Intracranial Hemorrhage: Diagnosis and Management

Case report: biotin-thiamine-responsive basal ganglia disease with severe subdural hematoma on magnetic resonance imaging

Background: Biotin-thiamine-responsive basal ganglia disease (BTBGD) is a rare, treatable autosomal recessive neurometabolic disorder. This condition eventually leads to severe disability and death if not treated correctly. The clinical features of BTBGD, especially those with unusual complications, are not widely known by neurologists or pediatricians.Case presentation: A 4-month-old male infant was admitted to the hospital with a history of cough for the past 7 days and convulsions of 6 h duration. Physical examination showed confusion, bilateral pupillary light reflex delays, hypertonia of limbs, and brisk tendon reflexes of the limbs. Brain magnetic resonance imaging (MRI) showed multiple abnormal signals in the bilateral basal ganglia, lobes, corpus callosum, brainstem, and brain atrophy. However, his condition continued to worsen. Computed tomography performed 3 months later showed severe subdural hematoma and effusion. Subsequently, he underwent puncture drainage; however, his condition did not improve postoperatively. Repeated MRIs showed increasing subdural hematoma and effusion, and brain atrophy. The patient was diagnosed with BTBGD following whole-genome sequencing, which identified a novel compound heterozygous mutation of SLC19A3 gene. He was treated with biotin and thiamine, and the symptoms gradually improved. Subsequent MRIs showed a decrease in the subdural hematoma and effusion and partial improvement in brain atrophy.Conclusion: To the best of our knowledge, this is the first reported case of BTBGD, complicated by severe subdural hematoma. These observations extend our understanding of the clinical features, neuroimaging spectrum, and gene mutation spectrum of BTBGD. The phenotypic spectrum and pathophysiology of BTBGD are not completely understood and need to be studied further.

Predictors of mortality after craniotomy for geriatric traumatic brain injury

BACKGROUND

With a sustained increase in the proportion of elderly trauma patients, geriatric traumatic brain injury (TBI) is a significant source of morbidity, mortality and resource utilization. The aim of our study was to assess the predictors of mortality in geriatric TBI patients who underwent craniotomy.

METHODS

We performed a 4-year analysis of ACS-TQIP database (2016-2019) and included all geriatric trauma patients (≥65y) with isolated severe TBI who underwent craniotomy. We calculated 11- point modified frailty index (mFI) for patients. Our primary and secondary outcomes were mortality and unfavorable outcome, respectively. Multivariate regression analysis was performed to identify the predictors of outcomes. Patients with mFI ≥ 0.25 were defined as Frail, whereas patient with mFI of 0.08 or higher (<0.25) were identified as pre-frail; Non-frail patients were identified as mFI of <0.08.

RESULTS

We analyzed data from 20,303 patients. The mortality rate was 17.7 % (3,587 patients). Having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 2.251, p < 0.001), and pre-hospital anticoagulant use (OR = 1.306, p < 0.001) increased the risks of mortality. Frailty, as a continuous variable, was not considered as a risk factor for mortality (p = 0.058) but after categorization, it was shown that compared to non-frails, patients with pre-frailty (OR = 1.946, p = 0.011) and frailty (OR = 1.786, p = 0.026) had increased risks of mortality. Higher mFI (OR = 4.841), age (OR = 1.034), ISS (OR = 1.052), having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 1.758), and use of anticoagulants (OR = 1.117) were significant risk factors for unfavorable outcomes (p < 0.001, for all).

CONCLUSIONS

Having more than two types of intra-cranial hemorrhage and pre-hospital anticoagulant use were significant risk factors for mortality. The study's findings also suggest that frailty may not be a sufficient predictor of mortality after craniotomy in geriatric patients with TBI. However, frailty still affects the discharge disposition and favorable outcome.

LEVEL OF EVIDENCE

Level III retrospective study.

Impaired Kidney Function Portended a Bleak Prognosis for Surgically Treated Hypertensive Intracerebral Hemorrhage Patients

Purpose

Spontaneous intracerebral hemorrhage (ICH) cases caused by hypertension often have poor prognoses. The use of dehydrant agents, such as mannitol, is common to reduce intracranial pressure and alleviate cerebral edema, but they may also pose a risk of worsening kidney function. This study aimed to investigate the impact of impaired kidney function on the outcomes of surgically treated hypertensive ICH patients.

Methods

We conducted a retrospective analysis of a consecutive cohort of patients who underwent surgical intervention due to hypertension-related ICH at our institute between December 1, 2017, and January 31, 2022. Demographic, clinical, radiological, and prognostic data were collected. Patients were categorized into two groups based on 90-day mortality: group A [overall survival (OS) ≤3 months] and group B (OS >3 months). Survival analysis was performed to identify factors associated with poor outcomes.

Results

Among the 232 eligible patients, group A exhibited significantly impaired kidney function, as indicated by mean estimated glomerular filtration rate (eGFR) at admission, postoperative, 3-day postoperative, and 7-day postoperative time points (91.9, 82.5, 73.5, 75.2 ml/min/1.73 m²). In contrast, group B did not show significant changes in kidney function (mean eGFR for the corresponding time points: 108.1, 106.5, 111.5, 109.6 ml/min/1.73 m²). The 3-day postoperative eGFR showed the strongest predictive ability for assessing prognosis [areas under the curve (AUC): 0.617, 0.675, 0.737, 0.730]. Univariate and multivariate analyses identified low Glasgow Coma Scale (GCS) score (3-8), ventricle intrusion of hematomas, cardiac failure, larger hematoma volume, infection, and lower 3-day postoperative eGFR as adverse factors for survival.

Conclusions

Preserving kidney function is crucial for achieving favorable outcomes in hypertensive ICH cases. Impaired 3-day postoperative eGFR emerged as an independent risk factor for overall survival. Patients with cardiac failure, infection, and larger hematoma volume should receive careful management to improve outcomes.

Resource utilization in management of spontaneous intracerebral hemorrhage without systemic risk factors. Does early surgical decompression matter?

BACKGROUND

Even though different subtypes of spontaneous ICH are frequently linked to a poor prognosis, their causes, pathological features, and prognoses vary. Atypical intracerebral hemorrhage is the subtype of spontaneous ICH that usually occurs due to an underlying localized vascular lesion. It is unrelated to systemic vascular risk factors, mostly affects children and young adults and is associated with a relatively good outcome. This fact should be considered when planning the evaluation and treatment. Investigating the cause of this subtype is fundamental to providing optimal management. However, if resources do not allow completing the investigations, the cause will be more difficult to discover. Treatment decisions will be made under stress to save the patient's life, especially with rapidly deteriorating patients.

METHODS

We described three cases of spontaneous ICH without systemic risk factors where the bleeding source could not be determined before surgery due to a lack of resources, preventing preoperative vascular investigation. Knowing that the atypical ICH has a distinct identity, regarding etiology and prognosis, encouraged the surgeons to resort to early surgical decompression as an alternative plan. We reviewed the literature searching for supporting evidence.

RESULTS

The results of treatment of the presented cases were satisfactory. The lack of reported similar cases was brought to light by a literature analysis that sought to provide backing for the proposed management strategy. In the end, we supplied two graphic organizers to help readers remember the different types and treatment of hemorrhagic stroke.

CONCLUSION

There isn't enough evidence to show that there are other ways to treat atypical intracerebral haemorrhage when resources are limited. The presented cases highlight the importance of decisionmaking in resource-constrained situations when patient outcomes can be improved.

Predictors of Social Participation Outcome after Traumatic Brain Injury Differ According to Rehabilitation Pathways

Social participation (SP) is one of many objectives in the rehabilitation of patients with traumatic brain injury (TBI). Studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were to: 1) characterize SP, as well as a set of pre-injury, injury-related, and post-injury variables in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care; and 2) examine the ability of pre-injury, injury-related, and post-injury variables in predicting SP outcome after TBI according to rehabilitation path. Participants (N = 372) were adults admitted to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a TBI between 2016 and 2020, and for whom Mayo-Portland Adaptability Intentory-4 (MPAI-4) outcomes were prospectively obtained at the start and end of rehabilitation. Additional data was collected from medical files. For both rehabilitation pathways, predicted SP outcome was MPAI-4 Participation score at discharge from outpatient rehabilitation. Multiple regression models investigated the predictive value of each variable for SP outcome, separately for each care pathway. Main findings show that for the inpatient-outpatient sample, three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 49% of the variance. For the outpatient sample, five variables (pre-morbid hypertension and mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 47% of the variance. In conclusion, different pre-morbid and post-injury variables are involved in predicting SP, depending on the rehabilitation path followed. The predictive value of those variables could help clinicians identify patients more likely of showing poorer SP at discharge and who may require additional or different interventions.

Suppressive role of lovastatin in intracerebral hemorrhage through repression of autophagy

Statins possess critical function in the brain. Here, we intended to investigate the role of lovastatin in brain damage after intracerebral hemorrhage (ICH). A collagenase-induced ICH rat model was established followed by lovastatin treatment. Then, the effect of lovastatin on ICH-induced brain damage was explored with cognitive function, learning and memory abilities, and neurological damage of rats analyzed. Besides, brain water content, number of degenerate neurons, Nissl's body, and apoptosis of neurons were detected. Oxidative stress levels, inflammation, and autophagy levels in ICH were measured after treatment of lovastatin. Lovastatin improved the cognitive impairment of rats, enhanced their spatial learning and memory abilities, reduced nervous system damage, lesion area, and brain water content after ICH. Lovastatin was capable of reducing the number of degenerated neurons, the apoptosis level, autophagy level, and increasing the number of Nissl's body. Lovastatin inhibited the oxidative stress response and inflammatory factors in the brain tissue after ICH, and increased the expression of anti-inflammatory factor IL-10. Lovastatin inhibited AMPK/mTOR signaling pathway after ICH. Our study highlighted the suppressive role of lovastatin in ICH-induced brain damage.

Developing and validating a mortality prediction model for ICH in ITP: a nationwide representative multicenter study

Intraparenchymal hemorrhage, platelet count, serious infections, severe bleeding events, and Glasgow coma scale predict poor prognosis.

A prognostic model was developed and validated, and an application was established.

Intracranial hemorrhage (ICH) is a rare and life-threatening hemorrhagic event in patients with immune thrombocytopenia (ITP). However, its mortality and related risk factors remain unclear. Herein, we conducted a nationwide multicenter real-world study of ICH in adult ITP patients. According to data from 27 centers in China from 2005 to 2020, the mortality rate from ICH was 33.80% (48/142) in ITP adults. We identified risk factors by logistic univariate and multivariate logistic regression for 30-day mortality in a training cohort of 107 patients as follows: intraparenchymal hemorrhage (IPH), platelet count ≤10 × 10⁹/L at ICH, a combination of serious infections, grade of preceding bleeding events, and Glasgow coma scale (GCS) level on admission. Accordingly, a prognostic model of 30-day mortality was developed based on the regression equation. Then, we evaluated the performance of the prognostic model through a bootstrap procedure for internal validation. Furthermore, an external validation with data from a test cohort with 35 patients from 11 other centers was conducted. The areas under the receiver operating characteristic (ROC) curves for the internal and external validation were 0.954 (95% confidence interval [CI], 0.910-0.998) and 0.942 (95% CI, 0.871-1.014), respectively. Both calibration plots illustrated a high degree of consistency in the estimated and observed risk. In addition, the decision curve analysis showed a considerable net benefit for patients. Thus, an application (47.94.162.105:8080/ich/) was established for users to predict 30-day mortality when ICH occurred in adult patients with ITP.

Role of Salivary Uric Acid Versus Serum Uric Acid in Predicting Maternal Complications of Pre-Eclampsia in a Rural Hospital in Central India: A Two-Year, Cross-Sectional Study

Background

Hypertensive disorders during pregnancy are an important topic of concern, specifically in rural and remote areas of India where there is a lack of awareness and it is difficult to maintain proper follow-up of pregnant females to screen them for complications developed during pregnancy. Gestational hypertension and pre-eclampsia result in the abruption of the placenta, hemolysis, elevated liver enzymes, low platelet count syndrome, eclampsia, and disseminated intravascular coagulation, which can be a serious threat to the health of the mother and the fetus. Therefore, it is important to identify biomarkers for diagnosing and predicting the complications of pre-eclampsia that may aid the obstetric high-dependency units based in rural areas to tackle this important health hazard during pregnancy.

Methodology

A total of 180 singleton pregnant women of more than 34 weeks of gestational age were enrolled in this study. All women were divided into three groups (control group, severe pre-eclampsia, and non-severe pre-eclampsia) based on the severity of blood pressure and the presence of proteinuria (≥+1 by the dipstick method). Salivary and serum uric acid levels were measured through morning samples, and all patients were monitored for the development of complications and outcomes. Salivary uric acid and serum uric acid levels were correlated with each other and with maternal complications of pre-eclampsia.

Results

Mean salivary uric acid (mg/dL) in severe pre-eclampsia was (6.72 ± 0.49) significantly higher compared to non-severe pre-eclampsia (4.75 ± 0.94) and control (3.13 ± 0.43). Mean serum uric acid (mg/dL) in severe pre-eclampsia was (8.13 ± 0.87) significantly higher compared to non-severe pre-eclampsia (6.23 ± 0.76) and control (3.85 ± 0.46).The lowest best cut-off value of maternal salivary uric acid was 5.06 mg/dL, above which one can predict maternal complications with a diagnostic accuracy of 78.33%.

Conclusions

Salivary uric acid and serum uric acid levels are significantly raised in cases of pre-eclampsia in comparison to normal pregnancy. Salivary uric acid and serum uric acid are correlated significantly indicating that salivary uric acid can function as a cost-effective, novel marker to provide an idea about serum uric acid levels. The prognostic accuracy of salivary uric acid was good in predicting maternal complications among cases of pre-eclampsia (severe and non-servere) and early-onset maternal complications. Therefore, it may be utilized as a helpful marker to identify high-risk patients.

Delayed awakening with apnea as a sign of cerebellar hemorrhage after vestibular schwannoma surgery: A case report

Cerebellar hemorrhage after surgery is a rare but critical complication requiring prompt diagnosis and intervention. However, anesthetics can mask most brain compression signs. Prolonged coma with apnea after tumor resection under general anesthesia may indicate the need for prompt imaging to detect or exclude cerebellar lesions.

Associations between MTHFR gene polymorphisms and the risk of intracranial hemorrhage: Evidence from a meta-analysis

INTRODUCTION

Previously, a number of genetic epidemiological studies have evaluated associations between MTHFR gene polymorphisms and the risk of intracranial hemorrhage (ICH), with controversial results. Accordingly, we carried out this meta-analysis to more conclusively evaluate associations between MTHFR gene polymorphisms and the risk of ICH.

METHODS

MEDLINE, EMBASE, Wanfang, VIP, and CNKI were searched comprehensively, and thirty-one genetic association studies were finally selected to be included in this meta-analysis.

RESULTS

Eight literatures (963 cases and 2,244 controls) assessed relationship between MTHFR rs1801131 (A1298C) polymorphism and the risk of ICH, and thirty-one literatures (3,679 cases and 9,067 controls) assessed relationship between MTHFR rs1801133 (C677T) polymorphism and the risk of ICH. We found that AA genotype of rs1801131 polymorphism was significantly associated with a decreased risk of intraventricular hemorrhage (IH) compared with AC/CC genotypes (OR = 0.63; p = .003), AC genotype was significantly associated with an increased risk of IH compared with AA/CC genotypes (OR = 1.55; p = .005), and A allele was significantly associated with a decreased risk of IH compared with C allele (OR = 0.75; p = .02). Additionally, CC genotype of rs1801133 polymorphism was significantly associated with a decreased risk of cerebral hemorrhage (CH) compared with CT/TT genotypes (OR = 0.75; p = .04), TT genotype was significantly associated with an increased risk of CH compared with CC/CT genotypes (OR = 1.27; p = .02), and C allele was significantly associated with a decreased risk of CH compared with T allele (OR = 0.85; p = .007).

CONCLUSIONS

This meta-analysis shows that rs1801131 polymorphism may influence the risk of IH, while rs1801133 polymorphism may influence the risk of CH.

Intracranial Hemorrhage Detection in Head CT Using Double-Branch Convolutional Neural Network, Support Vector Machine, and Random Forest

Brain hemorrhage is a severe threat to human life, and its timely and correct diagnosis and treatment are of great importance. Multiple types of brain hemorrhage are distinguished depending on the location and character of bleeding. The main division covers five subtypes: subdural, epidural, intraventricular, intraparenchymal, and subarachnoid hemorrhage. This paper presents an approach to detect these intracranial hemorrhage types in computed tomography images of the head. The model trained for each hemorrhage subtype is based on a double-branch convolutional neural network of ResNet-50 architecture. It extracts features from two chromatic representations of the input data: a concatenation of the image normalized in different intensity windows and a stack of three consecutive slices creating a 3D spatial context. The joint feature vector is passed to the classifier to produce the final decision. We tested two tools: the support vector machine and the random forest. The experiments involved 372,556 images from 11,454 CT series of 9997 patients, with each image annotated with labels related to the hemorrhage subtypes. We validated deep networks from both branches of our framework and the model with either of two classifiers under consideration. The obtained results justify the use of a combination of double-source features with the random forest classifier. The system outperforms state-of-the-art methods in terms of F1 score. The highest detection accuracy was obtained in intraventricular (96.7%) and intraparenchymal hemorrhages (93.3%).

Risk stratification and outcomes of intracranial hemorrhage in patients with immune thrombocytopenia under 60 years of age

Intracranial hemorrhage (ICH) is a devastating complication of immune thrombocytopenia (ITP). However, information on ICH in ITP patients under the age of 60 years is limited, and no predictive tools are available in clinical practice. A total of 93 adult patients with ITP who developed ICH before 60 years of age were retrospectively identified from 2005 to 2019 by 27 centers in China. For each case, 2 controls matched by the time of ITP diagnosis and the duration of ITP were provided by the same center. Multivariate analysis identified head trauma (OR = 3.216, 95%CI 1.296-7.979, P =.012), a platelet count ≤ 15,000/μL at the time of ITP diagnosis (OR = 1.679, 95%CI 1.044-2.698, P =.032) and severe/life-threatening bleeding (severe bleeding vs. mild bleeding, OR = 1.910, 95%CI 1.088-3.353, P =.024; life-threatening bleeding vs. mild bleeding, OR = 2.620, 95%CI 1.360-5.051, P =.004) as independent risk factors for ICH. Intraparenchymal hemorrhage (OR = 5.191, 95%CI 1.717-15.692, P =.004) and a history of severe bleeding (OR = 4.322, 95%CI 1.532-12.198, P =.006) were associated with the 30-day outcome of ICH. These findings may facilitate ICH risk stratification and outcome prediction in patients with ITP.

Antithrombotic Management After Intracranial Hemorrhage

PURPOSE OF REVIEW

Intracranial hemorrhage remains one of the most feared acute neurological emergencies. However, apart from the acute management, secondary risk factor management and prevention of ischemic events remains ambiguous. We present a thorough review of the current data available regarding management of antithrombotics after intracranial hemorrhage.

RECENT FINDINGS

The most robust evidence comes from the investigators of the RESTART trial which reassured the safety of resuming antiplatelet therapy after ICH, namely in patients with prior indication and treatment with antithrombotics. We conclude that based on available data, the risk of recurrent ICH is probably too small to exceed the found benefits of antiplatelet therapy in the secondary prevention of ischemic vascular disease.

[The role of interventional neuroradiology in treatment of hemorrhagic stroke]

Treatment of hemorrhagic strokes necessitates hospitalization in an accommodated hospital offering the possibility of a multidisciplinary approach. In this setting, over recent years interventional radiology has become increasingly important from the diagnostic as well as the therapeutic standpoint. In the context of subarachnoid hemorrhage by intracranial aneurysm rupture, the NICE (National Institute for Health and Clinical Excellence) and ASA (American Stroke Academy) recommendations suggest that endovascular coiling should be considered as an alternative to surgical clipping (class I, level of evidence B). As stenting is associated with increased morbidity and mortality in the ruptured aneurysms, it should be avoided (class III, level of evidence C). The patient's clinical status on presentation should be taken into account when deciding on therapeutic management and determining prognosis. Long-term clinical outcome depends on several factors: clinical status on arrival, comorbidities, age, occurrence of operative complications and complications of subarachnoid hemorrhage such as hydrocephaly, vasospasm and delayed cerebral ischemia, as well as complications stemming from prolonged bed rest. In the event of vasospasm refractory to maximal medical therapy, endovascular treatment by intra-arterial injection of Nimodipine and angioplasty can be envisioned. In the event of intracerebral hemorrhage (ICH) by rupture cerebral dural arteriovenous fistula, once the diagnosis has been confirmed, and given the exceedingly high risk of rebleeding, first-line treatment will consist in emergency endovascular embolization. In the event of intracerebral hemorrhage (ICH) by arteriovenous rupture, treatment is decided on during a multidisciplinary meeting and either carried out immediately or delayed according to several factors: clinical conditions, age of the patient, angioarchitecture and ICH location.

Neoplastic and Non-Neoplastic Causes of Acute Intracerebral Hemorrhage on CT : The Diagnostic Value of Perihematomal Edema

OBJECTIVE

The aim of this study was to investigate the diagnostic value of perihematomal edema (PHE) volume in non-enhanced computed tomography (NECT) to discriminate neoplastic and non-neoplastic causes of acute intracerebral hemorrhage (ICH).

METHODS

In this retrospective study, from 560 patients with acute ICH 91 patients fulfilled the inclusion criteria and were classified into neoplastic and non-neoplastic ICH. For each patient, ICH and total hemorrhage volume (ICH + PHE) were segmented semiautomatically. The PHE volume and relative PHE were further calculated and all parameters were compared between the different groups. Additionally, hematoma density was measured and compared between the groups.

RESULTS

The PHE volume and relative PHE on NECT were significantly higher in neoplastic vs. the non-neoplastic ICH (p = 0.003 and p < 0.001, respectively). Absolute ICH volume, symptom time onset to CT and ICH localization showed no significant difference between the two groups (p > 0.1). Univariate receiver operating characteristics (ROC) analysis revealed a high diagnostic performance for relative PHE in the discrimination of neoplastic and non-neoplastic ICH with an optimal cut-off of 0.50 (area under the curve, AUC 0.81, 60.0% sensitivity, 91.8% specificity), followed by PHE (AUC 0.69) and hematoma density (AUC 0.68).

CONCLUSION

Relative PHE with a cut-off of >0.50 is a specific and simple indicator for neoplastic causes of acute ICH and a potential tool for clinical implementation. This observation needs to be validated in an independent patient cohort.

Traumatic brain injury may worsen clinical outcomes after prolonged partial resuscitative endovascular balloon occlusion of the aorta in severe hemorrhagic shock model

BACKGROUND

The use of partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) in combined hemorrhagic shock (HS) and traumatic brain injury (TBI) has not been well studied. We hypothesized that the use of pREBOA in the setting of TBI would be associated with worse clinical outcomes.

METHODS

Female Yorkshire swine were randomized to the following groups: HS-TBI, HS-TBI-pREBOA, and HS-pREBOA (n = 5/cohort). Animals in the HS-TBI group were left in shock for a total of 2 hours, whereas animals assigned to pREBOA groups were treated with supraceliac pREBOA deployment (60 minutes) 1 hour into the shock period. All animals were then resuscitated, and physiologic parameters were monitored for 6 hours. Further fluid resuscitation and vasopressors were administered as needed. At the end of the observation period, brain hemispheric swelling (%) and lesion size (mm) were assessed.

RESULTS

Mortality was highest in the HS-TBI-pREBOA group (40% [2/5] vs. 0% [0/5] in the other groups, p = 0.1). Severity of shock was greatest in the HS-TBI-pREBOA group, as defined by peak lactate levels and pH nadir (p < 0.05). Fluid resuscitation and norepinephrine requirements were significantly higher in the HS-TBI-pREBOA group (p < 0.05). No significant differences were noted in brain hemispheric swelling and lesion size between the groups.

CONCLUSION

Prolonged application of pREBOA in the setting of TBI does not contribute to early worsening of brain lesion size and edema. However, the addition of TBI to HS-pREBOA may worsen the severity of shock. Providers should be aware of the potential physiologic sequelae induced by TBI.

Effect of integrated traditional Chinese and Western medicine therapy for acute hypertensive intracerebral hemorrhage: a meta-analysis

Intracerebral hemorrhage (ICH) is an important public health problem associated with high mortality and morbidity. The aim of this study was to evaluate the clinical efficacy of integrated traditional Chinese (TCM) and Western medicine (WM) therapy for acute hypertensive ICH. Randomized controlled trials were searched in PubMed, Medline, Embase, Wanfang and CNKI database published between January 2000 and June 2016. Our results showed that integrated TCM and WM therapy appeared to be able to improve the clinical effect for patients with acute hypertensive ICH.

Intracranial hemorrhage: frequency, location, and risk factors identified in a TeleStroke network

Intracranial hemorrhages are associated with high rates of disability and mortality. Telemedicine in general provides clinical healthcare at a distance by using videotelephony and teleradiology and is used particularly in acute stroke care medicine (TeleStroke). TeleStroke considerably improves quality of stroke care (for instance, by increasing thrombolysis) and may be valuable for the management of intracranial hemorrhages in rural hospitals and hospitals lacking neurosurgical departments, given that surgical/interventional therapy is only recommended for a subgroup of patients. The aim of this study was to analyze the frequency, anatomical locations of intracranial hemorrhage, risk factors, and the proportion of patients transferred to specialized hospitals. We evaluated teleconsultations conducted between 2008 and 2010 in a large cohort of patients consecutively enrolled in the Telemedical Project for Integrated Stroke Care (TEMPiS) network. In cases in which intracranial hemorrhage was detected, all images were re-examined and analyzed with a focus on frequency, location, risk factors, and further management. Overall, 6187 patients presented with stroke-like symptoms. Intracranial hemorrhages were identified in 631 patients (10.2%). Of these, intracerebral hemorrhages were found in 423 cases (67.0%), including 174 (41.1%) in atypical locations and 227 (53.7%) in typical sites among other locations. After 14 days of hospitalization in community facilities, the mortality rate in patients with intracranial hemorrhages was 15.1% (95/631). Two hundred and twenty-three patients (35.3%) were transferred to neurological/neurosurgical hospitals for diagnostic workup or additional treatment. Community hospitals are confronted with patients with intracranial hemorrhage, whose management requires specific neurosurgical and hematological expertise with respect to hemorrhage subtype and clinical presentation. TeleStroke networks help select patients who need advanced neurological and/or neurosurgical care. The relatively low proportion of interhospital transfers shown in this study reflects a differentiated decision process on the basis of both guidelines and standard operating procedures.

The impact of arterial hypertension on polytrauma and traumatic brain injury

BACKGROUND

Pre-hospital hypotension in trauma patients is associated with high mortality. Especially for patients with severe traumatic brain injury (TBI), arterial normotension or even hypertension (AHT) is considered an important mechanism for sustaining adequate cerebral perfusion pressure. The effect of pre-hospital arterial hypertension (pAHT) on in-hospital mortality after trauma has not been studied to date.

METHODS

We retrospectively analyzed data in the trauma registry of the German Society for Trauma Surgery (DGU) on all trauma patients in Germany from 1993 to 2008 who were 16 to 80 years old at the time of the trauma and had an injury severity score (ISS) of 9 or above (total, 42 500 patient data sets). For the analysis, we divided the patients into two groups: those with and those without TBI. We further divided the TBI patients into five subgroups depending on the course of their systolic blood pressure up to the moment of their arrival at the hospital. We also analyzed the patients' demographic data, patterns of injury, and accident mechanisms.

RESULTS

Trauma patients with TBI and pAHT (142 of 561 patients) had a significantly higher mortality than normotensive TBI patients (25.3% vs. 13.5%, p<0.001). Arterial hypertension that either rises or falls before the patient reaches the hospital is associated with higher in-hospital mortality. A logistical regression analysis of 5384 patients revealed that patients with pAHT (n = 561) had an odds ratio of 1.9 (95% confidence interval, 1.4 to 1.6) for death in the hospital compared to normotensive patients (n = 6020).

CONCLUSION

Systolic blood pressure values above 160 mm Hg before arrival in the hospital worsen the outcome of trauma patients with TBI.