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Tong P, Shan T, An J, Liu S, Jing G, Bi J, Wang Z. Analysis of Clinical Characteristic and Risk Factors for Short-Term Prognosis of Moyamoya Disease with Intraventricular Hemorrhage in Adults. World Neurosurg 2023; 171:e738-e744. [PMID: 36608789 DOI: 10.1016/j.wneu.2022.12.094] [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: 10/11/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) is the most common type of hemorrhage in moyamoya disease (MMD) with intracerebral hemorrhage (ICH), but the risk factors affecting the short-term prognosis of MMD with IVH in adults are still unclear. METHODS We retrospectively analyzed patients of MMD with IVH between January 1, 2018 and January 31, 2020 in the First Affiliated Hospital of Zhengzhou University. According to the modified Rankin Scale (mRS) score at 3 months after discharge, the patients were divided into mRS score ≤2 (good prognosis) group and mRS score >2 (poor prognosis) groups. Univariate and multivariate logistics regression analysis was used to analyze the risk factors affecting the short-term prognosis of adult MMD with IVH. RESULTS Univariable analyses showed that patients in the poor prognosis group had a significantly older age of onset (48.48 ± 8.34 vs. 43.74 ± 5.44 years; P = 0.002), a higher percentage of hypertension (57.97% vs. 33.33%; P = 0.014), a higher percentage of tracheotomy (23.19% vs. 2.56%; P = 0.005), a lower Glasgow Coma Scale (GCS) score (7.90 ± 3.58 vs. 11.19 ± 2.56; P = 0.000), a higher Graeb score (7.46 ± 4.04 vs. 5.23 ± 1.93; P = 0.002), and treatment methods (P = 0.000). Multiple logistic regression analysis showed that the lower GCS score (odds ratio [OR], 1.761; P = 0.001) and higher Graeb score (OR, 1.767; P = 0.002) were independently associated with the poor prognosis of MMD with IVH, and surgery treatment (OR, 0.032; P = 0.000) was independently related to the good prognosis of MMD with IVH. CONCLUSIONS Among patients with MMD with IVH, the lower GCS score and higher Graeb score are independent risk factors for poor prognosis, whereas in patients with MMD with IVH, surgery treatment acts as a protective factor.
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Affiliation(s)
- Pengfei Tong
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Tikun Shan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Jiyang An
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shuang Liu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Gehan Jing
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Jiajia Bi
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhengfeng Wang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.
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Continuous lumbar drainage after aneurysmal subarachnoid hemorrhage decreased malondialdehyde in cerebrospinal fluid and improved outcome. J Formos Med Assoc 2023; 122:164-171. [PMID: 36117035 DOI: 10.1016/j.jfma.2022.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/31/2022] [Accepted: 09/01/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The use of a continuous lumbar drain (LD) for the treatment of aneurysmal subarachnoid hemorrhage (aSAH), and malondialdehyde (MDA), a marker of oxidative stress, is correlated with clinical outcome. This study aimed to investigate the relationship between LD placement and MDA level after aSAH. METHODS Patients with modified Fisher's grade III and IV aSAH who underwent early aneurysm obliteration were enrolled. Cerebrospinal fluid (CSF) was obtained on day 7 after aSAH in non-LD group. In LD group, the LD was inserted on day 3 after aSAH for continuous CSF drainage. The levels of intrathecal hemoglobin, total bilirubin, ferritin, and MDA were measured. RESULTS There were 41 patients in non-LD group (age: 58.7 ± 13.7 years; female: 61.0%) and 48 patients in LD group (age: 58.3 ± 10.4 years; female: 79.2%). There were more favorable outcomes (Glasgow Outcome Scale ≥4) at 3 months after aSAH in LD group (p = 0.0042). The intrathecal hemoglobin, total bilirubin, ferritin, and MDA levels at day 7 after aSAH were all significantly lower in LD group. An older age (>60 years) (p = 0.0293), higher MDA level in the CSF (p = 0.0208), and delayed ischemic neurological deficit (p = 0.0451) were independent factors associated with unfavorable outcomes. LD placement was associated with a decreased intrathecal MDA level on day 7 after aSAH (p < 0.001). CONCLUSION The intrathecal MDA level at day 7 after aSAH can be an effective outcome indicator in modified Fisher's grade III/IV aSAH. Continuous CSF drainage via a LD can decrease the intrathecal MDA level and improve the functional outcome.
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Pacult MA, Catapano JS, Rumalla K, Winkler EA, Graffeo CS, Srinivasan VM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Intraventricular Tissue Plasminogen Activator and Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 170:242-243. [PMID: 36396046 DOI: 10.1016/j.wneu.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mark A Pacult
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Scurfield AK, Wilson MD, Gurkoff G, Martin R, Shahlaie K. Identification of Demographic and Clinical Prognostic Factors in Traumatic Intraventricular Hemorrhage. Neurocrit Care 2023; 38:149-157. [PMID: 36050537 PMCID: PMC9957945 DOI: 10.1007/s12028-022-01587-z] [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: 03/18/2022] [Accepted: 08/08/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The presence of traumatic intraventricular hemorrhage (tIVH) following traumatic brain injury (TBI) is associated with worse neurological outcome. The mechanisms by which patients with tIVH have worse outcome are not fully understood and research is ongoing, but foundational studies that explore prognostic factors within tIVH populations are also lacking. This study aimed to further identify and characterize demographic and clinical variables within a subset of patients with TBI and tIVH that may be implicated in tIVH outcome. METHODS In this observational study, we reviewed a large prospective TBI database to determine variables present on admission that predicted neurological outcome 6 months after injury. A review of 7,129 patients revealed 211 patients with tIVH on admission and 6-month outcome data. Hypothesized risk factors were tested in univariate analyses with significant variables (p < 0.05) included in logistic and linear regression models. Following the addition of either the Rotterdam computed tomography or Glasgow Coma Scale (GCS) score, we employed a backward selection process to determine significant variables in each multivariate model. RESULTS Our study found that that hypotension (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.13-0.94, p = 0.04) and the hemoglobin level (OR = 1.33, 95% CI = 1.09-1.63, p = 0.006) were significant predictors in the Rotterdam model, whereas only the hemoglobin level (OR = 1.29, 95% CI = 1.06-1.56, p = 0.01) was a significant predictor in the GCS model. CONCLUSIONS This study represents one of the largest investigations into prognostic factors for patients with tIVH and demonstrates that admission hemoglobin level and hypotension are associated with outcomes in this patient population. These findings add value to established prognostic scales, could inform future predictive modeling studies, and may provide potential direction in early medical management of patients with tIVH.
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Affiliation(s)
- Abby K Scurfield
- Frank H. Netter M.D. School of Medicine, Quinnipiac University, 830 Orange Street, New Haven, CT, 06511, USA
| | - Machelle D Wilson
- Division of Biostatistics, Department of Public Health Sciences, Davis Clinical and Translational Science Center, University of California, 2921 Stockton Blvd., Suite 1400, Sacramento, CA, 95817, USA
| | - Gene Gurkoff
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA
| | - Ryan Martin
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA
- Department of Neurology, University of California, 4860 Y Street, Suite 3740,, Davis, Sacramento, CA, USA
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA.
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Measuring the effect of thrombosis, thrombus maturation and thrombolysis on clot mechanical properties in an in-vitro model. J Biomech 2021; 129:110731. [PMID: 34601216 DOI: 10.1016/j.jbiomech.2021.110731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/23/2021] [Accepted: 07/25/2021] [Indexed: 01/05/2023]
Abstract
Changes in acute ischemic stroke thrombi structure and composition may result in significant differences in treatment responsiveness. Ischemic stroke patients are often treated with a thrombolytic agent to dissolve thrombi, however these patients may subsequently undergo mechanical thrombectomy to remove the occlusive clot. We set out to determine if rt-PA thrombolysis treatment of blood clots changes their mechanical properties, which in turn may impact mechanical thrombectomy. Using a design-of-experiment approach, ovine clot analogues were prepared with varying composition and further exposed to different levels of compaction force to simulate the effect of arterial blood pressure. Finally, clots were treated with three r-tPA doses for different durations. Clot mass and mechanical behaviour was analysed to assess changes due to (i) Platelet driven contraction (ii) Compaction force and (iii) Thrombolysis. Clots that were exposed to r-tPA for longer duration showed significant reduction in clot mass (p < 0.001). Exposure time to r-tPA (p < 0.001) was shown to be an independent predictor of lower clot stiffness. A decrease in energy dissipation ratio during mechanical compression was associated with longer exposure time in r-tPA (p = 0.001) and a higher platelet concentration ratio (p = 0.018). The dose of r-tPA was not a significant factor in reducing clot mass or changing mechanical properties of the clots. Fibrinolysis reduces clot stiffness which may explain increased distal clot migration observed in patients treated with r-tPA and should be considered as a potential clot modification factor before mechanical thrombectomy.
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Yoshizaki S, Kijima K, Hara M, Saito T, Tamaru T, Tanaka M, Konno DJ, Nakashima Y, Okada S. Tranexamic acid reduces heme cytotoxicity via the TLR4/TNF axis and ameliorates functional recovery after spinal cord injury. J Neuroinflammation 2019; 16:160. [PMID: 31358003 PMCID: PMC6661785 DOI: 10.1186/s12974-019-1536-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/05/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Spinal cord injury (SCI) is a catastrophic trauma accompanied by intralesional bleeding and neuroinflammation. Recently, there is increasing interest in tranexamic acid (TXA), an anti-fibrinolytic drug, which can reduce the bleeding volume after physical trauma. However, the efficacy of TXA on the pathology of SCI remains unknown. METHODS After producing a contusion SCI at the thoracic level of mice, TXA was intraperitoneally administered and the bleeding volume in the lesion area was quantified. Tissue damage was evaluated by immunohistochemical and gene expression analyses. Since heme is one of the degraded products of red blood cells (RBCs) and damage-associated molecular pattern molecules (DAMPs), we examined the influence of heme on the pathology of SCI. Functional recovery was assessed using the open field motor score, a foot print analysis, a grid walk test, and a novel kinematic analysis system. Statistical analyses were performed using Wilcoxon's rank-sum test, Dunnett's test, and an ANOVA with the Tukey-Kramer post-hoc test. RESULTS After SCI, the intralesional bleeding volume was correlated with the heme content and the demyelinated area at the lesion site, which were significantly reduced by the administration of TXA. In the injured spinal cord, toll-like receptor 4 (TLR4), which is a DAMP receptor, was predominantly expressed in microglial cells. Heme stimulation increased TLR4 and tumor necrosis factor (TNF) expression levels in primary microglial cells in a dose-dependent manner. Similarly to the in vitro experiments, the injection of non-lysed RBCs had little pathological influence on the spinal cord, whereas the injection of lysed RBCs or heme solution significantly upregulated the TLR4 and TNF expression in microglial cells. In TXA-treated SCI mice, the decreased expressions of TLR4 and TNF were observed at the lesion sites, accompanied by a significant reduction in the number of apoptotic cells and better functional recovery in comparison to saline-treated control mice. CONCLUSION The administration of TXA ameliorated the intralesional cytotoxicity both by reducing the intralesional bleeding volume and preventing heme induction of the TLR4/TNF axis in the SCI lesion. Our findings suggest that TXA treatment may be a therapeutic option for acute-phase SCI.
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Affiliation(s)
- Shingo Yoshizaki
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
- Department of Immunology and Neuroscience, Medical Institute of Bioregulation, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Ken Kijima
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
- Department of Immunology and Neuroscience, Medical Institute of Bioregulation, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Masamitsu Hara
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Takeyuki Saito
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Tetsuya Tamaru
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
- Department of Immunology and Neuroscience, Medical Institute of Bioregulation, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Masatake Tanaka
- Department of Immunology and Neuroscience, Medical Institute of Bioregulation, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Dai-jiro Konno
- Department of Immunology and Neuroscience, Medical Institute of Bioregulation, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Yasuharu Nakashima
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Seiji Okada
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
- Department of Immunology and Neuroscience, Medical Institute of Bioregulation, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
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Masomi-Bornwassser J, Freguia F, Müller-Werkmeister H, Kempski O, Giese A, Keric N. Effect of irrigation on fibrinolytic rtPA therapy in a clot model of intracerebral haemorrhage: a systematic in vitro study. Acta Neurochir (Wien) 2018; 160:1159-1165. [PMID: 29564653 DOI: 10.1007/s00701-018-3517-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 03/09/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Although fibrinolytic therapy is an upcoming treatment for intracerebral haemorrhage (ICH), standard guidelines are lacking, and some clinical issues persist. Here, we used our recently devised clot model of ICH to systematically analyse effects of irrigation and cerebrospinal fluid (CSF) on fibrinolysis. METHODS In vitro clots of human blood (25 ml) were generated and a catheter irrigation system was applied to deliver fluid/treatment. Clots were weighed before and after treatment and compared to rtPA treatment alone. First various drainage periods (15, 30 and 60 min; n = 3 each) and irrigation rates (0, 15, 90 and 180 ml/h; n = 3-5 each) were tested, followed by rtPA administration (1 mg, 15 min incubation) at each irrigation rate. Potential fibrinolytic effect of CSF was examined by incubation with 5 ml healthy vs. haemorrhagic CSF (n = 3 each). To assess a washout effect treatment with saline (0.9%), rtPA (1 mg) and high-rate irrigation (180 ml/h) were compared with measuring plasminogen level before and after. Furthermore clots were treated with a combination of plasminogen (150% serum concentration) and rtPA (1 mg). RESULTS Relative clot end weights after 60 min irrigation system treatments were 66.3 ± 3.8% (0 ml/h), 46.3 ± 9.5% (15 ml/h), 46.5 ± 7.1% (90 ml/h) and 53.3 ± 4.1% (180 ml/h). At a lower irrigation rate (15 ml/h), relative end weights were lowest (49.5 ± 4.6%) after 60 min (15 min: 62 ± 4.3%, p = 0.016; 30 min: 62.90 ± 1.88%, p = 0.012). The combination of rtPA and irrigation produced following relative end weights: 0 ml/h, 35 ± 3.2%; 15 ml/h, 32.1 ± 5.7%; 90 ml/h, 36.7 ± 6.3% and 180 ml/h, 41.9 ± 7.5%. No irrigation (0 ml/h) versus rtPA alone showed a significant difference (p < 0.0001) in higher clot weight reduction by rtPA. Similar rtPA+15 ml/h irrigation achieved a significant higher weight reduction compared to 15 ml/h irrigation alone (p = 0.0124). No differences were evident at 90 and 180 ml/h irrigation rates with and without rtPA. Healthy (55.1 ± 5%) or haemorrhagic (65.2 ± 6.2%) CSF showed no fibrinolytic activity. Plasminogen levels in clots declined dramatically (> 80% initially to < 10%) after 1 mg single rtPA dosing and high-rate (180 ml/h) irrigation. The fibrinolytic benefit of adding plasminogen to rtPA was marginal. CONCLUSIONS In our in vitro clot model, irrigation combined with rtPA (vs. rtPA alone) conferred no added lytic benefit. Likewise, exposure to haemorrhagic CSF did not increase clot lysis.
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Affiliation(s)
- Julia Masomi-Bornwassser
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Fabio Freguia
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
- Department of Neuropathology, University- and Knappschaft- Hospital Bochum, Bochum, Germany
| | - Hendrik Müller-Werkmeister
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Asklepios Klinikum Harburg, Hamburg, Germany
| | - Oliver Kempski
- Institute of Neurosurgical Pathophysiology, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Alf Giese
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
- OrthoCentrum Hamburg, Hansastr. 1-3, Hamburg, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
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Local Fibrinolytic Therapy for Intraventricular Hemorrhage: A Meta-Analysis of Randomized Controlled trials. World Neurosurg 2017; 107:1016-1024.e1. [PMID: 28778779 DOI: 10.1016/j.wneu.2017.07.135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 07/20/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The safety and efficacy of intraventricular fibrinolysis (IVF) in patients with intraventricular hemorrhage (IVH) are unclear. We aimed to determine these issues and to evaluate whether there are differences between recombinant tissue-plasminogen activator (rt-PA) and urokinase according to subgroup analyses. METHODS A meta-analysis was undertaken of randomized controlled trials in patients with IVH that compared the administration of rt-PA or urokinase through extraventricular drainage (EVD) with normal saline through EVD or EVD placement alone. RESULTS Six randomized controlled trials involving 607 patients with IVH were included; 2 trials investigated urokinase and 4 rt-PA. IVF reduced death from any cause at the end of follow-up (risk ratio [RR] 0.63, 95% confidence interval [CI] 0.47-0.83), which was driven mostly by rt-PA (RR 0.65, 95% CI 0.48-0.86). Urokinase did not reduce mortality (RR 0.30, 95% CI 0.06-1.53). However, rt-PA did not reduce the proportion of survivors with poor functional outcome (RR 1.36, 95% CI 1.04-1.77), or the composite endpoint of death and poor functional outcome (RR 0.96, 95% CI 0.83-1.11). IVF neither reduced the need for shunt placement (RR 1.06, 95% CI 0.75-1.49) nor increased ventriculitis (RR 0.57, 95% CI 0.35-0.93) and rebleeding (RR 1.65, 95% CI 0.79-3.45). CONCLUSIONS Although the use of IVF in patients with IVH appears generally safe, its benefit is limited to a reduction in mortality at the expense of an increased number of survivors with moderately-severe to severe disability. Subgroup analyses do not suggest an advantage of IVF with urokinase over rt-PA.
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Hanley DF, Lane K, McBee N, Ziai W, Tuhrim S, Lees KR, Dawson J, Gandhi D, Ullman N, Mould WA, Mayo SW, Mendelow AD, Gregson B, Butcher K, Vespa P, Wright DW, Kase CS, Carhuapoma JR, Keyl PM, Diener-West M, Muschelli J, Betz JF, Thompson CB, Sugar EA, Yenokyan G, Janis S, John S, Harnof S, Lopez GA, Aldrich EF, Harrigan MR, Ansari S, Jallo J, Caron JL, LeDoux D, Adeoye O, Zuccarello M, Adams HP, Rosenblum M, Thompson RE, Awad IA. Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet 2017; 389:603-611. [PMID: 28081952 PMCID: PMC6108339 DOI: 10.1016/s0140-6736(16)32410-2] [Citation(s) in RCA: 297] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome. METHODS In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134. FINDINGS Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88-1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90-1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41-0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22-3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31-0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64-0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37-3·91], p=0·771) was similar. INTERPRETATION In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status. FUNDING National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Daniel F Hanley
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA.
| | - Karen Lane
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Nichol McBee
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Wendy Ziai
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Stanley Tuhrim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Natalie Ullman
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - W Andrew Mould
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | | | | | | | | | - Paul Vespa
- University of California, Los Angeles, CA, USA
| | | | | | - J Ricardo Carhuapoma
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Penelope M Keyl
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Marie Diener-West
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - John Muschelli
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Joshua F Betz
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Carol B Thompson
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Elizabeth A Sugar
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Gayane Yenokyan
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Scott Janis
- National Institutes of Health, National institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | | | - Sagi Harnof
- Chaim Sheba Medical Center, Ramat Gan, Israel
| | | | | | | | | | - Jack Jallo
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - David LeDoux
- North Shore Long Island Jewish Medical Center, Manhasset, NY, USA
| | | | | | | | - Michael Rosenblum
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Richard E Thompson
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
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10
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Kornbluth J, Nekoovaght-Tak S, Ullman N, Carhuapoma JR, Hanley DF, Ziai W. Early Quantification of Hematoma Hounsfield Units on Noncontrast CT in Acute Intraventricular Hemorrhage Predicts Ventricular Clearance after Intraventricular Thrombolysis. AJNR Am J Neuroradiol 2015; 36:1609-15. [PMID: 26228884 DOI: 10.3174/ajnr.a4393] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 01/15/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Thrombolytic efficacy of intraventricular rtPA for acute intraventricular hemorrhage may depend on hematoma composition. We assessed whether hematoma Hounsfield unit quantification informs intraventricular hemorrhage clearance after intraventricular rtPA. MATERIALS AND METHODS Serial NCCT was performed on 52 patients who received intraventricular rtPA as part of the Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage trial and 12 controls with intraventricular hemorrhage, but no rtPA treatment. A blinded investigator calculated Hounsfield unit values for intraventricular hemorrhage volumes on admission (t0), days 3-4 (t1), and days 6-9 (t2). Controls were matched uniquely to 12 rtPA-treated patients for comparison. RESULTS Median intraventricular hemorrhage volume on admission for patients treated with intraventricular rtPA was 31.9 mL (interquartile range, 34.1 mL), and it decreased to 4.9 mL (interquartile range, 14.5 mL) (t2). Mean (±standard error of the mean) Hounsfield unit for intraventricular hemorrhage was 52.1 (0.59) at t0 and decreased significantly to 50.1 (0.63) (t1), and to 45.1 (0.71) (t2). Total intraventricular hemorrhage Hounsfield unit count was significantly correlated with intraventricular hemorrhage volume at all time points (t0: P = .002; t1: P < .001; t2: P < .001). On serologic and CSF analysis at t0, only higher CSF protein was positively correlated with intraventricular hemorrhage Hounsfield units (P = .03). In 24 matched patients treated with rtPA and controls, total intraventricular hemorrhage Hounsfield units were significantly lower in patients treated with rtPA at t2 (P = .02). Higher Hounsfield unit quantification of fourth ventricle hematomas independently predicted slower clearance of this ventricle (95% CI, 0.02-0.14; P = .02), along with higher intraventricular hemorrhage volume (95% CI, 0.02-0.41; P = .03) and lower CSF protein levels (95% CI, -0.003 to -0.002; P < .001). CONCLUSIONS Intraventricular hemorrhage Hounsfield unit counts decrease significantly in the acute phase and to a greater extent with intraventricular rtPA treatment. Intraventricular hemorrhage Hounsfield units are correlated significantly with CSF protein and not with serum erythrocyte or platelet concentrations. Hounsfield unit counts may reflect intraventricular hemorrhage clot composition and rtPA sensitivity.
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Affiliation(s)
- J Kornbluth
- From the Department of Neurology (J.K.), Division of Neurocritical Care, Tufts University School of Medicine, Boston, Massachusetts Department of Neurology (J.K., J.R.C., W.Z.), Division of Neurocritical Care
| | - S Nekoovaght-Tak
- Department of Neurology (S.N.-T., N.U., J.R.C., D.F.H., W.Z.), Division of Brain Injuries Outcomes, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - N Ullman
- Department of Neurology (S.N.-T., N.U., J.R.C., D.F.H., W.Z.), Division of Brain Injuries Outcomes, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - J R Carhuapoma
- Department of Neurology (J.K., J.R.C., W.Z.), Division of Neurocritical Care Department of Neurology (S.N.-T., N.U., J.R.C., D.F.H., W.Z.), Division of Brain Injuries Outcomes, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - D F Hanley
- Department of Neurology (S.N.-T., N.U., J.R.C., D.F.H., W.Z.), Division of Brain Injuries Outcomes, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - W Ziai
- Department of Neurology (J.K., J.R.C., W.Z.), Division of Neurocritical Care Department of Neurology (S.N.-T., N.U., J.R.C., D.F.H., W.Z.), Division of Brain Injuries Outcomes, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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11
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Khan NR, Tsivgoulis G, Lee SL, Jones GM, Green CS, Katsanos AH, Klimo P, Arthur AS, Elijovich L, Alexandrov AV. Fibrinolysis for Intraventricular Hemorrhage. Stroke 2014; 45:2662-9. [DOI: 10.1161/strokeaha.114.005990] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Nickalus R. Khan
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Georgios Tsivgoulis
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Siang Liao Lee
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - G. Morgan Jones
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Cain S. Green
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Aristeidis H. Katsanos
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Paul Klimo
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Adam S. Arthur
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Lucas Elijovich
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
| | - Andrei V. Alexandrov
- From the Department of Neurosurgery (N.R.K., G.M.J., P.K., A.S.A., L.E.), Department of Neurology (G.T., G.M.J., L.E., A.V.A.), Department of Clinical Pharmacy (G.M.J.), and College of Medicine (C.S.G.), University of Tennessee Health Sciences Center, Memphis; Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece (G.T.); International Clinical Research Center, Department of Neurology, St. Anne’s University Hospital, Brno, Czech Republic
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12
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Xi G, Strahle J, Hua Y, Keep RF. Progress in translational research on intracerebral hemorrhage: is there an end in sight? Prog Neurobiol 2014; 115:45-63. [PMID: 24139872 PMCID: PMC3961535 DOI: 10.1016/j.pneurobio.2013.09.007] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 09/11/2013] [Accepted: 09/24/2013] [Indexed: 02/08/2023]
Abstract
Intracerebral hemorrhage (ICH) is a common and often fatal stroke subtype for which specific therapies and treatments remain elusive. To address this, many recent experimental and translational studies of ICH have been conducted, and these have led to several ongoing clinical trials. This review focuses on the progress of translational studies of ICH including those of the underlying causes and natural history of ICH, animal models of the condition, and effects of ICH on the immune and cardiac systems, among others. Current and potential clinical trials also are discussed for both ICH alone and with intraventricular extension.
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Affiliation(s)
- Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States.
| | - Jennifer Strahle
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
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13
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Clearing bloody cerebrospinal fluid: clot lysis, neuroendoscopy and lumbar drainage. Curr Opin Crit Care 2013; 19:92-100. [PMID: 23337912 DOI: 10.1097/mcc.0b013e32835cae5e] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Bloody cerebrospinal fluid (CSF) is a major cause of morbidity and mortality in intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Different treatment strategies aiming at faster clearance of bloody CSF have emerged. The present review focuses on recent developments in the investigation of those treatments. RECENT FINDINGS Intraventricular fibrinolysis (IVF) for accelerated IVH-resolution has been clinically tested since the early 1990s. The lately summarized evidence from smaller studies indicates that IVF may result in a benefit in mortality and outcome. Recent investigations have elucidated different aspects of IVF, mainly related to safety. Neuroendoscopy has also emerged as a minimally invasive technique allowing fast removal of IVH. The capability of lumbar drainage to reduce vasospasm after SAH has been tested in a large trial. SUMMARY IVF is relatively well tolerated and accelerates clot clearance after IVH. The effect of IVF on clinical outcome and mortality is currently being investigated in a large-scale phase III clinical trial. Neuroendoscopy is feasible for the treatment of IVH, however, larger trials are lacking. Lumbar drainage reduces the incidence of vasospasm after SAH. An ongoing phase III trial has been designed to test its influence on outcome. Lumbar drainage may also reduce shunt-dependency after IVH.
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14
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Kuramatsu JB, Huttner HB, Schwab S. Advances in the management of intracerebral hemorrhage. J Neural Transm (Vienna) 2013; 120 Suppl 1:S35-41. [PMID: 23720189 DOI: 10.1007/s00702-013-1040-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/14/2013] [Indexed: 12/14/2022]
Abstract
Intracerebral hemorrhage (ICH) is one of the most detrimental sub-types of stroke and accounts for 10-15% of all strokes Qureshi et al. (Lancet 373(9675):1632-1644, 2009). ICH has an incidence of 10-30 cases per 100,000 people/year which is increasing and expected to double by the year 2050 Qureshi et al. (N Engl J Med 344 (19):1450-1460, 2001). Mortality rates still remain poor (30-50%) and functional dependency after ICH is high (~75%) van Asch et al. (Lancet Neurol 9 (2):167-176, 2010). Up to now, all randomized controlled trials investigating treatment approaches in ICH have failed to document improvements on clinical endpoints Mayer et al. (N Engl J Med 358 (20):2127-2137, 2008); Brouwers and Goldstein (Neurotherapeutics 9 (1):87-98, 2012). Only a specialized treatment of severely injured patients at dedicated neuro intensive care units [NICU] has been shown to be beneficial Qureshi et al. (Lancet 373(9675):1632-1644, 2009); Suarez et al. (Crit Care Med 32 (11):2311-2317, 2004). Currently, ongoing trials are investigating aggressive blood pressure lowering, hemostatic therapies, different operative strategies, intraventricular thrombolysis as well as neuroprotective approaches, and brain edema therapies. This review will summarize advanced treatment strategies and novel approaches which are currently under investigation.
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Affiliation(s)
- J B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany
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