1
|
Bah MG, Dowlati E, Fleigner M, Koduri S, Pandey A, Lin LY, Chenevert TL, Troost J, Xi G, Keep R, Chaudhary N. MR Imaging-based Biomarker Development in Hemorrhagic Stroke Patients Including Brain Iron Quantification, Diffusion Tensor Imaging, and Phenomenon of Ultra-early Erythrolysis. Neuroimaging Clin N Am 2024; 34:215-224. [PMID: 38604706 DOI: 10.1016/j.nic.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
This review article discusses the role of MR imaging-based biomarkers in understanding and managing hemorrhagic strokes, focusing on intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage. ICH is a severe type of stroke with high mortality and morbidity rates, primarily caused by the rupture of small blood vessels in the brain, resulting in hematoma formation. MR imaging-based biomarkers, including brain iron quantification, ultra-early erythrolysis detection, and diffusion tensor imaging, offer valuable insights for hemorrhagic stroke management. These biomarkers could improve early diagnosis, risk stratification, treatment monitoring, and patient outcomes in the future, revolutionizing our approach to hemorrhagic strokes.
Collapse
Affiliation(s)
- Momodou G Bah
- Michigan State University College of Human Medicine, Lansing, MI, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Max Fleigner
- Oakland University, William Beaumont School of Medicine, Detroit, MI, USA
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Aditya Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA; Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Leanne Y Lin
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Thomas L Chenevert
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jonathan Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Richard Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA; Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA; Department of Otorhinolaryngology, University of Michigan, Ann Arbor, MI 48109, USA.
| |
Collapse
|
2
|
Sobowale OA, Hostettler IC, Wu TY, Heal C, Wilson D, Shah DG, Strbian D, Putaala J, Tatlisumak T, Vail A, Sharma G, Davis SM, Werring DJ, Meretoja A, Allan SM, Parry-Jones AR. Baseline perihematomal edema, C-reactive protein, and 30-day mortality are not associated in intracerebral hemorrhage. Front Neurol 2024; 15:1359760. [PMID: 38645743 PMCID: PMC11026700 DOI: 10.3389/fneur.2024.1359760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/25/2024] [Indexed: 04/23/2024] Open
Abstract
Background The relationship between baseline perihematomal edema (PHE) and inflammation, and their impact on survival after intracerebral hemorrhage (ICH) are not well understood. Objective Assess the association between baseline PHE, baseline C-reactive protein (CRP), and early death after ICH. Methods Analysis of pooled data from multicenter ICH registries. We included patients presenting within 24 h of symptom onset, using multifactorial linear regression model to assess the association between CRP and edema extension distance (EED), and a multifactorial Cox regression model to assess the association between CRP, PHE volume and 30-day mortality. Results We included 1,034 patients. Median age was 69 (interquartile range [IQR] 59-79), median baseline ICH volume 11.5 (IQR 4.3-28.9) mL, and median baseline CRP 2.5 (IQR 1.5-7.0) mg/L. In the multifactorial analysis [adjusting for cohort, age, sex, log-ICH volume, ICH location, intraventricular hemorrhage (IVH), statin use, glucose, and systolic blood pressure], baseline log-CRP was not associated with baseline EED: for a 50% increase in CRP the difference in expected mean EED was 0.004 cm (95%CI 0.000-0.008, p = 0.055). In a further multifactorial analysis, after adjusting for key predictors of mortality, neither a 50% increase in PHE volume nor CRP were associated with higher 30-day mortality (HR 0.97; 95%CI 0.90-1.05, p = 0.51 and HR 0.98; 95%CI 0.93-1.03, p = 0.41, respectively). Conclusion Higher baseline CRP is not associated with higher baseline edema, which is also not associated with mortality. Edema at baseline might be driven by different pathophysiological processes with different effects on outcome.
Collapse
Affiliation(s)
- Oluwaseun A. Sobowale
- Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Center, University of Manchester, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Center, Manchester Academic Health Science Center, Northern Care Alliance NHS Foundation Trust and University of Manchester, Manchester, United Kingdom
| | - Isabel C. Hostettler
- Stroke Research Center, UCL Queen Square Institute of Neurology, and the National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Teddy Y. Wu
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Calvin Heal
- Center for Biostatistics, The University of Manchester, Manchester Academic Health Science Center, Manchester, United Kingdom
| | - Duncan Wilson
- Stroke Research Center, UCL Queen Square Institute of Neurology, and the National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Darshan G. Shah
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Department of Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andy Vail
- Center for Biostatistics, The University of Manchester, Manchester Academic Health Science Center, Manchester, United Kingdom
| | - Gagan Sharma
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Stephen M. Davis
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - David J. Werring
- Stroke Research Center, UCL Queen Square Institute of Neurology, and the National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Atte Meretoja
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Department of Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Stuart M. Allan
- Geoffrey Jefferson Brain Research Center, Manchester Academic Health Science Center, Northern Care Alliance NHS Foundation Trust and University of Manchester, Manchester, United Kingdom
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Adrian R. Parry-Jones
- Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Center, University of Manchester, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Center, Manchester Academic Health Science Center, Northern Care Alliance NHS Foundation Trust and University of Manchester, Manchester, United Kingdom
| |
Collapse
|
3
|
Abou Karam G, Tharmaseelan H, Aboian MS, Malhotra A, Gilmore EJ, Falcone GJ, de Havenon A, Sheth KN, Payabvash S. Clinical implications of Peri-hematomal edema microperfusion fraction in intracerebral hemorrhage intravoxel incoherent motion imaging - A pilot study. J Stroke Cerebrovasc Dis 2023; 32:107375. [PMID: 37738914 PMCID: PMC10591892 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND AND PURPOSE Perihematomal edema (PHE) represents the secondary brain injury after intracerebral hemorrhage (ICH). However, neurobiological characteristics of post-ICH parenchymal injury other than PHE volume have not been fully characterized. Using intravoxel incoherent motion imaging (IVIM), we explored the clinical correlates of PHE diffusion and (micro)perfusion metrics in subacute ICH. MATERIALS AND METHODS In 41 consecutive patients scanned 1-to-7 days after supratentorial ICH, we determined the mean diffusion (D), pseudo-diffusion (D*), and perfusion fraction (F) within manually segmented PHE. Using univariable and multivariable statistics, we evaluated the relationship of these IVIM metrics with 3-month outcome based on the modified Rankin Scale (mRS). RESULTS In our cohort, the average (± standard deviation) age of patients was 68.6±15.6 years, median (interquartile) baseline National Institute of Health Stroke Scale (NIHSS) was 7 (3-13), 11 (27 %) patients had poor outcomes (mRS>3), and 4 (10 %) deceased during the follow-up period. In univariable analyses, admission NIHSS (p < 0.001), ICH volume (p = 0.019), ICH+PHE volume (p = 0.016), and average F of the PHE (p = 0.005) had significant correlation with 3-month mRS. In multivariable model, the admission NIHSS (p = 0.006) and average F perfusion fraction of the PHE (p = 0.003) were predictors of 3-month mRS. CONCLUSION The IVIM perfusion fraction (F) maps represent the blood flow within microvasculature. Our pilot study shows that higher PHE microperfusion in subacute ICH is associated with worse outcomes. Once validated in larger cohorts, IVIM metrics may provide insight into neurobiology of post-ICH secondary brain injury and identify at-risk patients who may benefit from neuroprotective therapy.
Collapse
Affiliation(s)
- Gaby Abou Karam
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine. 333 Cedar St, New Haven, CT 06510, USA
| | - Hishan Tharmaseelan
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine. 333 Cedar St, New Haven, CT 06510, USA
| | - Mariam S Aboian
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine. 333 Cedar St, New Haven, CT 06510, USA
| | - Ajay Malhotra
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine. 333 Cedar St, New Haven, CT 06510, USA
| | - Emily J Gilmore
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA; Center for Brain and Mind Health, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Guido J Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA; Center for Brain and Mind Health, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Adam de Havenon
- Center for Brain and Mind Health, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, USA; Division of Vascular Neurology, Department of Neurology, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA; Center for Brain and Mind Health, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Seyedmehdi Payabvash
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine. 333 Cedar St, New Haven, CT 06510, USA; Center for Brain and Mind Health, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, USA.
| |
Collapse
|
4
|
Kung TFC, Wilkinson CM, Liddle LJ, Colbourne F. A systematic review and meta-analysis on the efficacy of glibenclamide in animal models of intracerebral hemorrhage. PLoS One 2023; 18:e0292033. [PMID: 37756302 PMCID: PMC10529582 DOI: 10.1371/journal.pone.0292033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Intracerebral hemorrhage (ICH) is a devastating stroke with many mechanisms of injury. Edema worsens outcome and can lead to mortality after ICH. Glibenclamide (GLC), a sulfonylurea 1- transient receptor potential melastatin 4 (Sur1-Trpm4) channel blocker, has been shown to attenuate edema in ischemic stroke models, raising the possibility of benefit in ICH. This meta-analysis synthesizes current pre-clinical (rodent) literature regarding the efficacy of post-ICH GLC administration (vs. vehicle controls) on behaviour (i.e., neurological deficit, motor, and memory outcomes), edema, hematoma volume, and injury volume. Six studies (5 in rats and 1 in mice) were included in our meta-analysis (PROSPERO registration = CRD42021283614). GLC significantly improved behaviour (standardized mean difference (SMD) = -0.63, [-1.16, -0.09], n = 70-74) and reduced edema (SMD = -0.91, [-1.64, -0.18], n = 70), but did not affect hematoma volume (SMD = 0.0788, [-0.5631, 0.7207], n = 18-20), or injury volume (SMD = 0.2892, [-0.4950, 1.0734], n = 24). However, these results should be interpreted cautiously. Findings were conflicted with 2 negative and 4 positive reports, and Egger regressions indicated missing negative edema data (p = 0.0001), and possible missing negative behavioural data (p = 0.0766). Experimental quality assessed via the SYRCLE and CAMARADES checklists was concerning, as most studies demonstrated high risks of bias. Studies were generally low-powered (e.g., average n = 14.4 for behaviour), and future studies should employ sample sizes of 41 to detect our observed effect size in behaviour and 33 to detect our observed effect in edema. Overall, missing negative studies, low study quality, high risk of bias, and incomplete attention to key recommendations (e.g., investigating female, aged, and co-morbid animals) suggest that further high-powered confirmatory studies are needed before conclusive statements about GLC's efficacy in ICH can be made, and before further clinical trials are performed.
Collapse
Affiliation(s)
- Tiffany F. C. Kung
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Lane J. Liddle
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
| | - Frederick Colbourne
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
5
|
Fainardi E, Busto G, Scola E, Casetta I, Mizutani K, Consoli A, Boulouis G, Padovani A, Morotti A. Perfusion gradients promote delayed perihaematomal oedema in intracerebral haemorrhage. Brain Commun 2023; 5:fcad133. [PMID: 37151226 PMCID: PMC10162681 DOI: 10.1093/braincomms/fcad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/23/2023] [Accepted: 04/20/2023] [Indexed: 05/09/2023] Open
Abstract
Perihaematomal oedema is a potential therapeutic target to improve outcome of patients with intracerebral haemorrhage, but its pathophysiology remains poorly elucidated. We investigated the longitudinal changes of cerebral perfusion and their influence on perihaematomal oedema development in 150 patients with intracerebral haemorrhage who underwent computed tomography perfusion within 6 h from onset, at 24 h and at 7 days. Perfusion parameters were measured in haemorrhagic core, perihaematomal rim, surrounding normal appearing and contralateral brain tissue. Computed tomography perfusion parameters gradually improved from the core to the periphery in each time interval with an early increase at 24 h followed by a delayed decline at 7 days compared with admission values (P < 0.001). Multivariable linear regression analysis showed that haematoma volume and cerebral blood flow gradient between normal appearing and perihaematomal rim were independently associated with absolute perihaematomal oedema volume in the different time points (within 6 h, B = 0.128, P = 0.032; at 24 h, B = 0.133, P = 0.016; at 7 days, B = 0.218, P < 0.001). In a secondary analysis with relative perihaematomal oedema as the outcome of interest, cerebral blood flow gradient between normal appearing and perihaematomal rim was an independent predictor of perihaematomal oedema only at 7 days (B = 0.239, P = 0.002). Our findings raise the intriguing hypothesis that perfusion gradients promote perihaematomal oedema development in the subacute phase after intracerebral haemorrhage.
Collapse
Affiliation(s)
- Enrico Fainardi
- Correspondence to: Enrico Fainardi, MD, PhD Struttura Organizzativa Dipartimentale di Neuroradiologia Dipartimento di Scienze Biomediche, Sperimentali e Cliniche ‘Mario Serio’ Università degli Studi di Firenze Ospedale Universitario Careggi Largo Brambilla 3, Firenze 50134, Italy E-mail:
| | - Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence 50139, Italy
| | - Elisa Scola
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence 50139, Italy
| | - Ilaria Casetta
- Section of Neurological, Psychiatric and Psychological Sciences, Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara 44121, Italy
| | - Katsuhiro Mizutani
- Department of Neurosurgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Arturo Consoli
- Department of Interventional and Diagnostic Neuroradiology, Hopitâl Foch, Suresnes, le de France, Paris 92150, France
| | - Gregoire Boulouis
- Department of Neuroradiology, University Hospital of Tours, Centre Val de Loire Region, Tours 37020, France
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia 25121, Italy
- Department of Neurological Sciences and Vision, Neurology Unit, ASST Spedali Civili, Brescia 25123, Italy
| | - Andrea Morotti
- Department of Neurological Sciences and Vision, Neurology Unit, ASST Spedali Civili, Brescia 25123, Italy
| |
Collapse
|
6
|
Zhang X, Zhu HC, Yang D, Zhang FC, Mane R, Sun SJ, Zhao XQ, Zhou J. Association between cerebral blood flow changes and blood-brain barrier compromise in spontaneous intracerebral haemorrhage. Clin Radiol 2022; 77:833-839. [PMID: 35786315 DOI: 10.1016/j.crad.2022.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 12/30/2022]
Abstract
AIM To quantitatively evaluate blood-brain barrier (BBB) permeability in the perihaematomal region of spontaneous intracerebral haemorrhage (ICH) and investigate the association between the alterations in cerebral blood flow and BBB permeability around the haematoma. MATERIALS AND METHODS Spontaneous ICH patients underwent unenhanced computed tomography (CT) and CT perfusion (CTP) simultaneously. Haematoma volume was measured on CT. The values of cerebral haemodynamic parameters including cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), time to peak (TTP), and permeability-surface area product (PS) were measured in the perihaematomal region and the contralateral mirror region, and then relative values were calculated for statistical analysis. Linear regression was used to evaluate associations between BBB permeability and variables. RESULTS A total of 87 ICH patients were included in this study. The focally elevated BBB permeability was observed in the perihaematomal region in ICH patients. Linear regression showed that reduced rCBF (β = -0.379, p=0.001) and increased rCBV (β = 0.412, p=0.000) correlated independently with increased relative PS (rPS) value in deep ICH, while only increased rCBV (β = 0.423, p=0.071) correlated to increased rPS value in patients with lobar ICH. CONCLUSIONS BBB permeability is focally elevated in the region around the haematoma. Cerebral haemodynamic alterations are associated with increased BBB permeability. Cerebral hypoperfusion may aggravate BBB compromise, and a compensatory increase in CBV may lead to reperfusion injury on BBB.
Collapse
Affiliation(s)
- X Zhang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - H C Zhu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - D Yang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - F C Zhang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - R Mane
- China National Clinical Research Center-Hanalytics Artificial Intelligence Research Centre for Neurological Disorders, Beijing, China
| | - S J Sun
- Department of Neuroradiology, Beijing Neurosurgical Institute, Affiliated Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - X Q Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - J Zhou
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
7
|
Yang J, Jing J, Chen S, Liu X, Tang Y, Pan C, Tang Z. Changes in Cerebral Blood Flow and Diffusion-Weighted Imaging Lesions After Intracerebral Hemorrhage. Transl Stroke Res 2022; 13:686-706. [PMID: 35305264 DOI: 10.1007/s12975-022-00998-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/25/2022]
Abstract
Intracerebral hemorrhage (ICH) is a common subtype of stroke and places a great burden on the family and society with a high mortality and disability rate and a poor prognosis. Many findings from imaging and pathologic studies have suggested that cerebral ischemic lesions visualized on diffusion-weighted imaging (DWI) in patients with ICH are not rare and are generally considered to be associated with poor outcome, increased risk of recurrent (ischemic and hemorrhagic) stroke, cognitive impairment, and death. In this review, we describe the changes in cerebral blood flow (CBF) and DWI lesions after ICH and discuss the risk factors and possible mechanisms related to the occurrence of DWI lesions, such as cerebral microangiopathy, cerebral atherosclerosis, aggressive early blood pressure lowering, hyperglycemia, and inflammatory response. We also point out that a better understanding of cerebral DWI lesions will be a key step toward potential therapeutic interventions to improve long-term recovery for patients with ICH.
Collapse
Affiliation(s)
- Jingfei Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China
| | - Jie Jing
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China
| | - Xia Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China
| | - Yingxin Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China.
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China.
| |
Collapse
|
8
|
Molecular, Pathological, Clinical, and Therapeutic Aspects of Perihematomal Edema in Different Stages of Intracerebral Hemorrhage. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3948921. [PMID: 36164392 PMCID: PMC9509250 DOI: 10.1155/2022/3948921] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/17/2022] [Accepted: 09/03/2022] [Indexed: 02/07/2023]
Abstract
Acute intracerebral hemorrhage (ICH) is a devastating type of stroke worldwide. Neuronal destruction involved in the brain damage process caused by ICH includes a primary injury formed by the mass effect of the hematoma and a secondary injury induced by the degradation products of a blood clot. Additionally, factors in the coagulation cascade and complement activation process also contribute to secondary brain injury by promoting the disruption of the blood-brain barrier and neuronal cell degeneration by enhancing the inflammatory response, oxidative stress, etc. Although treatment options for direct damage are limited, various strategies have been proposed to treat secondary injury post-ICH. Perihematomal edema (PHE) is a potential surrogate marker for secondary injury and may contribute to poor outcomes after ICH. Therefore, it is essential to investigate the underlying pathological mechanism, evolution, and potential therapeutic strategies to treat PHE. Here, we review the pathophysiology and imaging characteristics of PHE at different stages after acute ICH. As illustrated in preclinical and clinical studies, we discussed the merits and limitations of varying PHE quantification protocols, including absolute PHE volume, relative PHE volume, and extension distance calculated with images and other techniques. Importantly, this review summarizes the factors that affect PHE by focusing on traditional variables, the cerebral venous drainage system, and the brain lymphatic drainage system. Finally, to facilitate translational research, we analyze why the relationship between PHE and the functional outcome of ICH is currently controversial. We also emphasize promising therapeutic approaches that modulate multiple targets to alleviate PHE and promote neurologic recovery after acute ICH.
Collapse
|
9
|
Magid-Bernstein J, Girard R, Polster S, Srinath A, Romanos S, Awad IA, Sansing LH. Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions. Circ Res 2022; 130:1204-1229. [PMID: 35420918 PMCID: PMC10032582 DOI: 10.1161/circresaha.121.319949] [Citation(s) in RCA: 135] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.
Collapse
Affiliation(s)
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sean Polster
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Issam A. Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
10
|
Lansberg MG, Wintermark M, Kidwell CS, Albers GW. Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00048-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
11
|
Pan R, Yu S, Zhang H, Timmins GS, Weaver J, Yang Y, Zhou X, Liu KJ. Endogenous zinc protoporphyrin formation critically contributes to hemorrhagic stroke-induced brain damage. J Cereb Blood Flow Metab 2021; 41:3232-3247. [PMID: 34187233 PMCID: PMC8669275 DOI: 10.1177/0271678x211028475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hemorrhagic stroke is a leading cause of death. The causes of intracerebral hemorrhage (ICH)-induced brain damage are thought to include lysis of red blood cells, hemin release and iron overload. These mechanisms, however, have not proven very amenable to therapeutic intervention, and so other mechanistic targets are being sought. Here we report that accumulation of endogenously formed zinc protoporphyrin (ZnPP) also critically contributes to ICH-induced brain damage. ICH caused a significant accumulation of ZnPP in brain tissue surrounding hematoma, as evidenced by fluorescence microscopy of ZnPP, and further confirmed by fluorescence spectroscopy and supercritical fluid chromatography-mass spectrometry. ZnPP formation was dependent upon both ICH-induced hypoxia and an increase in free zinc accumulation. Notably, inhibiting ferrochelatase, which catalyzes insertion of zinc into protoporphyrin, greatly decreased ICH-induced endogenous ZnPP generation. Moreover, a significant decrease in brain damage was observed upon ferrochelatase inhibition, suggesting that endogenous ZnPP contributes to the damage in ICH. Our findings reveal a novel mechanism of ICH-induced brain damage through ferrochelatase-mediated formation of ZnPP in ICH tissue. Since ferrochelatase can be readily inhibited by small molecules, such as protein kinase inhibitors, this may provide a promising new and druggable target for ICH therapy.
Collapse
Affiliation(s)
- Rong Pan
- Department of Pharmaceutical Sciences, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Song Yu
- Department of Pharmaceutical Sciences, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Haikun Zhang
- Department of Pharmaceutical Sciences, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Graham S Timmins
- Department of Pharmaceutical Sciences, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - John Weaver
- Department of Pharmaceutical Sciences, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Yirong Yang
- Department of Pharmaceutical Sciences, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Xixi Zhou
- Department of Pharmaceutical Sciences, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Ke Jian Liu
- Department of Pharmaceutical Sciences, University of New Mexico Health Sciences Center, Albuquerque, USA
| |
Collapse
|
12
|
Chen Y, Chang J, Wei J, Feng M, Wang R. Assessing the Evolution of Intracranial Hematomas by using Animal Models: A Review of the Progress and the Challenges. Metab Brain Dis 2021; 36:2205-2214. [PMID: 34417943 DOI: 10.1007/s11011-021-00828-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/14/2021] [Indexed: 01/07/2023]
Abstract
Stroke has become the second leading cause of death in people aged higher than 60 years, with cancer being the first. Intracerebral hemorrhage (ICH) is the most lethal type of stroke. Using imaging techniques to evaluate the evolution of intracranial hematomas in patients with hemorrhagic stroke is worthy of ongoing research. The difficulty in obtaining ultra-early imaging data and conducting intensive dynamic radiographic imaging in actual clinical settings has led to the application of experimental animal models to assess the evolution of intracranial hematomas. Herein, we review the current knowledge on primary intracerebral hemorrhage mechanisms, focus on the progress of animal studies related to hematoma development and secondary brain injury, introduce preclinical therapies, and summarize related challenges and future directions.
Collapse
Affiliation(s)
- Yihao Chen
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Jianbo Chang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| |
Collapse
|
13
|
Morotti A, Busto G, Bernardoni A, Marini S, Casetta I, Fainardi E. Association Between Perihematomal Perfusion and Intracerebral Hemorrhage Outcome. Neurocrit Care 2021; 33:525-532. [PMID: 32043266 DOI: 10.1007/s12028-020-00929-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The prognostic impact of perihematomal hypoperfusion in patients with acute intracerebral hemorrhage (ICH) remains unclear. We tested the hypothesis that perihematomal hypoperfusion predicts poor ICH outcome and explored whether hematoma growth (HG) is the pathophysiological mechanism behind this association. METHODS A prospectively collected single-center cohort of consecutive ICH patients undergoing computed tomography perfusion on admission was analyzed. Cerebral blood flow (pCBF) was measured in the manually outlined perihematomal low-density area. pCBF was categorized into normal (40-55 mL/100 g/min), low (< 40 mL/100 g/min), and high (> 55 mL/100 g/min). HG was calculated as total volume increase from baseline to follow-up CT. A modified Rankin scale > 2 at three months was the outcome of interest. The association between cerebral perfusion and outcome was investigated with logistic regression, and potential mediators of this relationship were explored with mediation analysis. RESULTS A total of 155 subjects were included, of whom 55 (35.5%) had poor outcome. The rates of normal pCBF, low pCBF, and high pCBF were 17.4%, 68.4%, and 14.2%, respectively. After adjustment for confounders and keeping subjects with normal pCBF as reference, the risk of poor outcome was increased in patients with pCBF < 40 mL/100 g/min (odds ratio 6.11, 95% confidence interval 1.09-34.35, p = 0.040). HG was inversely correlated with pCBF (R = -0.292, p < 0.001) and mediated part of the association between pCBF and outcome (proportion mediated: 82%, p = 0.014). CONCLUSION Reduced pCBF is associated with poor ICH outcome in patients with mild-moderate severity. HG appears a plausible biological mediator but does not fully account for this association, and other mechanisms might be involved.
Collapse
Affiliation(s)
- Andrea Morotti
- Department of Neurology and Neurorehabilitation, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy.
| | - Giorgio Busto
- Diagnostic Imaging Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Andrea Bernardoni
- Neuroradiology Unit, Department of Radiology, Arcispedale S. Anna, Ferrara, Italy
| | - Sandro Marini
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, USA
| | - Ilaria Casetta
- Section of Neurology, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| |
Collapse
|
14
|
Kang H, Cai Q, Gong L, Wang Y. Nomogram Prediction of Short-Term Outcome After Intracerebral Hemorrhage. Int J Gen Med 2021; 14:5333-5343. [PMID: 34522130 PMCID: PMC8434878 DOI: 10.2147/ijgm.s330742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/25/2021] [Indexed: 11/29/2022] Open
Abstract
Background The early symptoms of patients with elevated intracranial pressure (ICP) after intracerebral hemorrhage (ICH) are easily overlooked, which will result in missing the optimal opportunity for clinical intervention. However, it is difficult for ICH patients admitted to the neurology department to receive invasive ICP monitoring, although it is crucial for the early identification of neurologic deterioration (ND). Objective The aim of this study is to investigate the association between the changes of transcranial Doppler (TCD) variables and ND after onset and establish a nomogram for predicting the short-term outcome of ICH. Methods A total of 297 patients were recruited and their clinical characteristics and the changes of TCD variables were recorded. The independent prognostic factors for the ND after onset in the ICH patients were screened from multivariate Logistic regression analysis, which were served as inputs for the nomogram construction. Discrimination and calibration validations were performed to assess the performance of the nomogram [concordance index (C-index) for discrimination and Hosmer–Lemeshow (HL) test for calibration] and the decision curve analysis was applied to assess the clinical suitability. Results ΔaPI [defined as the change of pulsatility index (PI) between the 1st and 3rd day after onset for affected hemisphere] was independently associated with the ND after onset. Moreover, hematoma volume, presence of intraventricular hemorrhage, and Glasgow coma scale were also the independent prognostic factors of ND. The developed nomogram incorporating ΔaPI showed good discrimination (C-index: 0.916 after 1000 bootstrapping) and calibration (P=0.412, HL test) and yielded net benefits. Conclusion The nomogram incorporating ΔaPI might be useful in predicting the risk of ND within 14 days after onset, which might help identify patients in the neurology department in need of further care.
Collapse
Affiliation(s)
- Huili Kang
- Department of Ultrasound, Shanghai Punan Hospital of Pudong New District, Shanghai, People's Republic of China
| | - Qiuqiong Cai
- Department of Ultrasound, Shanghai Punan Hospital of Pudong New District, Shanghai, People's Republic of China
| | - Liang Gong
- Department of Neurosurgery, Shanghai Punan Hospital of Pudong New District, Shanghai, People's Republic of China
| | - Ying Wang
- Department of Ultrasound, Shanghai Punan Hospital of Pudong New District, Shanghai, People's Republic of China
| |
Collapse
|
15
|
Novakovic N, Wilseck ZM, Chenevert TL, Xi G, Keep RF, Pandey AS, Chaudhary N. Assessing early erythrolysis and the relationship to perihematomal iron overload and white matter survival in human intracerebral hemorrhage. CNS Neurosci Ther 2021; 27:1118-1126. [PMID: 34145764 PMCID: PMC8446214 DOI: 10.1111/cns.13693] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/09/2021] [Accepted: 05/24/2021] [Indexed: 12/18/2022] Open
Abstract
AIMS Iron released from lysed red blood cells within the hematoma plays a role in intracerebral hemorrhage (ICH)-related neurotoxicity. This study utilizes magnetic resonance imaging (MRI) to examine the time course, extent of erythrolysis, and its correlation with perihematomal iron accumulation and white matter loss. METHODS The feasibility of assessing proportional erythrolysis using T2* MRI was examined using pig blood phantoms with specified degrees of erythrolysis. Fifteen prospectively enrolled ICH patients had MRIs (3-Tesla) at days 1-3, 14, and 30 (termed early, subacute, and late periods, respectively). Measurement was performed on T2*, 1/T2*, and fractional anisotropy (FA) maps. RESULTS Pig blood phantoms showed a linear relationship between 1/T2* signal and percent erythrolysis. MRI on patients showed an increase in erythrolysis within the hematoma between the early and subacute phases after ICH, almost completing by day 14. Although perihematomal iron overload (IO) correlated with the erythrolysis extent and hematoma volume at days 14 and 30, perihematomal white matter (WM) loss significantly correlated with both, only at day 14. CONCLUSION MRI may reliably assess the portion of the hematoma that lyses over time after ICH. Perihematomal IO and WM loss correlate with both the erythrolysis extent and hematoma volume in the early and subacute periods following ICH.
Collapse
Affiliation(s)
- Nemanja Novakovic
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
16
|
Luo H, Chevillard L, Bellivier F, Mégarbane B, Etain B, Cisternino S, Declèves X. The role of brain barriers in the neurokinetics and pharmacodynamics of lithium. Pharmacol Res 2021; 166:105480. [PMID: 33549730 DOI: 10.1016/j.phrs.2021.105480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/14/2021] [Accepted: 02/01/2021] [Indexed: 12/14/2022]
Abstract
Lithium (Li) is the most widely used mood stabilizer in treating patients with bipolar disorder. However, more than half of the patients do not or partially respond to Li therapy, despite serum Li concentrations in the serum therapeutic range. The exact mechanisms underlying the pharmacokinetic-pharmacodynamic (PK-PD) relationships of lithium are still poorly understood and alteration in the brain pharmacokinetics of lithium may be one of the mechanisms explaining the variability in the clinical response to Li. Brain barriers such as the blood-brain barrier (BBB) and the blood-cerebrospinal fluid barrier (BCSFB) play a crucial role in controlling blood-to-brain and brain-to-blood exchanges of various molecules including central nervous system (CNS) drugs. Recent in vivo studies by nuclear resonance spectroscopy revealed heterogenous brain distribution of Li in human that were not always correlated with serum concentrations, suggesting regional and variable transport mechanisms of Li through the brain barriers. Moreover, alteration in the functionality and integrity of brain barriers is reported in various CNS diseases, as a cause or a consequence and in this regard, Li by itself is known to modulate BBB properties such as the expression and activity of various transporters, metabolizing enzymes, and the specialized tight junction proteins on BBB. In this review, we will focus on recent knowledge into the role of the brain barriers as key-element in the Li neuropharmacokinetics which might improve the understanding of PK-PD of Li and its interindividual variability in drug response.
Collapse
Affiliation(s)
- Huilong Luo
- Université de Paris, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France; Department of Chemical and Biological Engineering, University of Wisconsin-Madison, USA
| | - Lucie Chevillard
- Université de Paris, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France
| | - Frank Bellivier
- Université de Paris, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France; Department of Psychiatry, Lariboisière Hospital, AP-HP, 75010 Paris, France
| | - Bruno Mégarbane
- Université de Paris, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France; Department of Medical and Toxicological Critical Care, Lariboisière Hospital, AP-HP, 75010 Paris, France
| | - Bruno Etain
- Université de Paris, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France; Department of Psychiatry, Lariboisière Hospital, AP-HP, 75010 Paris, France
| | - Salvatore Cisternino
- Université de Paris, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France; Service de Pharmacie, AP-HP, Hôpital Necker, 149 Rue de Sèvres, 75015 Paris, France
| | - Xavier Declèves
- Université de Paris, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France; Biologie du Médicament, AP-HP, Hôpital Cochin, 27 rue du Faubourg, St. Jacques, 75679 Paris Cedex 14, France.
| |
Collapse
|
17
|
Peri-hematoma corticospinal tract integrity in intracerebral hemorrhage patients: A diffusion-tensor imaging study. J Neurol Sci 2021; 421:117317. [PMID: 33476986 DOI: 10.1016/j.jns.2021.117317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 12/09/2020] [Accepted: 01/09/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The impact of perihematoma edema in Intracerebral Hemorrhage (ICH) on white matter integrity is uncertain. Fractional Anisotropy (FA), as measured with Diffusion Tensor Imaging (DTI), can be used to assess white matter microstructure. We tested the hypotheses that sections of the Corticospinal Tract (CST) passing through perihematoma edema would 1) have low FA relative to the contralateral CST and 2) would predict NIHSS motor score in ICH patients. METHODS Patients were prospectively imaged with DTI at 48 h and 7 days after onset. Edema volume/extent was measured on CT at baseline and 24 h. FA, mean, axial and radial diffusivity were measured in the perihematoma edema, contralateral CST and sections of CST passing through the edema ('edematous CST'). RESULTS Patients (n = 27, mean age 67 ± 13) were scanned with DTI at a median (IQR) of 42.3 (24.5) hours and 7.7 (1.8) days from onset. Median acute ICH volume was 8.8 (22) ml. FA in edematous CST at 72 h was decreased (0.37 ± 0.03) relative to contralateral CST (0.52 ± 0.06; p < 0.0001). Day 7 FA in edematous CST (0.35 ± 0.08) was also decreased compared to contralateral CST (0.54 ± 0.06; p < 0.0001). FA remained stable between 72 h (0.37 ± 0.03) and day 7 (0.35 ± 0.07; p = 0.350). FA at 72 h (ρ = -0.22, p = 0.420) and day 7 (ρ = -0.14, p = 0.624) was unrelated to 90-day motor score. CONCLUSIONS FA is decreased in the CST where it passes through the edema. Decreased FA in the edematous CST remained stable over time, was unrelated to motor score, and may represent water infiltration into the tracts rather than axonal injury.
Collapse
|
18
|
Klahr AC, Kosior JC, Dowlatshahi D, Buck BH, Beaulieu C, Gioia LC, Kalashyan H, Wilman AH, Jeerakathil T, Emery DJ, Shuaib A, Butcher KS. Lower Blood Pressure Is Not Associated With Decreased Arterial Spin Labeling Estimates of Perfusion in Intracerebral Hemorrhage. J Am Heart Assoc 2020; 8:e010904. [PMID: 31131671 PMCID: PMC6585347 DOI: 10.1161/jaha.118.010904] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background Subacute ischemic lesions in intracerebral hemorrhage (ICH) have been hypothesized to result from hypoperfusion. Although studies of cerebral blood flow (CBF) indicate modest hypoperfusion in ICH, these investigations have been limited to early time points. Arterial spin labeling (ASL), a magnetic resonance imaging technique, can be used to measure CBF without a contrast agent. We assessed CBF in patients with ICH using ASL and tested the hypothesis that CBF is related to systolic blood pressure (SBP). Methods and Results In this cross‐sectional study, patients with ICH were assessed with ASL at 48 hours, 7 days, and/or 30 days after onset. Relative CBF (rCBF; ratio of ipsilateral/contralateral perfusion) was measured in the perihematomal regions, hemispheres, border zones, and the perilesional area in patients with diffusion‐weighted imaging hyperintensities. Twenty‐patients (65% men; mean±SD age, 68.5±12.7 years) underwent imaging with ASL at 48 hours (N=12), day 7 (N=6), and day 30 (N=11). Median (interquartile range) hematoma volume was 13.1 (6.3–19.3) mL. Mean±SD baseline SBP was 185.4±25.5 mm Hg. Mean perihematomal rCBF was 0.9±0.2 at 48 hours at all time points. Baseline SBP and other SBP measurements were not associated with a decrease in rCBF in any of the regions of interest (P≥0.111). rCBF did not differ among time points in any of the regions of interest (P≥0.097). Mean perilesional rCBF was 1.04±0.65 and was unrelated to baseline SBP (P=0.105). Conclusions ASL can be used to measure rCBF in patients with acute and subacute ICH. Perihematomal CBF was not associated with SBP changes at any time point. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00963976.
Collapse
Affiliation(s)
- Ana C Klahr
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada
| | - Jayme C Kosior
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada
| | | | - Brian H Buck
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada
| | - Christian Beaulieu
- 2 Department of Biomedical Engineering University of Alberta Edmonton Alberta Canada
| | - Laura C Gioia
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada
| | | | - Alan H Wilman
- 2 Department of Biomedical Engineering University of Alberta Edmonton Alberta Canada
| | | | - Derek J Emery
- 3 Department of Radiology and Diagnostic Imaging University of Alberta Edmonton Alberta Canada
| | - Ashfaq Shuaib
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada
| | - Kenneth S Butcher
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada.,5 Prince of Wales Clinical School University of New South Wales Sydney New South Wales Australia
| |
Collapse
|
19
|
Blood pressure variability and outcome after acute intracerebral hemorrhage. J Neurol Sci 2020; 413:116766. [PMID: 32151850 DOI: 10.1016/j.jns.2020.116766] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/24/2020] [Accepted: 03/01/2020] [Indexed: 01/12/2023]
Abstract
Intracerebral hemorrhage (ICH) is life threatening neurologic event that results in significant rate of morbidity and mortality. Unfortunately, several randomized clinical trials aiming at limiting the hematoma expansion (HE) in the acute phase of ICH have not shown significant effects in improving the functional outcomes. Blood pressure variability (BPV) is common following ICH. High BPs have been associated with increased risk of bleeding and HE. Conversely, recurrent sudden decrease in BP promote perihematomal ischemia. However, it is still not clear weather BPV causes adverse prognosis following ICH or large ICHs cause fluctuations in BP. In the current review, we will discuss the mechanistic pathophysiology of BPV and the evidence regarding the role of BPV on the ICH outcomes.
Collapse
|
20
|
Boltze J, Ferrara F, Hainsworth AH, Bridges LR, Zille M, Lobsien D, Barthel H, McLeod DD, Gräßer F, Pietsch S, Schatzl AK, Dreyer AY, Nitzsche B. Lesional and perilesional tissue characterization by automated image processing in a novel gyrencephalic animal model of peracute intracerebral hemorrhage. J Cereb Blood Flow Metab 2019; 39:2521-2535. [PMID: 30239258 PMCID: PMC6893983 DOI: 10.1177/0271678x18802119] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/09/2018] [Accepted: 08/15/2018] [Indexed: 12/19/2022]
Abstract
Intracerebral hemorrhage (ICH) is an important stroke subtype, but preclinical research is limited by a lack of translational animal models. Large animal models are useful to comparatively investigate key pathophysiological parameters in human ICH. To (i) establish an acute model of moderate ICH in adult sheep and (ii) an advanced neuroimage processing pipeline for automatic brain tissue and hemorrhagic lesion determination; 14 adult sheep were assigned for stereotactically induced ICH into cerebral white matter under physiological monitoring. Six hours after ICH neuroimaging using 1.5T MRI including structural as well as perfusion and diffusion, weighted imaging was performed before scarification and subsequent neuropathological investigation including immunohistological staining. Controlled, stereotactic application of autologous blood caused a space-occupying intracerebral hematoma of moderate severity, predominantly affecting white matter at 5 h post-injection. Neuroimage post-processing including lesion probability maps enabled automatic quantification of structural alterations including perilesional diffusion and perfusion restrictions. Neuropathological and immunohistological investigation confirmed perilesional vacuolation, axonal damage, and perivascular blood as seen after human ICH. The model and imaging platform reflects key aspects of human ICH and enables future translational research on hematoma expansion/evacuation, white matter changes, hematoma evacuation, and other aspects.
Collapse
Affiliation(s)
- Johannes Boltze
- Department of Translational Medicine and
Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell
Technology, Lübeck, Germany
- Institute for Medical and Marine
Biotechnology, University of Lübeck, Lübeck, Germany
| | - Fabienne Ferrara
- Max Delbrück Center for Molecular
Medicine in the Helmholtz Association, Berlin, Germany
| | - Atticus H Hainsworth
- Cell Biology and Genetics Research
Centre, Molecular and Clinical Sciences Research Institute, St George’s University
of London, London, UK
| | - Leslie R Bridges
- Cell Biology and Genetics Research
Centre, Molecular and Clinical Sciences Research Institute, St George’s University
of London, London, UK
- Department of Cellular Pathology, St
George's University Hospitals NHS Foundation Trust, London, UK
| | - Marietta Zille
- Department of Translational Medicine and
Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell
Technology, Lübeck, Germany
- Institute for Medical and Marine
Biotechnology, University of Lübeck, Lübeck, Germany
- Institute for Experimental and Clinical
Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany
| | - Donald Lobsien
- Department of Neuroradiology, University
Hospital of Leipzig, Leipzig, Germany
| | - Henryk Barthel
- Clinic for Nuclear Medicine, University
of Leipzig, Leipzig, Germany
| | - Damian D McLeod
- OncoRay – National Center for Radiation
Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus,
Technische Universität Dresden, Helmholtz-Zentrum
- School of Biomedical Sciences and
Pharmacy, Faculty of Health and Medicine, and Hunter Medical Research Institute, The
University of Newcastle, Callaghan, Australia
| | - Felix Gräßer
- Institute of Biomedical Engineering,
Faculty of Electrical and Computer Engineering, Technical University of Dresden,
Dresden, Germany
| | - Sören Pietsch
- Department of Translational Medicine and
Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell
Technology, Lübeck, Germany
| | - Ann-Kathrin Schatzl
- Department for Cell Therapies,
Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Antje Y Dreyer
- Department for Cell Therapies,
Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Björn Nitzsche
- Clinic for Nuclear Medicine, University
of Leipzig, Leipzig, Germany
- Department of Pharmacology and
Personalised Medicine, Faculty of Health, Medicine and Life Sciences, Maastricht
University, Maastricht, The Netherlands
| |
Collapse
|
21
|
Abstract
Central nervous system hemorrhage has multiple pathophysiologic etiologies, including intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI). Given the nuances intrinsic to each of these etiologies and pathophysiologic processes, optimal blood pressure varies significantly and depends on type of hemorrhage and individual characteristics. This article reviews the most current evidence regarding blood pressure targets and provides guidance on reversal of anticoagulation for TBI, ICH, and SAH. It also describes the assessment, optimal therapeutic targets, and interventions to treat intracranial hypertension that can result from TBI, ICH, or SAH.
Collapse
Affiliation(s)
- Evie Marcolini
- Department of Surgery, Division of Emergency Medicine, University of Vermont College of Medicine, 111 Colchester Avenue, Burlington, VT 05401, USA; Department of Neurology, Division of Neurocritical Care, University of Vermont College of Medicine, 111 Colchester Avenue, Burlington, VT 05401, USA.
| | - Christoph Stretz
- Division of Vascular Neurology, Yale School of Medicine, 15 York Street, LLCI Building Suite 1004, New Haven, CT 06510, USA
| | - Kyle M DeWitt
- Department of Pharmacy, The University of Vermont Medical Center, 111 Colchester Avenue, Mailstop 272 BA1, Burlington, VT 05401, USA
| |
Collapse
|
22
|
Ironside N, Chen CJ, Ding D, Mayer SA, Connolly ES. Perihematomal Edema After Spontaneous Intracerebral Hemorrhage. Stroke 2019; 50:1626-1633. [PMID: 31043154 DOI: 10.1161/strokeaha.119.024965] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Natasha Ironside
- From the Department of Neurological Surgery, Columbia University Medical Center, New York, NY (N.I., E.S.C.)
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville (C.-J.C.)
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville School of Medicine, KY (D.D.)
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Detroit, MI (S.A.M.)
| | - Edward Sander Connolly
- From the Department of Neurological Surgery, Columbia University Medical Center, New York, NY (N.I., E.S.C.)
| |
Collapse
|
23
|
Zhang X, Zhou S, Zhang Q, Fu X, Wu Y, Liu J, Liang B, Yang Z, Wang X. Stereotactic aspiration for hypertensive intracerebral haemorrhage in a Chinese population: a retrospective cohort study. Stroke Vasc Neurol 2019; 4:14-21. [PMID: 31105974 PMCID: PMC6475080 DOI: 10.1136/svn-2018-000200] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/09/2019] [Accepted: 02/13/2019] [Indexed: 12/31/2022] Open
Abstract
Objective We aimed to compare the therapeutic effects of stereotactic aspiration and best medical management in patients who developed supratentorial hypertensive intracerebral haemorrhage (HICH) with a volume of haemorrhage between 20 and 40 mL. Methods The clinical data of 220 patients with supratentorial HICH with a volume between 20 and 40 mL were retrospectively analysed. Among them, 142 received stereotactic aspiration surgery (stereotactic aspiration group) and 78 received best medical management (conservative group). All were followed up for 6 months. Multivariate logistic regression and Kaplan-Meier survival curves were used to compare the outcome between the two groups. Results The rebleeding rate was lower in the group that had stereotactic aspiration when compared with the group with medical treatment (6 [4.2%] vs 9 [11.5%], χ2=4.364, p=0.037). After 6 months, although the mortality rate did not differ significantly between the two groups (8 cases [5.6%] vs 10 cases [12.8%], χ2=3.461, p=0.063), the rate of a favourable outcome was higher in the group who received stereotactic aspiration (χ2=15.870, p=0.000). Logistic regression identified that medical treatment (OR=1.64, p=0.000) was an independent risk factor for an unfavourable outcome. The Kaplan-Meier curves indicated that the median favourable outcome time in the stereotactic aspiration group was 59.5 days compared with that in the medically treated group (87.0 days). The log-rank test indicated that the prognosis at 6 months was better for those treated with stereotactic haematoma aspiration (χ2=29.866, p=0.000). However, the 6-month survival rate was similar between the two groups (χ2=3.253, p=0.068). Conclusions Stereotactic haematoma aspiration significantly improved the quality of life, although did not effectively reduce the rate of mortality. When selected appropriately, patients with HICH may benefit from this type of surgical intervention.
Collapse
Affiliation(s)
- Xuyang Zhang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shaolong Zhou
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiang Zhang
- Department of Radiation Oncology and Comprehensive Cancer Center, The University of Michigan, Ann Arbor, Michigan, USA
| | - Xudong Fu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuehui Wu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiasheng Liu
- Department of Neurosurgery, Neihuang People’s Hospital, Neihuang, China
| | - Bo Liang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhuo Yang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinjun Wang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
24
|
Ye Z, Ai X, Zheng J, Ma L, Lin S, You C, Li H. The Effect of Cerebrovascular Stenosis on -Peri-Hematoma Cerebral Perfusion and Clinical Outcomes in Patients with Supratentorial Spontaneous Intracerebral Hemorrhage. Med Sci Monit 2018; 24:8647-8654. [PMID: 30496154 PMCID: PMC6282907 DOI: 10.12659/msm.906284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Many factors are associated with the cerebral hypoperfusion after spontaneous intracerebral hemorrhage (sICH), however, the effect of cerebrovascular stenosis on peri-hematoma cerebral blood flow (CBF) and 90-day poor outcomes in patients with spontaneous intracerebral hemorrhage is still unclear. Material/Methods From September 2016 to March 2017, we prospectively collected data on adults with supratentorial spontaneous intracerebral hemorrhages. Using the Propensity Score model, we compared the peri-hematoma CBF and 90-day poor outcomes (mRS ≥3) in the stenosis group and the control group. Results Before matching, a total of 116 patients were included in this study, 25 patients in the stenosis group and 91 patients in the control group. After matching, the patients in the stenosis group had a higher absolute decrease of CBF (p=0.003), higher relative decrease of CBF (p=0.016), and higher incidence of 90-day poor outcomes (p=0.041) than the control group. With subgroup analysis, the patients with Glasgow Coma Scale from 13 to 15 (p=0.035), hematoma in the cerebral lobe (p=0.003), mean arterial pressure lower than 120 mm Hg (p=0.003), absolute decrease of CBF higher than 15 mL/100 g per minute (p=0.007), and relative decrease of CBF higher than 30% (p=0.020) had poorer outcomes. Conclusions In our series, the stenosis of main cerebral vessels decreased the peri-hematoma CBF and increased the rate of 90-day poor outcomes. Despite higher Glasgow Coma Scale, the evaluation of cerebral perfusion in patients with sICH is needed, especially for the patients with hematoma in the cerebral lobe and lower mean arterial pressure; and treatments to keep adequate cerebral perfusion are needed.
Collapse
Affiliation(s)
- Zengpanpan Ye
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Xiaolin Ai
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Lu Ma
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Sen Lin
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Hao Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| |
Collapse
|
25
|
Klahr AC, Kate M, Kosior J, Buck B, Shuaib A, Emery D, Butcher K. Early hematoma retraction in intracerebral hemorrhage is uncommon and does not predict outcome. PLoS One 2018; 13:e0205436. [PMID: 30300383 PMCID: PMC6177160 DOI: 10.1371/journal.pone.0205436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/25/2018] [Indexed: 11/19/2022] Open
Abstract
Background Clot retraction in intracerebral hemorrhage (ICH) has been described and postulated to be related to effective hemostasis and perihematoma edema (PHE) formation. The incidence and quantitative extent of hematoma retraction (HR) is unknown. Our aim was to determine the incidence of HR between baseline and time of admission. We also tested the hypothesis that patients with HR had higher PHE volume and good prognosis. Methods This was a retrospective single-centre study in which serial planimetric volume measurements of the total hematoma volume (parenchymal (IPH) and intraventricular (IVH)) and PHE were performed in ICH patients with baseline non-contrast computed tomography (CT) completed within 6 hours of onset and follow-up CT 24 (±12) hours from symptom onset. HR was defined as a decrease in volume of >3ml or >15%, and hematoma expansion (HE) as an increase of >6ml or >30%. All other patients were categorized as stable hematoma (HS). Good outcome was defined as modified Rankin Scale (mRS) 0–2 at 90 days. Results A total of 136 patients (mean age = 69.3±13.39 years, 58.1% male) were included. Median (interquartile range) baseline total hematoma volume was 14.96 (7.80, 31.88) ml. HR >3ml and >15% occurred in 6 (4.4%) and 8 (5.9%) patients, respectively. Neither definition of HR was associated with follow-up PHE (p>0.297) or good outcome (p>0.249). IVH was the only independent predictor of HR (p<0.0241). Conclusions Early HR is rare and associated with IVH, but not with PHE or clinical outcome. There was no relationship between HR, PHE, and patient prognosis. Therefore, HR is unlikely to be a useful endpoint in clinical ICH studies.
Collapse
Affiliation(s)
- Ana C. Klahr
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Mahesh Kate
- Department of Neurology, Christian Medical College Ludhiana, Ludhiāna, India
| | - Jayme Kosior
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Derek Emery
- Department of Radiology, University of Alberta, Edmonton, Canada
| | - Kenneth Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
- * E-mail:
| |
Collapse
|
26
|
Dineen RA, Pszczolkowski S, Flaherty K, Law ZK, Morgan PS, Roberts I, Werring DJ, Al-Shahi Salman R, England T, Bath PM, Sprigg N. Does tranexamic acid lead to changes in MRI measures of brain tissue health in patients with spontaneous intracerebral haemorrhage? Protocol for a MRI substudy nested within the double-blind randomised controlled TICH-2 trial. BMJ Open 2018; 8:e019930. [PMID: 29431141 PMCID: PMC5879748 DOI: 10.1136/bmjopen-2017-019930] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/28/2017] [Accepted: 12/12/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To test whether administration of the antifibrinolytic drug tranexamic acid (TXA) in patients with spontaneous intracerebral haemorrhage (SICH) leads to increased prevalence of diffusion-weighted MRI-defined hyperintense ischaemic lesions (primary hypothesis) or reduced perihaematomal oedema volume, perihaematomal diffusion restriction and residual MRI-defined SICH-related tissue damage (secondary hypotheses). DESIGN MRI substudy nested within the double-blind randomised controlled Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage (TICH)-2 trial (ISRCTN93732214). SETTING International multicentre hospital-based study. PARTICIPANTS Eligible adults consented and randomised in the TICH-2 trial who were also able to undergo MRI scanning. To address the primary hypothesis, a sample size of n=280 will allow detection of a 10% relative increase in prevalence of diffusion-weighted imaging (DWI) hyperintense lesions in the TXA group with 5% significance, 80% power and 5% imaging data rejection. INTERVENTIONS TICH-2 MRI substudy participants will undergo MRI scanning using a standardised protocol at day ~5 and day ~90 after randomisation. Clinical assessments, randomisation to TXA or placebo and participant follow-up will be performed as per the TICH-2 trial protocol. CONCLUSION The TICH-2 MRI substudy will test whether TXA increases the incidence of new DWI-defined ischaemic lesions or reduces perihaematomal oedema or final ICH lesion volume in the context of SICH. ETHICS AND DISSEMINATION The TICH-2 trial obtained ethical approval from East Midlands - Nottingham 2 Research Ethics Committee (12/EM/0369) and an amendment to allow the TICH-2 MRI sub study was approved in April 2015 (amendment number SA02/15). All findings will be published in peer-reviewed journals. The primary outcome results will also be presented at a relevant scientific meeting. TRIAL REGISTRATION NUMBER ISRCTN93732214; Pre-results.
Collapse
Affiliation(s)
- Rob A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Stefan Pszczolkowski
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Zhe K Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Paul S Morgan
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK
- Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - David J Werring
- Stroke Research Centre, University College London, London, UK
| | | | - Tim England
- Vascular Medicine, Division of Medical Sciences and GEM, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| |
Collapse
|
27
|
Al-Mufti F, Thabet AM, Singh T, El-Ghanem M, Amuluru K, Gandhi CD. Clinical and Radiographic Predictors of Intracerebral Hemorrhage Outcome. INTERVENTIONAL NEUROLOGY 2018; 7:118-136. [PMID: 29628951 PMCID: PMC5881146 DOI: 10.1159/000484571] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) represents 10-15% of all stroke cases in the US annually. Fewer than 40% of these patients ever reach long-term functional independence, and mortality rate is roughly 40% at 1 month. Due to the high morbidity and mortality rates after ICH, early detection of high-risk patients would be beneficial in directing the management course and goals of care. This review aims to discuss relevant clinical and radiographic characteristics that can serve as predictors of poor prognosis and examine their efficacy in predicting patient outcomes after ICH. SUMMARY A literature review was conducted on various clinical and radiographic factors. They were examined for their predictive value in relation to ICH outcome. Studies that focused on each of these factors were included, and their results analyzed for trends with regard to incidence, patient outcome, and mortality rate. KEY MESSAGE In this review, we examined clinical and radiographic characteristics that have been found to be significantly associated to a varying degree with poor outcome. Clinical and radiographic predictors of poor patient outcome are invaluable when it comes to identifying high-risk patients and triaging accordingly as well as guiding decision-making.
Collapse
Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Neurosurgery, and Radiology, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
| | - Ahmad M. Thabet
- Department of Neurology, Neurosurgery, and Radiology, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Tarundeep Singh
- Department of Neurology, Neurosurgery, and Radiology, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery, and Radiology, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
| | - Krishna Amuluru
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
- Department of Interventional Neuroradiology, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania, USA
| | - Chirag D. Gandhi
- Westchester Medical Center, New York College of Medicine, Valhalla, New York, USA
| |
Collapse
|
28
|
Gavito-Higuera J, Khatri R, Qureshi IA, Maud A, Rodriguez GJ. Aggressive blood pressure treatment of hypertensive intracerebral hemorrhage may lead to global cerebral hypoperfusion: Case report and imaging perspective. World J Radiol 2017; 9:448-453. [PMID: 29354210 PMCID: PMC5746648 DOI: 10.4329/wjr.v9.i12.448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 08/22/2017] [Accepted: 11/30/2017] [Indexed: 02/06/2023] Open
Abstract
Hypoperfusion injury related to blood pressure decrease in acute hypertensive intracerebral hemorrhage continues to be a controversial topic. Aggressive treatment is provided with the intent to stop the ongoing bleeding. However, there may be additional factors, including autoregulation and increased intracranial pressure, that may limit this approach. We present here a case of acute hypertensive intracerebral hemorrhage, in which aggressive blood pressure management to levels within the normal range led to global cerebral ischemia within multiple border zones. Global cerebral ischemia may be of concern in the management of hypertensive hemorrhage in the presence of premorbid poorly controlled blood pressure and increased intracranial pressure.
Collapse
Affiliation(s)
- Jose Gavito-Higuera
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Ihtesham A Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| |
Collapse
|
29
|
Schneider T, Frieling D, Schroeder J, Regelsberger J, Schoen G, Fiehler J, Gellißen S. Perihematomal diffusion restriction as a common finding in large intracerebral hemorrhages in the hyperacute phase. PLoS One 2017; 12:e0184518. [PMID: 28922367 PMCID: PMC5602530 DOI: 10.1371/journal.pone.0184518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/27/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose There is growing evidence that a perihematomal area of restricted diffusion (PDR) exists in intraparenchymal hemorrhages (IPH) within 1 week of symptom onset (SO). Here, we study characteristics and the clinical impact of the PDR in patients with hyperacute (≤ 6 hours from SO) IPH by means of apparent diffusion coefficient (ADC). Methods This monocentric, retrospective study includes 83 patients with first-ever primary IPH from 09/2002-10/2015. 3D volumetric segmentation was performed for the IPH, PDR, and perihematomal edema (PHE) on fluid-attenuated inversion recovery, T2*/susceptibility weighted images, and ADC images. Results A PDR was seen in 56/83 patients (67.5%) presenting with hyperacute IPH. Multivariate logistic regression analysis revealed every 10-year increase of age (HR 1.929, 95% CI 1.047–3.552, P = .035) and male gender (HR 5.672, 95% CI 1.038–30.992, P = .045) as significant predictors of the presence of a PDR, but not IPH size, IPH location, nor National Institutes of Health Stroke Scale Score (NIHSS) at admission. We found no difference in NIHSS at discharge, hematoma removal, or mortality rate in PDR-positive patients. ADC values of the PDR show a step-wise normalization with increasing time from SO. Conclusions Occurrence of a PDR is a common finding in supratentorial hyperacute IPH, but shows no adverse short-term clinical impact. It may represent transient oligemic and metabolic changes.
Collapse
Affiliation(s)
- Tanja Schneider
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Diagnostic and Interventional Radiology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
- * E-mail:
| | - David Frieling
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Schroeder
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schoen
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
30
|
Abstract
The incidence of spontaneous intracerebral hematoma (SICH) is even now high worldwide, especially higher in Japan than in Western countries, despite the development of advances in blood pressure (BP) management and food/alcohol intake education. Although mortality and morbidity for SICH are high, some controversies remain regarding the appropriate acute phase of treatment. Recent studies have revealed that BP lowering treatment than 140 mmHg resulted in better outcomes. However the efficacy of surgical treatment for SICH has not been well established, with the exception of that for cerebellar SICH over 3 cm in diameter and life-saving procedures, although many randomized control studies and systematic reviews focused on surgical treatment have been reported. In this review, we summarize some issues and discuss strategies in development for the treatment of SICH.
Collapse
Affiliation(s)
- Motohiro Morioka
- Department of Neurosurgery, Kurume University, School of Medicine
| | - Kimihiko Orito
- Department of Neurosurgery, Kurume University, School of Medicine
| |
Collapse
|
31
|
Bonsack F, Alleyne CH, Sukumari-Ramesh S. Resveratrol Attenuates Neurodegeneration and Improves Neurological Outcomes after Intracerebral Hemorrhage in Mice. Front Cell Neurosci 2017; 11:228. [PMID: 28848394 PMCID: PMC5550718 DOI: 10.3389/fncel.2017.00228] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 07/19/2017] [Indexed: 12/17/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a devastating type of stroke with a substantial public health impact. Currently, there is no effective treatment for ICH. The purpose of the study was to evaluate whether the post-injury administration of Resveratrol confers neuroprotection in a pre-clinical model of ICH. To this end, ICH was induced in adult male CD1 mice by collagenase injection method. Resveratrol (10 mg/kg) or vehicle was administered at 30 min post-induction of ICH and the neurobehavioral outcome, neurodegeneration, cerebral edema, hematoma resolution and neuroinflammation were assessed. The Resveratrol treatment significantly attenuated acute neurological deficits, neurodegeneration and cerebral edema after ICH in comparison to vehicle treated controls. Further, Resveratrol treated mice exhibited improved hematoma resolution with a concomitant reduction in the expression of proinflammatory cytokine, IL-1β after ICH. Altogether, the data suggest the efficacy of post-injury administration of Resveratrol in improving acute neurological function after ICH.
Collapse
Affiliation(s)
- Frederick Bonsack
- Department of Neurosurgery, Medical College of Georgia, Augusta UniversityAugusta, GA, United States
| | - Cargill H Alleyne
- Department of Neurosurgery, Medical College of Georgia, Augusta UniversityAugusta, GA, United States
| | - Sangeetha Sukumari-Ramesh
- Department of Neurosurgery, Medical College of Georgia, Augusta UniversityAugusta, GA, United States
| |
Collapse
|
32
|
Shimoda Y, Ohtomo S, Arai H, Okada K, Tominaga T. Satellite Sign: A Poor Outcome Predictor in Intracerebral Hemorrhage. Cerebrovasc Dis 2017; 44:105-112. [PMID: 28605739 DOI: 10.1159/000477179] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The presence of high-density starry dots around the intracerebral hemorrhage (ICH), which we termed as a satellite sign, is occasionally observed in CT. The relationship between ICH with a satellite sign and its functional outcome has not been identified. This study aimed to determine whether the presence of a satellite sign could be an independent prognostic factor for patients with ICH. METHODS Patients with acute spontaneous ICH were retrospectively identified and their initial CT scans were reviewed. A satellite sign was defined as scattered high-density lesions completely separate from the main hemorrhage in at least the single axial slice. Functional outcome was evaluated using the modified Rankin Scale (mRS) at discharge. Poor functional outcome was defined as mRS scores of 3-6. Univariate and multivariate logistic regression analyses were applied to assess the presence of a satellite sign and its association with poor functional outcome. RESULTS A total of 241 patients with ICH were enrolled in the study. Of these, 98 (40.7%) had a satellite sign. Patients with a satellite sign had a significantly higher rate of poor functional outcome (95.9%) than those without a satellite sign (55.9%, p < 0.0001). Multivariate logistic regression analysis revealed that higher age (OR 1.06; 95% CI 1.03-1.10; p = 0.00016), large hemorrhage size (OR 1.06; 95% CI 1.03-1.11; p = 0.00015), and ICH with a satellite sign (OR 13.5; 95% CI 4.42-53.4; p < 0.0001) were significantly related to poor outcome. A satellite sign was significantly related with higher systolic blood pressure (p = 0.0014), higher diastolic blood pressure (p = 0.0117), shorter activated partial thromboplastin time (p = 0.0427), higher rate of intraventricular bleeding (p < 0.0001), and larger main hemorrhage (p < 0.0001). CONCLUSIONS The presence of a satellite sign in the initial CT scan is associated with a significantly worse functional outcome in ICH patients.
Collapse
Affiliation(s)
- Yoshiteru Shimoda
- Department of Neurosurgery, South Miyagi Medical Center, Miyagi, Japan
| | | | | | | | | |
Collapse
|
33
|
Quantitative assessment on blood-brain barrier permeability of acute spontaneous intracerebral hemorrhage in basal ganglia: a CT perfusion study. Neuroradiology 2017; 59:677-684. [PMID: 28580533 DOI: 10.1007/s00234-017-1852-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/16/2017] [Indexed: 01/05/2023]
Abstract
PURPOSE Blood-brain barrier (BBB) damage aggravates perihematomal edema, and edema volume predicts prognosis independently. But the BBB permeability at the late stage of acute intracerebral hemorrhage (ICH) patients is uncertain. We aimed to assess the BBB permeability of spontaneous basal ganglia ICH using computed tomographic perfusion (CTP) and investigates its relationship with hematoma and perihematomal edema volume. METHODS We performed CTP on 54 consecutive ICH patients within 24 to 72 h after symptom onset. Permeability-surface area product (PS) derived from CTP imaging was measured in hematoma, "high-PS spot," perihematoma, normal-appearing, hemispheric, and contralateral regions. Hematoma and edema volumes were calculated from non-contrast CT. RESULTS "High-PS spot" and perihematoma regions had higher PS than the contralateral regions (p < 0.001). Hematoma PS was lower than that in the contralateral regions (p < 0.001). Perihematoma PS of the large-hematoma group was higher than that of the small-hematoma group (p = 0.011). Perihematomal edema volume correlated positively with hematoma volume (β = 0.864, p < 0.001) and perihematoma PS (β = 0.478, p < 0.001). Perihematoma PS correlated positively with hematoma volume (β = 0.373, p = 0.005). CONCLUSIONS Locally elevated perihematoma PS was found in most spontaneous basal ganglia ICH patients within 24 to 72 h after symptom onset. Perihematoma PS was higher in larger hematomas and was associated with larger edema volume. At this period, BBB leakage is likely to be an important factor in edema formation.
Collapse
|
34
|
Ye Z, Ai X, Zheng J, Hu X, Lin S, You C, Li H. Antihypertensive treatments for spontaneous intracerebral hemorrhage in patients with cerebrovascular stenosis: A randomized clinical trial (ATICHST). Medicine (Baltimore) 2017; 96:e7289. [PMID: 28658126 PMCID: PMC5500048 DOI: 10.1097/md.0000000000007289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Antihypertensive treatment is associated with clinical outcomes in patients with spontaneous intracerebral hemorrhage (sICH). ADAPT showed that intensive blood pressure lowering (<140 mm Hg) does not reduce peri-hematoma regional cerebral blood flow (rCBF) in patients with sICH. However, the stenosis of main cerebral arteries that has a high presence in patients with sICH is well-known related to the brain ischemia. The effect of intensive BP lowering for sICH in patients with cerebrovascular stenosis is still unknown. AIM The aim of this study was to determine the safety and effectiveness of intensive BP lowering for sICH in patients with cerebrovascular stenosis. METHODS AND ANALYSIS A pilot trial has been conducted to calculate the sample size and 80 patients of sICH with cerebrovascular stenosis will be involved. The target of systolic blood pressure (SBP) will be maintained at from 120 to 140 mm Hg or from 140 to 180 mm Hg for 7 days. Cerebral ischemia will be assessed at 24 hours after onset by computed tomography (CT) perfusion imaging and the follow-up will be conducted at 30-day and 90-day. The primary outcome is the reduction of peri-hematoma rCBF. The other cerebral perfusion indexes and the rate of ischemic stroke are regarded as other primary outcomes. The secondary outcomes include clinical outcome at 30 days and 90 days, complications, and hospital stays. DISCUSSION The ATICHST trial has been signed as a parallel, prospective, randomized, assessor-blinded clinical trial to determine the effects of intensive BP lowering on sICH in patients with cerebrovascular stenosis, the results of which will contribute to guide the management of blood pressure in sICH. CONCLUSION The protocol will determine the safety and effectiveness of intensive BP lowering for sICH with cerebrovascular stenosis.
Collapse
|
35
|
Gioia L, Klahr A, Kate M, Buck B, Dowlatshahi D, Jeerakathil T, Emery D, Butcher K. The intracerebral hemorrhage acutely decreasing arterial pressure trial II (ICH ADAPT II) protocol. BMC Neurol 2017; 17:100. [PMID: 28525977 PMCID: PMC5437568 DOI: 10.1186/s12883-017-0884-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/10/2017] [Indexed: 11/19/2022] Open
Abstract
Background Aggressively lowering blood pressure (BP) in acute intracerebral hemorrhage (ICH) may improve outcome. Although there is no evidence that BP reduction changes cerebral blood flow, retrospective magnetic resonance imaging (MRI) studies have demonstrated sub-acute ischemic lesions in ICH patients. The primary aim of this study is to assess ischemic lesion development in patients randomized to two different BP treatment strategies. We hypothesize aggressive BP reduction is not associated with ischemic injury after ICH. Methods The Intracerebral Hemorrhage Acutely Decreasing Blood Pressure Trial II (ICH ADAPT II) is a phase II multi-centre randomized open-label, blinded-endpoint trial. Acute ICH patients (N = 270) are randomized to a systolic blood pressure (SBP) target of <140 or <180 mmHg. Acute ICH patients within 6 h of onset and two SBP measurements ≥140 mmHg recorded >2 mins apart qualify. SBP is managed with a pre-defined treatment protocol. Patients undergo MRI at 48 h, Days 7 and 30, with clinical assessment at Day 30 and 90. The primary outcome is diffusion weighted imaging (DWI) lesion frequency at 48 h. Secondary outcomes include cumulative DWI lesion rate frequency within 30 days, absolute hematoma growth, prediction of DWI lesion incidence, 30-day mortality rates, day 90 functional outcome, and cognitive status. Discussion This trial will assess the impact of hypertensive therapies on physiological markers of ischemic injury. The findings of this study will provide evidence for the link, or lack thereof, between BP reduction and ischemic injury in ICH patients. Trial registration This study is registered with clinicaltrials.gov (NCT02281838, first received October 29, 2014). Electronic supplementary material The online version of this article (doi:10.1186/s12883-017-0884-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Laura Gioia
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Ana Klahr
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Mahesh Kate
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Brian Buck
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | | | - Thomas Jeerakathil
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Derek Emery
- Department of Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Kenneth Butcher
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada.
| |
Collapse
|
36
|
Helbok R, Schiefecker AJ, Friberg C, Beer R, Kofler M, Rhomberg P, Unterberger I, Gizewski E, Hauerberg J, Möller K, Lackner P, Broessner G, Pfausler B, Ortler M, Thome C, Schmutzhard E, Fabricius M. Spreading depolarizations in patients with spontaneous intracerebral hemorrhage: Association with perihematomal edema progression. J Cereb Blood Flow Metab 2017; 37:1871-1882. [PMID: 27207168 PMCID: PMC5435285 DOI: 10.1177/0271678x16651269] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 04/05/2016] [Accepted: 04/26/2016] [Indexed: 11/16/2022]
Abstract
Pathophysiologic mechanisms of secondary brain injury after intracerebral hemorrhage and in particular mechanisms of perihematomal-edema progression remain incompletely understood. Recently, the role of spreading depolarizations in secondary brain injury was established in ischemic stroke, subarachnoid hemorrhage and traumatic brain injury patients. Its role in intracerebral hemorrhage patients and in particular the association with perihematomal-edema is not known. A total of 27 comatose intracerebral hemorrhage patients in whom hematoma evacuation and subdural electrocorticography was performed were studied prospectively. Hematoma evacuation and subdural strip electrode placement was performed within the first 24 h in 18 patients (67%). Electrocorticography recordings started 3 h after surgery (IQR, 3-5 h) and lasted 157 h (median) per patient and 4876 h in all 27 patients. In 18 patients (67%), a total of 650 spreading depolarizations were observed. Spreading depolarizations were more common in the initial days with a peak incidence on day 2. Median electrocorticography depression time was longer than previously reported (14.7 min, IQR, 9-22 min). Postoperative perihematomal-edema progression (85% of patients) was significantly associated with occurrence of isolated and clustered spreading depolarizations. Monitoring of spreading depolarizations may help to better understand pathophysiologic mechanisms of secondary insults after intracerebral hemorrhage. Whether they may serve as target in the treatment of intracerebral hemorrhage deserves further research.
Collapse
Affiliation(s)
- Raimund Helbok
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | | | - Christian Friberg
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Ronny Beer
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Mario Kofler
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Paul Rhomberg
- Department of Neuroradiology, Medical University Innsbruck, Austria
| | - Iris Unterberger
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Elke Gizewski
- Department of Neuroradiology, Medical University Innsbruck, Austria
| | - John Hauerberg
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Möller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen, Denmark
| | - Peter Lackner
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Gregor Broessner
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Bettina Pfausler
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Martin Ortler
- Department of Neurosurgery, Medical University Innsbruck, Austria
| | - Claudius Thome
- Department of Neurosurgery, Medical University Innsbruck, Austria
| | - Erich Schmutzhard
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria
| | - Martin Fabricius
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
37
|
Abstract
Intracerebral hemorrhage (ICH) is a potentially devastating neurologic injury representing 10-15% of stroke cases in the USA each year. Numerous risk factors, including age, hypertension, male gender, coagulopathy, genetic susceptibility, and ethnic descent, have been identified. Timely identification, workup, and management of this condition remain a challenge for clinicians as numerous factors can present obstacles to achieving good functional outcomes. Several large clinical trials have been conducted over the prior decade regarding medical and surgical interventions. However, no specific treatment has shown a major impact on clinical outcome. Current management guidelines do exist based on medical evidence and consensus and these provide a framework for care. While management of hypertension and coagulopathy are generally considered basic tenets of ICH management, a variety of measures for surgical hematoma evacuation, intracranial pressure control, and intraventricular hemorrhage can be further pursued in the emergent setting for selected patients. The complexity of management in parenchymal cerebral hemorrhage remains challenging and offers many areas for further investigation. A systematic approach to the background, pathology, and early management of spontaneous parenchymal hemorrhage is provided.
Collapse
|
38
|
Bosche B, Molcanyi M, Rej S, Doeppner TR, Obermann M, Müller DJ, Das A, Hescheler J, Macdonald RL, Noll T, Härtel FV. Low-Dose Lithium Stabilizes Human Endothelial Barrier by Decreasing MLC Phosphorylation and Universally Augments Cholinergic Vasorelaxation Capacity in a Direct Manner. Front Physiol 2016; 7:593. [PMID: 27999548 PMCID: PMC5138228 DOI: 10.3389/fphys.2016.00593] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/15/2016] [Indexed: 01/25/2023] Open
Abstract
Lithium at serum concentrations up to 1 mmol/L has been used in patients suffering from bipolar disorder for decades and has recently been shown to reduce the risk for ischemic stroke in these patients. The risk for stroke and thromboembolism depend not only on cerebral but also on general endothelial function and health; the entire endothelium as an organ is therefore pathophysiologically relevant. Regardless, the knowledge about the direct impact of lithium on endothelial function remains poor. We conducted an experimental study using lithium as pharmacologic pretreatment for murine, porcine and human vascular endothelium. We predominantly investigated endothelial vasorelaxation capacities in addition to human basal and dynamic (thrombin-/PAR-1 receptor agonist-impaired) barrier functioning including myosin light chain (MLC) phosphorylation (MLC-P). Low-dose therapeutic lithium concentrations (0.4 mmol/L) significantly augment the cholinergic endothelium-dependent vasorelaxation capacities of cerebral and thoracic arteries, independently of central and autonomic nerve system influences. Similar concentrations of lithium (0.2–0.4 mmol/L) significantly stabilized the dynamic thrombin-induced and PAR-1 receptor agonist-induced permeability of human endothelium, while even the basal permeability appeared to be stabilized. The lithium-attenuated dynamic permeability was mediated by a reduced endothelial MLC-P known to be followed by a lessening of endothelial cell contraction and paracellular gap formation. The well-known lithium-associated inhibition of inositol monophosphatase/glycogen synthase kinase-3-β signaling-pathways involving intracellular calcium concentrations in neurons seems to similarly occur in endothelial cells, too, but with different down-stream effects such as MLC-P reduction. This is the first study discovering low-dose lithium as a drug directly stabilizing human endothelium and ubiquitously augmenting cholinergic endothelium-mediated vasorelaxation. Our findings have translational and potentially clinical impact on cardiovascular and cerebrovascular disease associated with inflammation explaining why lithium can reduce, e.g., the risk for stroke. However, further clinical studies are warranted.
Collapse
Affiliation(s)
- Bert Bosche
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Surgery, University of TorontoToronto, ON, Canada; Department of Neurology, University Hospital of Essen, University of Duisburg-EssenEssen, Germany
| | - Marek Molcanyi
- Institute of Neurophysiology, Medical Faculty, University of CologneCologne, Germany; Department of Neurosurgery, Research Unit for Experimental Neurotraumatology, Medical University GrazGraz, Austria
| | - Soham Rej
- Division of Geriatric Psychiatry, Department of Psychiatry, Sunny Brook Health Sciences Centre, University of TorontoToronto, ON, Canada; Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill UniversityMontréal, QC, Canada
| | - Thorsten R Doeppner
- Department of Neurology, University Hospital of Essen, University of Duisburg-EssenEssen, Germany; Department of Neurology, University of Göttingen Medical SchoolGöttingen, Germany
| | - Mark Obermann
- Department of Neurology, University Hospital of Essen, University of Duisburg-EssenEssen, Germany; Center for Neurology, Asklepios Hospitals SchildautalSeesen, Germany
| | - Daniel J Müller
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental HealthToronto, ON, Canada; Department of Psychiatry, University of TorontoToronto, ON, Canada
| | - Anupam Das
- Medical Faculty Carl Gustav Carus, Institute of Physiology, Technical University of Dresden Dresden, Germany
| | - Jürgen Hescheler
- Institute of Neurophysiology, Medical Faculty, University of Cologne Cologne, Germany
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Surgery, University of Toronto Toronto, ON, Canada
| | - Thomas Noll
- Medical Faculty Carl Gustav Carus, Institute of Physiology, Technical University of Dresden Dresden, Germany
| | - Frauke V Härtel
- Medical Faculty Carl Gustav Carus, Institute of Physiology, Technical University of Dresden Dresden, Germany
| |
Collapse
|
39
|
Mittal MK, LacKamp A. Intracerebral Hemorrhage: Perihemorrhagic Edema and Secondary Hematoma Expansion: From Bench Work to Ongoing Controversies. Front Neurol 2016; 7:210. [PMID: 27917153 PMCID: PMC5116572 DOI: 10.3389/fneur.2016.00210] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/08/2016] [Indexed: 12/30/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a medical emergency, which often leads to severe disability and death. ICH-related poor outcomes are due to primary injury causing structural damage and mass effect and secondary injury in the perihemorrhagic region over several days to weeks. Secondary injury after ICH can be due to hematoma expansion (HE) or a consequence of repair pathway along the continuum of neuroinflammation, neuronal death, and perihemorrhagic edema (PHE). This review article is focused on PHE and HE and will cover the animal studies, related human studies, and clinical trials relating to these mechanisms of secondary brain injury in ICH patients.
Collapse
Affiliation(s)
- Manoj K Mittal
- Department of Neurology, University of Kansas Medical Center , Kansas City, KS , USA
| | - Aaron LacKamp
- Department of Anesthesiology, University of Kansas Medical Center , Kansas City, KS , USA
| |
Collapse
|
40
|
Hu X, Bai X, Zai N, Sun X, Zhu L, Li X. Prognostic value of perfusion-weighted magnetic resonance imaging in acute intracerebral hemorrhage. Neurol Res 2016; 38:614-9. [PMID: 27197990 DOI: 10.1080/01616412.2016.1177932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study intends to investigate the prognostic value of perfusion-weighted magnetic resonance imaging in acute intracerebral hemorrhage. METHODS Demographic, clinical and biochemical data between acute intracerebral hemorrhage (AICH) and healthy volunteer groups were assessed in this study, such as rCBV and MTT values. The optimal cutoff values of rCBV and MTT for diagnosing AICH were determined by the ROC curves. Apart from that, we also investigated the association between rCBV/MTT values and cerebral hematoma volumes of AICH patients. The unconditional logistic regression was conducted to determine significant risk factors for AICH. RESULT AICH patients have significantly lower rCBV and higher MTT compared to the control group (all P < 0.05). As suggested by the relatively high sensitivity and specificity, both rCBV and MTT values could be utilized for AICH diagnosis. Moreover, rCBV and MTT were significantly associated with the cerebral hematoma volumes of AICH patients (all P < 0.05). Results from unconditional logistic regression analysis revealed that MTT was a significant risk factor for AICH (P < 0.05 and OR > 1), while rCBV is considered as a protective factor (P < 0.05 and OR < 1). CONCLUSION Perfusion-weighted magnetic resonance imaging produces a high prognostic value for diagnosing AICH.
Collapse
Affiliation(s)
- Xibin Hu
- a Department of Radiology , Affiliated Hospital of Jining Medical University , Jining , China
| | - Xueqin Bai
- a Department of Radiology , Affiliated Hospital of Jining Medical University , Jining , China
| | - Ning Zai
- a Department of Radiology , Affiliated Hospital of Jining Medical University , Jining , China
| | - Xinhai Sun
- a Department of Radiology , Affiliated Hospital of Jining Medical University , Jining , China
| | - Laimin Zhu
- a Department of Radiology , Affiliated Hospital of Jining Medical University , Jining , China
| | - Xian Li
- b Department of Medical Imaging , Jining Medical University , Jining , China
| |
Collapse
|
41
|
Kim H, Edwards NJ, Choi HA, Chang TR, Jo KW, Lee K. Treatment Strategies to Attenuate Perihematomal Edema in Patients With Intracerebral Hemorrhage. World Neurosurg 2016; 94:32-41. [PMID: 27373415 DOI: 10.1016/j.wneu.2016.06.093] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/20/2016] [Accepted: 06/21/2016] [Indexed: 11/24/2022]
Abstract
Spontaneous intracerebral hemorrhage (SICH) continues to be a significant cause of neurologic morbidity and mortality throughout the world. Although recent advances in the treatment of SICH have significantly decreased mortality rates, functional recovery has not been dramatically improved by any intervention to date. There are 2 predominant mechanisms of brain injury from intracerebral hemorrhage: mechanical injury from the primary hematoma (including growth of that hematoma), and secondary injury from perihematomal inflammation. For instance, in the hours to weeks after SICH as the hematoma is being degraded, thrombin and iron are released and can result in neurotoxicity, free radical damage, dysregulated coagulation, and harmful inflammatory cascades; this can clinically and radiologically manifest as perihematomal edema (PHE). PHE can contribute to mass effect, cause acute neurologic deterioration in patients, and has even been associated with poor long-term functional outcomes. PHE therefore lends itself to being a potential therapeutic target. In this article, we will review 1) the pathogenesis and time course of the development of PHE, and 2) the clinical series and trials exploring various methods, with a focus on minimally invasive surgical techniques, to reduce PHE and minimize secondary brain injury. Promising areas of continued research also will be discussed.
Collapse
Affiliation(s)
- Hoon Kim
- Department of Neurosurgery, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Nancy J Edwards
- Department of Neurosurgery and Neurology, University of Texas Medical School at Houston, Houston, Texas, USA
| | - Huimahn A Choi
- Department of Neurosurgery and Neurology, University of Texas Medical School at Houston, Houston, Texas, USA
| | - Tiffany R Chang
- Department of Neurosurgery and Neurology, University of Texas Medical School at Houston, Houston, Texas, USA
| | - Kwang Wook Jo
- Department of Neurosurgery, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kiwon Lee
- Department of Neurosurgery and Neurology, University of Texas Medical School at Houston, Houston, Texas, USA
| |
Collapse
|
42
|
Sun N, Keep RF, Hua Y, Xi G. Critical Role of the Sphingolipid Pathway in Stroke: a Review of Current Utility and Potential Therapeutic Targets. Transl Stroke Res 2016; 7:420-38. [PMID: 27339463 DOI: 10.1007/s12975-016-0477-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/12/2016] [Accepted: 06/15/2016] [Indexed: 12/16/2022]
Abstract
Sphingolipids are a series of cell membrane-derived lipids which act as signaling molecules and play a critical role in cell death and survival, proliferation, recognition, and migration. Sphingosine-1-phosphate acts as a key signaling molecule and regulates lymphocyte trafficking, glial cell activation, vasoconstriction, endothelial barrier function, and neuronal death pathways which plays a critical role in numerous neurological conditions. Stroke is a second leading cause of death all over the world and effective therapies are still in great demand, including ischemic stroke and hemorrhagic stroke as well as poststroke repair. Significantly, sphingolipid activities change after stroke and correlate with stroke outcome, which has promoted efforts to testify whether the sphingolipid pathway could be a novel therapeutic target in stroke. The sphingolipid metabolic pathway, the connection between the pathway and stroke, as well as therapeutic interventions to manipulate the pathway to reduce stroke-induced brain injury are discussed in this review.
Collapse
Affiliation(s)
- Na Sun
- Department of Neurosurgery, University of Michigan, 5018 BSRB, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, 5018 BSRB, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, 5018 BSRB, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, 5018 BSRB, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
| |
Collapse
|
43
|
Carcel C, Sato S, Anderson CS. Blood Pressure Management in Intracranial Hemorrhage: Current Challenges and Opportunities. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:22. [PMID: 26909816 DOI: 10.1007/s11936-016-0444-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OPINION STATEMENT Non-traumatic intracranial hemorrhage (i.e. intracerebral hemorrhage [ICH] and subarachnoid hemorrhage [SAH]) are more life threatening and least treatable despite being less common than ischemic stroke. Elevated blood pressure (BP) is a strong predictor of poor outcome in both ICH and SAH. Data from a landmark clinical trial INTERACT 2, wherein 2839 participants enrolled with spontaneous ICH were randomly assigned to receive intensive (target systolic BP <140 mmHg) or guideline recommended BP lowering therapy (target systolic BP <180 mmHg), showed that intensive BP lowering was safe, and more favorable functional outcome and better overall health-related quality of life were seen in survivors in the intensive treatment group. These results contributed to the shift in European and American guidelines towards more aggressive early management of elevated BP in ICH. In contrast, the treatment of BP in SAH is less well defined and more complex. Although there is consensus that hypertension needs to be controlled to prevent rebleeding in the acute setting, induced hypertension in the later stages of SAH has questionable benefits.
Collapse
Affiliation(s)
- Cheryl Carcel
- Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Neurology Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Shoichiro Sato
- Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia
| | - Craig S Anderson
- Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia. .,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia. .,Neurology Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. .,The George Institute for Global Health, PO Box M201, Missenden Road, Sydney, NSW, 2050, Australia.
| |
Collapse
|
44
|
Fung C, Murek M, Klinger-Gratz PP, Fiechter M, Z’Graggen WJ, Gautschi OP, El-Koussy M, Gralla J, Schaller K, Zbinden M, Arnold M, Fischer U, Mattle HP, Raabe A, Beck J. Effect of Decompressive Craniectomy on Perihematomal Edema in Patients with Intracerebral Hemorrhage. PLoS One 2016; 11:e0149169. [PMID: 26872068 PMCID: PMC4752325 DOI: 10.1371/journal.pone.0149169] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 01/07/2016] [Indexed: 12/01/2022] Open
Abstract
Background Perihematomal edema contributes to secondary brain injury in the course of intracerebral hemorrhage. The effect of decompressive surgery on perihematomal edema after intracerebral hemorrhage is unknown. This study analyzed the course of PHE in patients who were or were not treated with decompressive craniectomy. Methods More than 100 computed tomography images from our published cohort of 25 patients were evaluated retrospectively at two university hospitals in Switzerland. Computed tomography scans covered the time from admission until day 100. Eleven patients were treated by decompressive craniectomy and 14 were treated conservatively. Absolute edema and hematoma volumes were assessed using 3-dimensional volumetric measurements. Relative edema volumes were calculated based on maximal hematoma volume. Results Absolute perihematomal edema increased from 42.9 ml to 125.6 ml (192.8%) after 21 days in the decompressive craniectomy group, versus 50.4 ml to 67.2 ml (33.3%) in the control group (Δ at day 21 = 58.4 ml, p = 0.031). Peak edema developed on days 25 and 35 in patients with decompressive craniectomy and controls respectively, and it took about 60 days for the edema to decline to baseline in both groups. Eight patients (73%) in the decompressive craniectomy group and 6 patients (43%) in the control group had a good outcome (modified Rankin Scale score 0 to 4) at 6 months (P = 0.23). Conclusions Decompressive craniectomy is associated with a significant increase in perihematomal edema compared to patients who have been treated conservatively. Perihematomal edema itself lasts about 60 days if it is not treated, but decompressive craniectomy ameliorates the mass effect exerted by the intracerebral hemorrhage plus the perihematomal edema, as reflected by the reduced midline shift.
Collapse
Affiliation(s)
- Christian Fung
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
- Department of Neurosurgery, University Hospital Geneva, Geneva, Switzerland
| | - Michael Murek
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Pascal P. Klinger-Gratz
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Michael Fiechter
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | | | - Oliver P. Gautschi
- Department of Neurosurgery, University Hospital Geneva, Geneva, Switzerland
| | - Marwan El-Koussy
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Jan Gralla
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Karl Schaller
- Department of Neurosurgery, University Hospital Geneva, Geneva, Switzerland
| | - Martin Zbinden
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | | | - Andreas Raabe
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
- * E-mail:
| |
Collapse
|
45
|
Tamm AS, McCourt R, Gould B, Kate M, Kosior JC, Jeerakathil T, Gioia LC, Dowlatshahi D, Hill MD, Coutts SB, Demchuk AM, Buck BH, Emery DJ, Shuaib A, Butcher KS. Cerebral Perfusion Pressure is Maintained in Acute Intracerebral Hemorrhage: A CT Perfusion Study. AJNR Am J Neuroradiol 2016; 37:244-51. [PMID: 26450534 PMCID: PMC7959964 DOI: 10.3174/ajnr.a4532] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/14/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Although blood pressure reduction has been postulated to result in a fall in cerebral perfusion pressure in patients with intracerebral hemorrhage, the latter is rarely measured. We assessed regional cerebral perfusion pressure in patients with intracerebral hemorrhage by using CT perfusion source data. MATERIALS AND METHODS Patients with acute primary intracerebral hemorrhage were randomized to target systolic blood pressures of <150 mm Hg (n = 37) or <180 mm Hg (n = 36). Regional maps of cerebral blood flow, cerebral perfusion pressure, and cerebrovascular resistance were generated by using CT perfusion source data, obtained 2 hours after randomization. RESULTS Perihematoma cerebral blood flow (38.7 ± 11.9 mL/100 g/min) was reduced relative to contralateral regions (44.1 ± 11.1 mL/100 g/min, P = .001), but cerebral perfusion pressure was not (14.4 ± 4.6 minutes(-1) versus 14.3 ± 4.8 minutes(-1), P = .93). Perihematoma cerebrovascular resistance (0.34 ± 0.11 g/mL) was higher than that in the contralateral region (0.30 ± 0.10 g/mL, P < .001). Ipsilateral and contralateral cerebral perfusion pressure in the external (15.0 ± 4.6 versus 15.6 ± 5.3 minutes(-1), P = .15) and internal (15.0 ± 4.8 versus 15.0 ± 4.8 minutes(-1), P = .90) borderzone regions were all similar. Borderzone cerebral perfusion pressure was similar to mean global cerebral perfusion pressure (14.7 ± 4.7 minutes(-1), P ≥ .29). Perihematoma cerebral perfusion pressure did not differ between blood pressure treatment groups (13.9 ± 5.5 minutes(-1) versus 14.8 ± 3.4 minutes(-1), P = .38) or vary with mean arterial pressure (r = -0.08, [-0.10, 0.05]). CONCLUSIONS Perihematoma cerebral perfusion pressure is maintained despite increased cerebrovascular resistance and reduced cerebral blood flow. Aggressive antihypertensive therapy does not affect perihematoma or borderzone cerebral perfusion pressure. Maintenance of cerebral perfusion pressure provides physiologic support for the safety of blood pressure reduction in intracerebral hemorrhage.
Collapse
Affiliation(s)
- A S Tamm
- Department of Diagnostic Imaging (A.S.T., D.J.E.), University of Alberta, Edmonton, Alberta, Canada
| | - R McCourt
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - B Gould
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - M Kate
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - J C Kosior
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - T Jeerakathil
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - L C Gioia
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - D Dowlatshahi
- Division of Neurology (D.D.), University of Ottawa, Ottawa, Ontario, Canada
| | - M D Hill
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - S B Coutts
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - B H Buck
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - D J Emery
- Department of Diagnostic Imaging (A.S.T., D.J.E.), University of Alberta, Edmonton, Alberta, Canada
| | - A Shuaib
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - K S Butcher
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| |
Collapse
|
46
|
Orakcioglu B, Kentar MM, Schiebel P, Uozumi Y, Unterberg A, Sakowitz OW. Perihemorrhagic ischemia occurs in a volume-dependent manner as assessed by multimodal cerebral monitoring in a porcine model of intracerebral hemorrhage. Neurocrit Care 2016; 22:133-9. [PMID: 25052158 DOI: 10.1007/s12028-014-0027-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Changes in the perihemorrhagic zone (PHZ) of intracerebral hemorrhage (ICH) are variable. Different mechanisms contribute to secondary neuronal injury after ICH. This multimodal monitoring study investigated early changes in the PHZ of ICH. METHODS Twenty-four swine were anesthetized, ventilated, and underwent monitoring of vital parameters. Next to an intracranial pressure-probe (ICP), microdialysis (MD), thermodiffusion cerebral blood flow (td-CBF), and oxygen probes (PbrO2) were placed into the gray white matter junction for 12 h of monitoring. ICH was induced using the autologous blood injection model. Pre-defined volumes were 0 ml (sham), 1.5 ml ipsilateral (1.5 ml), 3.0 ml ipsilateral (3.0 ml), and 3.0 ml contralateral (3.0 ml contra). RESULTS ICP equally increased in all groups after ICH. In the 3.0 ml group tissue oxygenation decreased to ischemic values of 9 ± 7 mmHg early after 6 h of monitoring. This decrease was associated with a significant perfusion reduction from 36 ± 8 ml/100 g/min to 20 ± 10 ml/100 g/min. MD correlated with a threefold lactate/pyruvate ratio increase. Measurements in all other groups were unchanged. CONCLUSION Multimodal monitoring demonstrates volume-dependent changes of tissue oxygenation, blood flow, and ischemic MD markers in the PHZ independent of increased ICP suggesting early moderate ischemia. No evidence was found for the existence of a perihemorrhagic ischemia in the small hematoma groups.
Collapse
Affiliation(s)
- Berk Orakcioglu
- Department of Neurosurgery, Ruprecht-Karls-University, Heidelberg, Germany,
| | | | | | | | | | | |
Collapse
|
47
|
Clusters of cortical spreading depolarizations in a patient with intracerebral hemorrhage: a multimodal neuromonitoring study. Neurocrit Care 2016; 22:293-8. [PMID: 25142825 DOI: 10.1007/s12028-014-0050-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) is associated with high morbidity and mortality. Cortical spreading depolarizations (CSDs) increase brain matrix metalloproteinase (MMP)-9 activity leading to perihematomal edema expansion in experimental ICH. METHODS The purpose of this report is to describe cerebral metabolic changes and brain extracellular MMP-9 levels in a patient with CSDs and perihematomal edema expansion after ICH. RESULTS We present a 66-year-old male patient with ICH who underwent craniotomy for hematoma evacuation. Multimodal neuromonitoring data of the perihematomal region revealed metabolic distress and increased MMP-9 levels in the brain extracellular fluid during perihematomal edema progression. At the same time, subdural electrocorticography showed clusters of CSDs, which disappeared after ketamine anesthesia on day six. Perihematomal edema regression was associated with decreasing cerebral MMP-9 levels. CONCLUSIONS This novel association between clusters of CSDs, brain metabolic distress, and increased MMP-9 levels expands our knowledge about secondary brain injury after ICH. The role of ketamine after this devastating disorder needs further studies.
Collapse
|
48
|
Chen JW, Paff MR, Abrams-Alexandru D, Kaloostian SW. Decreasing the Cerebral Edema Associated with Traumatic Intracerebral Hemorrhages: Use of a Minimally Invasive Technique. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 121:279-284. [PMID: 26463961 DOI: 10.1007/978-3-319-18497-5_48] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Traumatic brain injury (TBI) is a major public health problem worldwide that affects all age groups. In the United States alone, there are approximately 50,000 deaths from severe traumatic brain injuries each year. In most studies, about 40 % of severe TBI have associated traumatic intracerebral hemorrhages (tICHs). The surgical treatment of tICH is debated largely because of its invasive nature, particularly in reaching deep tICHs. tICHs have a clear contribution to mass effect and exacerbate cerebral edema and ICP because of the break-down products of hemorrhage. We introduce a modification of the Mi SPACE technique (Minimally Invasive Subcortical Parafascicular Transsulcal Access for Clot Evacuation) that is applicable to tICH. In brief, this technique utilizes a trans-sulcal, stereotactic-guided technique in which a specially designed cannula is used to introduce a 13.5-mm-diameter tube into the epicenter of the tICH. We identified eight tICHs that were treated entirely or in part with the modified Mi SPACE technique during the time period from August 15, 2014 to December 15, 2014. This modified technique was readily deployed safely and efficaciously with significant removal of the tICH as demonstrated by postoperative CT scans. The removal of tICH using this minimally invasive technique may help with the control of ICP and cerebral edema.
Collapse
Affiliation(s)
- Jeff W Chen
- Department of Neurological Surgery, The University of California, Irvine, CA, USA.
| | - Michelle R Paff
- Department of Neurological Surgery, The University of California, Irvine, CA, USA
| | | | - Sean W Kaloostian
- Department of Neurological Surgery, The University of California, Irvine, CA, USA
| |
Collapse
|
49
|
Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00048-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
50
|
Majidi S, Rahim B, Gilani SI, Gilani WI, Adil MM, Qureshi AI. CT Evolution of Hematoma and Surrounding Hypodensity in a Cadaveric Model of Intracerebral Hemorrhage. J Neuroimaging 2015; 26:346-50. [DOI: 10.1111/jon.12306] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/03/2015] [Accepted: 08/31/2015] [Indexed: 11/30/2022] Open
Affiliation(s)
- Shahram Majidi
- Zeenat Qureshi Stroke Institute; St Cloud; MN
- Department of Neurology; George Washington University; Washington D.C
| | - Basit Rahim
- Zeenat Qureshi Stroke Institute; St Cloud; MN
| | | | | | | | | |
Collapse
|