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Wang JY, Wilson M, Andreev A, Tarsia J, Selim M, Lioutas VA. The role of hyperglycemia in the outcome of intracerebral hemorrhage: A causative analysis. J Stroke Cerebrovasc Dis 2023; 32:107439. [PMID: 38488808 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107439] [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: 08/07/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Hyperglycemia in the acute phase of intracerebral hemorrhage (ICH) has been associated with poor functional outcomes, however all interventions to lower glucose have yielded neutral or negative results. We attempt an explanation of the causal role of hyperglycemia in ΙCH outcome using generalized structural equation modeling. MATERIALS AND METHODS Consecutive primary ICH patients admitted to an academic hospital between 2007 and 2018 were identified. Patients with missing baseline or follow up CT scans and without 90 day follow up status were excluded. We constructed a causal model accounting for pre-defined markers of ICH severity to evaluate the association between mean 72 h glucose and 90 day functional outcome measured by modified Rankin Scale, dichotomized as favorable ≤2 or unfavorable >2. RESULTS Primary analyses included 410 patients (70.4 ± 13.8years, 43 % female). Mean 72 h glucose was 137.5 ± 33.4mg/dl and 102 (25 %) patients were diabetic. On univariable analysis, higher glucose levels were negatively correlated with favorable outcome (p < 0.0001). However in the structural equation model, this relationship was significantly attenuated (p = 0.06) after accounting for the causal effect of diabetes (p < 0.0001), hematoma volume (p < 0.0001), intraventricular extension (p = 0.01) and Glasgow coma scale (p = 0.001) on glucose levels. On secondary analyses stratifying by diagnosis of diabetes, higher glucose levels were negatively correlated with favorable outcome in patients without diabetes (p = 0.04), but not in patients with diabetes (p = 0.35). CONCLUSIONS Hyperglycemia may be a downstream effect of other markers of ICH severity, particularly among patients without diabetes, suggesting a possible explanation for the limited evidence of glucose lowering interventions in outcome.
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Affiliation(s)
- Jia-Yi Wang
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA.
| | - Mitchell Wilson
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA
| | - Alexander Andreev
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA
| | - Joseph Tarsia
- Department of Neurology, Ochsner Medical Center, New Orleans, LA, USA
| | - Magdy Selim
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA
| | - Vasileios-Arsenios Lioutas
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA
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2
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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.
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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.
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3
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Hasan M, Atiqur-Rahman M, Chowdhury S, Esteak T, Naznin J, Shahi MS. Efficacy and Safety of Analog Insulin in Comparison With Human Insulin for Hyperglycemia in Hospitalized Patients With Acute Stroke: A Randomized, Open-Label, Single-Center Trial. Endocr Pract 2023; 29:18-23. [PMID: 36332823 DOI: 10.1016/j.eprac.2022.10.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/23/2022] [Accepted: 10/26/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of analog insulins in comparison with human insulins for hyperglycemia in hospitalized patients with acute stroke. METHODS In this single-center, open-label, randomized trial, 102 patients (age 59.4 ± 11.7 years, 54 women) admitted with acute stroke (52 ischemic, 50 hemorrhagic) and hyperglycemia were assigned to analog insulin (n = 52) or human insulin (n = 50) group during February to June 2021. Insulin was initiated and titrated according to the predefined standard protocol. The capillary blood glucose (BG) level was monitored by standardized glucometers. The primary outcomes were mean daily BG and the number of hypoglycemic events. RESULTS Between the 2 treatment groups, there was no significant difference in the mean daily BG (P >.05 for all days) or in the frequency of hypoglycemic episodes (P =.727). Four participants experienced severe hypoglycemia; all were receiving human insulin (P =.054). In the analog insulin group, there was a tendency toward lower daily total requirement for insulin (P =.053). The difference in bolus insulin dose was significantly lower in the analog insulin group (P =.029), but the difference in basal insulin dose was similar (P =.167). Between the 2 groups, there were no significant differences in the hospital mortality rate, modified Rankin Scale score on outcome, or length of hospital stay (P =.729,.658, and.918, respectively). CONCLUSION Hospitalized patients acute stroke and hyperglycemia exhibited similar mean BG but a trend of lower incidence of severe hypoglycemia when treated with analog insulins in comparison with human insulin.
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Affiliation(s)
- Mashfiqul Hasan
- Department of Endocrinology, National Institute of Neurosciences and Hospital, Sher-E-Bangla Nagar, Agargaon, Dhaka, Bangladesh.
| | - Mohammad Atiqur-Rahman
- Department of Endocrinology, National Institute of Neurosciences and Hospital, Sher-E-Bangla Nagar, Agargaon, Dhaka, Bangladesh
| | - Sharmin Chowdhury
- Department of Neurology, National Institute of Neurosciences and Hospital, Sher-E-Bangla Nagar, Agargaon, Dhaka, Bangladesh
| | - Tareq Esteak
- Department of Neurology, National Institute of Neurosciences and Hospital, Sher-E-Bangla Nagar, Agargaon, Dhaka, Bangladesh
| | - Jobaida Naznin
- Department of Endocrinology, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh
| | - Mohammad Selim Shahi
- Department of Neurology, National Institute of Neurosciences and Hospital, Sher-E-Bangla Nagar, Agargaon, Dhaka, Bangladesh
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4
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Hillal A, Ullberg T, Ramgren B, Wassélius J. Computed tomography in acute intracerebral hemorrhage: neuroimaging predictors of hematoma expansion and outcome. Insights Imaging 2022; 13:180. [DOI: 10.1186/s13244-022-01309-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/24/2022] [Indexed: 11/24/2022] Open
Abstract
AbstractIntracerebral hemorrhage (ICH) accounts for 10–20% of all strokes worldwide and is associated with serious outcomes, including a 30-day mortality rate of up to 40%. Neuroimaging is pivotal in diagnosing ICH as early detection and determination of underlying cause, and risk for expansion/rebleeding is essential in providing the correct treatment. Non-contrast computed tomography (NCCT) is the most used modality for detection of ICH, identification of prognostic markers and measurements of hematoma volume, all of which are of major importance to predict outcome. The strongest predictors of 30-day mortality and functional outcome for ICH patients are baseline hematoma volume and hematoma expansion. Even so, exact hematoma measurement is rare in clinical routine practice, primarily due to a lack of tools available for fast, effective, and reliable volumetric tools. In this educational review, we discuss neuroimaging findings for ICH from NCCT images, and their prognostic value, as well as the use of semi-automatic and fully automated hematoma volumetric methods and assessment of hematoma expansion in prognostic studies.
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A Study of the Relationship between Blood Glucose and Serum Insulin in Acute Cerebrovascular Disease. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:9041551. [PMID: 35958906 PMCID: PMC9359818 DOI: 10.1155/2022/9041551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 12/03/2022]
Abstract
Objective The objective of this study was to examine the correlation between blood glucose and serum insulin with acute cerebrovascular disease. Methods A total of 1548 patients with acute cerebrovascular illness and 364 patients with a normal physical examination who were admitted to our hospital (endocrinology department) between January 2017 and July 2020 were recruited. Patients with acute cerebrovascular illness were included in the experimental group, while healthy individuals after physical examinations were included in the control group. All patients' blood glucose and serum insulin levels were measured, and the association of blood glucose and serum insulin with acute cerebrovascular illness was investigated. Results Acute cerebrovascular disease is associated with significantly higher blood glucose and serum insulin levels versus healthy status (P < 0.05). Blood glucose and serum insulin levels were observed to be significantly higher in the hemorrhagic stroke group than in the ischemic stroke or mild hemorrhagic group (P < 0.05). Severe ischemic strokes were associated with significantly higher blood glucose levels versus mild ischemic strokes (P < 0.05). There were no significant differences in serum insulin levels between the severe ischemic stroke group and the mild ischemic stroke group (P > 0.05). Conclusion A rise in blood glucose and serum insulin levels is associated with the incidence and prognosis of acute cerebrovascular disease, and it is positively correlated with the severity of the acute cerebrovascular disease.
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6
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Magid-Bernstein J, Girard R, Polster S, Srinath A, Romanos S, Awad IA, Sansing LH. Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions. Circ Res 2022; 130:1204-1229. [PMID: 35420918 PMCID: PMC10032582 DOI: 10.1161/circresaha.121.319949] [Citation(s) in RCA: 135] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.
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Affiliation(s)
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sean Polster
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Issam A. Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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7
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Duloquin G, Graber M, Baptiste L, Mohr S, Garnier L, Ndiaye M, Thomas Q, Hervieu-Bègue M, Osseby GV, Giroud M, Béjot Y. [Acute management of spontaneous intracerebral hemorrhage]. Rev Med Interne 2021; 43:293-300. [PMID: 34953622 DOI: 10.1016/j.revmed.2021.11.004] [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: 10/28/2021] [Accepted: 11/14/2021] [Indexed: 11/16/2022]
Abstract
Intracerebral hemorrhage accounts for approximately 15% of the 115,000 strokes occurring each year in France. Although therapeutic strategies are more limited than for ischemic stroke, major points in the management of intracerebral hemorrhage can reduce short term morbidity and mortality by limiting the expansion of the hematoma and the occurrence of early complications, and long term patients' outcome by reducing the risk of recurrence. This article aims to update the key elements that contribute to improve of the prognosis of intracerebral hemorrhage patients.
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Affiliation(s)
- G Duloquin
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - M Graber
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - L Baptiste
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - S Mohr
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - L Garnier
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - M Ndiaye
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - Q Thomas
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - M Hervieu-Bègue
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - G-V Osseby
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - M Giroud
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - Y Béjot
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France.
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Hou D, Zhong P, Ye X, Wu D. Persistent hyperglycemia is a useful glycemic pattern to predict stroke mortality: a systematic review and meta-analysis. BMC Neurol 2021; 21:487. [PMID: 34906119 PMCID: PMC8670037 DOI: 10.1186/s12883-021-02512-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 12/06/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Glycemic patterns have been reported to be prognostic factors for stroke; however, this remains to be further evaluated. This meta-analysis aimed to evaluate the usefulness of glycemic patterns such as persistent hyperglycemia (PH) including short duration and long duration PH (SPH; LPH), admission hyperglycemia (AH), short-duration hyperglycemia (SH), and persistent normoglycemia (PN) in predicting stroke prognosis using published results. METHODS Major scientific databases including but are not limited to PubMed, EMBASE, Web of Science, Ovid, CNKI (Chinese National Knowledge Infrastructure), and Clinicaltrials.gov were searched till 1st March 2021 for clinical trials on the correlation between glycemic patterns and stroke outcomes. The primary outcome was defined as short-term (1- or 3-month) post-stroke mortality, and the secondary outcome was post-stroke hemorrhage at 6 months. RESULTS Ten studies involving 3584 individuals were included in the final analysis. In subgroup analyses, PH patients with no history of diabetes had increased post-stroke mortality (odds ratio [OR]: 4.80, 95% CI: 3.06-7.54) than patients with no PH; and patients with glucose levels > 140 mg/dl had greater mortality (OR: 5.12, 95% CI: 3.21-8.18) than those with glucose levels < 140 mg/dl; compared with AH patients, PH patients had increased short-term mortality (OR: 0.31, 95% CI: 0.16-0.60). In the prediction of stroke mortality among patients without diabetes, SPH (OR: 0.28, 95%CI: 0.12-0.69) seemed to be more related to increased mortality than LPH (OR: 0.35, 95% CI: 0.14--0.90). CONCLUSIONS PH, especially SPH, could predict increased post-stroke mortality in non-diabetic patients. The rank of individual glycemic patterns in predicting stroke mortality in non-diabetic patients was SPH > LPH > AH > PN.
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Affiliation(s)
- Duanlu Hou
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, 801 Heqing Road, Minhang District, Shanghai, 200240, China
| | - Ping Zhong
- Department of Neurology, Shidong Hospital of Yangpu District, Shanghai, China
| | - Xiaofei Ye
- Department of Health Statistics, Naval Military Medical University, Shanghai, China
| | - Danhong Wu
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, 801 Heqing Road, Minhang District, Shanghai, 200240, China.
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Qureshi AI, Huang W, Lobanova I, Chandrasekaran PN, Hanley DF, Hsu CY, Martin RH, Steiner T, Suarez JI, Yamamoto H, Toyoda K. Effect of Moderate and Severe Persistent Hyperglycemia on Outcomes in Patients With Intracerebral Hemorrhage. Stroke 2021; 53:1226-1234. [PMID: 34844422 DOI: 10.1161/strokeaha.121.034928] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE We evaluated the effect of persistent hyperglycemia on outcomes in 1000 patients with intracerebral hemorrhage enrolled within 4.5 hours of symptom onset. METHODS We defined moderate and severe hyperglycemia based on serum glucose levels ≥140 mg/dL-<180 and ≥180 mg/dL, respectively, measured at baseline, 24, 48, and 72 hours. Persistent hyperglycemia was defined by 2 consecutive (24 hours apart) serum glucose levels. We evaluated the relationship between moderate and severe hyperglycemia and death or disability (defined by modified Rankin Scale score of 4-6) at 90 days in the overall cohort and in groups defined by preexisting diabetes. RESULTS In the multivariate analysis, both moderate (odds ratio, 1.8 [95% CI, 1.1-2.8]) and severe (odds ratio, 1.8 [95% CI, 1.2-2.7]) hyperglycemia were associated with higher 90-day death or disability after adjusting for Glasgow Coma Scale score, hematoma volume, presence or absence of intraventricular hemorrhage, hyperlipidemia, cigarette smoking, and hypertension (no interaction between hyperglycemia and preexisting diabetes, P=0.996). Among the patients without preexisting diabetes, both moderate (odds ratio, 1.8 [95% CI, 1.0-3.2]) and severe (odds ratio, 2.0 [95% CI, 1.1-3.7]) hyperglycemia were associated with 90-day death or disability after adjusting for above mentioned potential confounders. Among the patients with preexisting diabetes, moderate and severe hyperglycemia were not associated with 90-day death or disability. CONCLUSIONS Persistent hyperglycemia, either moderate or severe, increased the risk of death or disability in nondiabetic patients with intracerebral hemorrhage. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01176565.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, St Cloud, MN (A.I.Q., W.H., I.L.).,Department of Neurology, University of Missouri, Columbia (A.I.Q., W.H., I.L., P.N.C.)
| | - Wei Huang
- Zeenat Qureshi Stroke Institute, St Cloud, MN (A.I.Q., W.H., I.L.).,Department of Neurology, University of Missouri, Columbia (A.I.Q., W.H., I.L., P.N.C.)
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institute, St Cloud, MN (A.I.Q., W.H., I.L.).,Department of Neurology, University of Missouri, Columbia (A.I.Q., W.H., I.L., P.N.C.)
| | | | - Daniel F Hanley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD. (D.F.H.)
| | - Chung Y Hsu
- Graduate Institute of Clinical Medicine, China Medical University, Taichung, Taiwan (C.Y.H.)
| | - Renee H Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (R.H.M.)
| | - Thorsten Steiner
- Department of Neurology, University of Heidelberg, Germany (T.S.)
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD. (J.I.S.)
| | - Haruko Yamamoto
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan. (H.Y.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.T.)
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10
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Chen Y, Chen S, Chang J, Wei J, Feng M, Wang R. Perihematomal Edema After Intracerebral Hemorrhage: An Update on Pathogenesis, Risk Factors, and Therapeutic Advances. Front Immunol 2021; 12:740632. [PMID: 34737745 PMCID: PMC8560684 DOI: 10.3389/fimmu.2021.740632] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022] Open
Abstract
Intracerebral hemorrhage (ICH) has one of the worst prognoses among patients with stroke. Surgical measures have been adopted to relieve the mass effect of the hematoma, and developing targeted therapy against secondary brain injury (SBI) after ICH is equally essential. Numerous preclinical and clinical studies have demonstrated that perihematomal edema (PHE) is a quantifiable marker of SBI after ICH and is associated with a poor prognosis. Thus, PHE has been considered a promising therapeutic target for ICH. However, the findings derived from existing studies on PHE are disparate and unclear. Therefore, it is necessary to classify, compare, and summarize the existing studies on PHE. In this review, we describe the growth characteristics and relevant underlying mechanism of PHE, analyze the contributions of different risk factors to PHE, present the potential impact of PHE on patient outcomes, and discuss the currently available therapeutic strategies.
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Affiliation(s)
- Yihao Chen
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shengpan Chen
- Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Institute of Neuroscience, Guangdong Academy of Medical Sciences, Guangdong, China
| | - Jianbo Chang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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11
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Ren R, Lu Q, Sherchan P, Fang Y, Lenahan C, Tang L, Huang Y, Liu R, Zhang JH, Zhang J, Tang J. Inhibition of Aryl Hydrocarbon Receptor Attenuates Hyperglycemia-Induced Hematoma Expansion in an Intracerebral Hemorrhage Mouse Model. J Am Heart Assoc 2021; 10:e022701. [PMID: 34622690 PMCID: PMC8751882 DOI: 10.1161/jaha.121.022701] [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: 01/26/2023]
Abstract
Background Hyperglycemia is associated with greater hematoma expansion (HE) and worse clinical prognosis after intracerebral hemorrhage (ICH). However, the clinical benefits of intensive glucose normalization remain controversial, and there are no approved therapies for reducing HE. The aryl hydrocarbon receptor (AHR) has been shown to participate in hyperglycemia‐induced blood–brain barrier (BBB) dysfunction and brain injury after stroke. Herein, we investigated the role of AHR in hyperglycemia‐induced HE in a male mouse model of ICH. Methods and Results CD1 mice (n=387) were used in this study. Mice were subjected to ICH by collagenase injection. Fifty percent dextrose was injected intraperitoneally 3 hours after ICH. AHR knockout clustered regularly interspaced short palindromic repeat was administered intracerebroventricularly to evaluate the role of AHR after ICH. A selective AHR inhibitor, 6,2′,4′‐trimethoxyflavone, was administered intraperitoneally 2 hours or 6 hours after ICH for outcome study. To evaluate the effect of AHR on HE, 3‐methylcholanthrene, an AHR agonist, was injected intraperitoneally 2 hours after ICH. The results showed hyperglycemic ICH upregulated AHR accompanied by greater HE. AHR inhibition provided neurological benefits by restricting HE and preserving BBB function after hyperglycemic ICH. In vivo knockdown of AHR further limited HE and enhanced the BBB integrity. Hyperglycemia directly activated AHR as a physiological stimulus in vivo. The thrombospondin‐1/transforming growth factor‐β/vascular endothelial growth factor axis partly participated in AHR signaling after ICH, which inhibited the expressions of BBB‐related proteins, ZO‐1 and Claudin‐5. Conclusions AHR may serve as a potential therapeutic target to attenuate hyperglycemia‐induced hematoma expansion and to preserve the BBB in patients with ICH.
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Affiliation(s)
- Reng Ren
- Department of Neurosurgery The Second Affiliated HospitalZhejiang University School of Medicine Hangzhou Zhejiang China.,Department of Neurointensive Care Unit The Second Affiliated HospitalZhejiang University School of Medicine Hangzhou Zhejiang China.,Department of Physiology and Pharmacology Loma Linda University School of Medicine Loma Linda CA
| | - Qin Lu
- Department of Physiology and Pharmacology Loma Linda University School of Medicine Loma Linda CA
| | - Prativa Sherchan
- Department of Physiology and Pharmacology Loma Linda University School of Medicine Loma Linda CA
| | - Yuanjian Fang
- Department of Neurosurgery The Second Affiliated HospitalZhejiang University School of Medicine Hangzhou Zhejiang China.,Department of Physiology and Pharmacology Loma Linda University School of Medicine Loma Linda CA
| | - Cameron Lenahan
- Department of Physiology and Pharmacology Loma Linda University School of Medicine Loma Linda CA
| | - Lihui Tang
- Department of Physiology and Pharmacology Loma Linda University School of Medicine Loma Linda CA
| | - Yi Huang
- Department of Neurosurgery The Second Affiliated HospitalZhejiang University School of Medicine Hangzhou Zhejiang China.,Department of Physiology and Pharmacology Loma Linda University School of Medicine Loma Linda CA
| | - Rui Liu
- Department of Physiology and Pharmacology Loma Linda University School of Medicine Loma Linda CA
| | - John H Zhang
- Department of Physiology and Pharmacology Loma Linda University School of Medicine Loma Linda CA.,Department of Neurosurgery Loma Linda University School of Medicine Loma Linda CA.,Department of Anesthesiology Loma Linda University School of Medicine Loma Linda CA
| | - Jianmin Zhang
- Department of Neurosurgery The Second Affiliated HospitalZhejiang University School of Medicine Hangzhou Zhejiang China
| | - Jiping Tang
- Department of Physiology and Pharmacology Loma Linda University School of Medicine Loma Linda CA
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12
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Alex Matos Ribeiro J, Fernanda García-Salazar L, Regina Saade-Pacheco C, Shirley Moreira Silva É, Garcia Oliveira S, Flávia Silveira A, Sanches Garcia-Araújo A, Luiz Russo T. Prognostic molecular markers for motor recovery in acute hemorrhagic stroke: A systematic review. Clin Chim Acta 2021; 522:45-60. [PMID: 34389283 DOI: 10.1016/j.cca.2021.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Molecular biomarkers are associated with poor prognosis in ischemic stroke individuals. However, it might not be generalizable to post-acute hemorrhagic stroke since the underlying mechanisms of this brain damage differ from those found in ischemic stroke. The main purpose of this review was to synthesize the potential predictive molecular biomarkers for motor recovery following acute hemorrhagic stroke. MATERIALS AND METHODS An electronic search was conducted by 2 independent reviewers in the following databases: PubMed (Medline), EMBASE, Web of Science, and CINAHL. We included studies that addressed the following: collected blood, urine, or cerebrospinal fluid samples within 72 h after hemorrhagic stroke and that reported the prognostic association with functional motor recovery for each molecular biomarker. Screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers. RESULTS Twelve thousand, five hundred and sixty-four studies were identified and 218 were considered eligible. Finally, we included 70 studies, with 96 biomarkers analyzed, of which 61 were considered as independent prognostic biomarkers, and 10 presented controversial results. CONCLUSION This systematic review shows that motor functional recovery can be predicted by 61 independent prognostic molecular biomarkers assessed in the acute phase after a hemorrhagic stroke.
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Affiliation(s)
| | - Luisa Fernanda García-Salazar
- Federal University of São Carlos, Department of Physical Therapy, São Carlos, Brazil; Universidad del Rosario, School of Medicine and Health Sciences, Rehabilitation Science Research Group, Bogotá, Colombia.
| | - Cássia Regina Saade-Pacheco
- Federal University of São Carlos, Department of Physical Therapy, São Carlos, Brazil; Educational Foundation of the Municipality of Assis, Municipal Institute of Higher Education of Assis, Assis, Brazil.
| | | | | | - Ana Flávia Silveira
- Federal University of São Carlos, Department of Physical Therapy, São Carlos, Brazil.
| | | | - Thiago Luiz Russo
- Federal University of São Carlos, Department of Physical Therapy, São Carlos, Brazil.
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13
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Ye G, Huang S, Chen R, Zheng Y, Huang W, Gao Z, Cai L, Zhao M, Ma K, He Q, Lin F, Lin Y, Wang D, Fang W, Kang D, Wu X. Early Predictors of the Increase in Perihematomal Edema Volume After Intracerebral Hemorrhage: A Retrospective Analysis From the Risa-MIS-ICH Study. Front Neurol 2021; 12:700166. [PMID: 34385972 PMCID: PMC8353085 DOI: 10.3389/fneur.2021.700166] [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] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 06/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Perihematomal edema (PHE) is associated with poor functional outcomes after intracerebral hemorrhage (ICH). Early identification of risk factors associated with PHE growth may allow for targeted therapeutic interventions. Methods: We used data contained in the risk stratification and minimally invasive surgery in acute intracerebral hemorrhage (Risa-MIS-ICH) patients: a prospective multicenter cohort study. Patients' clinical, laboratory, and radiological data within 24 h of admission were obtained from their medical records. The absolute increase in PHE volume from baseline to day 3 was defined as iPHE volume. Poor outcome was defined as modified Rankin Scale (mRS) of 4 to 6 at 90 days. Binary logistic regression was used to assess the relationship between iPHE volume and poor outcome. The receiver operating characteristic curve was used to find the best cutoff. Linear regression was used to identify variables associated with iPHE volume (ClinicalTrials.gov Identifier: NCT03862729). Results: One hundred ninety-seven patients were included in this study. iPHE volume was significantly associated with poor outcome [P = 0.003, odds ratio (OR) 1.049, 95% confidence interval (CI) 1.016-1.082] after adjustment for hematoma volume. The best cutoff point of iPHE volume was 7.98 mL with a specificity of 71.4% and a sensitivity of 47.5%. Diabetes mellitus (P = 0.043, β = 7.66 95% CI 0.26-15.07), black hole sign (P = 0.002, β = 18.93 95% CI 6.84-31.02), and initial ICH volume (P = 0.018, β = 0.20 95% CI 0.03-0.37) were significantly associated with iPHE volume. After adjusting for hematoma expansion, the black hole sign could still independently predict the increase of PHE (P < 0.001, β = 21.62 95% CI 10.10-33.15). Conclusions: An increase of PHE volume >7.98 mL from baseline to day 3 may lead to poor outcome. Patients with diabetes mellitus, black hole sign, and large initial hematoma volume result in more PHE growth, which should garner attention in the treatment.
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Affiliation(s)
- Gengzhao Ye
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shuna Huang
- Department of Clinical Research and Translation Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Renlong Chen
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yan Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wei Huang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhuyu Gao
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Lueming Cai
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Mingpei Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Ke Ma
- Department of Clinical Research and Translation Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qiu He
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Fuxin Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yuanxiang Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Dengliang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wenhua Fang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xiyue Wu
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Hu S, Sheng W, Hu Y, Ma Q, Li B, Han R. A nomogram to predict early hematoma expansion of hypertensive cerebral hemorrhage. Medicine (Baltimore) 2021; 100:e24737. [PMID: 33607818 PMCID: PMC7899817 DOI: 10.1097/md.0000000000024737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 01/17/2021] [Indexed: 01/05/2023] Open
Abstract
Early hematoma expansion of hypertensive cerebral hemorrhage is affected by various factors. This study aimed to clarify the risk factors and develop a nomogram to predict early hematoma expansion.A retrospective analysis was carried out in patients with hypertensive cerebral hemorrhage admitted to our institution between January 1, 2012 and December 31, 2018; the patients were divided into 2 groups according to the presence of early hematoma expansion. Univariate and multivariate analyses were performed to analyze the risk factors of hematoma expansion. The nomogram was developed based on a multivariate logistic regression model, and the discriminative ability of the model was analyzed.A total of 477 patients with hypertensive cerebral hemorrhage and with a baseline hematoma volume <30 ml were included in our retrospective analysis. The hematoma expansion rate was 34.2% (163/477). After multivariate logistic regression, 9 variables (alcohol history, Glasgow coma scale score, total serum calcium, blood glucose, international normalized ratio, hematoma shape, hematoma density, volume of hematoma on initial computed tomography scan, and presence of intraventricular hemorrhage) identified as independent predictors of hematoma expansion were used to generate the nomogram. The area under the receiver operating characteristic curve of the nomogram was 0.883 (95% confidence interval 0.851-0.914), and the cutoff score was -0.19 with sensitivity of 75.5% and specificity of 87.3%.The nomogram can accurately predict the risk of early hematoma expansion.
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Affiliation(s)
- Si Hu
- Department of Neurosurgery
| | - WenGuo Sheng
- Department of Neurology, Affiliated Huzhou FuYin Hospital of Huzhou University, Huzhou, ZheJiang, China
| | - Yi Hu
- Department of Neurology, Affiliated Huzhou FuYin Hospital of Huzhou University, Huzhou, ZheJiang, China
| | | | - Bin Li
- Department of Neurosurgery
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15
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Agabi O, Ojo O, Danesi M, Ojini F, Okubadejo N. An investigation of the relationship of the admission hyperglycemia to severity and 30-day outcome in acute ishemic and intracerebral hemorraghic stroke: A comparative cross sectional study. JOURNAL OF CLINICAL SCIENCES 2021. [DOI: 10.4103/jcls.jcls_81_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Huang YH, Chung CL, Tsai HP, Tzou RD, Wu SC, Chai CY, Lee TC, Kwan AL. Impact of hyperglycemia on neuronal apoptosis after subarachnoid hemorrhage in rodent brain: An experimental research. Int J Surg 2020; 83:246-252. [PMID: 32739549 DOI: 10.1016/j.ijsu.2020.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/23/2020] [Accepted: 07/03/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Hyperglycemia, a derangement after subarachnoid hemorrhage (SAH), is known to be associated with unfavorable outcomes. Whether the connection between hyperglycemia and poor prognosis results from severe neuronal apoptosis is unknown, and we aim at investigating their relationship. MATERIAL AND METHODS Streptozotocin (STZ) was administrated to trigger hyperglycemia before SAH induction in Sprague-Dawley rats that were assigned to one of four groups: control, SAH only, hyperglycemia only, and SAH with hyperglycemia. The severity of neuronal apoptosis was analyzed by terminal deoxynucleotidyl transferase-mediated dUTP nickend labelling (TUNEL) staining of cerebral cortex. RESULTS When subjected to SAH, hyperglycemic animals had worse neurobehavioral functions than normoglycemic ones. Hyperglycemia-exacerbated apoptosis was evident by greater increases in cleaved caspase-3 expression and TUNEL-positive cell density in the SAH with hyperglycemia group than those in the SAH only group, whereas there was no significant difference in cleaved caspase-9 expression and Bax/Bcl-2 ratio between the two groups. Furthermore, there was a remarkable decrease in the ratio of phosphorylated extracellular regulated kinase (ERK)/total ERK in the hyperglycemic rats after SAH. CONCLUSION Hyperglycemia aggravated neuronal apoptosis after SAH and was associated with impaired neurological outcomes. Activation of the extrinsic caspase cascade through the ERK signal pathway may contribute to hyperglycemia-mediated apoptosis.
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Affiliation(s)
- Yu-Hua Huang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Li Chung
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | - Hung-Pei Tsai
- Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Rong-Dar Tzou
- Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shu-Chuan Wu
- Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chee-Yin Chai
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Pathology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tao-Chen Lee
- Department of Neurosurgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Aij-Lie Kwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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17
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Li Z, You M, Long C, Bi R, Xu H, He Q, Hu B. Hematoma Expansion in Intracerebral Hemorrhage: An Update on Prediction and Treatment. Front Neurol 2020; 11:702. [PMID: 32765408 PMCID: PMC7380105 DOI: 10.3389/fneur.2020.00702] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the most lethal type of stroke, but there is no specific treatment. After years of effort, neurologists have found that hematoma expansion (HE) is a vital predictor of poor prognosis in ICH patients, with a not uncommon incidence ranging widely from 13 to 38%. Herein, the progress of studies on HE after ICH in recent years is updated, and the topics of definition, prevalence, risk factors, prediction score models, mechanisms, treatment, and prospects of HE are covered in this review. The risk factors and prediction score models, including clinical, imaging, and laboratory characteristics, are elaborated in detail, but limited by sensitivity, specificity, and inconvenience to clinical practice. The management of HE is also discussed from bench work to bed practice. However, the upmost problem at present is that there is no treatment for HE proven to definitely improve clinical outcomes. Further studies are needed to identify more accurate predictors and effective treatment to reduce HE.
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Affiliation(s)
- Zhifang Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mingfeng You
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunnan Long
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rentang Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haoqiang Xu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Quanwei He
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Association of pre- and post-stroke glycemic status with clinical outcome in spontaneous intracerebral hemorrhage. Sci Rep 2019; 9:19054. [PMID: 31836800 PMCID: PMC6911072 DOI: 10.1038/s41598-019-55610-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/09/2019] [Indexed: 01/04/2023] Open
Abstract
In this study, we aimed to disclose the association of pre- and post-stroke glycemic status with clinical outcome in patients with spontaneous intracerebral hemorrhage (sICH). It was a multicenter, prospective, observational cohort study, conducted in 13 hospitals in Beijing from January 2014 to September 2016. The association of admission random blood glucose (RBG), fasting blood glucose (FBG) and hemoglobin A1c (HbA1c) with clinical outcome at 90 days after sICH onset were analyzed comprehensively. Poor outcome was defined as death or modified Rankin Scale (mRS) score >2. The results showed that elevated RBG and FBG were associated with larger hematoma volume, lower GCS, higher NIHSS (P < 0.001), and poor outcome, but HbA1c was not (P > 0.05). In stratified analysis, the association of poor outcome with elevated FBG or RBG retained statistical significance just in patients without diabetes. Kaplan-Meier curve and Cox regression showed that patients with elevated FBG or RBG had significantly higher risk of death within 90 days (P < 0.05). So we conclude that poststroke hyperglycemia was associated with larger hematoma volume, severe neurological damage and poor clinical outcome, but HbA1c was not relevant to hematoma volume or clinical outcome in patients with sICH.
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A paradoxical relationship between hemoglobin A1C and in-hospital mortality in intracerebral hemorrhage patients. Heliyon 2019; 5:e01659. [PMID: 31111113 PMCID: PMC6512558 DOI: 10.1016/j.heliyon.2019.e01659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 02/28/2019] [Accepted: 05/01/2019] [Indexed: 11/23/2022] Open
Abstract
Objectives The relationship between prior glycemic status and outcomes in intracerebral hemorrhage (ICH) is not established. We hypothesized that higher hemoglobin (Hb) A1c is associated with worse outcomes in ICH. Patients and methods Using the GWTG-Stroke registry, data on patients with ICH between April 1, 2003 and September 30, 2015 were harvested. Patients were divided into four ordinal groups based on HbA1c values of <5.7%, 5.7-6.4%, 6.5-8.0% and >8.0%. Outcomes (mortality, modified Rankin Scale (mRS), home discharge and independent ambulatory status) were analyzed for patients overall and separately for patients with or without history of diabetes using multivariable regression models. Results Among 75,455 patients with ICH (with available HbA1c data), patients with lower HbA1c (<5.7%) had higher rates of in-hospital mortality in the entire cohort (15.5%; 3947/25473); as well as those with history of diabetes (19.0%; 542/2852). Among those without history of diabetes, both lower HbA1c (15.1%; 3405/22621) and higher HbA1c (>8.0%), (15.0%; 205/1364) were associated with higher in-hospital mortality. Lower HbA1c was also associated with higher mRS, less chance of going home, and lower likelihood of having independent ambulatory status in patients with prior history of diabetes. Conclusions Among patients with no reported history of diabetes, both very low and very high HbA1c were directly associated with higher in-hospital mortality. Only very low HbA1c was associated with higher mortality in known diabetic patients. Further studies are needed to better define the relationship between HbA1c and outcomes, for it may have important implications for care of ICH patients.
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Zhang F, Zhang S, Tao C, Yang Z, Li X, You C, Xin T, Yang M. Association between serum glucose level and spot sign in intracerebral hemorrhage. Medicine (Baltimore) 2019; 98:e14748. [PMID: 30882643 PMCID: PMC6426545 DOI: 10.1097/md.0000000000014748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Hyperglycemia was proved to cause neuron death in both animal experiments and poor outcome of hemorrhage patients, but the predictive ability of admission blood glucose level for early hematoma growth in patients with intracranial hemorrhage (ICH) is still controversial. Spot sign is a well-established imaging predictor for early hematoma growth, implying active microvascular bleeding. Here, we aim to assess associations between admission serum glucose and early hematoma expansion in ICH patients, as well as spot sign.We retrospectively reviewed all the patients with ICH from January 2017 to March 2018 in West China Hospital, Sichuan University. Admission blood glucose, clinical variables, radiological characteristics, and laboratorial parameters were obtained from medical record. According to computed tomography (CT) and computed tomography angiography (CTA) scan results, hematoma expansion and spot sign were identified by 2 experienced neuroradiologists. Multivariate logistic regression analyses were employed to adjust the associations of hematoma expansion and spot sign with other clinical parameters.Around 42 patients exhibited early hematoma expansions and 26 exhibited spot signs over 138 enrolled patients. The average level of admission blood glucose was 7.55 mmol/L. Multivariate logistic regression analyses revealed that Glasgow Coma Scale (GCS) score on admission, hematoma volume, spot sign, and hyperglycemia were associated with hematoma expansion, whereas admission serum glucose and hematoma size were only associated with spot sign, respectively.Admission blood glucose level is correlated with hematoma growth and incidence of spot sign. These results indicated that hyperglycemia probably plays a critical role in the pathological process of the active bleeding. Further studies should be drawn urgently to understand the potential molecular mechanism of systemic hyperglycemia in affecting prognosis of patients with ICH.
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Affiliation(s)
- Fan Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- Department of Pathology, Case Western Reserve University, Ohio
| | - Si Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chuanyuan Tao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zijia Yang
- Department of Neurosurgery, Chengdu First People's Hospital, Chengdu
| | - Xi Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Xin
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Mu Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- Department of Neurology and Neurosurgery
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Canada
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Sakuta K, Komatsu T, Sakai K, Terasawa Y, Mitsumura H, Iguchi Y. The NAG Scale: Noble Predictive Scale for Hematoma Expansion in Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2018; 27:3675. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/15/2018] [Indexed: 11/16/2022] Open
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Zhang F, Li H, Qian J, Zhang S, Tao C, You C, Yang M. Hyperglycemia Is Associated with Island Sign in Patients with Intracerebral Hemorrhage. World Neurosurg 2018; 119:e703-e709. [DOI: 10.1016/j.wneu.2018.07.251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 07/27/2018] [Accepted: 07/28/2018] [Indexed: 11/15/2022]
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Highest In-Hospital Glucose Measurements are Associated With Neurological Outcomes After Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2018; 27:2662-2668. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/17/2018] [Accepted: 05/22/2018] [Indexed: 12/31/2022] Open
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Sakuta K, Sato T, Komatsu T, Sakai K, Terasawa Y, Mitsumura H, Iguchi Y. The NAG scale: Noble Predictive Scale for Hematoma Expansion in Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2018; 27:2606-2612. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/16/2018] [Accepted: 05/19/2018] [Indexed: 01/04/2023] Open
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Zhang F, Li H, Qian J, Tao C, Zheng J, You C, Yang M. Hyperglycemia Predicts Blend Sign in Patients with Intracerebral Hemorrhage. Med Sci Monit 2018; 24:6237-6244. [PMID: 30191900 PMCID: PMC6139114 DOI: 10.12659/msm.910024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Predictive values of admission blood glucose for early hematoma expansion in patients with intracranial hemorrhage (ICH) remain controversial. Blend sign is a novel image predictor for early hematoma growth that suggests presence of active bleeding. We investigated the association between hyperglycemia and blend sign in predicting early hematoma growth in ICH patients. Material/Methods All patients with intracranial hemorrhage were retrospectively reviewed. Clinical characteristics and radiological parameters were collected. Blood glucose was measured within 24 h after onset. CT scan results for hematoma expansion and blend sign were evaluated by 2 readers. Multivariate logistic regression analyses were applied to reveal the associations between hematoma growth and blend sign, as well as other variables. Results Out of 164 patients with ICH, 52 exhibited early hematoma growth and 18 of these were diagnosed with blend sign. Average blood glucose was 7.53 mmol/L among all patients. By using multivariate analyses, the time of CT scan baseline, GCS score, hematoma size, blend sign, and blood glucose were associated with hematoma expansion, whereas only hyperglycemia was associated with blend sign. Conclusions Admission hyperglycemia is associated with hematoma expansion in the presence of blend sign. These findings suggest that elevated blood glucose is a possible factor predicting continuous bleeding. Strategies to control blood glucose and ameliorate hematoma growth are urgently needed and will be investigated in our future studies.
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Affiliation(s)
- Fan Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Department of Pathology, Case Western Reserve University, Cleveland, OH, USA
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Juan Qian
- Department of Population and Quantitative Health, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Chuanyuan Tao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Mu Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada.,Alan Edwards Centre for Research on Pain, McGill University, Montreal, QC, Canada
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26
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Ding W, Gu Z, Song D, Liu J, Zheng G, Tu C. Development and validation of the hypertensive intracerebral hemorrhage prognosis models. Medicine (Baltimore) 2018; 97:e12446. [PMID: 30278523 PMCID: PMC6181527 DOI: 10.1097/md.0000000000012446] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/24/2018] [Indexed: 12/29/2022] Open
Abstract
To develop and validate the prognosis model of hypertensive intracerebral hemorrhage based on admission characteristics, which would be applied to predict the 3-month outcome.For developing the prognosis models, we studied data from 325 patients with retrospectively consecutive hypertensive intracerebral hemorrhage admitted between 2012 and 2016. The predictive value of admission characteristics was tested in logistic regression models, presenting 3-month outcome as the primary outcome. The performance of the models was tested by discrimination and calibration. After development, internal and external validations were used to test the function.The multivariate analysis of logistic regression indicated that age, Glasgow coma scale score, pupillary light reflex, hypoxemia, intracerebral hemorrhage volume, blood glucose, and D-dimer level were independent factors of the hypertensive intracerebral hemorrhage prognosis model. The prognosis model based on those admission risk factors worked well. The receiver operating characteristic curve was used to analyze the discriminant ability of model A, model A + B, and model A + B + C. Specifically, the area under the receiver operating characteristic curve increased from 0.816 (model A; 95% CI, 0.760-0.872) to 0.913 (model A + B + C; 95% CI, 0.881-0.946), and the models were not overoptimistic and were applicably confirmed by internal and external validations respectively.This prognosis model could be used to predict the prognosis of patients with hypertensive intracerebral hemorrhage early, simply and accurately, contributing to the clinical treatment eventually.
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Affiliation(s)
- Wu Ding
- Department of Oncological Surgery, Shaoxing Second Hospital
| | - Zhiwei Gu
- Department of Neurosurgery, Shaoxing Central Hospital, Shaoxing
| | - Dagang Song
- Department of Neurosurgery, Shaoxing Central Hospital, Shaoxing
| | - Jiansheng Liu
- Department of Neurosurgery, Shaoxing Central Hospital, Shaoxing
| | - Gang Zheng
- Department of Neurosurgery, Shaoxing Central Hospital, Shaoxing
| | - Chuanjian Tu
- Department of Surgery, Shaoxing Keqiao Women & Children's Hospital, China
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27
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Kongwad LI, Hegde A, Menon G, Nair R. Influence of Admission Blood Glucose in Predicting Outcome in Patients With Spontaneous Intracerebral Hematoma. Front Neurol 2018; 9:725. [PMID: 30210444 PMCID: PMC6121104 DOI: 10.3389/fneur.2018.00725] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/09/2018] [Indexed: 01/08/2023] Open
Abstract
Background and Aims: Hyperglycemia or elevated blood glucose levels have been associated with poor outcomes in patients with ischemic stroke yet control of hyperglycemia has not resulted in good outcomes. High admission blood glucose (ABG) values have been mitigated by other poor prognosticators like large hematoma volume, intraventricular extension (IVE) of hematoma and poor GCS. The aim of this study was to evaluate the effects of blood glucose levels at admission, on mortality and functional outcomes at discharge and 3 months follow up. Methods: This was a retrospective observational study conducted at a tertiary care. Patients with spontaneous SICH were enrolled from a prospective SICH register maintained at our hospital. Blood glucose values were recorded on admission. Patients with traumatic hematomas, vascular malformations, aneurysms, and coagulation abnormalities were excluded from our study. Results: A total of 510 patients were included in the study. We dichotomised our cohort into two groups, group A with ABG>160 mg/dl and group B with ABG<160 mg/dl. Mean blood glucose levels in these two groups were 220.73 mg/dl and 124.37 mg/dl respectively, with group A having twice the mortality. mRS at discharge and 3 months was better in Group B (p ≤ 0.001) as compared to Group A. Age, GCS, volume of hematoma, ABG, IVE and Hydrocephalus were significant predictors of mortality and poor outcome on univariate analysis with a p < 0.05. The relationship between ABG and mortality (P = 0.249, 95% CI 0.948-1.006) and outcome (P = 0.538, 95% CI 0.997-1.005) failed to reach statistical significance on multivariate logistic regression. Age, Volume of hematoma and GCS were stronger predictors of mortality and morbidity. Conclusion: Admission blood glucose levels was not an independent predictor of mortality in our study when adjusted with age, GCS, and hematoma volume. The effect of high ABG on SICH outcome is probably multifactorial and warrants further research.
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Affiliation(s)
| | - Ajay Hegde
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
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28
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Feng H, Jin Z, He W, Zhao X. Cerebral venous outflow participates in perihematomal edema after spontaneous intracerebral hemorrhage: A cross-sectional study. Medicine (Baltimore) 2018; 97:e12034. [PMID: 30170413 PMCID: PMC6392674 DOI: 10.1097/md.0000000000012034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cerebrospinal venous anatomy and hemodynamics changes are associated with many central nervous system disorders.The aim of this study was to detect whether perihematomal edema (PHE) after spontaneous intracerebral hemorrhage (sICH) is associated with cerebral venous outflow volume (CVFV) in the internal jugular veins and vertebral veins.Newly diagnosed cases of sICH between April 2016 and March 2017 were enrolled and patients were grouped to the mean value of PHE according to previous study. On computed tomography, absolute PHE volume was calculated as the difference between total lesion volume and intracerebral hemorrhage (ICH) volume. Relative PHE volume was defined as absolute PHE volume divided by ICH volume. CVFV was determined by Doppler ultrasound. Patients were divided according to mean values of absolute PHE at 3 and 12 days, and relative PHE (rPHE) at 3 and 12 days.Significant differences were observed in smoking, alcohol consumption, glycosylated hemoglobin (GHb), secondary intraventricular hemorrhage (sIVH), and CVFV in PHE at 72 hours. Only sIVH and CVFV were significantly different at 12 days in PHE. In rPHE, GHb and sIVH were significantly differed at 72 hours. No significant difference was observed at 12 days in rPHE. The multivariate analyses showed that CVFV was independently associated with late PHE (PHE at 12 ± 3 days) but not with early PHE (PHE at 72 hours) and rPHE.These results suggest that CVFV may be closely related to PHE after sICH.
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Affiliation(s)
- Hao Feng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
- China National Clinical Research Center for Neurological Diseases
- Center of Stroke, Beijing Institute for Brain Disorders
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
| | - Zhanqiang Jin
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wen He
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
- China National Clinical Research Center for Neurological Diseases
- Center of Stroke, Beijing Institute for Brain Disorders
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
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Zheng J, Yu Z, Ma L, Guo R, Lin S, You C, Li H. Association Between Blood Glucose and Functional Outcome in Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 114:e756-e765. [PMID: 29555604 DOI: 10.1016/j.wneu.2018.03.077] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/06/2018] [Accepted: 03/09/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a devastating subtype of stroke. Patients with ICH have poor functional outcomes. The association between blood glucose level and functional outcome in ICH remains unclear. This systematic review and meta-analysis aimed to investigate the association between blood glucose level and functional outcomes in patients with ICH. METHODS Literature was searched systemically in PubMed, EMBASE, Web of Science, and Cochrane Library. Published cohort studies evaluating the association between blood glucose and functional outcome in patients with ICH were included. This meta-analysis was performed using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS A total of 16 studies were included in our meta-analysis. Our data show that hyperglycemia defined by cutoff values was significantly associated with unfavorable functional outcome (OR, 1.80; 95% CI, 1.36-2.39; P < 0.001). Our analysis also suggested a significant association between increased blood glucose levels and functional outcomes (OR, 1.05; 95% CI, 1.03-1.07; P < 0.001). CONCLUSIONS High blood glucose level is significantly associated with poor functional outcome in ICH. Further studies with larger sample sizes, more time points, and longer follow-up times are necessary to confirm this association.
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Affiliation(s)
- Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rui Guo
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sen Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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30
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Suo Y, Chen WQ, Pan YS, Peng YJ, Yan HY, Zhao XQ, Liu LP, Wang YL, Liu GF, Wang YJ. The max-intracerebral hemorrhage score predicts long-term outcome of intracerebral hemorrhage. CNS Neurosci Ther 2018. [PMID: 29529353 DOI: 10.1111/cns.12846] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
AIMS Little is known about the performance of the maximally treated intracerebral hemorrhage (max-ICH) score in predicting unfavorable long-term functional outcome and death in patients with intracerebral hemorrhage (ICH) in China. We aimed to validate the performance of the max-ICH score and compared it with other recognized scores. METHODS We derived data from the China National Stroke Registry (CNSR). Receiver-operating characteristic (ROC) analysis and Hosmer-Lemeshow test were used to measure the score performance. We compared the performance of max-ICH score with six recognized models, including the ICH score, ICH functional outcome score (ICH-FOS), Essen-ICH score, modified intracerebral hemorrhage (MICH) score, intracerebral hemorrhage grading scale (ICH-GS), and functional outcome (FUNC) score. RESULTS A total of 2581 patients with spontaneous ICH were enrolled in the study. The max-ICH score was similar or superior to the six existing scores in predicting long-term unfavorable functional outcome after ICH with good discrimination (AUC 0.83, 95% confidence interval [CI] 0.81-0.84) and calibration (Hosmer-Lemeshow P = 0.19). For predicting death, the AUC of max-ICH was 0.81 (95% CI 0.79-0.83). CONCLUSIONS The easy-to-use max-ICH score is a reliable tool to predict unfavorable long-term (12-month) functional outcome and death after intracerebral hemorrhage in the Chinese population.
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Affiliation(s)
- Yue Suo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wei-Qi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yue-Song Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Yu-Jing Peng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Hong-Yi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xing-Quan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Li-Ping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi-Long Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Gai-Fen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yong-Jun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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31
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Fuentes B, Ntaios G, Putaala J, Thomas B, Turc G, Díez-Tejedor E. European Stroke Organisation (ESO) guidelines on glycaemia management in acute stroke. Eur Stroke J 2017; 3:5-21. [PMID: 31008333 DOI: 10.1177/2396987317742065] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 10/14/2017] [Indexed: 12/19/2022] Open
Abstract
Background Hyperglycaemia is a frequent complication in acute stroke that has been shown to be independently associated with larger infarct size, haematoma growth, poor clinical outcome and mortality. This Guideline Document presents the European Stroke Organisation (ESO) Guidelines for the management of blood glucose levels in patients with acute ischemic or haemorrhagic stroke. Methods The working group identified related questions and developed its recommendations based on evidence from randomised controlled trials following the standard operating procedure of the ESO. This Guideline Document was reviewed and approved by the European Stroke Organisation Guidelines Committee and the European Stroke Organisation Executive Committee. Results We found low-quality evidence from clinical trials in ischemic or haemorrhagic stroke exploring the use of intravenous insulin aimed to achieve a tight glycaemic control with different glucose level targets and several other sources of heterogeneity. None of these trials neither the meta-analysis of them have demonstrated any significant benefit of tight glycaemic control with intravenous insulin in acute ischemic or haemorrhagic stroke patients on functional outcome or in survival and they have shown an increased risk for hypoglycaemia. Conclusions We suggest against the routine use of tight glycaemic control with intravenous insulin as a means to improve outcomes. The currently available data about the management of glycaemia in patients with acute stroke are limited and the strengths of the recommendations are therefore weak. Nevertheless, this does not prevent that hyperglycaemia in acute stroke patients could be treated as any other hospitalised patient.
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Affiliation(s)
- Blanca Fuentes
- 1Department of Neurology and Stroke Center, La Paz University Hospital, Autonoma University of Madrid, IdiPaz Health Research Institute, Madrid, Spain
| | - George Ntaios
- 2Department of Medicine, University of Thessaly, Larissa, Greece
| | - Jukka Putaala
- 3Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Brenda Thomas
- Centre for Clinical Brain Sciences (CCBS), University of Edinburgh, Edinburgh, Scotland
| | - Guillaume Turc
- Department of Neurology, Sainte-Anne Hospital & INSERM U894, Paris, France
| | - Exuperio Díez-Tejedor
- 1Department of Neurology and Stroke Center, La Paz University Hospital, Autonoma University of Madrid, IdiPaz Health Research Institute, Madrid, Spain
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Abstract
Although commonly arising from poorly controlled hypertension, spontaneous intracerebral hemorrhage may occur secondary to several other etiologies. Clinical presentation to the emergency department ranges from headache with vomiting to coma. In addition to managing the ABCs, the crux of emergency management lies in stopping hematoma expansion and other complications to prevent clinical deterioration. This may be achieved primarily through anticoagulation reversal, blood pressure, empiric management of intracranial pressure, and early neurosurgical consultation for posterior fossa hemorrhage. Patients must be admitted to intensive care. The effects of intracerebral hemorrhage are potentially devastating with very poor prognoses for functional outcome and mortality.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA.
| | - Cappi Lay
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA; Department of Neurocritical Care, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
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33
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Wu TY, Putaala J, Sharma G, Strbian D, Tatlisumak T, Davis SM, Meretoja A. Persistent Hyperglycemia Is Associated With Increased Mortality After Intracerebral Hemorrhage. J Am Heart Assoc 2017; 6:e005760. [PMID: 28768643 PMCID: PMC5586431 DOI: 10.1161/jaha.117.005760] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 06/22/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hyperglycemia may be associated with worse outcome after intracerebral hemorrhage (ICH). We assessed the association of early glycemic trajectory on ICH mortality and edema growth. METHODS AND RESULTS We included patients from the Helsinki ICH study with glucose measurements at least once between both 0 to 24 and 24 to 72 hours from onset. Hyperglycemia was defined as blood glucose ≥8 mmol/L (144 mg/dL) based on the local threshold for treatment. Glycemic trajectory was defined on maximum values 0 to 24 and 24 to 72 hours after ICH: (1) persistent normoglycemia in both epochs; (2) late hyperglycemia (only between 24 and 72 hours); (3) early hyperglycemia (only before 24 hours); and (4) persistent hyperglycemia in both epochs. Logistic regression with known predictors of outcome estimated the association of glycemic trajectory and 6-month mortality. A generalized linear model assessed the association of glycemic trajectory and interpolated 72-hour edema extension distance. A total of 576 patients met eligibility criteria, of whom 214 (37.2%) had persistent normoglycemia, 44 (7.6%) late hyperglycemia, 151 (26.2%) early hyperglycemia, and 167 (29.0%) persistent hyperglycemia. Six-month mortality was higher in the persistent (51.1%) and early (26.3%) hyperglycemia groups than the normoglycemia (19.0%) and late hyperglycemia (3.6%) groups. Persistent hyperglycemia was associated with 6-month mortality (odds ratio 3.675, 95% CI 1.989-6.792; P<0.001). Both univariate (P=0.426) and multivariable (P=0.493) generalized linear model analyses showed no association between glycemic trajectory and 72-hour edema extension distance. CONCLUSION Early hyperglycemia after ICH is harmful if it is persistent. Strategies to achieve glycemic control after ICH may influence patient outcome and need to be assessed in clinical trials.
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Affiliation(s)
- Teddy Y Wu
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Gagan Sharma
- Department of Radiology at the Royal Melbourne Hospital, University of Melbourne, Australia
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
- Department of Clinical Neurosciences, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia
| | - Atte Meretoja
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
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34
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Chen S, Zhao B, Wang W, Shi L, Reis C, Zhang J. Predictors of hematoma expansion predictors after intracerebral hemorrhage. Oncotarget 2017; 8:89348-89363. [PMID: 29179524 PMCID: PMC5687694 DOI: 10.18632/oncotarget.19366] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 06/19/2017] [Indexed: 01/04/2023] Open
Abstract
Despite years of effort, intracerebral hemorrhage (ICH) remains the most devastating form of stroke with more than 40% 30-day mortality worldwide. Hematoma expansion (HE), which occurs in one third of ICH patients, is strongly predictive of worse prognosis and potentially preventable if high-risk patients were identified in the early phase of ICH. In this review, we summarize data from recent studies on HE prediction and classify those potential indicators into four categories: clinical (severity of consciousness disturbance; blood pressure; blood glucose at and after admission); laboratory (hematologic parameters of coagulation, inflammation and microvascular integrity status), radiographic (interval time from ICH onset; baseline volume, shape and density of hematoma; intraventricular hemorrhage; especially the spot sign and modified spot sign) and integrated predictors (9-point or 24-point clinical prediction algorithm and PREDICT A/B). We discuss those predictors’ underlying pathophysiology in HE and present opportunities to develop future therapeutic strategies.
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Affiliation(s)
- Sheng Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Binjie Zhao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Wei Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Ligen Shi
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Cesar Reis
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, California, USA.,Department of Preventive Medicine, Loma Linda University, Loma Linda, California, USA
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
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35
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Huang YH, Chung CL, Tsai HP, Wu SC, Chang CZ, Chai CY, Lee TC, Kwan AL. Hyperglycemia Aggravates Cerebral Vasospasm after Subarachnoid Hemorrhage in a Rat Model. Neurosurgery 2017; 80:809-815. [DOI: 10.1093/neuros/nyx016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 03/19/2017] [Indexed: 11/13/2022] Open
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36
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Tao C, Hu X, Wang J, You C. Effect of Admission Hyperglycemia on 6-Month Functional Outcome in Patients with Spontaneous Cerebellar Hemorrhage. Med Sci Monit 2017; 23:1200-1207. [PMID: 28273059 PMCID: PMC5353882 DOI: 10.12659/msm.900202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Cerebellar hemorrhage (CH) has a quite different treatment strategy and prognostic factors compared with supratentorial intracerebral hemorrhage (ICH). The prognostic role of hyperglycemia has been discussed mainly in cases of supratentorial hemorrhage; it remains to be elucidated following CH. We aimed to determine the association of hyperglycemia on admission with 6-month functional outcome in CH patients. Material/Methods We retrospectively analyzed 77 patients with acute CH between September 2010 and April 2015 in West China Hospital. Blood glucose level was measured when the patients were admitted. Primary outcome was 6-month functional outcome, which could comprehensively reflect the patient’s recovery of physical and social ability after stroke and was assessed by the modified Rankin scale (mRS). Association of hyperglycemia with functional outcome was identified in logistic regression models. Results There were 50 (64.9%) patients with poor functional outcomes. Patients with poor outcome were much older (P<0.001) and had a significantly higher glucose level on admission (P<0.001), a lower Glasgow Coma Scale score (P<0.001), a larger hematoma (P=0.003), and a higher incidence of intraventricular extension (P=0.002), brainstem compression (P=0.013), and hydrocephalus (P=0.023). Multivariate analysis showed that hyperglycemia (OR 1.50, 95% CI 1.07–2.08, P=0.017 when glucose level was analyzed as a continuous variable; OR 7.46, 95% CI 1.41–39.51, P=0.018 when glucose level was dichotomized by the critical threshold of 6.78 mmol/L) emerged as an independent predictor for adverse functional outcome at 6 months. Conclusions To the best of our knowledge, this is the first study focusing on the relationship between hyperglycemia and long-term functional outcome after CH. The study combined with previous pertinent reports definitely indicates the poor effect of hyperglycemia on both supra- and infratentorial ICH independent of hemorrhage site. Therefore, further controlled trials are urgently needed to evaluate the benefits of glucose-lowing treatment.
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Affiliation(s)
- Chuanyuan Tao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jiajing Wang
- Department of Critical Care Medicine, Neurosurgical Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
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Muschelli J, Sweeney EM, Ullman NL, Vespa P, Hanley DF, Crainiceanu CM. PItcHPERFeCT: Primary Intracranial Hemorrhage Probability Estimation using Random Forests on CT. Neuroimage Clin 2017; 14:379-390. [PMID: 28275541 PMCID: PMC5328741 DOI: 10.1016/j.nicl.2017.02.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/20/2016] [Accepted: 02/09/2017] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH), where a blood vessel ruptures into areas of the brain, accounts for approximately 10-15% of all strokes. X-ray computed tomography (CT) scanning is largely used to assess the location and volume of these hemorrhages. Manual segmentation of the CT scan using planimetry by an expert reader is the gold standard for volume estimation, but is time-consuming and has within- and across-reader variability. We propose a fully automated segmentation approach using a random forest algorithm with features extracted from X-ray computed tomography (CT) scans. METHODS The Minimally Invasive Surgery plus rt-PA in ICH Evacuation (MISTIE) trial was a multi-site Phase II clinical trial that tested the safety of hemorrhage removal using recombinant-tissue plasminogen activator (rt-PA). For this analysis, we use 112 baseline CT scans from patients enrolled in the MISTE trial, one CT scan per patient. ICH was manually segmented on these CT scans by expert readers. We derived a set of imaging predictors from each scan. Using 10 randomly-selected scans, we used a first-pass voxel selection procedure based on quantiles of a set of predictors and then built 4 models estimating the voxel-level probability of ICH. The models used were: 1) logistic regression, 2) logistic regression with a penalty on the model parameters using LASSO, 3) a generalized additive model (GAM) and 4) a random forest classifier. The remaining 102 scans were used for model validation.For each validation scan, the model predicted the probability of ICH at each voxel. These voxel-level probabilities were then thresholded to produce binary segmentations of the hemorrhage. These masks were compared to the manual segmentations using the Dice Similarity Index (DSI) and the correlation of hemorrhage volume of between the two segmentations. We tested equality of median DSI using the Kruskal-Wallis test across the 4 models. We tested equality of the median DSI from sets of 2 models using a Wilcoxon signed-rank test. RESULTS All results presented are for the 102 scans in the validation set. The median DSI for each model was: 0.89 (logistic), 0.885 (LASSO), 0.88 (GAM), and 0.899 (random forest). Using the random forest results in a slightly higher median DSI compared to the other models. After Bonferroni correction, the hypothesis of equality of median DSI was rejected only when comparing the random forest DSI to the DSI from the logistic (p < 0.001), LASSO (p < 0.001), or GAM (p < 0.001) models. In practical terms the difference between the random forest and the logistic regression is quite small. The correlation (95% CI) between the volume from manual segmentation and the predicted volume was 0.93 (0.9,0.95) for the random forest model. These results indicate that random forest approach can achieve accurate segmentation of ICH in a population of patients from a variety of imaging centers. We provide an R package (https://github.com/muschellij2/ichseg) and a Shiny R application online (http://johnmuschelli.com/ich_segment_all.html) for implementing and testing the proposed approach.
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Affiliation(s)
- John Muschelli
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth M. Sweeney
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Natalie L. Ullman
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Paul Vespa
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Daniel F. Hanley
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ciprian M. Crainiceanu
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Wu TY, Campbell BC, Strbian D, Yassi N, Putaala J, Tatlisumak T, Davis SM, Meretoja A. Impact of pre-stroke sulphonylurea and metformin use on mortality of intracerebral haemorrhage. Eur Stroke J 2016; 1:302-309. [PMID: 31008292 DOI: 10.1177/2396987316666617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/08/2016] [Indexed: 11/16/2022] Open
Abstract
Introduction Few proven therapies for intracerebral haemorrhage exist. Preliminary observational evidence suggests that sulphonylurea and metformin may be protective in ischaemic stroke. We assessed the association of pre-intracerebral haemorrhage sulphonylurea and metformin use on outcome in diabetic patients. Methods We merged datasets from the consecutive single-centre Helsinki ICH Study, the intracerebral haemorrhage arm of the Virtual International Stroke Trials Archive (VISTA-ICH) and the Royal Melbourne Hospital ICH Study. Logistic regression adjusting for known predictors of intracerebral haemorrhage outcome (age, sex, baseline Glasgow Coma Scale, National Institutes of Health Stroke Scale, intracerebral haemorrhage volume, infratentorial location, intraventricular extension, and pre-intracerebral haemorrhage warfarin use) estimated the association of metformin and sulphonylurea with all-cause 90-day mortality. Results From a dataset of 2404 consecutive intracerebral haemorrhage patients, we included 374 (16%) patients with diabetes. Of these, 113 (30%) died by 90 days. Metformin was used in 148 (40%) patients and sulphonylurea in 115 (31%) patients at intracerebral haemorrhage onset. After adjusting for baseline characteristics, metformin use was associated with lower 90-day mortality (OR 0.51; 95% CI 0.26-0.97; p = 0.041) irrespective of whether the drug was continued or not during the admission, while sulphonylurea use was not associated with mortality (OR 0.96; 95% CI 0.49-1.88; p = 0.906). Haematoma location or evacuation did not modify the association between metformin and mortality; neither did adding insulin use, baseline glucose and serum creatinine into the model (OR 0.50; 95% CI 0.25-0.99; p = 0.047). Conclusion Pre-intracerebral haemorrhage metformin use was associated with improved outcome in diabetic intracerebral haemorrhage patients. Our results generate hypotheses which after further validation could be tested in clinical trials.
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Affiliation(s)
- Teddy Y Wu
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Bruce Cv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.,Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Atte Meretoja
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.,Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
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Mittal MK, LacKamp A. Intracerebral Hemorrhage: Perihemorrhagic Edema and Secondary Hematoma Expansion: From Bench Work to Ongoing Controversies. Front Neurol 2016; 7:210. [PMID: 27917153 PMCID: PMC5116572 DOI: 10.3389/fneur.2016.00210] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/08/2016] [Indexed: 12/30/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a medical emergency, which often leads to severe disability and death. ICH-related poor outcomes are due to primary injury causing structural damage and mass effect and secondary injury in the perihemorrhagic region over several days to weeks. Secondary injury after ICH can be due to hematoma expansion (HE) or a consequence of repair pathway along the continuum of neuroinflammation, neuronal death, and perihemorrhagic edema (PHE). This review article is focused on PHE and HE and will cover the animal studies, related human studies, and clinical trials relating to these mechanisms of secondary brain injury in ICH patients.
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Affiliation(s)
- Manoj K Mittal
- Department of Neurology, University of Kansas Medical Center , Kansas City, KS , USA
| | - Aaron LacKamp
- Department of Anesthesiology, University of Kansas Medical Center , Kansas City, KS , USA
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Kobata H, Sugie A, Suehiro E, Dohi K, Kaneko T, Fujita M, Oda Y, Kuroda Y, Yamashita S, Maekawa T. Association between Blood Glucose Levels the Day after Targeted Temperature Initiation and Outcome in Traumatic Brain Injury: A Post-Hoc Analysis of the B-HYPO Study. J Neurotrauma 2016; 34:987-995. [PMID: 27673360 DOI: 10.1089/neu.2016.4662] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
We investigated associations between blood glucose levels and clinical outcomes in participants of the multi-center randomized controlled Brain-Hypothermia (B-HYPO) study. Patients with severe traumatic brain injury (TBI, Glasgow Coma Scale 4-8) were assigned to therapeutic hypothermia (TH, 32-34°C, n = 98) or fever control (35.5-37.0°C, n = 50) groups. TH patients were cooled as soon as possible for ≥72 h and rewarmed at a rate of <1°C/d. We recorded blood glucose (BG) levels on days 0, 1, and 3 after treatment initiation, and day 1 after rewarming. The Glasgow Outcome Scale was assessed at 6 months. Median BG levels decreased from day 0 to day 1 (163 vs. 132 mg/dL, p = 0.0062) in the fever control group. In contrast, a decrease was observed from day 1 to day 3 (157.5 vs. 126 mg/dL, p < 0.001) in the TH group. Day 1 BG was higher in the TH group compared with the fever control group (p = 0.0252). At day 0, BG levels were higher in non-survivors compared with survivors across all patients (p = 0.0035), the TH group (p = 0.0125), and the non-surgical group (p = 0.0236). Higher day 1 BG levels were observed in non-survivors compared with survivors across all patients (p = 0.0071), the fever control group (p = 0.0495), and the surgical group (p = 0.0364). In the TH group, the initial stress hyperglycemia was sustained the next day after TH induction. Day 1 BG predicted outcome in TBI patients with TH and fever control. Our findings indicate the significance of BG control particularly during TH treatment.
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Affiliation(s)
- Hitoshi Kobata
- 1 Osaka Mishima Emergency Critical Care Center , Osaka, Japan
| | - Akira Sugie
- 1 Osaka Mishima Emergency Critical Care Center , Osaka, Japan
| | - Eiichi Suehiro
- 2 Department of Neurosurgery, Yamaguchi University School of Medicine , Yamaguchi, Japan
| | - Kenji Dohi
- 3 Department of Emergency Medicine, The Jikei University , Tokyo, Japan
| | - Tadashi Kaneko
- 4 Emergency and General Medicine, Kumamoto University Hospital , Kumamoto, Japan
| | - Motoki Fujita
- 5 Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital , Yamaguchi, Japan
| | - Yasutaka Oda
- 5 Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital , Yamaguchi, Japan
| | - Yasuhiro Kuroda
- 6 Department of Emergency Medicine, Kagawa University School of Medicine , Kagawa, Japan
| | - Susumu Yamashita
- 7 Emergency and Critical Care Center , Tokuyama Central Hospital, Yamaguchi, Japan
| | - Takeshi Maekawa
- 8 Yamaguchi Prefectural Grand Medical Center , Yamaguchi, Japan
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Morotti A, Goldstein JN. Diagnosis and Management of Acute Intracerebral Hemorrhage. Emerg Med Clin North Am 2016; 34:883-899. [PMID: 27741993 DOI: 10.1016/j.emc.2016.06.010] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Intracerebral hemorrhage (ICH) is the deadliest type of stroke and up to half of patients die in hospital. Blood pressure management, coagulopathy reversal, and intracranial pressure control are the mainstays of acute ICH treatment. Prevention of hematoma expansion and minimally invasive hematoma evacuation are promising therapeutic strategies under investigation. This article provides an updated review on ICH diagnosis and management in the emergency department.
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Affiliation(s)
- Andrea Morotti
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA 02114, USA
| | - Joshua N Goldstein
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA 02114, USA; Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA.
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Yang J, Arima H, Wu G, Heeley E, Delcourt C, Zhou J, Chen G, Wang X, Zhang S, Yu S, Chalmers J, Anderson CS. Prognostic Significance of Perihematomal Edema in Acute Intracerebral Hemorrhage. Stroke 2015; 46:1009-13. [PMID: 25712944 DOI: 10.1161/strokeaha.114.007154] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jie Yang
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - Hisatomi Arima
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - Guojun Wu
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - Emma Heeley
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - Candice Delcourt
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - Junshan Zhou
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - Guofang Chen
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - Xia Wang
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - Shihong Zhang
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - Sungwook Yu
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - John Chalmers
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
| | - Craig S. Anderson
- From the Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y., J.Z.); The George Institute for Global Health, Central Clinical School, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (J.Y., H.A., G.W., E.H., C.D., G.C., X.W., S.Z., S.Y., J.C., C.S.A.); Department of Neurology, Hebei Yutian Hospital, Tangshan, China (G.W.); Department of Neurology, Xuzhou Central Hospital, Xuzhou, China (G
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Blood glucose levels during the initial 72h and 3-month functional outcomes in acute intracerebral hemorrhage: The SAMURAI–ICH study. J Neurol Sci 2015; 350:75-8. [DOI: 10.1016/j.jns.2015.02.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/05/2015] [Accepted: 02/09/2015] [Indexed: 11/20/2022]
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Wang MD, Wang Y, Xia YP, Dai JW, Gao L, Wang SQ, Wang HJ, Mao L, Li M, Yu SM, Tu Y, He QW, Zhang GP, Wang L, Xu GZ, Xu HB, Zhu LQ, Hu B. High Serum MiR-130a Levels Are Associated with Severe Perihematomal Edema and Predict Adverse Outcome in Acute ICH. Mol Neurobiol 2015; 53:1310-1321. [PMID: 25631713 DOI: 10.1007/s12035-015-9099-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 01/12/2015] [Indexed: 12/12/2022]
Abstract
The development and/or progression of perihematomal edema (PHE) in patients with acute spontaneous intracerebral hemorrhage (ICH) vary substantially with different individuals. Although hematoma volume is a useful indicator for predicting PHE, its predictive power was not good at the early stage of ICH. Better predictors are urgently needed. In this study, we found that miR-130a was elevated in the serum of ICH patients and was an independent indicator positively associated with PHE volume within the first 3 days after onset. The R (2) was further evaluated when it is used in combination with hematoma mass. Serum miR-130a levels were associated with clinical outcome (National Institute of Health Stroke Scale (NIHSS) scores at day 14 and modified Rankin Scale (mRS) scores at day 90) only in patients with deep hematoma. Moreover, miR-130a was significantly increased in rat serum and perihematomal tissues and was in line with the change in brain edema. MiR-130a inhibitors reduced brain edema, blood-brain barrier (BBB) permeability, and increased neurological deficit scores, and miR-130a mimics increased monolayer permeability. Thrombin-stimulated brain microvascular endothelial cells (BMECs) were a main source of miR-130a under ICH. In the experimental model, the elevated miR-130a level was accompanied by the decreased caveolin-1 and increased matrix metalloproleinase (MMP)-2/9. Meanwhile, caveolin-1 (cav-1) was reduced by miR-130a mimics, accompanied by an increase in MMP-2/9 expression. The upregulated MMP-2/9 was then downregulated by cavtratin, a cav-1 scaffolding domain peptide. This regulation mechanism was authenticated in a thrombin-induced cellular ICH model. Our results suggest that serum miR-130a may serve as a useful early biomarker for monitoring post-ICH PHE and predicting prognosis and may be helpful in the decision-making of individualized therapy.
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Affiliation(s)
- Meng-Die Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Yong Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Yuan-Peng Xia
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Jing-Wen Dai
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Lin Gao
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Si-Qi Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Hai-Jun Wang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Ling Mao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Man Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Shi-Meng Yu
- Department of Neurology, The Attached Hospital of Xinyang Vocational Technical College, Daqing Road, Xinyang, 464000, People's Republic of China
| | - Yan Tu
- Department of Geratology, Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Donghu Road, Wuhan, 430077, People's Republic of China
| | - Quan-Wei He
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Guo-Peng Zhang
- Department of Nuclear Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430030, People's Republic of China
| | - Lei Wang
- Department of Neurosurgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Shengli Street, Wuhan, 430014, People's Republic of China
| | - Guo-Zheng Xu
- Department of Neurosurgery, Wuhan General Hospital of Guangzhou Command, Wuluo Road, Wuhan, 430070, People's Republic of China
| | - Hai-Bo Xu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China
| | - Ling-Qiang Zhu
- Department of Pathophysiology, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430030, People's Republic of China.
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430022, People's Republic of China. .,Key Laboratory of Neurological Disease, Ministry of Education, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 430030, People's Republic of China.
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Urday S, Kimberly WT, Beslow LA, Vortmeyer AO, Selim MH, Rosand J, Simard JM, Sheth KN. Targeting secondary injury in intracerebral haemorrhage--perihaematomal oedema. Nat Rev Neurol 2015; 11:111-22. [PMID: 25623787 DOI: 10.1038/nrneurol.2014.264] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Perihaematomal oedema (PHO) is an important pathophysiological marker of secondary injury in intracerebral haemorrhage (ICH). In this Review, we describe a novel method to conceptualize PHO formation within the framework of Starling's principle of movement of fluid across a capillary wall. We consider progression of PHO through three stages, characterized by ionic oedema (stage 1) and progressive vasogenic oedema (stages 2 and 3). In this context, possible modifiers of PHO volume and their value in identifying patients who would benefit from therapies that target secondary injury are discussed; the practicalities of using neuroimaging to measure PHO volume are also considered. We examine whether PHO can be used as a predictor of neurological outcome following ICH, and we provide an overview of emerging therapies. Our discussion emphasizes that PHO has clinical relevance both as a therapeutic target, owing to its augmentation of the mass effect of a haemorrhage, and as a surrogate marker for novel interventions that target secondary injury.
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Affiliation(s)
- Sebastian Urday
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Lauren A Beslow
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Alexander O Vortmeyer
- Department of Pathology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Magdy H Selim
- Department of Neurology, Beth Israel Deaconess Medical Centre, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201-1559, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
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Chen S, Zeng L, Hu Z. Progressing haemorrhagic stroke: categories, causes, mechanisms and managements. J Neurol 2014; 261:2061-78. [PMID: 24595959 PMCID: PMC4221651 DOI: 10.1007/s00415-014-7291-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 02/14/2014] [Accepted: 02/17/2014] [Indexed: 01/19/2023]
Abstract
Haemorrhagic stroke is a severe stroke subtype with high rates of morbidity and mortality. Although this condition has been recognised for a long time, the progressing haemorrhagic stroke has not received adequate attention, and it accounts for an even worse clinical outcome than the nonprogressing types of haemorrhagic stroke. In this review article, we categorised the progressing haemorrhagic stroke into acute progressing haemorrhagic stroke, subacute haemorrhagic stroke, and chronic progressing haemorrhagic stroke. Haematoma expansion, intraventricular haemorrhage, perihaematomal oedema, and inflammation, can all cause an acute progression of haemorrhagic stroke. Specific 'second peak' of perihaematomal oedema after intracerebral haemorrhage and 'tension haematoma' are the primary causes of subacute progression. For the chronic progressing haemorrhagic stroke, the occult vascular malformations, trauma, or radiologic brain surgeries can all cause a slowly expanding encapsulated haematoma. The mechanisms to each type of progressing haemorrhagic stroke is different, and the management of these three subtypes differs according to their causes and mechanisms. Conservative treatments are primarily considered in the acute progressing haemorrhagic stroke, whereas surgery is considered in the remaining two types.
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Affiliation(s)
- Shiyu Chen
- Department of Neurology, Xiangya Second Hospital, Central South University, 139 Renmin Road, Changsha, 410011 Hunan People’s Republic of China
| | - Liuwang Zeng
- Department of Neurology, Xiangya Second Hospital, Central South University, 139 Renmin Road, Changsha, 410011 Hunan People’s Republic of China
| | - Zhiping Hu
- Department of Neurology, Xiangya Second Hospital, Central South University, 139 Renmin Road, Changsha, 410011 Hunan People’s Republic of China
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Ciura VA, Brouwers HB, Pizzolato R, Ortiz CJ, Rosand J, Goldstein JN, Greenberg SM, Pomerantz SR, Gonzalez RG, Romero JM. Spot sign on 90-second delayed computed tomography angiography improves sensitivity for hematoma expansion and mortality: prospective study. Stroke 2014; 45:3293-7. [PMID: 25300974 DOI: 10.1161/strokeaha.114.005570] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The computed tomography angiography (CTA) spot sign is a validated biomarker for poor outcome and hematoma expansion in intracerebral hemorrhage. The spot sign has proven to be a dynamic entity, with multimodal imaging proving to be of additional value. We investigated whether the addition of a 90-second delayed CTA acquisition would capture additional intracerebral hemorrhage patients with the spot sign and increase the sensitivity of the spot sign. METHODS We prospectively enrolled consecutive intracerebral hemorrhage patients undergoing first pass and 90-second delayed CTA for 18 months at a single academic center. Univariate and multivariate logistic regression were performed to assess clinical and neuroimaging covariates for relationship with hematoma expansion and mortality. RESULTS Sensitivity of the spot sign for hematoma expansion on first pass CTA was 55%, which increased to 64% if the spot sign was present on either CTA acquisition. In multivariate analysis the spot sign presence was associated with significant hematoma expansion: odds ratio, 17.7 (95% confidence interval, 3.7-84.2; P=0.0004), 8.3 (95% confidence interval, 2.0-33.4; P=0.004), and 12.0 (95% confidence interval, 2.9-50.5; P=0.0008) if present on first pass, delayed, or either CTA acquisition, respectively. Spot sign presence on either acquisitions was also significant for mortality. CONCLUSIONS We demonstrate improved sensitivity for predicting hematoma expansion and poor outcome by adding a 90-second delayed CTA, which may enhance selection of patients who may benefit from hemostatic therapy.
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Affiliation(s)
- Viesha A Ciura
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - H Bart Brouwers
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Raffaella Pizzolato
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Claudia J Ortiz
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Jonathan Rosand
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Joshua N Goldstein
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Steven M Greenberg
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Stuart R Pomerantz
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - R Gilberto Gonzalez
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Javier M Romero
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.).
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Liu RY, Wang JJ, Qiu X, Wu JM. Acute hyperglycemia together with hematoma of high-glucose blood exacerbates neurological injury in a rat model of intracerebral hemorrhage. Neurosci Bull 2014; 30:90-8. [PMID: 23884876 PMCID: PMC5561852 DOI: 10.1007/s12264-013-1371-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 06/09/2013] [Indexed: 01/27/2023] Open
Abstract
Recent evidence suggests that admission hyperglycemia has deleterious effects on the survival and functional outcome of patients with intracerebral hemorrhage (ICH). In this study, we first induced acute hyperglycemia in male adult Sprague-Dawley rats by intraperitoneal injection of 50% glucose (6 mL/kg), and created the ICH model thereafter by delivering autologous whole blood or homologous normal-glucose blood into the right basal ganglia. Twenty-four hours later, we assessed the neurological injury, evaluated the hematoma and brain water content, and investigated autophagy. We found elevations of neurological deficit scores, brain water content, and microtubule-associated protein light chain-3 (LC3) and beclin-1 protein levels, and decreased SQSTM1/ p62 levels after ICH with normal-glucose blood (without hyperglycemia). Acute hyperglycemia with ICH of high-glucose blood hematoma was associated with significantly increased forelimb-use asymmetry test scores, brain water content and SQSTM1/p62 protein levels, and evident decreases in the ratio of LC3-II/LC3-I and beclin-1 protein levels. On the other hand, acute hyperglycemia and ICH with normal-glucose blood hematoma only slightly increased the neurological deficit scores and brain water content (P >0.05). In conclusion, the autophagy pathway was activated after ICH, and acute hyperglycemia with hematoma of high-glucose blood exacerbates the neurological injury, and reduces autophagy around the hematoma.
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Affiliation(s)
- Rong-Yi Liu
- Department of Neurology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000 China
| | - Jun-Jun Wang
- Department of Neurology, Zhejiang Hospital, Hangzhou, 310000 China
| | - Xia Qiu
- Department of Neurology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000 China
| | - Ji-Min Wu
- Department of Neurology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000 China
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Liu X, You J, Zhao D, Guo M, Pan Y, Gao L, Liang X, Ma C. Dysregulated expression of T cell immunoglobulin and mucin domain 3 is associated with the disease severity and the outcome of patients with spontaneous intracerebral hemorrhage. Clin Biochem 2013; 46:1502-8. [PMID: 23665438 PMCID: PMC7124273 DOI: 10.1016/j.clinbiochem.2013.04.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 04/25/2013] [Accepted: 04/27/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We aimed to investigate the expression of T cell immunoglobulin and mucin domain 3 (Tim-3) on peripheral blood cells in spontaneous intracerebral hemorrhage (ICH) patients and to analyze its clinical significance. DESIGN AND METHODS Tim-3 expression on peripheral immunocytes from ICH patients and healthy volunteers was measured by flow cytometry. The correlation between Tim-3 expression and the clinical indices was estimated using linear regression. RESULTS Tim-3 expressions on peripheral CD3⁺ T cells and CD8⁺ T cells in ICH patients are significantly downregulated, while Tim-3 expressions on CD14⁺ monocytes and CD16⁺CD56⁺ NK cells are increased. Furthermore, Tim-3 expression on peripheral CD8⁺ cells was negatively correlated with the inflammatory response, the disease severity and the outcome of ICH patients. However, there was no relationship between Tim-3 expression and blood glucose concentration. CONCLUSIONS Altered expression of Tim-3 might play an important role in the pathogenesis of ICH, demonstrating that Tim-3 might be a novel candidate molecule for prognosis evaluation of ICH patients.
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Affiliation(s)
- Xiao Liu
- Key Laboratory for Experimental Teratology of Ministry of Education and Institute of Immunology, Shandong University School of Medicine, 44 Wenhua Xi Road, Jinan, Shandong, 250012, PR China
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Kramer AH, Roberts DJ, Zygun DA. Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R203. [PMID: 23082798 PMCID: PMC3682305 DOI: 10.1186/cc11812] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 08/29/2012] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hyper- and hypoglycemia are strongly associated with adverse outcomes in critical care. Neurologically injured patients are a unique subgroup, where optimal glycemic targets may differ, such that the findings of clinical trials involving heterogeneous critically ill patients may not apply. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing intensive insulin therapy with conventional glycemic control among patients with traumatic brain injury, ischemic or hemorrhagic stroke, anoxic encephalopathy, central nervous system infections or spinal cord injury. RESULTS Sixteen RCTs, involving 1248 neurocritical care patients, were included. Glycemic targets with intensive insulin ranged from 70-140 mg/dl (3.9-7.8 mmol/L), while conventional protocols aimed to keep glucose levels below 144-300 mg/dl (8.0-16.7 mmol/L). Tight glycemic control had no impact on mortality (RR 0.99; 95% CI 0.83-1.17; p = 0.88), but did result in fewer unfavorable neurological outcomes (RR 0.91; 95% CI 0.84-1.00; p = 0.04). However, improved outcomes were only observed when glucose levels in the conventional glycemic control group were permitted to be relatively high [threshold for insulin administration > 200 mg/dl (> 11.1 mmol/L)], but not with more intermediate glycemic targets [threshold for insulin administration 140-180 mg/dl (7.8-10.0 mmol/L)]. Hypoglycemia was far more common with intensive therapy (RR 3.10; 95% CI 1.54-6.23; p = 0.002), but there was a large degree of heterogeneity in the results of individual trials (Q = 47.9; p<0.0001; I2 = 75%). Mortality was non-significantly higher with intensive insulin in studies where the proportion of patients developing hypoglycemia was large (> 33%) (RR 1.17; 95% CI 0.79-1.75; p = 0.44). CONCLUSIONS Intensive insulin therapy significantly increases the risk of hypoglycemia and does not influence mortality among neurocritical care patients. Very loose glucose control is associated with worse neurological recovery and should be avoided. These results suggest that intermediate glycemic goals may be most appropriate.
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