Association of intracranial pressure with outcome in comatose patients with intracerebral hemorrhage

Intracranial Pressure Monitoring in Patients with Spontaneous Intracerebral Hemorrhage: A Systematic Review with Meta-Analysis

OBJECTIVE

To describe the potential effects of Intracranial pressure monitoring on the outcome of patients with spontaneous intracerebral hemorrhage (ICH).

METHODS

This study is a systematic review with meta-analysis. Patients with spontaneous ICH treated with intracranial pressure monitoring were included. The primary outcome was mortality at 6 months and in-hospital mortality. The secondary outcome was poor neurological function outcome at 6 months.

RESULTS

This analysis compares in-hospital and 6-month mortality rates between patients with intracranial pressure monitoring (ICPm) and those without (no ICPm). Although the ICPm group had a lower in-hospital mortality rate, it was not statistically significant (24.9% vs. 34.1%; OR 0.51, 95% CI 0.20 to 1.31, P = 0.16). Excluding patients with intraventricular hemorrhage revealed a significant reduction in in-hospital mortality for the ICPm group (23.5% vs. 43%; OR 0.39, 95% CI 0.29 to 0.53, P < 0.00001). For 6-month mortality, the ICPm group showed a significant reduction (32% vs. 39.6%; OR 0.76, 95% CI 0.61 to 0.94, P = 0.01), with the effect being more pronounced after excluding intraventricular hemorrhage patients (29.1% vs. 47.2%; OR 0.45, 95% CI 0.34 to 0.60, P < 0.0001). However, there were no statistically significant differences in 6-month functional outcomes between the groups. Increased ICP was associated with higher 3-month mortality (OR 1.12, 95% CI 1.07 to 1.18, P < 0.00001) and lower likelihood of good functional outcomes (OR 1.11, 95% CI 1.04 to 1.18, P < 0.00001).

CONCLUSIONS

Elevated ICP is associated with increased mortality and poor prognosis in ICH patients. Although continuous intracranial pressure monitoring may reduce short-term mortality rates in specific subgroups of ICH patients, it does not improve neurological functional outcomes. While potential patient populations may benefit from ICP monitoring, more research is needed to screen suitable populations for ICP monitoring.

Tissue Compliance and Intracranial Pressure Responses to Large Intracerebral Hemorrhage in Young and Aged Spontaneously Hypertensive Rats

BACKGROUND

After a large intracerebral hemorrhage (ICH), the hematoma and swelling cause intracranial pressure (ICP) to increase, sometimes causing brain herniation and death. This is partly countered by widespread tissue compliance, an acute decrease in tissue volume distal to the stroke, at least in young healthy animals. Intracranial compensation dynamics seem to vary with age, but there is no data on old animals or those with hypertension, major factors influencing ICH risk and outcome.

METHODS

We assessed hematoma volume, edema, ICP, and functional deficits in young and aged spontaneously hypertensive rats (SHRs) and young normotensive control strains after collagenase-induced ICH. Macroscopic and microscopic brain volume fractions, such as contralateral hemisphere volume, cortical thickness, and neuronal morphology, were assessed via histological and stereological techniques.

RESULTS

Hematoma volume was 52% larger in young versus aged SHRs; surprisingly, aged SHRs still experienced proportionally worse outcomes following ICH, with 2× greater elevations in edema and ICP relative to bleed volume and 3× the degree of tissue compliance. Aged SHRs also experienced equivalent neurological deficits following ICH compared with their younger counterparts, despite the lack of significant age-related behavioral effects. Importantly, tissue compliance occurred across strains and age groups and was not impaired by hypertension or old age.

CONCLUSIONS

Aged SHRs show considerable capacity for tissue compliance following ICH and seem to rely on such mechanisms more heavily in settings of elevated ICP. Therefore, the ICP compensation response to ICH mass effect varies across the lifespan according to risk factors such as chronic hypertension.

Intracranial Pressure Dysfunction Following Severe Intracerebral Hemorrhage in Middle-Aged Rats

Rising intracranial pressure (ICP) aggravates secondary injury and heightens risk of death following intracerebral hemorrhage (ICH). Long-recognized compensatory mechanisms that lower ICP include reduced cerebrospinal fluid and venous blood volumes. Recently, we identified another compensatory mechanism in severe stroke, a decrease in cerebral parenchymal volume via widespread reductions in cell volume and extracellular space (tissue compliance). Here, we examined how age affects tissue compliance and ICP dynamics after severe ICH in rats (collagenase model). A planned comparison to historical young animal data revealed that aged SHAMs (no stroke) had significant cerebral atrophy (9% reduction, p ≤ 0.05), ventricular enlargement (9% increase, p ≤ 0.05), and smaller CA1 neuron volumes (21%, p ≤ 0.05). After ICH in aged animals, contralateral striatal neuron density and CA1 astrocyte density significantly increased (12% for neurons, 7% for astrocytes, p ≤ 0.05 vs. aged SHAMs). Unlike young animals, other regions in aged animals did not display significantly reduced cell soma volume despite a few trends. Nonetheless, overall contralateral hemisphere volume was 10% smaller in aged ICH animals compared to aged SHAMs (p ≤ 0.05). This age-dependent pattern of tissue compliance is not due to absent ICH-associated mass effect (83.2 mm3 avg. bleed volume) as aged ICH animals had significantly elevated mean and peak ICP (p ≤ 0.01), occurrence of ICP spiking events, as well as bilateral evidence of edema (e.g., 3% in injured brain, p ≤ 0.05 vs. aged SHAMs). Therefore, intracranial compliance reserve changes with age; after ICH, these and other age-related changes may cause greater fluctuation from baseline, increasing the chance of adverse outcomes like mortality.

Perihematomal edema after minimally invasive surgery: a matter of concern to neurosurgeons

The purpose of this study is to explore the evolution of brain edema after minimally invasive surgery in deep spontaneous cerebral hemorrhage (DSICH) treatment and to analyze the differences in edema after different surgical methods. The clinical data of 105 patients with DSICH treated at Renmin Hospital of Wuhan University from January 2020 to June 2022 were analyzed retrospectively. Among them, 54 patients were treated with minimally invasive puncture and drainage surgery (MIPDS group), and 51 were treated with neuroendoscopic surgery (NES group). Continuous computed tomography images of patients in the hospital and 3D Slicer software were used to quantitatively calculate the edematous area to explore the changes in perihematomal edema volume in the two groups after the operation. The peak volume of postoperative edema (37.36±10.51 mL) in the MIPDS group was more extensive than that in the NES group, and its net increase in edema volume was 16.86±10.01 mL more than that in the NES group. The relative edema index (0.86±0.26) was lower in the NES group than in the MIPDS group (P < 0.05). The peak of postoperative edema in the MIPDS group was at 6-8 days after the operation, and that in the NES group was most often at 3-5 days after the operation. There are differences in perihematomal edema of DSICH treated by different minimally invasive methods. Compared with the MIPDS group, the NES group showed earlier peak of cerebral edema and lower degree of cerebral edema. The absolute regression volume of edema in the MIDPs group was greater than that in the NEs group, but there was no difference in the regression rate of edema between the two groups.

A review of invasive intracranial pressure monitoring following surgery for hypertensive cerebral hemorrhage

Hypertensive cerebral hemorrhage, the most common prevalent of spontaneous cerebral hemorrhage, poses a significant threat to patient mortality and morbidity, while therapeutic options remain limited, making the disease a burden not only for patients' families but also a major challenge for national healthcare systems. The elevation of intracranial pressure subsequent to hypertensive cerebral hemorrhage is a critical contributor to mortality. However, it often manifests before the onset of clinical symptoms, which are typically atypical, leading to delayed treatment and irreversible consequences for the patient. Hence, early detection of intracranial pressure variations can aid in timely, efficient, and precise treatment, reducing patient mortality. Invasive intracranial pressure monitoring enables real-time, accurate monitoring of intracranial pressure changes, providing clinicians with therapeutic guidance and overcoming the limitations of empirical treatment. This article aims to review the use of invasive intracranial pressure monitoring in postoperative hypertensive cerebral hemorrhage and hopes to contribute to clinical and scientific research.

Dilated Optic Nerve Sheath Diameter Predicts Poor Outcome in Acute Spontaneous Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Optic nerve sheath diameter (ONSD) enlargement occurs in patients with intracerebral hemorrhage (ICH). However, the relationship between ONSD and prognosis of ICH is uncertain. This study aimed to investigate the predictive value of ONSD on poor outcome of patients with acute spontaneous ICH.

METHODS

We studied 529 consecutive patients with acute spontaneous ICH who underwent initial CT within 6 h of symptom onset between October 2016 and February 2019. The ONSDs were measured 3 mm behind the eyeball on initial CT images. Poor outcome was defined as having a Glasgow Outcome Scale (GOS) score of 1-3, and favorable outcome was defined as having a GOS score of 4-5 at discharge.

RESULTS

The ONSD of the poor outcome group was significantly greater than that of the favorable outcome group (5.87 ± 0.86 vs. 5.21 ± 0.69 mm, p < 0.001). ONSD was related to hematoma volume (r = 0.475, p < 0.001). Adjusting other meaningful predictors, ONSD (OR: 2.83; 95% CI: 1.94-4.15) was associated with poor functional outcome by multivariable logistic regression analysis. Receiver operating characteristic curve showed that the ONSD improved the accuracy of ultraearly hematoma growth in the prediction of poor outcome (AUC: 0.790 vs. 0.755, p = 0.016). The multivariable logistic regression model with all the meaningful predictors showed a better predictive performance than the model without ONSD (AUC: 0.862 vs. 0.831, p = 0.001).

CONCLUSIONS

The dilated ONSD measured on initial CT indicated elevated intracranial pressure and poor outcome, so appropriate intervention should be taken in time.

Intracranial Pressure and Cerebral Perfusion Pressure in Large Spontaneous Intracranial Hemorrhage and Impact of Minimally Invasive Surgery

Introduction: We investigated the effect of hematoma volume reduction with minimally invasive surgery (MIS) on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with large spontaneous intracerebral hemorrhage (ICH).

Methods:Post-hoc analysis of the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE III) study, a clinical trial with blinded outcome assessments. The primary outcome was the proportion of ICP readings ≥20 and 30 mmHg, and CPP readings <70 and 60 mm Hg. Secondary outcomes included major disability (modified Rankin scale >3) and mortality at 30 and 365 days. We assessed the relationship between proportion of high ICP and low CPP events and MIS using binomial generalized linear models, and outcomes using multiple logistic regression.

Results: Of 499 patients enrolled in MISTIE III, 72 patients had guideline based ICP monitors placed, 34 in the MIS group and 38 in control (no surgery) group. Threshold ICP and CPP events ≥20/ <70 mmHg occurred in 31 (43.1%) and 52 (72.2%) patients respectively. On adjusted analyses, proportion of ICP readings ≥20 and 30 mmHg were significantly lower in the MIS group vs. control group [Odds Ratio (OR) 0.27, 95% Confidence Interval [CI] 0.11–0.63 (p = 0.002); OR = 0.18, 0.04–0.75, p = 0.02], respectively. Proportion of CPP readings <70 and 60 mm Hg were also significantly lower in MIS patients [OR 0.31, 95% CI 0.15–0.63 (p = 0.001); OR 0.30, 95% CI 0.11–0.83 (p = 0.02)], respectively. Higher proportions of CPP readings <70 and 60 mm were significantly associated with short term mortality (p = 0.04), and (p = 0.006), respectively. Long term mortality was significantly associated with higher proportion of time with ICP ≥ 20 (p = 0.04), ICP ≥ 30 (p = 0.04), and CPP <70 mmHg (p = 0.01).

Conclusion: Our results are consistent with the hypothesis that surgical reduction of ICH volume decreases proportion of high ICP and low CPP events and that these variables are associated with short- and long-term mortality.

Potential therapeutic effects of Nrf2 activators on intracranial hemorrhage

Intracranial hemorrhage (ICH) is a devastating disease which induces high mortality and poor outcomes including severe neurological dysfunctions. ICH pathology is divided into two types: primary brain injury (PBI) and secondary brain injury (SBI). Although there are numerous preclinical studies documenting neuroprotective agents in experimental ICH models, no effective drugs have been developed for clinical use due to complicated ICH pathology. Oxidative and inflammatory stresses play central roles in the onset and progression of brain injury after ICH, especially SBI. Nrf2 is a crucial transcription factor in the anti-oxidative stress defense system. Under normal conditions, Nrf2 is tightly regulated by the Keap1. Under ICH pathological conditions, such as overproduction of reactive oxygen species (ROS), Nrf2 is translocated into the nucleus where it up-regulates the expression of several anti-oxidative phase II enzymes such as heme oxygenase-1 (HO-1). Recently, many reports have suggested the therapeutic potential of Nrf2 activators (including natural or synthesized compounds) for treating neurodegenerative diseases. Moreover, several Nrf2 activators attenuate ischemic stroke-induced brain injury in several animal models. This review summarizes the efficacy of several Nrf2 activators in ICH animal models. In the future, Nrf2 activators might be approved for the treatment of ICH patients.

Monitoring of Cerebrovascular Reactivity in Intracerebral Hemorrhage and Its Relation with Survival

INTRODUCTION

Neuromonitoring analysis for intracerebral hemorrhage (ICH) is still rare, especially regarding vascular reactivity patterns. Our goal was to analyze neuromonitoring data and 28-day mortality for ICH patients.

METHODS

Neuromonitoring records were retrospectively reviewed from a cohort of ICH patients admitted to a neurocritical care unit between 2013 and 2016. Variables considered were intracranial pressure (ICP), cerebral perfusion pressure (CPP), optimal CPP, and pressure reactivity index (PRx), as well as ICP dose, PRx dose, and time percentage above critical value (T%abv). Information regarding demographics, surgical drainage, external ventricular drain placement, and 28-day mortality was recorded. Statistical analysis was performed using the t-test and Kaplan-Meier curves.

RESULTS

Forty-six patients were analyzed, with a mean of 263 ± 173 h of signal records and a median length of stay in the intensive care unit of 22 (interquartile range of 13) days. The mean age was 62.6 ± 11.8 years old, and 24 (52%) of the patients were male. Patients who died within 28 day (37.0%) had significantly higher mean ICP, PRx, ICP dose, PRx dose, and T%abv. Although their mean ICP was under 20 mmHg, they presented PRx > 0.25, indicating impaired cerebrovascular reactivity (0.30 ± 0.26). Also, patients with PRx > 0.25 had a lower survival rate, with a proportion of 14% at 28 days, as opposed to 85% of those with PRx < 0.25 (p < 0.001).

CONCLUSION

The data suggest that autoregulation indexes are associated with 28-day mortality for ICH patients.

Intracranial pressure monitoring in patients with spontaneous intracerebral hemorrhage

OBJECTIVE

The utility of ICP monitoring and its benefit with respect to outcomes after ICH is unknown. The aim of this study was to compare intracerebral hemorrhage (ICH) outcomes in patients who underwent intracranial pressure (ICP) monitoring to those who were managed by care-guided imaging and/or clinical examination alone.

METHODS

This was a retrospective analysis of data from the Ethnic/Racial variations of Intracerebral Hemorrhage (ERICH) study between 2010 and 2015. ICH patients who underwent ICP monitoring were propensity-score matched, in a 1:1 ratio, to those who did not undergo ICP monitoring. The primary outcome was 90-day mortality. Secondary outcomes were in-hospital mortality, hyperosmolar therapy use, ICH evacuation, length of hospital stay, and 90-day modified Rankin Scale (mRS) score, excellent outcome (mRS score 0-1), good outcome (mRS score 0-2), Barthel Index, and health-related quality of life (HRQoL; measured by EQ-5D and EQ-5D visual analog scale [VAS] scores). A secondary analysis for patients without intraventricular hemorrhage was performed.

RESULTS

The ICP and no ICP monitoring cohorts comprised 566 and 2434 patients, respectively. The matched cohorts comprised 420 patients each. The 90-day and in-hospital mortality rates were similar between the matched cohorts. Shift analysis of 90-day mRS favored no ICP monitoring (p < 0.001). The rates of excellent (p < 0.001) and good (p < 0.001) outcome, Barthel Index (p < 0.001), EQ-5D score (p = 0.026), and EQ-5D VAS score (p = 0.004) at 90 days were lower in the matched ICP monitoring cohort. Rates of mannitol use (p < 0.001), hypertonic saline use (p < 0.001), ICH evacuation (p < 0.001), and infection (p = 0.001) were higher, and length of hospital stay (p < 0.001) was longer in the matched ICP monitoring cohort. In the secondary analysis, the matched cohorts comprised 111 patients each. ICP monitoring had a lower rate of 90-day mortality (p = 0.041). Shift analysis of 90-day mRS, Barthel Index, and HRQoL metrics were comparable between the matched cohorts.

CONCLUSIONS

The findings of this study do not support the routine utilization of ICP monitoring in patients with ICH.

Intracranial Hypertension After Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis of Prevalence and Mortality Rate

The objective of this study was to determine the prevalence of intracranial hypertension (IHT) and the associated mortality rate in patients who suffered from primary intracerebral hemorrhage (ICH). A secondary objective was to assess predisposing factors to IHT development. We conducted a systematic literature search of major electronic databases (MEDLINE, EMBASE, and Cochrane Library), for studies that assessed intracranial pressure (ICP) monitoring in patients with acute ICH. Study level and outcome measures were extracted. The meta-analysis was performed using a random-effects model. A total of six studies comprising 381 patients were pooled to estimate the overall prevalence of any episode of IHT (ICP > 20 mmHg) after ICH. The pooled prevalence rate for any episode of IHT after ICH was 67% (95% CI 51-84%). Four studies comprising 239 patients were pooled in order to estimate the overall mortality rate associated with IHT. Pooled mortality rate was 50% (95% CI 24-76%). For both outcomes, heterogeneity was statistically significant, and risk of bias was nonsignificant. Reported variables correlated significantly with increased ICP were lower Glasgow Coma Scale score at admission, midline shift, hemorrhage volume, and hydrocephalus. The prevalence and mortality rates associated with IHT after ICH are high and may be underestimated. Predicting factors for the development of IHT reflect the magnitude of the primary injury. However, the results of present meta-analysis should be interpreted with caution due to methodological limitations such as selection bias of patients who had ICP monitoring, and lack of standardized IHT definition.

Interval between endoscopic surgery and decreased intracranial pressure related to putaminal hemorrhage prognosis

Background:

Endoscopic evacuation of a putaminal hemorrhage is effective and minimally invasive; however, it may not result in sufficient brain decompression. While monitoring postoperative intracranial pressure (ICP) is likely useful, specific ICP data in patients with a putaminal hemorrhage are limited. The aim of this study was to determine the association between postoperative ICP and the prognosis of patients with putaminal hemorrhage after endoscopic surgery.

Methods:

We retrospectively analyzed 24 consecutive patients with a putaminal hemorrhage in whom ICP monitoring after endoscopic surgery was performed. Clinical data regarding hematoma volume, evacuation rate, onset-to-treatment time, operation time, ICP max, ICP peak out time (T peak out), and neurological outcomes on discharge were investigated.

Results:

From August 2011 to October 2015, 24 patients with a putaminal hemorrhage were analyzed. Consciousness on admission and hemorrhage volume were associated with poor outcomes after endoscopic surgery for putaminal hemorrhage. The hematoma volume, operation time, and evacuation rate of hemorrhage were correlated to early peak out of ICP. Furthermore, a T peak out ≤24 h was significantly associated with good neurological outcomes on discharge.

Conclusions:

Our data suggest that early peak out (≤24 h) of ICP after endoscopic surgery is predictive of a good prognosis following putaminal hemorrhage. Operation time and evacuation rate of hemorrhage could hasten peak out of ICP and improve outcomes in patients with a putaminal hemorrhage after endoscopic surgery.

Prognostic value of intracranial pressure monitoring for the management of hypertensive intracerebral hemorrhage following minimally invasive surgery

BACKGROUND

The incidence of hypertensive intracerebral hemorrhage (HICH) has been increasing during the recent years in low- and middle-income countries. With high mortality and morbidity rates, it brings huge burden to the families. It lacks evidence regarding the application of intracranial pressure (ICP) monitoring in HICH. In the current study, the authors aimed to evaluate whether ICP monitoring could make any difference on the prognosis of HICH patients after minimally invasive surgery.

METHODS

A retrospective review of 116 HICH patients admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine, between 2014 and 2016, was performed. The effects of ICP monitoring on 6-month mortality and favorable outcomes were evaluated by univariate and logistic regression analysis.

RESULTS

ICP monitors were inserted into 50 patients. Patients with ICP monitoring had a significantly better outcome (P<0.05). The average in-hospital duration in patients with ICP monitoring was shorter than that in the patients without ICP monitoring (16.68 days vs. 20.47 days, P<0.05). Mortality rates between ICP monitoring and no ICP monitoring did not differ significantly (16.0% vs. 15.1%, P=0.901). On univariate analysis, age, Glasgow Coma Scale (GCS) on admission and presence of ICP monitor were independent predictors of 6-month favorable outcomes.

CONCLUSION

ICP monitoring is associated with a better 6-month functional outcome compared with no ICP monitoring. Future study is still needed to confirm our results and elucidate which subgroup of HICH patients will benefit most from the minimally invasive surgical intervention and ICP monitoring.

Intracranial Pressure Monitoring-Aided Management Associated with Favorable Outcomes in Patients with Hypertension-Related Spontaneous Intracerebral Hemorrhage

To investigate the effect of intracranial pressure (ICP) monitoring on the functional outcome of patients with hypertension-related spontaneous intracerebral hemorrhage (ICH). We included 196 patients with Glasgow Coma Scale (GCS) scores of 3-12 in this observational study, of which 103 underwent ICP monitors. Binary and ordinal regression analyses were used to estimate the effect of ICP monitoring on the functional outcome. The rate of adverse events, blood pressure control, and length of hospitalization were compared between the two groups. ICP monitoring had a significant impact on the clinical outcome of patients by shifting the Extended Glasgow Outcome Scale (GOS-E) scores in a favorable direction (p = 0.027) and reducing mortality at discharge (p = 0.004) and 6 months later (p = 0.02). The rate of favorable outcome at 6 months was higher in the ICP-monitored group (p = 0.03). However, subgroup analysis showed that no relationship between ICP monitoring and clinical outcome was found for patients with GCS scores of 3-8. For patients with GCS scores of 9-12, the distribution of GOS-E scores at 6 months shifted in a favorable direction in the ICP-monitored group (p = 0.001). The rate of favorable outcome at 6 months was higher in the ICP-monitored group (p = 0.01). The mortality at discharge and 6 months later was also lower in the ICP-monitored group. Thus, our study supports the value of ICP monitoring in hypertension-related ICH patients with GCS scores of 3-12, especially those with GCS scores of 9-12.

Intracranial Hypertension and Cerebral Perfusion Pressure Insults in Adult Hypertensive Intraventricular Hemorrhage: Occurrence and Associations With Outcome

OBJECTIVES

Elevated intracranial pressure and inadequate cerebral perfusion pressure may contribute to poor outcomes in hypertensive intraventricular hemorrhage. We characterized the occurrence of elevated intracranial pressure and low cerebral perfusion pressure in obstructive intraventricular hemorrhage requiring extraventricular drainage.

DESIGN

Prospective observational cohort.

SETTING

ICUs of 73 academic hospitals.

PATIENTS

Four hundred ninety-nine patients enrolled in the CLEAR III trial, a multicenter, randomized study to determine if extraventricular drainage plus intraventricular alteplase improved outcome versus extraventricular drainage plus saline.

INTERVENTIONS

Intracranial pressure and cerebral perfusion pressure were recorded every 4 hours, analyzed over a range of thresholds, as single readings or spans (≥ 2) of readings after adjustment for intracerebral hemorrhage severity. Impact on 30- and 180-days modified Rankin Scale scores was assessed, and receiver operating curves were analyzed to identify optimal thresholds.

MEASUREMENTS AND MAIN RESULTS

Of 21,954 intracranial pressure readings, median interquartile range 12 mm Hg (8-16), 9.7% were greater than 20 mm Hg and 1.8% were greater than 30 mm Hg. Proportion of intracranial pressure readings from greater than 18 to greater than 30 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 70 mm Hg were associated with day-30 mortality and partially mitigated by intraventricular alteplase. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and intracranial pressure greater than 20 mm Hg in spans were associated with both 30-day mortality and 180-day mortality. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 60 mm Hg were associated with poor day-30 modified Rankin Scale, whereas cerebral perfusion pressure less than 65 and less than 75 mm Hg were associated with poor day-180 modified Rankin Scale.

CONCLUSIONS

Elevated intracranial pressure and inadequate cerebral perfusion pressure are not infrequent during extraventricular drainage for severe intraventricular hemorrhage, and level and duration predict higher short-term mortality and long-term mortality. Burden of low cerebral perfusion pressure was also associated with poor short- and long-term outcomes and may be more significant than intracranial pressure. Adverse consequences of intracranial pressure-time burden and cerebral perfusion pressure-time burden should be tested prospectively as potential thresholds for therapeutic intervention.

Intracerebral haemorrhage: current approaches to acute management

Acute spontaneous intracerebral haemorrhage is a life-threatening illness of global importance, with a poor prognosis and few proven treatments. As a heterogeneous disease, certain clinical and imaging features help identify the cause, prognosis, and how to manage the disease. Survival and recovery from intracerebral haemorrhage are related to the site, mass effect, and intracranial pressure from the underlying haematoma, and by subsequent cerebral oedema from perihaematomal neurotoxicity or inflammation and complications from prolonged neurological dysfunction. A moderate level of evidence supports there being beneficial effects of active management goals with avoidance of early palliative care orders, well-coordinated specialist stroke unit care, targeted neurointensive and surgical interventions, early control of elevated blood pressure, and rapid reversal of abnormal coagulation.

Acetazolamide Mitigates Intracranial Pressure Spikes Without Affecting Functional Outcome After Experimental Hemorrhagic Stroke

Increased intracranial pressure (ICP) after stroke can lead to poor outcome and death. Novel treatments to combat ICP rises are needed. The carbonic anhydrase inhibitor acetazolamide diminishes cerebrospinal fluid (CSF) production, reduces ICP in healthy animals, and is beneficial for idiopathic intracranial hypertension patients. We tested whether acetazolamide mitigates ICP elevations by presumably decreasing CSF volume after collagenase-induced striatal hemorrhage in rats. We confirmed that acetazolamide did not adversely affect hematoma formation in this model or physiological variables, such as temperature. Then, we assessed the effects of acetazolamide on ICP. Lastly, we tested the effects of acetazolamide on behavioral and histological outcome. Acetazolamide reduced the magnitude and occurrence of short-timescale ICP spikes, assessed as disproportionate increases in ICP (sudden ICP increases > 10 mmHg), 1-min peak ICP, and the magnitude of spikes > 20 mmHg. However, mean ICP was unaffected. In addition, acetazolamide reduced ICP variability, reflecting improved intracranial compliance. Compliance measures were strongly correlated with high peak and mean ICP, whereas ipsilateral hemisphere water content was not correlated with ICP. Despite effects on ICP, acetazolamide did not improve behavioral function or affect lesion size. In summary, we show that intracerebral hemorrhage creates an impaired compliance state within the cranial space that can result in large, transient ICP spikes. Acetazolamide ameliorates intracranial compliance and mitigates ICP spikes, but does not improve functional outcome, at least for moderate-severity ICH in rats.

Development and validation of the hypertensive intracerebral hemorrhage prognosis models

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.

Neural Injuries Induced by Hydrostatic Pressure Associated With Mass Effect after Intracerebral Hemorrhage

Mass effect induced by growing hematoma is one of the mechanisms by which intracerebral hemorrhage (ICH) may result in brain injuries. Our goal was to investigate the damage mechanism of hydrostatic pressure associated with mass effect and the cooperative effect of hydrostatic pressure plus hemoglobin on neural injuries. Loading hydrostatic pressure on neurons and injecting agarose gel in the right striatum of rats was performed to establish the in vitro and vivo ICH models, respectively. The elevated hydrostatic pressure associated with ICH suppressed neurons and neural tissues viability, and disturbed the axons and dendrites in vitro and vivo. Moreover, hydrostatic pressure could upregulate the expression of cleaved-caspase-3 and BAX, and downregulate Bcl-2 and Bcl-xL. Meanwhile, the toxicity of hemoglobin would be enhanced when conducted with hydrostatic pressure together. Furthermore, the exclusive hydrostatic pressure could upregulate the Piezo-2 expression, which reached a plateau at 8 h after ICH. And hemoglobin increased Piezo-2 expression significantly in vivo, and that was also promoted significantly by the elevated volume of Gel in the cooperative groups. Results indicated that hydrostatic pressure induced by mass effect not only gave rise to brain injuries directly, but also increased the toxicity of hemoglobin in the progress of secondary brain injury after ICH.

The Effect of Transtemperal Approach and Placement of Intracranial Pressure Sensor Into Temporal Horn of Lateral Ventricle in Management of Spontaneous Supratentorial Intracerebral Hemorrhage Broken Into Ventricles

To investigate the effect of transtemperal approach and placement of intracranial pressure sensor into temporal horn of lateral ventricle in management of spontaneous supratentorial intracerebral hemorrhage broken into ventricles, a total of 37 patients with spontaneous supratentorial intracerebral hemorrhage broken into ventricles treated by operation from January 2016 to December 20l6 were analyzed retrospectively, of which 25 patients in simple transtemporal approach group and 12 patients in transtemperal approach and placement of intracranial pressure sensor into temporal horn of lateral ventricle group. All patients were followed up for 8 months to 1.5 years. Two groups were estimated by mortality, clearance rate of hematoma, removal rate of bone flap, good prognosis rate of ADL and incidence of hydrocephalus. The good prognosis rate of ADL and the incidence of hydrocephalus are only statistically significant between the two groups (P < 0.05). According to the result, the transtemperal approach and placement of intracranial pressure sensor into temporal horn of lateral ventricle in management of spontaneous supratentorial intracerebral hemorrhage broken into ventricles is a safe, effective, and less complication of treatment measure.

Measurement of Intracranial Pressure in Freely Moving Rats

Brain injury, such as from stroke and trauma, can be complicated by elevated intracranial pressure (ICP). Although raised ICP can be a significant determinant of morbidity and mortality, clinical studies often report widely varying ICP measurements depending on location of measurement and technique used. For the same reasons, reported ICP measurements also vary widely in animal models. The need for anesthesia or tethered connections with some methods of ICP measurement in animals may introduce additional confounds. Moreover, these methods are not well suited for prolonged, continuous measurement. Here, we describe an approach to continually measure ICP in awake, freely moving rats for several days. This technique uses a commercially available, wireless pressure sensor mounted on the head to measure ICP from the epidural space via a fluid-filled catheter. We have demonstrated that this approach reliably detects elevations in ICP that last for several days after ischemic and hemorrhagic strokes in rat.

Evidence for Decreased Brain Parenchymal Volume After Large Intracerebral Hemorrhages: a Potential Mechanism Limiting Intracranial Pressure Rises

Potentially fatal intracranial pressure (ICP) rises commonly occur after large intracerebral hemorrhages (ICH). We monitored ICP after infusing 100-160 μL of autologous blood (vs. 0 μL control) into the striatum of rats in order to test the validity of this common model with regard to ICP elevations. Other endpoints included body temperature, behavioral impairment, lesion volume, and edema. Also, we evaluated hippocampal CA1 sector and somatosensory cortical neuron morphology to assess whether global ischemic injury occurred. Despite massive blood infusions, ICP only modestly increased (160 μL 10.8 ± 2.1 mmHg for <36 h vs. control 3.4 ± 0.5 mmHg), with little peri-hematoma edema at 3 days. Body temperature was not affected. Behavioral deficits and tissue loss were infusion volume-dependent. There was no histological evidence of hippocampal or cortical injury, indicating that cell death was confined to the hematoma and closely surrounding tissue. Surprisingly, the most severe hemorrhages significantly increased cell density (~15-20%) and reduced cell body size (~30%) in regions outside the injury site. Additionally, decreased cell size and increased density were observed after collagenase-induced ICH. Parenchymal volume is seemingly reduced after large ICH. Thus, in addition to well-known compliance mechanisms (e.g., displacement of cerebrospinal fluid and cerebral blood), reduced brain parenchymal volume appears to limit ICP rises in rodents with very large mass lesions.

Impact of Hypothermia Initiation and Duration on Perihemorrhagic Edema Evolution After Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) causes high morbidity and mortality. Recently, perihemorrhagic edema (PHE) has been suggested as an important prognostic factor. Therapeutic hypothermia may be a promising therapeutic option to treat PHE. However, no data exist about the optimal timing and duration of therapeutic hypothermia in ICH. We examined the impact of therapeutic hypothermia timing and duration on PHE evolution.

METHODS

In this retrospective, single-center, case-control study, we identified patients with ICH treated with mild endovascular hypothermia (target temperature 35°C) from our institutional database. Patients were grouped according to hypothermia initiation (early: days 1-2 and late: days 4-5 after admission) and hypothermia duration (short: 4-8 days and long: 9-15 days). Patients with ICH matched for ICH volume, age, ICH localization, and intraventricular hemorrhage were identified as controls. Relative PHE, temperature, and intracranial pressure course were analyzed. Clinical outcome on day 90 was assessed using the modified Rankin scale (0-3=favorable and 4-6=poor).

RESULTS

Thirty-three patients with ICH treated with hypothermia and 37 control patients were included. Early hypothermia initiation led to relative PHE decrease between admission and day 3, whereas median relative PHE increased in control patients (-0.05 [interquartile range, -0.4 to 0.07] and 0.07 [interquartile range, -0.07 to 0.26], respectively; P=0.007) and patients with late hypothermia initiation (0.22 [interquartile range 0.12-0.27]; P=0.037). After day 3, relative PHE increased in all groups without difference. Outcome was not different between patients treated with hypothermia and controls.

CONCLUSIONS

Early hypothermia initiation after ICH onset seems to have an important impact on PHE evolution, whereas our data suggest only limited impact later than day 3 after onset.

Intracranial Pressure Monitoring as a Part of Multimodal Monitoring Management of Patients with Critical Polytrauma: Correlation between Optimised Intensive Therapy According to Intracranial Pressure Parameters and Clinical Picture

OBJECTIVE

Trauma patient requires a complex therapeutic management because of multiple severe injuries or secondary complications. The most significant injury found in patients with trauma is head injury, which has the greatest impact on mortality. Intracranial pressure (ICP) monitoring is required in severe traumatic head injury because it optimises treatment based on ICP values and cerebral perfusion pressure (CPP).

METHODS

From a total of 64 patients admitted in the intensive care unit (ICU) 'Casa Austria', from the Polytraumatology Clinic of the Emergency County Hospital "Pius Brinzeu" Timisoara, Romania, between January 2014 and December 2014; only patients who underwent ICP monitoring (n=10) were analysed. The study population was divided into several categories depending on the time passed since trauma to the time of installation of ICP monitoring (<18 h, 19-24 h and >24 h). Comparisons were made in terms of the number of days admitted in the ICU and mortality between patients with head injury who benefited and those who did not benefit from ICP monitoring.

RESULTS

The results show the positive influence of ICP monitoring on the number of admission days in ICU because of the possibility that the number of admission days to augment therapeutic effects in patients who benefited from ICP monitoring reduces by 1.93 days compared with those who did not undergo ICP monitoring.

CONCLUSION

ICP monitoring and optimizing therapy according to the ICP and CPP has significant influence on the rate of survival. ICP monitoring is necessary in all patients with head trauma injury according to recent guidelines. The main therapeutic goal in the management of the trauma patient with head injury is to minimize the destructive effects of the associated side effects.