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Kjølhede M, Hjort N, Homburg S, Nørholt M, Dalby RB, Simonsen CZ, Blauenfeldt RA. Diagnostic yield of computed tomography angiography in patients presenting with spontaneous intracerebral hemorrhage. Acta Radiol 2024:2841851241254516. [PMID: 38772562 DOI: 10.1177/02841851241254516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
BACKGROUND Hypertension and cerebral amyloid angiopathy are the most common causes of spontaneous intracerebral hemorrhage (ICH); however, these conditions do not imply macrovascular pathology. Still, computed tomography (CT) angiography (CTA) is often performed in the acute phase in patients with ICH. PURPOSE To assess the diagnostic yield of CTA in the detection of secondary etiology in consecutive patients with spontaneous ICH. MATERIAL AND METHODS We performed a retrospective analysis of data from a prospective single-center cohort study of 203 patients presenting with spontaneous ICH admitted to a comprehensive stroke center over a two-year period (15 October 2016 to 15 October 2018). The underlying vascular pathology was assessed using CTA. RESULTS CTA was performed in addition to non-contrast CT and/or magnetic resonance imaging (MRI). Vascular pathology was found in 11 of 203 (5.4%) patients and included arteriovenous malformations (n=4), aneurysms (n=4), vasospasms (n=1), cerebral venous thrombosis (n=1), and other vascular malformations (n=1). In eight cases, the finding was deemed symptomatic. Patients with vascular pathology on CTA more often had lobar located hemorrhages (63.6% vs. 36.4%, P = 0.049). Numerically, patients with vascular pathology were younger, had smaller hematoma volumes, and lower mortality. CONCLUSION Underlying macrovascular pathology was detected on CTA in only approximately 1 of 20 consecutive patients with ICH. The patients with vascular pathology more often had a hemorrhage with a lobar location and young age and the present study is supportive of a risk-based stratification approach in performing CTA.
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Affiliation(s)
- Maria Kjølhede
- Danish Stroke Centre, Department of Neurology, Aarhus University Hospital, Skejby, Denmark
| | - Niels Hjort
- Danish Stroke Centre, Department of Neurology, Aarhus University Hospital, Skejby, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
| | - Sif Homburg
- Danish Stroke Centre, Department of Neurology, Aarhus University Hospital, Skejby, Denmark
| | - Morten Nørholt
- Danish Stroke Centre, Department of Neurology, Aarhus University Hospital, Skejby, Denmark
| | - Rikke Beese Dalby
- Hospital South West Jutland, University hospital of Southern Denmark & Department of Neuroradiology, Aarhus University Hospital, Skejby, Denmark
| | - Claus Ziegler Simonsen
- Danish Stroke Centre, Department of Neurology, Aarhus University Hospital, Skejby, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
| | - Rolf Ankerlund Blauenfeldt
- Danish Stroke Centre, Department of Neurology, Aarhus University Hospital, Skejby, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
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Putora PM, Almeida GG, Wildermuth S, Weber J, Dietrich T, Vernooij MW, van Doormaal PJ, Smagge L, Zeleňák K, Krainik A, Bonneville F, van Den Hauwe L, Möhlenbruch M, Bruno F, Ramgren B, Ramos-González A, Schellhorn T, Waelti S, Fischer T. Diagnostic imaging strategies of acute intracerebral hemorrhage in European academic hospitals-a decision-making analysis. Neuroradiology 2023; 65:729-736. [PMID: 36633612 DOI: 10.1007/s00234-022-03110-9] [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: 09/27/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE To evaluate and compare which factors are relevant to the diagnostic decision-making and imaging workup of intracerebral hemorrhages in large, specialized European centers. METHODS Expert neuroradiologists from ten large, specialized centers (where endovascular stroke treatment is routinely performed) in nine European countries were selected in cooperation with the European Society of Neuroradiology (ESNR). The experts were asked to describe how and when they would investigate specific causes in a patient who presented with an acute, atraumatic, intracerebral hemorrhage for two given locations: (1) basal ganglia, thalamus, pons or cerebellum; (2) lobar hemorrhage. Answers were collected, and decision trees were compared. RESULTS Criteria that were considered relevant for decision-making reflect recommendations from current guidelines and were similar in all participating centers. CT Angiography or MR angiography was considered essential by the majority of centers regardless of other factors. Imaging in clinical practice tended to surpass guideline recommendations and was heterogeneous among different centers, e.g., in a scenario suggestive of typical hypertensive hemorrhage, recommendations ranged from no further follow-up imaging to CT angiography and MR angiography. In no case was a consensus above 60% achieved. CONCLUSION In European clinical practices, existing guidelines for diagnostic imaging strategies in ICH evaluation are followed as a basis but in most cases, additional imaging investigation is undertaken. Significant differences in imaging workup were observed among the centers. Results suggest a high level of awareness and caution regarding potentially underlying pathology other than hypertensive disease.
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Affiliation(s)
- Paul Martin Putora
- Department of Radio-Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Gonçalo G Almeida
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Simon Wildermuth
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Johannes Weber
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Tobias Dietrich
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Meike W Vernooij
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Lucas Smagge
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Alexandre Krainik
- Department of Neuroradiology, University Hospital of Grenoble, Grenoble, France
| | - Fabrice Bonneville
- Department of Neuroradiology, Toulouse University Hospital, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Luc van Den Hauwe
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Federico Bruno
- Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Birgitta Ramgren
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Ana Ramos-González
- Department of Neuroradiology, University Hospital, 12 de Octubre, Madrid, Spain
| | - Till Schellhorn
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Stephan Waelti
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Tim Fischer
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland.
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3
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Roumi A, Ben Hassen W, Hmeydia G, Posener S, Pallud J, Sharshar T, Calvet D, Mas JL, Baron JC, Oppenheim C, Naggara O, Turc G. Diagnostic performance of dynamic 3D magnetic resonance angiography in daily practice for the detection of intracranial arteriovenous shunts in patients with non-traumatic intracranial hemorrhage. Front Neurol 2023; 13:1085806. [PMID: 36776575 PMCID: PMC9911434 DOI: 10.3389/fneur.2022.1085806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/19/2022] [Indexed: 01/28/2023] Open
Abstract
Introduction Identification of treatable causes of intracranial hemorrhage (ICH) such as intracranial arteriovenous shunt is crucial to prevent recurrence. However, diagnostic approaches vary considerably across centers, partly because of limited knowledge of the diagnostic performance of first-line vascular imaging techniques. We assessed the diagnostic performance of dynamic three-dimensional magnetic resonance angiography (dynamic 3D MRA) in daily practice to detect intracranial arteriovenous shunts in ICH patients against subsequent digital subtraction angiography (DSA) as reference standard. Methods We reviewed all adult patients who underwent first-line dynamic 3D MRA and subsequent DSA for non-traumatic ICH between January 2016 and September 2021 in a tertiary center. Sensitivity, specificity, accuracy, positive and negative predictive values of dynamic 3D MRA for the detection of intracranial arteriovenous shunt were calculated with DSA as reference standard. Results Among 104 included patients, 29 (27.9%) had a DSA-confirmed arteriovenous shunt [19 pial arteriovenous malformations, 10 dural arteriovenous fistulae; median onset-to-DSA: 17 (IQR: 3-88) days]. The sensitivity and specificity of dynamic 3D MRA [median onset-to-dynamic 3D MRA: 14 (3-101) h] for the detection of intracranial arteriovenous shunt were 66% (95% CI: 48-83) and 91% (95% CI: 84-97), respectively. The corresponding accuracy, positive and negative predictive values were 84% (95% CI: 77-91), 73% (95% CI: 56-90), and 87% (95% CI: 80-95), respectively. Conclusion This study suggests that although first-line evaluation with dynamic 3D MRA may be helpful for the detection of intracranial arteriovenous shunts in patients with ICH, additional vascular imaging work-up should not be withheld if dynamic 3D MRA is negative. Comparative prospective studies are needed to determine the best imaging strategy to diagnose arteriovenous shunts after non-traumatic ICH.
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Affiliation(s)
- Arnaud Roumi
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - Wagih Ben Hassen
- Neuroradiology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - Ghazi Hmeydia
- Neuroradiology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - Sacha Posener
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - Johan Pallud
- Neurosurgery Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - Tarek Sharshar
- Neuro-Intensive Care Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - David Calvet
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - Jean-Louis Mas
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - Jean-Claude Baron
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - Catherine Oppenheim
- Neuroradiology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - Olivier Naggara
- Neuroradiology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France
| | - Guillaume Turc
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France,*Correspondence: Guillaume Turc ✉
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El-Abtah ME, Kashkoush A, Achey R, Patterson T, Moore NZ, Bain MD. Diagnostic yield of cerebral angiography for intracranial hemorrhage in young patients: A single-center retrospective analysis. Interv Neuroradiol 2023:15910199231152505. [PMID: 36691317 DOI: 10.1177/15910199231152505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Intracranial hemorrhage (ICH) secondary to hypertension (HTN) classically occurs in the basal ganglia, cerebellum, or pons. Vascular lesions such as aneurysms or arteriovenous malformations (AVMs) are more common in younger patients. We investigated the utility of diagnostic subtraction angiography (DSA) in young hypertensive patients with non-lobar ICH. METHODS A retrospective review (2013-2022) identified young (18-60 years) patients who underwent DSA for ICH. HTN history, ICH location, presence/absence of subarachnoid hemorrhage (SAH), and computed tomography angiography (CTA) findings were collected. The main outcome was DSA-positivity, defined as presence of an AVM, aneurysm, Moyamoya disease, reversible cerebral vasoconstriction syndrome, or dural arteriovenous fistula on DSA. RESULTS Two hundred sixty patients were included, and the DSA-positivity rate was 19%.DSA-positivity was lower in hypertensive patients with ICHs in the cerebellum, pons, or basal ganglia compared to the rest of the patient sample (9% vs 26%, p = 0.0002, Fisher's exact test). We developed the ICH-Angio score (0-5 points) based on CTA findings, ICH location, HTN history, and presence of SAH to predict risk of underlying vascular lesions. DSA-positivity was lower in those with a score of 0 (0/62; 0%) compared to a score of 1 (5/52; 10%), 2 (17/48; 35%), 3 (10/20; 50%), 4 (5/6; 83%), or 5 (3/3; 100%). CONCLUSION The ICH-Angio score was able to non-invasively rule out an underlying vascular etiology for ICH in up to one-third of patients. HTN, ICH location, CTA findings, and associated SAH can identify patients at low risk for harboring underlying vascular lesions.
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Affiliation(s)
- Mohamed E El-Abtah
- 12304Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ahmed Kashkoush
- Department of Neurological Surgery, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca Achey
- Department of Neurological Surgery, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Patterson
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nina Z Moore
- Department of Neurological Surgery, 2569Cleveland Clinic, Cleveland, OH, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark D Bain
- Department of Neurological Surgery, 2569Cleveland Clinic, Cleveland, OH, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, OH, USA
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5
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Raposo N, Zanon Zotin MC, Seiffge DJ, Li Q, Goeldlin MB, Charidimou A, Shoamanesh A, Jäger HR, Cordonnier C, Klijn CJM, Smith EE, Greenberg SM, Werring DJ, Viswanathan A. A Causal Classification System for Intracerebral Hemorrhage Subtypes. Ann Neurol 2023; 93:16-28. [PMID: 36197294 PMCID: PMC9839566 DOI: 10.1002/ana.26519] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Determining the underlying causes of intracerebral hemorrhage (ICH) is of major importance, because risk factors, prognosis, and management differ by ICH subtype. We developed a new causal CLASsification system for ICH Subtypes, termed CLAS-ICH, based on recent advances in neuroimaging. METHODS CLAS-ICH defines 5 ICH subtypes: arteriolosclerosis, cerebral amyloid angiopathy, mixed small vessel disease (SVD), other rare forms of SVD (genetic SVD and others), and secondary causes (macrovascular causes, tumor, and other rare causes). Every patient is scored in each category according to the level of diagnostic evidence: (1) well-defined ICH subtype; (2) possible underlying disease; and (0) no evidence of the disease. We evaluated CLAS-ICH in a derivation cohort of 113 patients with ICH from Massachusetts General Hospital, Boston, USA, and in a derivation cohort of 203 patients from Inselspital, Bern, Switzerland. RESULTS In the derivation cohort, a well-defined ICH subtype could be identified in 74 (65.5%) patients, including 24 (21.2%) with arteriolosclerosis, 23 (20.4%) with cerebral amyloid angiopathy, 18 (15.9%) with mixed SVD, and 9 (8.0%) with a secondary cause. One or more possible causes were identified in 42 (37.2%) patients. Interobserver agreement was excellent for each category (kappa value ranging from 0.86 to 1.00). Despite substantial differences in imaging modalities, we obtained similar results in the validation cohort. INTERPRETATION CLAS-ICH is a simple and reliable classification system for ICH subtyping, that captures overlap between causes and the level of diagnostic evidence. CLAS-ICH may guide clinicians to identify ICH causes, and improve ICH classification in multicenter studies. ANN NEUROL 2023;93:16-28.
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Affiliation(s)
- Nicolas Raposo
- Department of neurology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France,Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, France
| | - Maria Clara Zanon Zotin
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Center for Imaging Sciences and Medical Physics, Department of Medical Imaging, Hematology and Clinical Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - David J. Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Martina B. Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Andreas Charidimou
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ashkan Shoamanesh
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Hans Rolf Jäger
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
| | - Catharina JM Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Eric E. Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Steven M. Greenberg
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Anand Viswanathan
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Van Trigt WK, Kelly KM, Hughes CCW. GNAQ mutations drive port wine birthmark-associated Sturge-Weber syndrome: A review of pathobiology, therapies, and current models. Front Hum Neurosci 2022; 16:1006027. [PMID: 36405075 PMCID: PMC9670321 DOI: 10.3389/fnhum.2022.1006027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Port-wine birthmarks (PWBs) are caused by somatic, mosaic mutations in the G protein guanine nucleotide binding protein alpha subunit q (GNAQ) and are characterized by the formation of dilated, dysfunctional blood vessels in the dermis, eyes, and/or brain. Cutaneous PWBs can be treated by current dermatologic therapy, like laser intervention, to lighten the lesions and diminish nodules that occur in the lesion. Involvement of the eyes and/or brain can result in serious complications and this variation is termed Sturge-Weber syndrome (SWS). Some of the biggest hurdles preventing development of new therapeutics are unanswered questions regarding disease biology and lack of models for drug screening. In this review, we discuss the current understanding of GNAQ signaling, the standard of care for patients, overlap with other GNAQ-associated or phenotypically similar diseases, as well as deficiencies in current in vivo and in vitro vascular malformation models.
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Affiliation(s)
- William K. Van Trigt
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California, Irvine, Irvine, CA, United States,*Correspondence: William K. Van Trigt,
| | - Kristen M. Kelly
- Department of Dermatology, School of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Christopher C. W. Hughes
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California, Irvine, Irvine, CA, United States,Christopher C. W. Hughes,
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7
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Shabani Z, Schuerger J, Su H. Cellular loci involved in the development of brain arteriovenous malformations. Front Hum Neurosci 2022; 16:968369. [PMID: 36211120 PMCID: PMC9532630 DOI: 10.3389/fnhum.2022.968369] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
Brain arteriovenous malformations (bAVMs) are abnormal vessels that are prone to rupture, causing life-threatening intracranial bleeding. The mechanism of bAVM formation is poorly understood. Nevertheless, animal studies revealed that gene mutation in endothelial cells (ECs) and angiogenic stimulation are necessary for bAVM initiation. Evidence collected through analyzing bAVM specimens of human and mouse models indicate that cells other than ECs also are involved in bAVM pathogenesis. Both human and mouse bAVMs vessels showed lower mural cell-coverage, suggesting a role of pericytes and vascular smooth muscle cells (vSMCs) in bAVM pathogenesis. Perivascular astrocytes also are important in maintaining cerebral vascular function and take part in bAVM development. Furthermore, higher inflammatory cytokines in bAVM tissue and blood demonstrate the contribution of inflammatory cells in bAVM progression, and rupture. The goal of this paper is to provide our current understanding of the roles of different cellular loci in bAVM pathogenesis.
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Affiliation(s)
- Zahra Shabani
- Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, CA, United States
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
| | - Joana Schuerger
- Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, CA, United States
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
| | - Hua Su
- Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, CA, United States
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Hua Su, ; orcid.org/0000-0003-1566-9877
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8
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 355] [Impact Index Per Article: 177.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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Frequency, Predictors, Etiology, and Outcomes for Deep Intracerebral Hemorrhage without Hypertension. J Stroke Cerebrovasc Dis 2022; 31:106293. [PMID: 35016096 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106293] [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: 11/10/2021] [Revised: 12/10/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Some patients with deep intracerebral hemorrhage (ICH) have a transient hypertensive response and they may be erroneously classified as secondary to hypertension. We investigated frequency, risk factors, and outcomes for patients with deep ICH without hypertension. MATERIALS AND METHODS We consecutively recruited patients with spontaneous ICH attending two Spanish stroke centers (January 2015-June 2019). Excluded were patients with lobar/infratentorial ICH and patients who died during hospitalization. We defined deep ICH without hypertension when the bleeding was in a deep structure, no requirement for antihypertensive agents during follow-up and no evident chronic hypertension markers evaluated by transthoracic echocardiography, 24 h ambulatory blood pressure monitoring and/or electrocardiography. We compared clinical, radiological, and 3-month functional outcome data for deep-ICH patients with hypertension versus those without hypertension. RESULTS Of 759 patients with ICH, 219 (mean age 69.6 ± 15.4 years, 54.8% men) met the inclusion criteria and 36 (16.4%) did not have hypertension. Of these 36 patients, 19 (52.7%) had a transient hypertensive response. Independent predictors of deep ICH without hypertension were age (adjusted OR:0.94;95%CI:0.91-0.96) and dyslipidemia (adjusted OR:0.27;95% CI:0.08-0.85). One third of deep ICH without hypertension were secondary to vascular malformations. Favorable outcomes (modified Rankin Scale 0-2) were more frequent in patients with deep ICH without hypertension compared to those with hypertension (70.9% vs 33.8%; p < 0.001). CONCLUSION Of patients with deep ICH, 16.4% were unrelated with hypertension, around half showed hypertensive response, and around a third had vascular malformations. We suggest studying hypertension markers and performing a follow-up brain MRI in those patients with deep ICH without prior hypertension.
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McGurgan IJ, Ziai WC, Werring DJ, Al-Shahi Salman R, Parry-Jones AR. Acute intracerebral haemorrhage: diagnosis and management. Pract Neurol 2020; 21:practneurol-2020-002763. [PMID: 33288539 PMCID: PMC7982923 DOI: 10.1136/practneurol-2020-002763] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2020] [Indexed: 12/11/2022]
Abstract
Intracerebral haemorrhage (ICH) accounts for half of the disability-adjusted life years lost due to stroke worldwide. Care pathways for acute stroke result in the rapid identification of ICH, but its acute management can prove challenging because no individual treatment has been shown definitively to improve its outcome. Nonetheless, acute stroke unit care improves outcome after ICH, patients benefit from interventions to prevent complications, acute blood pressure lowering appears safe and might have a modest benefit, and implementing a bundle of high-quality acute care is associated with a greater chance of survival. In this article, we address the important questions that neurologists face in the diagnosis and acute management of ICH, and focus on the supporting evidence and practical delivery for the main acute interventions.
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Affiliation(s)
- Iain J McGurgan
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Wendy C Ziai
- Division of Brain Injury Outcomes, Department of Neurology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, UCL, London, UK
| | | | - Adrian R Parry-Jones
- Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
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Low diagnostic yield in follow-up MR imaging in patients with spontaneous intracerebral hemorrhage with a negative initial MRI. Neuroradiology 2020; 63:1009-1012. [PMID: 33226459 DOI: 10.1007/s00234-020-02570-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/23/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Follow-up MRI/MRA is historically obtained as outpatient when patients with a spontaneous intracerebral hemorrhage (ICH) have an initial MRI/MRA that is negative for an underlying structural lesion. However, the utility of repeating MR imaging in a delayed fashion remains uncertain. METHODS We retrospectively reviewed 396 patients with spontaneous ICH admitted at our institution between 2015 and 2017 and selected those whose initial MRI/MRA was negative for an underlying structural lesion and those who underwent follow-up MR imaging in a delayed fashion. RESULTS A total of 113 patients met the study criteria. The average age of those with negative follow-up MRI/MRA was 65.0 ± 12.6 (IQR: 55.0-74.0) years old. None of the 113 patients with a negative inpatient MRI/MRA had an underlying structural lesion on follow-up MRI/MRA (0%, 95% CI 0.0-0.032, p < 0.001). The mean time of the follow-up imaging from the initial study was 105.7 days (median: 62 days; IQR: 42.5-100.5). Of the 113, 83 (73.5%) underwent follow-up MRI with and without gadolinium, while 30 (26.5%) patients did not receive gadolinium. CONCLUSION Delayed follow-up MRI in patients with a negative initial MRI/MRA for workup of spontaneous ICH was not diagnostic in any of the patients included in the study. Our study suggests that a routine follow-up MRI for this patient population is not necessary.
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Affiliation(s)
- Lars Jakobsson
- From the Karolinska Institutet, Tomtebodavägen, Solna, Sweden (L.J.)
| | - Helen M Arthur
- From the Karolinska Institutet, Tomtebodavägen, Solna, Sweden (L.J.)
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13
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Chalouhi N, Mouchtouris N, Al Saiegh F, Das S, Sweid A, Flanders AE, Starke RM, Baldassari MP, Tjoumakaris S, Gooch MR, Shah SO, Hasan D, Herial N, D’Ambrosio R, Rosenwasser R, Jabbour P. Analysis of the utility of early MRI/MRA in 400 patients with spontaneous intracerebral hemorrhage. J Neurosurg 2020; 132:1865-1871. [DOI: 10.3171/2019.2.jns183425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/19/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEMRI and MRA studies are routinely obtained to identify the etiology of intracerebral hemorrhage (ICH). The diagnostic yield of MRI/MRA in the setting of an acute ICH, however, remains unclear. The authors’ goal was to determine the utility of early MRI/MRA in detecting underlying structural lesions in ICH and to identify patients in whom additional imaging during hospitalization could safely be foregone.METHODSThe authors reviewed data obtained in 400 patients with spontaneous ICH diagnosed on noncontrast head CT scans who underwent MRI/MRA between 2015 and 2017 at their institution. MRI/MRA studies were reviewed to identify underlying lesions, such as arteriovenous malformations, aneurysms, cavernous malformations, arteriovenous fistulas, tumors, sinus thrombosis, moyamoya disease, and abscesses.RESULTSThe median patient age was 65 ± 15.8 years. Hypertension was the most common (72%) comorbidity. Structural abnormalities were detected on MRI/MRA in 12.5% of patients. Structural lesions were seen in 5.7% of patients with basal ganglia/thalamic ICH, 14.1% of those with lobar ICH, 20.4% of those with cerebellar ICH, and 27.8% of those with brainstem ICH. Notably, the diagnostic yield of MRI/MRA was 0% in patients > 65 years with a basal ganglia/thalamic hemorrhage and 0% in those > 85 years with any ICH location, whereas it was 37% in patients < 50 years and 23% in those < 65 years. Multivariate analysis showed that decreasing age, absence of hypertension, and non–basal ganglia/thalamic location were predictors of finding an underlying lesion.CONCLUSIONSThe yield of MRI/MRA in ICH is highly variable, depending on patient age and hemorrhage location. The findings of this study do not support obtaining early MRI/MRA studies in patients ≥ 65 years with basal ganglia/thalamic ICH or in any ICH patients ≥ 85 years. In all other situations, early MRI/MRA remains valuable in ruling out underlying lesions.
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Affiliation(s)
| | | | | | | | | | - Adam E. Flanders
- Radiology, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurosurgery and Radiology, Miami Miller School of Medicine, Miami University Hospital, Miami, Florida; and
| | | | | | | | | | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa
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Rindler RS, Allen JW, Barrow JW, Pradilla G, Barrow DL. Neuroimaging of Intracerebral Hemorrhage. Neurosurgery 2020; 86:E414-E423. [DOI: 10.1093/neuros/nyaa029] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/28/2019] [Indexed: 02/05/2023] Open
Abstract
AbstractIntracerebral hemorrhage (ICH) accounts for 10% to 20% of strokes worldwide and is associated with high morbidity and mortality rates. Neuroimaging is indispensable for rapid diagnosis of ICH and identification of the underlying etiology, thus facilitating triage and appropriate treatment of patients. The most common neuroimaging modalities include noncontrast computed tomography (CT), CT angiography (CTA), digital subtraction angiography, and magnetic resonance imaging (MRI). The strengths and disadvantages of each modality will be reviewed. Novel technologies such as dual-energy CT/CTA, rapid MRI techniques, near-infrared spectroscopy, and automated ICH detection hold promise for faster pre- and in-hospital ICH diagnosis that may impact patient management.
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Affiliation(s)
- Rima S Rindler
- Department of Neurosurgery, Emory University Hospital, Atlanta, Georgia
| | - Jason W Allen
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Jack W Barrow
- Mercer University School of Medicine, Savannah, Georgia
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University Hospital, Atlanta, Georgia
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University Hospital, Atlanta, Georgia
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15
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Huang X, Cheng Z, Xu Y, Xia L, Zhan Z, Xu T, Cao Y, Han Z. Associations of Clinical Characteristics and Etiology With Death in Hospitalized Chinese Children After Spontaneous Intracerebral Hemorrhage: A Single-Center, Retrospective Cohort Study. Front Pediatr 2020; 8:576077. [PMID: 33614538 PMCID: PMC7890113 DOI: 10.3389/fped.2020.576077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/31/2020] [Indexed: 01/10/2023] Open
Abstract
Objective: We retrospectively analyzed clinical characteristics, etiology, and mortality risk factors in pediatric cases of non-traumatic spontaneous intracerebral hemorrhage. Methods: This study involved children between 29 days and 18 years old with confirmed spontaneous intracerebral hemorrhage based on head CT or MRI at the Second Affiliated Hospital of Wenzhou Medical University and Yuying Children's Hospital from January 2008 to March 2020. Demographic and clinical characteristics, etiology, imaging, and treatment data were collected at baseline. Potential risk factors of in-hospital death were identified using univariate analysis and multivariate logistic regression. Result: A total of 200 children (126 males, median age 5 years) were included in the study. Clinical symptoms of spontaneous intracerebral hemorrhage were typically non-specific (79.5%). One third of patients (31.1%) had a Glasgow Coma Scale score (GCS) ≤ 8, and nearly two-thirds (60.5%) showed a combination of ventricular hemorrhage or subarachnoid hemorrhage. Supratentorial hemorrhage was more common. Cerebrovascular disease (37.0%) and hematological disease (33.5%) were the most frequent etiologies of spontaneous intracerebral hemorrhage. Most patients (74.5%) received non-surgical treatment, while 25.5% received surgical treatment. After an average of 12 days of treatment, 167 children (83.5%) survived and 33 (16.5%) died. Multivariate logistic regression showed herniation syndrome, and low GCS (≤ 8) to be associated with increased risk of mortality, while hemorrhage due to arteriovenous malformation was associated with lower risk of mortality. Conclusion: Our data suggest that cerebrovascular disease is the most common cause of spontaneous intracerebral hemorrhage among children, and that arteriovenous malformation is associated with lower risk of death in hospital. Conversely, the presence of herniation syndrome, low GCS (≤ 8) increase risk of in-hospital mortality. Our results underscore the importance of timely imaging and supplementary examinations in cases of suspected spontaneous intracerebral hemorrhage.
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Affiliation(s)
- Xiaoyan Huang
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zicheng Cheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye Xu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lingfan Xia
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhenxiang Zhan
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Tong Xu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yungang Cao
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhao Han
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Barbosa Do Prado L, Han C, Oh SP, Su H. Recent Advances in Basic Research for Brain Arteriovenous Malformation. Int J Mol Sci 2019; 20:ijms20215324. [PMID: 31731545 PMCID: PMC6862668 DOI: 10.3390/ijms20215324] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/11/2019] [Accepted: 10/21/2019] [Indexed: 02/07/2023] Open
Abstract
Arteriovenous malformations (AVMs) are abnormal connections of vessels that shunt blood directly from arteries into veins. Rupture of brain AVMs (bAVMs) can cause life-threatening intracranial bleeding. Even though the majority of bAVM cases are sporadic without a family history, some cases are familial. Most of the familial cases of bAVMs are associated with a genetic disorder called hereditary hemorrhagic telangiectasia (HHT). The mechanism of bAVM formation is not fully understood. The most important advances in bAVM basic science research is the identification of somatic mutations of genes in RAS-MAPK pathways. However, the mechanisms by which mutations of these genes lead to AVM formation are largely unknown. In this review, we summarized the latest advance in bAVM studies and discussed some pathways that play important roles in bAVM pathogenesis. We also discussed the therapeutic implications of these pathways.
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Affiliation(s)
- Leandro Barbosa Do Prado
- Center for Cerebrovascular Research, Department of Anesthesia, University of California, San Francisco, CA 94143, USA;
| | - Chul Han
- Barrow Aneurysm & AVM Research Center, Barrow Neurological Institute/Dignity Health, Phoenix, AZ 85013, USA; (C.H.); (S.P.O.)
| | - S. Paul Oh
- Barrow Aneurysm & AVM Research Center, Barrow Neurological Institute/Dignity Health, Phoenix, AZ 85013, USA; (C.H.); (S.P.O.)
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia, University of California, San Francisco, CA 94143, USA;
- Correspondence: ; Tel.: +01-415-206-3162
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Hostettler IC, Seiffge DJ, Werring DJ. Intracerebral hemorrhage: an update on diagnosis and treatment. Expert Rev Neurother 2019; 19:679-694. [PMID: 31188036 DOI: 10.1080/14737175.2019.1623671] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Spontaneous non-traumatic intracerebral hemorrhage (ICH) is most often caused by small vessel diseases: deep perforator arteriopathy (hypertensive arteriopathy) or cerebral amyloid angiopathy (CAA). Although ICH accounts for only 10-15% of all strokes it causes a high proportion of stroke mortality and morbidity, with few proven effective acute or preventive treatments. Areas covered: We conducted a literature search on etiology, diagnosis, treatment, management and current clinical trials in ICH. In this review, We describe the causes, diagnosis (including new brain imaging biomarkers), classification, pathophysiological understanding, treatment (medical and surgical), and secondary prevention of ICH. Expert opinion: In recent years, significant advances have been made in deciphering causes, understanding pathophysiology, and improving acute treatment and prevention of ICH. However, the clinical outcome remains poor and many challenges remain. Acute interventions delivered rapidly (including medical therapies - targeting hematoma expansion, hemoglobin toxicity, inflammation, edema, anticoagulant reversal - and minimally invasive surgery) are likely to improve acute outcomes. Improved classification of the underlying arteriopathies (from neuroimaging and genetic studies) and prognosis should allow tailored prevention strategies (including sustained blood pressure control and optimized antithrombotic therapy) to further improve longer-term outcome in this devastating disease.
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Affiliation(s)
- Isabel C Hostettler
- a UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation , UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery , London , UK
| | - David J Seiffge
- a UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation , UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery , London , UK.,b Stroke Center, Department of Neurology and Department of Clinical Research , University of Basel and University Hospital Basel , Basel , Switzerland
| | - David J Werring
- a UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation , UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery , London , UK
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18
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Bazarde HA, Wenz F, Hänggi D, Etminan N. Radiosurgery of Brain Arteriovenous and Cavernous Malformations. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_10-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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19
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Hilkens NA, van Asch CJJ, Werring DJ, Wilson D, Rinkel GJE, Algra A, Velthuis BK, de Kort GAP, Witkamp TD, van Nieuwenhuizen KM, de Leeuw FE, Schonewille WJ, de Kort PLM, Dippel DWJ, Raaymakers TWM, Hofmeijer J, Wermer MJH, Kerkhoff H, Jellema K, Bronner IM, Remmers MJM, Bienfait HP, Witjes RJGM, Jäger HR, Greving JP, Klijn CJM. Predicting the presence of macrovascular causes in non-traumatic intracerebral haemorrhage: the DIAGRAM prediction score. J Neurol Neurosurg Psychiatry 2018; 89:674-679. [PMID: 29348301 DOI: 10.1136/jnnp-2017-317262] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/27/2017] [Accepted: 12/20/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE A substantial part of non-traumatic intracerebral haemorrhages (ICH) arises from a macrovascular cause, but there is little guidance on selection of patients for additional diagnostic work-up. We aimed to develop and externally validate a model for predicting the probability of a macrovascular cause in patients with non-traumatic ICH. METHODS The DIagnostic AngioGRAphy to find vascular Malformations (DIAGRAM) study (n=298; 69 macrovascular cause; 23%) is a prospective, multicentre study assessing yield and accuracy of CT angiography (CTA), MRI/ magnetic resonance angiography (MRA) and intra-arterial catheter angiography in diagnosing macrovascular causes in patients with non-traumatic ICH. We considered prespecified patient and ICH characteristics in multivariable logistic regression analyses as predictors for a macrovascular cause. We combined independent predictors in a model, which we validated in an external cohort of 173 patients with ICH (78 macrovascular cause, 45%). RESULTS Independent predictors were younger age, lobar or posterior fossa (vs deep) location of ICH, and absence of small vessel disease (SVD). A model that combined these predictors showed good performance in the development data (c-statistic 0.83; 95% CI 0.78 to 0.88) and moderate performance in external validation (c-statistic 0.66; 95% CI 0.58 to 0.74). When CTA results were added, the c-statistic was excellent (0.91; 95% CI 0.88 to 0.94) and good after external validation (0.88; 95% CI 0.83 to 0.94). Predicted probabilities varied from 1% in patients aged 51-70 years with deep ICH and SVD, to more than 50% in patients aged 18-50 years with lobar or posterior fossa ICH without SVD. CONCLUSION The DIAGRAM scores help to predict the probability of a macrovascular cause in patients with non-traumatic ICH based on age, ICH location, SVD and CTA.
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Affiliation(s)
- Nina A Hilkens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Charlotte J J van Asch
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Kempenhaeghe, Academic Centre for Epileptology, Heeze, The Netherlands
| | - David J Werring
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - Duncan Wilson
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - Gabriël J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ale Algra
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gérard A P de Kort
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Theo D Witkamp
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Paul L M de Kort
- Department of Neurology, St Elisabeth Hospital, Tilburg, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Korné Jellema
- Department of Neurology, MCH Westeinde, The Hague, The Netherlands
| | - Irene M Bronner
- Department of Neurology, Flevo Hospital, Almere, The Netherlands
| | | | | | - Ron J G M Witjes
- Department of Neurology, Tergooi Hospitals, Blaricum, The Netherlands
| | - H Rolf Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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Anderson CS. How useful are simple clinical features and non-invasive imaging at predicting an underlying structural cause of acute intracerebral haemorrhage? J Neurol Neurosurg Psychiatry 2018; 89:671. [PMID: 29449459 DOI: 10.1136/jnnp-2017-317564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 01/28/2018] [Accepted: 01/31/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Craig S Anderson
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia.,The George Institute, Peking University Health Science Center, Beijing, People's Republic of China
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Martí-Fàbregas J, Prats-Sánchez L, Guisado-Alonso D, Martínez-Domeño A, Delgado-Mederos R, Camps-Renom P. SMASH-U versus H-ATOMIC: A Head-to-Head Comparison for the Etiologic Classification of Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2018; 27:2375-2380. [PMID: 29779884 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 04/23/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND There is no agreement for the etiologic classification of patients with intracerebral hemorrhage (ICH). In a series of patients with ICH, we performed a randomized head-to-head comparison between the two recently proposed etiologic classification systems. METHODS We evaluated patients registered in a prospective database of consecutive patients. A simplified H-ATOMIC classification defines 8 categories: hypertension, amyloid, tumor, oral anticoagulants, malformation, infrequent, cryptogenic, and combination. SMASH-U also defines 8 categories: structural, medication, amyloid, systemic, hypertension, and undetermined, and nonstroke and stroke-non-ICH. Experienced stroke neurologists applied both classification systems to a randomly assigned list of patients. The concordances between the 2 systems were analyzed. In a subset of patients, the percent of agreement and the inter-rater reliability (kappa coefficient) were calculated. RESULTS A total of 156 patients (age 72.3 ± 13.5 years) were evaluated, and 54 of these patients were evaluated by 2 neurologists. Concordance (a patient classified in equivalent categories for both systems) was 63%. The percentage of interobserver agreement was 85.5% for SMASH-U and 87.6% for H-ATOMIC. Inter-rater reliability was similar for SMASH-U (kappa .82) and H-ATOMIC (kappa .76). The range of reliability among neurologists was .66-.93 for SMASH-U and .66-.94 for H-ATOMIC. CONCLUSIONS The percentage agreement among investigators is remarkably high for both classification systems, and the inter-rater reliability is substantial to almost perfect for both systems. However, discrepancies between the 2 systems are frequent (in about one third of the patients) due to different categories and definitions.
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Affiliation(s)
- Joan Martí-Fàbregas
- Biomedical Research Institute Hospital de la Santa Creu i Sant Pau, IIB Sant Pau, Barcelona Spain.
| | - Luis Prats-Sánchez
- Biomedical Research Institute Hospital de la Santa Creu i Sant Pau, IIB Sant Pau, Barcelona Spain
| | - Daniel Guisado-Alonso
- Biomedical Research Institute Hospital de la Santa Creu i Sant Pau, IIB Sant Pau, Barcelona Spain
| | | | - Raquel Delgado-Mederos
- Biomedical Research Institute Hospital de la Santa Creu i Sant Pau, IIB Sant Pau, Barcelona Spain
| | - Pol Camps-Renom
- Biomedical Research Institute Hospital de la Santa Creu i Sant Pau, IIB Sant Pau, Barcelona Spain
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23
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Abstract
Neuroradiology with computed tomography (CT) and magnetic resonance imaging (MRI) is essential for the initial evaluation of patients with a clinical suspicion of brain and spine disorders. Morphologic imaging is required to obtain a probable diagnosis to support the treatment decisions in pre- and perinatal disorders, vascular diseases, traumatic injuries, metabolic disorders, epilepsy, infection/inflammation, neurodegenerative disorders, degenerative spinal disease, and tumors of the central nervous system. Different postprocessing tools are increasingly used for three-dimensional visualization and quantification of lesions. Additional information is provided by angiographic methods and physiologic CT and MRI techniques, such as diffusion MRI, perfusion CT/MRI, MR spectroscopy, functional MRI, tractography, and nuclear medicine imaging methods. Positron emission tomography (PET) is now integrated with CT (PET/CT), and PET/MR scanners have recently also been introduced. These hybrid techniques facilitate the co-registration of lesions with different modalities, and give new possibilites for functional imaging. Repeated imaging is increasingly performed for treatment monitoring. The improved imaging techniques together with the neuropathologic diagnosis after biopsy or surgery allow more personalized treatment of the patient. Neuroradiology also includes endovascular treatment of aneurysms and arteriovenous malformations as well as thrombectomy in acute stroke. This catheter-based treatment has replaced invasive neurosurgery in many cases.
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Wilson D, Ogungbemi A, Ambler G, Jones I, Werring DJ, Jäger HR. Developing an algorithm to identify patients with intracerebral haemorrhage secondary to a macrovascular cause. Eur Stroke J 2017; 2:369-376. [PMID: 31008329 DOI: 10.1177/2396987317732874] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/24/2017] [Indexed: 11/16/2022] Open
Abstract
Introduction Determining the cause of spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is critical to guide treatment and prognosis. We investigated whether small vessel disease (SVD) in addition to clinical and other radiological findings on acute neuroimaging predicts a low risk of a macrovascular cause (e.g. an arterio-venous malformation, aneurysm or dural arteriovenous fistula). Patients and methods We identified patients with acute spontaneous ICH who underwent acute non-contrast CT, CT angiography (CTA) and intra-arterial digital subtraction angiography (IADSA) at our institution from January 2010 to April 2014. Logistic regression including CTA result, SVD, age, pre-ICH hypertension and ICH location was used to derive a prediction model, validated using bootstrapping. Results 173 patients (46% female, median age 49) of whom 78 had a macrovascular cause on IADSA were included. Predictors of a macrovascular cause were: abnormal CTA (OR 67.4; p < 0.001); absence of SVD (OR 5.0; p = 0.019); and absence of pre-ICH hypertension (OR 3.4; p = 0.05). In our internally derived prediction model, the combination of CTA, SVD and pre-ICH hypertension predicted the likelihood of an underlying macrovascular cause (optimism-adjusted ROC area 0.919). Patients with negative CTA, SVD and pre-ICH hypertension have a low likelihood of an underlying macrovascular cause (1.8%). Discussion and conclusion A combination of CTA, SVD and pre-ICH hypertension predict the likelihood of finding a macrovascular cause in patients with acute spontaneous ICH, allowing informed decisions regarding the likely benefit and risk of IADSA.
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Affiliation(s)
- Duncan Wilson
- 1Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Ayokunle Ogungbemi
- 2Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Ifan Jones
- 1Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - David J Werring
- 1Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Hans R Jäger
- 2Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017. [DOI: 10.1161/str.0000000000000134] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Managing acute intracerebral haemorrhage is a challenging task for physicians. Evidence shows that outcome can be improved with admission to an acute stroke unit and active care, including urgent reversal of anticoagulant effects and, potentially, intensive blood pressure reduction. Nevertheless, many management issues remain controversial, including the use of haemostatic therapy, selection of patients for neurosurgery and neurocritical care, the extent of investigations for underlying causes and the benefit versus risk of restarting antithrombotic therapy after an episode of intracerebral haemorrhage.
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Affiliation(s)
- Zhe Kang Law
- University of Nottingham, UK
- National University of Malaysia, Kuala Lumpur, Malaysia
| | | | - Philip M Bath
- University of Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Fam MD, Pang A, Zeineddine HA, Mayo S, Stadnik A, Jesselson M, Zhang L, Dlugash R, Ziai W, Hanley D, Awad IA. Demographic Risk Factors for Vascular Lesions as Etiology of Intraventricular Hemorrhage in Prospectively Screened Cases. Cerebrovasc Dis 2017; 43:223-230. [PMID: 28245439 DOI: 10.1159/000458452] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/28/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Spontaneous intraventricular hemorrhage (IVH) is associated with high rates of morbidity and mortality despite critical care and other advances. An important step in clinical management is to confirm/rule out an underlying vascular lesion, which influences further treatment, potential for further bleeding, and prognosis. Our aim is to compare demographic and clinical characteristics between IVH patients with and without an underlying vascular lesion, and among cohorts with different vascular lesions. METHODS We analyzed prospectively collected data of IVH patients screened for eligibility as part of the Clot Lysis: Evaluation Accelerated Resolution of IVH Phase III (CLEAR III) clinical trial. The trial adopted a structured screening process to systematically exclude patients with an underlying vascular lesion as the etiology of IVH. We collected age, sex, ethnicity, and primary diagnosis on these cases and vascular lesions were categorized prospectively as aneurysm, vascular malformation (arteriovenous malformation, dural arteriovenous fistula, and cavernoma), Moyamoya disease, or other vascular lesion. We excluded cases <18 or >80 years of age. Baseline characteristics were compared between the CLEAR group (IVH screened without vascular lesion) and the group of IVH patients screened and excluded from CLEAR because of an identified vascular lesion. We further analyzed the differential demographic and clinical characteristics among subcohorts with different vascular lesions. RESULTS A total of 10,538 consecutive IVH cases were prospectively screened for the trial between 2011 and 2015. Out of these, 496 cases (4.7%) screened negative for underlying vascular lesion, met the inclusion criteria, and were enrolled in the trial (no vascular etiology group); and 1,205 cases (11.4%) were concurrently screened and excluded from the trial because of a demonstrated underlying vascular lesion (vascular etiology group). Cases with vascular lesion were less likely to be >45 years of age (OR 0.28, 95% CI 0.20-0.40), African-American (OR 0.23, 95% CI 0.18-0.31), or male gender (OR 0.48, 95% CI 0.38-0.60), and more likely to present with primary IVH (OR 1.85, 95% CI 1.37-2.51) compared to those with no vascular etiology (p < 0.001). Other demographic factors were associated with specific vascular lesion etiologies. A combination of demographic features increases the association with the absence of vascular lesion, but not with absolute reliability (OR 0.1, 95% CI 0.06-0.17, p < 0.001). CONCLUSION An underlying vascular lesion as etiology of IVH cannot be excluded solely by demographic parameters in any patient. Some form of vascular imaging is necessary in screening patients before contemplating interventions like intraventricular fibrinolysis, where safety may be impacted by the presence of vascular lesion.
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Affiliation(s)
- Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, IL, USA
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Prognostic Significance of Intraventricular Hemorrhage in Vascular Structural Abnormality-Related Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2017; 26:636-643. [PMID: 28041901 DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/18/2016] [Accepted: 11/13/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The prognostic significance of intraventricular hemorrhage (IVH) in patients with vascular structural abnormality-related intracerebral hemorrhage (VSARICH) is poorly understood. METHOD We prospectively included consecutive patients diagnosed with VSARICH. Imaging of initial brain computed tomography (CT) scans within 48 hours of symptom onset was analyzed. The presence and severity of IVH were recorded. Severity of IVH was measured using the modified Graeb (mGraeb) score. Baseline characteristics and 3-month outcomes were compared between the IVH and non-IVH groups. Multivariate logistic regression was used to examine the independent association between IVH and 3-month outcomes. RESULTS A total of 132 VSARICH patients were included for analysis, and 71 (53.8%) of them had IVH on initial CT imaging. IVH patients had a median mGraeb score of 15 (6-21), and compared to non-IVH patients, they had shorter delay to first CT scan and higher stroke severity on admission (all P ≤ .005). At 3 months, IVH patients had higher death rates (30.3% versus 7.0%; P = .001) and poor outcome rates (48.5% versus 21.1%; P = .002) than non-IVH patients. After multivariate analysis, IVH severity was associated with 3-month death (Model 1 OR 1.112, 95% CI [1.027-1.204], P = .009; Model 2 OR 1.110, 95% CI [1.027-1.200], P = .009) and poor outcome (Model 2 OR 1.053, 95% CI [1.001-1.108], P = .047), although no independent association between IVH presence and outcomes was observed. CONCLUSION IVH severity measured by mGraeb score independently predicts death and poor functional outcome in patients with VSARICH.
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Casolla B, Tortuyaux R, Cordonnier C. Management of spontaneous intracerebral haemorrhages. Presse Med 2016; 45:e419-e428. [DOI: 10.1016/j.lpm.2016.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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The H-ATOMIC Criteria for the Etiologic Classification of Patients with Intracerebral Hemorrhage. PLoS One 2016; 11:e0156992. [PMID: 27275863 PMCID: PMC4898692 DOI: 10.1371/journal.pone.0156992] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 05/23/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE There are no generally accepted criteria for the etiologic classification of intracerebral hemorrhage (ICH). For this reason, we have developed a set of etiologic criteria and have applied them to a large number of patients to determine their utility. METHODS The H-ATOMIC classification includes 7 etiologic categories: Hypertension, cerebral Amyloid angiopathy, Tumour, Oral anticoagulants, vascular Malformation, Infrequent causes and Cryptogenic. For each category, the etiology is scored with three degrees of certainty: Possible(3), Probable(2) and Definite(1). Our aim was to perform a basic study consisting of neuroimaging, blood tests, and CT-angio when a numerical score (SICH) suggested an underlying structural abnormality. Combinations of >1 etiologic category for an individual patient were acceptable. The criteria were evaluated in a multicenter and prospective study of consecutive patients with spontaneous ICH. RESULTS Our study included 439 patients (age 70.8 ± 14.5 years; 61.3% were men). A definite etiology was achieved in 176 (40.1% of the patients: Hypertension 28.2%, cerebral Amyloid angiopathy 0.2%, Tumour 0.2%, Oral anticoagulants 2.2%, vascular Malformation 4.5%, Infrequent causes 4.5%). A total of 7 patients (1.6%) were cryptogenic. In the remaining 58.3% of the patients, ICH was attributable to a single (n = 56, 12.7%) or the combination of ≥2 (n = 200, 45.5%) possible/probable etiologies. The most frequent combinations of etiologies involved possible hypertension with possible CAA (H3A3, n = 38) or with probable CAA (H3A2, n = 29), and probable hypertension with probable OA (H2O2, n = 27). The most frequent category with any degree of certainty was hypertension (H1+2+3 = 80.6%) followed by cerebral amyloid angiopathy (A1+2+3 = 30.9%). CONCLUSIONS According to our etiologic criteria, only about 40% patients received a definite diagnosis, while in the remaining patients ICH was attributable to a single possible/probable etiology or to more than one possible/probable etiology. The use of these criteria would likely help in the management of patients with ICH.
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Zamroziewicz MK, Barbey AK. Nutritional Cognitive Neuroscience: Innovations for Healthy Brain Aging. Front Neurosci 2016; 10:240. [PMID: 27375409 PMCID: PMC4893495 DOI: 10.3389/fnins.2016.00240] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 05/17/2016] [Indexed: 11/29/2022] Open
Abstract
Nutritional cognitive neuroscience is an emerging interdisciplinary field of research that seeks to understand nutrition's impact on cognition and brain health across the life span. Research in this burgeoning field demonstrates that many aspects of nutrition—from entire diets to specific nutrients—affect brain structure and function, and therefore have profound implications for understanding the nature of healthy brain aging. The aim of this Focused Review is to examine recent advances in nutritional cognitive neuroscience, with an emphasis on methods that enable discovery of nutrient biomarkers that predict healthy brain aging. We propose an integrative framework that calls for the synthesis of research in nutritional epidemiology and cognitive neuroscience, incorporating: (i) methods for the precise characterization of nutritional health based on the analysis of nutrient biomarker patterns (NBPs), along with (ii) modern indices of brain health derived from high-resolution magnetic resonance imaging (MRI). By integrating cutting-edge techniques from nutritional epidemiology and cognitive neuroscience, nutritional cognitive neuroscience will continue to advance our understanding of the beneficial effects of nutrition on the aging brain and establish effective nutritional interventions to promote healthy brain aging.
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Affiliation(s)
- Marta K Zamroziewicz
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-ChampaignUrbana, IL, USA; Neuroscience Program, University of Illinois at Urbana-ChampaignChampaign, IL, USA
| | - Aron K Barbey
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-ChampaignUrbana, IL, USA; Neuroscience Program, University of Illinois at Urbana-ChampaignChampaign, IL, USA; Carle R. Woese Institute for Genomic Biology, University of Illinois at Urbana-ChampaignChampaign, IL, USA; Department of Bioengineering, University of Illinois at Urbana-ChampaignChampaign, IL, USA; Department of Internal Medicine, University of Illinois at Urbana-ChampaignChampaign, IL, USA; Department of Psychology, University of Illinois at Urbana-ChampaignChampaign, IL, USA; Department of Speech and Hearing Science, University of Illinois at Urbana-ChampaignChampaign, IL, USA
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Curcumin reduces brain-infiltrating T lymphocytes after intracerebral hemorrhage in mice. Neurosci Lett 2016; 620:74-82. [DOI: 10.1016/j.neulet.2016.03.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 03/22/2016] [Accepted: 03/25/2016] [Indexed: 11/19/2022]
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Rannikmäe K, Woodfield R, Anderson CS, Charidimou A, Chiewvit P, Greenberg SM, Jeng JS, Meretoja A, Palm F, Putaala J, Rinkel GJ, Rosand J, Rost NS, Strbian D, Tatlisumak T, Tsai CF, Wermer MJ, Werring D, Yeh SJ, Al-Shahi Salman R, Sudlow CL. Reliability of intracerebral hemorrhage classification systems: A systematic review. Int J Stroke 2016; 11:626-36. [PMID: 27091144 DOI: 10.1177/1747493016641962] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/04/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Accurately distinguishing non-traumatic intracerebral hemorrhage (ICH) subtypes is important since they may have different risk factors, causal pathways, management, and prognosis. We systematically assessed the inter- and intra-rater reliability of ICH classification systems. METHODS We sought all available reliability assessments of anatomical and mechanistic ICH classification systems from electronic databases and personal contacts until October 2014. We assessed included studies' characteristics, reporting quality and potential for bias; summarized reliability with kappa value forest plots; and performed meta-analyses of the proportion of cases classified into each subtype. SUMMARY OF REVIEW We included 8 of 2152 studies identified. Inter- and intra-rater reliabilities were substantial to perfect for anatomical and mechanistic systems (inter-rater kappa values: anatomical 0.78-0.97 [six studies, 518 cases], mechanistic 0.89-0.93 [three studies, 510 cases]; intra-rater kappas: anatomical 0.80-1 [three studies, 137 cases], mechanistic 0.92-0.93 [two studies, 368 cases]). Reporting quality varied but no study fulfilled all criteria and none was free from potential bias. All reliability studies were performed with experienced raters in specialist centers. Proportions of ICH subtypes were largely consistent with previous reports suggesting that included studies are appropriately representative. CONCLUSIONS Reliability of existing classification systems appears excellent but is unknown outside specialist centers with experienced raters. Future reliability comparisons should be facilitated by studies following recently published reporting guidelines.
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Affiliation(s)
| | | | - Craig S Anderson
- The George Institute for Global Health, Royal Prince Alfred Hospital and the University of Sydney, Australia
| | - Andreas Charidimou
- Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, UK
| | - Pipat Chiewvit
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand
| | | | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Atte Meretoja
- Department of Neurology, Helsinki University Central Hospital, Finland Departments of Medicine and the Florey, Royal Melbourne Hospital, University of Melbourne, Australia
| | - Frederic Palm
- Department of Neurology, Städtisches Klinikum Ludwigshafen, Germany
| | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital, Finland
| | - Gabriel Je Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, USA Center for Human Genetic Research, Massachusetts General Hospital, USA Program in Medical and Population Genetics, Broad Institute, USA
| | - Natalia S Rost
- Center for Human Genetic Research, Massachusetts General Hospital, USA
| | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Finland Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden Department of Neurology, Sahlgrenska University Hospital, Sweden
| | - Chung-Fen Tsai
- Department of Neurology, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, Taiwan
| | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center, The Netherlands
| | - David Werring
- Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, UK
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taiwan
| | | | - Cathie Lm Sudlow
- Centre for Clinical Brain Sciences, University of Edinburgh, UK Institute for Genetics and Molecular Medicine, University of Edinburgh, UK UK Biobank, UK
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Yang Z, Liu B, Zhong L, Shen H, Lin C, Lin L, Zhang N, Yuan B. Toll-like receptor-4-mediated autophagy contributes to microglial activation and inflammatory injury in mouse models of intracerebral haemorrhage. Neuropathol Appl Neurobiol 2016; 41:e95-106. [PMID: 25185720 DOI: 10.1111/nan.12177] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 08/08/2014] [Indexed: 01/09/2023]
Abstract
AIMS Much evidence demonstrates that Toll-like receptor-4 (TLR4)-mediated microglial activation is an important contributor to the inflammatory injury in intracerebral haemorrhage (ICH). However, the exact mechanism of TLR4-mediated microglial activation induced by ICH is not clear. In addition, microglial autophagy is involved other forms of nervous system injury. To explore the relationship between TLR4 and autophagy, we investigated the role of TLR4-mediated microglial autophagy and inflammation in ICH. METHODS We detected TLR4 expression, autophagy and inflammation of microglia treated with lysed erythrocytes in vitro, and observed the cerebral water content and neurological deficit of ICH mice [TLR4-/- and wild type (WT)] in vivo. RESULTS We found that lysed erythrocyte treated microglia (TLR4-/-) had reduced autophagy and inflammation compared with microglia (WT) in vitro. ICH mice (TLR4-/-) had reduced water content and neurological injury compared with ICH mice (WT). The autophagy inhibitor (3-methyladenine) decreased microglial activation and inflammatory injury due to lysed erythrocyte treatment, and improved the neurological function of ICH mice. CONCLUSIONS Taken together, these data suggested that TLR4 induced autophagy contributed to the microglial activation and inflammatory injury and might provide novel therapeutic interventions for ICH.
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Affiliation(s)
- Zhao Yang
- Department of Neurology, Yongchuan Hospital, Chongqing Medical University, Chongqing
| | - B Liu
- Department of Neurology, Yongchuan Hospital, Chongqing Medical University, Chongqing
| | - L Zhong
- Department of Neurology, Yongchuan Hospital, Chongqing Medical University, Chongqing
| | - Hanchao Shen
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian
| | - Chuangan Lin
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian
| | - Li Lin
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian
| | - Nan Zhang
- Department of Urology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bangqing Yuan
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian
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Domingues R, Rossi C, Cordonnier C. Diagnostic evaluation for nontraumatic intracerebral hemorrhage. Neurol Clin 2016; 33:315-28. [PMID: 25907908 DOI: 10.1016/j.ncl.2014.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating condition with multiple possible underlying causes. Early diagnosis of ICH associated with a precise diagnostic work-up is mandatory. Clinical signs may give clues to diagnosis but are not reliable enough and imaging remains the cornerstone of management. Noncontrast computed tomography and magnetic resonance imaging (MRI) are highly sensitive for ICH identification. Additionally, MRI may disclose brain parenchymal biomarkers that can contribute to the etiologic diagnosis. Vessel examination should be carried out whenever there is a clinical suspicion of underlying structural lesions, such as vascular malformations or tumors. To date, conventional angiography remains the gold standard to detect intracranial vascular malformations in patients with ICH.
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Affiliation(s)
- Renan Domingues
- Department of Neurology, University of Lille, UDSL, CHU Lille, Inserm U 1171, Lille 59000, France; CAPES Foundation, Ministry of Education, Quadra 2, Bloco L, Lote 06, Edifício Capes - CEP: 70.040-020 - Brasilia-DF, Brazil
| | - Costanza Rossi
- Department of Neurology, University of Lille, UDSL, CHU Lille, Inserm U 1171, Lille 59000, France
| | - Charlotte Cordonnier
- Department of Neurology, University of Lille, UDSL, CHU Lille, Inserm U 1171, Lille 59000, France.
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36
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van Asch CJJ, Velthuis BK, Rinkel GJE, Algra A, de Kort GAP, Witkamp TD, de Ridder JCM, van Nieuwenhuizen KM, de Leeuw FE, Schonewille WJ, de Kort PLM, Dippel DW, Raaymakers TWM, Hofmeijer J, Wermer MJH, Kerkhoff H, Jellema K, Bronner IM, Remmers MJM, Bienfait HP, Witjes RJGM, Greving JP, Klijn CJM. Diagnostic yield and accuracy of CT angiography, MR angiography, and digital subtraction angiography for detection of macrovascular causes of intracerebral haemorrhage: prospective, multicentre cohort study. BMJ 2015; 351:h5762. [PMID: 26553142 PMCID: PMC4637845 DOI: 10.1136/bmj.h5762] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2015] [Indexed: 11/29/2022]
Abstract
STUDY QUESTION What are the diagnostic yield and accuracy of early computed tomography (CT) angiography followed by magnetic resonance imaging/angiography (MRI/MRA) and digital subtraction angiography (DSA) in patients with non-traumatic intracerebral haemorrhage? METHODS This prospective diagnostic study enrolled 298 adults (18-70 years) treated in 22 hospitals in the Netherlands over six years. CT angiography was performed within seven days of haemorrhage. If the result was negative, MRI/MRA was performed four to eight weeks later. DSA was performed when the CT angiography or MRI/MRA results were inconclusive or negative. The main outcome was a macrovascular cause, including arteriovenous malformation, aneurysm, dural arteriovenous fistula, and cavernoma. Three blinded neuroradiologists independently evaluated the images for macrovascular causes of haemorrhage. The reference standard was the best available evidence from all findings during one year's follow-up. STUDY ANSWER AND LIMITATIONS A macrovascular cause was identified in 69 patients (23%). 291 patients (98%) underwent CT angiography; 214 with a negative result underwent additional MRI/MRA and 97 with a negative result for both CT angiography and MRI/MRA underwent DSA. Early CT angiography detected 51 macrovascular causes (yield 17%, 95% confidence interval 13% to 22%). CT angiography with MRI/MRA identified two additional macrovascular causes (18%, 14% to 23%) and these modalities combined with DSA another 15 (23%, 18% to 28%). This last extensive strategy failed to detect a cavernoma, which was identified on MRI during follow-up (reference strategy). The positive predictive value of CT angiography was 72% (60% to 82%), of additional MRI/MRA was 35% (14% to 62%), and of additional DSA was 100% (75% to 100%). None of the patients experienced complications with CT angiography or MRI/MRA; 0.6% of patients who underwent DSA experienced permanent sequelae. Not all patients with negative CT angiography and MRI/MRA results underwent DSA. Although the previous probability of finding a macrovascular cause was lower in patients who did not undergo DSA, some small arteriovenous malformations or dural arteriovenous fistulas may have been missed. WHAT THIS STUDY ADDS CT angiography is an appropriate initial investigation to detect macrovascular causes of non-traumatic intracerebral haemorrhage, but accuracy is modest. Additional MRI/MRA may find cavernomas or alternative diagnoses, but DSA is needed to diagnose macrovascular causes undetected by CT angiography or MRI/MRA. FUNDING, COMPETING INTERESTS, DATA SHARING Dutch Heart Foundation and The Netherlands Organisation for Health Research and Development, ZonMw. The authors have no competing interests. Direct requests for additional data to the corresponding author.
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Affiliation(s)
- Charlotte J J van Asch
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gabriël J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gérard A P de Kort
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Theo D Witkamp
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Johanna C M de Ridder
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Paul L M de Kort
- Department of Neurology, St Elisabeth Hospital, Tilburg, Netherlands
| | - Diederik W Dippel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | | | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Korné Jellema
- Department of Neurology, MCH Westeinde, The Hague, Netherlands
| | - Irene M Bronner
- Department of Neurology, Flevo Hospital, Almere, Netherlands
| | | | | | - Ron J G M Witjes
- Department of Neurology, Tergooi Hospitals, Blaricum, Netherlands
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
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Outcome after intracranial haemorrhage from dural arteriovenous fistulae; a systematic review and case-series. J Neurol 2015; 262:2678-83. [PMID: 26410748 PMCID: PMC4655013 DOI: 10.1007/s00415-015-7898-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/03/2015] [Accepted: 09/04/2015] [Indexed: 12/14/2022]
Abstract
Dural arteriovenous fistulae (DAVFs) are a rare cause of intracranial haemorrhage. We aimed to investigate outcome of patients with intracranial haemorrhage from a DAVF. We performed a systematic literature search for studies reporting outcome after intracranial haemorrhage caused by a DAVF. We used predefined selection criteria and assessed the quality of the studies. In addition, we studied outcome in all patients with DAVF who had presented with intracranial haemorrhage at two university centers in the Netherlands, between January 2007 and April 2012. We calculated case fatality and proportions of patients with poor outcome (defined as modified Rankin Scale ≥ 3 or Glasgow Outcome Scale ≤ 3) during follow-up. We investigated mean age, sex, mid-year of study and percentage of patients with parenchymal haemorrhage as determinants of case fatality and poor outcome. The literature search yielded 16 studies, all but two retrospective and all hospital-based. Combined with our cohort of 29 patients the total number of patients with DAVF-related intracranial haemorrhage was 326 (58 % intracerebral haemorrhage). At a median follow-up of 12 months case fatality was 4.7 % (95 % CI 2.5–7.5; 17 cohorts) and the proportion of patients with poor outcome 8.3 % (95 % CI 3.1–15.7; nine cohorts). We found no effect of mean age, sex, mid-year of the cohorts and percentage of patients with parenchymal haemorrhage on either outcome. Hospital based case-series suggest a relatively low risk of death and poor outcome in patients with intracranial haemorrhage due to rupture of a DAVF. These risks may be underestimated because of bias.
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Samarasekera N, Lerpiniere C, Fonville AF, Farrall AJ, Wardlaw JM, White PM, Torgersen A, Ironside JW, Smith C, Al-Shahi Salman R. Consent for Brain Tissue Donation after Intracerebral Haemorrhage: A Community-Based Study. PLoS One 2015; 10:e0135043. [PMID: 26302447 PMCID: PMC4547774 DOI: 10.1371/journal.pone.0135043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/17/2015] [Indexed: 11/18/2022] Open
Abstract
Background Spontaneous intracerebral haemorrhage is a devastating form of stroke and its incidence increases with age. Obtaining brain tissue following intracerebral haemorrhage helps to understand its cause. Given declining autopsy rates worldwide, the feasibility of establishing an autopsy-based collection and its generalisability are uncertain. Methods We used multiple overlapping sources of case ascertainment to identify every adult diagnosed with intracerebral haemorrhage between 1st June 2010-31st May 2012, whilst resident in the Lothian region of Scotland. We sought consent from patients with intracerebral haemorrhage (or their nearest relative if the patient lacked mental capacity) to conduct a research autopsy. Results Of 295 adults with acute intracerebral haemorrhage, 110 (37%) could not be approached to consider donation. Of 185 adults/relatives approached, 91 (49%) consented to research autopsy. There were no differences in baseline demographic variables or markers of intracerebral haemorrhage severity between consenters and non-consenters. Adults who died and became donors (n = 46) differed from the rest of the cohort (n = 249) by being older (median age 80, IQR 76–86 vs. 75, IQR 65–83, p = 0.002) and having larger haemorrhages (median volume 23ml, IQR 13–50 vs. 13ml, IQR 4–40; p = 0.002). Conclusions Nearly half of those approached consent to brain tissue donation after acute intracerebral haemorrhage. The characteristics of adults who gave consent were comparable to those in an entire community, although those who donate early are older and have larger haemorrhage volumes.
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Affiliation(s)
- Neshika Samarasekera
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Christine Lerpiniere
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Arthur F. Fonville
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrew J. Farrall
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Brain Research Imaging Centre, University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna M. Wardlaw
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Brain Research Imaging Centre, University of Edinburgh, Edinburgh, United Kingdom
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, United Kingdom
| | - Philip M. White
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Antonia Torgersen
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - James W. Ironside
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Colin Smith
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- * E-mail:
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Abstract
Imaging of acute neurologic disease in the emergency department can be challenging because of the wide range of possible causes and the overlapping imaging appearance of many of these entities on nonenhanced computed tomography (CT). The key to formulating a succinct, pertinent differential diagnosis includes characterizing the pattern of abnormalities on CT and identifying key features that suggest a particular diagnosis. This article divides neurologic emergencies into 5 scenarios based on the CT findings, including subarachnoid hemorrhage, intraparenchymal hemorrhage, vasogenic edema without and with underlying mass lesion, and acute hydrocephalus. Specific common or important diagnoses in each category are discussed.
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Affiliation(s)
- Kathleen R Fink
- Department of Radiology, University of Washington, Box 359728, 325 9th Avenue, Seattle, WA 98104, USA.
| | - Jayson L Benjert
- Department of Radiology, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA
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Enhanced Neuroprotection of Minimally Invasive Surgery Joint Local Cooling Lavage against ICH-induced Inflammation Injury and Apoptosis in Rats. Cell Mol Neurobiol 2015. [DOI: 10.1007/s10571-015-0245-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Laible M, Horstmann S, Möhlenbruch M, Wegele C, Rizos T, Schüler S, Zorn M, Veltkamp R. Renal dysfunction is associated with deep cerebral microbleeds but not white matter hyperintensities in patients with acute intracerebral hemorrhage. J Neurol 2015; 262:2312-22. [PMID: 26174652 DOI: 10.1007/s00415-015-7840-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/29/2015] [Accepted: 06/29/2015] [Indexed: 01/28/2023]
Abstract
Kidney disease is a risk factor for cerebral microangiopathy and spontaneous intracerebral hemorrhage (ICH). We aimed to determine the association of renal dysfunction (RD) with MRI correlates of different patterns of cerebral microangiopathies including cerebral microbleeds (CMB) and white matter lesions (WML) in patients with ICH. In a prospectively collected, single-center cohort of ICH patients, glomerular filtration rate (eGFR) was estimated using the Modification of Diet in Renal Disease equation. We classified the renal function in five categories: category 1 (eGFR ≥ 90 mL/min/1.73 m(2)), category 2 (eGFR 60-89), category 3 (eGFR 30-59), category 4 (eGFR 15-29), and category 5 (eGFR <15) and dichotomized at an eGFR of 60. Number, location, and extent of CMB and WML were measured on MRI. ICH and CMB locations were classified as lobar or deep. 97 ICH patients with MRI (mean age 65.9 ± 13.9 years) were included. Intracerebral hemorrhage was lobar in 52.6 %. Median eGFR was 85.8 mL/min/1.73 m(2) (IQR 34.3). Renal dysfunction was present in 12.4 % of the patients. At least one CMB was present in 57.7 % of patients, WML were even more frequent (97.7 %). Age and impaired renal function were factors independently associated with the presence of CMB. The presence of CMB was independently associated with the number and extent of WML. RD is a frequent comorbidity in patients with ICH. Associations of RD with hypertension and with CMB in deep location suggest a predominant impact of RD on deep rather than on lobar microangiopathy.
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Affiliation(s)
- Mona Laible
- Department of Neurology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany.
| | - Solveig Horstmann
- Department of Neurology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Christian Wegele
- Department of Neurology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Svenja Schüler
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Markus Zorn
- Department of Internal Medicine-I, University of Heidelberg, Heidelberg, Germany
| | - Roland Veltkamp
- Department of Neurology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
- Department of Stroke Medicine, Imperial College London, London, UK
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Samarasekera N, Fonville A, Lerpiniere C, Farrall AJ, Wardlaw JM, White PM, Smith C, Al-Shahi Salman R. Influence of intracerebral hemorrhage location on incidence, characteristics, and outcome: population-based study. Stroke 2015; 46:361-8. [PMID: 25586833 DOI: 10.1161/strokeaha.114.007953] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The characteristics of intracerebral hemorrhage (ICH) may vary by ICH location because of differences in the distribution of underlying cerebral small vessel diseases. Therefore, we investigated the incidence, characteristics, and outcome of lobar and nonlobar ICH. METHODS In a population-based, prospective inception cohort study of ICH, we used multiple overlapping sources of case ascertainment and follow-up to identify and validate ICH diagnoses in 2010 to 2011 in an adult population of 695 335. RESULTS There were 128 participants with first-ever primary ICH. The overall incidence of lobar ICH was similar to nonlobar ICH (9.8 [95% confidence interval, 7.7-12.4] versus 8.6 [95% confidence interval, 6.7-11.1] per 100 000 adults/y). At baseline, adults with lobar ICH were more likely to have preceding dementia (21% versus 5%; P=0.01), lower Glasgow Coma Scale scores (median, 13 versus 14; P=0.03), larger ICHs (median, 38 versus 11 mL; P<0.001), subarachnoid extension (57% versus 5%; P<0.001), and subdural extension (15% versus 3%; P=0.02) than those with nonlobar ICH. One-year case fatality was lower after lobar ICH than after nonlobar ICH (adjusted odds ratio for death at 1 year: lobar versus nonlobar ICH 0.21; 95% confidence interval, 0.07-0.63; P=0.006, after adjustment for known predictors of outcome). There were 4 recurrent ICHs, which occurred exclusively in survivors of lobar ICH (annual risk of recurrent ICH after lobar ICH, 11.8%; 95% confidence interval, 4.6%-28.5% versus 0% after nonlobar ICH; log-rank P=0.04). CONCLUSIONS The baseline characteristics and outcome of lobar ICH differ from other locations.
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Affiliation(s)
- Neshika Samarasekera
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (N.S., A.F., C.L., A.J.F., J.M.W., C.S., R.A.-S.S.), Brain Research Imaging Centre (A.J.F., J.M.W.), and Centre for Cognitive Ageing and Cognitive Epidemiology (J.M.W.), University of Edinburgh, Edinburgh, United Kingdom; and Newcastle University Institute for Ageing and Health, Newcastle upon Tyne, United Kingdom (P.M.W.)
| | - Arthur Fonville
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (N.S., A.F., C.L., A.J.F., J.M.W., C.S., R.A.-S.S.), Brain Research Imaging Centre (A.J.F., J.M.W.), and Centre for Cognitive Ageing and Cognitive Epidemiology (J.M.W.), University of Edinburgh, Edinburgh, United Kingdom; and Newcastle University Institute for Ageing and Health, Newcastle upon Tyne, United Kingdom (P.M.W.)
| | - Christine Lerpiniere
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (N.S., A.F., C.L., A.J.F., J.M.W., C.S., R.A.-S.S.), Brain Research Imaging Centre (A.J.F., J.M.W.), and Centre for Cognitive Ageing and Cognitive Epidemiology (J.M.W.), University of Edinburgh, Edinburgh, United Kingdom; and Newcastle University Institute for Ageing and Health, Newcastle upon Tyne, United Kingdom (P.M.W.)
| | - Andrew J Farrall
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (N.S., A.F., C.L., A.J.F., J.M.W., C.S., R.A.-S.S.), Brain Research Imaging Centre (A.J.F., J.M.W.), and Centre for Cognitive Ageing and Cognitive Epidemiology (J.M.W.), University of Edinburgh, Edinburgh, United Kingdom; and Newcastle University Institute for Ageing and Health, Newcastle upon Tyne, United Kingdom (P.M.W.)
| | - Joanna M Wardlaw
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (N.S., A.F., C.L., A.J.F., J.M.W., C.S., R.A.-S.S.), Brain Research Imaging Centre (A.J.F., J.M.W.), and Centre for Cognitive Ageing and Cognitive Epidemiology (J.M.W.), University of Edinburgh, Edinburgh, United Kingdom; and Newcastle University Institute for Ageing and Health, Newcastle upon Tyne, United Kingdom (P.M.W.)
| | - Philip M White
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (N.S., A.F., C.L., A.J.F., J.M.W., C.S., R.A.-S.S.), Brain Research Imaging Centre (A.J.F., J.M.W.), and Centre for Cognitive Ageing and Cognitive Epidemiology (J.M.W.), University of Edinburgh, Edinburgh, United Kingdom; and Newcastle University Institute for Ageing and Health, Newcastle upon Tyne, United Kingdom (P.M.W.)
| | - Colin Smith
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (N.S., A.F., C.L., A.J.F., J.M.W., C.S., R.A.-S.S.), Brain Research Imaging Centre (A.J.F., J.M.W.), and Centre for Cognitive Ageing and Cognitive Epidemiology (J.M.W.), University of Edinburgh, Edinburgh, United Kingdom; and Newcastle University Institute for Ageing and Health, Newcastle upon Tyne, United Kingdom (P.M.W.)
| | - Rustam Al-Shahi Salman
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (N.S., A.F., C.L., A.J.F., J.M.W., C.S., R.A.-S.S.), Brain Research Imaging Centre (A.J.F., J.M.W.), and Centre for Cognitive Ageing and Cognitive Epidemiology (J.M.W.), University of Edinburgh, Edinburgh, United Kingdom; and Newcastle University Institute for Ageing and Health, Newcastle upon Tyne, United Kingdom (P.M.W.).
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Lockhart SN, DeCarli C. Structural imaging measures of brain aging. Neuropsychol Rev 2014; 24:271-89. [PMID: 25146995 PMCID: PMC4163469 DOI: 10.1007/s11065-014-9268-3] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 08/05/2014] [Indexed: 01/18/2023]
Abstract
During the course of normal aging, biological changes occur in the brain that are associated with changes in cognitive ability. This review presents data from neuroimaging studies of primarily "normal" or healthy brain aging. As such, we focus on research in unimpaired or nondemented older adults, but also include findings from lifespan studies that include younger and middle aged individuals as well as from populations with prodromal or clinically symptomatic disease such as cerebrovascular or Alzheimer's disease. This review predominantly addresses structural MRI biomarkers, such as volumetric or thickness measures from anatomical images, and measures of white matter injury and integrity respectively from FLAIR or DTI, and includes complementary data from PET and cognitive or clinical testing as appropriate. The findings reveal highly consistent age-related differences in brain structure, particularly frontal lobe and medial temporal regions that are also accompanied by age-related differences in frontal and medial temporal lobe mediated cognitive abilities. Newer findings also suggest that degeneration of specific white matter tracts such as those passing through the genu and splenium of the corpus callosum may also be related to age-related differences in cognitive performance. Interpretation of these findings, however, must be tempered by the fact that comorbid diseases such as cerebrovascular and Alzheimer's disease also increase in prevalence with advancing age. As such, this review discusses challenges related to interpretation of current theories of cognitive aging in light of the common occurrence of these later-life diseases. Understanding the differences between "Normal" and "Healthy" brain aging and identifying potential modifiable risk factors for brain aging is critical to inform potential treatments to stall or reverse the effects of brain aging and possibly extend cognitive health for our aging society.
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Affiliation(s)
- Samuel N. Lockhart
- Department of Neurology and Center for Neuroscience, University of California at Davis, Sacramento, CA, USA
| | - Charles DeCarli
- Department of Neurology and Center for Neuroscience, University of California at Davis, Sacramento, CA, USA
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Josephson CB, White PM, Krishan A, Al‐Shahi Salman R. Computed tomography angiography or magnetic resonance angiography for detection of intracranial vascular malformations in patients with intracerebral haemorrhage. Cochrane Database Syst Rev 2014; 2014:CD009372. [PMID: 25177839 PMCID: PMC6544803 DOI: 10.1002/14651858.cd009372.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Intracranial vascular malformations (brain or pial/dural arteriovenous malformations/fistulae, and aneurysms) are the leading cause of intracerebral haemorrhage (ICH) in young adults. Early identification of the intracranial vascular malformation may improve outcome if treatment can prevent ICH recurrence. Catheter intra-arterial digital subtraction angiography (IADSA) is considered the reference standard for the detection an intracranial vascular malformation as the cause of ICH. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are less invasive than IADSA and may be as accurate for identifying some causes of ICH. OBJECTIVES To evaluate the diagnostic test accuracy of CTA and MRA versus IADSA for the detection of intracranial vascular malformations as a cause of ICH. SEARCH METHODS We searched MEDLINE (1948 to August 2013), EMBASE (1980 to August 2013), MEDION (August 2013), the Database of Abstracts of Reviews of Effects (DARE; August 2013), the Health Technology Assessment Database (HTA; August 2013), ClinicalTrials.gov (August 2013), and WHO ICTRP (International Clinical Trials Register Portfolio; August 2013). We also performed a cited reference search for forward tracking of relevant articles on Google Scholar (http://scholar.google.com/), screened bibliographies, and contacted authors to identify additional studies. SELECTION CRITERIA We selected studies reporting data that could be used to construct contingency tables that compared CTA or MRA, or both, with IADSA in the same patients for the detection of intracranial vascular malformations following ICH. DATA COLLECTION AND ANALYSIS Two authors (CBJ and RA-SS) independently extracted data on study characteristics and measures of test accuracy. Two authors (CBJ and PMW) independently extracted data on test characteristics. We obtained data restricted to the subgroup undergoing IADSA in studies using multiple reference standards. We combined data using the bivariate model. We generated forest plots of the sensitivity and specificity of CTA and MRA and created a summary receiver operating characteristic plot. MAIN RESULTS Eleven studies (n = 927 participants) met our inclusion criteria. Eight studies compared CTA with IADSA (n = 526) and three studies compared MRA with IADSA (n = 401). Methodological quality varied considerably among studies, with partial verification bias in 7/11 (64%) and retrospective designs in 5/10 (50%). In studies of CTA, the pooled estimate of sensitivity was 0.95 (95% confidence interval (CI) 0.90 to 0.97) and specificity was 0.99 (95% CI 0.95 to 1.00). The results remained robust in a sensitivity analysis in which only studies evaluating adult patients (≥ 16 years of age) were included. In studies of MRA, the pooled estimate of sensitivity was 0.98 (95% CI 0.80 to 1.00) and specificity was 0.99 (95% CI 0.97 to 1.00). An indirect comparison of CTA and MRA using a bivariate model incorporating test type as one of the parameters failed to reveal a statistically significant difference in sensitivity or specificity between the two imaging modalities (P value = 0.6). AUTHORS' CONCLUSIONS CTA and MRA appear to have good sensitivity and specificity following ICH for the detection of intracranial vascular malformations, although several of the included studies had methodological shortcomings (retrospective designs and partial verification bias in particular) that may have increased apparent test accuracy.
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Affiliation(s)
- Colin B Josephson
- University of CalgaryDepartment of Clinical Neurosciences12th Floor, Foothills Medical Centre1403‐29 Street NWCalgaryABCanadaT2N 2T9
- University of EdinburghDivision of Clinical NeurosciencesEdinburghUK
| | - Philip M White
- Newcastle UniversityInstitute for Ageing and Health3‐4 Claremont TerraceNewcastle Upon TyneUKNE2 4AE
| | - Ashma Krishan
- University of EdinburghEdinburgh Clinical Trials UnitOutpatients Building, 2nd FloorWestern General Hospital, Crewe Road SouthEdinburghUKEH4 2XU
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Olavarría VV, Bustamante G, López MJ, Lavados PM. Diagnostic accuracy of a simple clinical score to screen for vascular abnormalities in patients with intracerebral hemorrhage. J Stroke Cerebrovasc Dis 2014; 23:2069-2074. [PMID: 25106833 DOI: 10.1016/j.jstrokecerebrovasdis.2014.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 02/04/2014] [Accepted: 03/11/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Patients with intracerebral hemorrhage may have vascular abnormalities. There is no consensus about which patients should be studied with angiographic methods. Our aim was to derive a simple clinical score to screen for vascular abnormalities in intracerebral hemorrhage (ICH) and test its accuracy. METHODS The data were extracted from 2 different registries of patients with ICH. Variables associated with a vascular abnormality were studied in the derivation cohort. We derived a scale by assigning scores to the degree of association. We applied the score to the validation cohort and calculated sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios (LRs), receiver operating curves (ROC) and area under the curve (AUC). RESULTS The performance of the scale in the derivation cohort showed the maximum operating point (MOP) at ≥5 (sensitivity .77, specificity .5). In the validation cohort, the MOP was a cutoff point of ≥5 (sensitivity .76, specificity .467). The positive and negative LRs were 2.1 and .6, respectively. The ROC showed similar AUC for both cohorts: .7. The probability of a vascular malformation was 23% with scores ≤5 and 83% with scores ≥9 in the validation cohort. CONCLUSIONS This simple clinical score can be used immediately on diagnosing an ICH to decide accurately whether to perform an angiographic study or not. Further studies using this simple score should be used to validate it in larger prospective unselected cohorts and consecutive patients.
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Affiliation(s)
- Verónica V Olavarría
- Vascular Neurology and Stroke Unit, Neurology Service, Department of Medicine, Clínica Alemana de Santiago, Universidad del Desarrollo, Instituto de Neurociencias, Santiago, Chile; Department of Critical Care, Clínica Alemana de Santiago, Universidad del Desarrollo, Instituto de Neurociencias, Santiago, Chile
| | - Gonzalo Bustamante
- Department of Neurological Sciences, Universidad de Chile, Hospital del Salvador, Santiago, Chile
| | - Mirta Javiera López
- Vascular Neurology and Stroke Unit, Neurology Service, Department of Medicine, Clínica Alemana de Santiago, Universidad del Desarrollo, Instituto de Neurociencias, Santiago, Chile; Department of Critical Care, Clínica Alemana de Santiago, Universidad del Desarrollo, Instituto de Neurociencias, Santiago, Chile
| | - Pablo M Lavados
- Vascular Neurology and Stroke Unit, Neurology Service, Department of Medicine, Clínica Alemana de Santiago, Universidad del Desarrollo, Instituto de Neurociencias, Santiago, Chile; Department of Neurological Sciences, Universidad de Chile, Institute of Neurosurgery, Santiago, Chile.
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Yang Z, Yu A, Liu Y, Shen H, Lin C, Lin L, Wang S, Yuan B. Regulatory T cells inhibit microglia activation and protect against inflammatory injury in intracerebral hemorrhage. Int Immunopharmacol 2014; 22:522-5. [PMID: 25000335 DOI: 10.1016/j.intimp.2014.06.037] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 06/14/2014] [Accepted: 06/23/2014] [Indexed: 10/25/2022]
Abstract
Numerous evidence demonstrate that microglia mediated inflammatory injury plays a critical role in intracerebral hemorrhage (ICH). Therefore, the way to inhibit the inflammatory response is greatly needed. Treg cells have been shown to play a critical role in immunologic self-tolerance as well as anti-tumor immune responses and transplantation. In the current study, we transfered Treg cells in the ICH model, and investigated the effect. The cytokines of microglia were measured by ELISA, JNK/ERK and NF-κB were measured by Western blot and EMSA (Electrophoretic Mobility Shift Assay), animal behavior was evaluated by animal behavioristics. We found that Treg cells could inhibit microglia mediated inflammatory response through NF-κB activation via the JNK/ERK pathway in vitro, and improve neurological function in vivo. Our findings suggest that Treg cells could suppress inflammatory injury and represent a novel cell-based therapeutical strategy in ICH.
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Affiliation(s)
- Zhao Yang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Anyong Yu
- Department of Emergency, The First Affiliated Hospital of Zunyi Medical College, Guizhou 563003, China
| | - Yongping Liu
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China
| | - Hanchao Shen
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China
| | - Chuangan Lin
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China
| | - Li Lin
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China
| | - Shousen Wang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Bangqing Yuan
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China.
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Yang Z, Zhao T, Zou Y, Zhang JH, Feng H. Curcumin inhibits microglia inflammation and confers neuroprotection in intracerebral hemorrhage. Immunol Lett 2014; 160:89-95. [PMID: 24680995 DOI: 10.1016/j.imlet.2014.03.005] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 02/24/2014] [Accepted: 03/17/2014] [Indexed: 12/24/2022]
Abstract
Much evidence demonstrates that microglia mediated neuroinflammation is an important contributor to the inflammatory injury in intracerebral hemorrhage (ICH). Therefore, the compounds that can inhibit neuroinflammation are greatly needed. In the current study, we examined whether curcumin, present in a Chinese medicinal plant, could prevent ICH induced microglia activation and confer protection against neurotoxicity. The cytokines of microglia were measured by ELISA, p38MAPK/PKC and NF-κB were measured by Western blot and EMSA. Microglial toxicity was assessed using MTT and FACS assays. And neurological function was evaluated by animal behavioristics. We found that curcumin prevented ICH-induced inflammatory molecules through NF-κB activation via the p38MAPK/PKC pathway in vitro. In addition, curcumin protected hippocampal HT22 cells from indirect toxicity mediated by ICH-treated microglia cells. Further, curcumin also attenuated ICH-induced neurological deficit and cerebral water content in vivo. Together, our findings suggest that curcumin could suppress ICH induced inflammatory injury and represent a novel herbal sources for ICH therapeutical strategy.
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Affiliation(s)
- Zhao Yang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Tianzhi Zhao
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi Province, China
| | - Yongjie Zou
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - John H Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China.
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Affiliation(s)
- Federica Macellari
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Maurizio Paciaroni
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Valeria Caso
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
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Dye JA, Rees G, Yang I, Vespa PM, Martin NA, Vinters HV. Neuropathologic analysis of hematomas evacuated from patients with spontaneous intracerebral hemorrhage. Neuropathology 2013; 34:253-60. [PMID: 24354628 DOI: 10.1111/neup.12089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 11/08/2013] [Accepted: 11/09/2013] [Indexed: 01/01/2023]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is a devastating cause of morbidity and mortality. Intraparenchymal hematomas are often surgically evacuated. This generates fragments of perihematoma brain tissue that may elucidate their etiology. The goal of this study is to analyze the value of these specimens in providing a possible etiology for spontaneous ICH as well as the utility of using immunohistochemical markers to identify amyloid angiopathy. Surgically resected hematomas from 20 individuals with spontaneous ICH were examined with light microscopy. Hemorrhage locations included 11 lobar and nine basal ganglia hemorrhages. Aβ immunohistochemistry and Congo red stains were used to confirm the presence of amyloid angiopathy, when this was suspected. Evidence of cerebral amyloid angiopathy (CAA) was observed in eight of the 20 specimens, each of which came from lobar locations. Immunohistochemistry confirmed CAA in the brain fragments from these eight individuals. Patients with immunohistochemically confirmed CAA were older than patients without CAA, and more likely to have lobar hemorrhages (OR 3.0 and 3.7, respectively). Evidence of CAA was not found in any of the basal ganglia specimens. One specimen showed evidence of CAA-associated angiitis, with formation of a microaneurysm in an inflamed segment of a CAA-affected arteriole, surrounded by acute hemorrhage. In another specimen, Aβ immunohistochemistry showed the presence of senile plaques suggesting concomitant Alzheimer's disease (AD) changes. Surgically evacuated hematomas from patients with spontaneous ICH should be carefully examined, paying special attention to any fragments of included brain parenchyma. These fragments can provide evidence of the etiology of the hemorrhage. Markers such as Aβ 1-40 can help to identify underlying CAA, and should be utilized when microangiopathy is suspected. Given the association of (Aβ) CAA with AD, careful examination of entrapped brain fragments may also provide evidence of AD in a given patient.
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Affiliation(s)
- Justin A Dye
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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Abid KA, Vail A, Patel HC, King AT, Tyrrell PJ, Parry-Jones AR. Which factors influence decisions to transfer and treat patients with acute intracerebral haemorrhage and which are associated with prognosis? A retrospective cohort study. BMJ Open 2013; 3:e003684. [PMID: 24345898 PMCID: PMC3884585 DOI: 10.1136/bmjopen-2013-003684] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To identify factors associated with the decision to transfer and/or operate on patients with intracerebral haemorrhage (ICH) at a UK regional neurosurgical centre and test whether these decisions were associated with patient survival. DESIGN Retrospective cohort study. SETTING 14 acute and specialist hospitals served by the neurosurgical unit at Salford Royal NHS Foundation Trust, Salford, UK. PARTICIPANTS All patients referred acutely to neurosurgery from January 2008 to October 2010. OUTCOME MEASURES Primary outcome was survival and secondary outcomes were transfer to the neurosurgical centre and acute neurosurgery. RESULTS We obtained clinical data from 1364 consecutive spontaneous patients with ICH and 1175 cases were included in the final analysis. 140 (12%) patients were transferred and 75 (6%) had surgery. In a multifactorial analysis, the decision to transfer was more likely with younger age, women, brainstem and cerebellar location and larger haematomas. Risk of death in the following year was higher with advancing age, lower Glasgow Coma Scale, larger haematomas, brainstem ICH and intraventricular haemorrhage. The transferred patients had a lower risk of death relative to those remaining at the referring centre whether they had surgery (HR 0.46, 95% CI 0.32 to 0.67) or not (HR 0.41, 95% CI 0.22 to 0.73). Acute management decisions were included in the regression model for the 227 patients under either stroke medicine or neurosurgery at the neurosurgical centre and early do-not-resuscitate orders accounted for much of the observed difference, independently associated with an increased risk of death (HR 4.8, 95% CI 2.7 to 8.6). CONCLUSIONS The clear association between transfer to a specialist centre and survival, independent of established prognostic factors, suggests aggressive supportive care at a specialist centre may improve survival in ICH and warrants further investigation in prospective studies.
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Affiliation(s)
- Kamran A Abid
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, UK
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