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Yu K, Sun Y, Guo K, Peng J, Jiang Y. Early blood pressure management in hemorrhagic stroke: a meta-analysis. J Neurol 2023:10.1007/s00415-023-11654-w. [PMID: 36884070 DOI: 10.1007/s00415-023-11654-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023]
Abstract
The aim of the present meta-analysis was to evaluate the outcomes and effects of different systolic blood pressure (SBP) lowering in patients with hemorrhagic stroke using data from randomized controlled trials. A total of 2592 records were identified for this meta-analysis. We finally included 8 studies (6119 patients; mean age 62.8 ± 13.0, 62.7% men). No evidence of heterogeneity between estimates (I2 = 0% < 50%, P = 0.26), or publication bias in the funnel plots (P = 0.065, Egger statistical test) was detected. Death or major disability rates were similar between patients with intensive BP-lowering treatment (SBP < 140 mmHg) and those receiving guideline BP-lowering treatment (SBP < 180 mmHg). Intensive BP-lowering treatment may have a better functional outcome, but the results were not significantly different (log RR = - 0.03, 95% CI: - 0.09 to 0.02; P = 0.55). Intensive BP-lowering treatment tended to be associated with lower early hematoma growth compared with guideline treatment (log RR = - 0.24, 95% CI - 0.38, - 0.11; P < 0.001). Intensive BP-lowering helps reduce hematoma enlargement in the early stage of acute hemorrhagic stroke. However, this observation did not translate into functional outcomes. Further research is needed to clarify the specific scope and time of blood pressure reduction.
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Affiliation(s)
- Kuangyang Yu
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, No. 25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Yuxuan Sun
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, No. 25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Kecheng Guo
- Laboratory of Neurological Diseases and Brain Function, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
| | - Jianhua Peng
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, No. 25 of Taiping Street, Luzhou, 646000, Sichuan, China. .,Laboratory of Neurological Diseases and Brain Function, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China. .,Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou, 646000, China. .,Sichuan Clinical Research Center for Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China.
| | - Yong Jiang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, No. 25 of Taiping Street, Luzhou, 646000, Sichuan, China. .,Laboratory of Neurological Diseases and Brain Function, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China. .,Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou, 646000, China. .,Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China.
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Yang Z, Dong S, Zheng Q, Zhang L, Tan X, Zou J, Yan B, Chen Y. FTY720 attenuates iron deposition and glial responses in improving delayed lesion and long-term outcomes of collagenase-induced intracerebral hemorrhage. Brain Res 2019; 1718:91-102. [PMID: 31039342 DOI: 10.1016/j.brainres.2019.04.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/25/2019] [Accepted: 04/27/2019] [Indexed: 12/23/2022]
Abstract
Most intracerebral hemorrhage (ICH) survivors have poor long-term outcomes, such as cognitive deficits and depression. Delayed lesions of ICH include neuron loss and white matter injury and the pathology of the lesions involves iron deposition and glial responses, which contribute to depressive-like behavior and cognitive impairment in animals. This study aimed to investigate the effects of FTY720 (0.3 mg/kg/day for 4 weeks) on iron deposition, glial responses, histological abnormalities and behavioral dysfunction in mice with ICH. The primary adverse long-term outcomes in our study of ICH mice were depressive-like behavior and impaired recognition memory. We found that FTY720 safely ameliorated depressive-like behavior and impaired recognition without affecting recovery of grip function and locomotor activity 28 days post-ICH. Moreover, we measured neuron loss, white matter lesions, lesion volume and iron deposition at day 28, which were attenuated in the FTY720-treated group compared to the ICH-control group, without changing initial hematoma volume on day 1 post-ICH. Long-term elevation of glial responses, including microglia activity and astrogliosis with tumor necrosis factor alpha (TNFα) expression was demonstrated by Western blot and immunofluorescence staining, which we found was attenuated by FTY720 treatment. Hence, FTY720 could become a novel therapeutic agent for improving long-term outcomes after ICH.
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Affiliation(s)
- Zhiyong Yang
- The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu 225001, China
| | - Sisi Dong
- The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Qiuyue Zheng
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu 225001, China
| | - Lingling Zhang
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu 225001, China
| | - Xinmei Tan
- The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jun Zou
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu 225001, China
| | - Bingchun Yan
- Department of Integrative Traditional & Western Medicine, Medical College, Yangzhou University, Yangzhou, Jiangsu 225001, China; Jiangsu Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Senile Diseases, Yangzhou University, Yangzhou, Jiangsu 225001, China.
| | - Yingzhu Chen
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu 225001, China.
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Shi L, Xu S, Zheng J, Xu J, Zhang J. Blood Pressure Management for Acute Intracerebral Hemorrhage: A Meta-Analysis. Sci Rep 2017; 7:14345. [PMID: 29084953 PMCID: PMC5662650 DOI: 10.1038/s41598-017-13111-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 09/19/2017] [Indexed: 12/22/2022] Open
Abstract
Inconsistent data from the randomized trials ignites controversy on intensive blood pressure (BP) reduction for acute intracerebral hemorrhage (ICH). This study aims to examine the association between BP lowering and clinical outcomes among patients with acute ICH. We conducted this meta-analysis based on the published randomized controlled trials (RCTs). Data were included from 6 RCTs involving 4412 patients. No significant improvements were observed in hematoma growth at 24 hours, neurologic improvement at 24 hours, hypotension at 72 hours, death or dependency at 90 days, mortality at 90 days, and serious adverse events at 90 days between intensive and conservative BP lowering groups. High heterogeneity was observed between estimates in hematoma growth (I2 = 49). Univariate meta-regression and subgroup analysis showed that intensive BP lowering showed a significant decrease in hematoma growth in age ≤62 years, time from symptoms onset to treatment ≤6 hours, baseline hematoma volume ≤15 mL, and combined intraventricular hemorrhage ≤25% subgroups. In conclusion, intensive BP management in patients with ICH is safe. Intensive BP lowering could reduce hematoma growth in those patients (≤62 years old) with ICH volume less than 15 mL receiving BP management within 6 hours after randomization.
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Affiliation(s)
- Ligen Shi
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shenbin Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jingwei Zheng
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jing Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China. .,Brain Research Institute, Zhejiang University, Hangzhou, Zhejiang, China. .,Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou, Zhejiang, China.
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Zeng Y, Ma M, Liu B, Xia J, Xu H, Liu Y, Du X, Hu Z, Yang Q, Zhang L. Association between ECE1 gene polymorphisms and risk of intracerebral haemorrhage. J Int Med Res 2016; 44:444-52. [PMID: 27036146 PMCID: PMC5536701 DOI: 10.1177/0300060516635385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 02/03/2016] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine whether endothelin converting enzyme-1 (ECE1) gene polymorphisms contribute to susceptibility to intracerebral haemorrhage (ICH) by influencing blood pressure. METHODS This case-control study enrolled patients with ICH and healthy control subjects from a Southern Han Chinese population. The ECE1 gene polymorphisms rs212528 and rs213045 were genotyped. The association between the genotypes and the risk of ICH was assessed. The effects of these two ECE1 gene polymorphisms on blood pressure were also analysed. RESULTS A total of 389 patients with ICH and 404 healthy control subjects participated in the study. There was no significant association between the ECE1 rs212528 and rs213045 polymorphisms and ICH even after adjusting for different confounding variables. In patients with ICH, the systolic blood pressure of patients with the rs212528 AA genotype was significantly lower than that of patients with the AG/GG genotypes. CONCLUSIONS These results indicated that the ECE1 rs212528 and rs213045 polymorphisms had no major role to play in the genetic susceptibility to ICH, although rs212528 might influence blood pressure in patients with ICH.
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Affiliation(s)
- Yi Zeng
- Department of Geriatrics, Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Mingming Ma
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Baoqiong Liu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Jian Xia
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Hongwei Xu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Yunhai Liu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Xiaoping Du
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Zhiping Hu
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Qidong Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Le Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
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Al-Khaled M, Eggers J. Prognosis of Intracerebral Hemorrhage after Conservative Treatment. J Stroke Cerebrovasc Dis 2014; 23:230-4. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.12.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 11/25/2012] [Accepted: 12/28/2012] [Indexed: 10/27/2022] Open
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Treatments for reversing warfarin anticoagulation in patients with acute intracranial hemorrhage: a structured literature review. Int J Emerg Med 2011; 4:40. [PMID: 21740550 PMCID: PMC3141388 DOI: 10.1186/1865-1380-4-40] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 07/08/2011] [Indexed: 12/01/2022] Open
Abstract
Study objective The acute management of patients on warfarin with spontaneous or traumatic intracranial hemorrhage continues to be debated in the medical literature. The objective of this paper was to conduct a structured review of the medical literature and summarize the advantages and risks of the available treatment options for reversing warfarin anticoagulation in patients who present to the emergency department with acute intracranial hemorrhage. Methods A structured literature search and review of articles relevant to intracranial hemorrhage and warfarin and treatment in the emergency department was performed. Databases for PubMed, CINAHL, and Cochrane EBM Reviews were electronically searched using keywords covering the concepts of anticoagulation drugs, intracranial hemorrhage (ICH), and treatment. The results generated by the search were limited to English- language articles and reviewed for relevance to our topic. The multiple database searches revealed 586 papers for review for possible inclusion. The final consensus of our comprehensive search strategy was a total of 23 original studies for inclusion in our review. Results Warfarin not only increases the risk of but also the severity of ICH by causing hematoma expansion. Prothrombin complex concentrate is statistically significantly faster at correcting the INR compared to fresh frozen plasma transfusions. Recombinant factor VIIa appears to rapidly reverse warfarin's effect on INR; however, this treatment is not FDA-approved and is associated with a 5% thromboembolic event rate. Slow intravenous dosing of vitamin K is recommended in patients with ICH. The 30-day risk for ischemic stroke after discontinuation of warfarin therapy was 3-5%. The risks of not reversing the anticoagulation in ICH generally outweigh the risk of thrombosis in the acute setting. Conclusions Increasing numbers of patients are on anticoagulation including warfarin. There is no uniform standard for reversing warfarin in intracranial hemorrhage. Intravenous vitamin K in addition to fresh frozen plasma or prothrombin complex concentrate is recommended be used to reverse warfarin-associated intracranial hemorrhage. No mortality benefit for one treatment regimen over another has been shown. Emergency physicians should know their hospital's available warfarin reversal options and be comfortable administering these treatments to critically ill patients.
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The effects of poststroke captopril and losartan treatment on cerebral blood flow autoregulation in SHRsp with hemorrhagic stroke. J Cereb Blood Flow Metab 2011; 31:476-85. [PMID: 20648036 PMCID: PMC3049503 DOI: 10.1038/jcbfm.2010.110] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The ability of captopril and losartan treatment to restore cerebral blood flow (CBF) autoregulation after intracerebral hemorrhagic stroke (HS) was assessed in Kyoto-Wistar stroke-prone hypertensive rats (SHRsp). Laser Doppler techniques assessed CBF autoregulation in the middle cerebral artery (MCA) perfusion domain and a pressure myograph was used to measure pressure-dependent constriction (PDC) in isolated MCAs before and after stroke and after 13, 33, and 63 days of poststroke captopril or losartan treatment. The treatments did not lower blood pressure (BP) and equally suppressed plasma aldosterone after HS. The HS development was associated with the loss of CBF autoregulation, high CBF, increased CBF conductance to elevations in BP, and the loss of PDC in the MCAs. Both treatments restored these functions to prestroke levels within 13 days. The PDC and CBF autoregulation subsequently deteriorated after 63 days of captopril treatment while being maintained at prestroke levels over all durations of losartan treatment. The SHRsp subjected to 35 days of poststroke losartan treatment exhibited less blood-brain barrier (BBB) disruption and brain herniation than captopril-treated SHRsp. The superior ability of losartan to restore CBF autoregulation and myogenic function may have contributed to the more effective attenuation of cerebral damage after HS.
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Beray-Berthat V, Delifer C, Besson VC, Girgis H, Coqueran B, Plotkine M, Marchand-Leroux C, Margaill I. Long-term histological and behavioural characterisation of a collagenase-induced model of intracerebral haemorrhage in rats. J Neurosci Methods 2010; 191:180-90. [DOI: 10.1016/j.jneumeth.2010.06.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 06/19/2010] [Indexed: 10/19/2022]
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Yamahata H, Hirabaru M, Arita K. Rapid spontaneous resolution of neurological signs and cerebral herniation caused by intracerebral hemorrhage -case report-. Neurol Med Chir (Tokyo) 2010; 50:390-2. [PMID: 20505294 DOI: 10.2176/nmc.50.390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 47-year-old man presented with sudden consciousness disturbance and left hemiplegia caused by intracerebral hemorrhage. Initial computed tomography (CT) showed a massive subcortical right temporoparietal lobe hematoma and signs of impending uncal herniation. However, he became alert and his hemiplegia improved considerably in the course of 2 hours, so conservative treatment was preferred over surgical intervention. Follow-up CT acquired on the next day revealed dramatic diminution of the intracerebral hemorrhage. Small intracerebral hemorrhages occasionally produce transient symptoms with or without disappearance of the hematoma, but the present patient had a large hematoma that decreased in size within a short time with rapid improvement of the symptoms attributed to the hematoma. The mechanism underlying the diminution of the hematoma may be related to redistribution by cerebrospinal fluid flow.
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Aladdin Y, Butcher KS. Blood pressure management in acute intracerebral hemorrhage. FUTURE NEUROLOGY 2009. [DOI: 10.2217/fnl.09.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Primary intracerebral hemorrhage (ICH) results from spontaneous rupture of an intracranial vessel and is associated with high rates of early mortality and long-term morbidity. No surgical or medical intervention has been demonstrated to improve outcome. Acute blood pressure elevation is seen in the majority of patients with ICH and is correlated with poor outcome. Potential, but unproven, mechanisms for this association include facilitation of hematoma expansion as well as perihematomal edema growth. Conversely, the perihematomal region has also been hypothesized to have ischemic properties. Therefore, management of blood pressure in the acute phase lends itself to two competing rationales and the optimal target blood pressure remains unknown. A number of parenchymal and blood-flow imaging techniques have been utilized to improve our understanding of blood flow and metabolism in acute ICH. These studies generally indicate that ischemia is not a major pathophysiological mechanism of secondary injury in ICH. Ultimately, randomized, controlled trials, which are underway, will be required to definitively determine the safety and efficacy of acute blood pressure reduction. It appears most likely that earlier and more aggressive treatment of acute blood pressure will be recommended in the future.
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Affiliation(s)
- Yasser Aladdin
- Division of Neurology, 2E3 WMC Health Sciences Centre, University of Alberta, 8440 112th St, Edmonton, AB, T6G 2B7, Canada
| | - Ken S Butcher
- Division of Neurology, 2E3 WMC Health Sciences Centre, University of Alberta, 8440 112th St, Edmonton, AB, T6G 2B7, Canada
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