Current treatment options for intracerebral hemorrhage

"Cool" Topic: Feeding During Moderate Hypothermia After Intracranial Hemorrhage

BACKGROUND

Therapeutic moderate hypothermia (MH; T _core 33°C-34°C) is being studied for treatment of spontaneous intracerebral hemorrhage (ICH). Nutrition assessment begins with accurate basal metabolic rate (BMR) determination. Although early enteral nutrition (EN) is associated with improved outcomes, it is often deferred until rewarming. We sought to determine the accuracy of predictive BMR equations and the safety and tolerance of EN during MH after ICH.

MATERIALS AND METHODS

Patients were randomized to 72 hours of MH or normothermia (NT; T _core 36°C-37°C). Harris-Benedict (BMR-HB) and Penn-State equation (BMR-PS) calculations were compared with indirect calorimetry (IC) at day (D) 0 and D1-3. Patients with MH received trophic semi-elemental gastric EN. Occurrences of feeding intolerance, gastrointestinal (GI)-related adverse events, and ventilator-associated pneumonia (VAP) were analyzed with a double-sided matched pairs t test.

RESULTS

Thirteen patients with ICH participated (6 MH, 7 NT). Mean time to initiate EN: 29.9 (MH) vs 18.4 (NT) hours ( P = .046). Average daily EN calories received D0-3: 398 (MH) vs 1006 (NT) ( P < .01). Three patients with MH experienced high gastric residuals prior to prokinetic agents, 1 had mild ileus, and 1 patient with NT vomited. No GI-related adverse events were reported. One patient with MH and 1 patient with NT had VAP. Two patients with MH received IC, and from D0 to D1-3, BMR-HB remained stable (1331 kcal), BMR-PS decreased (1511 vs 1145 kcal, P = .5), and IC decreased (1413 vs 985 kcal, P = .2).

CONCLUSIONS

In patients with ICH undergoing MH, resting energy expenditure is decreased and predictive equations overestimate BMR. EN is feasible, although delayed EN initiation, high gastric residuals, and less EN provision are common. Future studies should focus on EN initiation within 24 hours, advanced EN rates, and postpyloric feeds during hypothermia.

Effects of minimally invasive procedures for evacuation of intracerebral hematoma in early stages on MMP-9 and BBB permeability in rabbits

BACKGROUND

The effects of performing a minimally invasive procedure at different stages after intracerebral hemorrhage on perihematomal MMP-9 expression and blood-brain barrier (BBB) permeability were evaluated.

METHODS

Sixty rabbits were randomly distributed into a model control group (MC group, 30 rabbits) or a minimally invasive group (MI group, 30 rabbits). A model of intracerebral hemorrhage was established in the MC and MI group. In the MI group, the intracerebral hematoma was evacuated by stereotactic minimally invasive procedures over 6 hours (6 rabbits), 12 hours (6 rabbits), 18 hours (6 rabbits) 24 hours or 48 hours (6 rabbits) following successful induction of intracerebral hemorrhage. The same procedure was performed in the MC group at the same time point but without evacuating the hematoma. All the animals were sacrificed within two weeks after the hematoma was surgically evacuated. A neurological deficit score was determined, and the perihematomal MMP-9 level and the BBB permeability were measured.

RESULTS

The neurological deficit score, perihematomal MMP-9 level and BBB permeability of the MI group decreased significantly compared to the MC group. Performing the MI procedure 6-12 h after intracerebral hemorrhage showed the most favorable outcome.

CONCLUSIONS

Regarding the pathophysiological changes surrounding the hematoma, the optimal time window of performing MI procedures for the intracerebral hematoma evacuation might be within 6-12 h after hemorrhage.

Perihematomal glutamate level is associated with the blood-brain barrier disruption in a rabbit model of intracerebral hemorrhage

Objective

To observe the relationship between the perihematomal glutamate levels and the blood–brain barrier (BBB) permeability in a rabbit model of intracerebral hemorrhage (ICH).

Methods

Seventy-two rabbits were randomly divided into an intracerebral hemorrhage (ICH) model group and a normal control (NC) group, and each group of 36 rabbits was subsequently divided into 6, 12, 18, 24, 48 and 72 h groups (n = 6 each). An ICH model was induced by stereotactic injection of autologous, arterial, non-anticoagulated blood into rabbit basal ganglia. The same procedures were performed in the NC group, but blood was not injected. The rabbits were sacrificed at specific time points after the experiment began depending on their group. Perihematomal brain tissues were collected to determine glutamate levels, BBB permeability and brain water content (BWC).

Results

All of the assessed parameters were increased 6 hour after blood infusion and continued to gradually increase, peaking at 48 hours. Differences were observed when ICH values were compared with those of the NC group (p < 0.05).

Conclusions

Perihematomal glutamate increased significantly after ICH. High levels of glutamate are closely associated with BBB disruption and the brain edema. Therefore, glutamate may play an important role in the pathogenesis of secondary brain injury after (ICH).

Intracerebral hemorrhage: clinical overview and pathophysiologic concepts

Intracerebral hemorrhage is by far the most destructive form of stroke. Apart from the management in a specialized stroke or neurological intensive care unit (NICU), no specific therapies have been shown to consistently improve outcomes after ICH. Current guidelines endorse early aggressive optimization of physiologic derangements with ventilatory support when indicated, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring for certain cases, osmotherapy, temperature modulation, seizure prophylaxis, treatment of hyerglycemia, and nutritional support in the stroke unit or NICU. Ventriculostomy is the cornerstone of therapy for control of intracranial pressure patients with intraventricular hemorrhage. Surgical hematoma evacuation does not improve outcome for more patients, but is a reasonable option for patients with early worsening due to mass effect due to large cerebellar or lobar hemorrhages. Promising experimental treatments currently include ultra-early hemostatic therapy, intraventricular clot lysis with thrombolytics, pioglitazone, temperature modulation, and deferoxamine to reduce iron-mediated perihematomal inflammation and tissue injury.