Factors associated with early deterioration after spontaneous intracerebral hemorrhage: a systematic review and meta-analysis

Influence of bundled care treatment on functional outcome in patients with intracerebral hemorrhage

Background and aims

General guideline recommendations in patients with intracerebral hemorrhage (ICH) include blood pressure-, temperature- and glucose management. The therapeutic effect of such a "care bundle" (blood pressure lowering, glycemic control, and treatment of pyrexia) on clinical outcomes becomes increasingly established. For the present study, we aimed to investigate associations of strict bundled care treatment (BCT) with clinical outcomes and characterize associations with key outcome effectors such as hematoma enlargement (HE) and peak perihemorrhagic edema (PHE).

Methods

We screened consecutive ICH patients (n = 1,322) from the prospective UKER-ICH cohort study. BCT was defined as achieving and maintaining therapeutic ranges for systolic blood pressure (110-160 mmHg), glucose (80-180 mg/dL), and body temperature (35.5-37.5°C) over the first 72 h. The primary outcome was the functional outcome at 12 months (modified Rankin Scale (mRS) 0-3). Secondary outcomes included mortality at 12 months, the occurrence of hematoma enlargement, and the development of peak perihemorrhagic edema. Confounding was addressed by a doubly robust methodology to calculate the absolute treatment effect (ATE) and by calculating e-values.

Results

A total of 681 patients remained for analysis, and 182 patients fulfilled all three BCT criteria and were compared to 499 controls. The ATE of BCT to achieve the primary outcome was 9.3%, 95% CI (1.7 to 16.9), p < 0.001; e-value: 3.1, CI (1.8). Mortality at 12 months was significantly reduced by BCT [ATE: -12.8%, 95% CI (-19.8 to -5.7), p < 0.001; e-value: 3.8, CI (2.2)], and no association was observed for HE or peak PHE. Significant drivers of BCT effect on the primary outcome were systolic blood pressure control (ATE: 15.9%) and maintenance of normothermia (ATE: 10.9%).

Conclusion

Strict adherence to this "care bundle" over the first 72 h during acute hospital care in patients with ICH was independently associated with improved functional long-term outcome, driven by systolic blood pressure control and maintenance of normothermia. Our findings strongly warrant prospective validation to determine the generalizability especially in Western countries.Clinical trial registration:ClinicalTrials.gov, identifier [ID: NCT03183167].

Predictors of early neurological deterioration in patients with intracerebral hemorrhage: a systematic review and meta-analysis

BACKGROUND

Early neurological deterioration, a common complication in patients with intracerebral hemorrhage, is associated with poor outcomes. Despite the fact that the prevalence and predictors of early neurological impairment are widely addressed, few studies have consolidated these findings. This study aimed to systematically investigate the prevalence and predictors of early neurological deterioration.

METHODS

The PubMed, Embase, Cochrane Library, CIHNAL, and Web of Science databases were systematically searched for relevant studies from the inception to December 2023. The data were extracted using a predefined worksheet. Quality assessment was conducted using the Newcastle-Ottawa Scale. Two reviewers independently performed the study selection, data extraction, and quality appraisal. The pooled effect size and 95% confidence intervals were calculated using the STATA 17.0 software package.

RESULTS

In total, 32 studies and 5,014 patients were included in this meta-analysis. The prevalence of early neurological deterioration was 23% (95% CI 21-26%, p < 0.01). The initial NIHSS score (OR = 1.24, 95% CI 1.17, 1.30, p < 0.01), hematoma volume (OR = 1.07, 95% CI 1.06, 1.09, p < 0.01), intraventricular hemorrhage (OR = 3.50, 95% CI 1.64, 7.47, p < 0.01), intraventricular extension (OR = 3.95, 95% CI 1.96, 7.99, p < 0.01), hematoma expansion (OR = 9.77, 95% CI 4.43, 17.40, p < 0.01), and computed tomographic angiography spot sign (OR = 5.77, 95% CI 1.53, 20.23, p = 0.01) were predictors of early neurological deterioration. The funnel plot and Egger's test revealed significant publication bias (p < 0.001).

CONCLUSIONS

This meta-analysis revealed a pooled prevalence of early neurological deterioration of 23% in patients with intracerebral hemorrhage. The initial NIHSS score, hematoma volume, intraventricular hemorrhage, intraventricular expansion, hematoma expansion, and spot sign enhanced the probability of early neurological deterioration. These findings provide healthcare providers with an evidence-based basis for detecting and managing early neurological deterioration in patients with intracerebral hemorrhage.

Clinical outcomes of posterior fossa arteriovenous malformations: a single center experience

BACKGROUND

Posterior fossa arterio-venous malformations (pfAVMs) are challenging lesions due to the anatomical particularities of the posterior fossa, and the high incidence of hemorrhagic presentation. The two most important goals when treating AVMs are preserving neurological function and preventing rupture, or a second hemorrhage. The aim of this study was to analyze the clinical and imaging features of pfAVMs to identify the factors that influence the prognosis of these patients.

METHODS

We conducted a single-center retrospective observational study that included patients treated at our institution with pfAVMs between January 1997 and December 2021.

RESULTS

A total of 48 patients were included. A good modified Rankin score (mRS) was observed in 33 cases (69%) at presentation. Thirty-four patients (71%) presented with a ruptured AVM. Out of these, 19 patients (40%) had intraventricular hemorrhage. Microsurgical resection was performed in 33 cases (69%), while in the other cases, the patients opted for conservative management (7 cases, 15%), stereotactic radiosurgery (SRS) (6 cases, 12%), or endovascular treatment (2 cases, 4%). Patients ≤ 30 years old were more prone to hemorrhagic presentation (OR: 5.23; 95% CI: 1.42-17.19; p = 0.024) and this remained an independent risk factor for rupture after multivariate analysis as well (OR: 4.81; 95% CI: 1.07-21.53; p = 0.040). Following multivariate analysis, the only factor independently associated with poor prognosis in the surgically treated subgroup was a poor clinical status (mRS 3-5) at admission (OR: 96.14; 95% CI: 5.15-1793.9; p = 0.002).

CONCLUSIONS

Management of posterior fossa AVMs is challenging, and patients who present with ruptured AVMs often have a poor clinical status at admission leading to a poor prognosis. Therefore, proper and timely management of these patients is essential.

Time-Dependent Changes in Hematoma Expansion Rate after Supratentorial Intracerebral Hemorrhage and Its Relationship with Neurological Deterioration and Functional Outcome

BACKGROUND

Hematoma expansion (HE) following an intracerebral hemorrhage (ICH) is a modifiable risk factor and a treatment target. We examined the association of HE with neurological deterioration (ND), functional outcome, and mortality based on the time gap from onset to baseline CT.

METHODS

We included 567 consecutive patients with supratentorial ICH and baseline head CT within 24 h of onset. ND was defined as a ≥4-point increase on the NIH stroke scale (NIHSS) or a ≥2-point drop on the Glasgow coma scale. Poor outcome was defined as a modified Rankin score of 4 to 6 at 3-month follow-up.

RESULTS

The rate of HE was higher among those scanned within 3 h (124/304, 40.8%) versus 3 to 24 h post-ICH onset (53/263, 20.2%) (p < 0.001). However, HE was an independent predictor of ND (p < 0.001), poor outcome (p = 0.010), and mortality (p = 0.003) among those scanned within 3 h, as well as those scanned 3-24 h post-ICH (p = 0.043, p = 0.037, and p = 0.004, respectively). Also, in a subset of 180/567 (31.7%) patients presenting with mild symptoms (NIHSS ≤ 5), hematoma growth was an independent predictor of ND (p = 0.026), poor outcome (p = 0.037), and mortality (p = 0.027).

CONCLUSION

Despite decreasing rates over time after ICH onset, HE remains an independent predictor of ND, functional outcome, and mortality among those presenting >3 h after onset or with mild symptoms.

Predictive value of hyponatremia for short-term mortality in supratentorial spontaneous intracerebral hemorrhage: a single center study

Background

Hyponatremia is a common electrolyte disturbance in patients with neurological disease; however, its predictive role for outcome in patients with supratentorial spontaneous intracerebral hemorrhage (sICH) is controversial. This study aims to explore the association between hyponatremia within 7 days after bleeding and 90-day mortality in patients with supratentorial sICH.

Methods

A retrospective analysis was conducted at our institution. Patients with sICH meeting the inclusion criteria were enrolled in this study. Multivariate regression analyses were performed to determine the predictive value of hyponatremia (serum sodium <135 mmol/L) for 90-day mortality and functional outcome. Subgroup analysis was performed based on the degree and duration of hyponatremia and therapeutic strategies. The Spearman correlation test was performed to explore the relationship between hyponatremia severity and duration with variables in a multivariate regression model. Kaplan-Meier curve was depicted to reveal the relationship between hyponatremia and mortality. The receiver operating characteristic (ROC) curve was plotted to show the diagnostic effect of the minimum concentration of serum sodium (sodiummin) on 90-day mortality.

Results

A total of 960 patients were enrolled, 19.6% (188) of whom were patients with hyponatremia and 26.0% (250) had 90-day mortality. The incidence of hyponatremia was roughly 2.5 times in non-survivors compared with survivors (34.8% vs. 14.2%). Multivariate regression analysis revealed that hyponatremia was the independent predictor of 90-day mortality (OR 2.763, 95%CI 1.836-4.157) and adverse outcome (OR 3.579, 95%CI 2.332-6.780). Subgroup analysis indicated an increased trend in mortality risk with both duration (more or less than 48 h) and severity of hyponatremia (mild, moderate, and severe) and confirmed the predictive value of hyponatremia for mortality in patients undergoing surgical intervention (external ventricular drainage, craniotomy, and decompressive craniectomy; all p < 0.05). The Spearman correlation test indicated no moderate or strong relationship between hyponatremia severity and duration with other variables in the multivariate model (all |rs| < 0.4). The ROC curve suggested the moderate diagnostic performance of sodiummin for mortality in both general patients and subgroups of therapeutic method patients (AUC from 0.6475 to 0.7384).

Conclusion

Hyponatremia occurring in the first 7 days after bleeding is an independent predictor of 90-day morality and adverse outcome. Rigorous electrolyte scrutiny in patients treated surgically is required.

Assessment of coagulation assays on Roche Cobas t711 analyzer: performance and clinical implications

OBJECTIVES

We performed an analytical assessment of five coagulation tests [i.e. prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, thrombin time (TT) and D-dimer] on the Roche Cobas t711 analyzer and a comparison study with the methodology in use at our laboratory (i.e. Werfen ACL Top 750 analyzer), expanding the analysis to the clinical implications of Cobas t711 implementation.

METHODS

Imprecision studies were performed following the Clinical and Laboratory Standards Institute (CLSI) H57 A:2008 guideline. Linearity of D-dimer and fibrinogen tests was analysed according to the CLSI EP06-A: 2003 recommendations. For method comparison, the results were analyzed using the Bland-Altman plot and Passing-Bablok regression.

RESULTS

Imprecision met manufacturer claims for PT, aPTT and TT. D-dimer and fibrinogen tests showed a coefficient of variation (CV)% over manufacturer claims at certain concentration levels. Linearity ranges could not be verified. Comparison study revealed that results are not interchangeable for any test, a lower correlation for aPTT test and lower D-dimer results from Roche Cobas t711.

CONCLUSION

The strength of this study relies on the analysis of the clinical implications of reporting Cobas t711 results compared to those obtained with the methodology in use at our laboratory. Different sensibility to factor deficiency, anticoagulant therapy and interferences might explain lower correlation rates obtained for the aPTT test. Different monoclonal antibodies used for D-dimer determination might explain the lower results obtained with the Cobas t711 analyzer. This aspect needs further studies given the relevance of D-dimer test to exclude thrombotic events and reinforces the need of harmonization in the haemostasis laboratory.

Significance of serum sestrin2 as a biomarker of severity and functional outcome in acute intracerebral hemorrhage: a prospective observational longitudinal study

BACKGROUND

Sestrin2 is a highly conserved stress-inducible protein with neuroprotective properties. Herein, we investigated the prognostic significance of serum sestrin2 in human intracerebral hemorrhage (ICH).

METHODS

In this prospective observational longitudinal study, we enrolled 126 patients with supratentorial ICH as cases together with 126 healthy individuals as controls. Severity indicators were National Institutes of Health Stroke Scale (NIHSS) and hematoma volume. Prognostic parameters were early neurologic deterioration (END) and post-stroke 6-month poor prognosis [modified Rankin Scale (mRS) scores of 3-6]. Multivariate analysis was performed to assess relations of serum sestrin2 levels to severity and prognosis.

RESULTS

Patients had statistically significantly higher serum sestrin2 levels than controls. Serum sestrin2 levels of patients were independently correlated with NIHSS scores and hematoma volume, as well as were substantially elevated in order of mRS scores from 0 to 6. Serum sestrin2 was identified as an independent predictor of END and poor prognosis. Based on the receiver operating characteristic curve, serum sestrin2 had a similar predictive ability for END and poor prognosis, as compared to NIHSS scores and hematoma volume. Prediction models of END and poor prognosis, in which serum sestrin2, NIHSS scores and hematoma volume were integrated, were visually described via nomogram, were reliable and stable under calibration curve and were of clinical benefit using decision curve analysis. Also, prediction model of poor prognosis showed dramatically higher discriminatory efficiency than any of NIHSS scores, hematoma volume and serum sestrin2.

CONCLUSION

Serum sestrin2 levels, which are obviously increased following acute ICH, are independently related to illness severity and poor clinical outcomes, substantializing serum sestrin2 as a clinically valuable prognostic biomarker of ICH.

Predictor of the Postoperative Swelling After Craniotomy for Spontaneous Intracerebral Hemorrhage: Sphericity Index as a Novel Parameter

Objective

Spontaneous intracerebral hemorrhage is a serious type of stroke with high mortality and disability rates. Surgical treatment options vary; however, predicting edema aggravation is crucial when choosing the optimal approach. We propose using the sphericity index, a measure of roundness, to predict the aggravation of edema and guide surgical decisions.

Methods

We analyzed 56 cases of craniotomy and hematoma evacuation to investigate the correlation between the sphericity index and patient outcomes, including the need for salvage decompressive craniectomy (DC).

Results

The patients included 35 (62.5%) men and 21 (37.5%) women, with a median age of 62.5 years. The basal ganglia was the most common location of hemorrhage (50.0%). The mean hematoma volume was 86.3 cc, with 10 (17.9%) instances of hematoma expansion. Cerebral herniation was observed in 44 (78.6%) patients, intraventricular hemorrhage in 34 (60.7%), and spot signs in 9 (16.1%). Salvage DC was performed in 13 (23.6%) patients to relieve intracranial pressure. The median follow-up duration was 6 months, with a mortality rate of 12.5%. The sphericity index was significantly correlated with delayed swelling and hematoma expansion but not salvage DC.

Conclusions

The sphericity index is a promising predictor of delayed swelling and hematoma expansion that may aid in the development of surgical guidelines and medication strategies. Further large-scale studies are required to explore these aspects and establish comprehensive guidelines.

Extracranial anticoagulant related bleedings admitted to intensive care units: a French multicenter retrospective study

BACKGROUND

Anticoagulants are widely used but can lead to iatrogenic events such as bleeding. Limited data exists regarding the characteristics and management of patients admitted to intensive care units (ICU) for severe anticoagulant-related extracranial bleeding.

METHODS

A retrospective observational study was conducted in five French ICUs. From January 2007 to December 2018, all patients aged over 18 years admitted to ICU for extracranial bleeding while receiving therapeutic anticoagulation were included.

RESULTS

486 patients were included, mainly male (61%) with an average age of 73 ± 13 years. Most patients had comorbidities, including hypertension (68%), heart disease (49%) and diabetes (33%). Patients were treated by vitamin K antagonists (VKA, 54%), heparins (25%) and direct oral anticoagulants (DOAC, 7%). The incidence of patients admitted to ICU for anticoagulant-related bleeding increased from 3.2/1000 admissions in 2007 to 5.8/1000 in 2018. This increase was particularly high for DOAC class. Upon admission, patients exhibited severe organ failure, as evidenced by a high SOFA score (7 ± 4) and requirement for organ support therapies such as vasopressors (31.5%) and invasive mechanical ventilation (34%). Adherence to guidelines for the specific treatment of anticoagulant-related bleeding was generally low. ICU mortality was 27%. In multivariate analysis, five factors were independently associated with mortality: chronic hypertension, need for vasopressors, impaired consciousness, hyperlactatemia and prolonged aPTT > 1.2.

CONCLUSION

Anticoagulant-related extracranial bleeding requiring ICU admission is a serious complication responsible for organ failure and significant mortality. Its incidence is rising. The therapeutic management is suboptimal and could be improved by educational programs.

Tranexamic Acid in Non-Traumatic Intracerebral Haemorrhage (TANICH II): Introducing the Potential Role of 3 g Tranexamic Acid in Haematoma Reduction

Background

Intracerebral haemorrhage (ICH) can be devastating, particularly if haematoma expansion occurs. The efficacy of tranexamic acid (TXA), an anti-fibrinolytic agent, in reducing haematoma expansion is now being studied worldwide. However, the optimal dosage of TXA has yet to be determined. This study was designed to further establish the potential of different doses of TXA.

Methods

A double-blinded, randomised, placebo-controlled study was carried out among adults with non-traumatic ICH. Eligible study subjects were randomly assigned to receive placebo, 2-g TXA treatment or 3-g TXA treatment. Haematoma volumes before and after intervention were measured using the planimetric method.

Results

A total of 60 subjects with 20 subjects in each treatment group were recruited for this study. Among the 60 subjects, the majority were male (n = 36, 60%), had known cases of hypertension (n = 43, 71.7%) and presented with full Glasgow coma scale (GCS) (n = 41, 68.3%). The results showed that there was no statistically significant difference (P = 0.315) in the mean changes of haematoma volume when compared with three study groups using ANCOVA, although the 3-g TXA group was the only group that showed haematoma volume reduction (mean reduction of 0.2 cm³) instead of expansion as in placebo (mean expansion 1.8 cm³) and 2-g TXA (mean expansion 0.3 cm³) groups. Good recovery was observed in all study groups, with only three subjects being moderately disabled. No adverse effects were reported in any of the study groups.

Conclusion

To the best of our knowledge, this is the first clinical study using 3 g of TXA in the management of non-traumatic ICH. From our study, 3 g of TXA may potentially be helpful in reducing haematoma volume. Nonetheless, a larger-scale randomised controlled trial should be carried out to further establish the role of 3 g of TXA in non-traumatic ICH.

Prognostic significance of serum NLRC4 in patients with acute supratentorial intracerebral hemorrhage: A prospective longitudinal cohort study

Objective

Caspase activation and recruitment domain-containing protein 4 (NLRC4) is implicated in neuroinflammation. The aim of the study was to discern the potential ability of serum NLRC4 in assessment of prognosis after intracerebral hemorrhage (ICH).

Methods

In this prospective, observational study, serum NLRC4 levels were quantified in 148 acute supratentorial ICH patients and 148 controls. Severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) and hematoma volume, and poststroke 6-month functional outcome was estimated according to the modified Rankin Scale (mRS). Early neurologic deterioration (END) and 6-month poor outcome (mRS 3–6) were deemed as the two prognostic parameters. Multivariate models were established for investigating associations, and receiver operating characteristic (ROC) curves were configured to indicate predictive capability.

Results

Patients had substantially higher serum NLRC4 levels than controls (median, 363.2 pg/ml vs. 74.7 pg/ml). Serum NLRC4 levels had independent correlation with NIHSS scores [β, 0.308; 95% confidence interval (CI), 0.088–0.520], hematoma volume (β, 0.527; 95% CI, 0.385–0.675), serum C-reactive protein levels (β, 0.288; 95% CI, 0.109–0.341) and 6-month mRS scores (β, 0.239; 95% CI, 0.100–0.474). Serum NLRC4 levels above 363.2 pg/ml were independently predictive of END (odds ratio, 3.148; 95% CI, 1.278–7.752) and 6-month poor outcome (odds ratio, 2.468; 95% CI, 1.036–5.878). Serum NLRC4 levels significantly distinguished END risk [area under ROC curve (AUC), 0.765; 95% CI, 0.685–0.846] and 6-month poor outcome (AUC, 0.795; 95% CI, 0.721–0.870). In terms of predictive ability for 6-month poor outcome, serum NLRC4 levels combined with NIHSS scores and hematoma volume was superior to NIHSS scores combined with hematoma volume, NIHSS scores and hematoma volume (AUC, 0.913 vs. 0.870, 0.864 and 0.835; all P &lt; 0.05). Nomograms were built to reflect prognosis and END risk of combination models, where serum NLRC4, NIHSS scores and hematoma volume were enforced. Calibration curves confirmed stability of combination models.

Conclusions

Markedly raised serum NLRC4 levels following ICH, in close relation to illness severity, are independently associated with poor prognosis. Such results are indicative of the notion that determination of serum NLRC4 may aid in severity assessment and prediction of functional outcome of ICH patients.

Prehospital Ultra-Early Neurological Deterioration in Intracerebral Hemorrhage: Definition, Prevalence, and Association with Outcomes

INTRODUCTION

The objective of this study was to define prehospital ultra-early neurological deterioration (UND) and to investigate the association with functional outcomes in patients with intracerebral hemorrhage (ICH).

METHODS

We conducted a prospective cohort study of consecutive acute ICH patients. The stroke severity at onset and hospital admission was assessed using the Chongqing Stroke Scale (CQSS), and prehospital UND was defined as a CQSS increase of ≥2 points between symptoms onset and admission. Early neurological deterioration (END) was defined as the increase of ≥4 points in NIHSS score within the first 24 h after admission. Poor outcome was defined as a modified Rankin Scale (mRS) of 4-6 at 3 months.

RESULTS

Prehospital UND occurred in 29 of 169 patients (17.2%). Patients with prehospital UND had a median admission NIHSS score of 17.0 as opposed to those without prehospital UND with a median NIHSS score of 8.5. There were three patterns of neurological deterioration: prehospital UND only in 21 of 169 patients (12.4%), END but without prehospital UND in 20 of 169 patients (11.8%), and continuous neurological deterioration in both phases in 8 patients (4.7%). Prehospital UND was associated with worse 3-month outcomes (median mRS score, 4.0 vs. 2.0, p = 0.002). After adjusting for age, time from onset to admission, END, and systolic blood pressure, prehospital UND was an independent predictor of poor outcome (odds ratio [OR] 3.27, 95% confidence interval [CI] 1.26-8.48, p = 0.015).

CONCLUSION

Prehospital UND occurs in approximately 1 in 7 patients between symptom onset and admission and is associated with poor functional outcome in patients with ICH. Further research is needed to investigate the prehospital UND in the prehospital phase in the triage of patients with ICH.

Decreased Hospital Length of Stay for ICH and PE after Adoption of an Artificial Intelligence-Augmented Radiological Worklist Triage System

The purpose of the study was to determine whether there was a difference in the length of stay (LOS) for inpatients diagnosed with intracranial hemorrhage (ICH) or pulmonary embolism (PE) prior to and following implementation of an (AI) triage software. A retrospective review was performed for patients that underwent CT imaging procedures related to ICH and PE from April 2016 to October 2019. All patient encounters that included noncontrast head computed tomography (CT) or CT chest angiogram (CTCA) procedures, identified by the DICOM study descriptions, from April 2016 to April 2019 were included for ICH and PE, respectively. All patients that were diagnosed with ICH or PE were identified using ICD9 and ICD10 codes. Three separate control groups were defined as follows: (i) all remaining patients that underwent the designated imaging studies, (ii) patients diagnosed with hip fractures, and (iii) all hospital wide encounters, during the study period. Pre-AI and post-AI time periods were defined around the deployment dates of the ICH and PE modules, respectively. The reduction in LOS was 1.30 days (95% C.I. 0.1–2.5), resulting in an observed percentage decrease of 11.9% (p value = 0.032), for ICH and 2.07 days (95% C.I. 0.1–4.0), resulting in an observed percentage decrease of 26.3% (p value = 0.034), for PE when comparing the pre-AI and post-AI time periods. Reductions in LOS were observed in the ICH pre-AI and post-AI time period group for patients that were not diagnosed with ICH, but that underwent related imaging, 0.46 days (95% C.I. 0.1–0.8) resulting in an observed percentage decrease of 5% (p value = 0.018), and inpatients that were diagnosed with hip fractures, 0.60 days (95% C.I. 0.1–1.2) resulting in an observed percentage decrease of 8.3% (p value = 0.004). No other significant decrease in length of stay was observed in any of the other patient groups. The introduction of computer-aided triage and prioritization software into the radiological workflow was associated with a significant decrease in length of stay for patients diagnosed with ICH and PE.

Usability of serum annexin A7 as a biochemical marker of poor outcome and early neurological deterioration after acute primary intracerebral hemorrhage: A prospective cohort study

Objective

Annexin A7 (ANXA7), a calcium-dependent phospholipid-binding protein, may act to aggravate brain injury. This study aimed to assess the clinical utility of serum ANXA7 as a predictor of severity, early neurological deterioration (END), and prognosis after intracerebral hemorrhage (ICH).

Methods

A total of 126 ICH patients and 126 healthy controls were enrolled. Symptomatic severity was evaluated utilizing the National Institutes of Health Stroke Scale (NIHSS) score. The lesion volume of ICH was measured according to the ABC/2 method. END was referred to as an increase of 4 or greater points in the NIHSS score or death at post-stroke 24 h. The unfavorable functional outcome was a combination of death and major disability at post-stroke 90 days.

Results

Serum ANXA7 levels were significantly higher in patients than in controls (median, 46.5 vs. 9.7 ng/ml; P &lt; 0.001). Serum ANXA7 levels were independently correlated with NIHSS score [beta: 0.821; 95% confidence interval (CI): 0.106–1.514; variance inflation factor: 5.180; t = 2.573; P = 0.014] and hematoma volume (beta: 0.794; 95% CI: 0.418–1.173; variance inflation factor: 5.281; t = 2.781; P = 0.007). Serum ANXA7 levels were significantly elevated with increase in modified Rankin scale scores (P &lt; 0.001). Also, serum ANXA7, which was identified as a categorical variable, independently predicted END and an unfavorable outcome with odds ratio values of 3.958 (95% CI: 1.290–12.143; P = 0.016) and 2.755 (95% CI: 1.051–7.220; P = 0.039), respectively. Moreover, serum ANXA7 levels efficiently differentiated END (area under the curve: 0.781; 95% CI: 0.698–0.849) and an unfavorable outcome (area under the curve: 0.776; 95% CI: 0.693–0.846).

Conclusion

Serum ANXA7 may represent a useful blood-derived biomarker for assessing the severity, END, and prognosis of ICH.

Fibrinogen to Albumin Ratio as Early Serum Biomarker for Prediction of Intra-Hospital Mortality in Neurosurgical Intensive Care Unit Patients with Spontaneous Intracerebral Hemorrhage

Background: The prognostic value of the fibrinogen to albumin ratio on intrahospital mortality has been investigated in patients with cardiovascular disease, cancer, sepsis, and ischemic stroke; however, it has not been investigated for neurosurgical patients with spontaneous intracerebral hemorrhage (ICH). The present study investigates the impact of the fibrinogen to albumin ratio upon admission for intrahospital mortality in neurosurgical intensive care unit (ICU) patients with spontaneous ICH. Methods: A total of 198 patients with diagnosis of spontaneous ICH treated from 10/2008 to 12/2017 at our ICU were retrospectively analyzed. Blood samples were drawn upon admission, and the patients’ demographic, medical data, and cranial imaging were collected. Binary logistic regression analysis was performed to identify independent prognostic factors for intrahospital mortality. Results: The total rate of intrahospital mortality was 35.4% (n = 70). In the multivariate regression analysis, higher fibrinogen to albumin ratio (OR = 1.16, CI = 1.02−1.31, p = 0.03) upon admission was an independent predictor of intrahospital mortality in neurosurgical ICU patients with ICH. Moreover, a fibrinogen to albumin ratio cut-off level of >0.075 was related to increased intrahospital mortality (Youden’s index = 0.26, sensitivity = 0.51, specificity = 0.77). Conclusion: A fibrinogen to albumin ratio > 0.075 was significantly associated with increased intrahospital mortality in ICH patients.

Impact of process of care in the short-term mortality in non-severe intracerebral hemorrhage in southern Portugal

INTRODUCTION

Patients with spontaneous intracerebral hemorrhage (SICH) face the worse functional and vital prognosis among all stroke subtypes. In cases of severe SICH, therapeutic inertia or nihilism complicates meaningful identification of outcome predictors. Therefore, we sought to investigate clinic-radiological and process of care predictors of short-term mortality in patients with mild to moderate SICH.

PATIENTS AND METHODS

Observational retrospective community representative consecutive case series of patients from Algarve, southern Portugal. Logistic regression was used to identify predictors of short-term (30-day) death.

RESULTS

Mortality was 23.9% (111/464). Most important predictors of death were unconsciousness at admission (OR = 12.392, 95% CI = 3.816-40.241, p < 0.001), hospital arrival ≥ 6 h after stroke onset (OR = 2.842, 95% CI = 1.380-5.852, p =.005), hematoma volume > 30 cc/cm3 (OR = 3.295, 95% CI 0 1.561-6.953, p =.002), intraventricular extension (OR = 2.885, 95% CI = 1.457-5.712, p =.002) and ≥ 24 h in the Emergency Department (OR = 19.675, 95% CI = 3.682-34.125, p =.009). Stroke Unit (SU) admission reduced the likelihood of death (OR = 0.293, 95% CI = 0.137-0.682, p =.002).

CONCLUSION

The observed mortality is high. Apart from the traditional clinic-radiological factors, in mild to moderate SICH, process of care related factors have strong impact on mortality. These results highlight the need of continuous improvement of SICH care to improve the prognosis.

A Prediction Model for Neurological Deterioration in Patients with Acute Spontaneous Intracerebral Hemorrhage

Aim

The aim of this study was to explore factors related to neurological deterioration (ND) after spontaneous intracerebral hemorrhage (sICH) and establish a prediction model based on random forest analysis in evaluating the risk of ND.

Methods

The clinical data of 411 patients with acute sICH at the Affiliated Hospital of Jining Medical University and Xuanwu Hospital of Capital Medical University between January 2018 and December 2020 were collected. After adjusting for variables, multivariate logistic regression was performed to investigate the factors related to the ND in patients with acute ICH. Then, based on the related factors in the multivariate logistic regression and four variables that have been identified as contributing to ND in the literature, we established a random forest model. The receiver operating characteristic curve was used to evaluate the prediction performance of this model.

Results

The result of multivariate logistic regression analysis indicated that time of onset to the emergency department (ED), baseline hematoma volume, serum sodium, and serum calcium were independently associated with the risk of ND. Simultaneously, the random forest model was developed and included eight predictors: serum calcium, time of onset to ED, serum sodium, baseline hematoma volume, systolic blood pressure change in 24 h, age, intraventricular hemorrhage expansion, and gender. The area under the curve value of the prediction model reached 0.795 in the training set and 0.713 in the testing set, which suggested the good predicting performance of the model.

Conclusion

Some factors related to the risk of ND were explored. Additionally, a prediction model for ND of acute sICH patients was developed based on random forest analysis, and the developed model may have a good predictive value through the internal validation.

Frequency, Risk Factors, and Outcomes of Unplanned Readmission to the Neurological Intensive Care Unit after Spontaneous Intracerebral Hemorrhage

BACKGROUND

Unplanned readmission to the neurological intensive care unit (ICU) is an underinvestigated topic in patients admitted after spontaneous intracerebral hemorrhage (ICH). The purpose of this study is to investigate the frequency, clinical risk factors, and outcome of bounce back to the neurological ICU in a cohort of patients admitted after ICH.

METHODS

This is a retrospective observational study inspecting bounce back to the neurological ICU in patients admitted with spontaneous ICH over an 8-year period. For each patient, demographics, medical history, clinical presentation, length of ICU stay, unplanned readmission to neurological ICU, cause of readmission, and mortality were reviewed. Bounce back to the neurological ICU was defined as an unplanned readmission to the neurological ICU from a general floor service during the same hospitalization. A multivariable analysis was used to define independent variables associated with bounce back to the neurological ICU as well as association between bounce back to the neurological ICU and mortality. The significance level was set at p < 0.05.

RESULTS

A total of 221 patients were included. Among those, 20 (9%) had a bounce back to the neurological ICU. Respiratory complications (n = 11) was the most common reason for bounce back to the neurological ICU, followed by neurological (n = 5) and cardiological (n = 4) complications. In a multivariable logistic regression, location of hemorrhage in the basal ganglia (odds ratio [OR]: 3.0, 95% confidence interval [CI]: 1.0-8.9, p = 0.03) and dysphagia at the time of transfer (OR: 3.9, 95% CI: 1.0-15.4, p = 0.04) were significantly associated with bounce back to the neurological ICU. After we controlled for ICH score, readmission to the ICU was also independently associated with higher mortality (OR: 14.1, 95% CI: 2.8-71.7, p < 0.01).

CONCLUSIONS

Bounce back to the neurological ICU is not an infrequent complication in patients with spontaneous ICH and is associated with higher hospital length of stay and mortality. We identified relevant and potentially modifiable risk factors associated with bounce back to the neurological ICU. Future prospective studies are necessary to develop patient-centered strategies that may improve transition from the neurological ICU to the general floor.

Emergency department point‑of‑care biomarkers and day 90 functional outcome in spontaneous intracerebral hemorrhage: A single‑center pilot study

Spontaneous intracerebral hemorrhage (sICH) results in high morbidity and mortality rates, thus identifying strategies for timely prognosis and treatment is important. The present study aimed to analyze the relationship between emergency department point-of-care (POC) blood biomarkers and day 90 functional outcome (FO) in patients with acute (<8 h) sICH. On-site POC determinations, including complete blood count, glucose, cardiac troponin I, D-dimer and C-reactive protein, and derived inflammatory indexes were performed for a cohort of 35 patients. The primary endpoint was a favorable day 90 FO (modified Rankin Score ≤3). Secondary endpoints included early neurological worsening (ENW), day 7/discharge neurological impairment, day 90 independence assessment (Barthel Index <60), hematoma enlargement and perihematomal edema (PHE) growth. A favorable three-month FO was reported in 16 (46%) participants. Older age, previous history of ischemic stroke and initial imagistic parameters, including intraventricular hemorrhage, enlarged contralateral ventricle and cerebral atrophy, significantly predicted an unfavorable FO. The admission D-dimer similarly predicted day 90 FO and the independence status, along with ENW and a more severe day 7/discharge neurological status. The D-dimer also correlated with the initial neurological status and PHE. PHE growth correlated with granulocytes, systemic immune-inflammation index and glycemia. The results suggested that a lower admission D-dimer could indicate an improved day 90 FO of patients with sICH, while also anticipating the development of PHE growth and ENW.

Feasibility of a pilot study on point-of-care biomarkers in spontaneous intracerebral hemorrhage in an emergency setting

Background and aims

Stroke is a worldwide leading cause of death and disability and spontaneous intracerebral hemorrhage (sICH) has significant economic and social impact, regardless of recent efforts towards outcome-bettering acute interventions. The aim of the study was to assess the feasibility of a prospective observational research regarding point-of-care (POC) biomarkers in sICH, conducted in a level one emergency department (ED).

Methods

Patients with acute (<8 hours) sICH were enrolled in this study. Patients presenting a Glasgow Coma Scale score <8, secondary causes of intracerebral hemorrhage, seizures, recent ischemic events, known thromboembolic disease, anticoagulant treatment, severe pre-stroke disability, terminal disease, scheduled neurosurgery/hemostatic treatment were excluded. Feasibility was defined as ED inclusion and follow-up rates, time-to-inclusion, and frequency of missing data. Baseline demographic, imaging and POC biochemical status of the study group were documented, including inflammatory (complete blood count, C-reactive protein), metabolic (glucose, hepatic, and renal function) and cardiovascular markers (cardiac troponin I, D-dimer).

Results

The inclusion rate was 2.16 patients/month with a final sample of 35 patients out of 239 potentially eligible patients. The median time from symptom onset to ED presentation was 128 minutes (IQR 96-239), with 21/35 patients having presented within the first 3 hours from ictus. Median times between symptoms' onset to Computer Tomography (CT) scan and ED presentation to CT scan were 170 minutes (IQR 126-317) and 25 minutes (IQR 17-62), respectively. The median time from patient's presentation to CBC result was 12 minutes (IQR 6.5-20), with 21/35 study participants having the results available within 15 minutes from ED arrival. The median cohort age was 72-years, with a 19/16 male/female ratio. Hypertension was the most frequent risk factor (77%), along with ischemic heart disease (31%) and diabetes (29%). One-third of the hypertensive patients did not undergo blood pressure lowering treatment. Median values of POC biomarkers on ED admission were within normal range.

Conclusions

It was feasible to determine point-of-care biomarkers in spontaneous intracerebral hemorrhage on admission in ED, despite the urgency of the medical condition.

Predictors and Outcomes of Neurological Deterioration in Intracerebral Hemorrhage: Results from the TICH-2 Randomized Controlled Trial

Neurological deterioration is common after intracerebral hemorrhage (ICH). We aimed to identify the predictors and effects of neurological deterioration and whether tranexamic acid reduced the risk of neurological deterioration. Data from the Tranexamic acid in IntraCerebral Hemorrhage-2 (TICH-2) randomized controlled trial were analyzed. Neurological deterioration was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) of ≥ 4 or a decline in Glasgow Coma Scale of ≥ 2. Neurological deterioration was considered to be early if it started ≤ 48 h and late if commenced between 48 h and 7 days after onset. Logistic regression was used to identify predictors and effects of neurological deterioration and the effect of tranexamic acid on neurological deterioration. Of 2325 patients, 735 (31.7%) had neurological deterioration: 590 (80.3%) occurred early and 145 (19.7%) late. Predictors of early neurological deterioration included recruitment from the UK, previous ICH, higher admission systolic blood pressure, higher NIHSS, shorter onset-to-CT time, larger baseline hematoma, intraventricular hemorrhage, subarachnoid extension and antiplatelet therapy. Older age, male sex, higher NIHSS, previous ICH and larger baseline hematoma predicted late neurological deterioration. Neurological deterioration was independently associated with a modified Rankin Scale of > 3 (aOR 4.98, 3.70-6.70; p < 0.001). Tranexamic acid reduced the risk of early (aOR 0.79, 0.63-0.99; p = 0.041) but not late neurological deterioration (aOR 0.76, 0.52-1.11; p = 0.15). Larger hematoma size, intraventricular and subarachnoid extension increased the risk of neurological deterioration. Neurological deterioration increased the risk of death and dependency at day 90. Tranexamic acid reduced the risk of early neurological deterioration and warrants further investigation in ICH. URL: https://www.isrctn.com Unique identifier: ISRCTN93732214.

Inhaled corticosteroids and risk of lung cancer: A systematic review and meta-analysis

INTRODUCTION

Current studies investigating the association between inhaled corticosteroid (ICS) use and risk of lung cancer have yielded inconsistent findings. The aim of this systematic review and meta-analysis was to pool all currently available data to estimate this association.

METHODS

We systematically searched MEDLINE (1946 to July 2020), EMBASE (1974 to July 2020) and the Cochrane Library (June 2020) via Ovid to identify relevant articles investigating the association between the ICS use and the risk of lung cancer. Random-effects analysis was used to calculate pooled relative risks (RRs) with 95% confidence intervals (CIs).

RESULTS

Ten articles including 234 920 patients were analysed. ICS use was identified to have a decreased risk of lung cancer in chronic obstructive pulmonary disease (8 studies, 1806 patients; RR = 0.73, 95% CI: 0.61-0.87, P < .01; I²  = 60.0 %), asthma (1 study, 41 438 patients; RR = 0.44, 95% CI: 0.34-0.57, P < .01) and mixed (1 study, 46 225 patients; RR = 0.79, 95% CI: 0.69-0.90, P < .01) patients. The findings of reduced risk of lung cancer were consistent in all subgroup analyses except for the short-term follow-up (≤5 years) (RR = 0.94, 95% CI: 0.81-1.07, P = .34) and free of immortal time bias (RR = 0.94, 95% CI: 0.82-1.08, P = .38) subgroups.

CONCLUSIONS

The present study suggested that ICS use was associated with decreased risk of lung cancer. However, our findings should be interpreted with caution because most original studies were judged to be at high risk of immortal time bias.

Risk of Short-Term Mortality after Intracerebral Haemorrhage due to Weekend Hospital Admission in Poland

Background

The mortality rate for spontaneous intracerebral haemorrhage (ICH) has remained high and stable for many years. The unfavourable prognostic factors include age, bleeding volume, location of the haematoma, high blood pressure, and disturbed consciousness on admission. Other risk factors associated with medical care also deserve attention. The study aimed to analyse the relationship between day of admission, concerning other prognostic factors, and short-term mortality in ICH, in a Polish specialist stroke unit.

Methods

Medical records of 156 patients (74 males, 82 females, mean age 68.7 years) diagnosed with spontaneous ICH and admitted to a specialist stroke center were retrospectively analysed. Demographics, location, volume of bleeding, blood pressure values, and the Glasgow Coma Scale (GCS), as well as the day of admission, were determined. The relationships were analysed between these factors and 30-day mortality in the patients with ICH.

Results

A total of 83 patients were admitted to the hospital during weekdays (Monday 8 am to Friday 3 pm) and 73 during weekends or holidays. Of these, 65 patients died within 30 days. Patients admitted at weekends initially presented with lower GCS scores. Admission on Saturday was associated with an increased risk of death (OR 3.38, 95% CI 1.2–9.48, p < 0.05), but after correction for clinical state measured with the GCS and ICH score, the association was no longer significant.

Conclusions

The time and mode of admission were not associated with increased risk of short-term mortality in ICH patients. Prehospital care issues should be additionally considered as prognostic factors of the outcome.

Association between out-of-bed mobilization and complications of immobility in acute phase of severe stroke: A retrospective observational study

BACKGROUND

Medical complications often occur, particularly in the acute phase of severe stroke, and lead to poor outcomes. However, it is unclear whether out-of-bed mobilization (OM) reduces such complications or not in the acute phase of severe stroke. Thus, we investigated the association between OM and complications of immobility in the acute phase of severe stroke.

METHODS

We enrolled 407 patients diagnosed with ischemic stroke or intracerebral hemorrhage and patients with modified Rankin Scale 5 at discharge in this study. Patients were divided into two groups: OM (303 patients) and bed rest (BR; 104 patients) at discharge based on their medical records. Complications of immobility (such as pneumonia, urinary tract infection, pressure sore, and falls) during hospitalization in each group were recorded.

RESULTS

The total complication rate of immobility, incidence of pneumonia, and the incidence of pressure sores were significantly lower in the OM group than in the BR group [60.7% vs. 88.5%, 45.5% vs. 62.5%, and 3.6% vs. 12.5%; odds ratio, 0.20, 0.50, and 0.26; and 95% confidence intervals, 0.11-0.39, 0.32-0.79, and 0.11-0.61, respectively]. Urinary tract infection and falls did not differ significantly between the two groups.

CONCLUSIONS

In the acute phase of severe stroke, OM was significantly associated with a lower risk of total complication rate of immobility, incidence of pneumonia, and incidence of pressure sore without increasing falls.

Brainstem iron overload and injury in a rat model of brainstem hemorrhage

BACKGROUND AND PURPOSE

Brainstem hemorrhage (BSH) is the most devastating subtype of intracerebral hemorrhage (ICH) with the highest mortality ranging from 56 % to 61.2 %. However, there is no effective medical or surgical therapy to improve its outcomes in clinic to date due to lack of understanding of its injury mechanisms. Herein, we explored the brainstem iron overload and injury in a rat model of BSH.

METHODS

Neurological scores were examined on day 1, 3, and 7 after modeling, and mortality of the rats was recorded to draft a survival curve. Rats were monitored by MRI using T2 and susceptibility weighted imaging (SWI) before sacrifice for examination of histology and immunofluorescence on day 1, 3, and 7.

RESULTS

BSH rats had a high mortality of 56 % and demonstrated the severe neurological deficits mimicking the clinical conditions. SWI showed that the same increasing tendency in change of hypointense area with that in iron deposition by Perls staining from day 1 to 7. Expression of heme oxygenase 1 (HO-1) and generation of reactive oxygen species (ROS) had similar tendency and both peaked on day 3. Neuronal degeneration occurred and stayed elevated from day 1 to 7, while myelin sheath injury was initially observed on day 1 but without significant difference within 7 days.

CONCLUSIONS

The time courses of erythrocyte lysis, HO-1 expression, iron deposition and ROS generation are related to each other after BSH. Besides, brainstem injury including neuronal degeneration and myelin damage were observed and discussed.

Mortality in patients with intracerebral hemorrhage associated with antiplatelet agents, oral anticoagulants or no antithrombotic therapy

The association between preceding treatment with antiplatelet agents (APs), vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) and mortality after intracerebral hemorrhage (ICH) remains unclear. The aim of this multicenter, prospective cohort study was to assess the risk for death after ICH in consecutive patients who were on treatment with APs, VKAs, DOACs, or no antithrombotic agent. The primary outcome was in-hospital death by day 30. ICH volume at admission and volume expansion were centrally assessed. Out of 598 study patients, in-hospital death occurred in 21% of patients who were on treatment with APs, 25% with VKAs, 30% with DOACs, and 13% with no antithrombotics. Crude death rate was higher in patients on antithrombotics as compared to patients receiving no antithrombotic agent. At multivariate analysis, age (HR 1.07; 95% CI 1.04-1.10), previous stroke (HR 1.83; 95% CI 1.14-2.93), GCS ≤8 at admission (HR 6.06; 95% CI 3.16-9.74) and GCS 9-12 (HR 3.38; 95% CI 1.81-6.33) were independent predictors of death. Treatment with APs (HR 1.29; 95% CI 0.61-2.76), VKAs (HR 1.42; 95% CI 0.70-2.88) or DOACs (HR 1.28; 95% CI 0.61-2.73) were not predictors of death in the overall study population, in non-trauma associated ICH as well as when GCS was not included in the model. ICH volume and volume expansion were independent predictors of death. In conclusion, preceding treatment with antithrombotic is associated with the severity of ICH. Age, previous stroke and clinical severity at presentation were independent predictors of in-hospital death in patients with ICH.

Baseline factors associated with early and late death in intracerebral haemorrhage survivors

Background and purpose

The aim of this study was to determine whether early and late death are associated with different baseline factors in intracerebral haemorrhage (ICH) survivors.

Methods

This was a secondary analysis of the multicentre prospective observational CROMIS‐2 ICH study. Death was defined as ‘early’ if occurring within 6 months of study entry and ‘late’ if occurring after this time point.

Results

In our cohort (n = 1094), there were 306 deaths (per 100 patient‐years: absolute event rate, 11.7; 95% confidence intervals, 10.5–13.1); 156 were ‘early’ and 150 ‘late’. In multivariable analyses, early death was independently associated with age [per year increase; hazard ratio (HR), 1.05, P = 0.003], history of hypertension (HR, 1.89, P = 0.038), pre‐event modified Rankin scale score (per point increase; HR, 1.41, P < 0.0001), admission National Institutes of Health Stroke Scale score (per point increase; HR, 1.11, P < 0.0001) and haemorrhage volume >60 mL (HR, 4.08, P < 0.0001). Late death showed independent associations with age (per year increase; HR, 1.04, P = 0.003), pre‐event modified Rankin scale score (per point increase; HR, 1.42, P = 0.001), prior anticoagulant use (HR, 2.13, P = 0.028) and the presence of intraventricular extension (HR, 1.73, P = 0.033) in multivariable analyses. In further analyses where time was treated as continuous (rather than dichotomized), the HR of previous cerebral ischaemic events increased with time, whereas HRs for Glasgow Coma Scale score, National Institutes of Health Stroke Scale score and ICH volume decreased over time.

Conclusions

We provide new evidence that not all baseline factors associated with early mortality after ICH are associated with mortality after 6 months and that the effects of baseline variables change over time. Our findings could help design better prognostic scores for later death after ICH.

Intracerebral hemorrhage: an update on diagnosis and treatment

Introduction: Spontaneous non-traumatic intracerebral hemorrhage (ICH) is most often caused by small vessel diseases: deep perforator arteriopathy (hypertensive arteriopathy) or cerebral amyloid angiopathy (CAA). Although ICH accounts for only 10-15% of all strokes it causes a high proportion of stroke mortality and morbidity, with few proven effective acute or preventive treatments. Areas covered: We conducted a literature search on etiology, diagnosis, treatment, management and current clinical trials in ICH. In this review, We describe the causes, diagnosis (including new brain imaging biomarkers), classification, pathophysiological understanding, treatment (medical and surgical), and secondary prevention of ICH. Expert opinion: In recent years, significant advances have been made in deciphering causes, understanding pathophysiology, and improving acute treatment and prevention of ICH. However, the clinical outcome remains poor and many challenges remain. Acute interventions delivered rapidly (including medical therapies - targeting hematoma expansion, hemoglobin toxicity, inflammation, edema, anticoagulant reversal - and minimally invasive surgery) are likely to improve acute outcomes. Improved classification of the underlying arteriopathies (from neuroimaging and genetic studies) and prognosis should allow tailored prevention strategies (including sustained blood pressure control and optimized antithrombotic therapy) to further improve longer-term outcome in this devastating disease.

Predictive factors of neurologic deterioration in patients with spontaneous cerebellar hemorrhage: a retrospective analysis

Background

Cerebellar hemorrhage is a potentially life-threatening condition and neurologic deterioration during hospitalization could lead to severe disability and poor outcome. Finds out the factors influencing neurologic deterioration during hospitalization is essential for clinical decision-making.

Methods

One hundred fifty-five consecutive patients who suffered a first spontaneous cerebellar hemorrhage (SCH) were evaluated in this 10-year retrospective study. This study aimed to identify potential clinical, radiological and clinical scales risk factors for neurologic deterioration during hospitalization and outcome at discharge.

Results

Neurologic deterioration during hospitalization developed in 17.4% (27/155) of the patient cohort. Obliteration of basal cistern (p≦0.001) and hydrocephalus (p≦0.001) on initial brain computed tomography (CT), median Glasgow Coma Scale (GCS) score at presentation (p≦0.001) and median intracerebral hemorrhage (ICH) score (P≦0.001) on admission were significant factors associated with neurologic deterioration. Stepwise logistic regression analysis showed that patients with obliteration of basal cistern on initial brain CT scan had an odds ratio (OR) of 9.17 (p = 0.002; 95% confidence interval (CI): 0.026 to 0.455) adjusted risk of neurologic deterioration compared with those without obliteration of basal cistern. An increase of 1 point in the ICH score on admission would increase the neurologic deterioration rate by 83.2% (p = 0.010; 95% CI: 1.153 to 2.912). The ROC curves showed that the AUC for ICH score on presentation was 0.719 (p = 0.000; 95% CI: 0.613–0.826) and the cutoff value was 2.5 (sensitivity 80.5% and specificity 73.7%).

Conclusion

Patients had obliteration of basal cistern on initial brain CT and ICH score greater or equal to 3 at admission implies a greater danger of neurologic deterioration during hospitalization. Cautious clinical assessments and repeated brain images study are mandatory for those high-risk patients to prevent neurologic deterioration during hospitalization.

Prognostic role of microvessel density in patients with glioma

BACKGROUND

The aim of this study was to systematically evaluate the prognostic role of microvessel density (MVD) in patients with glioma through performing a meta-analysis.

METHODS

Web of Science, EMBASE, PubMed, Cochrane Library, and China National Knowledge Infrastructure were searched for potentially relevant literature. The study characteristics and relevant data were extracted. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled to estimate the prognostic role of MVD in patients with glioma.

RESULTS

Nine studies with 536 patients were included. The pooled HR of higher MVD for overall survival (OS) was 1.64 (95% CI, 1.07-2.50) in patients with glioma. Subgroup analyses were also performed. The pooled HRs of higher MVD in studies from East Asia studies examining high-grade gliomas and studies using anti-CD105 antibodies were 1.99 (95% CI, 1.04-3.80), 1.60 (95% CI, 1.09-2.34) and 2.99 (95% CI, 1.50-5.99), respectively. No significant publication bias was found (P = .592), but significant between-study heterogeneity was observed (I = 80.5%, P <.001) in the meta-analysis.

CONCLUSION

Our results suggested that higher MVD was associated with worse OS in patients with glioma. The findings may assist future research on antiangiogenic therapy and help predict prognosis in glioma. However, due to the limited number of studies, more well-designed studies are warranted to further verify our results.

Prognostic role of early D-dimer level in patients with acute ischemic stroke

OBJECT

The purpose of our study was to assess the prognostic role of early D-dimer level in patients with acute ischemic stroke (AIS).

METHODS

The included patients' D-dimer levels have to be tested within 24 hours from stroke onset. Poor functional outcome was defined as modified Rankin Scale (mRS) ≥3. The endpoints included recurrence on 5-day diffusion-weighted imaging, 30-day mRS ≥3, 30-day mortality and 90-day mRS ≥3. Regarding to each endpoint, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to assess the prognostic role of D-dimer in patients with AIS.

RESULTS

A total of 2,479 patients were included. The results showed that elevated D-dimer levels were associated with recurrence on 5-day diffusion-weighted imaging (OR = 2.28, 95% CI = 1.32-3.95), 30-day mRS≥3 (OR = 1.59, 95% CI = 1.37-1.85), 30-day mortality (OR = 1.92, 95% CI = 1.27-2.90) and 90-day mRS≥3 (OR = 1.61, 95% CI = 1.05-2.46).

CONCLUSIONS

In conclusion, for patients with AIS, higher D-dimer level within 24 hours from stroke onset was associated with recurrence on 5-day diffusion-weighted imaging, mortality at 30 days, and poor functional outcome at both 30 days and 90 days. However, more studies are warranted to clarify this issue.

Favorable clinical outcome following surgical evacuation of deep-seated and lobar supratentorial intracerebral hemorrhage: a retrospective single-center analysis of 123 cases

Background

In spontaneous supratentorial intracerebral hemorrhage (ICH), the role of surgical treatment remains controversial, particularly in deep-seated ICHs. We hypothesized that early mortality and long-term functional outcome differ between patients with surgically treated lobar and deep-seated ICH.

Method

Patients who underwent craniotomy for ICH evacuation from 2009 to 2015 were retrospectively evaluated and categorized into two subgroups: lobar and deep-seated ICH. The modified Rankin Scale (mRS) was used to evaluate long-term functional outcome.

Result

Of the 123 patients operated for ICH, 49.6% (n = 61) had lobar and 50.4% (n = 62) deep-seated ICH. At long-term follow-up (mean 4.2 years), 25 patients (20.3%) were dead, while 51.0% of survivors had a favorable outcome (mRS score ≤ 3). Overall mortality was 13.0% at 30 days and 17.9% at 6 months post-ictus, not influenced by ICH location. Mortality was higher in patients ≥ 65 years old (p = 0.020). The deep-seated group had higher incidence and extent of intraventricular extension, younger age (52.6 ± 9.0 years vs. 58.5 ± 9.8 years; p < 0.05), more frequently pupillary abnormalities, and longer neurocritical care stay (p < 0.05). The proportion of patients with good outcome was 48.0% in deep-seated vs. 54.1% in lobar ICH (p = 0.552). In lobar ICH, independent predictors of long-term outcome were age, hemorrhage volume, preoperative level of consciousness, and pupillary reaction. In deep-seated ICHs, only high age correlated significantly with poor outcome.

Conclusions

At long-term follow-up, most ICH survivors had a favorable clinical outcome. Neither mortality nor long-term functional outcome differed between patients operated for lobar or deep-seated ICH. A combination of surgery and neurocritical care can result in favorable clinical outcome, regardless of ICH location.

Prognostic role of D-dimer level upon admission in patients with traumatic brain injury

BACKGROUND

The aim of this study was to evaluate the prognostic role of D-dimer level upon admission in patients with traumatic brain injury (TBI) through performing a meta-analysis.

METHODS

PubMed, Web of Science, Cochrane Library, and EMBASE were searched for potential eligible literature. The study characteristics and relevant data were extracted. Poor functional outcome was defined according to the Glasgow Outcome Scale (GOS ≤3). Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled to estimate the predictive value of D-dimer for progressive hemorrhagic injury (PHI) and poor functional outcome at 3 months (3M GOS ≤3) in patients with TBI.

RESULTS

Eleven studies with 2761 patients were included. Eight studies examined the predictive role of higher D-dimer level for the risk of PHI, and the pooled OR was 1.72 (95% CI, 1.23-2.42). Three studies examined the predictive role of higher D-dimer level for the risk of 3M GOS ≤3, and the pooled OR was 2.00 (95% CI, 0.87-4.59). Significant between-study heterogeneities were observed, and sensitivity analyses and subgroup analyses were performed. No significant publication bias was found.

CONCLUSIONS

In conclusion, in patients with TBI, higher D-dimer level upon admission was associated with higher risk of PHI, yet no significant relationship was found between D-dimer level and the risk of 3M GOS ≤3. In the future, this readily available marker could help identify patients at risk and tailor management of these patients, thus reducing PHI and improving outcome.

Prognostic role of survivin in patients with glioma

BACKGROUND

The aim of this study was to systematically evaluate the prognostic role of survivin in patients with glioma through performing a meta-analysis.

METHODS

PubMed, Web of Science, Cochrane Library, and EMBASE were searched for potentially eligible literature. The study characteristics and relevant data were extracted. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled to estimate the prognostic role of survivin in patients with glioma.

RESULTS

Sixteen studies with 1260 patients were included. The pooled HR of higher survivin expression for overall survival was 1.96 (95% CI, 1.57-2.45). The pooled HRs of higher survivin expression for progression- and disease-free survival were 1.62 (95% CI, 0.91-2.90) and 2.41 (95% CI, 0.98-5.90), respectively. Subgroup analyses were also performed.

CONCLUSION

Our results suggested that higher survivin expression was associated with worse overall survival in patients with glioma. The findings may assist future exploration on pathogenesis, diagnosis, anti-survivin therapy, and prognosis in glioma. However, due to the limited study number, more studies are warranted to verify our results.

Update on the Treatment of Spontaneous Intraparenchymal Hemorrhage: Medical and Interventional Management

PURPOSE OF REVIEW

Spontaneous intraparenchymal hemorrhage (IPH) is a prominent challenge faced globally by neurosurgeons, neurologists, and intensivists. Over the past few decades, basic and clinical research efforts have been undertaken with the goal of delineating biologically and evidence-based practices aimed at decreasing mortality and optimizing the likelihood of meaningful functional outcome for patients afflicted with this devastating condition. Here, the authors review the medical and surgical approaches available for the treatment of spontaneous intraparenchymal hemorrhage, identifying areas of recent progress and ongoing research to delineate the scope and scale of IPH as it is currently understood and treated.

RECENT FINDINGS

The approaches to IPH have broadly focused on arresting expansion of hemorrhage using a number of approaches. Recent trials have addressed the effectiveness of rapid blood pressure lowering in hypertensive patients with IPH, with rapid lowering demonstrated to be safe and at least partially effective in preventing hematoma expansion. Hemostatic therapy with platelet transfusion in patients on anti-platelet medications has been recently demonstrated to have no benefit and may be harmful. Hemostasis with administration of clotting complexes has not been shown to be effective in reducing hematoma expansion or improving outcomes although correcting these abnormalities as soon as possible remains good practice until further data are available. Stereotactically guided drainage of IPH with intraventricular hemorrhage (IVH) has been shown to be safe and to improve outcomes. Research on new stereotactic surgical methods has begun to show promise. Patients with IPH should have rapid and accurate diagnosis with neuroimaging with computed tomography (CT) and computed tomography angiography (CTA). Early interventions should include control of hypertension to a systolic BP in the range of 140 mmHg for small hemorrhages without intracranial hypertension with beta blockers or calcium channel blockers, correction of any coagulopathy if present, and assessment of the need for surgical intervention. IPH and FUNC (Functional Outcome in Patients with Primary Intracerebral Hemorrhage) scores should be assessed. Patients should be dispositioned to a dedicated neurologic ICU if available. Patients should be monitored for seizures and intracranial pressure issues. Select patients, particularly those with intraventricular extension, may benefit from evacuation of hematoma with a ventriculostomy or stereotactically guided catheter. Once stabilized, patients should be reassessed with CT imaging and receive ongoing management of blood pressure, cerebral edema, ICP issues, and seizures as they arise. The goal of care for most patients is to regain capacity to receive multidisciplinary rehabilitation to optimize functional outcome.

Elevated level of D-dimer increases the risk of stroke

The aim of this study was to systematically evaluate the association between D-dimer level and the risk of stroke through performing a meta-analysis. PubMed, Web of Science, EMBASE and Cochrane Library were searched for potentially eligible literature. Prospective observational studies or case-control studies were included. The study characteristics and relevant data were extracted. Hazard ratios (HRs) or odds ratios (ORs) with 95% confidence intervals (CIs) were pooled to estimate the association between D-dimer level and the risk of stroke. Seven prospective studies with 22,207 patients and three case-control studies with 2,248 patients were included. For the prospective studies, the pooled HRs of higher D-dimer level for all types of stroke, ischemic stroke and hemorrhagic stroke were 1.55 (95% CI, 1.28- 1.87), 1.62 (95% CI, 1.18-2.22) and 1.30 (95% CI, 0.63-2.68), respectively. The pooled HRs per SD increase in log D-dimer for all types of stroke, ischemic stroke and hemorrhagic stroke were 1.16 (95% CI, 1.06-1.26), 1.11 (95% CI, 1.03-1.21) and 1.11 (95% CI, 0.95-1.30), respectively. For the case-control studies, the pooled OR of higher D-dimer level for acute ischemic stroke was 2.06 (95% CI, 1.08-3.96). No significant publication bias was found in the meta-analysis. In conclusion, our results suggested that higher D-dimer level was associated with higher risk of stroke, especially ischemic stroke.

Short-Term Outcome of Spontaneous Intracerebral Hemorrhage in Algarve, Portugal: Retrospective Hospital-Based Study

BACKGROUND

The short-term outcome from spontaneous intracerebral hemorrhage (SICH) is influenced by local quality of care and population specificities. There are no studies about the SICH mortality in southern Portugal. The objective of this study was to describe the predictors of 30-day in-hospital SICH mortality in Algarve, the southernmost region of Portugal.

METHODS

Logistic regression was used to identify predictors of in-hospital death. Kaplan-Meier analysis was used to estimate survival over time based on SICH severity.

RESULTS

Of the 549 cases, 349 (63.6%) were men; the mean age was 71.4 years. Two hundred seventeen patients (39.5%) did not receive stroke unit (SU) care. The 30-day mortality was 34.4%. Independent predictors of death were older age (odds ratio [OR] = 1.096, 95% confidence interval [CI] = 1.031-2.062, P = .022) per additional year, vitamin K antagonists use (OR = 5.464, 95% CI = 2.088-25.714, P = .043), admission Glasgow Coma Scale (GCS) score of 8 or lower (OR = 20.511, 95% CI = 7.862-62.168, P < .0001) or GCS score of 9-12 (OR = 12.709, 95% CI = 3.078-44.113, P < .0001), hematoma volume (OR = 1.037, 95% CI = 1.004-1.071, P = .028) per additional milliliter, intraventricular dissection (OR = 1.916, 95% CI = 1.105-4.566, P = .046), and pneumonia (OR 12.918, 95% CI = 4.603-24.683, P < .0001). SU care was independently associated with reduction of death (OR .395, 95% CI = .126-.635, P = .004). Severity correlated with short time to death (P < .0001). Sixty-five of the patients (39.2%) died after the seventh day of SICH ("non-neurological deaths").

CONCLUSIONS

The in-hospital 30-day mortality is high in the region. Admitting more patients to the SU and implementation of preventive strategies of complications can reduce mortality.

Neuroprotection of brain-permeable iron chelator VK-28 against intracerebral hemorrhage in mice

Iron overload plays a key role in the secondary brain damage that develops after intracerebral hemorrhage (ICH). The significant increase in iron deposition is associated with the generation of reactive oxygen species (ROS), which leads to oxidative brain damage. In this study, we examined the protective effects of VK-28, a brain-permeable iron chelator, against hemoglobin toxicity in an ex vivo organotypic hippocampal slice culture (OHSC) model and in middle-aged mice subjected to an in vivo, collagenase-induced ICH model. We found that the effects of VK-28 were similar to those of deferoxamine (DFX), a well-studied iron chelator. Both decreased cell death and ROS production in OHSCs and in vivo, decreased iron-deposition and microglial activation around hematoma in vivo, and improved neurologic function. Moreover, compared with DFX, VK-28 polarized microglia to an M2-like phenotype, reduced brain water content, deceased white matter injury, improved neurobehavioral performance, and reduced overall death rate after ICH. The protection of VK-28 was confirmed in a blood-injection ICH model and in aged-male and young female mice. Our findings indicate that VK-28 is protective against iron toxicity after ICH and that, at the dosage tested, it has better efficacy and less toxicity than DFX does.

The effect of tranexamic acid in traumatic brain injury: A randomized controlled trial

PURPOSE

Traumatic brain injury (TBI) is a leading cause of death and disability. Intracranial hemorrhage (ICH) secondary to TBI is associated with a high risk of coagulopathy which leads to increasing risk of hemorrhage growth and higher mortality rate. Therefore, antifibrinolytic agents such as tranexamic acid (TA) might reduce traumatic ICH. The aim of the present study was to investigate the extent of ICH growth after TA administration in TBI patients.

METHODS

This single-blind randomized controlled trial was conducted on patients with traumatic ICH (with less than 30 ml) referring to the emergency department of Vali-Asr Hospital, Arak, Iran in 2014. Patients, based on the inclusion and exclusion criteria, were divided into intervention and control groups (40 patients each). All patients received a conservative treatment for ICH, as well as either intravenous TA or placebo. The extent of ICH growth as the primary outcome was measured by brain CT scan after 48 h.

RESULTS

Although brain CT scan showed a significant increase in hemorrhage volume in both groups after 48 h, it was significantly less in the TA group than in the control group (p = 0.04). The mean total hemorrhage expansion was (1.7 ± 9.7) ml and (4.3 ± 12.9) ml in TA and placebo groups, respectively (p < 0.001).

CONCLUSION

It has been established that TA, as an effective hospital-based treatment for acute TBI, could reduce ICH growth. Larger studies are needed to compare the effectiveness of different doses.

Assessing Sex Differences in the Risk of Cardiovascular Disease and Mortality per Increment in Systolic Blood Pressure: A Systematic Review and Meta-Analysis of Follow-Up Studies in the United States

In the United States (US), cardiovascular (CV) disease accounts for nearly 20% of national health care expenses. Since costs are expected to increase with the aging population, informative research is necessary to address the growing burden of CV disease and sex-related differences in diagnosis, treatment, and outcomes. Hypertension is a major risk factor for CV disease and mortality. To evaluate whether there are sex-related differences in the effect of systolic blood pressure (SBP) on the risk of CV disease and mortality, we performed a systematic review and meta-analysis. We conducted a comprehensive search using PubMed and Google Scholar to identify US-based studies published prior to 31 December, 2015. We identified eight publications for CV disease risk, which provided 9 female and 8 male effect size (ES) observations. We also identified twelve publications for CV mortality, which provided 10 female and 18 male ES estimates. Our meta-analysis estimated that the pooled ES for increased risk of CV disease per 10 mmHg increment in SBP was 25% for women (95% Confidence Interval (CI): 1.18, 1.32) and 15% for men (95% CI: 1.11, 1.19). The pooled increase in CV mortality per 10 mm Hg SBP increment was similar for both women and men (Women: 1.16; 95% CI: 1.10, 1.23; Men: 1.17; 95% CI: 1.12, 1.22). After adjusting for age and baseline SBP, the results demonstrated that the risk of CV disease per 10 mm Hg SBP increment for women was 1.1-fold higher than men (P<0.01; 95% CI: 1.04, 1.17). Heterogeneity was moderate but significant. There was no significant sex difference in CV mortality.

No sex differences in long-term functional outcome after intracerebral hemorrhage

Background There is conflicting evidence about the influence of sex on outcome after spontaneous intracerebral hemorrhage (sICH) and the majority of the research focused on mortality and short-term outcome only. We investigated sex differences in long-term functional outcome after sICH. Methods We used data from a prospective hospital registry and included all consecutive patients with ICH admitted to our institution between January 2006 and July 2014. Functional outcome was assessed by modified Rankin Scale evaluated 3 and 12 months after ICH. We explored the influence of sex on long-term functional outcome using multivariable regression models and additionally by means of propensity score matching. Results We analyzed 823 patients, of whom 380 (46%) women. Women were on average three years older (p < 0.001), men had more often deep hematomas (p = 0.01). Unadjusted mortality rates were significantly increased in women at three months (42% vs. 35%; odds ratio (OR): 1.35; 95% confidence interval (CI): 1.02-1.80). After adjusting for baseline prognostic factors there were no differences between men and women in short- and long-term mortality (OR = 1.01; 95% CI = 0.66-1.54 and OR = 1.04; 95%CI = 0.69-1.57, respectively) and short- and long-term unfavorable outcome (OR = 1.02; 95%CI = 0.67-1.55 and OR = 0.96; 95% CI = 0.62-1.48, respectively). Conclusion We found no sex-related differences in long-term functional outcome in patients with sICH. The apparently worse functional outcome in women can be explained by differences in age.

Development and Validation of an Automatic Segmentation Algorithm for Quantification of Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

ABC/2 is still widely accepted for volume estimations in spontaneous intracerebral hemorrhage (ICH) despite known limitations, which potentially accounts for controversial outcome-study results. The aim of this study was to establish and validate an automatic segmentation algorithm, allowing for quick and accurate quantification of ICH.

METHODS

A segmentation algorithm implementing first- and second-order statistics, texture, and threshold features was trained on manual segmentations with a random-forest methodology. Quantitative data of the algorithm, manual segmentations, and ABC/2 were evaluated for agreement in a study sample (n=28) and validated in an independent sample not used for algorithm training (n=30).

RESULTS

ABC/2 volumes were significantly larger compared with either manual or algorithm values, whereas no significant differences were found between the latter (P<0.0001; Friedman+Dunn's multiple comparison). Algorithm agreement with the manual reference was strong (concordance correlation coefficient 0.95 [lower 95% confidence interval 0.91]) and superior to ABC/2 (concordance correlation coefficient 0.77 [95% confidence interval 0.64]). Validation confirmed agreement in an independent sample (algorithm concordance correlation coefficient 0.99 [95% confidence interval 0.98], ABC/2 concordance correlation coefficient 0.82 [95% confidence interval 0.72]). The algorithm was closer to respective manual segmentations than ABC/2 in 52/58 cases (89.7%).

CONCLUSIONS

An automatic segmentation algorithm for volumetric analysis of spontaneous ICH was developed and validated in this study. Algorithm measurements showed strong agreement with manual segmentations, whereas ABC/2 exhibited its limitations, yielding inaccurate overestimations of ICH volume. The refined, yet time-efficient, quantification of ICH by the algorithm may facilitate evaluation of clot volume as an outcome predictor and trigger for surgical interventions in the clinical setting.

The critical care management of spontaneous intracranial hemorrhage: a contemporary review

Spontaneous intracerebral hemorrhage (ICH), defined as nontraumatic bleeding into the brain parenchyma, is the second most common subtype of stroke, with 5.3 million cases and over 3 million deaths reported worldwide in 2010. Case fatality is extremely high (reaching approximately 60 % at 1 year post event). Only 20 % of patients who survive are independent within 6 months. Factors such as chronic hypertension, cerebral amyloid angiopathy, and anticoagulation are commonly associated with ICH. Chronic arterial hypertension represents the major risk factor for bleeding. The incidence of hypertension-related ICH is decreasing in some regions due to improvements in the treatment of chronic hypertension. Anticoagulant-related ICH (vitamin K antagonists and the newer oral anticoagulant drugs) represents an increasing cause of ICH, currently accounting for more than 15 % of all cases. Although questions regarding the optimal medical and surgical management of ICH still remain, recent clinical trials examining hemostatic therapy, blood pressure control, and hematoma evacuation have advanced our understanding of ICH management. Timely and aggressive management in the acute phase may mitigate secondary brain injury. The initial management should include: initial medical stabilization; rapid, accurate neuroimaging to establish the diagnosis and elucidate an etiology; standardized neurologic assessment to determine baseline severity; prevention of hematoma expansion (blood pressure management and reversal of coagulopathy); consideration of early surgical intervention; and prevention of secondary brain injury. This review aims to provide a clinical approach for the practicing clinician.

Cerebellar Arteriovenous Malformations: Clinical Feature, Risk of Hemorrhage and Predictors of Posthemorrhage Outcome

OBJECTIVE

We aimed to summarize the clinical presentation, risk of hemorrhage, and predictors of posthemorrhage outcome in patients with cerebellar arteriovenous malformations (AVMs).

METHODS

We searched our AVM database at Beijing Tiantan Hospital and identified 225 patients with cerebellar AVMs between the year 2000 and 2015. The clinical presentation and hemorrhage risk were analyzed in all patients. Further analysis of predictors for immediate posthemorrhage outcome was performed in patients with ruptured AVMs. Posthemorrhage modified Rankin Scale (mRS) scores were dichotomized into nonsevere outcome (mRS ≤3) and severe outcome (mRS >3). Univariate and multivariate logistic regression analyses were applied to test the risk factors of hemorrhage and predictors of severe outcome.

RESULTS

Of the 225 patients, 197 (88%) presented with hemorrhage. Patients with initial hemorrhage were much younger than those with unruptured AVMs (univariate: P = 0.003; multivariate: P = 0.002). Single arterial supply (odds ratio [OR], 2.846; 95% confidence interval [CI], 1.022-7.922) and exclusively deep venous drainage (OR, 3.361; 95% CI, 1.045-10.813) were the other 2 independent risk factors for hemorrhagic presentation. Regarding the neurologic outcome immediately after hemorrhagic presentation, we used 3 models of multivariate logistic regression. Severe neurologic outcome (mRS >3) was associated with eloquent or deep AVM location, associated aneurysm, and the presence of intraventricular hemorrhage (all P < 0.05).

CONCLUSION

Cerebellar AVMs have an aggressive nature of hemorrhage. Younger age, single feeding artery, and exclusively deep venous drainage were independent risk factors for hemorrhagic presentation. Eloquent location, associated aneurysm, and presence of intraventricular hemorrhage may predict severe immediate posthemorrhage outcome.

Design and Experimental Evaluation of a Non-Invasive Microwave Head Imaging System for Intracranial Haemorrhage Detection

An intracranial haemorrhage is a life threatening medical emergency, yet only a fraction of the patients receive treatment in time, primarily due to the transport delay in accessing diagnostic equipment in hospitals such as Magnetic Resonance Imaging or Computed Tomography. A mono-static microwave head imaging system that can be carried in an ambulance for the detection and localization of intracranial haemorrhage is presented. The system employs a single ultra-wideband antenna as sensing element to transmit signals in low microwave frequencies towards the head and capture backscattered signals. The compact and low-profile antenna provides stable directional radiation patterns over the operating bandwidth in both near and far-fields. Numerical analysis of the head imaging system with a realistic head model in various situations is performed to realize the scattering mechanism of haemorrhage. A modified delay-and-summation back-projection algorithm, which includes effects of surface waves and a distance-dependent effective permittivity model, is proposed for signal and image post-processing. The efficacy of the automated head imaging system is evaluated using a 3D-printed human head phantom with frequency dispersive dielectric properties including emulated haemorrhages with different sizes located at different depths. Scattered signals are acquired with a compact transceiver in a mono-static circular scanning profile. The reconstructed images demonstrate that the system is capable of detecting haemorrhages as small as 1 cm³. While quantitative analyses reveal that the quality of images gradually degrades with the increase of the haemorrhage’s depth due to the reduction of signal penetration inside the head; rigorous statistical analysis suggests that substantial improvement in image quality can be obtained by increasing the data samples collected around the head. The proposed head imaging prototype along with the processing algorithm demonstrates its feasibility for potential use in ambulances as an effective and low cost diagnostic tool to assure timely triaging of intracranial hemorrhage patients.