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Murthy SB. Emergent Management of Intracerebral Hemorrhage. Continuum (Minneap Minn) 2024; 30:641-661. [PMID: 38830066 DOI: 10.1212/con.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH. LATEST DEVELOPMENTS Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques. ESSENTIAL POINTS This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.
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Newey C, Skaar JR, O'Hara M, Miao B, Post A, Kelly T. Systematic Literature Review of the Association of Fever and Elevated Temperature with Outcomes in Critically Ill Adult Patients. Ther Hypothermia Temp Manag 2024; 14:10-23. [PMID: 37158862 DOI: 10.1089/ther.2023.0004] [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] [Indexed: 05/10/2023] Open
Abstract
Although most commonly associated with infection, elevated temperature and fever also occur in a variety of critically ill populations. Prior studies have suggested that fever and elevated temperature may be detrimental to critically ill patients and can lead to poor outcomes, but the evidence surrounding the association of fever with outcomes is rapidly evolving. To broadly assess potential associations of elevated temperature and fever with outcomes in critically ill adult patients, we performed a systematic literature review focusing on traumatic brain injury, stroke (ischemic and hemorrhagic), cardiac arrest, sepsis, and general intensive care unit (ICU) patients. Searches were conducted in Embase® and PubMed® from 2016 to 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including dual-screening of abstracts, full texts, and extracted data. In total, 60 studies assessing traumatic brain injury and stroke (24), cardiac arrest (8), sepsis (22), and general ICU (6) patients were included. Mortality, functional, or neurological status and length of stay were the most frequently reported outcomes. Elevated temperature and fever were associated with poor clinical outcomes in patients with traumatic brain injury, stroke, and cardiac arrest but not in patients with sepsis. Although a causal relationship between elevated temperature and poor outcomes cannot be definitively established, the association observed in this systematic literature review supports the concept that management of elevated temperature may factor in avoidance of detrimental outcomes in multiple critically ill populations. The analysis also highlights gaps in our understanding of fever and elevated temperature in critically ill adult patients.
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Affiliation(s)
- Christopher Newey
- Department of Neurocritical Care, Sanford USD Medical Center, Sioux Falls, South Dakota, USA
| | | | | | | | - Andrew Post
- Trinity Life Sciences, Waltham, Massachusetts, USA
| | - Tim Kelly
- Becton Dickinson, Franklin Lakes, New Jersey, USA
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Tseng WC, Chiu YH, Chen YC, Chen HS, Hsiao MY. Early fever in patients with primary intracerebral hemorrhage is associated with worse long-term functional outcomes: a prospective study. BMC Neurol 2023; 23:375. [PMID: 37858049 PMCID: PMC10585771 DOI: 10.1186/s12883-023-03426-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Primary intracerebral hemorrhage (ICH) accounts for 85% of ICH cases and is associated with high morbidity and mortality rates. Fever can cause secondary injury after ICH; however, relevant studies have reported inconsistent results regarding the effects of fever on functional outcomes after ICH. This study examined the effects of early fever on the prognosis of ICH, particularly on long-term functional outcomes. METHODS This prospective study recruited patients with primary ICH at a tertiary medical center between 2019 and 2021. Early fever was defined as a tympanic body temperature of ≥ 38 °C upon admission. Barthel Index (BI) and modified Rankin scale (mRS) were examined at 1 year after ICH. A BI of ≤ 60 or mRS of ≥ 4 was considered as indicating severe disability. RESULTS We included 100 patients, and early fever was significantly associated with less functional independence at 1 year post-ICH, as determined using the mRS (p = 0.048; odds ratio [OR] = 0.23), and with severe functional dependency at 1 year post-ICH, as determined using the BI (p = 0.043; OR = 3) and mRS (p = 0.045; OR = 3). In addition, patients with early fever had a longer length of hospital stay (p = 0.002; 95% confidence interval = 21.80-95.91). CONCLUSIONS Fever is common among patients with primary ICH. Our data indicate a significant association between early fever and worse functional outcomes in ICH survivors at 1 year after ICH. Additionally, patients with early fever had a significantly longer length of hospital stay after ICH.
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Affiliation(s)
- Wen-Che Tseng
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Yunlin Branch, 579, Sec. 2, Yunlin Rd, Douliu City, Yunlin County, Taiwan
| | - Yi-Hsiang Chiu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan
| | - Yun-Chang Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan
| | - Hsin-Shui Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Yunlin Branch, 579, Sec. 2, Yunlin Rd, Douliu City, Yunlin County, Taiwan
| | - Ming-Yen Hsiao
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan.
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd, Taipei, Taiwan.
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McGlennen KM, Jannotta GE, Livesay SL. Nursing Management of Temperature in a Patient with Stroke. Crit Care Nurs Clin North Am 2023; 35:39-52. [PMID: 36774006 DOI: 10.1016/j.cnc.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Fever is common in patients with stroke and is associated with worse outcomes. Studies in brain injury informed interventions commonly termed therapeutic temperature management (TTM) to improve the monitoring and management of fever. While the role and benefit of TTM in stroke patients has not been well studied, the nurse and healthcare team must extrapolate existing data to determine how to best monitor and apply TTM after stroke. Nurses should be knowledgeable about interventions to monitor and manage complications of TTM (eg, shivering), the studies underway to quantify the impact of fever treatment and emerging technology expected to improve TTM.
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Affiliation(s)
| | - Gemi E Jannotta
- Department of Anesthesia and Pain Medicine, University of Washington
| | - Sarah L Livesay
- Department of Anesthesia and Pain Medicine, University of Washington, Rush University College of Nursing
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Yao Y, Wang X. Efficacy of intensive antibiotic regimens on postcraniotomy fever and cerebrospinal fluid examination results in patients with infratentorial surgeries. Medicine (Baltimore) 2022; 101:e32214. [PMID: 36550878 PMCID: PMC9771276 DOI: 10.1097/md.0000000000032214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Postcraniotomy fever is a common complication in patients undergoing infratentorial surgeries. There are few studies about it and the efficacy of intensive antibiotic regimens, which remain to be studied. We carried out a retrospective study in patients undergoing infratentorial surgeries to analyze the factors associated with postcraniotomy fever and further investigated the efficacy of different antibiotic regimens on fever and abnormal cerebrospinal fluid (CSF) results. Among the 115 patients, 74 (64.3%) had fever after craniotomy. Univariate analysis results showed that disease type, drainage tube placement, duration of drainage tube, and intraoperative bleeding volume were associated with postcraniotomy fever in patients undergoing infratentorial surgeries (P < .05). The multivariate analysis results showed that the duration of drainage tube (odds ratio = 1.010, 95% confidence interval: 1.232-6.178, P = .014) and duration of surgery (odds ratio = 1.010, 95% confidence interval: 1.002-1.017, P = .013) were associated with postcraniotomy fever in these patients. After treatment with different antibiotic regimens, the changes of white blood cells, sugar, chlorine and protein in CSF in patients with intensive antibiotic regimens were -638.48 × 106/L, 0.25 mmol/L, -0.76 mmol/L and -0.16 g/L respectively, which did not show significant differences when compared with ordinary antibiotic regimens (P > .05). Most cases of fever at the early stage after craniotomy in patients with infratentorial surgeries were nonintracranial infectious. Intensive antibiotic regimens did not show obvious advantages in improving the body temperature and CSF examination results. It is not necessary to use intensive antibiotic regimens too early, such as carbapenems or linezolids.
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Affiliation(s)
- Yuan Yao
- Department of Neurosurgery, The First Affiliated Hospital of Yangtze University, Jingzhou, China
| | - Xian Wang
- Department of Pharmacy, The First Affiliated Hospital of Yangtze University, Jingzhou, China
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Jelinek M, Duris K. Inflammatory Response in Sepsis and Hemorrhagic Stroke. BRAIN HEMORRHAGES 2022. [DOI: 10.1016/j.hest.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Prognostic Value of Circadian Brain Temperature Rhythm in Basal Ganglia Hemorrhage After Surgery. Neurol Ther 2021; 10:1045-1059. [PMID: 34561832 PMCID: PMC8571467 DOI: 10.1007/s40120-021-00283-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Intracerebral hemorrhage (ICH) is associated with high mortality and morbidity rates. However, both the rhythmic variation and prognostic value of brain temperature after ICH remain unknown. In this study, we investigated brain temperature rhythm and its prognostic value for post-operative mortality and long-term functional outcomes in patients with ICH. Methods Post-operative diurnal brain temperature patterns at the basal ganglion are described. Following surgery for ICH, 78 patients were enrolled, and intracranial pressure and brain temperature were monitored using a fiber optic device. Brain temperature mesor, amplitude, and acrophase were estimated from the recorded temperature measurements, using cosinor analysis, and the association between these patterns and clinical parameters, mortality, and functional outcomes at the 12-month follow-up were examined. Results According to cosinor analysis, brain temperature in 55.1% of patients showed a circadian rhythm within 72 h post-surgery. The rhythm-adjusted mesor of brain temperature (± standard deviation) was 37.6 (± 0.7) °C, with a diminished mean amplitude. A temperature acrophase shift was also observed. Multivariate logistic regression analysis revealed that initial age and circadian rhythm of brain temperature appeared to be predictive and prognostic of functional outcomes. Further, patients with higher brain temperature mesor were more likely to survive than those with a lower mesor. Conclusion For patients with ICH, brain temperature rhythm analysis is an improved prognostic tool for mortality and functional outcome predictions.
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Stösser S, Gotthardt M, Lindner-Pfleghar B, Jüttler E, Kassubek R, Neugebauer H. Severe Dysphagia Predicts Poststroke Fever. Stroke 2021; 52:2284-2291. [PMID: 33910366 DOI: 10.1161/strokeaha.120.033396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Sebastian Stösser
- Department of Neurology, University of Ulm, Germany (S.S., M.G., R.K., H.N.).,Department of Neurology, University Hospital Bonn, Germany (S.S.)
| | - Matthias Gotthardt
- Department of Neurology, University of Ulm, Germany (S.S., M.G., R.K., H.N.)
| | | | - Eric Jüttler
- Department of Neurology, Ostalb Hospital Aalen, Germany (E.J.)
| | - Rebecca Kassubek
- Department of Neurology, University of Ulm, Germany (S.S., M.G., R.K., H.N.)
| | - Hermann Neugebauer
- Department of Neurology, University of Ulm, Germany (S.S., M.G., R.K., H.N.).,Department of Neurology, University Hospital Würzburg, Germany (H.N.)
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Hanuska J, Klener J. Two Similar Cases of a Misdiagnosed Anterior Communicating Aneurysm Rupture. Case Rep Neurol 2021; 13:218-224. [PMID: 33976659 PMCID: PMC8077657 DOI: 10.1159/000514242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/01/2021] [Indexed: 11/19/2022] Open
Abstract
The misdiagnosis of a ruptured aneurysm directly endangers patient's life and health due to the high risk of rebleeding and its sequelae. In this paper, we present two uncommon cases of anterior communicating artery aneurysm rupture with a relatively small intracerebral bleeding, seemingly without a diffuse subarachnoid hemorrhage (SAH), and a relatively mild clinical presentation. In these cases, the initial diagnosis failed, leading to missed aneurysmal ruptures. The atypical or mild clinical presentation, and the absence of SAH on computed tomography (CT) and/or magnetic resonance imaging (MRI) scan or absent blood in the cerebrospinal fluid (CSF) are all factors which could lead to a false or delayed diagnosis. Meticulous evaluation of patient's symptoms, CT, MRI scans, and CSF findings are mandatory. The possibility of a small blood clot without a diffuse SAH must be considered.
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Affiliation(s)
- Jaromir Hanuska
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czechia
| | - Jan Klener
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czechia
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Prognostic significance of early pyrexia in acute intracerebral haemorrhage: The INTERACT2 study. J Neurol Sci 2021; 423:117364. [PMID: 33647734 DOI: 10.1016/j.jns.2021.117364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 01/25/2021] [Accepted: 02/18/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Uncertainty exists over the prognostic significance of pyrexia in acute intracerebral haemorrhage (ICH). We aimed to determine the association of elevated body temperature with clinical and imaging outcomes among participants of the main Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT2). METHODS Post-hoc analyses of INTERACT2, an international open, blinded outcome assessed, randomised trial of 2839 patients with spontaneous ICH (<6 h of onset) and elevated systolic blood pressure (SBP, 150-220 mmHg) randomly assigned to intensive (SBP target <140 mmHg) or guideline-recommended (SBP target < 180 mmHg) BP management. Multivariable logistic regression was used to determine associations of elevated baseline body temperature (<37.5 vs. ≥37.5 °C) and 90-day clinical outcome defined on the modified Rankin scale (mRS). Analysis of covariance determined relations of body temperature and haematoma and perihaematomal oedema (PHE) volumes, at baseline and 24 h post-randomisation. RESULTS Of 2792 participants with data available at admission, 39 (1.4%) patients had elevated body temperature ≥ 37.5 °C. Elevated body temperature was significantly associated with 90-day mortality (adjusted odds ratio 2.44; 95% confidence interval 1.02-5.82; P = .044) but not with major disability alone (mRS scores 3-5) and combination death or major disability (mRS scores 3-6). Elevated body temperature was also associated with larger PHE volume at baseline (10.89 vs. 3.14 cm3, P < .001;) and 24 h (12.43 vs 5.76 cm3, P = .018) but not with haematoma volumes at these time points. CONCLUSION Early pyrexia in mild to moderate ICH is associated with greater mortality and larger PHE volume, suggesting an early inflammatory-mediated reaction. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov (NCT00716079).
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Comparison of infection rate with tunneled vs standard external ventricular drainage: A prospective, randomized controlled trial. Clin Neurol Neurosurg 2019; 184:105416. [DOI: 10.1016/j.clineuro.2019.105416] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 11/20/2022]
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Saand AR, Yu F, Chen J, Chou SHY. Systemic inflammation in hemorrhagic strokes - A novel neurological sign and therapeutic target? J Cereb Blood Flow Metab 2019; 39:959-988. [PMID: 30961425 PMCID: PMC6547186 DOI: 10.1177/0271678x19841443] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Growing evidences suggest that stroke is a systemic disease affecting many organ systems beyond the brain. Stroke-related systemic inflammatory response and immune dysregulations may play an important role in brain injury, recovery, and stroke outcome. The two main phenomena in stroke-related peripheral immune dysregulations are systemic inflammation and post-stroke immunosuppression. There is emerging evidence suggesting that the spleen contracts following ischemic stroke, activates peripheral immune response and this may further potentiate brain injury. Whether similar brain-immune crosstalk occurs in hemorrhagic strokes such as intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is not established. In this review, we systematically examined animal and human evidence to date on peripheral immune responses associated with hemorrhagic strokes. Specifically, we reviewed the impact of clinical systemic inflammatory response syndrome (SIRS), inflammation- and immune-associated biomarkers, the brain-spleen interaction, and cellular mediators of peripheral immune responses to ICH and SAH including regulatory T cells (Tregs). While there is growing data suggesting that peripheral immune dysregulation following hemorrhagic strokes may be important in brain injury pathogenesis and outcome, details of this brain-immune system cross-talk remain insufficiently understood. This is an important unmet scientific need that may lead to novel therapeutic strategies in this highly morbid condition.
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Affiliation(s)
- Aisha R Saand
- 1 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Fang Yu
- 2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jun Chen
- 2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sherry H-Y Chou
- 1 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,3 Department of Neurosurgery, School of Medicine, University of Pittsburgh, PA, USA
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Nilsson A, Uvelius E, Cederberg D, Kronvall E. Silver-Coated Ventriculostomy Catheters Do Not Reduce Rates of Clinically Diagnosed Ventriculitis. World Neurosurg 2018; 117:e411-e416. [DOI: 10.1016/j.wneu.2018.06.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 11/24/2022]
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Iglesias-Rey R, Rodríguez-Yáñez M, Arias S, Santamaría M, Rodríguez-Castro E, López-Dequidt I, Hervella P, Sobrino T, Campos F, Castillo J. Inflammation, edema and poor outcome are associated with hyperthermia in hypertensive intracerebral hemorrhages. Eur J Neurol 2018; 25:1161-1168. [PMID: 29751370 PMCID: PMC6099376 DOI: 10.1111/ene.13677] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 05/03/2018] [Indexed: 01/20/2023]
Abstract
Background and purpose The deleterious effect of hyperthermia on intracerebral hemorrhage (ICH) has been studied. However, the results are not conclusive and new studies are needed to elucidate clinical factors that influence the poor outcome. The aim of this study was to identify the clinical factors (including ICH etiology) that influence the poor outcome associated with hyperthermia and ICH. We also tried to identify potential mechanisms involved in hyperthermia during ICH. Methods We conducted a retrospective study enrolling patients with non‐traumatic ICH from a prospective registry. We used logistic regression models to analyze the influence of hyperthermia in relation to different inflammatory and endothelial dysfunction markers, hematoma growth and edema volume in hypertensive and non‐hypertensive patients with ICH. Results We included 887 patients with ICH (433 hypertensive, 50 amyloid, 117 by anticoagulants and 287 with other causes). Patients with hypertensive ICH showed the highest body temperature (37.5 ± 0.8°C) as well as the maximum increase in temperature (0.9 ± 0.1°C) within the first 24 h. Patients with ICH of hypertensive etiologic origin, who presented hyperthermia, showed a 5.3‐fold higher risk of a poor outcome at 3 months. We found a positive relationship (r = 0.717, P < 0.0001) between edema volume and hyperthermia during the first 24 h but only in patients with ICH of hypertensive etiologic origin. This relationship seems to be mediated by inflammatory markers. Conclusion Our data suggest that hyperthermia, together with inflammation and edema, is associated with poor outcome only in ICH of hypertensive etiology.
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Affiliation(s)
- R Iglesias-Rey
- Clinical Neurosciences Research Laboratory, Department of Neurology, Clinical University Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - M Rodríguez-Yáñez
- Clinical Neurosciences Research Laboratory, Department of Neurology, Clinical University Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - S Arias
- Clinical Neurosciences Research Laboratory, Department of Neurology, Clinical University Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - M Santamaría
- Clinical Neurosciences Research Laboratory, Department of Neurology, Clinical University Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - E Rodríguez-Castro
- Clinical Neurosciences Research Laboratory, Department of Neurology, Clinical University Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - I López-Dequidt
- Clinical Neurosciences Research Laboratory, Department of Neurology, Clinical University Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - P Hervella
- Clinical Neurosciences Research Laboratory, Department of Neurology, Clinical University Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - T Sobrino
- Clinical Neurosciences Research Laboratory, Department of Neurology, Clinical University Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - F Campos
- Clinical Neurosciences Research Laboratory, Department of Neurology, Clinical University Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - J Castillo
- Clinical Neurosciences Research Laboratory, Department of Neurology, Clinical University Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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