REPRINT

Acute Traumatic Subdural Hematoma and Anticoagulation Risk

BACKGROUND

Anticoagulation is used to prevent thromboembolic events. It is a common practice to hold anticoagulation in the first few days following a traumatic brain injury (TBI) with intracranial hemorrhage. However, traumatic subdural hematomas (SDH) are prone to re-hemorrhage long after the trauma. Data are scarce in the literature on the best timing to resume anticoagulation following a TBI.

METHODS

Review of 95 consecutive patients admitted to a level 1 trauma center with a diagnosis of traumatic SDH and requiring anticoagulation. The reasons for anticoagulation, the amount of time without anticoagulation, CT characteristics, and the incidence of thromboembolic events or SDH re-hemorrhage were collected.

RESULTS

41.3% used anticoagulation for coronary artery disease and peripheral vascular disease, 24% for atrial fibrillation, 12% for cardiac valve replacement, and 12% for venous thromboembolic events. Anticoagulation was held a median of 67 days. For most patients (82.1%), anticoagulation was re-introduced once the SDH had completely resolved. For 17.9%, anticoagulation was restarted while the SDH had not completely resolved. One (1.1%) patient suffered from an atrial clot while anticoagulation was held. For those with residual SDH, 41.2% suffered from a SDH re-hemorrhage and 17.6% required surgery. The risk of re-hemorrhage climbed to 62.5% if the SDH remnant was large.

CONCLUSION

Anticoagulation while there is a residual SDH was associated with a significant risk of re-hemorrhage. This risk should be weighed against the risk of holding anticoagulation.

Mechanisms and Clinical Manifestations of Cognitive Decline in Atrial Fibrillation Patients: Potential Implications for Preventing Dementia

Atrial fibrillation (AF) patients face an approximate 1.5-fold increased risk of cognitive decline compared with the general population. Among poststroke AF patients, the risk of cognitive decline is even higher with an estimated threefold increase. This article provides a narrative review on the current evidence and highlights gaps in knowledge and areas for future research. Although earlier studies hypothesized that the association between AF and cognitive decline is mainly a consequence of previous ischemic strokes, more recent evidence also suggests such an association in AF patients without a history of clinical stroke. Because AF and cognitive decline mainly occur among elderly individuals, it is not surprising that both entities share multiple risk factors. In addition to clinically overt ischemic strokes, silent brain infarcts and other brain injury are likely mechanisms for the increased risk of cognitive decline among AF patients. Oral anticoagulation for stroke prevention in AF patients with additional stroke risk factors is one of the only proven therapies to prevent brain injury. Whether a broader use of oral anticoagulation, or more intense anticoagulation in some patients are beneficial in this context needs to be addressed in future studies. Although direct studies are lacking, it is reasonable to recommend optimal treatment of comorbidities and risk factors for the prevention of cognitive decline and dementia.

Gene expression changes implicate specific peripheral immune responses to Deep and Lobar Intracerebral Hemorrhages in humans

The peripheral immune system response to Intracerebral Hemorrhage (ICH) may differ with ICH in different brain locations. Thus, we investigated peripheral blood mRNA expression of Deep ICH, Lobar ICH, and vascular risk factor-matched control subjects (n = 59). Deep ICH subjects usually had hypertension. Some Lobar ICH subjects had cerebral amyloid angiopathy (CAA). Genes and gene networks in Deep ICH and Lobar ICH were compared to controls. We found 774 differentially expressed genes (DEGs) and 2 co-expressed gene modules associated with Deep ICH, and 441 DEGs and 5 modules associated with Lobar ICH. Pathway enrichment showed some common immune/inflammatory responses between locations including Autophagy, T Cell Receptor, Inflammasome, and Neuroinflammation Signaling. Th2, Interferon, GP6, and BEX2 Signaling were unique to Deep ICH. Necroptosis Signaling, Protein Ubiquitination, Amyloid Processing, and various RNA Processing terms were unique to Lobar ICH. Finding amyloid processing pathways in blood of Lobar ICH patients suggests peripheral immune cells may participate in processes leading to perivascular/vascular amyloid in CAA vessels and/or are involved in its removal. This study identifies distinct peripheral blood transcriptome architectures in Deep and Lobar ICH, emphasizes the need for considering location in ICH studies/clinical trials, and presents potential location-specific treatment targets.

Submassive Pulmonary Embolism in the Setting of Intracerebral Hemorrhage: A Case of Suction Thrombectomy

Pulmonary embolism (PE) in the setting of intracerebral hemorrhage (ICH) is an unfortunate, challenging, and highly morbid clinical problem. Interventional strategies have lower associated bleeding risks than the standby for PE treatment: systemic anticoagulation. Despite this benefit, there are few examples in the literature of its utilization in the management of PE in the setting of ICH. This present case provides an example of the successful utilization of suction thrombectomy to manage PE in the setting of ICH. An 80-year-old female presented to an outside hospital with complaints of dizziness, headache, nausea, and vomiting of abrupt onset one hour before arrival. Computed tomography (CT) of the head with CT Angiography (CTA) of the head and neck was performed and demonstrated hemorrhage in all ventricles; most prominently within the left lateral ventricle. Magnetic Resonance Imaging (MRI) of the brain suggested that the cause of her hemorrhage was reperfusion injury after a small acute infarction in the left internal capsule in the setting of anticoagulant use. Ten days after her diagnosis of ICH, a submassive PE was diagnosed with a class IV pulmonary embolism severity index (PESI). An interdisciplinary evaluation was conducted between hospitalist medicine, neurology, neurosurgery, and interventional radiology. A successful suction thrombectomy was performed on hospital day 11. No new neurologic deficits were appreciated post-procedure. The patient's heart rate remained elevated but improved. Blood pressure remained controlled. The patient was weaned off oxygen to room air. Neurosurgery assessed the patient to be of acceptable risk for discharge with the further deferment of anticoagulation until repeat CT head six weeks after discharge. The patient was discharged on hospital day 14. Treating PE in the setting of ICH is without clear guidelines. The appropriate treatment modality is reliant upon the clinical judgment and the individual details of each case. In this case, a high PESI with imaging demonstrating a stable hematoma without evidence of new blood resulted in the decision to use a suction thrombectomy. More research is needed to develop consistent evidence-based guidelines for this clinical challenge.

Animal models for the study of intracranial hematomas (Review)

Intracranial hematomas (ICH) are a frequent condition in neurosurgical and neurological practices, with several mechanisms of primary and secondary injury. Experimental research has been fundamental for the understanding of the pathophysiology implicated with ICH and the development of therapeutic interventions. To date, a variety of different animal approaches have been described that consider, for example, the ICH evolutive phase, molecular implications and hemodynamic changes. Therefore, choosing a test protocol should consider the scope of each particular study. The present review summarized investigational protocols in experimental research on the subject of ICH. With this subject, injection of autologous blood or bacterial collagenase, inflation of intracranial balloon and avulsion of cerebral vessels were the models identified. Rodents (mice) and swine were the most frequent species used. These different models allowed improvements on the understanding of intracranial hypertension establishment, neuroinflammation, immunology, brain hemodynamics and served to the development of therapeutic strategies.

Combined External Ventricular Drainage and Endoscope-Assisted Microsurgery Using the Middle Frontal Gyrus Approach in Severe Ventricular Hemorrhage with Casting of the Fourth Ventricle

OBJECTIVE

To investigate combined external ventricular drainage and endoscope-assisted microsurgery using the middle frontal gyrus approach in patients with severe ventricular hemorrhage with casting of the fourth ventricle and patients' recovery after this treatment.

METHODS

Patients with severe ventricular hemorrhage with casting of the fourth ventricle (n = 41) were randomly assigned to intervention and control groups. Modified Graeb score was used to assess 3-day hematoma clearance rate before and after surgery, drainage tube extubation time for the 2 groups was compared, and time when blood clot in the fourth ventricle was not blocked with cerebrospinal fluid was compared. Glasgow Coma Scale was used to assess consciousness after surgery; Glasgow Coma Scale scores recorded 1 and 7 days after surgery were also compared. Modified Rankin Scale was used to evaluate patients' recovery 1 and 6 months after surgery. Hydrocephalus and intracranial infections in patients after surgery were recorded for 90 days.

RESULTS

The 3-day hematoma clearance rate was dramatically higher in the intervention group. Modified Graeb score showed that more hemorrhage was delimited in 3 days in the intervention group. The intervention group exhibited significantly reduced length of block of the fourth ventricle and drainage tube extubation time. High Glasgow Coma Scale and modified Rankin Scale scores and significantly low incidence of complications (e.g., hydrocephalus and intracranial infection) were observed in patients in the intervention group.

CONCLUSIONS

Combined external ventricular drainage and endoscope-assisted microsurgery using the middle frontal gyrus approach can effectively improve severe ventricular hemorrhage with casting of the fourth ventricle and enhance patients' neurological function and recovery.

Symptomatic intracerebral hemorrhage after non-emergency percutaneous coronary intervention: Incidence, risk factors, and association with cardiovascular outcomes

Objective

To investigate the incidence, risk factors, and association with cardiovascular outcomes of patients who developed symptomatic intracerebral hemorrhage (ICH) after non-emergency percutaneous coronary intervention (PCI).

Methods

We conducted a single-institution retrospective study of patients who developed symptomatic ICH after non-emergency PCI. To identify associations between clinical variables and outcomes, Cox-proportional hazards regression models were constructed. Outcomes analyzed include (1) all-cause mortality, (2) acute ischemic stroke (AIS) or transient ischemic attack (TIA), and (3) major adverse cardiovascular events (MACE).

Results

A total of 1,732 patients were included in the analysis. The mean (±SD) age was 61.1 (±11.3) years, and 1,396 patients (80.6%) were male. The cumulative incidence of symptomatic ICH after non-emergency PCI was 1.3% (22 patients). Age, chronic kidney disease, and prior coronary artery bypass graft surgery were independently associated with a higher risk of ICH after PCI, while hyperlipidemia was independently associated with a lower risk of ICH after PCI. ICH after PCI was independently associated with a higher risk of all-cause mortality and AIS or TIA after PCI.

Conclusion

Patients who are older, who have chronic kidney disease, and who have had prior coronary artery bypass graft surgery should be monitored for symptomatic ICH after non-emergency PCI.

Hypertensive and Hypotensive Emergencies in Interventional Radiology

Hyper- and hypotensive emergencies represent some of the most severe clinical issues that can occur during or around an interventional radiology procedure. While some patients are known to be more predisposed to cardiovascular collapse, nearly all patients are at risk for such an outcome. This is particularly true of patients undergoing moderate sedation, with the possibility of cardiovascular compromise occurring not just due to the underlying pathology for which the patient is being treated, but as a complication of sedation itself. Understanding the underlying cause of hyper- or hypotension is paramount to performing an appropriate and timely intervention. While the underlying cause is being corrected-if possible-the changes in blood pressure themselves may need to be intervened upon to maintain cardiovascular stability in these patients. Interventional radiologists must be familiar with measures taken to correct hyper- or hypotensive emergencies, including the most commonly used medications to treat these disorders. This article discusses the most common etiologies of such clinical scenarios, and the most common interventions performed for these settings.

Development and Validation of an Automatic System for Intracerebral Hemorrhage Medical Text Recognition and Treatment Plan Output

The main purpose of the study was to explore a reliable way to automatically handle emergency cases, such as intracerebral hemorrhage (ICH). Therefore, an artificial intelligence (AI) system, named, H-system, was designed to automatically recognize medical text data of ICH patients and output the treatment plan. Furthermore, the efficiency and reliability of the H-system were tested and analyzed. The H-system, which is mainly based on a pretrained language model Bidirectional Encoder Representations from Transformers (BERT) and an expert module for logical judgment of extracted entities, was designed and founded by the neurosurgeon and AI experts together. All emergency medical text data were from the neurosurgery emergency electronic medical record database (N-eEMRD) of the First Affiliated Hospital of Chongqing Medical University, Chongqing Emergency Medical Center, and Chongqing First People’s Hospital, and the treatment plans of these ICH cases were divided into two types. A total of 1,000 simulated ICH cases were randomly selected as training and validation sets. After training and validating on simulated cases, real cases from three medical centers were provided to test the efficiency of the H-system. Doctors with 1 and 5 years of working experience in neurosurgery (Doctor-1Y and Doctor-5Y) were included to compare with H-system. Furthermore, the data of the H-system, for instance, sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and the area under the receiver operating characteristics curve (AUC), were calculated and compared with Doctor-1Y and Doctor-5Y. In the testing set, the time H-system spent on ICH cases was significantly shorter than that of doctors with Doctor-1Y and Doctor-5Y. In the testing set, the accuracy of the H-system’s treatment plan was 88.55 (88.16–88.94)%, the specificity was 85.71 (84.99–86.43)%, and the sensitivity was 91.83 (91.01–92.65)%. The AUC value of the H-system in the testing set was 0.887 (0.884–0.891). Furthermore, the time H-system spent on ICH cases was significantly shorter than that of doctors with Doctor-1Y and Doctor-5Y. The accuracy and AUC of the H-system were significantly higher than that of Doctor-1Y. In addition, the accuracy of the H-system was more closed to that of Doctor-5Y. The H-system designed in the study can automatically recognize and analyze medical text data of patients with ICH and rapidly output accurate treatment plans with high efficiency. It may provide a reliable and novel way to automatically and rapidly handle emergency cases, such as ICH.

Physical Activity and the Risk of Hemorrhagic Stroke: A Population-Based Longitudinal Follow-Up Study in Taiwan

Background: Data on the relationship between physical activity (PA) and hemorrhagic stroke (HS) are limited in Asian populations. This population-based longitudinal follow-up study therefore investigates whether PA is associated with a reduced risk of HS in Taiwan.

Methods: A total of 58,857 subjects who had participated in the Keelung Community-based Integrated Screening Program between 2005 and 2012 were enrolled. Information about their PA, obtained using questionnaires, was used to categorize them into three groups according to their average weekly time engaged in it: (1) no PA, (2) low PA (<90 min weekly), and (3) high PA (90 min per week or more). Cox proportional hazard regression was used to evaluate the effect of PA on HS. Stratified analysis by sex and comorbidities (diabetes mellitus, hypertension, and hyperlipidemia) were conducted to evaluate their impact on the relationship between PA and HS.

Results: Compared to the no-PA group, the adjusted hazard ratio of HS for the low-PA group was 0.74 (95% CI, 0.57–0.96, p = 0.0219), and for the high-PA group, 0.72 (95% CI, 0.58–0.90, p = 0.004). The stratified analyses showed that, for the non-comorbidity strata, the beneficial effect of PA on reducing HS risk became stronger as PA increased. However, in the diabetes and hypertension strata, high PA did not appear to have any greater protective effect than low PA.

Conclusions: Our findings suggested that even <90 min of PA per week might be beneficial to reduce HS risk. Such a low level of PA is likely to be more achievable and easier to maintain for the general population. Additionally, personalized recommendations based on pre-existing comorbidities may help optimize the beneficial effects of PA on HS prevention.

Nonhematologic and Hematologic Factors in Spontaneous Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage is defined as nontraumatic bleeding into the brain without vascular malformations or presence of tumor. It occurs in about a third of all strokes and has a high mortality and morbidity. Risk factors that determine the outcome are incompletely understood. Known factors include older age, male gender, Asian ethnicity, hypertension, and comorbidity such as inherited or acquired bleeding diathesis and use of antithrombotic drugs. Likewise, the clinical characteristics of the hematoma such as location and volume of the hematoma and other imaging features are also important. Hematoma extension or expansion is a complication with an unfavorable outcome. Recognition of risk factors for hematoma expansion and measures to prevent it, such as blood pressure lowering, will improve the outcome. Enhanced diagnostic methods, especially in imaging techniques developed over the past decade, have not only led to a better understanding of the pathophysiology of spontaneous intracerebral hemorrhage but also of the factors that influence hematoma expansion. An improved knowledge is essential to better management, minimizing hematoma expansion and leading to a healthier outcome.

Effect of genetic depletion of MMP-9 on neurological manifestations of hypertension-induced intracerebral hemorrhages in aged mice

Clinical and experimental studies show that hypertension induces intracerebral hemorrhages (ICH), including cerebral microhemorrhages in the aged brain, which contribute to the pathogenesis of vascular cognitive impairment (VCI). Previous studies showed that aging increased oxidative stress-mediated activation of matrix metalloproteinases (MMPs) that importantly contributes to the pathogenesis of ICHs. In particular, oxidative stress has been implicated in activation of MMP-9, which is known to be involved in the degradation of the extracellular matrix and cleavage of collagen IV, a key constituent of the basal membrane of cerebral vessels. To determine the role of MMP-9 activation in the genesis of ICHs, we induced hypertension in 20-month-old MMP-9 null and age-matched control mice by angiotensin II and L-NAME treatment. Contrary to our hypothesis, MMP-9 deficiency did not delay the onset or incidence of neurological consequences of hypertension-induced ICHs. Our results indicate that MMP-9 activation does not play a role in the age-related exacerbation of hypertension-induced ICH.

Rural-Urban Disparities in Intracerebral Hemorrhage Mortality in the USA: Preliminary Findings from the National Inpatient Sample

Objectives

To compare in-hospital mortality between intracerebral hemorrhage (ICH) patients in rural hospitals to those in urban hospitals of the USA.

Methods

We used the National Inpatient Sample to retrospectively identify all cases of ICH in the USA over the period 2004–2014. We used multivariable-adjusted models to compare odds of mortality between rural and urban hospitals. Joinpoint regression was used to evaluate trends in age- and sex-adjusted mortality in rural and urban hospitals over time.

Results

From 2004 to 2014, 5.8% of ICH patients were admitted in rural hospitals. Rural patients were older (mean [SE] 76.0 [0.44] years vs. 68.8 [0.11] years in urban), more likely to be white and have Medicare insurance. Age- and sex-adjusted mortality was greater in rural hospitals (32.2%) compared to urban patients (26.5%) (p value < 0.001). After multivariable adjustment, patients hospitalized in rural hospitals had two times the odds of in-hospital death compared to patients in urban hospitals (OR 2.07, 95% CI 1.77–2.41. p value < 0.001). After joinpoint regression, mortality declined in urban hospitals by an average of 2.8% per year (average annual percentage change, [AAPC] − 2.8%, 95% CI − 3.7 to − 1.8%), but rates in rural hospitals remained unchanged (AAPC − 0.54%, 95% CI − 1.66 to 0.58%).

Conclusions

Despite current efforts to reduce disparity in stroke care, ICH patients hospitalized in rural hospitals had two times the odds of dying compared to those in urban hospitals. In addition, the ICH mortality gap between rural and urban centers is increasing. Further studies are needed to identify and reverse the causes of this disparity.

Electronic supplementary material

The online version of this article (10.1007/s12028-020-00950-2) contains supplementary material, which is available to authorized users.

Epidemiological characteristics of 561 cases of intracerebral hemorrhage in Chengdu, China

ABSTRACT

To explore the epidemiology of patients with spontaneous intracerebral hemorrhage (sICH) in Chengdu, China, we retrieved the data of patients with spontaneous cerebral hemorrhage admitted to the First Affiliated Hospital of Chengdu Medical College from January 2017 to December 2019. We performed a comprehensive analysis of the location of hemorrhage, demographics, factors of hemorrhage, condition of body, severity of disturbance of consciousness, treatment, length of stay (days), inpatient costs, prognosis, and mortality rate in patients with sICH. In total, data of 561 in patients with sICH were included. The hemorrhage site was primarily located in the basal ganglia and thalamus (64.71%). The mean patient age was 63.2 ± 12.4 years (64.17% men, 35.83% women). Male patients (mean age 62.3 ± 12.5 year) were younger than female patients (mean age 64.9 ± 12.1 year). The age of sICH onset in our sample was between 40 and 79 years; this occurred in 87.70% of the included cases. There were more males than females, which may be related to more daily smoking, longer drinking years, and overweight in males than in females. Cases occurred most frequently during the winter and spring months, and the relationship between sICH visits and hospitalizations appeared as a U-shape. The median time from illness onset to hospital admission was 3.0 hours. According to the Glasgow Coma Scale (GCS) score at admission, 20.50% of sICH cases were of mild intensity, 39.93% were moderate, and 39.57% were severe. Moderate disorder is the most common sICH severity. Factors influencing the disturbance of consciousness were blood glucose level at the time of admission as well as the number of years with hypertension. The lower the degree of disturbance of consciousness and the more they smoked per day indicated they had a higher likelihood of receiving surgical treatment while in hospital. The median hospital stay was 13.0 days, while the median inpatient cost was USD 3609. The 30-day mortality rate was 18.36%. sICH is an important public health problem in Chengdu, China. A governmental initiative is urgently needed to establish a sICH monitoring system that covers the Chengdu region to develop more effective and targeted measures for sICH prevention, treatment, and rehabilitation.

Minimally Invasive Intracerebral Hematoma Evacuation Using a Novel Cost-Effective Tubular Retractor: Single-Center Experience

BACKGROUND

Spontaneous intracerebral hematoma (ICH) is a common disease with a dismal overall prognosis. Recent development of minimally invasive ICH evacuation techniques has shown promising results. Commercially available tubular retractors are commonly used for minimally invasive ICH evacuation yet are globally unavailable.

METHODS

A novel U.S. $7 cost-effective, off-the-shelf, atraumatic tubular retractor for minimally invasive intracranial surgery is described. Patients with acute spontaneous ICH underwent microsurgical tubular retractor-assisted minimally invasive ICH evacuation using the novel retractor. Patient outcome was retrospectively analyzed and compared with open surgery and with commercial tubular retractors.

RESULTS

Ten adult patients with spontaneous supratentorial ICH and median preoperative Glasgow Coma Scale score of 10 were included. ICH involved the frontal lobe, parietal lobe, occipitotemporal region, and solely basal ganglia in 3, 3, 2, and 2 patients, respectively. Mean preoperative ICH volume was 80 mL. Mean residual hematoma volume was 8.7 mL and mean volumetric hematoma reduction was 91% (median, 94%). Seven patients (70%) underwent >90% volumetric hematoma reduction. The total median length of hospitalization was 26 days. On discharge, the median Glasgow Coma Scale score was 12.5 (mean, 11.7). Thirty to 90 days' follow-up data were available for 9 patients (90%). The mean follow-up modified Rankin Scale score was 3.7 and 5 patients (56%) had a modified Rankin Scale score of 3.

CONCLUSIONS

The novel cost-effective tubular retractor and microsurgical technique offer a safe and effective method for minimally invasive ICH evacuation. Cost-effective tubular retractors may continue to present a valid alternative to commercial tubular retractors.

Challenging anticoagulation cases: A case of pulmonary embolism shortly after spontaneous brain bleeding

Venous thromboembolism (VTE) is a common complication after intracranial hemorrhage (ICH); the incidence has been reported to vary between 18% to 50% for deep vein thrombosis and between 0.5% to 5% for pulmonary embolism (PE). According to current clinical practice guidelines, patients with acute VTE should receive anticoagulant treatment for at least 3 months in the absence of contraindications. Anticoagulant treatment reduces mortality, prevents early recurrences and improves long-term outcome in patients with acute VTE. However, recent ICH is an absolute contraindication for anticoagulant treatment due to the potential increased risk of hematoma expansion or recurrent ICH. Hematoma expansion occurs in approximately a third of patients within 24 h following the diagnosis of a spontaneous ICH. The risk for recurrent ICH depends on patients' features as well as on the feature of index ICH. Limited evidence is available on the risks of therapeutic anticoagulation started shortly after ICH. Expert consensus around the introduction of therapeutic anticoagulation suggests delaying therapeutic anticoagulation for at least 2 weeks after spontaneous ICH, until the risk re-bleeding becomes acceptable. Vena cava filters should be inserted to reduce the risk for (non) fatal PE until therapeutic anticoagulation can be started; antithrombotic prophylaxis should be started as soon as possible to avoid recurrent VTE after vena cava filter insertion. For patients presenting PE with hemodynamic compromise, percutaneous embolectomy should be considered. Most patients will be able to receive anticoagulant treatment within 4 weeks following spontaneous ICH; direct oral anticoagulants are probably the treatment of choice for those ICH patients tolerating anticoagulant treatment.

Entinostat improves acute neurological outcomes and attenuates hematoma volume after Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) or hemorrhagic stroke is a major public health problem with no effective treatment. Given the emerging role of epigenetic mechanisms in the pathophysiology of ICH, we tested the hypothesis that a class 1 histone deacetylase inhibitor (HDACi), Entinostat, attenuates neurodegeneration and improves neurobehavioral outcomes after ICH. To address this, we employed a preclinical mouse model of ICH and Entinostat was administered intraperitoneally one-hour post induction of ICH. Entinostat treatment significantly reduced the number of degenerating neurons and TUNEL-positive cells after ICH in comparison to vehicle-treated controls. Moreover, Entinostat treatment significantly reduced hematoma volume, T2-weighted hemorrhagic lesion volume and improved acute neurological outcomes after ICH. Further, Entinostat significantly reduced the hemin-induced release of proinflammatory cytokines in vitro. Consistently, the expression of proinflammatory microglial/macrophage marker, CD16/32, was remarkably reduced in Entinostat treated group after ICH in comparison to control. Altogether, data implicates the potential of class 1 HDACi, Entinostat, in improving acute neurological function after ICH warranting further investigation.

Brain injury and repair after intracerebral hemorrhage: The role of microglia and brain-infiltrating macrophages

Intracerebral hemorrhage (ICH) is a major public health problem characterized by cerebral bleeding. Despite recent advances in preclinical studies, there is no effective treatment for ICH making it the deadliest subtype of stroke. The lack of effective treatment options partly attributes to the complexity as well as poorly defined pathophysiology of ICH. The emerging evidence indicates the potential of targeting secondary brain damage and hematoma resolution for improving neurological outcomes after ICH. Herein, we provide an overview of our understanding of the functional roles of activated microglia and brain-infiltrating monocyte-derived macrophages in brain injury and repair after ICH. The clinical and preclinical aspects that we discuss in this manuscript are related to ICH that occurs in adults, but not in infants. Also, we attempt to identify the knowledge gap in the field for future functional studies given the potential of targeting microglia and brain-infiltrating macrophages for therapeutic intervention after ICH.

Low diagnostic yield in follow-up MR imaging in patients with spontaneous intracerebral hemorrhage with a negative initial MRI

PURPOSE

Follow-up MRI/MRA is historically obtained as outpatient when patients with a spontaneous intracerebral hemorrhage (ICH) have an initial MRI/MRA that is negative for an underlying structural lesion. However, the utility of repeating MR imaging in a delayed fashion remains uncertain.

METHODS

We retrospectively reviewed 396 patients with spontaneous ICH admitted at our institution between 2015 and 2017 and selected those whose initial MRI/MRA was negative for an underlying structural lesion and those who underwent follow-up MR imaging in a delayed fashion.

RESULTS

A total of 113 patients met the study criteria. The average age of those with negative follow-up MRI/MRA was 65.0 ± 12.6 (IQR: 55.0-74.0) years old. None of the 113 patients with a negative inpatient MRI/MRA had an underlying structural lesion on follow-up MRI/MRA (0%, 95% CI 0.0-0.032, p < 0.001). The mean time of the follow-up imaging from the initial study was 105.7 days (median: 62 days; IQR: 42.5-100.5). Of the 113, 83 (73.5%) underwent follow-up MRI with and without gadolinium, while 30 (26.5%) patients did not receive gadolinium.

CONCLUSION

Delayed follow-up MRI in patients with a negative initial MRI/MRA for workup of spontaneous ICH was not diagnostic in any of the patients included in the study. Our study suggests that a routine follow-up MRI for this patient population is not necessary.

Molecular Correlates of Hemorrhage and Edema Volumes Following Human Intracerebral Hemorrhage Implicate Inflammation, Autophagy, mRNA Splicing, and T Cell Receptor Signaling

Intracerebral hemorrhage (ICH) and perihematomal edema (PHE) volumes are major determinants of ICH outcomes as is the immune system which plays a significant role in damage and repair. Thus, we performed whole-transcriptome analyses of 18 ICH patients to delineate peripheral blood genes and networks associated with ICH volume, absolute perihematomal edema (aPHE) volume, and relative PHE (aPHE/ICH; rPHE). We found 440, 266, and 391 genes correlated with ICH and aPHE volumes and rPHE, respectively (p < 0.005, partial-correlation > |0.6|). These mainly represented inflammatory pathways including NF-κB, TREM1, and Neuroinflammation Signaling-most activated with larger volumes. Weighted Gene Co-Expression Network Analysis identified seven modules significantly correlated with these measures (p < 0.05). Most modules were enriched in neutrophil, monocyte, erythroblast, and/or T cell-specific genes. Autophagy, apoptosis, HIF-1α, inflammatory and neuroinflammatory response (including Toll-like receptors), cell adhesion (including MMP9), platelet activation, T cell receptor signaling, and mRNA splicing were represented in these modules (FDR p < 0.05). Module hub genes, potential master regulators, were enriched in neutrophil-specific genes in three modules. Hub genes included NCF2, NCF4, STX3, and CSF3R, and involved immune response, autophagy, and neutrophil chemotaxis. One module that correlated negatively with ICH volume correlated positively with rPHE. Its genes and hubs were enriched in T cell-specific genes including hubs LCK and ITK, Src family tyrosine kinases whose modulation improved outcomes and reduced BBB dysfunction following experimental ICH. This study uncovers molecular underpinnings associated with ICH and PHE volumes and pathophysiology in human ICH, where knowledge is scarce. The identified pathways and hub genes may represent novel therapeutic targets.

Cerebellar Necrosectomy Instead of Suboccipital Decompression: A Suitable Alternative for Patients with Space-Occupying Cerebellar Infarction

OBJECTIVE

Space-occupying cerebellar ischemic strokes (SOCSs) often lead to neurological deterioration and require surgical intervention to release pressure from the posterior fossa. Current guidelines recommend suboccipital decompressive craniectomy (SDC) with dural expansion when medical therapy is not sufficient. However, no good-quality evidence is available to support this surgical practice, and the surgical timing and technique both remain controversial. We have described an alternative to SDC, surgical evacuation of infarcted tissue (necrosectomy) and its clinical outcomes.

METHODS

In the present retrospective, single-center study, 34 consecutive patients with SOCS undergoing necrosectomy via osteoplastic craniotomy were included. The patient characteristics and radiological findings were evaluated. To differentiate the effects of age on the functional outcomes, the patients were divided into 2 groups (group I, age ≤60 years; and group II, age >60 years). Functional outcomes were assessed using the Glasgow outcome scale, modified Rankin scale, and Barthel index at discharge and 30 days postoperatively.

RESULTS

In our cohort, we observed overall mortality of 21%, with good functional outcomes (Glasgow outcome scale score ≥4) for 76% of the patients. No statistically significant differences in mortality or functional outcomes were observed between the 2 patient groups. Comparing our data with a recent meta-analysis of SDC, the number of adverse events and unfavorable outcome showed equipoise between the 2 treatment modalities.

CONCLUSIONS

Necrosectomy appears to be a suitable alternative to SDC for SOCS, achieving comparable mortality and functional outcomes. Further trials are necessary to evaluate which surgical technique is more beneficial in the setting of SOCSs.

Recurrent intracerebral hemorrhages due to central nervous system vasculitis: A neuropsychological case report

OBJECTIVE

Primary angiitis of the central nervous system (PACNS) is a rare and devastating form of vasculitis that destroys the vessels of the brain and spinal cord, resulting in progressive and debilitating neurologic symptoms. The objective of the present study was to detail the diagnostic process of a case of a patient with PACNS who suffered from six intracerebral hemorrhages (ICHs).

METHOD

The patient was an African American woman with a history of recurrent ICHs of unclear etiology who received serial neuropsychological evaluations over the course of a 5-year period. Two comprehensive neuropsychological evaluations are included, as well as an overview of her clinical course, including differential diagnostic considerations and treatment planning.

RESULTS

Neuropsychological assessment revealed marked deficits in visuospatial abilities and processing speed associated with her underlying neuropathology. Integrated review of her medical records indicated a probable diagnosis of PACNS as the likely etiology of her recurrent ICHs.

CONCLUSIONS

This study demonstrates the importance of differential diagnosis of low base-rate conditions, functional neuroanatomy and neurobehavioral phenomenology, serial assessment, and cognitive reserve in clinical neuropsychological practice.

Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage

BACKGROUND

Do-not-resuscitate (DNR) orders are commonly used after intracerebral hemorrhage (ICH) and have been shown to be a predictor of mortality independent of disease severity. We determined the frequency of early DNR orders in ICH patients and whether a previously reported association with increased mortality still exists.

METHODS

We performed a retrospective analysis of patients discharged from non-federal California hospitals with a primary diagnosis of ICH from January 2013 through December 2014. Characteristics included hospital ICH volume and type and whether DNR order was placed within 24 h of admission (early DNR order). The risk of in-hospital mortality was evaluated both on the individual and hospital level using multivariable analyses. A case mix-adjusted hospital DNR index was calculated for each hospital by comparing the actual number of DNR cases with the expected number of DNR cases from a multivariate model.

RESULTS

A total of 9,958 patients were treated in 180 hospitals. Early DNR orders were placed in 20.1% of patients and 54.2% of these patients died during their hospitalization compared to 16.0% of patients without an early DNR order. For every 10% increase in a hospital's utilization of early DNR orders, there was a corresponding 26% increase in the likelihood of in-hospital mortality. Patients treated in hospitals within the highest quartile of adjusted DNR use had a higher relative risk of death compared to the lowest quartile (RR 3.9 vs 5.2) though the trend across quartiles was not statistically significant.

CONCLUSIONS

The use of early DNR orders for ICH continues to be a strong predictor of in-hospital mortality. However, patients treated at hospitals with an overall high or low use of early DNR had similar relative risks of death whether or not there was an early DNR order, suggesting that such orders may not be a proxy for less aggressive care as seen previously.

Prevalence of Intracranial Aneurysms in Patients with Infrarenal Abdominal Aortic Aneurysms: A Multicenter Experience

Prior studies suggest high prevalence of intracranial aneurysms (IA) in patients with infrarenal abdominal aortic aneurysms (AAA). We reviewed our multicenter experience in clinical detection/treatment of IAs in AAA patients and estimated the risk of IA in patients with AAA relative to patients without AAA. We reviewed cases of vascular surgery infrarenal AAA repairs at three Mayo Clinic sites from January 1998 to December 2018. Concurrent controls were randomly matched in a 1:1 ratio by age, sex, smoking history, and head imaging characteristics. Conditional logistic regression was used to calculate odds ratios. We reviewed 2,300 infrarenal AAA repairs. Mean size of AAA at repair was 56.9 ± 11.4 mm; mean age at repair, 75.8 ± 8.0 years. 87.5% of the cases ( n  = 2014) were men. Head imaging was available in 421 patients. Thirty-seven patients were found to have 45 IAs for a prevalence of 8.8%. Mean size of IA was 4.6 ± 3.5 mm; mean age at IA detection, 72.0 ± 10.8 years. Thirty (81%) out of 37 patients were men. Six patients underwent treatment for IA: four for ruptured IAs and two for unruptured IAs. All were diagnosed before AAA repair. Treatment included five clippings and one coil-assisted stenting. Time from IA diagnosis to AAA repair was 16.4 ± 11.0 years. Two of these patients presented with ruptured AAA, one with successful repair and a second one that resulted in death. Odds of IA were higher for patients with AAA versus those without AAA (8.8% [37/421] vs. 3.1% [13/421]; OR 3.18; 95% confidence interval, 1.62-6.27, p  < 0.001). Co-prevalence of IA among patients with AAA was 8.8% and is more than three times the rate seen in patients without AAA. All IAs were diagnosed prior to AAA repair. Surveillance for AAA after IA treatment could have prevented two AAA ruptures and one death.

The effects of mindfulness-based intervention on quality of life and poststroke depression in patients with spontaneous intracerebral hemorrhage in China

OBJECTIVE

Spontaneous intracerebral hemorrhage (sICH) is a devastating disease that can lead to poststroke depression (PSD) and greatest impact on the quality of life (QOL) of patients. Mindfulness meditation was viewed as one of the effective ways to reduce PSD in patients with cancer. The present study tried to investigate whether mindfulness meditation has potential benefits in PSD and QOL for sICH patients in China.

METHODS

Two hundred and two patients in West China Hospital, Sichuan University, enrolled from January 2017 to December 2018 were included in a randomized controlled trial. After removing missing values, there were 67 in control group and 67 in intervention group. Patients in intervention group received 2-month mindfulness-based cognitive therapy, and patients in control group received stress management education (ie, an active control).

RESULTS

The results suggested that the significant differences of depression, trait mindfulness, social well-being, emotional well-being, and total score of QOL were found in intervention group from time 1 to time 2. Physical well-being and the score of NIH stroke scale experienced significant changes in both control group and intervention group over time.

CONCLUSIONS

Mindfulness-based intervention has positive effects on sICH patients' depression, social well-being, and emotional well-being. However, the change of trait mindfulness over time could not explain these positive effects. Future studies could explore the mechanism of mindfulness-based intervention on sICH patients' depression and QOL and clarify the boundaries of the positive effects of mindfulness-based intervention.

Relation of Intracerebral Hemorrhage Descriptors with Clinical Factors

The association between intracerebral hemorrhage (ICH) shape and a poor treatment outcome has been established by few authors. We decided to analyze whether computationally assessed hemorrhage shape irregularity is associated with any known predictors of its poor treatment outcome. We retrospectively analyzed 48 patients with spontaneous intracerebral hemorrhage. For each patient we calculated Fractal Dimension, Compactness, Fourier Factor and Circle Factor. Our study showed that patients above 65 years old had significantly higher Compactness (0.70 ± 0.19 vs. 0.56 ± 0.20; p < 0.01), Fractal Dimension (0.46 ± 0.22 vs. 0.32 ± 0.20; p = 0.03) and Circle Factor (0.51 ± 0.25 vs. 0.35 ± 0.17; p < 0.01). Patients with hemorrhage growth had significantly higher Compactness (0.74 ± 0.23 vs. 0.58 ± 0.18; p < 0.01), Circle Factor (0.55 ± 0.27 vs. 0.37 ± 0.18; p < 0.01) and Fourier Factor (0.96 ± 0.06 vs. 0.84 ± 0.19; p = 0.03). In conclusion, irregularity resulting from the number of appendices can be a predictor of ICH growth; however, the size of those appendices is also important. Shape roughness better reflects the severity of brain tissue damage and a patient’s general condition.

Blast crisis of chronic myeloid leukemia initially presenting as severe acute intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is frequent pathology in emergency department. Coagulopathy leading to ICH are rare. Intracerebral hemorrhage is a leading cause of mortality among patients diagnosed with chronic myelogenous leukemia (CML). In this report we discussed the case of a previously healthy male patient, who presented with fatal ICH, newly diagnosed with blast crisis in CML.

Clinical Profile and Predictors of Outcome in Spontaneous Intracerebral Hemorrhage from a Tertiary Care Centre in South India

Background. This article attempts to evaluate the clinical profile and outcome determinants following hypertensive SICH in a South Indian population. The study represents the largest series of SICH reported from a single centre in India. Materials and Methods. Prospective data collection and analysis of patients with SICH admitted to our centre between 1st January 2015 and 31st December 2018. The variables analysed include: age, sex, comorbidities, Glasgow coma score (GCS) on admission, radiological features, treatment modality, and outcome at three months. Modified Rankin score (mRS) was used to assess the outcome at discharge and three months. Results. Our study group of 905 patients included 638 males and 267 females and the mean age at presentation was 58.10 ± 12.76 years. The study group included 523 patients (57.8%) previously diagnosed hypertensive, of whom 36.3% (n = 190) were on irregular medication. The most frequent locations of hematoma were basal ganglia (478), thalamus (202), lobar (106), cerebellar (61), brainstem (31), and primary intraventricular haemorrhage (27). Secondary intraventricular extension was seen in 425 (47%) patients on admission. The mean volume of the clot on admission was 23.45 ± 19.79 ml, and clot progression was seen in only 46 (5.08%) cases. Surgical evacuation through craniotomy was done in 147 (16.8%) patients, and external ventricular drainage (EVD) was placed in 56 (6.2%) patients. Overall 3-month mortality was 30.1% (266 patients). On the last follow up a favorable outcome (mRS 0-3) was observed in 412 (45.53%) patients and a poor outcome (mRS 4-5) in 207 patients (22.87%). Independent predictors of mortality are Age >70 (p = <0.001, OR 4.806, 95% CI 3.064-7.54), admission GCS <8 (p = <0.001, OR7.684, 95% CI 5.055#x2013;11.68), and Hematoma volume >30 ml (p = <0.001, OR 2.45, 95% CI 1.626-3.691). Intraventricular haemorrhage was an additional poor outcome predictor (p < 0.015, CI 1.105-2.585). Surgical evacuation reduced mortality in the group, but morbidity rates remained the same. Conclusions. SICH predominantly affects a younger population in India in comparison to the Western society. Elderly age, poor GCS on admission, clot volume above 30 ml and intraventricular extension remain the most consistent predictors of death and poor outcome. Further studies are needed to assess the risk of SICH among hypertensive patients and to prognosticate the outcome after SICH using novel predictors, including biomarkers.

Paramedic Global Impression of Change During Prehospital Evaluation and Transport for Acute Stroke

Background and Purpose- The prehospital setting is a promising site for therapeutic intervention in stroke, but current stroke screening tools do not account for the evolution of neurological symptoms in this early period. We developed and validated the Paramedic Global Impression of Change (PGIC) Scale in a large, prospective, randomized trial. Methods- In the prehospital FAST-MAG (Field Administration of Stroke Therapy-Magnesium) randomized trial conducted from 2005 to 2013, EMS providers were asked to complete the PGIC Scale (5-point Likert scale values: 1-much improved, 2-mildly improved, 3-unchanged, 4-mildly worsened, 5-much worsened) for neurological symptom change during transport for consecutive patients transported by ambulance within 2 hours of onset. We analyzed PGIC concurrent validity (compared with change in Glasgow Coma Scale, Los Angeles Motor Scale), convergent validity (compared with National Institutes of Health Stroke Scale severity measure performed in the emergency department), and predictive validity (of neurological deterioration after hospital arrival and of final 90-day functional outcome). We used PGIC to characterize differential prehospital course among stroke subtypes. Results- Paramedics completed the PGIC in 1691 of 1700 subjects (99.5%), among whom 635 (37.5%) had neurological deficit evolution (32% improvement, 5.5% worsening) during a median prehospital care period of 33 (IQR, 27-39) minutes. Improvement was associated with diagnosis of cerebral ischemia rather than intracranial hemorrhage, milder stroke deficits on emergency department arrival, and more frequent nondisabled and independent 3-month outcomes. Conversely, worsening on the PGIC was associated with intracranial hemorrhage, more severe neurological deficits on emergency department arrival, more frequent treatment with thrombolytic therapy, and poor disability outcome at 3 months. Conclusions- The PGIC scale is a simple, validated measure of prehospital patient course that has the potential to provide information useful to emergency department decision-making. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00059332.

Nontraumatic spontaneous intracerebral hemorrhage: Baseline characteristics and early outcomes

BACKGROUND AND PURPOSE

Hemorrhagic stroke, particularly nontraumatic spontaneous intracerebral hemorrhage (SICH), is a cerebrovascular condition with unfavorable outcomes. The aims of the present study were to evaluate patients who suffered from SICH and investigate the early outcomes in a single-center study.

METHODS

During a study -period of 6 years (2008-2014), 613 consecutive patients (mean age, 72 ± 12.7 years; 51.1% female), who suffered from nontraumatic SICH and were treated at the Department of Neurology at the University Hospital of Schleswig-Holstein, Campus Lübeck, Germany, were included and prospectively analyzed.

RESULTS

During a mean hospitalization time of 12 days, 148 patients (24.1%) died, 47% of those within the first 2 days and 79% within the first week. The patients who died stayed at the hospital for a shorter time (3) than those who survived (p < .001). In the multivariate logistic regression, following parameters were found to be associated with the in-hospital mortality: female sex (OR, 2.0; 95%-CI, 1.2-3.4; p = .009), a NIHSS score> 10 (OR, 10.5; 95%-CI, 5.6-19.5; p < .001), history of hypertension (OR, 0.35; 95%-CI, 0.19-0.64; p = .001), previous oral anticoagulation (OR, 2; 95%-CI, 1.0-3.8; p = .032), and intraventricular extension of hemorrhage (OR, 2.8; 95%-CI, 1.7-4.7; p = .001). At discharge, 192 patients (41.2%) showed favorable outcomes (mRS ≤ 2) whereas the median mRS of patients who survived was 3 (IQR 2-4). The good functional outcome at discharge from the acute hospital was decreased by an age> 70 years (OR, 0.56; 95%-CI, 0.35-0.9; p = .017), NIHSS score> 10 at admission (OR, 0.07; 95%-CI, 0.04-0.13; p < .001), and development of pneumonia during hospitalization (OR, 0.35; 95%-CI, 0.2-0.6; p < .001).

CONCLUSION

The present study showed that SICH is a serious disease causing high mortality and disability, particularly in the early period after event.

Clinical Significance of Nadir Hemoglobin in Predicting Neurologic Outcome in Infants With Abused Head Trauma

Traumatic brain injury (TBI) is a leading cause of pediatric morbidity and mortality and is categorized as abusive head trauma (AHT) and accidental head injury. A retrospective chart review of 124 children aged <1 year diagnosed with TBI were analyzed. Outcomes were evaluated at discharge and 6 months later by using the Pediatric Cerebral Performance Category (PCPC) Scale. The receiver operating characteristic (ROC) curve was applied to determine the cutoff values for hemoglobin (HB) levels. In the study, 50 infants (40.3%) achieved a favorable neurologic outcome (PCPC ≦ 2) and 74 (59.7%) had poor neurologic outcomes (PCPC ≧ 3). Infants with poor neurologic outcomes had lower HB on admission and nadir HB (p < 0.05). Based on multivariate logistic regression analysis, the nadir HB was a predictor of poor neurologic outcomes at discharge and 6 months later in both AHT and accidental head injury. Nadir HB had the largest area under the ROC curve for predicting poor neurologic outcomes. We determined the appropriate cutoff value of nadir HB as 9.35 g/dl for predicting neurologic outcomes in infants with TBI. Furthermore, the cutoff value of nadir HB in predicting poor neurologic outcomes in infants caused by AHT and accidental head injury were taken as 9.36 and 8.75 g/dl, respectively.

Abilities of a Densitometric Analysis of Computed Tomography Images and Hemorrhagic Parameters to Predict Outcome Favorability in Patients With Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is one of the most devastating subtypes of stroke. A rapid assessment of ICH severity involves the use of computed tomography (CT) and derivation of the hemorrhage volume, which is often estimated using the ABC/2 method. However, these estimates are highly inaccurate and may not be feasible for anticipating outcome favorability.

OBJECTIVE

To predict patient outcomes via a quantitative, densitometric analysis of CT images, and to compare the predictive power of these densitometric parameters with the conventional ABC/2 volumetric parameter and segmented hemorrhage volumes.

METHODS

Noncontrast CT images of 87 adult patients with ICH (favorable outcomes = 69, unfavorable outcomes = 12, and deceased = 6) were analyzed. In-house software was used to calculate the segmented hemorrhage volumes, ABC/2 and densitometric parameters, including the skewness and kurtosis of the density distribution, interquartile ranges, and proportions of specific pixels in sets of CT images. Nonparametric statistical analyses were conducted.

RESULTS

The densitometric parameter interquartile range exhibited greatest accuracy (82.7%) in predicting favorable outcomes. The combination of skewness and the interquartile range effectively predicted mortality (accuracy = 83.3%). The actual volume of the ICH exhibited good coherence with ABC/2 (R = 0.79). Both parameters predicted mortality with moderate accuracy (<78%) but were less effective in predicting unfavorable outcomes.

CONCLUSION

Hemorrhage volume was rapidly estimated and effectively predicted mortality in patients with ICH; however, this value may not be useful for predicting favorable outcomes. The densitometric analysis exhibited significantly higher power in predicting mortality and favorable outcomes in patients with ICH.

Intracerebral Hemorrhage

PURPOSE OF REVIEW

This article describes the advances in the management of spontaneous intracerebral hemorrhage in adults.

RECENT FINDINGS

Therapeutic intervention in intracerebral hemorrhage has continued to focus on arresting hemorrhage expansion, with large randomized controlled trials addressing the effectiveness of rapidly lowering blood pressure, hemostatic therapy with platelet transfusion, and other clotting complexes and clot volume reduction both of intraventricular and parenchymal hematomas using minimally invasive techniques. Smaller studies targeting perihematomal edema and inflammation may also show promise.

SUMMARY

The management of spontaneous intracerebral hemorrhage, long relegated to the management and prevention of complications, is undergoing a recent evolution in large part owing to stereotactically guided clot evacuation techniques that have been shown to be safe and that may potentially improve outcomes.

Effect of Cigarette Smoking on Functional Outcomes in Patients with Spontaneous Intracerebral Hemorrhage

BACKGROUND

Nicotine may have neuroprotective effects on the injured brain through modulation of the cholinergic anti-inflammatory pathway.

AIMS

This study aimed to evaluate the relationship between cigarette smoking and outcomes in patients with spontaneous intracerebral hemorrhage (ICH).

METHODS

This was a retrospective review of consecutive ICH patients enrolled in the ICH Outcomes Project from 2009 to 2017. Patients with age ≥18 years and baseline modified Rankin Scale (mRS) score 0-2 were included. Smoking patterns were categorized as recent smoker (≤30 days prior to ICH) and not recent smoker (>30 days prior to ICH). Not recent smokers were further categorized into former smokers and nonsmokers. The primary outcome was good outcome (90-day mRS ≤ 2). Secondary outcomes were excellent outcome (90-day mRS 0-1), 90-day Barthel Index, and in-hospital and 90-day mortality.

RESULTS

The study cohort comprised 545 patients, including 60 recent smokers and 485 not recent smokers. Recent smokers had higher rates of good (35% versus 23%; odds ratio [OR] = 1.787, P = .047) and excellent (25% versus 13%; OR = 2.220, P = .015) outcomes compared to not recent smokers. These differences were not significant after baseline adjustments. Recent smokers had higher rates of good (36% versus 24%; OR = 1.732, P = .063) and excellent (25% versus 13%; OR = 2.203, P = .018) outcomes compared to nonsmokers. These differences were not significant after baseline adjustments. A 90-day Barthel Index, in-hospital, and 90-day mortality were comparable between recent and not recent smokers, recent and nonsmokers, and former and nonsmokers.

CONCLUSIONS

Despite potential neuroprotective effects of nicotine found in cigarettes, these may be outweighed by the detrimental effects of cigarette smoking on health outcomes.

Long-Term Follow-up in Patients with Spontaneous Intracerebral Hemorrhage Treated With or Without Surgical Intervention: a Large-Scale Retrospective Study

Debates regarding the most beneficial medical or surgical procedures for patients with spontaneous intracerebral hemorrhage (sICH) are still ongoing. We aimed to evaluate the risk of subsequent vascular disease and mortality in patients with sICH treated with and without surgical intervention, in a large-scale Asian population. Patients hospitalized within 2000 to 2013 who were newly diagnosed with sICH were identified using the National Health Insurance Research Database of Taiwan. Neuroendoscopy and craniotomy groups comprised patients who underwent surgical treatment within 1 week, while those in the control group did not undergo early surgical treatment. Outcomes included subsequent hemorrhagic and ischemic stroke, following acute myocardial infarction, congestive heart failure, and mortality. After propensity score matching, there were 663 patients in each group. Compared to that in the control group, the neuroendoscopy and craniotomy groups had a significantly higher risk of secondary vascular events at 1 to 3 months of follow-up (adjusted HR, 2.08 and 1.95; 95% CI, 1.21-3.58 and 1.13-3.35; p < 0.01 and p < 0.05, respectively), but a significantly lower risk after 3 years of follow-up (adjusted HR, 0.52 and 0.52; 95% CI, 0.35-0.78 and 0.35-0.77; p < 0.01 and p < 0.01, respectively). The mortality rate was higher in the craniotomy group at 6 to 12 months of follow-up (adjusted HR, 2.18; 95% CI, 1.06-4.49; p < 0.05) compared to that in the control group. Thus, a timely surgical intervention for hematoma evacuation is advantageous in preventing secondary vascular events and improving outcomes in the long term. However, greater attention to secondary ischemic stroke following the initial sICH episode is needed.

Potential Neuroprotective Effect of miR-451 Against Cerebral Ischemia/Reperfusion Injury in Stroke Patients and a Mouse Model

OBJECTIVE

Recently, microRNAs (miRs) have been reported to be novel regulators in ischemic stroke. In this study, we investigated the pattern of miR-451 expression along with its clinical application in human ischemic stroke and in an in vivo mouse model.

METHODS

The level of miR-451 was evaluated in patients and mice after ischemic stroke. National Institute of Health Stroke Scale scores and brain infarct volume were analyzed to the correlation of miR-451 expression and clinical information. In addition, blood samples and brain tissues were collected from an established middle cerebral artery occlusion model consisting of 12 adult male mice at 24 hours after the middle cerebral artery occlusion.

RESULTS

The results showed that miR-451 levels in the circulating blood of ischemic stroke patients were greatly decreased compared with the control. Further correlation analysis revealed a negative association between miR-451 and National Institute of Health Stroke Scale scores (r = -0.6104, P < 0.001) and infarct volume (r = -0.5442, P < 0.001). Moreover, miR-451 was down-regulated in response to middle cerebral artery occlusion in vivo, along with a negative correlation between miR-451 in brain and blood (r = 0.9240, P < 0.01). In addition, forced expression of miR-451 weakened ischemic brain infarction and apoptosis levels in focal ischemia-stroked mice, while downregulation of miR-451 significantly augmented ischemic injury.

CONCLUSIONS

In conclusion, miR-451 displays the neuroprotective effect in ischemic stroke and might serve as a novel therapeutic target of ischemic stroke.

Differential Cellular Expression of Galectin-1 and Galectin-3 After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a devastating sub-type of stroke with no proven treatment. Given the emerging role of Galectin-1 and Galectin-3 in neuroimmune responses, the objective of the current manuscript is to elucidate hemorrhagic-injury induced modulation and cellular expression of Galectin-1 and Galectin-3 in the brain in a pre-clinical model of ICH. To address this, ICH was induced in male CD1 mice by collagenase injection method. Western blotting as well as Immunofluorescence staining was performed to characterize the temporal expression pattern as well as cellular localization of Galectin-1 and Galectin-3 after ICH. Further, genetic studies were conducted to assess the functional role of Galectin-1 and Galectin-3 in inflammatory response employing a murine macrophage cell line, RAW 264.7. Galectin-1 and Galectin-3 exhibited very profound and increased expression from day 3 to day 7-post-injury, in the perihematomal brain region after ICH in comparison to Sham. Further, Galectin-1 expression was mostly observed in GFAP-positive astrocytes whereas Galectin-3 expression was observed mostly in Iba1-positive microglia/macrophages as well as CD16/32 (M1 microglial/macrophage marker)-positive cells. Moreover, genetic studies revealed a negative regulatory role of both Galectin-1 and Galectin-3 in the release of a proinflammatory cytokine, IL-6 from RAW 264.7 cells depending on the stimulus. Altogether, the present manuscript demonstrates for the first time, increased expression as well as cellular localization of Galectin-1 and Galectin-3 in the perihematomal brain regions after ICH. In addition, the manuscript raises the potential of Galectin-1 and Galectin-3 in modulating glial responses and thereby brain injury after ICH, warranting further investigation.

The intra-neuroendoscopic technique (INET): a modified minimally invasive technique for evacuation of brain parenchyma hematomas

Background

Minimally invasive endoscopic hematoma evacuation is widely used in the treatment of intracerebral hemorrhage. However, this technique still has room for improvement. The intra-neuroendoscopic technique (INET) is a modified minimally invasive technique, and we report its safety and efficacy in evacuating brain parenchyma hematomas by comparing it with cranial puncture and drainage operation (CPDO).

Methods

The frontal, temporal, or occipital approaches were used according to the site of bleeding. The preoperative and postoperative hematoma volumes, Glasgow Coma Scale (GCS) score, Cerebral State Index (CSI), hematoma evacuation rate, operation time, complications, and 30-day mortality and Glasgow Outcome Scale (GOS) were retrospectively compared between the two groups.

Results

A total of 98 patients were enrolled. The evacuation rate (84 ± 7.1% versus 51.0 ± 8.4%, p = 0.00), 7-day GCS (11.8 ± 1.2 versus 10.4 ± 1.5, p = 0.01), and CSI (87.1 ± 8.7 versus 80.6 ± 10.2, p = 0.02) were higher, and the 30-day mortality rate (1.9% versus 15.6%, p = 0.036) was lower in the INET group. However, the operation time was longer in the INET group than in the control group (65.2 ± 12.5 min versus 45.6 ± 10.9 min, p = 0.000). Multivariable logistic regression showed that a good medium-term outcome (GOS scores 4–5) was significantly associated with INET (odds ratio (OR) 3.514, 95% confidence interval (CI) 1.463–8.440, p = 0.005), age under 65 years (OR 1.402, 95% CI, 1.041–1.888, p = 0.026), and hematoma volume less than 50 ml (OR 1.974, 95% CI 1.302–2.993, p = 0.001).

Conclusions

INET surgery for brain parenchyma hematoma evacuation is a safe and efficient modified technique. This technique is minimally invasive, has less complications, and may be helpful in providing optimal outcomes for selected patients.

Trial registration

ClinicalTrials.gov, NCT02515903. Registered on 5 August 2015.

Electronic supplementary material

The online version of this article (10.1186/s13017-019-0239-0) contains supplementary material, which is available to authorized users.

Direct Medical Cost of Hospitalization for Acute Stroke in Lebanon: A Prospective Incidence-Based Multicenter Cost-of-Illness Study

Stroke is a major social and health problem posing heavy burden on national economies. We provided detailed financial data on the direct in-hospital cost of acute stroke care in Lebanon and evaluated its drivers. This was an observational, quantitative, prospective, multicenter, incidence-based, bottom-up cost-of-illness study. Medical and billing records of stroke patients admitted to 8 hospitals in Beirut over 1 year were analyzed. Direct medical costs were calculated, and cost drivers were assessed using a multivariable linear regression analysis. In total, 203 stroke patients were included (male: 58%; mean age: 68.8 ± 12.9 years). The direct in-hospital cost for all cases was US$1 413 069 for 2626 days (US$538 per in-hospital day). The average in-hospital cost per stroke patient was US$6961 ± 15 663. Hemorrhagic strokes were the most costly, transient ischemic attack being the least costly. Cost drivers were hospital length of stay, intensive care unit length of stay, type of stroke, stroke severity, modified Rankin Scale, third party payer, surgery, and infectious complications. Direct medical cost of acute stroke care represents high financial burden to Lebanese health system. Development of targeted public health policies and primary prevention activities need to take priority to minimize stroke admission in future and to contain this cost.

Endovascular Metal Devices for the Treatment of Cerebrovascular Diseases

Cerebrovascular disease involves various medical disorders that obstruct brain blood vessels or deteriorate cerebral circulation, resulting in ischemic or hemorrhagic stroke. Nowadays, platinum coils with or without biological modification have become routine embolization devices to reduce the risk of cerebral aneurysm bleeding. Additionally, many intracranial stents, flow diverters, and stent retrievers have been invented with uniquely designed structures. To accelerate the translation of these devices into clinical usage, an in-depth understanding of the mechanical and material performance of these metal-based devices is critical. However, considering the more distal location and tortuous anatomic characteristics of cerebral arteries, present devices still risk failing to arrive at target lesions. Consequently, more flexible endovascular devices and novel designs are under urgent demand to overcome the deficiencies of existing devices. Herein, the pros and cons of the current structural designs are discussed when these devices are applied to the treatment of diseases ranging broadly from hemorrhages to ischemic strokes, in order to encourage further development of such kind of devices and investigation of their use in the clinic. Moreover, novel biodegradable materials and drug elution techniques, and the design, safety, and efficacy of personalized devices for further clinical applications in cerebral vasculature are discussed.

Effect of Pretreatment with the NADPH Oxidase Inhibitor Apocynin on the Therapeutic Efficacy of Human Placenta-Derived Mesenchymal Stem Cells in Intracerebral Hemorrhage

Several studies have demonstrated the beneficial effect of mesenchymal stem cells (MSCs) on intracerebral hemorrhage (ICH). Enhancement of the therapeutic efficacy of MSCs in ICH is necessary, considering the diseases high association with mortality and morbidity. Various preconditioning methods to enhance the beneficial properties of MSCs have been introduced. We suggested apocynin, a well-known nicotinamide adenine dinucleotide phosphate (NADPH) oxidase inhibitor, as a novel preconditioning regimen to enhance the therapeutic efficacy of MSCs in ICH. Rat ICH models were made using bacterial collagenase. 24 h after ICH induction, the rats were randomly divided into apocynin-preconditioned MSC-treated (Apo-MSC), naïve MSC-treated and control groups. Hematoma volume, brain edema, and degenerating neuron count were compared at 48 h after the ICH induction. The expression of tight junction proteins (occludin, zona occludens [ZO]-1) were also compared. Hematoma size, hemispheric enlargement and degenerating neuron count were significantly lower in the Apo-MSC group than in the naïve MSC group (p = 0.004, 0.013 and 0.043, respectively), while the expression of occludin was higher (p = 0.024). Apocynin treatment enhances the therapeutic efficacy of MSCs in ICH in the acute stage, through the improvement of the beneficial properties of MSCs, such as neuroprotection and the reinforcement of endovascular integrity of cerebral vasculature.

External Validation of Hematoma Expansion Scores in Spontaneous Intracerebral Hemorrhage in an Asian Patient Cohort

BACKGROUND

Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage (ICH) and is known to be a strong predictor of neurological deterioration as well as poor functional outcome. This study aims to externally validate three risk prediction models of HE (PREDICT, 9-point, and BRAIN scores) in an Asian population.

METHODS

A prospective cohort of 123 spontaneous ICH patients admitted to a tertiary hospital (certified stroke center) in Singapore was recruited. Logistic recalibrations were performed to obtain updated calibration slopes and intercepts for all models. The discrimination (c-statistic), calibration (Hosmer-Lemeshow test, le Cessie-van Houwelingen-Copas-Hosmer test, Akaike information criterion), overall performance (Brier score, R²), and clinical usefulness (decision curve analysis) of the risk prediction models were examined.

RESULTS

Overall, the recalibrated PREDICT performed best among the three models in our study cohort based on the novel matrix comprising of Akaike information criterion and c-statistic. The PREDICT model had the highest R² (0.26) and lowest Brier score (0.14). Decision curve analyses showed that recalibrated PREDICT was more clinically useful than 9-point and BRAIN models over the greatest range of threshold probabilities. The two scores (PREDICT and 9-point) which incorporated computed tomography (CT) angiography spot sign outperformed the one without (BRAIN).

CONCLUSIONS

To our knowledge, this is the first study to validate HE scores, namely PREDICT, 9-Point and BRAIN, in a multi-ethnic Asian ICH patient population. The PREDICT score was the best performing model in our study cohort, based on the performance metrics employed in this study. Our findings also showed support for CT angiography spot sign as a predictor of outcome after ICH. Although the models assessed are sufficient for risk stratification, the discrimination and calibration are at best moderate and could be improved.

Genetic testing for Mendelian stroke due to cerebrovascular anomalies and other syndromes

Stroke is defined as a focal or at times global neurological impairment of sudden onset and presumed vascular origin. 85% of strokes are due to cerebral ischemia and the other 15% to primary intracerebral hemorrhage.

Ischemic stroke (IS) is characterized by complete or partial obstruction of a vessel in the brain, resulting in lack of blood supply and death of brain tissue. The most common causes of IS are atherosclerosis, cardioembolism and small-vessel disease (lacunar stroke). Genetic factors play important role. Incidence rates for IS in the 15- to 45-year age range are ≈10 per 100,000 person years.

Hemorrhagic stroke (HS) is the least treatable and the most fatal form of cerebrovascular disease. Genetic mechanisms play a role in its development. Occurrence depends on many risk factors, including hypertension, heavy alcohol intake and anticoagulant treatment. According to the World Health Organization, 15 million people suffer stroke worldwide each year. The overall incidence of spontaneous HS worldwide is 24.6 per 100,000 person years. Strokes are the third most common cause of death and the most common cause of disability in developed countries.

This Utility Gene Test was developed on the basis of an analysis of the literature and existing diagnostic protocols. It is useful for confirming diagnosis, as well as for differential diagnosis, couple risk assessment and access to clinical trials.

Acute spontaneous intracerebral hemorrhage and traumatic brain injury are the most common causes of critical illness in the ICU and have high early mortality

Background

Critical care covers multiple disciplines. However, the causes of critical illness in the ICU, particularly the most common causes, remain unclear. We aimed to investigate the incidence and the most common causes of critical illness and the corresponding early mortality rates in ICU patients.

Methods

A retrospective cohort study was performed to examine critically ill patients (aged over 15 years) in the general ICU in Shuyang County in northern China (1/2014–12/2015). The incidences and causes of critical illnesses and their corresponding early mortality rates in the ICU were determined by an expert panel.

Results

During the 2-year study period, 1,211,138 person-years (PY) and 1645 critically ill patients (mean age, 61.8 years) were documented. The median Glasgow Coma Scale (GCS) score was 6 (range, 3–15). The mean acute physiology and chronic health evaluation II (APACHE II) score was 21.2 ± 6.8. The median length of the ICU stay was 4 days (range, 1–29 days). The most common causes of critical illness in the ICU were spontaneous intracerebral hemorrhage (SICH) (26%, 17.6/100,000 PY) and traumatic brain injury (TBI) (16.8%, 11.4/100,000 PY). During the first 7 days in the ICU, SICH was the most common cause of death (42.2%, 7.4/10,000 PY), followed by TBI (36.6%, 4.2/100,000 PY). Based on a logistic analysis, older patients had a significantly higher risk of death from TBI (risk ratio [RR], 1.7; 95% CI, 1.034–2.635), heart failure/cardiovascular crisis (RR, 0.2; 95% CI, 0.083–0.484), cerebral infarction (RR, 0.15; 95% CI, 0.050–0.486), or respiratory failure (RR, 0.35; 95% CI, 0.185–0.784) than younger patients. However, the risk of death from SICH in the two groups was similar.

Conclusions

The most common causes of critical illness in the ICU were SICH and TBI, and both critical illnesses showed a higher risk of death during the first 7 days in the ICU.