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Ou Yong BM, Awuah WA, Shah MH, Sanker V, Huk JKS, Venkata SY, Patel DH, Tan JK, Khan NA, Kulasekaran A, Sarkar M, Abdul-Rahman T, Atallah O. Intracerebral haemorrhage in multiple sclerosis: assessing the impact of disease-modifying medications. Eur J Med Res 2024; 29:344. [PMID: 38918831 PMCID: PMC11197372 DOI: 10.1186/s40001-024-01945-x] [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] [Received: 02/13/2024] [Accepted: 06/19/2024] [Indexed: 06/27/2024] Open
Abstract
Multiple Sclerosis (MS) is a complex autoimmune disorder that significantly impacts the central nervous system, leading to a range of complications. While intracranial haemorrhage (ICH) is a rare but highly morbid complication, more common CNS complications include progressive multifocal leukoencephalopathy (PML) and other CNS infections. This severe form of stroke, known for its high morbidity and mortality rates, presents a critical challenge in the management of MS. The use of disease-modifying drugs (DMDs) in treating MS introduces a nuanced aspect to patient care, with certain medications like Dimethyl Fumarate and Fingolimod showing potential in reducing the risk of ICH, while others such as Alemtuzumab and Mitoxantrone are associated with an increased risk. Understanding the intricate relationship between these DMDs, the pathophysiological mechanisms of ICH, and the individualised aspects of each patient's condition is paramount. Factors such as genetic predispositions, existing comorbidities, and lifestyle choices play a crucial role in tailoring treatment approaches, emphasising the importance of a personalised, vigilant therapeutic strategy. The necessity for ongoing and detailed research cannot be overstated. It is crucial to explore the long-term effects of DMDs on ICH occurrence and prognosis in MS patients, aiming to refine clinical practices and promote patient-centric, informed therapeutic decisions. This approach ensures that the management of MS is not only comprehensive but also adaptable to the evolving understanding of the disease and its treatments.
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Affiliation(s)
| | | | | | - Vivek Sanker
- Department of Neurosurgery, Trivandrum Medical College, Thiruvananthapuram, India
| | | | | | - Diti H Patel
- Nova Southeastern University Dr. Kiran C Patel College of Allopathic Medicine, Davie, FL, USA
| | | | - Noor Ayman Khan
- DOW Medical College, DOW University of Health Sciences (DUHS), Baba-E-Urdu Road, Karachi, Pakistan
| | | | - Manali Sarkar
- MGM Medical College Navi, Mumbai, Maharashtra, India
| | | | - Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
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2
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Choi BR, Johnson KR, Maric D, McGavern DB. Monocyte-derived IL-6 programs microglia to rebuild damaged brain vasculature. Nat Immunol 2023; 24:1110-1123. [PMID: 37248420 PMCID: PMC11531796 DOI: 10.1038/s41590-023-01521-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/25/2023] [Indexed: 05/31/2023]
Abstract
Cerebrovascular injury (CVI) is a common pathology caused by infections, injury, stroke, neurodegeneration and autoimmune disease. Rapid resolution of a CVI requires a coordinated innate immune response. In the present study, we sought mechanistic insights into how central nervous system-infiltrating monocytes program resident microglia to mediate angiogenesis and cerebrovascular repair after an intracerebral hemorrhage. In the penumbrae of human stroke brain lesions, we identified a subpopulation of microglia that express vascular endothelial growth factor A. These cells, termed 'repair-associated microglia' (RAMs), were also observed in a rodent model of CVI and coexpressed interleukin (IL)-6Ra. Cerebrovascular repair did not occur in IL-6 knockouts or in mice lacking microglial IL-6Ra expression and single-cell transcriptomic analyses revealed faulty RAM programming in the absence of IL-6 signaling. Infiltrating CCR2+ monocytes were the primary source of IL-6 after a CVI and were required to endow microglia with proliferative and proangiogenic properties. Faulty RAM programming in the absence of IL-6 or inflammatory monocytes resulted in poor cerebrovascular repair, neuronal destruction and sustained neurological deficits that were all restored via exogenous IL-6 administration. These data provide a molecular and cellular basis for how monocytes instruct microglia to repair damaged brain vasculature and promote functional recovery after injury.
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Affiliation(s)
- Bo-Ran Choi
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Kory R Johnson
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Dragan Maric
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Dorian B McGavern
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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3
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Shahbandi A, Shobeiri P, Azadnajafabad S, Saeedi Moghaddam S, Sharifnejad Tehrani Y, Ebrahimi N, Rezaei N, Rashidi MM, Ghamari SH, Abbasi-Kangevari M, Koolaji S, Haghshenas R, Rezaei N, Larijani B, Farzadfar F. Burden of stroke in North Africa and Middle East, 1990 to 2019: a systematic analysis for the global burden of disease study 2019. BMC Neurol 2022; 22:279. [PMID: 35896999 PMCID: PMC9327376 DOI: 10.1186/s12883-022-02793-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 07/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While several studies investigated the epidemiology and burden of stroke in the North Africa and Middle East region, no study has comprehensively evaluated the age-standardized attributable burden to all stroke subtypes and their risk factors yet. OBJECTIVE The aim of the present study is to explore the regional distribution of the burden of stroke, including ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage, and the attributable burden to its risk factors in 2019 among the 21 countries of North Africa and Middle East super-region. METHODS The data of the Global Burden of Disease Study (GBD) 2019 on stroke incidence, prevalence, death, disability-adjusted life years (DALYs), years of life lost (YLLs), years lived with disability (YLDs) rates, and attributed deaths, DALYs, YLLs, and YLDs to stroke risk factors were used for the present study. RESULTS The age-standardized deaths, DALYs, and YLLs rates were diminished statistically significant by 27.8, 32.0, and 35.1% from 1990 to 2019, respectively. Attributed deaths, DALYs, and YLLs to stroke risk factors, including high systolic blood pressure, high body-mass index, and high fasting plasma glucose shrank statistically significant by 24.9, 25.8, and 28.8%, respectively. CONCLUSION While the age-standardized stroke burden has reduced during these 30 years, it is still a concerning issue due to its increased burden in all-age numbers. Well-developed primary prevention, timely diagnosis and management of the stroke and its risk factors might be appreciated for further decreasing the burden of stroke and its risk factors and reaching Sustainable Development Goal 3.4 target for reducing premature mortality from non-communicable diseases.
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Affiliation(s)
- Ataollah Shahbandi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Parnian Shobeiri
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Sina Azadnajafabad
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Sahar Saeedi Moghaddam
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Yeganeh Sharifnejad Tehrani
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Narges Ebrahimi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Nazila Rezaei
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Mohammad-Mahdi Rashidi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Seyyed-Hadi Ghamari
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Mohsen Abbasi-Kangevari
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Sogol Koolaji
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Rosa Haghshenas
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran
| | - Negar Rezaei
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Jalal Al-e-Ahmad Highway, Tehran, 1411713119, Iran. .,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Zhang H, Wu ZS, Liu JQ, Huang H. Serum calcium channel subunit α2δ-1 concentrations and outcomes in patients with acute spontaneous intracerebral hemorrhage. Clin Chim Acta 2022; 527:17-22. [PMID: 35007528 DOI: 10.1016/j.cca.2022.01.002] [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: 12/09/2021] [Revised: 12/24/2021] [Accepted: 01/03/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Voltage-gated calcium channel subunit α2δ-1 plays an important role in acute brain injury. We attempted to investigate whether serum α2δ-1 subunit concentrations are correlated with severity and prognosis following intracerebral hemorrhage (ICH). METHODS Serum α2δ-1 subunit concentrations were quantified in 103 ICH patients and 103 healthy controls. National Institutes of Health Stroke Scale (NIHSS) score and hematoma volume were estimated for assessing illness severity. Modified Rankin scale score of 3-6 at 90 days after stroke onset was defined as a worse outcome. RESULTS Serum α2δ-1 subunit concentrations were markedly higher in patients than in controls (median, 875.1 vs. 209.3 pg/ml). Serum α2δ-1 subunit concentrations of patients were tightly correlated with NIHSS score (r = 0.589) and hematoma volume (r = 0.594). Serum α2δ-1 subunit concentrations ≥ 875.1 pg/ml independently discriminated development of 90-day poor outcome with odds ratio of 5.228 (95% CI, 2.201-12.418) and area under the receiver operating characteristic curve of 0.794 (95% CI, 0.703-0.867). Serum α2δ-1 subunit concentrations > 973.4 pg/ml predicted 90-day poor outcome with 64.0% sensitivity and 90.6% specificity. The prognostic predictive ability of serum α2δ-1 concentrations was equivalent to those of NIHSS score and hematoma volume (both P > 0.05), and serum α2δ-1 concentrations also significantly improved the prognostic predictive capabilities of NIHSS score and hematoma volume (both P < 0.05). CONCLUSIONS Serum α2δ-1 subunit concentrations are intimately correlated with illness severity and are independently associated with poor 90-day outcome, substantializing serum α2δ-1 subunit as a potential prognostic biomarker for ICH.
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Affiliation(s)
- Hao Zhang
- Department of Emergency Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 261 Huansha Road, Hangzhou 310006, China
| | - Ze-Sheng Wu
- Department of Emergency Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 261 Huansha Road, Hangzhou 310006, China
| | - Jing-Quan Liu
- Department of Urology, Hangzhou Ninth People's Hospital, 98 Yilong Road, Hangzhou 311225, China
| | - Huan Huang
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 261 Huansha Road, Hangzhou 310006, China.
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Bai R, Lang Y, Shao J, Deng Y, Refuhati R, Cui L. The Role of NLRP3 Inflammasome in Cerebrovascular Diseases Pathology and Possible Therapeutic Targets. ASN Neuro 2021; 13:17590914211018100. [PMID: 34053242 PMCID: PMC8168029 DOI: 10.1177/17590914211018100] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Cerebrovascular diseases are pathological conditions involving impaired blood flow in the brain, primarily including ischaemic stroke, intracranial haemorrhage, and subarachnoid haemorrhage. The nucleotide-binding and oligomerisation (NOD) domain-like receptor (NLR) family pyrin domain (PYD)-containing 3 (NLRP3) inflammasome is a protein complex and a vital component of the immune system. Emerging evidence has indicated that the NLRP3 inflammasome plays an important role in cerebrovascular diseases. The function of the NLRP3 inflammasome in the pathogenesis of cerebrovascular diseases remains an interesting field of research. In this review, we first summarised the pathological mechanism of cerebrovascular diseases and the pathological mechanism of the NLRP3 inflammasome in aggravating atherosclerosis and cerebrovascular diseases. Second, we outlined signalling pathways through which the NLRP3 inflammasome participates in aggravating or mitigating cerebrovascular diseases. Reactive oxygen species (ROS)/nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), ROS/thioredoxin-interacting protein (TXNIP) and purinergic receptor-7 (P2X7R) signalling pathways can activate the NLRP3 inflammasome; activation of the NLRP3 inflammasome can aggravate cerebrovascular diseases by mediating apoptosis and pyroptosis. Autophagy/mitochondrial autophagy, nuclear factor E2-related factor-2 (Nrf2), interferon (IFN)-β, sirtuin (SIRT), and phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT) reportedly alleviate cerebrovascular diseases by inhibiting NLRP3 inflammasome activation. Finally, we explored specific inhibitors of the NLRP3 inflammasome based on the two-step activation of the NLRP3 inflammasome, which can be developed as new drugs to treat cerebrovascular diseases.
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Affiliation(s)
- Rongrong Bai
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Yue Lang
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Jie Shao
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Yu Deng
- Department of Hepatopancreatobiliary Surgery, The First Hospital of Jilin University, Changchun, China
| | - Reyisha Refuhati
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Li Cui
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Changchun, China
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Rajdev K, Mehan S. Neuroprotective Methodologies of Co-Enzyme Q10 Mediated Brain Hemorrhagic Treatment: Clinical and Pre-Clinical Findings. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2020; 18:446-465. [PMID: 31187715 DOI: 10.2174/1871527318666190610101144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 04/22/2019] [Accepted: 05/07/2019] [Indexed: 12/13/2022]
Abstract
Cerebral brain hemorrhage is associated with the highest mortality and morbidity despite only constituting approximately 10-15% of all strokes classified into intracerebral and intraventricular hemorrhage where most of the patients suffer from impairment in memory, weakness or paralysis in arms or legs, headache, fatigue, gait abnormality and cognitive dysfunctions. Understanding molecular pathology and finding the worsening cause of hemorrhage will lead to explore the therapeutic interventions that could prevent and cure the disease. Mitochondrial ETC-complexes dysfunction has been found to increase neuroinflammatory cytokines, oxidative free radicals, excitotoxicity, neurotransmitter and energy imbalance that are the key neuropathological hallmarks of cerebral hemorrhage. Coenzyme Q10 (CoQ10), as a part of the mitochondrial respiratory chain can effectively restore these neuronal dysfunctions by preventing the opening of mitochondrial membrane transition pore, thereby counteracting cell death events as well as exerts an anti-inflammatory effect by influencing the expression of NF-kB1 dependent genes thus preventing the neuroinflammation and energy restoration. Due to behavior and biochemical heterogeneity in post cerebral brain hemorrhagic pattern different preclinical autologous blood injection models are required to precisely investigate the forthcoming therapeutic strategies. Despite emerging pre-clinical research and resultant large clinical trials for promising symptomatic treatments, there are very less pharmacological interventions demonstrated to improve post operative condition of patients where intensive care is required. Therefore, in current review, we explore the disease pattern, clinical and pre-clinical interventions under investigation and neuroprotective methodologies of CoQ10 precursors to ameliorate post brain hemorrhagic conditions.
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Affiliation(s)
- Kajal Rajdev
- Department of Pharmacology, ISF College of Pharmacy, Moga-142001, Punjab, India
| | - Sidharth Mehan
- Department of Pharmacology, ISF College of Pharmacy, Moga-142001, Punjab, India
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7
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Barks A, Behbahani M, Alqadi MM, Sandozi J, Du X, McGuire LS, Alaraj A, Amin-Hanjani S, Charbel FT, Dashti R. A New Scoring System for Prediction of Underlying Vascular Pathology in Patients with Intracerebral Hemorrhage: The Modified Secondary Intracerebral Hemorrhage Score. World Neurosurg 2020; 142:e126-e132. [PMID: 32593764 DOI: 10.1016/j.wneu.2020.06.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/15/2020] [Accepted: 06/17/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Secondary intracerebral hemorrhage (SICH) score is used to predict risk of intracranial hemorrhage (ICH) associated vascular lesions. However, it has low clinical utility in identifying patients without need for neurovascular imaging. This study aims to develop a modified scoring system to capture patients with low risk of underlying vascular pathology, thereby decreasing need for vascular imaging and its associated morbidity. METHODS A retrospective analysis of 994 patients with atraumatic ICH over 8 years was conducted, excluding known underlying pathology, subarachnoid hemorrhage, or lack of vascular imaging. Using a multivariate logistic regression model, independent predictors of vascular pathology were identified and utilized toward developing a modified Secondary Intracerebral Hemorrhage (mSICH) score. RESULTS Of 575 patients identified, 60 (10.4%) had underlying vascular etiology. Statistically significant predictors of vascular pathology included age; female sex; admission systolic blood pressure <160 mm Hg; locations other than basal ganglia, thalamus, pons, or midbrain; presence of high-risk imaging features; and proximity to large vessel-containing cisterns. The mSICH score correlated with an increasing incidence of vascular pathology [0-1 (0%), 9 (4.3%), 12 (9.7%), 21 (40.4%), 6 (33.3%), 8 (88.9%), and 4 (100%)] and had a significantly higher number of patients receiving scores with 0% incidence of vascular lesions compared with the SICH score [159 (27.6%) versus 12 (2.1%); P < 0.001)]. CONCLUSIONS The mSICH score can more accurately predict risk of underlying vascular pathology of ICH and identify patients with lowest risk of vascular pathology. This may minimize the cost and associated risks of invasive cerebrovascular imaging.
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Affiliation(s)
- Ashley Barks
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mandana Behbahani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Murad M Alqadi
- University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Junaid Sandozi
- University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Xinjian Du
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Laura S McGuire
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
| | - Reza Dashti
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA; Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
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8
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Niu J, Hu R. Role of flunarizine hydrochloride in secondary brain injury following intracerebral hemorrhage in rats. Int J Immunopathol Pharmacol 2017; 30:413-419. [PMID: 29164980 PMCID: PMC5806815 DOI: 10.1177/0394632017742224] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study aimed to explore the role and mechanism(s) of flunarizine hydrochloride in the intracerebral hemorrhage (ICH) rats. The 32 adult male Sprague Dawley (SD) rats were randomly assigned into four groups: control group, sham group, ICH group, and FLU + ICH group. The effects of flunarizine hydrochloride were assessed on the basis of hematoma volume, blood–brain barrier (BBB) integrity, and brain water content in the ICH rat models. The role of flunarizine hydrochloride in cell recovery was assessed by behavioral scores, quantitative real-time polymerase chain reaction (qRT-PCR), and western blot assay. Involvement of PI3K/AKT pathway in exerting the effect of flunarizine hydrochloride was also determined. Results showed that the hematoma volume, BBB integrity, and brain water content were significantly decreased in the FLU + ICH group. Cell apoptosis significantly increased in the ICH model group, while flunarizine hydrochloride decreased this increase. The expressions of glial cell line-derived neurotrophic factor (GDNF), neuroglobin (NGB), and p-AKT were increased after flunarizine hydrochloride treatment in ICH rats. In conclusion, flunarizine hydrochloride has protective effects against ICH by reducing brain injury, cell apoptosis, and the activation of P13K/AKT pathway. These findings provide a theoretical basis for the treatment of flunarizine hydrochloride in ICH.
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Affiliation(s)
- Jianping Niu
- 1 Department of Neurosurgery, Shanxi Academy of Medical Sciences, Shanxi Dayi Hospital, Taiyuan, China
| | - Rui Hu
- 2 Department of Laboratory, Taiyuan Hospital Health Center for Woman and Children, Taiyuan, China
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Liu DZ, Waldau B, Ander BP, Zhan X, Stamova B, Jickling GC, Lyeth BG, Sharp FR. Inhibition of Src family kinases improves cognitive function after intraventricular hemorrhage or intraventricular thrombin. J Cereb Blood Flow Metab 2017; 37:2359-2367. [PMID: 27624844 PMCID: PMC5531336 DOI: 10.1177/0271678x16666291] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Intraventricular hemorrhage causes spatial memory loss, but the mechanism remains unknown. Our recent studies demonstrated that traumatic brain injury activates Src family kinases, which cause spatial memory loss. To test whether the spatial memory loss was due to blood in the ventricles, which activated Src family kinases, we infused autologous whole blood or thrombin into the lateral ventricles of adult rats to model non-traumatic intraventricular hemorrhage. Hippocampal neuron loss was examined 1 day to 5 weeks later. Spatial memory function was assessed 29 to 33 days later using the Morris water maze. Five weeks after the ventricular injections of blood or thrombin, there was death of most hippocampal neurons and significant memory deficits compared with sham operated controls. These data show that intraventricular thrombin is sufficient to kill hippocampal neurons and produce spatial memory loss. In addition, systemic administration of the non-specific Src family kinase inhibitor PP2 or intraventricular injection of siRNA-Fyn, a Src family kinase family member, prevented hippocampal neuronal loss and spatial memory deficits following intraventricular hemorrhage. The data support the conclusions that thrombin mediates the hippocampal neuronal cell death and spatial memory deficits produced by intraventricular blood and that these can be blocked by non-specific inhibition of Src family kinases or by inhibiting Fyn.
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Affiliation(s)
- Da Zhi Liu
- 1 Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, USA
| | - Ben Waldau
- 2 Department of Neurological Surgery, University of California at Davis, Davis, USA
| | - Bradley P Ander
- 1 Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, USA
| | - Xinhua Zhan
- 1 Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, USA
| | - Boryana Stamova
- 1 Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, USA
| | - Glen C Jickling
- 1 Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, USA
| | - Bruce G Lyeth
- 2 Department of Neurological Surgery, University of California at Davis, Davis, USA
| | - Frank R Sharp
- 1 Department of Neurology and the M.I.N.D. Institute, University of California at Davis, Sacramento, USA
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10
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Hypercholesterolaemia and vascular dementia. Clin Sci (Lond) 2017; 131:1561-1578. [PMID: 28667059 DOI: 10.1042/cs20160382] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 03/08/2017] [Accepted: 03/21/2017] [Indexed: 12/30/2022]
Abstract
Vascular dementia (VaD) is the second commonest cause of dementia. Stroke is the leading cause of disability in adults in developed countries, the second major cause of dementia and the third commonest cause of death. Traditional vascular risk factors-diabetes, hypercholesterolaemia, hypertension and smoking-are implicated as risk factors for VaD. The associations between cholesterol and small vessel disease (SVD), stroke, cognitive impairment and subsequent dementia are complex and as yet not fully understood. Similarly, the effects of lipids and lipid-lowering therapy on preventing or treating dementia remain unclear; the few trials that have assessed lipid-lowering therapy for preventing (two trials) or treating (four trials) dementia found no evidence to support the use of lipid-lowering therapy for these indications. It is appropriate to treat those patients with vascular risk factors that meet criteria for lipid-lowering therapy for the primary and secondary prevention of cardiovascular and cerebrovascular events, and in line with current guidelines. Managing the individual patient in a holistic manner according to his or her own vascular risk profile is recommended. Although the paucity of randomized controlled evidence makes for challenging clinical decision making, it provides multiple opportunities for on-going and future research, as discussed here.
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11
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Biffi A, Bailey D, Anderson CD, Ayres AM, Gurol EM, Greenberg SM, Rosand J, Viswanathan A. Risk Factors Associated With Early vs Delayed Dementia After Intracerebral Hemorrhage. JAMA Neurol 2017; 73:969-76. [PMID: 27295605 DOI: 10.1001/jamaneurol.2016.0955] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Patients who have experienced intracerebral hemorrhage (ICH) appear to develop cognitive impairment at high rates, both early after ICH and over the long term. OBJECTIVE To identify and compare risk factors for early and delayed dementia after ICH. DESIGN, SETTING, AND PARTICIPANTS A longitudinal study enrolled patients who had experienced ICH from January 1, 2006, to December 31, 2013. A total of 738 participants 18 years or older, without pre-ICH dementia, who presented to a tertiary care academic institution with primary ICH were included in the analyses of early post-ICH dementia (EPID). After accounting for incident dementia and mortality at 6 months, 435 participants were included in the analyses of delayed post-ICH dementia (DPID). EXPOSURES Intracerebral hemorrhage. MAIN OUTCOMES AND MEASURES Cognitive performance was captured using the modified Telephone Interview for Cognitive Status test. Outcomes included EPID, diagnosed within 6 months after ICH, and DPID, diagnosed beyond 6 months after ICH. RESULTS Among 738 patients who had experienced ICH (mean [SD] age, 74.3 [12.1] years; 384 men [52.0%]), 140 (19.0%) developed dementia within 6 months. A total of 435 patients without dementia at 6 months were followed up longitudinally (median follow-up, 47.4 months; interquartile range, 43.4-52.1 months), with an estimated yearly incidence of dementia of 5.8% (95% CI, 5.1%-7.0%). Larger hematoma size (hazard ratio [HR], 1.47 per 10-mL increase; 95% CI, 1.09-1.97; P < .001 for heterogeneity) and lobar location of ICH (HR, 2.04; 95% CI, 1.06-3.91; P = .02 for heterogeneity) were associated with EPID but not with DPID. Educational level (HR, 0.60; 95% CI, 0.40-0.89; P < .001 for heterogeneity), incident mood symptoms (HR, 1.29; 95% CI, 1.02-1.63; P = .01 for heterogeneity), and white matter disease as defined via computed tomography (HR, 1.70; 95% CI, 1.07-2.71; P = .04 for heterogeneity) were associated with DPID but not EPID. CONCLUSIONS AND RELEVANCE Incident dementia early after ICH is strongly associated with hematoma size and location. Delayed incident dementia is frequent among patients who have experienced ICH and is not prominently associated with acute characteristics of ICH. These findings suggest the existence of heterogeneous biological mechanisms accounting for early vs delayed cognitive decline among patients who have experienced ICH.
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Affiliation(s)
- Alessandro Biffi
- Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Program in Medical and Population Genetics, Broad Institute, Cambridge, Massachusetts4Division of St
| | - Destiny Bailey
- Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Christopher D Anderson
- Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Program in Medical and Population Genetics, Broad Institute, Cambridge, Massachusetts6Division of Be
| | - Alison M Ayres
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Edip M Gurol
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston6Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston
| | - Steven M Greenberg
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston6Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston
| | - Jonathan Rosand
- Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Program in Medical and Population Genetics, Broad Institute, Cambridge, Massachusetts6Division of Be
| | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston6Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston
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Intracerebral Hemorrhage in a Patient with Multiple Sclerosis Receiving Interferon Beta-1α. ARCHIVES OF NEUROSCIENCE 2016. [DOI: 10.5812/archneurosci.42758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Pearce WJ, Doan C, Carreon D, Kim D, Durrant LM, Manaenko A, McCoy L, Obenaus A, Zhang JH, Tang J. Imatinib attenuates cerebrovascular injury and phenotypic transformation after intracerebral hemorrhage in rats. Am J Physiol Regul Integr Comp Physiol 2016; 311:R1093-R1104. [PMID: 27707720 DOI: 10.1152/ajpregu.00240.2016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/15/2016] [Accepted: 09/25/2016] [Indexed: 12/27/2022]
Abstract
This study explored the hypothesis that intracerebral hemorrhage (ICH) promotes release of diffusible factors that can significantly influence the structure and function of cerebral arteries remote from the site of injury, through action on platelet-derived growth factor (PDGF) receptors. Four groups of adult male Sprague-Dawley rats were studied (n = 8 each): 1) sham; 2) sham + 60 mg/kg ip imatinib; 3) ICH (collagenase method); and 4) ICH + 60 mg/kg ip imatinib given 60 min after injury. At 24 h after injury, sham artery passive diameters (+3 mM EGTA) averaged 244 ± 7 µm (at 60 mmHg). ICH significantly increased passive diameters up to 6.4% and decreased compliance up to 42.5%. For both pressure- and potassium-induced contractions, ICH decreased calcium mobilization up to 26.2% and increased myofilament calcium sensitivity up to 48.4%. ICH reduced confocal colocalization of smooth muscle α-actin (αActin) with nonmuscle myosin heavy chain (MHC) and increased its colocalization with smooth muscle MHC, suggesting that ICH promoted contractile differentiation. ICH also enhanced colocalization of myosin light chain kinase (MLCK) with both αActin and regulatory 20-kDa myosin light chain. All effects of ICH on passive diameter, compliance, contractility, and contractile protein colocalization were significantly reduced or absent in arteries from animals treated with imatinib. These findings support the hypothesis that ICH promotes release into the cerebrospinal fluid of vasoactive factors that can diffuse to and promote activation of cerebrovascular PDGF receptors, thereby altering the structure, contractile protein organization, contractility, and smooth muscle phenotype of cerebral arteries remote from the site of hemorrhage.
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Affiliation(s)
- William J Pearce
- Department of Physiology and Department of Pharmacology, Loma Linda University School of Medicine, Loma Linda, California; .,Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, California
| | - Coleen Doan
- Department of Physiology and Department of Pharmacology, Loma Linda University School of Medicine, Loma Linda, California.,Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, California
| | - Desirelys Carreon
- Department of Physiology and Department of Pharmacology, Loma Linda University School of Medicine, Loma Linda, California.,Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, California
| | - Dahlim Kim
- Department of Physiology and Department of Pharmacology, Loma Linda University School of Medicine, Loma Linda, California.,Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, California
| | - Lara M Durrant
- Department of Physiology and Department of Pharmacology, Loma Linda University School of Medicine, Loma Linda, California.,Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, California
| | - Anatol Manaenko
- Department of Physiology and Department of Pharmacology, Loma Linda University School of Medicine, Loma Linda, California
| | - Lauren McCoy
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California; and
| | - Andre Obenaus
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California; and
| | - John H Zhang
- Department of Physiology and Department of Pharmacology, Loma Linda University School of Medicine, Loma Linda, California.,Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California.,Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, California
| | - Jiping Tang
- Department of Physiology and Department of Pharmacology, Loma Linda University School of Medicine, Loma Linda, California
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Biffi A, Rattani A, Anderson CD, Ayres AM, Gurol EM, Greenberg SM, Rosand J, Viswanathan A. Delayed seizures after intracerebral haemorrhage. Brain 2016; 139:2694-2705. [PMID: 27497491 DOI: 10.1093/brain/aww199] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/20/2016] [Indexed: 12/29/2022] Open
Abstract
Late seizures after intracerebral haemorrhage occur after the initial acute haemorrhagic insult subsides, and represent one of its most feared long-term sequelae. Both susceptibility to late seizures and their functional impact remain poorly characterized. We sought to: (i) compare patients with new-onset late seizures (i.e. delayed seizures), with those who experienced a recurrent late seizure following an immediately post-haemorrhagic seizure; and (ii) investigate the effect of late seizures on long-term functional performance after intracerebral haemorrhage. We performed prospective longitudinal follow-up of consecutive intracerebral haemorrhage survivors presenting to a single tertiary care centre. We tested for association with seizures the following neuroimaging and genetic markers of cerebral small vessel disease: APOE variants ε2/ε4, computer tomography-defined white matter disease, magnetic resonance imaging-defined white matter hyperintensities volume and cerebral microbleeds. Cognitive performance was measured using the Modified Telephone Interview for Cognitive Status, and functional performance using structured questionnaires obtained every 6 months. We performed time-to-event analysis using separate Cox models for risk to develop delayed and recurrent seizures, as well as for functional decline risk (mortality, incident dementia, and loss of functional independence) after intracerebral haemorrhage. A total of 872 survivors of intracerebral haemorrhage were enrolled and followed for a median of 3.9 years. Early seizure developed in 86 patients, 42 of whom went on to experience recurrent seizures. Admission Glasgow Coma Scale, increasing haematoma volume and cortical involvement were associated with recurrent seizure risk (all P < 0.01). Recurrent seizures were not associated with long-term functional outcome (P = 0.67). Delayed seizures occurred in 37 patients, corresponding to an estimated incidence of 0.8% per year (95% confidence interval 0.5-1.2%). Factors associated with delayed seizures included cortical involvement on index haemorrhage (hazard ratio 1.63, P = 0.036), pre-haemorrhage dementia (hazard ratio 1.36, P = 0.044), history of multiple prior lobar haemorrhages (hazard ratio 2.50, P = 0.038), exclusively lobar microbleeds (hazard ratio 2.22, P = 0.008) and presence of ≥ 1 APOE ε4 copies (hazard ratio 1.95, P = 0.020). Delayed seizures were associated with worse long-term functional outcome (hazard ratio 1.83, P = 0.005), but the association was removed by adjusting for neuroimaging and genetic markers of cerebral small vessel disease. Delayed seizures after intracerebral haemorrhage are associated with different risk factors, when compared to recurrent seizures. They are also associated with worse functional outcome, but this finding appears to be related to underlying small vessel disease. Further investigations into the connections between small vessel disease and delayed seizures are warranted.
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Affiliation(s)
- Alessandro Biffi
- 1 Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA 1 Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA 3 Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Cambridge MA, USA
| | - Abbas Rattani
- 4 School of Medicine, Meharry Medical College, Nashville, TN, USA
| | - Christopher D Anderson
- 1 Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA 3 Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Cambridge MA, USA 5 Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, USA 6 Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Alison M Ayres
- 1 Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Edip M Gurol
- 1 Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA 7 Division of Stroke, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Steven M Greenberg
- 1 Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA 7 Division of Stroke, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Rosand
- 1 Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA 3 Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Cambridge MA, USA 5 Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, USA 6 Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Anand Viswanathan
- 1 Division of Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA 7 Division of Stroke, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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Gooch ME, Nader K, Kubicek GJ, Somer RA. Brain Metastasis Responsive to Pazopanib in Renal Cell Carcinoma: A Case Report and Review of the Literature. Clin Genitourin Cancer 2016; 14:e401-4. [PMID: 26873436 DOI: 10.1016/j.clgc.2016.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/18/2015] [Accepted: 01/16/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Megan E Gooch
- Department of Internal Medicine, Cooper University Hospital, Camden, NJ.
| | - Kamyar Nader
- Department of Hematology and Oncology, MD Anderson Cancer Center at Cooper, Camden, NJ
| | - Gregory J Kubicek
- Department of Radiation Oncology, MD Anderson Cancer Center at Cooper, Camden, NJ
| | - Robert A Somer
- Department of Hematology and Oncology, MD Anderson Cancer Center at Cooper, Camden, NJ
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16
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Abstract
Primary or nontraumatic spontaneous intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes, and has a poor prognosis. ICH has a mortality rate of almost 50% when associated with intraventricular hemorrhage within the first month, and 80% rate of dependency at 6 months from onset. Neuroimaging is critical in identifying the underlying etiology and thus assisting in the important therapeutic decisions. There are several imaging modalities available in the workup of patients who present with ICH, including computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA). A review of the current imaging approach, as well as a differential diagnosis of etiologies and imaging manifestations of primary versus secondary intraparenchymal hemorrhage, is presented. Active bleeding occurs in the first hours after symptom onset, with early neurologic deterioration. Identifying those patients who are more likely to have hematoma expansion is an active area of research, and there are many ongoing therapeutic trials targeting this specific patient population at risk.
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Affiliation(s)
- Javier M Romero
- Department of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Jonathan Rosand
- Neuroscience Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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Biffi A, Anderson CD, Battey TWK, Ayres AM, Greenberg SM, Viswanathan A, Rosand J. Association Between Blood Pressure Control and Risk of Recurrent Intracerebral Hemorrhage. JAMA 2015; 314:904-12. [PMID: 26325559 PMCID: PMC4737594 DOI: 10.1001/jama.2015.10082] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Intracerebral hemorrhage (ICH) is the most severe form of stroke. Survivors are at high risk of recurrence, death, and worsening functional disability. OBJECTIVE To investigate the association between blood pressure (BP) after index ICH and risk of recurrent ICH. DESIGN, SETTING, AND PARTICIPANTS Single-site, tertiary care referral center observational study of 1145 of 2197 consecutive patients with ICH presenting from July 1994 to December 2013. A total of 1145 patients with ICH survived at least 90 days and were followed up through December 2013 (median follow-up of 36.8 months [minimum, 9.8 months]). EXPOSURES Blood pressure measurements at 3, 6, 9, and 12 months, and every 6 months thereafter, obtained from medical personnel (inpatient hospital or outpatient clinic medical or nursing staff) or via patient self-report. Exposure was characterized in 3 ways: (1) recorded systolic and diastolic measurements; (2) classification as adequate or inadequate BP control based on American Heart Association/American Stroke Association recommendations; and (3) stage of hypertension based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 7 criteria. MAIN OUTCOMES AND MEASURES Recurrent ICH and its location within the brain (lobar vs nonlobar). RESULTS There were 102 recurrent ICH events among 505 survivors of lobar ICH and 44 recurrent ICH events among 640 survivors of nonlobar ICH. During follow-up adequate BP control was achieved on at least 1 measurement by 625 patients (54.6% of total [range, 49.2%-58.7%]) and consistently (ie, at all available time points) by 495 patients (43.2% of total [range, 34.5%-51.0%]). The event rate for lobar ICH was 84 per 1000 person-years among patients with inadequate BP control compared with 49 per 1000 person-years among patients with adequate BP control. For nonlobar ICH the event rate was 52 per 1000 person-years with inadequate BP control compared with 27 per 1000 person-years for patients with adequate BP control. In analyses modeling BP control as a time-varying variable, inadequate BP control was associated with higher risk of recurrence of both lobar ICH (hazard ratio [HR], 3.53 [95% CI, 1.65-7.54]) and nonlobar ICH (HR, 4.23 [95% CI, 1.02-17.52]). Systolic BP during follow-up was associated with increased risk of both lobar ICH recurrence (HR, 1.33 per 10-mm Hg increase [95% CI, 1.02-1.76]) and nonlobar ICH recurrence (HR, 1.54 [95% CI, 1.03-2.30]). Diastolic BP was associated with increased risk of nonlobar ICH recurrence (HR, 1.21 per 10-mm Hg increase [95% CI, 1.01-1.47]) but not with lobar ICH recurrence (HR, 1.36 [95% CI, 0.90-2.10]). CONCLUSIONS AND RELEVANCE In this observational single-center cohort study of ICH survivors, reported BP measurements suggesting inadequate BP control during follow-up were associated with higher risk of both lobar and nonlobar ICH recurrence. These data suggest that randomized clinical trials are needed to address the benefits and risks of stricter BP control in ICH survivors.
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Affiliation(s)
- Alessandro Biffi
- Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts Gener
| | - Christopher D Anderson
- Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts Gener
| | - Thomas W K Battey
- Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts Gener
| | - Alison M Ayres
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Steven M Greenberg
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston
| | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston
| | - Jonathan Rosand
- Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts Gener
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18
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Raffeld MR, Biffi A, Battey TWK, Ayres AM, Viswanathan A, Greenberg SM, Rosand J, Anderson CD. APOE ε4 and lipid levels affect risk of recurrent nonlobar intracerebral hemorrhage. Neurology 2015; 85:349-56. [PMID: 26115730 DOI: 10.1212/wnl.0000000000001790] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 03/27/2015] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Genetic variants ε2/ε4 within the APOE gene are established risk factors for lobar intracerebral hemorrhage (ICH). Published preliminary data suggest a potential role for APOE ε4 in risk of nonlobar ICH. We therefore investigated the role of APOE in recurrent nonlobar ICH, and sought to clarify whether effects of APOE on circulating lipids mediate this association. METHODS Three hundred sixty-three survivors of nonlobar ICH were followed prospectively for ICH recurrence, with APOE genotype determined at enrollment. All participants had clinical, demographic, and laboratory data captured at time of index ICH and during follow-up. Using a multivariate model, we performed association and interaction analyses of the relationships among APOE genotype, lipid levels, and recurrent nonlobar ICH. RESULTS We observed 29 nonlobar ICH recurrences among 363 survivors. APOE ε4 was associated with recurrent nonlobar ICH (hazard ratio = 1.31; 95% confidence interval = 1.02-2.69; p = 0.038) after adjustment for age/sex/ethnicity and cardiovascular risk factors. Increasing low-density lipoprotein (LDL) levels were associated with decreased risk of recurrent nonlobar ICH (p = 0.027), as were decreasing HDL levels (p = 0.046). LDL levels modified the association of APOE ε4 with recurrent nonlobar ICH (mediation p < 0.05). No associations were identified between APOE ε2 and recurrent nonlobar ICH. CONCLUSION APOE ε4 is associated with recurrent ICH in nonlobar brain regions, providing further evidence for its causal role in ICH unrelated to cerebral amyloid angiopathy. LDL levels modulated this effect, suggesting that circulating lipid levels may mediate a portion of the role of APOE ε4 in nonlobar ICH.
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Affiliation(s)
- Miriam R Raffeld
- From the Hemorrhagic Stroke Research Group (M.R.R., A.B., T.W.K.B., A.M.A., A.V., S.M.G., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), and Center for Human Genetic Research (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), Massachusetts General Hospital, Boston
| | - Alessandro Biffi
- From the Hemorrhagic Stroke Research Group (M.R.R., A.B., T.W.K.B., A.M.A., A.V., S.M.G., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), and Center for Human Genetic Research (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), Massachusetts General Hospital, Boston
| | - Thomas W K Battey
- From the Hemorrhagic Stroke Research Group (M.R.R., A.B., T.W.K.B., A.M.A., A.V., S.M.G., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), and Center for Human Genetic Research (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), Massachusetts General Hospital, Boston
| | - Alison M Ayres
- From the Hemorrhagic Stroke Research Group (M.R.R., A.B., T.W.K.B., A.M.A., A.V., S.M.G., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), and Center for Human Genetic Research (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), Massachusetts General Hospital, Boston
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Group (M.R.R., A.B., T.W.K.B., A.M.A., A.V., S.M.G., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), and Center for Human Genetic Research (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), Massachusetts General Hospital, Boston
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Group (M.R.R., A.B., T.W.K.B., A.M.A., A.V., S.M.G., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), and Center for Human Genetic Research (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), Massachusetts General Hospital, Boston
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Group (M.R.R., A.B., T.W.K.B., A.M.A., A.V., S.M.G., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), and Center for Human Genetic Research (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), Massachusetts General Hospital, Boston
| | - Christopher D Anderson
- From the Hemorrhagic Stroke Research Group (M.R.R., A.B., T.W.K.B., A.M.A., A.V., S.M.G., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), and Center for Human Genetic Research (M.R.R., A.B., T.W.K.B., J.R., C.D.A.), Massachusetts General Hospital, Boston.
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Maila SK. Factors affecting the outcome of surgical evacuation of spontaneous deep intra cerebral bleeds. Br J Neurosurg 2015; 29:668-71. [DOI: 10.3109/02688697.2015.1054345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Sharath K. Maila
- Department of Neurosurgery, Osmania Medical College and Hospital, Hyderabad, Telangana, India
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Kathirvelu B, Carmichael ST. Intracerebral hemorrhage in mouse models: therapeutic interventions and functional recovery. Metab Brain Dis 2015; 30:449-59. [PMID: 24810632 PMCID: PMC4226812 DOI: 10.1007/s11011-014-9559-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 04/28/2014] [Indexed: 12/11/2022]
Abstract
There has been strong pre-clinical research on mechanisms of initial cell death and tissue injury in intracerebral hemorrhage (ICH). This data has led to the evaluation of several therapeutics for neuroprotection or the mitigation of early tissue damage. Most of these studies have been done in the rat. Also, there has been little study of the mechanisms of tissue repair and recovery. This review examines the testing of candidate therapeutics in mouse models of ICH for their effect on tissue protection and repair. This review will help the readers compare it to the extensively researched rat model of ICH and thus enhance work that are pending in mouse model.
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Affiliation(s)
- Balachandar Kathirvelu
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA,
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Dey M, Stadnik A, Awad IA. Spontaneous intracerebral and intraventricular hemorrhage: advances in minimally invasive surgery and thrombolytic evacuation, and lessons learned in recent trials. Neurosurgery 2014; 74 Suppl 1:S142-50. [PMID: 24402483 DOI: 10.1227/neu.0000000000000221] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Optimal management of spontaneous intracerebral hemorrhage (ICH) remains one of the highly debated areas in the field of neurosurgery. Earlier studies comparing open surgical intervention with best medical management failed to show a clear benefit. More recent experience with minimally invasive techniques has shown greater promise. Well-designed phase II trials have confirmed the safety and preliminary treatment effect of thrombolytic aspiration and clearance of spontaneous ICH and associated intraventricular obstructive hemorrhage. Those trials are reviewed, including respective protocols and technical nuances, and lessons learned regarding patient selection, the concept of hemorrhage stabilization, optimization of the surgical procedure, and thrombolytic dosing decisions. These concepts have been incorporated in the design of ongoing definite phase III randomized trials (MISTIE and CLEAR) funded by the National Institutes of Health. These are presented including the role of surgical leadership in the training and monitoring of the surgical task and quality assurance. The impact of these techniques on neurosurgical practice is discussed.
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Affiliation(s)
- Mahua Dey
- Hemorrhagic Stroke Research Unit, Section of Neurosurgery and the Neurovascular Surgery Program, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
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Liu DZ, Sharp FR, Van KC, Ander BP, Ghiasvand R, Zhan X, Stamova B, Jickling GC, Lyeth BG. Inhibition of SRC family kinases protects hippocampal neurons and improves cognitive function after traumatic brain injury. J Neurotrauma 2014; 31:1268-76. [PMID: 24428562 DOI: 10.1089/neu.2013.3250] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Traumatic brain injury (TBI) is often associated with intracerebral and intraventricular hemorrhage. Thrombin is a neurotoxin generated at bleeding sites fater TBI and can lead to cell death and subsequent cognitive dysfunction via activation of Src family kinases (SFKs). We hypothesize that inhibiting SFKs can protect hippocampal neurons and improve cognitive memory function after TBI. To test these hypotheses, we show that moderate lateral fluid percussion (LFP) TBI in adult rats produces bleeding into the cerebrospinal fluid (CSF) in both lateral ventricles, which elevates oxyhemoglobin and thrombin levels in the CSF, activates the SFK family member Fyn, and increases Rho-kinase 1(ROCK1) expression. Systemic administration of the SFK inhibitor, PP2, immediately after moderate TBI blocks ROCK1 expression, protects hippocampal CA2/3 neurons, and improves spatial memory function. These data suggest the possibility that inhibiting SFKs after TBI might improve clinical outcomes.
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Affiliation(s)
- Da Zhi Liu
- 1 Department of Neurology and the M.I.N.D. Institute, University of California , Davis, Medical Center, Sacramento, California
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Kitkhuandee A, Sawanyawisuth K, Johns J, Kanpittaya J, Tuntapakul S, Johns NP. Pineal calcification is a novel risk factor for symptomatic intracerebral hemorrhage. Clin Neurol Neurosurg 2014; 121:51-4. [PMID: 24793475 DOI: 10.1016/j.clineuro.2014.03.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 01/19/2014] [Accepted: 03/18/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pineal calcification is associated with symptomatic cerebral infarction in humans. However, there are limited data on the association of pineal calcification and intracerebral hemorrhage. We evaluated this association of symptomatic intracerebral hemorrhage and pineal calcification by computed tomography of the brain. METHODS We reviewed all computed tomographic (CT) scans of the brains of patients over 15 years of age during the year 2011 at a university teaching hospital. Symptomatic intracerebral hemorrhage was identified by having clinical syndrome of stroke and acute intracerebral hemorrhage from brain CT scans. Pineal calcification was also evidenced by brain CT scans. Other stroke risk factors were recorded. The association of various risk factors including pineal calcification and intracerebral hemorrhage was calculated using logistic regression analysis. RESULTS There were 2140 CT scans of the brains during the study period. Of those, 1071 scans (50.05%) met the study criteria. Intracerebral hemorrhage and pineal calcification were found in 77 (7.2%) and 689 (64.3%) patients, respectively. Pineal calcification was a significant risk factor for intracerebral hemorrhage with an adjusted odds ratio of 2.36 (95% confidence interval of 1.22-4.54). Other significant factors were age>50 years, hypertension, and diabetes. CONCLUSION Pineal calcification is associated with symptomatic intracerebral hemorrhage.
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Affiliation(s)
- Amnat Kitkhuandee
- Department of Surgery, Faculty of Medicine, Khon Kean University, Khon Kaen, Thailand
| | - Kittisak Sawanyawisuth
- Department of Medicine, Faculty of Medicine, Khon Kean University, Khon Kaen, Thailand; The Research and Training Center for Enhancing Quality of Life of Working-Age People, Khon Kaen University, Khon Kaen, Thailand.
| | - Jeffrey Johns
- Faculty of Pharmaceutical Sciences and Melatonin Research Group, Khon Kaen University, Khon Kaen, Thailand
| | - Jaturat Kanpittaya
- Department of Radiology, Faculty of Medicine, Khon Kean University, Khon Kaen, Thailand
| | - Supinya Tuntapakul
- Faculty of Pharmaceutical Sciences and Melatonin Research Group, Khon Kaen University, Khon Kaen, Thailand
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Abstract
Intracranial hemorrhage (ICH) accounts for 10-15 % of all strokes, however it causes 30-50 % of stroke related mortality, disability and cost. The prevalence increases with age with only two cases/100,000/year for age less than 40 years to almost 350 cases/100,000/year for age more than 80 years. Several trials of open surgical evacuation of ICH have failed to show clear benefit over medical management. However, some small trials of minimal invasive hematoma evacuation in combination with thrombolytics have shown encouraging results. Based on these findings larger clinical trials are being undertaken to optimize and define therapeutic benefit of minimally invasive surgery in combination with thrombolytic clearance of hematoma. In this article we will review some of the background of minimally invasive surgery and the use of thrombolytics in the setting of ICH and intraventricular hemorrhage (IVH) and will highlight the early findings of MISTIE and CLEAR trials for these two entities respectively.
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Abstract
Intracranial hemorrhage refers to any bleeding within the intracranial vault, including the brain parenchyma and surrounding meningeal spaces. This article focuses on the acute diagnosis and management of primary nontraumatic intracerebral hemorrhage and subarachnoid hemorrhage in the emergency department.
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Affiliation(s)
- J Alfredo Caceres
- Department of Neurology, Massachusetts General Hospital, Suite 3B, Zero Emerson Place, Boston, MA 01940, USA
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Bekelis K, Desai A, Zhao W, Gibson D, Gologorsky D, Eskey C, Erkmen K. Computed tomography angiography: improving diagnostic yield and cost effectiveness in the initial evaluation of spontaneous nonsubarachnoid intracerebral hemorrhage. J Neurosurg 2012; 117:761-6. [PMID: 22880718 DOI: 10.3171/2012.7.jns12281] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Computed tomography angiography (CTA) is increasingly used as a screening tool in the investigation of spontaneous intracerebral hemorrhage (ICH). However, CTA carries additional costs and risks, necessitating its judicious use. The authors hypothesized that subsets of patients with nontraumatic, nonsubarachnoid ICH are unlikely to benefit from CTA as part of the diagnostic workup and that particular patient risk factors may be used to increase the yield of CTA in the detection of vascular sources. METHODS The authors performed a retrospective analysis of 1376 patients admitted to Dartmouth-Hitchcock Medical Center with ICH over an 8-year period. Patients with subarachnoid hemorrhage, hemorrhagic conversion of ischemic infarcts, trauma, and known prior malignancy were excluded from the analysis, resulting in 257 patients for final analysis. Records were reviewed for medical risk factors, hemorrhage location, and correlation of CTA findings with final diagnosis. Multiple logistic regression analysis was used to investigate the combined effects of baseline variables of interest. Model selection was conducted using the stepwise method with p = 0.10 as the significance level for variable entry and p = 0.05 the significance level for variable retention. RESULTS Computed tomography angiography studies detected vascular pathology in 34 patients (13.2%). Patient characteristics that were associated with a significantly higher likelihood of identifying a structural vascular lesion as the source of hemorrhage included patient age younger than 65 years (OR = 16.36, p = 0.0039), female sex (OR = 14.9, p = 0.0126), nonsmokers (OR = 103.8, p = 0.0008), patients with intraventricular hemorrhage (OR = 9.42, p = 0.0379), and patients without hypertension (OR = 515.78, p < 0.0001). Patients who were older than 65 years of age, with a history of hypertension, and hemorrhage located in the cerebellum or basal ganglia were never found to have an identified structural source of hemorrhage on CTA. CONCLUSIONS Patient characteristics and risk factors are important considerations when ordering diagnostic tests in the workup of nonsubarachnoid, nontraumatic spontaneous ICH. Although CTA is an accurate diagnostic examination, it can usually be omitted in the workup of patients with the described characteristics. The use of this algorithm has the potential to increase the yield, and thus the safety and cost effectiveness, of this diagnostic tool.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Masotti L, Godoy DA, Di Napoli M, Rabinstein AA, Paciaroni M, Ageno W. Pharmacological prophylaxis of venous thromboembolism during acute phase of spontaneous intracerebral hemorrhage: what do we know about risks and benefits? Clin Appl Thromb Hemost 2012; 18:393-402. [PMID: 22609819 DOI: 10.1177/1076029612441055] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Spontaneous intracerebral hemorrhage (sICH) represents a devastating clinical event with high mortality and morbidity rates. Only few patients with sICH are treated with neurosurgical evacuation of the hematoma, and the majority of them need only a good conservative medical approach. The goal of medical treatment is to avoid secondary neurological and systemic complications. Venous thromboembolism (VTE) represents one of the most feared complications of sICH, and it is a potential cause of death. The balance between the benefit of VTE prevention and the risk of hematoma enlargement and/or rebleeding with the use of pharmacologic thromboprophylaxis remains controversial because of the lack of consistent evidences in the literature. The efficacy of mechanical prophylaxis is also uncertain. Consequently, until now there are no clear guidelines and scientific evidences available for physicians in this field. The aim of this review is to analyze the available literature and guidelines about pharmacological VTE prophylaxis in patients with nonsurgical sICH.
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Affiliation(s)
- Luca Masotti
- Internal Medicine, Cecina Hospital, Cecina, Italy.
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Abstract
Hemorrhagic stroke accounts for only 10% to 15% of all strokes; however, it is associated with devastating outcomes. Extension of intracranial hemorrhage (ICH) into the ventricles or intraventricular hemorrhage (IVH) has been consistently demonstrated as an independent predictor of poor outcome. In most circumstances the increased intracranial pressure and acute hydrocephalus caused by ICH is managed by placement of an external ventricular drain (EVD). We present a systematic review of the literature on the topic of EVD in the setting of IVH hemorrhage, articulating the scope of the problem and prognostic factors, clinical indications, surgical adjuncts, and other management issues.
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Delgado Almandoz JE, Romero JM. Advanced CT imaging in the evaluation of hemorrhagic stroke. Neuroimaging Clin N Am 2012; 21:197-213, ix. [PMID: 21640295 DOI: 10.1016/j.nic.2011.01.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Multidetector computed tomographic (CT) angiography is rapidly becoming a pivotal examination in the initial evaluation of patients with hemorrhagic stroke. This article provides an update of the literature on this dynamic topic, focusing on (1) the utility of CT angiography in the identification of hemorrhagic stroke patients who harbor an underlying vascular etiology and the role of the secondary intracerebral hemorrhage score, as well as (2) the clinical value of the CT angiography spot sign and spot sign score in patients with primary intracerebral hemorrhage.
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Affiliation(s)
- Josser E Delgado Almandoz
- Division of Neuroradiology, Massachusetts General Hospital, Gray 2, Room 273A, 55 Fruit Street, Boston, MA 02114, USA.
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Delgado Almandoz JE, Jagadeesan BD, Moran CJ, Cross DT, Zipfel GJ, Lee JM, Romero JM, Derdeyn CP. Independent Validation of the Secondary Intracerebral Hemorrhage Score With Catheter Angiography and Findings of Emergent Hematoma Evacuation. Neurosurgery 2011; 70:131-40; discussion 140. [DOI: 10.1227/neu.0b013e31822fbf43] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
The secondary intracerebral hemorrhage (SICH) score, derived from a cohort of patients with intracerebral hemorrhage examined with computed tomographic (CT) angiography, predicts a patient's risk of harboring a vascular etiology.
OBJECTIVE
To validate the SICH score in an independent patient population.
METHODS
We retrospectively reviewed all adults with nontraumatic ICH who presented to our institution during a 5.4-year period and were evaluated with catheter angiography or underwent emergent hematoma evacuation, and applied the SICH score to this cohort. Receiver operating characteristic analysis was performed to determine the area under the curve (AUC) and maximum operating point (MOP). Patients with subarachnoid hemorrhage in the basal cisterns were excluded.
RESULTS
The study included 341 patients, with a mean age of 57.2 years (range, 18–88). Of these, 179 patients were male (52.5%) and 162 were female (47.5%). Two hundred ninety-two patients were evaluated with catheter angiography (85.6%), and 49 underwent emergent hematoma evacuation (14.4%). The SICH score successfully predicted an increasing risk of underlying vascular etiologies in the independent patient cohort, which was similar to the cohort examined with CT angiography. The MOP was reached at a SICH score >2, with the highest incidence of vascular etiologies in patients with SICH scores of 3 (18.8%), 4 (39%), and 5 (79.2%). There was no significant difference in the AUC between the 2 cohorts (0.82-0.87).
CONCLUSION
The SICH score successfully predicted the risk of a patient with ICH of harboring a vascular etiology in an independent patient population. This scoring system could be used to select patients with ICH for neurovascular evaluation to exclude an underlying vascular abnormality.
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Affiliation(s)
- Josser E. Delgado Almandoz
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bharathi D. Jagadeesan
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
| | - Christopher J. Moran
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
- Department of Neurological Surgery
| | - DeWitte T. Cross
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
- Department of Neurological Surgery
| | - Gregory J. Zipfel
- Department of Neurological Surgery
- Department of Neurology, Washington University, Saint Louis, Missouri
| | - Jin-Moo Lee
- Department of Neurology, Washington University, Saint Louis, Missouri
| | - Javier M. Romero
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Colin P. Derdeyn
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
- Department of Neurological Surgery
- Department of Neurology, Washington University, Saint Louis, Missouri
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Abstract
OPINION STATEMENT Intracerebral hemorrhage is a medical emergency. It is the most deadly and disabling form of stroke, and no individual therapy has been demonstrated to improve outcome. However, it appears that aggressive medical care in general, and management by neuroscience specialists in particular, offers substantial benefit. Therefore, providing the best supportive care based on currently available evidence may well improve outcomes. Airway management and management of blood pressure aimed at maximizing cerebral perfusion while minimizing ongoing bleeding, as well as rapid reversal of anticoagulation, are likely to be important in the early phase. Additionally, efforts should be undertaken to provide careful glucose management and temperature management and to maximize cerebral perfusion pressure. Selected patients are likely to benefit from external ventricular drainage or even hematoma evacuation. Except in rare circumstances, most patients should be managed in a neuroscience intensive care unit during the acute phase. Some patients appear to have no reasonable likelihood of recovery and can be considered for limitations of care such as Do Not Resuscitate orders or Comfort Measures Only orders. However, it can be difficult to accurately predict long-term outcome in the acute phase; formal prognostic tools should be used to offer information to patients and their families. After the hemorrhage has stabilized, efforts to minimize complications include thromboembolism prophylaxis, physical therapy, and acute rehabilitation.
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Suntrup S, Warnecke T, Kemmling A, Teismann IK, Hamacher C, Oelenberg S, Dziewas R. Dysphagia in patients with acute striatocapsular hemorrhage. J Neurol 2011; 259:93-9. [DOI: 10.1007/s00415-011-6129-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 05/09/2011] [Accepted: 05/26/2011] [Indexed: 11/29/2022]
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Manaenko A, Chen H, Zhang JH, Tang J. Comparison of different preclinical models of intracerebral hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 111:9-14. [PMID: 21725724 DOI: 10.1007/978-3-7091-0693-8_2] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Intracerebral hemorrhage (ICH) is the most devastating type of stroke. It is characterized by spontaneous bleeding in brain parenchyma and is associated with a high rate of morbidity and mortality. Presently, there is neither an effective therapy to increase survival after intracerebral hemorrhage nor a treatment to improve the quality of life for survivors. A reproducible animal model of spontaneous ICH mimicking the development of acute and delayed brain injury after ICH is an invaluable tool for improving our understanding of the underlying mechanisms of ICH-induced brain injury and evaluating potential therapeutic interventions. A number of models have been developed. While different species have been studied, rodents have become the most popular and widely utilized animals used in ICH research. The most often used methods for experimental induction of ICH are injection of bacterial collagenase and direct injection of blood into the brain parenchyma. The "balloon" method has also been used to mimic ICH for study. In this summary, we intend to provide a comparative overview of the technical methods, aspects, and pathologic findings of these types of ICH models. We will also focus on the similarities and differences among these rodent models, achievements in technical aspects of the ICH model, and discuss important aspects in selecting relevant models for study.
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Affiliation(s)
- Anatol Manaenko
- Department of Physiology and Pharmacology, Loma Linda University, School of Medicine, Risley Hall, Room 219, Loma Linda, CA 92350, USA
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Manaenko A, Fathali N, Williams S, Lekic T, Zhang JH, Tang J. Geldanamycin reduced brain injury in mouse model of intracerebral hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 111:161-5. [PMID: 21725749 PMCID: PMC3569067 DOI: 10.1007/978-3-7091-0693-8_27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
We investigated the effect of the heat shock protein inducer geldanamycin on the development of secondary brain injury after ICH in mice. The effect of the drug at two different concentrations was evaluated at two time points: 24 and 72 h after ICH induction. In the first part of this study, a total of 30 male CD-1 mice were randomly divided into four groups: one sham group and three ICH groups. ICH animals received either an intraperitoneal injection of vehicle or geldanamycin (1 or 10 mg/kg). Neurological deficits and brain water content were evaluated 24 h after ICH. In the second part of this study, the effect of a high concentration of geldanamycin was evaluated 72 h after ICH. Neurological deficits were evaluated by the Garcia neuroscoring, wire hanging and beam balance tests. For estimation of brain water content, the "wet/dry weight" method was used. We demonstrated that administration of geldanamycin (10 mg/kg) ameliorated ICH-induced increase of brain water content significantly in both parts of the study. Geldanamycin improved the neurological outcome according to performance on Garcia and beam balance tests in the 72 h part of this study. Geldanamycin-induced induction of heat shock protein after ICH has a neuroprotective effect and may be a therapeutic target for ICH.
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Delgado Almandoz JE, Schaefer PW, Goldstein JN, Rosand J, Lev MH, González RG, Romero JM. Practical scoring system for the identification of patients with intracerebral hemorrhage at highest risk of harboring an underlying vascular etiology: the Secondary Intracerebral Hemorrhage Score. AJNR Am J Neuroradiol 2010; 31:1653-60. [PMID: 20581068 DOI: 10.3174/ajnr.a2156] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE An ICH patient's risk of harboring an underlying vascular etiology varies according to baseline clinical and NCCT characteristics. Our aim was to develop a practical scoring system to stratify patients with ICH according to their risk of harboring a vascular etiology. MATERIALS AND METHODS Using a data base of 623 patients with ICH evaluated with MDCTA during a 9-year period, we developed a scoring system based on baseline clinical characteristics (age group [0-2 points], sex [0-1 point], neither known HTN nor impaired coagulation [0-1 point]), and NCCT categorization (0-2 points) to predict the risk of harboring a vascular lesion as the ICH etiology (SICH score). We subsequently applied the SICH score to a prospective cohort of 222 patients with ICH who presented to our emergency department during a 13-month period. Using ROC analysis, we calculated the AUC and MOP for the SICH score in both the retrospective and prospective patient cohorts separately and the entire patient population. Patients with SAH in the basal cisterns were excluded. RESULTS A vascular etiology was found in 120 of 845 patients with ICH evaluated with MDCTA (14.2%), most commonly AVMs (45.8%), aneurysms with purely intraparenchymal rupture (21.7%), and DVSTs (16.7%). The MOP was reached at a SICH score of >2, with the highest incidence of vascular ICH etiologies in patients with SICH scores of 3 (18.5%), 4 (39%), 5 (84.2%), and 6 (100%). There was no significant difference in the AUC between both patient cohorts (0.86-0.87). CONCLUSIONS The SICH score successfully predicts a given ICH patient's risk of harboring an underlying vascular etiology and could be used as a guide to select patients with ICH for neurovascular evaluation to exclude the presence of a vascular abnormality.
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Affiliation(s)
- J E Delgado Almandoz
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Abstract
BACKGROUND Spontaneous supratentorial intracerebral haemorrhage is a severe, frequent, and poorly understood condition. Despite the publication of 12 randomised controlled trials on this subject, the role of surgery remains controversial and no treatment has proved to be effective. We report on a ten year prospective cohort study based on a defined population treated with or without surgery and their outcome in terms of early survival. METHODS Population based, ten year prospective observational study directed to patients consecutively admitted to the Intensive Care Unit (ICU) in a tertiary centre with spontaneous supratentorial intracerebral haemorrhage. Patients were distributed in five groups according to the Glasgow Coma Score (GCS) at admission. Haemorrhages were classified as deep-seated or superficial. All patient received standard medical care, and additionally surgery if it was found indicated by the duty neurosurgeon. Primary endpoint was early mortality defined as dead occurred by any cause during the admission in the ICU. FINDINGS During the ten year period, 1.485 patients were admitted to our centre with primary intracerebral haemorrhage. Of these, 376 were admitted to the intensive care unit and 285 sustained supratentorial haemorrhages. Low GCS was strong predictor of early mortality. Despite the larger size of haematomas in patients undergoing surgical evacuation, surgery was associated with lower early mortality in all GCS subgroups. Maximal benefit was observed in patient with admission GCS of 4-8. Superficial haematomas were operated on more often, and were associated with lower mortality rate than deep-seated cases. CONCLUSIONS Our findings suggest that craniotomy for haematoma evacuation may reduce early mortality in patients with primary supratentorial intracerebral haemorrhage. Surgery seems specially useful in patients with admission GCS between 4 and 8, and in those with superficial haemorrhages.
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Lee JC, Cho GS, Choi BO, Kim HC, Kim WK. Aging exacerbates intracerebral hemorrhage-induced brain injury. J Neurotrauma 2009; 26:1567-76. [PMID: 19473060 DOI: 10.1089/neu.2008.0630] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aging may be an important factor affecting brain injury by intracerebral hemorrhage (ICH). In the present study, we investigated the responses of glial cells and monocytes to intracerebral hemorrhage in normal and aged rats. ICH was induced by microinjecting autologous whole blood (15 microL) into the striatum of young (4 month old) and aged (24 month old) Sprague-Dawley rats. Age-dependent relations of brain tissue damage with glial and macrophageal responses were evaluated. Three days after ICH, activated microglia/macrophages with OX42-positive processes and swollen cytoplasm were more abundantly distributed around and inside the hemorrhagic lesions. These were more dramatic in aged versus the young rats. Western blot and immunohistochemistry analyses showed that the expression of interleukin-1beta protein after ICH was greater in aged rats, whereas the expression of GFAP and ciliary neurotrophic factor protein after ICH was significantly lower in aged rats. These results suggest that ICH causes more severe brain injury in aged rats most likely due to overactivation of microglia/macrophages and concomitant repression of reactive astrocytes.
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Affiliation(s)
- Jae-Chul Lee
- Department of Neuroscience, College of Medicine, Korea University, Seoul, Republic of Korea
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Manaenko A, Lekic T, Sozen T, Tsuchiyama R, Zhang JH, Tang J. Effect of gap junction inhibition on intracerebral hemorrhage-induced brain injury in mice. Neurol Res 2009; 31:173-8. [PMID: 19298758 DOI: 10.1179/174313209x393591] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
It has been reported that gap junction contributes to ischemic brain injury and gap junction inhibitors improve neurological outcome in ischemic brain injury models. In the present study, we investigated the effects of gap junction inhibitor, carbenoxolone, on mortality, neurological deficits and brain edema in mice with intracerebral hemorrhage. A total of 80 male CD-1 mice were divided into two parts with two end-points for this study. In part one, animals were divided into four groups: sham, vehicle treatment following intracerebral hemorrhage induction, low-dose carbenoxolone (33 mg/kg) treatment 1 hour after intracerebral hemorrhage induction and high-dose carbenoxolone (100 mg/kg) treatment 1 hour after intracerebral hemorrhage induction groups. Animals were euthanized after 24 hours. In part two, animals were divided into four groups: sham, vehicle treatment 1 hour after intracerebral hemorrhage induction, single high-dose of carbenoxolone treatment at 1 hour after intracerebral hemorrhage induction and three high-doses of carbenoxolone treatment 1, 24 and 48 hours respectively after intracerebral hemorrhage induction. Animals were euthanized after 72 hours. Intracerebral hemorrhage was induced by collagenase injection. Neurological deficits were evaluated using modified Garcia's neurological test, wire hanging and beam balance tests. Brain edema was measured by brain water content. Our results showed that intracerebral hemorrhage produced brain edema and neurological deficits in mice. Carbenoxolone treatment failed to reduce brain edema and neurological deficits. In fact, the high dose of carbenoxolone aggravated neurological deficits and increased mortality 72 hours after the treatment. In conclusion, inhibition of gap junction has no short-term neuroprotective effect on intracerebral hemorrhage-induced brain injury. Further studies are required to assess the long-term effects of gap junction inhibitors in intracerebral hemorrhage models.
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Affiliation(s)
- Anatol Manaenko
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda CA 92350, USA
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Delgado Almandoz JE, Schaefer PW, Forero NP, Falla JR, Gonzalez RG, Romero JM. Diagnostic accuracy and yield of multidetector CT angiography in the evaluation of spontaneous intraparenchymal cerebral hemorrhage. AJNR Am J Neuroradiol 2009; 30:1213-21. [PMID: 19342546 DOI: 10.3174/ajnr.a1546] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Multidetector CT angiography (MDCTA) is emerging as the favored initial diagnostic examination in the evaluation of patients presenting with spontaneous intraparenchymal hemorrhage (IPH). This study aims to evaluate the diagnostic accuracy and yield of MDCTA for the detection of vascular etiologies in adult patients presenting to the emergency department with IPH. MATERIALS AND METHODS We conducted a retrospective study of 623 consecutive adult patients presenting to the emergency department with IPH, who were evaluated with MDCTA during a 9-year period. CT angiograms were reviewed by 2 neuroradiologists to determine the IPH site and the presence of a vascular etiology. Patients with associated subarachnoid hemorrhage in the basal cisterns were excluded from the study. Medical records were reviewed for risk factors and correlation with final diagnosis. The diagnostic accuracy of MDCTA compared with conventional angiography, intraoperative evaluation, and pathologic findings was determined, when available. Multiple-variable logistic regression analysis was performed to determine clinical and radiologic factors that predict a higher yield of MDCTA. RESULTS MDCTA demonstrated a vascular etiology in 91 patients (14.6%), with a sensitivity of 96%, specificity of 99%, and diagnostic accuracy of 98%. We found independent, statistically significant higher yields of MDCTA in patients with the following characteristics: 1) age younger than 46 years (47%); 2) lobar (20%) or infratentorial (16%) IPH, especially lobar IPH with associated intraventricular hemorrhage (25%); 3) female sex (18%); or 4) neither known hypertension nor impaired coagulation at presentation (33%). CONCLUSIONS MDCTA is an accurate diagnostic examination in the evaluation of adult patients presenting with spontaneous IPH and should be performed in all patients with the aforementioned clinical and radiologic characteristics.
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Affiliation(s)
- J E Delgado Almandoz
- Division of Neuroradiology, Radiology Department, Massachusetts General Hospital, Boston, MA 02114, USA.
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Wasserman JK, Yang H, Schlichter LC. Glial responses, neuron death and lesion resolution after intracerebral hemorrhage in young vs. aged rats. Eur J Neurosci 2009; 28:1316-28. [PMID: 18973558 DOI: 10.1111/j.1460-9568.2008.06442.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Intracerebral hemorrhage (ICH) usually affects older humans but almost no experimental studies have assessed aged animals. We address how aging alters inflammation, neuron death and lesion resolution after a hemorrhage in the rat striatum. In the normal aged brain, microglia displayed a 'dystrophic' phenotype, with shorter cellular processes and large gaps between adjacent cells, and there was more astrocyte reactivity. The ICH injury was monitored as hematoma volume and number of dying neurons at 1 and 3 days, and the volume of the residual lesion, ventricles and lost tissue at 28 days. Inflammation at 1 and 3 days was assessed from densities of microglia with resting vs. activated morphologies, or expressing the lysosomal marker ED1. Despite an initial delay in neuron death in aged animals, by 28 days, there was no difference in neuron density or volume of tissue lost. However, lesion resolution was impaired in aged animals and there was less compensatory ventricular expansion. At 1 day after ICH, there were fewer activated microglia/macrophages in the aged brain, but by 3 days there were more of these cells at the edge of the hematoma and in the surrounding parenchyma. In both age groups a glial limitans had developed by 3 days, but astrocyte reactivity and the spread of activated microglia/macrophages into the surrounding parenchyma was greater in the aged. These findings have important implications for efforts to reduce secondary injury after ICH and to develop anti-inflammatory therapies to treat ICH in aged humans.
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Affiliation(s)
- Jason K Wasserman
- Toronto Western Research Institute, University Health Network, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON, Canada
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Abstract
Stroke is the third leading cause of death and the leading cause of disability in the United States. This article summarizes the management of acute ischemic stroke, including conventional and novel therapies. The article provides an overview of the initial management, diagnostic work-up, treatment options, and supportive measures that need to be considered in the acute phase of ischemic stroke.
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Affiliation(s)
- Anna Finley Caulfield
- Department of Neurology and Neurological Sciences, Neurocritical Care Program, Stanford Stroke Center, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
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Andres RH, Guzman R, Ducray AD, Mordasini P, Gera A, Barth A, Widmer HR, Steinberg GK. Cell replacement therapy for intracerebral hemorrhage. Neurosurg Focus 2008; 24:E16. [DOI: 10.3171/foc/2008/24/3-4/e15] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
✓ Intracerebral hemorrhage (ICH), for which no effective treatment strategy is currently available, constitutes one of the most devastating forms of stroke. As a result, developing therapeutic options for ICH is of great interest to the medical community. The 3 potential therapies that have the most promise are cell replacement therapy, enhancing endogenous repair mechanisms, and utilizing various neuroprotective drugs. Replacement of damaged cells and restoration of function can be accomplished by transplantation of cells derived from different sources, such as embryonic or somatic stem cells, umbilical cord blood, and genetically modified cell lines. Early experimental data showing the benefits of cell transplantation on functional recovery after ICH have been promising. Nevertheless, several studies have focused on another therapeutic avenue, investigating novel ways to activate and direct endogenous repair mechanisms in the central nervous system, through exposure to specific neuronal growth factors or by inactivating inhibitory molecules. Lastly, neuroprotective drugs may offer an additional tool for improving neuronal survival in the perihematomal area. However, a number of scientific issues must be addressed before these experimental techniques can be translated into clinical therapy. In this review, the authors outline the recent advances in the basic science of treatment strategies for ICH.
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Affiliation(s)
- Robert H. Andres
- 1Department of Neurosurgery, Stanford University Medical Center, Stanford, California
- 2Departments of Neurosurgery and
| | - Raphael Guzman
- 1Department of Neurosurgery, Stanford University Medical Center, Stanford, California
| | | | - Pasquale Mordasini
- 2Departments of Neurosurgery and
- 3Neuroradiology, University of Berne, Inselspital, CH-3010 Berne, Switzerland; and
| | - Atul Gera
- 1Department of Neurosurgery, Stanford University Medical Center, Stanford, California
| | - Alain Barth
- 4Department of Neurosurgery, Medical University of Graz, A-8036 Graz, Austria
| | | | - Gary K. Steinberg
- 1Department of Neurosurgery, Stanford University Medical Center, Stanford, California
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Pouessel D, Culine S. High Frequency of Intracerebral Hemorrhage in Metastatic Renal Carcinoma Patients with Brain Metastases Treated with Tyrosine Kinase Inhibitors Targeting the Vascular Endothelial Growth Factor Receptor. Eur Urol 2008; 53:376-81. [PMID: 17825982 DOI: 10.1016/j.eururo.2007.08.053] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 08/23/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To report the high incidence of intracerebral hemorrhage (ICH) in patients with metastatic renal cell carcinoma (RCC) treated with the tyrosine kinase inhibitors targeting the vascular endothelial growth factor receptor (VEGFR). METHODS AND RESULTS Between October 2005 and December 2006, 67 patients with metastatic RCC were treated with sorafenib or sunitinib at the Montpellier Cancer Center in compassionate access programs. The medical records of five (7%) patients who died of ICH during therapy were reviewed retrospectively. Four of them had known brain metastases. Previous radiation therapy had been indicated in two patients. Two patients had a history of hypertension. Death from ICH occurred in the first 2 wk following the onset of treatment. Three other patients with brain metastases who received sorafenib or sunitinib during the same period did not experience ICH. CONCLUSIONS The frequency of fatal ICH in RCC patients with brain metastases treated with tyrosine kinase inhibitors targeting the VEGFR seems high. Prospective clinical trials will be necessary for assessing the true incidence and predictive factors related to this toxicity.
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Affiliation(s)
- Damien Pouessel
- Department of Medical Oncology, C.R.L.C. Val d'Aurelle, Montpellier, France
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Lim JK, Hwang HS, Cho BM, Lee HK, Ahn SK, Oh SM, Choi SK. Multivariate analysis of risk factors of hematoma expansion in spontaneous intracerebral hemorrhage. ACTA ACUST UNITED AC 2008; 69:40-5; discussion 45. [DOI: 10.1016/j.surneu.2007.07.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Accepted: 07/09/2007] [Indexed: 11/26/2022]
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Hemorrhagic stroke syndromes: clinical manifestations of intracerebral and subarachnoid hemorrhage. HANDBOOK OF CLINICAL NEUROLOGY 2008; 93:577-94. [PMID: 18804669 DOI: 10.1016/s0072-9752(08)93028-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Goals of hemorrhage management involve promoting coagulation and reducing fibrinolysis to enhance clot formation and stability, and minimizing hemorrhagic expansion to reduce the likelihood of adverse outcomes. The optimal hemostatic regimen to obtain these goals will differ according to the clinical scenario. Two hypothetical cases of patients with hemorrhage are presented that are typical of those encountered by clinical pharmacists who practice in centers that treat trauma or surgical patients or patients in need of emergency or critical care because of serious bleeding. To maximize therapy, the clinician must be aware of how best to clinically apply hemostatic agents, their comparative benefits and disadvantages, and the optimal methods for monitoring their effectiveness and toxicities.
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Affiliation(s)
- Robert MacLaren
- Department of Clinical Pharmacy, School of Pharmacy, University of Colorado at Denver and Health Sciences Center, Denver, Colorado 80262, USA.
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Abstract
Stroke is the third leading cause of death and the leading cause of disability in the United States. This article summarizes the critical care of acute ischemic stroke, including conventional and novel therapies. The article provided an overview of the initial management, diagnostic workup, treatment options, and supportive measures that need to be considered in the acute phase of ischemic stroke.
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Affiliation(s)
- Anna Finley Caulfield
- Department of Neurology and Neurological Sciences, Neurocritical Care Program, Stanford Stroke Center, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
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Gu YT, Zhang H, Xue YX. Dexamethasone treatment modulates aquaporin-4 expression after intracerebral hemorrhage in rats. Neurosci Lett 2007; 413:126-31. [PMID: 17240062 DOI: 10.1016/j.neulet.2006.11.072] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Revised: 11/16/2006] [Accepted: 11/17/2006] [Indexed: 11/28/2022]
Abstract
This study investigated whether dexamethasone (DEX) treatment could regulate the expression of aquaporin-4 (AQP4) in rats with intracerebral hemorrhage (ICH). The results demonstrated that DEX significantly reduced AQP4 mRNA level in the perihematomal area compared with control group, but it increased the level in the brain area surrounding the third ventricle at day 1 post-ICH. There was no difference in AQP4 protein levels between DEX group and control group at the two above-mentioned brain regions at day 1 after ICH. The changes in AQP4 protein induced by DEX were marked at day 3 following surgery and still lasted at day 5 post-ICH, which were accompanied by a reduction of brain edema. Our results demonstrated that the expression of AQP4 protein after ICH was region-specific, time-dependent, and also indicated that DEX-induced cerebral edema clearance was correlated with the regulation of AQP4 expression in different brain regions.
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Affiliation(s)
- Yan-ting Gu
- China Medical University, Department of Neurobiology, Beier Road No. 92, Heping District, Shenyang, Liaoning Province 110001, China
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Charil A, Yousry TA, Rovaris M, Barkhof F, De Stefano N, Fazekas F, Miller DH, Montalban X, Simon JH, Polman C, Filippi M. MRI and the diagnosis of multiple sclerosis: expanding the concept of "no better explanation". Lancet Neurol 2006; 5:841-52. [PMID: 16987731 DOI: 10.1016/s1474-4422(06)70572-5] [Citation(s) in RCA: 181] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although the diagnosis of multiple sclerosis relies on the demonstration of disease dissemination in space and time, the exclusion of other neurological disorders is also essential. The limited specificity of abnormalities disclosed by MRI may increase the likelihood of diagnosis of multiple sclerosis in patients affected by other disorders. The available criteria for diagnosis of multiple sclerosis have not taken advantage of the potential of MRI to detect features "not suggestive" of multiple sclerosis. Recognition of such features in the work-up of patients suspected of having multiple sclerosis may reduce the likelihood of a false positive diagnosis of the disorder in some, while suggesting the correct alternative diagnosis in other patients. On the basis of this, a workshop of the European MAGNIMS (Magnetic Resonance Network in Multiple Sclerosis) was held to define a series of MRI red flags in the setting of clinically suspected multiple sclerosis that is derived from evidence-based findings and educated guesses. The presence of such red flags should alert clinicians to reconsider the differential diagnosis more extensively. In this review we will report on the conclusions of this international consensus, which should represent a first step beyond the concept of "no better explanation", and inform future diagnostic criteria for multiple sclerosis.
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Affiliation(s)
- Arnaud Charil
- Neuroimaging Research Unit, Department of Neurology, Scientific Institute and University Ospedale San Raffaele, Milan, Italy
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