhage into the ventricles did not significantly correlate with mRS at discharge in our dataset. Conclusions: This study highlights significant differences in the characteristics and outcomes of intracranial hemorrhage (ICH) between Jews and Arabs in northern Israel. The findings reveal variations in age, obesity rates, and ICH location between the two groups. While hypertension was the most prevalent risk factor for both populations, other risk factors differed. Notably, hemorrhage volume emerged as a crucial prognostic factor, aligning with previously published data. These findings underscore the necessity for tailored approaches that consider ethnic-specific factors in the risk assessment, prevention, and management of ICH. Further research is warranted to elucidate the underlying mechanisms and develop interventions aimed at improving outcomes and enhancing healthcare practices in ICH management.
Collapse
Affiliation(s)
- Jamal Saad
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 1311502, Israel
| | - Chen Hanna Ryder
- Brain & Behavior Research Institute, Western Galilee Academic College, Acre 2412101, Israel
| | - Mahmod Hasan
- Orthopedic Department, Galilee Medical Center, Nahariya 2210001, Israel
| | - Galina Keigler
- Department of Neurology, Galilee Medical Center, Nahariya 2210001, Israel
| | - Samih Badarny
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 1311502, Israel
- Department of Neurology, Galilee Medical Center, Nahariya 2210001, Israel
| |
Collapse
|
178
|
Ironside N, Melmed K, Chen CJ, Omran S, Park S, Agarwal S, Connolly ES, Claassen J, Hod EA, Roh D. ABO Blood Type and Thromboembolic Complications after Intracerebral Hemorrhage: an exploratory analysis. RESEARCH SQUARE 2023:rs.3.rs-3108135. [PMID: 37546936 PMCID: PMC10402260 DOI: 10.21203/rs.3.rs-3108135/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Background and Purpose Non-O blood types are known to be associated with thromboembolic complications (TECs) in population-based studies. TECs are known drivers of morbidity and mortality in intracerebral hemorrhage (ICH) patients, yet the relationships of blood type on TECs in this patient population are unknown. We sought to explore the relationships between ABO blood type and TECs in ICH patients. Methods Consecutive adult ICH patients enrolled into a prospective observational cohort study with available ABO blood type data were analyzed. Patients with cancer history, prior thromboembolism, and baseline laboratory evidence of coagulopathy were excluded. The primary exposure variable was blood type (non-O versus O). The primary outcome was composite TEC, defined as pulmonary embolism, deep venous thrombosis, ischemic stroke or myocardial infarction, during the hospital stay. Relationships between blood type, TECs and clinical outcomes were separately assessed using logistic regression models after adjusting for sex, ethnicity and ICH score. Results Of 301 ICH patients included for analysis, 44% were non-O blood type. Non-O blood type was associated with higher admission GCS and lower ICH score on baseline comparisons. We identified TECs in 11.6% of our overall patient cohort. Although TECs were identified in 9.9% of non-O blood type patients compared to 13.0% in O blood type patients, we did not identify a significant relationship of non-O blood type with TECs (adjusted OR = 0.776, 95%CI: 0.348-1.733, p = 0.537). The prevalence of specific TECs were also comparable in unadjusted and adjusted analyses between the two cohorts. In additional analyses, we identified that TECs were associated with poor 90-day mRS (adjusted OR = 3.452, 95% CI: 1.001-11.903, p = 0.050). We did not identify relationships between ABO blood type and poor 90-day mRS (adjusted OR = 0.994, 95% CI:0.465-2.128, p = 0.988). Conclusions We identified that TECs were associated with worse ICH outcomes. However, we did not identify relationships in ABO blood type and TECs. Further work is required to assess best diagnostic and prophylactic and treatment strategies for TECs to improve ICH outcomes.
Collapse
Affiliation(s)
| | - Kara Melmed
- New York University Grossman School of Medicine
| | - Ching-Jen Chen
- University of Texas Health Science Center at Houston School of Dentistry: The University of Texas Health Science Center at Houston School of Dentistry
| | - Setareh Omran
- Oregon Health & Science University Neurological Sciences Institute: Oregon Health & Science University Brain Institute
| | - Soojin Park
- Columbia University Medical Center: Columbia University Irving Medical Center
| | | | | | - Jan Claassen
- Columbia University Medical Center: Columbia University Irving Medical Center
| | - Eldad A Hod
- CUIMC: Columbia University Irving Medical Center
| | - David Roh
- Columbia University Irving Medical Center
| |
Collapse
|
179
|
Angelillo-Scherrer A, Casini A, Studt JD, Gerber B, Alberio LA, Fontana P. Recommendations for the use of andexanet alfa in the management of bleeding in patients on oral factor Xa inhibitors in Switzerland: Guideline from the Working Party Hemostasis of the Swiss Society of Hematology. Swiss Med Wkly 2023; 153:40113. [PMID: 37499160 DOI: 10.57187/smw.2023.40113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Anticoagulants are essential in preventing and treating thrombosis. Unfortunately, their use is accompanied by an enhanced risk of bleeding. Since the introduction of direct oral anticoagulants (DOACs), the risk of major bleeding has been reduced but not eliminated. Major bleeding events related to the use of factor Xa inhibitors can be challenging to manage. In recent years, four-factor prothrombin complex concentrates have been used in patients with severe bleeding taking oral direct factor Xa inhibitors (apixaban, edoxaban and rivaroxaban). Andexanet alfa (OndexxyaTM, AstraZeneca AG) is a specially designed recombinant version of human factor Xa that acts as a decoy receptor to reverse the effects of factor Xa inhibitors. Since 2 December 2020, andexanet alfa has been used in Switzerland for adult patients receiving apixaban or rivaroxaban when reversal of anticoagulation is required because of life-threatening or uncontrolled bleeding. However, the use of andexanet alfa remains a challenge owing to its cost, the reported thrombotic complications and the fact that its efficacy mainly relates to intracranial haemorrhage. Moreover, the use of nonspecific reversal agents together with andexanet alfa is controversial. The present recommendations on the use of andexanet alfa in the management of bleeding in patients on factor Xa inhibitors in Switzerland were developed by a group of Swiss experts from the Working Party Hemostasis of the Swiss Society of Hematology. These recommendations aim to provide support to clinicians in their decision-making in the management of patients with major bleeding receiving factor Xa inhibitors.
Collapse
Affiliation(s)
- Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| | - Jan-Dirk Studt
- University Clinic of Hematology, Zurich University Hospital, Zurich, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Lorenzo A Alberio
- Service and Central Laboratory of Hematology, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| |
Collapse
|
180
|
Zhang Y, Xia X, Zhang T, Zhang C, Liu R, Yang Y, Liu S, Li X, Yue W. Relation between sleep disorders and post-stroke cognitive impairment. Front Aging Neurosci 2023; 15:1036994. [PMID: 37547745 PMCID: PMC10400888 DOI: 10.3389/fnagi.2023.1036994] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 07/10/2023] [Indexed: 08/08/2023] Open
Abstract
Objective To investigate the effects of sleep disorders on post-stroke cognitive impairment (PSCI) and other factors affecting post-stroke cognitive impairment. Methods A total of 1,542 first-ever stroke inpatients in department of neurology of Tianjin Huanhu Hospital from 2015.6.1 to 2016.12.31. We recorded the personal history of patients. The MMSE (mini-mental state examination), MoCA (Montreal Cognitive Assessment), HAMD (Hamilton Depression Scale), BI (Barthel index), mRS (Modified Rankin Scale), PSQI (Pittsburgh Sleep Quality Index), ESS (Epworth Sleepiness Scale), Berlin questionnaire, nocturnal TST (total sleep time) were assessed before discharge. All patients were followed up at 3 months, 6 months, and 4 years (2019-2020) after stroke. During follow-up, the above scales should be evaluated again to assess the sleep status and cognitive function of patients at that time. Results Nocturnal TST (>8 h) (OR 3.540, 95% CI 1.692-7.406, P = 0.001) was a risk factor for cognitive impairment 3 months after stroke. Nocturnal TST (<7 h) (OR 6.504, 95% CI 3.404-12.427, P < 0.001) was a risk factor for cognitive impairment 6 months after stroke. Low sleep quality (OR 2.079, 95% CI 1.177-3.672, P = 0.012), sleepiness (OR 3.988, 95% CI 1.804-8.818, P = 0.001), nocturnal TST (<7 h) (OR 11.334, 95% CI 6.365-20.183, P < 0.001), nocturnal TST (>8 h) (OR 4.096, 95% CI 1.682-9.975, P = 0.002) were risk factors for cognitive impairment 4 years after stroke. The prevalence of cognitive impairment with TIA were 79.3% at admission, 68.1% at 3-months follow-up, 62.1% at 6-months follow-up and 52.2% at 4-year follow-up. Conclusion Long or short nocturnal TST (<7 h or >8 h) was a risk factor for cognitive impairment after stroke (3 months, 6 months and 4 years). Poor sleep quality and sleepiness were shown to be risk factors for cognitive impairment at 4-year follow-up. Cognitive impairment was very common in patients with TIA.
Collapse
Affiliation(s)
- Yajing Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Xiaoshuang Xia
- Department of Neurology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Ting Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Chao Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Ran Liu
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Yun Yang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Shuling Liu
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Xin Li
- Department of Neurology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Wei Yue
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| |
Collapse
|
181
|
Zhang L, Mu Z, Shen G, Yang M. The accuracy and safety of intraoperative ultrasound-guided external ventricular drainage in intraventricular hemorrhage. Sci Rep 2023; 13:11525. [PMID: 37460575 DOI: 10.1038/s41598-023-38567-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
Severe IVH often results in a poor outcome. Currently, EVD is a standard treatment for IVH, but there is little research to show whether using ultrasound to guide the catheter placement improves outcome. Patients with severe IVH who had iUS-guided EVD (the iUS-guided group) were enrolled retrospectively and compared with a group who had EVD performed without ultrasound guidance (the control group) from January 2016 to July 2022. Data were collected on accuracy of the catheter placement, complications and outcome at 3 months assessed by mRS. The accuracy of the EVD placement was classified as optimal placement, sub-optimal placement and misplacement according to the position of the catheter tip. The complications reported are catheter-related hemorrhage, intracranial infection and hydrocephalus. There were 105 cases enrolled, with 72 patients in the iUS-guided group having 131 catheters inserted and 33 patients in the group where ultrasound was not used with a total of 59 catheters. 116 (88.55%) were optimally placed, 12 (9.16%) sub-optimal and 3 (2.29%) misplaced in the iUS-guided group, while 25 (42.37%) were in optimally placed, 30 (50.85%) sub-optimal and 4(6.78%) misplaced in the control group. Accuracy of placement was highly significantly improved using ultrasound (P < 0.001). The operation time and the average catheterized time were longer in the iUS-guided group (P < 0.05), but the complication rates were no different between the groups. The mRS at three months was not significantly different between the two groups. Using iUS to place EVD catheters in patients with severe IVH is a safe technique delivering more accurate catheter placement without increasing the complication rate compared with freehand placement.
Collapse
Affiliation(s)
- Lijun Zhang
- Department of Neurosurgery, Taizhou First People's Hospital, Taizhou, Zhejiang, 318020, People's Republic of China.
- Department of Neurosurgery, Wenzhou Medical University Affiliated Huangyan Hospital, Taizhou, Zhejiang, 318020, People's Republic of China.
| | - Zhaohui Mu
- Department of Neurosurgery, Taizhou First People's Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
- Department of Neurosurgery, Wenzhou Medical University Affiliated Huangyan Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
| | - Guoliang Shen
- Department of Neurosurgery, Taizhou First People's Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
- Department of Neurosurgery, Wenzhou Medical University Affiliated Huangyan Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
| | - Ming Yang
- Department of Neurosurgery, Taizhou First People's Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
- Department of Neurosurgery, Wenzhou Medical University Affiliated Huangyan Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
| |
Collapse
|
182
|
Vilionskis A, Korv J. Editorial: Quality of stroke care: what could be improved, and how? Front Neurol 2023; 14:1250872. [PMID: 37497011 PMCID: PMC10368399 DOI: 10.3389/fneur.2023.1250872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023] Open
Affiliation(s)
| | - Janika Korv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| |
Collapse
|
183
|
Gao CF, Zhang GH, Ye ZH, Xu YY, Li Z. Usability of Serum Stanniocalcin-1 as a Prognostic Biochemical Marker of Acute Supratentorial Intracerebral Hemorrhage: A Prospective Cohort Study. Int J Gen Med 2023; 16:2791-2803. [PMID: 37426521 PMCID: PMC10328107 DOI: 10.2147/ijgm.s420245] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023] Open
Abstract
Objective Stanniocalcin-1 (STC1) may be neuroprotective. This study aimed to evaluate the prognostic role of serum STC1 levels in intracerebral hemorrhage (ICH). Methods This prospective observational study was assigned in two parts. In the first part, blood samples of 48 patients with ICH were acquired on admission and on days 1, 2, 3, 5, and 7 after ICH, and those of 48 controls were collected at their entry into the study. In the second part, blood samples of 141 patients with ICH were obtained upon admission. Serum STC1 levels were measured, and the National Institutes of Health Stroke Scale (NIHSS), hematoma volume, and poststroke 6-month modified Rankin Scale (mRS) scores were recorded. Dynamic changes in serum STC levels and their correlation with disease severity and prognosis were investigated. Results Serum STC1 levels were elevated after ICH, peaked on day 1, plateaued on day 2, declined gradually afterwards, and were significantly higher than those in controls. Serum STC1 levels were independently correlated with NIHSS scores, hematoma volume, and the 6-month post-injury mRS scores. Serum STC1 levels, NIHSS scores, and hematoma volume independently predicted a poor prognosis (mRS scores of 3-6). The model integrating serum STC1 levels, NIHSS scores, and hematoma volume was visually displayed using a nomogram and was relatively stable using the Hosmer-Lemeshow test and calibration curve analysis. Under the receiver operating characteristic curve, serum STC1 levels efficiently predicted a poor prognosis and showed similar prognostic ability to NIHSS scores and hematoma volume. The preceding model had significantly higher prognostic capability than NIHSS scores and hematoma volume alone and their combination. Conclusion Substantial enhancement of serum STC1 levels after ICH, which is strongly correlated with severity, independently distinguished the risk of poor prognosis, assuming that serum STC1, as a prognostic parameter, may be clinically valuable in ICH.
Collapse
Affiliation(s)
- Chun-Fang Gao
- Department of Neurosurgery, The Shengzhou Hospital of Traditional Chinese Medicine, Shengzhou, Zhejiang Province, People’s Republic of China
| | - Guo-Hai Zhang
- Department of Neurosurgery, The Shengzhou Hospital of Traditional Chinese Medicine, Shengzhou, Zhejiang Province, People’s Republic of China
| | - Zhe-Hao Ye
- Department of Neurosurgery, The Shengzhou Hospital of Traditional Chinese Medicine, Shengzhou, Zhejiang Province, People’s Republic of China
| | - Yu-Yu Xu
- Department of Neurology, The Shengzhou Hospital of Traditional Chinese Medicine, Shengzhou, Zhejiang Province, People’s Republic of China
| | - Zhao Li
- Department of Neurosurgery, The Shengzhou Hospital of Traditional Chinese Medicine, Shengzhou, Zhejiang Province, People’s Republic of China
| |
Collapse
|
184
|
Zhong S, Liu T, Zhai Q, Zhang X, Jing H, Li K, Liu S, Liu G, Wang L, Li L, Tao S, Ren L, Shi X, Bao Y. Impacts of Statin Therapy Strategies on Incidence of Ischemic Cerebrovascular Events in Patients With Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Bayesian Network Meta-Analysis. Neurosurgery 2023; 93:24-32. [PMID: 36794961 DOI: 10.1227/neu.0000000000002392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 12/06/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND The exacerbation of neurological outcomes often occurs in aneurysmal subarachnoid hemorrhage (aSAH). Statins have been commonly used for aSAH; however, there is lack of evidence of the pharmacological efficacy of different dosages and types of statins. OBJECTIVE To apply the Bayesian network meta-analysis to analyze the optimal dosage and type of statins for the amelioration of ischemic cerebrovascular events (ICEs) in patients with aSAH. METHODS We developed the Bayesian network meta-analysis and systemic review to analyze the effects of statins on functional prognosis and the impacts of optimal dosage and type of statins on ICEs in patients with aSAH. The outcome variables of the analysis were the incidence of ICEs and functional prognosis. RESULTS A total of 2569 patients with aSAH across 14 studies were included. Analysis of 6 randomized controlled trials showed that statin use significantly improved functional prognosis in patients with aSAH (risk ratio [RR], 0.73; 95% CI, 0.55-0.97). Statins significantly reduced the incidence of ICEs (RR, 0.78; 95% CI, 0.67-0.90). Pravastatin (40 mg/d) decreased the incidence ICEs compared with placebo (RR, 0.14; 95% CI, 0.03-0.65) and was ranked the most effective, presenting with a significantly lower rate of the incidence ICEs than the worst-ranked simvastatin (40 mg/d) (RR, 0.13; 95% CI, 0.02-0.79). CONCLUSION Statins could significantly diminish the incidence of ICEs and enhance functional prognosis in patients with aSAH. Various types and dosages of statins show distinct efficacies.
Collapse
Affiliation(s)
- Shiyu Zhong
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Qingqing Zhai
- School of Management, Shanghai University, Shanghai, China
| | - Xudong Zhang
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Huiquan Jing
- School of Public Health, Capital Medical University, Beijing, China
| | - Kunhang Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shengyu Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Guojun Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Liang Wang
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Lishuai Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shanwei Tao
- Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang, China
| | - Lijie Ren
- Neurology Department of Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University Health Science Center, Futian, Shenzhen, China
| | - Xin Shi
- School of Maths and Information Science, Shandong University of Technology and Business, Yantai, Shandong, China
- Business School, All Saints Campus, Manchester Metropolitan University, Manchester, United Kingdom
| | - Yijun Bao
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| |
Collapse
|
185
|
Almeida T, Manfroi G, Silva S, Beggiora P, Schwingel D, Bertolin TE. Exploring the Neuroprotective Effects of Spirulina platensis: Insights Into Hemorrhagic Volume and Histological Outcomes. Cureus 2023; 15:e42078. [PMID: 37602106 PMCID: PMC10434819 DOI: 10.7759/cureus.42078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Background Hemorrhagic events can result in significant neurological damage, and identifying effective strategies for neuroprotection is crucial. Several studies have directed their attention to the alterations in perilesional parenchymal tissue. These investigations have sought to modify ischemic and metabolic changes by utilizing potential neuroprotective agents and to develop strategies that effectively mitigate secondary perilesional neuronal damage. By gaining a deeper understanding of its mechanisms and efficacy, Spirulina platensis can emerge as a promising therapeutic intervention for various neurological disorders. Methodology This controlled and blinded experimental study was conducted on adult male Wistar rats. The rats were divided into the treatment group, which received Spirulina platensis extract for 30 days before the hemorrhagic event, and the control group, where all animals underwent the same experimental hemorrhage model using collagenase. Each group was divided into the following three subgroups based on the sacrifice time: six hours, 24 hours, and 30 days. The brain section with the largest hemorrhage volume was selected for histological analysis. The number of viable neurons was analyzed in the perilesional zone and the cortical fields along the puncture trajectory. Neurofunctional evaluations were conducted on animals sacrificed 15 and 30 days after the procedure. Results Initial analysis showed no significant difference in viable neurons between groups (p = 0.63). Still, after 24 hours, the treatment group had a significantly higher number of viable neurons per peripheral fields (18.5) compared to the control group (13.4; p < 0.05). Neurofunctional tests at 15 days indicated a trend toward significance in absolute discrimination (p = 0.054), with the control group showing higher mean values (5.5, SD = 3.1) than the treatment group (-1, SD = 5.1). The discrimination index exhibited a significant difference (p < 0.01), with higher mean values in the control group (0.59, SD = 0.34) compared to the treatment group (-0.05, SD = 0.21). No significant differences were found in other neurofunctional parameters at this time point. At 30 days, no significant differences were observed in absolute discrimination, discrimination index, contralateral paw elevation, rearing time, and wire hanging time test (p > 0.1); however, the treatment group presented a better motor performance in the open field test (14.2, SD = 9.02) compared to the control group (5.25, SD = 2.06), approaching significance (p = 0.06). Conclusions The group treated with Spirulina platensis demonstrated significantly more viable neurons in the perilesional fields 24 hours after the induced hemorrhage. The treatment group also had a relatively better motor performance in the open field test 30 days after the hemorrhage (p = 0.06). These findings suggest a potential neuroprotection effect and warrant further investigations to explore the effects of Spirulina platensis and its active component phycocyanin in acute neurological conditions.
Collapse
Affiliation(s)
- Timoteo Almeida
- Department of Radiation Oncology, University of Miami, Miami, USA
- Department of Neurosurgery, University of Miami, Miami, USA
| | - Gregori Manfroi
- Department of Neurosurgery, Hospital Santa Marcelina, São Paulo, BRA
| | - Stephanya Silva
- Department of Morphology and Pathology, Federal University of São Carlos, São Carlos, BRA
| | - Pamella Beggiora
- Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, BRA
| | - Daniela Schwingel
- Department of Pathology, Faculdade Meridional School of Medicine, Passo Fundo, BRA
| | - Telma E Bertolin
- Graduate Program in Food Science and Technology, University of Passo Fundo, Passo Fundo, BRA
| |
Collapse
|
186
|
Alkhachroum A, Zhou L, Asdaghi N, Gardener H, Ying H, Gutierrez CM, Manolovitz BM, Samano D, Bass D, Foster D, Sur NB, Rose DZ, Jameson A, Massad N, Kottapally M, Merenda A, Starke RM, O'Phelan K, Romano JG, Claassen J, Sacco RL, Rundek T. Predictors and Temporal Trends of Withdrawal of Life-Sustaining Therapy After Acute Stroke in the Florida Stroke Registry. Crit Care Explor 2023; 5:e0934. [PMID: 37378082 PMCID: PMC10292735 DOI: 10.1097/cce.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
Temporal trends and factors associated with the withdrawal of life-sustaining therapy (WLST) after acute stroke are not well determined. DESIGN Observational study (2008-2021). SETTING Florida Stroke Registry (152 hospitals). PATIENTS Acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Importance plots were performed to generate the most predictive factors of WLST. Area under the curve (AUC) for the receiver operating curve were generated for the performance of logistic regression (LR) and random forest (RF) models. Regression analysis was applied to evaluate temporal trends. Among 309,393 AIS patients, 47,485 ICH patients, and 16,694 SAH patients; 9%, 28%, and 19% subsequently had WLST. Patients who had WLST were older (77 vs 70 yr), more women (57% vs 49%), White (76% vs 67%), with greater stroke severity on the National Institutes of Health Stroke Scale greater than or equal to 5 (29% vs 19%), more likely hospitalized in comprehensive stroke centers (52% vs 44%), had Medicare insurance (53% vs 44%), and more likely to have impaired level of consciousness (38% vs 12%). Most predictors associated with the decision to WLST in AIS were age, stroke severity, region, insurance status, center type, race, and level of consciousness (RF AUC of 0.93 and LR AUC of 0.85). Predictors in ICH included age, impaired level of consciousness, region, race, insurance status, center type, and prestroke ambulation status (RF AUC of 0.76 and LR AUC of 0.71). Factors in SAH included age, impaired level of consciousness, region, insurance status, race, and stroke center type (RF AUC of 0.82 and LR AUC of 0.72). Despite a decrease in the rates of early WLST (< 2 d) and mortality, the overall rates of WLST remained stable. CONCLUSIONS In acute hospitalized stroke patients in Florida, factors other than brain injury alone contribute to the decision to WLST. Potential predictors not measured in this study include education, culture, faith and beliefs, and patient/family and physician preferences. The overall rates of WLST have not changed in the last 2 decades.
Collapse
Affiliation(s)
| | - Lili Zhou
- Department of Neurology, University of Miami, Miami, FL
| | - Negar Asdaghi
- Department of Neurology, University of Miami, Miami, FL
| | | | - Hao Ying
- Department of Neurology, University of Miami, Miami, FL
| | | | | | - Daniel Samano
- Department of Neurology, University of Miami, Miami, FL
| | - Danielle Bass
- Department of Neurology, University of Miami, Miami, FL
| | - Dianne Foster
- Regional Director Quality Improvement, American Heart Association, Dallas, TX
| | - Nicole B Sur
- Department of Neurology, University of Miami, Miami, FL
| | - David Z Rose
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Angus Jameson
- Department of Emergency Medicine, Pinellas County Emergency Medical Services, Largo, FL
| | - Nina Massad
- Department of Neurology, University of Miami, Miami, FL
| | | | | | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, FL
| | | | - Jose G Romano
- Department of Neurology, University of Miami, Miami, FL
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miami, FL
| | | |
Collapse
|
187
|
Lam MSH, Luoma AMV, Reddy U. Acute perioperative neurological emergencies. Int Anesthesiol Clin 2023; 61:53-63. [PMID: 37249171 DOI: 10.1097/aia.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michelle S H Lam
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Astri M V Luoma
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| | - Ugan Reddy
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| |
Collapse
|
188
|
Rao X, Zhang J, Yu K, Sun Y, Zhou J, Jiang L, Liu T, Xie B, Peng J, Jiang Y. Effect of Early External Ventricular Drainage on Perihemorrhagic Edema and Functional Outcome in Patients with Intraventricular Hemorrhage. World Neurosurg 2023; 175:e1059-e1068. [PMID: 37087041 DOI: 10.1016/j.wneu.2023.04.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE External ventricular drainage (EVD) is the most common neurosurgical procedure that allows drainage of cerebrospinal fluid and intraventricular blood. A specific time threshold for insertion of an EVD catheter in patients with spontaneous intracerebral hemorrhage and intraventricular hemorrhage has not been established. This study aimed to evaluate the association of early EVD with functional outcome in patients with intracerebral hemorrhage and intraventricular hemorrhage. METHODS Propensity score matching was used to account for baseline imbalances. Modified Rankin Scale score at 3 and 6 months, mortality rates at 3 and 6 months, postoperative complications, time course of edema evolution, and peak perihemorrhagic edema (PHE) were compared in patients who received early EVD versus routine EVD. RESULTS The rate of favorable outcome at 3 months was higher in the early EVD group compared with the routine EVD group. There were no differences between groups in modified Rankin Scale score at 6 months or mortality rates at 3 and 6 months. Absolute peak PHE and relative PHE volumes were significantly less in the early EVD group compared with the routine EVD group. The incidence of postoperative infections was lower in the early EVD group compared with the routine EVD group. CONCLUSIONS Early EVD was associated with improved functional outcome at 3 months, reduced PHE, and lower rate of infection in intracerebral hemorrhage and intraventricular hemorrhage. However, survival at 3 and 6 months and functional outcome at 6 months were not improved.
Collapse
Affiliation(s)
- Xiao Rao
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiaqi Zhang
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Kuangyang Yu
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yuxuan Sun
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jian Zhou
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Laboratory of Neurological Diseases and Brain Function, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou, China
| | - Lu Jiang
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Tianjie Liu
- Sichuan Clinical Research Center for Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bingqing Xie
- Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou, China
| | - Jianhua Peng
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Laboratory of Neurological Diseases and Brain Function, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Academician (Expert) Workstation of Sichuan Province, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yong Jiang
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Laboratory of Neurological Diseases and Brain Function, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou, China.
| |
Collapse
|
189
|
Yindeedej V, Setprapha C, Komarapaj C, Osirichaivait K, Nimmannitya P, Noiphithak R. Applications of Machine Learning Model for Prediction of Outcomes in Primary Pontine Hemorrhage. World Neurosurg 2023; 175:e1348-e1359. [PMID: 37172714 DOI: 10.1016/j.wneu.2023.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Primary pontine hemorrhage (PPH) is a rare intracranial hemorrhage with a wide range of mortality rate. Predicting the prognosis of PPH is still challenging. Previous prognostic scoring tests have not been widely used due to limited external validation. This study applied machine learning (ML) algorithms to develop predictive models for mortality and prognosis of patients with PPH. METHODS Data of patients with PPH were retrospectively reviewed. Seven ML models were used to train and validate for predicting outcomes of PPH including 30-day mortality rate, 30-day, and 90-day functional outcomes. Accuracy, sensitivity, specificity, positive and negative predictive value, F1 score, Brier score, and area under the curve (AUC) of the receiver operating characteristic were calculated. The models with the highest AUC were then selected to evaluate the testing data. RESULTS One hundred and fourteen patients with PPH were included. Mean hematoma volume was 7 ml and most patients had hematoma in the central part of the pons. The 30-day mortality rate was 34.2% and favorable outcomes were observed in 71.1% and 70.2% during 30-day and 90-day follow-up. The ML model could predict 30-day mortality with an AUC of 0.97 using an artificial neural network. Regarding functional outcome, the gradient boosting machine could predict both 30-day and 90-day outcomes with an AUC of 0.94. CONCLUSIONS ML algorithms achieved a high performance and accuracy in predicting PPH outcomes. Despite the need for further validation, ML models are promising tools for clinical applications in the future.
Collapse
Affiliation(s)
- Vich Yindeedej
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Chaipatr Setprapha
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Claire Komarapaj
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Krit Osirichaivait
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Pree Nimmannitya
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand.
| |
Collapse
|
190
|
Steffensen AB, Edelbo BL, Barbuskaite D, Andreassen SN, Olsen MH, Møller K, MacAulay N. Nocturnal increase in cerebrospinal fluid secretion as a circadian regulator of intracranial pressure. Fluids Barriers CNS 2023; 20:49. [PMID: 37353833 DOI: 10.1186/s12987-023-00451-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/06/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND It is crucial to maintain the intracranial pressure (ICP) within the physiological range to ensure proper brain function. The ICP may fluctuate during the light-dark phase cycle, complicating diagnosis and treatment choice in patients with pressure-related disorders. Such ICP fluctuations may originate in circadian or sleep-wake cycle-mediated modulation of cerebrospinal fluid (CSF) flow dynamics, which in addition could support diurnal regulation of brain waste clearance. METHODS ICP was monitored continuously in patients who underwent placement of an external ventricular drain (EVD) and by telemetric monitoring in experimental rats. CSF was collected via the EVD in patients and the rodent CSF secretion rate determined by in vivo experimentation. Rodent choroid plexus transporter transcripts were quantified with RNAseq and transport activity with ex vivo isotope transport assays. RESULTS We demonstrated that ICP increases by 30% in the dark phase in both species, independently of vascular parameters. This increase aligns with elevated CSF collection in patients (12%) and CSF production rate in rats (20%), the latter obtained with the ventriculo-cisternal perfusion assay. The dark-phase increase in CSF secretion in rats was, in part, assigned to increased transport activity of the choroid plexus Na+,K+,2Cl- cotransporter (NKCC1), which is implicated in CSF secretion by this tissue. CONCLUSION CSF secretion, and thus ICP, increases in the dark phase in humans and rats, irrespective of their diurnal/nocturnal activity preference, in part due to altered choroid plexus transport activity in the rat. Our findings suggest that CSF dynamics are modulated by the circadian rhythm, rather than merely sleep itself.
Collapse
Affiliation(s)
- Annette Buur Steffensen
- Faculty of Health and Medical Sciences, Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark
| | - Beatriche Louise Edelbo
- Faculty of Health and Medical Sciences, Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark
| | - Dagne Barbuskaite
- Faculty of Health and Medical Sciences, Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark
| | - Søren Norge Andreassen
- Faculty of Health and Medical Sciences, Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nanna MacAulay
- Faculty of Health and Medical Sciences, Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark.
| |
Collapse
|
191
|
Yan Y, Ren H, Luo B, Fan W, Zhang X, Huang Y. Clinical characteristics of spontaneous intracranial basal ganglia hemorrhage and risk factors for hematoma expansion in the plateaus of China. Front Neurol 2023; 14:1183125. [PMID: 37396776 PMCID: PMC10313382 DOI: 10.3389/fneur.2023.1183125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Background and purpose The clinical features of intracranial cerebral hemorrhage (ICH) and the risk factors for hematoma expansion (HE) have been extensively studied. However, few studies have been performed in patients who live on a plateau. The natural habituation and genetic adaptation have resulted in differences in disease characteristics. The purpose of this study was to investigate the differences and consistency of clinical and imaging characteristics of patients in the plateaus of China compared with the plains, and to analyze the risk factors for HE of intracranial hemorrhage in the plateau patients. Methods From January 2020 to August 2022, we undertook a retrospective analysis of 479 patients with first-episode spontaneous intracranial basal ganglia hemorrhage in Tianjin and Xining City. The clinical and radiologic data during hospitalization were analyzed. Univariate and multivariate logistic regression analyzes were used to assess the risk factors for HE. Results HE occurred in 31 plateau (36.0%) and 53 plain (24.2%) ICH patients, and HE was more likely to occur in the plateau patients compared with the plain (p = 0.037). The NCCT images of plateau patients also showed heterogeneity of hematoma imaging signs, and the incidence of blend signs (23.3% vs. 11.0%, p = 0.043) and black hole signs (24.4% vs. 13.2%, p = 0.018) was significantly higher than in the plain. Baseline hematoma volume, black hole sign, island sign, blend sign, and PLT and HB level were associated with HE in the plateau. Baseline hematoma volume and the heterogeneity of hematoma imaging signs were independent predictors of HE in both the plain and plateau. Conclusion Compared with the plain, ICH patients in the plateau were more prone to HE. The patients showed the same heterogeneous signs on the NCCT images as in the plain, and also had predictive value for HE.
Collapse
Affiliation(s)
- Yujia Yan
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Hecheng Ren
- Department of Neurosurgery, Third People’s Hospital of Xining City, Xining, China
| | - Bin Luo
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Wanpeng Fan
- Department of Neurosurgery, Third People’s Hospital of Xining City, Xining, China
| | - Xiqiang Zhang
- Department of Neurosurgery, Third People’s Hospital of Xining City, Xining, China
| | - Ying Huang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| |
Collapse
|
192
|
Zhang P, Zhang Y. Association of Homocysteine with Acute Stroke and Its Subtypes in the Chinese Population. Neuropsychiatr Dis Treat 2023; 19:1435-1442. [PMID: 37342757 PMCID: PMC10278861 DOI: 10.2147/ndt.s409591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023] Open
Abstract
Purpose Homocysteine (Hcy) is recognized as a risk factor for stroke. Our study examined the relationship between plasma Hcy levels and stroke, along with its subtypes, among Chinese patients who experienced an acute stroke episode. Patients and Methods We retrospectively enrolled patients with acute stroke and age- and sex-matched healthy controls admitted to the First Affiliated Hospital of Xi'an Jiaotong University from October 2021 to September 2022. Ischemic stroke subtypes were classified using the modified TOAST criteria. Multivariate logistic regression models were employed to probe the associations of plasma Hcy levels with total stroke, ischemic stroke and its subtypes, and hypertensive intracerebral hemorrhage (HICH), and the correlation between plasma Hcy levels and the National Institute of Health Stroke Scale (NIHSS). Results The mean age of the total group was 63 years, with women representing 30.6% (246 individuals). Elevated Hcy levels were significantly associated with total stroke (OR 1.054, 95% CI: 1.038-1.070), HICH (OR 1.040, 95% CI: 1.020-1.060), ischemic stroke (OR 1.049, 95% CI: 1.034-1.065), and the TOAST subtypes of ischemic stroke in large-artery atherosclerosis (LAA) (OR 1.044, 95% CI: 1.028-1.062) and small-artery occlusion (SAO) (OR 1.035, 95% CI: 1.018-1.052), but not with cardioembolic (CE) stroke. Moreover, only in the case of SAO stroke were the Hcy levels positively correlated with the NIHSS score (B=0.030, 95% CI: 0.003-0.056, P=0.030). Conclusion Plasma Hcy levels were found to be positively correlated with the risk of stroke, particularly in the context of LAA, SAO stroke, and HICH. Additionally, Hcy levels demonstrated a positive correlation with stroke severity in patients presenting with SAO stroke. These findings suggest potential clinical implications in stroke prevention, particularly for ischemic stroke (LAA, SAO subtypes) and HICH by employing homocysteine-lowering therapies. Future investigations are warranted to fully elucidate these associations.
Collapse
Affiliation(s)
- Panpan Zhang
- Department of Neurology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, People’s Republic of China
| | - Yurong Zhang
- Department of Neurology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, People’s Republic of China
| |
Collapse
|
193
|
Cao H, Morotti A, Mazzacane F, Desser D, Schlunk F, Güttler C, Kniep H, Penzkofer T, Fiehler J, Hanning U, Dell'Orco A, Nawabi J. External Validation and Retraining of DeepBleed: The First Open-Source 3D Deep Learning Network for the Segmentation of Spontaneous Intracerebral and Intraventricular Hemorrhage. J Clin Med 2023; 12:4005. [PMID: 37373699 DOI: 10.3390/jcm12124005] [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: 05/10/2023] [Revised: 06/03/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The objective of this study was to assess the performance of the first publicly available automated 3D segmentation for spontaneous intracerebral hemorrhage (ICH) based on a 3D neural network before and after retraining. METHODS We performed an independent validation of this model using a multicenter retrospective cohort. Performance metrics were evaluated using the dice score (DSC), sensitivity, and positive predictive values (PPV). We retrained the original model (OM) and assessed the performance via an external validation design. A multivariate linear regression model was used to identify independent variables associated with the model's performance. Agreements in volumetric measurements and segmentation were evaluated using Pearson's correlation coefficients (r) and intraclass correlation coefficients (ICC), respectively. With 1040 patients, the OM had a median DSC, sensitivity, and PPV of 0.84, 0.79, and 0.93, compared to thoseo f 0.83, 0.80, and 0.91 in the retrained model (RM). However, the median DSC for infratentorial ICH was relatively low and improved significantly after retraining, at p < 0.001. ICH volume and location were significantly associated with the DSC, at p < 0.05. The agreement between volumetric measurements (r > 0.90, p > 0.05) and segmentations (ICC ≥ 0.9, p < 0.001) was excellent. CONCLUSION The model demonstrated good generalization in an external validation cohort. Location-specific variances improved significantly after retraining. External validation and retraining are important steps to consider before applying deep learning models in new clinical settings.
Collapse
Affiliation(s)
- Haoyin Cao
- Department of Radiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Andrea Morotti
- Neurology Unit, Department of Neurological Sciences and Vision, ASST-Spedali Civili, 25123 Brescia, Italy
| | - Federico Mazzacane
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
- U.C. Malattie Cerebrovascolari e Stroke Unit, IRCCS Fondazione Mondino, 27100 Pavia, Italy
| | - Dmitriy Desser
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Frieder Schlunk
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Christopher Güttler
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Tobias Penzkofer
- Department of Radiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), BIH Biomedical Innovation Academy, 10178 Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Andrea Dell'Orco
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), BIH Biomedical Innovation Academy, 10178 Berlin, Germany
| |
Collapse
|
194
|
El-Sherif AM, Rashad A, Rabie MM, Hegazy M, Adel M, Albialy M, El-Shandawely M, Mahmoud EA. Resource utilization in management of spontaneous intracerebral hemorrhage without systemic risk factors. Does early surgical decompression matter? Clin Neurol Neurosurg 2023; 231:107829. [PMID: 37331206 DOI: 10.1016/j.clineuro.2023.107829] [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: 02/13/2023] [Revised: 06/03/2023] [Accepted: 06/05/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Even though different subtypes of spontaneous ICH are frequently linked to a poor prognosis, their causes, pathological features, and prognoses vary. Atypical intracerebral hemorrhage is the subtype of spontaneous ICH that usually occurs due to an underlying localized vascular lesion. It is unrelated to systemic vascular risk factors, mostly affects children and young adults and is associated with a relatively good outcome. This fact should be considered when planning the evaluation and treatment. Investigating the cause of this subtype is fundamental to providing optimal management. However, if resources do not allow completing the investigations, the cause will be more difficult to discover. Treatment decisions will be made under stress to save the patient's life, especially with rapidly deteriorating patients. METHODS We described three cases of spontaneous ICH without systemic risk factors where the bleeding source could not be determined before surgery due to a lack of resources, preventing preoperative vascular investigation. Knowing that the atypical ICH has a distinct identity, regarding etiology and prognosis, encouraged the surgeons to resort to early surgical decompression as an alternative plan. We reviewed the literature searching for supporting evidence. RESULTS The results of treatment of the presented cases were satisfactory. The lack of reported similar cases was brought to light by a literature analysis that sought to provide backing for the proposed management strategy. In the end, we supplied two graphic organizers to help readers remember the different types and treatment of hemorrhagic stroke. CONCLUSION There isn't enough evidence to show that there are other ways to treat atypical intracerebral haemorrhage when resources are limited. The presented cases highlight the importance of decisionmaking in resource-constrained situations when patient outcomes can be improved.
Collapse
Affiliation(s)
- Ahmed M El-Sherif
- Al-Azhar University, Faculty of Medicine, Nasr City, 11651 Cairo, Egypt.
| | - Alaa Rashad
- Al-Azhar University, Faculty of Medicine, Nasr City, 11651 Cairo, Egypt
| | | | | | - Mostafa Adel
- Al-Azhar University, Faculty of Medicine, Al-Hussein Hospital, Egypt
| | - Mohammad Albialy
- Al-Azhar University, Faculty of Medicine, Nasr City, 11651 Cairo, Egypt
| | | | - Ehab Adel Mahmoud
- Uppsala University Hospital, Radiology Department, Neurointervention Unit, Sweden
| |
Collapse
|
195
|
Reed LK, Ajala RT, Lyon KA, Benardete EA. Quamdiu? Time to proficiency in endoscope-assisted minimally invasive clot evacuation. Clin Neurol Neurosurg 2023; 231:107817. [PMID: 37302379 DOI: 10.1016/j.clineuro.2023.107817] [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: 01/27/2023] [Revised: 05/06/2023] [Accepted: 06/04/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Spontaneous intraparenchymal brain hemorrhages are a devastating disease associated with significant disability or death. Minimally invasive clot evacuation (MICE) techniques can reduce mortality. We reviewed our experience with learning endoscope-assisted MICE to determine whether adequate results could be obtained in less than 10 cases. METHODS We performed a retrospective chart review of patients undergoing endoscope-assisted MICE at a single institution by a single surgeon from January 1, 2018 to January 1, 2023 using a neuro-endoscope, a commercial clot evacuation device, and frameless stereotaxis. Demographic data was collected along with surgical results and complications. Image analysis using software determined the degree of clot removal. Hospital length of stay and functional outcomes were assessed using the Glasgow Coma Scale score (GCS) and Glasgow Outcome Score (extended) (GOS-E). RESULTS Eleven patients were identified: average age 60.82 years old, 64 % male, all had hypertension. There was a clear improvement in IPH evacuation over the series. By case #7, greater than 80 % of clot volume was evacuated consistently. All patients remained neurologically stable or improved following surgery. In long-term follow-up, four patients (36.4 %) had good outcomes (GOS-E ≥ 6) and 2 patients had fair outcomes (GOS-E = 4) (18 %). There were no surgical mortalities, re-hemorrhages, or infections. CONCLUSIONS With an experience of less than 10 cases, it is possible to obtain results comparable to most published series of endoscope-assisted MICE. Benchmarks such as greater than 80 % volume removal, less than 15 mL residual, and 40 % good functional outcomes can be obtained.
Collapse
Affiliation(s)
- Laura K Reed
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, TX, USA
| | - Rodiyah T Ajala
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, TX, USA; Department of Surgery, Texas A&M University School of Medicine, Temple, TX USA
| | - Kristopher A Lyon
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, TX, USA
| | - Ethan A Benardete
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, TX, USA.
| |
Collapse
|
196
|
Carvalho Poyraz F, Boehme A, Cottarelli A, Eisler L, Elkind MSV, Ghoshal S, Agarwal S, Park S, Claassen J, Connolly ES, Hod EA, Roh DJ. Red Blood Cell Transfusions Are Not Associated With Incident Complications or Poor Outcomes in Patients With Intracerebral Hemorrhage. J Am Heart Assoc 2023; 12:e028816. [PMID: 37232240 PMCID: PMC10381991 DOI: 10.1161/jaha.122.028816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/14/2023] [Indexed: 05/27/2023]
Abstract
Background Anemia is associated with poor intracerebral hemorrhage (ICH) outcomes, yet the relationship of red blood cell (RBC) transfusions to ICH complications and functional outcomes remains unclear. We investigated the impact of RBC transfusion on hospital thromboembolic and infectious complications and outcomes in patients with ICH. Methods and Results Consecutive patients with spontaneous ICH enrolled in a single-center, prospective cohort study from 2009 to 2018 were assessed. Primary analyses assessed relationships of RBC transfusions on incident thromboembolic and infectious complications occurring after the transfusion. Secondary analyses assessed relationships of RBC transfusions with mortality and poor discharge modified Rankin Scale score 4 to 6. Multivariable logistic regression models adjusted for baseline demographics and medical disease severity (Acute Physiology and Chronic Health Evaluation II), and ICH severity (ICH score).Of 587 patients with ICH analyzed, 88 (15%) received at least one RBC transfusion. Patients receiving RBC transfusions had worse medical and ICH severity. Though patients receiving RBC transfusions had more complications at any point during the hospitalization (64.8% versus 35.9%), we found no association between RBC transfusion and incident complications in our regression models (adjusted odds ratio [aOR], 0.71 [95% CI, 0.42-1.20]). After adjusting for disease severity and other relevant covariates, we found no significant association between RBC transfusion and mortality (aOR, 0.87 [95% CI, 0.45-1.66]) or poor discharge modified Rankin Scale score (aOR, 2.45 [95% CI, 0.80-7.61]). Conclusions In our cohort with ICH, RBC transfusions were expectedly given to patients with higher medical and ICH severity. Taking disease severity and timing of transfusions into account, RBC transfusion was not associated with incident hospital complications or poor clinical ICH outcomes.
Collapse
Affiliation(s)
- Fernanda Carvalho Poyraz
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
- Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Azzurra Cottarelli
- Department of Pathology and Cell Biology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Lisa Eisler
- Department of Anesthesiology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
- Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Shivani Ghoshal
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Sachin Agarwal
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Soojin Park
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Jan Claassen
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - E. Sander Connolly
- Department of Neurological Surgery, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Eldad A. Hod
- Department of Pathology and Cell Biology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - David J. Roh
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| |
Collapse
|
197
|
Amer HA, El-Jaafary SIM, Sadek HMAEA, Fouad AM, Mohammed SS. Clinical and paraclinical predictors of early neurological deterioration and poor outcome in spontaneous intracerebral hemorrhage. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2023; 59:74. [PMID: 37305215 PMCID: PMC10242586 DOI: 10.1186/s41983-023-00675-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/28/2023] [Indexed: 06/13/2023] Open
Abstract
Background Spontaneous intracerebral hemorrhage (sICH) is the second most common form of stroke. It is a major cause of morbidity and mortality. Several clinical and radiological parameters are related to its poor outcome. The aim of this study is to elucidate the clinical, laboratory, and radiological factors associated with early neurological deterioration and poor outcome in patients with ICH. Results seventy patients diagnosed with sICH were evaluated within the first 72 h from the onset of symptoms by Clinical, radiological, and laboratory parameters. Patients were assessed for early neurological deterioration (END) during the hospital stay (up to 7 days from admission) using Glasgow coma scale (GSC), and the National Institutes of Health Stroke Scale (NIHSS), and within 3 months from stroke onset using modified Rankin scale (mRS). ICH score and Functional Outcome in Patients with Primary Intracerebral Hemorrhage (FUNC) Score were calculated for prognostication. 27.1% and 71.42% of patients had END and showed unfavorable outcome, respectively. Clinical indices, as NIHSS > 7 on admission and age > 51 years, radiological characteristics, as large hematoma size, leukoaraiosis, and mass effect detected on CT scan, as well as serum biomarkers; serum urea level > 50 mg/dL, high neutrophil:lymphocyte ratio on admission, high ALT and AST, as well as low total, LDL, and HDL cholesterol levels, all were significantly associated with poor outcome in the patients. Stepwise multivariate logistic regression analysis found the presence of aspiration to be an independent predictor of END, and the scores of NIHSS > 7 on admission, age > 51 years, and urea level > 50 mg/dL were independent predictors of poor outcome. Conclusions There are several predictors for END as well as poor outcome in ICH. Some are clinical, others are radiological and laboratory. Aspiration was an independent predictor of END during hospital stay (3-7 days) in patients with ICH, while older age, high NIHSS and urea level on admission were independent predictors of poor outcome.
Collapse
Affiliation(s)
| | | | | | - Amr Mohamed Fouad
- Neurology Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | | |
Collapse
|
198
|
Hieber M, Lambeck J, Halaby A, Roelz R, Demerath T, Niesen WD, Bardutzky J. Minimally-invasive bedside catheter haematoma aspiration followed by local thrombolysis in spontaneous supratentorial intracerebral haemorrhage: a retrospective single-center study. Front Neurol 2023; 14:1188717. [PMID: 37342780 PMCID: PMC10277509 DOI: 10.3389/fneur.2023.1188717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/16/2023] [Indexed: 06/23/2023] Open
Abstract
Background and purpose The role of surgery in the treatment of intracerebral haemorrhage (ICH) remains controversial. Whereas open surgery has failed to show any clinical benefit, recent studies have suggested that minimal invasive procedures can indeed be beneficial, especially when they are applied at an early time point. This retrospective study therefore evaluated the feasibility of a free-hand bedside catheter technique with subsequent local lysis for early haematoma evacuation in patients with spontaneous supratentorial ICH. Methods Patients with spontaneous supratentorial haemorrhage of a volume of >30 mL who were treated with bedside catheter haematoma evacuation were identified from our institutional database. The entry point and evacuation trajectory of the catheter were based on a 3D-reconstructed CT scan. The catheter was inserted bedside into the core of the haematoma, and urokinase (5,000 IE) was administered every 6 h for a maximum of 4 days. Evolution of haematoma volume, perihaemorrhagic edema, midline-shift, adverse events and functional outcome were analyzed. Results A total of 110 patients with a median initial haematoma volume of 60.6 mL were analyzed. Haematoma volume decreased to 46.1 mL immediately after catheter placement and initial aspiration (with a median time to treatment of 9 h after ictus), and to 21.0 mL at the end of urokinase treatment. Perihaemorrhagic edema decreased significantly from 45.0 mL to 38.9 mL and midline-shift from 6.0 mm to 2.0 mm. The median NIHSS score improved from 18 on admission to 10 at discharge, and the median mRS at discharge was 4; the latter was even lower in patients who reached a target volume ≤ 15 mL at the end of local lysis. The in-hospital mortality rate was 8.2%, and catheter/local lysis-associated complications occurred in 5.5% of patients. Conclusion Bedside catheter aspiration with subsequent urokinase irrigation is a safe and feasible procedure for treating spontaneous supratentorial ICH, and can immediately reduce the mass effects of haemorrhage. Additional controlled studies that assess the long-term outcome and generalizability of our findings are therefore warranted. Clinical trial registration [www.drks.de], identifier [DRKS00007908].
Collapse
Affiliation(s)
- Maren Hieber
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Amjad Halaby
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- Department of Neuroradiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Bardutzky
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
199
|
Zhang CL, Fang LL, Wang CL, Li P, Yang M, Xu JW. Prognostic potential of serum mesencephalic astrocyte-derived neurotrophic factor in acute intracerebral hemorrhage: a prospective observational study. BMC Neurol 2023; 23:213. [PMID: 37268902 DOI: 10.1186/s12883-023-03254-y] [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: 04/14/2023] [Accepted: 05/19/2023] [Indexed: 06/04/2023] Open
Abstract
OBJECTIVE Mesencephalic astrocyte-derived neurotrophic factor (MANF) expressions are dramatically up-regulated in injured brain tissues, thereby conferring neurological protective effects. We intended to determine significance of serum MANF as a prognostic biomarker of intracerebral hemorrhage (ICH). METHODS In this prospective, observational study done from February 2018 to July 2021, 124 patients with new-onset primary supratentorial ICH were consecutively enrolled. Also, a group of 124 healthy individuals constituted controls. Their serum MANF levels were detected using the Enzyme-Linked Immunosorbent Assay. National Institutes of Health Stroke Scale (NIHSS) and hematoma volume were designated as the two severity indicators. Early neurologic deterioration (END) was referred to as an increase of 4 or greater points in NIHSS scores or death at post-stroke 24 h. Post-stroke 90-day modified Rankin scale (mRS) scores of 3-6 was considered as a poor prognosis. Serum MANF levels were analyzed using multivariate analysis with respect to its association with stroke severity and prognosis. RESULTS Patients, in comparison to controls, displayed markedly elevated serum MANF levels (median, 24.7 versus 2.7 ng/ml; P < 0.001), and serum MANF levels were independently correlated with NIHSS scores (beta, 3.912; 95% confidence interval (CI), 1.623-6.200; VIF = 2.394; t = 3.385; P = 0.002), hematoma volumes (beta, 1.688; 95% CI, 0.764-2.612; VIF = 2.661; t = 3.617; P = 0.001) and mRS scores (beta, 0.018; 95% CI, 0.013-0.023; VIF = 1.984; t = 2.047; P = 0.043). Serum MANF levels significantly predicted END and poor 90-day prognosis with areas under receiver operating characteristic curve at 0.752 and 0.787 respectively. END and prognostic predictive abilities were similar between serum MANF levels and NIHSS scores plus hematoma volumes (all P > 0.05). Combination of serum MANF levels with NIHSS scores and hematoma volumes had significantly higher prognostic capability than each of them (both P < 0.05). Serum MANF levels above 52.5 ng/ml and 62.0 ng/ml distinguished development of END and poor prognosis respectively with median-high sensitivity and specificity values. Using multivariate analysis, serum MANF levels > 52.5 ng/ml predicted END with odds ratio (OR) value of 2.713 (95% CI, 1.004-7.330; P = 0.042) and > 62.0 ng/ml predicted a poor prognosis with OR value of 3.848 (95% CI, 1.193-12.417; P = 0.024). Using restricted cubic spline, there was a linear correlation between serum MANF levels and poor prognosis or END risk (both P > 0.05). Nomograms were well established to predict END and a poor 90-day prognosis. Under calibration curve, such combination models were comparatively stable (using Hosmer & Lemeshow test, both P > 0.05). CONCLUSION Increased serum MANF levels after ICH, in independent correlation with disease severity, independently distinguished risks of END and 90-day poor prognosis. Therefore, serum MANF may be a potential prognostic biomarker of ICH.
Collapse
Affiliation(s)
- Cheng-Liang Zhang
- Department of Neurology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, 100 Minjiang Road, Quzhou, Zhejiang Province, 324000, People's Republic of China
| | - Ling-Li Fang
- Department of Clinical Pharmacy, The Second People's Hospital of Yuhang District, 80 Anle Road, Hangzhou, Zhejiang Province, 311121, People's Republic of China
| | - Chuan-Liu Wang
- Department of Neurology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, 100 Minjiang Road, Quzhou, Zhejiang Province, 324000, People's Republic of China
| | - Ping Li
- Department of Respiratory and Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, 100 Minjiang Road, Quzhou, Zhejiang Province, 324000, People's Republic of China
| | - Ming Yang
- Department of Neurology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, 100 Minjiang Road, Quzhou, Zhejiang Province, 324000, People's Republic of China
| | - Jian-Wei Xu
- Department of Clinic, The Quzhou Hospital of TCM, Quzhou TCM Hospital at the Junction of Four Provinces Affiliated to Zhejiang Chinese Medical University, 117 Quhua Road, Quzhou, Zhejiang Province, 324000, People's Republic of China.
| |
Collapse
|
200
|
Teo KC, Fong SM, Leung WCY, Leung IYH, Wong YK, Choi OMY, Yam KK, Lo RCN, Cheung RTF, Ho SL, Tsang ACO, Leung GKK, Chan KH, Lau KK. Location-Specific Hematoma Volume Cutoff and Clinical Outcomes in Intracerebral Hemorrhage. Stroke 2023; 54:1548-1557. [PMID: 37216445 DOI: 10.1161/strokeaha.122.041246] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/17/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Major intracerebral hemorrhage (ICH) trials have largely been unable to demonstrate therapeutic benefit in improving functional outcomes. This may be partly due to the heterogeneity of ICH outcomes based on their location, where a small strategic ICH could be debilitating, thus confounding therapeutic effects. We aimed to determine the ideal hematoma volume cutoff for different ICH locations in predicting ICH outcomes. METHODS We retrospectively analyzed consecutive ICH patients enrolled in the University of Hong Kong prospective stroke registry from January 2011 to December 2018. Patients with premorbid modified Rankin Scale score >2 or who underwent neurosurgical intervention were excluded. ICH volume cutoff, sensitivity, and specificity in predicting respective 6-month neurological outcomes (good [modified Rankin Scale score 0-2], poor [modified Rankin Scale score 4-6], and mortality) for specific ICH locations were determined using receiver operating characteristic curves. Separate multivariate logistic regression models were also conducted for each location-specific volume cutoff to determine whether these cutoffs were independently associated with respective outcomes. RESULTS Among 533 ICHs, the volume cutoff for good outcome according to ICH location was 40.5 mL for lobar, 32.5 mL for putamen/external capsule, 5.5 mL for internal capsule/globus pallidus, 6.5 mL for thalamus, 17 mL for cerebellum, and 3 mL for brainstem. ICH smaller than the cutoff for all supratentorial sites had higher odds of good outcomes (all P<0.05). Volumes exceeding 48 mL for lobar, 41 mL for putamen/external capsule, 6 mL for internal capsule/globus pallidus, 9.5 mL for thalamus, 22 mL for cerebellum, and 7.5 mL for brainstem were at greater risk of poor outcomes (all P<0.05). Mortality risks were significantly higher for volumes that exceeded 89.5 mL for lobar, 42 mL for putamen/external capsule, and 21 mL for internal capsule/globus pallidus (all P<0.001). All receiver operating characteristic models for location-specific cutoffs had good discriminant values (area under the curve >0.8), except in predicting good outcome for cerebellum. CONCLUSIONS ICH outcomes differed with location-specific hematoma size. Location-specific volume cutoff should be considered in patient selection for ICH trials.
Collapse
Affiliation(s)
- Kay-Cheong Teo
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Sze-Man Fong
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - William C Y Leung
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Ian Y H Leung
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Yuen-Kwun Wong
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Olivia M Y Choi
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital (O.M.Y.C., A.C.O.T., G.K.K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Ka-Keung Yam
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Rachel C N Lo
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Raymond T F Cheung
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR (R.T.F.C., K.-H.C., K.-K.L.)
| | - Shu-Leong Ho
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Anderson C O Tsang
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital (O.M.Y.C., A.C.O.T., G.K.K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Gilberto K K Leung
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital (O.M.Y.C., A.C.O.T., G.K.K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Koon-Ho Chan
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR (R.T.F.C., K.-H.C., K.-K.L.)
| | - Kui-Kai Lau
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR (R.T.F.C., K.-H.C., K.-K.L.)
| |
Collapse
|