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Wang CY, Lai SZ, Kang BC, Lin YZ, Cao CJ, Huang XB, Wang JQ. Association of pulse pressure with hematoma expansion in patients with spontaneous supratentorial intracerebral hemorrhage. Front Neurol 2024; 15:1374198. [PMID: 38813243 PMCID: PMC11133623 DOI: 10.3389/fneur.2024.1374198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 04/26/2024] [Indexed: 05/31/2024] Open
Abstract
Objective Recent reports have demonstrated that a wider pulse pressure upon admission is correlated with heightened in-hospital mortality following spontaneous supratentorial intracerebral hemorrhage (ssICH). However, the underlying mechanism remains ambiguous. We investigated whether a wider pulse pressure was associated with hematoma expansion (HE). Methods Demographic information, clinical features, and functional outcomes of patients diagnosed with ssICH were retrospectively collected and analyzed. Multivariate logistic regression was conducted to identify independent predictors of HE. Weighted logistic regression, restricted cubic spline models, and propensity score matching (PSM) were employed to estimate the association between pulse pressure and HE. Results We included 234 eligible adult ssICH patients aged 60 (51-71) years, and 55.56% were male. The mean pulse pressure was 80.94 ± 23.32 mmHg. Twenty-seven patients (11.54%) developed early HE events, and 116 (49.57%) experienced a poor outcome (modified Rankin scale 3-6). A wider mean pulse pressure as a continuous variable was a predictor of HE [odds ratios (OR) 1.026, 95% confidence interval (CI) 1.007-1.046, p = 0.008] in multivariate analysis. We transformed pulse pressure into a dichotomous variable based on its cutoff value. After adjusting for confounding of HE variables, the occurrence of HE in patients with ssICH with wider pulse pressure levels (≥98 mmHg) had 3.78 times (OR 95% CI 1.47-9.68, p = 0.006) compared to those with narrower pulse pressure levels (<98 mmHg). A linear association was observed between pulse pressure and increased HE risk (P for overall = 0.036, P for nonlinear = 0.759). After 1:1 PSM (pulse pressure ≥98 mmHg vs. pulse pressure <98 mmHg), the rates of HE events and poor outcome still had statistically significant in wider-pulse pressure group [HE, 12/51 (23.53%) vs. 4/51 [7.84%], p = 0.029; poor outcome, 34/51 (66.67%) vs. 19/51 (37.25%), p = 0.003]. Conclusion Widened acute pulse pressure (≥98 mmHg) levels at admission are associated with increased risks of early HE and unfavorable outcomes in patients with ssICH.
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Affiliation(s)
- Chao-Ying Wang
- Department of Neurosurgery, Dehua County Hospital, Quanzhou, China
| | - Su-Zhen Lai
- Department of Imaging, Dehua County Hospital, Quanzhou, China
| | - Bao-Cai Kang
- Department of Internal Medicine, Dehua County Hospital, Quanzhou, China
- Department of Geriatrics, Changji People’s Hospital, Changji, China
| | - Yi-Zhao Lin
- Department of Laboratory Medicine, Dehua County Hospital, Quanzhou, China
| | - Chun-Juan Cao
- Department of Imaging, Dehua County Hospital, Quanzhou, China
| | - Xin-Bing Huang
- Department of Neurology, Dehua County Hospital, Quanzhou, China
| | - Jian-Qun Wang
- Department of Neurosurgery, Dehua County Hospital, Quanzhou, China
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Kotovich D, Twig G, Itsekson-Hayosh Z, Klug M, Simon AB, Yaniv G, Konen E, Tau N, Raskin D, Chang PJ, Orion D. The impact on clinical outcomes after 1 year of implementation of an artificial intelligence solution for the detection of intracranial hemorrhage. Int J Emerg Med 2023; 16:50. [PMID: 37568103 PMCID: PMC10422703 DOI: 10.1186/s12245-023-00523-y] [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: 03/13/2023] [Accepted: 07/17/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND To assess the effect of a commercial artificial intelligence (AI) solution implementation in the emergency department on clinical outcomes in a single level 1 trauma center. METHODS A retrospective cohort study for two time periods-pre-AI (1.1.2017-1.1.2018) and post-AI (1.1.2019-1.1.2020)-in a level 1 trauma center was performed. The ICH algorithm was applied to 587 consecutive patients with a confirmed diagnosis of ICH on head CT upon admission to the emergency department. Study variables included demographics, patient outcomes, and imaging data. Participants admitted to the emergency department during the same time periods for other acute diagnoses (ischemic stroke (IS) and myocardial infarction (MI)) served as control groups. Primary outcomes were 30- and 120-day all-cause mortality. The secondary outcome was morbidity based on Modified Rankin Scale for Neurologic Disability (mRS) at discharge. RESULTS Five hundred eighty-seven participants (289 pre-AI-age 71 ± 1, 169 men; 298 post-AI-age 69 ± 1, 187 men) with ICH were eligible for the analyzed period. Demographics, comorbidities, Emergency Severity Score, type of ICH, and length of stay were not significantly different between the two time periods. The 30- and 120-day all-cause mortality were significantly reduced in the post-AI group when compared to the pre-AI group (27.7% vs 17.5%; p = 0.004 and 31.8% vs 21.7%; p = 0.017, respectively). Modified Rankin Scale (mRS) at discharge was significantly reduced post-AI implementation (3.2 vs 2.8; p = 0.044). CONCLUSION The added value of this study emphasizes the introduction of artificial intelligence (AI) computer-aided triage and prioritization software in an emergent care setting that demonstrated a significant reduction in a 30- and 120-day all-cause mortality and morbidity for patients diagnosed with intracranial hemorrhage (ICH). Along with mortality rates, the AI software was associated with a significant reduction in the Modified Ranking Scale (mRs).
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Affiliation(s)
- Dmitry Kotovich
- The Institute for Research in Military Medicine, The Faculty of Medicine, The Hebrew University of Jerusalem, Tel Aviv, Israel.
- The IDF Medical Corps, 9112102, Tel Aviv, Israel.
| | - Gilad Twig
- The Institute for Research in Military Medicine, The Faculty of Medicine, The Hebrew University of Jerusalem, Tel Aviv, Israel
- The IDF Medical Corps, 9112102, Tel Aviv, Israel
| | - Zeev Itsekson-Hayosh
- Center of Stroke and Neurovascular Disorders, Sheba Medical Center, Tel HaShomer, Ramat Gan, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Maximiliano Klug
- Department of Diagnostic Imaging, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Asaf Ben Simon
- Sackler School of Medicine, Faculty of Medicine, Tel Aviv University, 69978, Tel Aviv, Israel
| | - Gal Yaniv
- Department of Diagnostic Imaging, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Eli Konen
- Department of Diagnostic Imaging, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Noam Tau
- Department of Diagnostic Imaging, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Daniel Raskin
- Department of Diagnostic Imaging, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | - Paul J Chang
- Department of Radiology, University of Chicago Medical Center, Chicago, Illinois, 60637, USA
| | - David Orion
- Center of Stroke and Neurovascular Disorders, Sheba Medical Center, Tel HaShomer, Ramat Gan, affiliated to Sackler Faculty of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
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Anand S, Choudhury SS, Pradhan S, Mulmuley MS. Normotensive state during acute phase of hypertensive intracerebral hemorrhage. J Neurosci Rural Pract 2023; 14:465-469. [PMID: 37692796 PMCID: PMC10483210 DOI: 10.25259/jnrp_168_2023] [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: 03/26/2023] [Accepted: 05/18/2023] [Indexed: 09/12/2023] Open
Abstract
Objectives Hypertensive hemorrhage is a leading cause of intracerebral haemorrhage (ICH), although some of these patients may not present with high blood pressure (BP) at the time of ICH. Materials and Methods This retrospective study included patients with history of hypertension presenting with ICH. Patients with systolic BP recording of more than 140 mmHg were included in hypertension group (group I). Patients whose BP rose to hypertension range after fluid correction were included in group II and patients with BP <140 mmHg on consecutive 1-week BP recordings were included in group III. Clinical features including volume of ICH of all the three groups were noted. Outcome in the form of mortality was analyzed. Chi-square test was used for categorical variables and independent t-test for continuous variables. P < 0.05 was considered significant. Results Ninety-two ICH patients with history of hypertension were included in the study. Of them, 20 patients (22%) presented with BP <140 mmHg systolic at the time of ICH. After fluid correction, it rose to hypertensive range in 9 (10%) but remained normal in 11 patients (12%) during consecutive recordings for 1-week post-admission. On comparing normotensive and hypertensive groups, significant difference was seen in survival and volume of ICH. Conclusion There is a subset of hypertensive patients who may present with normal BP recording during acute ICH. The BP rises subsequently with the correction of hypovolemia in some. The volume of hemorrhage in normotensives is relatively small but whether this translates into better prognosis needs further studies.
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Affiliation(s)
- Sucharita Anand
- Department of Neurology, All India Institute of Medical Sciences (AIIMS) Jodhpur, Jodhpur, Rajasthan, India
| | | | - Sunil Pradhan
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Madhura Sanjay Mulmuley
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Raval H, Shah K, Bhatt M. Minimally Invasive Technique for Spontaneous Intraparenchymal Hemorrhage. INDIAN JOURNAL OF NEUROSURGERY 2023. [DOI: 10.1055/s-0043-1761427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Abstract
Objective The aim of this study was to introduce a cost-effective and less invasive method for the evacuation of intraparenchymal hemorrhage (IPH).
Background IPH in the presence or absence of intraventricular hemorrhage has severe morbidity and has almost 50% mortality whether the patient is managed surgically or medically. Development of minimally invasive surgical techniques offers better outcomes but requires the use of special instruments and a unique skill set that is costly and requires special training.
Method We inserted infant feeding tube within the hematoma via the left Kocher's burr hole. We instilled 40,000 IU of urokinase serially at an 8 hours interval for 3 days to evacuate the left gangliocapsular hematoma.
Result We have treated a 50 years old hypertensive male patient with left gangliocapsular IPH and right hemiparesis (power: ⅖ on admission). After a month, on follow-up, the patient was conscious and oriented with improved right hemiparesis (power: ⅘).
Conclusion This technique of evacuating hematoma is instrumental in peripheral centers in developing as well as under-developed countries where there are limited resources and a better outcome is expected with minimal morbidity.
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Affiliation(s)
- Himanshu Raval
- Department of Neurosurgery, NHL Municipal Medical College, SVP Hospital Campus, Elisbridge, Ahmedabad, Gujarat, India
| | - Kalpesh Shah
- Department of Neurosurgery, NHL Municipal Medical College, SVP Hospital Campus, Elisbridge, Ahmedabad, Gujarat, India
| | - Mona Bhatt
- Medical Officer, Bhailal Hospital, Vadodara, Gujarat, India
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Shrestha D, Sharma U, Shrestha J, Nepal G, Shrestha B, Shrestha P, Acharya S, Gurung P, Shrestha R, Dhakal S, Rajbhandari P, Pant B. Surgical Management among Patients with Spontaneous Supratentorial Intracerebral Haemorrhage Admitted in a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2022; 60:697-701. [PMID: 36705228 PMCID: PMC9446498 DOI: 10.31729/jnma.7178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 07/28/2022] [Indexed: 01/31/2023] Open
Abstract
Introduction Spontaneous intracerebral haemorrhage is the second most common form of stroke and the most deadly one. An understanding of changing trends in the epidemiology of intracerebral haemorrhage prevalence, its risk factors, current practice in management, case fatality, and long-term outcome is essential to measure the effectiveness of stroke prevention and various treatment efforts. The objective of this study was to find out the prevalence of surgical management among patients with spontaneous supratentorial intracerebral haemorrhage in a tertiary centre. Methods A descriptive cross-sectional study was conducted in the Department of Neurosurgery from January 2017 to December 2019. Ethical approval was obtained from the Institutional Review Committee (Reference number: 06/2020/IRC-ANIAS). A convenience sampling method was used. Data of the patients were retrieved from online medical records. Point estimate and 95% Confidence Interval were calculated. Results Among 221 patients with spontaneous supratentorial intracerebral haemorrhage, 115 (52.04%) (45.45-58.63, 95% Confidence Interval) underwent surgical management. In-hospital mortality was seen in 23 (20%) and survivors at 3 months were 78 (67.82%) patients. Conclusions The prevalence of surgical management among spontaneous supratentorial intracerebral haemorrhages was higher than in other studies done in a similar setting. Keywords intracerebral haemorrhage; mortality; surgical procedure.
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Affiliation(s)
- Dinuj Shrestha
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal,Correspondence: Dr Dinuj Shrestha, Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal. , Phone: +977-9841211502
| | - Upama Sharma
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Janam Shrestha
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Gopi Nepal
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Bishal Shrestha
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Pranaya Shrestha
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Samir Acharya
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Pritam Gurung
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Resha Shrestha
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Sudan Dhakal
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Pravesh Rajbhandari
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Basant Pant
- Department of Neurosurgery, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
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Wang MD, Tian J, Zhang JH, Zhao SY, Song MJ, Wang ZX. Human Galectin-7 Gene LGALS7 Promoter Sequence Polymorphisms and Risk of Spontaneous Intracerebral Hemorrhage: A Prospective Study. Front Mol Neurosci 2022; 15:840340. [PMID: 35401111 PMCID: PMC8984465 DOI: 10.3389/fnmol.2022.840340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purposeDespite evidence for the role of genetic factors in stroke, only a small proportion of strokes have been clearly attributed to monogenic factors, due to phenotypic heterogeneity. The goal of this study was to determine whether a significant relationship exists between human galectin-7 gene LGALS7 promoter region polymorphisms and the risk of stroke due to non-traumatic intracerebral hemorrhage (ICH).MethodsThis two-stage genetic association study included an initial exploratory stage followed by a discovery stage. During the exploratory stage, transgenic galectin-7 mice or transgenic mice with the scrambled sequence of the hairpin structure –silenced down gene LGALS7—were generated and then expressed differentially expressed proteins and galectin-7-interacting proteins were identified through proteomic analysis. During the discovery stage, a single-nucleotide polymorphism (SNP) genotyping approach was used to determine associations between 2 LGALS7 SNPs and ICH stroke risk for a cohort of 24 patients with stroke of the Chinese Han population and 70 controls.ResultsDuring the exploratory phase, LGALS7 expression was found to be decreased in TGLGALS–DOWN mice as compared to its expression in TGLGALS mice. During the discovery phase, analysis of LGALS7 sequences of 24 non-traumatic ICH cases and 70 controls led to the identification of 2 ICH susceptibility loci: a genomic region on 19q13.2 containing two LGALS7 SNPs, rs567785577 and rs138945880, whereby the A allele of rs567785577 and the T allele of rs138945880 were associated with greater risk of contracting ICH [for T and A vs. C and G, unadjusted odds ratio (OR) = 13.5; 95% CI = 2.249–146.5; p = 0.002]. This is the first study to genotype the galectin-7 promoter in patients with hemorrhagic stroke. Genotype and allele association tests and preliminary analysis of patients with stroke revealed that a single locus may be a genetic risk factor for hemorrhagic stroke.ConclusionA and T alleles of two novel SNP loci of 19q13.2, rs567785577 and rs138945880, respectively, were evaluated for associations with susceptibility to ICH. Further studies with expanded case numbers that include subjects of other ethnic populations are needed to elucidate mechanisms underlying associations between these SNPs and ICH risk.
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Affiliation(s)
- Ming-Dong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Jing Tian
- Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, China National Clinical Research Center of Respiratory Disease, Beijing, China
| | - John H. Zhang
- Physiology Program, Department of Anesthesiology, Neurosurgery, Neurology, and Physiology, Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Shun-Ying Zhao
- Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, China National Clinical Research Center of Respiratory Disease, Beijing, China
- *Correspondence: Shun-Ying Zhao,
| | - Ming-Jing Song
- Medical School, Huanghe Science and Technology University, Zhengzhou, China
- Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China
- Ming-Jing Song,
| | - Zhan-Xiang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Zhan-Xiang Wang,
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Hawkes MA, Rabinstein AA. Acute Hypertensive Response in Patients With Acute Intracerebral Hemorrhage: A Narrative Review. Neurology 2021; 97:316-329. [PMID: 34031208 DOI: 10.1212/wnl.0000000000012276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/23/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review the role of the acute hypertensive response in patients with intracerebral hemorrhage, current treatment options, and areas for further research. METHODS Review of the literature to assess 1) frequency of acute hypertensive response in intracerebral hemorrhage; 2) consequences of acute hypertensive response in clinical outcomes; 3) acute hypertensive response and secondary brain injury: hematoma expansion and perihematomal edema; 4) vascular autoregulation, safety data side effects of acute antihypertensive treatment; and 5) randomized clinical trials and meta-analyses. RESULTS An acute hypertensive response is frequent in patients with acute intracerebral hemorrhage and is associated with poor clinical outcomes. However, it is not clear whether high blood pressure is a cause of poor clinical outcome or solely represents a marker of severity. Although current guidelines recommend intensive blood pressure treatment (<140 mm Hg) in patients with intracerebral hemorrhage, 2 randomized clinical trials have failed to demonstrate a consistent clinical benefit from this approach, and new data suggest that intensive blood pressure treatment could be beneficial for some patients but detrimental for others. CONCLUSIONS Intracerebral hemorrhage is a heterogenous disease, thus, a one-fit-all approach for blood pressure treatment may be suboptimal. Further research should concentrate on finding subgroups of patients more likely to benefit from aggressive blood pressure lowering, considering intracerebral hemorrhage etiology, ultra-early randomization, and risk markers of hematoma expansion on brain imaging.
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Affiliation(s)
- Maximiliano A Hawkes
- From the Department of Neurological Sciences (M.A.H.), University of Nebraska Medical Center, Omaha; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN.
| | - Alejandro A Rabinstein
- From the Department of Neurological Sciences (M.A.H.), University of Nebraska Medical Center, Omaha; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
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Derry PJ, Vo ATT, Gnanansekaran A, Mitra J, Liopo AV, Hegde ML, Tsai AL, Tour JM, Kent TA. The Chemical Basis of Intracerebral Hemorrhage and Cell Toxicity With Contributions From Eryptosis and Ferroptosis. Front Cell Neurosci 2020; 14:603043. [PMID: 33363457 PMCID: PMC7755086 DOI: 10.3389/fncel.2020.603043] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/06/2020] [Indexed: 12/12/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a particularly devastating event both because of the direct injury from space-occupying blood to the sequelae of the brain exposed to free blood components from which it is normally protected. Not surprisingly, the usual metabolic and energy pathways are overwhelmed in this situation. In this review article, we detail the complexity of red blood cell degradation, the contribution of eryptosis leading to hemoglobin breakdown into its constituents, the participants in that process, and the points at which injury can be propagated such as elaboration of toxic radicals through the metabolism of the breakdown products. Two prominent products of this breakdown sequence, hemin, and iron, induce a variety of pathologies including free radical damage and DNA breakage, which appear to include events independent from typical oxidative DNA injury. As a result of this confluence of damaging elements, multiple pathways of injury, cell death, and survival are likely engaged including ferroptosis (which may be the same as oxytosis but viewed from a different perspective) and senescence, suggesting that targeting any single cause will likely not be a sufficient strategy to maximally improve outcome. Combination therapies in addition to safe methods to reduce blood burden should be pursued.
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Affiliation(s)
- Paul J Derry
- Center for Genomics and Precision Medicine, Department of Translational Medical Sciences, Institute of Biosciences and Technology, College of Medicine, Texas A&M Health Science Center, Houston, TX, United States
| | - Anh Tran Tram Vo
- Center for Genomics and Precision Medicine, Department of Translational Medical Sciences, Institute of Biosciences and Technology, College of Medicine, Texas A&M Health Science Center, Houston, TX, United States
| | - Aswini Gnanansekaran
- Center for Genomics and Precision Medicine, Department of Translational Medical Sciences, Institute of Biosciences and Technology, College of Medicine, Texas A&M Health Science Center, Houston, TX, United States
| | - Joy Mitra
- Department of Neurosurgery, Center for Neuroregeneration, The Houston Methodist Research Institute, Houston, TX, United States
| | - Anton V Liopo
- Center for Genomics and Precision Medicine, Department of Translational Medical Sciences, Institute of Biosciences and Technology, College of Medicine, Texas A&M Health Science Center, Houston, TX, United States
| | - Muralidhar L Hegde
- Department of Neurosurgery, Center for Neuroregeneration, The Houston Methodist Research Institute, Houston, TX, United States
| | - Ah-Lim Tsai
- Division of Hematology, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - James M Tour
- Department of Chemistry, Rice University, Houston, TX, United States.,Department of Computer Science, George R. Brown School of Engineering, Rice University, Houston, TX, United States.,Department of Materials Science and NanoEngineering, George R. Brown School of Engineering, Rice University, Houston, TX, United States
| | - Thomas A Kent
- Center for Genomics and Precision Medicine, Department of Translational Medical Sciences, Institute of Biosciences and Technology, College of Medicine, Texas A&M Health Science Center, Houston, TX, United States.,Department of Chemistry, Rice University, Houston, TX, United States.,Stanley H. Appel Department of Neurology, Institute for Academic Medicine, Houston Methodist Hospital, Houston, TX, United States
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Mazhar K, Olson DM, Atem FD, Stutzman SE, Moreno J, Venkatachalam A, Aiyagari V. Supratentorial intracerebral hemorrhage volume and other CT variables predict the neurological pupil index. Clin Neurol Neurosurg 2020; 200:106410. [PMID: 33341651 DOI: 10.1016/j.clineuro.2020.106410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES There is growing interest in the ability of automated infrared pupillometry to assess severity of neurological illness. We studied the correlation between computed tomography (CT) indicators of intracerebral hemorrhage (ICH) severity with objective measures of the pupillary light reflex (PLR), and hypothesized that hemorrhage volume would predict the Neurological Pupil index™ (NPi™), an indicator of pupillary reactivity. METHODS This study examined data from patients with supratentorial ICH who underwent serial pupillometer evaluations. CT images were examined to determine the location and laterality of the hemorrhage, along with hematoma volume (using the simplified ABC/2 method), midline shift, hydrocephalus score, and modified Graeb score (indicating interventricular hemorrhage). Demographics were examined with standard measures of central tendency, hypotheses with logistic regression, categorical data with Fisher's Exact X2, and multivariate modeling with constructed MAX-R models. RESULTS Data were gathered from 44 subjects. ICH volume exhibited the strongest correlation with NPi (ipsilateral [r2 = 0.48, p < 0.0001, contralateral [(r2 = 0.39, p < 0.0001]). Horizontal midline shift of the septum pellucidum also correlated with NPi (ipsilateral [r2 = 0.25, p = 0.0006], contralateral [r2 = 0.15, p = 0.0106]), as did shift of the pineal gland (ipsilateral [r2 = 0.21, p = 0.0017], contralateral[r2 = 0.11, p = 0.0328]). ICH volume was the most predictive of abnormal NPi (AUC = 0.85 for ipsilateral and 0.88 for contralateral NPi), and multivariate modeling identified additional independent predictors of NPi. CONCLUSION ICH volume and shift of midline structures correlate with NPi, and abnormalities in NPi can be predicted by hematoma volume and other CT indicators of ICH severity. Future studies should explore the role of NPi in detecting early hematoma expansion and worsening midline shift.
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Affiliation(s)
- Khadijah Mazhar
- UT Southwestern Medical School, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - DaiWai M Olson
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States; Department of Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - Folefac D Atem
- Department of Biostatistics & Data Sciences, University of Texas Health Science Center, 5161 Harry Hines Blvd. CS5.106 Dallas, TX, 75390, United States
| | - Sonja E Stutzman
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - James Moreno
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - Aardhra Venkatachalam
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - Venkatesh Aiyagari
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States; Department of Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States.
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10
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Zhao W, Wu C, Stone C, Ding Y, Ji X. Treatment of intracerebral hemorrhage: Current approaches and future directions. J Neurol Sci 2020; 416:117020. [PMID: 32711191 DOI: 10.1016/j.jns.2020.117020] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/25/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) stands out among strokes, both for the severely morbid outcomes it routinely produces, and for the striking deficiency of defenses possessed against the same. The brain damage caused by ICH proceeds through multiple pathophysiological mechanisms, broadly differentiated into those considered primary, arising from the hematoma itself, and the secondary consequences of hematoma presence and expansion thereof. A number of interventions against ICH and its sequelae have been investigated (e.g., hemostatic therapies, blood pressure control, hematoma evacuation, and a variety of neuroprotective strategies), but conclusive demonstrations of clinical benefit have remained largely elusive. In this review, we begin with a description of these interventions and the trials in which they have been implemented, coupled with an attempt to account for their failure. Possible causes discussed include iatrogenic injury during hematoma evacuation, secondary injury initiated by hematoma persistence after evacuation, and inadequate therapeutic power arising from an excessively narrow focus on a single component of the complex pathophysiology of ICH injury. To conclude, we propose several strategies, such as enhancing endogenous hematoma resolution, hematoma evacuation-based neuroprotection, and multi-targeted therapy, that hold promise as prospects for the extension of anti-ICH therapy into the domain of clinical significance.
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Affiliation(s)
- Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Christopher Stone
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Municipal Geriatric Medical Research Center, Beijing, China.
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11
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Dharmalingam P, Talakatta G, Mitra J, Wang H, Derry PJ, Nilewski LG, McHugh EA, Fabian RH, Mendoza K, Vasquez V, Hegde PM, Kakadiaris E, Roy T, Boldogh I, Hegde VL, Mitra S, Tour JM, Kent TA, Hegde ML. Pervasive Genomic Damage in Experimental Intracerebral Hemorrhage: Therapeutic Potential of a Mechanistic-Based Carbon Nanoparticle. ACS NANO 2020; 14:2827-2846. [PMID: 32049495 PMCID: PMC7850811 DOI: 10.1021/acsnano.9b05821] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Therapy for intracerebral hemorrhage (ICH) remains elusive, in part dependent on the severity of the hemorrhage itself as well as multiple deleterious effects of blood and its breakdown products such as hemin and free iron. While oxidative injury and genomic damage have been seen following ICH, the details of this injury and implications remain unclear. Here, we discovered that, while free iron produced mostly reactive oxygen species (ROS)-related single-strand DNA breaks, hemin unexpectedly induced rapid and persistent nuclear and mitochondrial double-strand breaks (DSBs) in neuronal and endothelial cell genomes and in mouse brains following experimental ICH comparable to that seen with γ radiation and DNA-complexing chemotherapies. Potentially as a result of persistent DSBs and the DNA damage response, hemin also resulted in senescence phenotype in cultured neurons and endothelial cells. Subsequent resistance to ferroptosis reported in other senescent cell types was also observed here in neurons. While antioxidant therapy prevented senescence, cells became sensitized to ferroptosis. To address both senescence and resistance to ferroptosis, we synthesized a modified, catalytic, and rapidly internalized carbon nanomaterial, poly(ethylene glycol)-conjugated hydrophilic carbon clusters (PEG-HCC) by covalently bonding the iron chelator, deferoxamine (DEF). This multifunctional nanoparticle, DEF-HCC-PEG, protected cells from both senescence and ferroptosis and restored nuclear and mitochondrial genome integrity in vitro and in vivo. We thus describe a potential molecular mechanism of hemin/iron-induced toxicity in ICH that involves a rapid induction of DSBs, senescence, and the consequent resistance to ferroptosis and provide a mechanistic-based combinatorial therapeutic strategy.
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Affiliation(s)
- Prakash Dharmalingam
- Department of Radiation Oncology, Houston Methodist Research Institute, Houston, Texas 77030, United States
| | - Girish Talakatta
- Department of Radiation Oncology, Houston Methodist Research Institute, Houston, Texas 77030, United States
| | - Joy Mitra
- Department of Radiation Oncology, Houston Methodist Research Institute, Houston, Texas 77030, United States
| | - Haibo Wang
- Department of Radiation Oncology, Houston Methodist Research Institute, Houston, Texas 77030, United States
| | - Paul J Derry
- Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas 77030, United States
| | | | - Emily A McHugh
- Department of Chemistry, Rice University, Houston, Texas 77005, United States
| | - Roderic H Fabian
- Department of Neurology, Baylor College of Medicine, and Michael E. DeBakey VA Medical Center, Houston, Texas 77030, United States
| | - Kimberly Mendoza
- Department of Chemistry, Rice University, Houston, Texas 77005, United States
| | - Velmarini Vasquez
- Department of Radiation Oncology, Houston Methodist Research Institute, Houston, Texas 77030, United States
| | - Pavana M Hegde
- Department of Radiation Oncology, Houston Methodist Research Institute, Houston, Texas 77030, United States
| | - Eugenia Kakadiaris
- Department of Chemistry, Rice University, Houston, Texas 77005, United States
| | - Trenton Roy
- Department of Chemistry, Rice University, Houston, Texas 77005, United States
| | - Istvan Boldogh
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas 77555, United States
| | - Venkatesh L Hegde
- Department of Radiation Oncology, Houston Methodist Research Institute, Houston, Texas 77030, United States
| | - Sankar Mitra
- Department of Radiation Oncology, Houston Methodist Research Institute, Houston, Texas 77030, United States
- Weill Medical College of Cornell University, New York, New York 10065, United States
| | - James M Tour
- Departments of Chemistry, Computer Science, Materials Science and NanoEngineering, Smalley-Curl Institute and the NanoCarbon Center, Rice University, Houston, Texas 77005, United States
| | - Thomas A Kent
- Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas 77030, United States
- Department of Chemistry, Rice University, Houston, Texas 77005, United States
- Stanley H. Appel Department of Neurology, Houston Methodist Hospital and Research Institute, Houston, Texas 77030, United States
| | - Muralidhar L Hegde
- Department of Radiation Oncology, Houston Methodist Research Institute, Houston, Texas 77030, United States
- Weill Medical College of Cornell University, New York, New York 10065, United States
- Center for Neuroregeneration, Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist, Houston, Texas 77030, United States
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12
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Kim H, Yang X, Choi YH, Yoon BC, Kim K, Kim DJ. Abilities of a Densitometric Analysis of Computed Tomography Images and Hemorrhagic Parameters to Predict Outcome Favorability in Patients With Intracerebral Hemorrhage. Neurosurgery 2019; 83:226-236. [PMID: 28973583 DOI: 10.1093/neuros/nyx379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 06/19/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is one of the most devastating subtypes of stroke. A rapid assessment of ICH severity involves the use of computed tomography (CT) and derivation of the hemorrhage volume, which is often estimated using the ABC/2 method. However, these estimates are highly inaccurate and may not be feasible for anticipating outcome favorability. OBJECTIVE To predict patient outcomes via a quantitative, densitometric analysis of CT images, and to compare the predictive power of these densitometric parameters with the conventional ABC/2 volumetric parameter and segmented hemorrhage volumes. METHODS Noncontrast CT images of 87 adult patients with ICH (favorable outcomes = 69, unfavorable outcomes = 12, and deceased = 6) were analyzed. In-house software was used to calculate the segmented hemorrhage volumes, ABC/2 and densitometric parameters, including the skewness and kurtosis of the density distribution, interquartile ranges, and proportions of specific pixels in sets of CT images. Nonparametric statistical analyses were conducted. RESULTS The densitometric parameter interquartile range exhibited greatest accuracy (82.7%) in predicting favorable outcomes. The combination of skewness and the interquartile range effectively predicted mortality (accuracy = 83.3%). The actual volume of the ICH exhibited good coherence with ABC/2 (R = 0.79). Both parameters predicted mortality with moderate accuracy (<78%) but were less effective in predicting unfavorable outcomes. CONCLUSION Hemorrhage volume was rapidly estimated and effectively predicted mortality in patients with ICH; however, this value may not be useful for predicting favorable outcomes. The densitometric analysis exhibited significantly higher power in predicting mortality and favorable outcomes in patients with ICH.
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Affiliation(s)
- Hakseung Kim
- Department of Brain and Cognitive Engi-neering, Korea University, Seoul, South Korea
| | - Xiaoke Yang
- Department of Brain and Cognitive Engi-neering, Korea University, Seoul, South Korea
| | - Young Hun Choi
- Department of Radiology, Se-oul National University Hospital, College of Medicine, Seoul, South Korea
| | - Byung C Yoon
- De-partment of Radiology, Stanford Uni-versity School of Medicine, Stanford, California
| | - Keewon Kim
- Department of Rehabilitation, Seoul National University Hospital, Coll-ege of Medicine, Seoul, South Korea
| | - Dong-Joo Kim
- Department of Brain and Cognitive Engi-neering, Korea University, Seoul, South Korea
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13
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Intracerebral Hemorrhage in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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14
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Yanishevsky SN. Intracranial hemorrhage in patients taking oral anticoagulants. Current possibilities for therapy. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2019. [DOI: 10.14412/2074-2711-2019-3s-82-88] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The paper reviews an update on the possibilities of providing care for patients with spontaneous non-traumatic intracranial hemorrhage (ICH) developing in patients with atrial fibrillation who use oral anticoagulants. The incidence of ICH is shown to be considerably lower when nonvitamin K-dependent anticoagulants (NOACs) are used, but the hematoma evolution scenarios do not differ between the groups of patients receiving vitamin K antagonists or NOACs. The results of studies assessing hypertension therapy in patients with ICH are compared. The possibilities of using various reversal agents for various oral anticoagulants are also discussed. Since one of the main problems associated with increased mortality and severe disabilities is the progression rate of ICH, the possibility of using a specific antagonist can determine the choice of an anticoagulant for the primary prevention of ischemic stroke in a patient with atrial fibrillation.
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15
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Cai Q, Guo Q, Li Z, Wang W, Zhang W, Ji B, Chen Z, Liu J. Minimally invasive evacuation of spontaneous supratentorial intracerebral hemorrhage by transcranial neuroendoscopic approach. Neuropsychiatr Dis Treat 2019; 15:919-925. [PMID: 31043783 PMCID: PMC6469739 DOI: 10.2147/ndt.s195275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Spontaneous supratentorial intracerebral hemorrhage (SSICH) is one of the deadliest diseases, and neuroendoscopic surgery (NE) is a minimally invasive and promising treatment that might improve the functional recovery of patients. This study analyzed patient's experience with this treatment in terms of safety, efficacy, and surgical technique. PATIENTS AND METHODS Forty-two patients with SSICHs treated by transcranial neuroendoscopic approach were retrospectively reviewed from June 2016 to July 2018 in our department. Patients were classified into four groups according to the main location of the hematoma on CT scans: Group A (basal ganglia hemorrhage), Group B (subcortical hemorrhage), Group C (thalamic hemorrhage), and Group D (intraventricular hemorrhage [IVH]). The clinical data were collected, and the outcomes were analyzed. RESULTS All procedures were successfully completed, and no patient died in the perioperative period. The average hematoma evacuation rate was 90.1%, and the highest hematoma evacuation rate was achieved in Group B which was 92.7%. No severe complications occurred, and the average GCS score improvement was 4.0 at discharge. CONCLUSION These data suggest that evacuation hemorrhage by neuroendoscopy might be an effective and safe approach for SSICH. For better efficiency of this treatment, some details needed to be emphasized, such as setting up a good working channel, using of suction and bipolar forceps accurately.
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Affiliation(s)
- Qiang Cai
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Hubei Province, People's Republic of China,
| | - Qiao Guo
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Hubei Province, People's Republic of China,
| | - Zhiyang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Hubei Province, People's Republic of China,
| | - Wenju Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Hubei Province, People's Republic of China,
| | - Wenfei Zhang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Hubei Province, People's Republic of China,
| | - Baowei Ji
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Hubei Province, People's Republic of China,
| | - Zhibiao Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Hubei Province, People's Republic of China,
| | - Jun Liu
- Department of Emergency, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People's Republic of China,
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16
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Dong J, Yang X, Xiang J, Dong Q, Tang Y, Chu H. Hypodensities detected at 1.5–3 h after intracerebral hemorrhage better predicts secondary neurological deterioration. J Neurol Sci 2019; 396:219-224. [DOI: 10.1016/j.jns.2018.11.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/01/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
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17
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Zafar A, Quadri SA, Farooqui M, Ortega-Gutiérrez S, Hariri OR, Zulfiqar M, Ikram A, Khan MA, Suriya SS, Nunez-Gonzalez JR, Posse S, Mortazavi MM, Yonas H. MRI-Guided High-Intensity Focused Ultrasound as an Emerging Therapy for Stroke: A Review. J Neuroimaging 2018; 29:5-13. [PMID: 30295987 DOI: 10.1111/jon.12568] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/21/2018] [Indexed: 01/23/2023] Open
Abstract
Stroke, either ischemic or hemorrhagic, accounts for significantly high morbidity and mortality rates around the globe effecting millions of lives annually. For the past few decades, ultrasound has been extensively investigated to promote clot lysis for the treatment of stroke, myocardial infarction, and acute peripheral arterial occlusions, with or without the use of tPA or contrast agents. In the age of modern minimal invasive techniques, magnetic resonance imaging-guided high-intensity focused ultrasound is a new emerging modality that seems to promise therapeutic utilities for both ischemic and hemorrhagic stroke. High-intensity focused ultrasound causes thermal heating as the tissue absorbs the mechanical energy transmitted by the ultrasonic waves leading to tissue denaturation and coagulation. Several in-vitro and in-vivo studies have demonstrated the viability of this technology for sonothrombolysis in both types of stroke and have warranted clinical trials. Apart from safety and efficacy, initiation of trials would further enable answers regarding its practical application in a clinical setup. Though this technology has been under study for treatment of various brain diseases for some decades now, relatively very few neurologists and even neurosurgeons seem to be acquainted with it. The aim of this review is to provide basic understanding of this powerful technology and discuss its clinical application and potential role as an emerging viable therapeutic option for the future management of stroke.
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Affiliation(s)
- Atif Zafar
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM
| | - Syed A Quadri
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM.,California Institute of Neuroscience, Thousand Oaks, CA.,National Skull Base Center, Thousand Oaks, CA
| | - Mudassir Farooqui
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM
| | | | - Omid R Hariri
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Maryam Zulfiqar
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Asad Ikram
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM
| | - Muhammad Adnan Khan
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM.,California Institute of Neuroscience, Thousand Oaks, CA.,National Skull Base Center, Thousand Oaks, CA
| | - Sajid S Suriya
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM.,California Institute of Neuroscience, Thousand Oaks, CA.,National Skull Base Center, Thousand Oaks, CA
| | | | - Stefan Posse
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM
| | - Martin M Mortazavi
- California Institute of Neuroscience, Thousand Oaks, CA.,National Skull Base Center, Thousand Oaks, CA
| | - Howard Yonas
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM
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18
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Burchell SR, Tang J, Zhang JH. Hematoma Expansion Following Intracerebral Hemorrhage: Mechanisms Targeting the Coagulation Cascade and Platelet Activation. Curr Drug Targets 2018; 18:1329-1344. [PMID: 28378693 DOI: 10.2174/1389450118666170329152305] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/20/2016] [Accepted: 03/14/2017] [Indexed: 01/04/2023]
Abstract
Hematoma expansion (HE), defined as a greater than 33% increase in intracerebral hemorrhage (ICH) volume within the first 24 hours, results in significant neurological deficits, and enhancement of ICH-induced primary and secondary brain injury. An escalation in the use of oral anticoagulants has led to a surge in the incidences of oral anticoagulation-associated ICH (OAT-ICH), which has been associated with a greater risk for HE and worse functional outcomes following ICH. The oral anticoagulants in use include vitamin K antagonists, and direct thrombin and factor Xa inhibitors. Fibrinolytic agents are also frequently administered. These all act via differing mechanisms and thus have varying degrees of impact on HE and ICH outcome. Additionally, antiplatelet medications have also been increasingly prescribed, and result in increased bleeding risks and worse outcomes after ICH. Aspirin, thienopyridines, and GPIIb/IIIa receptor blockers are some of the most common agents in use clinically, and also have different effects on ICH and hemorrhage growth, based on their mechanisms of action. Recent studies have found that reduced platelet activity may be more effective in predicting ICH risk, hemorrhage expansion, and outcomes, than antiplatelet agents, and activating platelets may thus be a novel target for ICH therapy. This review explores how dysfunctions or alterations in the coagulation and platelet cascades can lead to, and/or exacerbate, hematoma expansion following intracerebral hemorrhage, and describe the mechanisms behind these effects and the drugs that induce them. We also discuss potential future therapy aimed at increasing platelet activity after ICH.
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Affiliation(s)
- Sherrefa R Burchell
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jiping Tang
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA.,Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda CA, USA
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19
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Slavin SJ, Sucharew H, Alwell K, Moomaw CJ, Woo D, Adeoye O, Flaherty ML, Ferioli S, McMullan J, Mackey J, De Los Rios La Rosa F, Martini S, Kissela BM, Kleindorfer DO. Prehospital neurological deterioration in stroke. Emerg Med J 2018; 35:507-510. [PMID: 29703777 DOI: 10.1136/emermed-2017-207265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 03/06/2018] [Accepted: 04/16/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND PURPOSE Patients with stroke can experience neurological deterioration in the prehospital setting. We evaluated patients with stroke to determine factors associated with prehospital neurological deterioration (PND). METHODS Among the Greater Cincinnati/Northern Kentucky region (population ~1.3 million), we screened all 15 local hospitals' admissions from 2010 for acute stroke and included patients aged ≥20. The GCS was compared between emergency medical services (EMS) arrival and hospital arrival, with decrease ≥2 points considered PND. Data obtained retrospectively included demographics, medical history and medication use, stroke subtype (eg, ischaemic stroke (IS), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH)) and IS subtype (eg, small vessel, large vessel, cardioembolic), seizure at onset, time intervals between symptom onset, EMS arrival and hospital arrival, EMS level of training, and blood pressure and serum glucose on EMS arrival. RESULTS Of 2708 total patients who had a stroke, 1092 patients (median (IQR) age 74 (61-83) years; 56% women; 21% black) were analysed. PND occurred in 129 cases (12%), including 9% of IS, 24% of ICH and 16% of SAH. In multivariable analysis, black race, atrial fibrillation, haemorrhagic subtype and ALS level of transport were associated with PND. CONCLUSION Haemorrhage and atrial fibrillation is associated with PND in stroke, and further investigation is needed to establish whether PND can be predicted. Further studies are also needed to assess whether preferential transport of patients with deterioration to hospitals equipped with higher levels of care is beneficial, identify why race is associated with deterioration and to test therapies targeting PND.
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Affiliation(s)
- Sabreena J Slavin
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Heidi Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kathleen Alwell
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Charles J Moomaw
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Opeolu Adeoye
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew L Flaherty
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Simona Ferioli
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jason McMullan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jason Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Felipe De Los Rios La Rosa
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,Baptist Health Neuroscience Center, Miami, Florida, USA
| | - Sharyl Martini
- McNair Campus, Baylor College of Medicine Medical Center, Houston, Texas, USA
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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20
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Admission Systolic Blood Pressure Predicts the Number of Blood Pressure Medications at Discharge in Patients With Primary Intracerebral Hemorrhage. Neurologist 2018; 23:60-64. [PMID: 29494438 DOI: 10.1097/nrl.0000000000000173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Control of systolic blood pressure (SBP) after primary intracerebral hemorrhage improves outcomes. Factors determining the number of blood pressure medications (BPM) required for goal SBP<160 mm Hg at discharge are unknown. We hypothesized that higher admission-SBPs require a greater number of BPM for goal discharge-SBP<160 mm Hg, and investigated factors influencing this goal. MATERIALS AND METHODS We conducted a retrospective review of 288 patients who presented with primary intracerebral hemorrhage. Admission-SBP was obtained. Primary outcome was the number of BPM at discharge. Comparison was made between patients presenting with and without a history of hypertension, and patients discharged on <3 and ≥3 BPM. RESULTS Patients with hypertension history had a higher median admission-SBP compared with those without (180 vs. 157 mm Hg, P=0.0001). In total, 133 of 288 (46.2%) patients were discharged on <3 BPM; 155/288 (53.8%) were discharged on ≥3 BPM. Hypertension history (P<0.0001) and admission-SBP (P<0.0001) predicted the number of BPM at discharge. In patients without hypertension history, every 10 mm Hg increase in SBP resulted in an absolute increase of 0.5 BPM at discharge (P=0.0011), whereas in those with hypertension, the absolute increase was 1.3 BPM (P=0.0012). In comparison with patients discharged on <3 BPM, patients discharged on ≥3 BPM were more likely to have a higher median admission-SBP, be younger in age, belong to the African-American race, have a history of diabetes, have higher median admission-National Institutes of Health Stroke Scale and modified Rankin Scale of 4 to 5 at discharge. CONCLUSIONS An understanding of the factors influencing BPM at discharge may help clinicians better optimize blood pressure control both before and after discharge.
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21
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Abstract
Intracerebral hemorrhage (ICH) remains a prevalent and severe cause of death and disability worldwide. Control of the hypertensive response in acute ICH has been a mainstay of ICH management, yet the optimal approaches and the yield of recommended strategies have been difficult to establish despite a large body of literature. Over the years, theoretical and observed risks and benefits of intensive blood pressure reduction in ICH have been studied in the form of animal models, radiographic studies, and two recent large, randomized patient trials. In this article, we review the historical and developing data and discuss remaining questions surrounding blood pressure management in acute ICH.
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Affiliation(s)
- Stacy Chu
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Lauren Sansing
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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22
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El Husseini N, Hoffman BM, Bennett ER, Li YW, Williamson Taylor RA, Hailey CE, Richardson K, Li YJ, Laskowitz DT, James ML. Association of IL6ST (gp130) Polymorphism with Functional Outcome Following Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2017; 27:125-131. [PMID: 28964648 DOI: 10.1016/j.jstrokecerebrovasdis.2017.08.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 08/12/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Genes associated with the inflammatory response and cytostructural integrity may influence recovery following a brain injury. To examine this in the setting of spontaneous intracerebral hemorrhage (ICH), selected single nucleotide polymorphisms (SNPs) were assessed for associations with patient outcome. METHODS A cohort of 54 patients with supratentorial ICH were enrolled. Based on known involvement with neuroinflammation and cytostructural integrity, 10 preselected SNPs from 6 candidate genes were tested for associations with 6-month functional outcome (modified Rankin Scale [mRS] ≥ 3), mortality, and in-hospital deterioration (Glasgow Coma Scale decrease by >2 within 7 days of admission) following ICH. Fisher's exact test and logistic regression with adjustment for race and ICH score were performed. RESULTS SNP rs10940495 (gp130 G/A) within the gp130 gene was the only SNP significantly associated with lower odds of an unfavorable 6-month functional outcome (odds ratio = .16 for mRS ≥ 3; 95% confidence interval, .03-.87, P = .03). Compared with major allele (A) homozygotes, minor allele (G) carriers in the IL6 signal transducer gene (gp130) locus were 84% less likely to have a poor outcome (mRS ≥ 3) at 6 months following spontaneous ICH. The SNP rs10940495 (gp130 G/A) and SNP rs3219119 (PARP-1 A/T) were associated with 6-month mortality (P = .02 and .04, respectively) only on univariate analysis. None of the SNPs examined were associated with in-hospital deterioration. CONCLUSION In this exploratory study, SNP rs10940495 in the gp130 locus was associated with functional outcome at 6 months following spontaneous ICH. These findings, which should be validated through a larger study, suggest that inflammation plays an important role in mediating outcomes after ICH.
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Affiliation(s)
- Nada El Husseini
- Department of Neurology, Duke University, Durham, North Carolina; Department of Neurology, Wake Forest Baptist Medical Center, Winston Salem, North Carolina.
| | - Benjamin M Hoffman
- Department of Neurology, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Ellen R Bennett
- Department of Neurology, Duke University, Durham, North Carolina; Brain Injury Translational Research Center, Duke University, Durham, North Carolina
| | - Yen-Wei Li
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | | | - Claire E Hailey
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Kara Richardson
- Department of Neurology, Duke University, Durham, North Carolina; Brain Injury Translational Research Center, Duke University, Durham, North Carolina
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Daniel T Laskowitz
- Department of Neurology, Duke University, Durham, North Carolina; Department of Anesthesiology, Duke University, Durham, North Carolina; Brain Injury Translational Research Center, Duke University, Durham, North Carolina
| | - Michael L James
- Department of Neurology, Duke University, Durham, North Carolina; Department of Anesthesiology, Duke University, Durham, North Carolina; Brain Injury Translational Research Center, Duke University, Durham, North Carolina
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Allison TA, Bowman S, Gulbis B, Hartman H, Schepcoff S, Lee K. Comparison of Clevidipine and Nicardipine for Acute Blood Pressure Reduction in Patients With Stroke. J Intensive Care Med 2017; 34:990-995. [PMID: 28820038 DOI: 10.1177/0885066617724340] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether clevidipine (CLEV) achieved faster blood pressure control compared to nicardipine (NIC) in patients presenting with either an acute ischemic stroke (AIS) or a spontaneous intracerebral hemorrhage (ICH). METHODS This was a retrospective, observational, cohort study conducted in patients with AIS or ICH admitted to the emergency department of a Comprehensive Stroke Center from November 2011 to June 2013 who received CLEV or NIC continuous infusion for acute blood pressure management. RESULTS The study included 210 patients: 70 in the CLEV group and 140 in the NIC group. There was no difference in mean time (standard deviation [SD]) from initiation of the infusion to goal systolic blood pressure (SBP), CLEV: 50 (83) minutes versus NIC: 74 (103) minutes, P = .101. Comparison of the 2 agents within diagnosis showed no difference. Hypotension developed in 5 (7.1%) CLEV patients versus 14 (10%) NIC patients (P = .003). There was no difference in the percentage change at 2 hours; CLEV: -20% (16%) versus NIC: -16% (16%), P = .058. Mean (SD) time to alteplase administration from admission was 56 (22) minutes in the CLEV group versus 59 (25) minutes in the NIC group (P = .684). CONCLUSIONS There was no difference in the mean time from initiation of the infusion to the SBP goal between agents or in the secondary outcomes. Due to the lack of differences observed, each agent should be considered based on the patient care needs of the institution.
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Affiliation(s)
- Teresa A Allison
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Stephanie Bowman
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Brian Gulbis
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Heather Hartman
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Sara Schepcoff
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Kiwon Lee
- Rutgers, The State University of New Jersey, Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
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24
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Majidi S, Suarez JI, Qureshi AI. Management of Acute Hypertensive Response in Intracerebral Hemorrhage Patients After ATACH-2 Trial. Neurocrit Care 2016; 27:249-258. [DOI: 10.1007/s12028-016-0341-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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25
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Lack of Aquaporin 9 Reduces Brain Angiogenesis and Exaggerates Neuronal Loss in the Hippocampus Following Intracranial Hemorrhage in Mice. J Mol Neurosci 2016; 61:351-358. [DOI: 10.1007/s12031-016-0862-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/11/2016] [Indexed: 12/18/2022]
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26
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Fan Z, Yuan Y, Wang F, Qi Y, Han H, Wu J, Zhang G, Yang L. Diabetes mitigates the recovery following intracranial hemorrhage in rats. Behav Brain Res 2016; 320:412-419. [PMID: 27818237 DOI: 10.1016/j.bbr.2016.10.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 10/24/2016] [Accepted: 10/29/2016] [Indexed: 10/20/2022]
Abstract
Intracranial hemorrhage (ICH) is a common subtype of stroke with high morbidity and mortality. However, few studies have examined the effects of diabetes on the recovery from ICH-induced brain injury. Therefore, we examined the effects of diabetes on protein levels of aquaporins, neuronal loss, angiogenesis, blood brain barrier (BBB) integrity, and neurological deficits following intra-DH collagenase-induced ICH in the hippocampus. We found that diabetic rats exhibited enhanced AQP9 expression in the hippocampus relative to non-diabetic rats, which was associated with increased behavioral deficits. Additionally, ICH induced neovascularization, proliferation of brain microvascular endothelial cells, and hippocampal neuronal loss. However, ICH-induced neovascularization and proliferation of brain microvascular endothelial cells was severely impaired in diabetic rats. Furthermore, ICH-induced hippocampal neuronal loss was exaggerated in diabetic rats. Finally, ICH impaired BBB integrity in the ipsilateral hemisphere, which was increased in diabetic rats. Taken together, the attenuated brain angiogenesis, increased hippocampal neuronal loss, and impaired BBB integrity in diabetic rats after ICH were associated with enhanced AQP9 expression. This may suggest that AQP9 is one of the underlying mechanisms that can mitigate the recovery from ICH in diabetic populations.
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Affiliation(s)
- Zhenzeng Fan
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Yunchao Yuan
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Feng Wang
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Yuepeng Qi
- Department of Neurosurgery, The Hospital of Pingshan County, Shijiazhuang 050000, China
| | - Haie Han
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Jianliang Wu
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Gengshen Zhang
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Lijun Yang
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050011, China.
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27
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Burchell SR, Iniaghe LO, Zhang JH, Tang J. Fucoidan from Fucus vesiculosus Fails to Improve Outcomes Following Intracerebral Hemorrhage in Mice. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 121:191-8. [PMID: 26463947 DOI: 10.1007/978-3-319-18497-5_34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Intracerebral hemorrhage (ICH) is the most fatal stroke subtype, with no effective therapies. Hematoma expansion and inflammation play major roles in the pathophysiology of ICH, contributing to primary and secondary brain injury, respectively. Fucoidan, a polysaccharide from the brown seaweed Fucus vesiculosus, has been reported to activate a platelet receptor that may function in limiting bleeding, and to exhibit anti-inflammatory effects. As such, the aim of the present study was to examine the effects of fucoidan on hemorrhaging and neurological outcomes after ICH. Male CD-1 mice were subjected to experimental ICH by infusion of bacterial collagenase. Animals were randomly divided into the following groups: sham, ICH + vehicle, ICH + 25 mg/kg fucoidan, ICH + 75 mg/kg fucoidan, and ICH + 100 mg/kg fucoidan. Brain water content, neurobehavioral outcomes, and hemoglobin content were evaluated at 24 h post ICH. Our findings show that fucoidan failed to attenuate the ICH-induced increase in BWC. The neurological deficits that result from ICH also did not differ in the treatment groups at all three doses. Finally, we found that fucoidan had no effect on the hemoglobin content after ICH. We postulate that fucoidan treatment did not improve the measured outcomes after ICH because we used crude fucoidan, which has a high molecular weight, in our study. High-molecular-weight fucoidans are reported to have less therapeutic potential than low molecular weight fucoidans. They have been shown to exhibit anti-coagulant and pro-apoptotic properties, which seem to outweigh their anti-inflammatory and potential procoagulant abilities. We propose that using a low-molecular-weight fucoidan, or fractionating the crude polysaccharide, may be effective in treating ICH. Future studies are needed to confirm this.
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Affiliation(s)
- Sherrefa R Burchell
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - Loretta O Iniaghe
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA
- Department of Pharmacology and Toxicology, University of Benin, Benin City, Nigeria
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA
- Department of Neurosurgery, Loma Linda University, Loma Linda, CA, USA
| | - Jiping Tang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, 92350, USA.
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28
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Krishnan K, Scutt P, Woodhouse L, Adami A, Becker JL, Berge E, Cala LA, Casado AM, Caso V, Chen C, Christensen H, Collins R, Czlonkowska A, Dineen RA, Gommans J, Koumellis P, Lees KR, Ntaios G, Ozturk S, Phillips SJ, Pocock SJ, de Silva A, Sprigg N, Szatmari S, Wardlaw JM, Bath PM. Glyceryl Trinitrate for Acute Intracerebral Hemorrhage. Stroke 2016; 47:44-52. [DOI: 10.1161/strokeaha.115.010368] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/26/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Kailash Krishnan
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Polly Scutt
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Lisa Woodhouse
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Alessandro Adami
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Jennifer L. Becker
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Eivind Berge
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Lesley A. Cala
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Ana M. Casado
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Valeria Caso
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Christopher Chen
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Hanna Christensen
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Ronan Collins
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Anna Czlonkowska
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Robert A. Dineen
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - John Gommans
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Panos Koumellis
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Kennedy R. Lees
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - George Ntaios
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Serefnur Ozturk
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Stephen J. Phillips
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Stuart J. Pocock
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Asita de Silva
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Nikola Sprigg
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Szabolcs Szatmari
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Joanna M. Wardlaw
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
| | - Philip M. Bath
- From the Stroke Trials Unit, Division of Clinical Neuroscience (K.K., P.S., L.W., N.S., P.M.B.) and Radiological Sciences Research Group, Division of Clinical Neuroscience (R.A.D.), University of Nottingham, Nottingham, United Kingdom; Stroke Centre, Ospedale Sacro Cuore, Verona, Italy (A.A.); Department of Medical Imaging, College of Medicine, The University of Arizona, Tucson (J.L.B.); Department of Internal Medicine, Oslo University Hospital, Oslo, Norway (E.B.); School of Pathology and
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29
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Patel AA, Mahajan A, Benjo A, Pathak A, Kar J, Jani VB, Annapureddy N, Agarwal SK, Sabharwal MS, Simoes PK, Konstantinidis I, Yacoub R, Javed F, El Hayek G, Menon MC, Nadkarni GN. A Nationwide Analysis of Outcomes of Weekend Admissions for Intracerebral Hemorrhage Shows Disparities Based on Hospital Teaching Status. Neurohospitalist 2015; 6:51-8. [PMID: 27053981 DOI: 10.1177/1941874415601164] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE With the "weekend effect" being well described, the Brain Attack Coalition released a set of "best practice" guidelines in 2005, with the goal to uniformly provide standard of care to patients with stroke. We attempted to define a "weekend effect" in outcomes among patients with intracranial hemorrhage (ICH) over the last decade, utilizing the Nationwide Inpatient Sample (NIS) data. We also attempted to analyze the trend of such an effect. MATERIALS AND METHODS We determined the association of ICH weekend admissions with hospital outcomes including mortality, adverse discharge, length of stay, and cost compared to weekday admissions using multivariable logistic regression. We extracted our study cohort from the NIS, the largest all-payer data set in the United States. RESULTS Of 485 329 ICH admissions from 2002 to 2011, 27.5% were weekend admissions. Overall, weekend admissions were associated with 11% higher odds of in-hospital mortality. When analyzed in 3-year groups, excess mortality of weekend admissions showed temporal decline. There was higher mortality with weekend admissions in nonteaching hospitals persisted (odds ratios 1.16, 1.13, and 1.09, respectively, for 3-year subgroups). Patients admitted during weekends were also 9% more likely to have an adverse discharge (odds ratio 1.09; 95% confidence interval: 1.07-1.11; P < .001) with no variation by hospital status. There was no effect of a weekend admission on either length of stay or cost of care. CONCLUSION Nontraumatic ICH admissions on weekends have higher in-hospital mortality and adverse discharge. This demonstrates need for in-depth review for elucidating this discrepancy and stricter adherence to standard-of-care guidelines to ensure uniform care.
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Affiliation(s)
- Achint A Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Alexandre Benjo
- Department of Internal Medicine, Division of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Ambarish Pathak
- Department of Public Health, New York Medical College, Valhalla, NY
| | - Jitesh Kar
- Neurology Consultants of Huntsville, Huntsville, AL, USA
| | - Vishal B Jani
- Department of Neurology, Michigan State University, East Lansing, MI, USA
| | - Narender Annapureddy
- Division of Rheumatology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shiv Kumar Agarwal
- Division of Cardiology, Department of Internal Medicine, University of Arkansas Medical Sciences, Little Rock, AR, USA
| | - Manpreet S Sabharwal
- Department of Internal Medicine, St. Luke's Roosevelt Medical Center at Mount Sinai, New York, NY, USA
| | - Priya K Simoes
- Department of Internal Medicine, St. Luke's Roosevelt Medical Center at Mount Sinai, New York, NY, USA
| | - Ioannis Konstantinidis
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rabi Yacoub
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Fahad Javed
- Department of Internal Medicine, Division of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Georges El Hayek
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhav C Menon
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Girish N Nadkarni
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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30
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Li Y, Fang W, Tao L, Li M, Yang Y, Gao Y, Ge S, Gao L, Zhang B, Li Z, Zhou W, Wang B, Li L. Efficacy and safety of intravenous nimodipine administration for treatment of hypertension in patients with intracerebral hemorrhage. Neuropsychiatr Dis Treat 2015; 11:1231-8. [PMID: 26056454 PMCID: PMC4446012 DOI: 10.2147/ndt.s76882] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Nicardipine (NC) is the most commonly used antihypertensive drug in neurological patients with hypertension. Although nimodipine (NM) is widely used to treat cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage, trials exploring its antihypertensive effect after intravenous administration in subjects with intracerebral hemorrhage (ICH) are scarce. METHODS A retrospective study was carried out to compare the safety and efficacy of NC and NM administered intravenously in patients with ICH. Therapeutic responses were assessed by achievement of goal blood pressure (BP); use of additional medications for BP control; proportion of time spent within goal; variability in BP; time to goal BP; number of dose adjustments; variability in ICH volume, Glasgow Coma Scale score, and intracranial pressure; and drug-related complications. RESULTS A total of 87 patients were eligible for analysis (n=46 [NC]; n=41 [NM]), and baseline characteristics between groups were similar. Both agents were effective in achieving goal BP during infusion, with 93.5% and 87.8% patients in the NC and NM groups achieving goal, respectively. Fewer additional medications were needed to control BP in the NC group. BP variability was similar and no differences were observed in the mean time to goal BP and mean numbers of dose adjustments between both groups. Interestingly, intracranial pressure declined (P=0.048) during NC administration but increased (P=0.066) after NM treatment. Finally, the incidences of hematoma expansion, neurological deterioration, and adverse drug events were similar in both groups. CONCLUSION NM is effective and safe for BP control in patients with ICH.
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Affiliation(s)
- Yuqian Li
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Wei Fang
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Lei Tao
- Department of Anesthesiology, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Min Li
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Yanlong Yang
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Yafei Gao
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Shunnan Ge
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Li Gao
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Bin Zhang
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Zhihong Li
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Wei Zhou
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Boliang Wang
- Department of Emergency, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Lihong Li
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
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31
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Manning L, Robinson TG, Anderson CS. Control of Blood Pressure in Hypertensive Neurological Emergencies. Curr Hypertens Rep 2014; 16:436. [DOI: 10.1007/s11906-014-0436-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hwang SK, Kim JS, Kim JH, Hong CK, Yang KH. Antihypertensive treatment of acute intracerebral hemorrhage by intravenous nicardipine hydrochloride: prospective multi-center study. J Korean Med Sci 2012; 27:1085-90. [PMID: 22969257 PMCID: PMC3429828 DOI: 10.3346/jkms.2012.27.9.1085] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/19/2012] [Indexed: 11/23/2022] Open
Abstract
The authors performed a multicenter prospective study to evaluate the feasibility and safety of intravenous nicardipine hydrochloride for acute hypertension in patients with intracerebral hemorrhage (ICH). This study included 88 patients (mean age: 58.3 yr, range 26-87 yr) with ICH and acute hypertension in 5 medical centers between August 2008 and November 2010, who were treated using intravenous nicardipine. Administration of nicardipine resulted in a decrease from mean systolic blood pressure (BP) (175.4 ± 33.7 mmHg) and diastolic BP (100.8 ± 22 mmHg) at admission to mean systolic BP (127.4 ± 16.7 mmHg) and diastolic BP (67.2 ± 12.9 mmHg) in 6 hr after infusion (P < 0.001, mixed-effect linear models). Among patients who underwent follow-up by computed tomography, hematoma expansion at 24 hr (more than 33% increase in hematoma size at 24 hr) was observed in 3 (3.4%) of 88 patients. Neurological deterioration (defined as a decrease in initial Glasgow coma scale ≥ 2) was observed in 2 (2.2%) of 88 patients during the treatment. Aggressive nicardipine treatment of acute hypertension in patients with ICH can be safe and effective with a low rate of neurological deterioration and hematoma expansion.
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Affiliation(s)
- Sung-Kyun Hwang
- Department of Neurosurgery, Ewha Womans University College of Medicine, Seoul, Korea.
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33
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Imaging of spontaneous intracerebral hemorrhages by means of transcranial color-coded sonography. Eur J Radiol 2012; 81:1253-8. [DOI: 10.1016/j.ejrad.2011.02.066] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 02/28/2011] [Indexed: 11/19/2022]
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34
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Fan JS, Huang HH, Chen YC, Yen DHT, Kao WF, Huang MS, Huang CI, Lee CH. Emergency department neurologic deterioration in patients with spontaneous intracerebral hemorrhage: incidence, predictors, and prognostic significance. Acad Emerg Med 2012; 19:133-8. [PMID: 22320363 DOI: 10.1111/j.1553-2712.2011.01285.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The objective was to explore the incidence, predictors, and prognostic significance of emergency department (ED) neurologic deterioration in patients with spontaneous intracerebral hemorrhage (SICH). METHODS This was a retrospective cohort study conducted at the ED, neurocritical care unit, and general intensive care unit of a university-affiliated medical center. Consecutive adult SICH patients treated in our ED from January 2002 through December 2009 were included, identified from the registered stroke data bank. These were cross-checked for coding with International Classification of Diseases, Ninth Revision, Clinical Modification 431 and 432.9. Enrolled patients had SICH with elapsed times of <12 hours and Glasgow Coma Scale (GCS) scores ≥ 13 on arrival. ED neurologic deterioration was defined as having a two-or-more-point decrease in consciousness noted in any GCS score assessment between ED presentation and admission. Comparisons of numerical data were performed using an unpaired t-test (parametric data) or Mann-Whitney U-test (nonparametric data). Comparisons of categorical data were done by chi-square tests. Variables with p < 0.1 in univariate analysis were further analyzed using multiple logistic regression. No variable automated or manual selection methods were used. RESULTS Among the 619 patients with SICH included in the study, 22.6% had ED neurologic deterioration. Independent predictors for ED neurologic deterioration included regular antiplatelet use, ictus to ED arrival time under 3 hours, initial body temperature ≥ 37.5°C, intraparenchymal hemorrhage associated with intraventricular hemorrhage (IVH), and presence of a midline shift of greater than 2 mm on computed tomography (CT). ED neurologic deterioration was associated with 1-week mortality, 30-day mortality, and poor neurologic outcome on discharge. CONCLUSIONS Nearly one-quarter of SICH patients with an initial GCS of 13 to 15 had a two points or more deterioration of their GCS while in the ED. ED neurologic deterioration was associated with death and poor neurologic outcomes on discharge. Several risk factors that are available early in the patients' courses appear to be associated with ED neurologic deterioration. By identifying patients at risk for early neurologic decline and intervening early, physicians may be able to improve patient outcomes.
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Affiliation(s)
- Ju-Sing Fan
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C
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35
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Malesker MA, Hilleman DE. Intravenous labetalol compared with intravenous nicardipine in the management of hypertension in critically ill patients. J Crit Care 2012; 27:528.e7-14. [PMID: 22300487 DOI: 10.1016/j.jcrc.2011.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 12/06/2011] [Accepted: 12/08/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND Critically ill patients with acute hypertension often require titratable rapid blood pressure (BP) reductions using parenteral administration of drugs. There are few comparative studies available to make informed drug product selection decisions. The purpose of this study was to evaluate the short-term clinical outcomes and costs of intravenous labetalol or intravenous nicardipine in the management of hypertension in critically ill patients. METHODS This study was a retrospective analysis of consecutive patients receiving intravenous labetalol or intravenous nicardipine in the intensive care unit with acute elevations in either systolic (>160 mm Hg) or diastolic (>90 mm Hg) BP. Patient demographics, clinical characteristics, and short-term clinical outcomes were abstracted from the medical record. Hospital costs were calculated from hospital billing forms. RESULTS A total of 189 patients receiving labetalol and 193 patients receiving nicardipine were included in the analysis. The average hourly dose was 37.3 ± 9.4 mg/h for labetalol compared with 7.1 ± 5.6 mg/h for nicardipine (P < .001). The average total dose of labetalol was 170.9 ± 32.6 mg compared with 112.2 ± 29.1 mg for nicardipine (P = .02). The duration of therapy was significantly shorter for labetalol (8.2 ± 6.2 hours) compared with nicardipine (15.8 ± 4.4 hours) (P = .03). There were a greater number of dose titrations with labetalol (6.1 ± 6.2) than with nicardipine (4.7 ± 4.9), but this difference was not significantly different (P = .29). There were no significant differences in the magnitude of the average change in systolic (P = .79) or diastolic (P = .82) BP between labetalol and nicardipine. The proportion of patients achieving their BP targets was significantly greater with nicardipine (83%) than with labetalol (67%) (P = .04). The proportion of patients requiring an alternate antihypertensive agent was significantly greater with labetalol than with nicardipine (31% vs 17%; P = .02). The total number of all-cause adverse events was significantly greater with labetalol (61%) than with nicardipine (48%) (P = .04). Labetalol was associated with a significantly greater incidence of hypotension and bradycardia or atrioventricular block compared with nicardipine. There was no significant difference in the frequency of other adverse events between these 2 drugs. The median hospital costs were not significantly different between patients receiving labetalol and patients receiving nicardipine. CONCLUSION Our study suggests that nicardipine is a more effective antihypertensive agent than labetalol in an unselected group of patients who develop hypertension in the intensive care unit setting. A major advantage of nicardipine compared with labetalol was fewer adverse effects. Nicardipine was associated with less hypotension and bradycardia or atrioventricular block, resulting in a lower rate of drug discontinuation compared with labetalol.
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Affiliation(s)
- Mark A Malesker
- Creighton University School of Pharmacy and Health Professions, NE 68178, USA.
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36
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Honner SK, Singh A, Cheung PT, Alter HJ, Dutaret CG, Patel AK, Acharya A. Emergency Department Control of Blood Pressure in Intracerebral Hemorrhage. J Emerg Med 2011; 41:355-61. [DOI: 10.1016/j.jemermed.2009.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 11/07/2008] [Accepted: 02/05/2009] [Indexed: 11/16/2022]
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37
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Lau D, El-Sayed AM, Ziewacz JE, Jayachandran P, Huq FS, Zamora-Berridi GJ, Davis MC, Sullivan SE. Postoperative outcomes following closed head injury and craniotomy for evacuation of hematoma in patients older than 80 years. J Neurosurg 2011; 116:234-45. [PMID: 21888477 DOI: 10.3171/2011.7.jns11396] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Advances in the management of trauma-induced intracranial hematomas and hemorrhage (epidural, subdural, and intraparenchymal hemorrhage) have improved survival in these conditions over the last several decades. However, there is a paucity of research investigating the relation between patient age and outcomes of surgical treatment for these conditions. In this study, the authors examined the relation between patient age over 80 years and postoperative outcomes following closed head injury and craniotomy for intracranial hemorrhage. METHODS A consecutive population of patients undergoing emergent craniotomy for evacuation of intracranial hematoma following closed head trauma between 2006 and 2009 was identified. Using multivariable logistic regression models, the authors assessed the relation between age (> 80 vs ≤ 80 years) and postoperative complications, intensive care unit stay, hospital stay, morbidity, and mortality. RESULTS Of 103 patients, 27 were older than 80 years and 76 patients were 80 years of age or younger. Older age was associated with longer length of hospital stay (p = 0.014), a higher rate of complications (OR 5.74, 95% CI 1.29-25.34), and a higher likelihood of requiring rehabilitation (OR 3.28, 95% CI 1.13-9.74). However, there were no statistically significant differences between the age groups in 30-day mortality or ability to recover to functional baseline status. CONCLUSIONS The findings suggest that in comparison with younger patients, patients over 80 years of age may be similarly able to return to preinjury functional baselines but may require increased postoperative medical attention in the forms of rehabilitation and longer hospital stays. Prospective studies concerned with the relation between older age, perioperative parameters, and postoperative outcomes following craniotomy for intracranial hemorrhage are needed. Nonetheless, the findings of this study may allow for more informed decisions with respect to the care of elderly patients with intracranial hemorrhage.
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Affiliation(s)
- Darryl Lau
- University of Michigan Medical School, Ann Arbor, Michigan, USA
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38
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Dubourg J, Messerer M. State of the art in managing nontraumatic intracerebral hemorrhage. Neurosurg Focus 2011; 30:E22. [DOI: 10.3171/2011.3.focus1145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nontraumatic intracerebral hemorrhage constitutes a major public health problem worldwide. Intracerebral hemorrhage leads to a high rate of morbidity and mortality. To date, no medical or surgical trials have clearly attested to the benefit of a particular therapy. The aim of this review was to summarize the best evidence for management decision-making in intracerebral hemorrhage.
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Affiliation(s)
- Julie Dubourg
- 1Centre d'Investigation Clinique CIC201, EPICIME, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Claude Bernard Lyon 1; and
| | - Mahmoud Messerer
- 2Département de Neurochirurgie A, Hôpital Neurologique Pierre Wertheimer, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Claude Bernard Lyon, Lyon, France
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39
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Ohwaki K, Yano E, Nagashima H, Hirata M, Nakagomi T, Tamura A. Blood pressure management in acute intracerebral haemorrhage: low blood pressure and early neurological deterioration. Br J Neurosurg 2011; 24:410-4. [PMID: 20632876 DOI: 10.3109/02688691003746282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECT Lowering the blood pressure (BP) of patients with intracerebral haemorrhage (ICH) can prevent haematoma enlargement but may also promote secondary infarction in areas adjacent to the haematoma, which can lead to neurological deterioration. Little is known about the effects of low BP on early neurological deterioration (END). We conducted a retrospective study to determine whether low BP after admission was associated with END in patients with acute ICH. METHODS We investigated 100 consecutive patients diagnosed with spontaneous ICH. We obtained data on minimum systolic blood pressure (SBP) in the 24 h after admission and related factors and assessed END in this time window. RESULTS END occurred in 38 patients. The frequencies of END by minimum SBP quartile were 52% ( <or= 100 mmHg), 29% (100-120 mmHg), 14% (120-130 mmHg), and 48% ( > 130 mmHg). A logistic regression model for predicting END was developed using SBP at admission, Glasgow Coma Scale at admission, haematoma volume, minimum SBP, and squared minimum SBP. A U-shaped relationship between minimum SBP and END (p = 0.02) was observed, with the lowest risk for END at a minimum SBP of 123 mmHg. The curve was nearly flat for a minimum SBP of 115-130 mmHg, indicating that the risk of END is relatively low across this range of minimum SBPs. CONCLUSIONS Our findings suggest that a minimum SBP of approximately 120-125 mmHg after admission is associated with a beneficial impact on a reduced risk of END.
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Affiliation(s)
- Kazuhiro Ohwaki
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan.
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40
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Shulkin DJ, Jewell KE, Alexandrov AW, Bernard DB, Brophy GM, Hess DC, Kohlbrenner J, Martin-Schild S, Mayer SA, Peacock WF, Qureshi AI, Sung GY, Lyles A. Impact of systems of care and blood pressure management on stroke outcomes. Popul Health Manag 2011; 14:267-75. [PMID: 21506730 DOI: 10.1089/pop.2010.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Stroke is the third leading cause of death in the United States and the leading cause of disability. Stroke patients' outcomes are strongly determined by how long they remain untreated ("time is brain"). The Joint Commission's adoption of stroke performance improvement measures combined with the Centers for Medicare and Medicaid's more recent adoption in October 2009 make a systems approach to improving stroke outcomes a higher priority. As hospitals establish local and regional stroke care systems to meet these performance measures, treatment of emergent high blood pressure (BP) is a major consideration to improve rapid triage and management of acute stroke patients. Intravenous thrombolysis with tissue plasminogen activator (tPA) is a critical quality of care component for acute ischemic stroke (AIS) treatment, but its administration is contingent on BP management. For patients with AIS who are potentially eligible for tPA and patients with intracerebral hemorrhage, timely, controlled BP may improve patient outcomes. Appropriate BP management, however, is still controversial given the heterogeneity of stroke subtypes, the varying attributes of candidate antihypertensive agents, and both local and central hemodynamics. Additionally, organizational delivery system factors may be suboptimal at some hospitals. Under current hospital stroke performance measures, payment mechanisms, and emergency department throughput measures, the impact of BP management may become transparent to patients and payers, and have important consequences for hospital-derived stroke outcomes.
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41
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Arima H, Anderson CS, Wang JG, Huang Y, Heeley E, Neal B, Woodward M, Skulina C, Parsons MW, Peng B, Tao QL, Li YC, Jiang JD, Tai LW, Zhang JL, Xu E, Cheng Y, Morgenstern LB, Chalmers J. Lower Treatment Blood Pressure Is Associated With Greatest Reduction in Hematoma Growth After Acute Intracerebral Hemorrhage. Hypertension 2010; 56:852-8. [PMID: 20823381 DOI: 10.1161/hypertensionaha.110.154328] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The pilot phase of the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT) showed that rapid blood pressure (BP) lowering can attenuate hematoma growth in acute intracerebral hemorrhage. We sought to define the systolic BP level associated with greatest attenuation of hematoma growth. INTERACT included 404 patients with computed tomographic–confirmed intracerebral hemorrhage, elevated systolic BP (150 to 220 mm Hg), and capacity to commence BP lowering treatment within 6 hours of onset. Computed tomography was done at baseline and at 24 hours using standardized techniques, with digital images analyzed centrally, blinded to clinical data. Associations of baseline and achieved on-treatment (mean during the first 24 hours) systolic BP levels with the primary outcome of increase in hematoma volume were explored. There were 346 patients with duplicate computed tomographic scans. There was no significant association between baseline systolic BP levels and either the absolute or proportional growth in hematoma volume (
P
trend=0.26 and 0.12, respectively). By contrast, achieved on-treatment systolic BP levels in the first 24 hours were clearly associated with both absolute and proportional hematoma growth (both
P
trend=0.03). Maximum reduction in hematoma growth occurred in the one third of participants with the lowest on-treatment systolic BP levels (median: 135 mm Hg). Intensive BP reduction to systolic levels between 130 and 140 mm Hg is likely to provide the maximum protection against hematoma growth after intracerebral hemorrhage.
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Affiliation(s)
- Hisatomi Arima
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Craig S. Anderson
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Ji Guang Wang
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Yining Huang
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Emma Heeley
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Bruce Neal
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Mark Woodward
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Christian Skulina
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Mark W. Parsons
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Bin Peng
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Qing Ling Tao
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Yue Chun Li
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Jian Dong Jiang
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Li Wen Tai
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Jin Li Zhang
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - En Xu
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Yan Cheng
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - Lewis B. Morgenstern
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
| | - John Chalmers
- From the George Institute for Global Health (H.A., C.S.A., E.H., B.N., M.W., C.S., J.C.), Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia; Center of Epidemiological Studies and Clinical Trials (J.G.W.), Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Peking University First Hospital (Y.H.), Beijing, China; John Hunter Hospital and the Hunter Medical Research Institute (M.W.P.), University of Newcastle, New Lambton, Australia; Peking
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Hocker S, Morales-Vidal S, Schneck MJ. Management of Arterial Blood Pressure in Acute Ischemic and Hemorrhagic Stroke. Neurol Clin 2010; 28:863-86. [DOI: 10.1016/j.ncl.2010.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Efficacy of the American Heart Association/American Stroke Association guidelines for ultra-early, intentional antihypertensive therapy in intracerebral hemorrhage. J Clin Neurosci 2010; 17:1136-9. [DOI: 10.1016/j.jocn.2010.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Revised: 12/31/2009] [Accepted: 01/04/2010] [Indexed: 11/22/2022]
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Blood pressure management in acute intracerebral haemorrhage guidelines are poorly implemented in clinical practice. Clin Neurol Neurosurg 2010; 112:858-64. [PMID: 20702032 DOI: 10.1016/j.clineuro.2010.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 05/26/2010] [Accepted: 07/10/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND Optimal management of blood pressure (BP) in spontaneous intracerebral haemorrhage (ICH) is controversial. We assessed adherence to BP guidelines and its management in ICH in a tertiary Canadian Stroke Centre. METHODS We conducted a retrospective analysis of 142 CT confirmed primary ICH patients admitted within 24h of symptoms between 2005 and 2006. Initial practice with respect to BP control was reviewed and compared with current guidelines. This retrospective sample was compared with a prospective cohort participating in a BP lowering trial for the attainment of pre-defined BP targets. We also assessed the effect of BP treatment on hematoma expansion and mortality. RESULTS Blood pressure treatment orders were established in 73% of the 142 patients (median age 71 years, 61% male). Only 26% of patients had target orders as advised in the current AHA guidelines. Only 54% achieved BP targets as compared with 83% of the prospective cohort within 1h. Patients with established BP orders were more likely to have repeat brain imaging (70.2%) than those without (39.5%; p=0.001 Mortality rates were 29.8% and 47.4% in those with and without BP targets respectively (p=0.051). CONCLUSIONS Management of BP varies considerably and there appears to be little adherence to recommended guidelines. Targets are achieved more rapidly if a BP treatment protocol is utilized.
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Butcher K, Jeerakathil T, Emery D, Dowlatshahi D, Hill MD, Sharma M, Buck B, Findlay M, Lee TY, Demchuk AM. The Intracerebral Haemorrhage Acutely Decreasing Arterial Pressure Trial: ICH ADAPT. Int J Stroke 2010; 5:227-33. [DOI: 10.1111/j.1747-4949.2010.00431.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The majority of intracerebral haemorrhage patients present with markedly elevated blood pressure immediately after symptom onset. Management of blood pressure in the first 24 h is extremely controversial and lends itself to two competing rationales. There is some evidence that early treatment may improve outcome, potentially by reducing the rate of haematoma expansion. It is also possible that this will reduce cerebral blood flow and therefore exacerbate the cerebral injury, particularly in the region surrounding the haematoma. Only a trial that includes both randomisation of patients to two different blood pressure management strategies and actual measurement of cerebral blood flow can effectively address this pressing debate. This is the only unequivocal way to demonstrate the haemodynamic effects of rapid blood pressure reduction. The Intracerebral Haemorrhage Acutely Decreasing Arterial Pressure Trial is designed to test the hypothesis that blood pressure reduction does not result in significant or harmful changes in cerebral blood flow in acute intracerebral haemorrhage. Two hours after randomisation to a systolic blood pressure target of <150 or <180 mmHg, cerebral blood flow is measured using computed tomography perfusion, which is the primary end-point of the trial. A study of this type is critical to establishing the safety of early blood pressure treatment and is necessary for planning larger efficacy trials in a rational manner. This trial is registered with clinicaltrials.gov (NCT00963976).
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Affiliation(s)
| | | | - Derek Emery
- Department of Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Dar Dowlatshahi
- Division of Neurology, University of Ottawa, Ottawa, ON, Canada
| | - Michael D. Hill
- Department of Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mukul Sharma
- Division of Neurology, University of Ottawa, Ottawa, ON, Canada
| | - Brian Buck
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Max Findlay
- Division of Neurosurgery, University of Alberta, Edmonton, AB, Canada
| | - Ting Y. Lee
- Robarts Research Institue, London, ON, Canada
| | - Andrew M. Demchuk
- Department of Neurosciences, University of Calgary, Calgary, AB, Canada
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Abstract
Hypertension is the most prevalent of the modifiable risk factors for stroke. The benefits of blood pressure (BP) lowering on primary and secondary prevention of stroke are undeniable. Despite this, BP control in hypertensive individuals and patients with prior cerebrovascular events is suboptimal. Noncompliance, inappropriate antihypertensive usage and under-utilization of medications contribute significantly to inadequate BP control. Recently, elegantly designed studies that assessed the preventive role of BP lowering in patients with cerebrovascular disease have helped clarify management issues in terms of BP targets and effective antihypertensive regimens. Current evidence suggests that BP targets for primary and secondary prevention are suboptimal and need reassessment. The effect of BP modulation in acute stroke is still not completely understood. Although the thresholds for BP treatment in acute stroke have been recommended, BP targets are as yet ill-defined. The available evidence supports early lowering of blood pressure following stroke. This review discusses the impact of blood pressure on stroke incidence and outcomes, outlines the recommendations for blood pressure lowering in stroke and delineates questions that still need to be addressed.
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Affiliation(s)
- Monica Saini
- Division of Neurology, Department of Medicine, University of Alberta, AB, Canada.
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Abstract
OBJECTIVE To determine the feasibility and acute (i.e., within 72 hrs) safety of three levels of systolic blood pressure reduction in subjects with supratentorial intracerebral hemorrhage treated within 6 hrs after symptom onset. DESIGN A traditional phase I, dose-escalation, multicenter prospective study. SETTINGS Emergency departments and intensive care units. PATIENTS Patients with intracerebral hemorrhage with elevated systolic blood pressure > or = 170 mm Hg who present to the emergency department within 6 hrs of symptom onset. INTERVENTION Intravenous nicardipine to reduce systolic blood pressure to a target of: (1) 170 to 200 mm Hg in the first cohort of patients; (2) 140 to 170 mm Hg in the second cohort; and (3) 110 to 140 mm Hg in the third cohort. MEASUREMENTS AND MAIN RESULTS Primary outcomes of interest were: (1) treatment feasibility (achieving and maintaining the systolic blood pressure goals for 18-24 hrs); (2) neurologic deterioration within 24 hrs; and (3) serious adverse events within 72 hrs. Safety stopping rules based on neurologic deterioration and serious adverse events were prespecified and approved by an NIH-appointed Data and Safety Monitoring Board, which provided oversight on subject safety. Each subject was followed-up for 3 months to preliminarily assess mortality and the clinical outcomes. A total of 18, 20, and 22 patients were enrolled in the respective three tiers of systolic blood pressure treatment goals. Overall, 9 of 60 patients had treatment failures (all in the last tier). A total of seven subjects with neurologic deterioration were observed: one (6%), two (10%), and four (18%) in tier one, two, and three, respectively. Serious adverse events were observed in one subject (5%) in tier two and in three subjects (14%) in tier three. However, the safety stopping rule was not activated in any of the tiers. Three (17%), two (10%), and five (23%) subjects in tiers one, two, and three, respectively, died within 3 months. CONCLUSIONS The observed proportions of neurologic deterioration and serious adverse events were below the prespecified safety thresholds, and the 3-month mortality rate was lower than expected in all systolic blood pressure tiers. The results form the basis of a larger randomized trial addressing the efficacy of systolic blood pressure reduction in patients with intracerebral hemorrhage.
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Peng SY, Chuang YC, Kang TW, Tseng KH. Random forest can predict 30-day mortality of spontaneous intracerebral hemorrhage with remarkable discrimination. Eur J Neurol 2010; 17:945-50. [PMID: 20136650 DOI: 10.1111/j.1468-1331.2010.02955.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Risk-stratification models based on patient and disease characteristics are useful for aiding clinical decisions and for comparing the quality of care between different physicians or hospitals. In addition, prediction of mortality is beneficial for optimizing resource utilization. We evaluated the accuracy and discriminating power of the random forest (RF) to predict 30-day mortality of spontaneous intracerebral hemorrhage (SICH). METHODS We retrospectively studied 423 patients admitted to the Taichung Veterans General Hospital who were diagnosed with spontaneous SICH within 24 h of stroke onset. The initial evaluation data of the patients were used to train the RF model. Areas under the receiver operating characteristic curves (AUC) were used to quantify the predictive performance. The performance of the RF model was compared to that of an artificial neural network (ANN), support vector machine (SVM), logistic regression model, and the ICH score. RESULTS The RF had an overall accuracy of 78.5% for predicting the mortality of patients with SICH. The sensitivity was 79.0%, and the specificity was 78.4%. The AUCs were as follows: RF, 0.87 (0.84-0.90); ANN, 0.81 (0.77-0.85); SVM, 0.79 (0.75-0.83); logistic regression, 0.78 (0.74-0.82); and ICH score, 0.72 (0.68-0.76). The discriminatory power of RF was superior to that of the other prediction models. CONCLUSIONS The RF provided the best predictive performance amongst all of the tested models. We believe that the RF is a suitable tool for clinicians to use in predicting the 30-day mortality of patients after SICH.
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Affiliation(s)
- S-Y Peng
- Institute of Biomedical Informatics, National Yang-Ming University, Taipei, Taiwan
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NISHIKAWA T, UEBA T, KAJIWARA M, IWATA R, MIYAMATSU N, YAMASHITA K. Preventive Effect of Aggressive Blood Pressure Lowering on Hematoma Enlargement in Patients With Ultra-acute Intracerebral Hemorrhage. Neurol Med Chir (Tokyo) 2010; 50:966-71. [DOI: 10.2176/nmc.50.966] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Tetsuya UEBA
- Department of Neurosurgery, Kishiwada City Hospital
| | | | | | - Naomi MIYAMATSU
- Department of Clinical Nursing Faculty of Medicine, Shiga University of Medical Science
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Does Early Intensive Lowering of Blood Pressure Reduce Hematoma Volume and Improve Clinical Outcome After Acute Cerebral Hemorrhage? J Emerg Med 2009; 37:433-8. [DOI: 10.1016/j.jemermed.2009.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Revised: 05/04/2009] [Accepted: 05/08/2009] [Indexed: 11/19/2022]
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