Surgical management of spontaneous intracerebral hemorrhage: insights from randomized controlled trials

Safety of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage in the Registry of Intracerebral Hemorrhage Treated by Endoscopic Hematoma Evacuation in Japan

OBJECTIVE

The long history of treatment for intracerebral hemorrhage (ICH) includes the development of surgical procedures. However, few studies have demonstrated that surgery improved the functional outcome. The present study used the prospective Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation of the outcomes in endoscopic surgery, which is widely followed in Japan, to try to establish clinical evidence.

METHODS

The Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation is a multicenter, prospective registry in Japan, and included 143 surgical cases treated by certified neurosurgeons. The etiology and the location of ICH was evaluated by univariate and multivariate analyses as follows: deep, surface, intraventricular hemorrhage, cerebellum, and surgical outcome.

RESULTS

Hematoma location was deep in 44.8% of cases, intraventricular hemorrhage in 19.6%, surface in 21.7%, and cerebellum in 14.0%. Most cases were treated in the ultraearly stage within 8 hours. Mean hematoma evacuation rate was 83.6% and median residual hematoma volume was 3.0 ml. Duration of surgery was median 78 minutes. Rebleeding as a complication was observed in 6.7%, but only 2.9% were symptomatic. 2 cases required reoperation. Favorable outcome at 6 months was achieved in 35.8% of cases, with a mortality rate of 5.6%.

CONCLUSIONS

Endoscopic surgery for spontaneous ICH is safe and comparable to conventional surgery. The time required for the procedure was significantly reduced, demonstrating the minimally invasive character of the surgical burden. However, this study did not establish whether minimally invasive surgery is superior to conservative treatment. Future randomized controlled trials should clarify the effectiveness of the treatment.

The clinical potential of radiomics to predict hematoma expansion in spontaneous intracerebral hemorrhage: a narrative review

Spontaneous intracerebral hemorrhage (sICH) is associated with significant morbidity and mortality, with subsequent hematoma expansion (HE) linked to worse neurologic outcomes. Accurate, real-time predictions of the risk of HE could enable tailoring management-including blood pressure control or surgery-based on individual patient risk. Although multiple radiographic markers of HE have been proposed based on standard imaging, their clinical utility remains limited by a reliance on subjective interpretation of often ambiguous findings and a poor overall predictive power. Radiomics refers to the quantitative analysis of medical images that can be combined with machine-learning algorithms to identify predictive features for a chosen clinical outcome with a granularity beyond human limitations. Emerging data have supported the potential utility of radiomics in the prediction of HE after sICH. In this review, we discuss the current clinical management of sICH, the impact of HE and standard imaging predictors, and finally, the current data and potential future role of radiomics in HE prediction and management of patients with sICH.

The Usefulness of the 3.1-mm-diameter 4K Rigid Endoscope for Intracerebral Hematoma Evacuation

The indication for surgical intervention in spontaneous intracerebral hemorrhage remains controversial. Although many clinical trials have failed to demonstrate its efficacy over medical treatment, less invasive endoscopic treatment is expected to demonstrate its superiority. A novel endoscopic system for hematoma removal consisting of a 3.1-mm-diameter 4K high-resolution rigid endoscope was used.The system was used in eight cases of spontaneous intracerebral hemorrhage. It provided improved maneuverability of the surgical instrument while maintaining satisfactory image quality. The surgical goal was achieved in all cases without any complications, including perioperative rebleeding.Endoscopic hematoma removal using the 3.1 mm high-resolution endoscope is an alternative minimally invasive approach to spontaneous intracerebral hemorrhage with improved reliability.

Remote ischemic conditioning after stroke: Research progress in clinical study

BACKGROUND AND PURPOSE

Stroke is a leading cause of global morbidity and mortality, indicating the necessity and urgency of effective prevention and treatment. Remote ischemic conditioning (RIC) is a convenient, simple, non-intrusive, and effective method that can be easily added to the treatment regime of stroke patients. Animal experiments and clinical trials have proved the neuroprotective effects of RIC on brain injury including (examples of neuroprotective effects). This neuroprotection is achieved by raising brain tolerance to ischemia, increasing local cerebral blood perfusion, promoting collateral circulations, neural regeneration, and reducing the incidence of hematomas in brain tissue. This current paper will summarize the studies within the last 2 years for the comprehensive understanding of the use of RIC in the treatment of stroke.

METHODS

This paper summarizes the clinical research progress of RIC on stroke (ischemic stroke and hemorrhagic stroke (HS)). This paper is a systematic review of research published on registered clinical trials using RIC in stroke from inception through November 2022. Four major databases (PUBMED, WEB OF SCIENCE, EMBASE, and ClinicalTrials.gov) were searched.

RESULTS

Forty-eight studies were identified meeting our criteria. Of these studies, 14 were in patients with acute ischemic stroke with onset times ranging from 6 h to 14 days, seven were in patients with intravenous thrombolysis or endovascular thrombectomy, 10 were in patients with intracranial atherosclerotic stenosis, six on patients with vascular cognitive impairment, three on patients with moyamoya disease, and eight on patients with HS. Of the 48 studies, 42 were completed and six are ongoing.

CONCLUSIONS

RIC is safe, feasible, and effective in the treatment of stroke. Large-scale research is still required to explore the optimal treatment options and mechanisms of RIC in the future to develop a breakthrough in stroke prevention and treatment.

Correlation and Prognostic Action of SAA, Hcy, and BNP Levels with the Condition of Patients with Spontaneous Intracerebral Hemorrhage

Objective

To explore the correlation of serum amyloid A (SAA), homocysteine (Hcy), and plasma B-type brain natriuretic peptide (BNP) levels in patients with spontaneous intracerebral hemorrhage (SICH) and their predictive value for the status and prognosis of SICH patients.

Methods

82 SICH patients admitted to our hospital from March 2017 to March 2020 were selected. According to the Glasgow coma scale (GCS) score, the patients were divided into GCS > 8 group (n = 44) and the GCS ≤ 8 group (n = 38). Based on the bleeding volume, the patients were divided into the massive bleeding group (>30 ml) (n = 21), the moderate bleeding group (10∼30 ml) (n = 28), and the small bleeding group (<10 ml) (n = 33). Based on the prognostic status of patients after 28 days of admission, they were divided into the survival group (n = 64) and the death group (n = 18). Serum SAA, Hcy, and plasma BNP levels of patients in different groups were compared, and the correlation between serum SAA, Hcy and plasma BNP levels with GCS score, cerebral hemorrhage, and the prognostic value of patients was analyzed.

Results

Serum SAA, Hcy, and plasma BNP levels in patients with GCS ≤ 8 groups were higher than those in GCS > 8 groups (P < 0.05). Serum SAA, Hcy, and plasma BNP levels of patients in the massive bleeding group were higher than those in the moderate and small bleeding groups. Besides, the level of serum SAA, Hcy, and plasma BNP in the moderate bleeding group was higher than that in the small bleeding group (P < 0.05). Serum SAA, Hcy and plasma BNP levels of patients were negatively correlated with GCS scores but positively correlated with bleeding volume (P < 0.05). The levels of serum SAA, Hcy and plasma BNP in dead patients were higher than those in the survival patients (P < 0.05). The combined prediction of serum SAA, Hcy, and plasma BNP for the prognosis of SICH patients was 0.910 (95% CI: 0.984∼0.837), which was higher than the serum SAA, Hcy, and plasma BNP alone predicted AUC 0.679 (95% CI: 0.564∼0.795), 0.720 (95% CI: 0.603∼0.836), and 0.726 (95% CI: 0.616∼0.849).

Conclusion

The levels of serum SAA, Hcy, and plasma BNP have a correlation with the severity and prognosis of patients with SICH, which is a feasible index for judging the prognosis of SICH. The levels of serum SAA, Hcy, and plasma BNP are conducive to timely judgment of the progression and prognosis of SICH patients.

Safety and efficacy of remote ischemic conditioning for the treatment of intracerebral hemorrhage: A proof-of-concept randomized controlled trial

BACKGROUND

Remote ischemic conditioning can promote hematoma resolution, attenuate brain edema, and improve neurological recovery in animal models of intracerebral hemorrhage.

AIMS

This study aimed to evaluate the safety and preliminary efficacy of remote ischemic conditioning in patients with intracerebral hemorrhage.

METHODS

In this multicenter, randomized, controlled trial, 40 subjects with supratentorial intracerebral hemorrhage presenting within 24-48 h of onset were randomly assigned to receive medical therapy plus remote ischemic conditioning for consecutive seven days or medical therapy alone. The primary safety outcome was neurological deterioration within seven days of enrollment, and the primary efficacy outcome was the changes of hematoma volume on CT images. Other outcomes included hematoma resolution rate at 7 days ([hematoma volume at 7 days - hematoma volume at baseline]/hematoma volume at baseline), perihematomal edema (PHE), and functional outcome at 90 days.

RESULTS

The mean age was 59.3 ± 11.7 years and hematoma volume was 13.9 ± 4.5 mL. No subjects experienced neurological deterioration within seven days of enrollment, and no subject died or experienced remote ischemic conditioning-associated adverse events during the study period. At baseline, the hematoma volumes were 14.19 ± 5.07 mL in the control group and 13.55 ± 3.99 mL in the remote ischemic conditioning group, and they were 8.54 ± 3.99 mL and 6.95 ± 2.71 mL at seven days after enrollment, respectively, which is not a significant difference (p > 0.05 each). The hematoma resolution rate in the remote ischemic conditioning group (49.25 ± 9.17%) was significantly higher than in the control group (41.92 ± 9.14%; MD, 7.3%; 95% CI, 1.51-13.16%; p = 0.015). The absolute PHE volume was 17.27 ± 8.34 mL in the control group and 12.92 ± 7.30 mL in the remote ischemic conditioning group at seven days after enrollment, which is not a significant between-group difference (p = 0.087), but the relative PHE in the remote ischemic conditioning group (1.77 ± 0.39) was significantly lower than in the control group (2.02 ± 0.27; MD, 0.25; 95% CI, 0.39-0.47; p = 0.023). At 90-day follow-up, 13 subjects (65%) in the remote ischemic conditioning group and 12 subjects (60%) in the control group achieved favorable functional outcomes (modified Rankin Scale score ≤ 3), which is not a significant between-group difference (p = 0.744).

CONCLUSIONS

Repeated daily remote ischemic conditioning for consecutive seven days was safe and well tolerated in patients with intracerebral hemorrhage, and it may be able to improve hematoma resolution rate and reduce relative PHE. However, the effects of remote ischemic conditioning on the absolute hematoma and PHE volume and functional outcomes in this patient population need further investigations.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03930940.

Significance of endoscopic hematoma evacuation in elderly patients with spontaneous putaminal hemorrhage

Background:

The efficacy of endoscopic surgery for spontaneous intracerebral hemorrhages (ICH) has been previously reported, but differences in the effect between early and late elderlies remain unclear.

Methods:

Ninety-seven patients diagnosed with putaminal hemorrhage (age, ≥65 years; hematoma volume, ≥30 mL) were included in this retrospective analysis and separated into three treatment groups: craniotomy surgery (CR), endoscopic surgery (EN), and non-surgical (NS) groups. The patients were additionally subdivided into two groups according to age: patients aged 65–74 years (“early elderlies”) and patients aged ≥75 years (“late elderlies”). Their clinical data and outcomes at discharge were compared using statistical analyses.

Results:

The CR and the EN groups were associated with lower mortality rates (P < 0.001), lower modified Rankin Scale (mRS; P = 0.007), and lower National Institutes of Health Stroke Scale (NIHSS; P = 0.029) compared to the NS group. Early elderlies in the CR and EN groups with ICH scores of 3 also had significantly better outcomes (P = 0.001). The proportion of patients with mRS ≤ 4 was highest in the early elderlies of the EN group (P = 0.553). Although significant differences in the change of NIHSS scores between the early and late elderlies was not observed, significantly improved NIHSS scores were observed in the EN group compared to the NS group, even in the late elderlies (P = 0.037).

Conclusion:

The evacuation of deep-seated intracranial hematomas using the endoscope might improve functional outcomes and mortality, regardless of age.

Emergency surgery is an effective way to improve the outcome of severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet therapy

The necessity of emergency surgery for severe spontaneous intracerebral hemorrhage (SSICH) patients on long-term oral antiplatelet therapy (LOAPT) remains unclear. The aim of this study was to investigate the effect and safety of emergency surgery for SSICH patients on LOAPT (SSICH-LOAPT patients). In this study, a retrospective review of patients admitted to our institution for SSICH from January 2012 to December 2018 was conducted. The collected data included demographic, clinical, and surgical information. The outcome was recorded at 3 months after primary hemorrhage. The outcome of SSICH-LOAPT patients receiving emergency surgery and conservative treatment were compared. The risk of postoperative intracranial bleeding (PIB) in operated SSICH-LOAPT patients was further investigated. A total of 522 SSICH patients were retrospectively reviewed, including 181 SSICH-LOAPT patients and 269 operated patients. The total mortality and in-hospital mortality were 40.6% and 19.3%, respectively. As compared with SSICH-LOAPT patients receiving conservative treatment, the operated SSICH-LOAPT patients showed a lower total (p = 0.043) and in-hospital mortality (p = 0.024). When compared with operated patients not on LOAPT, the operated patients on LOAPT exhibited a higher rate of PIB (OR, 2.34; 95% CI 1.14-4.79; p = 0.018). As demonstrated by the multivariate logistic analysis, dual antiplatelet therapy were independent risk factors associated with PIB in operated SSICH-LOAPT patients (OR, 3.42; CI, 1.01-11.51; p = 0.047). Despite of increasing risk of PIB, emergency surgery could improve the outcome of SSICH-LOAPT patients as it could be effective in reducing mortality. Dual antiplatelet therapy was the independent risk factor related to the PIB in operated SSICH-LOAPT patients.