Prognostic Factors of Clinical Outcomes in Patients with Spontaneous Thalamic Hemorrhage

Analysis of the association between location and patient prognosis in spontaneous intracerebral hemorrhage in the basal ganglia and thalamus: A retrospective single-center study

Spontaneous intracerebral hemorrhage (ICH) causes profound neurological sequelae in survivors. The patient's prognosis is closely linked to the location and amount of hemorrhage. Therefore, we explored the relationship between the hemorrhage location within the basal ganglia, including the thalamus, and its clinical outcomes in patients with spontaneous intracerebral hemorrhage. A retrospective analysis of consecutively enrolled patients with basal ganglia and thalamic intracerebral hemorrhage treated conservatively at a single tertiary neurosurgical center was conducted between January 2014 and December 2020. Patients were divided into 2 groups according to the lateralization of the right or left hemisphere hemorrhage. Furthermore, baseline patient demographics, hematoma volume, location of the hemorrhage (i.e., caudate nucleus, globus palidus, putamen, internal capsule anterior limb, internal capsule posterior limb, thalamus), and clinical outcomes were evaluated. Clinical outcomes were assessed using the modified Rankin scale at the 1-year follow-up. An modified Rankin scale score between 3 and 6 was considered a poor outcome. In the analysis according to location, the prognosis was poor when the ICH was localized to the posterior limb of the internal capsule (P < .000) and globus palidus (P = .001) in the right hemisphere. Similarly, the prognosis was also poor when the ICH was localized to the posterior limb of the internal capsule (P < .000), globus palidus (P < .000), putamen (P = .018), and thalamus (P < .000) of the left hemisphere. In the spontaneous intracerebral hemorrhages of the basal ganglia and thalamus, hemorrhaging within the internal capsule and the left thalamus's bilateral posterior limbs is associated with a poor prognosis. Multivariable logistic analysis showed that hematoma volume (odds ratio [OR] = 70.85, 95% confidence interval [CI]: 1.95-60.53, P = .007) and the posterior limb of the internal capsule (OR = 10.98, 95% CI:1.02-118.49, P = .048) were independent predictors of poor outcomes in the right hemisphere, while hematoma volume (OR = 70.85, 95% CI: 1.95-60.53, P = .007), the posterior limb of the internal capsule (OR = 10.98, 95% CI:1.02-118.49, P = .048) and thalamus (OR = 10.98, 95% CI:1.02-118.49, P = .048) were independent predictors of poor outcomes in the left hemisphere.

Delayed intracerebral hemorrhage associated with placement of a deep brain stimulating electrode over two years prior

INTRODUCTION AND IMPORTANCE

Most severe complications of DBS appear in the perioperative period. There are no published case reports of delayed ICH occurring more than three months from electrode implantation. The pathogenesis of delayed ICH remains unclear.

CASE PRESENTATION

We present a 64-year-old male with essential tremor who sustained a delayed intracerebral hemorrhage (ICH) 2.5 years after implantation of a deep brain stimulating electrode.

DISCUSSION

The patient sustained a thalamic-midbrain ICH that may have been related to the positioning of the electrode. An analysis was performed to determine the cause and risk factors that may have contributed. Based on these findings, it is possible that the proximity of the cannula or electrode may have mildly injured the wall of the superior thalamic vein during implantation, or perhaps being in contact with the vein over a longer-term having an effect, which in either of these scenarios can subsequently lead to ICH formation on the sudden rise of intracranial pressure.

CONCLUSION

It emphasizes the importance of proper surgical navigation planning, image- guidance, and the use of image verification.

Functional Outcome After Minimally Invasive Endoscopic Evacuation of Thalamic Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is the most devastating form of stroke, with thalamic hemorrhages carrying the worst outcomes. Minimally invasive (MIS) endoscopic ICH evacuation is a promising new therapy for the condition. However, it remains unclear whether therapy success is location dependent. Here we present long-term functional outcomes after MIS evacuation of spontaneous thalamic hemorrhages.

METHODS

Patients presenting to a single urban health system with spontaneous ICH were triaged to a central hospital for management of ICH. Operative criteria for MIS evacuation included hemorrhage volume ≥15 mL, age ≥18, National Institutes of Health Stroke Scale ≥6, and baseline modified Rankin Score (mRS) ≤3. Demographic, radiographic, and clinical data were collected prospectively, and descriptive statistics were performed retrospectively. Functional outcomes were assessed using 6-month mRS scores.

RESULTS

Endoscopic ICH evacuation was performed on 21 patients. Eleven patients had hemorrhage confined to the thalamus, whereas 10 patients had hemorrhages in the thalamus and surrounding structures. Eighteen patients (85.7%) had intraventricular extension. The average preoperative volume was 39.8 mL (standard deviation [SD]: 31.5 mL) and postoperative volume was 3.8 mL (SD: 6.1 mL), resulting in an average evacuation rate of 91.4% (SD: 11.1%). One month after hemorrhage, 2 patients (9.5%) had expired and all other patients remained functionally dependent (90.5%). At 6-month follow-up, 4 patients (19.0%) had improved to a favorable outcome (mRS ≤ 3).

CONCLUSION

Among patients with ICH undergoing medical management, those with thalamic hemorrhages have especially poor outcomes. This study suggests that MIS evacuation can be safely performed in a thalamic population. It also presents long-term functional outcomes that can aid in planning randomization schemes or subgroup analyses in future MIS evacuation clinical trials.

Hematoma Ventricle Distance on Computed Tomography Predicts Poor Outcome in Intracerebral Hemorrhage

OBJECTIVE

To investigate the relationship between hematoma ventricle distance (HVD) and clinical outcome in patients with intracerebral hemorrhage (ICH).

METHODS

We prospectively enrolled consecutive patients with ICH in a tertiary academic hospital between July 2011 and April 2018. We retrospectively reviewed images for all patients receiving a computed tomography (CT) within 6 h after onset of symptoms and at least one follow-up CT scan within 36 h. The minimum distance of hematoma border to nearest ventricle was measured as HVD. Youden index was used to evaluate the cutoff of HVD predicting functional outcome. Logistic regression model was used to assess the HVD data and clinical poor outcome (modified Rankin Scale 4-6) at 90 days.

RESULTS

A total of 325 patients were included in our final analysis. The median HVD was 2.4 mm (interquartile range, 0-5.7 mm), and 119 (36.6%) patients had poor functional outcome at 3 months. After adjusting for age, admission Glasgow coma scale, intraventricular hemorrhage, baseline ICH volume, admission systolic blood pressure, blood glucose, hematoma expansion, withdrawal of care, and hypertension, HVD ≤ 2.5 mm was associated with increased odds of clinical poor outcome [odd ratio, 3.59, (95%CI = 1.72-7.50); p = 0.001] in multivariable logistic regression analysis.

CONCLUSION

Hematoma ventricle distance allows physicians to quickly select and stratify patients in clinical trials and thereby serve as a novel and useful addition to predict ICH prognosis.

Influence of Intracerebral Hemorrhage Location on Outcomes in Patients With Severe Intraventricular Hemorrhage

Background and Purpose- We investigated the prognostic significance of spontaneous intracerebral hemorrhage location in presence of severe intraventricular hemorrhage. Methods- We analyzed diagnostic computed tomography scans from 467/500 (excluding primary intraventricular hemorrhage) subjects from the CLEAR (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) III trial. We measured intracerebral hemorrhage engagement with specific anatomic regions, and estimated association of each region with blinded assessment of dichotomized poor stroke outcomes: mortality, modified Rankin Scale score of 4 to 6, National Institutes of Health Stroke Scale score of >4, stroke impact scale score of <60, Barthel Index <86, and EuroQol visual analogue scale score of <50 and <70 at days 30 and 180, respectively, using logistic regression models. Results- Frequency of anatomic region involvement consisted of thalamus (332 lesions, 71.1% of subjects), caudate (219, 46.9%), posterior limb internal capsule (188, 40.3%), globus pallidus/putamen (127, 27.2%), anterior limb internal capsule (108, 23.1%), and lobar (29, 6.2%). Thalamic location was independently associated with mortality (days 30 and 180) and with poor outcomes on most stroke scales at day 180 on adjusted analysis. Posterior limb internal capsule and globus pallidus/putamen involvement was associated with increased odds of worse disability at days 30 and 180. Anterior limb internal capsule and caudate locations were associated with decreased mortality on days 30 and 180. Anterior limb internal capsule lesions were associated with decreased long-term morbidity. Conclusions- Acute intracerebral hemorrhage lesion topography provides important insights into anatomic correlates of mortality and functional outcomes even in severe intraventricular hemorrhage causing obstructive hydrocephalus. Models accounting for intracerebral hemorrhage location in addition to volumes may improve outcome prediction and permit stratification of benefit from aggressive acute interventions. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00784134.

Intracerebral Hemorrhage Location and Functional Outcomes of Patients: A Systematic Literature Review and Meta-Analysis

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) has the highest mortality rate among all strokes. While ICH location, lobar versus non-lobar, has been established as a predictor of mortality, less is known regarding the relationship between more specific ICH locations and functional outcome. This review summarizes current work studying how ICH location affects outcome, with an emphasis on how studies designate regions of interest.

METHODS

A systematic search of the OVID database for relevant studies was conducted during August 2015. Studies containing an analysis of functional outcome by ICH location or laterality were included. As permitted, the effect size of individual studies was standardized within a meta-analysis.

RESULTS

Thirty-seven studies met the inclusion criteria, the majority of which followed outcome at 3 months. Most studies found better outcomes on the Modified Rankin Scale (mRS) or Glasgow Outcome Score (GOS) with lobar compared to deep ICHs. While most aggregated deep structures for analysis, some studies found poorer outcomes for thalamic ICH in particular. Over half of the studies did not have specific methodological considerations for location designations, including blinding or validation.

CONCLUSIONS

Multiple studies have examined motor-centric outcomes, with few studies examining quality of life (QoL) or cognition. Better functional outcomes have been suggested for lobar versus non-lobar ICH; few studies attempted finer topographic comparisons. This study highlights the need for improved reporting in ICH outcomes research, including a detailed description of hemorrhage location, reporting of the full range of functional outcome scales, and inclusion of cognitive and QoL outcomes.

Acupuncture for acute moderate thalamic hemorrhage: randomized controlled trial study protocol

Background

Thalamic hemorrhage (TH) is a neurological insult with a high rate of morbidity and mortality. Moderate TH (10–30 ml) accounts for more than half of all TH. Treatment remains controversial. The role of acupuncture in patients with moderate TH is not clear.

Methods

We will conduct a single-center, randomized, parallel group, and assessor-blinded clinical trial. A total of 488 patients with moderate TH will be randomly assigned to one of eight groups: 10–15 cc left sided TH study group (N = 61) and a corresponding control group (N = 61), 10–15 cc right sided TH study group (N = 61) and a corresponding control group, 15–30 cc left sided TH study group (N = 61) and a corresponding control group (N = 61), and 15–30 cc right sided TH study group (N = 61) and a corresponding control group. Study groups will receive acupuncture in addition to standard treatment, while control groups will receive standard treatment alone. The primary outcome will be change in National Institutes of Health Stroke Scale scores at 30 and 90 days after TH. The secondary outcomes will be death or major disability, defined as a score of 3 to 6 on the modified Rankin scale (in which a score of 0 indicates no symptoms, a score of 5 indicates severe disability, and a score of 6 indicates death) at 90-days, need for surgery at 30-days, Glasgow Outcome Scale (GOS) score at 90-days following TH onset, and the results of several additional group specific tests. The rate of adverse events will then be compared between the groups.

Discussion

This study will attempt to answer the question of whether or not acupuncture can improve neurologic outcome following moderate TH.

 Trial registration

Chinese clinical trial registry (ChiCTR-IOR-16008362)

Retrospective analysis of prognostic factors in dengue infected patients with intracranial bleed

BACKGROUND

Dengue is one of the most common mosquito-transmitted arboviral disease of tropical and a few subtropical areas in the world. It is estimated that approximately 100 million cases occur per year and approximately 2.5 billion people are at risk of developing dengue infection. Hemorrhagic complications causing encephalopathy are quite rare but fatal consequences of this deadly disease. This study was conducted to discuss the prognostic factors in the management of intracranial hemorrhage in dengue infected patients.

METHODS

This retrospective study was conducted in the neurosurgery department of our tertiary healthcare centre. Duration of the study was 1 year, and 18 patients who presented with intracranial bleed and required neurosurgical care were included in this study. All patients had deranged coagulation profile and were thrombocytopenic. All the patients were given platelet concentrates for correction of thrombocytopenia. Eight of these patients had deterioration in their neurological status, and 6 of them underwent surgery.

RESULTS

Out of 18 patients, 12 (66.66%) were managed conservatively, including one case of cervical extradural hemorrhage. Five patients who were conservatively managed died because they had deep-seated bleed and rapid deterioration. The remaining 7 patients who were managed conservatively improved well with few residual deficits. Six (33.33%) patients who underwent surgery had excellent outcome with one case of mortality.

CONCLUSION

Very high index of suspicion is required in dengue infected patients for neurological complications, especially during the convalescence period. Special attention should be given to those patients who have altered sensorium, and should not be misinterpreted as fever delirium or toxic encephalopathy. It requires immediate attention and further neurological investigation (including thorough clinical examination). Timely diagnosis using a computed tomography scan and early neurosurgical intervention after rapid correction of thrombocytopenia can save many lives.

Predictive value of serum caspase-cleaved cytokeratin-18 concentrations after acute intracerebral hemorrhage

BACKGROUND

Caspase-cleaved Cytokeratin-18 (CCCK-18) is released during apoptosis. Serum CCCK-18 concentrations are associated with prognosis of some critical illness. We investigated the potential relationships between serum CCCK-18 concentrations and disease severity and long-term clinical outcomes after intracerebral hemorrhage.

METHODS

Serum CCCK-18 concentrations were determined in a total of 102 patients and 102 controls. Multivariate models were used to predict high concentration of CCCK-18 and 6-month clinical outcomes. The predictive values were evaluated based on areas under receiver operating curve.

RESULTS

Compared with controls, serum CCCK-18 concentrations were increased in patients (245.8±108.3U/l vs. 23.6±18.1U/l, P<0.001). National Institute of Health Stroke Scale scores [odds ratio (OR), 1.164; 95% confidence interval (CI), 1.027-1.320; P=0.003] and hematoma volumes (OR, 1.079; 95% CI, 1.018-1.205; P=0.008) were independent predictors of high concentration of CCCK-18. CCCK-18 was identified as an independent predictor of 6-month mortality (OR, 1.019; 95% CI, 1.010-1.038; P=0.013) and 6-month unfavorable outcome (OR, 1.017; 95% CI, 1.008-1.029; P=0.032) and possessed high predictive values.

CONCLUSION

Increased serum CCCK-18 concentrations are associated with disease severity and clinical outcomes, suggesting that CCCK represent a novel prognostic predictive biomarker after intracerebral hemorrhage.