The clinical management of acute intracerebral hemorrhage

Pericyte derivation and transplantation for blood-CNS barrier reconstitution in CNS disorders

Disruption of the blood-central nervous system barrier (BCB) is increasingly recognized as a pathological factor in diseases and trauma of the central nervous system. Despite the neuropathological impact, current treatment modalities do not target the BCB; strategies to reconstitute the impaired BCB have been restricted to nutritional and dietary remedies. As an integral cell type in the neurovascular unit, pericytes are crucial to the development, maintenance, and repair of the BCB. As such, pericytes are well poised as cellular agents for reconstitution of the impaired BCB. Here, we summarize recent revelations regarding the role of BCB disruption in diseases and trauma of the central nervous system and highlight how pericytes are harnessed to provide targeted therapeutic effect in each case. This review will also address how recent advances in pericyte derivation strategies can serve to overcome practical hurdles in the clinical use of pericytes.

Endovascular Management of Hemorrhagic Stroke

Significant advances in endovascular neurosurgery tools, devices, and techniques are changing the approach to the management of acute hemorrhagic stroke. The endovascular treatment of intracranial aneurysms emerged in the early 1990s with Guglielmi detachable coils, and since then, it gained rapid popularity that surpassed open surgery. Stent-assisted coiling and balloon remodeling techniques have made the treatment of wide-necked aneurysms more durable. With the introduction of flow diverters and flow disrupters, many aneurysms with complex geometrics can now be reliably managed. Arteriovenous malformations and fistulae can also benefit from endovascular therapy by embolization using n-butyl cyanoacrylate (NBCA), Onyx, polyvinyl alcohol (PVA), and coils. In this article, we describe the role of endovascular treatment for the most common causes of intracerebral and subarachnoid hemorrhages, particularly ruptured aneurysms and vascular malformations.

Verbascoside attenuates acute inflammatory injury in experimental cerebral hemorrhage by suppressing TLR4

Cerebral hemorrhage (ICH) is a common cerebrovascular condition with high mortality, disability and recurrence rates. TLR4-mediated acute inflammatory injury plays a pivotal role in ICH. Verbascoside (VB) is an active component of multiple medicinal plants, and exerts neuroprotective effects in ischemic stroke by targeting the inflammatory response. However, the effects of VB on ICH and the underlying mechanisms remain unclear. In this study, we analyzed the therapeutic effects of VB on acute ICH, and the possible involvement of TLR4-mediated inflammation. VB improved the behavioral score and reduced the hematoma volume, brain edema and neuronal apoptosis in a murine model of acute ICH. Mechanistically, VB attenuated macroglia activation and decreased inflammatory factor levels, which in turn protected the neurons. Furthermore, TLR4 knockout abolished the effects of VB both in vivo and in vitro. Taken together, VB attenuates the symptoms of ICH by targeting the TLR4-mediated acute inflammatory response.

NEMO-binding domain peptides alleviate perihematomal inflammation injury after experimental intracerebral hemorrhage

Inflammation aggravates the lethal consequences of intracerebral hemorrhage. Recently, many studies have found that nuclear factor-κB (NF-κB) is a crucial transcription factor that initiates inflammation in the perihematomal region of ICH. NF-κB essential modulator (NEMO)-binding domain (NBD) peptide, a cell-permeable peptide spanning the NBD of IKKα or IKKβ, functions as a highly specific inhibitor of NF-κB. This peptide can negatively regulate the NF-κB pathway. The present study aimed to explore the effects and underlying pathomechanisms of NBD peptides after ICH. Striatum infusion of whole blood or saline was performed on C57BL/6 mice (n = 198). Experimental animals were administered NBD or control (mutated) peptides 2 h before or after ICH by intracerebroventricular injection (icv.). NBD peptides significantly inhibited edema formation, ameliorated the neurological deficits, markedly reduced IκBα and p65 phosphorylation, blocked nuclear translocation of p65, and upregulated IκBα expression by NF-κB after ICH induction. Using an in vitro hemin toxicity model, we investigated the effects of NBD peptides on microglial inflammation. We found that NBD peptides suppressed microglia inflammation and lowered the expression of TNF-α and IL-1β in both in vivo and in vitro experiments. Further experiments were performed in mice and cultured microglia, which treated with NBD peptides in the presence of p65 siRNA confirmed that the specificity of NBD peptides inhibit ICH-induced NF-κB activation. This study demonstrated that NBD peptides exert a neuroprotective role after ICH and might be a potential candidate for a novel therapeutic strategy for ICH.

The Effect of Transtemperal Approach and Placement of Intracranial Pressure Sensor Into Temporal Horn of Lateral Ventricle in Management of Spontaneous Supratentorial Intracerebral Hemorrhage Broken Into Ventricles

To investigate the effect of transtemperal approach and placement of intracranial pressure sensor into temporal horn of lateral ventricle in management of spontaneous supratentorial intracerebral hemorrhage broken into ventricles, a total of 37 patients with spontaneous supratentorial intracerebral hemorrhage broken into ventricles treated by operation from January 2016 to December 20l6 were analyzed retrospectively, of which 25 patients in simple transtemporal approach group and 12 patients in transtemperal approach and placement of intracranial pressure sensor into temporal horn of lateral ventricle group. All patients were followed up for 8 months to 1.5 years. Two groups were estimated by mortality, clearance rate of hematoma, removal rate of bone flap, good prognosis rate of ADL and incidence of hydrocephalus. The good prognosis rate of ADL and the incidence of hydrocephalus are only statistically significant between the two groups (P < 0.05). According to the result, the transtemperal approach and placement of intracranial pressure sensor into temporal horn of lateral ventricle in management of spontaneous supratentorial intracerebral hemorrhage broken into ventricles is a safe, effective, and less complication of treatment measure.

Hemoglobin enhances miRNA-144 expression and autophagic activation mediated inflammation of microglia via mTOR pathway

Intracerebral hemorrhage promotes autophagic activation of microglia and enhances neuroinflammation. MiRNAs are key factors to autophagy, contributed to negatively and posttranscriptionally regulate gene expression and function. However, the specific miRNAs involved in the intracerebral hemorrhage mediated microglia autophagic activation are unidentified. In this experiment, microglia was treated with hemoglobin. And then, miRNA-144 expression, autophagic activation and inflammation of microglia were detected. In addition, the mTOR target of miRNA-144 and its regulation were identified. Our data demonstrated that hemoglobin promoted miRNA-144 expression and autophagic activation mediated inflammation. Additionally, miRNA-144 targeted mTOR by directly interacting with the 3' untranslated regions (UTRs), mutations of the binding sites abolish the miRNA-144 responsiveness. Overexpression of mTOR decreased autophagic activation and inflammation of microglia. Therefore, our results suggested that miRNA-144 contributed to hemoglobin mediated autophagic activation and inflammation of microglia via mTOR pathway. And miRNA based treatment provided novel therapeutical strategy for intracerebral hemorrhage.

Predictive Value of CTA Spot Sign on Hematoma Expansion in Intracerebral Hemorrhage Patients

Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage and leads to high rates of mortality and morbidity. Currently, contrast extravasation within hematoma, termed the spot sign on computed tomography angiography (CTA), has been identified as a strong independent predictor of early hematoma expansion. Past studies indicate that the spot sign is a dynamic entity and is indicative of active hemorrhage. Furthermore, to enhance the spot sign's accuracy of predicting HE, spot parameters observed on CTA or dynamic CTA were used for its quantification. In addition, spot signs detected on multiphase CTA and dynamic CTA are shown to have higher sensitivity and specificity when compared with simple standardized spot sign detection in recent studies. Based on the spot sign, novel methods such as leakage sign and rate of contrast extravasation were explored to redefine HE prediction in combination with clinical characteristics and spot sign on CTA to assist clinical judgment. The spot sign is an accepted independent predictor of active hemorrhage and is used in both secondary intracerebral hemorrhage and the process of surgical assessment for hemorrhagic risk in patients with ischemic stroke. Spot sign predicts patients at high risk for hematoma expansion.

Stages of the Inflammatory Response in Pathology and Tissue Repair after Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a major health concern, with high rates of mortality and morbidity and no highly effective clinical interventions. Basic research in animal models of ICH has provided insight into its complex pathology, in particular revealing the role of inflammation in driving neuronal death and neurologic deficits after hemorrhage. The response to ICH occurs in four distinct phases: (1) initial tissue damage and local activation of inflammatory factors, (2) inflammation-driven breakdown of the blood-brain barrier, (3) recruitment of circulating inflammatory cells and subsequent secondary immunopathology, and (4) engagement of tissue repair responses that promote tissue repair and restoration of neurologic function. The development of CNS inflammation occurs over many days after initial hemorrhage and thus may represent an ideal target for treatment of the disease, but further research is required to identify the mechanisms that promote engagement of inflammatory versus anti-inflammatory pathways. In this review, the authors examine how experimental models of ICH have uncovered critical mediators of pathology in each of the four stages of the inflammatory response, and focus on the role of the immune system in these processes.