Low Serum Calcium Levels Contribute to Larger Hematoma Volume in Acute Intracerebral Hemorrhage

Can baseline serum calcium levels predict outcomes of intracerebral hemorrhage? A systematic review and meta-analysis

OBJECTIVE

The prognostic role of baseline calcium levels in patients with intracerebral hemorrhage (ICH) is conflicting. We aimed to conduct the first meta-analysis in the literature to examine if baseline calcium levels can predict outcomes after ICH.

METHODS

English-language studies listed on the databases of Embase, PubMed, ScienceDirect, and Web of Science were searched up to 20th November 2023. Meta-analysis was conducted for baseline hematoma volume, hematoma expansion, unfavorable functional outcome, and mortality.

RESULTS

Ten studies were included. Meta-analysis showed that patients with hypocalcemia have significantly higher baseline hematoma volume (MD: 8.6 95 % CI: 3.30, 13.90 I2 = 88 %) but did not have a higher risk of hematoma expansion (OR: 1.82 95 % CI: 0.89, 3.73 I2 = 82 %). Meta-analysis of crude (OR: 1.86 95 % CI: 1.25, 2.78 I2 = 63 %) and adjusted data (OR: 2.05 95 % CI: 1.27, 3.28 I2 = 64 %) showed those with hypocalcemia had a significantly higher risk of unfavorable functional outcomes. Meta-analysis of both crude (OR: 2.09 95 % CI: 1.51, 2.88 I2 = 80 %) and adjusted data (OR: 1.38 95 % CI: 1.14, 1.69 I2 = 70 %) also demonstrated a significantly higher risk of mortality in patients with hypocalcemia.

CONCLUSION

Baseline serum calcium may have a prognostic role in ICH. Hypocalcemia at baseline may lead to large hematoma volume and poor functional and survival outcomes. However, there seems to be no relation between hypocalcemia and the risk of hematoma expansion. Further studies examining the role of calcium on ICH prognosis are needed.

Hypocalcemia and cardiovascular mortality in cinacalcet users

BACKGROUND

Calcimimetics are widely used in hemodialysis patients and influence serum calcium levels. Although the Kidney Disease: Improving Global Outcomes guidelines argued that low calcium levels induced by calcimimetics may be harmless, large observational studies investigating the association between hypocalcemia and mortality are scarce. We investigated the association between serum calcium levels and cardiovascular mortality in calcimimetics users using the nationwide Japanese registry for dialysis patients.

METHODS

In this 9-year prospective cohort study, the baseline data were collected at the end of 2009. We enrolled patients on maintenance hemodialysis or hemodiafiltration. We employed three models (baseline, time-dependent and time-averaged) to conduct Cox proportional hazard regression analyses.

RESULTS

Cinacalcet was prescribed to 12.7% (N = 22 853) at baseline. The median observation period was 98 (interquartile range 40-108) months and 108 (interquartile range 59-108) months in the whole cohort (N = 180 136) and in cinacalcet users, respectively. Three-quarters of survivors at the end of 2019 had continued calcimimetic therapy for 10 years, corresponding to a mean annual dropout rate of 2.9%. Hypocalcemia was not associated with cardiovascular mortality in the baseline or time-averaged model. In the time-dependent model, however, the lowest calcium decile (corrected calcium <8.4 mg/dL) was significantly associated with higher cardiovascular mortality than the reference (corrected calcium 8.7-8.9 mg/dL) in both cinacalcet users and all patients [hazard ratio (95% confidence interval) 1.32 (1.00, 1.75) and 1.15 (1.05, 1.26), respectively]. Hypocalcemia was especially associated with sudden death and death due to hemorrhagic stroke, heart failure and ischemic heart disease. Higher rate of fatal and non-fatal cardiovascular events was observed in hypocalcemic patients regardless of cinacalcet usage.

CONCLUSIONS

Our findings suggest that transient hypocalcemia was associated with an increased risk of cardiovascular death independent of cinacalcet usage. We should pay attention to hypocalcemia transiently induced by cinacalcet.

The association between preoperative blood calcium and postoperative blood loss in patients undergoing heart valve replacement surgery

INTRODUCTION

Bleeding after heart valve surgery is a serious clinical challenge. Hypocalcemia has been associated with the extent of bleeding in patients with spontaneous intracerebral hemorrhage. However, the association between blood calcium levels and bleeding extent in heart valve replacement patients has not been clearly established. This study aimed at determining the association between blood calcium levels and perioperative hemorrhage after heart valve replacement therapy.

METHODS

Based on preoperative blood calcium levels, patients were grouped into the hypocalcemia group and normocalcemia group. Postoperative bleeding, blood product use, and complications were monitored during hospitalization. The association between blood calcium levels and major bleeding was determined by multivariable logistic regression models.

RESULTS

In the first 12 h after surgery, bleeding in hypocalcemia group was significantly larger than that of the normocalcemia group (338 ± 234 mL vs 232 ± 96 mL; p = .024). The outcome was the same when the overall chest tube output was considered (950 ± 447 mL vs 738 ± 220 mL; p = .038). The incidence of major bleeding was 65.91% in the hypocalcemia group and 18.97% in the normocalcemia group (p = .001). Postoperative complications in the two groups were similar. After adjusting for multiple covariates, the adjusted odds ratios (OR) for participants in hypocalcemia group was 10.01 (95% CI 3.35-34.82), compared with that in normocalcemia group (p < .001).

CONCLUSION

In patients undergoing heart valve surgery, preoperative blood concentrations of calcium are associated with postoperative blood loss. Hypocalcemia before operation may increase the risk of postoperative bleeding. When patients with valvular heart disease present with hypocalcemia before surgery, prompt intervention may lead to better control of postoperative bleeding.

Elevated Calcium after Acute Ischemic Stroke Predicts Severity and Prognosis

The aim of this study is to investigate whether there is a correlation between serum calcium levels and clinical severity or functional outcome at discharge in Chinese patients with acute ischemic stroke. Data from 339 patients admitted to our hospital between July 2020 and July 2021 were analyzed. Baseline demographic and clinical information was collected within 24 h of admission, including serum calcium levels, stroke severity (measured by the National Institutes of Health Stroke Scale [NIHSS] score), and lesion volumes. The modified Rankin Scale [mRS] assessed functional outcomes at discharge. Our analysis showed that the median age of patients included in the study was 65 years (interquartile range [IQR], 60-70), and 60.8% were men. We found a positive correlation between serum calcium levels and stroke severity (r[spearman] = 0.266, P < 0.001), with calcium levels increasing as stroke severity increased. In a subgroup of 188 patients with available MRI data, serum calcium concentrations positively correlated with infarct size. Furthermore, in multivariate analysis, a calcium serum level in the highest quartile was associated with a higher risk of unfavorable outcome (odds ratios [OR] = 3.27; 95% confidence intervals [CI] = 1.91-5.59; P < 0.001). In conclusion, our study indicates that higher calcium serum levels are associated with stroke severity and early neurologic outcome after acute ischemic stroke, indicating that calcium may serve as a prognostic biomarker for stroke in Chinese patients.

Prognostic value of day-of-event serum calcium and magnesium for predicting 1-year prognosis after intracerebral hemorrhage

AIM

To investigate whether serum calcium and magnesium on the day of symptom onset contribute to prognosis at 1 year after intracerebral hemorrhage (ICH).

METHODS

We prospectively enrolled patients admitted < 24 h after symptom onset of primary ICH to West China Hospital between January 2012 and October 2014. Blood samples were collected at admission to determine the concentration of serum calcium and magnesium. We analyzed associations of the serum concentration of calcium and magnesium with unfavorable outcome (defined as modified Rankin scale, mRS ≥ 3) at 1 year.

RESULTS

We included 874 patients (mean age 59.1 ± 13.5 years, 67.6% males), of whom 470 patients had mRS ≥ 3 and 284 patients died at 1 year. Compared to patients with the highest tertile level of calcium concentration (≥ 2.29 mmol/L), patients in the lowest tertile (≤ 2.15 mmol/L) had higher odds of unfavorable outcome (odds ratio, OR 1.61, 95% confidence interval [CI] 1.04-2.50, P = 0.034). The Kaplan-Meier survival curve revealed a significant difference of cumulative survival rate across calcium tertiles (log-rank P value = 0.038). There was no significant association between serum concentration of magnesium and functional outcome at 1 year.

CONCLUSION

A reduced serum concentration of calcium on the day-of-event was associated with unfavorable outcome at 1 year after ICH. Future studies are needed to illustrate the pathophysiological mechanism of calcium and whether calcium could be a treatment target for improving outcomes after ICH.

Association of Serum Calcium With Infarct Size and Severity in Acute Ischemic Stroke: A Rural Hospital-Based Cross-Sectional Study

Background One of the major mediators of ischemic neuronal cell death is calcium. It has been found that elevated serum calcium is associated with a better prognosis in patients with ischemic stroke. This study highlights the association of serum calcium, albumin-corrected calcium, and ionic calcium with the size of acute ischemic stroke as well as severity outcome in terms of the National Institutes of Health Stroke Scale (NIHSS) score and Barthel Index. Methods This cross-sectional study was conducted on 85 cases of acute ischemic stroke (based on a computerized tomography scan of the brain) from September 2019 to October 2021. All included patients had undergone complete clinical history, systemic examination, as well as estimation of serum total calcium, albumin corrected calcium, and ionic calcium. NIHSS score and Barthel Index were used to access the severity of each subject.  Results A significant positive correlation was seen between infarct size with NIHSS with a correlation coefficient of 0.35. A significant negative correlation was seen between infarct size with serum calcium, albumin-corrected calcium, and Barthel Index with a correlation coefficient of -0.483, -0.354, and -0.365 respectively. No correlation was seen between infarct size and ionic calcium with a correlation coefficient of 0.082. Conclusion It can be concluded that higher normal levels of serum calcium and albumin-corrected calcium are associated with a smaller-sized infarct and had less severity index among patients with acute ischemic stroke.

Low serum calcium is a novel predictor of unfavorable prognosis after traumatic brain injury

Background

Accurate and convenient serological markers for prognosis after traumatic brain injury (TBI) are still lacking. We aimed to explore the predictive value of serum calcium for prognosing outcomes within 6 months after TBI.

Methods

In this multicenter retrospective study, 1255 and 719 patients were included in development and validation cohorts, respectively, and their 6-month prognoses were recorded. Serum calcium was measured through routine blood tests within 24 h of hospital admission. Two multivariate predictive models with or without serum calcium for prognosis were developed. Receiver operating characteristics and calibration curves were applied to estimate their performance.

Results

The patients with lower serum calcium levels had a higher frequency of unfavorable 6-month prognosis than those without. Lower serum calcium level at admission was associated with an unfavorable 6-month prognosis in a wide spectrum of patients with TBI. Lower serum calcium level and our prognostic model including calcium performed well in predicting the 6-month unfavorable outcome. The calcium nomogram maintained excellent performance in discrimination and calibration in the external validation cohort.

Conclusions

Lower serum calcium level upon admission is an independent risk factor for an unfavorable 6-month prognosis after TBI. Integrating serum calcium into a multivariate predictive model improves the performance for predicting 6-month unfavorable outcomes.

Association of hypocalcemia with in-hospital mortality in critically ill patients with intracerebral hemorrhage: A retrospective cohort study

Background and purpose

There was little evidence to study the relationship between hypocalcemia and mortality among critically ill patients with intracerebral hemorrhage (ICH) aged ≥16 years. This study aimed to determine the potential association between hypocalcemia and in-hospital and ICU mortality in patients with ICH in the United States.

Methods

We analyzed 1,954 patients with ICH from the e-Intensive Care Unit Collaborative Research Database and divided them into hypocalcemia and non-hypocalcemia groups. Hypocalcemia was defined as albumin-adjusted total calcium below 8.4 mg/dl. The primary and secondary outcomes were hospital and ICU mortality, respectively. We performed multivariable regression and subgroup analyses to evaluate the association of hypocalcemia with hospital and ICU mortality. Cumulative survival rate analysis was performed using Kaplan-Meier curves with log-rank statistics.

Results

We enrolled 1,954 patients with ICH who had been hospitalized in ICU for >24 h and were older than 16 years (average age, 61.8 years; men, 56.7%). We noted that 373 (19%) hospital mortality occurred, including 235 (12%) ICU mortality. In this sample, 195 patients had hypocalcemia. Multivariable logistic regression analyses showed that hypocalcemia was associated with a 67% increased risk of in-hospital and a 72% increased risk of ICU mortality. This association was consistent across subgroup analyses.

Conclusions

Hypocalcemia was associated with a high risk of hospital and ICU mortality among critically ill patients with ICH. Future prospective, randomized, controlled studies are needed to confirm our results.

L-shaped association of serum calcium with all-cause and CVD mortality in the US adults: A population-based prospective cohort study

Background

Calcium is involved in many biological processes, but the impact of serum calcium levels on long-term mortality in general populations has been rarely investigated.

Methods

This prospective cohort study analyzed data from the National Health and Nutrition Examination Survey (1999-2018). All-cause mortality, cardiovascular disease (CVD) mortality, and cancer mortality were obtained through linkage to the National Death Index. Survey-weighted multivariate Cox regression was performed to compute hazard ratios (HRs) and 95% confidential intervals (CIs) for the associations of calcium levels with risks of mortality. Restricted cubic spline analyses were performed to examine the non-linear association of calcium levels with all-cause and disease-specific mortality.

Results

A total of 51,042 individuals were included in the current study. During an average of 9.7 years of follow-up, 7,592 all-cause deaths were identified, including 2,391 CVD deaths and 1,641 cancer deaths. Compared with participants in the first quartile (Q1) of serum calcium level [≤2.299 mmol/L], the risk of all-cause mortality was lower for participants in the second quartile (Q2) [2.300-2.349 mmol/L], the third quartile (Q3) [2.350-2.424 mmol/L] and the fourth quartile (Q4) [≥2.425 mmol/L] with multivariable-adjusted HRs of 0.81 (95% CI, 0.74-0.88), 0.78 (95% CI, 0.71-0.86), and 0.80 (95% CI, 0.73, 0.88). Similar associations were observed for CVD mortality, with HRs of 0.82 (95% CI, 0.71-0.95), 0.87 (95% CI, 0.74-1.02), and 0.83 (95% CI, 0.72, 0.97) in Q2-Q4 quartile. Furthermore, the L-shaped non-linear associations were detected for serum calcium with the risk of all-cause mortality. Below the median of 2.350 mmol/L, per 0.1 mmol/L higher serum calcium was associated with a 24% lower risk of all-cause mortality (HR: 0.76, 95% CI, 0.70-0.83), however, no significant changes were observed when serum calcium was above the median. Similar L-shaped associations were detected for serum calcium with the risk of CVD mortality with a 25% reduction in the risk of CVD death per 0.1 mmol/L higher serum calcium below the median (HR: 0.75, 95% CI, 0.65-0.86).

Conclusion

L-shaped associations of serum calcium with all-cause and CVD mortality were observed in US adults, and hypocalcemia was associated with a higher risk of all-cause mortality and CVD mortality.

Association between serum calcium level and hemorrhagic progression in patients with traumatic intraparenchymal hemorrhage: Investigating the mediation and interaction effects of coagulopathy

In this study, we investigate the association of serum calcium with coagulopathy and hemorrhagic progression contusion (HPC) in patients with traumatic intraparenchymal hemorrhage (tIPH), and further explored the interaction and mediation effect between serum calcium as well as coagulopathy on HPC. Retrospective analyses of patients with tIPH admitted to the First Affiliated Hospital of Wenzhou Medical University between January 2016 to December 2019. The clinical data, coagulation parameters, and serum calcium levels were collected for further analysis. Multivariate logistic regression analysis was applied to identify the association of serum calcium level with coagulopathy and HPC. Causal mediation analysis (CMA) and additive interaction model were used to estimate the interaction and mediation effect between serum calcium as well as coagulopathy on HPC. Additionally, we repeated the analysis using corrected calcium. A total of 473 patients were included in this study. Of these, 54 (11.4%) patients had hypocalcemia at admission, 105 (22.2%) presented with coagulopathy, and 187 (39.5%) experienced HPC. Admission serum calcium level in patients presented with coagulopathy and HPC were 8.84 [IQR: 8.44-9.40] and 8.92 [IQR: 8.48-9.40] mg/dL respectively, which were significantly lower than that of patients without (9.10 [IQR: 8.68-9.88] and 9.12 [IQR: 8.72-9.89] mg/dL; all p < 0.001). Multivariate logistic regression analysis identified that hypocalcemia emerged as an independent risk factor for coagulopathy and HPC. However, no significant interaction was detected between hypocalcemia and coagulopathy. CMA showed that the mediator coagulopathy explained 24.4% (95% CI: 4.7-65.0%; p = 0.006) of the association between hypocalcemia and HPC. Moreover, comparable results were held using corrected calcium as well. Admission serum calcium level is associated with the HPC for patients with tIPH and this relationship is partially mediated by coagulopathy, but no significant interaction is detected. Further studies are needed to validate the findings and explore its mechanisms.

Prognostic molecular markers for motor recovery in acute hemorrhagic stroke: A systematic review

BACKGROUND AND AIMS

Molecular biomarkers are associated with poor prognosis in ischemic stroke individuals. However, it might not be generalizable to post-acute hemorrhagic stroke since the underlying mechanisms of this brain damage differ from those found in ischemic stroke. The main purpose of this review was to synthesize the potential predictive molecular biomarkers for motor recovery following acute hemorrhagic stroke.

MATERIALS AND METHODS

An electronic search was conducted by 2 independent reviewers in the following databases: PubMed (Medline), EMBASE, Web of Science, and CINAHL. We included studies that addressed the following: collected blood, urine, or cerebrospinal fluid samples within 72 h after hemorrhagic stroke and that reported the prognostic association with functional motor recovery for each molecular biomarker. Screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers.

RESULTS

Twelve thousand, five hundred and sixty-four studies were identified and 218 were considered eligible. Finally, we included 70 studies, with 96 biomarkers analyzed, of which 61 were considered as independent prognostic biomarkers, and 10 presented controversial results.

CONCLUSION

This systematic review shows that motor functional recovery can be predicted by 61 independent prognostic molecular biomarkers assessed in the acute phase after a hemorrhagic stroke.

Association Between Ionized Calcium Level and Neurological Outcome in Endovascularly Treated Patients with Spontaneous Subarachnoid Hemorrhage: A Retrospective Cohort Study

BACKGROUND

Spontaneous subarachnoid hemorrhage (SSAH) is associated with significant morbidity and mortality. Pathophysiological processes following initial bleeding are complex and not fully understood. In this study, we aimed to determine whether a low level of ionized calcium (Ca⁺⁺), an essential cofactor in the coagulation cascade and other cellular processes, is associated with adverse neurological outcome, development of early hydrocephalus, and symptomatic vasospasm among patients with SSAH.

METHODS

This was a retrospective single-center cohort study of all patients admitted for SSAH between January 1, 2009, and April 31, 2020. The primary outcome was an unfavorable neurological status at discharge, defined as a modified Rankin Scale score greater than or equal to 3. Secondary outcomes were the development of early hydrocephalus and symptomatic vasospasm. Multivariable logistic regression was performed to determine whether Ca⁺⁺ was an independent predictor of these outcomes.

RESULTS

A total of 255 patients were included in the final analysis. Hypocalcemia, older age, admission Glasgow Coma Scale (GCS) score, and admission Hunt-Hess classification scale (H&H) grades IV and V were independently associated with unfavorable neurological outcome, with adjusted odds ratios (ORs) of 1.93 (95% confidence interval [CI] 1.1-3.4; p = 0.02) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level, 1.04 (95% CI 1.01-1.08; p = 0.02) for each year increase, 0.82 (95% CI 0.68-0.99; p = 0.04), and 6.29 (95% CI 1.14-34.6; p = 0.03), respectively. Risk factors for the development of hydrocephalus were hypocalcemia and GCS score, with ORs of 1.85 (95% CI 1.26-2.71; p = 0.002) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level and 0.83 (95% CI 0.73-0.94; p = 0.005), respectively. Ca⁺⁺ was not associated with symptomatic vasospasm (OR 1.04 [95% CI 0.76-1.41]; p = 0.81). Among patients with admission H&H grade I-III bleeding, hypocalcemia was independently associated with unfavorable neurological outcome at discharge, with an adjusted OR of 1.99 (95% CI 1.03-3.84; p = 0.04) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level. Hypocalcemia was also an independent risk factor for the development of early hydrocephalus, with an adjusted OR of 2.95 (95% CI 1.49-5.84; p = 0.002) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level. Ca⁺⁺ was not associated with symptomatic vasospasm. No association was found between Ca⁺⁺ and predefined outcomes among patients with admission H&H grade IV and V bleeding.

CONCLUSIONS

Our study shows that hypocalcemia is associated with worse neurological outcome at discharge and development of early hydrocephalus in endovascularly treated patients with SSAH. Potential mechanisms include calcium-induced coagulopathy and higher blood pressure. Trials are needed to assess whether correction of hypocalcemia will lead to improved outcomes.

Association between electrolyte levels at presentation and hematoma expansion and outcome in spontaneous intracerebral hemorrhage: A systematic review

PURPOSE

To assess the association between specific electrolyte levels (sodium, potassium, calcium, magnesium, and phosphorus) on presentation and hematoma expansion (HE) and outcome in intracerebral hemorrhage (ICH).

METHODS

This review was conducted in accordance with the PRISMA statement recommendations. Three databases were searched (Pubmed, Scopus, and Cochrane). Risk of bias was computed using the Newcastle-Ottawa Scale tool.

RESULTS

18 full-text articles were included in this systematic review including 10,385 ICH patients. Hypocalcemia was associated with worse short-term outcome in four studies, and two other studies were neutral. All studies investigating HE in hypocalcemia (n = 5) reported an association between low calcium level and HE. Hyponatremia (Na < 135 mEq/L) was shown to correlate with worse short-term outcome in two studies, and worse long-term outcome in one. There was one report showing no association between sodium level and HE. Hypomagnesemia was shown to be associated with worse short-term outcome in one study, while other reports were neutral. Studies evaluating hypophosphatemia or hypokalemia in ICH were limited, with no demonstrable significant effect on outcome.

CONCLUSION

This review suggests a significant association between hypocalcemia, hyponatremia and, of lesser degree, hypomagnesemia on admission and HE or worse outcome in ICH.

Relationship of Serum Uric Acid to Hematoma Volume and Prognosis in Patients with Acute Supratentorial Intracerebral Hemorrhage

BACKGROUND

Oxidative stress and inflammation play important roles in the neuronal injury caused by intracerebral hemorrhage (ICH). Uric acid (UA), an important natural antioxidant, might reduce the neuronal injury caused by ICH. Delineating the relationship between UA and ICH will enhance our understanding of antioxidative mechanisms in recovery from ICH.

METHODS

We conducted a retrospective study of 325 patients with acute supratentorial ICH to investigate the relationship between serum UA levels and hematoma volumes and prognosis. A hematoma volume of ≥30 mL was defined as a large hematoma. An unfavorable outcome was defined as a modified Rankin scale score of 4-6 on day 30.

RESULTS

The serum UA level was significantly lower in the patients with a large hematoma volume (median, 306 μmol/L; 25th to 75th percentile, 243-411 μmol/L) than in those with a small hematoma volume (median, 357 μmol/L; 25th to 75th percentile, 271-442 μmol/L; P = 0.012). Similarly, the unfavorable outcome group had had lower serum UA levels (median, 309 vs. 363 μmol/L; P = 0.009) compared with the favorable outcome group. The results of the multivariate logistic analysis indicated that a lower serum UA level was associated with a larger hematoma volume (odds ratio, 0.996; P = 0.006) and an unfavorable outcome (odds ratio, 0.997; P = 0.030).

CONCLUSIONS

The results from the present study have indicated that in patients with acute supratentorial ICH, a low serum UA level might indicate that the patient has a large hematoma volume and might be a risk factor for a poor day 30 functional prognosis.

The Role of Serum Calcium Level in Intracerebral Hemorrhage Hematoma Expansion: Is There Any?

Spontaneous intracerebral hemorrhage (ICH) is a devastating form of stroke, with a high rate of mortality and morbidity. Even with the best current medical or surgical interventions, outcomes remain poor. The location and initial hematoma volume are strong predictors of mortality. Hematoma expansion (HE) is a further marker of poor prognosis that may be at least partly preventable. Several risk factors for HE have been identified, including baseline ICH volume, anticoagulation, and computed tomography angiography spot signs. Recent studies have shown the correlation of serum calcium (Ca⁺⁺) levels on admission with HE. Low serum Ca⁺⁺ level has been associated with larger hematoma volume at the time of presentation, HE, and worse outcome. Although the causal and mechanistic links between low serum Ca⁺⁺ level and HE are not well understood, several mechanisms have been proposed including coagulopathy, platelet dysfunction, and higher blood pressure (BP) in the context of low serum Ca⁺⁺ level. However, low serum Ca⁺⁺ level might be only a biomarker of the adaptive response due to acute inflammatory response following acute ICH. The purpose of the current review is to discuss the evidence regarding the possible role of low serum Ca⁺⁺ level on HE in acute ICH.

Lower serum calcium and pre-onset blood pressure elevation in cerebral hemorrhage patients undergoing hemodialysis

BACKGROUND

Asymptomatic blood pressure (BP) elevation may be associated with cerebral hemorrhage (CH); however, few studies have investigated this association. We aimed to evaluate BP elevation before CH in hemodialysis (HD) patients and elucidate its associated factors.

METHODS

We reviewed HD patients treated for CH at our hospital between 2008 and 2019 (CH group). The control group comprised HD patients treated at Nagasaki Renal Center between 2011 and 2012. Data were obtained from medical records and three consecutive HD charts, made immediately before CH. HD1 was the session closest to onset, followed by HD2 and HD3. Systolic and mean BP were evaluated at the beginning of HD, and factors associated with BP elevation were investigated.

RESULTS

The CH and control groups included 105 and 339 patients, respectively. Systolic and mean BP at HD1 were significantly higher than those at baseline (HD2 + HD3) in the CH group by 5 and 3 mmHg, respectively (P < 0.001). Multiple linear regression analysis showed that lower calcium levels were significantly associated with BP elevation in the CH group (P < 0.05). The CH group was sub-divided by June 2013; the latter group had lower calcium levels (9.2 mg/dL) and a marked systolic BP difference from baseline (+ 10 mmHg) compared with the former (9.5 mg/dL and - 4 mmHg).

CONCLUSION

Asymptomatic BP elevation was observed in HD patients before CH; this elevation was associated with lower serum calcium levels and observed more frequently in the recent era. The precise mechanism underlying this effect remains unknown.

The relationship between low serum calcium level and intracerebral hemorrhage hematoma expansion: A protocol of systematic review and meta-analysis

BACKGROUND

To investigate the relationship between intracerebral hemorrhage hematoma expansion with low serum calcium level.

METHODS

We will search the following electronic bibliographic databases: MEDLINE, Embase, PubMed, The Cochrane Library, and Web of Science. All sources have to be searched from the earliest date until May 1, 2019. The quality of the included studies will assess by 2 evaluation members according to the Cochrane Collaboration network standard or the Newcastle-Ottawa Scale. The included studies will analysis by using RevMan 5.3 software.

RESULTS AND CONCLUSION

This will be the first systematic review and meta-analysis to evaluate the association of hematoma following intracerebral hemorrhage with hypocalcemia. The study will provide more reliable, evidence-based data for clinical decision making.

PROSPERO REGISTRATION NUMBER

CRD42019135956.

Association between serum calcium levels and prognosis, hematoma volume, and onset of cerebral hemorrhage in patients undergoing hemodialysis

BACKGROUND

High serum calcium levels should be avoided in patients on hemodialysis (HD) because they can induce cardiovascular diseases and worsen the patient's prognosis. In contrast, low serum calcium levels worsen the prognosis of patients with cerebral hemorrhage in the general population. So far, whether serum calcium levels in patients on HD are associated with cerebral hemorrhage remains unknown. This study aimed to reveal the association between serum calcium and cerebral hemorrhage in patients on HD, including in-hospital death, volume of hematoma, and onset of cerebral hemorrhage.

METHODS

This cross-sectional case-control study included 99 patients on HD with cerebral hemorrhage at a single center between July 1, 2007 and December 31, 2017. Controls included 339 patients on HD at a single HD center between July 1, 2011 and June 30, 2012. Data on serum calcium level, patient demographics, and comorbid conditions were collected, and associations between cerebral hemorrhage and subsequent death were evaluated by multivariate logistic regression analysis. Further, the association of these backgrounds and hematoma volume was evaluated by multiple regression analysis.

RESULTS

Of the 99 patients, 32 (32%) died from cerebral hemorrhage. The corrected serum calcium level (odds ratio [OR], 2.49; 95% confidence interval [CI], 1.43-4.35; P < 0.001) and antiplatelet drug use (OR, 3.95; 95% CI, 1.50-10.4; P = 0.005) had significant effects on the prognosis. Moreover, the corrected serum calcium (P = 0.003) and antiplatelet drug use (P = 0.01) were significantly correlated with hematoma volume. In the patients, the corrected serum calcium level (OR, 1.54; 95% CI, 1.07-2.22; P = 0.02) was associated with the onset of cerebral hemorrhage, as was pre-hemodialysis systolic blood pressure (per 10 mmHg) (OR, 1.40; 95% CI, 1.23-1.59; P < 0.001).

CONCLUSIONS

Although the precise mechanisms remain unknown, a high serum calcium level is associated with cerebral hemorrhage in patients on HD. Thus, we should pay attentions to a patient's calcium level.

Hematoma Expansion Predictors: Laboratory and Radiological Risk Factors in Patients with Acute Intracerebral Hemorrhage: A Prospective Observational Study

BACKGROUND

Intracerebral hemorrhage (ICH) is considered a devastating neurologic emergency and carried a higher morbidity and mortality rates. Early hematoma expansion (HE) is considered one of the poor prognostic factors after ICH. Consequently, determination of the possible risk factors for HE could be effective in early detection of high-risk patients and hence directing management course aiming to improving ICH outcome.

METHODS

One-hundred and thirty-six spontaneous ICH patients were included and prospectively evaluated for the presence of HE. Demographic, laboratory, and certain radiological factors were studied and compared between those with HE and those without, the in-hospital mortality rates were assessed as well.

RESULTS

HE was observed in 30% of the studied cohort, those who developed HE had more neurologic impairment (Glasgow coma scale, median 9; National Institute of Health Stroke Scale, median 34), and higher in-hospital mortality rate (53.6%) than those without HE. HE was related to the presence of higher red blood cell distribution width (RDW), reduced total cholesterol, low-density lipoprotein-C (LDL-C), and Ca levels. Among the radiological factors, hematoma density (heterogeneous), and shape (irregular) are highly related to the occurrence of HE. The computed tomography angiography (CTA) spot sign among patients with ICH was associated with HE development.

CONCLUSIONS

Abnormal RDW; low cholesterol, LDL, and Ca level; heterogeneous density, irregular shape hemorrhage, and presence of CTA spot sign were associated with the development of HE in the setting of spontaneous ICH.

Admission Serum Calcium Level as a Prognostic Marker for Intracerebral Hemorrhage

BACKGROUND

Prognostic significance of serum calcium level in patients with intracerebral hemorrhage is not well studied. The aim of the study was to identify if a relationship between admission serum calcium level and prognosis exists in patients with intracerebral hemorrhage.

METHODS

A total of 1262 confirmed intracerebral hemorrhage patients were included. Demographic data, medical history, medicine history, laboratory data, imaging data, clinical score, and progress note were collected from their medical records. All images of head computed tomography were reanalyzed. Ninety-day prognosis was recorded, and poor outcome was defined as death or major disability caused by intracerebral hemorrhage.

RESULTS

During the 90-day follow-up period, 504 patients died and 226 patients suffered from major disability. Death and major disability were combined as poor prognosis. The remaining 532 patients showed good prognosis. Admission serum calcium level was lower in the patients with poor prognosis than in the patients with good prognosis (2.41 ± 0.23 mmol/l, 2.55 ± 0.26 mmol/l, P < 0.001). Admission INR and hematoma volume were higher in the patients with poor prognosis than in the patients with good prognosis (INR: 1.74 ± 0.29, 1.70 ± 0.29, P = 0.029; hematoma volume: 11.6 ± 4.4 ml, 10.7 ± 4.1 ml, P < 0.001). There was no difference in admission APTT level between the two prognosis groups (28.4 ± 5.6 s, 27.8 ± 5.4 s, P = 0.056). A multivariate COX regression analysis reported that admission serum calcium level ≤ 2.41 mmol/l was associated with the increased risk of poor prognosis (death or major disability) in the patients (HR 1.45, 95% CI 1.32-1.60). In addition, there was a significant linear association of serum calcium level with coagulation function markers and hematoma volume on admission (APTT: r = - 0.091, P = 0.001; INR: r = - 0.063, P = 0.025; hematoma volume: r = -0.108, P < 0.001).

CONCLUSIONS

Admission serum calcium level might be a prognostic marker for intracerebral hemorrhage. Potential mechanism involved calcium-induced coagulation function abnormality.

Time-effect relationship of acupuncture on histopathology, ultrastructure, and neuroethology in the acute phase of cerebral hemorrhage

Many clinical studies have addressed the treatment of acute cerebral hemorrhage using acupuncture. However, few studies have examined the relationship between time of acupuncture and curative effect on cerebral hemorrhage. By observing the effect of acupuncture on changes in histopathology, ultrastructure, and neuroethology in a cerebral hemorrhage model of rats, we have directly examined the time-effect relationship of acupuncture. The rat model of cerebral hemorrhage was produced by slowly injecting autologous blood to the right caudate nucleus. The experimental groups were: 3-, 9-, 24-, and 48-hour model groups; and 3-, 9-, 24-, and 48-hour acupuncture groups. The sham-operation group was used for comparison. Acupuncture was performed at the Neiguan (PC6) and Renzhong (DU26) acupoints, twice a day, 6 hours apart, for 5 consecutive days. Brain tissue changes were observed by light microscopy and transmission electron microscopy. Neuroethology was assessed using Bederson and Longa scores. Our results show that compared with the sham-operation and model groups, Bederson and Longa scores were lower in each acupuncture group, with visibly improved histopathology and brain tissue ultrastructure. Further, the results were better in the 3- and 9-hour acupuncture groups than the 24- and 48-hour acupuncture groups. Our findings show that acupuncture treatment can relieve pathological and ultrastructural deterioration and neurological impairment caused by the acute phase of cerebral hemorrhage, and may protect brain tissue during this period. In addition, earlier acupuncture intervention following cerebral hemorrhage (by 3 or 9 hours) is associated with a better treatment outcome.

Low Serum Calcium and Magnesium Levels and Rupture of Intracranial Aneurysms

BACKGROUND AND PURPOSE

Both low serum calcium and magnesium levels have been associated with the extent of bleeding in patients with intracerebral hemorrhage, suggesting hypocalcemia- and hypomagnesemia-induced coagulopathy as a possible underlying mechanism. We hypothesized that serum albumin-corrected total calcium and magnesium levels are associated with ruptured intracranial aneurysms.

METHODS

The medical records of 4701 patients, including 1201 prospective patients, diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016 were reviewed and analyzed. One thousand two hundred seventy-five patients had available serum calcium, magnesium, and albumin values within 1 day of diagnosis. Individuals were divided into cases with ruptured aneurysms and controls with unruptured aneurysms. Univariable and multivariable logistic regression analyses were performed to determine the association between serum albumin-corrected total calcium and magnesium levels and ruptured aneurysms.

RESULTS

In multivariable analysis, both albumin-corrected calcium (odds ratio, 0.33; 95% confidence interval, 0.27-0.40) and magnesium (odds ratio, 0.40; 95% confidence interval, 0.28-0.55) were significantly and inversely associated with ruptured intracranial aneurysms.

CONCLUSIONS

In this large case-control study, hypocalcemia and hypomagnesemia at diagnosis were significantly associated with ruptured aneurysms. Impaired hemostasis caused by hypocalcemia and hypomagnesemia may explain this association.

Clinical Characteristics and Outcomes of Intracerebral Hemorrhage in Very Elderly

BACKGROUND

Intracerebral hemorrhage (ICH) incidences increase with age. Patients of advanced age may have limitations during acute care and recovery. We investigated baseline characteristics, hematoma features, and outcomes of very elderly ICH patients (≥80 years old) and compared them with those of younger ICH patients (<80 years old).

METHODS

We studied 377 patients (122 women; 69 ± 11 years old) admitted within 24 hours of ICH onset. Outcome measures included hematoma volumes, National Institutes of Health Stroke Scale scores on admission, and vital and functional prognoses at 30 days.

RESULTS

After adjustments for sex, very elderly patients had a higher subcortical hematoma prevalence (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.39-4.86]. On multivariate analyses, very elderly patients had larger hematoma volumes (OR, 1.33; 95% CI, 1.01-1.75, per 10-mL increase). After adjustments for risk factors and comorbidities, modified Rankin scale scores of 0-2 in very elderly patients occurred less often (OR, .34; 95% CI, .14-.82), and those with scores of 5-6 occurred more often (OR, 3.01; 95% CI, 1.09-8.54).

CONCLUSIONS

Hematomas were relatively large and often found in the subcortex in very elderly ICH patients. Outcomes of very elderly ICH patients were relatively poor.

Association Between Serum Calcium Level and Extent of Bleeding in Patients With Intracerebral Hemorrhage

Importance

Calcium is a key cofactor of the coagulation cascade and may play a role in the pathophysiology of intracerebral hemorrhage (ICH).

Objective

To investigate whether a low serum calcium level is associated with an increase in the extent of bleeding in patients with ICH as measured by baseline hematoma volume and risk of hematoma expansion.

Design, Setting, and Participants

Prospective cohort study of 2103 consecutive patients with primary ICH ascertained during the period between 1994 and 2015 at an academic medical center. The statistical analysis was performed in January 2016.

Main Outcomes and Measures

Total calcium level was measured on admission, and hypocalcemia was defined as a serum calcium level of less than 8.4 mg/dL. Baseline and follow-up hematoma volumes, detected by noncontrast computed tomography, were measured using a computer-assisted semiautomatic analysis. Hematoma expansion was defined as an increase of more than 30% or 6 mL from baseline ICH volume. Associations between serum calcium level and baseline hematoma volume and between serum calcium level and ICH expansion were investigated in multivariable linear and logistic regression models, respectively.

Results

A total of 2123 patients with primary ICH were screened, and 2103 patients met the inclusion criteria (mean [SD] age, 72.7 [12.5] years; 54.3% male patients), of whom 229 (10.9%) had hypocalcemia on admission. Hypocalcemic patients had a higher median baseline hematoma volume than did normocalcemic patients (37 mL [IQR, 15-72 mL] vs 16 mL [IQR, 6-44 mL]; P < .001). Low calcium levels were independently associated with higher baseline ICH volume (β = -0.13, SE = .03, P < .001). A total of 1393 patients underwent follow-up noncontrast computed tomography and were included in the ICH expansion analysis. In this subgroup, a higher serum calcium level was associated with reduced risk of ICH expansion (odds ratio, 0.55 [95% CI, 0.35-0.86]; P = .01), after adjusting for other confounders.

Conclusions and Relevance

Hypocalcemia correlates with the extent of bleeding in patients with ICH. A low calcium level may be associated with a subtle coagulopathy predisposing to increased bleeding and might therefore be a promising therapeutic target for acute ICH treatment trials.

Unclear-onset intracerebral hemorrhage: Clinical characteristics, hematoma features, and outcomes

Background and purpose Although unclear-onset ischemic stroke, including wake-up ischemic stroke, is drawing attention as a potential target for reperfusion therapy, acute unclear-onset intracerebral hemorrhage has been understudied. Clinical characteristics, hematoma features, and outcomes of patients who developed intracerebral hemorrhage during sleep or those with intracerebral hemorrhage who were unconscious when witnessed were determined. Methods Consecutive intracerebral hemorrhage patients admitted within 24 hours after onset or last-known normal time were classified into clear-onset intracerebral hemorrhage and unclear-onset intracerebral hemorrhage groups. Outcomes included initial hematoma volume, initial National Institutes of Health Stroke Scale score, hematoma growth on 24-hour follow-up computed tomography, and vital and functional prognoses at 30 days. Results Of 377 studied patients (122 women, 69 ± 11 years old), 147 (39.0%) had unclear-onset intracerebral hemorrhage. Patients with unclear-onset intracerebral hemorrhage had larger hematoma volumes (p = 0.044) and higher National Institutes of Health Stroke Scale scores (p < 0.001) than those with clear-onset intracerebral hemorrhage after multivariable adjustment for risk factors and comorbidities. Hematoma growth was similarly common between the two groups (p = 0.176). There were fewer patients with modified Rankin Scale (mRS) scores of 0-2 (p = 0.033) and more patients with mRS scores of 5-6 (p = 0.009) and with fatal outcomes (p = 0.049) in unclear-onset intracerebral hemorrhage group compared with clear-onset intracerebral hemorrhage as crude values, but not after adjustment. Conclusions Patients with unclear-onset intracerebral hemorrhage presented with larger hematomas and higher National Institutes of Health Stroke Scale scores at emergent visits than those with clear-onset intracerebral hemorrhage, independent of underlying characteristics. Unclear-onset intracerebral hemorrhage patients showed poorer 30-day vital and functional outcomes than clear-onset intracerebral hemorrhage patients; these differences seem to be mainly due to initial hematoma volumes and National Institutes of Health Stroke Scale scores.

Nutritional Cognitive Neuroscience: Innovations for Healthy Brain Aging

Nutritional cognitive neuroscience is an emerging interdisciplinary field of research that seeks to understand nutrition's impact on cognition and brain health across the life span. Research in this burgeoning field demonstrates that many aspects of nutrition—from entire diets to specific nutrients—affect brain structure and function, and therefore have profound implications for understanding the nature of healthy brain aging. The aim of this Focused Review is to examine recent advances in nutritional cognitive neuroscience, with an emphasis on methods that enable discovery of nutrient biomarkers that predict healthy brain aging. We propose an integrative framework that calls for the synthesis of research in nutritional epidemiology and cognitive neuroscience, incorporating: (i) methods for the precise characterization of nutritional health based on the analysis of nutrient biomarker patterns (NBPs), along with (ii) modern indices of brain health derived from high-resolution magnetic resonance imaging (MRI). By integrating cutting-edge techniques from nutritional epidemiology and cognitive neuroscience, nutritional cognitive neuroscience will continue to advance our understanding of the beneficial effects of nutrition on the aging brain and establish effective nutritional interventions to promote healthy brain aging.

A cohort study of relationship between serum calcium levels and cerebral microbleeds (CMBs) in ischemic stroke patients with AF and/or RHD

Calcium is an essential element for life and has cerebroprotective property in stroke patients. Low serum calcium levels were found to be related to large hematoma volumes in intracerebral hemorrhagic patients and hemorrhagic transformation in ischemic stroke patients after thrombolysis. However, their impact on hemorrhage-prone small vessel disease represented by cerebral microbleeds (CMBs) is uncertain. We aim to investigate whether low serum calcium levels are associated with presence and location of CMBs.Ischemic stroke patients with atrial fibrillation (AF) and/or rheumatic heart disease admitted to our hospital were consecutively and prospectively enrolled. Demographic and clinical information were collected and analyzed according to the occurrence and location of CMBs, and levels of serum calcium. We used logistic regression analysis to estimate the multivariable adjusted relationship between serum calcium levels and the presence or location of CMBs.Among the 67 patients (28 males; mean age, 67.3 years) in the final analysis, 39 (58.2%) were found to have CMBs. After adjustment for age, sex, smoking habits, drinking habits, and renal impairment, the presence of CMBs and deep CMBs was, respectively, 4.96- and 4.83-fold higher in patients with lower serum calcium levels (≤2.15 mmol/L) than in patients with higher serum calcium levels.Lower serum calcium levels (≤2.15 mmol/L) are independently associated with the presence of CMBs and deep CMBs in ischemic stroke patients with AF and/or rheumatic heart disease, which should be verified and extended in large cohorts, with other types of stroke patients and the general population.

Lower serum calcium level is associated with hemorrhagic transformation after thrombolysis

BACKGROUND AND PURPOSE

We aim to investigate whether lower admission serum calcium levels are associated with hemorrhagic transformation (HT) after intravenous thrombolysis (IVT).

METHODS

A total of 362 patients treated with IVT was divided into 4 quartiles based on admission serum calcium levels (Q1[<2.16], Q2[2.16, 2.23], Q3[2.24, 2.31], and Q4[>2.31] mmol/L). HT was classified as hemorrhagic infarction and parenchymal hemorrhage. Logistic regression was applied to assess the association between serum calcium levels and the incidence of HT.

RESULTS

Compared with Q4, HT was more common in Q1 (odds ratio, 2.580; 95% CI, [1.258-5.292]; P=0.010), Q2 (odds ratio, 2.382; 95% CI, [1.163-4.877]; P=0.018), and Q3 (odds ratio, 2.293; 95% CI, [1.133-4.637]; P=0.021). Hemorrhagic infarction was more common in Q1 (P=0.037), and Q2 (P=0.018), compared with Q4, and parenchymal hemorrhage was more common in Q1 (P=0.029) than Q4.

CONCLUSIONS

Lower admission serum calcium level is independently associated with HT after IVT, and this hypothesis needs larger confirmatory trials.

CKD is associated with recurrent ischemia but not with hemorrhagic transformation in acute ischemic stroke patients

BACKGROUND

We investigated the associations of Recurrent Ischemic Stroke (RIS) and Hemorrhagic Transformation (HT) with CKD in acute ischemic stroke patients.

METHOD

The subjects were 160 patients, divided into two groups: with eGFR <60 mL/min/1.73 m2 (CKD), with eGFR ≥60 mL/min/1.73 m2 (without CKD).

RESULTS

Subjects having DM (p = 0.018), CKD (p = 0.025) and treated with ACEI/ARB (p = 0.039) revealed association with RIS. Regression analysis disclosed only CKD (p = 0.04). Carotid artery stenosis (p = 0.030) and serum calcium levels (p = 0.013) showed significant association with HT.

CONCLUSION

Our results disclosed that CKD could be a risk factor for RIS. There is no relation between CKD and HT.