Management of Spontaneous Intracerebral Hematoma

Retrospective Evaluation of Hematological and Clinical Factors Associated with 30-Day Mortality in 170 Patients Diagnosed with Intracerebral Hematoma in a Single Center in Turkey

BACKGROUND This retrospective study from a single center in Turkey aimed to evaluate hematological and clinical factors related with 30-day mortality in patients diagnosed with intracerebral hematoma (ICH) between 2013 and 2021. MATERIAL AND METHODS All 170 consecutive patients (>18 years) admitted to the Intensive Care Unit (ICU) with spontaneous ICH were analyzed. Cranial computed tomography was performed in all patients. Venous blood samples were routinely obtained upon admission. Demographic characteristics, blood test results, imaging data, and survival data were retrieved from the institutional digital database. The primary goal of this study was to investigate the role of presenting demographic and clinical characteristics and blood tests in predicting 30-day mortality in patients with spontaneous ICH. RESULTS Receiver operating characteristic curve analysis showed that the Glasgow coma scale (GCS) score (≤9), hematoma volume (>13.4 cm³), hemoglobin (≤13.1 g/dL), international normalized ratio (>1.25), C-reactive protein (CRP) (>7.5 mg/L), and third-day neutrophil-to-lymphocyte ratio (>17.8) could be used to predict 30-day mortality. Patients with low GCS scores (≤9) had a 14.432-fold higher risk of death than other patients (OR: 14.432, 95% CI: 6.421-32.441, P<0.001). Patients with high CRP levels (>7.5) had a 3.323-fold higher risk of death than other patients (OR: 3.323, 95% CI: 1.491-7.405, P=0.003). CONCLUSIONS Tailoring scoring systems to include CRP may be beneficial for predicting spontaneous ICH prognosis. However, further studies assessing CRP and other inflammatory markers are necessary to assess whether inflammatory activity could be associated with worse outcomes in patients with ICH.

A contemporary review of therapeutic and regenerative management of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) remains a common and debilitating form of stroke. This neurological emergency must be diagnosed and treated rapidly yet effectively. In this article, we review the medical, surgical, repair, and regenerative treatment options for managing ICH. Topics of focus include the management of blood pressure, intracranial pressure, coagulopathy, and intraventricular hemorrhage, as well as the role of surgery, regeneration, rehabilitation, and secondary prevention. Results of various phase II and III trials are incorporated. In summary, ICH patients should undergo rapid evaluation with neuroimaging, and early interventions should include systolic blood pressure control in the range of 140 mmHg, correction of coagulopathy if indicated, and assessment for surgical intervention. ICH patients should be managed in dedicated neurosurgical intensive care or stroke units where continuous monitoring of neurological status and evaluation for neurological deterioration is rapidly possible. Extravasation of hematoma may be helpful in patients with intraventricular extension of ICH. The goal of care is to reduce mortality and enable multimodal rehabilitative therapy.

Wnt Pathway: An Emerging Player in Vascular and Traumatic Mediated Brain Injuries

The Wnt pathway, which comprises the canonical and non-canonical pathways, is an evolutionarily conserved mechanism that regulates crucial biological aspects throughout the development and adulthood. Emergence and patterning of the nervous and vascular systems are intimately coordinated, a process in which Wnt pathway plays particularly important roles. In the brain, Wnt ligands activate a cell-specific surface receptor complex to induce intracellular signaling cascades regulating neurogenesis, synaptogenesis, neuronal plasticity, synaptic plasticity, angiogenesis, vascular stabilization, and inflammation. The Wnt pathway is tightly regulated in the adult brain to maintain neurovascular functions. Historically, research in neuroscience has emphasized essentially on investigating the pathway in neurodegenerative disorders. Nonetheless, emerging findings have demonstrated that the pathway is deregulated in vascular- and traumatic-mediated brain injuries. These findings are suggesting that the pathway constitutes a promising target for the development of novel therapeutic protective and restorative interventions. Yet, targeting a complex multifunctional signal transduction pathway remains a major challenge. The review aims to summarize the current knowledge regarding the implication of Wnt pathway in the pathobiology of ischemic and hemorrhagic stroke, as well as traumatic brain injury (TBI). Furthermore, the review will present the strategies used so far to manipulate the pathway for therapeutic purposes as to highlight potential future directions.

Total small vessel disease score and functional outcomes following acute intracerebral hemorrhage

BACKGROUND

Individual cerebral small vessel disease (SVD) markers are independent predictors for poor prognosis following intracerebral hemorrhage (ICH), however, the impact of the cumulative SVD burden on outcomes remains unclear. We aimed to investigate the association between the global SVD burden and functional outcomes following ICH.

METHODS

We retrospectively evaluated a consecutive cohort of patients with ICH who underwent brain magnetic resonance imaging and magnetic resonance angiography, from a prospective registry. We identified the presence and severity of the SVD markers (cerebral microbleeds, lacunar infarctions, periventricular hyperintensities, and deep white matter hyperintensities) and summed them to obtain the modified total SVD score (0-4). Poor functional outcomes were defined as a modified Rankin Scale score at discharge ≥ 3. A multivariate logistic regression model was used to assess the association between patient outcomes and the SVD score.

RESULTS

A total of 144 patients were included (65.0 ± 12.2 years, 67.4% male). The modified total SVD score was potentially associated with poor functional outcomes (odds ratio [OR] 1.72, 95% confidence interval [CI] 0.97-3.03) after adjustment for age, sex, history of stroke, chronic kidney disease, prior use of antithrombotic agents, the National Institutes of Health Stroke Scale score on admission, the non-lobar location of ICH, and hematoma volume on admission. Moreover, among older patients (≥ 65 years), the SVD score was associated with poor outcomes (OR 3.11, 95% CI 1.01-9.55). Among those with supratentorial ICH, the score remained significant (OR 2.06, 95% CI 1.11-3.83).

CONCLUSIONS

The modified total SVD score may have predictive value for poor functional outcomes following ICH.

Identification of hub genes and small-molecule compounds related to intracerebral hemorrhage with bioinformatics analysis

Background

Because of the complex mechanisms of injury, conventional surgical treatment and early blood pressure control does not significantly reduce mortality or improve patient prognosis in cases of intracerebral hemorrhage (ICH). We aimed to identify the hub genes associated with intracerebral hemorrhage, to act as therapeutic targets, and to identify potential small-molecule compounds for treating ICH.

Methods

The GSE24265 dataset, consisting of data from four perihematomal brain tissues and seven contralateral brain tissues, was downloaded from the Gene Expression Omnibus (GEO) database and screened for differentially expressed genes (DEGs) in ICH, with a fold change (FC) value of (|log2FC|) > 2 and a P-value of <0.05 set as cut-offs. The functional annotation of DEGs was performed using Gene Ontology (GO) resources, and the cell signaling pathway analysis of DEGs was performed using the Kyoto Encyclopedia of Genes and Genomes (KEGG), with a P-value of <0.05 set as the cut-off. We constructed a protein-protein interaction (PPI) network to clarify the interrelationships between the different DEGs and to select the hub genes with significant interactions. Next, the DEGs were analyzed using the CMap tool to identify small-molecule compounds with potential therapeutic effects. Finally, we verified the expression levels of the hub genes by RT-qPCR on the rat ICH model.

Result

A total of 59 up-regulated genes and eight down-regulated genes associated with ICH were identified. The biological functions of DEGs associated with ICH are mainly involved in the inflammatory response, chemokine activity, and immune response. The KEGG analysis identified several pathways significantly associated with ICH, including but not limited to HIF-1, TNF, toll-like receptor, cytokine-cytokine receptor interaction, and chemokine molecules. A PPI network consisting of 57 nodes and 373 edges was constructed using STRING, and 10 hub genes were identified with Cytoscape software. These hub genes are closely related to secondary brain injury induced by ICH. RT-qPCR results showed that the expression of ten hub genes was significantly increased in the rat model of ICH. In addition, a CMap analysis of three small-molecule compounds revealed their therapeutic potential.

Conclusion

In this study we obtained ten hub genes, such as IL6, TLR2, CXCL1, TIMP1, PLAUR, SERPINE1, SELE, CCL4, CCL20, and CD163, which play an important role in the pathology of ICH. At the same time, the ten hub genes obtained through PPI network analysis were verified in the rat model of ICH. In addition, we obtained three small molecule compounds that will have therapeutic effects on ICH, including Hecogenin, Lidocaine, and NU-1025.

Differences in neurosurgical treatment of intracerebral haemorrhage: a nation-wide observational study of 578 consecutive patients

BACKGROUND

Supratentorial intracerebral haemorrhage (ICH) carries an excessive mortality and morbidity. Although surgical ICH treatment can be life-saving, the indications for surgery in larger cohorts of ICH patients are controversial and not well defined. We hypothesised that surgical indications vary substantially among neurosurgical centres in Sweden.

OBJECTIVE

In this nation-wide retrospective observational study, differences in treatment strategies among all neurosurgical departments in Sweden were evaluated.

METHODS

Patient records, neuroimaging and clinical outcome focused on 30-day mortality were collected on each operated ICH patient treated at any of the six neurosurgical centres in Sweden from 1 January 2011 to 31 December 2015.

RESULTS

In total, 578 consecutive surgically treated ICH patients were evaluated. There was a similar incidence of surgical treatment among different neurosurgical catchment areas. Patient selection for surgery was similar among the centres in terms of patient age, pre-operative level of consciousness and co-morbidities, but differed in ICH volume, proportion of deep-seated vs. lobar ICH and pre-operative signs of herniation (p < .05). Post-operative patient management strategies, including the use of ICP-monitoring, CSF-drainage and mechanical ventilation, varied among centres (p < .05). The 30-day mortality ranged between 10 and 28%.

CONCLUSIONS

Although indications for surgical treatment of ICH in the six Swedish neurosurgical centres were homogenous with regard to age and pre-operative level of consciousness, important differences in ICH volume, proportion of deep-seated haemorrhages and pre-operative signs of herniation were observed, and there was a substantial variability in post-operative management. The present results reflect the need for refined evidence-based guidelines for surgical management of ICH.

Advancements in Managing Intracerebral Hemorrhage: Transition from Nihilism to Optimism

There have been significant advancements in the management of intracerebral hemorrhage (ICH) stemming from new knowledge on its pathogenesis. Major clinical trials, such as Surgical Trial in Lobar Intracerebral Hemorrhage (STICH I and II), have shown only a small, albeit clinically relevant, advantage of surgical interventions in specific subsets of patients suffering from ICH. Currently, the aim is to use a minimally invasive and safe trajectory in removing significant brain hematomas with the aid of neuro-endoscopy or precise guidance through neuro-navigation, thereby avoiding a collateral damage to the surrounding normal brain tissue. A fundamental rational to such approach is to safely remove hematoma, preventing the ongoing mass effect resulting in brain herniation, and to minimize deleterious effects of iron released from hematoma to brain cells. The clot lysis process is facilitated with the adjunctive use of recombinant tissue plasminogen activator and sonolysis. Revised recommendations for the management of ICH focus on a holistic approach, with special emphasis on early patient mobilization and graded rehabilitative process. There has been a paradigm shift in the management algorithm, putting emphasis on early and safe removal of brain hematoma and then focusing on the improvement of patients' quality of life. We have made significant progress in transition from nihilism toward optimism, based on evidence-based management of such a severe global health scourge as intracranial hemorrhage.