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Kang K, Shi K, Liu J, Li N, Wu J, Zhao X. Autonomic dysfunction and treatment strategies in intracerebral hemorrhage. CNS Neurosci Ther 2024; 30:e14544. [PMID: 38372446 PMCID: PMC10875714 DOI: 10.1111/cns.14544] [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: 08/09/2023] [Revised: 10/15/2023] [Accepted: 11/17/2023] [Indexed: 02/20/2024] Open
Abstract
AIMS Autonomic dysfunction with central autonomic network (CAN) damage occurs frequently after intracerebral hemorrhage (ICH) and contributes to a series of adverse outcomes. This review aims to provide insight and convenience for future clinical practice and research on autonomic dysfunction in ICH patients. DISCUSSION We summarize the autonomic dysfunction in ICH from the aspects of potential mechanisms, clinical significance, assessment, and treatment strategies. The CAN structures mainly include insular cortex, anterior cingulate cortex, amygdala, hypothalamus, nucleus of the solitary tract, ventrolateral medulla, dorsal motor nucleus of the vagus, nucleus ambiguus, parabrachial nucleus, and periaqueductal gray. Autonomic dysfunction after ICH is closely associated with neurological functional outcomes, cardiac complications, blood pressure fluctuation, immunosuppression and infection, thermoregulatory dysfunction, hyperglycemia, digestive dysfunction, and urogenital disturbances. Heart rate variability, baroreflex sensitivity, skin sympathetic nerve activity, sympathetic skin response, and plasma catecholamine concentration can be used to assess the autonomic functional activities after ICH. Risk stratification of patients according to autonomic functional activities, and development of intervention approaches based on the restoration of sympathetic-parasympathetic balance, would potentially improve clinical outcomes in ICH patients. CONCLUSION The review systematically summarizes the evidence of autonomic dysfunction and its association with clinical outcomes in ICH patients, proposing that targeting autonomic dysfunction could be potentially investigated to improve the clinical outcomes.
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Affiliation(s)
- Kaijiang Kang
- Department of NeurologyBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of StrokeBeijing Institute for Brain DisordersBeijingChina
| | - Kaibin Shi
- Department of NeurologyBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of StrokeBeijing Institute for Brain DisordersBeijingChina
| | - Jiexin Liu
- Department of NeurologyBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of StrokeBeijing Institute for Brain DisordersBeijingChina
| | - Na Li
- Department of NeurologyBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of StrokeBeijing Institute for Brain DisordersBeijingChina
| | - Jianwei Wu
- Department of NeurologyBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of StrokeBeijing Institute for Brain DisordersBeijingChina
| | - Xingquan Zhao
- Department of NeurologyBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of StrokeBeijing Institute for Brain DisordersBeijingChina
- Research Unit of Artificial Intelligence in Cerebrovascular DiseaseChinese Academy of Medical SciencesBeijingChina
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Huang B, Li J, Li P, Chen C, Cao S, Jiang Z, Zeng J. Risk Factors and Prognostic Implications of New-Onset Paroxysmal Atrial Fibrillation in Patients Hospitalized with Intracerebral Hemorrhage. Int J Gen Med 2023; 16:1973-1981. [PMID: 37251285 PMCID: PMC10224723 DOI: 10.2147/ijgm.s411722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/12/2023] [Indexed: 05/31/2023] Open
Abstract
Objective We aimed to assess the prevalence and risk factors of new-onset paroxysmal atrial fibrillation (PAF) in patients hospitalized with ICH and determine whether the new-onset PAF had influenced functional outcomes. Methods We analyzed a database of all consecutive patients with ICH from October 2013 to May 2022. Univariate and multivariable regression analyses were performed to identify risk factors for new-onset PAF in patients with ICH. Multivariate models were also constructed to assess whether the new-onset PAF was an independent predictor of poor functional outcome, as measured using the modified Rankin scale. Results This study included 650 patients with ICH, among whom 24 patients had new-onset PAF. In the multivariable model, older age (OR per 10-y increase, 2.26 [95% CI, 1.52-3.35]; P<0.001), hematoma volume (OR per 10-mL increase, 1.80 [95% CI, 1.26-2.57]; P=0.001), and heart failure (OR, 21.77 [95% CI, 5.52-85.91]; P<0.001) were independent risk factors for new-onset PAF. In a sensitivity analysis restricted to 428 patients with N-terminal pro-B-type natriuretic peptide (NT-proBNP), older age, larger hematoma volume, heart failure, and increased NT-proBNP were associated with new-onset PAF. After adjusting for baseline variables, new-onset PAF was an independent predictor of poor functional outcome (OR, 10.35 [95% CI, 1.08-98.80]; P=0.042). Conclusion Older age, larger hematoma volume, and heart failure were independent risk factors for new-onset PAF after ICH. Increased NT-proBNP is correlated with higher risks for new-onset PAF when their information is available at admission. Furthermore, new-onset PAF is a significant predictor of poor functional outcome.
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Affiliation(s)
- Baozi Huang
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
- Department of Neurology of the First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Jianle Li
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
| | - Pingping Li
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
- Department of Neurology of the First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Chunyong Chen
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
- Department of Neurology of the First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Suhan Cao
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
| | - Zimu Jiang
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
| | - Jinsheng Zeng
- Department of Neurology and Stroke Center, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, People’s Republic of China
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Maki Y, Ishibashi R, Yasuda T, Tokumasu H, Yamamoto Y, Goda A, Yamashita H, Morita T, Ikeda H, Chin M, Yamagata S. Correlation of Scoring Systems with the Requirement of an External Ventricular Drain in Intraventricular Hemorrhage. World Neurosurg 2022; 163:e532-e538. [PMID: 35405320 DOI: 10.1016/j.wneu.2022.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND External ventricular drainage (EVD) is required to resolve acute hydrocephalus associated with intraventricular hemorrhage (IVH). The correlation of scoring systems of IVH with indications for EVD for acute hydrocephalus related to IVH is currently unknown. METHODS We identified 213 hypertensive patients with IVH and divided them into 2 groups according to treatment method: 187 patients receiving blood pressure control alone and 26 patients undergoing EVD. The following patients were excluded: pediatric patients, patients undergoing intracranial hematoma removal, patients with fetal status, and patients without sufficient clinical data. We compared the Glasgow Coma Scale score, Graeb score, LeRoux score, Evans index, and bicaudate index values between the 2 groups and determined the prognostication accuracy of each scoring system. RESULTS There were significant differences in all 4 scoring systems between the 2 groups (P < 0.001). The cutoff values (sensitivity and specificity) of each scoring system were as follows: Glasgow Coma Scale, 8 (65.4%, 87.7%); Graeb score, 6 (80.8%, 75.4%); LeRoux score, 9 (80.8%, 76.5%); Evans index, 0.245 (80.8%, 67.9%); and bicaudate index, 0.186 (76.9%, 76.5%). The value of the area under the curve of each scoring system (95% confidence interval) was as follows: Glasgow Coma Scale, 0.806 (0.705-0.907); Graeb score, 0.852 (0.779-0.925); LeRoux score, 0.875 (0.812-0.937); Evans index, 0.788 (0.702-0.875); and bicaudate index, 0.778 (0.673-0.883). CONCLUSIONS The LeRoux score is better for identifying patients with IVH who are more likely to have EVD.
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Affiliation(s)
- Yoshinori Maki
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan.
| | - Ryota Ishibashi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takaya Yasuda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hironobu Tokumasu
- The Clinical Research Institute, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yoshiharu Yamamoto
- The Clinical Research Institute, Kurashiki Central Hospital, Kurashiki, Japan
| | - Akio Goda
- Faculty of Health Sciences, Department of Physical Therapy, Kyoto Tachibana University, Kyoto, Japan
| | - Hokuto Yamashita
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takumi Morita
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hiroyuki Ikeda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Sen Yamagata
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
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Wang MD, Tian J, Zhang JH, Zhao SY, Song MJ, Wang ZX. Human Galectin-7 Gene LGALS7 Promoter Sequence Polymorphisms and Risk of Spontaneous Intracerebral Hemorrhage: A Prospective Study. Front Mol Neurosci 2022; 15:840340. [PMID: 35401111 PMCID: PMC8984465 DOI: 10.3389/fnmol.2022.840340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purposeDespite evidence for the role of genetic factors in stroke, only a small proportion of strokes have been clearly attributed to monogenic factors, due to phenotypic heterogeneity. The goal of this study was to determine whether a significant relationship exists between human galectin-7 gene LGALS7 promoter region polymorphisms and the risk of stroke due to non-traumatic intracerebral hemorrhage (ICH).MethodsThis two-stage genetic association study included an initial exploratory stage followed by a discovery stage. During the exploratory stage, transgenic galectin-7 mice or transgenic mice with the scrambled sequence of the hairpin structure –silenced down gene LGALS7—were generated and then expressed differentially expressed proteins and galectin-7-interacting proteins were identified through proteomic analysis. During the discovery stage, a single-nucleotide polymorphism (SNP) genotyping approach was used to determine associations between 2 LGALS7 SNPs and ICH stroke risk for a cohort of 24 patients with stroke of the Chinese Han population and 70 controls.ResultsDuring the exploratory phase, LGALS7 expression was found to be decreased in TGLGALS–DOWN mice as compared to its expression in TGLGALS mice. During the discovery phase, analysis of LGALS7 sequences of 24 non-traumatic ICH cases and 70 controls led to the identification of 2 ICH susceptibility loci: a genomic region on 19q13.2 containing two LGALS7 SNPs, rs567785577 and rs138945880, whereby the A allele of rs567785577 and the T allele of rs138945880 were associated with greater risk of contracting ICH [for T and A vs. C and G, unadjusted odds ratio (OR) = 13.5; 95% CI = 2.249–146.5; p = 0.002]. This is the first study to genotype the galectin-7 promoter in patients with hemorrhagic stroke. Genotype and allele association tests and preliminary analysis of patients with stroke revealed that a single locus may be a genetic risk factor for hemorrhagic stroke.ConclusionA and T alleles of two novel SNP loci of 19q13.2, rs567785577 and rs138945880, respectively, were evaluated for associations with susceptibility to ICH. Further studies with expanded case numbers that include subjects of other ethnic populations are needed to elucidate mechanisms underlying associations between these SNPs and ICH risk.
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Affiliation(s)
- Ming-Dong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Jing Tian
- Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, China National Clinical Research Center of Respiratory Disease, Beijing, China
| | - John H. Zhang
- Physiology Program, Department of Anesthesiology, Neurosurgery, Neurology, and Physiology, Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Shun-Ying Zhao
- Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, China National Clinical Research Center of Respiratory Disease, Beijing, China
- *Correspondence: Shun-Ying Zhao,
| | - Ming-Jing Song
- Medical School, Huanghe Science and Technology University, Zhengzhou, China
- Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China
- Ming-Jing Song,
| | - Zhan-Xiang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Zhan-Xiang Wang,
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Changes of Electrocardiogram and Myocardial Enzymes in Patients with Intracerebral Hemorrhage. DISEASE MARKERS 2022; 2022:9309444. [PMID: 35432629 PMCID: PMC9007683 DOI: 10.1155/2022/9309444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/25/2022]
Abstract
Purpose Cardiac complications are common in patients with spontaneous intracerebral hemorrhage (ICH). The present study is aimed at observing the incidence of cardiac complications after ICH, so as at improving the understanding of the relationship between cardiac complications and ICH. Methods This is a retrospective study on analyzing electrocardiogram (ECG) and serum myocardial enzyme of 208 patients with ICH admitted to a tertiary hospital from 2018 to 2019. For each patient, demographics, medical history, clinical presentation, ECG, serum myocardial enzyme, and head CT on admission were reviewed. Mortality was noted. Results Among the 208 patients, 145 (69.71%) had one or more ECG abnormalities. The top three abnormalities were corrected QT interval (QTc) prolongation 52 (25%), ST depression 48 (23.08%), and T wave inversion 38 (18.27%). One hundred and thirty-nine patients (66.83%) had increased serum levels of at least one kind of myocardial enzyme, which were high-sensitive cardiac troponin T (hs-cTnT) 79 (37.98%), lactic dehydrogenase (LDH) 80 (38.46%), creatine kinase (CK) 57 (27.40%), and creatine kinase-myocardial subfraction (CKMB) 57 (27.40%). The logistic regression analysis showed the following: secondary intraventricular hemorrhage (SIVH) (odds ratio (OR) 5.32; 95% confidence interval (CI) 2.55–11.08; p < 0.001) and hematoma volume > 30 ml (OR 3.81; 95% CI 1.86–7.81; p < 0.001) were independent predictive factors of QTc prolongation; thalamus location (OR 5.79; 95% CI 1.94–17.28; p < 0.05), hematoma volume > 30 ml (OR 24.187; 95% CI 3.14-186.33; p < 0.05), insular involvement (OR 19.08; 95% CI 5.77-63.07; p < 0.001), and SIVH (OR 2.62; 95% CI 1.69-5.86; p < 0.05) were independent predictive factors of ST depression; insular involvement (OR 2.90; 95% CI 1.12–7.50; p < 0.05) and hematoma volume > 30 ml (OR 1.98; 95% CI 1.06–3.70; p < 0.05) were independent predictive factors of increase of CK; Glasgow Coma Scale (GCS) (OR 0.86; 95% CI 0.78–0.98; p < 0.05) and insular involvement (OR 5.56; 95% CI 1.98–15.62; p < 0.05) were independent predictive factors of increase of CKMB; SIVH (OR 2.05; 95% CI 1.07–3.92; p < 0.05) was independent predictive factor of increase of LDH; age (OR 1.03; 95% CI 1.01–1.06; p < 0.05), blood glucose on admission (OR 1.10; 95% CI 1.01–1.20; p < 0.05), and history of antiplatelet drug use (OR 3.50; 95% CI 1.01–12.12; p < 0.05) were independent predictive factors of hs-cTnT. All the injury indexes were not related to in-hospital mortality. Conclusion The study suggests that insular involvement, hematoma volume > 30 ml, and SIVH are the strongest risk factors for ECG abnormalities and elevated myocardial enzymes after ICH followed which are the risk factors such as GCS, age, admission blood glucose, and ICH location in the thalamus.
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Molecular Mechanisms of Neuroimmune Crosstalk in the Pathogenesis of Stroke. Int J Mol Sci 2021; 22:ijms22179486. [PMID: 34502395 PMCID: PMC8431165 DOI: 10.3390/ijms22179486] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/26/2021] [Accepted: 08/28/2021] [Indexed: 12/21/2022] Open
Abstract
Stroke disrupts the homeostatic balance within the brain and is associated with a significant accumulation of necrotic cellular debris, fluid, and peripheral immune cells in the central nervous system (CNS). Additionally, cells, antigens, and other factors exit the brain into the periphery via damaged blood–brain barrier cells, glymphatic transport mechanisms, and lymphatic vessels, which dramatically influence the systemic immune response and lead to complex neuroimmune communication. As a result, the immunological response after stroke is a highly dynamic event that involves communication between multiple organ systems and cell types, with significant consequences on not only the initial stroke tissue injury but long-term recovery in the CNS. In this review, we discuss the complex immunological and physiological interactions that occur after stroke with a focus on how the peripheral immune system and CNS communicate to regulate post-stroke brain homeostasis. First, we discuss the post-stroke immune cascade across different contexts as well as homeostatic regulation within the brain. Then, we focus on the lymphatic vessels surrounding the brain and their ability to coordinate both immune response and fluid homeostasis within the brain after stroke. Finally, we discuss how therapeutic manipulation of peripheral systems may provide new mechanisms to treat stroke injury.
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Nagai M, Dote K, Kato M. Autonomic response after hemorrhagic stroke in the right insular cortex: What is the common pathophysiology in rat and human? Auton Neurosci 2021; 230:102755. [DOI: 10.1016/j.autneu.2020.102755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/31/2020] [Accepted: 11/17/2020] [Indexed: 11/16/2022]
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Rass V, Lindner A, Ianosi BA, Schiefecker AJ, Loveys S, Kofler M, Rass S, Pfausler B, Beer R, Schmutzhard E, Helbok R. Early alterations in heart rate are associated with poor outcome in patients with intracerebral hemorrhage. J Crit Care 2020; 61:199-206. [PMID: 33186826 DOI: 10.1016/j.jcrc.2020.10.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/26/2020] [Accepted: 10/29/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Cardiac complications are common after spontaneous intracerebral hemorrhage (ICH). In this study we intended to investigate factors associated with higher alterations in heart rate and their impact on outcome. METHODS Eighty-eight ICH patients were included. A simplified approach to calculate heart rate variability (HRSD) in analogy to systolic blood pressure variability (SBPSD) with daily standard deviations of HR in the acute (first 24 h) and subacute phase (day1-day7) was used. Using multivariable regression, factors associated with higher HRSD and the association between higher HRSD and poor 3-month outcome (modified Rankin Scale > 3) were analyzed. All models were adjusted for age, atrial fibrillation, mechanical ventilation, vasopressor administration, and mean HR. RESULTS Patients were 71 (IQR = 60-79) years old and presented with an admission ICH-Score of 2 (IQR = 1-3). In multivariable analysis, intraventricular hemorrhage (adjOR = 8.66, 95%-CI = 1.89-39.60, p = 0.005), a QRS complex >120 ms (adjOR = 19.02; 95%-CI = 2.08-175.05, p = 0.009) and female sex (adjOR = 4.24; 95%-CI = 1.08-16.64, p = 0.038) were associated with higher HRSD in the acute phase. A higher HRSD (adjOR = 1.29, 95%-CI = 1.01-1.66, p = 0.045) in the acute but not in the subacute phase (p = 0.764) was associated with poor 3-month outcome. CONCLUSION The study suggests that a higher variation in heart rate in the early phase after ICH may discriminate patients with poor outcome.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - Anna Lindner
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - Bogdan-Andrei Ianosi
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria; Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, Hall 6060, Austria
| | - Alois Josef Schiefecker
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - Sebastian Loveys
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - Mario Kofler
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - Sofia Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - Bettina Pfausler
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - Ronny Beer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - Erich Schmutzhard
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria.
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Saand AR, Yu F, Chen J, Chou SHY. Systemic inflammation in hemorrhagic strokes - A novel neurological sign and therapeutic target? J Cereb Blood Flow Metab 2019; 39:959-988. [PMID: 30961425 PMCID: PMC6547186 DOI: 10.1177/0271678x19841443] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Growing evidences suggest that stroke is a systemic disease affecting many organ systems beyond the brain. Stroke-related systemic inflammatory response and immune dysregulations may play an important role in brain injury, recovery, and stroke outcome. The two main phenomena in stroke-related peripheral immune dysregulations are systemic inflammation and post-stroke immunosuppression. There is emerging evidence suggesting that the spleen contracts following ischemic stroke, activates peripheral immune response and this may further potentiate brain injury. Whether similar brain-immune crosstalk occurs in hemorrhagic strokes such as intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is not established. In this review, we systematically examined animal and human evidence to date on peripheral immune responses associated with hemorrhagic strokes. Specifically, we reviewed the impact of clinical systemic inflammatory response syndrome (SIRS), inflammation- and immune-associated biomarkers, the brain-spleen interaction, and cellular mediators of peripheral immune responses to ICH and SAH including regulatory T cells (Tregs). While there is growing data suggesting that peripheral immune dysregulation following hemorrhagic strokes may be important in brain injury pathogenesis and outcome, details of this brain-immune system cross-talk remain insufficiently understood. This is an important unmet scientific need that may lead to novel therapeutic strategies in this highly morbid condition.
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Affiliation(s)
- Aisha R Saand
- 1 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Fang Yu
- 2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jun Chen
- 2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sherry H-Y Chou
- 1 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,3 Department of Neurosurgery, School of Medicine, University of Pittsburgh, PA, USA
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Di Rienzo A, Colasanti R, Esposito D, Della Costanza M, Carrassi E, Capece M, Aiudi D, Iacoangeli M. Endoscope-assisted microsurgical evacuation versus external ventricular drainage for the treatment of cast intraventricular hemorrhage: results of a comparative series. Neurosurg Rev 2019; 43:695-708. [PMID: 31069562 DOI: 10.1007/s10143-019-01110-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 04/17/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
Cast intraventricular hemorrhage (IVH) is associated to high morbidity/mortality rates. External ventricular drainage (EVD), the most common treatment adopted in these patients, may be unsuccessful due to short-term drain obstruction and requires weeks for cerebrospinal fluid (CSF) clearing, increasing the risks of ventriculits. Administration of intraventricular fibrinolytic agents and endoscopic evacuation have been proposed as alternative treatments, but with equally poor results. We present a retrospective analysis of two groups of patients who respectively underwent endoscope-assisted microsurgical evacuation versus EVD for the treatment of cast IVH. In a 10-year time, 25 patients with cast IVH underwent microsurgical, endoscope-assisted evacuation. Twenty-seven were instead treated by EVD. The two groups were compared in terms of hematoma evacuation, CSF clearing time, infection rates, need for permanent shunting, short/long-term survival, and functional outcome. In endoscope-assisted surgeries, full CSF clearance required 14 ± 3 days in 20 patients and 21 ± 3 days in 5; in the EVD group, 21 ± 3 days were needed in 12 patients, 28 ± 3 days in 11, and 35 ± 3 days in 4. Permanent shunting was inserted respectively in 19 endoscopic and 23 EVD patients. Final mRs score was 0-3 in 13 endoscopic cases, 4-5 in the remaining 12. In the EVD group, 7 subjects scored mRs 0-3, 16 scored 4-5; 4 died. In our experience, endoscope-assisted evacuation of cast IVH reduced ICU staying and CSF clearance times. It also seemed to improve neurological outcome, but without affecting the need for permanent shunt. On the counterside, it increases the number of severely disabled survivors.
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Affiliation(s)
- Alessandro Di Rienzo
- Department of Neurosurgery, Università Politecnica delle Marche, Via Conca 71, 60126, Ancona, Italy
| | - Roberto Colasanti
- Department of Neurosurgery, Università Politecnica delle Marche, Via Conca 71, 60126, Ancona, Italy.
| | - Domenic Esposito
- Department of Neurosurgery, Università Politecnica delle Marche, Via Conca 71, 60126, Ancona, Italy
| | - Martina Della Costanza
- Department of Neurosurgery, Università Politecnica delle Marche, Via Conca 71, 60126, Ancona, Italy
| | - Erika Carrassi
- Department of Neurosurgery, Università Politecnica delle Marche, Via Conca 71, 60126, Ancona, Italy
| | - Mara Capece
- Department of Neurosurgery, Università Politecnica delle Marche, Via Conca 71, 60126, Ancona, Italy
| | - Denis Aiudi
- Department of Neurosurgery, Università Politecnica delle Marche, Via Conca 71, 60126, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica delle Marche, Via Conca 71, 60126, Ancona, Italy
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11
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Qureshi AI, Qureshi MH. Acute hypertensive response in patients with intracerebral hemorrhage pathophysiology and treatment. J Cereb Blood Flow Metab 2018; 38:1551-1563. [PMID: 28812942 PMCID: PMC6125978 DOI: 10.1177/0271678x17725431] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute hypertensive response is a common systemic response to occurrence of intracerebral hemorrhage which has gained unique prominence due to high prevalence and association with hematoma expansion and increased mortality. Presumably, the higher systemic blood pressure predisposes to continued intraparenchymal hemorrhage by transmission of higher pressure to the damaged small arteries and may interact with hemostatic and inflammatory pathways. Therefore, intensive reduction of systolic blood pressure has been evaluated in several clinical trials as a strategy to reduce hematoma expansion and subsequent death and disability. These trials have demonstrated either a small magnitude benefit (second intensive blood pressure reduction in acute cerebral hemorrhage trial and efficacy of nitric oxide in stroke trial) or no benefit (antihypertensive treatment of acute cerebral hemorrhage 2 trial) with intensive systolic blood pressure reduction compared with modest or standard blood pressure reduction. The differences may be explained by the variation in intensity of systolic blood pressure reduction between trials. A treatment threshold of systolic blood pressure of ≥180 mm with the target goal of systolic blood pressure reduction to values between 130 and 150 mm Hg within 6 h of symptom onset may be best supported by current evidence.
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12
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Impact of Supratentorial Cerebral Hemorrhage on the Complexity of Heart Rate Variability in Acute Stroke. Sci Rep 2018; 8:11473. [PMID: 30065287 PMCID: PMC6068137 DOI: 10.1038/s41598-018-29961-y] [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] [Received: 01/16/2018] [Accepted: 07/11/2018] [Indexed: 01/07/2023] Open
Abstract
Acute stroke commonly affects cardiac autonomic responses resulting in reduced heart rate variability (HRV). Multiscale entropy (MSE) is a novel non-linear method to quantify the complexity of HRV. This study investigated the influence of intracerebral hemorrhage (ICH) locations and intraventricular hemorrhage (IVH) on the complexity of HRV. We recruited 93 supratentorial ICH patients (male 59%, mean age 61 years), and the locations of ICH included basal ganglia (n = 40), thalamus (n = 35), and lobar (n = 18) group. Continuous one-hour electrocardiography signals were obtained from patients after admission, and the complexity index was defined as the area under the MSE curve. The complexity index was lower in lobar ICH (21.6 ± 7.9) than basal ganglia (27.9 ± 6.4) and thalamus (28.5 ± 7.2) groups. The complexity index was inversely correlated with initial stroke severity (r = −0.26), size of hematoma (r = −0.35) and ICH score (r = −0.26), especially among patients with intraventricular hemorrhage (r = −0.60, −0.60, and −0.41 respectively). A higher complexity can predict a good functional outcome (adjusted odds ratio 1.09, 95% confidence intervals 1.00–1.19) at post-stroke 3 months. In summary, more severe stroke and larger hematoma volume resulted in lower complexity of HRV. Lobar hemorrhage and IVH had great impacts on the cardiac autonomic function.
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13
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Lai YR, Lin YJ, Shih FY, Wang HC, Tsai NW, Kung CT, Lin WC, Cheng BC, Su YJ, Chang YT, Su CM, Hsiao SY, Huang CC, Lu CH. Effect of Baroreceptor Sensitivity on Outcomes in Patients with Acute Spontaneous Intracerebral Hemorrhage. World Neurosurg 2018; 109:e754-e760. [DOI: 10.1016/j.wneu.2017.10.076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 11/16/2022]
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14
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Staykov D, Kuramatsu JB, Bardutzky J, Volbers B, Gerner ST, Kloska SP, Doerfler A, Schwab S, Huttner HB. Efficacy and safety of combined intraventricular fibrinolysis with lumbar drainage for prevention of permanent shunt dependency after intracerebral hemorrhage with severe ventricular involvement: A randomized trial and individual patient data meta-analysis. Ann Neurol 2017; 81:93-103. [PMID: 27888608 DOI: 10.1002/ana.24834] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/24/2016] [Accepted: 11/25/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Intraventricular hemorrhage (IVH) is a negative prognostic factor in intracerebral hemorrhage (ICH) and is associated with permanent shunt dependency in a substantial proportion of patients post-ICH. IVH treatment by intraventricular fibrinolysis (IVF) was recently linked to reduced mortality rates in the CLEAR III study and IVF represents a safe and effective strategy to hasten clot resolution that may reduce shunt rates. Additionally, promising results from observational studies reported reductions in shunt dependency for a combined treatment approach of IVF plus lumbar drains (LDs). The present randomized, controlled trial investigated efficacy and safety of a combined strategy-IVF plus LD versus IVF alone-on shunt dependency in patients with ICH and severe IVH. METHODS This randomized, open-label, parallel-group study included patients aged 18 to 85 years, prehospital modified Rankin Scale ≤3, ICH volume < 60ml, Glasgow Coma Scale of <9, and severe IVH with tamponade of the third and fourth ventricles requiring placement of external ventricular drainage (EVD). Over a 3-year recruitment period, patients were allocated to either standard treatment (control group receiving IVF consisting of 1mg of recombinant human tissue plasminogen activator every 8 hours until clot clearance of third and fourth ventricles) or a combined treatment approach of IVF and-upon clot clearance of third and fourth ventricles-subsequent placement of an LD for drainage of cerebrospinal fluid (CSF; intervention group). The primary endpoint consisted of permanent shunt placement indicated after a total of three unsuccessful EVD clamping attempts or need for CSF drainage longer than 14 days in both groups. Secondary endpoints included IVF- and LD-related safety, such as bleeding or infections, and functional outcome at 90 and 180 days. Conducted endpoint analyses used individual patient data meta-analyses. The study was registered at clinicaltrials.gov (NCT01041950). RESULTS The trial was stopped upon predefined interim analysis after 30 patients because of significant efficacy of tested intervention. The primary endpoint was analyzed without dropouts and was reached in 43% (7 of 16) of the control group versus 0% (0 of 14) of the intervention group (p = 0.007). Meta-analyses were based on overall 97 patients, 45 patients receiving IVF plus LD versus 42 with IVF only. Meta-analyses on shunt dependency showed an absolute risk reduction of 24% for the intervention (LD, 2.2% [1 of 45] vs no-LD, 26.2% [11 of 42]; odds ratio [OR] = 0.062; confidence interval [CI], 0.011-0.361; p = 0.002). Secondary endpoints did not show significant differences for CSF infections (OR = 0.869;CI, 0.445-1.695; p = 0.680) and functional outcome at 90 days (OR = 0.478; CI, 0.190-1.201; p = 0.116), yet bleeding complications were significantly reduced in favor of the intervention (OR = 0.401; CI, 0.302-0.532; p < 0.001). INTERPRETATION The present trial and individual patient data meta-analyses provide evidence that, in patients with severe IVH, as compared to IVF alone, a combined approach of IVF plus LD treatment is feasible and safe and significantly reduces rates of permanent shunt dependency for aresorptive hydrocephalus post-ICH. ANN NEUROL 2017;81:93-103.
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Affiliation(s)
- Dimitre Staykov
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Neurology, St John Hospital Eisenstadt, Eisenstadt, Austria
| | - Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jürgen Bardutzky
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | - Bastian Volbers
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stephan P Kloska
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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15
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Yperzeele L, van Hooff RJ, Nagels G, De Smedt A, De Keyser J, Brouns R. Heart rate variability and baroreceptor sensitivity in acute stroke: a systematic review. Int J Stroke 2016. [PMID: 26202709 DOI: 10.1111/ijs.12573] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Autonomic nervous system dysfunction is common after acute stroke and is associated with elevated risk of cardiac arrhythmia and mortality. Heart rate variability and baroreceptor sensitivity have been investigated as parameters of autonomic nervous system dysfunction for the prediction of stroke outcome. SUMMARY We performed a systematic literature review on heart rate variability and baroreceptor sensitivity as parameters for autonomic nervous function in acute stroke. Twenty-two studies were included. Associations between heart rate variability or baroreceptor sensitivity and stroke severity, early and late complications, dependency and mortality were reported. However, interpretability of most studies and extrapolation to general stroke population are limited due to many confounding factors such as varying methodology, small sample sizes, survival selection, and exclusion of patients with frequently occurring comorbidities in stroke. Key issues, such as the effect of thrombolytic therapy on autonomic function, autonomic nervous system dysfunction in the hyperacute phase of stroke, and correlation with the risk of recurrent stroke have not been investigated. Also, nonlinear techniques have remained largely unexplored in this domain, in spite of their advantage to provide more solid evaluation in the occurrence of arrhythmia. KEY MESSAGES Cardiac autonomic dysfunction, represented by reduced heart rate variability or impaired baroreceptor sensitivity, is associated with stroke severity, early and late complications, dependency, and mortality. Large-scale prospective studies applying internationally accepted standards of measures for analysis of heart rate variability and baroreceptor sensitivity are needed in patients with acute stroke.
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Affiliation(s)
- Laetitia Yperzeele
- Department of Neurology, Universitair Ziekenhuis Antwerpen, Antwerp, Belgium.,Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Robbert-Jan van Hooff
- Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Guy Nagels
- Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium.,National MS Center, Melsbroek, Belgium
| | - Ann De Smedt
- Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jacques De Keyser
- Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Raf Brouns
- Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium
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16
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Xi G, Strahle J, Hua Y, Keep RF. Progress in translational research on intracerebral hemorrhage: is there an end in sight? Prog Neurobiol 2014; 115:45-63. [PMID: 24139872 PMCID: PMC3961535 DOI: 10.1016/j.pneurobio.2013.09.007] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 09/11/2013] [Accepted: 09/24/2013] [Indexed: 02/08/2023]
Abstract
Intracerebral hemorrhage (ICH) is a common and often fatal stroke subtype for which specific therapies and treatments remain elusive. To address this, many recent experimental and translational studies of ICH have been conducted, and these have led to several ongoing clinical trials. This review focuses on the progress of translational studies of ICH including those of the underlying causes and natural history of ICH, animal models of the condition, and effects of ICH on the immune and cardiac systems, among others. Current and potential clinical trials also are discussed for both ICH alone and with intraventricular extension.
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Affiliation(s)
- Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States.
| | - Jennifer Strahle
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
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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] [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
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18
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Clearing bloody cerebrospinal fluid: clot lysis, neuroendoscopy and lumbar drainage. Curr Opin Crit Care 2013; 19:92-100. [PMID: 23337912 DOI: 10.1097/mcc.0b013e32835cae5e] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Bloody cerebrospinal fluid (CSF) is a major cause of morbidity and mortality in intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Different treatment strategies aiming at faster clearance of bloody CSF have emerged. The present review focuses on recent developments in the investigation of those treatments. RECENT FINDINGS Intraventricular fibrinolysis (IVF) for accelerated IVH-resolution has been clinically tested since the early 1990s. The lately summarized evidence from smaller studies indicates that IVF may result in a benefit in mortality and outcome. Recent investigations have elucidated different aspects of IVF, mainly related to safety. Neuroendoscopy has also emerged as a minimally invasive technique allowing fast removal of IVH. The capability of lumbar drainage to reduce vasospasm after SAH has been tested in a large trial. SUMMARY IVF is relatively well tolerated and accelerates clot clearance after IVH. The effect of IVF on clinical outcome and mortality is currently being investigated in a large-scale phase III clinical trial. Neuroendoscopy is feasible for the treatment of IVH, however, larger trials are lacking. Lumbar drainage reduces the incidence of vasospasm after SAH. An ongoing phase III trial has been designed to test its influence on outcome. Lumbar drainage may also reduce shunt-dependency after IVH.
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19
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Block HS, Biller J. Management of intracerebral hemorrhage in the presence of anticoagulant therapy. Top Stroke Rehabil 2013; 20:131-8. [PMID: 23611854 DOI: 10.1310/tsr2002-131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intracerebral hemorrhage (ICH) represents a potentially lethal form of stroke. ICH in a patient taking anticoagulant therapy presents unique diagnostic and therapeutic challenges. Specific clinical circumstances, outcomes, and evidence-based or rationally derived treatments (when the evidence is incomplete) are reviewed.
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Affiliation(s)
- H Steven Block
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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20
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Volbers B, Wagner I, Willfarth W, Doerfler A, Schwab S, Staykov D. Intraventricular fibrinolysis does not increase perihemorrhagic edema after intracerebral hemorrhage. Stroke 2013; 44:362-6. [PMID: 23306318 DOI: 10.1161/strokeaha.112.673228] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Additional intraventricular hemorrhage leads to higher mortality and worse functional outcome after intracerebral hemorrhage (ICH). Intraventricular fibrinolysis (IVF) with recombinant tissue plasminogen activator (rtPA) is an emerging treatment strategy for such patients. However, experimental studies suggest that rtPA may exert proedematous effects and lead to increased perihemorrhagic edema (PHE) after ICH. We aimed to compare the course of PHE after ICH between patients who received IVF with rtPA and controls matched for ICH volume. METHODS Patients were identified retrospectively from our institutional ICH database. Sixty-four patients with ICH and intraventricular hemorrhage who were treated with IVF were compared with 64 controls, who did not receive IVF, matched for ICH volume. The course of PHE was assessed on computed tomography scans (day 1, days 2 and 3, days 4-6, 7-9, and 10-12) using a threshold-based semiautomatic volumetric algorithm. Relative PHE was calculated as a ratio of PHE volume and initial ICH volume. RESULTS The matching algorithm resulted in similar mean ICH volumes in both groups (20.01 ± 17.5 mL, IVF vs 20.08 ± 17.1 mL, control). Intraventricular hemorrhage volume was larger in the IVF group (26.8 ± 19.2 mL vs 9.2 ± 13.4 mL). The mean total rtPA dose used for IVF was 8 ± 6 mg. PHE increased over time in both groups until day 12. At all investigated time points, there was no significant difference in relative PHE between the IVF group and controls (F=0.39; P=0.844). CONCLUSIONS IVF with rtPA did not lead to a relevant increase in PHE after ICH. rtPA doses used in the current study seem to be safe regarding PHE.
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Affiliation(s)
- Bastian Volbers
- Department of Neurology, University of Erlangen-Nure, Schwabachanlage 6, 91054 Erlangen, Germany.
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