Risk factors for spontaneous intracerebral hemorrhage

Mesenchymal Stem Cell Therapy in Acute Intracerebral Hemorrhage: A Dose-Escalation Safety and Tolerability Trial

BACKGROUND

We conducted a preliminary phase I, dose-escalating, safety, and tolerability trial in the population of patients with acute intracerebral hemorrhage (ICH) by using human allogeneic bone marrow-derived mesenchymal stem/stromal cells.

METHODS

Eligibility criteria included nontraumatic supratentorial hematoma less than 60 mL and Glasgow Coma Scale score greater than 5. All patients were monitored in the neurosciences intensive care unit for safety and tolerability of mesenchymal stem/stromal cell infusion and adverse events. We also explored the use of cytokines as biomarkers to assess responsiveness to the cell therapy. We screened 140 patients, enrolling 9 who met eligibility criteria into three dose groups: 0.5 million cells/kg, 1 million cells/kg, and 2 million cells/kg.

RESULTS

Intravenous administration of allogeneic bone marrow-derived mesenchymal stem/stromal cells to treat patients with acute ICH is feasible and safe.

CONCLUSIONS

Future larger randomized, placebo-controlled ICH studies are necessary to validate this study and establish the effectiveness of this therapeutic approach in the treatment of patients with ICH.

Etiology, Risk Factors and Outcome of Spontaneous Intracerebral Hemorrhage in Young Adults Admitted to Tertiary Care Hospital in Mogadishu, Somalia

Introduction

Spontaneous Intracerebral hemorrhage (ICH) in young patients is less common and not well studied compared to ICH in older patients. The etiology, risk factors and outcome of ICH in young patients may have regional and ethnic differences. The study aims to investigate the clinical characteristics, risk factors, etiology and outcome of spontaneous intracerebral hemorrhage in young adults in Somalia.

Methods

The study enrolled 168 young patients with ICH (16-50 years) admitted to the neurology department of a tertiary hospital from 2019 to 2022. The information about the demographic details, documented ICH risk factors, etiology and patients' clinical status were retrieved. The etiology of ICH was determined based on clinical, laboratory and radiological findings. Intra-hospital survival status and associated factors were assessed.

Results

The mean age of the patients was 35±8.6 years. 99 (59%) of patients were male while 69 (41%) were females. Hypertension 48 (29%) was the most common risk factor, followed by substance abuse. Hypertensive hemorrhage was the most common etiology of ICH 60 (35.7%), followed by cerebral venous thrombosis (CVT) 5(15%), substance abuse 23 (13.7%) and arteriovenous malformation (AVM) in 10 (6%). AVM, CVT, cavernoma, eclampsia, substance abuse and cryptogenic etiology were more common in the 2nd and 3rd decades whereas hypertension was more common in the 4th and 5th decade. Intrahospital mortality was 28% in this study. Factors predicting intrahospital mortality were hematoma volume of greater than 30mL, thrombolytic etiology, brainstem ICH location, substance abuse related etiology, presence of associated mass effect, low GCS score on admission, high systolic blood pressure on admission, and the presence of chronic renal failure.

Conclusion

In this study, hypertension, substance abuse, CVT and vascular malformation are the leading causes of ICH in young adults. Intracerebral hemorrhage in the young has different spectrum of etiologies and factors associated with short-term mortality compared to older patients.

A Multicentre Randomized Controlled Clinical Study of Cross Electro-Nape-Acupuncture (CENA) for the Treatment of Pseudobulbar Palsy in Patients with Tracheotomy Intubation for Severe Cerebral Haemorrhage

Objective

The objective is to evaluate the clinical efficacy of cross electro-nape-acupuncture (CENA) in the treatment of pseudobulbar palsy in patients with tracheotomy intubation for severe cerebral haemorrhage and to provide an innovative acupuncture method for the treatment of such patients.

Methods

A total of 126 patients from six trial centres who met the inclusion criteria were randomly divided into three groups according to the random number table method in the ratio of 1 : 1 : 1, with 42 patients in each group, and the three groups were divided into CENA group, electro-acupuncture group, and acupuncture group. Each group's acupuncture treatment lasted for 30 minutes, and the needles were removed at the end of the treatment. Acupuncture was performed once a week on Sunday only and twice a day from Monday to Saturday, a total of 4 weeks of treatment. The SWT, FDA, ChSWAL-QOL, and TCRGS scores of the three groups of patients before and after treatment were compared to evaluate the effect of CENA on remodelling the function of swallowing reflex and cough reflex and promoting the recovery of dysarthria and swallowing quality of life in pseudobulbar palsy in patients with tracheotomy intubation for severe cerebral haemorrhage.

Results

After treatment, the WST and TCRGS grade scores decreased and the FDA and ChSWAL-QOL scores increased significantly in all three groups compared with the pretreatment scores and were statistically significant. There was a significant difference between the three groups for these four indicators after treatment; the comparison between groups showed significant differences in the CENA group compared to the electro-acupuncture and acupuncture groups. The efficiency of the CENA group was significantly better than that of the electro-acupuncture and acupuncture groups.

Conclusion

Compared with the acupuncture and electro-acupuncture groups, the CENA could better promote the remodelling of swallowing function and cough reflex function, promote the recovery of dysarthria, and better improve the quality of life of patients with pseudobulbar palsy from tracheotomy intubation in severe cerebral haemorrhage.

History of Nonsteroidal Anti-inflammatory Drug Use and Functional Outcomes After Spontaneous Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Preclinical and clinical studies have suggested a potential benefit from COX-2 inhibition on secondary injury activation after spontaneous intracerebral hemorrhage (ICH). The aim of this study was to investigate the effect of pre-admission NSAID use on functional recovery in spontaneous ICH patients.

METHODS

Consecutive adult ICH patients enrolled in the Intracerebral Hemorrhage Outcomes Project (2009-2018) with available 90-day follow-up data were included. Patients were categorized as NSAID (daily COX inhibitor use ≤ 7 days prior to ICH) and non-NSAID users (no daily COX inhibitor use ≤ 7 days prior to ICH). Primary outcome was the ordinal 90-day modified Rankin Scale (mRS) score. Outcomes were compared between cohorts using multivariable regression and propensity score-matched analyses. A secondary analysis excluding aspirin users was performed.

RESULTS

The NSAID and non-NSAID cohorts comprised 228 and 361 patients, respectively. After 1:1 matching, the matched cohorts each comprised 140 patients. The 90-day mRS were comparable between the NSAID and non-NSAID cohorts in both the unmatched (aOR = 0.914 [0.626-1.336], p = 0.644) and matched (aOR = 0.650 [0.392-1.080], p = 0.097) analyses. The likelihood of recurrent ICH at 90 days was also comparable between the NSAID and non-NSAID cohorts in both the unmatched (aOR = 0.845 [0.359-1.992], p = 0.701) and matched analyses (aOR = 0.732 [0.241-2.220], p = 0.581). In the secondary analysis, the non-aspirin NSAID and non-NSAID cohorts comprised 38 and 361 patients, respectively. After 1:1 matching, the matched cohorts each comprised 38 patients. The 90-day mRS were comparable between the non-aspirin NSAID and non-NSAID cohorts in both the unmatched (aOR = 0.615 [0.343-1.101], p = 0.102) and matched (aOR = 0.525 [0.219-1.254], p = 0.147) analyses. The likelihood of recurrent ICH at 90 days was also comparable between the non-aspirin NSAID and non-NSAID cohorts in both the unmatched (aOR = 2.644 [0.258-27.091], p = 0.413) and matched (aOR = 2.586 [0.228-29.309], p = 0.443) analyses. After the exclusion of patients with DNR or withdrawal of care status, NSAID use was associated with lower mRS at 90 days (aOR = 0.379 [0.212-0.679], p = 0.001), lower mRS at hospital discharge (aOR = 0.505 [0.278-0.919], p = 0.025) and lower 90-day mortality rates (aOR = 0.309 [0.108-0.877], p = 0.027).

CONCLUSIONS

History of nonselective COX inhibition may affect functional outcomes in ICH patients. Pre-admission NSAID use did not appear to worsen the severity of presenting ICH or increase the risk of recurrent ICH. Additional clinical studies may be warranted to investigate the effects of pre-admission NSAID use on ICH outcomes.

Tobacco Use: A Major Risk Factor of Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (sICH) is one of the deadliest subtypes of stroke, and no treatment is currently available. One of the major risk factors is tobacco use. In this article, we review literature on how tobacco use affects the risk of sICH and also summarize the known effects of tobacco use on outcomes following sICH. Several studies demonstrate that the risk of sICH is higher in current cigarette smokers compared to non-smokers. The literature also establishes that cigarette smoking not only increases the risk of sICH but also increases hematoma growth, results in worse outcomes, and increases the risk of death from sICH. This review also discusses potential mechanisms activated by tobacco use which result in an increase in risk and severity of sICH. Exploring the underlying mechanisms may help alleviate the risk of sICH in tobacco users as well as may help better manage tobacco user sICH patients.

Systematic review of brain arteriovenous malformation grading systems evaluating microsurgical treatment recommendation

When evaluating brain arteriovenous malformations (bAVMs) for microsurgical resection, the natural history of bAVM rupture must be balanced against the perioperative risks. It is therefore adamant to have a reliable surgical grading system, balancing these important factors. This study systematically reviews the literature in order to identify and assess the quality of grading systems with regard to microsurgical bAVM treatment. A systematic literature review was performed to provide an overview of all available bAVM grading systems relevant for microsurgical treatment evaluation and to assess the most comprehensive grading system specifically for each subgroup of bAVM (i.e., unruptured, ruptured, and posterior fossa). Screening of 865 papers revealed thirteen grading systems for bAVM microsurgical risk stratification. Among them, two systems were specifically developed for ruptured bAVM and one specifically for posterior fossa bAVM. With one system being fundamentally different for supratentorial bAVM, the remaining nine systems used the same parameters: “size,” “eloquence,” “venous drainage,” “arterial feeders,” “age,” “nidus compactness,” and “hemorrhagic presentation”. This study provides a comprehensive overview of all available bAVM grading systems relevant for surgical risk stratification. Furthermore, in the absence of a universal system appropriate to score all bAVMs, a workflow for selection of the best applicable scoring system in accordance with bAVM subgroups is presented.

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

BACKGROUND

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

OBJECTIVE

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

METHODS AND MATERIALS

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

CONCLUSION

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

Risk Factors of Intracerebral Hemorrhage: A Case-Control Study

BACKGROUND

Hypertension is a well-known risk factor for intracerebral hemorrhage (ICH). On many of the other potential risk factors, such as smoking, diabetes, and alcohol intake, results are conflicting. We assessed risk factors of ICH, taking also into account prior depression and fatigue.

METHODS

This is a population-based case-control study of 250 primary ICH patients, conducted in Helsinki University Hospital, Finland. The controls (n = 750) were participants of the FINRISK study, a large Finnish population survey on risk factors of chronic noncommunicable diseases, matched with cases by sex and age. Ages were matched in 5-year age bands. However, as the oldest FINRISK participants were 74-year-olds, controls for the age group 75-84 were selected from the age group of 70-74 years. Patients aged greater than or equal to 85 years were excluded. Patients and controls were compared in univariate analyses. The age categories less than 70, and greater than or equal to 70 years were also analyzed separately. Binary logistic regression analysis was performed for variables with P less than .1 in univariate analysis.

RESULTS

Analyzing all cases and controls, the cases had more hypertension, history of heart attack, lipid-lowering medication, and reported more frequently fatigue prior to ICH. In persons aged less than 70 years, hypertension and fatigue were more common among cases. In persons aged greater than or equal to 70 years, factors associated with risk of ICH were fatigue prior to ICH, use of lipid-lowering medication, and overweight.

CONCLUSIONS

Hypertension was associated with risk of ICH among all patients and in the group of patients under 70 years. Fatigue prior to ICH was more common among all ICH cases.

Extended Risk Factors for Stroke Prevention

Stroke causes disability and high mortality, while it can be prevented by increasing public awareness of risk factors. The common known risk factors are hypertension, atrial fibrillation, heart failure, smoking, alcohol consumption, low physical activity, overweight and hypercholesterolemia. However, the deep understanding of risk factors is limited. Moreover, more risk factor emerges in recent years. To further increase the awareness of risk factors for stroke prevention, this review indicates the reasonable application of antihypertensive agents according to the age-dependent changes of hypertension, and some new risk factors including chronic kidney disease, obstructive sleep apnea, migraine with aura, working environment, genetic factors and air pollution. Therefore, internal risk factors (e.g. heredity, hypertension, hyperglycemia) and external risk factors (e.g. working environment, air pollution) are both important for stroke prevention. All of these are reviewed to provide more information for the pre-hospital prevention and management, and the future clinical studies.

Epidemiology report: trends in sex-specific cerebrovascular disease mortality in Europe based on WHO mortality data

AIMS

There have been substantial declines in cerebrovascular disease mortality across much of Europe, mirroring trends in deaths from cardiovascular disease as a whole. No study has investigated trends in cerebrovascular disease, and its subtypes within all European countries. This study aimed to examine sex-specific trends in cerebrovascular disease, and three of its sub-types: ischaemic stroke, haemorrhagic stroke, and subarachnoid haemorrhage (SAH), in Europe between 1980 and 2016.

METHODS AND RESULTS

Sex-specific mortality data for each country of the World Health Organization (WHO) Europe region were extracted from the WHO global mortality database and analysed using Joinpoint software to examine trends. The number and location of significant joinpoints for each country by sex and subtype was determined using a log-linear model. The annual percentage change within each segment was calculated along with the average annual percentage change over the duration of all available data. The last 35 years have seen large overall declines in cerebrovascular disease mortality rates in the majority of European countries. While these declines have continued steadily in more than half of countries, this analysis has revealed evidence of recent plateauing and even increases in stroke mortality in a number of countries, in both sexes, and in all four geographical sub-regions of Europe. Analysis by stroke sub-type revealed that recent plateauing was most common for haemorraghic stroke and increases were most common for ischaemic stroke.

CONCLUSION

These findings highlight the need for continued research into the inequalities in both current stroke mortality outcomes and trends across Europe, as well as the causes behind any recent plateauing of total cerebrovascular disease or its subtypes.

Associated with Ischemic Stroke Risk Reduction after Endoscopic Thoracic Sympathectomy for Palmar Sweating

BACKGROUND

Endoscopic thoracic sympathectomy (ETS) was performed to cure palmar hyperhidrosis (PH). After ETS, blood pressure decreased, and cerebral flow velocity increased within 1 month. However, no studies distinguish between subsequent ischemic and hemorrhagic stroke following ETS for PH. The association between stroke type and PH after ETS must be evaluated.

METHODS

We surveyed newly diagnosed patients with PH using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code 780.8 from the Taiwan Longitudinal National Health Insurance Database. We matched patients with PH who underwent ETS (procedure code 05.29) and without surgery in the database between 2000 and 2010. We defined events as ischemic stroke (ICD-9-CM codes from 433 to 437) or hemorrhagic stroke (ICD-9-CM codes from 430 to 432). Patients were followed up until the first event or December 31, 2010. Risk factors for ischemic stroke and hemorrhagic stroke were analyzed using multivariable Cox proportional hazard regression.

RESULTS

The incidence of ischemic stroke was significantly lower in patients who underwent ETS (.22%) than in patients without surgery (.65%). The patients with PH who received ETS exhibited a reduced risk of ischemic stroke (adjusted hazard ratio [HR] .3; 95% confidence interval [CI] .12-.77). ETS treatment was not associated with a reduction in hemorrhagic stroke (adjusted HR .81; 95% CI .22-3; P = .755).

CONCLUSIONS

ETS in patients with PH was associated with reduced subsequent ischemic stroke risk. This additional ischemic stroke preventive effect should encourage health-care supporters to perform ETS in patients with severe PH.

Bleeding frequency and characteristics among hematologic malignancy inpatient rehabilitation patients with severe thrombocytopenia

OBJECTIVE

To identify the frequency and characteristics of bleeding complications during acute inpatient rehabilitation of hematologic malignancy patients with severe thrombocytopenia.

DESIGN

Retrospective descriptive analysis.

SETTING

Comprehensive cancer center acute inpatient rehabilitation unit.

PARTICIPANTS

Consecutive hematologic malignancy patients with a platelet count of less than or equal to 20,000/microliter (μL) on the day of acute inpatient rehabilitation admission from 1/1/2005 through 8/31/2016.

INTERVENTIONS

Medical records were retrospectively analyzed for demographic, laboratory, and medical data. Patients were rehabilitated using the institutional exercise guidelines for thrombocytopenic patients.

MAIN OUTCOME MEASURES

Bleeding events noted in the medical record.

RESULTS

Out of 135 acute inpatient rehabilitation admissions, 133 unique patients were analyzed with a total of 851 inpatient rehabilitation days. The mean platelet count was 14,000/μL on the day of admission and 22,000/μL over the course of the rehabilitation admission. There were 252 days of inpatient rehabilitation where patients had less than 10,000/μL platelets. A total of 97 bleeding events were documented in 77/135 (57%) admissions. Of the 97 bleeding events, 72 (74%), 14 (14%), and 11 (11%) were considered to be of low, medium, and high severity, respectively. There were 4/97 (4%) bleeding events that were highly likely attributable to physical activity but only 1/4 was considered high severity. Bleeding rates were .09, .08, .17, and .37 for > 20,000, 15-20,000, 10-15,000, and < 10,000/μL mean platelet counts respectively (p = .003). Forty-four percent of patients were transferred back to the primary acute care service with infection being the most common reason for transfer.

CONCLUSIONS

This study is the first to examine exercise-related bleeding complications during acute inpatient rehabilitation in severely thrombocytopenic hematologic cancer patients. Bleeding rates increased with lower platelet counts. However, using the exercise guidelines for severely thrombocytopenic patients, the risk of severe exercise-related bleeding events was low.

Is cirrhosis associated with lower odds of ischemic stroke: A nationwide analysis?

AIM

To determine the association between cirrhosis and ischemic stroke in a large nationally representative sample.

METHODS

A retrospective cross-sectional study of all hospitalized patients during 2012 and 2013 in the United States was performed using the National Inpatient Sample database. Hospitalizations with acute stroke, cirrhosis and other risk factors were identified using ICD-9-CM codes.

RESULTS

There were a total of 72082638 hospitalizations in the United States during the years 2012 and 2013. After excluding hospitalizations with missing demographic variables, that there were a total of 1175210 (1.6%) out of these were for acute ischemic stroke. Cirrhosis was present among 5605 (0.4%) cases of ischemic stroke. Mean age among the cirrhotic and non-cirrhotic groups with ischemic stroke were 66.4 and 70.5 years, respectively. Prevalence of risk factors among the two groups was also calculated. After adjusting for various known risk factors the odds of having an ischemic stroke (OR = 0.28, P < 0.001) were 72% lower in cirrhotics compared to non-cirrhotics.

CONCLUSION

Our study suggests that in a large, nationally representative sample of the United States population, cirrhosis is associated with a lower likelihood of stroke.

Secondary Prevention of Ischemic Cerebrovascular Disease. What Is the Evidence?

Patients who had a transient ischemic attack or stroke are at increased risk of experiencing recurrent cerebrovascular events. For this reason, secondary prevention of ischemic cerebrovascular disease is essential. Several modifiable, lifestyle-associated risk factors have been implicated, such as physical activity, smoking, and alcohol consumption. Established and emerging vascular risk factors are associated with an increased risk of stroke. Pharmacologic treatment, including the use of antiplatelet, antihypertensive, and lipid-lowering agents, has also been shown to reduce the risk of secondary cerebrovascular events. Surgical intervention, either open or endovascular, may be the preferred therapeutic option in well-defined subsets of patients. It is important to establish specific measures for the early detection and prevention of recurrent cerebrovascular disease. Therefore, further research and greater awareness in this field are needed.

The HAT Score-A Simple Risk Stratification Score for Coagulopathic Bleeding During Adult Extracorporeal Membrane Oxygenation

OBJECTIVE

The study objective was to create an adult extracorporeal membrane oxygenation (ECMO) coagulopathic bleeding risk score.

DESIGN

Secondary analysis was performed on an existing retrospective cohort. Pre-ECMO variables were tested for association with coagulopathic bleeding, and those with the strongest association were included in a multivariable model. Using this model, a risk stratification score was created. The score's utility was validated by comparing bleeding and transfusion rates between score levels. Bleeding also was examined after stratifying by nadir platelet count and overanticoagulation. Predictive power of the score was compared against the risk score for major bleeding during anti-coagulation for atrial fibrillation (HAS-BLED).

SETTING

Tertiary care academic medical center.

PARTICIPANTS

The study comprised patients who received venoarterial or venovenous ECMO over a 3-year period, excluding those with an identified source of surgical bleeding during exploration.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fifty-three (47.3%) of 112 patients experienced coagulopathic bleeding. A 3-variable score-hypertension, age greater than 65, and ECMO type (HAT)-had fair predictive value (area under the receiver operating characteristic curve [AUC] = 0.66) and was superior to HAS-BLED (AUC = 0.64). As the HAT score increased from 0 to 3, bleeding rates also increased as follows: 30.8%, 48.7%, 63.0%, and 71.4%, respectively. Platelet and fresh frozen plasma transfusion tended to increase with the HAT score, but red blood cell transfusion did not. Nadir platelet count less than 50×10³/µL and overanticoagulation during ECMO increased the AUC for the model to 0.73, suggesting additive risk.

CONCLUSIONS

The HAT score may allow for bleeding risk stratification in adult ECMO patients. Future studies in larger cohorts are necessary to confirm these findings.

Association between diabetes mellitus and the occurrence and outcome of intracerebral hemorrhage

OBJECTIVE

Whether diabetes mellitus (DM) is a risk factor for spontaneous intracerebral hemorrhage (ICH) and influences outcome after ICH remains unclear.

METHODS

One reviewer searched Ovid MEDLINE and Embase 1980-2014 inclusive for studies investigating the associations between DM and ICH occurrence or DM and ICH case fatality. Two reviewers independently confirmed each study's eligibility, assessed risk of bias, and extracted data. One reviewer combined studies using random effects meta-analysis.

RESULTS

Nineteen case-control studies involving 3,397 people with ICH and 5,747 people without ICH found an association between DM and ICH occurrence (unadjusted odds ratio [OR] 1.23, 95% confidence interval [CI] 1.04-1.45; I(2) = 22%), which did not differ between 17 hospital-based and 2 population-based studies (pdiff = 0.70), and was similar in the 16 studies that controlled for age and sex (unadjusted OR 1.15, 95% CI 0.95-1.40; I(2) = 14%). This association was not identified in 3 population-based cohort studies in which ICH occurred in 38 (0.66%) of 5,724 people with DM and 448 (0.57%) of 78,702 people without DM (unadjusted risk ratio [RR] 1.27, 95% CI 0.68-2.36; I(2) = 69%). DM was associated with a higher case fatality by 30 days or hospital discharge in 18 cohort studies involving 813 people with DM and 3,714 people without DM (unadjusted RR 1.52, 95% CI 1.28-1.81; I(2) = 49%).

CONCLUSIONS

The findings suggest that there may be modest associations between DM and ICH occurrence and outcome, but further information from large, population-based studies that account for confounding is required before the association can be confirmed.

Alcohol and Immediate Risk of Cardiovascular Events: A Systematic Review and Dose-Response Meta-Analysis

BACKGROUND

Although considerable research describes the cardiovascular effects of habitual moderate and heavy alcohol consumption, the immediate risks following alcohol intake have not been well characterized. Based on its physiological effects, alcohol may have markedly different effects on immediate and long-term risk.

METHODS AND RESULTS

We searched CINAHL, Embase, and PubMed from inception to March 12, 2015, supplemented with manual screening for observational studies assessing the association between alcohol intake and cardiovascular events in the following hours and days. We calculated pooled relative risks and 95% confidence intervals for the association between alcohol intake and myocardial infarction, ischemic stroke, and hemorrhagic stroke using DerSimonian and Laird random-effects models to model any alcohol intake or dose-response relationships of alcohol intake and cardiovascular events. Among 1056 citations and 37 full-text articles reviewed, 23 studies (29 457 participants) were included. Moderate alcohol consumption was associated with an immediately higher cardiovascular risk that was attenuated after 24 hours, and even protective for myocardial infarction and hemorrhagic stroke (≈2-4 drinks: relative risk=30% lower risk) and protective against ischemic stroke within 1 week (≈6 drinks: 19% lower risk). In contrast, heavy alcohol drinking was associated with higher cardiovascular risk in the following day (≈6-9 drinks: relative risk=1.3-2.3) and week (≈19-30 drinks: relative risk=2.25-6.2).

CONCLUSIONS

There appears to be a consistent finding of an immediately higher cardiovascular risk following any alcohol consumption, but, by 24 hours, only heavy alcohol intake conferred continued risk.

Ethanol downregulates N-acyl phosphatidylethanolamine-phospholipase D expression in BV2 microglial cells via epigenetic mechanisms

Excessive ethanol drinking has deleterious effects on the brain. However, the effects of alcohol on microglia, the main mediator of the brain's innate immune response remain poorly understood. On the other hand, the endocannabinoid system plays a fundamental role in regulating microglial reactivity and function. Here we studied the effects of acute ethanol exposure to murine BV2 microglial cells on N-acyl phosphatidylethanolamine-phospholipase D (NAPE-PLD), a major synthesizing enzyme of anandamide and other N-acylethanolamines. We found that ethanol downregulated microglial NAPE-PLD expression by activating cAMP/PKA and ERK1/2. These signaling pathways converged on increased phosphorylation of CREB. Moreover, ethanol induced and increase in histone acetyltransferase activity which led to higher levels of acetylation of histone H3. Taken together, our results suggest that ethanol actions on microglial NAPE-PLD expression might involve epigenetic mechanisms.

The use of serum glial fibrillary acidic protein test as a promising tool for intracerebral hemorrhage diagnosis in Chinese patients and prediction of the short-term functional outcomes

The objective of this study was to explore the efficacy of glial fibrillary acidic protein (GFAP) in differentiating intracerebral hemorrhage (ICH) from ischemic stroke (IS). Suspicious patients of acute stroke were screened and finally diagnosed by computed tomography and magnetic resonance imaging. Blood samples were collected within 2-6 h after onset of symptoms, and serum GFAP level was determined by ELISA assay. The functional outcome for the patients was determined by modified Rankin Scale (mRS) 90 days after onset of symptoms. 43 ICH patients and 65 IS patients were enrolled. GFAP concentration in ICH group was significantly higher than in IS group (p < 0.001). Significant correlation was found when comparing GFAP with National Institutes of Health Stroke Scale (NIHSS) (r = 0.418, p = 0.005) and hemorrhage volume (r = 0.840, p < 0.001) in ICH group, while such correlation was not observed in IS group. ROC analysis indicated that GFAP level at the cut-point of 0.7 ng/ml yielded an AUC of 0.901 (95 % CI 0.828-0.950) with high sensitivity (86.0 %) and specificity (76.9 %) to differentiate ICH from IS. Patients with higher serum GFAP concentration in ICH group experienced poorer functional disability (r = 0.755, p < 0.001), while this phenomenon was not observed in IS group (r = -0.114, p = 0.368). ROC curve analysis found that GFAP level at the cut-point of 1.04 ng/ml yielded an AUC of 0.936 (95 % CI 0.817-0.988) in identifying patients with poor functional outcome, at the sensitivity and specificity of 95.7 and 80.0 %, respectively. GFAP test is a promising technique for diagnosis of ICH from IS and prediction of short-term functional outcomes.

Blood coagulation factor XIII-A subunit Val34Leu polymorphisms and intracerebral hemorrhage risk: A meta-analysis of case-control studies

BACKGROUND

Previous studies investigating the association between factor XIII-A subunit (FXIII-A) Val34Leu polymorphisms and intracerebral hemorrhage (ICH) had provided inconsistent results and no large systematic review or meta-analysis had been conducted regarding this issue.

METHODS

We conducted a meta-analysis to confirm whether the FXIII-A Val34Leu polymorphisms increased the risk of ICH. Relevant studies were identified from the Pubmed, Medline, Embase, China National Knowledge Infrastructure, and Chinese Biomedicine Databases published up to September 2013. Summary odds ratios (ORs) and 95% confidence intervals (CIs) for FXIII-A Val34Leu polymorphisms and ICH were calculated in a fixed-effects model or a random-effects model when appropriate. We also carried out the stratified analyses and sensitivity analyses by region, source of control group, and sample size.

RESULTS

Eight eligible studies were reviewed. As FXIII Val34Leu was absent or had a very low prevalence among East Asians, only six studies in Caucasians were analyzed, involving 564 cases and 1276 controls. Overall, the Leu allele of FXIII gene had a trend to slightly increased odds of having ICH, but there is no statistic significance (OR1.23, 95% CI 0.94-1.61, P = 0.13). The OR of genotypes Leu+(Leu/Leu or Leu/Val) for the risk of ICH was 1.21, 95% CI 0.98-1.50, P = 0.08. And the OR of recessive model genotypes was 1.53, 95% CI 0.81-2.88, P = 0.19. There was no difference of the association between the Leu allele of FXIII gene and risk of ICH in stratified analysis.

CONCLUSIONS

Our meta-analysis suggests that there is no evidence for strong association between FXIII Val34Leu polymorphisms and ICH, but Leu allele of FXIII gene might slightly increase the risk of ICH in Caucasians. Since limited studies and subjects were included, larger scale association studies exploring the gene-gene interactions and gene-environment interactions are necessary to further validate the association.

Clinical and Angioarchitectural Risk Factors Associated with Intracranial Hemorrhage in Dural Arteriovenous Fistulas: A Single-Center Retrospective Study

Purpose

To investigate which clinical and angioarchitectural features were associated with the occurrence of intracranial hemorrhage in patients with intracranial dural arteriovenous fistulas (DAVFs).

Materials and Methods

We retrospectively reviewed the clinical and angioarchitectural features of 236 consecutive patients diagnosed with DAVF in our department from April 2009 to November 2013. Two groups of patients, with or without intracranial hemorrhage as clinical presentation at the initial diagnosis, were analysed to identify the differences in clinical and angioarchitectural features in univariate analysis. A multivariate logistic regression model was also developed to assess the independent contribution of the potential risk factors. Associations were considered significant for p<0.05.

Results

Fifty-six patients (23.7%) presented with intracranial hemorrhage at the initial diagnosis of DAVF. In univariate analysis, male patients (p = 0.002), patients with medical history of smoking (p<0.001) or alcohol consumption (p = 0.022), and DAVFs located at the tentorium (p = 0.010), frontalbasal (p = 0.007), foramen magnum (p = 0.043) or cerebral convexity (p<0.001) were associated with an increased risk of intracranial hemorrhage. A higher risk of hemorrhagic occurrence was also observed in DAVFs with superficial cortical venous drainage (p<0.001), deep venous drainage (p = 0.003), occluded venous sinus (p<0.032), or higher Borden type (p<0.001). A multivariate logistic regression model showed that intracranial hemorrhage in patients with DAVFs was correlated with higher Borden classification (OR 5.880; 95% CI, 3.370–10.257; p<0.001).

Conclusion

Venous drainage pattern was the only independent risk factor of intracranial hemorrhage in our patients with intracranial DAVF. The other potential risk factors may be confounding factors in predicting intracranial hemorrhage.

Aspirin and intracerebral hemorrhage: Where are we now?

For the past 3 decades, aspirin has been widely used for prevention of ischemic stroke and myocardial infarction. Although the evidence supporting the effectiveness of aspirin in prevention of vascular events is clear, data regarding the risk of acute and recurrent intracerebral hemorrhage related to the use of this medication have been conflicting. We review past and contemporary data on aspirin use in relation to intracerebral hemorrhage.

Cerebral microbleeds and macrobleeds: should they influence our recommendations for antithrombotic therapies?

Intracerebral hemorrhage (ICH, or macrobleeds) and cerebral microbleeds-smaller foci of hemosiderin deposits commonly detected by magnetic resonance imaging of older adults with or without ICH-are both associated with an increased risk of future ICH. These hemorrhagic pathologies also share risk factors with ischemic thromboembolic conditions that may require antithrombotic therapy, requiring specialists in cardiology, internal medicine, and neurology to weigh the benefits vs hemorrhagic risks of antithrombotics in individual patients. This paper will review recent advances in our understanding of hemorrhage prone cerebrovascular pathologies with a particular emphasis on use of these markers in decision making for antithrombotic use.

The outcomes of spontaneous intracerebral hemorrhage in young adults - a clinical study

Objective

Spontaneous intracerebral hemorrhage (ICH) in young adults is rare. The purpose of this study was to investigate causes, sites and other factors affecting the prognosis of ICH in young adults aged ≤ 40 years.

Methods

We reviewed 39 consecutive patients diagnosed with spontaneous ICH between January 2001 and June 2012. Patients with primary subarachnoid hemorrhage, previously diagnosed brain tumor bleeding, or vascular malformation were excluded. We analyzed the differences in prognostic factors such as hemorrhage location and vascular structural etiology. The outcome was measured using the Glasgow outcome scale (GOS), and a good outcome was defined as a score of 4 or more.

Results

We retrospectively evaluated 39 patients (mean age, 33 years; SD = 6.4, range 17 to 40 years). The most common structural etiology was arteriovenous malformation. A statistically significantly higher proportion of patients with good outcomes had a lower initial systolic blood pressure (SBP ≤ 160 mmHg, p = 0.036), a higher initial Glasgow coma scale (GCS) (9 or more, p = 0.034), lower cholesterol levels (< 200 mg/dl, p = 0.036), and smoking history (at discharge, p = 0.008; 6 months after discharge, p = 0.019).

Conclusion

In this study, cryptogenic ICH was the leading cause of spontaneous ICH. A GCS score of 9 or more on admission, a lower serum cholesterol level (< 200 mg/dl), and a lower SBP (< 160 mmHg) predicted a good outcome.

Lifestyle factors and risk of stroke in Seoul, south Korea

BACKGROUND AND PURPOSE

The importance of stroke risk factors, especially lifestyle associated ones, may differ among different ethnic groups. The purpose of the present study is to elucidate the risk factors for stroke in Seoul, Korea.

SUBJECTS AND METHODS

Three-hundred four stroke patients and 249 age-matched controls were studied. Patients were divided into those with cerebral infarction (CI) and intracerebral hemorrhage (ICH). Using a structured interview, we assessed risk factors for stroke including lifestyle-associated factors: hypertension (HT); diabetes mellitus (DM); cigarette smoking; alcohol drinking; sodium intake; salt taste preference; physical activity and exercise; consumption of vegetables, fat, fish and fruits; body mass index; total body fat; and skinfold thickness of triceps, subscapular, and abdomen. The results were compared between patients and controls, and between CI and ICH.

RESULTS

There were 232 CI and 72 ICH. Multivariate logistic regression analyses revealed the following independent risk factors; for CI in men, HT, DM, high sodium intake, low intake of vegetables, and excessive abdominal skinfold thickness; for ICH in men, HT, heavy alcohol drinking, high sodium intake, excessive abdominal skinfold thickness, and low fat consumption; for CI in women, excessive abdominal skinfold thickness, and low fat consumption; for CI in women, HT, high sodium intake, excessive abdominal skinfold thickness, decreased triceps skinfold thickness, and lack of recent physical exercise. On subgroup comparison, DM was found to be a discriminant risk factor favoring CI (v ICH) in women.

CONCLUSION

Our results showed that in Seoul, Korea, HT is the strongest risk factor for CI and ICH, and high sodium intake, lack of exercise, and central body fat deposition are relatively important factors related to stroke, whereas factors such as cigarette smoking, hypercholesterolemia, and body mass index are not. Low consumption of fat and heavy alcohol drinking appear to be related to the occurrence of ICH. Risk factors for stroke may differ among different ethnic groups and guidelines for stroke prevention should be based on a correct understanding of them.

Oral Anticoagulation Therapy for Elderly Patients With Atrial Fibrillation

Elderly individuals are prone to nonvalvular atrial fibrillation (AF) with associated risks of arterial thromboembolic disease. Despite definitive guidelines, oral anticoagulant therapy (OAC) is notoriously underutilized in patients with AF. Physicians cite excessive bleeding risk as one reason they omit OAC for their older patients with AF. Improved understanding of the pathophysiology of age-related bleeding may improve risk–benefit assessments for warfarin and newer antithrombotic agents. We reviewed the literature to identify age-related pathophysiological elements that can exacerbate the likelihood of bleeding. In the context of the Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly (HAS-BLED) bleeding risk framework, we highlight age-related physiological dynamics that predispose to hemorrhage. The combination of increased age (>65 years) with the other elements of the risk factor stratification model identifies patients with AF who are especially susceptible to OAC-related bleeding, irrespective of the agent used. Empirically adjusting OAC dose relative to these common bleeding risks may help to achieve an improved risk–benefit therapeutic ratio.

The hemorrhagic risk: how to evaluate it

This issue addresses the evaluation of hemorrhagic risk during antithrombotic treatment in atrial fibrillation patients. It illustrates the relevance of bleeding complications in the management of anticoagulation therapy and demonstrates the size of the problem among patients taking old and novel oral anticoagulant drugs. A survey of the main factors affecting the bleeding risk with pertinent supporting evidence is performed. Finally the paper discusses how to estimate the individual bleeding risk focusing on the HAS-BLED score, whose use is recommended by international guidelines.

Etiology and outcome determinants of intracerebral hemorrhage in a south Indian population, A hospital-based study

Background:

There is paucity of methodologically sound published studies on intracerebral hemorrhage (ICH) from India, on pub med/embase search.

Aims:

To explore etiology of ICH and correlate the causes, location, and size of hemorrhage to clinical outcome.

Materials and Methods:

A hospital-based descriptive study from South Indian eastern coastal town of Puducherry; 60 consecutive subjects aged > 12 years, predominantly of inbred Tamil population, with head CT evidence of intracerebral hemorrhage not associated with trauma and brain tumors, were recruited. Outcome at three months was measured using Glasgow Outcome scale, NIHSS and mortality. SPSS v 19 was used for statistical analysis.

Results:

Commonest etiological factor was hypertension, followed by bleeding diathesis, thrombolysis for myocardial infarction, and cortical vein thrombosis. Most frequent locations of hematoma were basal ganglia, thalamus, internal capsule, and cerebral and cerebellar parenchyma. Hematoma volume correlated significantly with systolic and mean arterial pressure but not with diastolic blood pressure. Poor outcome was correlated to size (P < 0.05) and intraventricular extension of hematoma (P < 0.05), and to systolic, diastolic and mean arterial pressure, but not to age, gender, smoking, alcoholism, ischemic heart disease, and blood sugar level. Among diabetic patients with ICH, the size of hematoma (P = 0.04) and severity of coma (P = 0.01) at admission were significantly worse compared to the non-diabetic, but not the outcome at three months [Glasgow outcome scale or mortality (P = 0.94 and 0.14)].

Conclusions:

The location of hemorrhage and correlation with outcome agreed with the patterns described for the non-white races in prior reports. Independence of outcome to diabetic status despite a more severe initial presentation may indicate importance of good care, even in high risk groups.

The role of ALDH2 and ADH1B polymorphism in alcohol consumption and stroke in Han Chinese

The genes encoding the enzymes for metabolising alcohol dehydrogenase 1B (ADH1B) and aldehyde dehydrogenase 2 (ALDH2) -- exhibit genetic polymorphism and ethnic variations. Although the ALDH2*2 variant allele has been widely accepted as protecting against the development of alcoholism in Asians, the association of the ADH1B*2 variant allele with drinking behaviour remains inconclusive. The goal of this study was to determine whether the polymorphic ADH1B and ALDH2 genes are associated with stroke in male Han Chinese with high alcohol consumption. Sixty-five stroke patients with a history of heavy drinking (HDS) and 83 stroke patients without such a history (NHDS) were recruited for analysis of the ADH1B and ALDH2 genotypes from the stroke registry in the Tri-Service General Hospital, Taipei, Taiwan, between January 2000 and December 2001. The allelotypes of ADH1B and ALDH2 were determined using the polymerase chain reaction-restriction fragment length polymorphism method. The HDS patients (3 per cent) showed a significantly lower ALDH2*2 allele frequency than NHDS patients (27 per cent) (p < 0.001). After controlling for age, patients with HDS were associated with a significantly higher occurrence of cigarette smoking (p < 0.01) and liver dysfunction (p < 0.01). Multiple logistic regression analyses revealed that the ALDH2*2 variant allele was an independent variable exhibiting strong protection (odds ratio 0.072; 95 per cent confidence interval 0.02-0.26) against HDS after adjustment for hypertension, diabetes mellitus, smoking status and liver dysfunction. By contrast, allelic variations in ADH1B exerted no significant effect on HDS. The present study indicated that, unlike ALDH2*2, ADH1B*2 appears not to be a significant negative risk factor for high alcohol consumption in male Han Chinese with stroke.

The value of magnetic resonance imaging for the detection of the bleeding source in non-traumatic intracerebral haemorrhages: a comparison with conventional digital subtraction angiography

INTRODUCTION

Conventional digital subtraction angiography (DSA) is currently regarded as the gold standard in detecting underlying vascular pathologies in patients with intracerebral haemorrhages (ICH). However, the use of magnetic resonance imaging (MRI) in the diagnostic workup of ICHs has considerably increased in recent years. Our aim was to evaluate the diagnostic accuracy and yield of MRI for the detection of the underlying aetiology in ICH patients.

METHODS

Sixty-seven consecutive patients with an acute ICH who underwent MRI (including magnetic resonance angiography (MRA) and DSA during their diagnostic workup) were included in the study. Magnetic resonance images were retrospectively analysed by two independent neuroradiologists to determine the localisation and cause of the ICH. DSA was used as a reference standard.

RESULTS

In seven patients (10.4%), a DSA-positive vascular aetiology was present (one aneurysm, four arteriovenous malformations, one dural arteriovenous fistula and one vasculitis). All of these cases were correctly diagnosed by both readers on MRI. In addition, MRI revealed the following probable bleeding causes in 39 of the 60 DSA-negative patients: cerebral amyloid angiopathy (17), cavernoma (9), arterial hypertension (8), haemorrhagic transformation of an ischaemic infarction (3) and malignant brain tumour with secondary ICH (2).

CONCLUSION

Performing MRI with MRA proved to be an accurate diagnostic tool in detecting vascular malformations in patients with ICH. In addition, MRI provided valuable information regarding DSA-negative ICH causes, and thus had a high diagnostic yield in ICH patients.

Comparative Effects of α-, β-, and γ-Carbolines on Platelet Aggregation and Lipid Membranes

Cigarette smoking and alcohol consumption possibly affect platelet functions. To verify the hypothesis that some α-, β-, and γ-carboline components in cigarette smoke and alcoholic beverages may change platelet aggregability, their effects on human platelets were determined by aggregometry together with investigating their membrane effects by turbidimetry. Carbolines inhibited platelet aggregation induced by five agents with the potency being 3-amino-1,4-dimethyl-5H-pyrido[4,3-b]indole > 3-amino-1-methyl-5H-pyrido[4,3-b]indole > 1-methyl-9H-pyrido[3,4-b]indole. The most potent 3-amino-1,4-dimethyl-5H-pyrido[4,3-b]indole showed 50% aggregation-inhibitory concentrations of 6–172 μM. Both γ-carbolines interacted with phosphatidylcholine membranes to lower the lipid phase transition temperature with the potency correlating to the antiplatelet activity, suggesting that the interaction with platelet membranes to increase their fluidity underlies antiplatelet effects. Given their possible concentration and accumulation in platelets, γ- and β-carbolines would provide cigarette smokers and alcohol drinkers with reduced platelet aggregability, and they may be responsible for the occurrence of hemorrhagic diseases associated with heavy smoking and alcoholics.

Post-coital intra-cerebral venous hemorrhage in a 78-year-old man with jugular valve incompetence: a case report

INTRODUCTION

Spontaneous intra-cerebral hemorrhage can occur in patients with venous disease due to obstructed venous outflow.

CASE PRESENTATION

We report the case of a 78-year-old Caucasian man with jugular valve incompetence who experienced an intra-cerebral temporo-occipital hemorrhage following sexual intercourse. He had no other risk factors for an intra-cerebral hemorrhage.

CONCLUSIONS

To the best of our knowledge, this is the first case of intra-cerebral hemorrhage due to jugular valve incompetence in association with the physical exertion associated with sexual intercourse.

Blood pressure, cholesterol and cardiovascular disease in Thailand

BACKGROUND

Although associations between risk factors such as hypertension and hypercholesterolaemia, and cardiovascular disease (CVD) are well-established it is not known to what extent these associations are similar in people from different ethnicities or regions. This study aims to measure the contributions of systolic blood pressure (SBP) and total cholesterol (TC) to ischaemic heart disease (IHD) and stroke in the Thai population.

METHODS AND RESULTS

Data from a Thai cohort study were used for analyses. Participants were 2702 males and 797 females aged between 35 and 54 years at the start of study in 1985. Cox Proportional Hazards Models were used to assess RRs of IHD or stroke associated with SBP or TC stratified by age at the time of an event of 30-44, 45-59, and 60-69 years. During the 17 years of follow-up, 96 IHD (40 non-fatal, 56 fatal), 69 strokes (32 non-fatal and 37 fatal) occurred. Each 1 mmol/l increase in TC was associated with a fivefold increase in IHD risk in people aged 30-44 years, but not with significant increase in stroke risk in any age group. The RRs (95% CIs) of IHD per 10 mm Hg increase in SBP were 1.31 (1.04 to 1.64) and 1.46 (1.15 to 1.87), and of stroke, 1.40 (1.10 to 1.79) and 1.85 (1.40 to 2.45) in people aged 45-59 and 60-69 years, respectively.

CONCLUSIONS

Increases in IHD and stroke risks associated with these two risk factors observed in Thailand are comparable with those in the Asia Pacific and western populations.

The incidence of major stroke subtypes in southern Italy: a population-based study

BACKGROUND AND PURPOSE

Stroke is characterized by well-defined clinical major subtypes, but there are few studies on incidence rates, aetiologies and outcomes in population-based setting. We assessed the age/sex incidence of the major stroke subtypes in a region of Southern Italy.

METHODS

We established a multisource, prospective population-based register in Puglia, Southern Italy to identify all residents with a first-ever stroke between 1 January 2001 and 31 December 2002.

RESULTS

One hundred and twenty-seven first-ever strokes were diagnosed, and stroke subtype was defined in 119 cases. The incidence rates per 100 000 adjusted to the European population (AEP) were 112 for cerebral infarction (CI), 30 for intracerebral haemorrhage (IH), four for subarachnoid haemorrhage (SH) and nine for undetermined stroke (US). The incidence rates for CI, IH and US approximately doubled with each decade of life and were higher in men. AEP incidence rates for CI in the age groups 45-84 were lower compared to other studies, whilst the corresponding rates for IH were higher.

CONCLUSIONS

This population had a lower incidence of CI compared to other population-based studies from Northern Europe and the United States. Furthermore, with the projected increase in the segment of the very old in the general population, our data indicate that both CI and IH will dramatically increase in the near future.