Pattern of elevation of urine catecholamines in intracerebral haemorrhage

Biochemical Assessment of Pheochromocytoma and Paraganglioma

Pheochromocytoma and paraganglioma (PPGL) require prompt consideration and efficient diagnosis and treatment to minimize associated morbidity and mortality. Once considered, appropriate biochemical testing is key to diagnosis. Advances in understanding catecholamine metabolism have clarified why measurements of the O-methylated catecholamine metabolites rather than the catecholamines themselves are important for effective diagnosis. These metabolites, normetanephrine and metanephrine, produced respectively from norepinephrine and epinephrine, can be measured in plasma or urine, with choice according to available methods or presentation of patients. For patients with signs and symptoms of catecholamine excess, either test will invariably establish the diagnosis, whereas the plasma test provides higher sensitivity than urinary metanephrines for patients screened due to an incidentaloma or genetic predisposition, particularly for small tumors or in patients with an asymptomatic presentation. Additional measurements of plasma methoxytyramine can be important for some tumors, such as paragangliomas, and for surveillance of patients at risk of metastatic disease. Avoidance of false-positive test results is best achieved by plasma measurements with appropriate reference intervals and preanalytical precautions, including sampling blood in the fully supine position. Follow-up of positive results, including optimization of preanalytics for repeat tests or whether to proceed directly to anatomic imaging or confirmatory clonidine tests, depends on the test results, which can also suggest likely size, adrenal vs extra-adrenal location, underlying biology, or even metastatic involvement of a suspected tumor. Modern biochemical testing now makes diagnosis of PPGL relatively simple. Integration of artificial intelligence into the process should make it possible to fine-tune these advances.

Early alterations in heart rate are associated with poor outcome in patients with intracerebral hemorrhage

PURPOSE

Cardiac complications are common after spontaneous intracerebral hemorrhage (ICH). In this study we intended to investigate factors associated with higher alterations in heart rate and their impact on outcome.

METHODS

Eighty-eight ICH patients were included. A simplified approach to calculate heart rate variability (HR_SD) in analogy to systolic blood pressure variability (SBP_SD) with daily standard deviations of HR in the acute (first 24 h) and subacute phase (day1-day7) was used. Using multivariable regression, factors associated with higher HR_SD and the association between higher HR_SD and poor 3-month outcome (modified Rankin Scale > 3) were analyzed. All models were adjusted for age, atrial fibrillation, mechanical ventilation, vasopressor administration, and mean HR.

RESULTS

Patients were 71 (IQR = 60-79) years old and presented with an admission ICH-Score of 2 (IQR = 1-3). In multivariable analysis, intraventricular hemorrhage (adjOR = 8.66, 95%-CI = 1.89-39.60, p = 0.005), a QRS complex >120 ms (adjOR = 19.02; 95%-CI = 2.08-175.05, p = 0.009) and female sex (adjOR = 4.24; 95%-CI = 1.08-16.64, p = 0.038) were associated with higher HR_SD in the acute phase. A higher HR_SD (adjOR = 1.29, 95%-CI = 1.01-1.66, p = 0.045) in the acute but not in the subacute phase (p = 0.764) was associated with poor 3-month outcome.

CONCLUSION

The study suggests that a higher variation in heart rate in the early phase after ICH may discriminate patients with poor outcome.

Acute hypertensive response in patients with intracerebral hemorrhage pathophysiology and treatment

Acute hypertensive response is a common systemic response to occurrence of intracerebral hemorrhage which has gained unique prominence due to high prevalence and association with hematoma expansion and increased mortality. Presumably, the higher systemic blood pressure predisposes to continued intraparenchymal hemorrhage by transmission of higher pressure to the damaged small arteries and may interact with hemostatic and inflammatory pathways. Therefore, intensive reduction of systolic blood pressure has been evaluated in several clinical trials as a strategy to reduce hematoma expansion and subsequent death and disability. These trials have demonstrated either a small magnitude benefit (second intensive blood pressure reduction in acute cerebral hemorrhage trial and efficacy of nitric oxide in stroke trial) or no benefit (antihypertensive treatment of acute cerebral hemorrhage 2 trial) with intensive systolic blood pressure reduction compared with modest or standard blood pressure reduction. The differences may be explained by the variation in intensity of systolic blood pressure reduction between trials. A treatment threshold of systolic blood pressure of ≥180 mm with the target goal of systolic blood pressure reduction to values between 130 and 150 mm Hg within 6 h of symptom onset may be best supported by current evidence.

Role of Interleukin-10 in Acute Brain Injuries

Interleukin-10 (IL-10) is an important anti-inflammatory cytokine expressed in response to brain injury, where it facilitates the resolution of inflammatory cascades, which if prolonged causes secondary brain damage. Here, we comprehensively review the current knowledge regarding the role of IL-10 in modulating outcomes following acute brain injury, including traumatic brain injury (TBI) and the various stroke subtypes. The vascular endothelium is closely tied to the pathophysiology of these neurological disorders and research has demonstrated clear vascular endothelial protective properties for IL-10. In vitro and in vivo models of ischemic stroke have convincingly directly and indirectly shown IL-10-mediated neuroprotection; although clinically, the role of IL-10 in predicting risk and outcomes is less clear. Comparatively, conclusive studies investigating the contribution of IL-10 in subarachnoid hemorrhage are lacking. Weak indirect evidence supporting the protective role of IL-10 in preclinical models of intracerebral hemorrhage exists; however, in the limited number of clinical studies, higher IL-10 levels seen post-ictus have been associated with worse outcomes. Similarly, preclinical TBI models have suggested a neuroprotective role for IL-10; although, controversy exists among the several clinical studies. In summary, while IL-10 is consistently elevated following acute brain injury, the effect of IL-10 appears to be pathology dependent, and preclinical and clinical studies often paradoxically yield opposite results. The pronounced and potent effects of IL-10 in the resolution of inflammation and inconsistency in the literature regarding the contribution of IL-10 in the setting of acute brain injury warrant further rigorously controlled and targeted investigation.

Cardiac troponin and cerebral herniation in acute intracerebral hemorrhage

OBJECTIVES

To explore the association, if any, between the relationship between cardiac troponin and cerebral herniation after intracerebral hemorrhage (ICH).

METHODS

Six hundred and eighty-seven consecutive ICH patients admitted to West China Hospital from May 1, 2014 to September 1, 2015 were retrospectively reviewed. Data on demographics, etiology, laboratory examinations at admission including serum cardiac troponin, computed tomography (CT) scans at admission and follow-up, and clinical outcomes were obtained. Using multiple logistic regression to identify the relationship of troponin and herniation. The association between troponin and hematoma volume was assessed using bivariate correlation and linear regression.

RESULTS

Among 188 (27.4%) patients who underwent the test of serum cardiac troponin at admission, 16 (8.5%) demonstrated cerebral herniation. The median time from symptom onset to CT at admission and follow-up was 4 and 30.25 hr, respectively. In multivariate analysis, elevated troponin was independently associated with cerebral herniation (adjusted odds ratio [OR] 5.19; 95% confidence interval [CI], 1.08-24.93). And those with elevated troponin had larger hematoma volume at follow-up in bivariate correlation (correlation coefficient, .375, p = .003) and linear regression (β, .370, 95% CI, 0.062-0.320, p = .005), higher National Institutes of Health Stroke Scale score (adjusted OR 2.06; 95% CI, 1.06-4.01, p = .033) and lower Glasgow Coma Scale score (adjusted OR 2.34; 95% CI, 1.17-4.68, p = .016) than those without.

CONCLUSIONS

Elevated cardiac troponin was associated with an almost five-fold increased risk of cerebral herniation, but not in-hospital mortality. The possibility of cerebral herniation should be considered when ICH patients with large hematoma volume and elevated troponin.

Primary aldosteronism presenting with an atypical aldosterone-renin ratio in the acute phase of cerebral hemorrhage

The aldosterone-renin ratio (ARR) is considered to be the most reliable and sensitive screening parameter for primary aldosteronism (PA). However, little is known regarding how stroke influences the ARR. We herein present a case of a 35-year-old man who was ultimately found to have PA after diagnostic challenges. The patient showed an atypical ARR in the acute phase of cerebral hemorrhage. We therefore conclude that the ARR may be inappropriately decreased immediately after stroke in patients with PA, presumably due to sympathetic activation and the effects of medications. When diagnosing PA in patients with stroke, we suggest reevaluating the ARR in the stable phase.

Elevated urinary catecholamines and adrenal haemorrhage mimicking phaeochromocytoma

A 51-year-old woman was admitted with left-sided flank pain initially thought to be renal colic. However, a CT urogram was normal. During the course of the admission the pain persisted and she developed severe sustained hypertension. A repeat CT scan of the abdomen revealed a 5×3 cm left adrenal abnormality consistent with haemorrhage, not seen on the original scan. Further assessment revealed elevated urine catecholamines and a short synacthen test showed a suboptimal cortisol response. The diagnosis was initially considered as a phaeochromocytoma, she received phenoxybenzamine with good resolution of hypertension and was referred for surgical opinion. However, serial urinary catecholamine concentrations returned to within the normal range and the diagnosis was revised to adrenal infarction and haemorrhage due to antiphospholipid syndrome. This case illustrates the importance of recognising adrenal infarction as a potential cause of 'pseudophaeochromocytoma'.

Management of acute intracranial and intraventricular hemorrhage

OBJECTIVE

Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage.

DATA SOURCES

PubMed search and review of the relevant medical literature.

SUMMARY

The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery.

CONCLUSIONS

Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.

Asymmetrical modulation of interleukin-10 release in patients with intracerebral hemorrhage

The brain modulates the immune system in an asymmetrical way. Intracerebral hemorrhage triggers IL-6 and IL-10 release into blood. We measured (using ELISA method) serum IL-6 and IL-10 in acute phase of intracerebral hemorrhage in 11 patients with right hemisphere's hematoma and 15 patients with left hemisphere's hematoma. These patients did not differ significantly with respect to their age, size, and location of hematoma. IL-6 level was comparable in patients with left hematoma and patients with right hematoma, but patients with left hematoma had significantly higher level of IL-10 than patients with right hematoma. These results suggest that left and right hemisphere could modulate IL-10 release in different way.

Early alterations in cerebral hemodynamics, brain metabolism, and blood-brain barrier permeability in experimental intracerebral hemorrhage

OBJECT

The authors sought to ascertain the nature of the hemodynamic and metabolic derangement underlying acute pathophysiological events that occur after intracerebral hemorrhage (ICH).

METHODS

Cerebral perfusion pressure (CPP), flow velocity (FV) of the middle cerebral artery, and the arteriovenous contents of oxygen and lactate were investigated in 24 dogs subjected to sham operations (Group A, four animals) or intracerebral injections of 3 ml (Group B, 11 animals) or 5 ml (Group C, nine animals) autologous arterial blood. Twelve additional dogs received intravenous injections of 2% Evans blue or trypan blue dye to evaluate blood-brain barrier (BBB) changes. Within 1 hour, animals with ICH exhibited a rise in FV associated with significant reductions (p<0.05) in CPP and the arteriovenous content difference (AVDO2). In Group C animals significant increases in lactate concentration were found in arterial and superior sagittal sinus (SSS) samples compared with those in the other two groups (p<0.05). Additionally, perihematomal dye extravasation was observed in animals subjected to ICH and trypan blue dye injections, with profound and mild leakages in Group C and Group B animals, respectively, but not in Group A and Evans blue dye-injected animals. During the subsequent 4 hours, the FV and AVDO2 returned to normal in Group B animals, indicating a balanced cerebral metabolic rate for oxygen (CMRO2) compared with a deranged CMRO2 in Group C animals due to their lowered FV and AVDO2. However, no coupling increase in brain lactate clearance in Group C animals accounted for either the early lactate elevation in SSS or the decrease in CMRO2.

CONCLUSIONS

Profound reductions in CPP and brain oxygenation after ICH may rapidly exhaust hemodynamic compensation and, thus, impede cerebral homeostasis; however, these reductions only modestly enhance anaerobic glycolysis. Furthermore, the data suggest that a selective increase in permeability, rather than anatomical disruption, of the BBB is involved in the acute pathophysiological events that occur after ICH, which may provide a possible gateway for systemic arterial lactate entering the SSS.