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Cheng R, Su K, Zhou X, Jiang X, Luo P, Zhang W, Qian X, Lai L. Does dual antiplatelet therapy increase the risk of haematoma enlargement in the acute stage? A retrospective study of the use of stent-assisted coiling versus coiling alone or balloon-assisted coiling for the treatment of ruptured intracranial aneurysms combined with intracranial haematoma. Neurosurg Rev 2023; 46:133. [PMID: 37266675 DOI: 10.1007/s10143-023-02036-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
This study aims to identify the efficacy and safety of stent-assisted coiling (SAC) treatment of ruptured intracranial aneurysms (RIAs) combined with intracranial haematoma (ICH) compared to coiling alone or balloon-assisted coiling (non-SAC). A retrospective analysis of 54 consecutive patients receiving endovascular therapy from 2014 to 2020 was performed. The data collected included baseline characteristics, angiographic results, perioperative complications, immediate aneurysm occlusion, clinical outcomes, follow-up at discharge and after 6 months, hospitalisation costs, and inpatient length of stay. Patients were categorised into the SAC group and the non-SAC group. Univariate and multivariate logistic regression analyses were used to identify risk factors related to clinical outcomes. Of the 54 patients harbouring RIAs with ICH, 22 (40.74%) and 32 (59.26%) patients were subject to SAC and non-SAC treatments, respectively. Postoperative rebleeding (1 [4.5%] and 3 [9.3%] in SAC and non-SAC groups, respectively, p > 0.05) and Hunt-Hess grade (IV-V) lesions (13.6% vs. 40.6%, p = 0.067) did not differ between the two groups. In total, 10 (45.5%) patients treated with SAC received a Fisher scale score of 0-3 compared with 6 (18.8%) patients treated with non-SAC methods (p = 0.035). Compared with the non-SAC group (7/21.9%), the rate of wide-necked aneurysms was increased in the SAC group (11/50%) (p = 0.031). No differences in poor outcomes (mRS > 2) were noted between the SAC and non-SAC groups (p > 0.05). Multivariate analysis revealed that ischaemic complication events (p = 0.016) represent the only independent risk factor for adverse outcomes, and a trend towards unfavourable clinical outcomes was noted for patients who smoke (p = 0.087). SAC is a safe and efficient treatment for RIAs combined with ICH when dual antiplatelet therapy (DAPT) is used in the perioperative period. In addition, SAC should be preferentially used in wide-neck RIAs. Ischaemic complications are a risk factor for poor clinical outcomes. Given the small sample size and retrospective bias of this study, these findings should be further verified in a study with a larger sample size or a randomised controlled trial (RCT).
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Affiliation(s)
- Ruoxi Cheng
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Kangtai Su
- The First Clinical Medical School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Xiaobing Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xin Jiang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Peiyi Luo
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Weiyun Zhang
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Xiao Qian
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Lingfeng Lai
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.
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Wang S, Chen F, Zhang M, Zhao X, Wen L, Wu W, Wu S, Li Z, Tian J, Liu T. Predicting prognosis of primary pontine hemorrhage using CT image and deep learning. Neuroimage Clin 2022; 36:103257. [PMID: 36510407 PMCID: PMC9668666 DOI: 10.1016/j.nicl.2022.103257] [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: 05/30/2022] [Revised: 10/22/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
Prognosis of primary pontine hemorrhage (PPH) is important for treatment planning and patient management. However, only few clinical factors were reported to have prognostic value to PPH. Here, we propose a deep learning (DL) model that mines high-dimensional prognostic information from computed tomography (CT) images and combines clinical factors for predicting individualized prognosis of PPH. We proposed a multi-task DL model to learn high-dimensional CT features of hematoma and perihematomal areas for predicting the risk of 30-day mortality, 90-day mortality and 90-day functional outcome of PPH simultaneously. We further explored the combination of the DL model and clinical factors by building a combined model. All the models were trained in a training cohort (n = 219) and tested in an independent testing cohort (n = 35). The DL model achieved area under the curve (AUC) of 0.886, 0.886, and 0.759 in predicting 30-day mortality, 90-day mortality and 90-day functional outcome of PPH in the independent testing cohort, which improved over the previously reported new PPH score and the clinical model. When combining the DL model and clinical factors, the combined model achieved improved performance (AUC = 0.920, 0.941, and 0.894), indicating that DL model mines CT information that complements clinical factors. Through DL visualization technique, we found that the internal structure of hematoma and its expansion to perihematomal regions are important for predicting the prognosis of PPH. This DL model provides an easy-to-use way for predicting individualized prognosis of PPH by mining high-dimensional information from CT images, and showed improvement over clinical factors and present methods.
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Affiliation(s)
- Shuo Wang
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University, Beijing, China,Key Laboratory of Big Data-Based Precision Medicine, Ministry of Industry and Information Technology, People’s Republic of China, Beijing, China
| | - Feng Chen
- Department of Radiology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Haikou, China,Corresponding authors at: Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University (J. Tian); Department of Neurology, Hainan General Hospital (Hannan Affiliated Hospital of Hainan Medical University) (T. Liu); and Department of Radiology, Hainan General Hospital (Hannan Affiliated Hospital of Hainan Medical University) (F. Chen).
| | - Mingyu Zhang
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University, Beijing, China,Key Laboratory of Big Data-Based Precision Medicine, Ministry of Industry and Information Technology, People’s Republic of China, Beijing, China
| | - Xiaolin Zhao
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Linghua Wen
- Department of Radiology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Haikou, China,Department of Radiology, Yueyang Central Hospital, Yueyang, China
| | - Wenyuan Wu
- Department of Radiology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Haikou, China
| | - Shina Wu
- Department of Neurology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Haikou, China
| | - Zhe Li
- School of Cyberspace Science and Technology, University of Science and Technology of China, Hefei, China
| | - Jie Tian
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University, Beijing, China,Key Laboratory of Big Data-Based Precision Medicine, Ministry of Industry and Information Technology, People’s Republic of China, Beijing, China,Corresponding authors at: Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University (J. Tian); Department of Neurology, Hainan General Hospital (Hannan Affiliated Hospital of Hainan Medical University) (T. Liu); and Department of Radiology, Hainan General Hospital (Hannan Affiliated Hospital of Hainan Medical University) (F. Chen).
| | - Tao Liu
- Department of Neurology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Haikou, China,Corresponding authors at: Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University (J. Tian); Department of Neurology, Hainan General Hospital (Hannan Affiliated Hospital of Hainan Medical University) (T. Liu); and Department of Radiology, Hainan General Hospital (Hannan Affiliated Hospital of Hainan Medical University) (F. Chen).
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TIPE2 attenuates neuroinflammation and brain injury through Bcl-2/Bax/cleaved caspase-3 apoptotic pathways after intracerebral hemorrhage in mice. Brain Res Bull 2022; 191:1-8. [PMID: 36179971 DOI: 10.1016/j.brainresbull.2022.09.020] [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: 07/08/2021] [Revised: 08/17/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a serious disease with high mortality and morbidity, and effective treatment is limited. A large amount of evidence suggests that the inflammatory response contributes to secondary brain damage following ICH. TIPE2 is an essential negative regulator of both innate and adaptive immunity, and depletion of TIPE2 causes inflammatory disease. However, the possible role of TIPE2 following ICH has not been reported. METHODS In this study, we investigated TIPE2 levels and inflammation in microglia treated with erythrocyte lysate in vitro. In addition, we analyzed the role of Bcl-2/Bax/cleaved caspase-3 apoptotic pathways in ICH mice. Furthermore, we observed proinflammatory cytokine production, BBB disruption, cerebral water content and neurological damage in ICH mice. RESULTS We found that TIPE2 levels were significantly decreased in erythrocyte lysate-treated microglia compared to control microglia.Upregulation of TIPE2 decreased microglia activation and cytokine production and accelerated brain damage in ICH mice. Furthermore, upregulation of TIPE2 decreased the higher ratio of Blc-2/Bax and increased cleaved caspase-3 levels in ICH mice. In addition, upregulation of TIPE2 attenuated proinflammatory cytokine production, BBB disruption, and severe brain inflammation after ICH. CONCLUSION These results demonstrated that TIPE2 was negatively correlated with the pathogenesis of ICH, which prevented brain injury and attenuated deleterious inflammatory responses following ICH. TIPE2 might serve as a novel target for ICH therapy.
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Goeldlin MB, Siepen BM, Mueller M, Volbers B, Z'Graggen W, Bervini D, Raabe A, Sprigg N, Fischer U, Seiffge DJ. Intracerebral haemorrhage volume, haematoma expansion and 3-month outcomes in patients on antiplatelets. A systematic review and meta-analysis. Eur Stroke J 2022; 6:333-342. [PMID: 35342809 PMCID: PMC8948504 DOI: 10.1177/23969873211061975] [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: 04/27/2021] [Accepted: 07/19/2021] [Indexed: 11/16/2022] Open
Abstract
Aims We assessed the association of prior antiplatelet therapy (APT) at onset of intracerebral haemorrhage (ICH) with haematoma characteristics and outcome. Methods We performed a systematic review and meta-analysis of studies comparing ICH outcomes of patients on APT (APT-ICH) with patients not taking APT (non-APT-ICH). Primary outcomes were haematoma volume (mean difference and 95% CI), haematoma expansion (HE), in-hospital 3-month mortality rates and good functional outcome (modified Rankin Scale score 0-2). We provide odds ratios (ORs) from random effects models and subgroup analyses for haematoma expansion and short-term mortality rates. Results We included 23 of 1551 studies on 30,949 patients with APT-ICH and 62,018 with non-APT-ICH. Patients on APT were older (Δmean 6.27 years, 95% CI 5.44-7.10), had larger haematoma volume (Δmean 5.74 mL, 95% CI 1.93-9.54), higher short-term mortality rates (OR 1.44, 95% CI 1.14-1.82), 3-month mortality rates (OR 1.58, 95% CI 1.14-2.19) and lower probability of good functional outcome (OR 0.61, 95% CI 0.49-0.77). While there was no difference in HE in the overall analysis (OR 1.32, 95% CI 0.85-2.06), HE occurred more frequently when assessed within 24 h (OR 2.58, 95% CI 1.18-5.67). We found insufficient data for comparison of single versus dual APT-ICH. Heterogeneity was substantial amongst studies. Discussion APT is associated with larger baseline haematoma volume, early (<24 h) haematoma expansion, mortality rates and morbidity in patients with ICH. Data on differences in single and dual APT-ICH are scarce and warrant further investigation. New treatment options for APT-ICH are urgently needed.
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Affiliation(s)
- Martina B Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Bernhard M Siepen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Madlaine Mueller
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Bastian Volbers
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Werner Z'Graggen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - David Bervini
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Nikola Sprigg
- Stroke, Division of Clinical Neuroscience, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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5
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Aspirin does not affect hematoma growth in severe spontaneous intracranial hematoma. Neurosurg Rev 2021; 45:1491-1499. [PMID: 34643829 DOI: 10.1007/s10143-021-01675-2] [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: 05/10/2021] [Revised: 08/20/2021] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Abstract
Hematoma growth (HG) affects the prognosis of patients with spontaneous intracranial hematoma (ICH), but there is still a lack of evidence about the effects of aspirin (acetylsalicylic acid, ASA) on HG in patients with severe ICH. This study retrospectively analyzed patients with severe ICH who met the inclusion and exclusion criteria in Beijing Tiantan Hospital, Capital Medical University, between January 1, 2015, and July 31, 2019. Severe ICH patients were divided into ASA group and nASA groups according to ASA usage, and the incidence of HG between the groups was compared. Univariate analysis was performed by the Mann-Whitney U test, chi-square test, or Fisher exact test. Multivariate logistic regression analysis was used to analyze the impact of ASA on HG and to screen for risk factors of HG. In total, 221 patients with severe ICH were consecutively enrolled in this study. There were 72 (32.6%) patients in the ASA group and 149 patients in the nASA group. Although the incidence of HG in the nASA group was higher than that in the ASA group (34.9% VS 22.2%, p = 0.056), ASA did not significantly affect the occurrence of HG (p = 0.285) after adjusting for initial hematoma volume, high blood pressure at admission, coronary heart disease, and GCS at admission. In addition, we found that high blood pressure at admission was a risk factor for HG. Prior ASA does not increase the incidence of HG in severe ICH patients, and high blood pressure at admission is a risk factor for HG.
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Yu N, Yu H, Li H, Ma N, Hu C, Wang J. A Robust Deep Learning Segmentation Method for Hematoma Volumetric Detection in Intracerebral Hemorrhage. Stroke 2021; 53:167-176. [PMID: 34601899 DOI: 10.1161/strokeaha.120.032243] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Hematoma volume (HV) is a significant diagnosis for determining the clinical stage and therapeutic approach for intracerebral hemorrhage (ICH). The aim of this study is to develop a robust deep learning segmentation method for the fast and accurate HV analysis using computed tomography. METHODS A novel dimension reduction UNet (DR-UNet) model was developed for computed tomography image segmentation and HV measurement. Two data sets, 512 ICH patients with 12 568 computed tomography slices in the retrospective data set and 50 ICH patients with 1257 slices in the prospective data set, were used for network training, validation, and internal and external testing. Moreover, 13 irregular hematoma cases, 11 subdural and epidural hematoma cases, and 50 different HV cases into 3 groups (<30, 30-60, and >60 mL) were selected to further evaluate the robustness of DR-UNet. The image segmentation performance of DR-UNet was compared with those of UNet, the fuzzy clustering method, and the active contour method. The HV measurement performance was compared using DR-UNet, UNet, and the Coniglobus formula method. RESULTS Using DR-UNet, the segmentation model achieved a performance similar to that of expert clinicians in 2 independent test data sets containing internal testing data (Dice of 0.861±0.139) and external testing data (Dice of 0.874±0.130). The HV measurement derived from DR-UNet was strongly correlated with that from manual segmentation (R2=0.9979; P<0.0001). In the irregularly shaped hematoma group and the subdural and epidural hematoma group, DR-UNet was more robust than UNet in both hematoma segmentation and HV measurement. There is no statistical significance in segmentation accuracy among 3 different HV groups. CONCLUSIONS DR-UNet can segment hematomas from the computed tomography scans of ICH patients and quantify the HV with better accuracy and greater efficiency than the main existing methods and with similar performance to expert clinicians. Due to robust performance and stable segmentation on different ICHs, DR-UNet could facilitate the development of deep learning systems for a variety of clinical applications.
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Affiliation(s)
- Nannan Yu
- Department of Artificial Intelligence, School of Electrical Engineering and Automation, Jiangsu Normal University, Xuzhou, China (N.Y., H.Y.)
| | - He Yu
- Department of Artificial Intelligence, School of Electrical Engineering and Automation, Jiangsu Normal University, Xuzhou, China (N.Y., H.Y.)
| | - Haonan Li
- Department of Biotechnology, College of Basic Medical Sciences, Dalian Medical University, China (H.L., J.W.)
| | - Nannan Ma
- Radiology Department, Xuzhou Central Hospital, China (N.M., C.H.)
| | - Chunai Hu
- Radiology Department, Xuzhou Central Hospital, China (N.M., C.H.)
| | - Jia Wang
- Department of Biotechnology, College of Basic Medical Sciences, Dalian Medical University, China (H.L., J.W.)
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7
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Wu Y, Zhang D, Chen H, Liu B, Zhou C. Effects of Prior Antiplatelet Therapy on Mortality, Functional Outcome, and Hematoma Expansion in Intracerebral Hemorrhage: An Updated Systematic Review and Meta-Analysis of Cohort Studies. Front Neurol 2021; 12:691357. [PMID: 34497575 PMCID: PMC8419415 DOI: 10.3389/fneur.2021.691357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/25/2021] [Indexed: 02/05/2023] Open
Abstract
Background and Objective: Antiplatelet therapy (APT) is widely used and believed to be associated with increased poor prognosis by promoting bleeding in patients with intracerebral hemorrhage (ICH). We performed a systematic review and meta-analysis to determine whether prior APT is associated with mortality, functional outcome, and hematoma expansion in ICH patients. Methods: The PubMed, Embase, and Web of Science databases were searched for relevant published studies up to December 11, 2020. Univariate and multivariable adjusted odds ratios (ORs) were pooled using a random effects model. Cochran's chi-squared test (Cochran's Q), the I 2 statistic, and meta-regression analysis were used to evaluate the heterogeneity. Meta-regression models were developed to explore sources of heterogeneity. Funnel plots were used to detect publication bias. A trim-and-fill method was performed to identify possible asymmetry and assess the robustness of the conclusions. Results: Thirty-one studies fulfilled the inclusion criteria and exhibited a moderate risk of bias. Prior APT users with intracerebral hemorrhage (ICH) had a slightly increased mortality in both univariate analyses [odds ratio (OR) 1.39, 95% CI 1.24-1.56] and multivariable adjusted analyses (OR 1.41, 95% CI 1.21-1.64). The meta-regression indicated that for each additional day of assessment time, the adjusted OR for the mortality of APT patients decreased by 0.0089 (95% CI: -0.0164 to -0.0015; P = 0.0192) compared to that of non-APT patients. However, prior APT had no effects on poor function outcome (pooled univariate OR: 0.99, 95% CI 0.59-1.66; pooled multivariable adjusted OR: 0.93, 95% CI 0.87-1.07) or hematoma growth (pooled univariate OR: 1.23, 95% CI 0.40-3.74, pooled multivariable adjusted OR: 0.94, 95% CI 0.24-3.60). Conclusions: Prior APT was not associated with hematoma expansion or functional outcomes, but there was modestly increased mortality in prior APT patients. Higher mortality of prior APT patients was related to the strong influence of prior APT use on early mortality. Systematic Review Registration:PROSPERO Identifier [CRD42020215243].
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Affiliation(s)
- Yujie Wu
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Donghang Zhang
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Hongyang Chen
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Bin Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Cheng Zhou
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
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Liu D, Gu H, Pu Y, Liu J, Yang K, Duan W, Liu X, Nie X, Zhang Z, Wang C, Zhao X, Wang Y, Li Z, Liu L. Prior Antithrombotic Therapy is Associated with Increased Risk of Death in Patients with Intracerebral Hemorrhage: Findings from the Chinese Stroke Center Alliance (CSCA) Study. Aging Dis 2021; 12:1263-1271. [PMID: 34341707 PMCID: PMC8279531 DOI: 10.14336/ad.2020.1205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/05/2020] [Indexed: 01/01/2023] Open
Abstract
The association of preceding antithrombotic therapy with outcomes of patients with intracerebral hemorrhage (ICH) has not been well clarified. We investigated the characteristics and associations of prior antithrombotic therapy (oral anticoagulants, antiplatelet therapy or both) in outcomes of in-hospital patients with ICH. Data were derived from the Chinese Stroke Center Alliance (CSCA) database. Enrolled patients were categorized by the different types of preceding antithrombotic therapy: antiplatelet therapy (APT), oral coagulants (OAs), both OAs and APT use and no-antithrombotic therapy (no-ATT). Among 85705 patients enrolled, 4969 (5.8%), 720 (0.8%), 905 (1.1%) and 79111 (92.3%) patients were on APT, OAs, both OAs and APT, and non-ATT respectively prior to their admission. Crude in-hospital death was 149(3.0%), 41(5.7%), 46(5.1%) and 1781(2.3%) in APT, OAs, both OAs and APT, and non-ATT groups, respectively (P<0.0001). Multivariate analysis revealed that patients in prior OAs (adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.18-3.21; P=0.0091) and both OAs and APT groups (aOR 1.92, 95% CI 1.17-3.15, P=0.0094) were associated with an increased risk of in-hospital mortality compared with the non-ATT group, but not in those who were on APT (aOR 1.12, 95% 0.93-1.36, P=0.2372). In the subgroup analysis, a stronger association between prior OAs and in-hospital death was found among patients who were older ≥ 65 years (P for interaction is 0.0382). In this nationwide prospective study, prior OAs and concomitant use of OAs and APT but not prior ATP were associated with increased odds of in-hospital mortality compared with ICH patients who were on no-ATT.
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Affiliation(s)
- Dacheng Liu
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongqiu Gu
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuehua Pu
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingyi Liu
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kaixuan Yang
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wanying Duan
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xin Liu
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ximing Nie
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhe Zhang
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chunjuan Wang
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2China National Clinical Research Center for Neurological Diseases, Beijing, China
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Law ZK, Desborough M, Roberts I, Al-Shahi Salman R, England TJ, Werring DJ, Robinson T, Krishnan K, Dineen R, Laska AC, Peters N, Egea-Guerrero JJ, Karlinski M, Christensen H, Roffe C, Bereczki D, Ozturk S, Thanabalan J, Collins R, Beridze M, Bath PM, Sprigg N. Outcomes in Antiplatelet-Associated Intracerebral Hemorrhage in the TICH-2 Randomized Controlled Trial. J Am Heart Assoc 2021; 10:e019130. [PMID: 33586453 PMCID: PMC8174262 DOI: 10.1161/jaha.120.019130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Antiplatelet therapy increases the risk of hematoma expansion in intracerebral hemorrhage (ICH) while the effect on functional outcome is uncertain. Methods and Results This is an exploratory analysis of the TICH‐2 (Tranexamic Acid in Intracerebral Hemorrhage‐2) double‐blind, randomized, placebo‐controlled trial, which studied the efficacy of tranexamic acid in patients with spontaneous ICH within 8 hours of onset. Multivariable logistic regression and ordinal regression were performed to explore the relationship between pre‐ICH antiplatelet therapy, and 24‐hour hematoma expansion and day 90 modified Rankin Scale score, as well as the effect of tranexamic acid. Of 2325 patients, 611 (26.3%) had pre‐ICH antiplatelet therapy. They were older (mean age, 75.7 versus 66.5 years), more likely to have ischemic heart disease (25.4% versus 2.7%), ischemic stroke (36.2% versus 6.3%), intraventricular hemorrhage (40.2% versus 27.5%), and larger baseline hematoma volume (mean, 28.1 versus 22.6 mL) than the no‐antiplatelet group. Pre‐ICH antiplatelet therapy was associated with a significantly increased risk of hematoma expansion (adjusted odds ratio [OR], 1.28; 95% CI, 1.01–1.63), a shift toward unfavorable outcome in modified Rankin Scale (adjusted common OR, 1.58; 95% CI, 1.32–1.91) and a higher risk of death at day 90 (adjusted OR, 1.63; 95% CI, 1.25–2.11). Tranexamic acid reduced the risk of hematoma expansion in the overall patients with ICH (adjusted OR, 0.76; 95% CI, 0.62–0.93) and antiplatelet subgroup (adjusted OR, 0.61; 95% CI, 0.41–0.91) with no significant interaction between pre‐ICH antiplatelet therapy and tranexamic acid (P interaction=0.248). Conclusions Antiplatelet therapy is independently associated with hematoma expansion and unfavorable functional outcome. Tranexamic acid reduced hematoma expansion regardless of prior antiplatelet therapy use. Registration URL: https://www.isrctn.com; Unique identifier: ISRCTN93732214.
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Affiliation(s)
- Zhe Kang Law
- Stroke Trials Unit Division of Clinical Neuroscience University of Nottingham United Kingdom.,Department of Medicine National University of Malaysia Kuala Lumpur Malaysia
| | - Michael Desborough
- Haemophilia and Thrombosis Centre Guy's and St Thomas' NHS Foundation Trust London United Kingdom
| | - Ian Roberts
- Clinical Trials Unit London School of Hygiene & Tropical Medicine London United Kingdom
| | | | - Timothy J England
- Vascular Medicine Division of Medical Sciences & GEM Royal Derby Hospital CentreUniversity of Nottingham United Kingdom
| | - David J Werring
- Stroke Research Centre UCL Queen Square Institute of Neurology London United Kingdom
| | - Thompson Robinson
- Department of Cardiovascular Sciences and National Institute for Health Research Biomedical Research Centre University of Leicester United Kingdom
| | - Kailash Krishnan
- Nottingham University Hospitals NHS Trust Nottingham United Kingdom
| | - Robert Dineen
- Radiological Sciences University of Nottingham United Kingdom.,National Institute for Health Research Nottingham Biomedical Research Centre Nottingham United Kingdom
| | - Ann Charlotte Laska
- Department of Clinical Sciences Karolinska InstitutetDanderyd Hospital Sweden
| | - Nils Peters
- Neurology and Stroke Center Klinik Hirslanden Zürich Switzerland.,Neurology and Neurorehabilitation Unit University Center for Medicine of Aging Felix Platter-Hospital Basel Switzerland.,Department of Neurology and Stroke Center University Hospital Basel and University of Basel Switzerland
| | | | | | - Hanne Christensen
- Department of Neurology Bispebjerg Hospital and University of Copenhagen Denmark
| | - Christine Roffe
- Stroke Research Faculty of Medicine and Health Sciences Keele University Stoke-on-Trent United Kingdom
| | - Daniel Bereczki
- Department of Neurology Semmelweis University Budapest Hungary
| | - Serefnur Ozturk
- Department of Neurology Selcuk University Faculty of Medicine Konya Turkey
| | - Jegan Thanabalan
- Division of Neurosurgery Department of Surgery National University of Malaysia Kuala Lumpur Malaysia
| | - Rónán Collins
- Tallaght University Hospital Dublin Republic of Ireland
| | - Maia Beridze
- The First University Clinic of Tbilisi State Medical University Tbilisi Georgia
| | - Philip M Bath
- Stroke Trials Unit Division of Clinical Neuroscience University of Nottingham United Kingdom.,Nottingham University Hospitals NHS Trust Nottingham United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit Division of Clinical Neuroscience University of Nottingham United Kingdom.,Nottingham University Hospitals NHS Trust Nottingham United Kingdom
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10
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Abstract
Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.
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Affiliation(s)
- Arturo Montaño
- Departments of Neurology and Neurosurgery, University of Colorado, Aurora, CO, United States
| | - Daniel F Hanley
- Departments of Neurology and Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - J Claude Hemphill
- Departments of Neurology and Neurosurgery, University of California San Francisco, San Francisco, CA, United States.
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11
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Zhai Q, Sun T, Sun C, Yan L, Wang X, Wang Y, Sun J, Zhao Y. High plasma levels of trimethylamine N-oxide are associated with poor outcome in intracerebral hemorrhage patients. Neurol Sci 2020; 42:1009-1016. [PMID: 32705490 DOI: 10.1007/s10072-020-04618-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/19/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS As a gut microbiota-dependent metabolite, trimethylamine N-oxide (TMAO) has been implicated in cardiovascular diseases. We aimed to investigate the relationship between the clinical outcomes and plasma TMAO concentrations in patients with acute intracerebral hemorrhage. METHODS From January 2019 to October 2019, we prospectively enrolled intracerebral hemorrhage patients diagnosed within 6 h of symptoms onset. Plasma TMAO levels was measured for all patients within 24 h after admission. The primary outcome was functional outcome at 3 months. Patients were dichotomized as good (modified Rankin scale 0-3) and poor (modified Rankin scale 4-6). Secondary outcome included early neurological deterioration (END) and hematoma enlargement (HE). RESULTS There were 307 patients (57.7% male) with a mean age of 66.8 years included in the study. The median TMAO levels was 3.2 μmol/L. END, HE, and 3-month poor outcome were detected in 59 (19.2%), 54 (17.6%), and 139 (45.3%) patients, respectively. After adjusting for potential confounders, the odds ratio for the highest quartile of TMAO compared with the lowest quartile was 3.65 (95% confidence interval, 1.43-9.30) for 3-month poor outcome. Furthermore, multiple-adjusted spline regression model showed a linear association between TMAO levels and poor outcome at 3 months (P = 0.013 for linearity). Similar significant findings were observed when functional outcome was analyzed by continuous mRS score. No association was found between TMAO levels and END and HE. CONCLUSIONS The present study demonstrated that increased TMAO levels were independently correlated with 3-month function outcome after intracerebral hemorrhage.
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Affiliation(s)
- Qijin Zhai
- Department of Neurology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, 223002, Jiangsu, China
| | - Taipeng Sun
- Department of Medical Psychology, The Third People's Hospital of Huaian, Huai'an, 223002, Jiangsu, China
| | - Chuanfu Sun
- Department of ICU in Emergency Center, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, 223002, Jiangsu, China
| | - Luxia Yan
- Department of Neurology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, 223002, Jiangsu, China
| | - Xiang Wang
- Department of Neurology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, 223002, Jiangsu, China
| | - Yuqian Wang
- Department of Neurology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, 223002, Jiangsu, China
| | - Junshan Sun
- Department of Neurology, Lianshui people's Hospital Affiliated to Kangda College of Nanjing Medical University, Lianshui, 223400, Jiangsu, China.
| | - Ying Zhao
- Department of Neurology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, 223002, Jiangsu, China.
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12
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The Role of Sartans in the Treatment of Stroke and Subarachnoid Hemorrhage: A Narrative Review of Preclinical and Clinical Studies. Brain Sci 2020; 10:brainsci10030153. [PMID: 32156050 PMCID: PMC7139942 DOI: 10.3390/brainsci10030153] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 12/30/2022] Open
Abstract
Background: Delayed cerebral vasospasm (DCVS) due to aneurysmal subarachnoid hemorrhage (aSAH) and its sequela, delayed cerebral ischemia (DCI), are associated with poor functional outcome. Endothelin-1 (ET-1) is known to play a major role in mediating cerebral vasoconstriction. Angiotensin-II-type-1-receptor antagonists such as Sartans may have a beneficial effect after aSAH by reducing DCVS due to crosstalk with the endothelin system. In this review, we discuss the role of Sartans in the treatment of stroke and their potential impact in aSAH. Methods: We conducted a literature research of the MEDLINE PubMed database in accordance with PRISMA criteria on articles published between 1980 to 2019 reviewing: "Sartans AND ischemic stroke". Of 227 studies, 64 preclinical and 19 clinical trials fulfilled the eligibility criteria. Results: There was a positive effect of Sartans on ischemic stroke in both preclinical and clinical settings (attenuating ischemic brain damage, reducing cerebral inflammation and infarct size, increasing cerebral blood flow). In addition, Sartans reduced DCVS after aSAH in animal models by diminishing the effect of ET-1 mediated vasoconstriction (including cerebral inflammation and cerebral epileptogenic activity reduction, cerebral blood flow autoregulation restoration as well as pressure-dependent cerebral vasoconstriction). Conclusion: Thus, Sartans might play a key role in the treatment of patients with aSAH.
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13
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 676] [Impact Index Per Article: 135.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
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