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

Clinical Course and Recurrence in Transient Global Amnesia: A Study From the TEMPiS Telestroke Network

BACKGROUND AND PURPOSE

While the clinical hallmarks of transient global amnesia (TGA) are well defined, its pathophysiological causes are poorly understood. Specifically, risk factors for recurrences are yet to be determined.

METHODS

This retrospective study analyzed TGA cases diagnosed and treated within the TEMPiS telestroke network and a university stroke center in Germany. Demographic and clinical data were assessed and characteristics of TGA episodes were recorded, such as season of occurrence, trigger factors, duration, and concomitant symptoms. Follow-up of the potential recurrence of TGA was performed using a standardized questionnaire.

RESULTS

Overall 109 patients were included (age 64±8 years [mean±SD], 59.6% female). The most common vascular risk factor was arterial hypertension (60.6%), and other concomitant conditions included migraine (11.9%), hypothyroidism (22.9%), and atrial fibrillation (4.6%). The most frequent concomitant clinical feature accompanying the TGA episode at admission was elevated blood pressure (48.6%). Nineteen patients experienced at least one recurrent TGA episode. Migraine and hypothyroidism were only observed in subjects with a single TGA episode without recurrence (migraine: 14.4% without recurrence vs. none in the recurrence group, p=0.02; hypothyroidism: 27.8% without recurrence vs. none in the recurrence group, p=0.009). In contrast, atrial fibrillation was more common in subjects with TGA recurrence (p<0.001).

CONCLUSIONS

Arterial hypertension is prevalent in TGA patients, with elevated blood pressure being the most-frequent concomitant condition. In our cohort, recurrence of TGA occurred in approximately one-fifth of patients. Concomitant conditions such as migraine, hypothyroidism, and atrial fibrillation occurred at different frequencies in the two groups.

Retracted: Stem cells from human exfoliated deciduous teeth transmit microRNA-26a to protect rats with experimental intracerebral hemorrhage from cerebral injury via suppressing CTGF

OBJECTIVE

A large number of studies have shown that stem cells from human exfoliated deciduous teeth (SHED) has a protective effect on brain damage, but its specific mechanism is unclear. This research focused on the effect of microRNA (miR)-26a that transmitted by SHED in intracerebral hemorrhage (ICH).

METHODS

SHED were extracted from deciduous teeth of healthy children and miR-26a expression in SHED was altered through transfection, and then the SHED were conducted with neuron differentiated induction, expression of β3 tubulin, MAP-2 and glial fibrillary acidic protein (GFAP), number of dendritic spines and cell proliferation were detected. ICH rat models were established by stereotactic injection of collagenase VII into the left striatum and the modeled rats were injected with miR-26a mimic or inhibitor-transfected SHED suspension. Then, the brain water content, blood-brain barrier permeability, pathological changes, and injury and apoptosis in the nervous cells in brain were assessed. The expression of miR-26a and CTGF in SHED and rats' brain tissues was evaluated and the target relation between miR-26a and CTGF was detected.

RESULTS

In SHED after induction, upregulated miR-26a could increase number of dendritic spines, cell proliferation, and expression of β3 tubulin, MAP-2 and GFAP, and restrain CTGF expression. In rat models, SHED engineered to overexpress miR-26a could attenuate brain water content, Evans blue content, apoptosis, pathological injury and expression of CTGF and Bax, while promoted number of Nissl bodies and expression of Bcl-2 in the nervous cells in brain in ICH rats. Furthermore, miR-26a competitively bound to CTGF.

CONCLUSION

Our findings provided the evidence that SHED could transmit miR-26a to protect ICH rats from cerebral injury by repressing CTGF, which may contribute to ICH therapy.

Interleukin-1 and Interleukin-6 Polymorphisms Might Influence Predisposition to Hemorrhagic Cerebral Vascular Diseases: A Meta-Analysis

BACKGROUND

Interleukin-1 (IL-1) and IL-6 polymorphisms might influence predisposition to hemorrhagic cerebral vascular diseases, but the results of already published studies regarding relationship between IL-1/IL-6 polymorphisms and hemorrhagic cerebral vascular diseases were still controversial and ambiguous.

OBJECTIVES

The authors designed this meta-analysis to more precisely estimate the relationship between IL-1/IL-6 polymorphisms and hemorrhagic cerebral vascular diseases by pooling the results of already published related studies.

METHODS

The authors searched PubMed, EMBASE, Web of Science, and CNKI for already published studies. Eighteen already published studies were pooled analyzed in this meta-analysis.

RESULTS

The pooled meta-analyses' results showed that distributions of IL-1A rs1800587, IL-1B rs16944, and IL-6 rs1800796 polymorphisms among patients and controls differed significantly. Moreover, distribution of the IL-6 rs1800795 polymorphism among patients and controls from Asians also differed significantly. Further analyses showed similar findings for IL-1A rs1800587, IL-1B rs16944, and IL-6 rs1800796 polymorphisms in aneurysmal subarachnoid hemorrhage (aSAH) subgroup.

CONCLUSIONS

This meta-analysis suggested that IL-1A rs1800587, IL-1B rs16944, and IL-6 rs1800796 polymorphisms might influence susceptibility to hemorrhagic cerebral vascular diseases, especially for aSAH. Moreover, IL-6 rs1800795 might influence susceptibility to hemorrhagic cerebral vascular diseases in Asians.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

eNOS rs2070744 polymorphism might influence predisposition to hemorrhagic cerebral vascular diseases in East Asians: A meta-analysis

INTRODUCTION

Endothelial nitric oxide synthase (eNOS) polymorphisms might influence predisposition to hemorrhagic cerebral vascular diseases, but the results of already published studies regarding relationship between eNOS polymorphisms and hemorrhagic cerebral vascular diseases were still controversial.

METHODS

The authors performed this meta-analysis to estimate relationship between eNOS polymorphisms and hemorrhagic cerebral vascular diseases in a larger pooled population by combing the results of already published related studies. The authors searched Pubmed, Embase, Web of Science, and CNKI for already published studies.

RESULTS

Eighteen already published studies were pooled analyzed in this meta-analysis. The pooled meta-analyses results showed that eNOS rs2070744 polymorphism was significantly associated with predisposition to hemorrhagic cerebral vascular diseases in East Asians (dominant comparison: OR = 0.77, p = .01; overdominant comparison: OR = 1.24, p = .04; allele comparison: OR = 0.78, p = .006) Nevertheless, the pooled meta-analyses did not reveal any positive results for eNOS rs1799983 and rs869109213 polymorphisms.

CONCLUSIONS

This meta-analysis suggested that eNOS rs2070744 polymorphism, but not rs1799983 and rs869109213 polymorphisms, might influence predisposition to hemorrhagic cerebral vascular diseases in East Asians.

MicroRNA-93 regulates the neurological function, cerebral edema and neuronal apoptosis of rats with intracerebral hemorrhage through TLR4/NF-κB signaling pathway

In recent years, many studies have unraveled the impact of microRNAs (miRNAs) in intracerebral hemorrhage (ICH). This study aims to explore the role of miR-93 in modulating neurological function, cerebral edema and neuronal apoptosis of rats with ICH by regulating TLR4/NF-κB signaling pathway. ICH models were constructed using Ⅶ collagenase method. The successfully modeled rats were injected with miR-93 antagomir, TLR4/NF-κB signaling pathway activator or inhibitor together with their controls. The expression of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-1β (IL-1β) and vascular endothelial growth factor (VEGF) was measured using enzyme-linked immunosorbent assay (ELISA). The expression of human aquaporin 4 (AQP-4), Caspase-3, Bax, Bcl-2 and TLR4/NF-κB signaling pathway-related proteins was also measured. MiR-93, TLR4 and NF-κB were all highly expressed in ICH, reduced miR-93 and inhibited TLR4/NF-κB signaling pathway could improve neurological function and suppress inflammation in ICH rats. Moreover, down-regulated miR-93 and suppressed TLR4/NF-κB signaling pathway were able to attenuate cerebral edema and abate pathological lesion. We have also found in this research that miR-93 knockdown as well as inhibited TLR4/NF-κB signaling pathway could relieve neuronal apoptosis in ICH rats. This study suggests that reduced miR-93 alleviates the neurological function and cerebral edema as well as repressed neuronal apoptosis of ICH rats via the inhibited activation of TLR4/NF-κB signaling pathway.

[Telemedicine projects in rural areas of Germany. A systematic evaluation with the "Model for Assessment of Telemedicine"]

BACKGROUND

The term telemedicine describes the delivery of healthcare services through the use of information and communication technologies in a situation where the actors are at different locations. While telemedical applications are piloted in research projects in Germany, they have rarely become part of everyday care. In order to find indications as to why the transfer of knowledge into practice has so far been slow, it is necessary to examine telemedical projects for aspects of implementation science.

METHODS

A systematic search looking for telemedical projects in Germany was conducted in the electronic databases PubMed, Web of Science and ACM Digital Library using a complex search strategy. The criteria and domains of the Model for Assessment of Telemedicine (MAST) were used to evaluate the publications.

RESULTS

A total of 336 publications were identified, 16 of which were ultimately included in the analysis. Much of the work deals with stroke and the implementation of telemedicine networks. The analysis according to MAST shows that most publications omit essential considerations.

CONCLUSION

Publications on telemedical projects are often characterized by unsystematic approaches. The MAST instrument identifies areas where the approaches to telemedical projects could be extended in the future to ensure the sustainability and feasibility of these prototypical telemedical applications.

Importance of the telemedicine network for neurosurgery in Slovenia

The number of invasive procedures in medicine is increasing, as is the employment of new technological achievements. In the era of information-communication technology, one such achievement is also the telemedicine network. In Slovenia, it is known as the Telekap (TeleStroke) network, which was primarily designed for fast and efficient management of stroke patients. In the neurosurgical community, the system is frequently used also for conveying vital information regarding subarachnoid haemorrhage and trauma. Especially in neurosurgical emergencies, this communication system offers thorough information about the extent and location of bleeding and facilitates the preoperative planning of neurosurgical interventions. From our experience so far, the system should be expanded to other neuro-centres as well to all neurosurgery departments in order to facilitate patient management, their acute hospital care, and inter-speciality collaboration.

Cost-effectiveness of Access to Critical Cerebral Emergency Support Services (ACCESS): a neuro-emergent telemedicine consultation program

AIMS

Access to Critical Cerebral Emergency Support Services (ACCESS) was developed as a low-cost solution to providing neuro-emergent consultations to rural hospitals in New Mexico that do not offer comprehensive stroke care. ACCESS is a two-way audio-visual program linking remote emergency department physicians and their patients to stroke specialists. ACCESS also has an education component in which hospitals receive training from stroke specialists on the triage and treatment of patients. This study assessed the clinical and economic outcomes of the ACCESS program in providing services to rural New Mexico from a healthcare payer perspective.

METHODS

A decision tree model was constructed using findings from the ACCESS program and existing literature, the likelihood that a patient will receive a tissue plasminogen activator (tPA), cost of care, and resulting quality adjusted life years (QALYs). Data from the ACCESS program includes emergency room patients in rural New Mexico from May 2015 to August 2016. Outcomes and costs have been estimated for patients who were taken to a hospital providing neurological telecare and patients who were not.

RESULTS

The use of ACCESS decreased neuro-emergent stroke patient transfers from rural hospitals to urban settings from 85% to 5% (no tPA) and 90% to 23% (tPA), while stroke specialist reading of patient CT/MRI imaging within 3 h of onset of stroke symptoms increased from 2% to 22%. Results indicate that use of ACCESS has the potential to save $4,241 ($3,952-$4,438) per patient and increase QALYs by 0.20 (0.14-0.22). This increase in QALYs equates to ∼73 more days of life at full health. The cost savings and QALYs are expected to increase when moving from a 90-day model to a lifetime model.

CONCLUSION

The analysis demonstrates potential savings and improved quality-of-life associated with the use of ACCESS for patients presenting to rural hospitals with acute ischemic stroke (AIS).

A systematic review of the methodologies used to evaluate telemedicine service initiatives in hospital facilities

BACKGROUND

The adoption of telemedicine into mainstream health services has been slower than expected. Many telemedicine projects tend not to progress beyond the trial phase; there are a large number of pilot or project publications and fewer 'service' publications. This issue has been noted since 1999 and continues to be acknowledged in the literature. While overall telemedicine uptake has been slow, some services have been successful. The reporting and evaluation of these successful services may help to improve future uptake and sustainability. The aim of this literature review was to identify peer-reviewed publications of deployed telemedicine services in hospital facilities; and to report, and appraise, the methodology used to evaluate these services.

METHODS

Computerised literature searches of bibliographic databases were performed using the MeSH terms for "Telemedicine" and "Hospital Services" or "Hospital", for papers published up to May 2016.

RESULTS

A total of 164 papers were identified, representing 137 telemedicine services. The majority of reported telemedicine services were based in the United States of America (n=61, 44.5%). Almost two thirds of the services (n=86, 62.7%) were delivered by real time telemedicine. Of the reviewed studies, almost half (n=81, 49.3%) assessed their services from three different evaluation perspectives: clinical outcomes, economics and satisfaction. While the remaining half (n=83, 50.6%) described their service and its activities without reporting any evaluation measures. Only 30 (18.2%) studies indicated a two-step implementation and evaluation process. There was limited information in all reported studies regarding description of a structured planning strategy.

CONCLUSION

Our systematic review identified only 137 telemedicine services. This suggests either telemedicine service implementation is still not a part of mainstream clinical services, or it is not being reported in the peer-reviewed literature. The depth and the quality of information were variable across studies, reducing the generalisability. The reporting of service implementation and planning strategies should be encouraged. Given the fast paced technology driven environment of telemedicine, this may enable others to learn and understand how to implement sustainable services. The key component of planning was underreported in these studies. Studies applying and reporting more rigorous methodology would contribute greatly to the evidence for telemedicine.