1
|
Ali M, Ascanio LC, Smith C, Odland I, Murtaza-Ali M, Vasan V, Downes M, Schuldt BR, Lin A, Dullea J, Schupper AJ, Hardigan T, Asghar N, Mocco J, Kellner CP. Early and effective intracerebral hemorrhage evacuation is associated with a lower 1-year residual cavity volume and better functional outcomes. J Neurointerv Surg 2024; 16:994-1004. [PMID: 37620128 DOI: 10.1136/jnis-2023-020787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND We explored the clinical significance of the residual hematoma cavity 1 year after minimally invasive intracerebral hemorrhage (ICH) evacuation. METHODS Patients presenting with spontaneous supratentorial ICH were evaluated for minimally invasive surgical evacuation. Inclusion criteria included age ≥18 years, preoperative hematoma volume (Hv) ≥15 mL, presenting National Institutes of Health Stroke Scale score ≥6, and premorbid modified Rankin Scale (mRS) score ≤3. Patients with longitudinal CT scans at least 3 months after evacuation were included in the study. Remnant cavity volumes (Cv) after evacuation were computed using semi-automatic volumetric segmentation software. Relative cavity volume (rCv) was defined as the ratio of the preoperative Hv to the remnant Cv. RESULTS 108 patients with a total of 484 head CT scans were included in the study. The median postoperative Cv was 2.4 (IQR 0.0-11) mL, or just 6% (0-33%) of the preoperative Hv. The median residual Cv on the final head CT scan a median of 13 months (range 11-27 months) after surgery had increased to 9.4 (IQR 3.1-18) mL, or 25% (10-60%) of the preoperative Hv. rCv on the final head CT scan was negatively associated with measures of operative success including evacuation percentage, postoperative Hv ≤15 mL, and decreased time from ictus to evacuation. rCv on the final head CT scan was also associated with a worse 6-month functional outcome (β per mRS point 17.6%, P<0.0001; area under the receiver operating characteristic curve 0.91). CONCLUSION After minimally invasive ICH evacuation the hematoma lesion decompresses significantly, with a residual Cv just 6% of the original lesion, but then gradually increases in size over time. Early and high percentage ICH evacuation may reduce the remnant Cv over time which, in turn, is associated with improved functional outcomes.
Collapse
Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luis C Ascanio
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Braxton Riley Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anthony Lin
- Department of Pathology, Weill Cornell Medical College, New York, New York, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nek Asghar
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | |
Collapse
|
2
|
Hollingworth M, Woodhouse LJ, Law ZK, Ali A, Krishnan K, Dineen RA, Christensen H, England TJ, Roffe C, Werring D, Peters N, Ciccone A, Robinson T, Członkowska A, Bereczki D, Egea-Guerrero JJ, Ozturk S, Bath PM, Sprigg N. The Effect of Tranexamic Acid on Neurosurgical Intervention in Spontaneous Intracerebral Hematoma: Data From 121 Surgically Treated Participants From the Tranexamic Acid in IntraCerebral Hemorrhage-2 Randomized Controlled Trial. Neurosurgery 2024; 95:605-616. [PMID: 38785451 PMCID: PMC11302947 DOI: 10.1227/neu.0000000000002961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/28/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES An important proportion of patients with spontaneous intracerebral hemorrhage (ICH) undergo neurosurgical intervention to reduce mass effect from large hematomas and control the complications of bleeding, including hematoma expansion and hydrocephalus. The Tranexamic acid (TXA) for hyperacute primary IntraCerebral Hemorrhage (TICH-2) trial demonstrated that tranexamic acid (TXA) reduces the risk of hematoma expansion. We hypothesized that TXA would reduce the frequency of surgery (primary outcome) and improve functional outcome at 90 days in surgically treated patients in the TICH-2 data set. METHODS Participants enrolled in TICH-2 were randomized to placebo or TXA. Participants randomized to either TXA or placebo were analyzed for whether they received neurosurgery within 7 days and their characteristics, outcomes, hematoma volumes (HVs) were compared. Characteristics and outcomes of participants who received surgery were also compared with those who did not. RESULTS Neurosurgery was performed in 5.2% of participants (121/2325), including craniotomy (57%), hematoma drainage (33%), and external ventricular drainage (21%). The number of patients receiving surgery who received TXA vs placebo were similar at 4.9% (57/1153) and 5.5% (64/1163), respectively (odds ratio [OR] 0.893; 95% CI 0.619-1.289; P -value = .545). TXA did not improve outcome compared with placebo in either surgically treated participants (OR 0.79; 95% CI 0.30-2.09; P = .64) or those undergoing hematoma evacuation by drainage or craniotomy (OR 1.19 95% 0.51-2.78; P -value = .69). Postoperative HV was not reduced by TXA (mean difference -8.97 95% CI -23.77, 5.82; P -value = .45). CONCLUSION TXA was not associated with less neurosurgical intervention, reduced HV, or improved outcomes after surgery.
Collapse
Affiliation(s)
- Milo Hollingworth
- Department of Neurosurgery, Nottingham University Hospitals, Nottingham, UK
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Zhe K. Law
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Azlinawati Ali
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Faculty of Health Sciences, School of Medical Imaging, University of Sultan Zainal Abidin, Kuala Nerus, Malaysia
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| | - Robert A. Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Timothy J. England
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Royal Derby Hospital, University Hospitals of Derby and Burton, Derby, UK
| | - Christine Roffe
- Stroke Research, School of Medicine, Keele University, Newcastle under Lyme, UK
| | - David Werring
- Stroke Research Centre, Brain Repair & Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Nils Peters
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alfonso Ciccone
- Azienda Socio Sanitaria Territoriale di Mantova, Mantova, Italy
| | | | | | - Dániel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | | | - Serefnur Ozturk
- Department of Neurology, Neurointensive Care- Stroke Center, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| |
Collapse
|
3
|
Krzyżewski RM, Kwinta BM, Stachura K, Popiela TJ, Pułyk R, Słowik A, Gąsowski J, Kliś KM. Association of Imaging-based Predictors with Outcome in Different Treatment Options for Intracerebral Hemorrhage. Clin Neuroradiol 2024; 34:685-692. [PMID: 38668867 PMCID: PMC11339125 DOI: 10.1007/s00062-024-01406-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 03/18/2024] [Indexed: 08/22/2024]
Abstract
PURPOSE Intracerebral hemorrhage is the deadliest form of stroke. This study aimed to enhance the prediction of 30-day mortality in intracerebral hemorrhage patients by integrating computational parameters. METHODS This study retrospectively analyzed 435 patients with spontaneous intracerebral hemorrhage (ICH). Utilizing the acquired computed tomography (CT) images, we extracted the contour and visual representation of ICH. For the extracted contour, the analysis encompassed factors including compactness, fractal dimension, Fourier factor, and circle factor. For the images depicting ICH, we calculated various factors related to density distribution including mean, coefficient of variance, skewness and kurtosis, as well as texture parameters, such as energy, entropy, contrast and homogeneity. To assess the impact of surgical treatment on 30-day mortality, logistic regression analysis was used. RESULTS A total of 126 patients (29.09%) died within 30 days. A total of 62 (14.25%) patients underwent surgical treatment. Multivariate logistic regression analysis revealed that surgical treatment was independently associated with a lower risk of 30-day mortality (odds ratio, OR 0.226, 95% confidence interval, CI 0.049-0.85; p = 0.039). Based on the moderated analysis, we found that the volume of ICH (OR 0.905, 95% CI 0.902-0.908; p < 0.001) and ICH energy (OR 1.389, 95%CI 0.884-0.988; p = 0.010) had positive moderating effect on such associations while the presence of intraventricular blood had negative moderating effect (OR 1.154, 95% CI 1.034-1.628; p = 0.010). CONCLUSION Patients exhibiting a higher volume and energy of ICH might benefit from surgical treatment; however, this efficacy was found to be diminished in cases involving the presence of intraventricular blood.
Collapse
Affiliation(s)
- Roger M Krzyżewski
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Borys M Kwinta
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Krzysztof Stachura
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Tadeusz J Popiela
- Department of Radiology, Jagiellonian University Medical College, Kraków, Poland
| | - Roman Pułyk
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Słowik
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Jerzy Gąsowski
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Kraków, Poland
| | - Kornelia M Kliś
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland.
| |
Collapse
|
4
|
Kumar A, Witsch J, Frontera J, Qureshi AI, Oermann E, Yaghi S, Melmed KR. Predicting hematoma expansion using machine learning: An exploratory analysis of the ATACH 2 trial. J Neurol Sci 2024; 461:123048. [PMID: 38749281 DOI: 10.1016/j.jns.2024.123048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH) is a key predictor of poor prognosis and potentially amenable to treatment. This study aimed to build a classification model to predict HE in patients with ICH using deep learning algorithms without using advanced radiological features. METHODS Data from the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) was utilized. Variables included in the models were chosen as per literature consensus on salient variables associated with HE. HE was defined as increase in either >33% or 6 mL in hematoma volume in the first 24 h. Multiple machine learning algorithms were employed using iterative feature selection and outcome balancing methods. 70% of patients were used for training and 30% for internal validation. We compared the ML models to a logistic regression model and calculated AUC, accuracy, sensitivity and specificity for the internal validation models respective models. RESULTS Among 1000 patients included in the ATACH-2 trial, 924 had the complete parameters which were included in the analytical cohort. The median [interquartile range (IQR)] initial hematoma volume was 9.93.mm3 [5.03-18.17] and 25.2% had HE. The best performing model across all feature selection groups and sampling cohorts was using an artificial neural network (ANN) for HE in the testing cohort with AUC 0.702 [95% CI, 0.631-0.774] with 8 hidden layer nodes The traditional logistic regression yielded AUC 0.658 [95% CI, 0.641-0.675]. All other models performed with less accuracy and lower AUC. Initial hematoma volume, time to initial CT head, and initial SBP emerged as most relevant variables across all best performing models. CONCLUSION We developed multiple ML algorithms to predict HE with the ANN classifying the best without advanced radiographic features, although the AUC was only modestly better than other models. A larger, more heterogenous dataset is needed to further build and better generalize the models.
Collapse
Affiliation(s)
- Arooshi Kumar
- Rush University Medical Center, Department of Neurology, Chicago, IL 60612, United States of America.
| | - Jens Witsch
- Hospital of the University of Pennsylvania, Department of Neurology, Philadelphia, PA 19104, United States of America
| | - Jennifer Frontera
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO 65201, United States of America
| | - Eric Oermann
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Shadi Yaghi
- Warren Alpert Medical School of Brown University, Department of Neurology, Providence, RI 02903, United States of America
| | - Kara R Melmed
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Neurosurgery, New York, NY 10016, United States of America
| |
Collapse
|
5
|
Murthy SB. Emergent Management of Intracerebral Hemorrhage. Continuum (Minneap Minn) 2024; 30:641-661. [PMID: 38830066 DOI: 10.1212/con.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH. LATEST DEVELOPMENTS Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques. ESSENTIAL POINTS This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.
Collapse
|
6
|
Kleinig TJ, Abou-Hamden A, Laidlaw J, Churilov L, Kellner CP, Wu T, Mocco J, Lau H, Adamides A, Kavar B, Dimou J, Cranefield J, McDonald A, Plummer S, Davis S, Campbell BCV. Early minimally invasive intracerebral hemorrhage evacuation: a phase 2a feasibility, safety, and promise of surgical efficacy study. J Neurointerv Surg 2024; 16:555-558. [PMID: 37611941 DOI: 10.1136/jnis-2023-020446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/13/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Surgical treatment of intracerebral hemorrhage (ICH) is unproven, although meta-analyses suggest that both early conventional surgery with craniotomy and minimally invasive surgery (MIS) may be beneficial. We aimed to demonstrate the safety, feasibility, and promise of efficacy of early MIS for ICH using the Aurora Surgiscope and Evacuator. METHODS We performed a prospective, single arm, phase IIa Simon's two stage design study at two stroke centers (10 patients with supratentorial ICH volumes ≥20 mL and National Institutes of Health Stroke Scale (NIHSS) score of ≥6, and surgery commencing <12 hours after onset). Positive outcome was defined as ≥50% 24 hour ICH volume reduction, with the safety outcome lack of significant ICH reaccumulation. RESULTS From December 2019 to July 2020, we enrolled 10 patients at two Australian Comprehensive Stroke Centers, median age 70 years (IQR 65-74), NIHSS score 19 (IQR 19-29), ICH volume 59 mL (IQR 25-77), at a median of 227 min (IQR 175-377) post-onset. MIS was commenced at a median time of 531 min (IQR 437-628) post-onset, had a median duration of 98 min (IQR 77-110), with a median immediate postoperative hematoma evacuation of 70% (IQR 67-80%). A positive outcome was achieved in 5/5 first stage patients and in 4/5 second stage patients. One patient developed significant 24 hour ICH reaccumulation; otherwise, 24 hour stability was observed (median reduction 71% (IQR 61-80), 5/9 patients <15 mL residual). Three patients died, unrelated to surgery. There were no surgical safety concerns. At 6 months, the median modified Rankin Scale score was 4 (IQR 3-6) with 30% achieving a score of 0-3. CONCLUSION In this study, early ICH MIS using the Aurora Surgiscope and Evacuator appeared to be feasible and safe, warranting further exploration. TRIAL REGISTRATION NUMBER ACTRN12619001748101.
Collapse
Affiliation(s)
- Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Medicine, The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Amal Abou-Hamden
- Neurosurgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Surgery, The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - John Laidlaw
- Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Leonid Churilov
- Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Teddy Wu
- Neurology, Christchurch Hospital, Christchurch, Canterbury, New Zealand
| | - J Mocco
- Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Hui Lau
- Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Alexios Adamides
- Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Bhadrakant Kavar
- Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - James Dimou
- Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jennifer Cranefield
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Amy McDonald
- Neurology, Royal Melbourne Hospital, Parkville, Victoria, Adelaide, Australia
| | - Stephanie Plummer
- Neurosurgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Stephen Davis
- Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neurology, Royal Melbourne Hospital, Parkville, Victoria, Adelaide, Australia
| | - Bruce C V Campbell
- Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neurology, Royal Melbourne Hospital, Parkville, Victoria, Adelaide, Australia
| |
Collapse
|
7
|
Wang CY, Lai SZ, Kang BC, Lin YZ, Cao CJ, Huang XB, Wang JQ. Association of pulse pressure with hematoma expansion in patients with spontaneous supratentorial intracerebral hemorrhage. Front Neurol 2024; 15:1374198. [PMID: 38813243 PMCID: PMC11133623 DOI: 10.3389/fneur.2024.1374198] [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: 01/21/2024] [Accepted: 04/26/2024] [Indexed: 05/31/2024] Open
Abstract
Objective Recent reports have demonstrated that a wider pulse pressure upon admission is correlated with heightened in-hospital mortality following spontaneous supratentorial intracerebral hemorrhage (ssICH). However, the underlying mechanism remains ambiguous. We investigated whether a wider pulse pressure was associated with hematoma expansion (HE). Methods Demographic information, clinical features, and functional outcomes of patients diagnosed with ssICH were retrospectively collected and analyzed. Multivariate logistic regression was conducted to identify independent predictors of HE. Weighted logistic regression, restricted cubic spline models, and propensity score matching (PSM) were employed to estimate the association between pulse pressure and HE. Results We included 234 eligible adult ssICH patients aged 60 (51-71) years, and 55.56% were male. The mean pulse pressure was 80.94 ± 23.32 mmHg. Twenty-seven patients (11.54%) developed early HE events, and 116 (49.57%) experienced a poor outcome (modified Rankin scale 3-6). A wider mean pulse pressure as a continuous variable was a predictor of HE [odds ratios (OR) 1.026, 95% confidence interval (CI) 1.007-1.046, p = 0.008] in multivariate analysis. We transformed pulse pressure into a dichotomous variable based on its cutoff value. After adjusting for confounding of HE variables, the occurrence of HE in patients with ssICH with wider pulse pressure levels (≥98 mmHg) had 3.78 times (OR 95% CI 1.47-9.68, p = 0.006) compared to those with narrower pulse pressure levels (<98 mmHg). A linear association was observed between pulse pressure and increased HE risk (P for overall = 0.036, P for nonlinear = 0.759). After 1:1 PSM (pulse pressure ≥98 mmHg vs. pulse pressure <98 mmHg), the rates of HE events and poor outcome still had statistically significant in wider-pulse pressure group [HE, 12/51 (23.53%) vs. 4/51 [7.84%], p = 0.029; poor outcome, 34/51 (66.67%) vs. 19/51 (37.25%), p = 0.003]. Conclusion Widened acute pulse pressure (≥98 mmHg) levels at admission are associated with increased risks of early HE and unfavorable outcomes in patients with ssICH.
Collapse
Affiliation(s)
- Chao-Ying Wang
- Department of Neurosurgery, Dehua County Hospital, Quanzhou, China
| | - Su-Zhen Lai
- Department of Imaging, Dehua County Hospital, Quanzhou, China
| | - Bao-Cai Kang
- Department of Internal Medicine, Dehua County Hospital, Quanzhou, China
- Department of Geriatrics, Changji People’s Hospital, Changji, China
| | - Yi-Zhao Lin
- Department of Laboratory Medicine, Dehua County Hospital, Quanzhou, China
| | - Chun-Juan Cao
- Department of Imaging, Dehua County Hospital, Quanzhou, China
| | - Xin-Bing Huang
- Department of Neurology, Dehua County Hospital, Quanzhou, China
| | - Jian-Qun Wang
- Department of Neurosurgery, Dehua County Hospital, Quanzhou, China
| |
Collapse
|
8
|
Lim MJR, Quek RHC, Ng KJ, Tan BYQ, Yeo LLL, Low YL, Soon BKH, Loh WNH, Teo K, Nga VDW, Yeo TT, Motani M. Prognostication of Outcomes in Spontaneous Intracerebral Hemorrhage: A Propensity Score-Matched Analysis with Support Vector Machine. World Neurosurg 2024; 182:e262-e269. [PMID: 38008171 DOI: 10.1016/j.wneu.2023.11.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE The role of surgery in spontaneous intracerebral hemorrhage (SICH) remains controversial. We aimed to use explainable machine learning (ML) combined with propensity-score matching to investigate the effects of surgery and identify subgroups of patients with SICH who may benefit from surgery in an interpretable fashion. METHODS We conducted a retrospective study of a cohort of 282 patients aged ≥21 years with SICH. ML models were developed to separately predict for surgery and surgical evacuation. SHapley Additive exPlanations (SHAP) values were calculated to interpret the predictions made by ML models. Propensity-score matching was performed to estimate the effect of surgery and surgical evacuation on 90-day poor functional outcomes (PFO). RESULTS Ninety-two patients (32.6%) underwent surgery, and 57 patients (20.2%) underwent surgical evacuation. A total of 177 patients (62.8%) had 90-day PFO. The support vector machine achieved a c-statistic of 0.915 when predicting 90-day PFO for patients who underwent surgery and a c-statistic of 0.981 for patients who underwent surgical evacuation. The SHAP scores for the top 5 features were Glasgow Coma Scale score (0.367), age (0.214), volume of hematoma (0.258), location of hematoma (0.195), and ventricular extension (0.164). Surgery, but not surgical evacuation of the hematoma, was significantly associated with improved mortality at 90-day follow-up (odds ratio, 0.26; 95% confidence interval, 0.10-0.67; P = 0.006). CONCLUSIONS Explainable ML approaches could elucidate how ML models predict outcomes in SICH and identify subgroups of patients who respond to surgery. Future research in SICH should focus on an explainable ML-based approach that can identify subgroups of patients who may benefit functionally from surgical intervention.
Collapse
Affiliation(s)
- Mervyn Jun Rui Lim
- Department of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore.
| | - Raphael Hao Chong Quek
- Department of Electrical and Computer Engineering, National University of Singapore, Singapore, Singapore
| | - Kai Jie Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Leonard Leong Litt Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Ying Liang Low
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Betsy Kar Hoon Soon
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Will Ne-Hooi Loh
- Department of Anesthesia, National University Hospital, Singapore, Singapore
| | - Kejia Teo
- Department of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore
| | - Vincent Diong Weng Nga
- Department of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore
| | - Tseng Tsai Yeo
- Department of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore
| | - Mehul Motani
- Department of Electrical and Computer Engineering, National University of Singapore, Singapore, Singapore; N.1 Institute for Health, National University of Singapore, Singapore, Singapore; Institute of Data Science, National University of Singapore, Singapore, Singapore; Institute for Digital Medicine (WisDM), National University of Singapore, Singapore, Singapore
| |
Collapse
|
9
|
Li Q, Yakhkind A, Alexandrov AW, Alexandrov AV, Anderson CS, Dowlatshahi D, Frontera JA, Hemphill JC, Ganti L, Kellner C, May C, Morotti A, Parry-Jones A, Sheth KN, Steiner T, Ziai W, Goldstein JN, Mayer SA. Code ICH: A Call to Action. Stroke 2024; 55:494-505. [PMID: 38099439 DOI: 10.1161/strokeaha.123.043033] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.
Collapse
Affiliation(s)
- Qi Li
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China (Q.L.)
| | | | | | | | - Craig S Anderson
- The George Institute for Global Heath, University of New South Wales, Sydney, Australia (C.S.A.)
| | - Dar Dowlatshahi
- University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | | | | | - Latha Ganti
- University of Central Florida College of Medicine, Orlando (L.G.)
| | | | - Casey May
- The Ohio State University College of Pharmacy, Columbus (C.M.)
| | | | | | - Kevin N Sheth
- Yale University School of Medicine, New Haven, CT (K.N.S.)
| | | | - Wendy Ziai
- John Hopkins University School of Medicine, Baltimore, MD (W.Z.)
| | | | | |
Collapse
|
10
|
Ali M, Smith C, Vasan V, Downes M, Schuldt BR, Odland I, Murtaza-Ali M, Dullea J, Rossitto CP, Schupper AJ, Hardigan T, Asghar N, Liang J, Mocco J, Kellner CP. Characterization of length of stay after minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurointerv Surg 2023; 16:15-23. [PMID: 36882321 DOI: 10.1136/jnis-2023-020152] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Minimally invasive evacuation may help ameliorate outcomes after intracerebral hemorrhage (ICH). However, hospital length of stay (LOS) post-evacuation is often long and costly. OBJECTIVE To examine factors associated with LOS in a large cohort of patients who underwent minimally invasive endoscopic evacuation. METHODS Patients presenting to a large health system with spontaneous supratentorial ICH qualified for minimally invasive endoscopic evacuation if they met the following inclusion criteria: age ≥18, premorbid modified Rankin Scale (mRS) score ≤3, hematoma volume ≥15 mL, and presenting National Institutes of Health Stroke Scale (NIHSS) score ≥6. Demographic, clinical, radiographic, and operative characteristics were included in a multivariate logistic regression for hospital and ICU LOS dichotomized into short and prolonged stay at 14 and 7 days, respectively. RESULTS Among 226 patients who underwent minimally invasive endoscopic evacuation, the median intensive care unit and hospital LOS were 8 (4-15) days and 16 (9-27) days, respectively. A greater extent of functional impairment on presentation (OR per NIHSS point 1.10 (95% CI 1.04 to 1.17), P=0.007), concurrent intraventricular hemorrhage (OR=2.46 (1.25 to 4.86), P=0.02), and deep origin (OR=per point 2.42 (1.21 to 4.83), P=0.01) were associated with prolonged hospital LOS. A longer delay from ictus to evacuation (OR per hour 1.02 (1.01 to 1.04), P=0.007) and longer procedure time (OR per hour 1.91 (1.26 to 2.89), P=0.002) were associated with prolonged ICU LOS. Prolonged hospital and ICU LOS were in turn longitudinally associated with a lower rate of discharge to acute rehabilitation (40% vs 70%, P<0.0001) and worse 6-month mRS outcomes (5 (4-6) vs 3 (2-4), P<0.0001). CONCLUSIONS We present factors associated with prolonged LOS, which in turn was associated with poor long-term outcomes. Factors associated with LOS may help to inform patient and clinician expectations of recovery, guide protocols for clinical trials, and select suitable populations for minimally invasive endoscopic evacuation.
Collapse
Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Braxton R Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Murtaza-Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nek Asghar
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
11
|
Liu S, Su S, Long J, Cao S, Ren J, Li F, Wang S, Niu H, Gao Z, Gao H, Wang D, Hu F, Zhang X. The impact of time to evacuation on outcomes in endoscopic surgery for supratentorial spontaneous intracerebral hemorrhage: a single-center retrospective study. Neurosurg Rev 2023; 47:2. [PMID: 38057420 DOI: 10.1007/s10143-023-02237-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 12/08/2023]
Abstract
Supratentorial spontaneous intracerebral hemorrhage (SICH) can be treated with endoscopic surgery, but the optimal timing remains uncertain. We retrospectively analyzed data from 46 patients who underwent endoscopic surgery for supratentorial SICH. We examined the relationship between time to evacuation and functional outcome at 3 months, adjusting for prognostic factors. Surgical outcomes and complications were compared between patients with early (≤ 12 h) or late (> 12 h) evacuation. Median time to evacuation was 12 h, and the rate of unfavorable outcome (modified Rankin Scale > 3 at 3 months) was 32.6%. Longer time to evacuation was independently associated with unfavorable outcome (odds ratio per hour delay: 1.26). Late evacuation carried a 7.25-fold higher risk of unfavorable outcome compared to early evacuation. This association held across subgroups based on hematoma volume, location, and intraventricular extension (P for interaction > 0.05). Patients with late evacuation had fewer spot signs (24% vs. 4.8%, P = 0.035) and markers of hemorrhagic expansion (36% vs. 9.5%, P = 0.018), longer neurosurgical intensive care unit (NSICU) stay (3.2 vs. 1.9 days, P = 0.011) and hospital stay (15.7 vs. 11.9 days, P = 0.014), and higher 30-day mortality (28.6 vs. 4%, P = 0.036) and complication rates (57.1% vs. 28.0%, P = 0.023). This study suggests a potential association between early endoscopic evacuation of supratentorial SICH and improved functional outcomes, lower 30-day mortality and reduced complications. The need for timely intervention in managing supratentorial SICH is highlighted, yet further validation through multi-center prospective studies is essential to substantiate these findings and provide a higher level of evidence.
Collapse
Affiliation(s)
- Shuang Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Shengyang Su
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Jinyong Long
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Shikui Cao
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Jirao Ren
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Fuhua Li
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Shoulong Wang
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
- Department of Neurological Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, China
| | - Huatao Niu
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
- Department of Neurological Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, China
| | - Zihui Gao
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Huaxing Gao
- Department of Neurology, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Deqiang Wang
- Department of Critical Care Medicine, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Fan Hu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Xiaobiao Zhang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| |
Collapse
|
12
|
Kashkoush AI, El-Abtah ME, Achey R, Winkelman R, Glauser G, Patterson TE, Moore NZ, Kshettry VR, Gomes JA, Bain M. Prognosticators of Functional Outcome After Supratentorial Minimally Invasive Intracranial Hemorrhage Evacuation With Tubular Retractor Systems. Oper Neurosurg (Hagerstown) 2023; 25:408-416. [PMID: 37668988 DOI: 10.1227/ons.0000000000000845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/29/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Prognosticators of good functional outcome after minimally invasive surgical (MIS) intracranial hemorrhage (ICH) evacuation are poorly defined. This study aims to investigate clinical and radiographic prognosticators of poor functional outcome after MIS evacuation of ICH with tubular retractor systems. METHODS Single-center retrospective review of adult (age ≥18 years) patients who underwent surgical evacuation of a spontaneous supratentorial ICH evacuation using tubular retractors from 2013 to 2022 was performed. Clinical and radiographic factors, such as antiplatelet/anticoagulant use, initial NIH Stroke Scale, ICH score, premorbid modified Rankin Scale (mRS), intraventricular hemorrhage (IVH) severity according to the modified Graeb scale, and preoperative/postoperative ICH volume, were collected. The main outcome was poor functional outcome, defined as mRS score of 4-6 within 1 year postoperatively. RESULTS Eighty-eight patients were included. Clinical follow-up data were available for 64 (73%) patients. Of those, 43 (67%) had a poor functional outcome. On multivariate Cox regression, postoperative ICH volume ≥15 mL (hazard ratio [HR] = 2.46 [95% CI: 1.25-4.87]; P = .010) and higher modified Graeb score (HR = 1.04 [95% CI: 1-1.1]; P = .035] significantly increased the risk of poor functional outcome. Elevated postoperative ICH volume was predicted by the presence of lobar ICH (vs nonlobar, OR = 3.32 [95% CI: 1.01-11.55]; P = .043) and higher preoperative ICH volume (OR = 1.05 [1.02-1.08]; P < .001). A minimum of 60% ICH evacuation yielded an improvement in mRS 4-6 rates (HR 0.3 [95% CI: 0.1-0.8], P = .013). In patients without IVH and with a >80% ICH evacuation, the rate of mRS 4-6 was 42% compared with 67% in the whole patient sample ( P = .017). CONCLUSION Increased IVH volumes and residual postoperative ICH volumes are associated with poor functional outcome after MIS ICH evacuation. Postoperative ICH volume was associated with lobar ICH location as well as preoperative ICH volume. These factors may help to prognosticate patient outcomes and improve selection criteria for MIS ICH evacuation techniques.
Collapse
Affiliation(s)
| | - Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Rebecca Achey
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert Winkelman
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gregory Glauser
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Nina Z Moore
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
- Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joao A Gomes
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
13
|
Xiao K, Chu H, Chen H, Zhong Y, Zhong L, Tang Y. Optimal time window for minimally invasive surgery in treating spontaneous intracerebral hemorrhage in the basal ganglia region: a multicenter and retrospective study. Br J Neurosurg 2023; 37:1061-1065. [PMID: 33292025 DOI: 10.1080/02688697.2020.1854682] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/19/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The current treatment spontaneous intracerebral hemorrhage (sICH) is limited. AIM To determine the optimal time window for minimally invasive surgery in patients with sICH. MATERIALS AND METHODS sICH patients with a hematoma volume of 30-80 mL in the basal ganglia region were included in our study. A total of 357 patients were divided into groups according to different operative times from ICH onset (group 1: 0-6 h, group 2: 6-12 h, group 3: >12 h) and hematoma volumes (30-50 mL and >50 mL). All patients were followed-up for three months' post-operation, and their clinical outcomes were compared. RESULTS In the three groups of patients with hematoma volumes of 30-50 mL, the rebleeding and mortality rate were higher in group 1 than groups 2 and 3 (p < .05). The activities of daily living evaluated by Barthel Index (BI) three months' post-operation was significantly lower in group 3 than other groups (p < .05) and group 2 had the highest proportion of good outcomes. Among the patients with the hematoma volumes of 50-80 mL, the rebleeding risk was higher in group 1 than groups 2 and 3 (p < .05). However, there were no significant differences in mortality rates among these three groups. Moreover, group 1 had significantly higher BI than groups 2 and 3 (p < .05). CONCLUSIONS Minimally invasive surgery is safe and effective in patients with sICH. 6-12 h after sICH onset is the optimal surgical window for patients with hematoma volumes of 30-50 mL, while ultra-early (≤6 h) may achieve better results in patients with hematoma volumes of >50 mL.
Collapse
Affiliation(s)
- Kaimin Xiao
- Department of Neurology, People's Hospital of Ganxian District, Ganzhou, China
| | - Heling Chu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongmei Chen
- Department of Neurology, People's Hospital of Ganxian District, Ganzhou, China
| | - Youan Zhong
- Department of Neurology, National Hospital, Guangxi Medical University, Nanning, China
| | - Liang Zhong
- Department of Neurology, National Hospital, Guangxi Medical University, Nanning, China
| | - Yuping Tang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
14
|
I Kh Almadhoun MK, Hattab AW, Alazzeh NN, Aladwan ST. Spontaneous Intracranial Hemorrhage Concurrent With Subarachnoid and Subdural Hemorrhages: Report of a Rare Case. Cureus 2023; 15:e46939. [PMID: 38021566 PMCID: PMC10640682 DOI: 10.7759/cureus.46939] [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] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Spontaneous intracerebral hemorrhage (SICH) is a rare occurrence in the temporal lobe, and its coexistence with other intracranial bleeding types such as subdural hemorrhage (SDH) and subarachnoid hemorrhage (SAH) is infrequently documented. Typically, SICH is managed conservatively without surgical intervention. In this case report, we present an unusual case of SICH in the temporal lobe, characterized by bleeding extending beyond the brain parenchyma into the subarachnoid and subdural spaces. Our approach involved tubular hematoma evacuation (surgical approach). Literature reports propose the coexistence of SICH, SAH, and SDH, particularly when there is bleeding through the cortical surface that extends into the subdural space. The decision to surgically remove a hematoma in supratentorial ICH remains a subject of debate, as the risks associated with the procedure may outweigh potential benefits in many cases. Surgical intervention is typically reserved for patients with supratentorial ICH causing life-threatening mass effect, with treatment plans tailored based on prognosis assessments with and without surgical intervention. In our patient, craniotomy with tubular evacuation of the hematoma proved effective in alleviating symptoms and preventing life-threatening herniation complications.
Collapse
|
15
|
Amano Y, Yamaguchi Y, Osato T, Watanabe T, Kamiyama K, Nakamura H. Long insular artery damage might be a key sign for predicting functional prognosis of putaminal hemorrhage. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:221-227. [PMID: 36775739 DOI: 10.1016/j.neucie.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/21/2022] [Indexed: 02/12/2023]
Abstract
OBJECTIVE Although the putamen is the most common area of spontaneous intracerebral hemorrhage, previous reports about the effects of surgery are limited. We sometimes experience a poor prognosis in patients in whom there is no damage to the internal capsule, but with injury in the long insular artery (LIA) region. The purpose of this study was to confirm the relationship between LIA damage and patient prognosis following surgery for putaminal hemorrhage. METHODS We retrospectively collected data of 287 surgical cases who presented with putaminal hemorrhage between January 2004 and March 2022. Among them, we chose patients without initial damage to the posterior limb of the internal capsule, and divided these patients into two groups, those without (Group A) and with (Group B) final damage in the LIA region. We compared positivity rates of final manual muscle test (MMT) scores≥3 and related factors. RESULTS Sixty-three of the 287 patients were included in this study. Of them, 11 cases in Group A were positive for MMT scores≥3 (68.8%) and 9 cases (19.1%) in Group B had MMT scores≥3 seven days after surgery. Group A thus had a significantly higher rate of MMT scores≥3 than group B (p=0.00). CONCLUSION In patients without initial damage to the internal capsule, LIA injury might be a key sign for predicting the functional prognosis of putaminal hemorrhage.
Collapse
Affiliation(s)
- Yuki Amano
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan.
| | - Yohei Yamaguchi
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Toshiaki Osato
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | | | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Hirohiko Nakamura
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| |
Collapse
|
16
|
Siahaan AMP, Tandean S, Nainggolan BWM, Tarigan J, Sitanggang JS. A Critical Analysis of Intracranial Hemorrhage as a Fatal Complication of Dengue Fever. J Korean Neurosurg Soc 2023; 66:494-502. [PMID: 36642946 PMCID: PMC10483153 DOI: 10.3340/jkns.2022.0205] [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: 09/14/2022] [Revised: 12/21/2022] [Accepted: 01/12/2023] [Indexed: 01/17/2023] Open
Abstract
Dengue fever is the most rapidly spreading mosquito-borne virus in the world, infecting about 100 million individuals. A rare but possibly dangerous consequence of dengue illness is intracranial hemorrhage (ICH). Currently, the pathogenesis of ICH is unknown. A number of studies have found a variety of risk factors for ICH in dengue. In addition, studies have reported the use of emergency surgery while monitoring thrombocytopenia in the therapy of dengue ICH. This review enumerates the potential predictors of ICH in dengue, discusses the use of brain imaging, and mentions the possibility of emergency surgery.
Collapse
Affiliation(s)
| | - Steven Tandean
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | | | - Junita Tarigan
- Division of Infection and Tropical Medicine, Department of Internal Medicine, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Johan Samuel Sitanggang
- Undergraduate Program in Medicine, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| |
Collapse
|
17
|
Ong PL, Seah JD, Chua KSG. Inpatient Rehabilitation Outcomes after Primary Severe Haemorrhagic Stroke: A Retrospective Study Comparing Surgical versus Non-Surgical Management. Life (Basel) 2023; 13:1766. [PMID: 37629627 PMCID: PMC10455087 DOI: 10.3390/life13081766] [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: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Haemorrhagic stroke, accounting for 10-20% of all strokes, often requires decompressive surgery as a life-saving measure for cases with massive oedema and raised intracranial pressure. This study was conducted to compare the demographics, characteristics and rehabilitation profiles of patients with severe haemorrhagic stroke who were managed surgically versus those who were managed non-surgically. METHODS A single-centre retrospective study of electronic medical records was conducted over a 3-year period from 1 January 2018 to 31 December 2020. The inclusion criteria were first haemorrhagic stroke, age of >18 years and an admission Functional Independence Measure (FIM™) score of 18-40 upon admission to the rehabilitation centre. The primary outcome measure was discharge FIM™. Secondary outcome measures included modified Rankin Scale (mRS), rehabilitation length of stay (RLOS) and complication rates. RESULTS A total of 107 patients' records were analysed; 45 (42.1%) received surgical intervention and 62 (57.9%) patients underwent non-surgical management. Surgically managed patients were significantly younger than non-surgical patients, with a mean age of [surgical 53.1 (SD 12) vs. non-surgical 61.6 (SD 12.3), p = 0.001]. Admission FIM was significantly lower in the surgical vs. non-surgical group [23.7 (SD6.7) vs. 26.71 (SD 7.4), p = 0.031). However, discharge FIM was similar between both groups [surgical 53.91 (SD23.0) vs. non-surgical 57.0 (SD23.6), p = 0.625). Similarly, FIM gain (surgical 30.1 (SD 21.1) vs. non-surgical 30.3 (SD 21.1), p = 0.094) and RLOS [surgical 56.2 days (SD 21.5) vs. non-surgical 52.0 days (SD 23.4), p = 0.134) were not significantly different between groups. The majority of patients were discharged home (surgical 73.3% vs. non-surgical 74.2%, p = 0.920) despite a high level of dependency. CONCLUSIONS Our findings suggest that patients with surgically managed haemorrhagic stroke, while older and more dependent on admission to rehabilitation, achieved comparable FIM gains, discharge FIM and discharge home rates after ~8 weeks of rehabilitation. This highlights the importance of rehabilitation, especially for surgically managed haemorrhagic stroke patients.
Collapse
Affiliation(s)
- Poo Lee Ong
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore; (J.D.S.); (K.S.G.C.)
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 639798, Singapore
| | - Justin Desheng Seah
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore; (J.D.S.); (K.S.G.C.)
| | - Karen Sui Geok Chua
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore; (J.D.S.); (K.S.G.C.)
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 639798, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| |
Collapse
|
18
|
Song P, Lei P, Li Z, Zhou L, Wei H, Gao L, Cheng L, Wang W, Hua Q, Chen Q, Luo M, Cai Q. Post-operative rebleeding in patients with spontaneous supratentorial intracerebral hemorrhage: factors and clinical outcomes. Am J Transl Res 2023; 15:5168-5183. [PMID: 37692943 PMCID: PMC10492089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/22/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE To explore factors affecting postoperative rebleeding in patients with spontaneous supratentorial intracerebral hemorrhage (SSICH). METHODS We retrospectively analyzed data from 724 patients with SSICH treated at Renmin Hospital of Wuhan University from December 2018 to October 2021. Finally, 294 people were eligible to be included in this study. Hematoma locations were classified as basal ganglia, thalamus, subcortex, or intraventricular. Surgery was categorized as neuroendoscopic surgery, burr hole (stereotactic drilling and drainage), or open craniotomy. Postoperative rebleeding was recorded. The incidence, risk factors, and prognosis of postoperative rebleeding were evaluated. RESULTS All procedures were successfully completed. Postoperative rebleeding occurred in 57 patients (19.83%, 57/294). Univariate logistic regression analysis identified these risk factors for rebleeding: admission Glasgow Coma Scale (GCS) score, irregular hematoma morphology by preoperative Computed Tomography (CT), postoperative hypertension, hematoma location, surgical method (P<0.05), and preoperative hematoma volume (P<0.1). Multivariate logistic regression analysis confirmed admission GCS score, irregular hematoma morphology by preoperative CT, postoperative hypertension, hematoma location, and surgical method as significant risk factors (P<0.05). Burr hole surgery and basal ganglia hematomas were associated with increased odds of rebleeding, and the mortality rates in patients with rebleeding versus no rebleeding were 7.02% versus 0.84%. CONCLUSIONS Neuroendoscopic surgery, craniotomy, and burr hole are all effective for treating SSICH, but burr hole surgery was an important risk factor for rebleeding and an adverse outcome. Admission GCS score, irregular hematoma morphology, blood pressure control, hematoma location, and surgical method are affected the risk of postoperative rebleeding. 3D Slicer-assisted neuroendoscopic surgery may be the most effective treatment for many patients with SSICH.
Collapse
Affiliation(s)
- Ping Song
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| | - Pan Lei
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| | - Zhiyang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| | - Long Zhou
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| | - Hangyu Wei
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| | - Lun Gao
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| | - Li Cheng
- Department of Intensive Care Units, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| | - Wenju Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| | - Qiuwei Hua
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| | - Ming Luo
- Department of Neurosurgery, The First Hospital of WuhanWuhan 430022, Hubei, China
| | - Qiang Cai
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityWuhan 430060, Hubei, China
| |
Collapse
|
19
|
Beynon C, Bernhard M, Brenner T, Dietrich M, Fiedler MO, Nusshag C, Weigand MA, Reuß CJ, Michalski D, Jungk C. [Focus neurosurgical intensive care medicine : Summary of selected intensive medical care studies]. DIE ANAESTHESIOLOGIE 2023; 72:518-525. [PMID: 37195500 DOI: 10.1007/s00101-023-01287-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Christopher Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - Thorsten Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - Maximilian Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Mascha O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christian Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christopher J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - Dominik Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Christine Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| |
Collapse
|
20
|
Rao X, Zhang J, Yu K, Sun Y, Zhou J, Jiang L, Liu T, Xie B, Peng J, Jiang Y. Effect of Early External Ventricular Drainage on Perihemorrhagic Edema and Functional Outcome in Patients with Intraventricular Hemorrhage. World Neurosurg 2023; 175:e1059-e1068. [PMID: 37087041 DOI: 10.1016/j.wneu.2023.04.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE External ventricular drainage (EVD) is the most common neurosurgical procedure that allows drainage of cerebrospinal fluid and intraventricular blood. A specific time threshold for insertion of an EVD catheter in patients with spontaneous intracerebral hemorrhage and intraventricular hemorrhage has not been established. This study aimed to evaluate the association of early EVD with functional outcome in patients with intracerebral hemorrhage and intraventricular hemorrhage. METHODS Propensity score matching was used to account for baseline imbalances. Modified Rankin Scale score at 3 and 6 months, mortality rates at 3 and 6 months, postoperative complications, time course of edema evolution, and peak perihemorrhagic edema (PHE) were compared in patients who received early EVD versus routine EVD. RESULTS The rate of favorable outcome at 3 months was higher in the early EVD group compared with the routine EVD group. There were no differences between groups in modified Rankin Scale score at 6 months or mortality rates at 3 and 6 months. Absolute peak PHE and relative PHE volumes were significantly less in the early EVD group compared with the routine EVD group. The incidence of postoperative infections was lower in the early EVD group compared with the routine EVD group. CONCLUSIONS Early EVD was associated with improved functional outcome at 3 months, reduced PHE, and lower rate of infection in intracerebral hemorrhage and intraventricular hemorrhage. However, survival at 3 and 6 months and functional outcome at 6 months were not improved.
Collapse
Affiliation(s)
- Xiao Rao
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiaqi Zhang
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Kuangyang Yu
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yuxuan Sun
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jian Zhou
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Laboratory of Neurological Diseases and Brain Function, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou, China
| | - Lu Jiang
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Tianjie Liu
- Sichuan Clinical Research Center for Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bingqing Xie
- Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou, China
| | - Jianhua Peng
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Laboratory of Neurological Diseases and Brain Function, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Academician (Expert) Workstation of Sichuan Province, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yong Jiang
- Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Laboratory of Neurological Diseases and Brain Function, the Affiliated Hospital of Southwest Medical University, Luzhou, China; Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou, China.
| |
Collapse
|
21
|
Noiphithak R, Yindeedej V, Ratanavinitkul W, Duangprasert G, Nimmannitya P, Yodwisithsak P. Treatment outcomes between endoscopic surgery and conventional craniotomy for spontaneous supratentorial intracerebral hemorrhage: a randomized controlled trial. Neurosurg Rev 2023; 46:136. [PMID: 37278839 DOI: 10.1007/s10143-023-02035-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/24/2023] [Accepted: 05/18/2023] [Indexed: 06/07/2023]
Abstract
Minimally invasive surgery (MIS) has been repeatedly evaluated in patients with ICH as a promising procedure for improved survival and functional outcome. Among MIS techniques, endoscopic surgery (ES) has shown superior efficacy for ICH removal due to rapid clot evacuation and immediate bleeding control. However, the results of ES are still uncertain due to insufficient data. In this study, participants with spontaneous supratentorial ICH who were indicated for surgery were randomly assigned (1:1) to undergo ES or conventional craniotomy (CC) between March 2019 and June 2022. The primary outcome was a difference in favorable modified Rankin Scale (mRS) outcome (0 to 3) at 180-day follow-up evaluated by blind assessors. There were 188 participants, 95 in the ES group and 93 in the CC group, who completed the trial. At 180-day follow-up, 46 (48.4%) participants in the ES group achieved favorable outcomes, compared to 33 (35.5%) in the CC group (risk difference [RD] 12.9, 95% CI - 1.1-27.0, p = 0.07). After covariate adjustment, the difference was slightly higher and significant (adjusted RD 17.3, 95% CI [4.6-30.0], p = 0.01). Moreover, the ES group had less operative duration and less intraoperative blood loss than the CC group. Clot evacuation rate and complications were similar between the two groups. Subgroup analyses showed a potential benefit of ES in age < 60 years, time to surgery ≥ 6 h, and deep ICH. This study showed that ES was safe and effective in ICH removal and provided a better functional outcome compared to CC.
Collapse
Affiliation(s)
- Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand.
| | - Vich Yindeedej
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Warot Ratanavinitkul
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Pree Nimmannitya
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Pornchai Yodwisithsak
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| |
Collapse
|
22
|
Hieber M, Lambeck J, Halaby A, Roelz R, Demerath T, Niesen WD, Bardutzky J. Minimally-invasive bedside catheter haematoma aspiration followed by local thrombolysis in spontaneous supratentorial intracerebral haemorrhage: a retrospective single-center study. Front Neurol 2023; 14:1188717. [PMID: 37342780 PMCID: PMC10277509 DOI: 10.3389/fneur.2023.1188717] [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: 03/17/2023] [Accepted: 05/16/2023] [Indexed: 06/23/2023] Open
Abstract
Background and purpose The role of surgery in the treatment of intracerebral haemorrhage (ICH) remains controversial. Whereas open surgery has failed to show any clinical benefit, recent studies have suggested that minimal invasive procedures can indeed be beneficial, especially when they are applied at an early time point. This retrospective study therefore evaluated the feasibility of a free-hand bedside catheter technique with subsequent local lysis for early haematoma evacuation in patients with spontaneous supratentorial ICH. Methods Patients with spontaneous supratentorial haemorrhage of a volume of >30 mL who were treated with bedside catheter haematoma evacuation were identified from our institutional database. The entry point and evacuation trajectory of the catheter were based on a 3D-reconstructed CT scan. The catheter was inserted bedside into the core of the haematoma, and urokinase (5,000 IE) was administered every 6 h for a maximum of 4 days. Evolution of haematoma volume, perihaemorrhagic edema, midline-shift, adverse events and functional outcome were analyzed. Results A total of 110 patients with a median initial haematoma volume of 60.6 mL were analyzed. Haematoma volume decreased to 46.1 mL immediately after catheter placement and initial aspiration (with a median time to treatment of 9 h after ictus), and to 21.0 mL at the end of urokinase treatment. Perihaemorrhagic edema decreased significantly from 45.0 mL to 38.9 mL and midline-shift from 6.0 mm to 2.0 mm. The median NIHSS score improved from 18 on admission to 10 at discharge, and the median mRS at discharge was 4; the latter was even lower in patients who reached a target volume ≤ 15 mL at the end of local lysis. The in-hospital mortality rate was 8.2%, and catheter/local lysis-associated complications occurred in 5.5% of patients. Conclusion Bedside catheter aspiration with subsequent urokinase irrigation is a safe and feasible procedure for treating spontaneous supratentorial ICH, and can immediately reduce the mass effects of haemorrhage. Additional controlled studies that assess the long-term outcome and generalizability of our findings are therefore warranted. Clinical trial registration [www.drks.de], identifier [DRKS00007908].
Collapse
Affiliation(s)
- Maren Hieber
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Amjad Halaby
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- Department of Neuroradiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Bardutzky
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
23
|
Tahara S, Hattori Y, Aso S, Uda K, Kumazawa R, Matsui H, Fushimi K, Yasunaga H, Morita A. Outcomes After Endoscopic Evacuation Versus Evacuation Using Craniotomy or Stereotactic Aspiration for Spontaneous Intracerebral Hemorrhage: Analysis Using a Japanese Nationwide Database. Neurocrit Care 2023; 38:667-675. [PMID: 36348138 DOI: 10.1007/s12028-022-01634-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Various surgical methods are available for managing large intracerebral hemorrhage. This study compared the prognosis of patients with spontaneous intracerebral hemorrhage who underwent endoscopic evacuation, stereotactic aspiration, and craniotomy by using a nationwide inpatient database in Japan. METHODS Using the Diagnosis Procedure Combination database, we identified patients who underwent surgery for spontaneous intracerebral hemorrhage within 48 h after admission between April 2014 and March 2018. Eligible patients were classified into three groups according to the type of surgery (endoscopic surgery, stereotactic surgery, and craniotomy). Propensity score matching weight analysis was conducted to compare poor modified Rankin Scale score at discharge (severe disability or death) and hospitalization cost among the groups. RESULTS Among 17,860 eligible patients, craniotomy, stereotactic surgery, and endoscopic surgery were performed in 14,354, 474, and 3,032 patients, respectively. In the matching weight analysis, all covariates were well balanced. Compared with the endoscopic surgery group, the proportion of poor prognosis (modified Rankin Scale score at discharge of 5 or 6) was significantly higher in craniotomy groups (odds ratio 2.51, 95% confidence interval 1.11-5.68; p = 0.028). Subgroup analysis based on hemorrhage location and consciousness level at the time of admission showed no significant difference between the surgical procedures. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (difference US $9,724, 95% confidence interval 2,169-17,259; p = 0.011). CONCLUSIONS Endoscopic surgery for spontaneous intracerebral hemorrhage was associated with improved prognosis compared with craniotomy at the hospital discharge. Future large-scale clinical trials are needed to evaluate the optimal surgical techniques for intracerebral hemorrhage.
Collapse
Affiliation(s)
- Shigeyuki Tahara
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
| | - Yujiro Hattori
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
- Department of Anatomy and Neurobiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Shotaro Aso
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Kazuaki Uda
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
| | - Ryosuke Kumazawa
- Department of Clinical Epidemiology and Health Economics, School of Public Health, the University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, the University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, the University of Tokyo, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
24
|
Mark DG, Huang J, Sonne DC, Rauchwerger AS, Reed ME. Mortality Following Diagnosis of Nontraumatic Intracerebral Hemorrhage Within an Integrated "Hub-and-Spoke" Neuroscience Care Model: Is Spoke Presentation Noninferior to Hub Presentation? Neurocrit Care 2023; 38:761-770. [PMID: 36600074 DOI: 10.1007/s12028-022-01667-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Practice guidelines recommend that patients with intracerebral hemorrhage (ICH) be treated in units with acute neuroscience care experience. However, most hospitals in the United States lack this degree of specialization. We sought to examine outcome differences for patients with nontraumatic ICH presenting to centers with and without advanced neuroscience care specialization. METHODS This was a retrospective study of adult patients presenting with nontraumatic ICH between 1/1/2011 and 9/30/2020 across 21 medical centers within Kaiser Permanente Northern California, an integrated care system that employs a "hub-and-spoke" model of neuroscience care in which two centers service as neuroscience "hubs" and the remaining 19 centers service as referral "spokes." Patients presenting to spokes can receive remote consultation (including image review) by neurosurgical or neurointensive care specialists located at hubs. The primary outcome was 90-day mortality. We used hierarchical logistic regression, adjusting for ICH score components, comorbidities, and demographics, to test a hypothesis that initial presentation to a spoke medical center was noninferior to hub presentation [defined as an odds ratio (OR) with an upper 95% confidence interval (CI) limit of 1.24 or less]. RESULTS A total of 6978 patients were included, with 6170 (88%) initially presenting to spoke medical centers. The unadjusted 90-day mortality for patients initially presenting to spoke versus hub medical centers was 32.2% and 32.7%, respectively. In adjusted analysis, presentation to a spoke medical center was neither noninferior nor inferior for 90-day mortality risk (OR 1.21, 95% CI 0.84-1.74). Sensitivity analysis excluding patients admitted to general wards or lacking continuous health plan insurance during the follow-up period trended closer to a noninferior result (OR 0.99, 95% CI 0.69-1.44). CONCLUSIONS Within an integrated "hub-and-spoke" neuroscience care model, the risk of 90-day mortality following initial presentation with nontraumatic ICH to a spoke medical center was not conclusively noninferior compared with initial presentation to a hub medical center. However, there was also no indication that care for selected patients with nontraumatic ICH within medical centers lacking advanced neuroscience specialization resulted in significantly inferior outcomes. This finding may support the safety and efficiency of a "hub-and-spoke" care model for patients with nontraumatic ICH, although additional investigations are warranted.
Collapse
Affiliation(s)
- Dustin G Mark
- Departments of Emergency Medicine and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
| | - Jie Huang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - D Chris Sonne
- Division of Neuroradiology, Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| |
Collapse
|
25
|
Sondag L, Schreuder FHBM, Pegge SAH, Coutinho JM, Dippel DWJ, Janssen PM, Vandertop WP, Boogaarts HD, Dammers R, Klijn CJM. Safety and technical efficacy of early minimally invasive endoscopy-guided surgery for intracerebral haemorrhage: the Dutch Intracerebral haemorrhage Surgery Trial pilot study. Acta Neurochir (Wien) 2023; 165:1585-1596. [PMID: 37103585 PMCID: PMC10134719 DOI: 10.1007/s00701-023-05599-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 04/13/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Previous randomised controlled trials could not demonstrate that surgical evacuation of intracerebral haemorrhage (ICH) improves functional outcome. Increasing evidence suggests that minimally invasive surgery may be beneficial, in particular when performed early after symptom onset. The aim of this study was to investigate safety and technical efficacy of early minimally invasive endoscopy-guided surgery in patients with spontaneous supratentorial ICH. METHODS The Dutch Intracerebral Haemorrhage Surgery Trial pilot study was a prospective intervention study with blinded outcome assessment in three neurosurgical centres in the Netherlands. We included adult patients with spontaneous supratentorial ICH ≥10mL and National Institute of Health Stroke Scale (NIHSS) score ≥2 for minimally invasive endoscopy-guided surgery within 8 h after symptom onset in addition to medical management. Primary safety outcome was death or increase in NIHSS ≥4 points at 24 h. Secondary safety outcomes were procedure-related serious adverse events (SAEs) within 7 days and death within 30 days. Primary technical efficacy outcome was ICH volume reduction (%) at 24 h. RESULTS We included 40 patients (median age 61 years; IQR 51-67; 28 men). Median baseline NIHSS was 19.5 (IQR 13.3-22.0) and median ICH volume 47.7mL (IQR 29.4-72.0). Six patients had a primary safety outcome, of whom two already deteriorated before surgery and one died within 24 h. Sixteen other SAEs were reported within 7 days in 11 patients (of whom two patients that already had a primary safety outcome), none device related. In total, four (10%) patients died within 30 days. Median ICH volume reduction at 24 h was 78% (IQR 50-89) and median postoperative ICH volume 10.5mL (IQR 5.1-23.8). CONCLUSIONS Minimally invasive endoscopy-guided surgery within 8 h after symptom onset for supratentorial ICH appears to be safe and can effectively reduce ICH volume. Randomised controlled trials are needed to determine whether this intervention also improves functional outcome. TRIAL REGISTRATION Clinicaltrials.gov : NCT03608423, August 1st, 2018.
Collapse
Affiliation(s)
- Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO-box 9101, 6500HB, Nijmegen, The Netherlands
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO-box 9101, 6500HB, Nijmegen, The Netherlands
| | - Sjoert A H Pegge
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paula M Janssen
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - W Peter Vandertop
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neurosciences, Neurovascular Disorders, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Neurosurgery, Amsterdam Neurosciences, Neurovascular Disorders, De Boelelaan, 1117, Amsterdam, Netherlands
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO-box 9101, 6500HB, Nijmegen, The Netherlands.
| |
Collapse
|
26
|
Ratcliff JJ, Hall AJ, Porto E, Saville BR, Lewis RJ, Allen JW, Frankel M, Wright DW, Barrow DL, Pradilla G. Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH): Study protocol for a multi-centered two-arm randomized adaptive trial. Front Neurol 2023; 14:1126958. [PMID: 37006503 PMCID: PMC10061000 DOI: 10.3389/fneur.2023.1126958] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundIntracerebral hemorrhage (ICH) is a potentially devastating condition with elevated early mortality rates, poor functional outcomes, and high costs of care. Standard of care involves intensive supportive therapy to prevent secondary injury. To date, there is no randomized control study demonstrating benefit of early evacuation of supratentorial ICH.MethodsThe Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) Trial was designed to evaluate the minimally invasive trans-sulcal parafascicular surgery (MIPS) approach, a technique for safe access to deep brain structures and ICH removal using the BrainPath® and Myriad® devices (NICO Corporation, Indianapolis, IN). ENRICH is a multi-centered, two-arm, randomized, adaptive comparative-effectiveness study, where patients are block randomized by ICH location and Glasgow Coma Score (GCS) to early ICH evacuation using MIPS plus standard guideline-based management vs. standard management alone to determine if MIPS results in improved outcomes defined by the utility-weighted modified Rankin score (UWmRS) at 180 days as the primary endpoint. Secondary endpoints include clinical and economic outcomes of MIPS using cost per quality-adjusted life years (QALYs). The inclusion and exclusion criteria aim to capture a broad group of patients with high risk of significant morbidity and mortality to determine optimal treatment strategy.DiscussionENRICH will result in improved understanding of the benefit of MIPS for both lobar and deep ICH affecting the basal ganglia. The ongoing study will lead to Level-I evidence to guide clinicians treatment options in the management of acute treatment of ICH.Trial registrationThis study is registered with clinicaltrials.gov (Identifier: NCT02880878).
Collapse
Affiliation(s)
- Jonathan J. Ratcliff
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
- Department of Neurology, Emory University School of Medicine, Grady Hospital, Atlanta, GA, United States
| | - Alex J. Hall
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Edoardo Porto
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Benjamin R. Saville
- Berry Consultants LLC, Austin, TX, United States
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Roger J. Lewis
- Berry Consultants LLC, Austin, TX, United States
- Department of Emergency Medicine, Harbor-UCLA Medical Center, UCLA, Torrance, CA, United States
| | - Jason W. Allen
- Department of Neurology, Emory University School of Medicine, Grady Hospital, Atlanta, GA, United States
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Michael Frankel
- Department of Neurology, Emory University School of Medicine, Grady Hospital, Atlanta, GA, United States
| | - David W. Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Daniel L. Barrow
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
- *Correspondence: Gustavo Pradilla
| |
Collapse
|
27
|
Ali M, Zhang X, Ascanio LC, Troiani Z, Smith C, Dangayach NS, Liang JW, Selim M, Mocco J, Kellner CP. Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurosurg 2023; 138:154-164. [PMID: 35561694 DOI: 10.3171/2022.3.jns22286] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/31/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation. METHODS Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression. RESULTS A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27-65) ml and the median postoperative volume was 1.2 (0.3-7.5) ml, resulting in a median evacuation percentage of 97% (85%-99%). The median hospital length of stay was 17 (IQR 9-25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67-0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05-0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91-0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90-164, p = 0.01) as compared to those who had undergone evacuation after 48 hours. CONCLUSIONS In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.
Collapse
Affiliation(s)
- Muhammad Ali
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Xiangnan Zhang
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Luis C Ascanio
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Zachary Troiani
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Colton Smith
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Neha S Dangayach
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - John W Liang
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Magdy Selim
- 2Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - J Mocco
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Christopher P Kellner
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| |
Collapse
|
28
|
Nontraumatic Neurosurgical Emergencies. Crit Care Nurs Q 2023; 46:2-16. [DOI: 10.1097/cnq.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
29
|
Inoue H, Kawano T, Iwasaki Y, Imada I, Yamada K, Tashima K, Muta D, Yamamoto K, Mukasa A. Two weeks administration of tranexamic acid for acute intracerebral hemorrhage: A hospital-based pilot study. Surg Neurol Int 2023; 14:76. [PMID: 36895235 PMCID: PMC9990797 DOI: 10.25259/sni_1110_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/15/2023] [Indexed: 03/11/2023] Open
Abstract
Background A previous report suggested that functional status does not differ between patients who received tranexamic acid and those who received placebo within the early hours of intracerebral hemorrhage (ICH). Our pilot study tested the hypothesis that 2 weeks administration of tranexamic acid would contribute to functional improvement. Methods Consecutive patients with ICH were administered 250 mg tranexamic acid 3 times a day continuously for 2 weeks. We also enrolled historical control consecutive patients. We collected clinical data that involved hematoma size, level of consciousness, and Modified Rankin Scale (mRS) scores. Results Univariate analysis showed that the mRS score on day 90 was better in the administration group (P = 0.0095). The mRS scores on the day of death or discharge suggested a favorable effect of the treatment (P = 0.0678). Multivariable logistic regression analysis also showed that the treatment was associated with good mRS scores on day 90 (odds ratio [OR] = 2.81, 95% confidence interval [CI]: 1.10-7.21, P = 0.0312). In contrast, ICH size was associated with poor mRS scores on day 90 (OR = 0.92, 95% CI: 0.88-0.97, P = 0.0005). After propensity score matching, there was no difference in the outcomes between the two groups. We did not detect mild and serious adverse events. Conclusion The study could not show the significant effect of 2 weeks administration of tranexamic acid on functional outcomes of ICH patients after the matching; however, suggested that this treatment is at least safe and feasible. A larger and adequately powered trial is needed.
Collapse
Affiliation(s)
- Hirotaka Inoue
- Department of Neurosurgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takayuki Kawano
- Department of Neurosurgery, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Yuri Iwasaki
- Clinical Research Center, Hitoyoshi Medical Center, Hitoyoshi, Japan
| | - Izumi Imada
- Neurosurgery Unit, Hitoyoshi Medical Center, Hitoyoshi, Japan
| | - Kazuhiro Yamada
- Community Medical Cooperation Office, Hitoyoshi Medical Center, Hitoyoshi, Japan
| | - Kouzo Tashima
- Department of Neurosurgery, Kumamoto Medical Center, Kumamoto, Japan
| | - Daisuke Muta
- Department of Neurosurgery, Hitoyoshi Medical Center, Hitoyoshi, Japan
| | - Keizo Yamamoto
- Healthcare Center, Kumamoto Red Cross Hospital, Kumamoto, Japan
| | - Akitake Mukasa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| |
Collapse
|
30
|
Wilting FNH, Sondag L, Schreuder FHBM, Vinke RS, Dammers R, Klijn CJM, Boogaarts HD. Surgery for spontaneous supratentorial intracerebral haemorrhage. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022; 2022:CD015387. [PMCID: PMC9743082 DOI: 10.1002/14651858.cd015387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the efficacy and safety of surgery plus standard medical management, compared to standard medical management alone, in people with spontaneous supratentorial ICH, and to assess whether the effect of surgery differs according to the surgical technique.
Collapse
Affiliation(s)
| | - Floor NH Wilting
- Department of Neurology, Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CentreNijmegenNetherlands
| | - Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CentreNijmegenNetherlands
| | - Floris HBM Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CentreNijmegenNetherlands
| | - R Saman Vinke
- Department of NeurosurgeryRadboud University Medical CentreNijmegenNetherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical CentreErasmus MC Stroke CentreRotterdamNetherlands
| | - Catharina JM Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CentreNijmegenNetherlands
| | | |
Collapse
|
31
|
Li Z, Khan S, Liu Y, Wei R, Yong VW, Xue M. Therapeutic strategies for intracerebral hemorrhage. Front Neurol 2022; 13:1032343. [PMID: 36408517 PMCID: PMC9672341 DOI: 10.3389/fneur.2022.1032343] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/17/2022] [Indexed: 09/03/2023] Open
Abstract
Stroke is the second highest cause of death globally, with an increasing incidence in developing countries. Intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes. ICH is associated with poor neurological outcomes and high mortality due to the combination of primary and secondary injury. Fortunately, experimental therapies are available that may improve functional outcomes in patients with ICH. These therapies targeting secondary brain injury have attracted substantial attention in their translational potential. Here, we summarize recent advances in therapeutic strategies and directions for ICH and discuss the barriers and issues that need to be overcome to improve ICH prognosis.
Collapse
Affiliation(s)
- Zhe Li
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, China
| | - Suliman Khan
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, China
| | - Yang Liu
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, China
| | - Ruixue Wei
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, China
| | - V. Wee Yong
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Mengzhou Xue
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, China
| |
Collapse
|
32
|
Amano Y, Yamaguchi Y, Osato T, Watanabe T, Kamiyama K, Nakamura H. Long insular artery damage might be a key sign for predicting functional prognosis of putaminal hemorrhage. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
33
|
Ovenden CD, Hewitt J, Kovoor J, Gupta A, Edwards S, Abou-Hamden A, Kleinig T. Time to hospital presentation following intracerebral haemorrhage: Proportion of patients presenting within eight hours and factors associated with delayed presentation. J Stroke Cerebrovasc Dis 2022; 31:106758. [PMID: 36137452 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106758] [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: 12/05/2021] [Revised: 08/21/2022] [Accepted: 09/04/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Prolonged time to diagnosis of primary intracerebral haemorrhage (ICH) can result in delays in obtaining appropriate blood pressure control, reversal of coagulopathy or surgical intervention in select cases. We sought to characterise the time to diagnosis in a cohort of patients with ICH and identify factors associated with delayed diagnosis. METHODOLOGY The stroke database of our hospital was retrospectively reviewed to identify patients presenting to our hospitals emergency department with ICH over two years (January 2017-December 2018.) Data collected included demographics (age and sex), comorbidities, anticoagulation status, clinical scores (NIHSS, GCS, ICH score), and imaging (anatomical site, haematoma size). Time from symptom onset to diagnosis and hospital presentation were recorded. Factors associated with diagnosis >8 h post ictus were assessed using a univariate and then multivariable analysis. RESULTS 235 patients were identified with 125 males (53%) and a median age of 76 (range 40-98). For the 200 patients that initially presented to our hospital, median time to presentation was 179 min (IQR 77-584 min), and median time from ictus to imaging diagnosis was 268 min (IQR 114-717 min). 139 (70%) presented within 8 h of symptom onset, and 129 (65%) patients had imaging of the brain performed within 8 h of symptom onset. Factors associated with presentation >8 h post symptom onset included wake up stroke (OR 5.31, 95% confidence interval (CI) 2.36-11.96, p < 0.0001) and age (OR 1.04, 95% CI 1.01-1.08, p = 0.01). Patients with hemiplegia were less likely to present >8 h following ictus (OR 0.41, 95% CI 0.21-0.84, p = 0.01). CONCLUSIONS The majority of patients with ICH presented within 8 h of ictus. Cases of delayed diagnosis involved patients who had not incurred hemiplegia.
Collapse
Affiliation(s)
- Christopher Dillon Ovenden
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.
| | - Joseph Hewitt
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua Kovoor
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Aashray Gupta
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Amal Abou-Hamden
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Timothy Kleinig
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia; Stroke Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| |
Collapse
|
34
|
Shrestha D, Sharma U, Shrestha J, Nepal G, Shrestha B, Shrestha P, Acharya S, Gurung P, Shrestha R, Dhakal S, Rajbhandari P, Pant B. Surgical Management among Patients with Spontaneous Supratentorial Intracerebral Haemorrhage Admitted in a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2022; 60:697-701. [PMID: 36705228 PMCID: PMC9446498 DOI: 10.31729/jnma.7178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 07/28/2022] [Indexed: 01/31/2023] Open
Abstract
Introduction Spontaneous intracerebral haemorrhage is the second most common form of stroke and the most deadly one. An understanding of changing trends in the epidemiology of intracerebral haemorrhage prevalence, its risk factors, current practice in management, case fatality, and long-term outcome is essential to measure the effectiveness of stroke prevention and various treatment efforts. The objective of this study was to find out the prevalence of surgical management among patients with spontaneous supratentorial intracerebral haemorrhage in a tertiary centre. Methods A descriptive cross-sectional study was conducted in the Department of Neurosurgery from January 2017 to December 2019. Ethical approval was obtained from the Institutional Review Committee (Reference number: 06/2020/IRC-ANIAS). A convenience sampling method was used. Data of the patients were retrieved from online medical records. Point estimate and 95% Confidence Interval were calculated. Results Among 221 patients with spontaneous supratentorial intracerebral haemorrhage, 115 (52.04%) (45.45-58.63, 95% Confidence Interval) underwent surgical management. In-hospital mortality was seen in 23 (20%) and survivors at 3 months were 78 (67.82%) patients. Conclusions The prevalence of surgical management among spontaneous supratentorial intracerebral haemorrhages was higher than in other studies done in a similar setting. Keywords intracerebral haemorrhage; mortality; surgical procedure.
Collapse
Affiliation(s)
- Dinuj Shrestha
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal,Correspondence: Dr Dinuj Shrestha, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal. , Phone: +977-9841211502
| | - Upama Sharma
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Janam Shrestha
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Gopi Nepal
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Bishal Shrestha
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Pranaya Shrestha
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Samir Acharya
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Pritam Gurung
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Resha Shrestha
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Sudan Dhakal
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Pravesh Rajbhandari
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Basant Pant
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| |
Collapse
|
35
|
Liu M, Wang Z, Meng X, Zhou Y, Hou X, Li L, Li T, Chen F, Xu Z, Li S, Wang W. Predictive Nomogram for Unfavorable Outcome of Spontaneous Intracerebral Hemorrhage. World Neurosurg 2022; 164:e1111-e1122. [PMID: 35654327 DOI: 10.1016/j.wneu.2022.05.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The goal of this retrospective study was to evaluate the effect of surgical timing on patient outcomes after spontaneous intracerebral hemorrhage (ICH). We also identified risk factors associated with poor prognosis. METHODS We reviewed all patients who underwent surgery for ICH between January 2014 and January 2021. The outcome was measured using the modified Rankin Scale (mRS) score at 6 months after the surgery. Patients with mRS 0-2 were considered having favorable outcomes, and those with mRS 3-5 were considered having unfavorable outcomes. The relationships of surgical timing with the risk of unfavorable outcomes were identified using the interaction and stratified analyses, and generalized additive and logistic regression models. A nomogram was established and evaluated using a receiver operating characteristic curve analysis, plotted decision curve, and calibration curve. RESULTS We identified 53 patients with favorable outcomes and 144 with unfavorable outcomes. The number of cases who underwent surgery at >12 hours and <36 hours in the favorable outcome group was more than that in the unfavorable outcome group (P < 0.001). When the time to operating room (TOR) was less than 21 hours, a shorter TOR was associated with unfavorable outcomes, using the smoothing spline analysis (odds ratio = 0.8, P < 0.001). Finally, we developed a nomogram using systolic blood pressure, Glasgow Coma Scale, midline shift, hematoma volume, and TOR for predicting the unfavorable outcome. The area under the curve, accuracy, specificity, and sensitivity of nomogram were 0.90, 0.87, 0.72, and 0.93, respectively. CONCLUSION Surgical timing between 12 and 26 hours after ICH was associated with favorable outcomes. The nomogram including systolic blood pressure, Glasgow Coma Scale, midline shift, hematoma volume, and TOR was reliable for predicting the ICH outcome.
Collapse
Affiliation(s)
- Mingxing Liu
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China
| | - Zijun Wang
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China
| | - Xiankun Meng
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China
| | - Yong Zhou
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China
| | - Xiaoqun Hou
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China
| | - Luo Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China
| | - Tong Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China
| | - Feng Chen
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China.
| | - Zhiming Xu
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China
| | - Shengli Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China
| | - Weimin Wang
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, Shandong, P. R. China.
| |
Collapse
|
36
|
Irregular shape as an independent predictor of prognosis in patients with primary intracerebral hemorrhage. Sci Rep 2022; 12:8552. [PMID: 35595831 PMCID: PMC9123162 DOI: 10.1038/s41598-022-12536-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 05/12/2022] [Indexed: 11/09/2022] Open
Abstract
The utility of noncontrast computed tomography markers in the prognosis of spontaneous intracerebral hemorrhage has been studied. This study aimed to investigate the predictive value of the computed tomography (CT) irregularity shape for poor functional outcomes in patients with spontaneous intracerebral hemorrhage. We retrospectively reviewed all 782 patients with intracranial hemorrhage in our stroke emergency center from January 2018 to September 2019. Laboratory examination and CT examination were performed within 24 h of admission. After three months, the patient's functional outcome was assessed using the modified Rankin Scale. Multinomial logistic regression analyses were applied to identify independent predictors of functional outcome in patients with intracerebral hemorrhage. Out of the 627 patients included in this study, those with irregular shapes on CT imaging had a higher proportion of poor outcomes and mortality 90 days after discharge (P < 0.001). Irregular shapes were found to be significant independent predictors of poor outcome and mortality on multiple logistic regression analysis. In addition, the increase in plasma D-dimer was associated with the occurrence of irregular shapes (P = 0.0387). Patients with irregular shapes showed worse functional outcomes after intracerebral hemorrhage. The elevated expression level of plasma D-dimers may be directly related to the formation of irregular shapes.
Collapse
|
37
|
Hsu CH, Chou SC, Kuo LT, Huang SJ, Yang SH, Lai DM, Huang APH. Minimally Invasive Neurosurgery for Spontaneous Intracerebral Hemorrhage-10 Years of Working Progress at National Taiwan University Hospital. Front Neurol 2022; 13:817386. [PMID: 35669873 PMCID: PMC9163304 DOI: 10.3389/fneur.2022.817386] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/20/2022] [Indexed: 11/30/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a life-threatening disease with a global health burden. Traditional craniotomy has neither improved functional outcomes nor reduced mortality. Minimally invasive neurosurgery (MIN) holds promise for reducing mortality and improving functional outcomes. To evaluate the feasibility of MIN for ICH, a retrospective analysis of patients with ICH undergoing endoscopic-assisted evacuation was performed. From 2012 to 2018, a total of 391 patients who underwent ICH evacuation and 76 patients who received early (<8 h) MIN were included. The rebleeding, mortality, and morbidity rates were 3.9, 7.9, and 3.9%, respectively, 1 month after surgery. At 6 months, the median [interquartile range (IQR)] Glasgow Coma Scale score was 12 (4.75) [preoperative: 10 (4)], the median (IQR) Extended Glasgow Outcome Scale score was 3 (1), and the median (IQR) Modified Rankin Scale score was 4 (1). The results suggested that early (<8 h) endoscope-assisted ICH evacuation is safe and effective for selected patients with ICH. The rebleeding, morbidity, and mortality rates of MIN in this study are lower than those of traditional craniotomy reported in previous studies. However, the management of intraoperative bleeding and hard clots is critical for performing endoscopic evacuation. With this retrospective analysis of MIN cases, we hope to promote the specialization of ICH surgery in the field of MIN.
Collapse
Affiliation(s)
- Chiu-Hao Hsu
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Biomedical Park Hospital, Hsin-Chu, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sheng-Chieh Chou
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Lu-Ting Kuo
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sheng-Jean Huang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shih-Hung Yang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Dar-Ming Lai
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Abel Po-Hao Huang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
38
|
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: 417] [Impact Index Per Article: 208.5] [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
| | | | | | | |
Collapse
|
39
|
Advancing the Surgical Treatment of Intracerebral Hemorrhage: Study Design and Research Directions. World Neurosurg 2022; 161:367-375. [DOI: 10.1016/j.wneu.2022.01.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 12/23/2022]
|
40
|
Kim KH, Ro YS, Park JH, Jeong J, Shin SD, Moon S. Association between time to emergency neurosurgery and clinical outcomes for spontaneous hemorrhagic stroke: A nationwide observational study. PLoS One 2022; 17:e0267856. [PMID: 35482789 PMCID: PMC9049323 DOI: 10.1371/journal.pone.0267856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/16/2022] [Indexed: 11/19/2022] Open
Abstract
Objective
Spontaneous hemorrhagic stroke is a devastating disease with high mortality and grave neurological outcomes worldwide. This study aimed to evaluate the association between the elapsed time from emergency department (ED) visit to emergency neurosurgery and clinical outcomes in patients with spontaneous hemorrhagic stroke.
Methods
A nationwide cross-sectional study was conducted using the nationwide emergency database in Korea. Spontaneous hemorrhagic stroke patients who received neurosurgery within 12 hours of ED visit between January 2018 and December 2019 were enrolled. The main exposure was time to neurosurgery and the primary outcome was in-hospital mortality. Multivariable logistic regression was conducted.
Results
Among 2,602 study populations (incidence rate: 2.5 per 100,000 person-years, 15.8% of SAH, 78.6% of ICH, and 5.6% of mixed type), 525 (20.2%) patients received surgery in the ultra-early (0–2 hours) group, 1,093 (42.0%) in the early (2–4 hours) group, and 984 (37.8%) in the late (4–12 hours) group. The early group showed better survival outcomes than the ultra-early and late group (in-hospital mortality 22.2% vs. 26.5% and 26.1%, p = 0.06). Compared to the late group, adjusted OR (95% CI) for in-hospital mortality was 0.78 (0.63–0.96) for the early group, while there was no significant difference in the ultra-early group (0.90 (0.69–1.16)).
Conclusions
Early neurosurgery within 2–4 hours of the ED visit was associated with favorable survival outcomes in patients with spontaneous hemorrhagic stroke.
Collapse
Affiliation(s)
- Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- National Emergency Medical Center, National Medical Center, Seoul, Korea
- * E-mail:
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Joo Jeong
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Sungwoo Moon
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- National Emergency Medical Center, National Medical Center, Seoul, Korea
- Department of Emergency Medicine, Korea University Ansan Hospital, Gyeonggi, Korea
| |
Collapse
|
41
|
Park G, Agarwal T, Wang A, Doan N. Stereotactic Vacuum-Assisted Minimally Invasive Aspiration of Hemorrhagic Stroke. Cureus 2022; 14:e23706. [PMID: 35505704 PMCID: PMC9056157 DOI: 10.7759/cureus.23706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 11/18/2022] Open
Abstract
Intracerebral hemorrhage (ICH), accounting for 9-27% of all strokes, carries substantial rates of morbidity and mortality that have not shown much improvement in the past decades. The poor outcomes of ICH can be attributed to the primary and secondary brain injuries caused by mass effects and inflammatory mechanisms, respectively. Early ICH evacuation is a critical component of treatment, as it mitigates the effect of both the primary and secondary mechanisms of brain injury and is associated with significant improvement in patient outcomes. However, no standardized evacuation technique exists. This technical report introduces a novel stereotactic vacuum-assisted minimally invasive (MIS) aspiration of a hemorrhagic stroke with its effectiveness evidenced by excellent patient recovery.
Collapse
|
42
|
Cai Q, Wang W, Li Z, Song P, Zhou L, Cheng L, Wei H, Lei P, Chen Q, Yang Z. New approach of minimally invasive evacuation for spontaneous supratentorial intracerebral hemorrhage. Am J Transl Res 2022; 14:1969-1978. [PMID: 35422949 PMCID: PMC8991136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/03/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE We developed a new clinical surgery approach termed the "two-in-one technique" that combines neuroendoscopy with stereotactic aspiration for spontaneous supratentorial intracerebral hemorrhage (SSICH). This study was designed to explore its feasibility, safety, and effectiveness. METHODS Starting in December 2018, 40 patients (Group A) were prospectively studied after undergoing this new technique. The time to access the hematoma, average hematoma evacuation rate, and Glasgow Coma Scale (GCS) improvement at discharge were analyzed. Two patients had increased intracranial pressure (ICP) caused by the transparent plastic sheath and two other patients experienced ICP decreases following the two-in-one technique. The control groups included 42 patients treated by stereotactic aspiration (Group B) and 40 cases treated by neuroendoscopy (Group C). RESULTS All procedures were successfully completed. The average access time to hematoma was 4.675 minutes in Group A, which was much less than in Group C (10.20 minutes). The average hematoma evacuation rate was 91.91% which was much higher than Group B (44.2%), and the average GCS improvement at discharge was 3.82. The ICP increased sharply when the transparent plastic sheath was inserted, while ICP decreased significantly when using the new technique. CONCLUSIONS The two-in-one technique can decrease ICP quickly and avoid transient ICP increases caused by transparent sheath insertion. This approach can also avoid the shortcomings of stereotactic aspiration and offers the advantages of neuroendoscopy. More importantly, it was effective and safe, making it a promising method for the surgical treatment of SSICH.
Collapse
Affiliation(s)
- Qiang Cai
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityHubei Province, China
| | - Wenju Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityHubei Province, China
| | - Zhiyang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityHubei Province, China
| | - Ping Song
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityHubei Province, China
| | - Long Zhou
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityHubei Province, China
| | - Li Cheng
- Department of Critical Care Medicine, Eastern Campus, Renmin Hospital of Wuhan UniversityHubei Province, China
| | - Hangyu Wei
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityHubei Province, China
| | - Pan Lei
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityHubei Province, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan UniversityHubei Province, China
| | - Zhaohui Yang
- Department of Radiology, Renmin Hospital of Wuhan UniversityHubei Province, China
| |
Collapse
|
43
|
Crilly S, Parry-Jones A, Wang X, Selley JN, Cook J, Tapia VS, Anderson CS, Allan SM, Kasher PR. Zebrafish drug screening identifies candidate therapies for neuroprotection after spontaneous intracerebral haemorrhage. Dis Model Mech 2022; 15:274873. [PMID: 35098999 PMCID: PMC8990924 DOI: 10.1242/dmm.049227] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 01/19/2022] [Indexed: 11/20/2022] Open
Abstract
Despite the global health burden, treatment of spontaneous intracerebral haemorrhage (ICH) is largely supportive and translation of specific medical therapies has not been successful. Zebrafish larvae offer a unique platform for drug screening to rapidly identify neuroprotective compounds following ICH. We applied the Spectrum Library compounds to zebrafish larvae acutely after ICH to screen for decreased brain cell death and identified 150 successful drugs. Candidates were then evaluated for possible indications with other cardiovascular diseases. Six compounds were identified including two angiotensin converting enzyme inhibitors (ACE-I). Ramipril and quinapril were further assessed to confirm a significant 55% reduction in brain cell death. Proteomic analysis revealed potential mechanisms of neuroprotection. Using the INTERACT2 clinical trial dataset, we demonstrate a significant reduction in the adjusted odds of an unfavourable shift in the modified Rankin Scale at 90 days for patients receiving an ACE-I after ICH (vs. no ACE-I; odds ratio 0.80; 95% confidence interval 0.68-0.95; P=0.009). The zebrafish larval model of spontaneous ICH can be used as a reliable drug screening platform, and has identified therapeutics which may offer neuroprotection.
Collapse
Affiliation(s)
- Siobhan Crilly
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester; Oxford Road, Manchester, M13 9PT, UK.,Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, UK
| | - Adrian Parry-Jones
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester; Oxford Road, Manchester, M13 9PT, UK.,Manchester Centre for Clinical Neurosciences, Salford Royal, NHS Foundation Trust, Manchester Academic Health Science Centre; Stott Lane, Salford, M6 8HD, UK
| | - Xia Wang
- The George Institute for Global Health; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Julian N Selley
- The Biological Mass Spectrometry Core Research Facility, Faculty of Biology, Medicine and Health, The University of Manchester, M13 9PL, UK
| | - James Cook
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester; Oxford Road, Manchester, M13 9PT, UK.,Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, UK
| | - Victor S Tapia
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester; Oxford Road, Manchester, M13 9PT, UK.,Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, UK
| | - Craig S Anderson
- The George Institute for Global Health; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Stuart M Allan
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester; Oxford Road, Manchester, M13 9PT, UK.,Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, UK
| | - Paul R Kasher
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester; Oxford Road, Manchester, M13 9PT, UK.,Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, UK
| |
Collapse
|
44
|
Lin F, He Q, Tong Y, Zhao M, Ye G, Gao Z, Huang W, Cai L, Wang F, Fang W, Lin Y, Wang D, Dai L, Kang D. Early Deterioration and Long-Term Prognosis of Patients With Intracerebral Hemorrhage Along With Hematoma Volume More Than 20 ml: Who Needs Surgery? Front Neurol 2022; 12:789060. [PMID: 35069417 PMCID: PMC8766747 DOI: 10.3389/fneur.2021.789060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: The treatment of patients with intracerebral hemorrhage along with moderate hematoma and without cerebral hernia is controversial. This study aimed to explore risk factors and establish prediction models for early deterioration and poor prognosis. Methods: We screened patients from the prospective intracerebral hemorrhage (ICH) registration database (RIS-MIS-ICH, ClinicalTrials.gov Identifier: NCT03862729). The enrolled patients had no brain hernia at admission, with a hematoma volume of more than 20 ml. All patients were initially treated by conservative methods and followed up ≥ 1 year. A decline of Glasgow Coma Scale (GCS) more than 2 or conversion to surgery within 72 h after admission was defined as early deterioration. Modified Rankin Scale (mRS) ≥ 4 at 1 year after stroke was defined as poor prognosis. The independent risk factors of early deterioration and poor prognosis were determined by univariate and multivariate regression analysis. The prediction models were established based on the weight of the independent risk factors. The accuracy and value of models were tested by the receiver operating characteristic (ROC) curve. Results: After screening 632 patients with ICH, a total of 123 legal patients were included. According to statistical analysis, admission GCS (OR, 1.43; 95% CI, 1.18–1.74; P < 0.001) and hematoma volume (OR, 0.9; 95% CI, 0.84–0.97; P = 0.003) were the independent risk factors for early deterioration. Hematoma location (OR, 0.027; 95% CI, 0.004–0.17; P < 0.001) and hematoma volume (OR, 1.09; 95% CI, 1.03–1.15; P < 0.001) were the independent risk factors for poor prognosis, and island sign had a trend toward significance (OR, 0.5; 95% CI, 0.16-1.57; P = 0.051). The admission GCS and hematoma volume score were combined for an early deterioration prediction model with a score from 2 to 5. ROC curve showed an area under the curve (AUC) was 0.778 and cut-off point was 3.5. Combining the score of hematoma volume, island sign, and hematoma location, a long-term prognosis prediction model was established with a score from 2 to 6. ROC curve showed AUC was 0.792 and cutoff point was 4.5. Conclusions: The novel early deterioration and long-term prognosis prediction models are simple, objective, and accurate for patients with ICH along with a hematoma volume of more than 20 ml.
Collapse
Affiliation(s)
- Fuxin Lin
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Clinical Research and Translation Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Clinical Research Center for Neurological Diseases, Fuzhou, China
| | - Qiu He
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Youliang Tong
- Department of Neurosurgery, Wupin County Hospital, Wupin, China
| | - Mingpei Zhao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Gezhao Ye
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zhuyu Gao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wei Huang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Lveming Cai
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Fangyu Wang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Department of Neurosurgery, Wupin County Hospital, Wupin, China
| | - Wenhua Fang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Department of Neurosurgery, Wupin County Hospital, Wupin, China
| | - Yuanxiang Lin
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Clinical Research Center for Neurological Diseases, Fuzhou, China
| | - Dengliang Wang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Clinical Research Center for Neurological Diseases, Fuzhou, China
| | - Linsun Dai
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Clinical Research Center for Neurological Diseases, Fuzhou, China
| | - Dezhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Clinical Research and Translation Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Clinical Research Center for Neurological Diseases, Fuzhou, China
| |
Collapse
|
45
|
Berthaud JV, Morgenstern LB, Zahuranec DB. Medical Therapy of Intracerebral and Intraventricular Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00059-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
46
|
Porwal T, Mohanty S. Predictors of outcome in spontaneous intracerebral hemorrhage with special reference to hyponatremia. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2022. [DOI: 10.4103/injms.injms_78_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
47
|
Anderson CS. Intracerebral Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
48
|
Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
49
|
Surgery for Intracerebral Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
50
|
Duloquin G, Graber M, Baptiste L, Mohr S, Garnier L, Ndiaye M, Thomas Q, Hervieu-Bègue M, Osseby GV, Giroud M, Béjot Y. [Acute management of spontaneous intracerebral hemorrhage]. Rev Med Interne 2021; 43:293-300. [PMID: 34953622 DOI: 10.1016/j.revmed.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/14/2021] [Indexed: 11/16/2022]
Abstract
Intracerebral hemorrhage accounts for approximately 15% of the 115,000 strokes occurring each year in France. Although therapeutic strategies are more limited than for ischemic stroke, major points in the management of intracerebral hemorrhage can reduce short term morbidity and mortality by limiting the expansion of the hematoma and the occurrence of early complications, and long term patients' outcome by reducing the risk of recurrence. This article aims to update the key elements that contribute to improve of the prognosis of intracerebral hemorrhage patients.
Collapse
Affiliation(s)
- G Duloquin
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - M Graber
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - L Baptiste
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - S Mohr
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - L Garnier
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - M Ndiaye
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - Q Thomas
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - M Hervieu-Bègue
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - G-V Osseby
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - M Giroud
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France
| | - Y Béjot
- Service hospitalo-universitaire de neurologie, CHU Dijon Bourgogne, Registre Dijonnais des AVC, EA7460, université de Bourgogne, UBFC, Dijon, France.
| |
Collapse
|