The risk of subarachnoid and intracerebral hemorrhages in blacks as compared with whites

Psychosocial Stress and Risk for Intracerebral Hemorrhage in the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) Study

BACKGROUND

Intracerebral hemorrhage (ICH) carries a 30-day mortality rate of 40% to 50% and a high burden of disability. Prior studies found that psychosocial stressors are associated with hypertension, ischemic stroke, and important racial/ethnic differences in baseline stress exist. We sought to determine whether stress, including distinct subtypes, predicts risk of ICH after controlling for important risk factors; whether its effect is mediated by hypertension; and whether important racial/ethnic differences in stress-associated ICH exist.

METHODS

Data from the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) study, a prospective, multicenter, case-control study of ICH among White, Black, and Hispanic patients were used. Controls matched 1:1 by sex and race or ethnicity. Participants rated 4 stress subtypes (financial, health, emotional well-being, and family) on a 0 to 10 scale for the week before ICH, with 0 signifying no stress and 10 highest stress. Univariate and multivariable logistic regressions to assess each stress type as a risk factor for ICH and mediation analyses to determine whether hypertension mediated the association between stress and ICH were performed.

RESULTS

There were 2964 case/control matches (41.4% female, 33.7% Black, and 32.7% Hispanic). Higher levels of each stress subtype increased probability of ICH: financial, health, emotional well-being, family, and total stress. Financial stress was associated with nonlobar ICH and disproportionately affected Black and Hispanic patients. Hypertension was found to mediate the ICH risk effects of health, emotional well-being, and family stress.

CONCLUSIONS

Psychosocial stress remains a risk factor for ICH after controlling for hypertension. Novel mechanisms underlying this association warrant further study and offer a new target for ICH risk mitigation.

REGISTRATION

URL: clinicaltrials.gov; Unique Identifier: NCT01202864.

Hereditary Haemorrhagic Cerebrovascular Disease: Implications for Clinical Management

Background

At present, treatment of hereditary haemorrhagic cerebrovascular disease remains in the symptomatic stage. It is more important to provide strategies for developing rational treatment methods, expanding our understanding with regard to the pathophysiology in the context of familial diseases.

Summary

In this article, the combined data from the literature on diseases, including familial cerebral cavernous haemangiomas, hereditary cerebral haemorrhage with amyloidosis, familial intracranial aneurysms, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, were reviewed to manage the haemorrhagic diseases discussed through genetic counselling and early prevention and treatment of these patients and their families, the genetics, pathogenesis, clinical manifestations and treatment.

Key Messages

It is important to understand and treat hereditary haemorrhagic cerebrovascular disease through genetic treatment options.

Political economics in health and implications for neurosurgery diseases

The field of political economics in health has a significant and far-reaching impact on public health. It encompasses a diverse range of interconnected domains, including the economy, welfare, the environment, food and drug safety, pollution emissions, occupational safety, the quality of medical services, consumer rights, public health policy, healthcare policy, scientific research, and marketing management. In this review, we examine the global influence of political economics on health outcomes and delineate the impact of prevalent neurosurgical conditions on individual and collective healthcare resources. This review will discuss the effects of political-economic factors on the prevalence and treatment of neurosurgical diseases, including stroke, traumatic brain injury (TBI), intracerebral hemorrhage (ICH), and brain malignant tumors. Furthermore, the current challenges and future directions will be discussed. We intend this review to facilitate the exchange and integration of political economics, public health, and neurosurgery, provide a foundation for policy development, enhance the prevention, diagnosis, and treatment of neurosurgical diseases, and ultimately promote public health.

Emergent Management of Intracerebral Hemorrhage

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.

Cumulative Systolic Blood Pressure and Incident Stroke Type Variation by Race and Ethnicity

Importance

Stroke risk varies by systolic blood pressure (SBP), race, and ethnicity. The association between cumulative mean SBP and incident stroke type is unclear, and whether this association differs by race and ethnicity remains unknown.

Objective

To examine the association between cumulative mean SBP and first incident stroke among 3 major stroke types-ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH)-and explore how these associations vary by race and ethnicity.

Design, Setting, and Participants

Individual participant data from 6 US longitudinal cohorts (January 1, 1971, to December 31, 2019) were pooled. The analysis was performed from January 1, 2022, to January 2, 2024. The median follow-up was 21.6 (IQR, 13.6-31.8) years.

Exposure

Time-dependent cumulative mean SBP.

Main Outcomes and Measures

The primary outcome was time from baseline visit to first incident stroke. Secondary outcomes consisted of time to first incident IS, ICH, and SAH.

Results

Among 40 016 participants, 38 167 who were 18 years or older at baseline with no history of stroke and at least 1 SBP measurement before the first incident stroke were included in the analysis. Of these, 54.0% were women; 25.0% were Black, 8.9% were Hispanic of any race, and 66.2% were White. The mean (SD) age at baseline was 53.4 (17.0) years and the mean (SD) SBP at baseline was 136.9 (20.4) mm Hg. A 10-mm Hg higher cumulative mean SBP was associated with a higher risk of overall stroke (hazard ratio [HR], 1.20 [95% CI, 1.18-1.23]), IS (HR, 1.20 [95% CI, 1.17-1.22]), and ICH (HR, 1.31 [95% CI, 1.25-1.38]) but not SAH (HR, 1.13 [95% CI, 0.99-1.29]; P = .06). Compared with White participants, Black participants had a higher risk of IS (HR, 1.20 [95% CI, 1.09-1.33]) and ICH (HR, 1.67 [95% CI, 1.30-2.13]) and Hispanic participants of any race had a higher risk of SAH (HR, 3.81 [95% CI, 1.29-11.22]). There was no consistent evidence that race and ethnicity modified the association of cumulative mean SBP with first incident stroke and stroke type.

Conclusions and Relevance

The findings of this cohort study suggest that cumulative mean SBP was associated with incident stroke type, but the associations did not differ by race and ethnicity. Culturally informed stroke prevention programs should address modifiable risk factors such as SBP along with social determinants of health and structural inequities in society.

Cerebral Aneurysm Characteristics and Surgical Outcomes: An In-Depth Analysis of 346 Cases Operated Using Microsurgical Clipping

This comprehensive study analyzes 346 surgically treated intracranial aneurysms, emphasizing the importance of understanding risk factors and prevalent characteristics in patients. Intracranial aneurysms, primarily of the saccular or berry type, significantly contribute to nontraumatic subarachnoid hemorrhages and demonstrate a rising incidence due to advances in imaging techniques. The study highlights a gender discrepancy in aneurysm occurrence and a higher prevalence in individuals over 30 years old. The research delves into various aspects, including aneurysm localization, diameter, neck dimensions, and rupture status, with a focus on the anterior communicating artery and middle communicating artery as predominant locations. Significant findings include the prevalence of ruptured aneurysms and the impact of arterial hypertension, atherosclerosis, obesity, and diabetes on aneurysm epidemiology. The study also investigates the occurrence of vasospasm, a significant factor in delayed morbidity and mortality in aneurysmal subarachnoid hemorrhage. The utilization of the Glasgow Outcome Scale and other quantification scales aids in understanding the severity and postoperative outcomes of intracranial aneurysms. Challenges such as the incidence of reopenings and postoperative osteomyelitis are addressed, underlining the need for refined protocols and multidisciplinary approaches in treatment. The study's results contribute to the existing knowledge base on intracranial aneurysms, emphasizing the importance of ongoing research and tailored treatment strategies. The comprehensive nature of this analysis, covering preoperative, intraoperative, and postoperative factors, provides valuable insights into the complex interplay of risk factors and clinical outcomes in patients with intracranial aneurysms.

A novel flow diverter device (Tubridge) for the treatment of intracranial aneurysms: a systematic review and meta-analysis

The flow diverter (FD) device has become a feasible and effective option for treating intracranial aneurysms. This study aimed to evaluate the efficacy and safety of Tubridge FD (TFD) in treating intracranial aneurysms and provide evidence for further research and clinical application. Electronic databases, including PubMed, Web of Science, Embase, and the Cochrane Library from inception to July 31, 2022, were searched. The eligible studies should include TFD investigations in treating intracranial aneurysms. Pooled technical success rate, complete occlusion rate, improvement rate, stable rate, symptom elimination rate, and adverse events rate were calculated with either the fixed-effects model or the random-effects model, depending on the results of tests for heterogeneity. Egger's tests were performed to assess the potential publication bias. A total of 7 studies (145 patients) were included in this study. The pooled technical success rate was 0.98, the complete occlusion rate was 0.79, the improvement rate was 0.21, and the stable rate was 0.05. One included study reported that the surgery-related mortality rate in the Tubridge group was higher than that in the control group (3.66% vs. 1.61%), while the surgery-related morbidity rate in the Tubridge group was 2.4% and that in the control group was 0. Findings of this meta-analysis indicate that TFD manifests promising and effective performance with acceptable adverse events in the treatment of intracranial aneurysms.

Normotensive state during acute phase of hypertensive intracerebral hemorrhage

Objectives

Hypertensive hemorrhage is a leading cause of intracerebral haemorrhage (ICH), although some of these patients may not present with high blood pressure (BP) at the time of ICH.

Materials and Methods

This retrospective study included patients with history of hypertension presenting with ICH. Patients with systolic BP recording of more than 140 mmHg were included in hypertension group (group I). Patients whose BP rose to hypertension range after fluid correction were included in group II and patients with BP <140 mmHg on consecutive 1-week BP recordings were included in group III. Clinical features including volume of ICH of all the three groups were noted. Outcome in the form of mortality was analyzed. Chi-square test was used for categorical variables and independent t-test for continuous variables. P < 0.05 was considered significant.

Results

Ninety-two ICH patients with history of hypertension were included in the study. Of them, 20 patients (22%) presented with BP <140 mmHg systolic at the time of ICH. After fluid correction, it rose to hypertensive range in 9 (10%) but remained normal in 11 patients (12%) during consecutive recordings for 1-week post-admission. On comparing normotensive and hypertensive groups, significant difference was seen in survival and volume of ICH.

Conclusion

There is a subset of hypertensive patients who may present with normal BP recording during acute ICH. The BP rises subsequently with the correction of hypovolemia in some. The volume of hemorrhage in normotensives is relatively small but whether this translates into better prognosis needs further studies.

Sex and Racial Disparity in Outcome of Aneurysmal Subarachnoid Hemorrhage in the United States: A 20-Year Analysis

BACKGROUND

Aneurysmal subarachnoid hemorrhage is associated with high rate of morbidity and mortality. We aimed to assess prognostic impact of sex, race, and ethnicity in these patients.

METHODS

Nationwide Inpatient Sample (2000-2019) was used to identify patients presenting with aneurysmal subarachnoid hemorrhage as primary diagnosis. Patient age, sex, race/ethnicity, insurance status, socioeconomic status, comorbidities, type of the hospital, and treatment modality used for aneurysm repair were extracted. The previously validated Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Scale was used to estimate the clinical severity. Discharge destination and in-hospital mortality was used as outcome measured. The impact of race/ethnicity and sex on clinical outcome was analyzed using multivariate regression models.

RESULTS

A total of 161 086 patients with aneurysmal subarachnoid hemorrhage were identified. Mean age was 55.0±13.8 years. Sixty-nine percent of the patients were female, 60% White patients, and 17% Black patients. There was no difference in the Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Scale score between the 2 sexes. Women had significantly lower odds of good clinical outcome (defined as discharge to home or acute rehabilitation facility; RR, 0.83 [95% CI, 0.74-0.94]; P=0.004). Hispanic patients (RR, 1.12 [95% CI, 1.07-1.17]; P<0.001) had higher odds of excellent clinical outcome compared with White patients, and lower risk of mortality were observed in Black patients (RR, 0.73 [95% CI, 0.66-0.81]) and Hispanic patients (RR, 0.78 [95% CI, 0.70-0.86]) compared with the White patients.

CONCLUSIONS

In this nationally representative study, women were less likely to have excellent outcomes following aneurysmal subarachnoid hemorrhage, and White patients had disproportionately higher likelihood of worse clinical outcomes. Lower rates of mortality were seen among Black and Hispanic patients.

Trends in the Incidence of Spontaneous Subarachnoid Hemorrhages in the United States, 2007-2017

BACKGROUND AND OBJECTIVE

To test the hypothesis that age-specific, sex-specific, and race-specific and ethnicity-specific incidence of nontraumatic subarachnoid hemorrhage (SAH) increased in the United States over the last decade.

METHODS

In this retrospective cohort study, validated International Classification of Diseases codes were used to identify all new cases of SAH (n = 39,475) in the State Inpatients Databases of New York and Florida (2007-2017). SAH counts were combined with Census data to calculate incidence. Joinpoint regression was used to compute the annual percentage change (APC) in incidence and to compare trends over time between demographic subgroups.

RESULTS

Across the study period, the average annual age-standardized/sex-standardized incidence of SAH in cases per 100,000 population was 11.4, but incidence was significantly higher in women (13.1) compared with that in men (9.6), p < 0.001. Incidence also increased with age in both sexes (men aged 20-44 years: 3.6; men aged 65 years or older: 22.0). Age-standardized and sex-standardized incidence was greater in Black patients (15.4) compared with that in non-Hispanic White (NHW) patients (9.9) and other races and ethnicities, p < 0.001. On joinpoint regression, incidence increased over time (APC 0.7%, p < 0.001), but most of this increase occurred in men aged 45-64 years (APC 1.1%, p = 0.006), men aged 65 years or older (APC 2.3%, p < 0.001), and women aged 65 years or older (APC 0.7%, p = 0.009). Incidence in women aged 20-44 years declined (APC -0.7%, p = 0.017), while those in other age/sex groups remained unchanged over time. Incidence increased in Black patients (APC 1.8%, p = 0.014), whereas that in Asian, Hispanic, and NHW patients did not change significantly over time.

DISCUSSION

Nontraumatic SAH incidence in the United States increased over the last decade predominantly in middle-aged men and elderly men and women. Incidence is disproportionately higher and increasing in Black patients, whereas that in other races and ethnicities did not change significantly over time.

Predictors of Time to Aneurysm Repair and Mortality in Aneurysmal Subarachnoid Hemorrhage

ABSTRACT

BACKGROUND : Prompt aneurysm repair is essential to prevent rebleeding after aneurysmal subarachnoid hemorrhage. To date, most studies on this topic have focused on 1 set of predictors (eg, hospital or patient characteristics) and on 1 outcome (either time to aneurysm repair or mortality). The purpose of this study was to test a model that includes hospital and patient characteristics as predictors of time to aneurysm repair and mortality, controlling for disease severity and comorbidity, and considering time to aneurysm repair as a potential influence in these relationships. METHODS : A sample of aneurysmal subarachnoid hemorrhage patients with a principal procedure of clipping or coiling was selected (n = 387) from a statewide administrative database for cross-sectional retrospective analysis. The primary study outcome was in-hospital mortality. Independent variables were level of stroke center, age, race, sex, and type of aneurysm repair. Hierarchical logistic regression was used to estimate the probability of in-hospital death. RESULTS : Patients who underwent a coiling procedure were more likely to be treated within the first 24 hours of admission compared with those undergoing clipping (odds ratio, 0.54; 95% CI, 0.35-0.84; P = .01). Patients treated at a certified comprehensive stroke center (CSC) had a 72% reduction in odds of death compared with those treated at primary stroke centers (odds ratio, 0.28; 95% CI, 0.10-0.77; P = .01), after controlling for disease severity and comorbid conditions. Time to aneurysm repair was not significantly associated with mortality and did not influence the relationship between hospital and patient characteristics and mortality. CONCLUSION : Our results indicate that treatment at a CSC was associated with a lower risk of in-hospital mortality. Time to aneurysm repair did not influence mortality and did not explain the mortality benefit observed in CSCs. Research is needed to explore interdisciplinary hospital factors including nursing and nurse-sensitive interventions that may explain the relationship between CSCs and mortality outcomes.

Racial and Ethnic Differences in Short- and Long-term Mortality by Stroke Type

BACKGROUND AND OBJECTIVES

Racial and ethnic disparities in stroke outcomes exist, but differences by stroke type are less understood. We studied the association of race and ethnicity with stroke mortality, by stroke type, in a national sample of hospitalized patients in the Veterans Health Administration.

METHODS

A retrospective observational study was performed including non-Hispanic White, non-Hispanic Black, and Hispanic patients with a first hospitalization for stroke between 2002 and 2012. Stroke was determined using ICD-9 codes and date of death was obtained from the National Death Index. For each of acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), we constructed a piecewise multivariable model for all-cause mortality, using follow-up intervals of ≤30 days, 31-90 days, 91 days to 1 year, and >1 year.

RESULTS

Among 37,790 patients with stroke (89% AIS, 9% ICH, 2% SAH), 25,492 (67%) were non-Hispanic White, 9,752 (26%) were non-Hispanic Black, and 2,546 (7%) were Hispanic. The cohort was predominantly male (98%). Compared with White patients, Black patients experienced better 30-day survival after AIS (hazard ratio [HR] 0.80, 95% CI 0.73-0.88; 1.4% risk difference) and worse 30-day survival after ICH (HR 1.24, 95% CI 1.06-1.44; 3.2% risk difference). Hispanic patients experienced reduced risk for >1-year mortality after AIS (HR 0.87, 95% CI 0.80-0.94), but had greater risk of 30-day mortality after SAH compared with White patients (HR 1.61, 95% CI 1.03-2.52; 10.3% risk difference).

DISCUSSION

Among US Veterans, absolute risk of 30-day mortality after ICH was 3.2% higher for Black patients and after SAH was 10.3% higher for Hispanic patients compared with White patients. These findings underscore the importance of investigating stroke outcomes by stroke type to better understand the factors driving observed racial and ethnic disparities.

The Cerebral Arterial Wall in the Development and Growth of Intracranial Aneurysms

A considerable number of people harbor intracranial aneurysms (IA), which is a focal or segmental disease of the arterial wall. The pathophysiologic mechanisms of IAs formation, growth, and rupture are complex. The mechanism also differs with respect to the type of aneurysm. In broad aspects, aneurysms may be considered a disease of the vessel wall. In addition to the classic risk factors and the genetic/environmental conditions, altered structural and pathologic events along with the interaction of the surrounding environment and luminal flow dynamics contribute to the aneurysm’s development and growth. In this review, we have tried to simplify the complex interaction of a multitude of events in relation to vessel wall in the formation and growth of IAs.

Uncontrolled HIV and inflammation is associated with intracranial saccular aneurysm presence

OBJECTIVE

To study biomarkers of inflammation in cerebrovascular disease, exploring modifiable and non-modifiable biochemical and clinical risk factors associated with the presence of intracranial saccular aneurysms (ISAs) in an HIV-positive cohort.

DESIGN

A cross-sectional community-based study was used to study blood biomarkers of inflammation as predictors of cerebrovascular disease, specifically the presence of ISAs in persons with HIV. Potential biochemical and clinical predictors of ISA presence were identified.

METHODS

Time of flight magnetic resonance angiography and magnetic resonance imaging data identified the presence of ISAs in an HIV-positive cohort. Quantitative assays for neuroinflammatory biomarkers were performed on plasma blood samples. Lasso regression models were used to identify neuroinflammatory biomarkers and clinical risk factors associated with ISAs.

RESULTS

Eight of 72 participants had radiographically identified ISAs. ISAs were more common in non-Hispanic black participants (18.5% vs. 0% presence in nonblack patients). Participants with well controlled HIV (defined as CD4+ count >200 cells/ml and undetectable viral load at time of magnetic resonance imaging) had lower odds of ISAs (odds ratio: 0.19, 95% confidence interval 0.05-0.79) independent of age, sex, ethnicity and vascular risk factors. Macrophage inflammatory protein-1 p, an HIV- suppressive factor detected in participant blood samples, was inversely associated with aneurysm presence.

CONCLUSION

Well controlled HIV is associated with fewer ISAs. The identification of non-modifiable and modifiable risk factors contributing to ISA formation may provide valuable insight to impact clinical practice and inform the pathophysiology underlying ISA formation.

Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions

Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.

Therapeutic Approaches for Cerebrovascular Dysfunction After Aneurysmal Subarachnoid Hemorrhage: An Update and Future Perspectives

Aneurysmal subarachnoid hemorrhage (aSAH) is a severe subtype of stroke occurring at a relatively young age with a significant socioeconomic impact. Treatment of aSAH includes early aneurysm exclusion, intensive care management, and prevention of complications. Once the aneurysm rupture occurs, blood spreading within the subarachnoid space triggers several molecular pathways causing early brain injury and delayed cerebral ischemia. Pathophysiologic mechanisms underlying brain injury after aSAH are not entirely characterized, reflecting the difficulties in identifying effective therapeutic targets for patients with aSAH. Although the improvements of the last decades in perioperative management, early diagnosis, aneurysm exclusion techniques, and medical treatments have increased survival, vasospasm and delayed cerebral infarction are associated with high mortality and morbidity. Clinical practice can rely on a few specific therapeutic agents, such as nimodipine, a calcium-channel blocker proved to reduce severe neurologic deficits in these patients. Therefore, new pharmacologic approaches are needed to improve the outcome of this life-threatening condition, as well as a tailored rehabilitation plan to maintain the quality of life in aSAH survivors. Several clinical trials are investigating the efficacy and safety of emerging drugs, such as magnesium, clazosentan, cilostazol, interleukin 1 receptor antagonists, deferoxamine, erythropoietin, and nicardipine, and continuous lumbar drainage in the setting of aSAH. This narrative review focuses on the most promising therapeutic interventions after aSAH.

Clinical Outcomes of Primary Subarachnoid Hemorrhage: An Exploratory Cohort Study from Sudan

Background

Although Subarachnoid Hemorrhage (SAH) is an emergency condition, its epidemiology and prognosis remain poorly understood in Africa. We aim to explore the clinical presentations, outcomes, and potential mortality predictors of primary SAH patients within 3 weeks of hospitalization in a tertiary hospital in Sudan.

Methods

We prospectively studied 40 SAH patients over 5 months, with 3 weeks of follow-up for the symptomatology, signs, Glasgow coma scale (GCS), CT scan findings, and outcomes. The fatal outcome group was defined as dying within 3 weeks.

Results

The mean age was 53.5 years (SD, 6.9; range, 41–65), and 62.5% were women. One-third (30.0%) were smokers, 37.5% were hypertensive, two-thirds (62.5%) had elevated blood pressure on admission, 37.5% had >24 hours delayed presentation, and 15% had missed SAH diagnosis. The most common presenting symptoms were headache and neck pain/stiffness, while seizures were reported in 12.5%. Approximately one-quarter of patients (22.5%) had large-sized Computed Tomography scan hemorrhage, and 40.0% had moderate size. In-hospital mortality rate was 40.0% (16/40); and 87.5% of them passed away within the first week. Compared to survivors, fatal outcome patients had significantly higher rates of smoking (50.0%), hypertension (68.8%), elevated presenting blood pressure (93.8%), delayed diagnosis (56.2%), large hemorrhage (56.2%), lower GCS scores at presentation, and cerebral rebleeding ( P < 0.05 for each). The primary causes of death were the direct effect of the primary hemorrhage (43.8%), rebleeding (31.3%), and delayed cerebral infarction (12.5%).

Conclusions

SAH is associated with a high in-hospital mortality rate in this cohort of Sudanese SAH patients due to modifiable factors such as delayed diagnosis, hypertension, and smoking. Strategies toward minimizing these factors are recommended.

Rehabilitation of Upper Limb Motor Impairment in Stroke: A Narrative Review on the Prevalence, Risk Factors, and Economic Statistics of Stroke and State of the Art Therapies

Stroke has been one of the leading causes of disability worldwide and is still a social health issue. Keeping in view the importance of physical rehabilitation of stroke patients, an analytical review has been compiled in which different therapies have been reviewed for their effectiveness, such as functional electric stimulation (FES), noninvasive brain stimulation (NIBS) including transcranial direct current stimulation (t-DCS) and transcranial magnetic stimulation (t-MS), invasive epidural cortical stimulation, virtual reality (VR) rehabilitation, task-oriented therapy, robot-assisted training, tele rehabilitation, and cerebral plasticity for the rehabilitation of upper extremity motor impairment. New therapeutic rehabilitation techniques are also being investigated, such as VR. This literature review mainly focuses on the randomized controlled studies, reviews, and statistical meta-analyses associated with motor rehabilitation after stroke. Moreover, with the increasing prevalence rate and the adverse socio-economic consequences of stroke, a statistical analysis covering its economic factors such as treatment, medication and post-stroke care services, and risk factors (modifiable and non-modifiable) have also been discussed. This review suggests that if the prevalence rate of the disease remains persistent, a considerable increase in the stroke population is expected by 2025, causing a substantial economic burden on society, as the survival rate of stroke is high compared to other diseases. Compared to all the other therapies, VR has now emerged as the modern approach towards rehabilitation motor activity of impaired limbs. A range of randomized controlled studies and experimental trials were reviewed to analyse the effectiveness of VR as a rehabilitative treatment with considerable satisfactory results. However, more clinical controlled trials are required to establish a strong evidence base for VR to be widely accepted as a preferred rehabilitation therapy for stroke.

Endovascular Management of Hemorrhagic Stroke

Significant advances in endovascular neurosurgery tools, devices, and techniques are changing the approach to the management of acute hemorrhagic stroke. The endovascular treatment of intracranial aneurysms emerged in the early 1990s with Guglielmi detachable coils, and since then, it gained rapid popularity that surpassed open surgery. Stent-assisted coiling and balloon remodeling techniques have made the treatment of wide-necked aneurysms more durable. With the introduction of flow diverters and flow disrupters, many aneurysms with complex geometrics can now be reliably managed. Arteriovenous malformations and fistulae can also benefit from endovascular therapy by embolization using n-butyl cyanoacrylate (NBCA), Onyx, polyvinyl alcohol (PVA), and coils. In this article, we describe the role of endovascular treatment for the most common causes of intracerebral and subarachnoid hemorrhages, particularly ruptured aneurysms and vascular malformations.

Ethnic and Racial Variation in Intracerebral Hemorrhage Risk Factors and Risk Factor Burden

Importance

Black and Hispanic individuals have an increased risk of intracerebral hemorrhage (ICH) compared with their White counterparts, but no large studies of ICH have been conducted in these disproportionately affected populations.

Objective

To examine the prevalence, odds, and population attributable risk (PAR) percentage for established and novel risk factors for ICH, stratified by ICH location and racial/ethnic group.

Design, Setting, and Participants

The Ethnic/Racial Variations of Intracerebral Hemorrhage Study was a case-control study of ICH among 3000 Black, Hispanic, and White individuals who experienced spontaneous ICH (1000 cases in each group). Recruitment was conducted between September 2009 and July 2016 at 19 US sites comprising 42 hospitals. Control participants were identified through random digit dialing and were matched to case participants by age (±5 years), sex, race/ethnicity, and geographic area. Data analyses were conducted from January 2019 to May 2020.

Main Outcomes and Measures

Case and control participants underwent a standardized interview, physical measurement for body mass index, and genotyping for the ɛ2 and ɛ4 alleles of APOE, the gene encoding apolipoprotein E. Prevalence, multivariable adjusted odds ratio (OR), and PAR percentage were calculated for each risk factor in the entire ICH population and stratified by racial/ethnic group and by lobar or nonlobar location.

Results

There were 1000 Black patients (median [interquartile range (IQR)] age, 57 [50-65] years, 425 [42.5%] women), 1000 Hispanic patients (median [IQR] age, 58 [49-69] years; 373 [37.3%] women), and 1000 White patients (median [IQR] age, 71 [59-80] years; 437 [43.7%] women). The mean (SD) age of patients with ICH was significantly lower among Black and Hispanic patients compared with White patients (eg, lobar ICH: Black, 62.2 [15.2] years; Hispanic, 62.5 [15.7] years; White, 71.0 [13.3] years). More than half of all ICH in Black and Hispanic patients was associated with treated or untreated hypertension (PAR for treated hypertension, Black patients: 53.6%; 95% CI, 46.4%-59.8%; Hispanic patients: 46.5%; 95% CI, 40.6%-51.8%; untreated hypertension, Black patients: 45.5%; 95% CI, 39.%-51.1%; Hispanic patients: 42.7%; 95% CI, 37.6%-47.3%). Lack of health insurance also had a disproportionate association with the PAR percentage for ICH in Black and Hispanic patients (Black patients: 21.7%; 95% CI, 17.5%-25.7%; Hispanic patients: 30.2%; 95% CI, 26.1%-34.1%; White patients: 5.8%; 95% CI, 3.3%-8.2%). A high sleep apnea risk score was associated with both lobar (OR, 1.68; 95% CI, 1.36-2.06) and nonlobar (OR, 1.62; 95% CI, 1.37-1.91) ICH, and high cholesterol was inversely associated only with nonlobar ICH (OR, 0.60; 95% CI, 0.52-0.70); both had no interactions with race and ethnicity. In contrast to the association between the ɛ2 and ɛ4 alleles of APOE and ICH in White individuals (eg, presence of APOE ɛ2 allele: OR, 1.84; 95% CI, 1.34-2.52), APOE alleles were not associated with lobar ICH among Black or Hispanic individuals.

Conclusions and Relevance

This study found sleep apnea as a novel risk factor for ICH. The results suggest a strong contribution from inadequately treated hypertension and lack of health insurance to the disproportionate burden and earlier onset of ICH in Black and Hispanic populations. These findings emphasize the importance of addressing modifiable risk factors and the social determinants of health to reduce health disparities.

Risk of major bleeding by ethnicity and socioeconomic deprivation among 488,107 people in primary care: a cohort study

BACKGROUND

Antithrombotic medications (antiplatelets and anticoagulants) reduce the risk of cardiovascular disease (CVD), but with the disadvantage of increasing bleeding risk. Ethnicity and socioeconomic deprivation are independent predictors of major bleeds among patients without CVD, but it is unclear whether they are also predictors of major bleeds among patients with CVD or atrial fibrillation (AF) after adjustment for clinical variables.

METHODS

Prospective cohort study of 488,107 people in New Zealand Primary Care (including 64,420 Māori, the indigenous people of New Zealand) aged 30-79 years who had their CVD risk assessed between 2007 and 2016. Participants were divided into three mutually exclusive subgroups: (1) AF with or without CVD (n = 15,212), (2) CVD and no AF (n = 43,790), (3) no CVD or AF (n = 429,105). Adjusted hazards ratios (adjHRs) were estimated from Cox proportional hazards models predicting major bleeding risk for each of the three subgroups to determine whether ethnicity and socioeconomic deprivation are independent predictors of major bleeds in different cardiovascular risk groups.

RESULTS

In all three subgroups (AF, CVD, no CVD/AF), Māori (adjHR 1.63 [1.39-1.91], 1.24 [1.09-1.42], 1.57 [95% CI 1.45-1.70], respectively), Pacific people (adjHR 1.90 [1.58-2.28], 1.30 [1.12-1.51], 1.62 [95% CI 1.49-1.75], respectively) and Chinese people (adjHR 1.53 [1.08-2.16], 1.15 [0.90-1.47], 1.13 [95% CI 1.01-1.26], respectively) were at increased risk of a major bleed compared to Europeans, although for Chinese people the effect did not reach statistical significance in the CVD subgroup. Compared to Europeans, Māori and Pacific peoples were generally at increased risk of all bleed types (gastrointestinal, intracranial and other bleeds). An increased risk of intracranial bleeds was observed among Chinese and Other Asian people and, in the CVD and no CVD/AF subgroups, among Indian people. Increasing socioeconomic deprivation was also associated with increased risk of a major bleed in all three subgroups (adjHR 1.07 [1.02-1.12], 1.07 [1.03-1.10], 1.10 [95% CI 1.08-1.12], respectively, for each increase in socioeconomic deprivation quintile).

CONCLUSION

Ethnicity and socioeconomic status should be considered in bleeding risk assessments to guide the use of antithrombotic medication for the management of AF and CVD.

Endovascular Treatment of Intracranial Aneurysms

Traditionally, surgical clipping was the only available treatment modality for intracranial aneurysms. However, in the last few decades, the endovascular therapy of intracranial aneurysms (IAs) has seen a tremendous evolution and development. From coiling to flow diversion and flow disruptor devices, endovascular treatment modalities have increased in number and received broader indications throughout the years. In this review article, the treatment modalities for the endovascular management of IAs are presented, emphasizing newer devices and technologies.

Impact of Intracranial Pressure Monitor-Guided Therapy on Neurologic Outcome After Spontaneous Nontraumatic Intracranial Hemorrhage

OBJECTIVES

Intracranial pressure (ICP) monitors have been used in some patients with spontaneous intracranial hemorrhage (ICH) to provide information to guide treatment without clear evidence for its use in this population. We assessed the impact of ICP monitor placement, including external ventricular drains and intraparenchymal monitors, on neurologic outcome in this population.

MATERIALS AND METHODS

In this secondary analysis of the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation III trial, the primary outcome was poor outcome (modified Rankin Scale score 4-6) and the secondary outcome was death, at 1 year from onset. We compared outcomes in patients with or without an ICP monitor using unadjusted and adjusted logistic regression models. The analyses were repeated in a balanced cohort created with propensity score matching.

RESULTS

Seventy patients underwent ICP monitor placement and 424 did not. Poor outcome was seen in 77.1% of patients in the ICP-monitor subgroup compared with 53.8% in the no-monitor subgroup (p<0.001). Of patients in the ICP-monitor subgroup, 31.4% died, compared with 21.0% in the no-monitor subgroup (p=0.053). In multivariate models, ICP monitor placement was associated with a >2-fold greater risk of poor outcome (odds ratio 2.76, 95% CI 1.30-5.85, p=0.008), but not with death (p=0.652). Our findings remained consistent in the propensity score-matched cohort.

CONCLUSION

These results question whether ICP monitor-guided therapy in patients with spontaneous nontraumatic ICH improves outcome. Further work is required to define the causal pathway and improve identification of patients that might benefit from invasive ICP monitoring.

The prevalence, mortality rate and functional outcome of intracerebral hemorrhage according to age sex and ethnic group in the state of Qatar

OBJECTIVE

To investigate the prevalence of intracerebral hemorrhage (ICH) using stroke database from the main tertiary hospital in Qatar (Hamad General Hospital) over the period of Dec 2013 to Oct 2017.

METHODS

The prevalence of ICH was calculated based on age groups and ethnicity (Qatari nationals, non-Qatari Arab, South east Indian (SI) and Far East Asians (FE)). Thirty-day case fatality rate, poor clinical outcome at discharge (modified Rankin scale (mRS):3-6) and poor long-term outcome (mRS at 90 days: 3-6) were calculated per each age group sex and ethnicity.

RESULT

There were 653/4039 (16 %) with ICH. The median age was 53 (IQ range: 45-64) with a male/female ratio: 557/96 (85.3/14.7 %). The 30-day mortality rate was 14.7 % (96/653), poor outcome at discharge (mRS 3-6): 66.8 % (436/653) and poor long-term outcome (mRS 90 days:3-6) 50.1 % (199/397). The prevalence of ICH in Qatar was 24.9 per 100 000. The highest mortality rate was seen in the elderly (≥ 70 years old) (16/67 (23.9 %)) and young group (48/291 (16.5 %)). The most common ethnic group among our ICH population are the following: FE (40.59 per 100 000), Qatari (25.26 per 100 000) and SI ethnic group (24.97 per 100 000). In multiple logistic regression analysis only, old age (≥ 70 years old) was associated with 30 days mortality (adj OR: 2.51, 95 % CI: 1.14-5.54, P = 0.023). Similar regression analysis was also observed that age ≥ 70 years old (adj. OR: 4.18, 95 % CI: 1.27-13.77, P = 0.019), sex (male) (adj. OR: 0.21, 95 % CI: 0.08-0.56, P = 0.002), and ethnicity (SI vs Qatari: adj. OR: 4.08, 95 % CI: 1.28-12.92, P = 0.017); (FE vs Qatari: adj. OR: 2.22, 95 % CI: 0.65-7.67, P = 0.203) are statistically associated with poor outcome.

CONCLUSION

The prevalence of ICH was high in the elderly and in the FE, Qatari, and SI ethnic group. Further studies are needed to better understand the differences in ICH prognosis in multiethnic groups.

Intracranial pressure monitoring in patients with spontaneous intracerebral hemorrhage

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Antithrombotics in intracerebral hemorrhage in the era of novel agents and antidotes: A review

BACKGROUND

Intracerebral hemorrhage (ICH)1 is characterized by the pathological accumulation of blood within the brain parenchyma, most commonly associated with hypertension, arteriovenous malformations, or trauma. However, it can also present in patients receiving antithrombotic drugs, either anticoagulants such as acenocoumarol/warfarin-novel oral anticoagulants or antiplatelets, for the prevention and treatment of thromboembolic disease.

OBJECTIVE

The purpose of this review is to present current bibliographic data regarding ICH irrespective of the cause, as well as post-hemorrhage use of antithrombotic agents. Moreover, this review attempts to provide guidelines concerning the termination, inversion, and of course resumption of antithrombotic therapy.

METHODS AND MATERIALS

We reviewed the most recently presented available data for patients who dealt with intracerebral hemorrhagic events while on antithrombotic agents (due to atrial fibrillation, prosthetic mechanical valves or recent/recurrent deep vein thrombosis). Furthermore, we examined and compared the thromboembolic risk, the bleeding risk, as well as the re-bleeding risk in two groups: patients receiving antithrombotic therapy versus patients not on antithrombotic therapy.

CONCLUSION

Antithrombotic therapy is of great importance when indicated, though it does not come without crucial side-effects, such as ICH. Optimal timing of withdrawal, reversal, and resumption of antithrombotic treatment should be determined by a multidisciplinary team consisting of a stroke specialist, a cardiologist, and a neurosurgeon, who will individually approach the needs and risks of each patient.

Age as a prognostic factor of 30-day mortality in hemorrhagic stroke patients: A Thai large tertiary care referral center

OBJECTIVE

The aim of the present study was to identify incidences and prognostic factors for 30-day mortality of hemorrhagic strokes (HS) and divide them into intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH).

METHODS

This retrospective cohort study was conducted using medical records of patients who underwent surgery due to HS, between January 2013 and April 2017, at Chiang Mai University Hospital, a large tertiary referral center, in Northern Thailand. 30-day mortality was followed after surgery. Prognostic factors included patients' characteristics, and clinical date related to early death, were determined. Data analysis was performed using Cox's proportional hazards model.

RESULTS

460 patients were enrolled. The 30-day mortality rate was 8.8% and 12.3%, in ICH and SAH patients, respectively. Multivariable analyses demonstrated that the prognostic factors of early mortality in ICH patients were age 65-70 years (Adjusted HR 3.10 (95%CI 1.14-8.41)), >70 years (Adj.HR 2.64 (95%CI 1.09-6.36)) and hypertension (HT) (Adj.HR 2.98 (95%CI 1.25-7.12)). In SAH patients, prognostic factors were HT (Adj.HR 7.32 (95%CI 2.12-25.29)), and atrial fibrillation (AF) (Adj.HR 5.48 (95% CI 1.57-19.09)).

CONCLUSIONS

Ages over 65 years and HT were an important predictor of 30-day mortality in a subgroup of ICH patients, whereas HT and AF were significant prognostic factors in SAH. To reduce early death, management for stroke cases needed to take into account the specifics for older age patients with HT, and AF.

Preventable Readmissions and Predictors of Readmission After Subarachnoid Hemorrhage

OBJECTIVE

To estimate rates of all-cause and potentially preventable readmissions up to 90 days after discharge for aneurysmal subarachnoid hemorrhage (SAH) and medical comorbidities associated with readmissions BACKGROUND: Readmission rate is a common metric linked to compensation and used as a proxy to quality of care. Prior studies in SAH have reported 30-day readmission rates of 7-17% with a higher readmission risk among those with the higher SAH severity, ≥ 3 comorbidities, and non-home discharge. Intermediate-term rates, up to 90-days, and the proportion of these readmissions that are potentially preventable are unknown. Furthermore, the specific medical comorbidities associated with readmissions are unknown.

METHODS

Index SAH admissions were identified from the 2013 Nationwide Readmissions Database. All-cause readmissions were defined as any readmission during the 30-, 60-, and 90-day post-discharge period. Potentially preventable readmissions were identified using Prevention Quality Indicators developed by the US Agency for Healthcare Research and Quality. Unadjusted and adjusted Poisson models were used to identify factors associated with increased readmission rates.

RESULTS

Out of 9987 index admissions for SAH, 7949 (79%) survived to discharge. The percentage of 30-, 60-, and 90-day all-cause readmissions were 7.8, 16.6, and 26%, respectively. Up to 14% of readmissions in the first 30 days were considered potentially preventable and acute conditions (dehydration, bacterial pneumonia, and urinary tract infections) accounted for over half, whereas acute cerebrovascular disease was the most common cause for neurological return. In multivariable analysis, significant predictors of a higher readmission rate included diabetes (rate ratio [RR] 1.09, 95% confidence interval [CI] 1.03-1.15), congestive heart failure (RR 1.09, 1.003-1.18), and renal impairment (RR 1.35, 1.13-1.61). Only discharge home was associated with a lower readmission rate (RR 0.89, 0.85-0.93).

CONCLUSIONS

SAH has a 30-day readmission rate of 7.8% which continues to rise into the intermediate-term. A low but constant proportion of readmissions are potentially preventable. Several chronic medical comorbidities were associated with readmissions. Prospective studies are warranted to clarify causal relationships.

Characteristics of Unruptured Compared to Ruptured Intracranial Aneurysms: A Multicenter Case-Control Study

BACKGROUND

Only a minority of intracranial aneurysms rupture to cause subarachnoid hemorrhage.

OBJECTIVE

To test the hypothesis that unruptured aneurysms have different characteristics and risk factor profiles compared to ruptured aneurysms.

METHODS

We recruited patients with unruptured aneurysms or aneurysmal subarachnoid hemorrhages at 22 UK hospitals between 2011 and 2014. Demographic, clinical, and imaging data were collected using standardized case report forms. We compared risk factors using multivariable logistic regression.

RESULTS

A total of 2334 patients (1729 with aneurysmal subarachnoid hemorrhage, 605 with unruptured aneurysms) were included (mean age 54.22 yr). In multivariable analyses, the following variables were independently associated with rupture status: black ethnicity (odds ratio [OR] 2.42; 95% confidence interval [CI] 1.29-4.56, compared to white) and aneurysm location (anterior cerebral artery/anterior communicating artery [OR 3.21; 95% CI 2.34-4.40], posterior communicating artery [OR 3.92; 95% CI 2.67-5.74], or posterior circulation [OR 3.12; 95% CI 2.08-4.70], compared to middle cerebral artery). The following variables were inversely associated with rupture status: antihypertensive medication (OR 0.65; 95% CI 0.49-0.84), hypercholesterolemia (0.64 OR; 95% CI 0.48-0.85), aspirin use (OR 0.28; 95% CI 0.20-0.40), internal carotid artery location (OR 0.53; 95% CI 0.38-0.75), and aneurysm size (per mm increase; OR 0.76; 95% CI 0.69-0.84).

CONCLUSION

We show substantial differences in patient and aneurysm characteristics between ruptured and unruptured aneurysms. These findings support the hypothesis that different pathological mechanisms are involved in the formation of ruptured aneurysms and incidentally detected unruptured aneurysms. The potential protective effect of aspirin might justify randomized prevention trials in patients with unruptured aneurysms.

Impact of Spot Sign Etiology in Supratentorial Intracerebral Hemorrhage on Outcomes of Endoscopic Surgery

BACKGROUND

The spot sign (SS) in spontaneous intracerebral hemorrhage has been reported to be a predictive factor of poor outcome; however, how SS is related with the clinical outcome remains unclear. We aimed to investigate how etiology associated with SS affects the clinical outcome of endoscopic surgery.

METHODS

We retrospectively analyzed data from 104 patients (43 women and 61 men, mean age: 64.2 ± 11.0 years) who underwent endoscopic surgery for supratentorial intracerebral hemorrhage. The outcome variables analyzed were in-hospital mortality and modified Rankin scale score at 90 days from onset.

RESULTS

The prevalence of intraventricular hemorrhage and the mean initial modified Graeb score were greater in SS-positive than in SS-negative patients (100% vs. 47.7%, P < 0.001, and 14.4 ± 5.4 vs. 10.6 ± 6.0, P = 0.03, respectively). Postoperative rebleeding occurred more frequently in SS-positive than -negative patients (25.0% vs. 6.8%, P = 0.045). The in-hospital mortality rate was 7.7% and was not significantly different between the groups (18.8% vs. 5.7%, P = 0.09). There was a significant unfavorable shift in modified Rankin scale scores at 90 days among SS-positive patients compared with SS-negative patients in an analysis with ordinal logistic regression (adjusted common odds ratio, 4.38; 95% confidence interval 0.06-0.79, P = 0.02).

CONCLUSIONS

Intraventricular hemorrhage and postoperative rebleeding were considered to be associated with the poor outcome in patients with SS. The SS on computed tomography angiography may be valuable in predicting rebleeding and clinical outcome after surgery.

Haplotype analysis of SERPINE1 gene: Risk for aneurysmal subarachnoid hemorrhage and clinical outcomes

Background

Aneurysmal subarachnoid hemorrhage (aSAH) has high fatality and permanent disability rates due to the severe damage to brain cells and inflammation. The SERPINE1 gene that encodes PAI‐1 for the regulation of tissue plasminogen activator is considered an important therapeutic target for aSAH.

Methods

Six SNPs in the SERPINE1 gene (in order of rs2227631, rs1799889, rs6092, rs6090, rs2227684, rs7242) were investigated. Blood samples were genotyped with Taqman genotyping assays and pyrosequencing. The experiment‐wide statistically significant threshold for single marker analysis was set at p < 0.01 after evaluation of independent markers. Haplotype analysis was performed in Haplo.stats package with permutation tests. Bonferroni correction for multiple comparison in dominant, additive, and recessive model was applied.

Results

A total of 146 aSAH patients and 49 control subjects were involved in this study. The rs2227631 G allele is significant (p = 0.01) for aSAH compared to control. In aSAH group, haplotype analysis showed that G5GGGT homozygotes in recessive model were associated with delayed cerebral ischemia (p < 0.01, Odds Ratio = 5.14, 95% CI = 1.45–18.18), clinical vasospasm (p = 0.01, Odds Ratio = 4.58, 95% CI = 1.30–16.13), and longer intensive care unit stay (p = 0.01). By contrast, the G5GGAG carriers were associated with less incidence of cerebral edema (p < 0.01) and higher Glasgow Coma Scale (p < 0.01). The A4GGGT carriers were associated with less incidence of severe hypertension (>140/90) (p < 0.01).

Conclusion

The results suggested an important regulatory role of the SERPINE1 gene polymorphism in clinical outcomes of aSAH.

Intracerebral Hemorrhage Induces Inflammatory Gene Expression in Peripheral Blood: Global Transcriptional Profiling in Intracerebral Hemorrhage Patients

To perform global transcriptome profiling using RNA-seq in the peripheral blood of intracerebral hemorrhage (ICH) patients. In 11 patients with ICH, peripheral blood was collected within 24 h of symptom onset or last known well, and a second blood draw occurred 72 h (±6) after the first. RNA-seq identified differentially expressed genes (DEGs) between the first and second samples. Biological pathway enrichment analysis was performed with Ingenuity® Pathway Analysis (IPA). A total of 16,640 genes were identified and 218 were significant DEGs after ICH (false discovery rate <0.1). IPA identified 97 disease and functional categories that were significantly upregulated (z-score >2) post-ICH; 46 categories were specifically related to immune cell activation, 22 to general cellular activation processes, and 4 to other inflammation-related responses. In the canonical pathway and network analysis, inflammatory mediators of particular importance included interleukin-8, NF-κB, ERK1/2, and members of the integrin class. ICH induced peripheral blood gene expression at 72 to 96 h compared with 0 to 24 h from symptom onset. DEGs that were highly expressed included those related to inflammation and activation of the immune response. Further research is needed to determine whether these changes affect outcomes and may represent new therapeutic targets.

Intracranial Mirror Aneurysm: Epidemiology, Rupture Risk, New Imaging, Controversies, and Treatment Strategies

There are some controversies about the surgical treatment strategy of mirror aneurysms. Whether to choose 1-stage or 2-stage surgery, bilateral or unilateral craniotomy, or surgical or interventional treatment are the main points in dispute. In this review, the different surgery strategies faced by patients are discussed. Different surgical methods are adopted based on the patient's individual state and the location and size of the aneurysm. A new imaging method is introduced using 3D Slicer, which clearly recognizes the relationship among aneurysm, brain tissue, skull, and nerve. The 3D Slicer can help surgeons undertake adequate preoperative preparation. In addition, we also introduce some ruptured factors (e.g., age, gender, hypertension, morphologic, and hemodynamic) concerning mirror aneurysm. Systematic discussion of the controversies and methods in surgical treatment of mirror aneurysms may provide new perspectives in future research for the prevention and treatment of mirror aneurysms.

Association of Apolipoprotein E With Intracerebral Hemorrhage Risk by Race/Ethnicity: A Meta-analysis

Importance

Genetic studies of intracerebral hemorrhage (ICH) have focused mainly on white participants, but genetic risk may vary or could be concealed by differing nongenetic coexposures in nonwhite populations. Transethnic analysis of risk may clarify the role of genetics in ICH risk across populations.

Objective

To evaluate associations between established differences in ICH risk by race/ethnicity and the variability in the risks of apolipoprotein E (APOE) ε4 alleles, the most potent genetic risk factor for ICH.

Design, Setting, and Participants

This case-control study of primary ICH meta-analyzed the association of APOE allele status on ICH risk, applying a 2-stage clustering approach based on race/ethnicity and stratified by a contributing study. A propensity score analysis was used to model the association of APOE with the burden of hypertension across race/ethnic groups. Primary ICH cases and controls were collected from 3 hospital- and population-based studies in the United States and 8 in European sites in the International Stroke Genetic Consortium. Participants were enrolled from January 1, 1999, to December 31, 2017. Participants with secondary causes of ICH were excluded from enrollment. Controls were regionally matched within each participating study.

Main Outcomes and Measures

Clinical variables were systematically obtained from structured interviews within each site. APOE genotype was centrally determined for all studies.

Results

In total, 13 124 participants (7153 [54.5%] male with a median [interquartile range] age of 66 [56-76] years) were included. In white participants, APOE ε2 (odds ratio [OR], 1.49; 95% CI, 1.24-1.80; P < .001) and APOE ε4 (OR, 1.51; 95% CI, 1.23-1.85; P < .001) were associated with lobar ICH risk; however, within self-identified Hispanic and black participants, no associations were found. After propensity score matching for hypertension burden, APOE ε4 was associated with lobar ICH risk among Hispanic (OR, 1.14; 95% CI, 1.03-1.28; P = .01) but not in black (OR, 1.02; 95% CI, 0.98-1.07; P = .25) participants. APOE ε2 and ε4 did not show an association with nonlobar ICH risk in any race/ethnicity.

Conclusions and Relevance

APOE ε4 and ε2 alleles appear to affect lobar ICH risk variably by race/ethnicity, associations that are confirmed in white individuals but can be shown in Hispanic individuals only when the excess burden of hypertension is propensity score-matched; further studies are needed to explore the interactions between APOE alleles and environmental exposures that vary by race/ethnicity in representative populations at risk for ICH.

Cigarette Smoking History and Functional Outcomes After Spontaneous Intracerebral Hemorrhage

Background and Purpose- Although cigarette use may be a risk for intracerebral hemorrhage (ICH), animal models suggest that nicotine has a potential neuroprotective effect. The aim of this multicenter study is to determine the effect of smoking history on outcome in ICH patients. Methods- We analyzed prospectively collected data from the Ethnic/Racial Variations of Intracerebral Hemorrhage study and included patients with smoking status data in the analysis. Patients were dichotomized into nonsmokers versus ever-smokers, and the latter group was further categorized as former (>30 days before ICH) or current (≤30 days before ICH) smokers. The primary outcome was 90-day modified Rankin Scale score shift analysis. Secondary outcomes were in-hospital mortality and mortality, Barthel Index, and self-reported health status measures at 90 days. Results- The overall study cohort comprised 1509 nonsmokers and 1423 ever-smokers (841 former, 577 current, 5 unknown). No difference in primary outcome was observed between nonsmokers versus ever-smokers (adjusted odds ratio [aOR], 1.041; 95% CI, 0.904-1.199; P=0.577). No differences in primary outcome were observed between former (aOR, 0.932; 95% CI, 0.791-1.178; P=0.399) or current smokers (aOR, 1.178; 95% CI, 0.970-1.431; P=0.098) versus nonsmokers. Subgroup analyses by race/ethnicity demonstrated no differences in primary outcome when former and current smokers were compared with nonsmokers. Former, but not current, smokers had a lower in-hospital mortality rate (aOR, 0.695; 95% CI, 0.500-0.968; P=0.031), which was only observed in Hispanics (aOR, 0.533; 95% CI, 0.309-0.921; P=0.024). Differences in self-reported health status measures were only observed in whites. Conclusions- Cigarette smoking history does not seem to provide a beneficial effect on 90-day functional outcome in patients with ICH.

Quantitative assessment of local perfusion change in acute intracerebral hemorrhage areas with and without "dynamic spot sign" using CT perfusion imaging

BACKGROUND

Positive "dynamic spot sign" has been proven to be a potential risk factor for acute intracerebral hemorrhage (ICH) expansion, but local perfusion change has not been quantitatively investigated.

PURPOSE

To quantitatively evaluate perfusion changes at the ICH area using computed tomography perfusion (CTP) imaging.

MATERIAL AND METHODS

Fifty-three patients with spontaneous ICH were recruited. Unenhanced computed tomography (NCCT), CTP within 6 h, and follow-up NCCT were performed for 21 patients in the "spot sign"-positive group and 32 patients in the control group. Cerebral perfusion change was quantitatively measured on regional cerebral blood flow/regional cerebral blood volume (rCBF/rCBV) maps. Regions of interest (ROIs) were set at the "spot-sign" region and the whole hematoma area for "spot-sign"-positive cases, and at one of the highest values of three interested areas and the whole hematoma area for the control group. Hematoma expansion was determined by follow-up NCCT.

RESULTS

For the "spot-sign"-positive group, the average rCBF (rCBV) values at the "spot-sign" region and the whole hematoma area were 21.34 ± 15.24 mL/min/100 g (21.64 ± 21.48 mL/100g) and 5.78 ± 6.32 mL/min/100 g (6.07 ± 5.45 mL/100g); for the control group, the average rCBF (rCBV) values at the interested area and whole hematoma area were 2.50 ± 1.83 mL/min/100 g (3.13 ± 1.96 mL/100g) and 3.02 ± 1.80 mL/min/100 g (3.40 ± 1.44 mL/100g), respectively. Average rCBF and rCBV values of the "spot-sign" region were significantly different from other regions ( P < 0.001; P = 0.004). The average volumes of hematoma expansion in the "spot-sign"-positive and control groups were 25.24 ± 19.38 mL and -0.41 ± 1.34 mL, respectively.

CONCLUSION

The higher perfusion change at ICH on CTP images may reflect the contrast extravasation and be associated with the hematoma expansion.

Predictors of Surgical Intervention in Patients with Spontaneous Intracerebral Hemorrhage

OBJECTIVE

Despite no clear evidence from randomized trials, surgical intervention of spontaneous intracerebral hemorrhage (ICH) still occurs. We sought to describe the characteristics of patients undergoing surgical intervention in ICH.

METHODS

Data from the ERICH (ERICH Ethnic/Racial Variations of Intracerebral Hemorrhage) study were analyzed, and patients with ICH were categorized into surgical intervention or nonoperative management groups. Patients with primary intraventricular hemorrhage and those without data regarding the use of surgical intervention were excluded.

RESULTS

The study cohort comprised 2947 patients, and surgical intervention was performed in 289 (10%). Younger age (odds ratio [OR], 0.967; P < 0.001), lower baseline modified Rankin Scale score (OR, 0.728; P < 0.001), higher admission Glasgow Coma Scale score (OR, 1.059; P = 0.007), larger ICH volume (OR, 1.037; P < 0.001), infratentorial ICH location (OR, 5.966; P < 0.001), lobar ICH location (OR, 1.906; P = 0.001), lack of intraventricular hemorrhage (OR, 0.567; P = 0.001), intracranial pressure (ICP) monitoring (OR, 5.022; P < 0.001), and mannitol use (OR, 2.389; P < 0.001) were independent predictors of surgical intervention. Younger age (OR, 0.953; P < 0.001), lower baseline modified Rankin Scale score (OR, 0.713; P = 0.002), larger ICH volume (OR, 1.033; P < 0.001), lobar ICH location (OR, 2.467; P < 0.001), ICP monitoring (OR, 3.477; P < 0.001), and mannitol use (OR, 2.139; P < 0.001) were independent predictors of surgical interventions in supratentorial ICHs. Larger ICH volume (OR, 1.078; P < 0.001), ICP monitoring (OR, 6.099; P < 0.001), and mannitol use (OR, 2.952; P = 0.005) were independent predictors of surgical interventions in infratentorial ICHs.

CONCLUSIONS

We identified multiple factors associated with surgical intervention for patients with ICH. Younger age, good neurologic function at baseline, large ICH volume on presentation, and lobar or infratentorial hematomas were independently associated with surgical intervention in patients with ICH .

Intracerebral Hemorrhage in Multiple Sclerosis: A Retrospective Cohort Study

BACKGROUND

To identify the vascular risk factors associated with the occurrence of intracerebral hemorrhage (ICH) in Multiple Sclerosis (MS) patients.

METHODS

This is an observational, retrospective cohort study using the nationwide electronic medical records (EMR) database. Patients with the diagnosis of MS were extracted from inpatient and outpatient EMR using the international classification of diseases, ninth/tenth revisions, clinical modification codes. We excluded patients younger than 18 years, and those where gender was not specified. Patients were further stratified based on their demographics, risk factors, medications, and comorbidities. Tobacco, diabetes, hypertension, and alcohol were the predicting variables; antiplatelet medication, and anticoagulant agents were the primary exposures for the development of ICH. A validated diagnosis code algorithm defined the diagnosis of ICH. Multivariable logistic regression models were utilized to assess the risk of ICH in MS patients.

RESULTS

Of the total 57,099 MS patients (women: 75%, n = 41,517), 107 (.19%) sustained an ICH. Age (OR = 2.74, CI = 1.13-6.62), use of anticoagulants (OR = 2.15, 95% CI = 1.30-3.56, P = .0028), and history of tobacco exposure (OR = 2.44, CI = 1.37-4.36, P = .0025) were associated with increased risk of ICH. Use of antiplatelet and disease-modifying drugs (DMDs) showed a protective trend against ICH.

CONCLUSIONS

Tobacco exposure and anticoagulant use were strongly associated with increased risk of ICH in patients with MS. There might be a protective effect that antiplatelet and DMDs have in the pathophysiology of this disease. Further prospective investigations are warranted to establish these associations.

Hypertension and intracerebral hemorrhage recurrence among white, black, and Hispanic individuals

OBJECTIVE

To clarify whether recurrence risk for intracerebral hemorrhage (ICH) is higher among black and Hispanic individuals and whether this disparity is attributable to differences in blood pressure (BP) measurements and their variability.

METHODS

We analyzed data from survivors of primary ICH enrolled in 2 separate studies: (1) the longitudinal study conducted at Massachusetts General Hospital (n = 759), and (2) the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) study (n = 1,532). Participants underwent structured interview at enrollment (including self-report of race/ethnicity) and were followed longitudinally via phone calls and review of medical records. We captured systolic BP (SBP) and diastolic BP measurements, and quantified variability as SBP and diastolic BP variation coefficients. We used multivariable (Cox regression) survival analysis to identify risk factors for ICH recurrence.

RESULTS

We followed 2,291 ICH survivors (1,121 white, 529 black, 605 Hispanic, and 36 of other race/ethnicity). Both black and Hispanic patients displayed higher SBP during follow-up (p < 0.05). Black participants also displayed greater SBP variability during follow-up (p = 0.032). In univariable analyses, black and Hispanic patients were at higher ICH recurrence risk (p < 0.05). After adjusting for BP measurements and their variability, both Hispanic (hazard ratio = 1.51, 95% confidence interval 1.14-2.00, p = 0.004) and black (hazard ratio = 1.98, 95% confidence interval 1.36-2.86, p < 0.001) patients remained at higher risk of ICH recurrence.

CONCLUSION

Black and Hispanic patients are at higher risk of ICH recurrence; hypertension severity (average BP and its variability) does not fully account for this finding. Additional studies will be required to further elucidate determinants for this health disparity.

Packing of metalized polymer nanofibers for aneurysm embolization

Aneurysmal subarachnoid hemorrhage (SAH) is the extravasation of blood into the subarachnoid space and is fatal in most cases. Platinum coils have been used to fill the hemorrhage site and prevent the extravasation of blood. Here we explored the use of Pt-coated polymer nanofibers (NF) to prevent blood extravasation and were able to achieve improved results in vitro. The polymer nanofibers were produced via electrospinning and were subsequently electroplated with Pt, resulting in metalized nanofibers. These nanofibers were installed within a microfluidic channel, and the resulting reduction in the permeability was evaluated using a fluid similar to blood. Based on the obtained results, these newly developed nanofibers are expected to decrease the operation cost for SAH, owing to their reduced size and low material cost. Furthermore, it is expected that these nanofibers will be used in a smaller amount during SAH operation while having the same preventive effect. This should reduce the operational risk associated with the multiple steps required to place the Pt coils at the SAH site. Finally, the underlying hydrodynamic mechanism responsible for the reduced permeability of the synthesized nanofibers is described.

Effect of Hyperosmolar Therapy on Outcome Following Spontaneous Intracerebral Hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

PURPOSE

We aimed to identify the effect of hyperosmolar therapy (mannitol and hypertonic saline) on outcomes after intracerebral hemorrhage (ICH) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study.

METHODS

Comparison of ICH cases treated with hyperosmolar therapy versus untreated cases was performed using a propensity score based on age, initial Glasgow Coma Scale, location of ICH (lobar, deep, brainstem, and cerebellar), log-transformed initial ICH volume, presence of intraventricular hemorrhage, and surgical interventions. ERICH subjects with a pre-ICH modified Rankin Scale (mRS) score of 3 or lower were included. Treated cases were matched 1:1 to untreated cases by the closest propensity score (difference ≤.15), gender, and race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic). The McNemar and the Wilcoxon signed-rank tests were used to compare 3-month mRS outcomes between the 2 groups. Good outcome was defined as a 3-month mRS score of 3 or lower.

RESULTS

As of December 31, 2013, the ERICH study enrolled 2279 cases, of which 304 hyperosmolar-treated cases were matched to 304 untreated cases. Treated cases had worse outcome at 3 months compared with untreated cases (McNemar, P = .0326), and the mean 3-month mRS score was lower in the untreated group (Wilcoxon, P = .0174). Post hoc analysis revealed more brain edema, herniation, and death at discharge for treated cases.

CONCLUSIONS

Hyperosmolar therapy was not associated with better 3-month mRS outcomes for ICH cases in the ERICH study. This finding likely resulted from greater hyperosmolar therapy use in patients with edema and herniation rather than those agents leading to worse outcomes. Further studies should be performed to determine if hyperosmolar agents are effective in preventing poor outcomes.

Race and stroke in an atrial fibrillation inception cohort: Findings from the Penn Atrial Fibrillation Free study

BACKGROUND

Stroke may be the initial manifestation of atrial fibrillation (AF). Limited studies, however, have evaluated racial differences in stroke before the diagnosis of AF.

OBJECTIVE

We assessed racial differences in strokes that occurred before and after AF diagnosis in the Penn Atrial Fibrillation Free study.

METHODS

The Penn Atrial Fibrillation Free study consists of 56,835 patients from the University of Pennsylvania Health System who were free of AF at the index visit. We developed an inception cohort of 3507 patients with incident AF and without any remote history of stroke.

RESULTS

Among the AF inception cohort, there were 538 patients with ischemic strokes and 54 with hemorrhagic strokes. Nearly half (n = 254; 47%) of the ischemic strokes occurred within a 6-month period before the diagnosis of AF. Of these, the majority of strokes occurred either on the day of (n = 158) or within a 7-day period before (n = 30) the diagnosis of incident AF. The remaining 284 (53%) ischemic strokes occurred a median of 3.6 years (interquartile range 1.9-5.4 years) after AF diagnosis. Compared with whites, blacks had an independently higher risk of having an ischemic stroke either before (adjusted odds ratio 1.37; 95% confidence interval 1.03-1.81) or after (adjusted hazard ratio 1.67; 95% confidence interval 1.30-2.14) AF diagnosis.

CONCLUSION

In the population with incident AF, nearly half of the ischemic strokes occurred before the diagnosis of AF. Compared with whites, blacks had a higher risk of developing an ischemic stroke that persisted whether the stroke occurred in the period either before or after AF diagnosis.

Surgical Outcome in Patients with Spontaneous Supratentorial Intracerebral Hemorrhage

The aim of the paper was to evaluate the surgical outcome in patients with spontaneous supratentorial intracerebral hemorrhage (ICH) after surgical intervention, in respect to the initial clinical conditions, age, sex, hemispheric side and anatomic localization of ICH. Thirty-eight surgically treated patients with spontaneous supratentorial intracerebral hemorrhage were included in the study. The surgical outcome was evaluated three months after the initial admission, according to the Glasgow Outcome Scale (GOS). The surgical treatment was successful in 14 patients (37%), whereas it was unsuccessful in 24 patients (63%). We have detected a significant negative correlation between the Glasgow Coma Scale (GCS) scores on admission and the GOS scores after three months, suggesting worse neurological outcome in patients with initially lower GCS scores. The surgical outcome in patients with ICH was not affected by the sex, the hemispheric side and the anatomic localization of ICH, but the age of the patients was estimated as a significant factor for their functional outcome, with younger patients being more likely to be treated successfully. The surgical outcome is affected from the initial clinical state of the patients and their age. The treatment of ICH is still an unsolved clinical problem and the development of new surgical techniques with larger efficiency in the evacuation of the hematoma is necessary, thus making a minimal damage to the normal brain tissue, as well as decreasing the possibility of postoperative bleeding.

Risk factors analysis of mirror aneurysms: A multi-center retrospective study based on clinical and demographic profile of patients

As a special subgroup of multiple intracranial aneurysms, mirror aneurysms are located bilaterally on the corresponding intracranial arteries. The current study sought to compare the clinical and demographic features of patients harboring mirror aneurysm, and to elucidate the corresponding risk factors. We performed a retrospective cohort study of 2641 intracranial aneurysms patients, who were admitted to our hospitals between January 2005 and June 2014. Patients were subdivided into three groups based on the inclusion criteria: (i) single (n=2250); (ii) non-mirror multiple (n=285); and (iii) mirror aneurysms (n=106). Clinical and demographic files of the three groups were collected and compared, and medical histories including stroke, hyperlipemia, hypertension, hyperglycemia, valvular heart disease were considered as potential risk factors. Potential morphological reasons for mirror cerebral aneurysms rupture, including aneurysms size, irregular walls and cerebral hemispheric dominance, were also compared. Our data showed that the male to female ratio of mirror aneurysms patients was 1:3.61, which was significantly different from that of single aneurysm (1:1.27) and multiple aneurysms (1:2.00). The prevalence of mirror aneurysms in women is higher than that in men (P<0.001). Older patients (especially 60-69 years old) also appear to be more vulnerable to mirror aneurysm than single aneurysm (P<0.001). In 84 mirror aneurysm patients the aneurysms were located on the internal carotid arteries (79.2%), most typically at the PComA or in the Cavernous ICA. Patients with medical history of hyperlipemia appear to have an increased risk of harboring mirror aneurysms. Larger aneurysm size and presence of an irregular aneurysm wall appear to be the morphological factors that predispose for mirror aneurysms rupture.

Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association

BACKGROUND AND PURPOSE

Population-wide reductions in cardiovascular disease incidence and mortality have not been shared equally by African Americans. The burden of cardiovascular disease in the African American community remains high and is a primary cause of disparities in life expectancy between African Americans and whites. The objectives of the present scientific statement are to describe cardiovascular health in African Americans and to highlight unique considerations for disease prevention and management.

METHOD

The primary sources of information were identified with PubMed/Medline and online sources from the Centers for Disease Control and Prevention.

RESULTS

The higher prevalence of traditional cardiovascular risk factors (eg, hypertension, diabetes mellitus, obesity, and atherosclerotic cardiovascular risk) underlies the relatively earlier age of onset of cardiovascular diseases among African Americans. Hypertension in particular is highly prevalent among African Americans and contributes directly to the notable disparities in stroke, heart failure, and peripheral artery disease among African Americans. Despite the availability of effective pharmacotherapies and indications for some tailored pharmacotherapies for African Americans (eg, heart failure medications), disease management is less effective among African Americans, yielding higher mortality. Explanations for these persistent disparities in cardiovascular disease are multifactorial and span from the individual level to the social environment.

CONCLUSIONS

The strategies needed to promote equity in the cardiovascular health of African Americans require input from a broad set of stakeholders, including clinicians and researchers from across multiple disciplines.

M2 Monocyte Microparticles Are Increased in Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is a severe neurologic condition with no proven treatment. Recent evidence suggests that monocytes, a heterogenous group of cells with M1 and M2 phenotypes, contribute to secondary damage following ICH. Microparticles are vesicles .1-1 µm in size that are released from cells. We hypothesized that M1 and M2 monocyte microparticles (mMP) would be differentially expressed in ICH cases and controls.

METHODS

In a single-center, prospective, observational study, consecutive ICH cases were enrolled within 12 hours of symptom onset. Age (±5 years)-, race-, and sex-matched controls were recruited. M1 and M2 mMP numbers were determined in plasma samples using flow cytometry and protein biomarkers using standardized assays. The Mann-Whitney U test compared M1 and M2 mMP counts between cases and controls. Standardized regression coefficients compared M1 and M2 mMP with C-reactive protein (CRP) and serum amyloid A (SAA).

RESULTS

Nineteen ICH case-control pairs were enrolled. The median number of M1 mMP was not significantly different between ICH cases (8.63 × 10⁷/milliliter (mL)) compared with controls (8.64 × 10⁷/mL), (P = .525). The median number of M2 mMP was significantly higher in ICH cases (1.61 × 10⁶/mL) compared with controls (4.46 × 10⁵/mL) (P = .027). There were no significant associations for M1 or M2 mMP with CRP or SAA.

CONCLUSION

Higher numbers of M2 mMP in ICH cases compared with controls is hypothesis generating. It may represent differences in the chronic inflammatory status in patients susceptible to ICH, such as cellular activation or apoptosis. Further research is needed, including serial plasma samples, to elucidate the pathophysiology of monocytes and mMP following ICH.