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Yakhkind A, Yu W, Li Q, Goldstein JN, Mayer SA. Code-ICH: A New Paradigm for Emergency Intervention. Curr Neurol Neurosci Rep 2024; 24:365-371. [PMID: 39088163 DOI: 10.1007/s11910-024-01364-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE OF REVIEW Intracerebral hemorrhage (ICH) is the most devastating type of stroke, causing widespread disability and mortality. Unfortunately, the acute care of ICH has lagged behind that of ischemic stroke. There is an increasing body of evidence supporting the importance of early interventions including aggressive control of blood pressure and reversal of anticoagulation in the initial minutes to hours of presentation. This review highlights scientific evidence behind a new paradigm to care for these patients called Code-ICH. RECENT FINDINGS While numerous trials aimed at decreasing hematoma expansion through single interventions had failed to show statistically significant effects on primary outcomes, time-sensitive, multifaceted, bundled care approaches have recently shown substantial promise in improving functional outcomes in patients with ICH. The concept of Code-ICH can serve as a structural platform for the practice of acute care neurology to continuously measure its performance, reflect on best practices, advance care, and address disparities.
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Affiliation(s)
- Aleksandra Yakhkind
- Department of Neurology and Neurosurgery, Tufts University School of Medicine, Boston, MA, USA.
| | - Wenzheng Yu
- Department of Neurology, Tufts University School of Medicine, Hefei, China
| | - Qi Li
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY, USA
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Piqueras-Sanchez C, Esteve-Pastor MA, Moreno-Fernandez J, Soler-Espejo E, Rivera-Caravaca JM, Roldán V, Marín F. Advances in the medical treatment and diagnosis of intracranial hemorrhage associated with oral anticoagulation. Expert Rev Neurother 2024; 24:913-928. [PMID: 39039686 DOI: 10.1080/14737175.2024.2379413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 07/09/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION With the increasing prevalence of atrial fibrillation (AF), it entails expanding oral anticoagulants (OACs) use, carrying a higher risk of associated hemorrhagic events, including intracranial hemorrhage (ICH). Despite advances in OACs development with a better safety profile and reversal agent for these anticoagulants, there is still no consensus on the optimal management of patients with OACs-associated ICH. AREAS COVERED In this review, the authors have carried out an exhaustive search on the advances in recent years. The authors provide an update on the management of ICH in anticoagulated patients, as well as an update on the latest evidence on anticoagulation resumption, recent therapeutic strategies, and investigational drugs that could play a role in the future. EXPERT OPINION Following an ICH event in an anticoagulated patient, a comprehensive clinical evaluation is imperative. Anticoagulation should be promptly withdrawn and reversed. Once the patient is stabilized, a reintroduction of anticoagulation should be considered, typically within a timeframe of 4-8 weeks, if feasible. If re-anticoagulation is not possible, alternative options such as Left Atrial Appendage Occlusion are available.
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Affiliation(s)
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- CIBERCV, Murcia, Spain
| | - Jorge Moreno-Fernandez
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Eva Soler-Espejo
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- Department of Hematology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | | | - Vanessa Roldán
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- Department of Hematology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- CIBERCV, Murcia, Spain
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Alhadidi QM, Nash KM, Bahader GA, Zender E, McInerney MF, Shah ZA. Hyperglycemia in a NOD Mice Model of Type-I Diabetes Aggravates Collagenase-Induced Intracerebral Hemorrhagic Injury. Biomedicines 2024; 12:1867. [PMID: 39200331 PMCID: PMC11352023 DOI: 10.3390/biomedicines12081867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 07/30/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a severe type of stroke with high mortality. Persistent hyperglycemia following ICH is linked to deteriorated neurological functions and death. However, the exacerbating effect of hyperglycemia on ICH injury at the molecular level is still unclear. Therefore, this study explores the impact of diabetes on ICH injury using a non-obese diabetic (NOD) mouse model of type I diabetes mellitus. METHODS NOD and non-diabetic (non-obese resistant) mice subjected to ICH by intrastriatal injection of collagenase were sacrificed three days following the ICH. Brains were collected for hematoma volume measurement and immunohistochemistry. Neurobehavioral assays were conducted 24 h before ICH and then repeated at 24, 48 and 72 h following ICH. RESULTS NOD mice showed increased hematoma volume and impairment in neurological function, as revealed by rotarod and grip strength analyses. Immunohistochemical staining showed reduced glial cell activation, as indicated by decreased GFAP and Iba1 staining. Furthermore, the expression of oxidative/nitrosative stress markers represented by 3-nitrotyrosine and inducible nitric oxide synthase was reduced in the diabetic group. CONCLUSIONS Overall, our findings support the notion that hyperglycemia exacerbates ICH injury and worsens neurological function and that the mechanism of injury varies depending on the type of diabetes model used.
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Affiliation(s)
- Qasim M. Alhadidi
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, OH 43606, USA
- Department of Pharmacy, Al-Yarmok University College, Diyala 21163, Iraq
| | - Kevin M. Nash
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, OH 43606, USA
| | - Ghaith A. Bahader
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, OH 43606, USA
| | - Emily Zender
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, OH 43606, USA
| | - Marcia F. McInerney
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, OH 43606, USA
| | - Zahoor A. Shah
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, OH 43606, USA
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, OH 43606, USA
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Robinson DJ, Ding L, Howard G, Stanton RJ, Khoury J, Sucharew H, Haverbusch M, Nobel L, Khatri P, Adeoye O, Broderick JP, Ferioli S, Mackey J, Woo D, Rios La Rosa FDL, Flaherty M, Slavin S, Star M, Martini SR, Demel S, Walsh KB, Coleman E, Jasne AS, Mistry EA, Kleindorfer D, Kissela B. Temporal Trends and Racial Disparities in Long-Term Survival After Stroke. Neurology 2024; 103:e209653. [PMID: 39008784 PMCID: PMC11249510 DOI: 10.1212/wnl.0000000000209653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/20/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Few studies have examined trends and disparities in long-term outcome after stroke in a representative US population. We used a population-based stroke study in the Greater Cincinnati Northern Kentucky region to examine trends and racial disparities in poststroke 5-year mortality. METHODS All patients with acute ischemic strokes (AISs) and intracerebral hemorrhages (ICHs) among residents ≥20 years old were ascertained using ICD codes and physician-adjudicated using a consistent case definition during 5 periods: July 1993-June 1994 and calendar years 1999, 2005, 2010, and 2015. Race was obtained from the medical record; only those identified as White or Black were included. Premorbid functional status was assessed using the modified Rankin Scale, with a score of 0-1 being considered "good." Mortality was assessed with the National Death Index. Trends and racial disparities for each subtype were analyzed with logistic regression. RESULTS We identified 8,428 AIS cases (19.3% Black, 56.3% female, median age 72) and 1,501 ICH cases (23.5% Black, 54.8% female, median age 72). Among patients with AIS, 5-year mortality improved after adjustment for age, race, and sex (53% in 1993/94 to 48.3% in 2015, overall effect of study year p = 0.009). The absolute decline in 5-year mortality in patients with AIS was larger than what would be expected in the general population (5.1% vs 2.8%). Black individuals were at a higher risk of death after AIS (odds ratio [OR] 1.23, 95% CI 1.08-1.39) even after adjustment for age and sex, and this effect was consistent across study years. When premorbid functional status and comorbidities were included in the model, the primary effect of Black race was attenuated but race interacted with sex and premorbid functional status. Among male patients with a good baseline functional status, Black race remained associated with 5-year mortality (OR 1.4, 95% CI 1.1-1.7, p = 0.002). There were no changes in 5-year mortality after ICH over time (64.4% in 1993/94 to 69.2% in 2015, overall effect of study year p = 0.32). DISCUSSION Long-term survival improved after AIS but not after ICH. Black individuals, particularly Black male patients with good premorbid function, have a higher mortality after AIS, and this disparity did not change over time.
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Affiliation(s)
- David J Robinson
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Lili Ding
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - George Howard
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Robert J Stanton
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Jane Khoury
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Heidi Sucharew
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Mary Haverbusch
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Lisa Nobel
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Pooja Khatri
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Opeolu Adeoye
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Joseph P Broderick
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Simona Ferioli
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Jason Mackey
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Daniel Woo
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Felipa De Los Rios La Rosa
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Matthew Flaherty
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Sabreena Slavin
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Michael Star
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Sharyl R Martini
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Stacie Demel
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Kyle B Walsh
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Elisheva Coleman
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Adam S Jasne
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Eva A Mistry
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Dawn Kleindorfer
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
| | - Brett Kissela
- From the Department of Neurology and Rehabilitation Medicine (D.R., R.J.S., M.H., L.N., P.K., J.P.B., S.F., D.W., M.L.F., S.D., E.A.M., B.K.), University of Cincinnati, OH; Department of Biostatistics (L.D., J.C.K.), Cincinnati Children's Medical Center, OH; Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health, AL; Department of Emergency Medicine (H.S., K.B.W.), University of Cincinnati, OH; Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida, Miami; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; VA National TeleStroke Program (S.R.M.), Veterans Health Administration, Houston, TX; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.S.J.), Yale University, New Haven, CT; and Department of Neurology (D.K.), University of Michigan, Ann Arbor
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5
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Loughlin E, Gabr A, Galvin R, McCormack J, Brych O, O'Donnell MJ, Collins R, Thornton J, Harbison J, O'Connor M. The impact of hospital presentation time on stroke outcomes: A nationally representative Irish cohort study. PLoS One 2024; 19:e0304536. [PMID: 38995918 PMCID: PMC11244793 DOI: 10.1371/journal.pone.0304536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 05/14/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVES There is conflicting evidence regarding the outcomes of acute stroke patients who present to hospital within normal working hours ('in-hours') compared with the 'out-of-hours' period. This study aimed to assess the effect of time of stroke presentation on outcomes within the Irish context, to inform national stroke service delivery. MATERIALS AND METHODS A secondary analysis of data from the Irish National Audit of Stroke (INAS) from Jan 2016 to Dec 2019 was carried out. Patient and process outcomes were assessed for patients presenting 'in-hours' (8:00-17:00 Monday-Friday) compared with 'out-of-hours' (all other times). RESULTS Data on arrival time were available for 13,996 patients (male 56.2%; mean age 72.5 years), of which 55.7% presented 'out-of-hours'. In hospital mortality was significantly lower among those admitted 'in-hours' (11.3%, n = 534) compared with 'out-of-hours' (12.8%, n = 749); (adjusted Odds Ratio (OR) 0.82; 95% Confidence Interval CI [95% CI] 0.72-0.89). Poor functional outcome at discharge (Modified Rankin Scale ≥ 3) was also significantly lower in those presenting 'in-hours' (adjusted OR 0.79; 95% CI 0.68-0.91). In patients receiving thrombolysis, mean door to needle time was shorter for 'in-hours' presentation at 55.8 mins (n = 562; SD 35.43 mins), compared with 'out-of-hours' presentation at 80.5 mins (n = 736; SD 38.55 mins, p < .001). CONCLUSION More than half of stroke patients in Ireland present 'out-of-hours' and these presentations are associated with a higher mortality and a lower odds of functional independence at discharge. It is imperative that stroke pathways consider the 24 hour period to ensure the delivery of effective stroke care, and modification of 'out-of-hours' stroke care is required to improve overall outcomes.
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Affiliation(s)
- Elaine Loughlin
- Department of Ageing and Therapeutics, and Ageing Research Centre, University of Limerick Hospitals Group, Limerick, Ireland
| | - Ahmed Gabr
- Department of Ageing and Therapeutics, and Ageing Research Centre, University of Limerick Hospitals Group, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Ageing Research Centre, University of Limerick, Limerick, Ireland
| | | | - Olga Brych
- National Office of Clinical Audit, Ireland
| | | | - Rónán Collins
- Clinical Lead, National Stroke Programme, Royal College of Physicians of Ireland and Health Service Executive, Ireland
| | - John Thornton
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Joseph Harbison
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, and Ageing Research Centre, University of Limerick Hospitals Group, Limerick, Ireland
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6
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Loggini A, Hornik J, Hornik A, Braksick SA, Klaas JP. Safety and Outcome of Admission to Step-Down Level of Care in Patients with Low-Risk Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis. Neurocrit Care 2024:10.1007/s12028-024-02044-9. [PMID: 38955932 DOI: 10.1007/s12028-024-02044-9] [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: 03/14/2024] [Accepted: 06/05/2024] [Indexed: 07/04/2024]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke, and it is associated with high morbidity and mortality. Patients with a spontaneous ICH are routinely admitted to an intensive care unit (ICU). However, an ICU is a valuable and limited resource, and not all patients may require this level of care. The authors conducted a systematic review and meta-analysis evaluating the safety and outcome of admission to a step-down level of care or stroke unit (SU) compared to intensive care in adult patients with low-risk spontaneous ICH. PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials and observational cohort studies. The Mantel-Haenszel method or inverse variance, as applicable, was applied to calculate an overall effect estimate for each outcome by combining the specific risk ratio (RR) or standardized mean difference. Risk of bias was analyzed using the Newcastle-Ottawa Scale. The protocol was registered in PROSPERO (CRD42023481915). The primary outcome examined was in-hospital mortality. Secondary outcomes were unfavorable short-term outcome, length of hospital stay, and (re)admission to the ICU. Five retrospective cohort studies involving 1347 patients were included in the qualitative analysis. Two of the studies had severity-matched groups. The definition of low-risk ICH was heterogeneous among the studies. Admission to an SU was associated with a similar rate of mortality compared to admission to an ICU (1.4% vs. 0.6%; RR 1.66; 95% confidence interval [CI] 0.24-11.41; P = 0.61), a similar rate of unfavorable short-term outcome (14.6% vs. 19.2%; RR 0.77; 95% CI 0.43-1.36; P = 0.36), and a significantly shorter mean length of stay (standardized mean difference - 0.87 days; 95% CI - 1.15 to - 0.60; P < 0.01). Risk of bias was low to moderate for each outcome. The available literature suggests that a select subgroup of patients with ICH may be safely admitted to the SU without affecting short-term outcome, potentially saving in-hospital resources and reducing length of stay. Further studies are needed to identify specific and reliable characteristics of this subgroup of patients.
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Affiliation(s)
- Andrea Loggini
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA.
- Southern Illinois University School of Medicine, Carbondale, IL, USA.
| | - Jonatan Hornik
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
- Southern Illinois University School of Medicine, Carbondale, IL, USA
| | - Alejandro Hornik
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
- Southern Illinois University School of Medicine, Carbondale, IL, USA
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7
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Morán Gallego FJ, Sanchez Casado M, López de Toro Martin Consuegra I, Marina Martinez L, Alvarez Fernandez J, Sánchez Carretero MJ. Evaluation of the last 2 decades in the characteristics of presentation, management and prognosis of serious spontaneous intracerebral hemorrhage in a third level hospital. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:169-176. [PMID: 38295901 DOI: 10.1016/j.neucie.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/12/2023] [Indexed: 02/05/2024]
Abstract
OBJECTIVE To analyze the change in the characteristics of presentation, evolution and treatment in the ICU, as well as the functional evolution at 12 months of spontaneous intracranial hemorrhages (ICHs) treated in an ICU reference center. PATIENT AND METHODS Descriptive, retrospective study in a Neurocritical Reference Hospital. All admissions of patients with HICE during three periods are studied: 1999-2001 (I), 2015-2016 (II) and 2020-2021 (III). Evolution in the three periods of demographic variables, baseline characteristics of the patients, clinical variables and characteristics of bleeding, evolutionary data in the ICU are studied. At one year we assessed the GOS scale (Glasgow Outcome Score) according to whether they had a poor (GOS 1-3) or good (GOS 4-5) prognosis. RESULTS 300 admitted patients, distributed in periods: I: 28.7%, II: 36.3% and III: 35%. 56.7% were males aged 66 (55.5-74) years; ICH score 2 (1-3). The ICU stay was 5 (2-14) days with a mortality of 36.8%. GOS 1-3 a year in 67.3% and GOS 4-5 in 32.7%. Comparing the three periods, we observed a higher prevalence in women, and the presence of cardiovascular factors; no changes in etiology; in relation to the location, it increases cerebellar hemorrhage and in the brainstem. Although the severity was greater, the stay in the ICU, the use of invasive mechanical ventilation and tracheostomy were lower. Open surgery has decreased its use by 50%. Mortality continues to be high, stagnating in the ICU at 35% and entails a high degree of disability one year after assessment. CONCLUSIONS Severe ICH is a complex pathology that has changed some characteristics in the last two decades, with more severe patients, with more cardiovascular history and a greater predominance of brainstem and cerebellar hemorrhage. Despite the increase in severity, better parameters during the ICU stay, with open surgery used 50% less. Mortality remains stagnant at 35% with high disability per year.
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8
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Whaley PM, Franco-Martinez C, Lock AE, Ramaswamy D, Young EH, Allen SM, Barthol CA. Hemostatic Efficacy and Safety of 4-Factor Prothrombin Complex Concentrate in Doac-Associated Intracranial Hemorrhage. J Pharm Pract 2024; 37:557-562. [PMID: 36564900 DOI: 10.1177/08971900221148034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Factor Xa (FXa) inhibitor use has increased over the last decade and though associated rates of major bleeding are lower compared to warfarin, outcomes from intracranial hemorrhage (ICH) are still significant. Targeted FXa inhibitor reversal agent became available in 2018, however use of 4-factor prothrombin complex concentrate (4F-PCC) for FXa inhibitor-associated ICH continues at many institutions. Objective: Evaluate the safety and hemostatic efficacy of 4F-PCC for FXa inhibitor-associated ICH. Methods: Single-center, retrospective study of patients who received 4F-PCC for FXa inhibitor-associated ICH. The primary efficacy endpoint was hemostasis and thrombosis was the main safety endpoint. Secondary endpoints included in-hospital mortality and discharge disposition. Results: 76 patients on apixaban or rivaroxaban were included. Good or excellent hemostasis was achieved in 80.3% of patients. Five patients experienced a thrombotic event. Favorable discharge disposition and lower in-hospital mortality was more likely in patients who achieved excellent hemostasis. Conclusion: 4F-PCC is safe and effective for FXa inhibitor associated ICH.
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Affiliation(s)
- Patrick M Whaley
- University Health, San Antonio, TX, USA
- UT Health San Antonio, San Antonio, TX, USA
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Crystal Franco-Martinez
- University Health, San Antonio, TX, USA
- UT Health San Antonio, San Antonio, TX, USA
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Ashley E Lock
- University Health, San Antonio, TX, USA
- UT Health San Antonio, San Antonio, TX, USA
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Davana Ramaswamy
- University Health, San Antonio, TX, USA
- UT Health San Antonio, San Antonio, TX, USA
| | - Eric H Young
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Stefan M Allen
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Colleen A Barthol
- University Health, San Antonio, TX, USA
- UT Health San Antonio, San Antonio, TX, USA
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
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9
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Wiśniewski K, Zaczkowski K, Podstawka M, Szmyd BM, Bobeff EJ, Stefańczyk L, Brandel MG, Jaskólski DJ, Fahlström A. Predictors of 30-Day Mortality for Surgically Treated Patients with Spontaneous Supratentorial Intracerebral Hemorrhage and Validation of the Surgical Swedish Intracerebral Hemorrhage Score: A Retrospective Single-Center Analysis of 136 Cases. World Neurosurg 2024; 186:e539-e551. [PMID: 38583570 DOI: 10.1016/j.wneu.2024.03.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 03/30/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE We aimed to identify independent risk factors of 30-day mortality in patients with surgically treated spontaneous supratentorial intracerebral hemorrhage (ICH), validate the Surgical Swedish ICH (SwICH) score within Polish healthcare system, and compare the SwICH score to the ICH score. METHODS We carried out a single-center retrospective analysis of the medical data juxtaposed with computed tomography scans of 136 ICH patients treated surgically between 2008 and 2022. Statistical analysis was performed using the same characteristics as in the SwICH score and the ICH score. Backward stepwise logistic regression with both 5-fold crossvalidation and 1000× bootstrap procedure was used to create new scoring system. Finally predictive potential of these scales were compared. RESULTS The most important predictors of 30-day mortality were: ICH volume (P < 0.01), Glasgow Coma Scale at admission (P < 0.01), anticoagulant status (P = 0.03), and age (P < 0.01). The SwICH score appears to have a better predictive potential than the ICH score, although this did not reach statistical significance [area under the curve {AUC}: 0.789 (95% confidence interval {CI}: 0.715-0.863) vs. AUC: 0.757 (95% CI: 0.677-0.837)]. Moreover, based on the analyzed characteristics, we developed our score (encompassing: age, ICH volume, anticoagulants status, Glasgow Coma Scale at admission), [AUC of 0.872 (95% CI: 0.815-0.929)]. This score was significantly better than previous ones. CONCLUSIONS Differences in health care systems seem to affect the accuracy of prognostic scales for patients with ICH, including possible differences in indications for surgery and postoperative care. Thus, it is important to validate assessment tools before they can be applied in a new setting and develop population-specific scores. This may improve the effectiveness of risk stratification in patients with ICH.
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Affiliation(s)
- Karol Wiśniewski
- Department of Neurosurgery and Neurooncology, Medical University of Łódź, Barlicki University Hospital, Łódź, Poland.
| | - Karol Zaczkowski
- Department of Neurosurgery and Neurooncology, Medical University of Łódź, Barlicki University Hospital, Łódź, Poland
| | - Małgorzata Podstawka
- Department of Neurosurgery and Neurooncology, Medical University of Łódź, Barlicki University Hospital, Łódź, Poland
| | - Bartosz M Szmyd
- Department of Neurosurgery and Neurooncology, Medical University of Łódź, Barlicki University Hospital, Łódź, Poland
| | - Ernest J Bobeff
- Department of Neurosurgery and Neurooncology, Medical University of Łódź, Barlicki University Hospital, Łódź, Poland; Department of Sleep Medicine and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
| | - Ludomir Stefańczyk
- Department of Radiology-Diagnostic Imaging, Medical University of Łódź, Barlicki University Hospital, Łódź, Poland
| | - Michael G Brandel
- Department of Neurosurgery, University of California, San Diego, USA
| | - Dariusz J Jaskólski
- Department of Neurosurgery and Neurooncology, Medical University of Łódź, Barlicki University Hospital, Łódź, Poland
| | - Andreas Fahlström
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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10
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Horn M, Banerjee A, Kasickova L, Volny O, Choi HS, Letteri F, Ohara T, Tanaka K, Connolly S, Ladenvall P, Crowther M, Beyer‐Westendorf J, Shoamanesh A, Demchuk AM, Al Sultan AS. Total intracranial hemorrhage volume measurement summating all compartments best in traumatic and nontraumatic intracranial bleeding. Brain Behav 2024; 14:e3481. [PMID: 38680018 PMCID: PMC11056697 DOI: 10.1002/brb3.3481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 03/25/2024] [Accepted: 04/01/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND AND PURPOSE The ANNEXA-4 trial measured hemostatic efficacy of andexanet alfa in patients with major bleeding taking factor Xa inhibitors. A proportion of this was traumatic and nontraumatic intracranial bleeding. Different measurements were applied in the trial including volumetrics to assess for intracranial bleeding depending on the compartment involved. We aimed to determine the most reliable way to measure intracranial hemorrhage (ICrH) volume by comparing individual brain compartment and total ICrH volume. METHODS Thirty patients were randomly selected from the ANNEXA-4 database to assess measurement of ICrH volume by compartment and in total. Total and compartmental hemorrhage volumes were measured by five readers using Quantomo software. Each reader measured baseline hemorrhage volumes twice separated by 1 week. Twenty-eight different ANNEXA-4 subjects were also randomly selected to assess intra-rater reliability of total ICrH volume measurement change at baseline and 12-h follow up, performed by three readers twice to assess hemostatic efficacy categories used in ANNEXA-4. RESULTS Compartmental minimal detectable change percentages (MDC%) ranged between 9.72 and 224.13, with the greatest measurement error occurring in patients with a subdural hemorrhage. Total ICrH volume measurements had the lowest MDC%, which ranged between 6.57 and 33.52 depending on the reader. CONCLUSION Measurement of total ICrH volumes is more accurate than volume by compartment with less measurement error. Determination of hemostatic efficacy was consistent across readers, and within the same reader, as well as when compared to consensus read. Volumetric analysis of intracranial hemostatic efficacy is feasible and reliable when using total ICrH volumes.
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Affiliation(s)
- MacKenzie Horn
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryCanada
- Department of RadiologyUniversity of CalgaryCalgaryCanada
| | - Ankur Banerjee
- Department of Medicine, Division of NeurologyUniversity of AlbertaEdmontonCanada
| | | | - Ondrej Volny
- Department of NeurologyUniversity Hospital OstravaOstravaCzech Republic
- Czech National Centre for Evidence‐Based Healthcare and Knowledge Translation, Faculty of MedicineMasaryk UniversityBrnoCzech Republic
- International Clinical Research Center (ICRC)St. Anne's University HospitalBrnoCzech Republic
| | - Hyun Seok Choi
- Department of RadiologySeoul Medical CenterSeoulSouth Korea
| | | | - Tomoyuki Ohara
- Department of NeurologyKyoto Prefectural University of MedicineKyotoJapan
| | - Koji Tanaka
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryCanada
| | - Stuart Connolly
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
| | | | - Mark Crowther
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
| | | | | | - Andrew M. Demchuk
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryCanada
- Department of RadiologyUniversity of CalgaryCalgaryCanada
| | - Abdulaziz S. Al Sultan
- Department of Medicine, Division of NeurologyRoyal Columbian HospitalNew WestminsterCanada
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11
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Hwang DY, Kim KS, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Madzar D, Mahanes D, Mainali S, Sakowitz OW, Varelas PN, Weimar C, Westermaier T, Meixensberger J. Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage. Neurocrit Care 2024; 40:395-414. [PMID: 37923968 PMCID: PMC10959839 DOI: 10.1007/s12028-023-01854-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The objective of this document is to provide recommendations on the formal reliability of major clinical predictors often associated with intracerebral hemorrhage (ICH) neuroprognostication. METHODS A narrative systematic review was completed using the Grading of Recommendations Assessment, Development, and Evaluation methodology and the Population, Intervention, Comparator, Outcome, Timing, Setting questions. Predictors, which included both individual clinical variables and prediction models, were selected based on clinical relevance and attention in the literature. Following construction of the evidence profile and summary of findings, recommendations were based on Grading of Recommendations Assessment, Development, and Evaluation criteria. Good practice statements addressed essential principles of neuroprognostication that could not be framed in the Population, Intervention, Comparator, Outcome, Timing, Setting format. RESULTS Six candidate clinical variables and two clinical grading scales (the original ICH score and maximally treated ICH score) were selected for recommendation creation. A total of 347 articles out of 10,751 articles screened met our eligibility criteria. Consensus statements of good practice included deferring neuroprognostication-aside from the most clinically devastated patients-for at least the first 48-72 h of intensive care unit admission; understanding what outcomes would have been most valued by the patient; and counseling of patients and surrogates whose ultimate neurological recovery may occur over a variable period of time. Although many clinical variables and grading scales are associated with ICH poor outcome, no clinical variable alone or sole clinical grading scale was suggested by the panel as currently being reliable by itself for use in counseling patients with ICH and their surrogates, regarding functional outcome at 3 months and beyond or 30-day mortality. CONCLUSIONS These guidelines provide recommendations on the formal reliability of predictors of poor outcome in the context of counseling patients with ICH and surrogates and suggest broad principles of neuroprognostication. Clinicians formulating their judgments of prognosis for patients with ICH should avoid anchoring bias based solely on any one clinical variable or published clinical grading scale.
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599-7025, USA.
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Susanne Muehlschlegel
- Division of Neurosciences Critical Care, Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | - Christian Weimar
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper-Kliniken Dachau, University of Wuerzburg, Würzburg, Germany
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12
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Chaisawasthomrong C, Saetia K. Independent Factors Associated with 30-Day In-Hospital Mortality from Acute Spontaneous Intracerebral Hemorrhage. World Neurosurg 2024; 184:e774-e783. [PMID: 38354769 DOI: 10.1016/j.wneu.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVE This study aims to investigate independent factors associated with 30-day mortality in patients with acute spontaneous intracerebral hemorrhage (SICH) before treatment. METHODS A retrospective analysis was performed on medical records of patients hospitalized with acute SICH between 2019 and 2021. Data included personal history, hospital stay duration, symptom onset, chief complaint, underlying diseases, medication, and alcohol/smoking habits. Physical examination records comprised baseline blood pressure, Glasgow Coma Scale assessment, and pupil reaction evaluation. Diagnostic imaging, specifically computed tomography brain scans, was examined for hemorrhage details. Multivariable logistic analysis was utilized for data analysis. RESULTS Among 663 cases, 185 (27.9%) experienced mortality. Risk factors for mortality included chronic kidney disease, ischemic heart disease, loss of follow-up in hypertension clinic, and pontine hemorrhage. Conversely, motor response (m), reactive pupils, and basal cistern persistence significantly decreased the risk of mortality in multivariable analysis. Receiver operating characteristic analysis identified a m score of 5 as the cutoff for predicting survival. CONCLUSIONS Chronic kidney disease, ischemic heart disease, loss of hypertension follow-up, m, reactive pupils, pontine hemorrhage, and basal cistern persistence were independent variables associated with the 30-day mortality rate in SICH patients before treatment initiation. A m, pupil reaction, and basal cistern persistence serve as predictive tools for assessing mortality in SICH before treatment.
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Affiliation(s)
| | - Kriangsak Saetia
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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13
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Yang W, Feghali J, Sattari SA, Hung AL, Chen Y, Huang J. The Natural History of Hemorrhage in Brain Arteriovenous Malformations-Poisson Regression Analysis of 1066 Patients in a Single Institution. Neurosurgery 2024; 94:389-398. [PMID: 37681967 DOI: 10.1227/neu.0000000000002674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/17/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Natural history of hemorrhage in brain arteriovenous malformations (bAVM) is reported at 2%-4% per year. Published studies using survival analysis fail to account for recurrent hemorrhagic events. In this study, we present a large, single institution series to elucidate the natural history of bAVM using multivariable Poisson regression. METHODS This is a retrospective cohort study. All patients with bAVM seen at our institution from 1990 to 2021 were included. Hemorrhages after detection of bAVM during the untreated interval were recorded. Natural history of hemorrhage was calculated by dividing number of hemorrhages by untreated interval. The frequency of hemorrhages followed a Poisson distribution. Multivariable Poisson regression with an offset variable of untreated interval in patient-years was constructed. Model selection was through a stepwise Akaike information criterion method. Stratified hemorrhagic rate was presented using different combinations of significant factors. RESULTS A total of 1066 patients with nonhereditary hemorrhagic telangiectasia harboring a single bAVM were included. Ninety (8.44%) patients had 101 hemorrhages during an untreated interval of 3596.3344 patient-years, translating to an overall hemorrhagic rate of 2.81% per year. Significant factors increasing hemorrhage risk included ruptured presentation ( P < .001), increasing age ( P < .001), female sex ( P = .043), and deep location ( P = .040). Adult male patients with ruptured presentation and deep bAVMs sustained the highest annual risk at 10.81%, whereas no hemorrhages occurred in unruptured pediatric male patients or ruptured pediatric (younger than 18 years) male patients with superficial bAVMs. CONCLUSION Hemorrhage after bAVM detection occurs in 8.41% of all patients, and the rate averages 2.81% per year. However, this risk varies from 0.00% to 10.81% per year depending on various risk factor combinations. Efforts should be made to stratify bAVM hemorrhage rate by risk factors for more precise estimation of bleeding risk if left untreated.
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Affiliation(s)
- Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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14
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Krause M, Mandrekar J, Harmsen WS, Wijdicks E, Hocker S. Hospital to Hospital Transfers of Cerebral Hemorrhage: Characteristics of Early Withdrawal of Life-Sustaining Treatment. Neurocrit Care 2024; 40:272-281. [PMID: 36241772 DOI: 10.1007/s12028-022-01597-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 08/25/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Large intracerebral hemorrhages (ICHs) are associated with significant morbidity and mortality. Patient transfer to higher level centers is common, but care in these centers rarely demonstrably improves morbidity or reduces mortality. Patients may rapidly progress to brain death, but a large number die shortly after transferring because of withdrawal of life-sustaining treatment (WOLST). This outcome may result in poor resource use and unnecessary cost to patients, families, and institutions. We sought to determine clinical and radiographic predictors of early death or WOLST that may alter potential transfer. METHODS We performed a retrospective review of patients admitted from outside medical centers to the neurosciences intensive care unit at Saint Marys Mayo Clinic Hospital in Rochester, MN, from January 2014 to December 2019. Patients ≥ 18 years old with a spontaneous ICH were included. Exclusion criteria included trauma, subarachnoid hemorrhage, and subdural hematoma. We identified patients who died or underwent WOLST within 24 h of transfer. Descriptive characteristics of patients and ICH were collected. Data were analyzed with univariable, multivariable, and logistic regression. Predictive modeling was performed. An additional case-matched study was completed to evaluate for characteristics further. RESULTS A total of 317 consecutive patients were identified. Forty-two patients were found with early death or WOLST within 24 h of transfer. Do not resuscitate/do not intubate (DNR/DNI) code status (odds ratio [OR] 5.23, confidence interval [CI] 3.31-8.28), anticoagulation use (OR 2.11, CI 1.09-4.09), and lower level of consciousness at presentation based on Glasgow Coma Score (OR 1.41, CI 1.29-1.54) and Full Outline of Unresponsiveness (FOUR) score (OR 1.34, CI 1.26-1.46) were associated with WOLST. Associated characteristics on the computed tomography scan included midline shift (OR 4.64, CI 2.32-9.29), hydrocephalus (OR 9.30, CI 4.56-18.96), and intraventricular extension (OR 5.27, CI 2.60-10.68). Case matching restricted to midline shift demonstrated similarity between patients with aggressive care and WOLST. DNR/DNI code status, warfarin use, ICH score, and composite FOUR score were the best predictive characteristics (area under the curve 0.942). CONCLUSIONS Early death or WOLST after ICH within 24 h of presentation was most associated with DNR/DNI code status, warfarin use, ICH score, and lower level of consciousness at presentation. These characteristics may be used by clinicians to guide conversations prior to transfer to tertiary care centers.
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Affiliation(s)
- Monica Krause
- Neuroscience Intensive Care Unit, St. Marys Hospital, Mayo Clinic, 200 First St., Rochester, MN, USA.
| | - Jay Mandrekar
- Division of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Division of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Eelco Wijdicks
- Neuroscience Intensive Care Unit, St. Marys Hospital, Mayo Clinic, 200 First St., Rochester, MN, USA
| | - Sara Hocker
- Neuroscience Intensive Care Unit, St. Marys Hospital, Mayo Clinic, 200 First St., Rochester, MN, USA
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15
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Li Q, Yakhkind A, Alexandrov AW, Alexandrov AV, Anderson CS, Dowlatshahi D, Frontera JA, Hemphill JC, Ganti L, Kellner C, May C, Morotti A, Parry-Jones A, Sheth KN, Steiner T, Ziai W, Goldstein JN, Mayer SA. Code ICH: A Call to Action. Stroke 2024; 55:494-505. [PMID: 38099439 DOI: 10.1161/strokeaha.123.043033] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.
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Affiliation(s)
- Qi Li
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China (Q.L.)
| | | | | | | | - Craig S Anderson
- The George Institute for Global Heath, University of New South Wales, Sydney, Australia (C.S.A.)
| | - Dar Dowlatshahi
- University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | | | | | - Latha Ganti
- University of Central Florida College of Medicine, Orlando (L.G.)
| | | | - Casey May
- The Ohio State University College of Pharmacy, Columbus (C.M.)
| | | | | | - Kevin N Sheth
- Yale University School of Medicine, New Haven, CT (K.N.S.)
| | | | - Wendy Ziai
- John Hopkins University School of Medicine, Baltimore, MD (W.Z.)
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16
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Hou Y, Xie Y, Liu X, Chen Y, Zhou F, Yang B. Oxygen glucose deprivation-pretreated astrocyte-derived exosomes attenuates intracerebral hemorrhage (ICH)-induced BBB disruption through miR-27a-3p /ARHGAP25/Wnt/β-catenin axis. Fluids Barriers CNS 2024; 21:8. [PMID: 38243347 PMCID: PMC10799414 DOI: 10.1186/s12987-024-00510-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Blood brain barrier (BBB) breakdown is one of the key mechanisms of secondary brain injury following intracerebral hemorrhage (ICH). Astrocytes interact with endothelial and regulate BBB integrity via paracrine signaling factors. More and more studies reveal astrocyte-derived extracellular vesicles (ADEVs) as an important way of intercellular communication. However, the role of ADEV in BBB integrity after ICH remains unclear. METHODS ADEVs were obtained from astrocytes with or without oxygen and glucose deprivation (OGD) pre-stimulation and the role of ADEVs in ICH was investigated using ICH mice model and ICH cell model. The potential regulatory effect of ADEVs on endothelial barrier integrity was identified by TEER, western blot and immunofluorescence in vitro. In vivo, functional evaluation, Evans-blue leakage and tight junction proteins (TJPs) expression were analyzed. MiRNA sequencing revealed that microRNA-27a-3p (miR-27a-3p) was differentially expressed miRNA in the EVs from OGD-pretreated astrocytes compared with normal control. The regulatory mechanism of miR-27a-3p was assessed using Luciferase assay, RT-PCR, western blot and immunofluorescence. RESULTS OGD-activated astrocytes reduced hemin-induced endothelial hyper-permeability through secreting EVs. OGD-activated ADEVs alleviated BBB dysfunction after ICH in vivo and in vitro. MicroRNA microarray analysis indicated that miR-27a-3p is a major component that was highly expressed miRNA in OGD pretreated-ADEVs. OGD-ADEVs mitigated BBB injury through transferring miR-27a-3p into bEnd.3 cells and regulating ARHGAP25/Wnt/β-catenin pathway. CONCLUSION Taken together, these findings firstly revealed that miR-27a-3p, as one of the main components of OGD-pretreated ADEVs, attenuated BBB destruction and improved neurological deficits following ICH by regulating endothelial ARHGAP25/Wnt/β-catenin axis. OGD-ADEVs might be a novel strategy for the treatment of ICH. this study implicates that EVs from OGD pre-stimulated astrocytes.
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Affiliation(s)
- Ying Hou
- Department of Neurology, 2nd Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, Hunan, China
| | - Ye Xie
- Department of Neurology, 2nd Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, Hunan, China
| | - Xiaoxuan Liu
- Department of Neurology, 2nd Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, Hunan, China
| | - Yushan Chen
- Department of Neurology, 2nd Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, Hunan, China
| | - Fangfang Zhou
- Department of Neurology, 2nd Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, Hunan, China
| | - Binbin Yang
- Department of Neurology, 2nd Xiangya Hospital, Central South University, No. 139, Middle Renmin Road, Changsha, Hunan, China.
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17
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Yu N, Tian W, Liu C, Zhang P, Zhao Y, Nan C, Jin Q, Li X, Liu Y. miR-122-5p Promotes Peripheral and Central Nervous System Inflammation in a Mouse Model of Intracerebral Hemorrhage via Disruption of the MLLT1/PI3K/AKT Signaling. Neurochem Res 2023; 48:3665-3682. [PMID: 37594575 DOI: 10.1007/s11064-023-04014-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/08/2023] [Accepted: 08/08/2023] [Indexed: 08/19/2023]
Abstract
Intracerebral hemorrhage (ICH) is a recognized central nervous system inflammation complication. Several microRNAs (miRNAs or miRs) have been documented to be vital modulators in peripheral and central nervous system inflammation. Based on whole transcriptome sequencing and bioinformatics analysis, this study aims to reveal the possible molecular mechanisms by which miR-122-5p affects the inflammatory response in the peripheral and central nervous system in a mouse model of ICH. Differentially expressed ICH-related miRNAs were screened. Adeno-associated viral vectors were used to knock down miR-122-5p in mice to evaluate the effect of miR-122-5p on peripheral and central nervous system inflammation. The downstream target gene of miR-122-5p was analyzed. Neurons were isolated from mice and treated with hemin to construct an in vitro model of ICH, followed by transduction with miR-122-5p mimic or combined with oe-MLLT1. The neurons were then co-cultured with microglia BV2 to assess their activation. It was found that miR-122-5p was highly expressed in ICH, and MLLT1 was lowly expressed. In vivo experiments showed that miR-122-5p knockdown decreased neurological deficits, BBB permeability, and inflammation in the peripheral and central nervous system in ICH mice. It involved its binding to MLLT1 and downregulation of the activity of the PI3K/AKT pathway. In vitro data exhibited that miR-122-5p stimulated the generation of inflammatory factors and microglia activation by targeting MLLT1 and inhibiting the PI3K/AKT pathway. Collectively, our work reveals a novel miR-122-5p/MLLT1-mediated regulatory network in ICH that may be a viable target for neuroinflammation alleviation.
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Affiliation(s)
- Ning Yu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, Hebei Province, 050000, P.R. China
| | - Wenbin Tian
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, Hebei Province, 050000, P.R. China
| | - Chao Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, Hebei Province, 050000, P.R. China
| | - Pei Zhang
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, Hebei Province, 050000, P.R. China
| | - Yinlong Zhao
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, Hebei Province, 050000, P.R. China
| | - Chengrui Nan
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, Hebei Province, 050000, P.R. China
| | - Qianxu Jin
- Department of Neurosurgery, Hebei Medical University, Shijiazhuang, 050000, P.R. China
| | - Xiaopeng Li
- Department of Neurosurgery, The First Hospital of Handan City, Handan, 056000, P.R. China
| | - Ya Liu
- Department of Anesthesiology and Intensive Care Unit, The Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, Hebei Province, 050000, P.R. China.
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18
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Sreekrishnan A, Giurgiutiu DV, Kitamura F, Martinelli C, Abdala N, Haerian H, Dehkharghani S, Kwok K, Yedavalli V, Heit JJ. Decreasing false-positive detection of intracranial hemorrhage (ICH) using RAPID ICH 3. J Stroke Cerebrovasc Dis 2023; 32:107396. [PMID: 37883825 PMCID: PMC10877378 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 09/17/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
INTRODUCTION The prompt detection of intracranial hemorrhage (ICH) on a non-contrast head CT (NCCT) is critical for the appropriate triage of patients, particularly in high volume/high acuity settings. Several automated ICH detection tools have been introduced; however, at present, most suffer from suboptimal specificity leading to false-positive notifications. METHODS NCCT scans from 4 large databases were evaluated for the presence of an ICH (IPH, IVH, SAH or SDH) of >0.4 ml using fully-automated RAPID ICH 3.0 as compared to consensus detection from at least two neuroradiology experts. Scans were excluded for (1) severe CT artifacts, (2) prior neurosurgical procedures, or (3) recent intravenous contrast. ICH detection accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios by were determined. RESULTS A total of 881 studies were included. The automated software correctly identified 453/463 ICH-positive cases and 416/418 ICH-negative cases, resulting in a sensitivity of 97.84% and specificity 99.52%, positive predictive value 99.56%, and negative predictive value 97.65% for ICH detection. The positive and negative likelihood ratios for ICH detection were similarly favorable at 204.49 and 0.02 respectively. Mean processing time was <40 seconds. CONCLUSIONS In this large data set of nearly 900 patients, the automated software demonstrated high sensitivity and specificity for ICH detection, with rare false-positives.
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Affiliation(s)
| | | | - Felipe Kitamura
- DasaInova, Dasa, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Nitamar Abdala
- Department of Diagnostic Imaging, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Hafez Haerian
- Department of Neuroradiology, Northwest Hospital, Randallstown, MD, USA
| | - Seena Dehkharghani
- Departments of Radiology and Neurology, New York University Langone Health, New York, NY, USA
| | - Keith Kwok
- Department of Radiology, Central Valley Imaging Medical Associates/Regional Medical Center of San Jose, San Jose, CA, USA
| | - Vivek Yedavalli
- Department of Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jeremy J Heit
- Department of Neurosurgery, Stanford Hospital, Palo Alto, CA, USA
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19
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Xing Y, Cheng H, Yang C, Xiao Z, Yan C, Chen F, Li J, Zhang Y, Cui C, Li J, Liu C. Evaluation of skin sympathetic nervous activity for classification of intracerebral hemorrhage and outcome prediction. Comput Biol Med 2023; 166:107397. [PMID: 37804780 DOI: 10.1016/j.compbiomed.2023.107397] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/02/2023] [Accepted: 08/26/2023] [Indexed: 10/09/2023]
Abstract
Classification and outcome prediction of intracerebral hemorrhage (ICH) is critical for improving the survival rate of patients. Early or delayed neurological deterioration is common in ICH patients, which may lead to changes in the autonomic nervous system (ANS). Therefore, we proposed a new framework for ICH classification and outcome prediction based on skin sympathetic nervous activity (SKNA) signals. A customized measurement device presented in our previous papers was used to collect data. 117 subjects (50 healthy control subjects and 67 ICH patients) were recruited for this study to obtain their 5-min electrocardiogram (ECG) and SKNA signals. We extracted the signal's time-domain, frequency-domain, and nonlinear features and analyzed their differences between healthy control subjects and ICH patients. Subsequently, we established the ICH classification and outcome evaluation model based on the eXtreme Gradient Boosting (XGBoost). In addition, heart rate variability (HRV) as an ANS assessment method was also included as a comparison method in this study. The results showed significant differences in most features of the SKNA signal between healthy control subjects and ICH patients. The ICH patients with good outcomes have a higher change rate and complexity of SKNA signal than those with bad outcomes. In addition, the accuracy of the model for ICH classification and outcome prediction based on the SKNA signal was more than 91% and 83%, respectively. The ICH classification and outcome prediction based on the SKNA signal proved to be a feasible method in this study. Furthermore, the features of change rate and complexity, such as entropy measures, can be used to characterize the difference in SKNA signals of different groups. The method can potentially provide a new tool for rapid classification and outcome prediction of ICH patients. Index Terms-intracerebral hemorrhage (ICH), skin sympathetic nervous activity (SKNA), classification, outcome prediction, cardiovascular and cerebrovascular diseases.
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Affiliation(s)
- Yantao Xing
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Hongyi Cheng
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210096, China
| | - Chenxi Yang
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Zhijun Xiao
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Chang Yan
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - FeiFei Chen
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Jiayi Li
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Yike Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210096, China
| | - Chang Cui
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210096, China
| | - Jianqing Li
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China.
| | - Chengyu Liu
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China.
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20
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Helmuth TB, Kumari R, Palsa K, Neely EB, Slagle-Webb B, Simon SD, Connor JR. Common Mutation in the HFE Gene Modifies Recovery After Intracerebral Hemorrhage. Stroke 2023; 54:2886-2894. [PMID: 37750297 PMCID: PMC10996156 DOI: 10.1161/strokeaha.123.043799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is characterized by bleeding into the brain parenchyma. During an ICH, iron released from the breakdown of hemoglobin creates a cytotoxic environment in the brain through increased oxidative stress. Interestingly, the loss of iron homeostasis is associated with the pathological process of other neurological diseases. However, we have previously shown that the H63D mutation in the homeostatic iron regulatory (HFE) gene, prevalent in 28% of the White population in the United States, acts as a disease modifier by limiting oxidative stress. The following study aims to examine the effects of the murine homolog, H67D HFE, on ICH. METHODS An autologous blood infusion model was utilized to create an ICH in the right striatum of H67D and wild-type mice. The motor recovery of each animal was assessed by rotarod. Neurodegeneration was measured using fluorojade-B and mitochondrial damage was assessed by immunofluorescent numbers of CytC+ (cytochrome C) neurons and CytC+ astrocytes. Finally, the molecular antioxidant response to ICH was quantified by measuring Nrf2 (nuclear factor-erythroid 2 related factor), GPX4 (glutathione peroxidase 4), and FTH1 (H-ferritin) levels in the ICH-affected and nonaffected hemispheres via immunoblotting. RESULTS At 3 days post-ICH, H67D mice demonstrated enhanced performance on rotarod compared with wild-type animals despite no differences in lesion size. Additionally, H67D mice displayed higher levels of Nrf2, GPX4, and FTH1 in the ICH-affected hemisphere; however, these levels were not different in the contralateral, non-ICH-affected hemisphere. Furthermore, H67D mice showed decreased degenerated neurons, CytC+ Neurons, and CytC+ astrocytes in the perihematomal area. CONCLUSIONS Our data suggest that the H67D mutation induces a robust antioxidant response 3 days following ICH through Nrf2, GPX4, and FTH1 activation. This activation could explain the decrease in degenerated neurons, CytC+ neurons, and CytC+ astrocytes in the perihematomal region, leading to the improved motor recovery. Based on this study, further investigation into the mechanisms of this neuroprotective response and the effects of the H63D HFE mutation in a population of patients with ICH is warranted.
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Affiliation(s)
- Timothy B Helmuth
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
| | - Rashmi Kumari
- Department of Neural and Behavioral Sciences (R.K.), Penn State College of Medicine, Hershey, PA
| | - Kondaiah Palsa
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
| | - Elizabeth B Neely
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
| | - Becky Slagle-Webb
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
| | - Scott D Simon
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
| | - James R Connor
- Department of Neurosurgery (T.B.H., K.P., E.B.N., B.S.-W., S.D.S., J.R.C.), Penn State College of Medicine, Hershey, PA
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21
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Cardona S, Baqai H, Mikdashi F, Aligabi A, Solomon J, Frederick H, Seyoum N, Olexa J, Stokum JA, Sharma A, Pergakis MB, Tran QK. Intracranial and Blood Pressure Variability and In-Hospital Outcomes in Intracranial Device-Monitored Patients with Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2023; 39:357-367. [PMID: 36759420 DOI: 10.1007/s12028-023-01677-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/09/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (sICH) is a major health concern and has high mortality rates up to 52%. Despite a decrease in its incidence, fatality rates remain unchanged; understanding and preventing of factors associated with mortality and treatments for these are needed. Blood pressure variability (BPV) has been shown to be a potential modifiable factor associated with clinical outcomes in patients with traumatic intracerebral hemorrhage and sICH. Few data are available on the effect of intracranial pressure (ICP) variability (ICPV) and outcomes in patients with sICH. The goal of our study was to investigate the association between ICPV and BPV during the first 24 h of intensive care unit (ICU) admission and external ventricular drain (EVD) placement, and mortality in patients with sICH who were monitored with an EVD. METHODS We conducted a single-center retrospective study of adult patients admitted to an ICU with a diagnosis of sICH who required EVD placement during hospitalization. We excluded patients with ICH secondary to other pathological conditions such as trauma, underlying malignancy, or arteriovenous malformation. Blood pressure and ICP measurements were collected and recorded hourly during the first 24 h of ICU admission and EVD placement, respectively. Measures of variability used were standard deviation (SD) and successive variation (SV). Primary outcome of interest was in-hospital mortality, and secondary outcomes were hematoma expansion and discharge home (a surrogate for good functional outcome at discharge). Descriptive statistics and multivariable logistic regressions were performed. RESULTS We identified 179 patients with sICH who required EVD placement. Of these, 52 (29%) patients died, 121 (68%) patients had hematoma expansion, and 12 (7%) patients were discharged home. Patient's mean age (± SD) was 56 (± 14), and 87 (49%) were women. The mean opening ICP (± SD) was 21 (± 8) and median ICH score (interquartile range) was 2 (2-3). Multivariable logistic regression found an association between ICP-SV and ICP-SD and hematoma expansion (odds ratio 1.6 [1.03-2.30], p = 0.035 and odds ratio 0.77 [0.63-0.93] p = 0.009, respectively). CONCLUSIONS Our study found an association between ICPV and hematoma expansion in patients with sICH monitored with an EVD. Measures of ICPV relating to rapid changes in ICP (ICP-SV) were associated with a higher odds of hematoma expansion, whereas measures relating to tight control of ICP (ICP-SD) were associated with a lower odds of hematoma expansion. One measure of BPV, sytolic blood pressure maximum-minimum (SBP max-min), was found to be weakly associated with discharge home (a surrogate for good functional outcome at hospital discharge). More research is needed to support these findings.
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Affiliation(s)
- Stephanie Cardona
- Department of Critical Care Medicine, The Mount Sinai Hospital, 1468 Madison Ave, New York, NY, 10029, USA.
| | - Hammad Baqai
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Fatima Mikdashi
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ayah Aligabi
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Julianna Solomon
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hannah Frederick
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nahom Seyoum
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ashish Sharma
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa B Pergakis
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Quincy K Tran
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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22
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Ramos-Pachón A, Rodríguez-Luna D, Martí-Fàbregas J, Millán M, Bustamante A, Martínez-Sánchez M, Serena J, Terceño M, Vera-Cáceres C, Camps-Renom P, Prats-Sánchez L, Rodríguez-Villatoro N, Cardona-Portela P, Urra X, Solà S, del Mar Escudero M, Salvat-Plana M, Ribó M, Abilleira S, Pérez de la Ossa N, Silva Y. Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage: A Secondary Analysis of the RACECAT Randomized Clinical Trial. JAMA Neurol 2023; 80:1028-1036. [PMID: 37603325 PMCID: PMC10442788 DOI: 10.1001/jamaneurol.2023.2754] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/05/2023] [Indexed: 08/22/2023]
Abstract
Importance Prehospital transfer protocols are based on rapid access to reperfusion therapies for patients with ischemic stroke. The effect of different protocols among patients receiving a final diagnosis of intracerebral hemorrhage (ICH) is unknown. Objective To determine the effect of direct transport to an endovascular treatment (EVT)-capable stroke center vs transport to the nearest local stroke center. Design, Setting, and Participants This was a prespecified secondary analysis of RACECAT, a multicenter, population-based, cluster-randomized clinical trial conducted from March 2017 to June 2020 in Catalonia, Spain. Patients were evaluated by a blinded end point assessment. All consecutive patients suspected of experiencing a large vessel occlusion stroke (Rapid Arterial Occlusion Evaluation Scale [RACE] score in the field >4 on a scale of 0 to 9, with lower to higher stroke severity) with final diagnosis of ICH were included. A total of 1401 patients were enrolled in RACECAT with suspicion of large vessel occlusion stroke. The current analysis was conducted in October 2022. Intervention Direct transport to an EVT-capable stroke center (n = 137) or to the closest local stroke center (n = 165). Main Outcomes and Measures The primary outcome was tested using cumulative ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI of the shift analysis of disability at 90 days as assessed by the modified Rankin Scale (mRS) score (range, 0 [no symptoms] to 6 [death]) in the intention-to-treat population. Secondary outcomes, included 90-day mortality, death or severe functional dependency, early neurological deterioration, early mortality, ICH volume and enlargement, rate of neurosurgical treatment, rate of clinical complications during initial transport, and rate of adverse events until day 5. Results Of 1401 patients enrolled, 1099 were excluded from this analysis (32 rejected informed consent, 920 had ischemic stroke, 29 had transient ischemic attack, 12 had subarachnoid hemorrhage, and 106 had stroke mimic). Thus, 302 patients were included (204 [67.5%] men; mean [SD] age 71.7 [12.8] years; and median [IQR] RACE score, 7 [6-8]). For the primary outcome, direct transfer to an EVT-capable stroke center (mean [SD] mRS score, 4.93 [1.38]) resulted in worse functional outcome at 90 days compared with transfer to the nearest local stroke center (mean [SD] mRS score, 4.66 [1.39]; adjusted common OR, 0.63; 95% CI, 0.41-0.96). Direct transfer to an EVT-capable stroke center also suggested potentially higher 90-day mortality compared with transfer to the nearest local stroke center (67 of 137 [48.9%] vs 62 of 165 [37.6%]; adjusted hazard ratio, 1.40; 95% CI, 0.99-1.99). The rates of medical complications during the initial transfer (30 of 137 [22.6%] vs 9 of 165 patients [5.6%]; adjusted OR, 5.29; 95% CI, 2.38-11.73) and in-hospital pneumonia (49 of 137 patients [35.8%] vs 29 of 165 patients [17.6%]; OR, 2.61; 95% CI, 1.53-4.44) were higher in the EVT-capable stroke center group. Conclusions and Relevance In this secondary analysis of the RACECAT randomized clinical trial, bypassing the closest stroke center resulted in reduced chances of functional independence at 90 days for patients who received a final diagnosis of ICH. Trial Registration ClinicalTrials.gov Identifier: NCT02795962.
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Affiliation(s)
- Anna Ramos-Pachón
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Joan Martí-Fàbregas
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Mònica Millán
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Alejandro Bustamante
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Marina Martínez-Sánchez
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Joaquín Serena
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | - Mikel Terceño
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | | | - Pol Camps-Renom
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Luis Prats-Sánchez
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Pere Cardona-Portela
- Stroke Unit, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain
| | - Xabier Urra
- Stroke Unit, Hospital Clínic, and August Pi i Sunyer Biomedical Research Institute Barcelona, Barcelona, Spain
| | - Silvia Solà
- Sistema d’Emergències Mèdiques, Barcelona, Spain
| | | | - Mercè Salvat-Plana
- Catalan Stroke Program, Agency for Health Quality and Assessment of Catalonia, and CIBER Epidemiology and Public Health, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Sònia Abilleira
- Catalan Stroke Program, Agency for Health Quality and Assessment of Catalonia, and CIBER Epidemiology and Public Health, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Yolanda Silva
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
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23
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Yang C, Sui YG, Wang BC, Xu YL, Wu NQ, Wu YJ, Li JJ, Qian J. Intracranial Hemorrhage in Hospitalized Patients Following Percutaneous Coronary Intervention: A Large Cohort Analysis from a Single Center. Diagnostics (Basel) 2023; 13:2422. [PMID: 37510165 PMCID: PMC10378240 DOI: 10.3390/diagnostics13142422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND There are several reports on the prevalence and characteristics of intracranial hemorrhage (ICH) following percutaneous coronary intervention (PCI), which is a rare but severe complication with high mortality. However, the clinical landscapes of computed tomography (CT)-confirmed, symptomatic ICH in hospitalized patients are not fully characterized. METHODS Among 121,066 patients receiving PCI treatment in the Fu Wai Hospital between 2013 and 2022, there were 18 CT-defined, symptomatic patients with ICH occurring during post-PCI hospitalization. Symptomatic ICH was defined as clinical suspicion of hemorrhage and/or new focal neurological signs. We analyzed ICH timing, clinical and imaging features, and subsequent outcomes. RESULTS Overall, in this retrospective analysis, the incidence of CT-defined, symptomatic ICH was 0.015% (18/121,066). More than half of the cases (55.6%) occurred within the first 12 h following PCI. The most common initial manifestation of ICH patients was disturbance of consciousness. Thirteen patients (72.2%) had a hematoma volume ≥ 30 cm3. Additionally, the ICH was observed in the cerebral lobe (66.7%), cerebellum (22.2%), and the basal ganglia and thalamus (11.1%). The 90-day mortality of ICH patients undergoing PCI was very high (72.2%). Consciousness disturbance (p = 0.036), intracerebral hemorrhage volume > 30 mm3 (p = 0.001), and intracerebral hemorrhage originating from the infratentorial origin (p = 0.044) were significantly higher in patients who died. CONCLUSIONS Symptomatic ICH events occur with a rate of around 0.015%, with significantly higher short-term mortality risk in our cohort receiving PCI, which has not yet been demonstrated in other cohorts.
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Affiliation(s)
- Cheng Yang
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yong-Gang Sui
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Bin-Cheng Wang
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yan-Lu Xu
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Na-Qiong Wu
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yong-Jian Wu
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jian-Jun Li
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jie Qian
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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24
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Mark DG, Huang J, Sonne DC, Rauchwerger AS, Reed ME. Mortality Following Diagnosis of Nontraumatic Intracerebral Hemorrhage Within an Integrated "Hub-and-Spoke" Neuroscience Care Model: Is Spoke Presentation Noninferior to Hub Presentation? Neurocrit Care 2023; 38:761-770. [PMID: 36600074 DOI: 10.1007/s12028-022-01667-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Practice guidelines recommend that patients with intracerebral hemorrhage (ICH) be treated in units with acute neuroscience care experience. However, most hospitals in the United States lack this degree of specialization. We sought to examine outcome differences for patients with nontraumatic ICH presenting to centers with and without advanced neuroscience care specialization. METHODS This was a retrospective study of adult patients presenting with nontraumatic ICH between 1/1/2011 and 9/30/2020 across 21 medical centers within Kaiser Permanente Northern California, an integrated care system that employs a "hub-and-spoke" model of neuroscience care in which two centers service as neuroscience "hubs" and the remaining 19 centers service as referral "spokes." Patients presenting to spokes can receive remote consultation (including image review) by neurosurgical or neurointensive care specialists located at hubs. The primary outcome was 90-day mortality. We used hierarchical logistic regression, adjusting for ICH score components, comorbidities, and demographics, to test a hypothesis that initial presentation to a spoke medical center was noninferior to hub presentation [defined as an odds ratio (OR) with an upper 95% confidence interval (CI) limit of 1.24 or less]. RESULTS A total of 6978 patients were included, with 6170 (88%) initially presenting to spoke medical centers. The unadjusted 90-day mortality for patients initially presenting to spoke versus hub medical centers was 32.2% and 32.7%, respectively. In adjusted analysis, presentation to a spoke medical center was neither noninferior nor inferior for 90-day mortality risk (OR 1.21, 95% CI 0.84-1.74). Sensitivity analysis excluding patients admitted to general wards or lacking continuous health plan insurance during the follow-up period trended closer to a noninferior result (OR 0.99, 95% CI 0.69-1.44). CONCLUSIONS Within an integrated "hub-and-spoke" neuroscience care model, the risk of 90-day mortality following initial presentation with nontraumatic ICH to a spoke medical center was not conclusively noninferior compared with initial presentation to a hub medical center. However, there was also no indication that care for selected patients with nontraumatic ICH within medical centers lacking advanced neuroscience specialization resulted in significantly inferior outcomes. This finding may support the safety and efficiency of a "hub-and-spoke" care model for patients with nontraumatic ICH, although additional investigations are warranted.
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Affiliation(s)
- Dustin G Mark
- Departments of Emergency Medicine and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
| | - Jie Huang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - D Chris Sonne
- Division of Neuroradiology, Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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25
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Sreekrishnan A, Venkatasubramanian C, Heit JJ. Automated cerebral hemorrhage volume calculation and stability detection using automated software. RESEARCH SQUARE 2023:rs.3.rs-2944493. [PMID: 37292654 PMCID: PMC10246251 DOI: 10.21203/rs.3.rs-2944493/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Introduction The measurement of intracerebral hemorrhage (ICH) volume is important for management, particularly in evaluating expansion on subsequent imaging. However manual volumetric analysis is time-consuming, especially in busy hospital settings. We aimed to use automated Rapid Hyperdensity software to accurately measure ICH volume across repeated imaging. Methods We identified ICH cases, with repeat imaging conducted within 24 hours, from two randomized clinical trials where enrollment was not based on ICH volume. Scans were excluded if there was (1) severe CT artifacts, (2) prior neurosurgical procedures, (3) recent intravenous contrast, or (4) ICH < 1 ml. Manual ICH measurements were conducted by one neuroimaging expert using MIPAV software and compared to the performance of automated software. Results 127 patients were included with median baseline ICH volume manually measured at 18.18 cc (IQR: 7.31 - 35.71) compared to automated detection of 18.93 cc (IQR: 7.55, 37.88). The two modalities were highly correlated (r = 0.994, p < 0.001). On repeat imaging, the median absolute difference in ICH volume was 0.68cc (IQR: -0.60-4.87) compared to automated detection at 0.68cc (IQR: -0.45-4.63). These absolute differences were also highly correlated (r = 0.941, p < 0.001), with the ability of the automated software to detect ICH expansion with a Sensitivity of 94.12% and Specificity 97.27%. Conclusion In our proof-of-concept study, the automated software has high reliability in its ability to quickly determine IPH volume with high sensitivity and specificity and to detect expansion on subsequent imaging.
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Bako AT, Potter T, Pan A, Tannous J, Rahman O, Langefeld C, Woo D, Britz G, Vahidy FS. Geographic Disparities in Case Fatality and Discharge Disposition Among Patients With Primary Intracerebral Hemorrhage. J Am Heart Assoc 2023; 12:e027403. [PMID: 37158120 DOI: 10.1161/jaha.122.027403] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Background We evaluate nationwide trends and urban-rural disparities in case fatality (in-hospital mortality) and discharge dispositions among patients with primary intracerebral hemorrhage (ICH). Methods and Results In this repeated cross-sectional study, we identified adult patients (≥18 years of age) with primary ICH from the National Inpatient Sample (2004-2018). Using a series of survey design Poisson regression models, with hospital location-time interaction, we report the adjusted risk ratio (aRR), 95% CI, and average marginal effect (AME) for factors associated with ICH case fatality and discharge dispositions. We performed a stratified analysis of each model among patients with extreme loss of function and minor to major loss of function. We identified 908 557 primary ICH hospitalizations (overall mean age [SD], 69.0 [15.0] years; 445 301 [49.0%] women; 49 884 [5.5%] rural ICH hospitalizations). The crude ICH case fatality rate was 25.3% (urban hospitals: 24.9%, rural hospitals:32.5%). Urban (versus rural) hospital patients had a lower likelihood of ICH case fatality (aRR, 0.86 [95% CI, 0.83-0.89]). ICH case fatality is declining over time; however, it is declining faster in urban hospitals (AME, -0.049 [95% CI, -0.051 to -0.047]) compared with rural hospitals (AME, -0.034 [95% CI, -0.040 to -0.027]). Conversely, home discharge is increasing significantly among urban hospitals (AME, 0.011 [95% CI, 0.008-0.014]) but not significantly changing in rural hospitals (AME, -0.001 [95% CI, -0.010 to 0.007]). Among patients with extreme loss of function, hospital location was not significantly associated with ICH case fatality or home discharge. Conclusions Improving access to neurocritical care resources, particularly in resource-limited communities, may reduce the ICH outcomes disparity gap.
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Affiliation(s)
| | - Thomas Potter
- Department of Neurosurgery Houston Methodist Houston TX
| | - Alan Pan
- Department of Neurosurgery Houston Methodist Houston TX
| | | | - Omar Rahman
- Department of Critical Care Medicine Indiana University School of Medicine Indianapolis IN
| | - Carl Langefeld
- Department of Biostatistics and Data Science Wake Forest School of Medicine Winston-Salem NC
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Gavin Britz
- Department of Neurosurgery Houston Methodist Houston TX
| | - Farhaan S Vahidy
- Department of Neurosurgery Houston Methodist Houston TX
- Department of Population Health Sciences Weill Cornell Medical College New York NY
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1355] [Impact Index Per Article: 1355.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Mowla A, Shakibajahromi B, Shahjouei S, Baharvahdat H, Harandi AA, Rahmani F, Mondello S, Rahimian N, Cernigliaro A, Hokmabadi ES, Ebrahimzadeh SA, Ramezani M, Mehrvar K, Farhoudi M, Naderi S, Fenderi SM, Pishjoo M, Alizada O, Purroy F, Requena M, Tsivgoulis G, Zand R. SARS-CoV-2 infection might be a predictor of mortality in intracerebral hemorrhage. J Neurol Sci 2023; 444:120497. [PMID: 36455388 PMCID: PMC9683865 DOI: 10.1016/j.jns.2022.120497] [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: 06/28/2022] [Revised: 10/10/2022] [Accepted: 11/12/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND SARS-CoV-2 infection may be associated with uncommon complications such as intracerebral hemorrhage (ICH), with a high mortality rate. We compared a series of hospitalized ICH cases infected with SARS-CoV-2 with a non-SARS-CoV-2 infected control group and evaluated if the SARS-CoV-2 infection is a predictor of mortality in ICH patients. METHODS In a multinational retrospective study, 63 cases of ICH in SARS-CoV-2 infected patients admitted to 13 tertiary centers from the beginning of the pandemic were collected. We compared the clinical and radiological characteristics and in-hospital mortality of these patients with a control group of non-SARS-CoV-2 infected ICH patients of a previous cohort from the country where the majority of cases were recruited. RESULTS Among 63 ICH patients with SARS-CoV-2 infection, 23 (36.5%) were women. Compared to the non-SARS-CoV-2 infected control group, in SARS-CoV-2 infected patients, ICH occurred at a younger age (61.4 ± 18.1 years versus 66.8 ± 16.2 years, P = 0.044). These patients had higher median ICH scores ([3 (IQR 2-4)] versus [2 (IQR 1-3)], P = 0.025), a more frequent history of diabetes (34% versus 16%, P = 0.007), and lower platelet counts (177.8 ± 77.8 × 109/L versus 240.5 ± 79.3 × 109/L, P < 0.001). The in-hospital mortality was not significantly different between cases and controls (65% versus 62%, P = 0.658) in univariate analysis; however, SARS-CoV-2 infection was significantly associated with in-hospital mortality (aOR = 4.3, 95% CI: 1.28-14.52) in multivariable analysis adjusting for potential confounders. CONCLUSION Infection with SARS-CoV-2 may be associated with increased odds of in-hospital mortality in ICH patients.
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Affiliation(s)
- Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, California, USA
| | | | - Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA
| | - Humain Baharvahdat
- Division of Neuroendovascular Surgery, Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Amini Harandi
- Brain Mapping Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Rahmani
- Department of Emergency Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Nasrin Rahimian
- Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | | | | | - Seyed Amir Ebrahimzadeh
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mahtab Ramezani
- Department of Neurology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kaveh Mehrvar
- Department of Neurology, Tabriz Branch, Islamic Azad University, Tabriz, Iran
| | - Mehdi Farhoudi
- Neurosciences Resarch Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Soheil Naderi
- Neurosurgery Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahab Mahmoudnejad Fenderi
- Division of Neuroendovascular Surgery, Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Masoud Pishjoo
- Division of Neuroendovascular Surgery, Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Orkhan Alizada
- Department of Neurosurgery, Baskent University, Faculty of Medicine, Istanbul, Turkey
| | - Francisco Purroy
- Department of Neurology, Hospital Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLLeida), Universitat de Lleida UdL Lleida, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Department de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA.
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Wan Y, Holste KG, Hua Y, Keep RF, Xi G. Brain edema formation and therapy after intracerebral hemorrhage. Neurobiol Dis 2023; 176:105948. [PMID: 36481437 PMCID: PMC10013956 DOI: 10.1016/j.nbd.2022.105948] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/28/2022] [Accepted: 12/04/2022] [Indexed: 12/12/2022] Open
Abstract
Intracerebral hemorrhage (ICH) accounts for about 10% of all strokes in the United States of America causing a high degree of disability and mortality. There is initial (primary) brain injury due to the mechanical disruption caused by the hematoma. There is then secondary injury, triggered by the initial injury but also the release of various clot-derived factors (e.g., thrombin and hemoglobin). ICH alters brain fluid homeostasis. Apart from the initial hematoma mass, ICH causes blood-brain barrier disruption and parenchymal cell swelling, which result in brain edema and intracranial hypertension affecting patient prognosis. Reducing brain edema is a critical part of post-ICH care. However, there are limited effective treatment methods for reducing perihematomal cerebral edema and intracranial pressure in ICH. This review discusses the mechanisms underlying perihematomal brain edema formation, the effects of sex and age, as well as how edema is resolved. It examines progress in pharmacotherapy, particularly focusing on drugs which have been or are currently being investigated in clinical trials.
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Affiliation(s)
- Yingfeng Wan
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
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Muacevic A, Adler JR, Stead TS, Mangal RK, Ganti L. Intraparenchymal Hematoma With Significant Mass Effect Treated With Factor Eight Inhibitor Bypass Activity. Cureus 2022; 14:e31385. [PMID: 36514613 PMCID: PMC9741993 DOI: 10.7759/cureus.31385] [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] [Accepted: 11/06/2022] [Indexed: 11/13/2022] Open
Abstract
The authors present the case of an 80-year-old female with myelodysplastic syndrome treated with chemotherapy and apixaban, a direct oral anticoagulant who suffered an intracranial hemorrhage. She presented to the emergency department with altered mental status and was found to have a large intraparenchymal hematoma with a significant mass effect. Our patient was given FEIBA (Factor Eight Inhibitor Bypass Activity) to reverse the hemorrhage. Anticoagulant-related bleeding reversal strategies are discussed.
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Luo J, Chen Y, Tang G, Li Z, Yang X, Shang X, Huang T, Huang G, Wang L, Han Y, Zhou Y, Wang C, Wu B, Guo Q, Gong B, Li M, Wang R, Yang J, Cui W, Zhong J, Zhong LL, Guo J. Gut microbiota composition reflects disease progression, severity and outcome, and dysfunctional immune responses in patients with hypertensive intracerebral hemorrhage. Front Immunol 2022; 13:869846. [PMID: 36439158 PMCID: PMC9699794 DOI: 10.3389/fimmu.2022.869846] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 06/08/2022] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVE In this study, we aimed to explore the alterations in gut microbiota composition and cytokine responses related to disease progression, severity, and outcomes in patients with hypertensive intracerebral hemorrhage (ICH). METHODS Fecal microbiota communities of 64 patients with ICH, 46 coronary heart disease controls, and 23 healthy controls were measured by sequencing the V3-V4 region of the 16S ribosomal RNA (16S rRNA) gene. Serum concentrations of a broad spectrum of cytokines were examined by liquid chips and ELISA. Relationships between clinical phenotypes, microbiotas, and cytokine responses were analyzed in the group with ICH and stroke-associated pneumonia (SAP), the major complication of ICH. RESULTS In comparison with the control groups, the gut microbiota of the patients with ICH had increased microbial richness and diversity, an expanded spectrum of facultative anaerobes and opportunistic pathogens, and depletion of anaerobes. Enterococcus enrichment and Prevotella depletion were more significant in the ICH group and were associated with the severity and functional outcome of ICH. Furthermore, Enterococcus enrichment and Prevotella depletion were also noted in the SAP group in contrast to the non-SAP group. Enterococci were also promising factors in the prognosis of ICH. The onset of ICH induced massive, rapid activation of the peripheral immune system. There were 12 cytokines (Eotaxin, GM-CSF, IL-8, IL-9, IL-10, IL-12p70, IL-15, IL-23, IL-1RA, IP-10, RANTES, and TNF-α) changed significantly with prolongation of ICH, and the Th2 responses correlated with the 90-day outcomes. Cytokines TNF-α, IP-10, IL-1RA, IL-8, IL-18, and MIP-1β in SAP group significantly differed from non-SAP group. Among these cytokines, only IP-10 levels decreased in the SAP group. Enterococcus was positively associated with IL-1RA and negatively associated with IP-10, while Prevotella was inversely associated in both the ICH and SAP groups. CONCLUSION This study revealed that gut dysbiosis with enriched Enterococcus and depleted Prevotella increased the risk of ICH and subsequently SAP. The altered gut microbiota composition and serum cytokine profiles are potential biomarkers that reflect the inciting physiologic insult/stress involved with ICH.
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Affiliation(s)
- Jielian Luo
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Yang Chen
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Guanghai Tang
- Department of Neurology, Shenyang Second Hospital of Traditional Chinese Medicine, Shenyang, China
| | - Zhuo Li
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- Genetic Testing Lab, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaobo Yang
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Key Laboratory of Clinical Research on Traditional Chinese Medicine Syndrome, Guangzhou, China
| | - Xiaoxiao Shang
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Tao Huang
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Gan Huang
- Department of Neurology, Yangjiang Hospital of Traditional Chinese Medicine, Yangjiang, China
| | - Lixin Wang
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yun Han
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- Department of Intensive Care Unit, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuexiang Zhou
- Department of Community Healthcare Service, Shenzhen FuYong People’s Hospital, Shenzhen, China
| | - Chuyang Wang
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- Biological Resource Center, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bin Wu
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- Genetic Testing Lab, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qihua Guo
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Baoying Gong
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Mengzhen Li
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Ruihua Wang
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- The Fourth Affiliated Hospital of Guangzhou Medical University Research Team of Traditional Chinese Medicine for the Prevention and Treatment of Cerebral Hemorrhage, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiecong Yang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Wanzhen Cui
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Jianbin Zhong
- Department of Neurology, The Fourth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Linda Ld Zhong
- Hong Kong Chinese Medicine Clinical Study Centre, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China
| | - Jianwen Guo
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Scott CA, Li L, Rothwell PM. Diverging Temporal Trends in Stroke Incidence in Younger vs Older People: A Systematic Review and Meta-analysis. JAMA Neurol 2022; 79:1036-1048. [PMID: 35943738 PMCID: PMC9364236 DOI: 10.1001/jamaneurol.2022.1520] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/15/2022] [Indexed: 12/25/2022]
Abstract
Importance Overall stroke incidence is falling in high-income countries, but data on time trends in incidence of young stroke (ie, stroke in individuals younger than 55 years) are conflicting. An age-specific divergence in incidence, with less favorable trends at younger vs older ages, might be a more consistent underlying finding across studies. Objective To compare temporal trends in incidence of stroke at younger vs older ages in high-income countries. Data Sources PubMed and EMBASE were searched from inception to February 2022. One additional population-based study (Oxford Vascular Study) was also included. Study Selection Studies reporting age-specific stroke incidence in high-income countries at more than 1 time point. Data Extraction and Synthesis For all retrieved studies, 2 authors independently reviewed the full text against the inclusion criteria to establish their eligibility. Meta-analysis was performed with the inverse variance-weighted random-effects model. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed. Main Outcomes and Measures The main outcome was age-specific divergence (<55 vs ≥55 years) in temporal trends in stroke incidence (relative temporal rate ratio [RTTR]) in studies extending to at least 2000. RTTRs were calculated for each study and pooled by random-effects meta-analysis, with stratification by administrative vs prospective population-based methodology, sex, stroke subtype (ischemic vs intracerebral hemorrhage vs subarachnoid hemorrhage) and geographical region. Results Among 50 studies in 20 countries, 26 (13 prospective population-based and 13 administrative studies) reported data allowing calculation of the RTTR for stroke incidence at younger vs older ages across 2 or more periods, the latest extending beyond 2000. Reported trends in absolute incidence of young individuals with stroke were heterogeneous, but all studies showed a less favorable trend in incidence at younger vs older ages (pooled RTTR = 1.57 [95% CI, 1.42-1.74]). The overall RTTR was consistent by stroke subtype (ischemic, 1.62 [95% CI, 1.44-1.83]; intracerebral hemorrhage, 1.32 [95% CI, 0.91-1.92]; subarachnoid hemorrhage, 1.54 [95% CI, 1.00-2.35]); and by sex (men, 1.46 [95% CI, 1.34-1.60]; women, 1.41 [95% CI, 1.28-1.55]) but was greater in studies reporting trends solely after 2000 (1.51 [95% CI, 1.30-1.70]) vs solely before (1.18 [95% CI, 1.12-1.24]) and was highest in population-based studies in which the most recent reported period of ascertainment started after 2010 (1.87 [95% CI, 1.55-2.27]). Conclusions and Relevance Temporal trends in stroke incidence are diverging by age in high-income countries, with less favorable trends at younger vs older ages, highlighting the urgent need to better understand etiology and prevention of stroke at younger ages.
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Affiliation(s)
- Catherine A. Scott
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, United Kingdom
| | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, United Kingdom
| | - Peter M. Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, United Kingdom
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Wang S, Zou XL, Wu LX, Zhou HF, Xiao L, Yao T, Zhang Y, Ma J, Zeng Y, Zhang L. Epidemiology of intracerebral hemorrhage: A systematic review and meta-analysis. Front Neurol 2022; 13:915813. [PMID: 36188383 PMCID: PMC9523083 DOI: 10.3389/fneur.2022.915813] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 08/16/2022] [Indexed: 12/03/2022] Open
Abstract
Background Intracerebral hemorrhage (ICH) is associated with high mortality and disability rates. This study aimed to investigate the relationship between sex, age, study year, risk factors, bleeding site, median year of study, and the incidence of ICH. Method Literature on the incidence of ICH published on 1 January 1980 and 1 January 2020, was systematically retrieved from PubMed and Embase databases. The random-effects model and subgroup analysis were used to explore the relationship between the incidence of ICH and different ages, sex, bleeding sites, and risk factors. Results We summarized the epidemiological changes in ICH in the past 40 years according to 52 studies and found that the total incidence of ICH is 29.9 per 100,000 person-years (95% CI: 26.5–33.3), which has not decreased worldwide. The incidence of ICH in the Asian population is much higher than in other continents. In addition, the incidence of ICH increases with age and differs at the 85-year-old boundary. Men are more likely to develop ICH than women, and the basal ganglia region is the most common area for ICH. Of the 10 risk factors examined in this study, those with hypertension had the highest incidence of ICH, followed by those with excessive alcohol consumption and heart disease. Conclusion The prevention and treatment of ICH still need to be improved continuously according to age, sex, risk factors, and other factors, and targeted and normative strategies should be gradually developed in the future.
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Affiliation(s)
- Sai Wang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xue-Lun Zou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Lian-Xu Wu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Hui-Fang Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Linxiao Xiao
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Tianxing Yao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yupeng Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Junyi Ma
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Zeng
- Department of Geriatrics, Second Xiangya Hospital, Central South University, Changsha, China
| | - Le Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Multi-Modal Monitoring Technology for Severe Cerebrovascular Disease of Human Engineering Research Center, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Le Zhang
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Gil-Garcia CA, Alvarez EF, Garcia RC, Mendoza-Lopez AC, Gonzalez-Hermosillo LM, Garcia-Blanco MDC, Valadez ER. Essential topics about the imaging diagnosis and treatment of Hemorrhagic Stroke: a comprehensive review of the 2022 AHA guidelines. Curr Probl Cardiol 2022; 47:101328. [PMID: 35870549 DOI: 10.1016/j.cpcardiol.2022.101328] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/17/2022] [Indexed: 11/03/2022]
Abstract
Intracerebral hemorrhage (ICH) is a severe stroke with a high death rate (40 % mortality). The prevalence of hemorrhagic stroke has increased globally, with changes in the underlying cause over time as anticoagulant use and hypertension treatment have improved. The fundamental etiology of ICH and the mechanisms of harm from ICH, particularly the complex interaction between edema, inflammation, and blood product toxicity, have been thoroughly revised by the American Heart Association (AHA) in 2022. Although numerous trials have investigated the best medicinal and surgical management of ICH, there is still no discernible improvement in survival and functional tests. Small vessel diseases, such as cerebral amyloid angiopathy (CAA) or deep perforator arteriopathy (hypertensive arteriopathy), are the most common causes of spontaneous non-traumatic intracerebral hemorrhage (ICH). Even though ICH only causes 10-15% of all strokes, it contributes significantly to morbidity and mortality, with few acute or preventive treatments proven effective. Current AHA guidelines acknowledge up to 89% sensitivity for unenhanced brain CT and 81% for brain MRI. The imaging findings of both methods are helpful for initial diagnosis and follow-up, sometimes necessary a few hours after admission, especially for detecting hemorrhagic transformation or hematoma expansion. This review summarized the essential topics on hemorrhagic stroke epidemiology, risk factors, physiopathology, mechanisms of injury, current management approaches, findings in neuroimaging, goals and outcomes, recommendations for lifestyle modifications, and future research directions ICH. A list of updated references is included for each topic.
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Affiliation(s)
| | | | | | | | | | | | - Ernesto-Roldan Valadez
- Directorado de investigación, Hospital General de Mexico "Dr. Eduardo Liceaga," 06720, CDMX, Mexico; I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
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Daniel D, Santos D, Maillie L, Dhamoon MS. Variability in intensive care utilization for intracerebral hemorrhage in the United States: Retrospective cohort study. J Stroke Cerebrovasc Dis 2022; 31:106619. [PMID: 35780718 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106619] [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: 05/08/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES There are urban-rural geographic health disparities in intracerebral hemorrhage (ICH) outcomes. However, there is limited data regarding the relationship between intensive care (ICU) availability and ICH outcomes. We examined whether ICU availability was a significant contributor to ICH outcomes by US geographic region. MATERIALS AND METHODS We used de-identified Medicare inpatient datasets from January 2016 to December 2019 and identified all index ICH admissions, stratifying by ICU care received during the hospitalization. Distributions of teaching hospital status, quartile of ICH volume, hospital urban-rural designation, and ICU availability were obtained using chi-square test. Propensity-score matching was utilized to compare outcomes of more favorable outcome, inpatient mortality, and 30-day all-cause readmissions by ICU availability at each hospital. RESULTS Out of a total of 119,891 hospitalizations for ICH, 66,306 (55.3%) received ICU-level care. Of hospitals that treated at least one ICH, 42.6% did not provide ICU level care for any ICH admission during the study period. Teaching hospitals (48.0% vs 7.0%; p<0.0001), hospitals with higher ICH case volumes (p<0.0001) and in larger metropolitan areas (p<0.0001) were more likely to have an ICU available. Propensity score-matched models showed that hospital ICU availability was associated with a lower likelihood of inpatient mortality (29.4% vs 33.7%; p=0.0016) CONCLUSIONS: Rural-urban disparities in ICH outcomes are likely multifactorial, but ICU availability likely contributes to the disparity. Additional studies are necessary to elucidate other contributing mechanisms.
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Affiliation(s)
- David Daniel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Daniel Santos
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Luke Maillie
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
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Tarko L, Costa L, Galloway A, Ho YL, Gagnon D, Lioutas V, Seshadri S, Cho K, Wilson P, Aparicio HJ. Racial and Ethnic Differences in Short- and Long-term Mortality by Stroke Type. Neurology 2022; 98:e2465-e2473. [PMID: 35649728 DOI: 10.1212/wnl.0000000000200575] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 03/01/2022] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Racial and ethnic disparities in stroke outcomes exist, but differences by stroke type are less understood. We studied the association of race and ethnicity with stroke mortality, by stroke type, in a national sample of hospitalized patients in the Veterans Health Administration. METHODS A retrospective observational study was performed including non-Hispanic White, non-Hispanic Black, and Hispanic patients with a first hospitalization for stroke between 2002 and 2012. Stroke was determined using ICD-9 codes and date of death was obtained from the National Death Index. For each of acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), we constructed a piecewise multivariable model for all-cause mortality, using follow-up intervals of ≤30 days, 31-90 days, 91 days to 1 year, and >1 year. RESULTS Among 37,790 patients with stroke (89% AIS, 9% ICH, 2% SAH), 25,492 (67%) were non-Hispanic White, 9,752 (26%) were non-Hispanic Black, and 2,546 (7%) were Hispanic. The cohort was predominantly male (98%). Compared with White patients, Black patients experienced better 30-day survival after AIS (hazard ratio [HR] 0.80, 95% CI 0.73-0.88; 1.4% risk difference) and worse 30-day survival after ICH (HR 1.24, 95% CI 1.06-1.44; 3.2% risk difference). Hispanic patients experienced reduced risk for >1-year mortality after AIS (HR 0.87, 95% CI 0.80-0.94), but had greater risk of 30-day mortality after SAH compared with White patients (HR 1.61, 95% CI 1.03-2.52; 10.3% risk difference). DISCUSSION Among US Veterans, absolute risk of 30-day mortality after ICH was 3.2% higher for Black patients and after SAH was 10.3% higher for Hispanic patients compared with White patients. These findings underscore the importance of investigating stroke outcomes by stroke type to better understand the factors driving observed racial and ethnic disparities.
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Affiliation(s)
- Laura Tarko
- From the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) (L.T., L.C., A.G., Y.-L.H., D.G., V.L., S.S., K.C., H.J.A.), VA Boston Healthcare System; Department of Biostatistics (D.G.), Boston University School of Public Health; Department of Neurology (V.L.), Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Neurology (S.S., H.J.A.), Boston University School of Medicine, MA; Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases (S.S.), University of Texas Health San Antonio; Division of Aging (K.C.), Brigham & Women's Hospital, Harvard Medical School, Boston, MA; Atlanta VA Medical Center (P.W.), Decatur; Division of Cardiology (P.W.), Emory University School of Medicine; Department of Epidemiology (P.W.), Rollins School of Public Health, Emory University, Atlanta, GA; and Boston Medical Center (H.J.A.), MA
| | - Lauren Costa
- From the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) (L.T., L.C., A.G., Y.-L.H., D.G., V.L., S.S., K.C., H.J.A.), VA Boston Healthcare System; Department of Biostatistics (D.G.), Boston University School of Public Health; Department of Neurology (V.L.), Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Neurology (S.S., H.J.A.), Boston University School of Medicine, MA; Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases (S.S.), University of Texas Health San Antonio; Division of Aging (K.C.), Brigham & Women's Hospital, Harvard Medical School, Boston, MA; Atlanta VA Medical Center (P.W.), Decatur; Division of Cardiology (P.W.), Emory University School of Medicine; Department of Epidemiology (P.W.), Rollins School of Public Health, Emory University, Atlanta, GA; and Boston Medical Center (H.J.A.), MA
| | - Ashley Galloway
- From the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) (L.T., L.C., A.G., Y.-L.H., D.G., V.L., S.S., K.C., H.J.A.), VA Boston Healthcare System; Department of Biostatistics (D.G.), Boston University School of Public Health; Department of Neurology (V.L.), Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Neurology (S.S., H.J.A.), Boston University School of Medicine, MA; Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases (S.S.), University of Texas Health San Antonio; Division of Aging (K.C.), Brigham & Women's Hospital, Harvard Medical School, Boston, MA; Atlanta VA Medical Center (P.W.), Decatur; Division of Cardiology (P.W.), Emory University School of Medicine; Department of Epidemiology (P.W.), Rollins School of Public Health, Emory University, Atlanta, GA; and Boston Medical Center (H.J.A.), MA
| | - Yuk-Lam Ho
- From the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) (L.T., L.C., A.G., Y.-L.H., D.G., V.L., S.S., K.C., H.J.A.), VA Boston Healthcare System; Department of Biostatistics (D.G.), Boston University School of Public Health; Department of Neurology (V.L.), Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Neurology (S.S., H.J.A.), Boston University School of Medicine, MA; Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases (S.S.), University of Texas Health San Antonio; Division of Aging (K.C.), Brigham & Women's Hospital, Harvard Medical School, Boston, MA; Atlanta VA Medical Center (P.W.), Decatur; Division of Cardiology (P.W.), Emory University School of Medicine; Department of Epidemiology (P.W.), Rollins School of Public Health, Emory University, Atlanta, GA; and Boston Medical Center (H.J.A.), MA
| | - David Gagnon
- From the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) (L.T., L.C., A.G., Y.-L.H., D.G., V.L., S.S., K.C., H.J.A.), VA Boston Healthcare System; Department of Biostatistics (D.G.), Boston University School of Public Health; Department of Neurology (V.L.), Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Neurology (S.S., H.J.A.), Boston University School of Medicine, MA; Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases (S.S.), University of Texas Health San Antonio; Division of Aging (K.C.), Brigham & Women's Hospital, Harvard Medical School, Boston, MA; Atlanta VA Medical Center (P.W.), Decatur; Division of Cardiology (P.W.), Emory University School of Medicine; Department of Epidemiology (P.W.), Rollins School of Public Health, Emory University, Atlanta, GA; and Boston Medical Center (H.J.A.), MA
| | - Vasileios Lioutas
- From the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) (L.T., L.C., A.G., Y.-L.H., D.G., V.L., S.S., K.C., H.J.A.), VA Boston Healthcare System; Department of Biostatistics (D.G.), Boston University School of Public Health; Department of Neurology (V.L.), Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Neurology (S.S., H.J.A.), Boston University School of Medicine, MA; Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases (S.S.), University of Texas Health San Antonio; Division of Aging (K.C.), Brigham & Women's Hospital, Harvard Medical School, Boston, MA; Atlanta VA Medical Center (P.W.), Decatur; Division of Cardiology (P.W.), Emory University School of Medicine; Department of Epidemiology (P.W.), Rollins School of Public Health, Emory University, Atlanta, GA; and Boston Medical Center (H.J.A.), MA
| | - Sudha Seshadri
- From the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) (L.T., L.C., A.G., Y.-L.H., D.G., V.L., S.S., K.C., H.J.A.), VA Boston Healthcare System; Department of Biostatistics (D.G.), Boston University School of Public Health; Department of Neurology (V.L.), Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Neurology (S.S., H.J.A.), Boston University School of Medicine, MA; Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases (S.S.), University of Texas Health San Antonio; Division of Aging (K.C.), Brigham & Women's Hospital, Harvard Medical School, Boston, MA; Atlanta VA Medical Center (P.W.), Decatur; Division of Cardiology (P.W.), Emory University School of Medicine; Department of Epidemiology (P.W.), Rollins School of Public Health, Emory University, Atlanta, GA; and Boston Medical Center (H.J.A.), MA
| | - Kelly Cho
- From the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) (L.T., L.C., A.G., Y.-L.H., D.G., V.L., S.S., K.C., H.J.A.), VA Boston Healthcare System; Department of Biostatistics (D.G.), Boston University School of Public Health; Department of Neurology (V.L.), Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Neurology (S.S., H.J.A.), Boston University School of Medicine, MA; Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases (S.S.), University of Texas Health San Antonio; Division of Aging (K.C.), Brigham & Women's Hospital, Harvard Medical School, Boston, MA; Atlanta VA Medical Center (P.W.), Decatur; Division of Cardiology (P.W.), Emory University School of Medicine; Department of Epidemiology (P.W.), Rollins School of Public Health, Emory University, Atlanta, GA; and Boston Medical Center (H.J.A.), MA
| | - Peter Wilson
- From the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) (L.T., L.C., A.G., Y.-L.H., D.G., V.L., S.S., K.C., H.J.A.), VA Boston Healthcare System; Department of Biostatistics (D.G.), Boston University School of Public Health; Department of Neurology (V.L.), Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Neurology (S.S., H.J.A.), Boston University School of Medicine, MA; Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases (S.S.), University of Texas Health San Antonio; Division of Aging (K.C.), Brigham & Women's Hospital, Harvard Medical School, Boston, MA; Atlanta VA Medical Center (P.W.), Decatur; Division of Cardiology (P.W.), Emory University School of Medicine; Department of Epidemiology (P.W.), Rollins School of Public Health, Emory University, Atlanta, GA; and Boston Medical Center (H.J.A.), MA
| | - Hugo J Aparicio
- From the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) (L.T., L.C., A.G., Y.-L.H., D.G., V.L., S.S., K.C., H.J.A.), VA Boston Healthcare System; Department of Biostatistics (D.G.), Boston University School of Public Health; Department of Neurology (V.L.), Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Neurology (S.S., H.J.A.), Boston University School of Medicine, MA; Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases (S.S.), University of Texas Health San Antonio; Division of Aging (K.C.), Brigham & Women's Hospital, Harvard Medical School, Boston, MA; Atlanta VA Medical Center (P.W.), Decatur; Division of Cardiology (P.W.), Emory University School of Medicine; Department of Epidemiology (P.W.), Rollins School of Public Health, Emory University, Atlanta, GA; and Boston Medical Center (H.J.A.), MA.
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 395] [Impact Index Per Article: 197.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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Advani R, Faigle R, Ko SB. Editorial: Critical Care After Stroke. Front Neurol 2022; 13:903417. [PMID: 35493821 PMCID: PMC9043444 DOI: 10.3389/fneur.2022.903417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Rajiv Advani
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
- Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
- *Correspondence: Rajiv Advani
| | - Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sang-Bae Ko
- Department of Neurology, Department of Critical Care Medicine, Seoul National University College of Medicine, Seoul, South Korea
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Finley Caulfield A, Mlynash M, Eyngorn I, Lansberg MG, Afjei A, Venkatasubramanian C, Buckwalter MS, Hirsch KG. Prognostication of ICU Patients by Providers with and without Neurocritical Care Training. Neurocrit Care 2022; 37:190-199. [PMID: 35314970 DOI: 10.1007/s12028-022-01467-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 02/04/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Predictions of functional outcome in neurocritical care (NCC) patients impact care decisions. This study compared the predictive values (PVs) of good and poor functional outcome among health care providers with and without NCC training. METHODS Consecutive patients who were intubated for ≥ 72 h with primary neurological illness or neurological complications were prospectively enrolled and followed for 6-month functional outcome. Medical intensive care unit (MICU) attendings, NCC attendings, residents (RES), and nurses (RN) predicted 6-month functional outcome on the modified Rankin scale (mRS). The primary objective was to compare these four groups' PVs of a good (mRS score 0-3) and a poor (mRS score 4-6) outcome prediction. RESULTS Two hundred eighty-nine patients were enrolled. One hundred seventy-six had mRS scores predicted by a provider from each group and were included in the primary outcome analysis. At 6 months, 54 (31%) patients had good outcome and 122 (69%) had poor outcome. Compared with other providers, NCC attendings expected better outcomes (p < 0.001). Consequently, the PV of a poor outcome prediction by NCC attendings was higher (96% [95% confidence interval [CI] 89-99%]) than that by MICU attendings (88% [95% CI 80-93%]), RES (82% [95% CI 74-88%]), and RN (85% [95% CI 77-91%]) (p = 0.047, 0.002, and 0.012, respectively). When patients who had withdrawal of life-sustaining therapy (n = 67) were excluded, NCC attendings remained better at predicting poor outcome (NCC 90% [95% CI 75-97%] vs. MICU 73% [95% CI 59-84%], p = 0.064). The PV of a good outcome prediction was similar among groups (MICU 65% [95% CI 52-76%], NCC 63% [95% CI 51-73%], RES 71% [95% CI 55-84%], and RN 64% [95% CI 50-76%]). CONCLUSIONS Neurointensivists expected better outcomes than other providers and were better at predicting poor functional outcomes. The PV of a good outcome prediction was modest among all providers.
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Affiliation(s)
- Anna Finley Caulfield
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA.
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Irina Eyngorn
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Anousheh Afjei
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Chitra Venkatasubramanian
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
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Seyam M, Weikert T, Sauter A, Brehm A, Psychogios MN, Blackham KA. Utilization of Artificial Intelligence-based Intracranial Hemorrhage Detection on Emergent Noncontrast CT Images in Clinical Workflow. Radiol Artif Intell 2022; 4:e210168. [PMID: 35391777 DOI: 10.1148/ryai.210168] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 01/10/2022] [Accepted: 01/20/2022] [Indexed: 01/23/2023]
Abstract
Authors implemented an artificial intelligence (AI)-based detection tool for intracranial hemorrhage (ICH) on noncontrast CT images into an emergent workflow, evaluated its diagnostic performance, and assessed clinical workflow metrics compared with pre-AI implementation. The finalized radiology report constituted the ground truth for the analysis, and CT examinations (n = 4450) before and after implementation were retrieved using various keywords for ICH. Diagnostic performance was assessed, and mean values with their respective 95% CIs were reported to compare workflow metrics (report turnaround time, communication time of a finding, consultation time of another specialty, and turnaround time in the emergency department). Although practicable diagnostic performance was observed for overall ICH detection with 93.0% diagnostic accuracy, 87.2% sensitivity, and 97.8% negative predictive value, the tool yielded lower detection rates for specific subtypes of ICH (eg, 69.2% [74 of 107] for subdural hemorrhage and 77.4% [24 of 31] for acute subarachnoid hemorrhage). Common false-positive findings included postoperative and postischemic defects (23.6%, 37 of 157), artifacts (19.7%, 31 of 157), and tumors (15.3%, 24 of 157). Although workflow metrics such as communicating a critical finding (70 minutes [95% CI: 54, 85] vs 63 minutes [95% CI: 55, 71]) were on average reduced after implementation, future efforts are necessary to streamline the workflow all along the workflow chain. It is crucial to define a clear framework and recognize limitations as AI tools are only as reliable as the environment in which they are deployed. Keywords: CT, CNS, Stroke, Diagnosis, Classification, Application Domain © RSNA, 2022.
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Affiliation(s)
- Muhannad Seyam
- Department of Diagnostic and Interventional Neuroradiology, Clinic of Radiology and Nuclear Medicine (M.S., A.B., M.N.P., K.A.B.), and Department of Radiology and Nuclear Medicine (T.W., A.S.), University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland; and Department of Neurologic Sciences, University of Vermont Medical Center, Burlington, Vt (M.S.)
| | - Thomas Weikert
- Department of Diagnostic and Interventional Neuroradiology, Clinic of Radiology and Nuclear Medicine (M.S., A.B., M.N.P., K.A.B.), and Department of Radiology and Nuclear Medicine (T.W., A.S.), University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland; and Department of Neurologic Sciences, University of Vermont Medical Center, Burlington, Vt (M.S.)
| | - Alexander Sauter
- Department of Diagnostic and Interventional Neuroradiology, Clinic of Radiology and Nuclear Medicine (M.S., A.B., M.N.P., K.A.B.), and Department of Radiology and Nuclear Medicine (T.W., A.S.), University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland; and Department of Neurologic Sciences, University of Vermont Medical Center, Burlington, Vt (M.S.)
| | - Alex Brehm
- Department of Diagnostic and Interventional Neuroradiology, Clinic of Radiology and Nuclear Medicine (M.S., A.B., M.N.P., K.A.B.), and Department of Radiology and Nuclear Medicine (T.W., A.S.), University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland; and Department of Neurologic Sciences, University of Vermont Medical Center, Burlington, Vt (M.S.)
| | - Marios-Nikos Psychogios
- Department of Diagnostic and Interventional Neuroradiology, Clinic of Radiology and Nuclear Medicine (M.S., A.B., M.N.P., K.A.B.), and Department of Radiology and Nuclear Medicine (T.W., A.S.), University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland; and Department of Neurologic Sciences, University of Vermont Medical Center, Burlington, Vt (M.S.)
| | - Kristine A Blackham
- Department of Diagnostic and Interventional Neuroradiology, Clinic of Radiology and Nuclear Medicine (M.S., A.B., M.N.P., K.A.B.), and Department of Radiology and Nuclear Medicine (T.W., A.S.), University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland; and Department of Neurologic Sciences, University of Vermont Medical Center, Burlington, Vt (M.S.)
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2544] [Impact Index Per Article: 1272.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Peeters MTJ, Vroman F, Schreuder TAHCML, van Oostenbrugge RJ, Staals J. Decrease in incidence of oral anticoagulant-related intracerebral hemorrhage over the past decade in the Netherlands. Eur Stroke J 2022; 7:20-27. [PMID: 35300253 PMCID: PMC8921786 DOI: 10.1177/23969873211062011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022] Open
Abstract
Background Data on oral anticoagulant-related (OAC) intracerebral hemorrhage (ICH) incidence are scarce. Most studies on incidence time trends were performed before the introduction of Direct Oral Anticoagulants (DOACs). Between 2008 and 2018, the number of OAC-users in the Netherlands increased by 63%, with the number of DOAC-users almost equaling that of Vitamin K Antagonists (VKA)-users. We aimed to determine the recent total and OAC-related ICH incidence and assess changes over the last decade, including the effect of DOAC introduction. Methods All adult non-traumatic ICH patients presenting in any of three hospitals in the enclosed region of South-Limburg, the Netherlands, were retrospectively included, during two 3-year time periods: 2007–2009 and 2017–2019. OAC-related ICH was defined as ICH in patients using VKAs or DOACs. We calculated the incidence rate ratio (IRR) between the two study periods. Results In the 2007–2009 period, we registered 652 ICHs of whom 168 (25.8%) were OAC-related (all VKA). In the 2017–2019 period, we registered 522 ICHs, 121 (23.2%) were OAC-related (70 VKA and 51 DOAC). In 2007–2009, the annual incidence of total ICH and OAC-related ICH was 40.9 and 10.5 per 100,000 person-years, respectively, which decreased to 32.4 and 7.5 per 100,000 person-years in 2017–2019. The IRR for total ICH and OAC-related ICH was 0.67 (95%-CI: 0.60–0.75) and 0.58 (0.46–0.73), respectively. Conclusion Both total ICH and OAC-related ICH incidence decreased over the past decade in South-Limburg, the Netherlands, despite the aging population and increasing number of OAC-users. The introduction of DOACs, and possibly an improved cardiovascular risk management and change in OAC prescription pattern, could explain these findings.
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Affiliation(s)
- Michaël TJ Peeters
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
| | - Florence Vroman
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
- Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Center, the Netherlands
| | | | - Robert J van Oostenbrugge
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
| | - Julie Staals
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
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Bako AT, Pan A, Potter T, Tannous J, Johnson C, Baig E, Meeks J, Woo D, Vahidy FS. Contemporary Trends in the Nationwide Incidence of Primary Intracerebral Hemorrhage. Stroke 2022; 53:e70-e74. [PMID: 35109682 DOI: 10.1161/strokeaha.121.037332] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We report contemporary trends in nationwide incidence of intracerebral hemorrhage (ICH) across demographic and regional strata over a 15-year period. METHODS Utilizing the Nationwide Inpatient Sample (2004-2018) and US Census Bureau data, we calculated ICH incidence rates for age, race/ethnicity, sex, and hospital region sub-cohorts across 5 consecutive 3-year periods (2004-2006 to 2016-2018). We fit Poisson and log binomial regression models to evaluate demographic and regional differences in ICH incidence and trends in prevalence of hypertension and past/current anticoagulant use among hospitalized ICH patients. RESULTS Overall, the annual incidence rate (95% CI) of ICH per 100 000 was 23.15 (23.10-23.20). The 3-year incidence of ICH (per 100 000) increased from 62.79 in 2004 to 2006 to 78.86 in 2016 to 2018 (adjusted incidence rate ratio, CI: 1.11 [1.02-1.20]), coinciding with increased 3-year prevalence of hypertension and anticoagulant use among hospitalized ICH patients (adjusted risk ratio, CI: hypertension-1.16 [1.15-1.17]; anticoagulant use-2.30 [2.14-2.47]). We found a significant age-time interaction, whereby ICH incidence increased significantly faster among those aged 18 to 44 years (adjusted incidence rate ratio, CI: 1.10 [1.05-1.14]) and 45 to 64 years (adjusted incidence rate ratio, CI: 1.08 [1.03-1.13]), relative to those aged ≥75 years. CONCLUSIONS Rising ICH incidence among young and middle-aged Americans warrants ICH prevention strategies targeting these economically productive age groups.
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Affiliation(s)
- Abdulaziz T Bako
- Center for Outcomes Research, Houston Methodist, TX (A.T.B., A.P., T.P., J.T., C.J., E.B., J.M., F.S.V.)
| | - Alan Pan
- Center for Outcomes Research, Houston Methodist, TX (A.T.B., A.P., T.P., J.T., C.J., E.B., J.M., F.S.V.)
| | - Thomas Potter
- Center for Outcomes Research, Houston Methodist, TX (A.T.B., A.P., T.P., J.T., C.J., E.B., J.M., F.S.V.)
| | - Jonika Tannous
- Center for Outcomes Research, Houston Methodist, TX (A.T.B., A.P., T.P., J.T., C.J., E.B., J.M., F.S.V.)
| | - Carnayla Johnson
- Center for Outcomes Research, Houston Methodist, TX (A.T.B., A.P., T.P., J.T., C.J., E.B., J.M., F.S.V.)
| | - Eman Baig
- Center for Outcomes Research, Houston Methodist, TX (A.T.B., A.P., T.P., J.T., C.J., E.B., J.M., F.S.V.)
| | - Jennifer Meeks
- Center for Outcomes Research, Houston Methodist, TX (A.T.B., A.P., T.P., J.T., C.J., E.B., J.M., F.S.V.)
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (D.W.)
| | - Farhaan S Vahidy
- Center for Outcomes Research, Houston Methodist, TX (A.T.B., A.P., T.P., J.T., C.J., E.B., J.M., F.S.V.).,Houston Methodist Neurological Institute, TX (F.S.V.).,Weill Cornell Medicine, New York (F.S.V.)
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Sadaf H, Desai VR, Misra V, Golanov E, Hegde ML, Villapol S, Karmonik C, Regnier‐Golanov A, Sayenko D, Horner PJ, Krencik R, Weng YL, Vahidy FS, Britz GW. A contemporary review of therapeutic and regenerative management of intracerebral hemorrhage. Ann Clin Transl Neurol 2021; 8:2211-2221. [PMID: 34647437 PMCID: PMC8607450 DOI: 10.1002/acn3.51443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 06/25/2021] [Accepted: 08/03/2021] [Indexed: 11/27/2022] Open
Abstract
Intracerebral hemorrhage (ICH) remains a common and debilitating form of stroke. This neurological emergency must be diagnosed and treated rapidly yet effectively. In this article, we review the medical, surgical, repair, and regenerative treatment options for managing ICH. Topics of focus include the management of blood pressure, intracranial pressure, coagulopathy, and intraventricular hemorrhage, as well as the role of surgery, regeneration, rehabilitation, and secondary prevention. Results of various phase II and III trials are incorporated. In summary, ICH patients should undergo rapid evaluation with neuroimaging, and early interventions should include systolic blood pressure control in the range of 140 mmHg, correction of coagulopathy if indicated, and assessment for surgical intervention. ICH patients should be managed in dedicated neurosurgical intensive care or stroke units where continuous monitoring of neurological status and evaluation for neurological deterioration is rapidly possible. Extravasation of hematoma may be helpful in patients with intraventricular extension of ICH. The goal of care is to reduce mortality and enable multimodal rehabilitative therapy.
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Affiliation(s)
- Humaira Sadaf
- Punjab Medical CollegeUniversity of Health ScienceFaisalabadPakistan
| | - Virendra R. Desai
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
| | - Vivek Misra
- Department of NeurologyHouston Methodist Neurological InstituteHoustonTexasUSA
| | - Eugene Golanov
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
| | - Muralidhar L. Hegde
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Sonia Villapol
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Christof Karmonik
- Translational Imaging CenterHouston Methodist Research InstituteHoustonTexasUSA
| | | | - Dimitri Sayenko
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Philip J. Horner
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Robert Krencik
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Yi Lan Weng
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Farhaan S. Vahidy
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for Outcomes ResearchHouston Methodist Research InstituteHoustonTexasUSA
| | - Gavin W. Britz
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
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45
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Binder H, Majdan M, Leitgeb J, Payr S, Breuer R, Hajdu S, Tiefenboeck TM. Management and Outcome of Traumatic Intracerebral Hemorrhage in 79 Infants and Children from a Single Level 1 Trauma Center. CHILDREN (BASEL, SWITZERLAND) 2021; 8:854. [PMID: 34682119 PMCID: PMC8534601 DOI: 10.3390/children8100854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Traumatic brain injury is a leading form of pediatric trauma and a frequent cause of mortality and acquired neurological impairment in children. The aim of this study was to present the severity and outcomes of traumatic intracerebral bleeding in children and adolescence. METHODS Seventy-nine infants and children with intracerebral bleedings were treated between 1992 and 2020 at a single level 1 trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. The Glasgow Outcome Scale was used to classify the outcome at hospital discharge and at follow-up visits. CT scans of the brain were classified according to the Rotterdam score. RESULTS In total, 41 (52%) patients with intracerebral bleedings were treated surgically, and 38 (48%) patients were treated conservatively; in 15% of the included patients, delayed surgery was necessary. Patients presenting multiple trauma (p < 0.04), higher ISS (p < 0.01), poor initial neurological status (p < 0.001) and a higher Rotterdamscore (p = 0.038) were significantly more often treated surgically. Eighty-three percent of patients were able to leave the hospital, and out of these patients, about 60% showed good recovery at the latest follow-up visit. Overall, 11 patients (14%) died. CONCLUSION The findings in this study verified intracerebral bleeding as a rare but serious condition. Patients presenting with multiple traumas, higher initial ISS, poor initial neurological status and a higher Rotterdamscore were more likely treated by surgery. TRIAL REGISTRATION (researchregistry 2686).
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Affiliation(s)
- Harald Binder
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, 91701 Trnava, Slovakia;
| | - Johannes Leitgeb
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, 91701 Trnava, Slovakia;
| | - Stephan Payr
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Robert Breuer
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Stefan Hajdu
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Thomas M. Tiefenboeck
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
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Pedersen TGB, Vinter N, Schmidt M, Frost L, Cordsen P, Andersen G, Johnsen SP. Trends in the incidence and mortality of intracerebral hemorrhage, and the associated risk factors, in Denmark from 2004 to 2017. Eur J Neurol 2021; 29:168-177. [PMID: 34528344 DOI: 10.1111/ene.15110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The distribution of the major modifiable risk factors for intracerebral hemorrhage (ICH) changes rapidly. These changes call for contemporary data from large-scale population-based studies. The aim of the present study was to examine trends in incidence, risk factors, and mortality in ICH patients from 2004 to 2017. METHODS In a population-based cohort study, we calculated age- and sex-standardized incidence rates (SIRs), incidence rates (IRs) stratified by age and sex per 100,000 person-years, and trends in risk profiles. We estimated absolute mortality risk, and the Cox proportional hazards regression multivariable-adjusted hazard ratios for 30-day and 1-year mortality. RESULTS We included 16,902 patients (53% men; median age 75 years) from 2004 to 2017. The SIR of ICH decreased from 33 (95% confidence interval [CI] 32-34) in 2004/2005 to 28 (95% CI 27-29) in 2016/2017. Among patients aged ≥70 years, the IR decreased from 137 (95% CI 130-144) in 2004/2005 to 112 (95% CI 106-117) in 2016/2017. The IR in patients aged <70 years was unchanged. From 2004 to 2017, the proportion of patients with hypertension increased from 49% to 66%, the use of oral anticoagulants increased from 7% to 18%, and the use of platelet inhibitors decreased from 40% to 28%. The adjusted hazard ratio for 30-day mortality in 2016/2017 was 0.94 (95% CI 0.89-1.01) and 1-year mortality was 0.98 (95% CI 0.93-1.04) compared with 2004/2005. CONCLUSION The incidence of spontaneous ICH decreased from 2004 to 2017, with no clear trend in mortality. The risk profile of ICH patients changed substantially, with increasing proportions of hypertension and anticoagulant treatment. Given the high mortality rate of ICH, further advances in prevention and treatment are urgently needed.
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Affiliation(s)
- Tine Glavind Bülow Pedersen
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Nicklas Vinter
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Morten Schmidt
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Cardiology, Regional Hospital West Jutland, Herning, Denmark
| | - Lars Frost
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Pia Cordsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Grethe Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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47
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Carlsson M, Wilsgaard T, Johnsen SH, Johnsen LH, Løchen ML, Njølstad I, Mathiesen EB. Long-Term Survival, Causes of Death, and Trends in 5-Year Mortality After Intracerebral Hemorrhage: The Tromsø Study. Stroke 2021; 52:3883-3890. [PMID: 34496620 DOI: 10.1161/strokeaha.120.032750] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Data on long-term survival after intracerebral hemorrhage (ICH) are scarce. In a population-based nested case-control study, we compared long-term survival and causes of death within 5 years in 30-day survivors of first-ever ICH and controls, assessed the impact of cardiovascular risk factors on 5-year mortality, and analyzed time trend in 5-year mortality in ICH patients over 2 decades. METHODS We included 219 participants from the population-based Tromsø Study, who after the baseline participation had a first-ever ICH between 1994 to 2013 and 1095 age- and sex-matched participants without ICH. Cumulative survival was presented using the Kaplan-Meier method. Hazard ratios (HRs) for mortality and for the association between cardiovascular risk factors and 5-year mortality in 30-day survivors were estimated by stratified Cox proportional hazards models. Trend in 5-year mortality was assessed by logistic regression. RESULTS Risk of death during follow-up (median time, 4.8 years) was increased in the ICH group compared with controls (HR, 1.62 [95% CI, 1.27-2.06]). Cardiovascular disease was the leading cause of death, with a higher proportion in ICH patients (22.9% versus 9.0%; P<0.001). Smoking increased the risk of 5-year mortality in cases and controls (HR, 1.59 [95% CI, 1.15-2.19]), whereas serum cholesterol was associated with 5-year mortality in cases only (HR, 1.39 [95% CI, 1.04-1.86]). Use of anticoagulants at ICH onset increased the risk of death (HR, 2.09 [95% CI, 1.09-4.00]). There was no difference according to ICH location (HR, 1.15 [95% CI, 0.56-2.37]). Five-year mortality did not change during the study period (odds ratio per calendar year, 1.01 [95% CI, 0.93-1.09]). CONCLUSIONS Survival rates were significantly lower in cases than in controls, driven by a 2-fold increased risk of cardiovascular death. Smoking, serum cholesterol, and use of anticoagulant drugs were associated with increased risk of death in ICH patients. Five-year mortality rates in ICH patients remained stable over time.
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Affiliation(s)
- Maria Carlsson
- Department of Clinical Medicine (M.C., S.H.J., L.-H.J., E.B.M.), UiT The Arctic University of Norway, Tromsø.,Department of Neurology, Nordland Hospital Trust, Bodø, Norway (M.C.)
| | - Tom Wilsgaard
- Department of Community Medicine (T.W., M.-L.L., I.N.), UiT The Arctic University of Norway, Tromsø
| | - Stein Harald Johnsen
- Department of Clinical Medicine (M.C., S.H.J., L.-H.J., E.B.M.), UiT The Arctic University of Norway, Tromsø.,Department of Neurology (S.H.J., E.B.M.), University Hospital of North Norway, Tromsø
| | - Liv-Hege Johnsen
- Department of Clinical Medicine (M.C., S.H.J., L.-H.J., E.B.M.), UiT The Arctic University of Norway, Tromsø.,Department of Radiology (L.-H.J.), University Hospital of North Norway, Tromsø
| | - Maja-Lisa Løchen
- Department of Community Medicine (T.W., M.-L.L., I.N.), UiT The Arctic University of Norway, Tromsø
| | - Inger Njølstad
- Department of Community Medicine (T.W., M.-L.L., I.N.), UiT The Arctic University of Norway, Tromsø
| | - Ellisiv B Mathiesen
- Department of Clinical Medicine (M.C., S.H.J., L.-H.J., E.B.M.), UiT The Arctic University of Norway, Tromsø.,Department of Neurology (S.H.J., E.B.M.), University Hospital of North Norway, Tromsø
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Beynon C, Bernhard M, Brenner T, Dietrich M, Fiedler MO, Nusshag C, Weigand MA, Reuß CJ, Michalski D, Jungk C. [Neurosurgical intensive care medicine : Intensive medical care studies from 2020/2021]. Anaesthesist 2021; 70:789-794. [PMID: 34378066 DOI: 10.1007/s00101-021-00978-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/20/2022]
Affiliation(s)
- C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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49
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Mansour A, Loggini A, El Ammar F, Alvarado-Dyer R, Polster S, Stadnik A, Das P, Warnke PC, Yamini B, Lazaridis C, Kramer C, Mould WA, Hildreth M, Sharrock M, Hanley DF, Goldenberg FD, Awad IA. Post-Trial Enhanced Deployment and Technical Performance with the MISTIE Procedure per Lessons Learned. J Stroke Cerebrovasc Dis 2021; 30:105996. [PMID: 34303090 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/04/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We hypothesize that procedure deployment rates and technical performance with minimally invasive surgery and thrombolysis for intracerebral hemorrhage (ICH) evacuation (MISTIE) can be enhanced in post-trial clinical practice, per Phase III trial results and lessons learned. MATERIALS AND METHODS We identified ICH patients and those who underwent MISTIE procedure between 2017-2021 at a single site, after completed enrollments in the Phase III trial. Deployment rates, complications and technical outcomes were compared to those observed in the trial. Initial and final hematoma volume were compared between site measurements using ABC/2, MISTIE trial reading center utilizing manual segmentation, and a novel Artificial Intelligence (AI) based volume assessment. RESULTS Nineteen of 286 patients were eligible for MISTIE. All 19 received the procedure (6.6% enrollment to screening rate 6.6% compared to 1.6% at our center in the trial; p=0.0018). Sixteen patients (84%) achieved evaculation target < 15 mL residual ICH or > 70% removal, compared to 59.7% in the trial surgical cohort (p=0.034). No poor catheter placement occurred and no surgical protocol deviations. Limitations of ICH volume assessments using the ABC/2 method were shown, while AI based methodology of ICH volume assessments had excellent correlation with manual segmentation by experienced reading centers. CONCLUSIONS Greater procedure deployment and higher technical success rates can be achieved in post-trial clinical practice than in the MISTIE III trial. AI based measurements can be deployed to enhance clinician estimated ICH volume. Clinical outcome implications of this enhanced technical performance cannot be surmised, and will need assessment in future trials.
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Affiliation(s)
- Ali Mansour
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Andrea Loggini
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Faten El Ammar
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Ronald Alvarado-Dyer
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Sean Polster
- Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Agnieszka Stadnik
- Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Paramita Das
- Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Peter C Warnke
- Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Bakhtiar Yamini
- Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christopher Kramer
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - W Andrew Mould
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA.
| | - Meghan Hildreth
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA.
| | - Matthew Sharrock
- Division of Neurocritical Care, Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA.
| | - Fernando D Goldenberg
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Issam A Awad
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
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50
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Li L, Zuurbier SM, Kuker W, Warlow CP, Rothwell PM. Blood Pressure Control and Recurrent Stroke After Intracerebral Hemorrhage in 2002 to 2018 Versus 1981 to 1986: Population-Based Study. Stroke 2021; 52:3243-3248. [PMID: 34233466 PMCID: PMC8478103 DOI: 10.1161/strokeaha.121.034432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. The PROGRESS trial (Perindopril Protection Against Recurrent Stroke Study) conducted in the early 1990s showed that blood pressure (BP) lowering therapy reduced the risks of recurrent stroke by about 50% after spontaneous intracerebral hemorrhage (ICH). However, the ICH subgroup was a minority, and trial cohorts are invariably selective. Therefore, it is unclear whether the impact of BP control on risk of recurrent stroke in ICH observed in PROGRESS would be as great in real-world practice.
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Affiliation(s)
- Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom (L.L., S.M.Z., W.K., C.P.W., P.M.R.)
| | - Susanna M Zuurbier
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom (L.L., S.M.Z., W.K., C.P.W., P.M.R.)
| | - Wilhelm Kuker
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom (L.L., S.M.Z., W.K., C.P.W., P.M.R.)
| | - Charles P Warlow
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom (L.L., S.M.Z., W.K., C.P.W., P.M.R.).,Department of Clinical Neurosciences, University of Edinburgh, United Kingdom (C.P.W.)
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom (L.L., S.M.Z., W.K., C.P.W., P.M.R.)
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