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Ma K, Bebawy JF. Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature. Anesth Analg 2024; 138:992-1002. [PMID: 38109853 DOI: 10.1213/ane.0000000000006772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Anemia is a highly prevalent condition that may compromise oxygen delivery to vital organs, especially among the critically ill. Although current evidence supports the adoption of a restrictive transfusion strategy and threshold among the nonbleeding critically ill patient, it remains unclear whether this practice should apply to the brain-injured patient, given the predisposition to cerebral ischemia in this patient population, in which even nonprofound anemia may exert a detrimental effect on clinical outcomes. The purpose of this review is to provide an overview of the pathophysiological changes related to impaired cerebral oxygenation in the brain-injured patient and to present the available evidence on the effect of anemia and varying transfusion thresholds on the clinical outcomes of patients with acute brain injury.
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Affiliation(s)
- Kan Ma
- From the Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John F Bebawy
- Department of Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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2
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Chow TK, Chiu KL, Chan CH, Ma WH. Abnormal Cerebral FDG Accumulation in Acute Intracerebral and Subarachnoid Hemorrhages Due to Different Mechanisms. Clin Nucl Med 2023; 48:1076-1077. [PMID: 37801555 DOI: 10.1097/rlu.0000000000004900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
ABSTRACT Changes in cerebral glucose metabolism after acute intracranial hemorrhage have been rarely described. We present a patient with abnormal cerebral FDG accumulation in acute intracerebral and subarachnoid hemorrhages due to different mechanisms on FDG PET/CT. The patient received conservative management and died 2 months later. This case demonstrated the different mechanisms of cerebral FDG accumulation in different types of intracranial hemorrhage, which may be helpful for future research to optimize patient care.
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Affiliation(s)
- Tsz-Kit Chow
- From the Nuclear Medicine Unit, Department of Radiology and Nuclear Medicine, Tuen Mun Hospital, Hong Kong
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3
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Ibrahim A, Arifianto MR, Al Fauzi A. Minimally Invasive Neuroendoscopic Surgery for Spontaneous Intracerebral Hemorrhage: A Review of the Rationale and Associated Complications. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:103-108. [PMID: 37548729 DOI: 10.1007/978-3-030-12887-6_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is associated with a poor prognosis. Its mortality rate exceeds 40%, and 10-15% of survivors remain fully dependent. Considering the limited number of effective therapeutic options in such cases, the possibilities for surgical interventions aimed at removal of a hematoma should always be borne in mind. Although conventional surgery for deep-seated ICH has failed to show an improvement in outcomes, use of minimally invasive techniques-in particular, neuroendoscopic procedures-may be more effective and has demonstrated promising results. Although there are certain risks of morbidities (including rebleeding, epilepsy, meningitis, infection, pneumonia, and digestive tract disorders) and a nonnegligible risk of mortality, their incidence rates after neuroendoscopic evacuation of ICH compare favorably with those after conventional surgery. Prevention of complications requires careful postoperative surveillance of the patient and, preferably, treatment in a neurointensive care unit, as well as early detection and appropriate management of associated comorbidities.
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Affiliation(s)
- Arie Ibrahim
- Department of Neurosurgery, A. Wahab Syahranie Hospital and Faculty of Medicine, Mulawarman University, Kota Samarinda, Kalimantan Timur, Indonesia.
| | - Muhammad Reza Arifianto
- Department of Neurosurgery, Dr. Soetomo General Hospital and Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Asra Al Fauzi
- Department of Neurosurgery, Dr. Soetomo General Hospital and Faculty of Medicine, Airlangga University, Surabaya, Indonesia
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4
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Li G, Wang S, Xiong Y, Gu H, Jiang Y, Yang X, Wang C, Wang C, Li Z, Zhao X. Higher fasting blood glucose was associated with worse in-hospital clinical outcomes in patients with primary intracerebral hemorrhage: From a large-scale nationwide longitudinal registry. CNS Neurosci Ther 2022; 28:2260-2267. [PMID: 36152306 PMCID: PMC9627374 DOI: 10.1111/cns.13972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/19/2022] [Accepted: 09/07/2022] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Studies that investigated the relationship between fasting blood glucose (FBG) and intracerebral hemorrhage (ICH) outcomes were insufficient. AIM We aimed to investigate the association between FBG level and in-hospital clinical outcomes in patients with primary ICH. RESULTS A total of 34,507 patients were enrolled in the final study. Compared with the reference group, the ≥6.1 and <7 mmol/L group showed nonsignificant higher in-hospital mortality (adjusted odds ratio [OR] 1.20, 95% confidence interval [CI] 0.69-2.11, p = 0.52), and a significant higher proportion of intracranial hematoma evacuation (adjusted OR 1.56, 95% CI 1.26-1.92, p < 0.001). The ≥7 mmol/L group showed both significant higher in-hospital mortality (adjusted OR 2.08, 95% CI 1.42-3.04, p = 0.52) and a significant higher proportion of intracranial hematoma evacuation (adjusted OR 2.09, 95% CI 1.78-2.47, p < 0.001). CONCLUSION Higher FBG level was correlated with both higher mortality and proportion of evacuation of intracranial hematoma.
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Affiliation(s)
- Guangshuo Li
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Shang Wang
- Neurocardiology Center, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,Chinese Institute for Brain ResearchBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Yingyu Jiang
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Xin Yang
- China National Clinical Research Center for Neurological DiseasesBeijingChina,National Center for Healthcare Quality Management in Neurological DiseasesBeijingChina
| | - Chunjuan Wang
- China National Clinical Research Center for Neurological DiseasesBeijingChina,National Center for Healthcare Quality Management in Neurological DiseasesBeijingChina
| | - Chuanying Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,Chinese Institute for Brain ResearchBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijingChina
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5
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Liu M, Wu H, Shan L, Dong A, Han Y. Focal FDG Uptake in the Cerebral Parenchyma Beneath the Subdural Hematoma. Clin Nucl Med 2022; 47:553-554. [PMID: 35044957 DOI: 10.1097/rlu.0000000000004048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Changes in cerebral glucose metabolism after subdural hematoma have been rarely reported. We present a case with acute subdural hematoma detected unexpectedly on FDG PET/CT. Focal intense FDG uptake in the cerebral parenchyma beneath the subdural hematoma was seen on PET. The density of the cerebral parenchyma was normal on CT. The patient received conservative management. He recovered without any complication. This case indicates that familiarity with the changes in cerebral glucose metabolism on PET after subdural hematoma may be helpful for optimal patient care.
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Affiliation(s)
- Mingyuan Liu
- From the Department of Neurology, Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine
| | - Haibo Wu
- From the Department of Neurology, Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine
| | - Lili Shan
- From the Department of Neurology, Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine
| | - Aisheng Dong
- Department of Nuclear Medicine, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Yan Han
- From the Department of Neurology, Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine
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6
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Powers WJ, An H, Diringer MN. Cerebral Blood Flow and Metabolism. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00003-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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7
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Katyal A, Bhaskar SMM. Value of pre-intervention CT perfusion imaging in acute ischemic stroke prognosis. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:774-785. [PMID: 34792033 DOI: 10.5152/dir.2021.20805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Noninvasive imaging plays an important role in acute stroke towards diagnosis and ongoing management of patients. Systemic thrombolysis and endovascular thrombectomy (EVT) are proven treatments currently used in standards of care in acute stroke settings. The role of computed tomography angiography (CTA) in selecting patients with large vessel occlusion for EVT is well established. However, the value of CT perfusion (CTP) imaging in predicting outcomes after stroke remains ambiguous. This article critically evaluates the value of multimodal CT imaging in early diagnosis and prognosis of acute ischemic stroke with a focus on the role of CTP in delineating tissue characteristics, patient selection, and outcomes after reperfusion therapy. Insights on various technical and clinical considerations relevant to CTP applications in acute ischemic stroke, recommendations for existing workflow, and future areas of research are discussed.
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Affiliation(s)
- Anubhav Katyal
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; Department of Neurology - Neurophysiology, Liverpool Hospital - South West Sydney Local Health District (SWSLHD), Sydney, Australia;University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia; Ingham Institute for Applied Medical Research, Stroke - Neurology Research Group, Sydney, Australia; NSW Brain Clot Bank, NSW Health Statewide Biobank and NSW Health Pathology, Sydney, NSW, Australia;Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, Australia
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8
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Garg RK, Khan J, Dawe RJ, Conners J, John S, Prabhakaran S, Kocak M, Bhabad S, Simpson SL, Ouyang B, Jhaveri M, Bleck TP. The Influence of Diffusion Weighted Imaging Lesions on Outcomes in Patients with Acute Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2021; 33:552-564. [PMID: 32072457 DOI: 10.1007/s12028-020-00933-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND/OBJECTIVE Diffusion weighted imaging (DWI) lesions have been well described in patients with acute spontaneous intracerebral hemorrhage (sICH). However, there are limited data on the influence of these lesions on sICH functional outcomes. We conducted a prospective observational cohort study with blinded imaging and outcomes assessment to determine the influence of DWI lesions on long-term outcomes in patients with acute sICH. We hypothesized that DWI lesions are associated with worse modified Rankin Scale (mRS) at 3 months after hospital discharge. METHODS Consecutive sICH patients meeting study criteria were consented for an magnetic resonance imaging (MRI) scan of the brain and evaluated for remote DWI lesions by neuroradiologists blinded to the patients' hospital course. Blinded mRS outcomes were obtained at 3 months. Logistic regression was used to determine significant factors (p < 0.05) associated with worse functional outcomes defined as an mRS of 4-6. The generalized estimating equation (GEE) approach was used to investigate the effect of DWI lesions on dichotomized mRS (0-3 vs 4-6) longitudinally. RESULTS DWI lesions were found in 60 of 121 patients (49.6%). The presence of a DWI lesion was associated with increased odds for an mRS of 4-6 at 3 months (OR 5.987, 95% CI 1.409-25.435, p = 0.015) in logistic regression. Using the GEE model, patients with a DWI lesion were less likely to recover over time between 14 days/discharge and 3 months (p = 0.005). CONCLUSIONS DWI lesions are common in primary sICH, occurring in almost half of our cohort. Our data suggest that DWI lesions are associated with worse mRS at 3 months in good grade sICH and are predictive of impaired recovery after hospital discharge. Further research into the pathophysiologic mechanisms underlying DWI lesions may lead to novel treatment options that may improve outcomes associated with this devastating disease.
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Affiliation(s)
- Rajeev K Garg
- Rush University Medical Center, 1725 West Harrison Street, Suite 1106, Chicago, IL, 60612, USA.
| | - Jawad Khan
- Rush University Medical Center, 1725 West Harrison Street, Suite 1106, Chicago, IL, 60612, USA
| | - Robert J Dawe
- Rush University Medical Center, 1725 West Harrison Street, Suite 1106, Chicago, IL, 60612, USA
| | - James Conners
- Rush University Medical Center, 1725 West Harrison Street, Suite 1106, Chicago, IL, 60612, USA
| | - Sayona John
- Rush University Medical Center, 1725 West Harrison Street, Suite 1106, Chicago, IL, 60612, USA
| | | | - Mehmet Kocak
- Rush University Medical Center, 1725 West Harrison Street, Suite 1106, Chicago, IL, 60612, USA
| | - Sudeep Bhabad
- Rush University Medical Center, 1725 West Harrison Street, Suite 1106, Chicago, IL, 60612, USA
| | | | - Bichun Ouyang
- Rush University Medical Center, 1725 West Harrison Street, Suite 1106, Chicago, IL, 60612, USA
| | - Miral Jhaveri
- Rush University Medical Center, 1725 West Harrison Street, Suite 1106, Chicago, IL, 60612, USA
| | - Thomas P Bleck
- Rush University Medical Center, 1725 West Harrison Street, Suite 1106, Chicago, IL, 60612, USA
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Mishima K, Ayano M, Nishida T, Tatsutani T, Inokuchi S, Kimoto Y, Mitoma H, Akahoshi M, Arinobu Y, Akashi K, Horiuchi T, Niiro H. Use of 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography to successfully diagnose central nervous system vasculitis in systemic lupus erythematosus and antiphospholipid syndrome: a case report. Mod Rheumatol Case Rep 2021; 5:278-284. [PMID: 33783324 DOI: 10.1080/24725625.2021.1905220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A 53-year-old woman was admitted to our hospital for headache secondary to an acute subdural haematoma in the right cerebellar tentorium. She had been diagnosed with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) two years before presentation and was initiated on prednisolone (PSL) 40 mg/day as induction therapy, which was subsequently tapered to 5 mg/day. Her thrombocytopenia and renal impairment were managed by warfarin with a target prothrombin time-international normalised ratio of 2-3. Her history also included 5 instances of triggerless acute subdural haematoma in the right cerebellar tentorium in the preceding 8 months. Warfarin therapy was suspected as the cause of her bleeding; however, dose adjustment was ineffective. During the current admission, neither magnetic resonance imaging nor cerebral angiography could reveal the cause of the bleeding. However, spinal fluid IL-6 was 25.7 pg/mL, and 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography showed fluorodeoxyglucose accumulation in the right medial occipital lobe cortex in the proximity of the haemorrhage site. Based on these two findings, we suspected vasculitis as the cause of recurrent bleeding. After ruling out malignancy, re-induction therapy with intravenous cyclophosphamide 500 mg/m2/month and PSL 30 mg/day was initiated. PSL was tapered to 2 mg/day and no signs of relapse have developed at 2 years after discharge. Her clinical course also supported vasculitis as the cause of recurrent central nervous system (CNS) bleeding and we discuss the usefulness of 18F-Fluorodeoxyglucose-Positron Emission Tomography in the diagnosis and treatment of CNS vasculitis in SLE and/or APS.
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Affiliation(s)
- Koji Mishima
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan.,Department of Cancer Stem Cell Research, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Tomoya Nishida
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Tomofumi Tatsutani
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Shoichiro Inokuchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasutaka Kimoto
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Mitsuteru Akahoshi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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10
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The Importance of Probe Location for the Interpretation of Cerebral Microdialysis Data in Subarachnoid Hemorrhage Patients. Neurocrit Care 2021; 32:135-144. [PMID: 31037640 PMCID: PMC7012974 DOI: 10.1007/s12028-019-00713-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background There is no uniform definition for cerebral microdialysis (CMD) probe location with respect to focal brain lesions, and the impact of CMD-probe location on measured molecule concentrations is unclear. Methods We retrospectively analyzed data of 51 consecutive subarachnoid hemorrhage patients with CMD-monitoring between 2010 and 2016 included in a prospective observational cohort study. Microdialysis probe location was assessed on all brain computed tomography (CT) scans performed during CMD-monitoring and defined as perilesional in the presence of a focal hypodense or hyperdense lesion within a 1-cm radius of the gold tip of the CMD-probe, or otherwise as normal-appearing brain tissue. Results Probe location was detected in normal-appearing brain tissue on 53/143 (37%) and in perilesional location on 90/143 (63%) CT scans. In the perilesional area, CMD-glucose levels were lower (p = 0.003), whereas CMD-lactate (p = 0.002), CMD-lactate-to-pyruvate-ratio (LPR; p < 0.001), CMD-glutamate (p = 0.002), and CMD-glycerol levels (p < 0.001) were higher. Neuroglucopenia (CMD-glucose < 0.7 mmol/l, p = 0.002), metabolic distress (p = 0.002), and mitochondrial dysfunction (p = 0.005) were more common in perilesional compared to normal-appearing brain tissue. Development of new lesions in the proximity of the CMD-probe (n = 13) was associated with a decrease in CMD-glucose levels, evidence of neuroglucopenia, metabolic distress, as well as increasing CMD-glutamate and CMD-glycerol levels. Neuroglucopenia was associated with poor outcome independent of probe location, whereas elevated CMD-lactate, CMD-LPR, CMD-glutamate, and CMD-glycerol levels were only predictive of poor outcome in normal-appearing brain tissue. Conclusions Focal brain lesions significantly impact on concentrations of brain metabolites assessed by CMD. With the exception of CMD-glucose, the prognostic value of CMD-derived parameters seems to be higher when assessed in normal-appearing brain tissue. CMD was sensitive to detect the development of new focal lesions in vicinity to the neuromonitoring probe. Probe location should be described in the research reporting brain metabolic changes measured by CMD and integrated in statistical models. Electronic supplementary material The online version of this article (10.1007/s12028-019-00713-8) contains supplementary material, which is available to authorized users.
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11
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Liang F, Wang J, Zhu X, Wang Z, Zheng J, Sun Z, Xu S, Zhang J, Zhou J, Shi L. Melatonin Alleviates Neuronal Damage After Intracerebral Hemorrhage in Hyperglycemic Rats. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:2573-2584. [PMID: 32753840 PMCID: PMC7342491 DOI: 10.2147/dddt.s257333] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/16/2020] [Indexed: 12/24/2022]
Abstract
Background This study sought to investigate a novel effect of melatonin in reducing brain injury in an in vivo hyperglycemic intracerebral hemorrhage (ICH) model and further explore the mechanisms of protection. Methods Hyperglycemia ICH was induced in Sprague-Dawley rats by streptozocin injection followed by autologous blood injection into the striatum. A combined approach including RNA-specific depletion, electron microscopy, magnetic resonance, Western blots, and immunohistological staining was applied to quantify the brain injuries after ICH. Results Hyperglycemia resulted in enlarged hematoma volume, deteriorated brain edema, and aggravated neuronal mitochondria damage 3 days after ICH. Post-treatment with melatonin 2 hours after ICH dose-dependently improved neurological behavioral performance lasting out to 14 days after ICH. This improved neurological function was associated with enhanced structural and functional integrity of mitochondria. Mechanistic studies revealed that melatonin alleviated mitochondria damage in neurons via activating the PPARδ/PGC-1α pathway. Promisingly, melatonin treatment delayed until 6 hours after ICH still reduced brain edema and improved neurological functions. Melatonin supplementation reduces neuronal damage after hyperglycemic ICH by alleviating mitochondria damage in a PPARδ/PGC-1α-dependent manner. Conclusion Melatonin may represent a therapeutic strategy with a wide therapeutic window to reduce brain damage and improve long-term recovery after ICH.
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Affiliation(s)
- Feng Liang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Jianli Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Xiangyu Zhu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zhen Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Jingwei Zheng
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Zeyu Sun
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Shenbin Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Brain Research Institute, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Jingyi Zhou
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Ligen Shi
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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12
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Gong L, Gu Y, Yu Q, Wang H, Zhu X, Dong Q, Xu R, Zhao Y, Liu X. Prognostic Factors for Cognitive Recovery Beyond Early Poststroke Cognitive Impairment (PSCI): A Prospective Cohort Study of Spontaneous Intracerebral Hemorrhage. Front Neurol 2020; 11:278. [PMID: 32411073 PMCID: PMC7198781 DOI: 10.3389/fneur.2020.00278] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/25/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Poststroke cognitive impairment (PSCI) has been increasingly recognized in patients, but some stroke survivors appear to show cognitive improvement beyond the acute stage. The risk factors associated with cognitive recovery after spontaneous intracerebral hemorrhage (ICH) onset have not yet been sufficiently investigated in prospective studies. Objective: We aimed to identify the trajectory of post-ICH cognitive impairment and the association of potential prognostic factors with follow-up cognitive recovery beyond early PSCI. Methods: In this stroke center-based cohort study, 141 consecutive dementia-free patients with spontaneous ICH were included and underwent Montreal Cognitive Assessment (MoCA) evaluation for cognitive function at baseline (within 2 weeks of ICH onset) and the shortened MoCA (short-MoCA) at a 6-month follow-up. To explore the prognostic factors associated with trajectory of cognition after an ICH onset, we adjusted for demographic and vascular risk factors, using multivariate logistic regression analysis. Results: Of the 141 ICH patients, approximately three quarters (106/141) were diagnosed with early PSCI (MoCA score <26) within 2 weeks of ICH onset. The multiple logistic regression indicated independent positive associations between risk of early PSCI and dominant-hemisphere hemorrhage [odd's ratio (OR): 8.845 (3.347–23.371); P < 0.001], mean corpuscular volume (MCV) [OR: 1.079 (1.002–1.162); P = 0.043], admission systolic blood pressure (sBP) [OR: 1.021 (1.005–1.038); P = 0.012]. Furthermore, 36% (33/90) of ICH survivors who had early PSCI exhibited cognitive recovery at the 6-month follow-up. After examining potential predictors through multiple linear regression based on stepwise, there were independent negative associations between cognitive recovery and dominant hemisphere hemorrhage [OR: 6.955 (1.604–30.162); P < 0.01], lobar ICH [OR: 8.363 (1.479–47.290); P = 0.016], years of education ≤ 9 [OR: 5.145 (1.254–21.105); P = 0.023], and MCV [OR: 1.660 (1.171–2.354); P = 0.004]. Baseline cognitive performance in the domains of visuospatial/executive function, attention, orientation, and language showed positive correlations with cognitive improvement (P < 0.05). Conclusion: In this cohort study of dementia-free survivors of ICH, our results show that one in three early PSCI survivors exhibit cognitive recovery, in relation to dominant-hemisphere hematoma, lobar ICH, educational history, and MCV levels. Future clinical trials including ICH survivors with cognitive dysfunction should assess these factors.
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Affiliation(s)
- Li Gong
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Yongzhe Gu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Qiuyue Yu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Haichao Wang
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xiaoping Zhu
- School of Nursing, Second Military Medical University, Shanghai, China.,Department of Nursing, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Qiong Dong
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Rong Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yanxin Zhao
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xueyuan Liu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
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13
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Cavitation-induced traumatic cerebral contusion and intracerebral hemorrhage in the rat brain by using an off-the-shelf clinical shockwave device. Sci Rep 2019; 9:15614. [PMID: 31666607 PMCID: PMC6821893 DOI: 10.1038/s41598-019-52117-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 10/09/2019] [Indexed: 12/20/2022] Open
Abstract
Traumatic cerebral contusion and intracerebral hemorrhages (ICH) commonly result from traumatic brain injury and are associated with high morbidity and mortality rates. Current animal models require craniotomy and provide less control over injury severity. This study proposes a highly reproducible and controllable traumatic contusion and ICH model using non-invasive extracorporeal shockwaves (ESWs). Rat heads were exposed to ESWs generated by an off-the-shelf clinical device plus intravenous injection of microbubbles to enhance the cavitation effect for non-invasive induction of injury. Results indicate that injury severity can be effectively adjusted by using different ESW parameters. Moreover, the location or depth of injury can be purposefully determined by changing the focus of the concave ESW probe. Traumatic contusion and ICH were confirmed by H&E staining. Interestingly, the numbers of TUNEL-positive cells (apoptotic cell death) peaked one day after ESW exposure, while Iba1-positive cells (reactive microglia) and GFAP-positive cells (astrogliosis) respectively peaked seven and fourteen days after exposure. Cytokine assay showed significantly increased expressions of IL-1β, IL-6, and TNF-α. The extent of brain edema was characterized with magnetic resonance imaging. Conclusively, the proposed non-invasive and highly reproducible preclinical model effectively simulates the mechanism of closed head injury and provides focused traumatic contusion and ICH.
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14
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Association between neutrophil to lymphocyte ratio and blood glucose level at admission in patients with spontaneous intracerebral hemorrhage. Sci Rep 2019; 9:15623. [PMID: 31666624 PMCID: PMC6821865 DOI: 10.1038/s41598-019-52214-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/14/2019] [Indexed: 02/05/2023] Open
Abstract
Previous studies indicated that both inflammatory responses and hyperglycemia are involved in the similar pathophysiological mechanisms after onset of intracerebral hemorrhage (ICH). However the relationship between hyperglycemia and inflammation remains unknown. We aim to evaluate the associations of hyperglycemia with inflammation and neutrophil to lymphocyte ratio (NLR) in patients with ICH. Patients with acute ICH were retrospectively enrolled. Clinical characteristics and imaging features were obtained. The associations between outcome and laboratory biomarkers were assessed by multivariable logistic regression analysis. Spearman analysis and multiple linear regression analysis were performed to estimate the association of NLR and serum glucose. 175 patients were enrolled. Poor outcome occurred in 86 patients at 30 days. Elevated blood glucose level (BGL) and NLR were strongly associated with outcome in patients with ICH. Moreover, combined NLR-BGL exhibited a better predictive accuracy compared with the peripheral leukocyte counts. Furthermore, there was a robust association between BGL and NLR. We first demonstrated both of NLR and BGL were independently associated with each other. Our results indicate that inflammatory responses and the pathological process of hyperglycemia may influence each other by several complex pathological mechanisms and have a mutual promoting effect to secondary brain injury.
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15
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Stroke detection with 3 different PET tracers. Radiol Case Rep 2019; 14:1447-1451. [PMID: 31695834 PMCID: PMC6823742 DOI: 10.1016/j.radcr.2019.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 12/24/2022] Open
Abstract
Stroke is a common cause of patient morbidity and mortality, being the fifth leading cause of death in the United States. Positron emission tomography (PET) is a proven tool for oncology patients, and may have utility in patients with stroke. We demonstrate findings of stroke incidentally detected on oncologic PET/CTs using 18F-FDG, 11C-Choline, and 68Ga-DOTATATE radiotracers. Specifically, focal 11C-Choline or 68Ga-DOTATATE uptakes localized in areas of MRI confirmed ischemia, and paradoxically increased 18F-FDG activity was visualized surrounding a region of hemorrhage, in different patients. These cases demonstrate that PET may have utility in evaluating patients with stroke based on flow dynamics, metabolic activity, and receptor expression.
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16
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Oh TK, Heo E, Song IA, Jeong WJ, Han M, Bang JS. Increased Glucose Variability During Long-Term Therapeutic Hypothermia as a Predictor of Poor Neurological Outcomes and Mortality: A Retrospective Study. Ther Hypothermia Temp Manag 2019; 10:106-113. [PMID: 31161969 DOI: 10.1089/ther.2019.0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Therapeutic hypothermia (TH) is considered as a treatment option in patients with stroke and brain injury for controlling intracranial pressure. A relatively longer duration of TH is required in such patients than in cardiac arrest patients. We aimed to investigate blood glucose parameters during TH that predict unfavorable neurological outcomes and mortality in patients admitted to the neurological or neurosurgical intensive care unit (ICU). This retrospective study evaluated electronic medical records of patients admitted to the ICU from January 1, 2012, to May 20, 2017. A total of 103 patients were included in the analyses. Multivariable analyses revealed that age and glycemic variability (GV) index were significantly associated with poor neurological outcomes (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.03-1.15, p = 0.002, and OR 1.04, 95% CI 1.02-1.06, p < 0.001, respectively); furthermore, cumulative input-output balance, sequential organ failure assessment score, and glucose variability index were associated with 90-day mortality (hazard ratio [HR] 1.13, 95% CI 1.05-1.21, p < 0.001; HR 1.20, 95% CI 1.04-1.38, p = 0.010; and HR 1.01, 95% CI 1.01-1.02, p < 0.001, respectively). Receiver operating characteristic curve analyses of the GV index for prediction of 90-day mortality and poor neurological outcomes revealed that the areas under the curves were 0.747 (95% CI 0.65-0.85) and 0.826 (95% CI 0.75-0.91), respectively. In conclusion, variability in glucose levels may be valuable for predicting 90-day mortality and poor neurological outcomes in patients undergoing long-term TH.
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Affiliation(s)
- Tak Kyu Oh
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eunjeong Heo
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - In-Ae Song
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Won Joo Jeong
- Department of Neurosurgery, School of Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - Moonku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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17
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Law I, Albert NL, Arbizu J, Boellaard R, Drzezga A, Galldiks N, la Fougère C, Langen KJ, Lopci E, Lowe V, McConathy J, Quick HH, Sattler B, Schuster DM, Tonn JC, Weller M. Joint EANM/EANO/RANO practice guidelines/SNMMI procedure standards for imaging of gliomas using PET with radiolabelled amino acids and [ 18F]FDG: version 1.0. Eur J Nucl Med Mol Imaging 2018; 46:540-557. [PMID: 30519867 PMCID: PMC6351513 DOI: 10.1007/s00259-018-4207-9] [Citation(s) in RCA: 319] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 10/29/2018] [Indexed: 01/12/2023]
Abstract
These joint practice guidelines, or procedure standards, were developed collaboratively by the European Association of Nuclear Medicine (EANM), the Society of Nuclear Medicine and Molecular Imaging (SNMMI), the European Association of Neurooncology (EANO), and the working group for Response Assessment in Neurooncology with PET (PET-RANO). Brain PET imaging is being increasingly used to supplement MRI in the clinical management of glioma. The aim of these standards/guidelines is to assist nuclear medicine practitioners in recommending, performing, interpreting and reporting the results of brain PET imaging in patients with glioma to achieve a high-quality imaging standard for PET using FDG and the radiolabelled amino acids MET, FET and FDOPA. This will help promote the appropriate use of PET imaging and contribute to evidence-based medicine that may improve the diagnostic impact of this technique in neurooncological practice. The present document replaces a former version of the guidelines published in 2006 (Vander Borght et al. Eur J Nucl Med Mol Imaging. 33:1374–80, 2006), and supplements a recent evidence-based recommendation by the PET-RANO working group and EANO on the clinical use of PET imaging in patients with glioma (Albert et al. Neuro Oncol. 18:1199–208, 2016). The information provided should be taken in the context of local conditions and regulations.
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Affiliation(s)
- Ian Law
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, 9, Blegdamsvej, 2100-DK, Copenhagen Ø, Denmark.
| | - Nathalie L Albert
- Department of Nuclear Medicine, Ludwig-Maximilians-University, Munich, Germany
| | - Javier Arbizu
- Department of Nuclear Medicine, Clínica Universidad de Navarra, University of Navarre, Pamplona, Spain
| | - Ronald Boellaard
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands.,Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Alexander Drzezga
- Department of Nuclear Medicine, University Hospital Cologne, Cologne, Germany
| | - Norbert Galldiks
- Department of Neurology, University Hospital Cologne, Cologne, Germany.,Institute of Neuroscience and Medicine (INM-3, -4), Forschungszentrum Julich, Julich, Germany
| | - Christian la Fougère
- Division of Nuclear Medicine and Clinical Molecular Imaging, Department of Radiology, University of Tübingen, Tübingen, Germany
| | - Karl-Josef Langen
- Institute of Neuroscience and Medicine (INM-3, -4), Forschungszentrum Julich, Julich, Germany.,Department of Nuclear Medicine, RWTH University Aachen, Aachen, Germany
| | - Egesta Lopci
- Department of Nuclear Medicine, Humanitas Clinical and Research Hospital, Rozzano, Italy
| | - Val Lowe
- Department of Radiology, Nuclear Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jonathan McConathy
- Division of Molecular Imaging and Therapeutics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Harald H Quick
- High-Field and Hybrid MR Imaging, University Hospital Essen, Essen, Germany
| | - Bernhard Sattler
- Department for Nuclear Medicine, University Hospital Leipzig, Leipzig, Germany
| | - David M Schuster
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Jörg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Weller
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
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18
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Absolute risk and predictors of the growth of acute spontaneous intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data. Lancet Neurol 2018; 17:885-894. [PMID: 30120039 PMCID: PMC6143589 DOI: 10.1016/s1474-4422(18)30253-9] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/26/2018] [Accepted: 06/26/2018] [Indexed: 12/13/2022]
Abstract
Background Intracerebral haemorrhage growth is associated with poor clinical outcome and is a therapeutic target for improving outcome. We aimed to determine the absolute risk and predictors of intracerebral haemorrhage growth, develop and validate prediction models, and evaluate the added value of CT angiography. Methods In a systematic review of OVID MEDLINE—with additional hand-searching of relevant studies' bibliographies— from Jan 1, 1970, to Dec 31, 2015, we identified observational cohorts and randomised trials with repeat scanning protocols that included at least ten patients with acute intracerebral haemorrhage. We sought individual patient-level data from corresponding authors for patients aged 18 years or older with data available from brain imaging initially done 0·5–24 h and repeated fewer than 6 days after symptom onset, who had baseline intracerebral haemorrhage volume of less than 150 mL, and did not undergo acute treatment that might reduce intracerebral haemorrhage volume. We estimated the absolute risk and predictors of the primary outcome of intracerebral haemorrhage growth (defined as >6 mL increase in intracerebral haemorrhage volume on repeat imaging) using multivariable logistic regression models in development and validation cohorts in four subgroups of patients, using a hierarchical approach: patients not taking anticoagulant therapy at intracerebral haemorrhage onset (who constituted the largest subgroup), patients taking anticoagulant therapy at intracerebral haemorrhage onset, patients from cohorts that included at least some patients taking anticoagulant therapy at intracerebral haemorrhage onset, and patients for whom both information about anticoagulant therapy at intracerebral haemorrhage onset and spot sign on acute CT angiography were known. Findings Of 4191 studies identified, 77 were eligible for inclusion. Overall, 36 (47%) cohorts provided data on 5435 eligible patients. 5076 of these patients were not taking anticoagulant therapy at symptom onset (median age 67 years, IQR 56–76), of whom 1009 (20%) had intracerebral haemorrhage growth. Multivariable models of patients with data on antiplatelet therapy use, data on anticoagulant therapy use, and assessment of CT angiography spot sign at symptom onset showed that time from symptom onset to baseline imaging (odds ratio 0·50, 95% CI 0·36–0·70; p<0·0001), intracerebral haemorrhage volume on baseline imaging (7·18, 4·46–11·60; p<0·0001), antiplatelet use (1·68, 1·06–2·66; p=0·026), and anticoagulant use (3·48, 1·96–6·16; p<0·0001) were independent predictors of intracerebral haemorrhage growth (C-index 0·78, 95% CI 0·75–0·82). Addition of CT angiography spot sign (odds ratio 4·46, 95% CI 2·95–6·75; p<0·0001) to the model increased the C-index by 0·05 (95% CI 0·03–0·07). Interpretation In this large patient-level meta-analysis, models using four or five predictors had acceptable to good discrimination. These models could inform the location and frequency of observations on patients in clinical practice, explain treatment effects in prior randomised trials, and guide the design of future trials. Funding UK Medical Research Council and British Heart Foundation.
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19
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Wada S, Yoshimura S, Inoue M, Matsuki T, Arihiro S, Koga M, Kitazono T, Makino H, Hosoda K, Ihara M, Toyoda K. Outcome Prediction in Acute Stroke Patients by Continuous Glucose Monitoring. J Am Heart Assoc 2018; 7:JAHA.118.008744. [PMID: 29650712 PMCID: PMC6015417 DOI: 10.1161/jaha.118.008744] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The purpose of this study was to examine the relationships between glucose parameters obtained by continuous glucose monitoring and clinical outcomes in acute stroke patients. METHODS AND RESULTS Consecutive patients with acute ischemic stroke or intracerebral hemorrhage within 24 hours after onset were included. A continuous glucose monitoring device (iPro2) was attached for the initial 72 hours after emergent admission. Eight glucose parameters were obtained from continuous glucose monitoring: maximum, minimum, mean, and SD of blood glucose levels, as well as area under the curve more than 8 mmol/L of blood glucose, distribution time more than 8 mmol/L of blood glucose, coefficient of variation (%CV), and presence of time less than 4 mmol/L over 72 hours. The primary outcome measure was death or dependency at 3 months (modified Rankin Scale score ≥3). One hundred patients with acute ischemic stroke (n=58) or intracerebral hemorrhage (n=42) were included. Blood glucose levels varied between 5.2±1.4 and 11.4±3.2 mmol/L over 72 hours, with area under the curve more than 8 mmol/L of blood glucose of 0.7±1.4 min×mmol/L, distribution time more than 8 mmol/L of blood glucose of 31.7±32.7%, coefficient of variation of 15.5±5.4%, and presence of hypoglycemia in 20% of overall patients. Mean glucose level (adjusted odds ratio, 1.60, 95% confidence interval, 1.12-2.28/1 mmol/L), area under the curve more than 8 mmol/L of blood glucose (2.13, 1.12-4.02/1 min×mmol/L), and distribution time more than 8 mmol/L of blood glucose (1.25, 1.05-1.50/10%) were related to death or dependency for overall patients, as well as for acute ischemic stroke patients (2.05, 1.15-3.65; 2.38, 1.04-5.44; 1.85, 1.10-3.10, respectively). CONCLUSIONS High mean glucose levels, distribution time more than 8 mmol/L of blood glucose, and areas under the curve more than 8 mmol/L of blood glucose during the initial 72 hours of acute stroke were associated with death or dependency at 3 months.
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Affiliation(s)
- Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takayuki Matsuki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shoji Arihiro
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Hisashi Makino
- Department of Atherosclerosis and Diabetic Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kiminori Hosoda
- Department of Atherosclerosis and Diabetic Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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20
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Schiefecker AJ, Kofler M, Gaasch M, Beer R, Unterberger I, Pfausler B, Broessner G, Lackner P, Rhomberg P, Gizewski E, Hackl WO, Mulino M, Ortler M, Thome C, Schmutzhard E, Helbok R. Brain temperature but not core temperature increases during spreading depolarizations in patients with spontaneous intracerebral hemorrhage. J Cereb Blood Flow Metab 2018; 38:549-558. [PMID: 28436257 PMCID: PMC5851146 DOI: 10.1177/0271678x17703940] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Spreading depolarizations (SDs) are highly active metabolic events, commonly occur in patients with intracerebral hemorrhage (ICH) and may be triggered by fever. We investigated the dynamics of brain-temperature (Tbrain) and core-temperature (Tcore) relative to the occurrence of SDs. Twenty consecutive comatose ICH patients with multimodal electrocorticograpy (ECoG) and Tbrain monitoring of the perihematomal area were prospectively enrolled. Clusters of SDs were defined as ≥2 SDs/h. Generalized estimating equations were used for statistical calculations. Data are presented as median and interquartile range. During 3097 h (173 h [81-223]/patient) of ECoG monitoring, 342 SDs were analyzed of which 51 (15%) occurred in clusters. Baseline Tcore and Tbrain was 37.3℃ (36.9-37.8) and 37.4℃ (36.7-37.9), respectively. Tbrain but not Tcore significantly increased 25 min preceding the onset of SDs by 0.2℃ (0.1-0.2; p < 0.001) and returned to baseline 35 min following SDs. During clusters, Tbrain increased to a higher level (+0.4℃ [0.1-0.4]; p = 0.006) when compared to single SDs. A higher probability (OR = 36.9; CI = 36.8-37.1; p < 0.001) of developing SDs was observed during episodes of Tbrain ≥ 38.0℃ (23% probability), than during Tbrain ≤ 36.6℃ (9% probability). Spreading depolarizations - and in particular clusters of SDs - may increase brain temperature following ICH.
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Affiliation(s)
- Alois J Schiefecker
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Mario Kofler
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Max Gaasch
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Iris Unterberger
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Bettina Pfausler
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Gregor Broessner
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Peter Lackner
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Paul Rhomberg
- 2 Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Elke Gizewski
- 2 Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Werner O Hackl
- 3 Institute of Biomedical Informatics, University for Health Sciences, Medical Informatics and Technology (UMIT), Hall, Austria
| | - Miriam Mulino
- 4 Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Martin Ortler
- 4 Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Claudius Thome
- 4 Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
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21
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Cerebrospinal fluid and brain extracellular fluid in severe brain trauma. HANDBOOK OF CLINICAL NEUROLOGY 2018; 146:237-258. [DOI: 10.1016/b978-0-12-804279-3.00014-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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22
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Wu TY, Putaala J, Sharma G, Strbian D, Tatlisumak T, Davis SM, Meretoja A. Persistent Hyperglycemia Is Associated With Increased Mortality After Intracerebral Hemorrhage. J Am Heart Assoc 2017; 6:e005760. [PMID: 28768643 PMCID: PMC5586431 DOI: 10.1161/jaha.117.005760] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 06/22/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hyperglycemia may be associated with worse outcome after intracerebral hemorrhage (ICH). We assessed the association of early glycemic trajectory on ICH mortality and edema growth. METHODS AND RESULTS We included patients from the Helsinki ICH study with glucose measurements at least once between both 0 to 24 and 24 to 72 hours from onset. Hyperglycemia was defined as blood glucose ≥8 mmol/L (144 mg/dL) based on the local threshold for treatment. Glycemic trajectory was defined on maximum values 0 to 24 and 24 to 72 hours after ICH: (1) persistent normoglycemia in both epochs; (2) late hyperglycemia (only between 24 and 72 hours); (3) early hyperglycemia (only before 24 hours); and (4) persistent hyperglycemia in both epochs. Logistic regression with known predictors of outcome estimated the association of glycemic trajectory and 6-month mortality. A generalized linear model assessed the association of glycemic trajectory and interpolated 72-hour edema extension distance. A total of 576 patients met eligibility criteria, of whom 214 (37.2%) had persistent normoglycemia, 44 (7.6%) late hyperglycemia, 151 (26.2%) early hyperglycemia, and 167 (29.0%) persistent hyperglycemia. Six-month mortality was higher in the persistent (51.1%) and early (26.3%) hyperglycemia groups than the normoglycemia (19.0%) and late hyperglycemia (3.6%) groups. Persistent hyperglycemia was associated with 6-month mortality (odds ratio 3.675, 95% CI 1.989-6.792; P<0.001). Both univariate (P=0.426) and multivariable (P=0.493) generalized linear model analyses showed no association between glycemic trajectory and 72-hour edema extension distance. CONCLUSION Early hyperglycemia after ICH is harmful if it is persistent. Strategies to achieve glycemic control after ICH may influence patient outcome and need to be assessed in clinical trials.
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Affiliation(s)
- Teddy Y Wu
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Gagan Sharma
- Department of Radiology at the Royal Melbourne Hospital, University of Melbourne, Australia
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
- Department of Clinical Neurosciences, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia
| | - Atte Meretoja
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
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Castaneda Vega S, Weinl C, Calaminus C, Wang L, Harant M, Ehrlichmann W, Thiele D, Kohlhofer U, Reischl G, Hempel JM, Ernemann U, Quintanilla Martinez L, Nordheim A, Pichler BJ. Characterization of a novel murine model for spontaneous hemorrhagic stroke using in vivo PET and MR multiparametric imaging. Neuroimage 2017; 155:245-256. [DOI: 10.1016/j.neuroimage.2017.04.071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/29/2017] [Accepted: 04/29/2017] [Indexed: 01/07/2023] Open
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24
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Babi MA, James ML. Peri-Hemorrhagic Edema and Secondary Hematoma Expansion after Intracerebral Hemorrhage: From Benchwork to Practical Aspects. Front Neurol 2017; 8:4. [PMID: 28154550 PMCID: PMC5243823 DOI: 10.3389/fneur.2017.00004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/04/2017] [Indexed: 12/13/2022] Open
Abstract
Spontaneous intracerebral hemorrhage (SICH) is the most lethal type of stroke. Half of these deaths occur within the acute phase. Frequently observed deterioration during the acute phase is often due to rebleeding or peri-hematomal expansion. The exact pathogenesis that leads to rebleeding or peri-hemorrhagic edema remains under much controversy. Numerous trials have investigated potential predictor of peri-hemorrhagic edema formation or rebleeding but have yet to come with consistent results. Unfortunately, almost all of the "classical" approaches have failed to show a significant impact in regard of significant clinical outcome in randomized clinical trials. Current treatment strategies may remain "double-edged swords," for inherent reasons to the pathophysiology of sICH. Therefore, the right balance and possibly the combination of current accepted strategies as well as the evaluation of future approaches seem urgent. This article reviews the role of disturbed autoregulation following SICH, surgical and non-surgical approaches in management of SICH, peri-hematoma edema, peri-hematoma expansion, and future therapeutic trends.
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Affiliation(s)
- Marc-Alain Babi
- Division of Neuro-Critical Care, Department of Neurology, Duke University, Durham, NC, USA
| | - Michael L. James
- Division of Neuro-Critical Care, Department of Neurology, Duke University, Durham, NC, USA
- Division of Neurosurgical Anesthesia, Department of Anesthesiology, Duke University, Durham, NC, USA
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Abstract
PURPOSE OF REVIEW Alterations of blood glucose levels are secondary insults with detrimental consequences for the injured brain. Here, we review various aspects of brain glucose metabolism and analyze the evidence on glycemic control during acute brain injury. RECENT FINDINGS An essential component in the overall management of acute brain injury, especially during the acute phase, is maintaining adequate and appropriate control of serum glucose. This is one of the few physiological parameters that is modifiable. Hypoglycemia should be rigorously avoided. However, intensive insulin therapy is associated with unacceptable rates of hypoglycemia and metabolic crisis, and does not necessarily provide benefit. Hyperglycemia is harmful to the injured brain as it compromises microcirculatory blood flow, increases blood-brain barrier permeability, and promotes inflammation. In addition, it triggers osmotic diuresis, hypovolemia, and immunosuppression. SUMMARY Glucose is the primary energy substrate for the brain. During injury, the brain increases its needs and is vulnerable to glucose deficit. In these situations, alternative fuel can be lactate, which has potential implications for future research. In this review, various pathophysiological aspects of glucose metabolism during acute brain injury, as well as the risks, causes, and consequences of glucose deficiency or excess, will be discussed.
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Zhao Y, Yang J, Zhao H, Ding Y, Zhou J, Zhang Y. The association between hyperglycemia and the prognosis of acute spontaneous intracerebral hemorrhage. Neurol Res 2016; 39:152-157. [PMID: 28019142 DOI: 10.1080/01616412.2016.1270575] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Yanxia Zhao
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jie Yang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hongdong Zhao
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yunlong Ding
- Department of Neurology, Jingjiang People’s Hospital, Jingjiang, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yingdong Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Orakcioglu B, Kentar MM, Schiebel P, Uozumi Y, Unterberg A, Sakowitz OW. Perihemorrhagic ischemia occurs in a volume-dependent manner as assessed by multimodal cerebral monitoring in a porcine model of intracerebral hemorrhage. Neurocrit Care 2016; 22:133-9. [PMID: 25052158 DOI: 10.1007/s12028-014-0027-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Changes in the perihemorrhagic zone (PHZ) of intracerebral hemorrhage (ICH) are variable. Different mechanisms contribute to secondary neuronal injury after ICH. This multimodal monitoring study investigated early changes in the PHZ of ICH. METHODS Twenty-four swine were anesthetized, ventilated, and underwent monitoring of vital parameters. Next to an intracranial pressure-probe (ICP), microdialysis (MD), thermodiffusion cerebral blood flow (td-CBF), and oxygen probes (PbrO2) were placed into the gray white matter junction for 12 h of monitoring. ICH was induced using the autologous blood injection model. Pre-defined volumes were 0 ml (sham), 1.5 ml ipsilateral (1.5 ml), 3.0 ml ipsilateral (3.0 ml), and 3.0 ml contralateral (3.0 ml contra). RESULTS ICP equally increased in all groups after ICH. In the 3.0 ml group tissue oxygenation decreased to ischemic values of 9 ± 7 mmHg early after 6 h of monitoring. This decrease was associated with a significant perfusion reduction from 36 ± 8 ml/100 g/min to 20 ± 10 ml/100 g/min. MD correlated with a threefold lactate/pyruvate ratio increase. Measurements in all other groups were unchanged. CONCLUSION Multimodal monitoring demonstrates volume-dependent changes of tissue oxygenation, blood flow, and ischemic MD markers in the PHZ independent of increased ICP suggesting early moderate ischemia. No evidence was found for the existence of a perihemorrhagic ischemia in the small hematoma groups.
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Affiliation(s)
- Berk Orakcioglu
- Department of Neurosurgery, Ruprecht-Karls-University, Heidelberg, Germany,
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Clusters of cortical spreading depolarizations in a patient with intracerebral hemorrhage: a multimodal neuromonitoring study. Neurocrit Care 2016; 22:293-8. [PMID: 25142825 DOI: 10.1007/s12028-014-0050-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) is associated with high morbidity and mortality. Cortical spreading depolarizations (CSDs) increase brain matrix metalloproteinase (MMP)-9 activity leading to perihematomal edema expansion in experimental ICH. METHODS The purpose of this report is to describe cerebral metabolic changes and brain extracellular MMP-9 levels in a patient with CSDs and perihematomal edema expansion after ICH. RESULTS We present a 66-year-old male patient with ICH who underwent craniotomy for hematoma evacuation. Multimodal neuromonitoring data of the perihematomal region revealed metabolic distress and increased MMP-9 levels in the brain extracellular fluid during perihematomal edema progression. At the same time, subdural electrocorticography showed clusters of CSDs, which disappeared after ketamine anesthesia on day six. Perihematomal edema regression was associated with decreasing cerebral MMP-9 levels. CONCLUSIONS This novel association between clusters of CSDs, brain metabolic distress, and increased MMP-9 levels expands our knowledge about secondary brain injury after ICH. The role of ketamine after this devastating disorder needs further studies.
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Cerebral Blood Flow and Metabolism. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00003-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Zhu HT, Bian C, Yuan JC, Liao XJ, Liu W, Zhu G, Feng H, Lin JK. Hyperbaric oxygen therapy ameliorates acute brain injury after porcine intracerebral hemorrhage at high altitude. Crit Care 2015; 19:255. [PMID: 26073666 PMCID: PMC4522125 DOI: 10.1186/s13054-015-0976-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 06/04/2015] [Indexed: 11/10/2022] Open
Abstract
Introduction Intracerebral hemorrhage (ICH) at high altitude is not well understood to date. This study investigates the effects of high altitude on ICH, and examines the acute neuroprotection of hyperbaric oxygen (HBO) therapy against high-altitude ICH. Methods Minipigs were placed in a hypobaric chamber for 72 h before the operation. ICH was induced by an infusion of autologous arterial blood (3 ml) into the right basal ganglia. Animals in the high-altitude ICH group received HBO therapy (2.5 ATA for 60 min) 30 min after ICH. Blood gas, blood glucose and brain tissue oxygen partial pressure (PbtO2) were monitored continuously for animals from all groups, as were microdialysis products including glucose, lactate, pyruvate and glutamate in perihematomal tissue from 3 to 12 h post-ICH. Results High-altitude ICH animals showed significantly lower PbtO2, higher lactate/pyruvate ratio (LPR) and glutamate levels than low-altitude ICH animals. More severe neurological deficits, brain edema and neuronal damage were also observed in high-altitude ICH. After HBO therapy, PbtO2 was significantly increased and LPR and glutamate levels were significantly decreased. Brain edema, neurological deficits and neuronal damage were also ameliorated. Conclusions The data suggested a more serious disturbance of tissue oxygenation and cerebral metabolism in the acute stage after ICH at high altitude. Early HBO treatment reduced acute brain injury, perhaps through a mechanism involving the amelioration of the derangement of cerebral oxygenation and metabolism following high-altitude ICH.
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Affiliation(s)
- Hai-tao Zhu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Street, Chongqing, 400038, China.
| | - Chen Bian
- Department of Military Psychology, College of Psychology, Third Military Medical University, 30 Gaotanyan Street, Chongqing, 400038, China.
| | - Ji-chao Yuan
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Street, Chongqing, 400038, China.
| | - Xiao-jun Liao
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Street, Chongqing, 400038, China.
| | - Wei Liu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Street, Chongqing, 400038, China.
| | - Gang Zhu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Street, Chongqing, 400038, China.
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Street, Chongqing, 400038, China.
| | - Jiang-kai Lin
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Street, Chongqing, 400038, China.
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Shang H, Cui D, Yang D, Liang S, Zhang W, Zhao W. The radical scavenger edaravone improves neurologic function and perihematomal glucose metabolism after acute intracerebral hemorrhage. J Stroke Cerebrovasc Dis 2014; 24:215-22. [PMID: 25440340 DOI: 10.1016/j.jstrokecerebrovasdis.2014.08.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/29/2014] [Accepted: 08/22/2014] [Indexed: 12/30/2022] Open
Abstract
Oxidative injury caused by reactive oxygen species plays an important role in the progression of intracerebral hemorrhage (ICH)-induced secondary brain injury. Previous studies have demonstrated that the free radical scavenger edaravone may prevent neuronal injury and brain edema after ICH. However, the influence of edaravone on cerebral metabolism in the early stages after ICH and the underlying mechanism have not been fully investigated. In the present study, we investigated the effect of edaravone on perihematomal glucose metabolism using (18)F-fluorordeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT). Additionally, the neurologic deficits, brain edemas, and cell death that followed ICH were quantitatively analyzed. After blood infusion, the rats treated with edaravone showed significant improvement in both forelimb placing and corner turn tests compared with those treated with vehicle. Moreover, the brain water content of the edaravone-treated group was significantly decreased compared with that of the vehicle group on day 3 after ICH. PET/CT images of ICH rats exhibited obvious decreases in FDG standardized uptake values in perihematomal region on day 3, and the lesion-to-normal ratio of the edaravone-treated ICH rats was significantly increased compared with that of the control rats. Calculation of the brain injury volumes from the PET/CT images revealed that the volumes of the blood-induced injuries were significantly smaller in the edaravone group compared with the vehicle group. Terminal Deoxynucleotidyl Transferase-mediated dUTP Nick End Labeling assays performed 3 days after ICH revealed that the numbers of apoptotic cells in perihematomal region of edaravone-treated ICH rats were decreased relative to the vehicle group. Thus, the present study demonstrates that edaravone has scavenging properties that attenuate neurologic behavioral deficits and brain edema in the early period of ICH. Additionally, edaravone may improve cerebral metabolism around the hematoma by attenuating apoptotic cell death after ICH.
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Affiliation(s)
- Hanbing Shang
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Derong Cui
- Department of Anesthesiology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dehua Yang
- The Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences and Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sheng Liang
- Department of Nuclear Medicine and Micro PET/CT Research Center, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weifeng Zhang
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiguo Zhao
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Kurtz P, Claassen J, Helbok R, Schmidt J, Fernandez L, Presciutti M, Stuart RM, Connolly ES, Lee K, Badjatia N, Mayer SA. Systemic glucose variability predicts cerebral metabolic distress and mortality after subarachnoid hemorrhage: a retrospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R89. [PMID: 24887049 PMCID: PMC4056693 DOI: 10.1186/cc13857] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 04/24/2014] [Indexed: 01/04/2023]
Abstract
Introduction Cerebral glucose metabolism and energy production are affected by serum glucose levels. Systemic glucose variability has been shown to be associated with poor outcome in critically ill patients. The objective of this study was to assess whether glucose variability is associated with cerebral metabolic distress and outcome after subarachnoid hemorrhage. Methods A total of 28 consecutive comatose patients with subarachnoid hemorrhage, who underwent cerebral microdialysis and intracranial pressure monitoring, were studied. Metabolic distress was defined as lactate/pyruvate ratio (LPR) >40. The relationship between daily glucose variability, the development of cerebral metabolic distress and hospital outcome was analyzed using a multivariable general linear model with a logistic link function for dichotomized outcomes. Results Daily serum glucose variability was expressed as the standard deviation (SD) of all serum glucose measurements. General linear models were used to relate this predictor variable to cerebral metabolic distress and mortality at hospital discharge. A total of 3,139 neuromonitoring hours and 181 days were analyzed. After adjustment for Glasgow Coma Scale (GCS) scores and brain glucose, SD was independently associated with higher risk of cerebral metabolic distress (adjusted odds ratio = 1.5 (1.1 to 2.1), P = 0.02). Increased variability was also independently associated with in hospital mortality after adjusting for age, Hunt Hess, daily GCS and symptomatic vasospasm (P = 0.03). Conclusions Increased systemic glucose variability is associated with cerebral metabolic distress and increased hospital mortality. Therapeutic approaches that reduce glucose variability may impact on brain metabolism and outcome after subarachnoid hemorrhage.
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Keigler G, Goldberg I, Eichel R, Gomori JM, Cohen JE, Leker RR. Diffusion-weighted imaging at b1000 for identifying intracerebral hemorrhage: preliminary sensitivity, specificity, and inter-rater variability. J Stroke Cerebrovasc Dis 2014; 23:1934-8. [PMID: 24795096 DOI: 10.1016/j.jstrokecerebrovasdis.2014.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 01/06/2014] [Accepted: 02/01/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Noncontrast computed tomography (NCCT) is the gold standard to detect intracerebral hemorrhage (ICH) and ischemic stroke (IS) in patients presenting with acute focal syndromes. Diffusion-weighted magnetic resonance imaging (DW-MRI) obtained at b1000 is highly sensitive to identify acute IS but its sensitivity and specificity to detect ICH has not been systematically studied. METHODS Patients with a diagnosis of ICH on NCCT were prospectively enrolled and underwent DW-MRI at b1000. Patients with suspected ischemia and a negative NCCT served as controls. All diffusion-weighted imaging (DWI) scans were evaluated blindly by 4 experienced raters. Sensitivity, specificity, and inter-rater variability of the DWI b1000 scans for detection of ICH were determined. RESULTS In this preliminary pilot study, 15 patients with ICH and 17 patients with IS were included. All ICH lesions seen on NCCT showed a typical pattern on DW-MRI at b1000 with a hypointense core surrounded by a hyperintense rim. ICH volumes and size were similar on NCCT and MRI. All cases of IS were identified on the DWI scans but none were apparent on NCCT. The mean sensitivity and specificity of DW-MRI at b1000 for ICH were 94% and 93.5%, respectively, and the inter-rater variability for ICH detection on DWI was excellent (κ = .84). CONCLUSIONS DW-MRI at b1000 has a diagnostic yield similar to NCCT for detecting ICH and superior to NCCT for detecting IS. Therefore, DW-MRI may be considered as the initial screening tool for imaging patients presenting with focal neurologic symptoms suggestive of stroke.
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Affiliation(s)
- Galina Keigler
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ilan Goldberg
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Roni Eichel
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - John M Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jose E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Tapia-Pérez J, Gehring S, Zilke R, Schneider T. Effect of increased glucose levels on short-term outcome in hypertensive spontaneous intracerebral hemorrhage. Clin Neurol Neurosurg 2014; 118:37-43. [DOI: 10.1016/j.clineuro.2013.12.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 12/13/2013] [Accepted: 12/25/2013] [Indexed: 10/25/2022]
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Kirkman MA, Smith M. Intracranial pressure monitoring, cerebral perfusion pressure estimation, and ICP/CPP-guided therapy: a standard of care or optional extra after brain injury? Br J Anaesth 2013; 112:35-46. [PMID: 24293327 DOI: 10.1093/bja/aet418] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Measurement of intracranial pressure (ICP) and mean arterial pressure (MAP) is used to derive cerebral perfusion pressure (CPP) and to guide targeted therapy of acute brain injury (ABI) during neurointensive care. Here we provide a narrative review of the evidence for ICP monitoring, CPP estimation, and ICP/CPP-guided therapy after ABI. Despite its widespread use, there is currently no class I evidence that ICP/CPP-guided therapy for any cerebral pathology improves outcomes; indeed some evidence suggests that it makes no difference, and some that it may worsen outcomes. Similarly, no class I evidence can currently advise the ideal CPP for any form of ABI. 'Optimal' CPP is likely patient-, time-, and pathology-specific. Further, CPP estimation requires correct referencing (at the level of the foramen of Monro as opposed to the level of the heart) for MAP measurement to avoid CPP over-estimation and adverse patient outcomes. Evidence is emerging for the role of other monitors of cerebral well-being that enable the clinician to employ an individualized multimodality monitoring approach in patients with ABI, and these are briefly reviewed. While acknowledging difficulties in conducting robust prospective randomized studies in this area, such high-quality evidence for the utility of ICP/CPP-directed therapy in ABI is urgently required. So, too, is the wider adoption of multimodality neuromonitoring to guide optimal management of ICP and CPP, and a greater understanding of the underlying pathophysiology of the different forms of ABI and what exactly the different monitoring tools used actually represent.
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Affiliation(s)
- M A Kirkman
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK
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Reduced Brain/Serum Glucose Ratios Predict Cerebral Metabolic Distress and Mortality After Severe Brain Injury. Neurocrit Care 2013; 19:311-9. [DOI: 10.1007/s12028-013-9919-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Affiliation(s)
- Paul M Vespa
- David Geffen School of Medicine at UCLA, 757 Westwood Blvd, Los Angeles, CA 90095, USA.
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Bussière M, Gupta M, Sharma M, Dowlatshahi D, Fang J, Dhar R. Anaemia on Admission is Associated with More Severe Intracerebral Haemorrhage and Worse Outcomes. Int J Stroke 2013; 10:382-7. [DOI: 10.1111/j.1747-4949.2012.00951.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 06/20/2012] [Indexed: 11/29/2022]
Abstract
Background Lower haemoglobin levels may impair cerebral oxygen delivery and threaten tissue viability in the setting of acute brain injury. Few studies have examined the association between haemoglobin levels and outcomes after spontaneous intracerebral haemorrhage. Aims We evaluated whether anaemia on admission was associated with greater intracerebral haemorrhage severity and worse outcome. Methods Consecutive patients with spontaneous intracerebral haemorrhage were analyzed from the Registry of the Canadian Stroke Network. Admission haemoglobin was related to stroke severity (using the Canadian Neurological Scale), modified Rankin score at discharge, and one-year mortality. Adjustment was made for potential confounders including age, gender, medical history, warfarin use, glucose, creatinine, blood pressure, and intraventricular haemorrhage. Results Two thousand four hundred six patients with intracerebral haemorrhage were studied of whom 23% had anaemia (haemoglobin <120 g/l) on admission, including 4% with haemoglobin <100 g/l. Patients with anaemia were more likely to have severe neurological deficits at presentation [haemoglobin ≤100 g/l, adjusted odds ratio 4·04 (95% confidence interval 2·39, 6·84); haemoglobin 101–120 g/l, adjusted odds ratio 1·93 (95% confidence interval 1·43, 2·59), both P < 0·0001]. In nonanticoagulated patients, severe anaemia was also associated with poor outcome (modified Rankin score 4–6) at discharge [haemoglobin ≤100 g/l, adjusted odds ratio 2·42 (95% confidence interval 1·07–5·47), P= 0·034] and increased mortality at one-year [haemoglobin ≤100 g/l, adjusted hazard ratio 1·73 (95% confidence interval 1·22–2·45), P = 0·002]. Conclusions Anaemia on admission is associated with greater intracerebral haemorrhage severity and worse outcomes. The utility of transfusion remains unclear in this setting.
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Affiliation(s)
- Miguel Bussière
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Meera Gupta
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mukul Sharma
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Dar Dowlatshahi
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Rajat Dhar
- Division of Neurocritical Care, Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
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Li N, Worthmann H, Heeren M, Schuppner R, Deb M, Tryc AB, Bueltmann E, Lanfermann H, Donnerstag F, Weissenborn K, Raab P. Temporal pattern of cytotoxic edema in the perihematomal region after intracerebral hemorrhage: a serial magnetic resonance imaging study. Stroke 2013; 44:1144-6. [PMID: 23391767 DOI: 10.1161/strokeaha.111.000056] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Knowledge about cytotoxic edema (CE) in intracerebral hemorrhage is still limited. We aimed to analyze its presence, temporal pattern, and prognostic meaning. METHODS Twenty-one patients with primary intracerebral hemorrhage underwent magnetic resonance imaging at days 1, 3, and 7 after symptom onset. CE was identified using diffusion-weighted imaging. Hematoma and perihematomal edema volumes were measured on fluid-attenuated inversion recovery images. National Institutes of Health Stroke Scale score was assessed at admission and with each magnetic resonance imaging. Clinical outcome was assessed by modified Rankin scale at 90 days. RESULTS CE appeared in half of the patients within the first 24 hours. The apparent diffusion coefficient values decreased until day 3 and were significantly reversed from days 3 through 7 (P<0.01). Patients with CE showed significantly faster perihematomal edema growth from day 0 to 1 (P=0.036) than those without. Larger 3-day perihematomal edema volume (P=0.02) and presence of CE on day 3 (P=0.07) were associated with poor clinical outcome. CONCLUSIONS CE is associated with stroke severity, perihematomal edema volume, and poor outcome. It is considered to indicate ongoing neuronal injury and, thus, might emerge as new treatment target.
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Affiliation(s)
- Na Li
- Department of Neurology, Hannover Medical School, Hannover, Germany.
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Tsai YH, Hsu LM, Weng HH, Lee MH, Yang JT, Lin CP. Functional diffusion map as an imaging predictor of functional outcome in patients with primary intracerebral haemorrhage. Br J Radiol 2013; 86:20110644. [PMID: 23255534 DOI: 10.1259/bjr.20110644] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Predicting outcome in patients with primary intracerebral haemorrhage (ICH) in the acute stage can provide information to determine the best therapeutic and rehabilitation strategies. We prospectively investigated the predictive value of the functional diffusion map (fDM) in the acute stage of ICH. METHODS 47 patients with ICH were enrolled for clinical evaluation and MRI within 24 h of symptom onset and 5 days after ICH. Functional diffusion mapping prospectively monitored the apparent diffusion coefficient (ADC) maps of perihaematomal oedema. Consequently, the change in perihaematomal oedema was classified into three categories: increased, decreased, or no significant change. Clinical outcomes were evaluated 6 months after ICH according to the modified Rankin Scale. Correlation between clinical outcome and the fDMs was performed. RESULTS Among the clinical variables, thalamic haematoma, serum glucose level and National Institutes of Health Stroke Scale scores were significantly different between the good- and poor-outcome groups. The percentage of oedematous tissue undergoing significant change between baseline and Day 5 was also significantly different between the groups. CONCLUSION fDMs allow for spatial voxel-by-voxel tracking of changes in ADC values. It may be feasible to use fDMs to predict the functional outcome of patients with ICH during the acute stage. Advances in knowledge The use of fDMs for stroke study is demonstrated. fDMs may be more suitable to reflect the pathophysiological heterogeneity within oedemas and may facilitate another thinking process for imaging study of stroke and other neurological diseases.
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Affiliation(s)
- Y-H Tsai
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
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Tomura N, Ito Y, Matsuoka H, Saginoya T, Numazawa SI, Mizuno Y, Watanabe K. PET findings of intramedullary tumors of the spinal cord using [18F] FDG and [11C] methionine. AJNR Am J Neuroradiol 2012; 34:1278-83. [PMID: 23275592 DOI: 10.3174/ajnr.a3374] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Only a few reports on intramedullary tumors of the spinal cord using PET have been published. We report findings of PET by using [(18)F] fluorodeoxyglucose and [(11)C] methionine and discuss the usefulness of the findings in patients with intramedullary tumors of the spinal cord. MATERIALS AND METHODS PET/CT was performed in 9 patients with intramedullary tumors of the spinal cord: Six had ependymomas, 1 had an anaplastic astrocytoma, 1 had a hemangioblastoma, and 1 had a cavernous angioma. The maximum standardized uptake value of the tumor was measured and compared with pathologic findings. RESULTS The SUVmax of FDG and MET in a case of anaplastic astrocytoma was high. The SUVmax of FDG and MET was relatively high in 4 of 6 cases of ependymoma (excluding myxopapillary ependymomas). A case of hemangioblastoma showed decreased uptake of both FDG and MET (SUVmax = 2.0 and 1.4, respectively). Three cases with hemorrhage (1 case of ependymoma, 1 case of cellular ependymoma, and 1 case of cavernous angioma) showed a relatively increased uptake of FDG. CONCLUSIONS Both FDG and MET accumulated to a large degree in an anaplastic astrocytoma and accumulated in ependymomas (excluding a myxopapillary ependymoma). FDG can accumulate in tumors with hemorrhage. More investigation of a larger number of patients is required to evaluate the diagnostic value of PET with FDG and MET for imaging intramedullary tumors of the spinal cord.
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Affiliation(s)
- N Tomura
- Departments of Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital, Fukushima, Japan.
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Babu R, Bagley JH, Di C, Friedman AH, Adamson C. Thrombin and hemin as central factors in the mechanisms of intracerebral hemorrhage-induced secondary brain injury and as potential targets for intervention. Neurosurg Focus 2012; 32:E8. [PMID: 22463118 DOI: 10.3171/2012.1.focus11366] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Intracerebral hemorrhage (ICH) is a subtype of stoke that may cause significant morbidity and mortality. Brain injury due to ICH initially occurs within the first few hours as a result of mass effect due to hematoma formation. However, there is increasing interest in the mechanisms of secondary brain injury as many patients continue to deteriorate clinically despite no signs of rehemorrhage or hematoma expansion. This continued insult after primary hemorrhage is believed to be mediated by the cytotoxic, excitotoxic, oxidative, and inflammatory effects of intraparenchymal blood. The main factors responsible for this injury are thrombin and erythrocyte contents such as hemoglobin. Therapies including thrombin inhibitors, N-methyl-D-aspartate antagonists, chelators to bind free iron, and antiinflammatory drugs are currently under investigation for reducing this secondary brain injury. This review will discuss the molecular mechanisms of brain injury as a result of intraparenchymal blood, potential targets for therapeutic intervention, and treatment strategies currently in development.
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Affiliation(s)
- Ranjith Babu
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Menon RS, Burgess RE, Wing JJ, Gibbons MC, Shara NM, Fernandez S, Jayam-Trouth A, German L, Sobotka I, Edwards D, Kidwell CS. Predictors of highly prevalent brain ischemia in intracerebral hemorrhage. Ann Neurol 2012; 71:199-205. [PMID: 22367992 PMCID: PMC3298034 DOI: 10.1002/ana.22668] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study was undertaken to determine the prevalence, characteristics, risk factors, and temporal profile of concurrent ischemic lesions in patients with acute primary intracerebral hemorrhage (ICH). METHODS Patients were recruited within a prospective, longitudinal, magnetic resonance imaging (MRI)-based study of primary ICH. Clinical, demographic, and MRI data were collected on all subjects at baseline and 1 month. RESULTS Of the 138 patients enrolled, mean age was 59 years, 54% were male, 73% were black, and 84% had a history of hypertension. At baseline, ischemic lesions on diffusion-weighted imaging (DWI) were found in 35% of patients. At 1 month, lesions were present in 27%, and of these lesions, 83% were new and not present at baseline. ICH volume (p = 0.025), intraventricular hemorrhage (p = 0.019), presence of microbleeds (p = 0.024), and large, early reductions in mean arterial pressure (p = 0.003) were independent predictors of baseline DWI lesions. A multivariate logistical model predicting the presence of 1-month DWI lesions included history of any prior stroke (p = 0.012), presence of 1 or more microbleeds (p = 0.04), black race (p = 0.641), and presence of a DWI lesion at baseline (p = 0.007). INTERPRETATION This study demonstrates that >⅓ of patients with primary ICH have active cerebral ischemia at baseline remote from the index hematoma, and ¼ of patients experience ongoing, acute ischemic events at 1 month. Multivariate analyses implicate blood pressure reductions in the setting of an active vasculopathy as a potential underlying mechanism. Further studies are needed to determine the impact of these lesions on outcome and optimal management strategies to arrest vascular damage.
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Affiliation(s)
- Ravi S Menon
- Department of Neurology, Georgetown University, Washington, DC, USA.
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Kirkman MA, Allan SM, Parry-Jones AR. Experimental intracerebral hemorrhage: avoiding pitfalls in translational research. J Cereb Blood Flow Metab 2011; 31:2135-51. [PMID: 21863040 PMCID: PMC3210340 DOI: 10.1038/jcbfm.2011.124] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 07/20/2011] [Accepted: 07/28/2011] [Indexed: 12/12/2022]
Abstract
Intracerebral hemorrhage (ICH) has the highest mortality of all stroke subtypes, yet treatments are mainly limited to supportive management, and surgery remains controversial. Despite significant advances in our understanding of ICH pathophysiology, we still lack preclinical models that accurately replicate the underlying mechanisms of injury. Current experimental ICH models (including autologous blood and collagenase injection) simulate different aspects of ICH-mediated injury but lack some features of the clinical condition. Newly developed models, notably hypertension- and oral anticoagulant therapy-associated ICH models, offer added benefits but further study is needed to fully validate them. Here, we describe and discuss current approaches to experimental ICH, with suggestions for changes in how this condition is studied in the laboratory. Although advances in imaging over the past few decades have allowed greater insight into clinical ICH, there remains an important role for experimental models in furthering our understanding of the basic pathophysiologic processes underlying ICH, provided limitations of animal models are borne in mind. Owing to differences in existing models and the failed translation of benefits in experimental ICH to clinical practice, putative neuroprotectants should be trialed in multiple models using both histological and functional outcomes until a more accurate model of ICH is developed.
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Affiliation(s)
- Matthew A Kirkman
- Faculty of Life Sciences, The University of Manchester, Manchester, UK
| | - Stuart M Allan
- Faculty of Life Sciences, The University of Manchester, Manchester, UK
| | - Adrian R Parry-Jones
- The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
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[Intensive care management [corrected] of patients with intracerebral hemorrhage]. DER NERVENARZT 2011; 82:431-2, 434-6, 438-46. [PMID: 21431439 DOI: 10.1007/s00115-010-3072-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Approximately 10-15% of acute strokes are caused by non-aneurysmatic intracerebral hemorrhage (ICH) and incidences are expected to increase due to an aging population. Studies from the 1990s estimated mortality of ICH to be as high as 50%. However, these figures may partly be attributed to the fact that patients suffering from ICH frequently received only supportive therapy and the poor prognosis may therefore be more a self-fulfilling prophecy. Recently it has been shown that treatment in a specialized neurological intensive care unit alone was associated with better outcomes after ICH. In recent years considerable efforts have been undertaken in order to develop new therapies for ICH and to assess them in randomized controlled trials. Apart from admission status, hemorrhage volume is considered to be the main prognostic factor and impeding the spread of the hematoma is thus a basic therapeutic principle. The use of activated factor VIIa (aFVIIa) to stop hematoma enlargement has been assessed in two large randomized controlled trials, however the promising results of the dose-finding study could not be confirmed in a phase III trial. Although hemostatic therapy with aFVIIa reduced growth of the hematoma it failed to improve clinical outcome. Similar results were found in a randomized controlled trial on blood pressure management in acute ICH. The link between reduction of hematoma growth and improved outcome is therefore still lacking. Likewise the value of surgical hematoma evacuation remains uncertain. In the largest randomized controlled trial on surgical treatment in ICH so far, only a small subgroup of patients with superficial hemorrhages seemed to benefit from hematoma evacuation. Whether improved intensive care can contribute to improved outcome after ICH will be shown by data obtained in the coming years.
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Abstract
Intracerebral haemorrhage is a devastating condition lacking effective therapies, with an uncertain role for surgery in many. Early research described an ischaemic penumbra around the haematoma, representing an area of potential therapeutic intervention. This article discusses the evidence for and against the existence of an ischaemic penumbra in ICH, with particular reference to recent imaging studies.
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Illanes S, Liesz A, Sun L, Dalpke A, Zorn M, Veltkamp R. Hematoma size as major modulator of the cellular immune system after experimental intracerebral hemorrhage. Neurosci Lett 2011; 490:170-4. [DOI: 10.1016/j.neulet.2010.11.065] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 11/23/2010] [Accepted: 11/23/2010] [Indexed: 11/16/2022]
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Shimamura N, Munakata A, Naraoka M, Nakano T, Ohkuma H. Decompressive hemi-craniectomy is not necessary to rescue supratentorial hypertensive intracerebral hemorrhage patients: consecutive single-center experience. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 111:415-9. [PMID: 21725793 DOI: 10.1007/978-3-7091-0693-8_71] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE A consensus on decompressive surgery for hypertensive intracranial hemorrhage (ICH) has not been reached. We retrospectively analyzed our single-center experience with ICH. MATERIAL AND METHODS From January 2004 to August 2009, 65 consecutive supratentorial ICH patients underwent surgery in our institute. Supratentorial ICHs that exhibited a hematoma volume of over 50 mL according to the xyz/2 method were included in this study. We compared a hematoma removal plus decompressive craniectomy group (DC) and a hematoma removal group (HR) with regard to GCS, preoperative hematoma volume, shift from the midline, time from the ictus to surgery, post-surgical hematoma volume, brain swelling, hospitalization periods, and m-RS after 3 months. Statistical analysis was done using the t-test or χ2 test, and the odds ratio was calculated. RESULTS Twenty-five patients participated in this study. The DC group included 5 male patients, and the HR group 20 patients (F/M=8/12). Mean DC group age was 44.2 years, and 56.8 years for the HR group (p<0.05). GCS, preoperative hematoma volume, shift from the midline, time from the ictus to surgery, and postoperative hematoma volume were similar between both groups. Brain swelling on post-operative [corrected] CT was demonstrated to be mild and delimited within the cranium in the DC group, similar to the HR group. Hospitalization periods increased in the DC group (p<0.05). The m-RS after 3 months was similar for both groups. The factors relevant for m-RS were age, postoperative hematoma volume, and GCS at 24 h after surgery. CONCLUSION Decompressive craniectomy is not necessary for rescue in ICH if the hematoma can be removed completely.
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Affiliation(s)
- Norihito Shimamura
- Department of Neurosurgery, Hirosaki University School of Medicine, 5-Zaihuchou, Hirosaki, Aomori, 036-8562, Japan.
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Powers WJ. Intracerebral hemorrhage and head trauma: common effects and common mechanisms of injury. Stroke 2010; 41:S107-10. [PMID: 20876480 DOI: 10.1161/strokeaha.110.595058] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nontraumatic intracerebral hemorrhage (ICH) remains a devastating condition with 30-day mortality rates of 35% to 52%. Until the pathophysiology of this condition is better understood, it will not be possible to develop effective therapies. Studies of cerebral blood flow and metabolism in patients with acute ICH show similar abnormalities to those that occur in patients with traumatic brain injury, thus raising the question of whether there are common mechanisms of injury shared by the 2 conditions. In both ICH and traumatic brain injury, there is an early reduction in the cerebral metabolic rate of oxygen without ischemia, mitochondrial dysfunction, and transient focal increases in regional glucose metabolism that occur after a few days. ICH and traumatic brain injury share barotrauma from pressure waves that propagate through the intracranial contents as a common mechanism of brain injury. Recent data demonstrating contralateral hemispheric damage in patients with acute ICH provide further support for this theory of common injury mechanisms.
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Affiliation(s)
- William J Powers
- Department of Neurology, University of North Carolina, Chapel Hill, NC 27599-7025, USA.
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