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Chen CC, Ke CH, Wu CH, Lee HF, Chao Y, Tsai MC, Shyue SK, Chen SF. Transient receptor potential vanilloid 1 inhibition reduces brain damage by suppressing neuronal apoptosis after intracerebral hemorrhage. Brain Pathol 2024; 34:e13244. [PMID: 38308041 PMCID: PMC11328348 DOI: 10.1111/bpa.13244] [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: 11/17/2023] [Accepted: 01/19/2024] [Indexed: 02/04/2024] Open
Abstract
Intracerebral hemorrhage (ICH) induces a complex sequence of apoptotic cascades and inflammatory responses, leading to neurological impairment. Transient receptor potential vanilloid 1 (TRPV1), a nonselective cation channel with high calcium permeability, has been implicated in neuronal apoptosis and inflammatory responses. This study used a mouse ICH model and neuronal cultures to examine whether TRPV1 activation exacerbates brain damage and neurological deficits by promoting neuronal apoptosis and neuroinflammation. ICH was induced by injecting collagenase in both wild-type (WT) C57BL/6 mice and TRPV1-/- mice. Capsaicin (CAP; a TRPV1 agonist) or capsazepine (a TRPV1 antagonist) was administered by intracerebroventricular injection 30 min before ICH induction in WT mice. The effects of genetic deletion or pharmacological inhibition of TRPV1 using CAP or capsazepine on motor deficits, histological damage, apoptotic responses, blood-brain barrier (BBB) permeability, and neuroinflammatory reactions were explored. The antiapoptotic mechanisms and calcium influx induced by TRPV1 inactivation were investigated in cultured hemin-stimulated neurons. TRPV1 expression was upregulated in the hemorrhagic brain, and TRPV1 was expressed in neurons, microglia, and astrocytes after ICH. Genetic deletion of TRPV1 significantly attenuated motor deficits and brain atrophy for up to 28 days. Deletion of TRPV1 also reduced brain damage, neurodegeneration, microglial activation, cytokine expression, and cell apoptosis at 1 day post-ICH. Similarly, the administration of CAP ameliorated brain damage, neurodegeneration, brain edema, BBB permeability, and cytokine expression at 1 day post-ICH. In primary neuronal cultures, pharmacological inactivation of TRPV1 by CAP attenuated neuronal vulnerability to hemin-induced injury, suppressed apoptosis, and preserved mitochondrial integrity in vitro. Mechanistically, CAP reduced hemin-stimulated calcium influx and prevented the phosphorylation of CaMKII in cultured neurons, which was associated with reduced activation of P38 and c-Jun NH2-terminal kinase mitogen-activated protein kinase signaling. Our results suggest that TRPV1 inhibition may be a potential therapy for ICH by suppressing mitochondria-related neuronal apoptosis.
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Affiliation(s)
- Chien-Cheng Chen
- Department of Physical Medicine and Rehabilitation, Cheng Hsin General Hospital, Taipei, Taiwan, Republic of China
- Graduate Institute of Gerontology and Health Care Management, Chang Gung University of Science and Technology, Taoyuan, Taiwan, Republic of China
| | - Chia-Hua Ke
- Department of Physical Medicine and Rehabilitation, Cheng Hsin General Hospital, Taipei, Taiwan, Republic of China
| | - Chun-Hu Wu
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan, Republic of China
| | - Hung-Fu Lee
- Department of Neurosurgery, Cheng Hsin General Hospital, Taipei, Taiwan, Republic of China
- National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, Republic of China
| | - Yuan Chao
- Department of Medical Education, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
| | - Min-Chien Tsai
- Department of Physiology and Biophysics, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Song-Kun Shyue
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan, Republic of China
| | - Szu-Fu Chen
- Department of Physical Medicine and Rehabilitation, Cheng Hsin General Hospital, Taipei, Taiwan, Republic of China
- Department of Physiology and Biophysics, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Fu Y, Liu R, Zhao Y, Xie Y, Ren H, Wu Y, Zhang B, Chen X, Guo Y, Yao Y, Jiang W, Han R. Veliparib exerts protective effects in intracerebral hemorrhage mice by inhibiting the inflammatory response and accelerating hematoma resolution. Brain Res 2024; 1838:148988. [PMID: 38729332 DOI: 10.1016/j.brainres.2024.148988] [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: 01/22/2024] [Revised: 03/29/2024] [Accepted: 05/05/2024] [Indexed: 05/12/2024]
Abstract
Poly (ADP-ribose) polymerase (PARP) inhibitors have potent anti-inflammatory effects, including the suppression of brain microglial activation. Veliparib, a well-known PARP1/2 inhibitor, exhibits particularly high brain penetration, but its effects on stroke outcome is unknown. Here, the effects of veliparib on the short-term outcome of intracerebral hemorrhage (ICH), the most lethal type of stroke, were investigated. Collagenase-induced mice ICH model was applied, and the T2-weighted magnetic resonance imaging was performed to evaluate lesion volume. Motor function and hematoma volume were also measured. We further performed immunofluorescence, enzyme linked immunosorbent assay, flow cytometry, and blood-brain barrier assessment to explore the potential mechanisms. Our results demonstrated veliparib reduced the ICH lesion volume dose-dependently and at a dosage of 5 mg/kg, veliparib significantly improved mouse motor function and promoted hematoma resolution at days 3 and 7 post-ICH. Veliparib inhibited glial activation and downregulated the production of pro-inflammatory cytokines. Veliparib significantly decreased microglia counts and inhibited peripheral immune cell infiltration into the brain on day 3 after ICH. Veliparib improved blood-brain barrier integrity at day 3 after ICH. These findings demonstrate that veliparib improves ICH outcome by inhibiting inflammatory responses and may represent a promising novel therapy for ICH.
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Affiliation(s)
- Yiwei Fu
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China
| | - Rongrong Liu
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China
| | - Yuexin Zhao
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China
| | - Yuhan Xie
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China; Department of Neurology, Nankai Hospital, Tianjin Medical University, Tianjin, China
| | - Honglei Ren
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China
| | - Yu Wu
- Department of Neurology, Nankai Hospital, Tianjin Medical University, Tianjin, China
| | - Bohao Zhang
- Department of Radiology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xiuju Chen
- Department of Neurology, Nankai Hospital, Tianjin Medical University, Tianjin, China
| | - Ying Guo
- Department of Otorhinolaryngology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yang Yao
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.
| | - Wei Jiang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.
| | - Ranran Han
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.
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Geest V, Oblak JP, Popović KŠ, Nawabi J, Elsayed S, Friedrich C, Böhmer M, Akkurt B, Sporns P, Morotti A, Schlunk F, Steffen P, Broocks G, Meyer L, Hanning U, Thomalla G, Gellissen S, Fiehler J, Frol S, Kniep H. How much of the variance in functional outcome related to intracerebral hemorrhage volume is already apparent in neurological status at admission? J Neurol 2024; 271:5003-5011. [PMID: 38775933 PMCID: PMC11319529 DOI: 10.1007/s00415-024-12427-9] [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: 04/02/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Hematoma volume is a major pathophysiological hallmark of acute intracerebral hemorrhage (ICH). We investigated how the variance in functional outcome induced by the ICH volume is explained by neurological deficits at admission using a mediation model. METHODS Patients with acute ICH treated in three tertiary stroke centers between January 2010 and April 2019 were retrospectively analyzed. Mediation analysis was performed to investigate the effect of ICH volume (0.8 ml (5% quantile) versus 130.6 ml (95% quantile)) on the risk of unfavorable functional outcome at discharge defined as modified Rankin Score (mRS) ≥ 3 with mediation through National Institutes of Health Stroke Scale (NIHSS) at admission. Multivariable regression was conducted to identify factors related to neurological improvement and deterioration. RESULTS Three hundred thirty-eight patients were analyzed. One hundred twenty-one patients (36%) achieved mRS ≤ 3 at discharge. Mediation analysis showed that NIHSS on admission explained 30% [13%; 58%] of the ICH volume-induced variance in functional outcome at smaller ICH volume levels, and 14% [4%; 46%] at larger ICH volume levels. Higher ICH volume at admission and brainstem or intraventricular location of ICH were associated with neurological deterioration, while younger age, normotension, lower ICH volumes, and lobar location of ICH were predictors for neurological improvement. CONCLUSION NIHSS at admission reflects 14% of the functional outcome at discharge for larger hematoma volumes and 30% for smaller hematoma volumes. These results underscore the importance of effects not reflected in NIHSS admission for the outcome of ICH patients such as secondary brain injury and early rehabilitation.
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Affiliation(s)
- Vincent Geest
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Janja Pretnar Oblak
- Department of Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Katarina Šurlan Popović
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Department of Neuroradiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Jawed Nawabi
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Elsayed
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Constanze Friedrich
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maik Böhmer
- Department of Radiology, University Hospital Muenster, Muenster, Germany
| | - Burak Akkurt
- Department of Radiology, University Hospital Muenster, Muenster, Germany
| | - Peter Sporns
- Department of Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Andrea Morotti
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy
| | - Frieder Schlunk
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Paul Steffen
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Senta Frol
- Department of Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Jun HS, Yang K, Kim J, Jeon JP, Kim SJ, Ahn JH, Lee SJ, Choi HJ, Chang IB, Park JJ, Rhim JK, Jin SC, Cho SM, Joo SP, Sheen SH, Lee SH. Telemedicine Protocols for the Management of Patients with Acute Spontaneous Intracerebral Hemorrhage in Rural and Medically Underserved Areas in Gangwon State : Recommendations for Doctors with Less Expertise at Local Emergency Rooms. J Korean Neurosurg Soc 2024; 67:385-396. [PMID: 37901932 PMCID: PMC11220410 DOI: 10.3340/jkns.2023.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 10/31/2023] Open
Abstract
Previously, we reported the concept of a cloud-based telemedicine platform for patients with intracerebral hemorrhage (ICH) at local emergency rooms in rural and medically underserved areas in Gangwon state by combining artificial intelligence and remote consultation with a neurosurgeon. Developing a telemedicine ICH treatment protocol exclusively for doctors with less ICH expertise working in emergency rooms should be part of establishing this system. Difficulties arise in providing appropriate early treatment for ICH in rural and underserved areas before the patient is transferred to a nearby hub hospital with stroke specialists. This has been an unmet medical need for decade. The available reporting ICH guidelines are realistically possible in university hospitals with a well-equipped infrastructure. However, it is very difficult for doctors inexperienced with ICH treatment to appropriately select and deliver ICH treatment based on the guidelines. To address these issues, we developed an ICH telemedicine protocol. Neurosurgeons from four university hospitals in Gangwon state first wrote the guidelines, and professors with extensive ICH expertise across the country revised them. Guidelines and recommendations for ICH management were described as simply as possible to allow more doctors to use them easily. We hope that our effort in developing the telemedicine protocols will ultimately improve the quality of ICH treatment in local emergency rooms in rural and underserved areas in Gangwon state.
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Affiliation(s)
- Hyo Sub Jun
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon, Korea
| | - Kuhyun Yang
- Department of Neurosurgery, Gangneung Asan Hospital, Gangneung, Korea
| | - Jongyeon Kim
- Department of Neurosurgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Sun Jeong Kim
- Department of Convergence Software, Hallym University, Chuncheon, Korea
| | - Jun Hyong Ahn
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon, Korea
| | - Seung Jin Lee
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon, Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - In Bok Chang
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong Jin Park
- Department of Neurology, Konkuk University Medical Center, Seoul, Korea
| | - Jong-Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju, Korea
| | - Sung-Chul Jin
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Sung Min Cho
- Department of Neurosurgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sang Hyung Lee
- Department of Neurosurgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - on behalf of the Gangwon State Neurosurgery Consortium
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon, Korea
- Department of Neurosurgery, Gangneung Asan Hospital, Gangneung, Korea
- Department of Neurosurgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
- Department of Convergence Software, Hallym University, Chuncheon, Korea
- Department of Neurology, Konkuk University Medical Center, Seoul, Korea
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju, Korea
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, Busan, Korea
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
- Department of Neurosurgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
- Department of Neurosurgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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Sterenstein A, Garg R. The impact of sex on epidemiology, management, and outcome of spontaneous intracerebral hemorrhage (sICH). J Stroke Cerebrovasc Dis 2024; 33:107755. [PMID: 38705497 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107755] [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: 10/30/2023] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 05/07/2024] Open
Abstract
OBJECTIVE Data on sex differences in spontaneous intracerebral hemorrhages are limited. METHODS An automated comprehensive scoping literature review was performed using PubMed and Scopus. Articles written in English about spontaneous intracerebral hemorrhage and sex were reviewed. RESULTS Males experience spontaneous intracerebral hemorrhage more frequently than females, at younger ages, and have a higher prevalence of deep bleeds compared to females. Risk factors between sexes vary and may contribute to differing incidences and locations of spontaneous intracranial hemorrhage. Globally, females receive less aggressive care than males, likely impacting survival. CONCLUSIONS Epidemiology, risk factors, and treatment of spontaneous intracranial hemorrhage vary by sex, with limited and oftentimes conflicting data available. Further research into the sex-based differences of spontaneous intracranial hemorrhage is necessary for clinicians to better understand how to evaluate and guide treatment in the future.
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Affiliation(s)
- Andrea Sterenstein
- Rush University Medical Center, Division of Critical Care Neurology, Department of Neurological Sciences.
| | - Rajeev Garg
- Rush University Medical Center, Division of Critical Care Neurology, Department of Neurological Sciences
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Morán Gallego FJ, Sanchez Casado M, López de Toro Martin Consuegra I, Marina Martinez L, Alvarez Fernandez J, Sánchez Carretero MJ. Evaluation of the last 2 decades in the characteristics of presentation, management and prognosis of serious spontaneous intracerebral hemorrhage in a third level hospital. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:169-176. [PMID: 38295901 DOI: 10.1016/j.neucie.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/12/2023] [Indexed: 02/05/2024]
Abstract
OBJECTIVE To analyze the change in the characteristics of presentation, evolution and treatment in the ICU, as well as the functional evolution at 12 months of spontaneous intracranial hemorrhages (ICHs) treated in an ICU reference center. PATIENT AND METHODS Descriptive, retrospective study in a Neurocritical Reference Hospital. All admissions of patients with HICE during three periods are studied: 1999-2001 (I), 2015-2016 (II) and 2020-2021 (III). Evolution in the three periods of demographic variables, baseline characteristics of the patients, clinical variables and characteristics of bleeding, evolutionary data in the ICU are studied. At one year we assessed the GOS scale (Glasgow Outcome Score) according to whether they had a poor (GOS 1-3) or good (GOS 4-5) prognosis. RESULTS 300 admitted patients, distributed in periods: I: 28.7%, II: 36.3% and III: 35%. 56.7% were males aged 66 (55.5-74) years; ICH score 2 (1-3). The ICU stay was 5 (2-14) days with a mortality of 36.8%. GOS 1-3 a year in 67.3% and GOS 4-5 in 32.7%. Comparing the three periods, we observed a higher prevalence in women, and the presence of cardiovascular factors; no changes in etiology; in relation to the location, it increases cerebellar hemorrhage and in the brainstem. Although the severity was greater, the stay in the ICU, the use of invasive mechanical ventilation and tracheostomy were lower. Open surgery has decreased its use by 50%. Mortality continues to be high, stagnating in the ICU at 35% and entails a high degree of disability one year after assessment. CONCLUSIONS Severe ICH is a complex pathology that has changed some characteristics in the last two decades, with more severe patients, with more cardiovascular history and a greater predominance of brainstem and cerebellar hemorrhage. Despite the increase in severity, better parameters during the ICU stay, with open surgery used 50% less. Mortality remains stagnant at 35% with high disability per year.
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Chen Y, Rivier CA, Mora SA, Torres Lopez V, Payabvash S, Sheth KN, Harloff A, Falcone GJ, Rosand J, Mayerhofer E, Anderson CD. Deep learning survival model predicts outcome after intracerebral hemorrhage from initial CT scan. Eur Stroke J 2024:23969873241260154. [PMID: 38880882 DOI: 10.1177/23969873241260154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Predicting functional impairment after intracerebral hemorrhage (ICH) provides valuable information for planning of patient care and rehabilitation strategies. Current prognostic tools are limited in making long term predictions and require multiple expert-defined inputs and interpretation that make their clinical implementation challenging. This study aimed to predict long term functional impairment of ICH patients from admission non-contrast CT scans, leveraging deep learning models in a survival analysis framework. METHODS We used the admission non-contrast CT scans from 882 patients from the Massachusetts General Hospital ICH Study for training, hyperparameter optimization, and model selection, and 146 patients from the Yale New Haven ICH Study for external validation of a deep learning model predicting functional outcome. Disability (modified Rankin scale [mRS] > 2), severe disability (mRS > 4), and dependent living status were assessed via telephone interviews after 6, 12, and 24 months. The prediction methods were evaluated by the c-index and compared with ICH score and FUNC score. RESULTS Using non-contrast CT, our deep learning model achieved higher prediction accuracy of post-ICH dependent living, disability, and severe disability by 6, 12, and 24 months (c-index 0.742 [95% CI -0.700 to 0.778], 0.712 [95% CI -0.674 to 0.752], 0.779 [95% CI -0.733 to 0.832] respectively) compared with the ICH score (c-index 0.673 [95% CI -0.662 to 0.688], 0.647 [95% CI -0.637 to 0.661] and 0.697 [95% CI -0.675 to 0.717]) and FUNC score (c-index 0.701 [95% CI- 0.698 to 0.723], 0.668 [95% CI -0.657 to 0.680] and 0.727 [95% CI -0.708 to 0.753]). In the external independent Yale-ICH cohort, similar performance metrics were obtained for disability and severe disability (c-index 0.725 [95% CI -0.673 to 0.781] and 0.747 [95% CI -0.676 to 0.807], respectively). Similar AUC of predicting each outcome at 6 months, 1 and 2 years after ICH was achieved compared with ICH score and FUNC score. CONCLUSION We developed a generalizable deep learning model to predict onset of dependent living and disability after ICH, which could help to guide treatment decisions, advise relatives in the acute setting, optimize rehabilitation strategies, and anticipate long-term care needs.
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Affiliation(s)
- Yutong Chen
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Cyprien A Rivier
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
| | - Samantha A Mora
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Victor Torres Lopez
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
| | - Sam Payabvash
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
| | - Andreas Harloff
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Ernst Mayerhofer
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher D Anderson
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
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Tseng WC, Wang YF, Chen HS, Wang TG, Hsiao MY. Spot sign score is associated with hematoma expansion and longer hospital stay but not functional outcomes in primary intracerebral hemorrhage survivors. Jpn J Radiol 2024:10.1007/s11604-024-01597-1. [PMID: 38833105 DOI: 10.1007/s11604-024-01597-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/16/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE The computed tomography angiography (CTA) spot sign is a validated predictor of 30-day mortality in intracerebral hemorrhage (ICH). However, its role in predicting unfavorable functional outcomes remains unclear. This study explores the frequency of the spot sign and its association with functional outcomes, hematoma expansion, and length of hospital stay among survivors of ICH. MATERIALS AND METHODS This was a retrospective analysis of consecutive patients with primary ICH who received CTA within 24 h of admission to two medical centers between January 2007 and August 2022. Patients who died before discharge and those referred from other hospitals were excluded. Spot signs were assessed by an experienced neuroradiologist. Functional outcomes were determined by modified Rankin Scale (mRS) scores and the Barthel Index (BI). RESULTS In total, 98 patients were included; 14 (13.64%) had a spot sign. No significant differences were observed in the baseline characteristics between the patients with and without a spot sign. Higher spot sign scores were associated with higher odds of experiencing hematoma expansion (p = 0.013, 95% CI = 1.16-3.55), undergoing surgery (p = 0.012, 95% CI = 0.19-1.55), and having longer hospital stay (p = 0.02, 95% CI = 1.22-13.92). However, higher spot sign scores were not associated with unfavorable functional outcomes (p = 0.918 for BI, and p = 0.782 for mRS). CONCLUSION Spot signs are common findings among patients with ICH, and higher spot sign scores were associated with subsequent hematoma expansion and longer hospital stays but not unfavorable functional outcomes.
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Affiliation(s)
- Wen-Che Tseng
- Department of Physical Medicine and Rehabilitation, Yunlin Rd, National Taiwan University Hospital Yunlin Branch, Yunlin County, Sec. 2, 579, Douliu City, Taiwan
| | - Yu-Fen Wang
- Department of Medical Imaging, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan
| | - Hsin-Shui Chen
- Department of Physical Medicine and Rehabilitation, Yunlin Rd, National Taiwan University Hospital Yunlin Branch, Yunlin County, Sec. 2, 579, Douliu City, Taiwan
| | - Tyng-Guey Wang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd, Taipei, Taiwan
| | - Ming-Yen Hsiao
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan.
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd, Taipei, Taiwan.
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Nakaoku Y, Ogata S, Ren N, Tanaka T, Kurogi R, Nishimura K, Iihara K. Ten-year national trends in in-hospital mortality and functional outcomes after intracerebral hemorrhage by age in Japan: J-ASPECT study. Eur Stroke J 2024; 9:398-408. [PMID: 38288694 PMCID: PMC11318425 DOI: 10.1177/23969873231222736] [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: 08/16/2023] [Accepted: 12/08/2023] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION National-level data on trends in the prognosis of age-stratified patients with intracerebral hemorrhage (ICH) are lacking. This study aimed to assess time trends in in-hospital mortality and functional outcomes of ICH patients by sex and age, and to explore factors associated with changes in in-hospital mortality trend. PATIENTS AND METHODS Using the largest nationwide, J-ASPECT stroke database in Japan, this serial cross-sectional study included ICH patients aged ⩾18 years who were hospitalized for non-traumatic ICH from April 2010 to March 2020. We examined trends in in-hospital mortality and functional outcomes using the modified Rankin Scale at discharge, as well as differences in in-hospital mortality change between age groups. RESULTS Among 262,399 ICH patients from 934 hospitals, crude in-hospital mortality showed a significant decreasing time trend (from 19.5% to 16.7%), and this trend was consistent across sex and age groups. In addition, differences in in-hospital mortality change over the 10-year study period were significant between male patients aged ⩾75 years and those aged ⩽64 years (-3.9% [95% confidence interval, -5.4 to -2.4] for 75-84 years; -4.1% [-6.3 to -1.9] for ⩾85 years). On the other hand, the proportion of dependent patients (mRS 3-5) at discharge increased from 52.0% to 54.9% over the 10-year study period. CONCLUSION The in-hospital mortality of ICH patients improved, whereas the proportion of patients with dependent functional outcome at discharge increased, over the 10-year study period. Elucidating the mechanism underlying differences in in-hospital mortality reduction in men may provide insights into effective interventions in the future.
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Affiliation(s)
- Yuriko Nakaoku
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Nice Ren
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Iihara
- National Cerebral and Cardiovascular Center Hospital, Suita, Japan
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10
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Gabriele F, Foschi M, Conversi F, Ciuffini D, De Santis F, Orlandi B, De Santis F, Ornello R, Sacco S. Epidemiology and outcomes of intracerebral hemorrhage associated with oral anticoagulation over 10 years in a population-based stroke registry. Int J Stroke 2024; 19:515-525. [PMID: 37997897 DOI: 10.1177/17474930231218594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
BACKGROUND Recent years have seen a change in the use of anticoagulants in the general population due to the availability of direct oral anticoagulants (DOACs) as an alternative to vitamin K antagonists (VKAs) and increased detection of atrial fibrillation. It is important to have updated epidemiological data to understand how this change is impacting on the occurrence and outcome of intracerebral hemorrhage (ICH). PATIENTS AND METHODS Our prospective population-based registry included patients with first-ever ICH occurring from January 2011 to December 2020. Oral anticoagulants (OAC)-related ICH was defined as an ICH occurring within 48 h from the intake of DOAC or VKAs, regardless of the measured international normalized ratio on hospital admission. RESULTS We included 748 first-ever ICH, of whom 108 (14.4%) were OAC-related. Specifically, 75 (69.4%) ICHs occurred on VKA and 33 (30.6%) on DOAC. The incidence of oral anticoagulation-associated intracerebral hemorrhage (OAC-ICH) was stable over time (p = 0.226). Among OAC-ICHs, we observed an increase in the overall incidence of DOAC-ICH (p for trend < 0.001) which overcome that of VKA-ICH in 2020 (incidence rate ratio (IRR) 4.71, 95% confidence interval (CI): 1.22-33.54; p = 0.022). Patients with OAC-ICH showed higher 30-day case fatality rates than those with non-OAC-ICH (48.1% vs 34.1%; p = 0.007). CONCLUSION No changes over time were detected in the incidence of OAC-ICH, but throughout the study period, there was a change in OAC-ICH from mostly VKA-related to mostly DOAC-related. Mortality in patients with OAC-ICH was higher than in patients with non-OAC-ICH.
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Affiliation(s)
- Francesca Gabriele
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Conversi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Davide Ciuffini
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Federica De Santis
- Department of Neurology and Stroke Unit of Avezzano-Sulmona, ASL 1 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | - Berardino Orlandi
- Department of Neurology and Stroke Unit of Avezzano-Sulmona, ASL 1 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | - Federico De Santis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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11
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Murthy SB. Emergent Management of Intracerebral Hemorrhage. Continuum (Minneap Minn) 2024; 30:641-661. [PMID: 38830066 DOI: 10.1212/con.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH. LATEST DEVELOPMENTS Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques. ESSENTIAL POINTS This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.
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12
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Carhuapoma L, Murthy S, Shah VA. Outcome Trajectories after Intracerebral Hemorrhage. Semin Neurol 2024; 44:298-307. [PMID: 38788763 DOI: 10.1055/s-0044-1787104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is the most morbid of all stroke types with a high early mortality and significant early disability burden. Traditionally, outcome assessments after ICH have mirrored those of acute ischemic stroke, with 3 months post-ICH being considered a standard time point in most clinical trials, observational studies, and clinical practice. At this time point, the majority of ICH survivors remain with moderate to severe functional disability. However, emerging data suggest that recovery after ICH occurs over a more protracted course and requires longer periods of follow-up, with more than 40% of ICH survivors with initial severe disability improving to partial or complete functional independence over 1 year. Multiple other domains of recovery impact ICH survivors including cognition, mood, and health-related quality of life, all of which remain under studied in ICH. To further complicate the picture, the most important driver of mortality after ICH is early withdrawal of life-sustaining therapies, before initiation of treatment and evaluating effects of prolonged supportive care, influenced by early pessimistic prognostication based on baseline severity factors and prognostication biases. Thus, our understanding of the true natural history of ICH recovery remains limited. This review summarizes the existing literature on outcome trajectories in functional and nonfunctional domains, describes limitations in current prognostication practices, and highlights areas of uncertainty that warrant further research.
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Affiliation(s)
- Lourdes Carhuapoma
- Division of Neurosciences Critical Care, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Santosh Murthy
- Department of Neurology, Weil Cornell Medical College, New York
| | - Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Neurology, Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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13
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Vitt JR, Mainali S. Artificial Intelligence and Machine Learning Applications in Critically Ill Brain Injured Patients. Semin Neurol 2024; 44:342-356. [PMID: 38569520 DOI: 10.1055/s-0044-1785504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
The utilization of Artificial Intelligence (AI) and Machine Learning (ML) is paving the way for significant strides in patient diagnosis, treatment, and prognostication in neurocritical care. These technologies offer the potential to unravel complex patterns within vast datasets ranging from vast clinical data and EEG (electroencephalogram) readings to advanced cerebral imaging facilitating a more nuanced understanding of patient conditions. Despite their promise, the implementation of AI and ML faces substantial hurdles. Historical biases within training data, the challenge of interpreting multifaceted data streams, and the "black box" nature of ML algorithms present barriers to widespread clinical adoption. Moreover, ethical considerations around data privacy and the need for transparent, explainable models remain paramount to ensure trust and efficacy in clinical decision-making.This article reflects on the emergence of AI and ML as integral tools in neurocritical care, discussing their roles from the perspective of both their scientific promise and the associated challenges. We underscore the importance of extensive validation in diverse clinical settings to ensure the generalizability of ML models, particularly considering their potential to inform critical medical decisions such as withdrawal of life-sustaining therapies. Advancement in computational capabilities is essential for implementing ML in clinical settings, allowing for real-time analysis and decision support at the point of care. As AI and ML are poised to become commonplace in clinical practice, it is incumbent upon health care professionals to understand and oversee these technologies, ensuring they adhere to the highest safety standards and contribute to the realization of personalized medicine. This engagement will be pivotal in integrating AI and ML into patient care, optimizing outcomes in neurocritical care through informed and data-driven decision-making.
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Affiliation(s)
- Jeffrey R Vitt
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, California
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
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14
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Nagaraja N, Ballur Narayana Reddy V. Prevalence of Concomitant Neurological Disorders and Long-Term Outcome of Patients Hospitalized for Intracerebral Hemorrhage with Versus without Cerebral Amyloid Angiopathy. Neurocrit Care 2024; 40:486-494. [PMID: 37258986 DOI: 10.1007/s12028-023-01753-x] [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: 10/18/2022] [Accepted: 05/10/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Patients with intracerebral hemorrhage (ICH) related to cerebral amyloid angiopathy (CAA) are at increased risk of developing epilepsy and cognitive disorders such as Alzheimer's disease (AD), mild cognitive impairment (MCI), and vascular dementia. In a retrospective cohort observation study of patients hospitalized for ICH with CAA versus ICH without CAA, we evaluated the prevalence of neurological comorbidities at admission and the risk of new diagnosis of epilepsy, relevant cognitive disorders, and mortality at 1 year. METHODS In the TriNetX health research network, adult patients aged ≥ 55 years hospitalized with a diagnosis of ICH were stratified based on presence or absence of concomitant CAA diagnosis. Demographics and medical comorbidities were compared by using χ2 test and Student's t-test. After 1:1 propensity score matching, 1-year survival was assessed with Kaplan-Meier curves. The 1-year risk of new diagnosis of epilepsy, AD, MCI, vascular dementia, and dementia unspecified was assessed with Cox proportional hazards estimate. RESULTS The study included a total of 1757 patients with ICH and CAA and 53,364 patients with ICH without CAA. Patients with CAA were older compared with those without CAA (74.1 ± 7.5 vs. 69.8 ± 8.8 years, p ≤ 0.001). Compared with ICH without CAA, patients with ICH and CAA had higher baseline prevalence of cerebral infarction (30% vs. 20%), nontraumatic ICH (36% vs. 7%), nontraumatic subarachnoid hemorrhage (14% vs. 5%), epilepsy (11% vs. 6%), and AD (5% vs. 2%) with significance at p < 0.001. After propensity score matching, a total of 1746 patients were included in both cohorts. In the matched cohorts, compared with patients with ICH without CAA, patients with ICH and CAA had lower 1-year all-cause mortality (479 [27%] vs. 563 [32%]; hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.71-0.90) and higher risk of new diagnosis of epilepsy (280 [18%] vs. 167 [11%]; HR 1.70; 95% CI 1.40-2.06), AD (101 [6%] vs. 38 [2%]; HR 2.62; 95% CI 1.80-3.80), MCI (85 [5%] vs. 35 [2%]; HR 2.39; 95% CI 1.61-3.54), vascular dementia (117 [7%] vs. 60 [4%]; HR 1.92; 95% CI 1.41-2.62), and dementia unspecified (245 [16%] vs. 150 [9%]; HR 1.70; 95% CI 1.39-2.08). CONCLUSIONS Among patients admitted for ICH, patients with CAA have lower mortality but have 2-3 times more risk of diagnosis of epilepsy and dementia at 1 year, compared with those without CAA.
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Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, Milton S. Hershey Medical Center, Penn State College of Medicine, 30 Hope Drive EC037, Hershey, PA, 17033, USA.
| | - Varalakshmi Ballur Narayana Reddy
- Department of Neurology, Milton S. Hershey Medical Center, Penn State College of Medicine, 30 Hope Drive EC037, Hershey, PA, 17033, USA
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15
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Foschi M, D’Anna L, Gabriele C, Conversi F, Gabriele F, De Santis F, Orlandi B, De Santis F, Ornello R, Sacco S. Sex Differences in the Epidemiology of Intracerebral Hemorrhage Over 10 Years in a Population-Based Stroke Registry. J Am Heart Assoc 2024; 13:e032595. [PMID: 38410943 PMCID: PMC10944030 DOI: 10.1161/jaha.123.032595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/14/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND We investigated incidence and outcome of spontaneous intracerebral hemorrhage (ICH) in a population-based stroke registry and provided data to inform on the figures of the disease in women and in men. METHODS AND RESULTS Our prospective population-based registry included patients with first-ever ICH occurring from January 2011 to December 2020. Incidence rates were standardized to the 2011 Italian and European population, and incidence rate ratios were calculated. Multivariate hazard ratios for 30-day and 1-year fatality were estimated with Cox regression, including components of the ICH score and sex. We included 748 first-ever ICHs (41.3% women). Women were significantly older than men at ICH onset (78.9±12.6 versus 73.2±13.6 years; P<0.001) and showed higher clinical severity on presentation (median National Institutes of Health Stroke Scale score, 11 [interquartile range, 6-20] versus 9 [interquartile range, 4-15], respectively; P=0.016). The crude annual incidence rate was 20.2 (95% CI, 18.0-22.6) per 100 000 person-years in women and 30.2 (95% CI, 27.4-33.2) per 100 000 person-years in men); incidence was lower in women versus men (incidence rate ratio, 0.67 [95% CI, 0.58-0.78]; P<0.001) and did not change over time in both sexes (P for trend=0.073 and 0.904, respectively). Unadjusted comparison showed higher 1-year case-fatality rates in women versus men (48.5% versus 40.1%; P=0.026). After adjusting for components of the ICH score, female sex lost significance as a predictor of mortality. CONCLUSIONS We found lower ICH incidence in women than in men. However, women showed a higher 1-year case-fatality rate versus men, which was likely related to older age at ICH onset and higher clinical severity. Identification of factors explaining the reported differences is important to develop targeted interventions.
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Affiliation(s)
- Matteo Foschi
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Lucio D’Anna
- Department of Stroke and Neuroscience, Charing Cross HospitalImperial College London National Health Service Healthcare TrustLondonUK
- Department of Brain SciencesImperial College LondonLondonUK
| | - Claudia Gabriele
- Department of Life, Health and Environmental SciencesUniversity of L’AquilaL’AquilaItaly
| | - Francesco Conversi
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Francesca Gabriele
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Federica De Santis
- Department of Neurology and Stroke Unit of Avezzano‐SulmonaL’AquilaItaly
| | - Berardino Orlandi
- Department of Neurology and Stroke Unit of Avezzano‐SulmonaL’AquilaItaly
| | - Federico De Santis
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
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16
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Luo Z, Sheng Z, Hu L, Shi L, Tian Y, Zhao X, Yang W, Xiao Z, Shen D, Wu W, Lan T, Zhao B, Wang X, Zhuang N, Zhang JN, Wang Y, Lu Y, Wang L, Zhang C, Wang P, An J, Yang F, Li Q. Targeted macrophage phagocytosis by Irg1/itaconate axis improves the prognosis of intracerebral hemorrhagic stroke and peritonitis. EBioMedicine 2024; 101:104993. [PMID: 38324982 PMCID: PMC10862510 DOI: 10.1016/j.ebiom.2024.104993] [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: 10/11/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Macrophages are innate immune cells whose phagocytosis function is critical to the prognosis of stroke and peritonitis. cis-aconitic decarboxylase immune-responsive gene 1 (Irg1) and its metabolic product itaconate inhibit bacterial infection, intracellular viral replication, and inflammation in macrophages. Here we explore whether itaconate regulates phagocytosis. METHODS Phagocytosis of macrophages was investigated by time-lapse video recording, flow cytometry, and immunofluorescence staining in macrophage/microglia cultures isolated from mouse tissue. Unbiased RNA-sequencing and ChIP-sequencing assays were used to explore the underlying mechanisms. The effects of Irg1/itaconate axis on the prognosis of intracerebral hemorrhagic stroke (ICH) and peritonitis was observed in transgenic (Irg1flox/flox; Cx3cr1creERT/+, cKO) mice or control mice in vivo. FINDINGS In a mouse model of ICH, depletion of Irg1 in macrophage/microglia decreased its phagocytosis of erythrocytes, thereby exacerbating outcomes (n = 10 animals/group, p < 0.05). Administration of sodium itaconate/4-octyl itaconate (4-OI) promoted macrophage phagocytosis (n = 7 animals/group, p < 0.05). In addition, in a mouse model of peritonitis, Irg1 deficiency in macrophages also inhibited phagocytosis of Staphylococcus aureus (n = 5 animals/group, p < 0.05) and aggravated outcomes (n = 9 animals/group, p < 0.05). Mechanistically, 4-OI alkylated cysteine 155 on the Kelch-like ECH-associated protein 1 (Keap1), consequent in nuclear translocation of nuclear factor erythroid 2-related factor 2 (Nrf2) and transcriptional activation of Cd36 gene. Blocking the function of CD36 completely abolished the phagocytosis-promoting effects of Irg1/itaconate axis in vitro and in vivo. INTERPRETATION Our findings provide a potential therapeutic target for phagocytosis-deficiency disorders, supporting further development towards clinical application for the benefit of stroke and peritonitis patients. FUNDING The National Natural Science Foundation of China (32070735, 82371321 to Q. Li, 82271240 to F. Yang) and the Beijing Natural Science Foundation Program and Scientific Research Key Program of Beijing Municipal Commission of Education (KZ202010025033 to Q. Li).
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Affiliation(s)
- Zhaoli Luo
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Ziyang Sheng
- Department of Microbiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Liye Hu
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Lei Shi
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Yichen Tian
- School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Xiaochu Zhao
- School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Wei Yang
- Department of Microbiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Zhongnan Xiao
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Danmin Shen
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Weihua Wu
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Ting Lan
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Boqian Zhao
- School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Xiaogang Wang
- School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Nan Zhuang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Jian-Nan Zhang
- Department of Neurobiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Yamei Wang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Yabin Lu
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Liyong Wang
- Core Facilities for Molecular Biology, Capital Medical University, Beijing 100069, China
| | - Chenguang Zhang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Peipei Wang
- Department of Neurobiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Jing An
- Department of Microbiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Fei Yang
- Department of Neurobiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China; Laboratory for Clinical Medicine, Beijing Key Laboratory of Neural Regeneration and Repair, Capital Medical University, Beijing 100069, China.
| | - Qian Li
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China; Laboratory for Clinical Medicine, Beijing Key Laboratory of Neural Regeneration and Repair, Capital Medical University, Beijing 100069, China; Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Capital Medical University, Beijing 100069, China.
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17
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Shen J, Xue X, Yuan H, Song Y, Wang J, Cui R, Ke K. Deubiquitylating Enzyme OTUB1 Facilitates Neuronal Survival After Intracerebral Hemorrhage Via Inhibiting NF-κB-triggered Apoptotic Cascades. Mol Neurobiol 2024; 61:1726-1736. [PMID: 37775718 DOI: 10.1007/s12035-023-03676-2] [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: 07/04/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023]
Abstract
The deubiquitylase OTU domain-containing ubiquitin aldehyde-binding protein 1 (OTUB1) has been implicated in the pathogenesis of various human diseases. However, the molecular mechanism by which OTUB1 participates in the pathogenesis of intracerebral hemorrhage (ICH) remains elusive. In the present study, we established an autologous whole blood fusion-induced ICH model in C57BL/6 J mice. We showed that the upregulation of OTUB1 contributes to the attenuation of Nuclear factor kappa B (NF-κB) and its downstream apoptotic signaling after ICH. OTUB1 directly associates with NF-κB precursors p105 and p100 after ICH, leading to attenuated polyubiquitylation of p105 and p100. Moreover, we revealed that NF-κB signaling was modestly activated both in ICH tissues and hemin-exposed HT-22 neuronal cells, accompanied with the activation of NF-κB downstream pro-apoptotic signaling. Notably, overexpression of OTUB1 strongly inhibited hemin-induced NF-κB activation, whereas interference of OTUB1 led to the opposite effect. Finally, we revealed that lentiviral transduction of OTUB1 markedly ameliorated hemin-induced apoptotic signaling and HT-22 neuronal death. Collectively, these findings suggest that the upregulation of OTUB1 serves as a neuroprotective mechanism in antagonizing neuroinflammation-induced NF-κB signaling and neuronal death, shed new light on manipulating intracellular deubiquitylating pathways as novel interventive approaches against ICH-induced secondary neuronal damage and death.
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Affiliation(s)
- Jiabing Shen
- Department of Neurology, Affiliated Hospital and Medical School of Nantong University, Nantong, 226001, People's Republic of China
| | - Xiaoli Xue
- Department of Neurology, Affiliated Hospital and Medical School of Nantong University, Nantong, 226001, People's Republic of China
- Department of Neurology, Qidong People's Hospital, Qidong, Jiangsu, People's Republic of China
| | - Huimin Yuan
- Department of Neurology, Affiliated Hospital and Medical School of Nantong University, Nantong, 226001, People's Republic of China
- Department of Neurology, Qidong People's Hospital, Qidong, Jiangsu, People's Republic of China
| | - Yan Song
- Department of Neurology, Affiliated Hospital and Medical School of Nantong University, Nantong, 226001, People's Republic of China
| | - Jinglei Wang
- Department of Neurology, Affiliated Hospital and Medical School of Nantong University, Nantong, 226001, People's Republic of China
- Department of Neurology, Affiliated Hai'an Hospital of Nantong University and Hai'an People's Hospital, Hai'an, People's Republic of China
| | - Ronghui Cui
- Department of Neurology, Affiliated Hospital and Medical School of Nantong University, Nantong, 226001, People's Republic of China.
| | - Kaifu Ke
- Department of Neurology, Affiliated Hospital and Medical School of Nantong University, Nantong, 226001, People's Republic of China.
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18
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Xu S, Wu Q, Tang Z, Li P. Identification and Analysis of DNA Methylation Inflammation-Related Key Genes in Intracerebral Hemorrhage. Biochem Genet 2024; 62:395-412. [PMID: 37354351 DOI: 10.1007/s10528-023-10430-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/12/2023] [Indexed: 06/26/2023]
Abstract
Inflammation and DNA methylation have been reported to play key roles in intracerebral hemorrhage (ICH). This study aimed to investigate new diagnostic biomarkers associated with inflammation and DNA methylation using a comprehensive bioinformatics approaches. GSE179759 and GSE125512 were collected from the Gene Expression Omnibus database, and 3222 inflammation-related genes (IFRGs) were downloaded from the Molecular Signatures Database. Key differentially expressed methylation-regulated and inflammation-related genes (DE-MIRGs) were identified by overlapping methylation-regulated differentially expressed genes (MeDEGs) between patients with ICH and control samples, module genes from weighted correlation network analysis, and IFRGs. Functional annotation of DE-MIRGs was performed using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG). A protein-protein interaction (PPI) network was constructed to clarify the interrelationships between different DE-MIRGs. The key genes were categorized by least absolute shrinkage selection operator (LASSO) and support vector machine-recursive feature elimination (SVM-RFE), and gene set enrichment analysis (GSEA). A total of 22 DE-MIRGs were acquired from 451 MeDEGs, 3222 IFRGs, and 302 module genes, and were mainly enriched in the GO terms of wound healing, blood coagulation, and hemostasis; and the KEGG pathways of PI3K/Akt signaling, focal adhesion, and regulation of actin cytoskeleton. A PPI network with 22 nodes and 87 edges was constructed based on the 22 DE-MIRGs, 11 of which were selected for key gene selection. Two 2 key genes (SELP and S100A4) were identified using LASSO and SVM-RFE. Finally, SELP was mainly enriched in cell morphogenesis involved in differentiation, cytoplasmic translation, and actin binding of GO terms, and the KEGG pathway including endocytosis, focal adhesion, and platelet activation. S100A4 was mainly enriched in GO terms including mitochondrial inner membrane; mitochondrial respirasome and lysosomal membrane; and the KEGG pathway of oxidative phosphorylation, regulation of actin cytoskeleton, and chemical carcinogenesis-reactive oxygen species. Twenty-two DE-MIRGs-associated inflammation and DNA methylation were identified between patients with ICH and normal controls, and two key genes (SELP and S100A4) were identified and regarded as biomarkers for ICH, which could provide the research foundation for further investigation of the pathological mechanism of ICH.
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Affiliation(s)
- Sanpeng Xu
- Changchun University of Traditional Chinese Medicine, Changchun, China
| | - Qiong Wu
- Xin Yang Central Hospital, Xinyang, China
| | - Zhe Tang
- Changchun University of Traditional Chinese Medicine, Changchun, China
| | - Ping Li
- Changchun University of Traditional Chinese Medicine, Changchun, China.
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Rizk HI, Magdy R, Emam K, Mohammed MS, Aboulfotooh AM. Substance use disorder in young adults with stroke: clinical characteristics and outcome. Acta Neurol Belg 2024; 124:65-72. [PMID: 37454034 PMCID: PMC10874343 DOI: 10.1007/s13760-023-02317-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Stroke incidence among young adults has risen in the last decade. This research attempts to determine the effect of substance use disorder (SUD) on the clinical characteristics of stroke, mortality, outcome after IV thrombolysis, and functional dependency after 1 month among young adults. METHODS Through a retrospective study, data were extracted from the electronic medical records of stroke in young adults admitted to intensive care units in Kasr Al-Ainy Hospital (February 2018-January 2021). The National Institute of Health Stroke Scale (NIHSS) and the Modified Rankin Scale were documented at the onset and after 1 month. RESULTS The study included 225 young adults with stroke (median age of 40, IQR: 34-44). Only 93 young adults (41%) met the criteria of SUD. Anabolic steroid use disorder was significantly associated with cerebral venous thrombosis (P-value = 0.02), while heroin use disorder was significantly associated with a hemorrhagic stroke (P-value = 0.01). Patients with tramadol, cannabis, and cocaine use disorders had significantly more frequent strokes in the posterior than the anterior circulation. Patients with heroin use disorders had significantly higher mortality than those without heroin use disorders (P-value = 0.01). The risk of poor outcomes was doubled by alcohol or heroin use disorder, while it was tripled by cocaine use disorder (P-value = 0.01 for each). CONCLUSION Forty-one percent of young adults diagnosed with a stroke had SUD, with a relatively higher posterior circulation involvement. Increased mortality was associated with heroin use disorder more than other substances. Poor stroke outcome was associated with alcohol, heroin, and cocaine use disorders.
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Affiliation(s)
- Hoda Ibrahim Rizk
- Department of Public Health and Community Medicine, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rehab Magdy
- Department of Neurology, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Khadiga Emam
- Department of Public Health and Community Medicine, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona Soliman Mohammed
- Department of Public Health and Community Medicine, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
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Li Z, Bu X, Cheng J, Deng L, Lv X, Wang Z, Hu X, Yang T, Yin H, Liu X, Zhao L, Xie P, Li Q. Impact of early cognitive impairment on outcome trajectory in patients with intracerebral hemorrhage. Ann Clin Transl Neurol 2024; 11:368-376. [PMID: 38009388 PMCID: PMC10863917 DOI: 10.1002/acn3.51957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/21/2023] [Accepted: 11/11/2023] [Indexed: 11/28/2023] Open
Abstract
OBJECTIVE To assess the prevalence and factors associated with early cognitive impairment in intracerebral hemorrhage (ICH) patients and to describe short-term recovery trajectories among ICH patients with early cognitive impairment. METHODS We prospectively enrolled ICH patients without baseline dementia in our institutions. Cognitive function was assessed using mini-mental state examination (MMSE), and functional outcome was evaluated at discharge, 3, and 6 months after symptoms onset using the modified Rankin Scale (mRS). We used multinomial logistic regression models to investigate potential risk factors and generalized linear models to analyze the functional outcome data. RESULTS Out of 181 patients with ICH, 167 were included in the final analysis. Early cognitive impairment occurred in 60.48% of patients with ICH. Age (odds ratio [OR] per 1-year increase, 1.037; 95% confidence interval [CI], 1.003-1.071; p = 0.034), National Institutes of Health Stroke Scale (NIHSS) score (OR per 1-point increase, 1.146; 95% CI, 1.065-1.233; p < 0.001) and lobar ICH location (OR, 4.774; 95% CI, 1.810-12.593; p = 0.002) were associated with early cognitive impairment in ICH patients. Patients with ≥10 years of education were less likely to experience early cognitive impairment (OR, 0.323; 95% CI, 0.133-0.783; p = 0.012). Participants with early cognitive impairment had a higher risk of poor outcome (OR, 4.315; 95% CI, 1.503-12.393; p = 0.005) than those without. Furthermore, there was a significantly faster functional recovery rate for those without early cognitive impairment compared with those with at 3 and 6 months (p < 0.05). INTERPRETATION Early cognitive impairment was prevalent and associated with poor outcomes in ICH patients, which decelerated short-term functional recovery.
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Affiliation(s)
- Zuo‐Qiao Li
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Xiao‐Qing Bu
- Department of Epidemiology, School of Public HealthChongqing Medical UniversityChongqingChina
| | - Jing Cheng
- Department of Neurology and NeurosurgeryThe Third Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Lan Deng
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Xin‐Ni Lv
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Zi‐Jie Wang
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Xiao Hu
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Tian‐Nan Yang
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Hao Yin
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Xue‐Yun Liu
- Department of NeurologyThe Second Affiliated Hospital of Anhui Medical UniversityAnhuiChina
| | - Li‐Bo Zhao
- Department of NeurologyYongchuan Hospital of Chongqing Medical UniversityChongqingChina
- Chongqing Key Laboratory of Cerebrovascular Disease ResearchChongqingChina
| | - Peng Xie
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional DiseasesThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Qi Li
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
- Department of NeurologyThe Second Affiliated Hospital of Anhui Medical UniversityAnhuiChina
- Chongqing Key Laboratory of Cerebrovascular Disease ResearchChongqingChina
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21
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Guo P, Zou W. Neutrophil-to-lymphocyte ratio, white blood cell, and C-reactive protein predicts poor outcome and increased mortality in intracerebral hemorrhage patients: a meta-analysis. Front Neurol 2024; 14:1288377. [PMID: 38288330 PMCID: PMC10824245 DOI: 10.3389/fneur.2023.1288377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
Objective Inflammation participates in the pathology and progression of secondary brain injury after intracerebral hemorrhage (ICH). This meta-analysis intended to explore the prognostic role of inflammatory indexes, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), white blood cell (WBC), and C-reactive protein (CRP) in ICH patients. Methods Embase, PubMed, Web of Science, and Cochrane Library were searched until June 2023. Two outcomes, including poor outcome and mortality were extracted and measured. Odds ratio (OR) and 95% confidence interval (CI) were presented for outcome assessment. Results Forty-six studies with 25,928 patients were included in this meta-analysis. The high level of NLR [OR (95% CI): 1.20 (1.13-1.27), p < 0.001], WBC [OR (95% CI): 1.11 (1.02-1.21), p = 0.013], and CRP [OR (95% CI): 1.29 (1.08-1.54), p = 0.005] were related to poor outcome in ICH patients. Additionally, the high level of NLR [OR (95% CI): 1.06 (1.02-1.10), p = 0.001], WBC [OR (95% CI): 1.39 (1.16-1.66), p < 0.001], and CRP [OR (95% CI): 1.02 (1.01-1.04), p = 0.009] were correlated with increased mortality in ICH patients. Nevertheless, PLR was not associated with poor outcome [OR (95% CI): 1.00 (0.99-1.01), p = 0.749] or mortality [OR (95% CI): 1.00 (0.99-1.01), p = 0.750] in ICH patients. The total score of risk of bias assessed by Newcastle-Ottawa Scale criteria ranged from 7-9, which indicated the low risk of bias in the included studies. Publication bias was low, and stability assessed by sensitivity analysis was good. Conclusion This meta-analysis summarizes that the high level of NLR, WBC, and CRP estimates poor outcome and higher mortality in ICH patients.
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Affiliation(s)
- Peixin Guo
- Integrated Traditional Chinese and Western Medicine, Heilongjiang University of Traditional Chinese Medicine, Harbin, China
| | - Wei Zou
- Third Ward of Acupuncture Department, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
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Liu L, Dong X, Liu Y, Wang S, Wei L, Duan L, Zhang Q, Zhang K. Predictive value of white blood cell to hemoglobin ratio for 30-day mortality in patients with severe intracerebral hemorrhage. Front Neurol 2024; 14:1222717. [PMID: 38283683 PMCID: PMC10811233 DOI: 10.3389/fneur.2023.1222717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/10/2023] [Indexed: 01/30/2024] Open
Abstract
Aim To explore the predictive value of white blood cell to hemoglobin ratio (WHR) for 30-day mortality in patients with intracerebral hemorrhage (ICH). Methods In this cohort study, 2,848 patients with ICH were identified in the Medical Information Mart for Intensive Care (MIMIC)-III and MIMIC-IV. Least absolute shrinkage and selection operator (LASSO) regression screened covariates of 30-day mortality of ICH patients. COX regression analysis was used to study the association of different levels of WHR, white blood cell (WBC), and hemoglobin (Hb) with 30-day mortality. The median follow-up time was 30 (20.28, 30.00) days. Results In total, 2,068 participants survived at the end of the follow-up. WHR was negatively correlated with the Glasgow Coma Score (GCS) (spearman correlation coefficient = -0.143, p < 0.001), and positively associated with the Sepsis-related Organ Failure Assessment (SOFA) score (spearman correlation coefficient = 0.156, p < 0.001), quick SOFA (qSOFA) score (spearman correlation coefficient = 0.156, p < 0.001), and Simplified Acute Physiology Score II (SAPS-II) (spearman correlation coefficient = 0.213, p < 0.001). After adjusting for confounders, WHR >0.833 (HR = 1.64, 95%CI: 1.39-1.92) and WBC >10.9 K/uL (HR = 1.49, 95%CI: 1.28-1.73) were associated with increased risk of 30-day mortality of patients with ICH. The area under the curve (AUC) value of the prediction model based on WHR and other predictors was 0.78 (95%CI: 0.77-0.79), which was higher than SAPSII (AUC = 0.75, 95%CI: 0.74-0.76), SOFA score (AUC = 0.69, 95%CI: 0.68-0.70) and GCS (AUC = 0.59, 95%CI: 0.57-0.60). Conclusion The level of WHR was associated with 30-day mortality in patients with severe ICH, and the WHR-based prediction model might provide a tool to quickly predict 30-day mortality in patients with ICH.
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Affiliation(s)
| | | | | | | | | | | | | | - Kun Zhang
- Department of Neurosurgery, Chui Yang Liu Hospital Affiliated to Tsinghua University, Beijing, China
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23
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Pierini P, Novelli A, Bossi F, Corinaldesi R, Paciaroni M, Mosconi MG, Alberti A, Venti M, de Magistris IL, Caso V. Medical versus neurosurgical treatment in ICH patients: a single center experience. Neurol Sci 2024; 45:223-229. [PMID: 37578629 PMCID: PMC10761447 DOI: 10.1007/s10072-023-07015-0] [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: 06/27/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND AND AIMS The effect of surgical treatment for spontaneous intracerebral hemorrhage (ICH) remains uncertain. We conducted an observational retrospective cohort study on supra-centimeter spontaneous ICH treated with either neurosurgical or conservative management. The baseline demographics and risk factors were correlated with in-hospital mortality and 3 and 6-month survival rates stratified by management. METHODS We included all patients with evidence of spontaneous ICH > 1 cm detected by CT and admitted between august 2020 and march 2021 to the "SMM" Hospital in Perugia. RESULTS Onehundredandtwentytwo patients were included in the study, and 45% (n.55) were surgically treated. The mean age was 71.9 ± 15.3, and 61% (n.75) were males. Intra-hospital mortality ended up being 31% (n.38), 3 months-survival was 63% (n.77) and 6 months-survival was 60% (n.73). From the multivariate analysis of the surgical patients versus medical patient, we observed that the surgical patients were younger (67.5 ± 14.9 vs 75.5 ± 14.7 y; OR 0.87; Cl 95% 0.85-0.94; p 0.001), with greater ICH volume at the onset (61 ± 39.4 cc vs 51 ± 64 cc; OR 1.03; Cl 95% 1.005-1.07; p 0.05), more midline shift (7.61 ± 5.54 mm vs 4.09 ± 5.88 mm; OR 1.37; Cl 95% 1.045-1.79; p 0.023), and a higher ICH score (3 vs 2 mean ICH score; OR 21.12; Cl 95% 2.6-170.6; p 0.004). Intra-hospital mortality in the surgical group and in the conservative treatment group was respectively 33% vs 30%, 3 month-survival was 64% vs 63% and 6 month- survival were 60% in both groups. CONCLUSIONS Our patient cohort shows no overall benefit from surgery over conservative treatment, but surgical patients were younger and had larger ICH volume.
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Affiliation(s)
- P Pierini
- Department of Emergency Medicine, Città Di Castello Hospital, Città Di Castello, Italy
| | - Agnese Novelli
- Internal, Vascular and Emergency Medicine-Stroke Unit, Santa Maria della Misericordia University of Perugia, 06139, Perugia, Italy.
| | - F Bossi
- Internal, Vascular and Emergency Medicine-Stroke Unit, Santa Maria della Misericordia University of Perugia, 06139, Perugia, Italy
| | - R Corinaldesi
- Neurosurgery Department, Santa Maria Della Misericordia Hospital, Perugia, Italy
| | - M Paciaroni
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - M G Mosconi
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - A Alberti
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - M Venti
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - I Leone de Magistris
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - V Caso
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
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Wang R, Liang Z, Xue X, Mei H, Ji L, Wang B, Chen W, Gao C, Yuan S, Wu T, Qi H, Hu S, Yi L, Song Y, Liao R, Chen B. Microglial FoxO3a deficiency ameliorates ferroptosis-induced brain injury of intracerebral haemorrhage via regulating autophagy and heme oxygenase-1. J Cell Mol Med 2024; 28:e18007. [PMID: 37890842 PMCID: PMC10805503 DOI: 10.1111/jcmm.18007] [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: 02/23/2023] [Revised: 08/17/2023] [Accepted: 09/30/2023] [Indexed: 10/29/2023] Open
Abstract
Microglial HO-1 regulates iron metabolism in the brain. Intracerebral haemorrhage (ICH) shares features of ferroptosis and necroptosis; hemin is an oxidized product of haemoglobin from lysed red blood cells, leading to secondary injury. However, little is known about the underlying molecular mechanisms attributable to secondary injury by hemin or ICH. In this study, we first show that FoxO3a was highly co-located with neurons and microglia but not astrocytes area of ICH model mice. Hemin activated FoxO3a/ATG-mediated autophagy and HO-1 signalling resulting in ferroptosis in vitro and in a mice model of brain haemorrhage. Accordingly, autophagy inhibitor Baf-A1 or HO-1 inhibitor ZnPP protected against hemin-induced ferroptosis. Hemin promoted ferroptosis of neuronal cells via FoxO3a/ATG-mediated autophagy and HO-1 signalling pathway. Knock-down of FoxO3a inhibited autophagy and prevented hemin-induced ferroptosis dependent of HO-1 signalling. We first showed that hemin stimulated microglial FoxO3a/HO-1 expression and enhanced the microglial polarisation towards the M1 phenotype, while knockdown of microglial FoxO3a inhibited pro-inflammatory cytokine production in microglia. Furthermore, the microglia activation in the striatum showed significant along with a high expression level of FoxO3a in the ICH mice. We found that conditional knockout of FoxO3a in microglia in mice alleviated neurological deficits and microglia activation as well as ferroptosis-induced striatum injury in the autologous blood-induced ICH model. We demonstrate, for the first time, that FoxO3a/ATG-mediated autophagy and HO-1 play an important role in microglial activation and ferroptosis-induced striatum injury of ICH, identifying a new therapeutic avenue for the treatment of ICH.
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Affiliation(s)
- Rikang Wang
- Department of NeurosurgeryPeking University Shenzhen HospitalShenzhenChina
| | - Zhi Liang
- Jiangxi University of Chinese MedicineNanchangChina
| | | | - Hua Mei
- Department of PharmacyGuangdong No.2 Provincial People's HospitalGuangzhouChina
| | - Lianru Ji
- Jiangxi University of Chinese MedicineNanchangChina
| | - Bocheng Wang
- Department of NeurosurgeryPeking University Shenzhen HospitalShenzhenChina
| | - Wenjin Chen
- Department of NeurosurgeryPeking University Shenzhen HospitalShenzhenChina
| | - Chao Gao
- Department of NeurosurgeryPeking University Shenzhen HospitalShenzhenChina
| | - Shun Yuan
- Jiangxi University of Chinese MedicineNanchangChina
| | - Tao Wu
- Department of NeurosurgeryPeking University Shenzhen HospitalShenzhenChina
| | - Hui Qi
- Department of NeurosurgeryPeking University Shenzhen HospitalShenzhenChina
| | - Suifa Hu
- Jiangxi University of Chinese MedicineNanchangChina
| | - Li Yi
- Department of NeurosurgeryPeking University Shenzhen HospitalShenzhenChina
| | - Yonggui Song
- Jiangxi University of Chinese MedicineNanchangChina
| | - Rifang Liao
- Department of Pharmacy, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Baodong Chen
- Department of NeurosurgeryPeking University Shenzhen HospitalShenzhenChina
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Jin Y, Huang YH, Chen YP, Zhang YD, Li J, Yang KC, Ye X, Jin LH, Wu J, Yuan CZ, Gao F, Tong LS. Combined effect of cortical superficial siderosis and cerebral microbleed on short-term and long-term outcomes after intracerebral haemorrhage. Stroke Vasc Neurol 2023:svn-2023-002439. [PMID: 37949481 DOI: 10.1136/svn-2023-002439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND AND PURPOSE Cortical superficial siderosis (cSS) and cerebral microbleed (CMB) have distinct effects on intracerebral haemorrhage (ICH). We aim to investigate the combined effect of cSS and CMB on outcomes after ICH. METHODS Based on a single-centre stroke registry database, patients with spontaneous ICH who had CT scan within 48 hours after ictus and MRI subsequently were identified. Eligible patients were divided into four groups (cSS-CMB-, cSS-CMB+, cSS+CMB-, cSS+CMB+) according to cSS and CMB on susceptibility-weighted image of MRI. Primary outcomes were haematoma volume on admission and unfavourable outcome defined as modified Rankin Scale scores ≥3 at 3 months. Secondary outcomes were all-cause death, recurrence of stroke and ICH during follow-up (median follow-up 2.0 years, IQR 1.0-3.0 years). RESULTS A total of 673 patients were identified from 1044 patients with spontaneous ICH. 131 (19.5%) had cSS and 468 (69.5%) had CMB. Patients with cSS+CMB+ had the highest rate of poor outcome at 3 months, as well as all-cause death, recurrent stroke and ICH during follow-up. In cSS- patients, CMB was associated with smaller haematoma (β -0.13; 95% CI -0.22 to -0.03; p=0.009), but it still increased risks of recurrent ICH (OR 4.6; 95% CI 1.3 to 15.6; p=0.015) and stroke (OR 2.0; 95% CI 1.0 to 4.0; p=0.049). These effects of CMB became unremarkable in the context of cSS+. CONCLUSIONS Patients with different combinations of cSS and CMB have distinct patterns of short-term and long-term outcomes. Although CMB is related to restrained haematoma, it does not improve long-term outcomes. TRIAL REGISTRATION NUMBER NCT04803292.
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Affiliation(s)
- Yujia Jin
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Yu-Hui Huang
- School of Public Health, Zhejiang University, Hangzhou, China
| | - Yu-Ping Chen
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Yao-Dan Zhang
- School of Public Health, Zhejiang University, Hangzhou, China
| | - Jiawen Li
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Kai-Cheng Yang
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xianghua Ye
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Lu-Hang Jin
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jian Wu
- Department of Neurology, Tiantai People's Hospital of Zhejiang Province, Taizhou, China
| | | | - Feng Gao
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Lu-Sha Tong
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Helmuth TB, Kumari R, Palsa K, Neely EB, Slagle-Webb B, Simon SD, Connor JR. Common Mutation in the HFE Gene Modifies Recovery After Intracerebral Hemorrhage. Stroke 2023; 54:2886-2894. [PMID: 37750297 PMCID: PMC10996156 DOI: 10.1161/strokeaha.123.043799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is characterized by bleeding into the brain parenchyma. During an ICH, iron released from the breakdown of hemoglobin creates a cytotoxic environment in the brain through increased oxidative stress. Interestingly, the loss of iron homeostasis is associated with the pathological process of other neurological diseases. However, we have previously shown that the H63D mutation in the homeostatic iron regulatory (HFE) gene, prevalent in 28% of the White population in the United States, acts as a disease modifier by limiting oxidative stress. The following study aims to examine the effects of the murine homolog, H67D HFE, on ICH. METHODS An autologous blood infusion model was utilized to create an ICH in the right striatum of H67D and wild-type mice. The motor recovery of each animal was assessed by rotarod. Neurodegeneration was measured using fluorojade-B and mitochondrial damage was assessed by immunofluorescent numbers of CytC+ (cytochrome C) neurons and CytC+ astrocytes. Finally, the molecular antioxidant response to ICH was quantified by measuring Nrf2 (nuclear factor-erythroid 2 related factor), GPX4 (glutathione peroxidase 4), and FTH1 (H-ferritin) levels in the ICH-affected and nonaffected hemispheres via immunoblotting. RESULTS At 3 days post-ICH, H67D mice demonstrated enhanced performance on rotarod compared with wild-type animals despite no differences in lesion size. Additionally, H67D mice displayed higher levels of Nrf2, GPX4, and FTH1 in the ICH-affected hemisphere; however, these levels were not different in the contralateral, non-ICH-affected hemisphere. Furthermore, H67D mice showed decreased degenerated neurons, CytC+ Neurons, and CytC+ astrocytes in the perihematomal area. CONCLUSIONS Our data suggest that the H67D mutation induces a robust antioxidant response 3 days following ICH through Nrf2, GPX4, and FTH1 activation. This activation could explain the decrease in degenerated neurons, CytC+ neurons, and CytC+ astrocytes in the perihematomal region, leading to the improved motor recovery. Based on this study, further investigation into the mechanisms of this neuroprotective response and the effects of the H63D HFE mutation in a population of patients with ICH is warranted.
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Affiliation(s)
- Timothy B Helmuth
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
| | - Rashmi Kumari
- Department of Neural and Behavioral Sciences (R.K.), Penn State College of Medicine, Hershey, PA
| | - Kondaiah Palsa
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
| | - Elizabeth B Neely
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
| | - Becky Slagle-Webb
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
| | - Scott D Simon
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
| | - James R Connor
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
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Yuan M, Xiao Z, Zhou H, Fu A, Pei Z. Association between platelet-lymphocyte ratio and 90-day mortality in patients with intracerebral hemorrhage: data from the MIMIC-III database. Front Neurol 2023; 14:1234252. [PMID: 37877032 PMCID: PMC10591107 DOI: 10.3389/fneur.2023.1234252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/15/2023] [Indexed: 10/26/2023] Open
Abstract
Background Recent evidence suggested that platelet-lymphocyte ratio (PLR) may play a role in the pathophysiology of intracerebral hemorrhage (ICH), but the results are controversial. This study aimed to explore the relationship between PLR and mortality in patients with ICH. Methods All data were extracted from the Medical Information Mart for Intensive Care (MIMIC) III database. The study outcome was 90-day mortality. Multivariable Cox regression analyses were used to calculate the adjusted hazard ratio (HR) with a 95% confidence interval (CI), and curve-fitting (restricted cubic spline) was used to assess the non-linear relationship. Results Of 1,442 patients, 1,043 patients with ICH were included. The overall 90-day mortality was 29.8% (311/1,043). When PLR was assessed in quartiles, the risk of 90-day mortality for ICH was lowest for quartile 2 (120.9 to <189.8: adjusted HR, 0.67; 95% CI: 0.48-0.93; P = 0.016), compared with those in quartile 1 (<120.9). Consistently in the threshold analysis, for every 1 unit increase in PLR, there was a 0.6% decrease in the risk of 90-day mortality for ICH (adjusted HR, 0.994; 95% CI: 0.988-0.999) in those with PLR <145.54, and a 0.2% increase in 90-day mortality (adjusted HR, 1.002; 95% CI: 1.000-1.003) in participants with PLR ≥145.54. Conclusion There was a non-linear relationship between PLR and 90-day mortality for patients with ICH, with an inflection point at 145.54 and a minimal risk at 120.9 to <189.8 of PLR.
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Affiliation(s)
- Min Yuan
- Graduate School, Nanchang University, Nanchang, China
- Department of Neurology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Zhilong Xiao
- Department of Neurology, The Third Hospital of Nanchang, Nanchang, China
| | - Huangyan Zhou
- Department of Blood Transfusion, Jiangxi Cancer Hospital, The Second Affiliated Hospital of Nanchang Medical College, Jiangxi Clinical Research Center for Cancer, Nanchang, China
| | - Anxia Fu
- Department of Neurology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Zhimin Pei
- The Second People's Hospital of Nanchang County, Nanchang, China
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Sterling LH, Fernando SM, Talarico R, Qureshi D, van Diepen S, Herridge MS, Price S, Brodie D, Fan E, Di Santo P, Jung RG, Parlow S, Basir MB, Scales DC, Combes A, Mathew R, Thiele H, Tanuseputro P, Hibbert B. Long-Term Outcomes of Cardiogenic Shock Complicating Myocardial Infarction. J Am Coll Cardiol 2023; 82:985-995. [PMID: 37648357 DOI: 10.1016/j.jacc.2023.06.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Cardiogenic shock secondary to acute myocardial infarction (AMI-CS) is associated with substantial short-term mortality; however, there are limited data on long-term outcomes and trends. OBJECTIVES This study sought to examine long-term outcomes of AMI-CS patients. METHODS This was a population-based, retrospective cohort study in Ontario, Canada of critically ill adult patients with AMI-CS who were admitted to hospitals between April 1, 2009 and March 31, 2019. Outcome data were captured using linked health administrative databases. RESULTS A total of 9,789 consecutive patients with AMI-CS from 135 centers were included. The mean age was 70.5 ± 12.3 years, and 67.7% were male. The incidence of AMI-CS was 8.2 per 100,000 person-years, and it increased over the study period. Critical care interventions were common, with 5,422 (55.4%) undergoing invasive mechanical ventilation, 1,425 (14.6%) undergoing renal replacement therapy, and 1,484 (15.2%) receiving mechanical circulatory support. A total of 2,961 patients (30.2%) died in the hospital, and 4,004 (40.9%) died by 1 year. Mortality at 5 years was 58.9%. Small improvements in short- and long-term mortality were seen over the study period. Among survivors to discharge, 2,870 (42.0%) required increased support in care from their preadmission baseline, 3,244 (47.5%) were readmitted to the hospital within 1 year, and 1,047 (15.3%) died within 1 year. The mean number of days at home in the year following discharge was 307.9 ± 109.6. CONCLUSIONS Short- and long-term mortality among patients with AMI-CS is high, with minimal improvement over time. AMI-CS survivors experience significant morbidity, with high risks of readmission and death. Future studies should evaluate interventions to minimize postdischarge morbidity and mortality among AMI-CS survivors.
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Affiliation(s)
- Lee H Sterling
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Shannon M Fernando
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Critical Care, Lakeridge Health Corporation, Oshawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Robert Talarico
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Danial Qureshi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES, Toronto, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Susanna Price
- Royal Brompton & Harefield Hospitals, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Pietro Di Santo
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard G Jung
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Simon Parlow
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Damon C Scales
- ICES, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne University, Paris, France; Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Institut de Cardiologie, Paris, France
| | - Rebecca Mathew
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES, Toronto, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Benjamin Hibbert
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Renwick CM, Curley J. Optic Nerve Ultrasound for Monitoring Deteriorating Intracranial Hemorrhage in a Patient on Extracorporeal Membrane Oxygenation: A Case Report. Cureus 2023; 15:e42719. [PMID: 37654933 PMCID: PMC10466261 DOI: 10.7759/cureus.42719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/02/2023] Open
Abstract
We present a 52-year-old male patient with cardiogenic shock who was placed on veno-arterial extracorporeal membrane oxygenation (ECMO) as a bridge to an orthotopic heart transplant. While on ECMO, the patient developed an acute intracranial bleed confirmed on computerized tomography (CT). However, his clinical status deteriorated and he was unstable for transport to evaluate for worsening hemorrhage. Instead, optic nerve sheath (ONS) ultrasonography was utilized to confirm increased intracranial pressure, which guided the goals of care until he stabilized enough to transport for advanced imaging. Repeat CT confirmed the worsening of his cerebellar bleed with obstructing hydrocephalus and brainstem compression. This case demonstrates how ONS ultrasound can be utilized in a cardiothoracic intensive care unit to evaluate sedated patients for new or worsening intracranial hemorrhage. In ECMO patients, who are often unstable with the risks of transportation for CT outweighing potential benefits, ONS ultrasonography can provide the care team with meaningful data on a patient's neurologic status.
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Affiliation(s)
- Christian M Renwick
- Anesthesiology and Critical Care, University of Virginia, Charlottesville, USA
| | - Jonathan Curley
- Anesthesiology and Critical Care, University of Virginia, Charlottesville, USA
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Carvalho Poyraz F, Boehme A, Cottarelli A, Eisler L, Elkind MSV, Ghoshal S, Agarwal S, Park S, Claassen J, Connolly ES, Hod EA, Roh DJ. Red Blood Cell Transfusions Are Not Associated With Incident Complications or Poor Outcomes in Patients With Intracerebral Hemorrhage. J Am Heart Assoc 2023; 12:e028816. [PMID: 37232240 PMCID: PMC10381991 DOI: 10.1161/jaha.122.028816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/14/2023] [Indexed: 05/27/2023]
Abstract
Background Anemia is associated with poor intracerebral hemorrhage (ICH) outcomes, yet the relationship of red blood cell (RBC) transfusions to ICH complications and functional outcomes remains unclear. We investigated the impact of RBC transfusion on hospital thromboembolic and infectious complications and outcomes in patients with ICH. Methods and Results Consecutive patients with spontaneous ICH enrolled in a single-center, prospective cohort study from 2009 to 2018 were assessed. Primary analyses assessed relationships of RBC transfusions on incident thromboembolic and infectious complications occurring after the transfusion. Secondary analyses assessed relationships of RBC transfusions with mortality and poor discharge modified Rankin Scale score 4 to 6. Multivariable logistic regression models adjusted for baseline demographics and medical disease severity (Acute Physiology and Chronic Health Evaluation II), and ICH severity (ICH score).Of 587 patients with ICH analyzed, 88 (15%) received at least one RBC transfusion. Patients receiving RBC transfusions had worse medical and ICH severity. Though patients receiving RBC transfusions had more complications at any point during the hospitalization (64.8% versus 35.9%), we found no association between RBC transfusion and incident complications in our regression models (adjusted odds ratio [aOR], 0.71 [95% CI, 0.42-1.20]). After adjusting for disease severity and other relevant covariates, we found no significant association between RBC transfusion and mortality (aOR, 0.87 [95% CI, 0.45-1.66]) or poor discharge modified Rankin Scale score (aOR, 2.45 [95% CI, 0.80-7.61]). Conclusions In our cohort with ICH, RBC transfusions were expectedly given to patients with higher medical and ICH severity. Taking disease severity and timing of transfusions into account, RBC transfusion was not associated with incident hospital complications or poor clinical ICH outcomes.
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Affiliation(s)
- Fernanda Carvalho Poyraz
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
- Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Azzurra Cottarelli
- Department of Pathology and Cell Biology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Lisa Eisler
- Department of Anesthesiology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
- Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Shivani Ghoshal
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Sachin Agarwal
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Soojin Park
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Jan Claassen
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - E. Sander Connolly
- Department of Neurological Surgery, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Eldad A. Hod
- Department of Pathology and Cell Biology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - David J. Roh
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
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Al-Ajlan FS, Gladstone DJ, Song D, Thorpe KE, Swartz RH, Butcher KS, Del Campo M, Dowlatshahi D, Gensicke H, Lee GJ, Flaherty ML, Hill MD, Aviv RI, Demchuk AM. Time Course of Early Hematoma Expansion in Acute Spot-Sign Positive Intracerebral Hemorrhage: Prespecified Analysis of the SPOTLIGHT Randomized Clinical Trial. Stroke 2023; 54:715-721. [PMID: 36756899 DOI: 10.1161/strokeaha.121.038475] [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] [Indexed: 02/10/2023]
Abstract
BACKGROUND In the SPOTLIGHT trial (Spot Sign Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy), patients with a computed tomography (CT) angiography spot-sign positive acute intracerebral hemorrhage were randomized to rFVIIa (recombinant activated factor VIIa; 80 μg/kg) or placebo within 6 hours of onset, aiming to limit hematoma expansion. Administration of rFVIIa did not significantly reduce hematoma expansion. In this prespecified analysis, we aimed to investigate the impact of delays from baseline imaging to study drug administration on hematoma expansion. METHODS Hematoma volumes were measured on the baseline CT, early post-dose CT, and 24 hours CT scans. Total hematoma volume (intracerebral hemorrhage+intraventricular hemorrhage) change between the 3 scans was calculated as an estimate of how much hematoma expansion occurred before and after studying drug administration. RESULTS Of the 50 patients included in the trial, 44 had an early post-dose CT scan. Median time (interquartile range) from onset to baseline CT was 1.4 hours (1.2-2.6). Median time from baseline CT to study drug was 62.5 (55-80) minutes, and from study drug to early post-dose CT was 19 (14.5-30) minutes. Median (interquartile range) total hematoma volume increased from baseline CT to early post-dose CT by 10.0 mL (-0.7 to 18.5) in the rFVIIa arm and 5.4 mL (1.8-8.3) in the placebo arm (P=0.96). Median volume change between the early post-dose CT and follow-up scan was 0.6 mL (-2.6 to 8.3) in the rFVIIa arm and 0.7 mL (-1.6 to 2.1) in the placebo arm (P=0.98). Total hematoma volume decreased between the early post-dose CT and 24-hour scan in 44.2% of cases (rFVIIa 38.9% and placebo 48%). The adjusted hematoma growth in volume immediately post dose for FVIIa was 0.998 times that of placebo ([95% CI, 0.71-1.43]; P=0.99). The hourly growth in FFVIIa was 0.998 times that for placebo ([95% CI, 0.994-1.003]; P=0.50; Table 3). CONCLUSIONS In the SPOTLIGHT trial, the adjusted hematoma volume growth was not associated with Factor VIIa treatment. Most hematoma expansion occurred between the baseline CT and the early post-dose CT, limiting any potential treatment effect of hemostatic therapy. Future hemostatic trials must treat intracerebral hemorrhage patients earlier from onset, with minimal delay between baseline CT and drug administration. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01359202.
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Affiliation(s)
- Fahad S Al-Ajlan
- Department of Neurosciences (Neurology), King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia (F.S.A.-A.)
| | - David J Gladstone
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program and Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G., R.H.S.).,Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Dongbeom Song
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Kevin E Thorpe
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Canada (K.E.T.)
| | - Rick H Swartz
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program and Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G., R.H.S.).,Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Kenneth S Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, AustraliaDepartment of Medicine (Neurology), University of Alberta, Edmonton, Canada (K.S.B.)
| | - Martin Del Campo
- Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | - Henrik Gensicke
- Stroke Center and Neurology, University Hospital Basel, Switzerland (H.G.)
| | - Gloria Jooyoung Lee
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Matthew L Flaherty
- Department of Neurology, University of Cincinnati, OH (M.L.F., R.I.A.). Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Richard I Aviv
- Department of Neurology, University of Cincinnati, OH (M.L.F., R.I.A.). Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
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Mayerhofer E, Parodi L, Prapiadou S, Malik R, Rosand J, Georgakis MK, Anderson CD. Genetic Risk Score Improves Risk Stratification for Anticoagulation-Related Intracerebral Hemorrhage. Stroke 2023; 54:791-799. [PMID: 36756894 PMCID: PMC9992221 DOI: 10.1161/strokeaha.122.041764] [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: 10/25/2022] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is the most devastating adverse outcome for patients on anticoagulants. Clinical risk scores that quantify bleeding risk can guide decision-making in situations when indication or duration for anticoagulation is uncertain. We investigated whether integration of a genetic risk score into an existing risk factor-based CRS could improve risk stratification for anticoagulation-related ICH. METHODS We constructed 153 genetic risk scores from genome-wide association data of 1545 ICH cases and 1481 controls and validated them in 431 ICH cases and 431 matched controls from the population-based UK Biobank. The score that explained the largest variance in ICH risk was selected and tested for prediction of incident ICH in an independent cohort of 5530 anticoagulant users. A CRS for major anticoagulation-related hemorrhage, based on 8/9 components of the HAS-BLED score, was compared with a combined clinical and genetic risk score incorporating an additional point for high genetic risk for ICH. RESULTS Among anticoagulated individuals, 94 ICH occurred over a mean follow-up of 11.9 years. Compared with the lowest genetic risk score tertile, being in the highest tertile was associated with a two-fold increased risk for incident ICH (hazard ratio, 2.08 [95% CI, 1.22-3.56]). Although the CRS predicted incident ICH with a hazard ratio of 1.24 per 1-point increase (95% CI [1.01-1.53]), adding a point for high genetic ICH risk led to a stronger association (hazard ratio of 1.33 per 1-point increase [95% CI, 1.11-1.59]) with improved risk stratification (C index 0.57 versus 0.53) and maintained calibration (integrated calibration index 0.001 for both). The new clinical and genetic risk score showed 19% improvement in high-risk classification among individuals with ICH and a net reclassification improvement of 0.10. CONCLUSIONS Among anticoagulant users, a prediction score incorporating genomic information is superior to a clinical risk score alone for ICH risk stratification and could serve in clinical decision-making.
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Affiliation(s)
- Ernst Mayerhofer
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, USA
| | - Livia Parodi
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, USA
- Department of Neurology, Brigham and Women’s Hospital, Boston, USA
| | - Savvina Prapiadou
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, USA
| | - Rainer Malik
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-University (LMU) Munich, Germany
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, USA
| | - Marios K Georgakis
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, USA
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-University (LMU) Munich, Germany
| | - Christopher D Anderson
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, USA
- Department of Neurology, Brigham and Women’s Hospital, Boston, USA
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De Rosa L, Manara R, Vodret F, Kulyk C, Montano F, Pieroni A, Viaro F, Zedde ML, Napoletano R, Ermani M, Baracchini C. The "SALPARE study" of spontaneous intracerebral hemorrhage: part 1. Neurol Res Pract 2023; 5:5. [PMID: 36726162 PMCID: PMC9893659 DOI: 10.1186/s42466-023-00231-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/10/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) is a devastating type of stroke with a huge impact on patients and families. Expanded use of oral anticoagulants and ageing population might contribute to an epidemiological change. In view of these trends, we planned a study to obtain a contemporary picture and identify early prognostic factors to improve secondary prevention. METHODS This multicenter prospective cohort study included consecutive adult patients with non-traumatic ICH admitted to three academic Italian hospitals (Salerno, Padova, Reggio Emilia) over a 2-year period. Demographic characteristics, vascular risk profile, clinical data and main radiological characteristics were correlated to 90-day clinical outcome. RESULTS Out of 682 patients [mean age: 73 ± 14 years; 316 (46.3%) females] enrolled in this study, 40% died [86/180 (47.8%) in Salerno, 120/320 (37.5%) in Padova, 67/182 (36.8%) in Reggio Emilia; p < 0.05)] and 36% were severely disabled at 90 days. Several factors were associated with a higher risk of poor functional outcome such as antithrombotic drug use, hyperglycemia, previous cerebrovascular accident, low platelet count, and pontine/massive/intraventricular hemorrhage. However, at multivariate analysis only pre-ICH mRS score (OR 30.84), GCS score at presentation (OR 11.88), initial hematoma volume (OR 29.71), and NIHSS score at presentation (OR 25.89) were independent predictors of death and poor functional outcome. CONCLUSION Despite the heterogeneity among centers, this study on ICH has identified four simple prognostic factors that can independently predict patients outcome, stratify their risk, and guide their management.
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Affiliation(s)
- Ludovica De Rosa
- grid.411474.30000 0004 1760 2630Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Renzo Manara
- grid.411474.30000 0004 1760 2630Neuroradiology Unit, Padua University Hospital, Padua, Italy
| | - Francesca Vodret
- grid.411474.30000 0004 1760 2630Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Caterina Kulyk
- grid.9970.70000 0001 1941 5140Stroke Unit and Neurosonology Laboratory, Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Florian Montano
- grid.11780.3f0000 0004 1937 0335Neuroradiology, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Alessio Pieroni
- grid.411474.30000 0004 1760 2630Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Federica Viaro
- grid.411474.30000 0004 1760 2630Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Maria Luisa Zedde
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Rosa Napoletano
- UOC Neurologia AOU S. Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy
| | - Mario Ermani
- grid.411474.30000 0004 1760 2630Service of Medical Statistics, Department of Neurology, Padua University Hospital, Padua, Italy
| | - Claudio Baracchini
- grid.411474.30000 0004 1760 2630Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
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Jin YJ, Li JW, Wu J, Huang YH, Yang KC, An HN, Yuan CZ, Gao F, Tong LS. Cortical superficial siderosis, hematoma volume, and outcomes after intracerebral hemorrhage: a mediation analysis. Front Neurol 2023; 14:1122744. [PMID: 37213900 PMCID: PMC10196120 DOI: 10.3389/fneur.2023.1122744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/03/2023] [Indexed: 05/23/2023] Open
Abstract
Background Previous studies have shown that cortical superficial siderosis (cSS) can increase hematoma volume and predict poor outcomes following primary intracerebral hemorrhage (ICH). Objective We aimed to determine whether a large hematoma volume was the essential factor contributing to worse outcomes of cSS. Methods Patients with spontaneous ICH underwent a CT scan within 48 h after ictus. Evaluation of cSS was performed using magnetic resonance imaging (MRI) within 7 days. The 90-day outcome was assessed using the modified Rankin Scale (mRS). In addition, we investigated the correlation between cSS, hematoma volume, and 90-day outcomes using multivariate regression and mediation analyses. Results Among the 673 patients with ICH [mean (SD) age, 61 (13) years; 237 female subjects (35.2%); median (IQR) hematoma volume, 9.0 (3.0-17.6) ml], 131 (19.5%) had cSS. There was an association between cSS and larger hematoma volume (β = 4.449, 95% CI 1.890-7.009, p < 0.001) independent of hematoma location and was also related to worse 90-day mRS (β = 0.333, 95% CI 0.008-0.659, p = 0.045) in multivariable regression. In addition, mediation analyses revealed that hematoma volume was an essential factor mediating the effect of cSS on unfavorable 90-day outcomes (proportion mediated:66.04%, p = 0.01). Conclusion Large hematoma volume was the major charge of directing cSS to worse outcomes in patients with mild to moderate ICH, and cSS was related to a larger hematoma in both lobar and non-lobar areas. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT04803292, identifier: NCT04803292.
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Affiliation(s)
- Yu-jia Jin
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jia-wen Li
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jian Wu
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Yu-hui Huang
- School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Kai-cheng Yang
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Hong-na An
- Department of Neurology, The 2nd People's Hospital of Quzhou, Quzhou, China
| | - Chang-zheng Yuan
- School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Feng Gao
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
- Feng Gao
| | - Lu-sha Tong
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
- *Correspondence: Lu-sha Tong
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Ratnayake C, Okonkwo DO, Branstetter BF. Hematoma Progression Rates on Head Computed Tomography for Fluid Levels versus Mimics in Patients with Primary Intracerebral Hemorrhage. World Neurosurg 2023; 169:e230-e234. [PMID: 36334718 DOI: 10.1016/j.wneu.2022.10.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Among stroke patients, primary intracerebral hemorrhage has the highest mortality rate. Expansion of hematoma plays a prognostic role in these patients. Although fluid levels have been shown to predict subsequent hematoma expansion, there are mimics of fluid levels that may confuse interpretation. We hypothesized that patients with true fluid levels on head computed tomography (CT) have higher hematoma progression rates and worse outcomes compared with patients who have fluid level mimics on CT. METHODS Adult patients presenting with intracerebral hemorrhage described as a fluid level on initial CT interpretation were included. Medical records were reviewed to extract relevant clinical variables. A CAQ-certified neuroradiologist retrospectively determined whether there was a true fluid level or mimic on CT and then evaluated follow-up CT scans for radiologic progression. We compared radiologic progression, mortality, and anticoagulation status between patients with true fluid levels and fluid level mimics. RESULTS The study included 12 patients, 8 with true fluid levels and 4 with radiologic mimics. The patients with true fluid levels had a significantly higher likelihood of radiographic progression (P = 0.014). Differences in outcome, use of anticoagulation therapy, and average international normalized ratio were not significant. CONCLUSIONS A fluid level within intraparenchymal hemorrhage on head CT scan is associated with higher likelihood of intracerebral hemorrhage progression. However, this applies only to true fluid levels, with mimics having a lower likelihood of progression. A careful analysis of potential fluid levels is necessary before assigning prognostic implications.
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Affiliation(s)
- Charith Ratnayake
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Barton F Branstetter
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Yuan M, Zhou X, Lu X, Xiao Z, Zhou H, Wang X. Association between statin use during hospitalisation and mortality in patients with intracerebral haemorrhage: a propensity score-matched cohort study. BMJ Open 2022; 12:e065849. [PMID: 36585154 PMCID: PMC9809250 DOI: 10.1136/bmjopen-2022-065849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES We examined the relationship between statin use during hospitalisation and mortality in patients with intracerebral haemorrhage (ICH). DESIGN Retrospective propensity-matched cohort study. SETTING Patients with ICH (≥18 years old) admitted to Beth Israel Deaconess Medical Center (Boston, Massachusetts, USA) from 2001 to 2012 registered in the Medical Information Mart for Intensive Care III database. PARTICIPANTS 1043 patients with ICH (≥18 years) were evaluated for the relationship between statin use during hospitalisation and mortality. INTERVENTIONS Statin use. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was 90-day mortality. We used multivariable Cox regression analyses to calculate the adjusted HR with 95% CI and used propensity score analysis and an inverse probability weighting (IPW) model to ensure the robustness of our findings. RESULTS We included 1043 patients with ICH (362 and 681 were statins and non-statin users, respectively) between 2001 and 2012. The overall 90-day mortality was 29.8% (311/1043); it was 33.3% (227/681) and 23.2% (84/362) for non-statin and statin users, respectively. After adjusted for potential confounders, we found that statin use was associated with 29% lower of 90-day mortality (HR=0.71, 95% CI 0.52 to 0.97, p<0.05). IPW also demonstrated a significantly lower 90-day mortality in statin users. The HR was 0.69 (95% CI 0.54 to 0.88, p<0.01). The results remain stable in subgroup analyses and propensity score matching. CONCLUSION Statin use during hospitalisation may be associated with reduced risk-adjusted mortality in patients with ICH. Further randomised controlled trials are needed to clarify this association.
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Affiliation(s)
- Min Yuan
- Department of Neurology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Xinhua Zhou
- Department of Neurology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Xiaoqing Lu
- Department of Neurology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Zhilong Xiao
- Department of Neurology, The Third Hospital of Nanchang, Nanchang, China
| | - Huangyan Zhou
- Department of Blood Transfusion, Jiangxi Cancer Hospital, The Second Affiliated Hospital of Nanchang Medical College, Jiangxi Clinical Research Center for Cancer, Nanchang, China
| | - Xiaohua Wang
- Department of General Practice/General Family Medicine, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
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Liang H, Xu H, Zheng H, Li C. Editorial: Herbal medicines in managing stroke and neurodegenerative diseases—Is there evidence based on basic and clinical studies?, volume II. Front Pharmacol 2022; 13:1059848. [DOI: 10.3389/fphar.2022.1059848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
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Nakagawa K, Chen R, Greenberg SM, Ross GW, Willcox BJ, Donlon TA, Allsopp RC, Willcox DC, Morris BJ, Masaki KH. Forkhead box O3 longevity genotype may attenuate the impact of hypertension on risk of intracerebral haemorrhage. J Hypertens 2022; 40:2230-2235. [PMID: 35943066 PMCID: PMC9553272 DOI: 10.1097/hjh.0000000000003249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/31/2022] [Accepted: 06/05/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Since the G allele of forkhead box O3 ( FOXO3 ) single nucleotide polymorphism (SNP) rs2802292 is associated with resilience and longevity, ostensibly by mitigating the adverse effects of chronic cardiometabolic stress on mortality, our aim was to determine the association between the FOXO3 SNP rs2802292 genotype and risk of hypertension-mediated intracerebral haemorrhage (ICH). METHODS From a prospective population-based cohort of Japanese American men from the Kuakini Honolulu Heart Program (KHHP), age-adjusted prevalence of ICH by hypertension was assessed for the whole cohort after stratifying by FOXO3 genotype. Cox regression models, adjusted for age, cardiovascular risk factors and, FOXO3 and APOE genotypes, were utilized to determine relative risk of hypertension's effect on ICH. All models were created for the whole cohort and stratified by FOXO3 G -allele carriage vs. TT genotype. RESULTS Among 6469 men free of baseline stroke, FOXO3 G -allele carriage was seen in 3009 (46.5%) participants. Overall, 183 participants developed ICH over the 34-year follow-up period. Age-adjusted ICH incidence was 0.90 vs. 1.32 per 1000 person-years follow-up in those without and with hypertension, respectively ( P = 0.002). After stratifying by FOXO3 genotype, this association was no longer significant in G allele carriers. In the whole cohort, hypertension was an independent predictor of ICH (relative risk [RR] = 1.70, 95% confidence interval [CI] 1.25, 2.32; P = 0.0007). In stratified analyses, hypertension remained an independent predictor of ICH among the FOXO3 TT -genotype group (RR = 2.02, 95% CI 1.33, 3.07; P = 0.001), but not in FOXO3 G -allele carriers (RR = 1.39, 95% CI 0.88, 2.19; P = 0.15). CONCLUSIONS The longevity-associated FOXO3 G allele may attenuate the impact of hypertension on ICH risk.
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Affiliation(s)
- Kazuma Nakagawa
- Department of Research, Kuakini Medical Center
- Neuroscience Institute, The Queen's Medical Center
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Randi Chen
- Department of Research, Kuakini Medical Center
| | - Steven M. Greenberg
- Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - G. Webster Ross
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
- Pacific Health Research and Education Institute
- Veterans Affairs Pacific Islands Healthcare Systems
- Department of Geriatric Medicine
| | - Bradley J. Willcox
- Department of Research, Kuakini Medical Center
- Department of Geriatric Medicine
| | - Timothy A. Donlon
- Department of Research, Kuakini Medical Center
- Department of Cell and Molecular Biology
| | - Richard C. Allsopp
- Department of Anatomy, Biochemistry and Physiology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - D. Craig Willcox
- Department of Research, Kuakini Medical Center
- Department of Human Welfare, Okinawa International University, Ginowan, Okinawa, Japan
| | - Brian J. Morris
- Department of Research, Kuakini Medical Center
- Department of Geriatric Medicine
- School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Kamal H. Masaki
- Department of Research, Kuakini Medical Center
- Department of Geriatric Medicine
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Mayerhofer E, Malik R, Parodi L, Burgess S, Harloff A, Dichgans M, Rosand J, Anderson CD, Georgakis MK. Genetically predicted on-statin LDL response is associated with higher intracerebral haemorrhage risk. Brain 2022; 145:2677-2686. [PMID: 35598204 PMCID: PMC9612789 DOI: 10.1093/brain/awac186] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/30/2022] [Accepted: 05/12/2022] [Indexed: 11/14/2022] Open
Abstract
Statins lower low-density lipoprotein cholesterol and are widely used for the prevention of atherosclerotic cardiovascular disease. Whether statin-induced low-density lipoprotein reduction increases risk of intracerebral haemorrhage has been debated for almost two decades. Here, we explored whether genetically predicted on-statin low-density lipoprotein response is associated with intracerebral haemorrhage risk using Mendelian randomization. Using genomic data from randomized trials, we derived a polygenic score from 35 single nucleotide polymorphisms of on-statin low-density lipoprotein response and tested it in the population-based UK Biobank. We extracted statin drug and dose information from primary care data on a subset of 225 195 UK Biobank participants covering a period of 29 years. We validated the effects of the genetic score on longitudinal low-density lipoprotein measurements with generalized mixed models and explored associations with incident intracerebral haemorrhage using Cox regression analysis. Statins were prescribed at least once to 75 973 (31%) of the study participants (mean 57 years, 55% females). Among statin users, mean low-density lipoprotein decreased by 3.45 mg/dl per year [95% confidence interval (CI): (-3.47, -3.42)] over follow-up. A higher genetic score of statin response [1 standard deviation (SD) increment] was associated with significant additional reductions in low-density lipoprotein levels [-0.05 mg/dl per year, (-0.07, -0.02)], showed concordant lipidomic effects on other lipid traits as statin use and was associated with a lower risk for incident myocardial infarction [hazard ratio per SD increment 0.98 95% CI (0.96, 0.99)] and peripheral artery disease [hazard ratio per SD increment 0.93 95% CI (0.87, 0.99)]. Over a 11-year follow-up period, a higher genetically predicted statin response among statin users was associated with higher intracerebral haemorrhage risk in a model adjusting for statin dose [hazard ratio per SD increment 1.16, 95% CI (1.05, 1.28)]. On the contrary, there was no association with intracerebral haemorrhage risk among statin non-users (P = 0.89). These results provide further support for the hypothesis that statin-induced low-density lipoprotein reduction may be causally associated with intracerebral haemorrhage risk. While the net benefit of statins for preventing vascular disease is well-established, these results provide insights about the personalized response to statin intake and the role of pharmacological low-density lipoprotein lowering in the pathogenesis of intracerebral haemorrhage.
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Affiliation(s)
- Ernst Mayerhofer
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology and Neurophysiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rainer Malik
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Livia Parodi
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen Burgess
- University of Cambridge, MRC Biostatistics Unit, Cambridge, UK
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher D Anderson
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Marios K Georgakis
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
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Puy L, Forman R, Cordonnier C, Sheth KN. Protecting the Brain, From the Heart: Safely Mitigating the Consequences of Thrombosis in Intracerebral Hemorrhage Survivors With Atrial Fibrillation. Stroke 2022; 53:2152-2160. [PMID: 35759545 DOI: 10.1161/strokeaha.122.036888] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Optimal antithrombotic management after intracerebral hemorrhage remains one of the central unresolved issues for patients who survive, especially for those patients with atrial fibrillation. Given the observational nature of the studies regarding anticoagulation resumption after intracerebral hemorrhage, there is uncertainty regarding resumption of oral anticoagulation therapy and its timing. There is limited high-quality evidence to guide clinical practice, leading to significant practice variation and uncertainty for patients and providers. Here, we aim to provide the key elements to guide clinicians in their individual decision: whether or not to start or resume anticoagulation in patients with a history of intracerebral hemorrhage.
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Peeters MTJ, Vroman F, Schreuder TAHCML, van Oostenbrugge RJ, Staals J. Decrease in incidence of oral anticoagulant-related intracerebral hemorrhage over the past decade in the Netherlands. Eur Stroke J 2022; 7:20-27. [PMID: 35300253 PMCID: PMC8921786 DOI: 10.1177/23969873211062011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022] Open
Abstract
Background Data on oral anticoagulant-related (OAC) intracerebral hemorrhage (ICH) incidence are scarce. Most studies on incidence time trends were performed before the introduction of Direct Oral Anticoagulants (DOACs). Between 2008 and 2018, the number of OAC-users in the Netherlands increased by 63%, with the number of DOAC-users almost equaling that of Vitamin K Antagonists (VKA)-users. We aimed to determine the recent total and OAC-related ICH incidence and assess changes over the last decade, including the effect of DOAC introduction. Methods All adult non-traumatic ICH patients presenting in any of three hospitals in the enclosed region of South-Limburg, the Netherlands, were retrospectively included, during two 3-year time periods: 2007–2009 and 2017–2019. OAC-related ICH was defined as ICH in patients using VKAs or DOACs. We calculated the incidence rate ratio (IRR) between the two study periods. Results In the 2007–2009 period, we registered 652 ICHs of whom 168 (25.8%) were OAC-related (all VKA). In the 2017–2019 period, we registered 522 ICHs, 121 (23.2%) were OAC-related (70 VKA and 51 DOAC). In 2007–2009, the annual incidence of total ICH and OAC-related ICH was 40.9 and 10.5 per 100,000 person-years, respectively, which decreased to 32.4 and 7.5 per 100,000 person-years in 2017–2019. The IRR for total ICH and OAC-related ICH was 0.67 (95%-CI: 0.60–0.75) and 0.58 (0.46–0.73), respectively. Conclusion Both total ICH and OAC-related ICH incidence decreased over the past decade in South-Limburg, the Netherlands, despite the aging population and increasing number of OAC-users. The introduction of DOACs, and possibly an improved cardiovascular risk management and change in OAC prescription pattern, could explain these findings.
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Affiliation(s)
- Michaël TJ Peeters
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
| | - Florence Vroman
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
- Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Center, the Netherlands
| | | | - Robert J van Oostenbrugge
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
| | - Julie Staals
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
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Witsch J, Roh DJ, Avadhani R, Merkler AE, Kamel H, Awad I, Hanley DF, Ziai WC, Murthy SB. Association Between Intraventricular Alteplase Use and Parenchymal Hematoma Volume in Patients With Spontaneous Intracerebral Hemorrhage and Intraventricular Hemorrhage. JAMA Netw Open 2021; 4:e2135773. [PMID: 34860246 PMCID: PMC8642781 DOI: 10.1001/jamanetworkopen.2021.35773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Intraventricular thrombolysis reduces intraventricular hemorrhage (IVH) volume in patients with spontaneous intracerebral hemorrhage (ICH), but it is unclear if a similar association with parenchymal ICH volume exists. OBJECTIVE To evaluate the association between intraventricular alteplase use and ICH volume as well as the association between a change in parenchymal ICH volume and long-term functional outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a post hoc exploratory analysis of data from the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage phase 3 randomized clinical trial with blinded outcome assessments. Between September 1, 2009, and January 31, 2015, patients with ICH and IVH were randomized to receive either intraventricular alteplase or normal saline via an external ventricular drain. Participants with primary IVH were excluded. Data analyses were performed between January 1 and June 30, 2021. EXPOSURE Randomization to receive intraventricular alteplase. MAIN OUTCOMES AND MEASURES The primary outcome was the change in parenchymal ICH volume between the hematoma stability and end-of-treatment computed tomography scans. Secondary outcomes were a modified Rankin Scale score higher than 3 and mortality, both of which were assessed at 6 months. The association between alteplase and change in parenchymal ICH volume was assessed using multiple linear regression, whereas the associations between change in parenchymal ICH volume and 6-month outcomes were assessed using multiple logistic regression. Prespecified subgroup analyses were performed for baseline IVH volume, admission ICH volume, and ICH location. RESULTS A total of 454 patients (254 men [55.9%]; mean [SD] age, 59 [11] years) were included in the study. Of these patients, 230 (50.7%) were randomized to receive alteplase and 224 (49.3%) to receive normal saline. The alteplase group had a greater mean (SD) reduction in parenchymal ICH volume compared with the saline group (1.8 [0.2] mL vs 0.4 [0.1] mL; P < .001). In the primary analysis, alteplase use was associated with a change in the parenchymal ICH volume in the unadjusted analysis per 1-mL change (β, 1.37; 95% CI, 0.92-1.81; P < .001) and in multivariable linear regression analysis that was adjusted for demographic characteristics, stability ICH and IVH volumes, ICH location, and time to first dose of study drug per 1-mL change (β, 1.20; 95% CI, 0.79-1.62; P < .001). In the secondary analyses, no association was found between change in parenchymal ICH volume and poor outcome (odds ratio [OR], 0.97; 95% CI 0.87-1.10; P = .64) or mortality (OR, 0.97; 95% CI 0.99-1.08; P = .59). Similar results were observed in the subgroup analyses. CONCLUSIONS AND RELEVANCE This study found that intraventricular alteplase use in patients with a large IVH was associated with a small reduction in parenchymal ICH volume, but this association did not translate into improved functional outcomes or mortality. Intraventricular thrombolysis should be examined in patients with moderate to large ICH with IVH, especially in a thalamic location.
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Affiliation(s)
- Jens Witsch
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia
| | - David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, Illinois
| | - Daniel F. Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy C. Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
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Kashif H, Shah D, Sukumari-Ramesh S. Dysregulation of microRNA and Intracerebral Hemorrhage: Roles in Neuroinflammation. Int J Mol Sci 2021; 22:8115. [PMID: 34360881 PMCID: PMC8347974 DOI: 10.3390/ijms22158115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 12/23/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a major public health problem and devastating subtype of stroke with high morbidity and mortality. Notably, there is no effective treatment for ICH. Neuroinflammation, a pathological hallmark of ICH, contributes to both brain injury and repair and hence, it is regarded as a potential target for therapeutic intervention. Recent studies document that microRNAs, small non-coding RNA molecules, can regulate inflammatory brain response after ICH and are viable molecular targets to alter brain function. Therefore, there is an escalating interest in studying the role of microRNAs in the pathophysiology of ICH. Herein, we provide, for the first time, an overview of the microRNAs that play roles in ICH-induced neuroinflammation and identify the critical knowledge gap in the field, as it would help design future studies.
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Affiliation(s)
| | | | - Sangeetha Sukumari-Ramesh
- Department of Pharmacology and Toxicology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA; (H.K.); (D.S.)
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Fernando SM, Qureshi D, Talarico R, Dowlatshahi D, Sood MM, Smith EE, Hill MD, McCredie VA, Scales DC, English SW, Rochwerg B, Tanuseputro P, Kyeremanteng K. Short- and Long-term Health Care Resource Utilization and Costs Following Intracerebral Hemorrhage. Neurology 2021; 97:e608-e618. [PMID: 34108269 DOI: 10.1212/wnl.0000000000012355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/03/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We sought to evaluate the short- and long-term resource use and costs associated with intracerebral hemorrhage (ICH) taken from an entire population. We in addition sought to evaluate the association of oral anticoagulation (OAC) and health care costs. METHODS This was a retrospective cohort study of adult patients (≥18 years) with ICH in the entire population of Ontario, Canada (2009-2017). We captured outcomes through linkage to health administrative databases. We used generalized linear models to identify factors associated with total cost. Analysis of OAC use was limited to patients ≥66 years of age. The primary outcome was total 1-year direct health care costs in 2020 US dollars. RESULTS Among 16,248 individuals with ICH (mean age 71.2 years, male 52.3%), 1-year mortality was 46.0%, and 24.2% required mechanical ventilation. The median total 1-year cost was $26,886 (interquartile range [IQR] $9,641-$62,907) with costs for those who died in hospital of $7,268 (IQR $4,031-$14,966) vs $44,969 (IQR $20,264-$82,414, p < 0.001) for survivors to discharge. OAC use (analysis limited to individuals ≥66 years old) was associated with higher total 1-year costs (cost ratio 1.06 [95% confidence interval 1.01-1.11]). Total 1-year costs for the entire cohort exceeded $120 million per year over the study period. CONCLUSIONS ICH is associated with significant health care costs, and the median cost of a patient with ICH is roughly 10 times the median inpatient cost in Ontario. Costs were higher among survivors than deceased patients. OAC use is independently associated with increased costs. To maximize cost-effectiveness, future therapies for ICH must aim to reduce disability, not only improve mortality.
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Affiliation(s)
- Shannon M Fernando
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada.
| | - Danial Qureshi
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Robert Talarico
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Manish M Sood
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Eric E Smith
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Michael D Hill
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Victoria A McCredie
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Damon C Scales
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Shane W English
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Bram Rochwerg
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
| | - Kwadwo Kyeremanteng
- From the Division of Critical Care (S.M.F., S.W.E., K.K.), Department of Medicine, and Department of Emergency Medicine (S.M.F.), University of Ottawa; ICES (D.Q., R.T., M.M.S., D.C.S., P.T.), Toronto; Clinical Epidemiology Program (D.Q., R.T., D.D., M.M.S., S.W.E., P.T., K.K.), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (D.Q., D.D., M.M.S., S.W.E., P.T.), University of Ottawa; Bruyère Research Institute (D.Q., P.T.); Division of Palliative Care (D.Q., P.T., K.K.), Department of Medicine, Division of Neurology (D.D.), Department of Medicine, and Division of Nephrology (M.M.S.), Department of Medicine, University of Ottawa, Ontario; Calgary Stroke Program (E.E.S., M.D.H.), Hotchkiss Brain Institute, and Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta; Interdepartmental Division of Critical Care Medicine (V.A.M., D.C.S.), University of Toronto; Krembil Research Institute (V.A.M.), Toronto Western Hospital, University Health Network; Department of Critical Care Medicine (V.A.M., D.C.S.), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (D.C.S.), St. Michael's Hospital, Toronto; Department of Medicine (B.R.), Division of Critical Care and Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton; and Institut du Savoir Montfort (K.K.), Ottawa, Ontario, Canada
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