Efficacy and safety of intravenous nimodipine administration for treatment of hypertension in patients with intracerebral hemorrhage

Radiomics features from perihematomal edema for prediction of prognosis in the patients with basal ganglia hemorrhage

Objective

We developed and validated a clinical-radiomics nomogram to predict the prognosis of basal ganglia hemorrhage patients.

Methods

Retrospective analyses were conducted in 197 patients with basal ganglia hemorrhage (training cohort: n = 136, test cohort: n = 61) who were admitted to The First Affiliated Hospital of Shandong First Medical University (Shandong Provincial Qianfoshan Hospital) and underwent computed tomography (CT) scan. According to different prognoses, patients with basal ganglia hemorrhage were divided into two groups. Independent clinical risk factors were derived with univariate and multivariate regression analysis. Radiomics signatures were obtained using least absolute shrinkage and selection operator. A radiomics score (Rad-score) was generated by 12 radiomics signatures of perihematomal edema (PHE) from CT images that were correlated with the prognosis of basal ganglia hemorrhage patients. A clinical-radiomics nomogram was conducted by combing the Rad-score and clinical risk factors using logistic regression analysis. The prediction performance of the nomogram was tested in the training cohort and verified in the test cohort.

Results

The clinical model conducted by four clinical risk factors and 12 radiomcis features were used to establish the Rad-score. The clinical-radiomics nomogram outperformed the clinical model in the training cohort [area under the curve (AUC), 0.92 vs. 0.85] and the test cohort (AUC, 0.91 vs 0.85). The clinical-radiomics nomogram showed good calibration and clinical benefit in both the training and test cohorts.

Conclusion

Radiomics features of PHE in patients with basal ganglia hemorrhage could contribute to the outcome prediction. The clinical-radiomics nomogram may help first-line clinicians to make individual clinical treatment decisions for patients with basal ganglia hemorrhage.

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.

Blood Pressure Management After Intracerebral and Subarachnoid Hemorrhage: The Knowns and Known Unknowns

Blood pressure (BP) elevations often complicate the management of intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage, the most serious forms of acute stroke. Despite consensus on potential benefits of BP lowering in the acute phase of intracerebral hemorrhage, controversies persist over the timing, mechanisms, and approaches to treatment. BP control is even more complex for subarachnoid hemorrhage, where there are rationales for both BP lowering and elevation in reducing the risks of rebleeding and delayed cerebral ischemia, respectively. Efforts to disentangle the evidence has involved detailed exploration of individual patient data from clinical trials through meta-analysis to determine strength and direction of BP change in relation to key outcomes in intracerebral hemorrhage, and which likely also apply to subarachnoid hemorrhage. A wealth of hemodynamic data provides insights into pathophysiological interrelationships of BP and cerebral blood flow. This focused update provides an overview of current evidence, knowledge gaps, and emerging concepts on systemic hemodynamics, cerebral autoregulation and perfusion, to facilitate clinical practice recommendations and future research.

Therapeutic Variation in Lowering Blood Pressure: Effects on Intracranial Pressure in Acute Intracerebral Haemorrhage

INTRODUCTION

Intracerebral haemorrhage (ICH) is associated with high morbidity and mortality. Blood pressure (BP) control is one of the main management strategies in acute ICH. Limited data currently exist regarding intracranial pressure (ICP) in acute ICH. The relationship between BP lowering and ICP is yet to be fully elucidated.

METHODS

We conducted a systematic review to investigate the effects of BP lowering on ICP in acute ICH. The study protocol was registered on PROSPERO (CRD42019134470).

RESULTS

Following PRISMA guidelines, MEDLINE, EMBASE and CENTRAL were searched for studies on ICH with BP and ICP or surrogate measures. 1096 articles were identified after duplicates were removed; 18 studies meeting the inclusion criteria. Dihydropyridine calcium channel blockers (CCBs) were the most common agent used to lower BP, but had a varying effect on ICP. Other BP-lowering agents used also had a varying effect on ICP.

DISCUSSION AND CONCLUSION

Further work, including large observational or randomized interventional studies, is needed to develop a better understanding of the effect of BP lowering on ICP in acute ICH, which will assist the development of more effective management strategies.

TRIAL REGISTRATION

The study protocol was registered on PROSPERO (CRD42019134470) on 29/05/2019.

Proteomic Analysis Reveals that Di Dang Decoction Protects Against Acute Intracerebral Hemorrhage Stroke in Rats by Regulating S100a8, S100a9 Col1a1, and Col1a2

OBJECTIVE

The present study aimed to explore the neuroprotective mechanism of Di Dang decoction (DDD) during acute intracerebral hemorrhage (AICH) stroke in Sprague Dawley rats through proteomic analysis.

METHODS

A total of 135 healthy Sprague Dawley rats were randomly divided into five groups: control (n = 27), model (n = 27), DDD low-dose (n = 27), DDD medium-dose (n = 27), and DDD high-dose (n = 27). AICH stroke in rats was induced by injecting autologous blood into the caudate nucleus. The modified Neurological Severity Score (mNSS) was used to evaluate the cerebral nerve function deficit. Hematoxylin and eosin (HE) staining was performed to observe the brain tissue at the lesion site. Albumin concentration was assessed on obvious blood-brain barrier damaged and brain water content was used to evaluate the brain injury. For quantitative proteomics, proteins were extracted from the cerebral cortices. Target proteins were identified using mass spectrometer-based targeted proteomic quantification.

RESULTS

mNSS score, HE staining results, albumin concentration, and brain water content showed the most significant improvements in the neuroprotective in the high-dose group 7 days after DDD exposure. Furthermore, quantitative proteomics analysis showed that, relative to the control group, S100a8 and S100a9 were downregulated by 0.614 (p = 0.033702) and 0.506 times (p = 0.000024) in the high-dose group. Compared with the control group, Col1a1 and Col1a2 were upregulated by 1.319 (p = 0.000184) and 1.348 (p = 0.014097) times in the high-dose group. These results were confirmed using mass spectrometer-based targeted proteomic quantification.

CONCLUSION

Application of a high-dose DDD for 7 days in AICH stroke rats showed the most significant improvements in neuroprotective. Mechanistically, this effect was mediated by S100a8 and S100a9 protein downregulation and Col1a1 and Col1a2 upregulation.

Antihypertensive use for stroke in United States emergency departments

OBJECTIVE

Timely emergency department (ED) control of hypertension in the acute phase of stroke is associated with improved outcomes. It is unclear how emergency physicians use antihypertensive medications to treat severe hypertension associated with stroke. We sought to determine national patterns of antihypertensive use associated with ED visits for stroke in the United States.

METHODS

We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2008-2017. We included ED visits associated with ischemic stroke (ICD9 433-434, ICD10 I630-I639) or hemorrhagic stroke (ICD9 430-432, ICD10 I600-I629). We estimated the number and proportions of stroke ED visits with triage blood pressure meeting treatment thresholds (triage systolic blood pressure [SBP] ≥180 mm Hg). We identified the frequency of antihypertensive use, as well as the most commonly used agents.

RESULTS

Between 2008-2017, of a total 135,012,819 ED visits, 619,791 were associated with stroke (78.3% ischemic strokes and 21.7% hemorrhage strokes). Of all stroke visits, 21.8% received antihypertensive medications. Of the identified visits, 9.0% (95% confidence interval [CI] = 6.0%, 13.1%) ischemic stroke visits and 58.2% (95% CI = 49.0%, 66.9%) hemorrhagic stroke visits met criteria for BP reduction. A total of 47.6% (95% CI = 29.1%, 66.7%) of eligible ischemic stroke visits and 41.5% (95% CI = 30.5%, 53.3%) of eligible hemorrhagic strokes visits received antihypertensives. The most common agents used in ischemic stroke were beta-blockers, calcium-channel blockers, and ACE inhibitors. The most common agents used in hemorrhagic stroke included calcium-channel blockers, beta-blockers, and vasodilators.

CONCLUSION

In this national sample, less than half of strokes presenting to the ED with hypertension received antihypertensive therapy.

Prognostic factors of delayed cerebral ischemia after subarachnoid hemorrhage including CT perfusion: a prospective cohort study

Background

Delayed cerebral ischemia (DCI) is the worst sequel following subarachnoid hemorrhage (SAH), representing a challenge in prediction and prevention. The current study aims to identify the optimum predictors of DCI including CT perfusion (CTP) and to determine the best prognostic thresholds.

This prospective study included 49 SAH patients. All patients were treated with the standard therapy and underwent non-contrast CT, CTP, and CTA within 3 days after SAH. Hunt and Hess and Fisher scales were assessed besides quantitative CTP parameters. The primary endpoint was DCI within 21 days after SAH, defined as clinical deterioration or infarction.

Results

Out of 49 eligible patients with SAH, 9 patients developed DCI. Univariate analysis revealed that Hunt and Hess scale, Fisher scale, the presence of a cerebral aneurysm, and mean transit time (MTT) were predictive for DCI. Diagnostic threshold values by ROC curve analysis with optimal sensitivity and specificity were Hunt and Hess scale > 2, Fisher scale > 2, and MTT of 4.65 s.

Conclusion

MTT is a sensitive and specific predictor of DCI. However, Hunt and Hess scale has the optimal sensitivity and specificity to distinguish between patients who developed DCI and clinically stable patients.

Long noncoding RNA MEG3 contributes to dysfunction of brain microvascular endothelial cells after intracerebral hemorrhage by regulating the miR-1930-5p/Mllt1 axis

BACKGROUND

Intracerebral hemorrhage (ICH) is a subtype of stroke and causes disability and death worldwide. The roles of long noncoding RNAs (lncRNAs) in brain function and neurological diseases have been revealed. LncRNA maternally expressed gene 3 (MEG3) is involved in neurological impairment, but its role in ICH remains unknown.

AIMS

The aim of this research is to explore the role of MEG3 in ICH.

METHODS AND RESULTS

Here, we established an ICH mouse model via intracerebral injection of autologous blood. Primary brain microvascular endothelial cells (BMECs) were treated with oxygen-and-glucose-deprivation (OGD) plus hemin to establish the model in vitro. We observed that MEG3 expression was significantly upregulated in both ICH mouse model and OGD/hemin (OGD/H) induced BMECs. The downregulation of MEG3 suppressed cell apoptosis and the activation of NOD-like receptor family protein 3 (NLRP3) inflammasome in OGD/H-induced BMECs. In ICH mice, MEG3 downregulation inhibited cell apoptosis and improved brain dysfunction. Mechanistically, MEG3 was confirmed to act as a molecular sponge for microRNA (miR)-1930-5p, and Mllt1 was a downstream target for miR-1930-5p. MEG3 competitively bound with miR-1930-5p to upregulate Mllt1. We further verified that Mllt1 overexpression reversed the inhibitory effect of miR-1930-5p in OGD/H-induced BMECs.

CONCLUSIONS

In conclusion, lncRNA MEG3 promoted the dysfunction of BMECs by modulating the miR-1930-5p/Mllt1 axis, which provides a potential target in gene therapy for brain injury following ICH.

LncRNA Snhg3 contributes to dysfunction of cerebral microvascular cells in intracerebral hemorrhage rats by activating the TWEAK/Fn14/STAT3 pathway

LncRNA small nucleolar RNA host gene 3 (Snhg3) has been involved in cell proliferation and migration in malignant cells. However, its role in regulating functions of non-malignant cells has been hardly reported. Here, we found Snhg3 expression was sharply induced in primary brain microvascular endothelial cells (BMVECs) treated with oxygen-and-glucose-deprivation (OGD) plus hemin, an in vitro model of intracerebral hemorrhage (ICH). Downregulation of Snhg3 by siRNA transfection improved cell proliferation and migration abilities and reduced cell apoptosis and monolayer permeability in BMVECs under treatment with OGD plus hemin. Snhg3 overexpression suppressed cell proliferation and migration and increased cell apoptosis and monolayer permeability under normal condition. In ICH rats, downregulation of Snhg3 by siRNA injection improved behavioral and histological manifestations, including number of right turns, limb placement score, integrity of blood-brain barrier (BBB), brain water content and cell apoptosis in vivo. In the mechanism exploration, we found that, TWEAK and Snhg3 displayed a positive correlation with each other. Snhg3 overexpression increased expression of TWEAK protein and its receptor Fn14, that were also induced by OGD plus hemin, activating the downstream neuroinflammatory pathway STAT3 and enhancing the secretion of MMP-2/9. Finally, the TWEAK-siRNA, the Fn14 inhibitor ATA and the STAT3 blocker AG490 were respectively used to treat BMVECs under treatment with OGD plus hemin. Our results showed either TWEAK downregulation, Fn14 inhibition, or STAT3 blockade, could rescue Snhg3-induced impairment of BMVEC functions. In conclusion, the lncRNA Snhg3 contributes to dysfunction of cerebral microvascular cells in ICH rats by activating the TWEAK/Fn14/STAT3 pathway.

Tight Control of Systolic Blood Pressure in Spontaneous Intraparenchymal Brain Hemorrhage

Background Tight blood pressure control is critical in neurosurgical patients. Systolic blood pressure (SBP) must be low enough to avoid injury and minimize intraparenchymal hemorrhage (IPH) but high enough to maintain cerebral perfusion. American Heart Association (AHA) guidelines recommend SBP <140 in intracerebral hemorrhage. This paper sought to elucidate the effect of early control of SBP on IPH expansion. Methods 134 patients with spontaneous IPH between 2011 and 2015 were analyzed utilizing chart review. Initial versus follow-up bleed size, presentation and discharge condition, discharge disposition, and blood pressure control adequacy were analyzed using the generalized linear model. Results Altered mental status was the most common presenting complaint (78%). Presenting GCS failed to demonstrate a significant main effect. Age, initial IPH volume, presenting SBP, and one-hour SBP significantly affected IPH percent expansion (p=0.002, =0.002, <0.0005, and =0.026). Several two-way interactions affected IPH percent change implying synergistic effects of the predictor variables. Conclusion Patients aged 60-70 years had the largest percent IPH expansion followed by patients aged 20-30 years. Initial IPH volume of 65.23-78.26 ml showed the largest expansion. Initial IPH volume of 52.18-65.22 ml demonstrated the least percentage of IPH expansion. One-hour control of SBP to binned groups of 111-121 mmHg or 121-132 mmHg portends relative minima in bleed expansion corresponding with AHA recommendations for IPH patients. This study suggests that this degree of early and aggressive control of SBP is achievable, safe, and may minimize IPH expansion. Future studies are needed to elucidate the role of co-morbidities and to confirm these findings in broader populations.

A Narrative Review of Cardiovascular Abnormalities After Spontaneous Intracerebral Hemorrhage

BACKGROUND

The recommended cardiac workup of patients with spontaneous intracerebral hemorrhage (ICH) includes an electrocardiogram (ECG) and cardiac troponin. However, abnormalities in other cardiovascular domains may occur. We reviewed the literature to examine the spectrum of observed cardiovascular abnormalities in patients with ICH.

METHODS

A narrative review of cardiovascular abnormalities in ECG, cardiac biomarkers, echocardiogram, and hemodynamic domains was conducted on patients with ICH.

RESULTS

We searched PubMed for articles using MeSH Terms "heart," "cardiac," hypertension," "hypotension," "blood pressure," "electro," "echocardio," "troponin," "beta natriuretic peptide," "adverse events," "arrhythmi," "donor," "ICH," "intracerebral hemorrhage." Using Covidence software, 670 articles were screened for title and abstracts, 482 articles for full-text review, and 310 extracted. A total of 161 articles met inclusion and exclusion criteria, and, included in the manuscript. Cardiovascular abnormalities reported after ICH include electrocardiographic abnormalities (56% to 81%) in form of prolonged QT interval (19% to 67%), and ST-T changes (19% to 41%), elevation in cardiac troponin (>0.04 ng/mL), and beta-natriuretic peptide (BNP) (>156.6 pg/mL, up to 78%), echocardiographic abnormalities in form of regional wall motion abnormalities (14%) and reduced ejection fraction. Location and volume of ICH affect the prevalence of cardiovascular abnormalities. Prolonged QT interval, elevated troponin-I, and BNP associated with increased in-hospital mortality after ICH. Blood pressure control after ICH aims to preserve cerebral perfusion pressure and maintain systolic blood pressure between 140 and 179 mm Hg, and avoid intensive blood pressure reduction (110 to 140 mm Hg). The recipients of ICH donor hearts especially those with reduced ejection fraction experience increased early mortality and graft rejection.

CONCLUSIONS

Various cardiovascular abnormalities are common after spontaneous ICH. The workup of patients with spontaneous ICH should involve 12-lead ECG, cardiac troponin-I, as well as BNP, and echocardiogram to evaluate for heart failure. Blood pressure control with preservation of cerebral perfusion pressure is a cornerstone of hemodynamic management after ICH. The perioperative implications of hemodynamic perturbations after ICH warrant urgent further examination.

Experimental study on the detection of cerebral hemorrhage in rabbits based on broadband antenna technology

Hematoma enlargement often occurs in patients with spontaneous intracerebral hemorrhage (ICH), so it is necessary to monitor the amount of intracranial hemorrhage in patients after admission. At present, the commonly used intracranial pressure (ICP) method has the disadvantages of trauma and infection, and the Computer Tomography (CT) method cannot achieve continuous monitoring. So it is urgent to develop a non-contact and non-invasive method for continuous monitoring of cerebral hemorrhage. The dielectric properties of blood are different from those of brain tissue, so the hematoma will affect the amplitude and phase of the electromagnetic waves passing through the head. A microstrip antenna was designed to construct the detection system for cerebral hemorrhage. Based on the animal model of acute cerebral hemorrhage, the detecting experiment was carried out on thirteen rabbits. Each rabbit had three bleeding states: 1, 2, and 3 ml, which represented the severity of cerebral hemorrhage. According to the measured data of high dimension and small sample, the support vector machine (SVM) algorithm was used to assess the severity of cerebral hemorrhage. According to simulation results, the antenna's forward radiation was 5 dB larger than the backward radiation, which ensured the antenna being not affected by external signals during the measurement. According to test results, the -10 dB workband of the antenna was 1.55-2.05 GHz and the frequency range of the transmission parameters S₂₁ above -30 dB is 1.2 - 3 GHz. In the animal experiment, the phase difference of Transmission coefficient S₂₁ was gradually increased with the increase of bleeding volume. Through the classification of 39 bleeding states of the 13 rabbits, the total accuracy was about 77%. Through animal experiments, the feasibility of detection method has been proved. But the classification accuracy need to be further improved. The detection system is based on broadband antenna has the potential to realize non-contact, non-invasive and continuous monitoring for cerebral hemorrhage.

Urokinase vs Tissue-Type Plasminogen Activator for Thrombolytic Evacuation of Spontaneous Intracerebral Hemorrhage in Basal Ganglia

Spontaneous intracerebral hemorrhage (ICH) is a devastating form of stroke, which leads to a high rate of mortality and poor neurological outcomes worldwide. Thrombolytic evacuation with urokinase-type plasminogen activator (uPA) or tissue-type plasminogen activator (tPA) has been showed to be a hopeful treatment for ICH. However, to the best of our knowledge, no clinical trials were reported to compare the efficacy and safety of these two fibrinolytics administrated following minimally invasive stereotactic puncture (MISP) in patients with spontaneous basal ganglia ICH. Therefore, the authors intended here to evaluate the differential impact of uPA and tPA in a retrospective study. In the present study, a total of 86 patients with spontaneous ICH in basal ganglia using MISP received either uPA (uPA group, n = 45) or tPA (tPA group, n = 41), respectively. The clinical baseline characteristics prior to the operation were collected. In addition, therapeutic responses were assessed by the short-term outcomes within 30 days postoperation, as well as long-term outcomes at 1 year postoperation. Our findings showed that, in comparison with tPA, uPA was able to better promote hematoma evacuation and ameliorate perihematomal edema, but the differences were not statistically significant. Moreover, the long-term functional outcomes of both groups were similar, with no statistical difference. In conclusion, these results provide evidence supporting that uPA and tPA are similar in the efficacy and safety for thrombolytic evacuation in combination with MISP in patients with spontaneous basal ganglia ICH.