Primary Pontine Hemorrhage in the Acute Stage: Clinical Features and a Proposed New Simple Scoring System

Development and validation of a clinical prediction model for prognostic factors in patients with primary pontine hemorrhage

We aimed to develop a prognostic model for primary pontine hemorrhage (PPH) patients and validate the predictive value of the model for a good prognosis at 90 days. A total of 254 PPH patients were included for screening of the independent predictors of prognosis, and data were analyzed by univariate and multivariable logistic regression tests. The cases were then divided into training cohort (n=219) and validation cohort (n=35) based on the two centers. A nomogram was developed using independent predictors from the training cohort to predict the 90-day good outcome and was validated from the validation cohort. Glasgow Coma Scale score, normalized pixels (used to describe bleeding volume), and mechanical ventilation were significant predictors of a good outcome of PPH at 90 days in the training cohort (all P<0.05). The U test showed no statistical difference (P=0.892) between the training cohort and the validation cohort, suggesting the model fitted well. The new model showed good discrimination (area under the curve=0.833). The decision curve analysis of the nomogram of the training cohort indicated a great net benefit. The PPH nomogram comprising the Glasgow Coma Scale score, normalized pixels, and mechanical ventilation may facilitate predicting a 90-day good outcome.

Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage

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.

Curative effect analysis of robot-assisted drainage surgery in treatment of spontaneous hypertensive brainstem hemorrhage

Objective

Spontaneous hypertensive brainstem hemorrhage (HBSH) is characterized by sudden onset, rapid progression and poor prognosis. There has been a growing tendency of surgical treatment for HBSH. This study aimed to investigate outcomes and potential factors associated with the prognosis of robot-assisted drainage surgery for HBSH treatment.

Methods

Patients with HBSH from July 2016 to March 2023 at a single neurosurgery center were included and divided into conservative group and surgical groups. Baseline and clinical data, radiographic characteristics, complications, and outcome evaluations were recorded and analyzed.

Results

A total of 125 patients, with 74 in the conservative group and 51 in the surgical group, were enrolled in the study. Mortality at 6 months was 59/74 (79.7%) in the conservative group and 9/51 (17.6%) in the surgical group. Twenty-four patients (47.1%) achieved favorable outcomes in the surgical group, whereas this rate in the conservative group was only 5.4% (4/74). There was a significant difference in NIHSS, GCS, and mRS at 6 months between surviving patients in the conservative and surgical groups. In prognostic analysis in the surgical subgroup, initial GCS score [5 (IQR 4-7) vs. 3 (IQR 3-4), p < 0.001], NIHSS [36 (IQR 32-38) vs. 40 (IQR 38-40), p < 0.001], smoking history [45.8% (11/24) vs. 74.1% (20/27), p = 0.039], hematoma volume [6.9 (IQR 6.2-7.6) vs. 9.6 (IQR 7.3-11.4), p = 0.001], and hemorrhage location (p = 0.001) were potential risk factors for poor 6-month prognosis after robot-assisted surgery for HBSH.

Conclusion

Based on the results of this study, robot-assisted minimally invasive drainage of brain stem hematoma may significantly reduce mortality and improve prognosis. Surgery should be conducted for selected patients.

Applications of Machine Learning Model for Prediction of Outcomes in Primary Pontine Hemorrhage

BACKGROUND

Primary pontine hemorrhage (PPH) is a rare intracranial hemorrhage with a wide range of mortality rate. Predicting the prognosis of PPH is still challenging. Previous prognostic scoring tests have not been widely used due to limited external validation. This study applied machine learning (ML) algorithms to develop predictive models for mortality and prognosis of patients with PPH.

METHODS

Data of patients with PPH were retrospectively reviewed. Seven ML models were used to train and validate for predicting outcomes of PPH including 30-day mortality rate, 30-day, and 90-day functional outcomes. Accuracy, sensitivity, specificity, positive and negative predictive value, F1 score, Brier score, and area under the curve (AUC) of the receiver operating characteristic were calculated. The models with the highest AUC were then selected to evaluate the testing data.

RESULTS

One hundred and fourteen patients with PPH were included. Mean hematoma volume was 7 ml and most patients had hematoma in the central part of the pons. The 30-day mortality rate was 34.2% and favorable outcomes were observed in 71.1% and 70.2% during 30-day and 90-day follow-up. The ML model could predict 30-day mortality with an AUC of 0.97 using an artificial neural network. Regarding functional outcome, the gradient boosting machine could predict both 30-day and 90-day outcomes with an AUC of 0.94.

CONCLUSIONS

ML algorithms achieved a high performance and accuracy in predicting PPH outcomes. Despite the need for further validation, ML models are promising tools for clinical applications in the future.

Effect of hematoma volume on the 30-day mortality rate of patients with primary hypertensive brainstem hemorrhage: a retrospective cohort study

Objective

The purpose of this study is to investigate the effect of hematoma volume on the 30-Day Mortality Rate of patients with Primary Hypertensive Brainstem Hemorrhage (PHBH).

Methods

Retrospective analysis was done on the clinical information of 74 patients who underwent treatment for primary hypertensive brainstem hemorrhage at the Department of Neurosurgery of the 908th Hospital of the Joint Logistic Support Force of the Chinese People's Liberation Army between January 2018 and December 2021. Both univariate and multivariate logistic regression were used to assess clinical signs and risk factors that affect 30-day mortality.

Results

In the 74 patients with primary hypertensive brainstem hemorrhage included in this investigation, 46 patients died and 28 patients survived. The mortality rate at 30 days was 62.16%. A statistically significant difference was seen (P < 0.001) in the results of the univariate analysis, which suggested that hematoma volume may be a factor affecting the prognosis of patients with hypertensive brainstem hemorrhage. Hematoma volume was further demonstrated to be a risk factor and an independent factor impacting death in patients with brainstem hemorrhage (P < 0.001) by multivariate logistic regression analysis (OR: 2.6, 95% CI: 1.7-3.9, P < 0.001 Crude Model, OR: 3.6, 95% CI: 1.7-7.7, P < 0.001 Multivariate-Adjusted Model). After adjusting for confounding variables such as age, body mass index, sex, history of diabetes mellitus, history of hypertension, admission GCS score, stereotactic aspiration, combined hydrocephalus, admission systolic and diastolic blood pressure, the hematoma volume was revealed to be an independent predictor of 30-day death in patients with brainstem hemorrhage. We discovered by smooth curve fitting that hematoma volume increased in a non-linear manner with 30-day mortality. The 30-day mortality rate did not alter significantly when the hematoma volume was less than 4 ml. When the hematoma volume was greater than 4 ml, the 30-day mortality rate increased rapidly, and when the hematoma volume was 10 ml, the 30-day mortality rate reached the maximum.

Conclusions

Hematoma volume is an independent factor affecting 30-day mortality in patients with primary hypertensive brainstem hemorrhage. The severe and extensive neurological damage caused by primary hypertensive brainstem hemorrhage is highly unlikely to be fundamentally altered by a single protocol, and new avenues need to be explored scientifically and continuously.

Predicting prognosis of primary pontine hemorrhage using CT image and deep learning

Prognosis of primary pontine hemorrhage (PPH) is important for treatment planning and patient management. However, only few clinical factors were reported to have prognostic value to PPH. Here, we propose a deep learning (DL) model that mines high-dimensional prognostic information from computed tomography (CT) images and combines clinical factors for predicting individualized prognosis of PPH. We proposed a multi-task DL model to learn high-dimensional CT features of hematoma and perihematomal areas for predicting the risk of 30-day mortality, 90-day mortality and 90-day functional outcome of PPH simultaneously. We further explored the combination of the DL model and clinical factors by building a combined model. All the models were trained in a training cohort (n = 219) and tested in an independent testing cohort (n = 35). The DL model achieved area under the curve (AUC) of 0.886, 0.886, and 0.759 in predicting 30-day mortality, 90-day mortality and 90-day functional outcome of PPH in the independent testing cohort, which improved over the previously reported new PPH score and the clinical model. When combining the DL model and clinical factors, the combined model achieved improved performance (AUC = 0.920, 0.941, and 0.894), indicating that DL model mines CT information that complements clinical factors. Through DL visualization technique, we found that the internal structure of hematoma and its expansion to perihematomal regions are important for predicting the prognosis of PPH. This DL model provides an easy-to-use way for predicting individualized prognosis of PPH by mining high-dimensional information from CT images, and showed improvement over clinical factors and present methods.

Management of Primary Brainstem Hemorrhage: A Review of Outcome Prediction, Surgical Treatment, and Animal Model

Primary brainstem hemorrhage (PBH) has the worst prognosis of all types of intracerebral hemorrhage. Currently, the management of PBH is controversial. Hematoma classification, scoring systems, and electrophysiological monitoring are critical for predicting the outcome of PBH. Surgery may be an effective treatment for PBH. Clinical studies have emphasized the importance of animal models for understanding the pathogenesis and pathological mechanisms of PBH. In this study, combined with recent studies, the outcome prediction, surgical treatment, and animal models of PBH were reviewed.

The truths behind the statistics of surgical treatment for hypertensive brainstem hemorrhage in China: a review

Hypertensive brainstem hemorrhage (HBSH) is of high morbidity and mortality rate. But many clinical studies were written in Chinese and had not been reviewed. A systemic review of Chinese clinical studies for HBSH was performed. A systemic literature search in PubMed, Web of Science, China National Knowledge Infrastructure, and Weipu database and Wanfang database up to March 2020 was performed. Clinical control studies including a surgical evacuation (SE) group and a conservative management (CM) group were included. The clinical outcome and mortality rate were compared. Ten cohort studies were included, involving 944 participants (304 in the SE group and 640 in the CM group). All included patients were comatose, with the average age ranged from 45 to 65 years old. Among five studies using mRS or GOS as outcome score, a total of 16.6% (89/535) of patients achieve self-maintenance with minor disabilities, including 26.8% (34/127) in the SE group and 13.5% (55/408) in the CM group. The overall mortality rate in the SE group was 27.6%, ranged from 9.3 to 60% among different studies. The overall mortality rate in the CM group was 60.6%, ranged from 18.5 to 100.0%. Elder and comatose HBSH patients are not contraindicated for surgery. The review showed that this group of patients obtained a better outcome and lower mortality rate after surgical treatment. The quality of included studies was relatively low, but a high-level clinical study on HBSH is of great difficulty, as both clinicians and patients faced various sociological issues rather than pure medical problems.

The benefit and outcome prediction of acute surgery for hemorrhagic brainstem cavernous malformation with impending respiratory failure

OBJECTIVES

Impending respiratory failure is catastrophic neurological deterioration caused by repeated c of a brainstem cavernous malformation (BSCM). The benefit and outcome prediction of acute surgery for this fatal condition is rarely reported. In this study, the authors reported a case series of acute surgical treatment (≤3 weeks after the last hemorrhagic episode) for the BSCM with impending respiratory failure and reviewed literature over the past 20 years.

MATERIALS AND METHODS

Clinical and outcome data from 6 consecutive acute surgically-treated BSCM patients were analyzed. Intracerebral hemorrhage (ICH) scores, primary pontine hemorrhage (PPH) scores, and Lawton's BSCM grading were applied for surgical outcome prediction. Ten related articles were included for the literature review.

RESULTS

There were three men and three women, with a mean age of 32.2 ± 9.3 years (range 15-45 years). The BSCMs were located at the pons in 5 cases and the medulla in 1 case. The ICH score was 1-2 in all cases, while the PPH score was 0 in all pontine BSCMs. For Lawton's BSCM grading, 3 cases were grade 2, 2 cases were grade 3, and 1 case was grade 1. All patients achieved spontaneous respiratory dysfunction relief postoperatively and significantly improved at follow-up (mean 4.47 ± 0.24 years;range4.0-5.6 years).

CONCLUSIONS

Repeated hemorrhagic BSCM with impending respiratory failure can benefit from acute surgical treatment. The ICH score, PPH score, and Lawton's BSCM grading are promisingly useful tools for fast and efficient surgical outcome prediction.

Primary Brainstem Hemorrhage: A Review of Prognostic Factors and Surgical Management

Primary brainstem hemorrhage (PBSH) is the most fatal subtype of intracerebral hemorrhage and is invariably associated with poor prognosis. Several prognostic factors are involved, of which the two most predominant and consistent are the initial level of consciousness and hemorrhage size. Other predictors, such as age, hyperthermia, and hydrocephalus, are generally not dependable indicators for making prognoses. Scoring systems have now been developed that can predict mortality and functional outcomes in patients suffering from PBSH, which can thus guide treatment decision-making. A novel grading scale, entitled “the new primary pontine hemorrhage (PPH) score,” represents the latest approach in scoring systems. In this system, patients with a score of 2–3 points appear to benefit from surgical management, although this claim requires further verification. The four main surgical options for the treatment of PBSH are craniotomy, stereotactic hematoma puncture and drainage, endoscopic hematoma removal, and external ventricular drainage. Nevertheless, the management of PBSH still primarily involves conservative treatment methods and surgery is generally not recommended, according to current practice. However, the ongoing clinical trial, entitled Safety and Efficacy of Surgical Treatment in Severe Primary Pontine Hemorrhage Evacuation (STIPE), should provide additional evidence to support the surgical treatment of PBSH. Therefore, we advocate the update of epidemiological data and re-evaluation of PBSH treatment in a contemporary context.

Brainstem iron overload and injury in a rat model of brainstem hemorrhage

BACKGROUND AND PURPOSE

Brainstem hemorrhage (BSH) is the most devastating subtype of intracerebral hemorrhage (ICH) with the highest mortality ranging from 56 % to 61.2 %. However, there is no effective medical or surgical therapy to improve its outcomes in clinic to date due to lack of understanding of its injury mechanisms. Herein, we explored the brainstem iron overload and injury in a rat model of BSH.

METHODS

Neurological scores were examined on day 1, 3, and 7 after modeling, and mortality of the rats was recorded to draft a survival curve. Rats were monitored by MRI using T2 and susceptibility weighted imaging (SWI) before sacrifice for examination of histology and immunofluorescence on day 1, 3, and 7.

RESULTS

BSH rats had a high mortality of 56 % and demonstrated the severe neurological deficits mimicking the clinical conditions. SWI showed that the same increasing tendency in change of hypointense area with that in iron deposition by Perls staining from day 1 to 7. Expression of heme oxygenase 1 (HO-1) and generation of reactive oxygen species (ROS) had similar tendency and both peaked on day 3. Neuronal degeneration occurred and stayed elevated from day 1 to 7, while myelin sheath injury was initially observed on day 1 but without significant difference within 7 days.

CONCLUSIONS

The time courses of erythrocyte lysis, HO-1 expression, iron deposition and ROS generation are related to each other after BSH. Besides, brainstem injury including neuronal degeneration and myelin damage were observed and discussed.

Prediction of intracranial hemorrhages after mechanical thrombectomy of basilar artery occlusion

Background

Mechanical thrombectomy (MT) achieves high recanalization rates in basilar artery occlusion (BAO). A severe complication of MT in BAO is intracranial hemorrhage (ICH). Yet, knowledge of risk factors for ICH after MT in BAO is limited.

Objective

To evaluate clinical and procedural parameters of patients treated with MT owing to BAO to identify potential risk factors for ICH—in particular, symptomatic ICH (sICH), and assess their clinical relevance.

Methods

We conducted a retrospective analysis of 101 consecutive patients presenting with BAO, who were treated with MT in our centre. Important clinical and procedural parameters were analysed as possible predictors for any ICH and sICH according to the Heidelberg Bleeding Classification using univariate tests and multivariate logistic regressions.

Results

ICH occurred in 25 (24.8%) patients, with a total of 7 (6.9%) developing sICH. Treatment with glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors was independently associated with any ICH (OR=24.67, 95% CI 4.90 to 124.03) and sICH (OR=7.08, 95% CI 1.36 to 36.78). Also, a longer onset-to-recanalization time increased the risk of both any ICH (OR=1.17, 95% CI 1.07 to 1.31) and sICH (OR=1.22, 95% CI 1.08 to 1.42). Higher serum glucose levels were associated with a higher incidence of any ICH (OR=1.39, 95% CI 1.06 to 1.85) and a higher risk of a fatal outcome (OR=1.03, 95% CI 1.01 to 1.05).

Conclusion

Administration of GPIIb/IIIa inhibitor during the course of MT of BAO was identified as an important risk factor in the development of any ICH and sICH.

Deferoxamine Alleviates Iron Overload and Brain Injury in a Rat Model of Brainstem Hemorrhage

BACKGROUND

Brainstem hemorrhage (BSH) is the most dangerous and devastating subtype of intracerebral hemorrhage and is associated with high morbidity and mortality. However, to date, no effective prevention methods or specific therapies have been available to improve its clinical outcomes. We preliminarily explored the efficacy of deferoxamine (DFO), a clinical chelator known for its iron-scavenging activities, in a rat model of BSH induced with collagenase infusion.

METHODS

DFO or saline was administrated 6 hours after BSH induction and then every 12 hours for ≤7 days. The survival curve of the rats was created, and the neurological scores were examined on days 1, 3, and 7 after BSH. The rats were sacrificed after 1, 3, and 7 days of DFO treatment for histological examination and immunohistochemistry.

RESULTS

The results showed that administration of DFO delayed erythrocytes lysis, reduced iron deposition, reduced reactive oxygen species generation, reduced heme oxygenase-1 expression, and alleviated brain injury such as neuron degeneration and myelin sheath injury. However, DFO did not improve the survival rate and neurobehavioral outcomes in this model.

CONCLUSIONS

Administration of DFO had limited therapeutic effects on collagenase-induced brainstem hemorrhage in rats. Some potential explanations were proposed, and more preclinical work is required to clarify the controversial curative effect of DFO in ICH.

Prognostic factors in pontine haemorrhage: A systematic review

Background

Pontine haemorrhage comprises approximately 10% of intracerebral haemorrhages. There is a common presumption that pontine haemorrhage is inherently associated with poor outcome.

Purpose

The aim of the review was to identify chief predictors of prognosis in (pontine haemorrhage) through systematic review of published literature.

Methods

A query of PubMed/MEDLINE was conducted in search of studies in English language since, 1980 focusing specifically on outcome in pontine haemorrhage. References for each publication were reviewed for additional studies not detected by the PubMed/MEDLINE probe. Surgical outcome studies were excluded from the review.

Findings

The query identified 7867 titles, after removal of duplicates and irrelevant studies, 20 titles were included in the review. In a total of 1437 pontine haemorrhage patients included in the 20 studies, the overall rate for early all-cause mortality was 48.1%. Level of consciousness on admission and haemorrhage size were the most consistent predictors of mortality in patients with pontine haemorrhage. Haemorrhage localisation within the pons was also a prognostic factor, but not consistently. Age and intraventricular extension were not found to be powerful prognostic predictors.

Discussion/Conclusion

Based on this review, level of consciousness on admission and haemorrhage size were the most influential prognostic factors in pontine haemorrhage, whereas age, haemorrhage localisation, and intraventricular haemorrhage did not consistently predict prognosis.

Development and Validation of a Grading Scale for Primary Pontine Hemorrhage

Background and Purpose—

We aimed to develop and validate a grading scale for predicting 30-day mortality and 90-day functional outcome in patients with primary pontine hemorrhage (PPH).

Methods—

We retrospectively reviewed records of consecutive patients with first-ever pontine hemorrhage from 3 teaching hospitals between 2005 and 2012. Independent factors associated with 30-day mortality were identified by logistic regression to establish a risk stratification scale, named the new PPH score. For validation of the new PPH score, we prospectively recruited subjects from 10 units between December 2014 and November 2015. The performance of the new PPH score was presented as discrimination and calibration, measured by area under the curve of the receiver operating characteristic and Hosmer–Lemeshow goodness-of-fit, respectively.

Results—

Data of 171 patients were available for scale development. The new PPH score consisted of 2 independent factors with individual points assigned as follows: Glasgow Coma Scale score 3 to 4 (=2 points), 5 to 7 (=1 point), and 8 to 15 (=0 point); PPH volume >10 mL (=2 points), 5 to 10 mL (=1 point), and <5 mL (=0 point). An independent cohort of 98 patients was applied as an external validation of the new PPH score. Results showed that the new PPH score was discriminative in predicting both 30-day mortality (area under the curve, 0.902) and 90-day good outcome (area under the curve, 0.927). Furthermore, the new PPH score revealed a good calibration (χ 2 =1.387; P =0.846) in 30-day mortality prediction.

Conclusions—

The new PPH score is simple and reliable in predicting short-term and long-term outcome for PPH patients.

Clinical Trial Registration—

URL: http://www.chictr.org.cn . Unique identifier: ChiCTR-OOC-14005533.

Dynamic Diffusion Tensor Imaging Reveals Structural Changes in the Bilateral Pyramidal Tracts after Brain Stem Hemorrhage in Rats

BACKGROUND AND PURPOSE

Few studies have concentrated on pyramidal tract (PY) changes after brain stem hemorrhage (BSH). In this study, we used a diffusion tensor imaging (DTI) technique and histologic identification to investigate longitudinal PY changes on both the contralateral and ipsilateral sides after experimental BSH.

METHODS

BSH was induced in 61 Sprague-Dawley rats by infusing 30 μl of autogenous tail blood into each rat's right pons. DTI and motor function examinations were performed repeatedly on days 1, 3, 7, 14, and 28 after surgery. Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity, and radial diffusivity were measured in the bilateral PYs. The axon and myelin injury in the PY were evaluated by histologic study.

RESULTS

As compared with normal controls, the bilateral PYs in rats with induced BSH showed an early decrease and a late increase in FA and an early increase and a late decrease in MD. A progressive decrease in axial diffusivity with dramatic axon loss from day 1 to day 28 after BSH was found bilaterally. The bilateral PYs showed an early increase and a late decrease in radial diffusivity. Early myelin injury and late repair were also detected pathologically in the bilateral PYs of rats with BSH. Thus, the early motor function deficits of rats with BSH began to improve on day 14 and had almost completely disappeared by day 28.

CONCLUSIONS

DTI revealed dynamic changes in the bilateral PYs after BSH, which was confirmed by histologic findings and which correlated with motor function alteration. These findings support the idea that quantitative DTI can track structural changes in the bilateral PYs and that DTI may serve as a noninvasive tool to predict the prognoses of patients with BSH.