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Morris NA, Simard JM, Chaturvedi S. Surgical Management for Primary Intracerebral Hemorrhage. Neurology 2024; 103:e209714. [PMID: 39074339 DOI: 10.1212/wnl.0000000000209714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Abstract
The incidence of primary intracerebral hemorrhage (ICH) is increasing, particularly in younger patients, in part, because of increased prescription of anticoagulants. The ICH incidence rate from 2016 to 2018 in the United States was nearly 79 per 100,000 person-years and as high as 367 per 100,000 person-years among those 75 years or older. Worldwide, ICH comprises 28% of all new strokes, but a higher disease burden than ischemic stroke because of its higher morbidity and mortality. While mortality seems to be decreasing, functional outcomes are not improving. After negative trials of open surgical evacuation, recent trials of medical management strategies including intensive blood pressure control and prothrombotic agents intended to reduce hematoma expansion failed to demonstrate efficacy. Concomitantly, continued interest in minimally invasive surgical approaches arose from appreciation of secondary iatrogenic injury incurred to subcortical white matter tracts from open surgical techniques. A positive trial of minimally invasive surgery for lobar hemorrhage has recently been reported, bringing new optimism and demanding a reconsideration of surgical management of ICH. In this narrative review, we summarize the landmark studies, review recent literature, and consider the outstanding questions surrounding surgical management of ICH.
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Affiliation(s)
- Nicholas A Morris
- From the Departments of Neurology & Program in Trauma (N.A.M.), Neurosurgery (J.M.S.), and Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - J Marc Simard
- From the Departments of Neurology & Program in Trauma (N.A.M.), Neurosurgery (J.M.S.), and Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Seemant Chaturvedi
- From the Departments of Neurology & Program in Trauma (N.A.M.), Neurosurgery (J.M.S.), and Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
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2
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Kleinig TJ, McMullan P, Cloud GC, Bladin PC, Ranta A. Hyper-Acute Stroke Systems of Care and Workflow. Curr Neurol Neurosci Rep 2024:10.1007/s11910-024-01367-6. [PMID: 39150649 DOI: 10.1007/s11910-024-01367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2024] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW Recent stroke treatment advances have necessitated agile, broad-scale healthcare system redesign, to achieve optimal patient outcomes and access equity. Optimised hyperacute stroke care requires integrated pre-hospital, emergency department, stroke specialist, radiology, neurosurgical and endovascular neurointervention services, guided by a population-wide needs analysis. In this review, we survey system integration efforts, providing case studies, and identify common elements of successful initiatives. RECENT FINDINGS Different regions and nations have evolved varied acute stroke systems depending on geography, population density and workforce. However, common facilitators to these solutions have included stroke unit care as a foundation, government-clinician synergy, pre-hospital pathway coordination, service centralisation, and stroke data guiding system improvement. Further technological advantages will minimize the geographical distance disadvantages and facilitate virtual expertise redistribution to remote areas. Continued treatment advances necessitate an integrated, adaptable, population-wide trans-disciplinary approach. A well-designed clinician-led and government-supported system can facilitate hyperacute care and scaffold future system enhancements.
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Affiliation(s)
- Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia, 5000, Australia.
| | - Patrick McMullan
- Department of Neurology, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia, 5000, Australia
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, VIC, Australia
| | | | - Anna Ranta
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
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Wang L, Li X, Deng Z, Cai Q, Lei P, Xu H, Zhu S, Zhou T, Luo R, Zhang C, Yin Y, Zhang S, Wu N, Feng H, Hu R. Neuroendoscopic Parafascicular Evacuation of Spontaneous Intracerebral Hemorrhage (NESICH Technique): A Multicenter Technical Experience with Preliminary Findings. Neurol Ther 2024; 13:1259-1271. [PMID: 38914793 PMCID: PMC11263518 DOI: 10.1007/s40120-024-00642-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 06/12/2024] [Indexed: 06/26/2024] Open
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) is a severe manifestation of stroke, demonstrating notably elevated global mortality and morbidity. Thus far, effective therapeutic strategies for ICH have proven elusive. Currently, minimally invasive techniques are widely employed for ICH management, particularly using endoscopic hematoma evacuation in cases of deep ICH. Exploration of strategies to achieve meticulous surgery and diminish iatrogenic harm, especially to the corticospinal tract, with the objective of enhancing the neurological prognosis of patients, needs further efforts. METHODS We comprehensively collected detailed demographic, clinical, radiographic, surgical, and postoperative treatment and recovery data for patients who underwent endoscopic hematoma removal. This thorough inclusion of data intends to offer a comprehensive overview of our technical experience in this study. RESULTS One hundred fifty-four eligible patients with deep supratentorial intracerebral hemorrhage who underwent endoscopic hematoma removal were included in this study. The mean hematoma volume was 42 ml, with 74 instances of left-sided hematoma and 80 cases of right-sided hematoma. The median Glasgow Coma Scale (GCS) score at admission was 10 (range from 4 to 15), and the median time from symptom onset to surgery was 18 (range 2 to 96) h. The mean hematoma clearance rate was 89%. The rebleeding and mortality rates within 1 month after surgery were 3.2% and 7.8%, respectively. At the 6-month mark, the proportion of patients with modified Rankin Scale (mRS) scores of 0-3 was 58.4%. CONCLUSION Both the reduction of surgery-related injury and the protection of the residual corticospinal tract through endoscopic hematoma removal may potentially enhance neurological functional outcomes in patients with deep ICH, warranting validation in a forthcoming multicenter clinical study.
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Affiliation(s)
- Long Wang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Xiaodong Li
- Department of Neurosurgery, Siping Central People's Hospital, Siping, Jilin Province, China
| | - Zhongyong Deng
- Department of Neurosurgery, Wuzhou Gongren Hospital, Wuzhou, Guangxi Province, China
| | - Qiang Cai
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Pan Lei
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Hui Xu
- Department of Neurosurgery, Hejiang County People's Hospital, Luzhou, Sichuan Province, China
| | - Sheng Zhu
- Department of Neurosurgery, Dazhu County People's Hospital, Dazhou, Sichuan Province, China
| | - Tengyuan Zhou
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Ran Luo
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Chao Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Yi Yin
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Shuixian Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Na Wu
- Department of Epidemiology, College of Preventive Medicine, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Rong Hu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
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Yakhkind A, Yu W, Li Q, Goldstein JN, Mayer SA. Code-ICH: A New Paradigm for Emergency Intervention. Curr Neurol Neurosci Rep 2024:10.1007/s11910-024-01364-9. [PMID: 39088163 DOI: 10.1007/s11910-024-01364-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE OF REVIEW Intracerebral hemorrhage (ICH) is the most devastating type of stroke, causing widespread disability and mortality. Unfortunately, the acute care of ICH has lagged behind that of ischemic stroke. There is an increasing body of evidence supporting the importance of early interventions including aggressive control of blood pressure and reversal of anticoagulation in the initial minutes to hours of presentation. This review highlights scientific evidence behind a new paradigm to care for these patients called Code-ICH. RECENT FINDINGS While numerous trials aimed at decreasing hematoma expansion through single interventions had failed to show statistically significant effects on primary outcomes, time-sensitive, multifaceted, bundled care approaches have recently shown substantial promise in improving functional outcomes in patients with ICH. The concept of Code-ICH can serve as a structural platform for the practice of acute care neurology to continuously measure its performance, reflect on best practices, advance care, and address disparities.
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Affiliation(s)
- Aleksandra Yakhkind
- Department of Neurology and Neurosurgery, Tufts University School of Medicine, Boston, MA, USA.
| | - Wenzheng Yu
- Department of Neurology, Tufts University School of Medicine, Hefei, China
| | - Qi Li
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY, USA
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Wang D, Zhang J, Dong H, Huang C, Zhang Q, Ma Y, Zhao H, Li S, Deng J, Dong Q, Xiao J, Zhou J, Huang X. Enhancing Outcome Prediction in Intracerebral Hemorrhage Through Deep Learning: A Retrospective Multicenter Study. Acad Radiol 2024:S1076-6332(24)00460-4. [PMID: 39095262 DOI: 10.1016/j.acra.2024.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 07/02/2024] [Accepted: 07/15/2024] [Indexed: 08/04/2024]
Abstract
RATIONALE AND OBJECTIVES This study aimed to employ deep learning techniques to analyze and validate an automatic prognostic biomarker for predicting outcomes following intracerebral hemorrhage (ICH). MATERIALS AND METHODS This study included patients with ICH whose onset-to-imaging time (OIT) was less than 6 h. Patients were randomly divided into training and test sets at a 7:3 ratio. Using the Resnet50 deep learning method, we extracted features from the hematoma and perihematomal edema (PHE) areas and constructed a 90-day prognosis prediction model using logistic regression. To evaluate predictive efficacy and clinical significance, we employed logistic regression to train three models: Clinical, Deep Score, and the combined Clinical-Deep Learning (Merge). RESULTS Our study comprised 1098 patients (652 male, 446 female), with a mean Glasgow Coma Scale (GCS) score of 10. Univariate and multivariate analyses identified age, intraventricular hemorrhage (IVH), hematoma and PHE volume, and admission GCS score as independent prognostic factors. Additionally, 15 deep learning features were retained through LASSO regression. In the training set, the AUC values for the three models were as follows: Clinical model (0.88), Deep Score (0.91), and Merge model (0.94). In the test set, the Merge model exhibited a significantly higher AUC value than the other models. Calibration curves revealed satisfactory calibration of the Merge model nomogram in both training and test sets. CONCLUSION Our Merge model nomogram is an objective and effective prognostic tool, offering personalized risk assessments for 90-day functional outcomes in patients with ICH.
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Affiliation(s)
- Dan Wang
- Department of Radiology, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai 519100, China
| | - Jing Zhang
- Department of Radiology, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai 519100, China
| | - Hao Dong
- Department of Research Collaboration, R&D center, Beiiing Deepwise & League of PHD Technology Co., Ltd, Beijing 10080, China; Data Center, Yixing People's Hospital, Yixing 214200, China
| | - Chencui Huang
- Department of Research Collaboration, R&D center, Beiiing Deepwise & League of PHD Technology Co., Ltd, Beijing 10080, China
| | - Qiaoying Zhang
- Department of Radiology, Xi'an Central Hospital, Xi An 710000, China
| | - Yaqiong Ma
- Department of Radiology, Gansu Provincial Hospital, Lanzhou 730030, China
| | - Hui Zhao
- Department of Radiology, Bao Ji High-Tech Hospital, BaoJi 721000, China
| | - Shenglin Li
- Second Clinical School, Lanzhou University, Lanzhou 730030, China
| | - Juan Deng
- Second Clinical School, Lanzhou University, Lanzhou 730030, China
| | - Qiang Dong
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Jinhong Xiao
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai 519100, China
| | - Junlin Zhou
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Xiaoyu Huang
- Department of Radiology, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai 519100, China.
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Seiffge DJ. Good Treatment of Hyperacute Intracerebral Hemorrhage Is as Easy as ABC. Neurology 2024; 103:e209614. [PMID: 38875509 DOI: 10.1212/wnl.0000000000209614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Affiliation(s)
- David J Seiffge
- From the Department of Neurology, Inselspital University Hopsital and University of Bern, Switzerland
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Tenhoeve SA, Findlay MC, Cole KL, Gautam D, Nelson JR, Brown J, Orton CJ, Bounajem MT, Brandel MG, Couldwell WT, Rennert RC. The clinical potential of radiomics to predict hematoma expansion in spontaneous intracerebral hemorrhage: a narrative review. Front Neurol 2024; 15:1427555. [PMID: 39099779 PMCID: PMC11297354 DOI: 10.3389/fneur.2024.1427555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 07/10/2024] [Indexed: 08/06/2024] Open
Abstract
Spontaneous intracerebral hemorrhage (sICH) is associated with significant morbidity and mortality, with subsequent hematoma expansion (HE) linked to worse neurologic outcomes. Accurate, real-time predictions of the risk of HE could enable tailoring management-including blood pressure control or surgery-based on individual patient risk. Although multiple radiographic markers of HE have been proposed based on standard imaging, their clinical utility remains limited by a reliance on subjective interpretation of often ambiguous findings and a poor overall predictive power. Radiomics refers to the quantitative analysis of medical images that can be combined with machine-learning algorithms to identify predictive features for a chosen clinical outcome with a granularity beyond human limitations. Emerging data have supported the potential utility of radiomics in the prediction of HE after sICH. In this review, we discuss the current clinical management of sICH, the impact of HE and standard imaging predictors, and finally, the current data and potential future role of radiomics in HE prediction and management of patients with sICH.
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Affiliation(s)
- Samuel A. Tenhoeve
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Matthew C. Findlay
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Kyril L. Cole
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Diwas Gautam
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Jayson R. Nelson
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Julian Brown
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Cody J. Orton
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Michael T. Bounajem
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Michael G. Brandel
- Department of Neurosurgery, University of California San Diego, San Diego, CA, United States
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Robert C. Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
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Henningsen M, Herrmann ML, Meier S, Bergmann U, Busch HJ, Taschner CA, Brich J. Parallel activation of helicopter and ground transportation after dispatcher identification of suspected anterior large vessel occlusion stroke in rural areas: a proof-of-concept case with modeling from the LESTOR trial. Scand J Trauma Resusc Emerg Med 2024; 32:62. [PMID: 38971748 PMCID: PMC11227698 DOI: 10.1186/s13049-024-01233-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/30/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND When stroke patients with suspected anterior large vessel occlusion (aLVO) happen to live in rural areas, two main options exist for prehospital transport: (i) the drip-and-ship (DnS) strategy, which ensures rapid access to intravenous thrombolysis (IVT) at the nearest primary stroke center but requires time-consuming interhospital transfer for endovascular thrombectomy (EVT) because the latter is only available at comprehensive stroke centers (CSC); and (ii) the mothership (MS) strategy, which entails direct transport to a CSC and allows for faster access to EVT but carries the risk of IVT being delayed or even the time window being missed completely. The use of a helicopter might shorten the transport time to the CSC in rural areas. However, if the aLVO stroke is only recognized by the emergency service on site, the helicopter must be requested in addition, which extends the prehospital time and partially negates the time advantage. We hypothesized that parallel activation of ground and helicopter transportation in case of aLVO suspicion by the dispatcher (aLVO-guided dispatch strategy) could shorten the prehospital time in rural areas and enable faster treatment with IVT and EVT. METHODS As a proof-of-concept, we report a case from the LESTOR trial where the dispatcher suspected an aLVO stroke during the emergency call and dispatched EMS and HEMS in parallel. Based on this case, we compare the provided aLVO-guided dispatch strategy to the DnS and MS strategies regarding the times to IVT and EVT using a highly realistic modeling approach. RESULTS With the aLVO-guided dispatch strategy, the patient received IVT and EVT faster than with the DnS or MS strategies. IVT was administered 6 min faster than in the DnS strategy and 22 min faster than in the MS strategy, and EVT was started 47 min earlier than in the DnS strategy and 22 min earlier than in the MS strategy. CONCLUSION In rural areas, parallel activation of ground and helicopter emergency services following dispatcher identification of stroke patients with suspected aLVO could provide rapid access to both IVT and EVT, thereby overcoming the limitations of the DnS and MS strategies.
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Affiliation(s)
- Max Henningsen
- Department of Neurology and Neuroscience, Faculty of Medicine and Medical Center, University of Freiburg, Breisacher Str. 64, Freiburg, Germany.
| | - Matthias L Herrmann
- Department of Neurology and Neuroscience, Faculty of Medicine and Medical Center, University of Freiburg, Breisacher Str. 64, Freiburg, Germany
| | - Simone Meier
- Department of Neurology and Neuroscience, Faculty of Medicine and Medical Center, University of Freiburg, Breisacher Str. 64, Freiburg, Germany
| | - Ulrike Bergmann
- Department of Neurology and Neuroscience, Faculty of Medicine and Medical Center, University of Freiburg, Breisacher Str. 64, Freiburg, Germany
| | - Hans-Jörg Busch
- Department of Emergency Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Christian A Taschner
- Department of Neuroradiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Jochen Brich
- Department of Neurology and Neuroscience, Faculty of Medicine and Medical Center, University of Freiburg, Breisacher Str. 64, Freiburg, Germany
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Mutimer CA, Yassi N, Wu TY. Blood Pressure Management in Intracerebral Haemorrhage: when, how much, and for how long? Curr Neurol Neurosci Rep 2024; 24:181-189. [PMID: 38780706 PMCID: PMC11199276 DOI: 10.1007/s11910-024-01341-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE OF REVIEW When compared to ischaemic stroke, there have been limited advances in acute management of intracerebral haemorrhage. Blood pressure control in the acute period is an intervention commonly implemented and recommended in guidelines, as elevated systolic blood pressure is common and associated with haematoma expansion, poor functional outcomes, and mortality. This review addresses the uncertainty around the optimal blood pressure intervention, specifically timing and length of intervention, intensity of blood pressure reduction and agent used. RECENT FINDINGS Recent pivotal trials have shown that acute blood pressure intervention, to a systolic target of 140mmHg, does appear to be beneficial in ICH, particularly when bundled with other therapies such as neurosurgery in selected cases, access to critical care units, blood glucose control, temperature management and reversal of coagulopathy. Systolic blood pressure should be lowered acutely in intracerebral haemorrhage to a target of approximately 140mmHg, and that this intervention is generally safe in the ICH population.
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Affiliation(s)
- Chloe A Mutimer
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, 3050, Australia.
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, 3050, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, 3052, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
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Murakami T, Toyota S, Okuhara S, Takahara M, Touhara K, Hoshikuma Y, Yamada S, Achiha T, Shimizu T, Kobayashi M, Kishima H. A Keyhole Approach for Intracranial Hematoma Removal Using ORBEYE. World Neurosurg 2024:S1878-8750(24)01081-7. [PMID: 38942140 DOI: 10.1016/j.wneu.2024.06.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 06/21/2024] [Accepted: 06/22/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVE By maximizing the advantages of exoscopy, we developed a keyhole approach for intracranial hematoma removal. Herein, we validated the utility of this procedure, and compared it with conventional microscopic hematoma removal and endoscopic hematoma removal in our institution. METHODS We included 12 consecutive patients who underwent this procedure from June 2022 to March 2024. A 4-cm-long skin incision was made, and a keyhole craniotomy (diameter, 2.5 cm) was performed. An assistant manipulated a spatula, and an operator performed hematoma removal and hemostasis using typical microsurgical techniques under an exoscope. The dura mater was reconstructed without sutures using collagen matrix and fibrin glue. The outcomes of this series were compared with those of 12 consecutive endoscopic hematoma removals and 19 consecutive conventional microscopic hematoma removals from October 2018 to March 2024. RESULTS The mean age was 72±10 years, and 7 (58%) patients were men. Hematoma location was the putamen in 5 patients and subcortical in 7 patients. The mean operative time was 122±34 min, the mean hematoma removal rate was 95%±8%, and the mortality rate was 0%. Although the preoperative hematoma volume was similar between the 3 groups, the operative time and total time in the operating room was significantly shorter in the exoscope group than in the microscope group (P<0.0001). CONCLUSIONS This procedure may be simpler and faster than conventional microscopic hematoma removal, and comparable to endoscopic hematoma removal.
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Affiliation(s)
- Tomoaki Murakami
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Shingo Toyota
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan.
| | - Shuki Okuhara
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Motohide Takahara
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Kazuhiro Touhara
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Yuhei Hoshikuma
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Shuhei Yamada
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Takamune Achiha
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Takeshi Shimizu
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Maki Kobayashi
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
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11
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Kiernan MC, Davis SM. Stroke is not optional for neurologists. Pract Neurol 2024:pn-2024-004230. [PMID: 38908862 DOI: 10.1136/pn-2024-004230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/24/2024]
Affiliation(s)
- Matthew C Kiernan
- CEO and Director, Neuroscience Research Australia; University of New South Wales and the South Eastern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Stephen M Davis
- Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Parkville, Victoria, Australia
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12
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Horner D, Bredow Z, Wood A, Clarke G, Burgess P, Hill O, Baldwin C, Darbyshire D. Journal update monthly top five. Emerg Med J 2024; 41:436-437. [PMID: 38901881 DOI: 10.1136/emermed-2024-214256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 05/29/2024] [Indexed: 06/22/2024]
Affiliation(s)
- Daniel Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Zosia Bredow
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Alexander Wood
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Graham Clarke
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Paul Burgess
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Oliver Hill
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Claire Baldwin
- Major Trauma Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
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13
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Fu X, Wang M, Wan Y, Hua Y, Keep RF, Xi G. Formation of Multinucleated Giant Cells after Experimental Intracerebral Hemorrhage: Characteristics and Role of Complement C3. Biomedicines 2024; 12:1251. [PMID: 38927458 PMCID: PMC11201741 DOI: 10.3390/biomedicines12061251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/16/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
Hematoma clearance is critical for mitigating intracerebral hemorrhage (ICH)-induced brain injury. Multinucleated giant cells (MGCs), a type of phagocyte, and the complement system may play a pivotal role in hematoma resolution, but whether the complement system regulates MGC formation after ICH remains unclear. The current study investigated the following: (1) the characteristics of MGC formation after ICH, (2) whether it was impacted by complement C3 deficiency in mice and (3) whether it also influenced hematoma degradation (hemosiderin formation). Young and aged male mice, young female mice and C3-deficient and -sufficient mice received a 30 μL injection of autologous whole blood into the right basal ganglia. Brain histology and immunohistochemistry were used to examine MGC formation on days 3 and 7. Hemosiderin deposition was examined by autofluorescence on day 28. Following ICH, MGCs were predominantly located in the peri-hematoma region exhibiting multiple nuclei and containing red blood cells or their metabolites. Aging was associated with a decrease in MGC formation after ICH, while sex showed no discernible effect. C3 deficiency reduced MGC formation and reduced hemosiderin formation. Peri-hematomal MGCs may play an important role in hematoma resolution. Understanding how aging and complement C3 impact MGCs may provide important insights into how to regulate hematoma resolution.
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Affiliation(s)
- Xiongjie Fu
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Neurosurgery, The 2nd Affiliated Hospital, Zhejiang University, Hangzhou 310027, China
| | - Ming Wang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yingfeng Wan
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Richard F. Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA
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14
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Azadian MM, Macedo N, Yu BJ, Fame RM, Airan RD. Ultrasonic cerebrospinal fluid clearance improves outcomes in hemorrhagic brain injury models. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.02.597001. [PMID: 38895304 PMCID: PMC11185536 DOI: 10.1101/2024.06.02.597001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Impaired clearance of the byproducts of aging and neurologic disease from the brain exacerbates disease progression and severity. We have developed a noninvasive, low intensity transcranial focused ultrasound protocol that facilitates the removal of pathogenic substances from the cerebrospinal fluid (CSF) and the brain interstitium. This protocol clears neurofilament light chain (NfL) - an aging byproduct - in aged mice and clears red blood cells (RBCs) from the central nervous system in two mouse models of hemorrhagic brain injury. Cleared RBCs accumulate in the cervical lymph nodes from both the CSF and interstitial compartments, indicating clearance through meningeal lymphatics. Treating these hemorrhagic brain injury models with this ultrasound protocol reduced neuroinflammatory and neurocytotoxic profiles, improved behavioral outcomes, decreased morbidity and, importantly, increased survival. RBC clearance efficacy was blocked by mechanosensitive channel antagonism and was effective when applied in anesthetized subjects, indicating a mechanosensitive channel mediated mechanism that does not depend on sensory stimulation or a specific neural activity pattern. Notably, this protocol qualifies for an FDA non-significant risk designation given its low intensity, making it readily clinically translatable. Overall, our results demonstrate that this low-intensity transcranial focused ultrasound protocol clears hemorrhage and other harmful substances from the brain via the meningeal lymphatic system, potentially offering a novel therapeutic tool for varied neurologic disorders.
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Affiliation(s)
- Matine M. Azadian
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Nicholas Macedo
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Brenda J. Yu
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Ryann M. Fame
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Raag D. Airan
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
- Department of Materials Science and Engineering, Stanford University School of Medicine, Stanford, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
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15
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Seiffge DJ, Anderson CS. Treatment for intracerebral hemorrhage: Dawn of a new era. Int J Stroke 2024; 19:482-489. [PMID: 38803115 DOI: 10.1177/17474930241250259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Intracerebral hemorrhage (ICH) is a devastating disease, causing high rates of death, disability, and suffering across the world. For decades, its treatment has been shrouded by the lack of reliable evidence, and consequently, the presumption that an effective treatment is unlikely to be found. Neutral results arising from several major randomized controlled trials had established a negative spirit within and outside the stroke community. Frustration among researchers and a sense of nihilism in clinicians has created the general perception that patients presenting with ICH have a poor prognosis irrespective of them receiving any form of active management. All this changed in 2023 with the positive results on the primary outcome in randomized controlled trials showing treatment benefits for a hyperacute care bundle approach (INTERACT3), early minimal invasive hematoma evacuation (ENRICH), and use of factor Xa-inhibitor anticoagulation reversal with andexanet alfa (ANNEXa-I). These advances have now been extended in 2024 by confirmation that intensive blood pressure lowering initiated within the first few hours of the onset of symptoms can substantially improve outcome in ICH (INTERACT4) and that decompressive hemicraniectomy is a viable treatment strategy in patients with large deep ICH (SWITCH). This evidence will spearhead a change in the perception of ICH, to revolutionize the care of these patients to ultimately improve their outcomes. We review these and other recent developments in the hyperacute management of ICH. We summarize the results of randomized controlled trials and discuss related original research papers published in this issue of the International Journal of Stroke. These exciting advances demonstrate how we are now at the dawn of a new, exciting, and brighter era of ICH management.
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Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Institute for Science and Technology for Brain-inspired Intelligence, Fudan University, Shanghai, China
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16
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Beck J, Fung C, Strbian D, Bütikofer L, Z'Graggen WJ, Lang MF, Beyeler S, Gralla J, Ringel F, Schaller K, Plesnila N, Arnold M, Hacke W, Jüni P, Mendelow AD, Stapf C, Al-Shahi Salman R, Bressan J, Lerch S, Hakim A, Martinez-Majander N, Piippo-Karjalainen A, Vajkoczy P, Wolf S, Schubert GA, Höllig A, Veldeman M, Roelz R, Gruber A, Rauch P, Mielke D, Rohde V, Kerz T, Uhl E, Thanasi E, Huttner HB, Kallmünzer B, Jaap Kappelle L, Deinsberger W, Roth C, Lemmens R, Leppert J, Sanmillan JL, Coutinho JM, Hackenberg KAM, Reimann G, Mazighi M, Bassetti CLA, Mattle HP, Raabe A, Fischer U. Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial. Lancet 2024; 403:2395-2404. [PMID: 38761811 DOI: 10.1016/s0140-6736(24)00702-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/16/2024] [Accepted: 04/04/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND It is unknown whether decompressive craniectomy improves clinical outcome for people with spontaneous severe deep intracerebral haemorrhage. The SWITCH trial aimed to assess whether decompressive craniectomy plus best medical treatment in these patients improves outcome at 6 months compared to best medical treatment alone. METHODS In this multicentre, randomised, open-label, assessor-blinded trial conducted in 42 stroke centres in Austria, Belgium, Finland, France, Germany, the Netherlands, Spain, Sweden, and Switzerland, adults (18-75 years) with a severe intracerebral haemorrhage involving the basal ganglia or thalamus were randomly assigned to receive either decompressive craniectomy plus best medical treatment or best medical treatment alone. The primary outcome was a score of 5-6 on the modified Rankin Scale (mRS) at 180 days, analysed in the intention-to-treat population. This trial is registered with ClincalTrials.gov, NCT02258919, and is completed. FINDINGS SWITCH had to be stopped early due to lack of funding. Between Oct 6, 2014, and April 4, 2023, 201 individuals were randomly assigned and 197 gave delayed informed consent (96 decompressive craniectomy plus best medical treatment, 101 best medical treatment). 63 (32%) were women and 134 (68%) men, the median age was 61 years (IQR 51-68), and the median haematoma volume 57 mL (IQR 44-74). 42 (44%) of 95 participants assigned to decompressive craniectomy plus best medical treatment and 55 (58%) assigned to best medical treatment alone had an mRS of 5-6 at 180 days (adjusted risk ratio [aRR] 0·77, 95% CI 0·59 to 1·01, adjusted risk difference [aRD] -13%, 95% CI -26 to 0, p=0·057). In the per-protocol analysis, 36 (47%) of 77 participants in the decompressive craniectomy plus best medical treatment group and 44 (60%) of 73 in the best medical treatment alone group had an mRS of 5-6 (aRR 0·76, 95% CI 0·58 to 1·00, aRD -15%, 95% CI -28 to 0). Severe adverse events occurred in 42 (41%) of 103 participants receiving decompressive craniectomy plus best medical treatment and 41 (44%) of 94 receiving best medical treatment. INTERPRETATION SWITCH provides weak evidence that decompressive craniectomy plus best medical treatment might be superior to best medical treatment alone in people with severe deep intracerebral haemorrhage. The results do not apply to intracerebral haemorrhage in other locations, and survival is associated with severe disability in both groups. FUNDING Swiss National Science Foundation, Swiss Heart Foundation, Inselspital Stiftung, and Boehringer Ingelheim.
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Affiliation(s)
- Jürgen Beck
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Christian Fung
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lukas Bütikofer
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurology, University of Bern, Bern, Switzerland
| | - Matthias F Lang
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | - Seraina Beyeler
- Department of Neurology, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva, Geneva, Switzerland
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research, LMU University Hospital, Munich, Germany
| | - Marcel Arnold
- Department of Neurosurgery, University of Bern, Bern, Switzerland
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Jüni
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Christian Stapf
- Department of Neurosciences, Université de Montréal, and Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences and Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jenny Bressan
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Stefanie Lerch
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | | | - Anna Piippo-Karjalainen
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gerrit A Schubert
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany; Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Philip Rauch
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Dorothee Mielke
- Department of Neurosurgery, University Hospital Goettingen, Goettingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Hospital Goettingen, Goettingen, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Enea Thanasi
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Hagen B Huttner
- Department of Neurology, Justus-Liebig-Universität Gießen, Gießen, Germany; Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - L Jaap Kappelle
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Christian Roth
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Robin Lemmens
- University Hospitals Leuven, Department of Neurology, Leuven, Belgium
| | - Jan Leppert
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jose L Sanmillan
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Katharina A M Hackenberg
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gernot Reimann
- Klinikum Dortmund, Klinikum der Universität Witten-Herdecke, Dortmund, Germany
| | - Mikael Mazighi
- Department of Neurology, Lariboisière University Hospital and Department of Interventional Neuroradiology, Rothschild Foundation Hospital, FHU Neurovasc, INSERM 1144, Paris Cité Université, Paris, France; Department of Neurointensive Care, Rothschild Foundation Hospital, Paris France
| | | | | | - Andreas Raabe
- Department of Neurosurgery, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Neurology, Basel University Hospital, University of Basel, Basel, Switzerland.
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17
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Dangayach NS, Morozov M, Cossentino I, Liang J, Chada D, Bageac D, Salgado L, Malekebu W, Kellner C, Bederson J. A Narrative Review of Interhospital Transfers for Intracerebral Hemorrhage. World Neurosurg 2024; 190:1-9. [PMID: 38830508 DOI: 10.1016/j.wneu.2024.05.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024]
Abstract
Of the 750,000 strokes in the United States every year, 15% patients suffer from hemorrhagic stroke. Intracerebral hemorrhage (ICH) is a subtype of hemorrhagic stroke. Despite advances in acute management, patients with hemorrhagic stroke continue to suffer from high mortality and survivors suffer from multidomain impairments in the physical, cognitive, and mental health domains which could last for months to years from their index stroke. Long-term prognosis after ICH is critically dependent on the quality and efficacy of care a patient receives during the acute phase of care. With ongoing care consolidation in stroke systems of care, the number of ICH patients who need to undergo interhospital transfers (IHTs) is increasing. However, the associations between IHT and ICH outcomes have not been well described in literature. In this review, we describe the epidemiology of IHT for ICH, the relationship between IHT and ICH patient outcomes, and proposed improvements to the IHT process to ensure better long-term patient outcomes. Our review indicates that evidence regarding the safety and benefit of IHT for ICH patients is conflicting, with some studies reporting poorer outcomes for transferred patients compared to direct admissions via emergency rooms and other studies showing no effect on outcomes. The American Heart Association guidelines for ICH provide recommendations for timely blood pressure control and anticoagulation reversal to improve patient outcomes. The American Heart Association stroke systems of care guidelines provide recommendations for transfer agreements and but do not provide details on how patients should be managed while undergoing IHT. Large, prospective, and multicenter studies comparing outcomes of IHT patients to direct admissions are necessary to provide more definitive guidance to optimize IHT protocols and aid clinical decision-making.
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Affiliation(s)
- Neha S Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Masha Morozov
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Cossentino
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Deeksha Chada
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Devin Bageac
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura Salgado
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Wheatonia Malekebu
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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18
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Murthy SB. Emergent Management of Intracerebral Hemorrhage. Continuum (Minneap Minn) 2024; 30:641-661. [PMID: 38830066 DOI: 10.1212/con.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH. LATEST DEVELOPMENTS Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques. ESSENTIAL POINTS This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.
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19
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Penckofer M, Kazmi KS, Thon J, Tonetti DA, Ries C, Rajagopalan S. Neuro-imaging in intracerebral hemorrhage: updates and knowledge gaps. Front Neurosci 2024; 18:1408288. [PMID: 38784090 PMCID: PMC11111865 DOI: 10.3389/fnins.2024.1408288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Intracerebral hemorrhage (ICH) is characterized by hematoma development within the brain's parenchyma, contributing significantly to the burden of stroke. While non-contrast head computed tomography (CT) remains the gold standard for initial diagnosis, this review underscores the pivotal role of magnetic resonance imaging (MRI) in ICH management. Beyond diagnosis, MRI offers invaluable insights into ICH etiology, prognosis, and treatment. Utilizing echo-planar gradient-echo or susceptibility-weighted sequences, MRI demonstrates exceptional sensitivity and specificity in identifying ICH, aiding in differentiation of primary and secondary causes. Moreover, MRI facilitates assessment of hemorrhage age, recognition of secondary lesions, and evaluation of perihematomal edema progression, thus guiding tailored therapeutic strategies. This comprehensive review discusses the multifaceted utility of MRI in ICH management, highlighting its indispensable role in enhancing diagnostic accuracy as well as aiding in prognostication. As MRI continues to evolve as a cornerstone of ICH assessment, future research should explore its nuanced applications in personalized care paradigms.
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Affiliation(s)
- Mary Penckofer
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Khuram S. Kazmi
- Cooper Medical School of Rowan University, Camden, NJ, United States
- Department of Neuroradiology, Cooper University Health Care, Camden, NJ, United States
| | - Jesse Thon
- Cooper Medical School of Rowan University, Camden, NJ, United States
- Department of Neurology, Cooper University Health Care, Camden, NJ, United States
| | - Daniel A. Tonetti
- Cooper Medical School of Rowan University, Camden, NJ, United States
- Department of Neurosurgery, Cooper University Health Care, Camden, NJ, United States
| | - Casey Ries
- Department of Radiology, Cooper University Health Care, Camden, NJ, United States
| | - Swarna Rajagopalan
- Cooper Medical School of Rowan University, Camden, NJ, United States
- Department of Neurology, Cooper University Health Care, Camden, NJ, United States
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20
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Mendelow AD. New Hope for Adults with Lobar Intracerebral Hemorrhage. N Engl J Med 2024; 390:1328-1329. [PMID: 38598801 DOI: 10.1056/nejme2401643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- A David Mendelow
- From the Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
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