Update in intracerebral hemorrhage

Characteristics of rehabilitation duration in patients with intracerebral hemorrhage

Background and Purpose

No consensus exists on the ideal duration of rehabilitation in patients with intracerebral hemorrhage (ICH). The aim of this study is to identify demographic and clinical characteristics associated with rehabilitation duration (RD) in patients with ICH during hospitalization.

Methods

This retrospective study followed consecutive patients admitted to a tertiary care center between 2016 and 2019 with primary diagnosis of ICH. The primary outcome, RD was calculated by adding the total number of therapy (speech, occupational, and physical) minutes received during admission, divided by the hospital length of stay. Variables abstracted included demographic and clinical characteristics (ICH score, neurosurgical procedure). Multiple linear regression models were used to measure adjusted association between select predictors and mean RD.

Results

A total of 316 ICH patients (62.5 ± 15.9 years, 49 % White) were included in the final analysis. Compared to Whites, other racial minorities (β= -9.017, p = 0.002) received rehabilitation therapy for a significantly shorter duration in the adjusted model. Age was significantly associated with having higher RD (β=0.320, p < 0.001). Patients with lobar ICH (β= -7.486, p = 0.014) had significantly shorter RD compared to deep. ICH score was significantly associated with having a lower RD (β= -8.624, p < 0.001).

Conclusion

Age, race, ICH score, and location were significantly associated with RD. Non-White patients had significantly shorter RD, indicating a potential racial disparity in the rehabilitation of patients with ICH.

Outcome after Intracerebral Haemorrhage and Decompressive Craniectomy in Older Adults

OBJECTIVE

There is a relationship between the incidence of spontaneous intracerebral haemorrhage (ICH) and age. The incidence increases with age. This study aims to facilitate the decision-making process in the treatment of ICH. It therefore investigated the outcome after ICH and decompressive craniectomy (DC) in older adults (>65 years of age).

METHODS

Retrospective, multicentre, descriptive observational study including only consecutive patients who received DC as the consequence of ICH. Additive evacuation of ICH was performed after the individual decision of the neurosurgeon. Besides demographic data, clinical outcomes both at discharge and 12 months after surgery were evaluated according to the Glasgow Outcome Scale (GOS). Patients were divided into age groups of ≤65 and >65 years and cohorts with favourable outcome (GOS IV-V) and unfavourable outcome (GOS I to III).

RESULTS

56 patients were treated. Mean age was 53.3 (SD: 16.13) years. There were 41 (73.2%) patients aged ≤65 years and 15 (26.8%) patients aged >65 years. During hospital stay, 10 (24.4%) patients in the group of younger (≤65 years) and 5 (33.3%) in the group of older patients (>65 years) died. Mean time between ictus and surgery was 44.4 (SD: 70.79) hours for younger and 27.9 (SD: 41.71) hours for older patients. A disturbance of the pupillary function on admission occurred in 21 (51.2%) younger and 2 (13.3%) older patients (p = 0.014). Mean arterial pressure was 99.9 (SD: 17.00) mmHg for younger and 112.9 (21.80) mmHg in older patients. After 12 months, there was no significant difference in outcome between younger patients (≤65 years) and older patients (>65 years) after ICH and DC (p = 0.243). Nevertheless, in the group of younger patients (≤65 years), 9% had a very good and 15% had a good outcome. There was no good recovery in the group of older patients (>65 years).

CONCLUSION

Patients >65 years of age treated with microsurgical haematoma evacuation and DC after ICH are likely to have a poor outcome. Furthermore, in the long term, only a few older adults have a good functional outcome with independence in daily life activities.

Serum and cerebrospinal fluid neurofilament light chain and glial fibrillary acid protein levels in early and advanced stages of cerebral amyloid Angiopathy

BACKGROUND

Neurofilament light chain (NFL) is a biomarker for neuroaxonal damage and glial fibrillary acidic protein (GFAP) for reactive astrocytosis. Both processes occur in cerebral amyloid angiopathy (CAA), but studies investigating the potential of NFL and GFAP as markers for CAA are lacking. We aimed to investigate NFL and GFAP as biomarkers for neuroaxonal damage and astrocytosis in CAA.

METHODS

For this cross-sectional study serum and cerebrospinal fluid (CSF) samples were collected between 2010 and 2020 from controls, (pre)symptomatic Dutch-type hereditary (D-CAA) mutation-carriers and participants with sporadic CAA (sCAA) from two prospective CAA studies at two University hospitals in the Netherlands. NFL and GFAP levels were measured with Simoa-assays. The association between NFL and GFAP levels and age, cognitive performance (MoCA), CAA-related MRI markers (CAA-CSVD-burden) and Aβ40 and Aβ42 levels in CSF were assessed with linear regression adjusted for confounders. The control group was divided in age < 55 and ≥55 years to match the specific groups.

RESULTS

We included 187 participants: 28 presymptomatic D-CAA mutation-carriers (mean age 40 years), 29 symptomatic D-CAA participants (mean age 58 years), 59 sCAA participants (mean age 72 years), 33 controls < 55 years (mean age 42 years) and 38 controls ≥ 55 years (mean age 65 years). In presymptomatic D-CAA, only GFAP in CSF (7.7*103pg/mL vs. 4.4*103pg/mL in controls; P<.001) was increased compared to controls. In symptomatic D-CAA, both serum (NFL:26.2pg/mL vs. 12.5pg/mL; P=0.008, GFAP:130.8pg/mL vs. 123.4pg/mL; P=0.027) and CSF (NFL:16.8*102pg/mL vs. 7.8*102pg/mL; P=0.01 and GFAP:11.4*103pg/mL vs. 7.5*103pg/mL; P<.001) levels were higher than in controls and serum levels (NFL:26.2pg/mL vs. 6.7pg/mL; P=0.05 and GFAP:130.8pg/mL vs. 66.0pg/mL; P=0.004) were higher than in pre-symptomatic D-CAA. In sCAA, only NFL levels were increased compared to controls in both serum (25.6pg/mL vs. 12.5pg/mL; P=0.005) and CSF (20.0*102pg/mL vs 7.8*102pg/mL; P=0.008). All levels correlated with age. Serum NFL correlated with MoCA (P=0.008) and CAA-CSVD score (P<.001). NFL and GFAP in CSF correlated with Aβ42 levels (P=0.01/0.02).

CONCLUSIONS

GFAP level in CSF is an early biomarker for CAA and is increased years before symptom onset. NFL and GFAP levels in serum and CSF are biomarkers for advanced CAA.

Clinical features and associated factors of coexisting intracerebral hemorrhage in patients with cerebral small vessel disease: a cross-sectional study

Intracerebral hemorrhage (ICH) is generally considered to be closely related to cerebral small vessel disease (CSVD), leading to a poor prognosis. However, the coexistence of ICH in general CSVD patients and related factors remain underreported. In our cross-sectional study, we screened 414 CSVD patients from a database at the Department of Neurology, First Affiliated Hospital of Zhengzhou University (September 2018 to April 2022). Imaging biomarkers of CSVD and coexisting ICH lesion were assessed. Factors associated with coexisting ICH in CSVD were determined using multivariate logistic regression analysis. ICH was observed in 59 patients (14.3%). Multivariate logistic regression showed that previous history of ischemic stroke or transient ischemic attack (OR 5.189, 95%CI 2.572-10.467, P < 0.001), high-grade perivascular space in the basal ganglia (n > 10) (OR 2.051, 95%CI 1.044-4.027, P = 0.037) and low adjusted calcium-phosphorus product (OR 0.728 per 1 [mmol/L]2 increase, 95%CI 0.531-0.998, P = 0.049) were associated with coexisting ICH in CSVD patients. The considerable proportion of coexisting ICH and revelation of associated factors in general CSVD patients alert physicians of the potential risk of the reoccurrence of ICH, and might have a significant impact on therapeutic strategies.

Case Report: Case report: Administration of anticoagulant therapy after neuro-anesthesia procedure for hemorrhagic stroke patients with COVID-19 complications and its ethical and medicolegal consideration

Background

Ethical dilemmas can occur in any situation in clinical medicine. In patients undergoing neuro-anesthesia for surgical procedure evacuation of intracerebral hemorrhage with a history of hemorrhagic stroke, anticoagulants should not be given because they can cause recurrent bleeding. Meanwhile, at the same time, the patient could also be infected with coronavirus disease 2019 (COVID-19), one of treatment is the administration of anticoagulants.

Methods

A case report. A 46-year-old male patient was admitted to hospital with a loss of consciousness and was diagnosed with intracerebral hemorrhage due to a hemorrhagic stroke and was confirmed positive for COVID-19. Giving anticoagulants to patients is considered counterproductive so, an ethical dilemma arises. For this reason, a joint conference was held to obtain the best ethical and medicolegal solutions for the patient.

Results

By using several methods of resolving ethical dilemmas such as basic ethical principles, supporting ethical principles, and medicolegal considerations, it was decided that the patient was not to be given anticoagulants.

Conclusions

Giving anticoagulants to hemorrhagic stroke patients is dangerous even though it is beneficial for COVID-19 patients, so here the principle of risk-benefit balance is applied to patients who prioritize risk prevention rather than providing benefits. This is also supported by the prima facie principle by prioritizing the principle of non-maleficence rather than beneficence, the minus malum principle by seeking the lowest risk, and the double effect principle by making the best decision even in a slightly less favorable way as well as the medicolegal aspect by assessing patient safety and risk management.

Microstructural white matter integrity in relation to vascular reactivity in Dutch-type hereditary cerebral amyloid angiopathy

Cerebral Amyloid Angiopathy (CAA) is characterized by cerebrovascular amyloid-β accumulation leading to hallmark cortical MRI markers, such as vascular reactivity, but white matter is also affected. By studying the relationship in different disease stages of Dutch-type CAA (D-CAA), we tested the relation between vascular reactivity and microstructural white matter integrity loss. In a cross-sectional study in D-CAA, 3 T MRI was performed with Blood-Oxygen-Level-Dependent (BOLD) fMRI upon visual activation to assess vascular reactivity and diffusion tensor imaging to assess microstructural white matter integrity through Peak Width of Skeletonized Mean Diffusivity (PSMD). We assessed the relationship between BOLD parameters - amplitude, time-to-peak (TTP), and time-to-baseline (TTB) - and PSMD, with linear and quadratic regression modeling. In total, 25 participants were included (15/10 pre-symptomatic/symptomatic; mean age 36/59 y). A lowered BOLD amplitude (unstandardized β = 0.64, 95%CI [0.10, 1.18], p = 0.02, Adjusted R2 = 0.48), was quadratically associated with increased PSMD levels. A delayed BOLD response, with prolonged TTP (β = 8.34 × 10-6, 95%CI [1.84 × 10-6, 1.48 × 10-5], p = 0.02, Adj. R2 = 0.25) and TTB (β = 6.57 × 10-6, 95%CI [1.92 × 10-6, 1.12 × 10-5], p = 0.008, Adj. R2 = 0.29), was linearly associated with increased PSMD. In D-CAA subjects, predominantly in the symptomatic stage, impaired cerebrovascular reactivity is related to microstructural white matter integrity loss. Future longitudinal studies are needed to investigate whether this relation is causal.

Resource utilization in management of spontaneous intracerebral hemorrhage without systemic risk factors. Does early surgical decompression matter?

BACKGROUND

Even though different subtypes of spontaneous ICH are frequently linked to a poor prognosis, their causes, pathological features, and prognoses vary. Atypical intracerebral hemorrhage is the subtype of spontaneous ICH that usually occurs due to an underlying localized vascular lesion. It is unrelated to systemic vascular risk factors, mostly affects children and young adults and is associated with a relatively good outcome. This fact should be considered when planning the evaluation and treatment. Investigating the cause of this subtype is fundamental to providing optimal management. However, if resources do not allow completing the investigations, the cause will be more difficult to discover. Treatment decisions will be made under stress to save the patient's life, especially with rapidly deteriorating patients.

METHODS

We described three cases of spontaneous ICH without systemic risk factors where the bleeding source could not be determined before surgery due to a lack of resources, preventing preoperative vascular investigation. Knowing that the atypical ICH has a distinct identity, regarding etiology and prognosis, encouraged the surgeons to resort to early surgical decompression as an alternative plan. We reviewed the literature searching for supporting evidence.

RESULTS

The results of treatment of the presented cases were satisfactory. The lack of reported similar cases was brought to light by a literature analysis that sought to provide backing for the proposed management strategy. In the end, we supplied two graphic organizers to help readers remember the different types and treatment of hemorrhagic stroke.

CONCLUSION

There isn't enough evidence to show that there are other ways to treat atypical intracerebral haemorrhage when resources are limited. The presented cases highlight the importance of decisionmaking in resource-constrained situations when patient outcomes can be improved.

Neutrophil-to-leukocyte ratio and admission glycemia as predictors of short-term death in very old elderlies with lobar intracerebral hemorrhage

BACKGROUND

The incidence of spontaneous intracerebral hemorrhage (SICH) is highest in very old elderlies (≥75 years). The increasing use of antithrombotic drugs is shifting the epidemiology of SICH towards predominance of lobar subtype, suggesting an incremented propensity of bleeding associated with underlying cerebral amyloid angiopathy. With population aging and antithrombotic use, a parallel raise of proportion of lobar SICH is occurring. Improvement of prognostication in this specific age group and SICH type is needed. Routine blood biomarkers can contribute to prediction of short-term mortality after SICH.

OBJECTIVE

Our aim was to investigate the contribution of routine blood biomarkers for short-term mortality (30-days) in elderly patients with lobar SICH.

METHODS

Retrospective analysis of consecutive 130 patients with ≥ 75 years and lobar SICH. The outcome was 30-day mortality. Logistic regression analysis was used to investigate whether admission routine biomarkers can be used as predictors.

RESULTS

The case fatality was 40.8%. Admission glycaemia level, neutrophil to lymphocyte ratio and mean platelet volume were significantly different between groups (p = 0.001, p = 0.024, p = 0.038, respectively). There was no significant difference in all other routine biomarkers. On multivariate analysis, admission higher mean BG level (odds ratio [OR]: 1.010, 95% confidence interval [CI]: 1.001-1.019, p = 0.026) and neutrophil to lymphocyte ratio (OR: 1.070, 95% CI: 1.008-1.136, p = 0.027) emerged as predictors.

CONCLUSION

In very old patients with lobar SICH, higher BG level and neutrophil to lymphocyte ratio are associated with increased risk of short-term death.

Radiosurgery effects and adverse effects in symptomatic eloquent brain-located Cavernomas

In this study, the dose schedule efficacy, safety and late adverse effects of stereotactic radiosurgery (SRS) were evaluated for patients with symptomatic cavernomas who were not eligible for surgery and treated with SRS. Between January 2013 and December 2018, 53 patients with cavernomas were treated using SRS with the CyberKnife® system. Patients' diseases were deeply located or were in subcortical functional brain regions. In addition to bleeding, 23 (43.4%) patients had epilepsy, 12 (22.6%) had neurologic symptoms and 16 patients (30.2%) had severe headaches. The median volume was 741 (range, 421-1351) mm3, and the median dose was 15 (range, 14-16) Gy in one fraction. After treatment, six (50%) of 12 patients with neurologic deficits still had deficits. Rebleeding after treatment developed in only two (3.8%) patients. The drug was completely stopped in 14 (60.9%) out of 23 patients who received epilepsy treatment, and the dose of levetiracetam decreased from 2000 mg to 1000 mg in four (17.3%) of nine patients. Radiologically, complete response (CR) was observed in 13 (24.5%) patients, and partial responses (PR) were observed in 32 (60.2%) patients. Clinical response of CR was observed in 30 (56.6%) patients, PR was observed in 16 (30.2%), stable disease (SD) was observed in three (5.7%) and four (7.5%) patients progressed. In conclusion, SRS applied in the appropriate dose schedule may be an effective and reliable method in terms of symptom control and prevention of rebleeding, especially in patients with inoperable cavernomas.

Hyperlipidemia and Hypertension Are Associated With Intracerebral Hemorrhage Incidence: A Retrospective Study

Introduction Stroke places a huge burden on the socioeconomic systems. Hemorrhagic stroke (HS) is the second most common type of stroke and the second leading cause of disability and death. The updated data on the prevalence of intracerebral hemorrhage (ICH) stroke and related physiological risk factors in Saudi Arabia were limited. The aim of this study was to identify the prevalence of ICH stroke and the related physiological risk factors. Methods This was a retrospective, hospital-based, and chart review study that utilized the BESTCare system at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. Patients who attended the neurology department (inpatient/outpatient) between 2015 and 2020 were studied. The statistical tool JMP (JMP Inc., Cary, NC, USA) was used for data entry and analysis. Results Patient data (N = 1,870, 58.6 ± 13.87 years old) were screened for comorbidities, hypertension (66.1%), diabetes mellitus (DM) (57.7%), hyperlipidemia (28.4%), and history of an old stroke (22.3%). Ischemic stroke (IS) was more dominant than ICH stroke with ratios of 94.5% (n = 1767) versus 5.5% (n = 103), respectively. The prevalence of ICH stroke among the patients (n = 103) was 10.6%, 20.3%, 24.2%, and 28.1% in the age groups of <40, 41-50, 51-60, and 61-70 years old, respectively. There was a significant gender effect on the distribution of both IS and ICH (p = 0.003). ICH strokes were more prevalent in males than in females. Body mass index (BMI) has no significant effect on the prevalence of IS and ICH stroke (p = 0.081). ICH stroke was significantly associated with DM (p = 0.032), hypertension (p = 0.01), and hyperlipidemia (p = 0.002). Regression analyses show that only hypertension (positive association) and hyperlipidemia (negative association) were significantly associated with the incidence of ICH stroke. Conclusion IS was more prevalent than ICH stroke. ICH strokes were more prevalent in males than in females. Also, hypertension was the most common factor leading to ICH stroke, unlike hyperlipidemia, which was revealed to be protective against ICH stroke.

Gene expression changes implicate specific peripheral immune responses to Deep and Lobar Intracerebral Hemorrhages in humans

The peripheral immune system response to Intracerebral Hemorrhage (ICH) may differ with ICH in different brain locations. Thus, we investigated peripheral blood mRNA expression of Deep ICH, Lobar ICH, and vascular risk factor-matched control subjects (n = 59). Deep ICH subjects usually had hypertension. Some Lobar ICH subjects had cerebral amyloid angiopathy (CAA). Genes and gene networks in Deep ICH and Lobar ICH were compared to controls. We found 774 differentially expressed genes (DEGs) and 2 co-expressed gene modules associated with Deep ICH, and 441 DEGs and 5 modules associated with Lobar ICH. Pathway enrichment showed some common immune/inflammatory responses between locations including Autophagy, T Cell Receptor, Inflammasome, and Neuroinflammation Signaling. Th2, Interferon, GP6, and BEX2 Signaling were unique to Deep ICH. Necroptosis Signaling, Protein Ubiquitination, Amyloid Processing, and various RNA Processing terms were unique to Lobar ICH. Finding amyloid processing pathways in blood of Lobar ICH patients suggests peripheral immune cells may participate in processes leading to perivascular/vascular amyloid in CAA vessels and/or are involved in its removal. This study identifies distinct peripheral blood transcriptome architectures in Deep and Lobar ICH, emphasizes the need for considering location in ICH studies/clinical trials, and presents potential location-specific treatment targets.

Potential role of IGF-1/GLP-1 signaling activation in intracerebral hemorrhage

IGF-1 and GLP-1 receptors are essential in all tissues, facilitating defense by upregulating anabolic processes. They are abundantly distributed throughout the central nervous system, promoting neuronal proliferation, survival, and differentiation. IGF-1/GLP-1 is a growth factor that stimulates neurons' development, reorganization, myelination, and survival. In primary and secondary brain injury, the IGF-1/GLP-1 receptors are impaired, resulting in further neuro complications such as cerebral tissue degradation, neuroinflammation, oxidative stress, and atrophy. Intracerebral hemorrhage (ICH) is a severe condition caused by a stroke for which there is currently no effective treatment. While some pre-clinical studies and medications are being developed as symptomatic therapies in clinical trials, there are specific pharmacological implications for improving post-operative conditions in patients with intensive treatment. Identifying the underlying molecular process and recognizing the worsening situation can assist researchers in developing effective therapeutic solutions to prevent post-hemorrhagic symptoms and the associated neural dysfunctions. As a result, in the current review, we have addressed the manifestations of the disease that are aggravated by the downregulation of IGF-1 and GLP-1 receptors, which can lead to ICH or other neurodegenerative disorders. Our review summarizes that IGF-1/GLP-1 activators may be useful for treating ICH and its related neurodegeneration.

Dose-dependent benefits of iron-magnetic nanoparticle-coated human umbilical-derived mesenchymal stem cell treatment in rat intracranial hemorrhage model

BACKGROUND

This study tested whether two doses of human umbilical-derived mesenchymal stem cells (hUC-MSCs) were superior to one dose for protecting the brain against intracranial hemorrhage (ICH) induced by intracranial injection collagenase and the capacity of ironic-magnetic-nanoparticles (Ir-MNa) coated hUC-MSCs tracked by MRI.

METHODS AND RESULTS

Adult male SD rats (n = 40) were equally categorized into group 1 (sham-operated-control), group 2 (ICH), group 3 [ICH + Ir-MNa-coated hUC-MSCs/1.2 × 10⁶ cells with an extracorporeal magnet over rat head (eCMag)/administered by left internal carotid artery (LICA) at post-3 h ICH], and group 4 (ICH + Ir-MNa-coated hUC-MSCs/1.2 × 10⁶ cells with an eCMag/administered post-3 h ICH by LICA and 24 h by IV) and euthanized by day 28. The result showed that by day 28 after ICH induction the neurological function was severely impaired in group 2 than in group 1 that was significantly improved in group 3 and further significantly improved in group 4, whereas ICH volume exhibited an opposite pattern of neurological impairment among the groups (all p < 0.0001). Brain MRI demonstrated that by 4 h after ICH, Ir-MNa-coated hUC-MSCs were abundantly identified in ischemic area in group 4. The protein expressions of inflammatory (TNF-α/MMP-9/IL-1ß/iNOS)/oxidative-stress (NOX-1/NOX-2/oxidized protein)/apoptotic (caspase-3/mitochondrial Bax/PARP)/fibrotic (Smad3/TGF-ß)/mitochondrial-damaged (cytosolic-cytochrome-C) biomarkers displayed an identical pattern of neurological impairment among the groups (all p < 0.0001). The cellular expressions of inflammation (CD68+/CD11b+)/brain edema (AQP4+) biomarkers exhibited an identical pattern, whereas the neuronal-myelin (Doublecortin+/NeuN/nestin) biomarkers displayed an opposite pattern of neurological impairment (all p < 0.0001).

CONCLUSION

Two doses of hUC-MSCs were superior to just one dose for protecting the brain against ICH-induced damage and Ir-MNa-coated hUC-MSCs offered a well adopted method for tracking hUC-MSCs homing into the brain.

Hypoxia- and Inflammation-Related Transcription Factor SP3 May Be Involved in Platelet Activation and Inflammation in Intracranial Hemorrhage

The purpose of this study was to identify the biomarkers implicated in the development of intracranial hemorrhage (ICH) and potential regulatory pathways. In the transcriptomic data for patients with ICH, we identified DEmiRNAs and DEmRNAs related to hypoxia, inflammation, and their transcription factors (TFs). An ICH-based miRNA-TF-mRNA regulatory network was thus constructed, and four biomarkers (TIMP1, PLAUR, DDIT3, and CD40) were screened for their association with inflammation or hypoxia by machine learning. Following this, SP3 was found to be a transcription factor involved in hypoxia and inflammation, which regulates TIMP1 and PLAUR. From the constructed miRNA-TF-mRNA regulatory network, we identified three axes, hsa-miR-940/RUNX1/TIMP1, hsa-miR-571/SP3/TIMP1, and hsa-miR-571/SP3/PLAUR, which may be involved in the development of ICH. Upregulated TIMP1 and PLAUR were validated in an independent clinical cohort 3 days after ICH onset. According to Gene Set Enrichment Analysis (GSEA), SP3 was discovered to be important in interleukin signaling and platelet activation for hemostasis. Transcription factor SP3 associated with hypoxia or inflammation plays an important role in development of ICH. This study provides potential targets for monitoring the severity of inflammation and hypoxia in patients with ICH.

Brainstem lesions: MRI review of standard morphological sequences

MRI signal changes in the brainstem are observed in a multitude of disorders including vascular diseases, neoplastic lesions, degenerative diseases, inflammatory disorders, metabolic diseases, infections, and trauma. In some diseases, brainstem involvement is typical and sometimes isolated, while in other diseases, brainstem lesions are only observed occasionally in the presence of other typical extra-brainstem abnormalities. In this review, we will discuss the MRI characteristics of brainstem lesions observed in different disorders associated with frequent and less frequent brainstem involvement. Identification of the origin of the brainstem lesion depends on the exact localisation of the lesion(s) inside the brainstem, the presence and the characteristics of associated lesions seen outside the brainstem, the signal changes on different MRI sequences, the evolution over time of the radiological abnormalities, the history and clinical state of the patient, and other radiological and non-radiological examinations.

Surgical vs. Conservative Management for Lobar Intracerebral Hemorrhage, a Meta-Analysis of Randomized Controlled Trials

Background

Outcomes regarding the conventional surgical and conservative treatment for the lobar intracerebral hemorrhage (ICH) have not been previously compared. The current meta-analysis was designed to review and compile the evidence regarding the management of patients with lobar intracerebral hemorrhage.

Methods

Online electronic databases, including PubMed, Embase, Medline, Cochrane Library, and Google Scholar, were searched for randomized controlled trials (RCTs). Studies were selected on the basis of the inclusion and exclusion criteria. Trials with CT-confirmed lobar intracerebral hemorrhage patients of which treatment regimen was started within 72 h following the stroke were included. Low quality trials were excluded. Death or dependence was defined as primary outcome and death at the end of the follow up was the secondary outcome.

Results

One hundred five RCTs were screened and 96 articles were excluded on the basis of abstract. Nine articles were assessed for the eligibility and 7 trials were included that involved 1,102 patients. The Odds ratio (OR) for the primary outcome was 0.80 (95% CI, 0.62–1.04, p = 0.09) and for the secondary outcome was 0.79 (95%CI, 0.60–1.03, p = 0.09).

Conclusion

Our findings suggested that surgical treatments did not significantly improve the functional outcome as compared with the conservative medical management for patients with lobar ICH.

Volumetric accuracy of different imaging modalities in acute intracerebral hemorrhage

Background

Follow-up imaging in intracerebral hemorrhage is not standardized and radiologists rely on different imaging modalities to determine hematoma growth. This study assesses the volumetric accuracy of different imaging modalities (MRI, CT angiography, postcontrast CT) to measure hematoma size.

Methods

28 patients with acute spontaneous intracerebral hemorrhage referred to a tertiary stroke center were retrospectively included between 2018 and 2019. Inclusion criteria were (1) spontaneous intracerebral hemorrhage (supra- or infratentorial), (2) noncontrast CT imaging performed on admission, (3) follow-up imaging (CT angiography, postcontrast CT, MRI), and (4) absence of hematoma expansion confirmed by a third cranial image within 6 days. Two independent raters manually measured hematoma volume by drawing a region of interest on axial slices of admission noncontrast CT scans as well as on follow-up imaging (CT angiography, postcontrast CT, MRI) using a semi-automated segmentation tool (Visage image viewer; version 7.1.10). Results were compared using Bland–Altman plots.

Results

Mean admission hematoma volume was 18.79 ± 19.86 cc. All interrater and intrarater intraclass correlation coefficients were excellent (1; IQR 0.98–1.00). In comparison to hematoma volume on admission noncontrast CT volumetric measurements were most accurate in patients who received postcontrast CT (bias of − 2.47%, SD 4.67: n = 10), while CT angiography often underestimated hemorrhage volumes (bias of 31.91%, SD 45.54; n = 20). In MRI sequences intracerebral hemorrhage volumes were overestimated in T2* (bias of − 64.37%, SD 21.65; n = 10). FLAIR (bias of 6.05%, SD 35.45; n = 13) and DWI (bias of-14.6%, SD 31.93; n = 12) over- and underestimated hemorrhagic volumes.

Conclusions

Volumetric measurements were most accurate in postcontrast CT while CT angiography and MRI sequences often substantially over- or underestimated hemorrhage volumes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12880-022-00735-3.

B-Mode Ultrasound, a Reliable Tool for Monitoring Experimental Intracerebral Hemorrhage

Background: Magnetic resonance imaging (MRI) is currently used for the study of intracerebral hemorrhage (ICH) in animal models. However, ultrasound is an inexpensive, non-invasive and rapid technique that could facilitate the diagnosis and follow-up of ICH. This study aimed to evaluate the feasibility and reliability of B-mode ultrasound as an alternative tool for in vivo monitoring of ICH volume and brain structure displacement in an animal model.

Methods: A total of 31 male and female Sprague-Dawley rats were subjected to an ICH model using collagenase-IV in the striatum following stereotaxic references. The animals were randomly allocated into 3 groups: healthy (n = 10), sham (n = 10) and ICH (n = 11). B-mode ultrasound studies with a 13-MHz probe were performed pre-ICH and at 5 h, 48 h, 4 d and 1 mo post-ICH for the assessment of ICH volume and displacement of brain structures, considering the distance between the subarachnoid cisterns and the dura mater. The same variables were studied by MRI at 48 h and 1 mo post-ICH.

Results: Both imaging techniques showed excellent correlation in measuring ICH volume at 48 h (r = 0.905) and good at 1 mo (r = 0.656). An excellent correlation was also observed in the measured distance between the subarachnoid cisterns and the dura mater at 1 mo between B-mode ultrasound and MRI, on both the ipsilateral (r = 0.870) and contralateral (r = 0.906) sides of the lesion.

Conclusion: B-mode ultrasound imaging appears to be a reliable tool for in vivo assessment of ICH volume and displacement of brain structures in animal models.

Mesoporous Silica Nanoparticles Carrying MicroRNA-124 to Target P2Y12 Facilitates Cerebral Angiogenesis in Lacunar Cerebral Infarction Through Stem Cell Factor/c-Kit Signaling Pathway

MicroRNA (miRNA)-124 inhibitor may enhance cerebral blood vessel formation in lacunar cerebral infarction (LCI) and mesoporous silica nanoparticles are highlighted as a drug carrier which improves patients' outcome. This study explored the impact of miR-124 and its promising targeted gene P2Y₁₂ encapsulated by mesoporous silica nanoparticles (MSNs) on progression of LCI, and its interaction between SCF/c-kit signaling pathway. After establishment of animal models, the animals were divided into 6 groups, namely: model group, blank group, empty carrier group, carrier + miR-124 inhibitor group, SCF/c-kit inhibitor group, and P2Y₁₂ agonist group. Western blot analysis and microscope determined the expression level of miR-124 in the rat brain tissue slices. MVD, SCF and c-kit P2Y₁₂ protein expression levels were detected and their targeting relationship was verified. miR-124 was poorly expressed in the cells of rats with LCI upon injection of MSNs carrying miR-124-inhibitor. The LCI model group had the highest number of VEGF-positive. Compared with the model group, the number in the carrier + miR-124 inhibitor group was lowest. Moreover, treatment with SCF/c-kit inhibitor and P2Y₁₂ agonist also obtained reduction in the number of VEGF-positive cells with less prominent effect (P < 0.05). With elevation of MVD in the LCI rats, injection of P2Y₁₂ agonist or SCF/c-kit inhibitor significantly decreased the amount of MVD, while miR-124 inhibitor-loaded MSNs better reduced the MVD level. Besides, the LCI rats exhibited up-regulated level of P2Y₁₂ protein. Injection of P2Y₁₂ agonist or SCF/c-kit inhibitor dramatically decreased the level of P2Y₁₂, where the level was still higher than that of carrier + miR-124 inhibitor group. Moreover, administration of miR-124 inhibitor-loaded MSNs resulted in increased SCF and c-kit protein level, and SCF/c-kit inhibitor group and P2Y₁₂ agonist group also had increased SCF and c-kit protein level, compared to the model group. Mechanistically, the miR-124 was indicated to target P2Y₁₂ with stronger fluorescence intensity in mutant plasmid (P < 0.05). MSN-encapsulated miR-124 inhibitor increased the expression of SCF/c-kit protein by targeting P2Y₁₂, thereby enhancing regeneration of cerebral blood vessels in LCI.

Early Tranexamic Acid in Intracerebral Hemorrhage: A Meta-Analysis of Randomized Controlled Trials

Objective: Intracranial hemorrhage (ICH) is a common complication of traumatic brain, in which tranexamic acid has been recommended as an additional therapy to prevent a second bleeding. However, the effect of early administration of tranexamic acid for ICH patients remains controversial.

Methods: A systematic search was performed in Cochrane Library, Medline, Embase, and Web of Science. Poor outcome refers to significant hemorrhage growth, new intracranial hemorrhage, new focal cerebral ischaemic lesions, the need for neurosurgery, or death. Study heterogeneity and publication bias were estimated.

Results: Seven randomized controlled trials involving 3,192 participants were included in our meta-analysis. Tranexamic acid administration in ICH patients was associated with better outcomes of hematoma expansion (odd ratios [OR] 0.79; 95% confidence interval (CI) CI, 0.67–0.93; I² = 0%; P = 0.006) and growth of hemorrhagic lesions (weighted mean difference [WMD], −1.97 ml; 95% CI, −2.94 to −1.00; I² = 14%; P < 0.001) than the placebo. No difference was found between the mortality, poor outcome, neurosurgical intervention, new bleeding, and the duration of hospital stay. Moreover, no publication bias was found.

Conclusion: Our analysis reveals that the early treatment with tranexamic acid can significantly reduce the incidence of hematoma expansion and the volume of hemorrhagic lesion, but does not exert considerable effects on mortality, poor outcome, neurosurgery, rebleeding, and the duration of stay.

Spatial and temporal intracerebral hemorrhage patterns in Dutch-type hereditary cerebral amyloid angiopathy

Aim

To investigate whether there is a topographical and temporal pattern of index and recurrent intracerebral hemorrhages (ICH) in Dutch-type hereditary Cerebral Amyloid Angiopathy (D-CAA) to increase our understanding on CAA-related ICH development.

Methods

We included patients with DNA confirmed D-CAA or a history with ≥1 lobar ICH and ≥1 first-degree relative with D-CAA. Topographical pattern was studied by location (proportion frontal/parietal/temporal/occipital; infra/supratentorial and occurrence ratios relative to lobe volume) and volume of index and recurrent ICHs were determined on CT. Temporal pattern was examined by time between recurrent ICHs was retrieved from medical records.

Results

We included 72 patients with D-CAA (mean age at index ICH 55 years) with in total 214 ICH. The median follow-up time was 7 years (range 0.8 to 28 years). All ICH were lobar and supratentorial. The index ICH was most frequently located in the occipital lobe (34% vs. 22% in the other three lobes; with index ICH occurrence ratios relative to lobe volume of 1.9 for occipital, 1.0 for temporal, 1.2 for parietal, and 0.5 for frontal, p = 0.001). In 16/47 (34%) patients with multiple ICH, the second ICH was located in the same lobe as the index ICH. The median time-interval between subsequent ICH was #1-2 ICH 27 months, #2-3 ICH 14 months, and #3-4 ICH 7 months (p = 0.6) There was no difference in volume between index and recurrent ICHs.

Conclusions

We found that index and recurrent ICHs in D-CAA have a preference for the occipital lobe and are least frequent in the frontal lobe, which adds to the existing knowledge of histopathological studies on amyloid load in CAA. Surprisingly, there was no acceleration in time nor gradual increase of hematoma volume between subsequent ICHs.

Contribution of Various Types of Transfusion to Acute and Delayed Intracerebral Hemorrhage Injury

Intracerebral hemorrhage (ICH) is the second most prevalent type of stroke, after ischemic stroke, and has exceptionally high morbidity and mortality rates. After spontaneous ICH, one primary goal is to restrict hematoma expansion, and the second is to limit brain edema and secondary injury. Various types of transfusion therapies have been studied as treatment options to alleviate the adverse effects of ICH etiopathology. The objective of this work is to review transfusions with platelets, fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), and red blood cells (RBCs) in patients with ICH. Furthermore, tranexamic acid infusion studies have been included due to its connection to ICH and hematoma expansion. As stated, the first line of therapy is limiting bleeding in the brain and hematoma expansion. Platelet transfusion is used to promote recovery and mitigate brain damage, notably in patients with severe thrombocytopenia. Additionally, tranexamic acid infusion, FFP, and PCC transfusion have been shown to affect hematoma expansion rate and volume. Although there is limited available research, RBC transfusions have been shown to cause higher tissue oxygenation and lower mortality, notably after brain edema, increases in intracranial pressure, and hypoxia. However, these types of transfusion have varied results depending on the patient, hemostasis status/blood thinner, hemolysis, anemia, and complications, among other variables. Inconsistencies in published results on various transfusion therapies led us to review the data and discuss issues that need to be considered when establishing future guidelines for patients with ICH.

Retrospective analysis of the surgical management of spontaneous supratentorial intracerebral hemorrhage: A single-center study

Background: Intracerebral hemorrhage (ICH) remains a devastating disease with high morbidity and mortality. The mortality rate ranges from 40% at 1 month to 54% at 1 year, and only 12%–39% achieve good outcomes and functional independence. The current management guidelines for spontaneous supratentorial ICH are still controversial.

Objective: Patients who presented with ICH and underwent craniotomy with hematoma evacuation or minimal procedures from January 2016 to May 2020 were included in the analysis. Several clinical, radiological, and surgical variables were collected to identify the variables most likely related to lower mortality and better functional outcomes.

Results: A total of 87 patients presented with HMC with ICH from January 2016 to May 2020.

The mean age was 44.7 (42.2–47.2) years. There were 76 male (87.4%)/11 female (12.6%) patients, which reflect the population distribution in Qatar, which is mainly male predominant. Although Qatar is mainly a Middle-Eastern country, the ethnic distribution of patients was mainly of South Asian and Indian (60.9%) and Far-Eastern (20.7%) ethnicities because of diversity. The mean baseline Glasgow coma scale (GCS) was 8.2+/ − 3.7. The mean baseline functional independence measure (FIM) score was 59.4+/ − 36.7. Most hematomas were located in the basal ganglia (79.3%%). Baseline characteristics based on long-term outcomes are summarized in Table 1. The following variables were correlated with poor outcome: low GCS on postoperative day 1 (P = 0.06), low FIM score (P = 0.006), ICH location (P = 0.04), distance of the closest point to the surface (P = 0.009), and presence of uncal herniation (P = 0.04). The baseline characteristics based on mortality are outlined in Table 2. The following variables were correlated with mortality: diabetes mellitus (P = 0.02), baseline GCS (P = 0.04), GCS on postoperative day 1 (P = 0.002), unequal pupils (P = 0.05), and postoperative midline shift (P = 0.001).

Conclusion: The preoperative clinical neurological status as well as mass effect (uncal herniation and midline shift) can be determinants of functional outcome and mortality. A deeper hematoma may result in poor functional outcome because of more surgical damage in functional brain tissues. Thus, the goal of surgery in spontaneous supratentorial ICH is to reduce mortality, but no evidence support that it can improve functional outcome. Although our findings are interesting, more prospective studies with a larger sample size are needed to confirm our results.

Hematoma Expansion Context Guided Intracranial Hemorrhage Segmentation and Uncertainty Estimation

Accurate segmentation of the Intracranial Hemorrhage (ICH) in non-contrast CT images is significant for computer-aided diagnosis. Although existing methods have achieved remarkable results, none of them ever incorporated ICH's prior information in their methods. In this work, for the first time, we proposed a novel SLice EXpansion Network (SLEX-Net), which incorporated hematoma expansion in the segmentation architecture by directly modeling the spatial variation of hematoma expansion. Firstly, a new module named Slice Expansion Module (SEM) was built, which can effectively transfer contextual information between two adjacent slices by mapping predictions from one slice to another. Secondly, to perceive label correlation information from both upper and lower slices, we designed two information transmission paths: forward and backward slice expansion. By further exploiting intra-slice and inter-slice context with the information paths, the network significantly improved the accuracy and continuity of segmentation results. Moreover, the proposed SLEX-Net enables us to conduct an uncertainty estimation with one-time inference, which is much more efficient than existing methods. We evaluated the proposed SLEX-Net and compared it with some state-of-the-art methods. Experimental results demonstrate that our method makes significant improvements in all metrics on segmentation performance and outperforms other existing uncertainty estimation methods in terms of several metrics. The code will be available from https://github.com/JohnleeHIT/SLEX-Net.

Intracranial Hemorrhage in COVID-19 patients: A Case Series

Background

The coronavirus disease 2019 (COVID-19) pandemic is an ongoing public health emergency. While most cases end in asymptomatic or minor illness, there is growing evidence that some COVID-19 infections result in nonconventional dire consequences. We sought to describe the characteristics of patients with intracranial hemorrhage who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Also, with the existing literature, we raise the idea of a possible association between SARS-CoV-2 infection and intracranial hemorrhage and propose possible pathophysiological mechanisms connecting the two.

Methods

We retrospectively collected and analyzed intracranial hemorrhage cases who were also positive for SARS-CoV-2 from 4 tertiary-care cerebrovascular centers.

Results

We identified a total of 19 patients consisting of 11 males (58%) and 8 females (42%). Mean age was 52.2, with 95% younger than 75 years of age. With respect to COVID-19 illness, 50% had mild-to-moderate disease, 21% had severe disease, and 20% had critical disease requiring intubation. Of the 19 cases, 12 patients had intraparenchymal hemorrhage (63%), 6 had subarachnoid hemorrhage (32%), and 1 patient had a subdural hematoma (5%). A total of 43% had an intracerebral hemorrhage score of 0–2 and 57% a score of 3–6. Modified Rankin Scale cores at discharge were 0–2 in 23% and 3–6 in 77%. The mortality rate was 59%.

Conclusions

Our series sheds light on a distinct pattern of intracerebral hemorrhage in COVID-19–positive cases compared with typical non–COVID-19 cases, namely the severity of hemorrhage, high mortality rate, and the young age of patients. Further research is warranted to delineate a potential association between SARS-CoV-2 infection and intracranial hemorrhage.

Characterization of a Temporal Profile of Biomarkers as an Index for Ischemic Stroke Onset Definition

Background and purpose: Stroke is a dynamic process in terms of molecular mechanisms, with prominent glutamate-mediated excitotoxicity at the onset of symptoms followed by IL-6-mediated inflammation. Our aim was to study a serum glutamate/IL-6 ratio as an index for stroke onset definition. Methods: A total of 4408 ischemic stroke patients were recruited and then subdivided into four quartiles according to latency time in minutes (0–121, 121–185, 185–277 and >277). Latency time is defined as the time between stroke onset and treatment at the neurological unit. The primary endpoint of the study was the association of early latency times with different clinical aspects and serum markers. Serum glutamate and interleukin-6 (IL-6) levels at admission were selected as the main markers for excitotoxicity and inflammation, respectively. Results: Glutamate serum levels were significantly higher in the earlier latency time compared with the higher latency times (p < 0.0001). IL-6 levels were lower in early latency times (p < 0.0001). Patients with a glutamate/IL-6 index on admission of >5 were associated with a latency time of <121 min from the onset of symptoms with a sensitivity of 88% and a specificity of 80%. Conclusions: The glutamate/IL-6 index allows the development of a ratio for an easy, non-invasive early identification of the onset of ischemic stroke symptoms, thus offering a new tool for selecting early stroke patient candidates for reperfusion therapies.

Glibenclamide does not improve outcome following severe collagenase-induced intracerebral hemorrhage in rats

Intracerebral hemorrhage (ICH) is a devastating insult with few effective treatments. Edema and raised intracranial pressure contribute to poor outcome after ICH. Glibenclamide blocks the sulfonylurea 1 transient receptor potential melastatin 4 (Sur1-Trpm4) channel implicated in edema formation. While glibenclamide has been found to improve outcome and reduce mortality in animal models of severe ischemic stroke, in ICH the effects are less clear. In our previous study, we found no benefit after a moderate-sized bleed, while others have reported benefit. Here we tested the hypothesis that glibenclamide may only be effective in severe ICH, where edema is an important contributor to outcome. Glibenclamide (10 μg/kg loading dose, 200 ng/h continuous infusion) was administered 2 hours post-ICH induced by collagenase injection into the striatum of adult rats. A survival period of 24 hours was maintained for experiments 1–3, and 72 hours for experiment 4. Glibenclamide did not affect hematoma volume (~81 μL) or other safety endpoints (e.g., glucose levels), suggesting the drug is safe. However, glibenclamide did not lessen striatal edema (~83% brain water content), ionic dyshomeostasis (Na⁺, K⁺), or functional impairment (e.g., neurological deficits (median = 10 out of 14), etc.) at 24 hours. It also did not affect edema at 72 h (~86% brain water content), or overall mortality rates (25% and 29.4% overall in vehicle vs. glibenclamide-treated severe strokes). Furthermore, glibenclamide appears to worsen cytotoxic edema in the peri-hematoma region (cell bodies were 46% larger at 24 h, p = 0.0017), but no effect on cell volume or density was noted elsewhere. Overall, these findings refute our hypothesis, as glibenclamide produced no favorable effects following severe ICH.

Factors Associated With Emergency Department Length of Stay and In-hospital Mortality in Intracerebral Hemorrhage Patients

ABSTRACT

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is a medical emergency that requires rapid identification and focused assessment early to ensure the best possible outcomes. The purpose of this study is to evaluate the associations between system and patient factors and emergency department (ED) length of stay and in-hospital mortality in patients given a diagnosis of ICH. METHODS: A sample of 3108 ICH patients was selected from a statewide administrative database for cross-sectional retrospective analysis. System characteristic (hospital stroke certification), patient characteristics (age, sex, and race), and covariate conditions (stroke severity and comorbidities) were analyzed using descriptive statistics and hierarchical logistic regression models to address the study questions. RESULTS: The mean ED length of stay is 2.9 ± 3 hours (range, 0-42 hours) before admission to an inpatient unit. Inpatient mortality is 14.9%. Stroke center certification (P < .000) and stroke severity (P ≤ .000) are significant predictors of ED length of stay, whereas age (P < .000), stroke severity (P < .000), comorbidities (P = .047), and ED length of stay (P = .04) are significant predictors of in-hospital mortality. Most notably, an ED length of stay of 3 hours or longer has a 37% increase in the odds of in-hospital mortality. CONCLUSION: Our findings support age, stroke severity, and ED length of stay as predictors of in-hospital mortality for ICH patients. The importance of timely admission to an inpatient unit is emphasized. Optimal systems of care and expedited inpatient admission are vital to reduce morbidity and mortality for ICH stroke patients.

Inpatient mortality and healthcare resource utilization of nontraumatic intracerebral hemorrhage complications in the US

OBJECTIVE

Nontraumatic, primary intracerebral hemorrhage (ICH) accounts for 2 million strokes worldwide annually and has a 1-year survival rate of 50%. Recent studies examining functional outcomes from ICH evacuation have been performed, but limited work has been done quantifying the incidence of subsequent complications and their healthcare economic impact. The purpose of this study was to quantify the incidence and healthcare resource utilization (HCRU) for major complications that can arise from ICH.

METHODS

The IBM MarketScan Research databases were used to retrospectively identify patients with ICH from 2010 to 2015. Complications examined included cerebral edema, hydrocephalus, venous thromboembolic events (VTEs), pneumonia, urinary tract infections (UTIs), and seizures. For each complication, inpatient mortality and HCRU were assessed.

RESULTS

Of 25,322 adult patients included, 10,619 (42%) developed complications during the initial admission of ICH: 22% had cerebral edema, 11% hydrocephalus, 10% pneumonia, 6% UTIs, 5% seizures, and 5% VTEs. The inpatient mortality rates at 7 and 30 days for each complication of ICH ranked from highest to lowest were hydrocephalus (24% and 32%), cerebral edema (15% and 20%), pneumonia (8% and 18%), seizure (7% and 13%), VTE (4% and 11%), and UTI (4% and 8%). Hydrocephalus had the highest total cost (median $92,776, IQR $39,308-$180,716) at 7 days post-ICH diagnosis and the highest cumulative total cost (median $170,839, IQR $91,462-$330,673) at 1 year post-ICH diagnosis.

CONCLUSIONS

This study characterizes one of the largest cohorts of patients with nontraumatic ICH in the US. More than 42% of the patients with ICH developed complications during initial admission, which resulted in high inpatient mortality and considerable HCRU.

Cognitive Impairment After Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

The present systematic review and meta-analysis analyzes the available clinical literature on post-intracerebral hemorrhage (ICH) cognitive impairment.

METHODS

We conducted a systematic review with meta-analysis following PRISMA guidelines. A search of bibliographic databases up to July 31, 2020 yielded 2155 studies. Twenty articles were included in our final qualitative systematic review and 18 articles in quantitative meta-analysis.

RESULTS

Based on analysis of data from 18 studies (3270 patients), we found prevalence of post-ICH cognitive impairment to be 46% (confidence interval, 35.9-55.9), with a follow-up duration ranging from 8 days to 4 years. The estimated pooled prevalence of cognitive decline decreased over longitudinal follow-up, from 55% (range, 37.7%-71.15%) within 6 months of ICH to 35% (range, 27%-42.7%) with >6 months to 4 years follow-up after ICH. The modalities used to evaluate cognitive performance after ICH in studies varied widely, ranging from global cognitive measures to domain-specific testing. The cognitive domain most commonly affected included nonverbal IQ, information processing speed, executive function, memory, language, and visuoconstructive abilities. Prognostic factors for poor cognitive performance included severity of cortical atrophy, age, lobar ICH location, and higher number of hemorrhages at baseline.

CONCLUSIONS

The prevalence of post-ICH cognitive impairment is high. Despite the heterogeneity among studies, the present study identified cognitive domains most commonly affected and predictors of cognitive impairment after ICH. In future, prospective cohort studies with larger sample sizes and standardized cognitive domains testing could more accurately determine prevalence and prognostic factors of post-ICH cognitive decline.

Is the CT Blend Sign Composed of Two Parts of Blood with Different Age?

BACKGROUND

Blend sign on initial computed tomography (CT) is associated with poor outcome in patients with intracerebral hemorrhage (ICH). However, the mechanisms underlying the blend sign formation are poorly understood. The present study aimed to explore the possible mechanism of the CT blend sign in patients with ICH.

METHODS

Seventy healthy rabbits were selected to prepare an ICH model. The animals were assigned to a whole blood group + whole blood group (ww group, 50 rabbits), a whole blood + plasma group (wp group, 10 rabbits) or a whole blood + serum group (ws group, 10 rabbits). The animals of the ww group were allocated to five subgroups based on the interval between the first infusion of blood and the second one. The subgroups included ww 1 h group (with an interval of 1 h), ww 2 h group, ww 3 h group, ww 4 h group and ww 5 h group. The rabbits from each group received first infusion of 0.3 mL of whole blood into the basal ganglia area to form a hematoma. Then, they received a second infusion of the same amount of whole blood, plasma or serum into the brain to form another hematoma adjacent to the first one.

RESULTS

A hematoma with two densities on brain CT could be formed in each group after a second infusion of blood into the brain. A significant difference in CT attenuation values was observed between the hyperattenuation and the hypoattenuation in all the groups. However, only the morphological features of the hematoma in the ww group was in accordance with the CT blend sign observed in humans. The CT attenuation values in the hypodensity area of the ww 4 h group or the ww 5 h group were decreased compared with the ww 1 h group to the ww 3 h group.

CONCLUSIONS

The CT blend sign observed in humans might be composed of two parts of blood with different ages. The hypodense area might be blood with older age and the hyperdense area might be new bleeding.

The Chemical Basis of Intracerebral Hemorrhage and Cell Toxicity With Contributions From Eryptosis and Ferroptosis

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.

Supratentorial intracerebral hemorrhage volume and other CT variables predict the neurological pupil index

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.

A Multi-Model Pipeline for Translational Intracerebral Haemorrhage Research

Apart from acute and chronic blood pressure lowering, we have no specific medications to prevent intracerebral haemorrhage (ICH) or improve outcomes once bleeding has occurred. One reason for this may be related to particular limitations associated with the current pre-clinical models of ICH, leading to a failure to translate into the clinic. It would seem that a breakdown in the 'drug development pipeline' currently exists for translational ICH research which needs to be urgently addressed. Here, we review the most commonly used pre-clinical models of ICH and discuss their advantages and disadvantages in the context of translational studies. We propose that to increase our chances of successfully identifying new therapeutics for ICH, a bi-directional, 2- or 3-pronged approach using more than one model species/system could be useful for confirming key pre-clinical observations. Furthermore, we highlight that post-mortem/ex-vivo ICH patient material is a precious and underused resource which could play an essential role in the verification of experimental results prior to consideration for further clinical investigation. Embracing multidisciplinary collaboration between pre-clinical and clinical ICH research groups will be essential to ensure the success of this type of approach in the future.

Amelioration of cognitive impairment following growth hormone replacement therapy: A case report and review of literature

BACKGROUND

Stroke is one of the leading causes of death and disability worldwide. In patients suffering from strokes and other acute brain injuries, the prevalence of pituitary dysfunction is high, and growth hormone deficiency is commonly found. Previous studies have demonstrated that administration of recombinant human growth hormone provides adult growth hormone deficiency (AGHD) patients with beneficial effects such as improving body compositions and quality of life. Nevertheless, other physiological benefits of growth hormone substitution are still controversial and inconclusive.

CASE SUMMARY

A female with a history of hypertension suffered intracranial hemorrhage, intraventricular hemorrhage, and hydrocephalus at 56 years of age. Her mobility, fluency of speech, and mentality were impaired ever since the event occurred. After five years, the 61-year-old patient was further diagnosed with AGHD and received six-month growth hormone replacement therapy (GHRT). After six months of GHRT, the patient’s body composition was improved. A substantial improvement in Mini-Mental State Examination score was also observed, accompanying with ameliorations in mobility, fluency of speech, and mentality.

CONCLUSION

In addition to improvements in body composition, GHRT for AGHD may provide further beneficial effects in patients with cognitive or motor impairments due to intracerebral hemorrhage.

Brain injury and repair after intracerebral hemorrhage: The role of microglia and brain-infiltrating macrophages

Intracerebral hemorrhage (ICH) is a major public health problem characterized by cerebral bleeding. Despite recent advances in preclinical studies, there is no effective treatment for ICH making it the deadliest subtype of stroke. The lack of effective treatment options partly attributes to the complexity as well as poorly defined pathophysiology of ICH. The emerging evidence indicates the potential of targeting secondary brain damage and hematoma resolution for improving neurological outcomes after ICH. Herein, we provide an overview of our understanding of the functional roles of activated microglia and brain-infiltrating monocyte-derived macrophages in brain injury and repair after ICH. The clinical and preclinical aspects that we discuss in this manuscript are related to ICH that occurs in adults, but not in infants. Also, we attempt to identify the knowledge gap in the field for future functional studies given the potential of targeting microglia and brain-infiltrating macrophages for therapeutic intervention after ICH.

Quality evaluation of case series describing four-factor prothrombin complex concentrate in oral factor Xa inhibitor-associated bleeding: a systematic review

INTRODUCTION

As oral factor Xa (oFXa) inhibitor use has increased, so has publication of case series describing related bleeding managed with four-factor prothrombin complex concentrate (4F-PCC).

OBJECTIVE

This review aimed to identify case series describing 4F-PCC management of oFXa inhibitor-related bleeding and appraise their methodological and reporting quality.

DESIGN

We searched Medline and EMBASE (1 January 2011 to 31 May 2020) to identify series of ≥10 patients with oFXa inhibitor-related major bleeding given off-label 4F-PCC. Case series were evaluated using a validated tool adapted for this topic. The tool addressed patient selection, bleed/outcome ascertainment, causal/temporal association and reporting.

RESULTS

We identified 14 case series. None had ≥100 patients (range=13-84), three were prospective, two detailed appropriate inclusion criteria and four noted consecutive inclusion. While 12 series provided clear/appropriate methods for diagnosis of intracranial haemorrhage (ICH); none did so for extracranial bleeds and it was not clear whether bleeding was adjudicated in any. Haemostatic effectiveness, thrombosis and mortality were together evaluated in 12 series, but only seven used validated methods to evaluate/diagnosis haemostasis in ICH, six in gastrointestinal bleeds, five in other bleeds and three in thrombosis. Independent adjudication of haemostasis (n=1) and thrombosis (n=2) was infrequent. Thirty-day follow-up for mortality and thrombosis was noted in five and seven series. Anticoagulation measurement/levels in at least some patients were conveyed in three series. Few series provided data on anticoagulant agent/dose (n=4), time from anticoagulant (n=4), time-to-reversal (n=7), baseline (n=7) or change (n=0) in neurologic function.

CONCLUSIONS

Although many case series describe off-label use of 4F-PCC for oFXa inhibitor-related bleeding, methodological flaws and/or poor reporting necessitates caution in interpretation.

Neuroprotective Methodologies of Co-Enzyme Q10 Mediated Brain Hemorrhagic Treatment: Clinical and Pre-Clinical Findings

Cerebral brain hemorrhage is associated with the highest mortality and morbidity despite only constituting approximately 10-15% of all strokes classified into intracerebral and intraventricular hemorrhage where most of the patients suffer from impairment in memory, weakness or paralysis in arms or legs, headache, fatigue, gait abnormality and cognitive dysfunctions. Understanding molecular pathology and finding the worsening cause of hemorrhage will lead to explore the therapeutic interventions that could prevent and cure the disease. Mitochondrial ETC-complexes dysfunction has been found to increase neuroinflammatory cytokines, oxidative free radicals, excitotoxicity, neurotransmitter and energy imbalance that are the key neuropathological hallmarks of cerebral hemorrhage. Coenzyme Q10 (CoQ10), as a part of the mitochondrial respiratory chain can effectively restore these neuronal dysfunctions by preventing the opening of mitochondrial membrane transition pore, thereby counteracting cell death events as well as exerts an anti-inflammatory effect by influencing the expression of NF-kB1 dependent genes thus preventing the neuroinflammation and energy restoration. Due to behavior and biochemical heterogeneity in post cerebral brain hemorrhagic pattern different preclinical autologous blood injection models are required to precisely investigate the forthcoming therapeutic strategies. Despite emerging pre-clinical research and resultant large clinical trials for promising symptomatic treatments, there are very less pharmacological interventions demonstrated to improve post operative condition of patients where intensive care is required. Therefore, in current review, we explore the disease pattern, clinical and pre-clinical interventions under investigation and neuroprotective methodologies of CoQ10 precursors to ameliorate post brain hemorrhagic conditions.

Dexamethasone in Patients with Spontaneous Intracerebral Hemorrhage: An Updated Meta-Analysis

<b><i>Background:</i></b> Spontaneous intracerebral hemorrhage (ICH) is a frequent cerebrovascular disorder and still associated with high mortality and poor clinical outcomes. The purpose of this review was to update a 15-year-old former meta-analysis on randomized clinical trials (RCTs) addressing the question of whether ICH patients treated with dexamethasone have better outcomes than controls. <b><i>Methods:</i></b> The electronic databases PubMed, SCOPUS, and Cochrane as well as web platforms on current clinical trials were searched for the years 1970–2020 without constriction on language. Data were extracted and outcomes were pooled for conventional and cumulative meta-analysis using a commercial software program (www.Meta-Analysis.com). <b><i>Results:</i></b> Finally, 7 RCTs were identified and analyzed including 248 participants in the dexamethasone groups and 242 in the control groups. Five studies showed a high risk of bias. The overall relative risk (RR) for death was 1.32 (95% confidence interval [CI] 0.99–1.76; <i>p</i> = 0.06) and did not differ significantly between the 2 groups. After exclusion of studies with high risk of bias, the RR for death was 1.37 (95% CI 0.54–3.42; <i>p</i> = 0.51). The RR for poor outcome did not differ significantly between the 2 groups analyzed for all included studies (RR = 0.69; 95% CI 0.47–1; <i>p</i> = 0.05) and after exclusion of studies with high risk of bias (RR = 0.7; 95% CI 0.45–1.08; <i>p</i> = 0.11). The RR for complications did not differ significantly including all studies (RR = 1.29; 95% CI 0.77–2.17; <i>p</i> = 0.34) and after exclusion of studies with high risk of bias (RR = 1.27; 95% CI 0.18–8.89; <i>p</i> = 0.81). The cumulative statistics delivered no other results; however, it pointed out fewer complications over time in the dexamethasone group. <b><i>Conclusion:</i></b> Clear evidence of a beneficial or negative effect of dexamethasone is still lacking. Modern RCTs or observational studies with propensity design are necessary to evaluate the efficacy and safety of treatment with dexamethasone in patients with ICH.

Intracerebral haemorrhage and COVID-19: Clinical characteristics from a case series

•We demonstrate five consecutive cases of predominantly lobar COVID-19-associated intracerebral haemorrhage (ICH). •Patients were typically relatively young with a severe, prolonged inflammatory prodrome. •COVID-19-induced endotheliitis/endotheliopathy may underlie associated cerebrovascular events. •For the clinician, anticoagulation decisions must balance risk of thrombosis with risk of haemorrhage.

Circulating TIMP-1 is associated with hematoma volume in patients with spontaneous intracranial hemorrhage

Matrix metalloproteinases (MMPs) are proteolytic zinc-endopeptidases regulated by tissue Inhibitors of matrix metalloproteinases (TIMPs). We evaluated the potential of MMPs and TIMPs as clinical tools for Intracranial Haemorrhage (ICH). Spontaneous non-traumatic ICH patients were recruited from two hospitals: Complejo Hospitalario de Navarra (CHN = 29) and Vall d´Hebron (VdH = 76). Plasmatic levels of MMP-1, -2, -7, -9, -10 and TIMP-1 and their relationship with clinical, radiological and functional variables were evaluated. We further studied the effect of TIMP-1 (0.05-0.2 mg/Kg) in an experimental tail-bleeding model. In CHN, TIMP-1 was associated with admission-hematoma volume and MMP-7 was elevated in patients with deep when compared to lobar hematoma. In VdH, admission-hematoma volume was associated with TIMP-1 and MMP-7. When data from both hospitals were combined, we observed that an increase in 1 ng/ml in TIMP-1 was associated with an increase of 0.14 ml in haemorrhage (combined β = 0.14, 95% CI = 0.08-0.21). Likewise, mice receiving TIMP-1 (0.2 mg/Kg) showed a shorter bleeding time (p < 0.01). Therefore, the association of TIMP-1 with hematoma volume in two independent ICH cohorts suggests its potential as ICH biomarker. Moreover, increased TIMP-1 might not be sufficient to counterbalance MMPs upregulation indicating that TIMP-1 administration might be a beneficial strategy for ICH.

A systematic review and meta-analysis of traumatic intracranial hemorrhage in patients taking prehospital antiplatelet therapy: Is there a role for platelet transfusions?

BACKGROUND

Platelet transfusion has been utilized to reverse platelet dysfunction in patients on preinjury antiplatelets who have sustained a traumatic intracranial hemorrhage (tICH); however, there is little evidence to substantiate this practice. The objective of this study was to perform a systematic review on the impact of platelet transfusion on survival, hemorrhage progression and need for neurosurgical intervention in patients with tICH on prehospital antiplatelet medication.

METHODS

Controlled, observational and randomized, prospective and retrospective studies describing tICH, preinjury antiplatelet use, and platelet transfusion reported in PubMed, Embase, Cochrane Reviews, Cochrane Trials and Cochrane DARE databases between January 1987 and March 2019 were included. Investigations of concomitant anticoagulant use were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. We calculated pooled estimates of relative effect of platelet transfusion on the risk of death, hemorrhage progression and need for neurosurgical intervention using the methods of Dersimonian-Laird random-effects meta-analysis. Sensitivity analysis established whether study size contributed to heterogeneity. Subgroup analyses determined whether antiplatelet type, additional blood products/reversal agents, or platelet function assays impacted effect size using meta-regression.

RESULTS

Twelve of 18,609 screened references were applicable to our questions and were qualitatively and quantitatively analyzed. We found no association between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.76-2.18; p = 0.346; I = 32.5%). There was no significant reduction in hemorrhage progression (OR, 0.88; 95% CI, 0.34-2.28; p = 0.788; I = 78.1%). There was no significant reduction in the need for neurosurgical intervention (OR, 1.00; 95% CI, 0.53-1.90, p = 0.996; I = 59.1%; p = 0.032).

CONCLUSION

Current evidence does not support the use of platelet transfusion in patients with tICH on prehospital antiplatelets, highlighting the need for a prospective evaluation of this practice.

LEVEL OF EVIDENCE

Systematic Reviews and Meta-Analyses, Level III.

Prediction of mortality after evacuation of supratentorial intracerebral hemorrhage using NSQIP data

Spontaneous intracerebral hemorrhage (sICH) is associated with high rates of morbidity and mortality. Neurosurgical clot evacuation is controversial but often a life saving maneuver in the setting of severe mass effect and cerebral herniation. Outcomes from large multicenter databases are sparsely reported. Patients who underwent craniotomy for evacuation of a supratentorial sICH between 2006 and 2017 were systematically extracted from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Our primary outcomes of interest were 30-day mortality, non-routine discharge disposition, and extended length of stay ([eLOS], defined as the top quartile for the cohort). Individual binary logistic regression models were constructed to query the associations between pre- and perioperative variables and each outcome. A total of 751 patients met the inclusion criteria. The 30-day mortality rate was 23.3% and increased from 2011 to 2017 (pooled OR 2.060 [95% CI 1.437 - 2.953]). Older age, morbid obesity, preoperative mechanical ventilation, preoperative systemic inflammatory response syndrome (SIRS) or septic shock, and thrombocytopenia were associated with mortality. Older age, race, and preoperative mechanical ventilation were associated with non-routine discharge. Patients who were mechanically ventilated or were insulin-dependent diabetics had greater odds of experiencing eLOS. A formula for estimating 30-day mortality was developed and found to have a strong linear association with actual mortality rates (R² = 0.777, p = 0.002). Preoperative mechanical ventilation is a consistent predictor of poor outcomes following surgery for supratentorial sICH. Mortality is also influenced by older age, body habitus, SIRS, septic shock, and thrombocytopenia.

Predictors of localization, outcome, and etiology of spontaneous intracerebral hemorrhages: focus on cerebral amyloid angiopathy

Despite its clinical relevance, cerebral amyloid angiopathy (CAA) is underdiagnosed worldwide. This retrospective study aimed to assess the incidence, etiology, predictors, and outcome of intracerebral hemorrhages (ICHs) in this region, with special focus on possible underlying CAA. Database screening of acute cares with intracranial hemorrhage diagnosis within 01/07/2014–01/07/2018 were conducted analyzing medical records and imaging. Spontaneous ICHs were classified as deep (basal ganglionic/thalamic/brainstem) and lobar/cerebellar (i.e., CAA-compatible) ICHs. Probable/definite CAA was established using the modified Boston criteria in a subgroup with ‘complete’ radiological/neuropathological work-up. The ability of several factors to discriminate between deep and lobar/cerebellar ICHs, between probable/definite CAA and non-probable CAA cases, and to predict 1-month case fatality was assessed. Of the 213 ICHs identified, 121 were in deep and 92 in lobar/cerebellar localization. Sub-analysis of 47 lobar/cerebellar ICHs with ‘complete’ work-up identified 16 probable/definite CAA patients, yielding an estimated 14.7% prevalence of CAA-related ICHs. Chronic hypertension was the most prevalent risk factor for all types of ICHs (including CAA-related), with hypertensive excess and younger age being independent predictors of deep whereas antiplatelet use of lobar/cerebellar localization. The 1-month case fatality was 33.8%, driven predominantly by age and INR > 1.4. Probable/definite CAA diagnosis was independently predicted by age, prior intracranial hemorrhage, and antiplatelet use. First in this region and among the few in the literature, this study reports a remarkable prevalence of CAA-related ICHs, emphasizing the need for an increased awareness of CAA and its therapeutic implications, especially regarding antiplatelets among the elderly.

Acute Treatment With Gleevec Does Not Promote Early Vascular Recovery Following Intracerebral Hemorrhage in Adult Male Rats

Intracerebral hemorrhage (ICH) remains one of the most debilitating types of stroke and is characterized by a sudden bleeding from a ruptured blood vessel. ICH often results in high mortality and in survivors, permanent disability. Most studies have focused on neuroprotective strategies designed to minimize secondary consequences and prevent further pathology. Lacking is an understanding of how ICH acutely affects cerebrovascular components and their response to therapeutic interventions. We hypothesized that ICH alters cortical vessel complexity in the parenchyma adjacent to site of the initial vascular disruption and that vascular abnormalities would be mitigated by administration of the PDGFR inhibitor, Imatinib mesylate (Gleevec). Briefly, ICH was induced in male adult rats by injection of collagenase into basal ganglia, followed by Gleevec administration (60 mg/kg) 1 h after injury. Rats were then perfused using vessel painting methodology (Salehi et al., 2018b) to stain whole brain vascular networks at 1 day post-ICH. Axial and coronal wide field fluorescence microscopy was performed. Analyses for vascular features were undertaken and fractal analysis for vascular complexity. Data were collected from four groups of rats: Sham + Vehicle; Sham + Gleevec; ICH + Vehicle; ICH + Gleevec. Microscopy revealed that cortical vessels in both ipsi- and contralateral hemispheres exhibited significantly reduced density and branching by 22 and 34%, respectively. Fractal measures confirmed reduced complexity as well. Gleevec treatment further reduced vascular parameters, including reductions in vessel density in tissues adjacent to the ICH. The reductions in brain wide vascular networks after Gleevec in the current study after ICH is contrasted by previous reports of improved behavioral outcomes and decreased lCH lesion volumes Reductions in the vascular network after Gleevec may be involved in long-term repair mechanisms by pruning injured vessels to ultimately promote new vessel growth.