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Sterba A, Sedova P, Brown RD, Stehlik A, Bryndziar T, Cimflova P, Zvolsky M, Belaskova S, Kovacova I, Bednarik J, Mikulík R. Predictors of spontaneous intracerebral hemorrhage mortality: a community-based study in Brno, Czech Republic. Acta Neurol Belg 2024:10.1007/s13760-024-02612-y. [PMID: 39102105 DOI: 10.1007/s13760-024-02612-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 07/13/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND AND OBJECTIVE Intracerebral hemorrhage (ICH) is a serious medical condition with high mortality. However, factors leading to long-term mortality after ICH are largely unclear. The aim of this community-based study is to assess predictors of long-term mortality after spontaneous ICH. METHODS We identified all patients admitted with spontaneous ICH to hospitals with a certified stroke unit in Brno, the second largest city in the Czech Republic (CR), in 2011, the year of the Czech Population and Housing Census. We reviewed their medical records for risk factors, radiographic parameters, and measures of post-stroke neurological deficit [National Institutes of Health Stroke Scale (NIHSS)]. Using the dates of death from the Czech National Mortality Register, we calculated mortality at 30 days, six months, one year, and three years after the ICH. Multivariate analysis with forward stepwise logistic regression was performed to determine independent predictors of mortality (p < 0.05). RESULTS In 2011, 1086 patients with stroke were admitted to the four stroke-certified hospitals in Brno, CR. Of these, 134 had spontaneous ICH, with complete data available in 93 of them entering the final analysis. The mortality at 30 days, 6 months, 1 year, and 3 years post-ICH was 34%, 47%, 51%, and 63%, respectively. The mortality was highest in the first few days post-event, with 50% of patients dying in 255 days and average survival being 884 ± 90 days. Both NIHSS and modified ICH (MICH) score showed to be strong and reliable predictors of short- as well as long-term mortality; the risk of death post-ICH increased with older age and size of ICH. Other risk factors contributing to higher, primarily shorter-term mortality included history of cardiac failure, myocardial infarction, or atrial fibrillation. CONCLUSIONS In our community-based study, we found that severity of neurological deficit at admission (NIHSS), combined with age and size of ICH, well predicted short- as well as long-term mortality after spontaneous ICH. A history of cardiac failure, myocardial infarction, or atrial fibrillation at presentation were also predictors of mortality, underscoring the need for optimal cardiac management in patients with ICH.
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Affiliation(s)
- Albert Sterba
- International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Neurosurgical Clinic, Kralovske Vinohrady University Hospital, Prague, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petra Sedova
- International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic.
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic.
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Albert Stehlik
- International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Bryndziar
- International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petra Cimflova
- International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic
- Clinic of Imaging Methods, St Anne's University Hospital, Brno, Czech Republic
| | - Miroslav Zvolsky
- Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Silvie Belaskova
- International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic
| | - Ingrid Kovacova
- International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic
| | - Josef Bednarik
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Neurological Clinic, University Hospital Brno, Brno, Czech Republic
| | - Robert Mikulík
- International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Neurological Clinic, St Anne's University Hospital, Brno, Czech Republic
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Hwang DY, Kim KS, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Madzar D, Mahanes D, Mainali S, Sakowitz OW, Varelas PN, Weimar C, Westermaier T, Meixensberger J. Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage. Neurocrit Care 2024; 40:395-414. [PMID: 37923968 PMCID: PMC10959839 DOI: 10.1007/s12028-023-01854-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The objective of this document is to provide recommendations on the formal reliability of major clinical predictors often associated with intracerebral hemorrhage (ICH) neuroprognostication. METHODS A narrative systematic review was completed using the Grading of Recommendations Assessment, Development, and Evaluation methodology and the Population, Intervention, Comparator, Outcome, Timing, Setting questions. Predictors, which included both individual clinical variables and prediction models, were selected based on clinical relevance and attention in the literature. Following construction of the evidence profile and summary of findings, recommendations were based on Grading of Recommendations Assessment, Development, and Evaluation criteria. Good practice statements addressed essential principles of neuroprognostication that could not be framed in the Population, Intervention, Comparator, Outcome, Timing, Setting format. RESULTS Six candidate clinical variables and two clinical grading scales (the original ICH score and maximally treated ICH score) were selected for recommendation creation. A total of 347 articles out of 10,751 articles screened met our eligibility criteria. Consensus statements of good practice included deferring neuroprognostication-aside from the most clinically devastated patients-for at least the first 48-72 h of intensive care unit admission; understanding what outcomes would have been most valued by the patient; and counseling of patients and surrogates whose ultimate neurological recovery may occur over a variable period of time. Although many clinical variables and grading scales are associated with ICH poor outcome, no clinical variable alone or sole clinical grading scale was suggested by the panel as currently being reliable by itself for use in counseling patients with ICH and their surrogates, regarding functional outcome at 3 months and beyond or 30-day mortality. CONCLUSIONS These guidelines provide recommendations on the formal reliability of predictors of poor outcome in the context of counseling patients with ICH and surrogates and suggest broad principles of neuroprognostication. Clinicians formulating their judgments of prognosis for patients with ICH should avoid anchoring bias based solely on any one clinical variable or published clinical grading scale.
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599-7025, USA.
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Susanne Muehlschlegel
- Division of Neurosciences Critical Care, Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | - Christian Weimar
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper-Kliniken Dachau, University of Wuerzburg, Würzburg, Germany
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Li Q, Goldstein JN. Neurological Deterioration in Intracerebral Hemorrhage: Can We Predict It, and What Would We Do If We Could? J Am Heart Assoc 2022; 11:e026760. [PMID: 35862150 PMCID: PMC9375501 DOI: 10.1161/jaha.122.026760] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Qi Li
- Department of Neurology The Second Affiliated Hospital of Anhui Medical University Hefei China.,Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Department of Emergency Medicine Massachusetts General Hospital, Harvard Medical School Boston MA
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Head-to-head comparison of prognostic models of spontaneous intracerebral hemorrhage: tools for personalized care and clinical trial in ICH. Neurol Res 2021; 44:146-155. [PMID: 34431446 DOI: 10.1080/01616412.2021.1967678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
To systematically compare 27 ICH models with regard to mortality and functional outcome at 1-month, 3-month and 1-year after ICH. The validation cohort was derived from the Beijing Registration of Intracerebral Hemorrhage. Poor functional outcome was defined as modified Rankin Scale score (mRS) ≥3 at 1-month, 3-month and 1-year after ICH, respectively. The area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow goodness-of-fit test were used to assess model discrimination and calibration. A total number of 1575 patients were included. The mean age was 57.2 ± 14.3 and 67.2% were male. The median NIHSS score on admission was 11 (IQR: 3-21). For predicting mortality at 3-month after ICH, AUROC of 27 ICH models ranged from 0.604 to 0.856. In pairwise comparison, the ICH-FOS (0.856, 95%CI = 0.835-0.878, P < 0.001) showed statistically better discrimination than other models for mortality at 3-month after ICH (all P < 0.05). For predicting poor functional outcome (mRS≥3) at 3-month after ICH, AUROC of 27 ICH models ranged from 0.602 to 0.880. In pairwise comparison with other prediction models, the ICH-FOS was superior in predicting poor functional outcome at 3-month after ICH (all P < 0.001). The ICH-FOS showed the largest Cox and Snell R-square. Similar results were verified for mortality and poor functional outcome at 1-month and 1-year after ICH. Several risk models are externally validated to be effective for risk stratification and outcome prediction after ICH, especially the ICH-FOS, which would be useful tools for personalized care and clinical trial in ICH.
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Zyck S, Du L, Gould G, Latorre JG, Beutler T, Bodman A, Krishnamurthy S. Scoping Review and Commentary on Prognostication for Patients with Intracerebral Hemorrhage with Advances in Surgical Techniques. Neurocrit Care 2021; 33:256-272. [PMID: 32270428 DOI: 10.1007/s12028-020-00962-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The intracerebral hemorrhage (ICH) score provides an estimate of 30-day mortality for patients with intracerebral hemorrhage in order to guide research protocols and clinical decision making. Several variations of such scoring systems have attempted to optimize its prognostic value. More recently, minimally invasive surgical techniques are increasingly being used with promising results. As more patients become candidates for surgical intervention, there is a need to re-discuss the best methods for predicting outcomes with or without surgical intervention. METHODS We systematically performed a scoping review with a comprehensive literature search by two independent reviewers using the PubMed and Cochrane databases for articles pertaining to the "intracerebral hemorrhage score." Relevant articles were selected for analysis and discussion of potential modifications to account for increasing surgical indications. RESULTS A total of 64 articles were reviewed in depth and identified 37 clinical grading scales for prognostication of spontaneous intracerebral hemorrhage. The original ICH score remains the most widely used and validated. Various authors proposed modifications for improved prognostic accuracy, though no single scale showed consistent superiority. Most recently, scales to account for advances in surgical techniques have been developed but lack external validation. CONCLUSION We provide the most comprehensive review to date of prognostic grading scales for patients with intracerebral hemorrhage. Current prognostic tools for patients with intracerebral hemorrhage remain limited and may overestimate risk of a poor outcome. As minimally invasive surgical techniques are developed, prognostic scales should account for surgical candidacy and outcomes.
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Affiliation(s)
- Stephanie Zyck
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA.
| | - Lydia Du
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Grahame Gould
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | | | - Timothy Beutler
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | - Alexa Bodman
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Satish Krishnamurthy
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
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Mohamed WS, Kamel AE, Abdelwahab AH, Mahdy ME. High neutrophil-to-lymphocyte ratio predicts early neurological deterioration in spontaneous intracerebral hemorrhage patients. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-020-00267-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Intracerebral hemorrhage (ICH) is caused by bleeding, primarily into parenchymal brain tissue, and accounts for 9 to 27% of all strokes worldwide. Higher neutrophils, lower lymphocytes, and higher neutrophil-to-lymphocytes ratio (NLR) values predict worse outcomes after spontaneous intracranial hemorrhage (sICH) and could aid in the risk stratification of patients.
Methods
Eighty patients with sICH within the first 24 h of stroke onset and admitted into the neurology intensive care unit of an Egyptian university hospital and were assessed by GCS for consciousness level and NIHSS for stroke severity assessment, complete blood count, and special attention to NLR. Patients were reevaluated by GCS and NIHSS on the 7th day of the stroke. Early neurological deterioration (END) was defined as four points or a greater increase in the NIHSS score or two points or a greater decrease in GCS or death.
Results
END was recorded in 21.25% of patients while non-END was recorded in 78.75%. END was highly significantly associated with a low grade of GCS, high grade of NIHSS, elevated absolute lymphocyte count (ALC), and elevated NLR. Lower GCS score, higher NIHSS score, larger hematoma volume, and higher NLR values were independent predictors for END. The best cutoff of NLR in END prediction was > 9.1.
Conclusion
NLR is a trustworthy early predictor of sICH outcome.
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Hong S, Maruyama K, Noguchi A, Hirano T, Nagane M, Shiokawa Y. Is using intracerebral hemorrhage scoring systems valid for mortality prediction in surgically treated patients? Neurosurg Rev 2021; 44:2747-2753. [PMID: 33411094 DOI: 10.1007/s10143-020-01451-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/18/2020] [Accepted: 11/27/2020] [Indexed: 11/28/2022]
Abstract
While intracerebral hemorrhage (ICH) scoring systems provide mortality and morbidity prediction, the actual mortality rates seem to be lower than those predicted by scoring systems in our clinical impression. To assess the validity of the ICH score and the Surgical Swedish ICH (SwICH) score, we retrospectively reviewed surgically treated ICH patients between 2012 and 2019. Uni- and multivariate analyses were performed to identify variables in predicting 30-day mortality. We identified 203 patients (mean ICH score 2.7; mean SwICH score 2.0). The actual 30-day mortality was 7%, which was significantly lower than those predicted by the ICH and the SwICH scores (55% and 16%, respectively; p < 0.001). Both scores were strongly correlated with the modified Rankin scale (mRS) at discharge (correlation coefficient 0.97 and 0.98; critical value 0.81). The only significant prognostic factors for the 30-day mortality by multivariate analysis were anisocoria (p = 0.03) and preoperative Glasgow Coma Scale (p = 0.03). These two factors also predicted mRS at discharge (p < 0.001). After discharge, 15% of patients improved regarding mRS and 29% of wheelchair-bound patients gained the ability to ambulate. No significant relationship existed between the degree of recovery after discharge and preoperative ICH score (p = 0.25). The ICH and SwICH scores were more valid in predicting morbidity, rather than mortality after surgical intervention for ICH. Anisocoria and Glasgow Coma Scale < 7 were the only two factors that predicted 30-day mortality and morbidity at discharge.
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Affiliation(s)
- Sukwoo Hong
- Department of Neurosurgery, Kyorin University Hospital, Tokyo, Japan.
| | - Keisuke Maruyama
- Department of Neurosurgery, Kyorin University Hospital, Tokyo, Japan
| | - Akio Noguchi
- Department of Neurosurgery, Kyorin University Hospital, Tokyo, Japan
| | - Teruyuki Hirano
- Department of Stroke, Kyorin University Hospital, Tokyo, Japan
| | - Motoo Nagane
- Department of Neurosurgery, Kyorin University Hospital, Tokyo, Japan
| | - Yoshiaki Shiokawa
- Department of Neurosurgery, Kyorin University Hospital, Tokyo, Japan
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Lim MJR, Neo AYY, Singh GD, Liew YST, Rajendram MF, Tan MWX, Ragupathi T, Lwin S, Chou N, Sharma VK, Yeo TT. The Evaluation of Prognostic Scores in Spontaneous Intracerebral Hemorrhage in an Asian Population: A Retrospective Study. J Stroke Cerebrovasc Dis 2020; 29:105360. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022] Open
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Wartenberg KE, Hwang DY, Haeusler KG, Muehlschlegel S, Sakowitz OW, Madžar D, Hamer HM, Rabinstein AA, Greer DM, Hemphill JC, Meixensberger J, Varelas PN. Gap Analysis Regarding Prognostication in Neurocritical Care: A Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society. Neurocrit Care 2020; 31:231-244. [PMID: 31368059 PMCID: PMC6757096 DOI: 10.1007/s12028-019-00769-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background/Objective Prognostication is a routine part of the delivery of neurocritical care for most patients with acute neurocritical illnesses. Numerous prognostic models exist for many different conditions. However, there are concerns about significant gaps in knowledge regarding optimal methods of prognostication. Methods As part of the Arbeitstagung NeuroIntensivMedizin meeting in February 2018 in Würzburg, Germany, a joint session on prognostication was held between the German NeuroIntensive Care Society and the Neurocritical Care Society. The purpose of this session was to provide presentations and open discussion regarding existing prognostic models for eight common neurocritical care conditions (aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, traumatic spinal cord injury, status epilepticus, Guillain–Barré Syndrome, and global cerebral ischemia from cardiac arrest). The goal was to develop a qualitative gap analysis regarding prognostication that could help inform a future framework for clinical studies and guidelines. Results Prognostic models exist for all of the conditions presented. However, there are significant gaps in prognostication in each condition. Furthermore, several themes emerged that crossed across several or all diseases presented. Specifically, the self-fulfilling prophecy, lack of accounting for medical comorbidities, and absence of integration of in-hospital care parameters were identified as major gaps in most prognostic models. Conclusions Prognostication in neurocritical care is important, and current prognostic models are limited. This gap analysis provides a summary assessment of issues that could be addressed in future studies and evidence-based guidelines in order to improve the process of prognostication.
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Affiliation(s)
- Katja E Wartenberg
- Neurocritical Care and Stroke Unit, Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520-8018, USA
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Strasse 11, 97080, Würzburg, Germany
| | - Susanne Muehlschlegel
- Department of Neurology, Anesthesiology and Surgery, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Oliver W Sakowitz
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany
| | - Dominik Madžar
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hajo M Hamer
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | | | - David M Greer
- Department of Neurology, Boston University Medical Center, 72 East Concord St, Boston, MA, 02118, USA
| | - J Claude Hemphill
- Department of Neurology, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Juergen Meixensberger
- Department of Neurosurgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Panayiotis N Varelas
- Department of Neurology and Neurosurgery, Henry Ford Hospital, 2799 W. Grand Blvd Neurosurgery - K-11, Detroit, MI, 48202, USA
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Mahdy ME, Ghonimi NA, Elserafy TS, Mahmoud W. The NIHSS score can predict the outcome of patients with primary intracerebral hemorrhage. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0056-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Ironside N, Chen CJ, Pucci J, Connolly ES. Effect of Cigarette Smoking on Functional Outcomes in Patients with Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2019; 28:2496-2505. [PMID: 31279697 DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/25/2019] [Accepted: 06/08/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Nicotine may have neuroprotective effects on the injured brain through modulation of the cholinergic anti-inflammatory pathway. AIMS This study aimed to evaluate the relationship between cigarette smoking and outcomes in patients with spontaneous intracerebral hemorrhage (ICH). METHODS This was a retrospective review of consecutive ICH patients enrolled in the ICH Outcomes Project from 2009 to 2017. Patients with age ≥18 years and baseline modified Rankin Scale (mRS) score 0-2 were included. Smoking patterns were categorized as recent smoker (≤30 days prior to ICH) and not recent smoker (>30 days prior to ICH). Not recent smokers were further categorized into former smokers and nonsmokers. The primary outcome was good outcome (90-day mRS ≤ 2). Secondary outcomes were excellent outcome (90-day mRS 0-1), 90-day Barthel Index, and in-hospital and 90-day mortality. RESULTS The study cohort comprised 545 patients, including 60 recent smokers and 485 not recent smokers. Recent smokers had higher rates of good (35% versus 23%; odds ratio [OR] = 1.787, P = .047) and excellent (25% versus 13%; OR = 2.220, P = .015) outcomes compared to not recent smokers. These differences were not significant after baseline adjustments. Recent smokers had higher rates of good (36% versus 24%; OR = 1.732, P = .063) and excellent (25% versus 13%; OR = 2.203, P = .018) outcomes compared to nonsmokers. These differences were not significant after baseline adjustments. A 90-day Barthel Index, in-hospital, and 90-day mortality were comparable between recent and not recent smokers, recent and nonsmokers, and former and nonsmokers. CONCLUSIONS Despite potential neuroprotective effects of nicotine found in cigarettes, these may be outweighed by the detrimental effects of cigarette smoking on health outcomes.
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Affiliation(s)
- Natasha Ironside
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York.
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Josephine Pucci
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Edward Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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Shamalov NA, Stakhovskaya LV, Klochihina OA, Polunina OS, Polunina EA. [An analysis of the dynamics of the main types of stroke and pathogenetic variants of ischemic stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:5-10. [PMID: 31184619 DOI: 10.17116/jnevro20191190325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To analyze the main changes in the prevalence of stroke types and pathogenetic variants of ischemic stroke based on the data obtained from seven regions of the Russian Federation among the population aged 25 years and older. MATERIAL AND METHODS: In total, 29 779 cases of stroke, of which 4167 cases were registered in 2009 and 3402 cases in 2016, were detected during the period from 2009 to 2016. RESULTS AND CONCLUSION: The comparative analysis showed that the proportion of unspecified stroke (unspecified as a hemorrhage and or heart attack) decreased by 11 times from 4.7% to 0.4% (p<0.001). A decrease in 28-day mortality in ischemic stroke, intracerebral and subarachnoid hemorrhage was registered. A change in the ratio of the prevalence of pathogenetic variants of ischemic stroke was revealed. Over the 8-year period, the prevalence of cardioembolic stroke decreased from 35% to 21% (p=0.037). The prevalence of other pathogenetic variants of ischemic stroke has undergone changes. The changes in the ratio of the types of stroke studied are primarily related to the improvement of the diagnosis of stroke types, due to an increase in the percentage of computer tomography/magnetic resonance imaging performed, as well as the introduction of high-tech methods of helping patients with stroke and its effective prevention.
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Affiliation(s)
- N A Shamalov
- Federal Center for Cerebrovascular Pathology and Styroke, Moscow, Russia
| | - L V Stakhovskaya
- Federal Center for Cerebrovascular Pathology and Styroke, Moscow, Russia
| | - O A Klochihina
- Federal Center for Cerebrovascular Pathology and Styroke, Moscow, Russia
| | - O S Polunina
- Astrakhan State Medical University, Astrakhan, Russia
| | - E A Polunina
- Astrakhan State Medical University, Astrakhan, Russia
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Ironside N, Chen CJ, Dreyer V, Christophe B, Buell TJ, Connolly ES. Location-specific differences in hematoma volume predict outcomes in patients with spontaneous intracerebral hemorrhage. Int J Stroke 2019; 15:90-102. [PMID: 30747614 DOI: 10.1177/1747493019830589] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Functional outcome after spontaneous intracerebral hemorrhage (ICH) may vary depending on hematoma volume and location. We assessed the interaction between hematoma volume and location, and modified the original ICH score to include such an interaction. METHODS Consecutive ICH patients were enrolled in the Intracerebral Hemorrhage Outcomes Project from 2009 to 2017. Inclusion criteria were age≥18 years, baseline modified Rankin Scale (mRS) score 0-2, neuroimaging, and follow-up. Functional dependence and mortality were defined as 90-day mRS>2 and death, respectively. A location ICH score was developed using multivariable regression and area under the receiver operator characteristic curve (AUROC) analyses. RESULTS The study cohort comprised 311 patients, and the derivation and validation cohorts comprised 209 and 102 patients, respectively. Interactions between hematoma volume and location predicted functional dependence (p = 0.008) and mortality (p = 0.025). The location ICH score comprised age≥80 years (1 point), Glasgow Coma Scale score (3-9 = 2 points; 10-13 = 1 point), volume-location (lobar:≥24 mL=2 points, 21-24 mL=1 point; deep:≥8 mL=2 points, 7-8 mL=1 point; brainstem:≥6 mL=2 points, 3-6 mL=1 point; cerebellum:≥24 mL=2 points, 12-24 mL=1 point), and intraventricular hemorrhage (1 point). AUROC of the location ICH score was higher in functional dependence (0.883 vs. 0.770, p = 0.002) but not mortality (0.838 vs. 0.841, p = 0.918) discrimination compared to the original ICH score. CONCLUSIONS The interaction between hematoma volume and location exerted an independent effect on outcomes. Excellent discrimination of functional dependence and mortality was observed with incorporation of location-specific volume thresholds into a prediction model. Therefore, the volume-location relationship plays an important role in ICH outcome prediction.
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Affiliation(s)
- Natasha Ironside
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Victoria Dreyer
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Brandon Christophe
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Edward Sander Connolly
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Gregório T, Pipa S, Cavaleiro P, Atanásio G, Albuquerque I, Chaves PC, Azevedo L. Prognostic models for intracerebral hemorrhage: systematic review and meta-analysis. BMC Med Res Methodol 2018; 18:145. [PMID: 30458727 PMCID: PMC6247734 DOI: 10.1186/s12874-018-0613-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/07/2018] [Indexed: 12/23/2022] Open
Abstract
Background Prognostic tools for intracerebral hemorrhage (ICH) patients are potentially useful for ascertaining prognosis and recommended in guidelines to facilitate streamline assessment and communication between providers. In this systematic review with meta-analysis we identified and characterized all existing prognostic tools for this population, performed a methodological evaluation of the conducting and reporting of such studies and compared different methods of prognostic tool derivation in terms of discrimination for mortality and functional outcome prediction. Methods PubMed, ISI, Scopus and CENTRAL were searched up to 15th September 2016, with additional studies identified using reference check. Two reviewers independently extracted data regarding the population studied, process of tool derivation, included predictors and discrimination (c statistic) using a predesignated spreadsheet based in the CHARMS checklist. Disagreements were solved by consensus. C statistics were pooled using robust variance estimation and meta-regression was applied for group comparisons using random effect models. Results Fifty nine studies were retrieved, including 48,133 patients and reporting on the derivation of 72 prognostic tools. Data on discrimination (c statistic) was available for 53 tools, 38 focusing on mortality and 15 focusing on functional outcome. Discrimination was high for both outcomes, with a pooled c statistic of 0.88 for mortality and 0.87 for functional outcome. Forty three tools were regression based and nine tools were derived using machine learning algorithms, with no differences found between the two methods in terms of discrimination (p = 0.490). Several methodological issues however were identified, relating to handling of missing data, low number of events per variable, insufficient length of follow-up, absence of blinding, infrequent use of internal validation, and underreporting of important model performance measures. Conclusions Prognostic tools for ICH discriminated well for mortality and functional outcome in derivation studies but methodological issues require confirmation of these findings in validation studies. Logistic regression based risk scores are particularly promising given their good performance and ease of application. Electronic supplementary material The online version of this article (10.1186/s12874-018-0613-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tiago Gregório
- Department of Internal Medicine, Vila Nova de Gaia Hospital Cente, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal. .,Stroke Unit, Vila Nova de Gaia Hospital Center, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal.
| | - Sara Pipa
- Department of Internal Medicine, Vila Nova de Gaia Hospital Cente, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Pedro Cavaleiro
- Intensive Care Department, Algarve University Hospital Center, Rua Leão Penedo, 8000-386, Faro, Portugal
| | - Gabriel Atanásio
- Department of Internal Medicine, Vila Nova de Gaia Hospital Cente, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Inês Albuquerque
- Department of Internal Medicine, São João Hospital Center, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Paulo Castro Chaves
- Department of Internal Medicine, São João Hospital Center, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal.,Stroke Unit, São João Hospital Center, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal.,Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Luís Azevedo
- Center for Health Technology and Services Research & Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal
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15
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Zhou HX, Hao N, Xu XL. Related Factors of Early Mortality in Young Adults with Cerebral Hemorrhage. Open Med (Wars) 2018; 13:214-220. [PMID: 29915811 PMCID: PMC6004518 DOI: 10.1515/med-2018-0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/14/2018] [Indexed: 01/08/2023] Open
Abstract
Background The main causes of intracerebral hemorrhage differ between young adults and older adults. Data regarding potential targets for early intervention in young adult patients with intracerebral hemorrhage are lacking. Methods We retrospectively analysed data for 196 young adult patients with intracerebral hemorrhage who were admitted to Tianjin Huanhu Hospital and died within 30 days of admission between June 2005 and June 2015. The Kaplan–Meier method was used to calculate survival rate, and the log-rank test was used to determine survival rate significance. A Cox proportional hazards regression model was used for univariate and multivariate analyses. Results Univariate analysis revealed a statistically significant association of age, disturbance of consciousness, National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, seizure occurrence, infratentorial hemorrhage, intraventricular extension, hernia, glucose level, white blood cell count, albumin level, creatinine level, uric acid level, and surgical treatment with early mortality (P<0.05). However, multivariate regression analysis revealed that only infratentorial hemorrhage (P=0.003) and intraventricular extension (P=0.003) were significant risk factors for early mortality. Conclusions Our results suggest that young adult patients who exhibit infratentorial hemorrhage and intraventricular extension in the early stages of intracerebral hemorrhage onset exhibit an increased risk of early mortality.
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Affiliation(s)
- Hong Xia Zhou
- Department of Neurology, Tianjin Hospital, 406 Jiefang South Road, Hexi, Tianjin 300211, China
| | - Nina Hao
- Department of Radiation, Tianjin HuanHu Hospital, 6 Jizhao Road, Jinnan, Tianjin 300350, China
| | - Xiao Lin Xu
- Department of Neurology, Tianjin HuanHu Hospital, 6 Jizhao Road, Jinnan, Tianjin 300350, China, Tel.: +8613512066111
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16
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Gupta S, Abbot AK, Srinath R, Tewari AK, Gupta A, Gorthi SP, Narayanan CS, Totlani SI, Sirohi YS, Anadure R. Randomized trial to assess safety and clinical efficacy of intensive blood pressure reduction in acute spontaneous intracerebral haemorrhage. Med J Armed Forces India 2018; 74:120-125. [PMID: 29692476 DOI: 10.1016/j.mjafi.2017.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 03/31/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Haematoma expansion due to raised blood pressure in spontaneous intracerebral haemorrhage may determine outcome. The aim of this study was to determine safety and efficacy of lowering blood pressure in acute spontaneous intracerebral haemorrhage. METHODS This open label, multicentric trial randomized patients ≥18 years with spontaneous intracerebral haemorrhage with no secondary cause within 72 h of onset to tight BP control arm where treatment was initiated if mean arterial pressure (MAP) was ≥115 mm of Hg and conventional BP control arm where treatment was initiated if MAP was ≥130 mm of Hg. The MAP was maintained in the respective arm for another 72 h after which both arms had MAP below 115 mm of Hg. Primary outcome was modified Rankin Scale at 90 days. RESULTS 118 patients, 59 in each arm were included. Follow up was available for all. Baseline characteristics were similar. At 90 days there was no significant difference between median mRS between the two arms. Odds Ratio for "poor outcome" (mRS 3-6) in the tight control arm (safety of the intervention) against "good outcome" (mRS 0-2) was not significant (OR 0.70 [95% CI 0.34-1.47] p = 0.35). Efficacy of the intervention in the form of Odds Ratio for "good outcome" in the tight control arm was not significant (OR 1.43 [95% CI 0.68-2.99], p = 0.35). CONCLUSION In patients with spontaneous intracerebral haemorrhage who present within 72 h of the onset of symptoms, MAP can be safely lowered if it crosses 115 mm of Hg but it does not improve clinical outcome.
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Affiliation(s)
- Salil Gupta
- Professor & Head (Neurology), Army Hospital (R&R), New Delhi, India
| | - A K Abbot
- Graded Specialist (Medicine), Military Hospital Partapur, India
| | - R Srinath
- Classified Specialist (Medicine) & Neurologist, Command Hospital (Eastern Command), Kolkata, India
| | - A K Tewari
- Commandant, Base Hospital Delhi Cantt, New Delhi, India
| | - Aditya Gupta
- Senior Adviser (Medicine) & Neurologist, Command Hospital (Western Command), Chandimandir, India
| | - S P Gorthi
- Professor, Department of Neurology, Kasturba Gandhi Medical College, Manipal, India
| | | | - S I Totlani
- Senior Adviser (Medicine) & Neurologist, Command Hospital (Southern Command), Pune 411040, India
| | - Y S Sirohi
- Associate Professor (Internal Medicine), Armed Forces Medical College, Pune 411040, India
| | - Ravi Anadure
- Senior Adviser (Medicine) & Neurologist, Command Hospital Air Force, Bengaluru, India
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17
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Houben R, Schreuder FHBM, Bekelaar KJ, Claessens D, van Oostenbrugge RJ, Staals J. Predicting Prognosis of Intracerebral Hemorrhage (ICH): Performance of ICH Score Is Not Improved by Adding Oral Anticoagulant Use. Front Neurol 2018. [PMID: 29541054 PMCID: PMC5836590 DOI: 10.3389/fneur.2018.00100] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The intracerebral hemorrhage (ICH) score is a commonly used prognostic model for 30-day mortality in ICH, based on five independent predictors (ICH volume, location, Glasgow Coma Scale, age, and intraventricular extension). Use of oral anticoagulants (OAC) is also associated with mortality but was not considered in the ICH score. We investigated (a) whether the predictive performance of ICH score is similar in OAC-ICH and non-OAC-ICH and (b) whether addition of OAC use to the ICH score increases the prognostic performance of the score. Methods We retrospectively selected all consecutive adult non-traumatic ICH cases (three hospitals, region South-Limburg, the Netherlands 2004-2009). Mortality at 30 days was recorded. Using univariable and multivariable logistic regression, association between OAC use and 30-day mortality was tested. Then (a) we computed receiver operating characteristic (ROC) curves for ICH score and determined the area under the curve (AUC) in OAC-ICH and non-OAC-ICH. Then (b) we created a New ICH score by adding OAC use to the ICH score. We calculated correlation between 30-day mortality and ICH score, respectively, New ICH score using Spearman correlation test. We computed ROC curves and calculated the AUC. Results We analyzed 1,232 cases, 282 (22.9%) were OAC related ICH. Overall, 30-day mortality was 39.3%. OAC use was independently associated with 30-day mortality (OR 2.09, 95% CI, 1.48-2.95; p < 0.001), corrected for the five predictors of the ICH score. The ICH score performed slightly better in non-OAC-ICH (AUC 0.840) than in OAC-ICH (AUC 0.816), but this difference was not significant (p = 0.39). The ICH score and the New ICH score were both significantly correlated with 30-day mortality (rho 0.58, p < 0.001 and 0.59, p < 0.001, respectively). The AUC for the ICH score was 0.837, for New ICH score 0.840. This difference was not significant. Conclusion The ICH score is a useful tool for predicting 30-day mortality both in patient who use and patients who do not use OAC. Although OAC use is an independent predictor of 30-day mortality, addition of OAC use to the existing ICH score does not increase the prognostic performance of this score.
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Affiliation(s)
- Rik Houben
- Department of Neurology, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | - Kim J Bekelaar
- Department of Neurology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Danny Claessens
- Department of Neurology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Centre, Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Centre, Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
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18
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Masotti L, Lorenzini G, Di Napoli M, Godoy DA. Prognostic ability of four clinical grading scores in spontaneous intracerebral hemorrhage. Acta Neurol Belg 2017; 117:325-327. [PMID: 26848965 DOI: 10.1007/s13760-016-0609-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/20/2016] [Indexed: 10/22/2022]
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19
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Zhao Y, Yang J, Zhao H, Ding Y, Zhou J, Zhang Y. The association between hyperglycemia and the prognosis of acute spontaneous intracerebral hemorrhage. Neurol Res 2016; 39:152-157. [PMID: 28019142 DOI: 10.1080/01616412.2016.1270575] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Yanxia Zhao
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jie Yang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hongdong Zhao
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yunlong Ding
- Department of Neurology, Jingjiang People’s Hospital, Jingjiang, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yingdong Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Tan G, Hao Z, Lei C, Chen Y, Yuan R, Xu M, Liu M. Subclinical change of liver function could also provide a clue on prognosis for patients with spontaneous intracerebral hemorrhage. Neurol Sci 2016; 37:1693-700. [DOI: 10.1007/s10072-016-2656-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/01/2016] [Indexed: 11/28/2022]
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21
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EDICH; a Novel Grading Scale for Predicting the 30-Day Case Fatality of Primary Inoperable Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2015; 24:1104-5. [PMID: 25802112 DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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22
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Masotti L, Di Napoli M, Godoy DA, Lorenzini G. Predictive Ability of a Modified Version of Emergency Department Intracerebral Hemorrhage Grading Scale for Short-term Prognosis of Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2015; 24:1100-4. [PMID: 25802114 DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 01/04/2015] [Indexed: 11/17/2022] Open
Affiliation(s)
- Luca Masotti
- Internal Medicine, Santa Maria Nuova Hospital, Florence, Italy; Internal Medicine, Cecina Hospital, Cecina, Italy
| | - Mario Di Napoli
- Neurological Service, San Camillo de' Lellis Hospital, Rieti, Italy
| | - Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur and Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina
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