Aspirin-associated intracerebral hemorrhage: clinical and radiologic features

Influence of Tau on Neurotoxicity and Cerebral Vasculature Impairment Associated with Alzheimer's Disease

Alzheimer's disease is a fatal chronic neurodegenerative condition marked by a gradual decline in cognitive abilities and impaired vascular function within the central nervous system. This affliction initiates its insidious progression with the accumulation of two aberrant protein entities including Aβ plaques and neurofibrillary tangles. These chronic elements target distinct brain regions, steadily erasing the functionality of the hippocampus and triggering the erosion of memory and neuronal integrity. Several assumptions are anticipated for AD as genetic alterations, the occurrence of Aβ plaques, altered processing of amyloid precursor protein, mitochondrial damage, and discrepancy of neurotropic factors. In addition to Aβ oligomers, the deposition of tau hyper-phosphorylates also plays an indispensable part in AD etiology. The brain comprises a complex network of capillaries that is crucial for maintaining proper function. Tau is expressed in cerebral blood vessels, where it helps to regulate blood flow and sustain the blood-brain barrier's integrity. In AD, tau pathology can disrupt cerebral blood supply and deteriorate the BBB, leading to neuronal neurodegeneration. Neuroinflammation, deficits in the microvasculature and endothelial functions, and Aβ deposition are characteristically detected in the initial phases of AD. These variations trigger neuronal malfunction and cognitive impairment. Intracellular tau accumulation in microglia and astrocytes triggers deleterious effects on the integrity of endothelium and cerebral blood supply resulting in further advancement of the ailment and cerebral instability. In this review, we will discuss the impact of tau on neurovascular impairment, mitochondrial dysfunction, oxidative stress, and the role of hyperphosphorylated tau in neuron excitotoxicity and inflammation.

Acute Spontaneous Subdural Hematoma in a Patient With an End-Stage Renal Disease After Starting Dual Antiplatelet Therapy Post Drug-Eluting Stent Insertion: A Case Report

Dual antiplatelet therapy (DAPT) has been widely utilized for secondary prevention in patients with cardiovascular diseases, such as post-drug eluting stent insertion, stroke, and peripheral vascular disease. The occurrence of bleeding complications, including intracranial hemorrhage, has been extensively studied in relation to DAPT. However, the occurrence of acute spontaneous subdural hematomas in this context is relatively rare. These hematomas can manifest through various symptoms, including altered mental status (AMS) and confusion. The risk of intracranial hemorrhage is particularly higher in patients receiving aspirin with ticagrelor, especially in those with reduced estimated glomerular filtration rate (eGFR) and liver disease. In this case report, we present the case of a patient with end-stage renal disease undergoing peritoneal hemodialysis and a remote history of liver transplant. The patient presented to the hospital with chest pain, subsequently underwent drug-eluting stent placement, and was initiated on DAPT. Following the initiation of DAPT, the patient developed confusion and was diagnosed with an acute spontaneous subdural hematoma. The patient underwent middle meningeal artery embolization to manage the hematoma.

Development and validation of risk prediction models for stroke and mortality among patients with type 2 diabetes in northern China

BACKGROUND

Stroke is one of the leading causes of disability and mortality in patients with type 2 diabetes mellitus (T2DM). Risk models have been developed for predicting stroke and stroke-associated mortality among patients with T2DM. Here, we evaluated risk factors of stroke for individualized prevention measures in patients with T2DM in northern China.

METHODS

In the community-based Tianjin Chronic Disease Cohort study, 58,042 patients were enrolled between January 2014 and December 2019. We used multiple imputation (MI) to impute missing variables and univariate and multivariate Cox's proportional hazard regression to screen risk factors of stroke. Furthermore, we established and validated first-ever prediction models for stroke (Model 1 and Model 2) and death from stroke (Model 3) and evaluated their performance.

RESULTS

In the derivation and validation groups, the area under the curves (AUCs) of Models 1-3 was better at 5 years than at 8 years. The Harrell's C-index for all models was above 0.7. All models had good calibration, discrimination, and clinical net benefit. Sensitivity analysis using the MI dataset indicated that all models had good and stable prediction performance.

CONCLUSION

In this study, we developed and validated first-ever risk prediction models for stroke and death from stroke in patients with T2DM, with good discrimination and calibration observed in all models. Based on lifestyle, demographic characteristics, and laboratory examination, these models could provide multidimensional management and individualized risk assessment. However, the models developed here may only be applicable to Han Chinese.

Development and validation of a risk prediction model for the recurrence of foot ulcer in type 2 diabetes in China: A longitudinal cohort study based on a systematic review and meta-analysis

AIMS

To develop and validate a risk prediction model for Chinese patients with type 2 diabetes with the recurrence of diabetic foot ulcers (DFUs) based on a systematic review and meta-analysis.

METHODS

A prospective analysis was performed with 1333 participants and followed up for 60 months. Three models were analysed using a derived cohort. The risk factors were screened using meta-analysis and logistic regression, and the missing variables were interpolated by multiple imputation. The internal validation was performed using the bootstrap procedure, and the validation cohort was applied to the external validation. The performance of the model was evaluated in the area under the discrimination Receiver Operating Characteristic Curve (ROC). Calibration and discrimination methods were used for the validation cohort. The variables were selected according to their clinical and statistical importance to construct the nomograms.

RESULTS

Three models were developed and validated. Model 1 included seven social and clinical indicators like sex, diabetes mellitus duration, previous DFU, location of ulcer, smoking, history of amputation, and foot deformity. Model 2 included four more indicators besides those in Model 1, which were statin agents used, antiplatelet agents used, systolic blood pressure, and body mass index. Model 3 added further laboratory indicators to Model 2, such as LDL-C, HbA1C, fibrinogen, and blood urea nitrogen. In the derivation cohort, 20.1% (206/1027) participants with DFU recurred as compared to the validation cohort, which was 38.2% (117/306). The areas under the curve in the derivation cohort for Models 1-3 were 0.781 (0.744-0.817), 0.843 (0.813-0.873), and 0.899 (0.876-0.922), respectively. The Youden indexes for Models 1-3 were 0.430, 0.559, and 0.653, respectively. Model 3 showed the highest sensitivity and specificity. All models performed well for both discrimination and calibration.

CONCLUSIONS

Models 1-2 were non-invasive, which indicate their role in general screening for patients at a high risk of recurrence of DFU. However, Model 3 offers a more specific screening due to its best performance in predicting the risk of DFU recurrence amongst the three models.

Spontaneous subdural hematoma in a patient receiving dual antiplatelet therapy following percutaneous coronary intervention: A case report

Introduction

and importance: Dual antiplatelet therapy with clopidogrel and aspirin is routinely prescribed after coronary artery stenting, plays a critical role in secondary prevention among patients with acute coronary syndrome and has decreased the rates of re-infarction and stent thrombosis after percutaneous coronary intervention, but they are prone to internal bleeding. Intracranial hemorrhage is the most serious bleeding complication in a patient put on antiplatelet therapy following PCI. Acute spontaneous subdural hematoma (ASSDH) without trauma is a rare event, which needs to be promptly recognized and managed.

Case presentation

In this mini-review, we report a case of a 71-year-old man who represented spontaneous acute subdural hematoma receiving dual antiplatelet (aspirin and clopidogrel) following percutaneous coronary intervention for acute coronary syndrome. Rapid discontinuation of all of the antiplatelet drugs and hematoma evacuation were performed with good postoperative evolution.

Clinical discussion

Management of hemorrhagic patients under antithrombotic therapy is very difficult. Resuming the treatment could lead to recurrence bleeding, on the other hand, suspension or stopping of treatment could expand the thrombotic risk. ASSDH after PCI is true diagnostic then therapeutic emergency, especially in patients with rapid neurological degradation. Treatment may be managed by nonoperative conservative approach in selected cases.

Conclusion

Spontaneous subdural hematoma is a rare, serious entity, although it can engage the functional and vital prognosis of the patient, hence the interest of diagnosis and prompt treatment to improve the prognosis.

Gastrodia elata Blume and Zanthoxylum schinifolium Siebold & Zucc Mixed Extract Suppress Platelet Aggregation and Thrombosis

Background and objectives: Blood vessel thrombosis causes blood circulation disorders, leading to various diseases. Currently, various antiplatelet and anticoagulant drugs, such as aspirin, warfarin, heparin, and non-vitamin K antagonist oral anticoagulants (NOACs), are used as the major drugs for the treatment of a wide range of thrombosis. However, these drugs have a side effect of possibly causing internal bleeding due to poor hemostasis when taken for a long period of time. Materials and Methods: Gastrodia elata Blume (GE) and Zanthoxylum schinifolium Siebold & Zucc (ZS) are known to exhibit hemostatic and antiplatelet effects as traditional medicines that have been used for a long time. In this study, we investigated the effect of a mixed extract of GE and ZS (MJGE09) on platelet aggregation and plasma coagulation. Results: We found that MJGE09 inhibited collagen-and ADP-induced platelet aggregation in vitro. In addition, collagen- and ADP-induced platelet aggregation were also inhibited in a dose-dependent manner on the platelets of mice that were orally administered MJGE09 ex vivo. However, compared with aspirin, MJGE09 did not prolong the rat tail vein bleeding time in vivo and did not show a significant effect on the increase in the prothrombin time (PT) and activated partial thromboplastin time (aPTT). Conclusions: These results suggest that MJGE09 can be used as a potential anticoagulant with improved antithrombotic efficacy.

A practical approach to the management of cerebral amyloid angiopathy

Cerebral amyloid angiopathy is a common small vessel disease in the elderly involving vascular amyloid-β deposition. Cerebral amyloid angiopathy is one of the leading causes of intracerebral hemorrhage and a significant contributor to age-related cognitive decline. The awareness of a diagnosis of cerebral amyloid angiopathy is important in clinical practice as it impacts decisions to use lifelong anticoagulation or nonpharmacological alternatives to anticoagulation such as left atrial appendage closure in patients who have concurrent atrial fibrillation, another common condition in older adults. This review summarizes the latest literature regarding the management of patients with sporadic cerebral amyloid angiopathy, including diagnostic criteria, imaging biomarkers for cerebral amyloid angiopathy severity, and management strategies to decrease intracerebral hemorrhage risk. In a minority of patients, the presence of cerebral amyloid angiopathy triggers an autoimmune inflammatory reaction, referred to as cerebral amyloid angiopathy-related inflammation, which is often responsive to immunosuppressive treatment in the acute phase. Diagnosis and management of cerebral amyloid angiopathy-related inflammation will be presented separately. While there are currently no effective therapeutics available to cure or halt the progression of cerebral amyloid angiopathy, we discuss emerging avenues for potential future interventions.

The Impact of Antiplatelet Use on the Risk of Intracerebral Hemorrhage in Patients with Alzheimer's Disease: A Nationwide Cohort Study

BACKGROUND

Antiplatelet use on the risk of intracerebral hemorrhage (ICH) in patients with Alzheimer's disease (AD) has not yet been completely elucidated.

OBJECTIVE

This large epidemiologic study aims to estimate the risk of ICH in AD patients treated with antiplatelet therapy (APT).

METHODS

Using data from Taiwan's National Health Insurance Research Database, ICH risk in APT-treated AD patients with a validated diagnosis (N = 824) was determined. AD without APT and non-AD with and without APT comparison cohorts were selected. To adjust for confounders and competing risk of death, inverse probability of treatment weighting using propensity scores and competing risks regression (CRR) were applied. Cox proportional hazards regression analysis estimated ICH risk in all cohorts comparing with non-AD without APT.

RESULTS

Among the 824 AD patients with APT, 79.6% were prescribed aspirin. ICH incidence rates in the AD (with/without APT) and non-AD (with/without APT) cohorts were 2.88/2.70 and 2.24/1.20 per 1,000 person-years, respectively. Overall, AD with (adjusted hazards ratio (aHR), 2.29; 95% CI, 1.19-4.38) and without (aHR, 1.97; 95% CI, 1.08-3.61) APT and non-AD with APT (aHR, 1.80; 95% CI, 1.34-2.42) were at a higher risk and had elevated subdistribution HR obtained from CRR than non-AD without APT controls. However, the risk was comparable between the AD cohorts with and without APT (HR, 1.16; 95% CI, 0.51-2.66).

CONCLUSIONS

Our study indicated both the APT and non-APT users in AD population yielded higher ICH risks. However, whether APT use potentiate the risk of ICH in AD patients may warrant further evaluation.

Incidental De Novo Cerebral Microhemorrhages are Predictive of Future Symptomatic Macrohemorrhages After Surgical Revascularization in Moyamoya Disease

BACKGROUND

Patients with moyamoya disease who develop incidental cerebral microhemorrhages (CMHs) on magnetic resonance imaging (MRI) have higher risk of developing subsequent symptomatic repeat macro hemorrhages.

OBJECTIVE

To evaluate the effect of surgical revascularization on development of de novo CMHs and assess its correlation with repeat hemorrhage rates and functional outcome in hemorrhagic onset moyamoya disease (HOMMD).

METHODS

We retrospectively reviewed a prospectively managed departmental database of all patients presenting with HOMMD treated between 1987 and 2019. The search yielded 121 patients with adequate MRI follow-up for inclusion into the study.

RESULTS

In total, 42 preoperative CMHs were identified in 18 patients (15%). Patients presenting with preoperative CMH were more likely to develop de novo CMH after surgical revascularization. 7 de novo CHMs were identified in 6 patients (5%) on routine postoperative MRI at distinct locations from previous sites of hemorrhage or CMH. Symptomatic repeat macro hemorrhage was confirmed radiographically in 15 patients (12%). A total 5 (83%) of 6 patients with de novo CMHs later suffered symptomatic repeat macro hemorrhage with 4 of 5 (80%) hemorrhages occurring at sites of previous CMH. On univariate and multivariate analysis, de novo CMHs was the only significant variable predictive for developing repeat symptomatic hemorrhage. Development of delayed repeat symptomatic hemorrhage was prognostic for higher modified Rankin Score and therefore poorer functional status, whereas preoperative functional status was predictive of final outcome.

CONCLUSION

De novo CMHs after surgical revascularization might serve as a radiographic biomarker for refractory disease and suggest patients are at risk for future symptomatic macro hemorrhage.

An Integrated View on Vascular Dysfunction in Alzheimer's Disease

BACKGROUND

Cerebrovascular disease is a common comorbidity in patients with Alzheimer's disease (AD). It is believed to contribute additively to the cognitive impairment and to lower the threshold for the development of dementia. However, accumulating evidence suggests that dysfunction of the cerebral vasculature and AD neuropathology interact in multiple ways. Vascular processes even proceed AD neuropathology, implicating a causal role in the etiology of AD. Thus, the review aims to provide an integrated view on vascular dysfunction in AD.

SUMMARY

In AD, the cerebral vasculature undergoes pronounced cellular, morphological and structural changes, which alters regulation of blood flow, vascular fluid dynamics and vessel integrity. Stiffening of central blood vessels lead to transmission of excessive pulsatile energy to the brain microvasculature, causing end-organ damage. Moreover, a dysregulated hemostasis and chronic vascular inflammation further impede vascular function, where its mediators interact synergistically. Changes of the cerebral vasculature are triggered and driven by systemic vascular abnormalities that are part of aging, and which can be accelerated and aggravated by cardiovascular diseases. Key Messages: In AD, the cerebral vasculature is the locus where multiple pathogenic processes converge and contribute to cognitive impairment. Understanding the molecular mechanism and pathophysiology of vascular dysfunction in AD and use of vascular blood-based and imaging biomarker in clinical studies may hold promise for future prevention and therapy of the disease.

Prior Antithrombotic Therapy Is Associated With Cerebral Microbleeds in Ischemic Stroke Patients With Atrial Fibrillation and/or Rheumatic Heart Disease

Background and purpose: Cerebral microbleeds (CMBs) could contribute to an increased risk of intracerebral hemorrhage in patients with antithrombotic therapy (antiplatelets or anticoagulants). Antithrombotic agents are commonly prescribed to the patients with atrial fibrillation (AF) and/or rheumatic heart disease (RHD) for preventing ischemic stroke. However, the impact of antithrombotic therapy on CMBs remained controversial. We aimed to explore the association between the prevalence of CMBs and prior antithrombotic therapy in ischemic stroke patients with AF and/or RHD.

Materials and Methods: Ischemic stroke patients with AF and/or RHD within 7 days of onset from two hospitals were enrolled. Clinical information, prior use of antiplatelets or anticoagulation, presence and location of CMBs on susceptibility weighted imaging were recorded. We investigated the association of antithrombotic use with the presence or location of CMBs using multivariable logistic regression.

Results: A total of 160 patients (68 males; median age, 71 years) were included. CMBs were observed in 90 (56.3%) patients, of whom 37 were with strictly lobar CMBs and 53 were with deep or infratentorial CMBs. There was a significant difference in antiplatelet use between patients with and without CMBs (33.3 vs. 11.4%, P = 0.001), but not found in anticoagulants. Prior use of antiplatelets was independently associated with the presence of CMBs (OR 3.075, 95% CI 1.175–8.045, P = 0.022) and especially strictly lobar CMBs (OR 2.635, 95% CI 1.050–6.612, P = 0.039) in multivariate analysis.

Conclusions: The present study suggests that CMBs are common in ischemic stroke patients with AF and/or RHD and prior antiplatelet use may relate to the presence of CMBs predominantly in the strictly lobar region. Whether anticoagulants could cause CMBs need to be determined in future longitudinal studies.

Aspirin treatment does not increase microhemorrhage size in young or aged mice

Microhemorrhages are common in the aging brain and are thought to contribute to cognitive decline and the development of neurodegenerative diseases, such as Alzheimer’s disease. Chronic aspirin therapy is widespread in older individuals and decreases the risk of coronary artery occlusions and stroke. There remains a concern that such aspirin usage may prolong bleeding after a vessel rupture in the brain, leading to larger bleeds that cause more damage to the surrounding tissue. Here, we aimed to understand the influence of aspirin usage on the size of cortical microhemorrhages and explored the impact of age. We used femtosecond laser ablation to rupture arterioles in the cortex of both young (2–5 months old) and aged (18–29 months old) mice dosed on aspirin in their drinking water and measured the extent of penetration of both red blood cells and blood plasma into the surrounding tissue. We found no difference in microhemorrhage size for both young and aged mice dosed on aspirin, as compared to controls (hematoma diameter = 104 +/- 39 (97 +/- 38) μm in controls and 109 +/- 25 (101 +/- 28) μm in aspirin-treated young (aged) mice; mean +/- SD). In contrast, young mice treated with intravenous heparin had an increased hematoma diameter of 136 +/- 44 μm. These data suggest that aspirin does not increase the size of microhemorrhages, supporting the safety of aspirin usage.

Cerebral Amyloid Angiopathy in Stroke Medicine

BACKGROUND

Cerebral amyloid angiopathy (CAA) is a degenerative vasculopathy that is classically associated with lobar intracerebral or sulcal hemorrhage. Its prevalence is estimated at 30% in the seventh decade and 50% in the eighth and ninth decades. In this review, we summarize the risks linked to CAA with respect to the treatment and prevention of stroke.

METHODS

This review is based on pertinent publications retrieved by a selective search employing the terms "amyloid cerebral angiopathy," "stroke," "intra - cerebral bleeding," and "acute stroke therapy."

RESULTS

Among patients given systemic lytic treatment for stroke, those who have microhemorrhages tend to have a higher risk of treatment-associated brain hemorrhage. In a meta-analysis, 70% of patients who sustained a hemorrhage after thrombolytic therapy were found to have CAA, compared to only 22% in a control population. Patients with cerebral hemorrhages have microhemorrhages more commonly than patients with transient ischemic attacks (TIA) or infarcts. This was observed among persons under treatment with vitamin K antagonists (odds ratio, 2.7) or platelet aggregation inhibitors (odds ratio, 1.7). Moreover, the apolipoprotein E2 allele is associated with a higher incidence of intracerebral hemorrhage (ICH) under oral anticoagulation. Strict treatment of arterial hypertension can lower the risk of ICH in persons with probable CAA by 77%. On the other hand, the use of statins after a lobar ICH increases the risk for a clinically manifest recurrent hemorrhage from 14% to 22%.

CONCLUSION

In patients with CAA, arterial hypertension should be tightly controlled. On the other hand, caution should be exercised in prescribing oral anticoagulants or platelet aggregation inhibitors for patients with CAA, or statins for patients who have already sustained a lobar ICH.

Spontaneous subdural hematoma and antiplatelet therapy: Does efficacy of Ticagrelor come with added risk?

Antiplatelet therapy has established clinical benefit on cardiovascular outcome and has reduced the rates of re-infarction/in stent thrombosis following percutaneous coronary intervention in acute coronary syndromes. Major bleeding episodes can occur with antiplatelet therapy and intracranial hemorrhage (ICH) is one of the most feared complications resulting in significant morbidity and mortality. Identification of high risk groups and judicious use of antiplatelet therapy reduces the bleeding risk. Ticagrelor is a newer P2Y12 receptor antagonist with established clinical benefit. However, risks of having an ICH with these newer molecules cannot be ignored. Here, we report a case of spontaneous acute subdural hematoma developing in a patient on antiplatelet therapy with aspirin and ticagrelor. Early recognition, discontinuation of the medication and appropriate management resulted in resolution of hematoma and good clinical outcome. Authors have reviewed the antithrombotic drugs and their tendencies in causing intracranial bleeds from a neurophysicians perspective.

Aspirin and intracerebral hemorrhage: Where are we now?

For the past 3 decades, aspirin has been widely used for prevention of ischemic stroke and myocardial infarction. Although the evidence supporting the effectiveness of aspirin in prevention of vascular events is clear, data regarding the risk of acute and recurrent intracerebral hemorrhage related to the use of this medication have been conflicting. We review past and contemporary data on aspirin use in relation to intracerebral hemorrhage.

Cerebral microbleeds: a review of clinical, genetic, and neuroimaging associations

Cerebral microbleeds (microbleeds) are small, punctuate hypointense lesions seen in T2* Gradient-Recall Echo (GRE) and Susceptibility-Weighted (SWI) Magnetic Resonance Imaging (MRI) sequences, corresponding to areas of hemosiderin breakdown products from prior microscopic hemorrhages. They occur in the setting of impaired small vessel integrity, commonly due to either hypertensive vasculopathy or cerebral amyloid angiopathy. Microbleeds are more prevalent in individuals with Alzheimer’s disease (AD) dementia and in those with both ischemic and hemorrhagic stroke. However they are also found in asymptomatic individuals, with increasing prevalence with age, particularly in carriers of the Apolipoprotein (APOE) ε4 allele. Other neuroimaging findings that have been linked with microbleeds include lacunar infarcts and white matter hyperintensities on MRI, and increased cerebral β-amyloid burden using ¹¹C-PiB Positron Emission Tomography. The presence of microbleeds has been suggested to confer increased risk of incident intracerebral hemorrhage – particularly in the setting of anticoagulation – and of complications of immunotherapy for AD. Prospective data regarding the natural history and sequelae of microbleeds are currently limited, however there is a growing evidence base that will serve to inform clinical decision-making in the future.

Cerebral microbleeds: their associated factors, radiologic findings, and clinical implications

Cerebral microbleeds (CMBs) are tiny, round dark-signal lesions that are most often detected on gradient-echo MR images. CMBs consist of extravasations of blood components through fragile microvascular walls characterized by lipohyalinosis and surrounding macrophages. The prevalence of CMBs in elderly subjects with no history of cerebrovascular disease is around 5%, but is much higher in patients with ischemic or hemorrhagic stroke. Development of CMBs is closely related to various vascular risk factors; in particular, lobar CMBs are thought to be associated with cerebral amyloid angiopathy. The presence of CMBs has been hypothesized to reflect cerebral-hemorrhage-prone status in patients with hypertension or amyloid microangiopathy. Stroke survivors with CMBs have been consistently found to have an elevated risk of subsequent hemorrhagic stroke or an antithrombotic-related hemorrhagic complication, although studies have failed to establish a link between CMBs and hemorrhagic transformation after thrombolytic treatment. A large prospective study is required to clarify the clinical significance of CMBs and their utility in a decision-making index.

Cerebral Amyloidal Angiopathy--a disease with implications for neurology and psychiatry

Cerebral Amyloidal Angiopathy (CAA), which occurs sporadically in most cases but can also occur hereditarily, belongs to the group amyloidoses and is characterized by the deposition and accumulation of beta-amyloid (Aβ) in smaller arterial vessels of the brain. The deposition of Aβ leads to degenerative changes in the cerebral vessel system (thickening of the vessel wall, microaneurysm, constriction of vascular lumen, dissection), which favour the development of the clinical symptomatology most often associated with CAA. Besides haemorrhages, cerebral ischaemia, transient neurological symptoms, leukoencephalopathy as well as cognitive decline and even dementia may appear in connection with CAA. A definite diagnosis of CAA can only be made on the basis of a pathological assessment, even though diagnostic findings of cerebral neuroimaging and clinical symptoms allow the diagnosis of a probable CAA. At present, no causal therapy options are available. Although CAA is placed within the range of neurological illnesses, psychiatric symptoms such as cognitive impairment, personality change or behavioural problems as well as depression are plausible clinical manifestations of CAA and may even dominate the clinical picture. Apart from epidemiological, pathogenetical, clinical and diagnostical aspects, possible psychiatric implications of CAA are discussed in the review article.

Risk of intracerebral hemorrhage in patients with cerebral microbleeds undergoing endovascular intervention

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMBs) on MRI gradient echo images are hemosiderin deposits, which may predict intracerebral hemorrhage (ICH). The risk of ICH in patients with CMBs could be exacerbated by the use of antithrombotics. The purpose of our study is to prospectively evaluate the risk of ICH in patients with ischemic stroke who receive dual antiplatelet therapy for endovascular intervention.

METHODS

We analyzed MRI of 133 patients admitted consecutively for intra- and extracranial stenting for symptomatic large artery atherosclerosis who received aspirin and clopidogrel. Quantity and location of CMBs were recorded by neuroradiologists independent from the angioplasty team. The primary end point was symptomatic ICH as evident in CT of the brain within 12 weeks of procedure.

RESULTS

CMBs were identified in 23 patients. Mean number of CMBs was 2.3 ± 1.6. Four patients had >5 CMBs. Forty-seven patients had intracranial stents, 84 patients had extracranial stents, and 2 patients had both intracranial and extracranial stents. There was no difference in risk of symptomatic ICH between those with (4.3%) and without CMBs (5.5%) patient with CMBs (P=1.000).

CONCLUSIONS

The presence of a small number of CMBs does not cause a large increase in the short-term risk of symptomatic ICH in patients with ischemic stroke who undergo endovascular intervention with dual antiplatelet therapy. The risk of ICH in patients with ≥ 5 CMBs, however, remains unclear. Further studies with a larger sample size of patients with multiple CMBs are needed.

Cerebral amyloid angiopathy in East and West

Cerebral amyloid angiopathy, a vasculopathy characterised by the deposition of amyloid fibrils in the arteries and arterioles in the cerebral cortex and meninges, has been reported to be associated with intracerebral haemorrhage and cognitive impairment in the elderly. Advances in neuroimaging and validation of the clinical diagnostic criteria aid in making a correct clinical diagnosis. Associations with Alzheimer's disease, asymptomatic microbleeds and white matter changes on neuroimaging have an influence on the clinical treatment for patients with probable cerebral amyloid angiopathy. Reviewing the reports from Asian countries, we found that patients with cerebral amyloid angiopathy have a strong age-related prevalence and a consistent association with dementia, but a weaker correlation with intracerebral haemorrhage, most likely due to a higher incidence of hypertensive intracerebral haemorrhage. Involvement of the occipital lobe arteries by CAA is common in all races and ethnicities, while frontal lobe arteries may be more frequently involved in the East compared to the West. The clinical impact of cerebral amyloid angiopathy on intracerebral haemorrhage and cognitive impairment could be increasingly obvious in Asian countries with ageing populations, especially with improving control of hypertension, the leading cause of intracerebral haemorrhage.

Aspirin and recurrent intracerebral hemorrhage in cerebral amyloid angiopathy

OBJECTIVE

To identify and compare clinical and neuroimaging predictors of primary lobar intracerebral hemorrhage (ICH) recurrence, assessing their relative contributions to recurrent ICH.

METHODS

Subjects were consecutive survivors of primary ICH drawn from a single-center prospective cohort study. Baseline clinical, imaging, and laboratory data were collected. Survivors were followed prospectively for recurrent ICH and intercurrent aspirin and warfarin use, including duration of exposure. Cox proportional hazards models were used to identify predictors of recurrence stratified by ICH location, with aspirin and warfarin exposures as time-dependent variables adjusting for potential confounders.

RESULTS

A total of 104 primary lobar ICH survivors were enrolled. Recurrence of lobar ICH was associated with previous ICH before index event (hazard ratio [HR] 7.7, 95% confidence interval [CI] 1.4-15.7), number of lobar microbleeds (HR 2.93 with 2-4 microbleeds present, 95% CI 1.3-4.0; HR = 4.12 when >or=5 microbleeds present, 95% CI 1.6-9.3), and presence of CT-defined white matter hypodensity in the posterior region (HR 4.11, 95% CI 1.01-12.2). Although aspirin after ICH was not associated with lobar ICH recurrence in univariate analyses, in multivariate analyses adjusting for baseline clinical predictors, it independently increased the risk of ICH recurrence (HR 3.95, 95% CI 1.6-8.3, p = 0.021).

CONCLUSIONS

Recurrence of lobar ICH is associated with previous microbleeds or macrobleeds and posterior CT white matter hypodensity, which may be markers of severity for underlying cerebral amyloid angiopathy. Use of an antiplatelet agent following lobar ICH may also increase recurrence risk.

PATCH: platelet transfusion in cerebral haemorrhage: study protocol for a multicentre, randomised, controlled trial

Background

Patients suffering from intracerebral haemorrhage have a poor prognosis, especially if they are using antiplatelet therapy. Currently, no effective acute treatment option for intracerebral haemorrhage exists. Limiting the early growth of intracerebral haemorrhage volume which continues the first hours after admission seems a promising strategy. Because intracerebral haemorrhage patients who are on antiplatelet therapy have been shown to be particularly at risk of early haematoma growth, platelet transfusion may have a beneficial effect.

Methods/Design

The primary objective is to investigate whether platelet transfusion improves outcome in intracerebral haemorrhage patients who are on antiplatelet treatment. The PATCH study is a prospective, randomised, multi-centre study with open treatment and blind endpoint evaluation. Patients will be randomised to receive platelet transfusion within six hours or standard care. The primary endpoint is functional health after three months. The main secondary endpoints are safety of platelet transfusion and the occurrence of haematoma growth. To detect an absolute poor outcome reduction of 20%, a total of 190 patients will be included.

Discussion

To our knowledge this is the first randomised controlled trial of platelet transfusion for an acute haemorrhagic disease.

Trial registration

The Netherlands National Trial Register (NTR1303)

Medullary Hemorrhage after Ischemic Wallenberg's Syndrome in a Patient with Cavernous Angioma

Background

The main complication of cerebral cavernous angioma is hemorrhage. Ischemic stroke as a complication of cerebral cavernous angioma has rarely been described, and hemorrhage after ischemic Wallenberg's syndrome has not been reported before.

Case Report

A 45-year-old woman presented with perioral numbness, hoarseness, dysphagia, and worsening of her previous sensory symptoms. The patient had been taking aspirin for 3 years after suffering from ischemic Wallenberg's syndrome with left paresthesia as a residual symptom. Brain computed tomography revealed an acute medullary hematoma in the previously infarcted area. Follow-up magnetic resonance imaging revealed a cavernous angioma in the right medulla.

Conclusions

We presume that cerebral cavernous angioma was responsible for both the ischemia and the hemorrhage, and we also cautiously speculate that the aspirin contributed to the development of hemorrhage in the previously infarcted area.

Effect of anticoagulant and antiplatelet therapy in patients with spontaneous intra-cerebral hemorrhage: Does medication use predict worse outcome?

OBJECTIVES

To assess the impact of anticoagulants and antiplatelet agents on the severity and outcome of spontaneous non-traumatic intra-cerebral hemorrhage (ICH). To evaluate associations between reversal of anticoagulation and mortality/morbidity in these patients.

METHODS

Data was collected on a consecutive cohort of adults presenting with ICH to an academic Emergency Department over a 3-year period starting January 2006.

RESULTS

The final cohort of 245 patients consisted of 125 females (51.1%). The median age of the cohort was 73 years [inter-quartile (IQR) range of 59-82 years]. Antiplatelet (AP) use was seen in 32.6%, 18.4% were using anticoagulant (AC) and 8.9% patients were on both drugs (AC+AP). Patients on AC had significantly higher INR (median 2.3) and aPTT (median 31 s) when compared to patients not on AP/AC (median INR 1.0, median aPTT 24s; p<0.001). Similarly patients on AC+AP also had higher INR (median 1.9) and aPTT (median 30s) when compared to those not on AC/AP (p<0.001). Hemorrhage volumes were significantly higher for patients on AC alone (median 64.7 cm(3)) when compared to those not on either AC/AP (median 27.2 cm(3); p=0.05). The same was not found for patients using AP (median volume 20.5 cm(3); p=0.813), or both AC+AP (median volume 27.7 cm(3); p=0.619). Patients on AC were 1.43 times higher at risk to have intra-ventricular extension of hemorrhage (IVE) as compared to patients not on AC/AP (95% CI 1.04-1.98; p=0.035). There was no relationship between the use of AC/AP/AC+AP and functional outcome of patients. Patients on AC were 1.74 times more likely to die within 7 days (95% CI 1.0-3.03; p=0.05). No relationship was found between use of AP or AC+AP use and mortality. Of the 82 patients with INR>1.0, 52 patients were given reversal (minimum INR 1.4, median 2.3). Therapy was heterogeneous, with fresh frozen plasma (FFP) being the most commonly used agent (86.5% patients, median dose 4U). Vitamin K, activated factor VIIa and platelets were the other agents used. Post reversal, INR normalized within 24h (median 1.2, IQR 1.1-1.3). There was no association between reversal and volume of hemorrhage, IVE, early mortality (death<7 days) or functional outcome.

CONCLUSIONS

Anticoagulated patients were at 1.7 times higher risk of early mortality after ICH. Reversal of INR to normal did not influence mortality or functional outcome.

Lack of benefits for prevention of cardiovascular disease with aspirin therapy in type 2 diabetic patients--a longitudinal observational study

Background

The risk-benefit ratio of aspirin therapy in prevention of cardiovascular disease (CVD) remains contentious, especially in type 2 diabetes. This study examined the benefit and harm of low-dose aspirin (daily dose < 300 mg) in patients with type 2 diabetes.

Methods

This is a longitudinal observational study with primary and secondary prevention cohorts based on history of CVD at enrolment. We compared the occurrence of primary composite (non-fatal myocardial infarction or stroke and vascular death) and secondary endpoints (upper GI bleeding and haemorrhagic stroke) between aspirin users and non-users between January 1995 and July 2005.

Results

Of the 6,454 patients (mean follow-up: median [IQR]: 4.7 [4.4] years), usage of aspirin was 18% (n = 1,034) in the primary prevention cohort (n = 5731) and 81% (n = 585) in the secondary prevention cohort (n = 723). After adjustment for covariates, in the primary prevention cohort, aspirin use was associated with a hazard-ratio of 2.07 (95% CI: 1.66, 2.59, p < 0.001) for primary endpoint. There was no difference in CVD event rate in the secondary prevention cohort. Overall, aspirin use was associated with a hazard-ratio of 2.2 (1.53, 3.15, p < 0.001) of GI bleeding and 1.71 (1.00, 2.95, p = 0.051) of haemorrhagic stroke. The absolute risk of aspirin-related GI bleeding was 10.7 events per 1,000 person-years of treatment.

Conclusion

In Chinese type 2 diabetic patients, low dose aspirin was associated with a paradoxical increase in CVD risk in primary prevention and did not confer benefits in secondary prevention. In addition, the risk of GI bleeding in aspirin users was rather high.

Location of acute brain hemorrhage in patients undergoing antithrombotic therapy

INTRODUCTION

The relationship between antithrombotic therapy and the anatomical location of acute brain hematoma remains disputed. The current study was therefore designed to address this issue.

METHODS

The medical records and CT images were retrospectively reviewed in 484 consecutive patients with an acute brain hemorrhage (291 men, 193 women; mean age, 67.2+/-12.3 years) who were admitted to the hospital within 7 days of stroke onset from January 1999 through October 2003. Antithrombotic therapy had been performed in 116 patients (AT Group): warfarin (n=38), antiplatelet therapy (n=70), or both (n=8). The other 368 patients had not received antithrombotic therapy (non-AT Group). The hematoma location was compared among the groups.

RESULTS

The location of the hematoma was significantly different between the two groups (p<0.0001). The following locations were seen more frequently in the AT Group than in the non-AT Group: thalamic hemorrhage (44.8% vs. 30.7%), cerebellar hemorrhage (7.8% vs. 2.7%), and lobar hemorrhage (18.1% vs. 11.4%). The clinical characteristics in patients with thalamic, cerebellar, or lobar hemorrhage were compared with those with putaminal hemorrhage. A multivariate analysis using the logistic regression model showed that antithrombotic therapy was an independent factor for cerebellar hemorrhage (OR 3.66, 95%CI 1.31-10.18), lobar hemorrhage (OR 2.27, 95%CI 1.12-4.57), and thalamic hemorrhage (OR 2.20, 95%CI 1.06-4.54) in comparison to putaminal hemorrhage.

CONCLUSIONS

It therefore appears that antithrombotic therapy is independently associated with thalamic, cerebellar, and lobar hemorrhage.

Aspects of intracerebral hematomas--an update

BACKGROUND

In Norway, there are approximately 16000 strokes each year and 15% of these are caused by intracerebral hematomas. Intracerebral hemorrhage (ICH) results from the rupture of blood vessels within the brain parenchyma. ICH occurs as a complication of several diseases, the most prevalent of which is chronic hypertension. When hemorrhage develops in the absence of a pre-existing vascular malformation or brain parenchymal lesion, it is denoted primary ICH. Secondary ICH refers to hemorrhage complicating a pre-existing lesion. Primary ICH is the most common type of hemorrhagic stroke, accounting for approximately 10% of all strokes. Despite aggressive management strategies, the 30-day mortality remains high, at almost 50%, with the majority of deaths occurring within the first 2 days. At 6 months, only 20-30% achieve independent status.

MATERIAL AND METHODS

This article is based on clinical experience, modern therapeutic guidelines for the treatment of intracerebral hematomas and up-to-date medical literature found in Medline. The article discusses the pathophysiology, clinical aspects, treatment, and the prognosis of intracerebral hematomas.

RESULTS AND DISCUSSION

Advances in diagnosis, prognosis, pathophysiology, and treatment over the past few decades have significantly advanced our knowledge of ICH; however, much work still needs to be carried out. Future genetic and epidemiologic studies will help identify at-risk populations and hopefully allow for primary prevention. Randomized controlled studies focusing on novel therapeutics should help to minimize secondary injury and hopefully improve morbidity and mortality.

THE PRESENCE OF MULTIPLE MICROBLEEDS AS A PREDICTOR OF SUBSEQUENT CEREBRAL HEMORRHAGE IN PATIENTS WITH MOYAMOYA DISEASE

OBJECTIVE

To examine the relationship between asymptomatic microbleeds (MBs) and the occurrence of subsequent stroke in patients with moyamoya disease.

METHODS

Beginning in October 2003, 50 consecutive patients with moyamoya disease were enrolled in a prospective study using 3-T magnetic resonance imaging. These patients were followed from the date of the initial magnetic resonance study until the date of the first subsequent stroke or final magnetic resonance study. The median follow-up period was 15 months. The patients were comprised of 13 men and 37 women ranging in age from 9 to 68 years (mean age, 40.5 ± 16.2 yr).

RESULTS

Although no MBs were found in 27 patients in the initial magnetic resonance study, a total of 66 MBs were found in the remaining 23 patients. Eleven patients had a single MB and 12 had multiple MBs. The patients were divided into three groups according to the number of MBs: a non-MB group, a single-MB group, and a multi-MB group. Kaplan-Meier curves of the three groups showed a significantly higher likelihood of subsequent hemorrhage in the multi-MB group than in either the non-MB or single-MB groups (P = 0.0380). No significant differences among the three groups were seen in terms of their subsequent infarction-free ratios. Age-adjusted analysis performed with the Cox proportional hazard model also showed the presence of multiple MBs as an independent risk factor (hazard ratio, 2.89; 95% confidence interval, 1.001–13.24).

CONCLUSION

The presence of multiple MBs might be a predictor of subsequent hemorrhage in patients with moyamoya disease. Confirmation of these results will require a study with a larger number of patients and a longer follow-up period.

Platelet count and function in spontaneous intracerebral hemorrhage

Impaired platelet function has been associated with an increased propensity for intracerebral hemorrhage (ICH). The role of platelet count and dysfunction in spontaneous ICH (SICH) is poorly understood. We tested the hypotheses that patients with SICH have subtle platelet dysfunction associated with ICH progression and larger ICH size. In a retrospective case series, we compared platelet counts in patients with SICH with age-matched controls with neuromuscular disorders admitted to a Neurosciences Critical Care Unit (NCCU). In a subset of patients, platelet function was measured within one week of ICH. Computerized tomography (CT) scans were performed within 24 hours of the event and ICH volume determined by the ABC/2 method. Comparison of 43 patients with SICH and 35 age-matched controls with neuromuscular disease demonstrated significant decreases in platelet counts over the first few days of admission to the NCCU (Nadir: 149 +/- 9 vs 202 +/- 12 IU/mm3; P = .001). There was a significant correlation between a fall in platelet count and change in hematoma size in 28 patients (P = .01). Seventeen patients were enrolled prospectively to study platelet function. Patients were divided into 2 groups based on ICH volume: < or = 30 cc and > 30 cc. There was an association of low platelet count at a median of 4 days with larger ICH volume (P = .01). Platelet function abnormalities, including aggregation to arachidonic acid, collagen, and ADP and ATP release reactions to thrombin and collagen, and a prolonged bleeding time were common findings in ICH patients compared to standardized controls. Platelet dysfunction was more common in large versus small ICH (80% vs 50%). Two patients with significant (>15%) hematoma enlargement within the first 24 hours had significant early decreases in platelet counts and extensive platelet dysfunction. In conclusion, platelet dysfunction is common among patients with SICH. Low platelet count and platelet dysfunction may be factors in expansion of ICH volume. Further prospective studies with larger sample size are needed to assess this association.

Development and validation of stroke risk equation for Hong Kong Chinese patients with type 2 diabetes: the Hong Kong Diabetes Registry

OBJECTIVE

We sought to develop stroke risk equations for Chinese patients with type 2 diabetes in Hong Kong.

RESEARCH DESIGN AND METHODS

A total of 7,209 Hong Kong Chinese type 2 diabetic patients without a history of stroke at baseline were analyzed. The data were randomly and evenly divided into the training subsample and the test subsample. In the training subsample, stepwise Cox models were used to develop the risk equation. Validation of the U.K. Prospective Diabetes Study (UKPDS) stroke risk engine and the current stroke equation was performed in the test dataset. The life-table method was used to check calibration, and the area under the receiver operating characteristic curve (aROC) was used to check discrimination.

RESULTS

A total of 372 patients developed incident stroke during a median of 5.37 years (interquartile range 2.88-7.78) of follow-up. Age, A1C, spot urine albumin-to-creatinine ratio (ACR), and history of coronary heart disease (CHD) were independent predictors. The performance of the UKPDS stroke engine was suboptimal in our cohort. The newly developed risk equation defined by these four predictors had adequate performance in the test subsample. The predicted stroke-free probability by the current equation was within the 95% CI of the observed probability. The aROC was 0.77 for predicting stroke within 5 years. The risk score was computed as follows: 0.0634 x age (years) + 0.0897 x A1C + 0.5314 x log(10) (ACR) (mg/mmol) + 0.5636 x history of CHD (1 if yes). The 5-year stroke probability can be calculated by: 1 - 0.9707(EXP (Risk Score - 4.5674)).

CONCLUSIONS

Although the risk equation performed reasonably well in Chinese type 2 diabetic patients, external validation is required in other populations.

Delayed posttraumatic acute subdural hematoma in elderly patients on anticoagulation

OBJECTIVE

To discuss delayed acute subdural hematoma (DASH), a relatively neglected entity, and to emphasize the potentially elevated risk for DASH among elderly, anticoagulated mild traumatic brain injury (TBI) patients.

METHODS

The authors reviewed clinical and radiological data for four patients who had normal neurological examinations and normal computed tomographic scans after mild TBI, and who subsequently developed DASH and deteriorated rapidly.

RESULTS

The patients included two men and two women, aged 65 to 86 years, who presented to the emergency department after mild TBI between January 2002 and June 2004. All were treated with chronic anticoagulation or anti-aggregation therapy. They deteriorated owing to DASH from 9 hours to 3 days after TBI. Three of the four patients underwent craniotomy for evacuation of their hematomas. One patient, who suffered only focal neurological deficit, was treated conservatively, and her hematoma gradually resolved. Two patients died and two reached Glasgow Outcome Scores of 3 and 4 after extended inpatient rehabilitation.

CONCLUSION

A suspicion of DASH should be raised in elderly, anticoagulated, mild TBI patients, including those who present to the emergency department with Glasgow Coma Scores of 15 and normal computed tomographic scans after injury. Based on our experience, we recommend that elderly, anticoagulated mild TBI patients should be admitted for 24 to 48 hours of observation after injury.

Cerebral Microhemorrhage

Background and Purpose— With the advent of modern MRI imaging techniques, cerebral microhemorrhages have been increasingly recognized on gradient-echo (GE) or T2*-weighted MRI sequences in different populations. However, in clinical practice, their diagnostic value, associated risk, and prognostic significance are often unclear. This review summarizes the pathophysiology, differential diagnosis, epidemiology, and clinical significance of cerebral microhemorrhages.

Summary of Review— Focal areas of signal loss on GE MRI imaging pathologically represent focal hemosiderin deposition associated with previous hemorrhagic events. Cerebral microhemorrhages have been noted in healthy elderly, ischemic cerebrovascular disease, intracerebral hemorrhage (ICH), cerebral amyloid angiopathy (CAA), and in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. Microhemorrhages have been associated with older age, hypertension, smoking, white matter disease, lacunar infarcts, previous ischemic stroke, or ICH. In CAA, microhemorrhages predict both the risk of recurrent lobar ICH and future clinical decline. In patients with ischemic cerebrovascular disease, microhemorrhage number and location may be associated with executive dysfunction and may predict the occurrence of ICH and lacunar infarction.

Conclusions— When cerebral microhemorrhages are diagnosed on MRI, conclusions regarding their significance and associated risks should be made based on the population examined. Further studies to characterize the associated risks of cerebral microhemorrhages in different stroke populations are needed to use this new imaging marker in therapeutic decisions.

Intracerebral Hemorrhage

INTRODUCTION

Intracerebral hemorrhage (ICH) occurs from the rupture of small vessels into the brain parenchyma and accounts for approximately 10% of all strokes in the United States, and carries with it a significantly high morbidity and mortality.

SUMMARY

This article reviews the course and management of ICH. The most common chronic vascular diseases that lead to ICH are chronic hypertension and cerebral amyloid angiopathy. Additional factors that predispose to ICH include vascular malformations, chronic alcohol use, hypocholesterolemia, and use of anticoagulant medications. The understanding of mechanisms leading to ICH has advanced significantly, but questions regarding site predilection and timing of spontaneous hemorrhage still remain. Management in the acute setting is first focused on reducing hematoma expansion. Although no specific therapy has yet been proven effective, promising agents, particularly recombinant Factor VIIa, are on the horizon. Subsequent care is focused on controlling hemostasis, hemodynamics, and intracranial pressure in efforts to minimize secondary brain injury.

CONCLUSION

The morbidity and mortality associated with ICH remain high despite recent advances in our understanding of the clinical course of ICH. Novel preventive and acute treatment therapies are needed and may be on the horizon.

Risk of hemorrhagic stroke with aspirin use: an update

BACKGROUND

Low-dose aspirin is an important therapeutic option in the secondary prevention of myocardial infarction (MI) and ischemic stroke, especially in light of its unique cost-effectiveness and widespread availability. In addition, based on the results of a number of large studies, aspirin is also widely used in the primary prevention of MI. This review provides an update of the available data to offer greater clarity regarding the risks of aspirin with respect to hemorrhagic stroke, as well as insights regarding patient selection to minimize the risk of this complication.

SUMMARY OF REVIEW

In the secondary prevention of cardiovascular, cerebrovascular, and ischemic events, the evidence supports that the benefits of aspirin treatment significantly outweigh the risk of a major hemorrhage. The evidence from primary prevention of MI studies, including that from the recent Women's Health Study evaluation of aspirin use in healthy women, demonstrate that the increased risk for hemorrhagic stroke is small, is comparable to the secondary prevention studies, and fails to achieve statistical significance. A reasonable estimate of the risk of hemorrhagic stroke associated with the use of aspirin in primary prevention patients is 0.2 events per 1000 patient-years, which is comparable to estimates of the risk associated with the use of aspirin in secondary prevention patients.

CONCLUSIONS

When considering whether aspirin is appropriate, the absolute therapeutic cardiovascular benefits of aspirin must be balanced with the possible risks associated with its use, with the most serious being hemorrhagic stroke.

Previous antiplatelet therapy is an independent predictor of 30-day mortality after spontaneous supratentorial intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) constitutes 10% to 15% of all strokes. Despite several existing outcome prediction models for ICH, there are some factors with equivocal value as well as others that still have not been evaluated.

PATIENTS AND METHODS

All patients with first ever supratentorial ICH presenting to our institution between December 1995 and December 2002 were prospectively enrolled into the study. Patients with historic modified Rankin Scale > 2 and those under anticoagulant treatment or with multiple ICH were excluded. The following parameters were analyzed in 194 consecutive patients: age, gender, past history of hypertension, diabetes mellitus, hypercholesterolemia, past history of ischemic stroke, presence of ischemic heart disease or cardioembolic disease, current antiplatelet treatment, current alcohol overuse, smoking, Glasgow Coma Scale score (GSS) at admission, volume and location (deep or lobar) of ICH, ventricular extension, glycemia and temperature at admission, and leukoaraiosis. We correlated these data with the 30-day mortality identifying the independent predictors by logistic regression analysis.

RESULTS

Factors independently associated with 30-day mortality were: age, Glasgow Coma Scale score at admission, ICH volume, ventricular extension, glucose level at admission, and previous antiplatelet use.

CONCLUSIONS

Apart from the classical outcome predictors, the previous use of antiplatelet agents and the glucose value at admission are independent predictors of 30-day mortality in patients suffering a supratentorial ICH.

High-dose aspirin is neuroprotective in a rat focal ischemia model

Acetylsalicylic acid (ASA) is neuroprotective through various pharmacological action sites. We used a temporary middle cerebral artery occlusion (tMCAO) model in 56 Wistar rats to assess whether repeated ASA injections at 30 min, 6 h, 1, 2, 3, and 4 days after stroke onset are neuroprotective. Animals were sacrificed 5 days after MCAO; infarct size was analyzed with 2,3,5-triphenyltetrazolium chloride staining. As compared to saline (164+/-13 mm(3), n=14), only repeated injections of 40 mg/kg ASA (79+/-18 mm(3), n=14, P=0.0029), but not of 20 mg/kg ASA (129+/-19 mm(3), n=15), reduced infarct volume significantly. No significant change was noted with 40 mg/kg ASA injected only once at 30 min after MCAO (117+/-16 mm(3), n=13).

Asymptomatic microbleeds as a risk factor for aspirin-associated intracerebral hemorrhages

The authors measured the presence and extent of asymptomatic microbleeds on gradient-recalled-echo MRI in 21 aspirin users who developed intracerebral hemorrhage and 21 aspirin users without history of intracerebral hemorrhage. Microbleeds were more frequent (19 vs 7, p < 0.001) and more extensive (mean number of microbleeds 13.3 vs 0.4, p < 0.001) in the intracerebral hemorrhage group than in the control group. Asymptomatic microbleeds may be a risk factor for aspirin-associated intracerebral hemorrhage.