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Essibayi MA, Ibrahim Abdallah O, Mortezaei A, Zaidi SE, Vaishnav D, Cherian J, Parikh G, Altschul D, Labib M. Natural History, Pathophysiology, and Recent Management Modalities of Intraventricular Hemorrhage. J Intensive Care Med 2024; 39:813-819. [PMID: 37769332 DOI: 10.1177/08850666231204582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Intraventricular hemorrhage (IVH) is a clinical challenge observed among 40-45% of intracerebral hemorrhage (ICH) cases. IVH can be classified according to the source of the hemorrhage into primary and secondary IVH. Primary intraventricular hemorrhage (PIVH), unlike secondary IVH, involves only the ventricles with no hemorrhagic parenchymal source. Several risk factors of PIVH were reported which include hypertension, smoking, age, and excessive alcohol consumption. IVH is associated with high mortality and morbidity and several prognostic factors were identified such as IVH volume, number of ventricles with blood, involvement of fourth ventricle, baseline Glasgow Coma Scale score, and hydrocephalus. Prompt management of patients with IVH is required to stabilize the clinical status of patients upon admission. Nevertheless, further advanced management is crucial to reduce the morbidity and mortality associated with intraventricular bleeding. Recent treatments showed promising outcomes in the management of IVH patients such as intraventricular anti-inflammatory drugs, lumbar drainage, and endoscopic evacuation of IVH, however, their safety and efficacy are still in question. This literature review presents the epidemiology, physiopathology, risk factors, and outcomes of IVH in adults with an emphasis on recent treatment options.
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Affiliation(s)
- Muhammed Amir Essibayi
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
- Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Ali Mortezaei
- School of Medicine, Gonabad University of Medical Sciences, Gonabad, Razavi Khorasan, Iran
| | - Saif Eddine Zaidi
- School of Medicine, University of Paris, Paris, France
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Dhrumil Vaishnav
- Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jacob Cherian
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| | - Gunjan Parikh
- Department of Neurology and Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David Altschul
- Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mohamed Labib
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
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Wang C, Bai J, He Q, Jiao Y, Zhang W, Huo R, Wang J, Xu H, Zhao S, Wu Z, Sun Y, Yu Q, Tang J, Zeng X, Yang W, Cao Y. Therapy management and outcome of acute hydrocephalus secondary to intraventricular hemorrhage in adults. Chin Neurosurg J 2024; 10:17. [PMID: 38831472 PMCID: PMC11149196 DOI: 10.1186/s41016-024-00369-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/21/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) refers to bleeding within the brain's ventricular system, and hydrocephalus is a life-threatening complication of IVH characterized by increased cerebrospinal fluid accumulation in the ventricles resulting in elevated intracranial pressure. IVH poses significant challenges for healthcare providers due to the complexity of the underlying pathophysiology and lack of standardized treatment guidelines. Herein, we performed a systematic review of the treatment strategies for hydrocephalus secondary to IVH. METHODS This systematic review was prospectively registered with PROSPERO (CRD42023450786). The search was conducted in PubMed, Cochrane Library, and Web of Science on July 15, 2023. We included original studies containing valid information on therapy management and outcome of hydrocephalus secondary to primary, spontaneous, and subarachnoid or intracranial hemorrhage following IVH in adults that were published between 2000 and 2023. Glasgow Outcome Scale (GOS) or modified Ranking Scale (mRS) scores during follow-up were extracted as primary outcomes. The risk of bias was assessed using the Newcastle-Ottawa Scale for Cohort Studies or Cochrane Risk of Bias 2.0 Tool. RESULTS Two hundred and seven patients from nine published papers, including two randomized controlled trials, were included in the analysis. The GOS was used in five studies, while the mRS was used in four. Seven interventions were applied, including craniotomy for removal of hematoma, endoscopic removal of hematoma with/without endoscopic third ventriculostomy (ETV), traditional external ventricular drainage (EVD), and various combinations of EVD, lumbar drainage (LD), and intraventricular fibrinolysis (IVF). Endoscopic removal of hematoma was performed in five of nine studies. Traditional EVD had no obvious benefit compared with new management strategies. Three different combinations of EVD, LD, and IVF demonstrated satisfactory outcomes, although more studies are required to confirm their reliability. Removal of hematoma through craniotomy generated reliable result. Generally, endoscopic removal of hematoma with ETV, removal of hematoma through craniotomy, EVD with IVF, and EVD with early continuous LD were useful. CONCLUSION EVD is still crucial for the management of IVH and hydrocephalus. Despite a more reliable result from the removal of hematoma through craniotomy, a trend toward endoscopic approach was observed due to a less invasive profile.
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Affiliation(s)
- Chaoyang Wang
- Department of Neurosurgery, Shenzhen Qianhai Shekou Free Trade Zone Hospital, Shenzhen, China
| | - Jianuo Bai
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Wenqian Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Ran Huo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Jie Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Hongyuan Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Shaozhi Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Zhiyou Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Yingfan Sun
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Qifeng Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Jinyi Tang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China
| | - Xianwei Zeng
- Department of Neurosurgery, National Research Center for Rehabilitation Technical Aids, Beijing, China
- Department of Neurosurgery, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China
- Key Laboratory of Neuro-Functional Information and Rehabilitation Engineering of the Ministry of Civil Affairs, Beijing, China
| | - Wuyang Yang
- Department of Neurosurgery, The Johns Hopkins Hospital, 1800 Orleans Street Suite 6007, Baltimore, MD, 21287, USA.
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South West 4th Ring Road, Beijing, China.
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Murthy SB. Emergent Management of Intracerebral Hemorrhage. Continuum (Minneap Minn) 2024; 30:641-661. [PMID: 38830066 DOI: 10.1212/con.0000000000001422] [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: 06/05/2024]
Abstract
OBJECTIVE Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH. LATEST DEVELOPMENTS Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques. ESSENTIAL POINTS This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.
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Haldrup M, Miscov R, Mohamad N, Rasmussen M, Dyrskog S, Simonsen CZ, Grønhøj M, Poulsen FR, Bjarkam CR, Debrabant B, Korshøj AR. Treatment of Intraventricular Hemorrhage with External Ventricular Drainage and Fibrinolysis: A Comprehensive Systematic Review and Meta-Analysis of Complications and Outcome. World Neurosurg 2023; 174:183-196.e6. [PMID: 36642373 DOI: 10.1016/j.wneu.2023.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND External ventricular drainage (EVD) is a key factor in the treatment of intraventricular hemorrhage (IVH) but associated with risks and complications. Intraventricular fibrinolysis (IVF) has been proposed to improve clinical outcome and reduce complications of EVD treatment. The following review and metaanalysis provides a comprehensive evaluation of IVH treatment with external ventricular drainage (EVD) and intraventricular fibrinolysis (IVF) with regards to complications and clinical outcomes. METHODS The PRISMA guidelines were followed preparing this review. Studies included in the meta-analysis were compared using forest plots and the related odds ratios. RESULTS After a literature search, 980 articles were identified and 65 and underwent full-text review. Forty-two articles were included in the review and meta-analysis. We found that bolted and antibiotic-coated catheters were superior to tunnelled/uncoated catheters (P < 0.001) and antibiotic- vs. silver-impregnated catheters (P < 0.001]) in preventing infection. Shunt dependency was related to the volume of blood in the ventricles but unaffected by IVF (P = 0.98). IVF promoted hematoma clearance, decreased mortality (22.4% vs. 40.9% with IVF vs. no IVF, respectively, P < 0.00001), improved good functional outcomes (47.2% [IVF] vs. 38.3% [no IVF], P = 0.03), and reduced the rate of catheter occlusion from 37.3% without IVF to 10.6% with IVF (P = 0.0003). CONCLUSIONS We present evidence and best practice recommendations for the treatment of IVH with EVD and intraventricular fibrinolysis. Our analysis further provides a comprehensive quantitative reference of the most relevant clinical endpoints for future studies on novel IVH technologies and treatments.
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Affiliation(s)
- Mette Haldrup
- Department of Neurosurgery, Aarhus University Hospital, Aarhus N, Denmark.
| | - Rares Miscov
- Department of Neurosurgery, Aalborg University Hospital, Aalborg, Denmark
| | - Niwar Mohamad
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Mads Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Stig Dyrskog
- Department of Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Mads Grønhøj
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | | | | | - Birgit Debrabant
- Department of Mathematics and Computer Science, Data Science and Statistics, University of Southern Denmark, Odense M, Denmark
| | - Anders Rosendal Korshøj
- Department of Neurosurgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Hostettler IC, Lange N, Schwendinger N, Ambler G, Hirle T, Frangoulis S, Trost D, Gempt J, Kreiser K, Meyer B, Winter C, Wostrack M. VPS dependency after aneurysmal subarachnoid haemorrhage and influence of admission hyperglycaemia. Eur Stroke J 2023; 8:301-308. [PMID: 37021154 PMCID: PMC10069185 DOI: 10.1177/23969873221147087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction Hydrocephalus after aneurysmal subarachnoid haemorrhage (aSAH) is a common complication which may lead to insertion of a ventriculoperitoneal shunt (VPS). Our aim is to evaluate a possible influence of specific clinical and biochemical factors on VPS dependency with special emphasis on hyperglycaemia on admission. Patients and methods Retrospective analysis of a monocentric database of aSAH patients. Using univariable and multivariable logistic regression analysis we evaluated factors influencing VPS dependency, with a special focus on hyperglycaemia on blood sample within 24 h of admission, dichotomised at 126 mg/dl. Factors evaluated in the univariable analysis were age, sex, known diabetes, Hunt and Hess grade, Barrow Neurological Institute scale, treatment modality, extra-ventricular drain (EVD) insertion, complications (rebleeding, vasospasm, infarction, decompressive craniectomy, ventriculitis), outcome variables and laboratory parameters (glucose, C-reactive protein, procalcitonin). Results We included 510 consecutive patients treated with acute aSAH requiring a VPS (mean age 58.2 years, 66% were female). An EVD was inserted in 387 (75.9%) patients. In the univariable analysis, VPS dependency was associated with hyperglycaemia on admission (OR 2.56, 95%CI 1.58-4.14, p < 0.001). In the multivariable regression analysis after stepwise backward regression, factors associated with VPS dependency were hyperglycaemia >126 mg/dl on admission (OR 1.93, 95%CI 1.13-3.30, p = 0.02), ventriculitis (OR 2.33, 95%CI 1.33-4.04, p = 0.003), Hunt and Hess grade (overall p-value 0.02) and decompressive craniectomy (OR 2.68, 95%CI 1.55-4.64, p < 0.001). Conclusion Hyperglycaemia on admission was associated with an increased probability of VPS placement. If confirmed, this finding might facilitate treatment of these patients by accelerating insertion of a permanent draining system.
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Affiliation(s)
- Isabel Charlotte Hostettler
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Nicole Lange
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Nina Schwendinger
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Theresa Hirle
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Samira Frangoulis
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dominik Trost
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kornelia Kreiser
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christof Winter
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Jiang W, You L, Hu D. Effect of combined fenestration of lamina terminalis and Liliequist membrane during surgical clipping on the incidence of chronic hydrocephalus in patients with anterior circulation ruptured aneurysms. Clin Neurol Neurosurg 2022; 224:107575. [PMID: 36577294 DOI: 10.1016/j.clineuro.2022.107575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/28/2022] [Accepted: 12/23/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE To explore the effects of combined fenestration of lamina terminalis and Liliequist membrane during surgical clipping on the occurrence of chronic hydrocephalus in patients with ruptured anterior circulation aneurysm. METHODS Clinical data of 78 patients with anterior circulation ruptured aneurysms who were treated between June 2018 and January 2021 were retrospectively analyzed. Based on the surgical treatment, patients were divided into 3 groups: clipping group (26 cases); fenestration group (lamina terminalis fenestration combined with clipping, 28 cases); and combination group (lamina terminalis fenestration and Liliequist membrane opening combined with clipping, 24 cases). The incidence of postoperative chronic hydrocephalus, the postoperative hydrocephalus shunt rate, and the Glasgow prognostic score (GOS) were evaluated. RESULTS The incidence of postoperative chronic hydrocephalus in the combined group (16.6 %, 4/24) was significantly lower than that in the clipping group (46.1 %, 12/26) and the fenestration group (35.7 %, 10/28; P < 0.05). The shunt rate of chronic hydrocephalus in the combined group (4.1 %, 1/24) was significantly lower than that in the clipping group (30.7 %, 8/26) and the fenestration group (17.8 %, 5/28; P < 0.05). The rate of postoperative GOS score of 5 in the combined group (75.0 %, 18/24) was significantly higher than that in the clipping group (23.0 %, 6/26) and the fenestration group (57.1 %, 16/28; P < 0.05). CONCLUSION Aneurysm clipping combined with lamina terminalis fenestration and Liliequist membrane opening can reduce the occurrence of chronic hydrocephalus and the rate of chronic hydrocephalus shunt surgery, thereby improving the prognosis of patients.
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Affiliation(s)
- Wuqiang Jiang
- Department of Neurosurgery, The Central Hospital of Yongzhou, Yongzhou 425000, China.
| | - Linshuang You
- Department of Nephrology, The Central Hospital of Yongzhou, Yongzhou 425000, China.
| | - Dan Hu
- Department of Neurosurgery, The Central Hospital of Yongzhou, Yongzhou 425000, China.
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Blitz SE, Bernstock JD, Dmytriw AA, Ditoro DF, Kappel AD, Gormley WB, Peruzzi P. Ruptured Suprasellar Dermoid Cyst Treated With Lumbar Drain to Prevent Postoperative Hydrocephalus: Case Report and Focused Review of Literature. Front Surg 2021; 8:714771. [PMID: 34458316 PMCID: PMC8385128 DOI: 10.3389/fsurg.2021.714771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/15/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Ruptured intracranial dermoid cysts are extremely rare. Standard treatment consists of endonasal decompression or craniotomy with evacuation and copious irrigation of subarachnoid spaces to remove any disseminated cystic contents. Disseminated fat particles in the subarachnoid space may be the cause of further sequalae, including the subsequent development of chemical meningitis and hydrocephalus. Here, we present a case of ruptured suprasellar dermoid cyst treated with craniotomy for emergent optic nerve decompression, followed by postoperative hydrocephalus successfully treated with lumbar drain. Case description: We describe a 30-year-old man with a history of migraines who presented with acute onset of headache, photophobia, nausea, vomiting, and vision loss in the left eye. Head CT and brain MRI demonstrated a ruptured suprasellar dermoid cyst with associated mass effect on the optic nerves and frontal lobes as well as fat attenuation material within the subarachnoid spaces. The patient underwent left frontotemporal craniotomy for cyst resection and developed non-obstructive hydrocephalus on postoperative day 1, refractory to external ventricular drainage. Placement of a lumbar drain cleared the subarachnoid space of debris derived from the ruptured dermoid cyst, and the hydrocephalus resolved. The patient did not require permanent CSF diversion. Conclusions: Intracranial dermoid cysts are uncommon, and rupture is a rare event. Standard surgical treatment with craniotomy for evacuation may leave disseminated dermoid contents and fat particles throughout the subarachnoid spaces. We highlight a case of ruptured suprasellar dermoid cyst with postoperative communicating hydrocephalus treated with lumbar drain when external ventricular drain (EVD) was ineffective. Review of the current literature reveals inconsistent findings on the effects of remaining fat particles. In cases with clinical evidence of increased intracranial pressure due to non-obstructive hydrocephalus attributable to chemical meningitis, temporary lumbar drainage is an option to be considered before committing the patient to permanent shunting.
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Affiliation(s)
| | - Joshua D Bernstock
- Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Brigham and Women's Hospital, Harvard University, Boston, MA, United States
| | - Adam A Dmytriw
- Harvard Medical School, Boston, MA, United States.,Department of Radiology, Brigham and Women's Hospital, Harvard University, Boston, MA, United States
| | - Daniel Francis Ditoro
- Harvard Medical School, Boston, MA, United States.,Department of Pathology, Brigham and Women's Hospital, Harvard University, Boston, MA, United States
| | - Ari D Kappel
- Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Brigham and Women's Hospital, Harvard University, Boston, MA, United States
| | - William B Gormley
- Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Brigham and Women's Hospital, Harvard University, Boston, MA, United States
| | - Pierpaolo Peruzzi
- Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Brigham and Women's Hospital, Harvard University, Boston, MA, United States
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Stokum JA, Cannarsa GJ, Wessell AP, Shea P, Wenger N, Simard JM. When the Blood Hits Your Brain: The Neurotoxicity of Extravasated Blood. Int J Mol Sci 2021; 22:5132. [PMID: 34066240 PMCID: PMC8151992 DOI: 10.3390/ijms22105132] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 12/15/2022] Open
Abstract
Hemorrhage in the central nervous system (CNS), including intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and aneurysmal subarachnoid hemorrhage (aSAH), remains highly morbid. Trials of medical management for these conditions over recent decades have been largely unsuccessful in improving outcome and reducing mortality. Beyond its role in creating mass effect, the presence of extravasated blood in patients with CNS hemorrhage is generally overlooked. Since trials of surgical intervention to remove CNS hemorrhage have been generally unsuccessful, the potent neurotoxicity of blood is generally viewed as a basic scientific curiosity rather than a clinically meaningful factor. In this review, we evaluate the direct role of blood as a neurotoxin and its subsequent clinical relevance. We first describe the molecular mechanisms of blood neurotoxicity. We then evaluate the clinical literature that directly relates to the evacuation of CNS hemorrhage. We posit that the efficacy of clot removal is a critical factor in outcome following surgical intervention. Future interventions for CNS hemorrhage should be guided by the principle that blood is exquisitely toxic to the brain.
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Affiliation(s)
- Jesse A. Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
| | - Gregory J. Cannarsa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
| | - Aaron P. Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
| | - Phelan Shea
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
| | - Nicole Wenger
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
- Departments of Pathology and Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Kuo LT, Huang APH. The Pathogenesis of Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage. Int J Mol Sci 2021; 22:ijms22095050. [PMID: 34068783 PMCID: PMC8126203 DOI: 10.3390/ijms22095050] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 12/11/2022] Open
Abstract
Hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) and reportedly contributes to poor neurological outcomes. In this review, we summarize the molecular and cellular mechanisms involved in the pathogenesis of hydrocephalus following aSAH and summarize its treatment strategies. Various mechanisms have been implicated for the development of chronic hydrocephalus following aSAH, including alterations in cerebral spinal fluid (CSF) dynamics, obstruction of the arachnoid granulations by blood products, and adhesions within the ventricular system. Regarding molecular mechanisms that cause chronic hydrocephalus following aSAH, we carried out an extensive review of animal studies and clinical trials about the transforming growth factor-β/SMAD signaling pathway, upregulation of tenascin-C, inflammation-dependent hypersecretion of CSF, systemic inflammatory response syndrome, and immune dysregulation. To identify the ideal treatment strategy, we discuss the predictive factors of shunt-dependent hydrocephalus between surgical clipping and endovascular coiling groups. The efficacy and safety of other surgical interventions including the endoscopic removal of an intraventricular hemorrhage, placement of an external ventricular drain, the use of intraventricular or cisternal fibrinolysis, and an endoscopic third ventriculostomy on shunt dependency following aSAH were also assessed. However, the optimal treatment is still controversial, and it necessitates further investigations. A better understanding of the pathogenesis of acute and chronic hydrocephalus following aSAH would facilitate the development of treatments and improve the outcome.
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Rychen J, O'Neill A, Lai LT, Bervini D. Natural history and surgical management of spontaneous intracerebral hemorrhage: a systematic review. J Neurosurg Sci 2020; 64:558-570. [PMID: 32972110 DOI: 10.23736/s0390-5616.20.04940-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Management of spontaneous intracerebral hemorrhage (ICH) remains controversial despite efforts to produce high level evidence in the past few years. We systematically examined the pooled literature data on the natural history and surgical management of ICH. EVIDENCE ACQUISITION A systematic review was performed using the PubMed and Embase databases, encompassing English, full-text articles, reporting treatment outcomes for the conservative and surgical management of ICH. EVIDENCE SYNTHESIS A total of 91 studies met the eligibility criteria (total of 16,411 ICH cases). The most common locations for an ICH were the basal ganglia for both the conservative (68.7%) and surgical cohorts (58.4%). Patients in the non-operative group (40.5%) were older (mean age 62.9 years; range 12.0-94.0), had a higher Glasgow Coma Scale (GCS) score at presentation (mean GCS 10.2; range 3-15) and lower ICH volume (mean 36.9 mL). When managed non-operatively, a favorable functional outcome was encountered in 25.7% (95% CI 16.9-34.5) of patients, with a 22.2% (95% CI 16.6-27.8) mortality rate. Patients who underwent surgery (59.5%) were younger (mean age 58.8 years; range 12.0-94.0), had a lower GCS at presentation (mean GCS 8.2; range 3-15) and larger ICH volume (mean 58.3 mL; range 8.2-140.0). Craniotomy with hematoma evacuation was the preferred surgical technique (38.6%). A favorable functional outcome was encountered in 29.8% (95% CI 23.8-35.8) of operated patients, with a 21.3% (95% CI 16.3-26.3) mortality rate. CONCLUSIONS For many ICH cases, the reviewed literature allows to define surgical and conservative candidates. However, there are still some ICH-cases where management remains controversial.
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Affiliation(s)
- Jonathan Rychen
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Anthea O'Neill
- Department of Neurosurgery, Monash Health, Melbourne, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Melbourne, Australia
| | - David Bervini
- Department of Neurosurgery, University Hospital of Bern, Bern, Switzerland -
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11
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Mei L, Fengqun M, Qian H, Dongpo S, Zhenzhong G, Tong C. Exploration of Efficacy and Safety of Interventions for Intraventricular Hemorrhage: A Network Meta-Analysis. World Neurosurg 2019; 136:382-389.e6. [PMID: 31698131 DOI: 10.1016/j.wneu.2019.10.177] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/26/2019] [Accepted: 10/28/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To explore whether endoscopy surgery (ES) and extraventricular drainage (EVD) combined with intraventricular fibrinolytic (IVF) are superior to EVD alone in patients with intraventricular hemorrhage (IVH) and to determine which procedure is more suitable in such patients. METHODS We searched the following databases: PubMed, MEDLINE, Ovid, Embase, and Cochrane Library. Randomized controlled trials and nonrandomized studies comparing ≥2 different interventions in patients with IVH were included. The quality of the included studies was assessed. Pairwise and network meta-analysis were performed using software Stata 13.0 and Revman 5.3. RESULTS Compared with the EVD-alone intervention, the ES regimen, EVD combined with urokinase (UK), and EVD combined with recombinant tissue plasminogen activator (rt-PA) regimens all resulted in better survival and prognosis in patients with IVH. For both survival rate and prognosis, the order from best to worst was ES, EVD combined with UK, EVD combined with rt-PA, and EVD-alone. However, EVD combined with IVF had a high risk of intracranial rebleeding; the order of intracranial rebleeding risk from lowest to highest was ES, EVD-alone, EVD combined with rt-PA, and EVD combined with UK. The risk of intracranial infection in EVD combined with rt-PA was lower than that of EVD-alone, but EVD combined with UK also had a higher risk than did EVD-alone. The risk of intracranial infection from lowest to the highest was ES, EVD combined with rt-PA, EVD-alone, and EVD combined with UK. CONCLUSIONS Our analysis showed that ES is more suitable for patients with IVH. ES not only improved the survival and prognosis but also had the lowest risk of ventriculoperitoneal shunt and intracranial rebleeding or infection.
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Affiliation(s)
- Li Mei
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei Province, China
| | - Mu Fengqun
- Department of Neurology, Gongren Hospital, Tangshan, Hebei Province, China
| | - Han Qian
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei Province, China
| | - Su Dongpo
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei Province, China
| | - Guo Zhenzhong
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei Province, China
| | - Chen Tong
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei Province, China.
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12
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Bosche B, Mergenthaler P, Doeppner TR, Hescheler J, Molcanyi M. Complex Clearance Mechanisms After Intraventricular Hemorrhage and rt-PA Treatment-a Review on Clinical Trials. Transl Stroke Res 2019; 11:337-344. [PMID: 31522408 DOI: 10.1007/s12975-019-00735-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/29/2019] [Accepted: 09/04/2019] [Indexed: 12/15/2022]
Abstract
Intracerebral hemorrhage in combination with intraventricular hemorrhage (IVH) is a severe type of stroke frequently leading to prolonged clinical care, continuous disability, shunt dependency, and high mortality. The molecular mechanisms induced by IVH are complex and not fully understood. Moreover, the treatment options for IVH are limited. Intraventricular recombinant tissue plasminogen activator (rt-PA) dissolves the blood clot in the ventricular system; however, whether the clinical outcome is thereby positively affected is still being debated. The mechanistic cascade induced by intraventricular rt-PA therapy may cure and harm in parallel. Despite the fact that intraventricular blood clots are thereby dissolved, blood derivatives enter the parenchyma and may still adversely affect functional structures of the brain: Smaller blood clots may obstruct the perivascular (Virchow-Robin) space and thereby the glymphatic system with detrimental consequences for cerebrospinal fluid (CSF)/interstitial fluid (ISF) flow. These clots, blood cells but also blood derivatives in the perivascular space, destabilize the blood-brain barrier from the brain parenchyma side, thereby also functionally weakening the neurovascular unit. This may lead to further accommodation of serum proteins in the ISF and particularly in the perivascular space further contributing to the adverse effects on the neuronal microenvironment. Finally, the arterial (Pacchionian) granulations have to cope with ISF containing this "blood, cell, and protein cocktail," resulting in obstruction and insufficient function of the arterial granulations, followed by a malresorptive hydrocephalus. Particularly in light of currently improved knowledge on the physiologic and pathophysiologic clearance of cerebrospinal fluid and interstitial fluid, a critical discussion and reevaluation of our current therapeutic strategies to treat intraventricular hemorrhages are needed to successfully treat patients suffering from this severe type of stroke. In this review, we therefore summarize and discuss recent clinical trials and future directions for the field of IVH with respect to the currently increased understanding of the glymphatic system and the neurovascular unit pathophysiology.
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Affiliation(s)
- Bert Bosche
- Department of Neurocritical Care, Neurological and Neurosurgical First Stage Rehabilitation and Weaning, MediClin Klinik Reichshof, Berglandstr.1, 51580, Reichshof-Eckenhagen, Germany. .,Faculty of Medicine, Department of Neurology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany. .,Institute of Neurophysiology, Medical Faculty, University of Cologne, Cologne, Germany. .,Department of Surgery, Division of Neurosurgery, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada.
| | - Philipp Mergenthaler
- Departments of Experimental Neurology and Neurology, Center for Stroke Research Berlin, NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Thorsten R Doeppner
- Department of Neurology, University of Göttingen Medical School, Göttingen, Germany.
| | - Jürgen Hescheler
- Institute of Neurophysiology, Medical Faculty, University of Cologne, Cologne, Germany
| | - Marek Molcanyi
- Institute of Neurophysiology, Medical Faculty, University of Cologne, Cologne, Germany.,Department of Neurosurgery, Research Unit for Experimental Neurotraumatology, Medical University Graz, Graz, Austria
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13
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Guo R, Chen R, Yu Z, Zhao X, You C, Li H, Ma L. Primary Intraventricular Hemorrhage in Pediatric Patients: Causes, Characteristics, and Outcomes. World Neurosurg 2019; 133:e121-e128. [PMID: 31476469 DOI: 10.1016/j.wneu.2019.08.145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/17/2019] [Accepted: 08/22/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Primary intraventricular hemorrhage (PIVH) is rare, and causes, characteristics, and outcomes remain unknown in children. METHODS We retrospectively analyzed the clinical characteristics of patients 1 month to 21 years of age who were admitted to the hospital with PIVH over a 7-year period. PIVH was defined as bleeding confined to the ventricular system without parenchymal or subarachnoid hemorrhage involvement. RESULTS Of 18 included patients, 55.6% were female, and mean age was 13.8 ± 6.0 years. The most common presenting symptoms were headache (77.8%) and vomiting (33.3%). In 15 patients (83.3%), known etiologies were diagnosed, including arteriovenous malformations (66.7%), moyamoya disease (11.1%), and aneurysms (5.6%). Idiopathic PIVH was the diagnosis in 3 patients (16.7%). Surgery was performed in 15 patients (83.3%), and 3 patients (16.7%) received conservative treatment. Four patients (28.6%) had an unfavorable outcome at discharge, and 3 patients (16.7%) had an unfavorable outcome at the 3-month follow-up. Higher Graeb score was associated with an unfavorable outcome in both short-term and long-term follow-up. CONCLUSIONS Arteriovenous malformations were diagnosed in most pediatric patients with PIVH. Specific surgical treatment of underlying etiologies should be required to increase clinical improvement. Children with a higher Graeb score at admission tended to have poor early and late outcomes.
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Affiliation(s)
- Rui Guo
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruiqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xin Zhao
- West China School of Clinical Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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14
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Xia D, Jiang X, Li Z, Jin Y, Dai Y. External ventricular drainage combined with continuous lumbar drainage in the treatment of ventricular hemorrhage. Ther Clin Risk Manag 2019; 15:677-682. [PMID: 31213820 PMCID: PMC6549662 DOI: 10.2147/tcrm.s207750] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/30/2019] [Indexed: 12/02/2022] Open
Abstract
Objective: Intraventricular hemorrhage (IVH) is characterized by acute onset, rapid progression, and high disability and mortality rates. In this study, we investigated the clinical effect of external ventricular drainage combined with continuous lumbar drainage in IVH treatments. Methods: 114 patients with IVH treated at the Department of Neurosurgery, First Affiliated Hospital of Wannan Medical College from January 2015 to December 2017, were included in the study. Based on the different surgical methods, patients were divided into control (n=79) and study groups (n=35). The control group was treated with external ventricular drainage, whereas the study group was treated with external ventricular drainage combined with continuous lumbar drainage. The incidence of intracranial infection and hydrocephalus was compared between the two groups. The Glasgow coma scale (GCS) and the Glasgow outcome scale (GOS) were compared between the two groups 7 days postoperatively and at follow-up visits, respectively. Results: The incidence of intracranial infection and hydrocephalus in the study group was significantly lower compared with those in the control group (P<0.05). Seven days postoperatively, the GCS score of the study group was significantly higher than that of the control group (P<0.05). At the 3-month follow-up visit, the GOS score of the study group was higher than that of the control group (P<0.05). Conclusions: Using external ventricular drainage combined with continuous lumbar drainage can reduce the incidence of intracranial infection and hydrocephalus and improve the prognoses and quality of life in patients with IVH.
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Affiliation(s)
- Dayong Xia
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College, Wuhu 241000, Anhui Province, People's Republic of China
| | - Xiaochun Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College, Wuhu 241000, Anhui Province, People's Republic of China
| | - Zhenbao Li
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College, Wuhu 241000, Anhui Province, People's Republic of China
| | - Yuelong Jin
- School of Public Health, Wannan Medical College, Wuhu 241000, Anhui Province, People's Republic of China
| | - Yi Dai
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College, Wuhu 241000, Anhui Province, People's Republic of China
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15
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Sembill JA, Huttner HB, Kuramatsu JB. Impact of Recent Studies for the Treatment of Intracerebral Hemorrhage. Curr Neurol Neurosci Rep 2018; 18:71. [DOI: 10.1007/s11910-018-0872-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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16
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Abunimer AM, Abou-Al-Shaar H, Cavallo C, Mahan MA, Labib MA. Minimally invasive approaches for the management of intraventricular hemorrhage. J Neurosurg Sci 2018; 62:734-744. [PMID: 29808639 DOI: 10.23736/s0390-5616.18.04511-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Adult-onset intraventricular hemorrhage is a potentially life-threatening condition associated with a high morbidity and mortality rates. Intraventricular hemorrhage remains one of the most challenging entities for neurosurgeons to treat. Various medical and surgical modalities have been employed for the management of this entity with variable success and complications rates. In this paper, we review the neurosurgical interventions for the management of intraventricular hemorrhage and describe new approaches and potential therapeutic modalities for the management of this devastating condition.
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Affiliation(s)
- Abdullah M Abunimer
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York, NY, USA.,Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Mark A Mahan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA -
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17
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Klebe D, Flores JJ, McBride DW, Krafft PR, Rolland WB, Lekic T, Zhang JH. Dabigatran ameliorates post-haemorrhagic hydrocephalus development after germinal matrix haemorrhage in neonatal rat pups. J Cereb Blood Flow Metab 2017; 37:3135-3149. [PMID: 28155585 PMCID: PMC5584693 DOI: 10.1177/0271678x16684355] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We aim to determine if direct thrombin inhibition by dabigatran will improve long-term brain morphological and neurofunctional outcomes and if potential therapeutic effects are dependent upon reduced PAR-1 stimulation and consequent mTOR activation. Germinal matrix haemorrhage was induced by stereotaxically injecting 0.3 U type VII-S collagenase into the germinal matrix of P7 rat pups. Animals were divided into five groups: sham, vehicle (5% DMSO), dabigatran intraperitoneal, dabigatran intraperitoneal + TFLLR-NH2 (PAR-1 agonist) intranasal, SCH79797 (PAR-1 antagonist) intraperitoneal, and dabigatran intranasal. Neurofunctional outcomes were determined by Morris water maze, rotarod, and foot fault evaluations at three weeks. Brain morphological outcomes were determined by histological Nissl staining at four weeks. Expression levels of p-mTOR/p-p70s6k at three days and vitronectin/fibronectin at 28 days were quantified. Intranasal and intraperitoneal dabigatran promoted long-term neurofunctional recovery, improved brain morphological outcomes, and reduced intracranial pressure at four weeks after GMH. PAR-1 stimulation tended to reverse dabigatran's effects on post-haemorrhagic hydrocephalus development. Dabigatran also reduced expression of short-term p-mTOR and long-term extracellular matrix proteins, which tended to be reversed by PAR-1 agonist co-administration. PAR-1 inhibition alone, however, did not achieve the same therapeutic effects as dabigatran administration.
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Affiliation(s)
- Damon Klebe
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jerry J Flores
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Devin W McBride
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Paul R Krafft
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - William B Rolland
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Tim Lekic
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA.,2 Department of Anaesthesiology and Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
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18
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Murthy SB, Awad I, Harnof S, Aldrich F, Harrigan M, Jallo J, Caron JL, Huang J, Camarata P, Lara LR, Dlugash R, McBee N, Eslami V, Hanley DF, Ziai WC. Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial. Neurology 2017; 89:355-362. [PMID: 28659429 DOI: 10.1212/wnl.0000000000004155] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 04/11/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To study factors associated with permanent CSF diversion and the relationship between shunting and functional outcomes in spontaneous intraventricular hemorrhage (IVH). METHODS Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III), a randomized, multicenter, double-blind, placebo-controlled trial, was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular alteplase improved outcome, in comparison to EVD plus saline. Outcome measures were predictors of shunting and blinded assessment of mortality and modified Rankin Scale at 180 days. RESULTS Among the 500 patients with IVH, CSF shunting was performed in 90 (18%) patients at a median of 18 (interquartile range [IQR] 13-30) days. Patient demographics and IVH characteristics were similar among patients with and without shunts. In the multivariate analysis, black race (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.18-3.34), duration of EVD (OR 1.10; CI 1.05-1.15), placement of more than one EVD (OR 1.93; CI 1.13-3.31), daily drainage CSF per 10 mL (OR 1.07; CI 1.04-1.10), and intracranial pressure >30 mm Hg (OR 1.70; CI 1.09-2.88) were associated with higher odds of permanent CSF shunting. Patients who had CSF shunts had similar odds of 180-day mortality, while survivors with shunts had increased odds of poor functional outcome, compared to survivors without shunts. CONCLUSIONS Among patients with spontaneous IVH requiring emergency CSF diversion, those with early elevated intracranial pressure, high CSF output, and placement of more than one EVD are at increased odds of permanent ventricular shunting. Administration of intraventricular alteplase, early radiographic findings, and CSF measures were not useful predictors of permanent CSF diversion.
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Affiliation(s)
- Santosh B Murthy
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD.
| | - Issam Awad
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Sagi Harnof
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Francois Aldrich
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Mark Harrigan
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Jack Jallo
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Jean-Louis Caron
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Judy Huang
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Paul Camarata
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Lucia Rivera Lara
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Rachel Dlugash
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Nichol McBee
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Vahid Eslami
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Daniel F Hanley
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Wendy C Ziai
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
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Staykov D, Kuramatsu JB, Bardutzky J, Volbers B, Gerner ST, Kloska SP, Doerfler A, Schwab S, Huttner HB. Efficacy and safety of combined intraventricular fibrinolysis with lumbar drainage for prevention of permanent shunt dependency after intracerebral hemorrhage with severe ventricular involvement: A randomized trial and individual patient data meta-analysis. Ann Neurol 2017; 81:93-103. [PMID: 27888608 DOI: 10.1002/ana.24834] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/24/2016] [Accepted: 11/25/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Intraventricular hemorrhage (IVH) is a negative prognostic factor in intracerebral hemorrhage (ICH) and is associated with permanent shunt dependency in a substantial proportion of patients post-ICH. IVH treatment by intraventricular fibrinolysis (IVF) was recently linked to reduced mortality rates in the CLEAR III study and IVF represents a safe and effective strategy to hasten clot resolution that may reduce shunt rates. Additionally, promising results from observational studies reported reductions in shunt dependency for a combined treatment approach of IVF plus lumbar drains (LDs). The present randomized, controlled trial investigated efficacy and safety of a combined strategy-IVF plus LD versus IVF alone-on shunt dependency in patients with ICH and severe IVH. METHODS This randomized, open-label, parallel-group study included patients aged 18 to 85 years, prehospital modified Rankin Scale ≤3, ICH volume < 60ml, Glasgow Coma Scale of <9, and severe IVH with tamponade of the third and fourth ventricles requiring placement of external ventricular drainage (EVD). Over a 3-year recruitment period, patients were allocated to either standard treatment (control group receiving IVF consisting of 1mg of recombinant human tissue plasminogen activator every 8 hours until clot clearance of third and fourth ventricles) or a combined treatment approach of IVF and-upon clot clearance of third and fourth ventricles-subsequent placement of an LD for drainage of cerebrospinal fluid (CSF; intervention group). The primary endpoint consisted of permanent shunt placement indicated after a total of three unsuccessful EVD clamping attempts or need for CSF drainage longer than 14 days in both groups. Secondary endpoints included IVF- and LD-related safety, such as bleeding or infections, and functional outcome at 90 and 180 days. Conducted endpoint analyses used individual patient data meta-analyses. The study was registered at clinicaltrials.gov (NCT01041950). RESULTS The trial was stopped upon predefined interim analysis after 30 patients because of significant efficacy of tested intervention. The primary endpoint was analyzed without dropouts and was reached in 43% (7 of 16) of the control group versus 0% (0 of 14) of the intervention group (p = 0.007). Meta-analyses were based on overall 97 patients, 45 patients receiving IVF plus LD versus 42 with IVF only. Meta-analyses on shunt dependency showed an absolute risk reduction of 24% for the intervention (LD, 2.2% [1 of 45] vs no-LD, 26.2% [11 of 42]; odds ratio [OR] = 0.062; confidence interval [CI], 0.011-0.361; p = 0.002). Secondary endpoints did not show significant differences for CSF infections (OR = 0.869;CI, 0.445-1.695; p = 0.680) and functional outcome at 90 days (OR = 0.478; CI, 0.190-1.201; p = 0.116), yet bleeding complications were significantly reduced in favor of the intervention (OR = 0.401; CI, 0.302-0.532; p < 0.001). INTERPRETATION The present trial and individual patient data meta-analyses provide evidence that, in patients with severe IVH, as compared to IVF alone, a combined approach of IVF plus LD treatment is feasible and safe and significantly reduces rates of permanent shunt dependency for aresorptive hydrocephalus post-ICH. ANN NEUROL 2017;81:93-103.
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Affiliation(s)
- Dimitre Staykov
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Neurology, St John Hospital Eisenstadt, Eisenstadt, Austria
| | - Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jürgen Bardutzky
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | - Bastian Volbers
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stephan P Kloska
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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Abstract
In Germany dedicated neurological-neurosurgical critical care (NCC) is the fastest growing specialty and one of the five big disciplines integrated within the German critical care society (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin; DIVI). High-quality investigations based on resilient evidence have underlined the need for technical advances, timely optimization of therapeutic procedures, and multidisciplinary team-work to treat those critically ill patients. This evolution has repeatedly raised questions, whether NCC-units should be run independently or better be incorporated within multidisciplinary critical care units, whether treatment variations exist that impact clinical outcome, and whether nowadays NCC-units can operate cost-efficiently? Stroke is the most frequent disease entity treated on NCC-units, one of the most common causes of death in Germany leading to a great socio-economic burden due to long-term disabled patients. The main aim of NCC employs surveillance of structural and functional integrity of the central nervous system as well as the avoidance of secondary brain damage. However, clinical evaluation of these severely injured commonly sedated and mechanically ventilated patients is challenging and highlights the importance of neuromonitoring to detect secondary damaging mechanisms. This multimodal strategy not only requires medical expertise but also enforces the need for specialized teams consisting of qualified nurses, technical assistants and medical therapists. The present article reviews most recent data and tries to answer the aforementioned questions.
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Guo R, Ma L, Shrestha BK, Yu Z, Li H, You C. A retrospective clinical study of 98 adult idiopathic primary intraventricular hemorrhage cases. Medicine (Baltimore) 2016; 95:e5089. [PMID: 27759637 PMCID: PMC5079321 DOI: 10.1097/md.0000000000005089] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of the study is to define the clinical features, risk factors, treatment and prognosis of idiopathic primary intraventricular hemorrhage (IPIVH).We retrospectively collected the data of consecutively admitted patients who were diagnosed and treated for IPIVH in our hospital from January 2010 to December 2014. The clinical information, treatment, and prognosis at the 6-month follow-up were analyzed.Among the 3798 cases of spontaneous intracranial hemorrhage (ICH), 98 IPIVH (2.58%) patients were recruited for the study. The study population consisted of 60 males and 38 females, with an average age (± standard deviation, SD) of 51.20 ± 15.48 years. The initial symptoms were headache (75 cases) and impaired consciousness (23 cases). The surgical treatments included hematoma evacuation under a microscope or an endoscope in 8 cases (8.16%), external ventricular drainage (EVD) in 11 cases (11.22%), lumbar drainage (LD) in 10 cases (10.20%), and a combination of EVD and LD in 11 cases (11.22%). In total, 4 patients died in the hospital (4.08%). At the 6-month follow-up, 73 patients (74.49%) had an improved outcome (modified Rankin scale [mRS] < 3), and 21 patients (21.43%) had a poor outcome (mRS ≥ 3 points) at the end of the 6-month follow-up.IPIVH is rare in clinical practice, and hypertension is the most common risk factor. Furthermore, the treatment of IPIVH is still controversial. Hematoma evacuation under a microscope or an endoscope, EVD, LD and a combination of EVD and LD could be surgical options for the treatment of IPIVH patients. The outcomes for IPIVH patients could be relatively favorable with individualized treatment.
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Affiliation(s)
| | | | | | | | | | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
- Correspondence: Chao You, Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China (e-mail: )
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Effects of lumbar drainage on CSF dynamics in subarachnoid hemorrhage condition: A computational study. Comput Biol Med 2016; 77:49-58. [DOI: 10.1016/j.compbiomed.2016.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 07/30/2016] [Accepted: 08/02/2016] [Indexed: 11/24/2022]
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Strinitz M, Kuramatsu J, Kaschka I, Kloska S, Dörfler A, Schwab S, Huttner HB, Seifert F. Fibrinolysis Treatment for Cerebral Intraventricular Hemorrhage: A Temporal and Spatial Voxel-Based Analysis. J Neuroimaging 2016; 26:525-31. [PMID: 26988440 DOI: 10.1111/jon.12343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/06/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE A voxel-based statistical approach on computer tomographic data in patients with intracerebral hemorrhage (ICH) and acute intraventricular hemorrhage (IVH) was used to evaluate spatial and temporal patterns of intraventricular blood in patients treated with intraventricular fibrinolysis (IVF) or without. METHODS IVH shapes were systematically assessed three dimensionally in patients with supratentorial ICH at three intervals of time (day of admission, day 4 ± 1, day 7+). The boundaries of the intraventricular blood clot were delineated on computed tomography (CT) scans using dedicated software. The CT scan and the IVH shape were transferred into stereotaxic space. In a second step, voxel-based statistics on group level were used to correlate the distribution of intraventricular blood with the interval and the treatment group. RESULTS Altogether 45 patients, 29 with IVF therapy and 16 without, were eligible to be included into this study. We found significant (false discovery rate [FDR] correction, q < .05) reduction of the intraventricular blood between day of admission and day 7 + for the third and fourth ventricle and parts of both lateral ventricles. In addition, we were able to show a significant difference between the IVF therapy and the conventionally treated group at day 4 ± 1 for the third ventricle. CONCLUSIONS The data indicate that voxel-based analysis on group level can be used to compare the time course and the distribution of intraventricular hemorrhage. This technique could be an interesting tool for future research on ICH with IVH.
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Affiliation(s)
- Marc Strinitz
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Joji Kuramatsu
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Iris Kaschka
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stephan Kloska
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Frank Seifert
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
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Del Bigio MR, Di Curzio DL. Nonsurgical therapy for hydrocephalus: a comprehensive and critical review. Fluids Barriers CNS 2016; 13:3. [PMID: 26846184 PMCID: PMC4743412 DOI: 10.1186/s12987-016-0025-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 01/15/2016] [Indexed: 12/13/2022] Open
Abstract
Pharmacological interventions have been tested experimentally and clinically to prevent hydrocephalus and avoid the need for shunting beginning in the 1950s. Clinical trials of varied quality have not demonstrated lasting and convincing protective effects through manipulation of cerebrospinal fluid production, diuresis, blood clot fibrinolysis, or manipulation of fibrosis in the subarachnoid compartment, although there remains some promise in the latter areas. Acetazolamide bolus seems to be useful for predicting shunt response in adults with hydrocephalus. Neuroprotection in the situation of established hydrocephalus has been tested experimentally beginning more recently. Therapies designed to modify blood flow or pulsation, reduce inflammation, reduce oxidative damage, or protect neurons are so far of limited success; more experimental work is needed in these areas. As has been recommended for preclinical studies in stroke and brain trauma, stringent conditions should be met for preclinical studies in hydrocephalus.
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Affiliation(s)
- Marc R Del Bigio
- Department of Pathology, University of Manitoba; Children's Hospital Research Institute of Manitoba, Diagnostic Services Manitoba, 401 Brodie Centre, 715 McDermot Avenue, Winnipeg, MB, R3E 3P5, Canada.
| | - Domenico L Di Curzio
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada.
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Godoy DA, Piñero GR, Koller P, Masotti L, Napoli MD. Steps to consider in the approach and management of critically ill patient with spontaneous intracerebral hemorrhage. World J Crit Care Med 2015; 4:213-229. [PMID: 26261773 PMCID: PMC4524818 DOI: 10.5492/wjccm.v4.i3.213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 03/03/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023] Open
Abstract
Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurological-neurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it’s important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery.
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Gerner ST, Kuramatsu JB, Abel H, Kloska SP, Lücking H, Eyüpoglu IY, Doerfler A, Schwab S, Huttner HB. Intraventricular fibrinolysis has no effects on shunt dependency and functional outcome in endovascular-treated aneurysmal SAH. Neurocrit Care 2015; 21:435-43. [PMID: 24566979 DOI: 10.1007/s12028-014-9961-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intraventricular fibrinolysis (IVF) in subarachnoid hemorrhage (SAH) is an emerging strategy aiming to hasten clot lysis, treat hydrocephalus, and reduce permanent shunt rates. Because of clinical heterogeneity of investigated patient effects of IVF on permanent shunt incidence and functional outcome are widely debated. The present study is the first to investigate solely endovascular-treated SAH patients. METHODS Overall, 88 consecutive patients with aneurysmal SAH requiring external ventricular drain placement and endovascular aneurysm closure were included. Functional outcome and shunt dependency were assessed 90 days after event. A matched controlled sub-analysis was carried out to investigate the effects of IVF treatment (n = 14; matching criteria: age, neuro-status and imaging). Multivariate modeling was performed to identify independent predictors for permanent shunt dependency. RESULTS In IVF-patients neurological status was significantly poorer [Hunt&Hess: IVF = 4(3-5) vs. non-IVF = 3(1-5); p = 0.035] and the extent of ventricular hemorrhage was increased [Graeb Score: IVF = 7(6-8) vs. non-IVF = 3(1-4); p ≤ 0.001]. Consecutive matched controlled sub-analysis revealed no significant therapeutic effect of IVF with respect to shunt dependency rate and functional outcome. Multivariate analysis revealed Graeb score [OR = 1.34(1.02-1.76); p = 0.035] and sepsis [OR = 11.23(2.28-55.27); p = 0.003] as independent predictors for shunt dependency, whereas IVF did not exert significant effects (p = 0.820). CONCLUSIONS In endovascular-treated SAH patients IVF neither reduced permanent shunt dependency nor influenced functional outcome. Despite established effects on intraventricular clot resolution IVF appears less powerful in SAH as compared to ICH. Given the reported positive effects of lumbar drainage (LD) in SAH, a prospective analysis of a combined treatment approach of IVF and subsequent lumbar drain sOeems warranted aiming to reduce permanent shunting and improve functional outcome.
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Affiliation(s)
- Stefan T Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
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Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032-60. [PMID: 26022637 DOI: 10.1161/str.0000000000000069] [Citation(s) in RCA: 2007] [Impact Index Per Article: 223.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. METHODS A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. RESULTS Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. CONCLUSIONS Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
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Bösel J, Möhlenbruch M, Sakowitz OW. [News and perspectives in neurocritical care]. DER NERVENARZT 2015; 85:928-38. [PMID: 25096787 DOI: 10.1007/s00115-014-4040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neurocritical care is an ever-evolving discipline and its implementation in intensive care leads to reduction in mortality and to improvement of functional outcome in patients with devastating injuries to the nervous system. However, the decisive elements of the complete field of neurocritical care remain relatively unclear, as well as the exact ways to optimize them. During recent years new insights have been gained and new exciting studies have been initiated from which results are soon to be expected. This review focuses on the following management aspects: neuromonitoring, airway and ventilation, endovascular therapy, cerebrospinal fluid drainage, decompressive craniectomy, hematoma evacuation, blood pressure, and targeted temperature management. The application of these measures to brain diseases and injuries frequently treated in neurointensive care units will be addressed in the context of current studies.
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Affiliation(s)
- J Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland,
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Khan NR, Tsivgoulis G, Lee SL, Jones GM, Green CS, Katsanos AH, Klimo P, Arthur AS, Elijovich L, Alexandrov AV. Fibrinolysis for Intraventricular Hemorrhage. Stroke 2014; 45:2662-9. [DOI: 10.1161/strokeaha.114.005990] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Nickalus R. Khan
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Georgios Tsivgoulis
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Siang Liao Lee
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - G. Morgan Jones
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Cain S. Green
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Aristeidis H. Katsanos
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Paul Klimo
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Adam S. Arthur
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Lucas Elijovich
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Andrei V. Alexandrov
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
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Steiner T, Al-Shahi Salman R, Beer R, Christensen H, Cordonnier C, Csiba L, Forsting M, Harnof S, Klijn CJM, Krieger D, Mendelow AD, Molina C, Montaner J, Overgaard K, Petersson J, Roine RO, Schmutzhard E, Schwerdtfeger K, Stapf C, Tatlisumak T, Thomas BM, Toni D, Unterberg A, Wagner M. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 2014; 9:840-55. [PMID: 25156220 DOI: 10.1111/ijs.12309] [Citation(s) in RCA: 495] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/23/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) accounted for 9% to 27% of all strokes worldwide in the last decade, with high early case fatality and poor functional outcome. In view of recent randomized controlled trials (RCTs) of the management of ICH, the European Stroke Organisation (ESO) has updated its evidence-based guidelines for the management of ICH. METHOD A multidisciplinary writing committee of 24 researchers from 11 European countries identified 20 questions relating to ICH management and created recommendations based on the evidence in RCTs using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS We found moderate- to high-quality evidence to support strong recommendations for managing patients with acute ICH on an acute stroke unit, avoiding hemostatic therapy for acute ICH not associated with antithrombotic drug use, avoiding graduated compression stockings, using intermittent pneumatic compression in immobile patients, and using blood pressure lowering for secondary prevention. We found moderate-quality evidence to support weak recommendations for intensive lowering of systolic blood pressure to <140 mmHg within six-hours of ICH onset, early surgery for patients with a Glasgow Coma Scale score 9-12, and avoidance of corticosteroids. CONCLUSION These guidelines inform the management of ICH based on evidence for the effects of treatments in RCTs. Outcome after ICH remains poor, prioritizing further RCTs of interventions to improve outcome.
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Affiliation(s)
- Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany; Department of Neurology, Heidelberg University, Heidelberg, Germany
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Xia C, Cheng C, Li D, Niu C. A new protocol to treat moderate to severe intraventricular hemorrhage with obstructive hydrocephalus. Neurol Res 2014; 36:955-61. [DOI: 10.1179/1743132814y.0000000378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Xi G, Strahle J, Hua Y, Keep RF. Progress in translational research on intracerebral hemorrhage: is there an end in sight? Prog Neurobiol 2014; 115:45-63. [PMID: 24139872 PMCID: PMC3961535 DOI: 10.1016/j.pneurobio.2013.09.007] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 09/11/2013] [Accepted: 09/24/2013] [Indexed: 02/08/2023]
Abstract
Intracerebral hemorrhage (ICH) is a common and often fatal stroke subtype for which specific therapies and treatments remain elusive. To address this, many recent experimental and translational studies of ICH have been conducted, and these have led to several ongoing clinical trials. This review focuses on the progress of translational studies of ICH including those of the underlying causes and natural history of ICH, animal models of the condition, and effects of ICH on the immune and cardiac systems, among others. Current and potential clinical trials also are discussed for both ICH alone and with intraventricular extension.
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Affiliation(s)
- Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States.
| | - Jennifer Strahle
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
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Romero L, Ros B, Ríus F, González L, Medina JM, Martín A, Carrasco A, Arráez MA. Ventriculoperitoneal shunt as a primary neurosurgical procedure in newborn posthemorrhagic hydrocephalus: report of a series of 47 shunted patients. Childs Nerv Syst 2014; 30:91-7. [PMID: 23881422 DOI: 10.1007/s00381-013-2177-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 05/20/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE Intraventricular hemorrhage is the most common cause of infantile acquired hydrocephalus. Our objective is to determine if the implantation of ventriculoperitoneal shunt in posthemorrhagic hydrocephalus as a primary and definitive neurosurgical treatment, with no previous temporary procedures, would decrease complication rates with good functional outcomes. METHODS Two hundred seventy-one patients with germinal matrix hemorrhage were diagnosed at the Carlos Haya Hospital between 2003 and 2010. Forty-seven patients underwent ventriculoperitoneal shunt after developing symptomatic hydrocephalus. The minimum weight required for shunt implantation was 1,500 g. We recorded complications related to the surgical procedure and analyzed functional state with a self-developed four-grade scale. RESULTS One hundred thirty-nine (51.3 %) patients with intraventricular hemorrhage developed ventricular dilatation, but only 47 patients (17.34 %) needed shunting. In seven cases, temporary neurosurgical procedures were performed, but in all of them, this was followed by ventriculoperitoneal shunt implantation. The infection rate was 4.25 %, and shunt obstruction rate was 4.25 %. More than 80 % of patients were classified as good or excellent functional state. Mean follow-up period was 38.75 months (SD, 27.09; range, 1-102 months). CONCLUSIONS Ventriculoperitoneal shunting as a primary neurosurgical treatment in posthemorrhagic hydrocephalus would decrease surgical morbidity with good functional outcome.
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Affiliation(s)
- L Romero
- Department of Neurosurgery, HRU Carlos Haya, Málaga, Spain,
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Fabiano AJ, Gruber TJ, Baxter MS. Increased ventriculostomy infection rate with use of intraventricular tissue plasminogen activator: A single-center observation. Clin Neurol Neurosurg 2013; 115:2362-4. [DOI: 10.1016/j.clineuro.2013.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 06/16/2013] [Accepted: 08/18/2013] [Indexed: 11/30/2022]
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Clearing bloody cerebrospinal fluid: clot lysis, neuroendoscopy and lumbar drainage. Curr Opin Crit Care 2013; 19:92-100. [PMID: 23337912 DOI: 10.1097/mcc.0b013e32835cae5e] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Bloody cerebrospinal fluid (CSF) is a major cause of morbidity and mortality in intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Different treatment strategies aiming at faster clearance of bloody CSF have emerged. The present review focuses on recent developments in the investigation of those treatments. RECENT FINDINGS Intraventricular fibrinolysis (IVF) for accelerated IVH-resolution has been clinically tested since the early 1990s. The lately summarized evidence from smaller studies indicates that IVF may result in a benefit in mortality and outcome. Recent investigations have elucidated different aspects of IVF, mainly related to safety. Neuroendoscopy has also emerged as a minimally invasive technique allowing fast removal of IVH. The capability of lumbar drainage to reduce vasospasm after SAH has been tested in a large trial. SUMMARY IVF is relatively well tolerated and accelerates clot clearance after IVH. The effect of IVF on clinical outcome and mortality is currently being investigated in a large-scale phase III clinical trial. Neuroendoscopy is feasible for the treatment of IVH, however, larger trials are lacking. Lumbar drainage reduces the incidence of vasospasm after SAH. An ongoing phase III trial has been designed to test its influence on outcome. Lumbar drainage may also reduce shunt-dependency after IVH.
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Treatment of huge hypertensive putaminal hemorrhage by surgery and cerebrospinal fluid drainage. Clin Neurol Neurosurg 2013; 115:1602-8. [DOI: 10.1016/j.clineuro.2013.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2012] [Revised: 01/21/2013] [Accepted: 02/03/2013] [Indexed: 10/27/2022]
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Ziai WC, Tuhrim S, Lane K, McBee N, Lees K, Dawson J, Butcher K, Vespa P, Wright DW, Keyl PM, Mendelow AD, Kase C, Wijman C, Lapointe M, John S, Thompson R, Thompson C, Mayo S, Reilly P, Janis S, Awad I, Hanley DF. A multicenter, randomized, double-blinded, placebo-controlled phase III study of Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III). Int J Stroke 2013; 9:536-42. [PMID: 24033910 DOI: 10.1111/ijs.12097] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 04/16/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND In adults, intraventricular thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) facilitates resolution of intraventricular haemorrhage (IVH), reduces intracranial pressure, decreases duration of cerebrospinal fluid diversion, and may ameliorate direct neural injury. We hypothesize that patients with small parenchymal haematoma volumes (<30 cc) and relatively large IVH causing acute obstructive hydrocephalus would have improved clinical outcomes when given injections of low-dose rtPA to accelerate lysis and evacuation of IVH compared with placebo. METHODS The Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage III trial is an investigator-initiated, phase III, randomized, multicenter, double-blind, placebo-controlled study comparing the use of external ventricular drainage (EVD) combined with intraventricular injection of rtPA to EVD plus intraventricular injection of normal saline (placebo) for the treatment of IVH. Patients with known symptom onset within 24 h of the computed tomography scan confirmed IVH and third or fourth ventricle obstruction, with or without supratentorial intracerebral haemorrhage volume <30 cc, who require EVD are screened with a computed tomography scan at least six hours after EVD placement and, if necessary, at consecutive 12-h intervals until stabilization of any intracranial bleeding has been established. Patients who meet clinical and imaging criteria (no ongoing coagulopathy and no suspicion of aneurysm, arteriovenous malformation, or any other vascular anomaly) will be randomized to either intraventricular rtPA or placebo. RESULTS The primary outcome measure is dichotomized modified Rankin Scale 0-3 vs. 4-6 at 180 days. Clinical secondary outcomes include additional modified Rankin Scale dichotomizations at 180 days (0-4 vs. 5-6), ordinal modified Rankin Scale (0-6), mortality and safety events at 30 days, mortality at 180 days, functional status measures, type and intensity of intensive care unit management, rate and extent of ventricular blood clot removal, and quality of life measures.
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Affiliation(s)
- Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Brandner S, Thaler C, Lewczuk P, Lelental N, Buchfelder M, Kleindienst A. Neuroprotein dynamics in the cerebrospinal fluid: intraindividual concomitant ventricular and lumbar measurements. Eur Neurol 2013; 70:189-94. [PMID: 23969528 DOI: 10.1159/000352032] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 05/05/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The measurement of neuromarker/neuroproteins in the cerebrospinal fluid (CSF) is gaining increased popularity. However, insufficient information is available on the rostrocaudal distribution of neuroproteins in the CSF to guarantee an appropriate interpretation of ventricular versus lumbar concentrations. METHODS In 10 patients treated with both an external ventricular and a lumbar CSF drain, we collected concomitant CSF samples. We measured CSF concentrations of the glial S100B protein, the neuron-specific enolase (Cobas e411®; Roche Diagnostics), the leptomeningeal β-trace protein (BN Pro Spec®; Dade Behring/Siemens), and the blood-derived albumin (Immage; Beckman Coulter). Statistical analysis was performed with a paired Wilcoxon signed ranks test. RESULTS In patients with a free CSF circulation without any recent neurosurgical procedure, S100B and neuron-specific enolase concentrations did not differ between the ventricular and lumbar CSF while β-trace and albumin levels were significantly higher in the lumbar than in the ventricular CSF (p=0.008 and p=0.005). Following posterior fossa tumor surgery, all proteins accumulate in the lumbar CSF. CONCLUSION For brain-derived proteins, we could not confirm a rostrocaudal CSF gradient while lepto-meningeal and blood-derived proteins accumulate in the lumbar CSF. We conclude that for the interpretation of protein CSF concentrations, the source of the sample is of crucial importance.
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Affiliation(s)
- Sebastian Brandner
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
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Huttner HB, Kiphuth IC, Teuber L, Lücking H, Kloska SP, Staykov D, Kuramatsu JB, Mauer C, Breuer L, Doerfler A, Köhrmann M. Neuroendocrine changes in patients with spontaneous supratentorial intracerebral hemorrhage. Neurocrit Care 2013; 18:39-44. [PMID: 21837535 DOI: 10.1007/s12028-011-9622-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neuroendocrine changes have been reported after ischemic stroke, subarachnoid hemorrhage, and brain trauma. As there are no corresponding data in patients with intracerebral hemorrhage (ICH) we analyzed various neuroendocrine parameters to investigate possible alterations in hormone profiles of patients with ICH. METHODS Twenty patients with ICH were prospectively enrolled in the study. Patients were a priori parted into two groups: Ten non-ventilated patients treated on the stroke-unit (hemorrhage volumes <20 ml, "small ICH"), and 10 ventilated patients treated on the neurocritical care unit (hematoma volumes >20 ml with possible additional ventricular involvement ("large ICH"). Neuroendocrine parameters were compared between both groups referring to reference values. The following parameters were obtained over a period of 9 days in 20 patients with spontaneous supratentorial ICH: thyrotropin, free thiiodothyronine and thyroxine, human growth hormone, insulin-like growth factor 1, luteinizing hormone, follicle-stimulating hormone, testosterone, prolactin, adrenocorticotropic hormone, and cortisol. RESULTS Small ICH patients were in a median 71 (54-88) years old and had a mean ICH volume of 9.5 ± 6.5 ml, whereas large ICH patients were 65 (47-80) years old and showed a mean volume of 56 ± 30.2 ml. None of the patients revealed pathological alterations for thyrotropin, free thiiodothyronine, thyroxine, human growth hormone, insulin-like growth factor 1, and testosterone. There was only a mild decrease of adrenocorticotropic hormone and cortisol on day 3 in large ICH patients. Small ICH patients showed pathologically elevated levels of luteinizing and follicle-stimulating hormone throughout the observation period. Large ICH patients showed a marked increase of prolactin that developed during the course. CONCLUSIONS Overall, neuroendocrine changes in ICH patients are not as profound as reported for ischemic stroke or subarachnoid hemorrhage. The clinical significance of increased LH and FSH levels in small ICH is unclear, whereas elevation of prolactin in large ICH was anticipated. Future randomized controlled trials should also focus on neuroendocrine parameters to clarify the impact of possible hormonal alterations on functional outcome.
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Affiliation(s)
- Hagen B Huttner
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany.
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Staykov D, Köhrmann M, Unterberg A. [Management of intracerebral hemorrhage: can we still learn something?]. DER NERVENARZT 2013. [PMID: 23180056 DOI: 10.1007/s00115-012-3531-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intracerebral hemorrhage (ICH) is the most devastating form of stroke. It affects approximately 2 million people worldwide every year and is a major cause of mortality and morbidity. Despite the focus of intensive scientific research on ICH for decades there is still no proven treatment strategy for this disease. Advances in knowledge on the underlying pathomechanisms of ICH and the clinical impact have contributed to the development of novel treatment approaches. Currently, surgical treatment, aggressive blood pressure management and intraventricular fibrinolysis in patients with additional severe intraventricular hemorrhage are being investigated in large scale phase III clinical trials.
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Affiliation(s)
- D Staykov
- Neurologische Klinik, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054 Erlangen, Deutschland.
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Kuramatsu JB, Huttner HB, Schwab S. Advances in the management of intracerebral hemorrhage. J Neural Transm (Vienna) 2013; 120 Suppl 1:S35-41. [PMID: 23720189 DOI: 10.1007/s00702-013-1040-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/14/2013] [Indexed: 12/14/2022]
Abstract
Intracerebral hemorrhage (ICH) is one of the most detrimental sub-types of stroke and accounts for 10-15% of all strokes Qureshi et al. (Lancet 373(9675):1632-1644, 2009). ICH has an incidence of 10-30 cases per 100,000 people/year which is increasing and expected to double by the year 2050 Qureshi et al. (N Engl J Med 344 (19):1450-1460, 2001). Mortality rates still remain poor (30-50%) and functional dependency after ICH is high (~75%) van Asch et al. (Lancet Neurol 9 (2):167-176, 2010). Up to now, all randomized controlled trials investigating treatment approaches in ICH have failed to document improvements on clinical endpoints Mayer et al. (N Engl J Med 358 (20):2127-2137, 2008); Brouwers and Goldstein (Neurotherapeutics 9 (1):87-98, 2012). Only a specialized treatment of severely injured patients at dedicated neuro intensive care units [NICU] has been shown to be beneficial Qureshi et al. (Lancet 373(9675):1632-1644, 2009); Suarez et al. (Crit Care Med 32 (11):2311-2317, 2004). Currently, ongoing trials are investigating aggressive blood pressure lowering, hemostatic therapies, different operative strategies, intraventricular thrombolysis as well as neuroprotective approaches, and brain edema therapies. This review will summarize advanced treatment strategies and novel approaches which are currently under investigation.
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Affiliation(s)
- J B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany
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Litrico S, Almairac F, Gaberel T, Ramakrishna R, Fontaine D, Sedat J, Lonjon M, Paquis P. Intraventricular fibrinolysis for severe aneurysmal intraventricular hemorrhage: a randomized controlled trial and meta-analysis. Neurosurg Rev 2013; 36:523-30; discussion 530-1. [PMID: 23636409 DOI: 10.1007/s10143-013-0469-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 12/09/2012] [Accepted: 01/13/2013] [Indexed: 01/18/2023]
Abstract
UNLABELLED The aim of this study was to assess the safety and efficacy of intraventricular fibrinolysis (IVF) for aneurysmal subarachnoid hemorrhage (aSAH) with severe intraventricular hemorrhage (IVH). In this randomized controlled trial, between 2005 and 2009, patients with aSAH and severe IVH were randomly assigned into two groups: one treated with external ventricular drainage (EVD) combined with intraventricular recombinant tissue plasminogen activator (rt-PA) and the second with EVD alone. The primary end-point was mortality rate within the first 30 days. We performed meta-analysis including all published articles that compared IVF + EVD to EVD alone in patients with aSAH IVH. Eleven patients were included in the rt-PA group, eight in the control group. At 30 days, mortality rate was lower in the rt-PA group (45.5 vs. 62.5%), but results were not statistically significant (p = 0.65). Clearance of third and fourth ventricles was obtained previously in the rt-PA group (4.25 days) compared to the control group (10.67 days) (p = 0.001). There was no statistically significant difference concerning the occurrence of complications. The meta-analysis showed a better survival rate with IVF without raised statistical significance (odds ratio = 0.32 [95% confidence interval, 0.10-1.03]). This study shows that IVF is as safe as EVD alone for aSAH with severe IVH. It accelerates blood clot resolution in the ventricular system. Mortality rate could be improved by IVF but without significant results. Because of the severity and rarity of this pathology, a multicenter study is required. CLINICAL TRIAL REGISTRATION INFORMATION www.clinicaltrials.gov (NCT00823485).
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Affiliation(s)
- Stephane Litrico
- Department of Neurosurgery, University Hospital of Nice, Hôpital Pasteur, avenue de la voie Romaine, Nice, France
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Castaño Ávila S, Corral Lozano E, Vallejo De La Cueva A, Maynar Moliner J, Martín López A, Fonseca San Miguel F, Urturi Matos J, Manzano Ramírez A. Intraventricular hemorrhage treated with intraventricular fibrinolysis. A 10-year experience. Med Intensiva 2013; 37:61-6. [DOI: 10.1016/j.medin.2012.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 01/26/2012] [Accepted: 02/16/2012] [Indexed: 11/28/2022]
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Ventriculomegaly after decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage. Clin Neurol Neurosurg 2013; 115:317-22. [DOI: 10.1016/j.clineuro.2012.05.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 05/19/2012] [Accepted: 05/27/2012] [Indexed: 11/24/2022]
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Volbers B, Wagner I, Willfarth W, Doerfler A, Schwab S, Staykov D. Intraventricular fibrinolysis does not increase perihemorrhagic edema after intracerebral hemorrhage. Stroke 2013; 44:362-6. [PMID: 23306318 DOI: 10.1161/strokeaha.112.673228] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Additional intraventricular hemorrhage leads to higher mortality and worse functional outcome after intracerebral hemorrhage (ICH). Intraventricular fibrinolysis (IVF) with recombinant tissue plasminogen activator (rtPA) is an emerging treatment strategy for such patients. However, experimental studies suggest that rtPA may exert proedematous effects and lead to increased perihemorrhagic edema (PHE) after ICH. We aimed to compare the course of PHE after ICH between patients who received IVF with rtPA and controls matched for ICH volume. METHODS Patients were identified retrospectively from our institutional ICH database. Sixty-four patients with ICH and intraventricular hemorrhage who were treated with IVF were compared with 64 controls, who did not receive IVF, matched for ICH volume. The course of PHE was assessed on computed tomography scans (day 1, days 2 and 3, days 4-6, 7-9, and 10-12) using a threshold-based semiautomatic volumetric algorithm. Relative PHE was calculated as a ratio of PHE volume and initial ICH volume. RESULTS The matching algorithm resulted in similar mean ICH volumes in both groups (20.01 ± 17.5 mL, IVF vs 20.08 ± 17.1 mL, control). Intraventricular hemorrhage volume was larger in the IVF group (26.8 ± 19.2 mL vs 9.2 ± 13.4 mL). The mean total rtPA dose used for IVF was 8 ± 6 mg. PHE increased over time in both groups until day 12. At all investigated time points, there was no significant difference in relative PHE between the IVF group and controls (F=0.39; P=0.844). CONCLUSIONS IVF with rtPA did not lead to a relevant increase in PHE after ICH. rtPA doses used in the current study seem to be safe regarding PHE.
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Affiliation(s)
- Bastian Volbers
- Department of Neurology, University of Erlangen-Nure, Schwabachanlage 6, 91054 Erlangen, Germany.
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Management of non-traumatic intraventricular hemorrhage. Neurosurg Rev 2012; 35:485-94; discussion 494-5. [PMID: 22732889 DOI: 10.1007/s10143-012-0399-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 04/03/2012] [Indexed: 01/15/2023]
Abstract
Intraventricular hemorrhage (IVH) is defined as the eruption of blood in the cerebral ventricular system and is mostly secondary to spontaneous intracerebral hemorrhage and aneurysmal and arteriovenous malformation rupture. IVH is a proven risk factor of increased mortality and poor functional outcome. Its seriousness is correlated not only with the amount of blood but also with the involvement of the third and fourth ventricles. There are four mechanisms that explain the pathophysiology of this event: acute obstructive hydrocephalus, the mass effect exerted by the blood clot, the toxicity of blood-breaking products on the adjacent brain parenchyma, and, lastly, the development of a chronic hydrocephalus. It is thus obvious that the clearance of blood from the ventricles should be a therapeutic goal. In cases of acute hydrocephalus, external ventricular drainage is a mandatory step, but proven often insufficient. The concomitant use of intraventricular fibrinolytics such as recombinant tissue plasminogen activator or urokinase seems to be beneficial at least in the context of spontaneous intracerebral hemorrhage, in which their use is now accepted but not yet validated by a randomized trial. Given the potential neurotoxicity of these agents, further research is needed in order to identify the best treatment for intraventricular fibrinolysis (IVF). The endoscopic retrieval of intraventricular blood was also described recently and seems to be as efficient as IVF, but its use is limited to specialized centers. IVH represents a therapeutic challenge for neurosurgeons, neurologists, and intensivists. Thus, a better understanding of this dramatic event will help in better tailoring the treatment strategies.
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Kollmar R, Juettler E, Huttner HB, Dörfler A, Staykov D, Kallmuenzer B, Schmutzhard E, Schwab S, Broessner G. Cooling in intracerebral hemorrhage (CINCH) trial: protocol of a randomized German-Austrian clinical trial. Int J Stroke 2012; 7:168-72. [PMID: 22264371 DOI: 10.1111/j.1747-4949.2011.00707.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intracerebral hemorrhage accounts for up to 15% of all strokes and is frequently associated with poor functional outcome and high mortality. So far, there is no clear evidence for a specific therapy, apart from general stroke unit or neurointensive care and management of secondary complications. Promising experimental and pilot clinical data support the use of therapeutic hypothermia after intracerebral hemorrhage. AIMS The study aims to determine if therapeutic hypothermia improves survival rates and reduces cerebral lesion volume after large intracerebral hemorrhage compared with conventional treatment. MATERIAL AND METHODS The Cooling in IntraCerebral Hemorrhage trial is a prospective, multicenter, interventional, randomized, parallel, two-arm (1 : 1) phase II trial with blinded end-point adjudication. Enrolment: 50 patients (age: 18 to 65 years) with large (25 to 64 ml on cranial computertomography), primary intracerebral hemorrhage of the basal ganglia or thalamus within 6 to 18 h after symptom onset are randomly allocated to therapeutic hypothermia for eight-days or conventional temperature management. In the therapeutic hypothermia group, a target temperature of 35.0°C is achieved by endovascular catheters and followed by slow controlled rewarming. Data analysis is based on the intent-to-treat population. The primary outcome measure of the study is the development in total lesion volume on cranial computertomography (intracerebral hemorrhage plus perihemorrhagic edema on day 8 ± 0.5 and day 1 ± 0.5 after intracerebral hemorrhage) and the mortality after 30 days. Secondary end-points are the in-hospital mortality, mortality, and functional outcome (modified Rankin Scale and Barthel-Index) after 90 and 180 days. Safety measures include any adverse events associated with therapeutic hypothermia. DISCUSSION In the face of a lack of evidence-based therapies for patients with large intracerebral hemorrhage, new promising approaches are desperately needed, but need evaluation in randomized controlled trials. CONCLUSION The results of Cooling in IntraCerebral Hemorrhage trial are believed to directly influence future therapy of large intracerebral hemorrhage.
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Affiliation(s)
- Rainer Kollmar
- Department of Neurology, University Hospital Erlangen; Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
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Staykov D, Huttner HB, Schwab S. [New treatment strategies for intraventricular hemorrhage]. Med Klin Intensivmed Notfmed 2012; 107:192-6. [PMID: 22526062 DOI: 10.1007/s00063-012-0100-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 05/04/2011] [Accepted: 06/01/2011] [Indexed: 11/26/2022]
Abstract
The presence of additional intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH) is associated with a much higher mortality and worse functional outcome. Although evidence-based specific treatment options for this entity are still lacking, knowledge about the pathophysiology of IVH has grown in recent decades, leading to the development of promising treatment strategies. Intraventricular fibrinolysis (IVF) accelerates IVH resolution and removal from the ventricular system. The additional usage of lumbar drains probably reduces the incidence of permanent posthemorrhagic hydrocephalus. The influence of these treatment modalities on functional outcome is currently being investigated in ongoing studies. The present article gives an overview of pathophysiological and clinical aspects of IVH, emphasizing novel treatment options.
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Affiliation(s)
- D Staykov
- Neurologische Klinik, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland.
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Zacharia BE, Vaughan KA, Hickman ZL, Bruce SS, Carpenter AM, Petersen NH, Deiner S, Badjatia N, Connolly ES. Predictors of long-term shunt-dependent hydrocephalus in patients with intracerebral hemorrhage requiring emergency cerebrospinal fluid diversion. Neurosurg Focus 2012; 32:E5. [DOI: 10.3171/2012.2.focus11372] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intracerebral hemorrhage (ICH) is frequently complicated by acute hydrocephalus, necessitating emergency CSF diversion with a subset of patients, ultimately requiring long-term treatment via placement of permanent ventricular shunts. It is unclear what factors may predict the need for ventricular shunt placement in this patient population.
Methods
The authors performed a retrospective analysis of a prospective database (ICH Outcomes Project) containing patients with nontraumatic ICH admitted to the neurological ICU at Columbia University Medical Center between January 2009 and September 2011. A multiple logistic regression model was developed to identify independent predictors of shunt-dependent hydrocephalus after ICH. The following variables were included: patient age, admission Glasgow Coma Scale score, temporal horn diameter on admission CT imaging, bicaudate index, admission ICH volume and location, intraventricular hemorrhage volume, Graeb score, LeRoux score, third or fourth ventricle hemorrhage, and intracranial pressure (ICP) and ventriculitis during hospital stay.
Results
Of 210 patients prospectively enrolled in the ICH Outcomes Project, 64 required emergency CSF diversion via placement of an external ventricular drain and were included in the final cohort. Thirteen of these patients underwent permanent ventricular CSF shunting prior to discharge. In univariate analysis, only thalamic hemorrhage and elevated ICP were significantly associated with the requirement for permanent CSF diversion, with p values of 0.008 and 0.033, respectively. Each remained significant in a multiple logistic regression model in which both variables were present.
Conclusions
Of patients with ICH requiring emergency CSF diversion, those with persistently elevated ICP and thalamic location of their hemorrhage are at increased odds of developing persistent hydrocephalus, necessitating permanent ventricular shunt placement. These factors may assist in predicting which patients will require permanent CSF diversion and could ultimately lead to improvements in the management of this disorder and the outcome in patients with ICH.
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Affiliation(s)
| | | | | | | | | | | | - Stacie Deiner
- 3Departments of Anesthesiology, Neurosurgery, Geriatrics, and Palliative Care, Mount Sinai Hospital, New York, New York
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