Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage

Iron/ROS/Itga3 mediated accelerated depletion of hippocampal neural stem cell pool contributes to cognitive impairment after hemorrhagic stroke

Hemorrhagic stroke, specifically intracerebral hemorrhage (ICH), has been implicated in the development of persistent cognitive impairment, significantly compromising the quality of life for affected individuals. Nevertheless, the precise underlying mechanism remains elusive. Here, we report for the first time that the accumulation of iron within the hippocampus, distal to the site of ICH in the striatum, is causally linked to the observed cognitive impairment with both clinical patient data and animal model. Both susceptibility-weighted imaging (SWI) and quantitative susceptibility mapping (QSM) demonstrated significant iron accumulation in the hippocampus of ICH patients, which is far from the actual hematoma. Logistical regression analysis and multiple linear regression analysis identified iron level as an independent risk factor with a negative correlation with post-ICH cognitive impairment. Using a mouse model of ICH, we demonstrated that iron accumulation triggers an excessive activation of neural stem cells (NSCs). This overactivation subsequently leads to the depletion of the NSC pool, diminished neurogenesis, and the onset of progressive cognitive dysfunction. Mechanistically, iron accumulation elevated the levels of reactive oxygen species (ROS), which downregulated the expression of Itga3. Notably, pharmacological chelation of iron accumulation or scavenger of aberrant ROS levels, as well as conditionally overexpressed Itga3 in NSCs, remarkably attenuated the exhaustion of NSC pool, abnormal neurogenesis and cognitive decline in the mouse model of ICH. Together, these results provide molecular insights into ICH-induced cognitive impairment, shedding light on the value of maintaining NSC pool in preventing cognitive dysfunction in patients with hemorrhagic stroke or related conditions.

Cognitive outcomes following aneurysmal subarachnoid hemorrhage: Rehabilitation strategies

Despite decreases in mortality rate, the treatment of cognitive deficits following aneurysmal subarachnoid hemorrhage (aSAH) remains a serious challenge for clinicians and survivors alike. Deficits in executive function, language, and memory prevent more than half of survivors from returning to their previous level of work and put a tremendous amount of stress on the individual and their family. New therapies are needed for survivors of aSAH in order to improve cognitive outcomes and quality of life. The aim of this review is to discuss the prevalence and contributing factors of cognitive deficits following aSAH, as well as areas for therapeutic intervention. Due to the limited research on cognitive rehabilitative strategies for aSAH, a literature search of traumatic brain injury (TBI) was used to explore therapies with the potential to improve cognitive outcomes in aSAH. Across cognitive domains, existing rehabilitative and pharmacotherapeutic strategies for TBI show promise to be useful for survivors of aSAH. However, further study of these therapies in addition to consistent assessment of cognitive deficits are required to determine their efficacy in survivors of aSAH.

Prevalence of Cognitive Impairment and Dementia After Intracerebral Hemorrhage

Objective

To study the prevalence of cognitive impairment in survivors of intracerebral hemorrhage (ICH).

Methods

Survivors of spontaneous ICH were followed up in the neurology outpatient department when they reported for follow-up after 6 months. Neuroimaging records at the onset and at follow-up visits are studied for the location of ICH, volume of ICH, intraventricular extension, and hydrocephalus. The volume of ICH is calculated by ABC/2 method on a CT scan. All patients underwent cognitive assessment with Addenbrooke's cognitive examination ACE III and were categorized as patients having cognitive impairment (or) no cognitive impairment.

Results

A total of 120 patients were studied, out of which 77 (64%) are males and 43 (36%) are females with age groups ranging from 26 to 75 years. In the study population, the mean age was found to be 62.3 years. Specifically, the mean age for males was 56.9 years, while for females it was 63.4 years. Cognitive impairment was noted in 34 of 120 patients (28%) during 6 to 12 months of examination, of which 11 of 19 were in lobar location, 21 of 94 were in sub-cortical location, and 2 of 7 were in infratentorial location.

Conclusion

It was found that 28% of survivors of ICH were cognitively impaired. Hence, it is essential to assess cognition in post-ICH patients during follow-up, so that suitable adjustments can be made in their employment, and also in educating family members in providing a good quality of life.

Description of the Quality of Life of Patients With Subarachnoid Hemorrhage at King Abdulaziz University Hospital in Jeddah

Objective Stroke is a serious medical condition that causes long-term morbidity and disability. There are two types of stroke, i.e., ischemic and hemorrhagic stroke. Subarachnoid hemorrhage (SAH) accounts for 5% of all stroke cases worldwide. Stroke survivors may experience cognitive dysfunction in many forms. Evidence regarding the quality of life (QoL) of patients post-SAH in the Middle East is limited. Therefore, this study aims to describe the quality of life in patients with SAH at the King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia, from April 2021 to October 2021. Methods We included patients who were diagnosed with SAH ≤ 10 years prior at our hospital and were admitted within 72 hours of the ictus. Patients were included using non-probability convenience sampling without randomization. We collected the Glasgow Coma Scale (GCS), World Federation of Neurosurgeons (WFNS), and Modified Glasgow Outcome Scale (MGOS) scores. Results We included 48 patients (mean age: 49.78 ± 19.44 years, male proportion: 62.5%). More than 50% of the participants had comorbidities. The mean baseline GCS, WFNS, and MGOS scores at admission were 12.62 ± 3.56, 2.19 ± 1.54, and 3.58 ± 1.67, respectively. Women had significantly higher MGOS scores than men (p ≤ 0.05). Death was significantly associated with low MGOS scores (p ≤ 0.05). Age showed a non-significant negative correlation with the MGOS score (r = - 0.17, p-value = 0.24). Finally, the MGOS score was significantly correlated with the baseline GCS and WFNS scores at admission (r = 0.68 and r = - 0.67, respectively). Conclusion Our findings demonstrated that a low MGOS score, which indicates more comorbidities, greatly affects the quality of life of patients with SAH. Moreover, the baseline GCS score was the best prognostic predictor for patients with SAH.

Higher Hospital Frailty Risk Score is associated with increased complications and healthcare resource utilization after endovascular treatment of ruptured intracranial aneurysms

AIM

To use the Hospital Frailty Risk Score (HFRS) to investigate the impact of frailty on complication rates and healthcare resource utilization in patients who underwent endovascular treatment of ruptured intracranial aneurysms (IAs).

METHODS

A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample database. All adult patients (≥18 years) undergoing endovascular treatment for IAs after subarachnoid hemorrhage were identified using ICD-10-CM codes. Patients were categorized into frailty cohorts: low (HFRS <5), intermediate (HFRS 5-15) and high (HFRS >15). Patient demographics, adverse events, length of stay (LOS), discharge disposition, and total cost of admission were assessed. Multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, increased cost, and non-routine discharge.

RESULTS

Of the 33 840 patients identified, 7940 (23.5%) were found to be low, 20 075 (59.3%) intermediate and 5825 (17.2%) high frailty by HFRS criteria. The rate of encountering any adverse event was significantly greater in the higher frailty cohorts (low: 59.9%; intermediate: 92.4%; high: 99.2%, p<0.001). There was a stepwise increase in mean LOS (low: 11.7±8.2 days; intermediate: 18.7±14.1 days; high: 26.6±20.1 days, p<0.001), mean total hospital cost (low: $62 888±37 757; intermediate: $99 670±63 446; high: $134 937±80 331, p<0.001), and non-routine discharge (low: 17.3%; intermediate: 44.4%; high: 69.4%, p<0.001) with increasing frailty. On multivariate regression analysis, a similar stepwise impact was found in prolonged LOS (intermediate: OR 2.38, p<0.001; high: OR 4.49, p<0.001)], total hospital cost (intermediate: OR 2.15, p<0.001; high: OR 3.62, p<0.001), and non-routine discharge (intermediate: OR 2.13, p<0.001; high: OR 4.17, p<0.001).

CONCLUSIONS

Our study found that greater frailty as defined by the HFRS was associated with increased complications, LOS, total costs, and non-routine discharge.

Thermal and Postural Effects on Fluid Mixing and Irrigation Patterns for Intraventricular Hemorrhage Treatment

Intraventricular hemorrhage is characterized by blood leaking into the cerebral ventricles and mixing with cerebrospinal fluid. A standard treatment method involves inserting a passive drainage catheter, known as an external ventricular drain (EVD), into the ventricle. EVDs have common adverse complications, including the occlusion of the catheter, that may lead to permanent neural damage or even mortality. In order to prevent such complications, a novel dual-lumen catheter (IRRAflow®) utilizing an active fluid exchange mechanism has been recently developed. However, the fluid dynamics of the exchange system have not been investigated. In this study, convective flow in a three-dimensional cerebral lateral ventricle with an inserted catheter is evaluated using an in-house lattice-Boltzmann-based fluid-solid interaction solver. Different treatment conditions are simulated, including injection temperature and patient position. Thermal and gravitational effects on medication distribution are studied using a dye simulator based on a recently-introduced (pseudo)spectral convection-diffusion equation solver. The effects of injection temperature and patient position on catheter performance are presented and discussed in terms of hematoma irrigation, vortical structures, mixing, and medication volume distribution. Results suggest that cold-temperature injections can increase catheter efficacy in terms of dye distribution and irrigation potential, both of which can be further guided by patient positioning.

In-hospital outcomes of patients with spontaneous supratentorial intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) in the brain parenchyma accounts for 16.1% of all stroke types in Taiwan. It is responsible for high morbidity and mortality in some underlying causes. The objective of this study is to discover the predicting factors focusing on in-hospital outcomes of patients with spontaneous supratentorial ICH. Between June 2014 and October 2018, there were a total of 159 patients with spontaneous supratentorial ICH ranging from 27 to 91 years old in our institution. Twenty-three patients died during hospitalization, whereas 59 patients had an extended length of stay of >30 days. The outcomes were measured by inpatient death, length of stay, and activity of daily living (ADL). Both univariate and multivariate binary logistic regression, as well as multivariate linear regression, were used for statistical analysis. Multivariate binary linear regression analysis showed the larger hematoma in initial computed tomography scan of >30 cm3 (odds ratio [OR] = 2.505, P = .013) and concurrent in-hospital infection (OR = 4.173, P = .037) were both statistically related to higher mortality. On the other hand, in-hospital infection (≥17.41 days, P = .000) and surgery (≥11.23 days, P = .001) were correlated with a longer length of stay. Lastly, drastically poor change of ADL (ΔADL <-30) was associated with larger initial ICH (>30 cc, OR = 2.915, P = .049), in-hospital concurrent infection (OR = 4.695, P = .01), and not receiving a rehabilitation training program (OR = 3.473, P = .04). The results of this study suggest that age, prothrombin, initial Glasgow Coma Scale, computed tomography image, location of the lesion, and surgery could predict the mortality and morbidity of the spontaneous ICH, which cannot be reversed at the time of occurrence. However, effective control of international normalized ratio level, careful prevention against infection, and the aid of rehabilitation programs might be important factors toward a decrease of inpatient mortality rate, the length of stay, and ADL recovery.

Dose-dependent benefits of iron-magnetic nanoparticle-coated human umbilical-derived mesenchymal stem cell treatment in rat intracranial hemorrhage model

BACKGROUND

This study tested whether two doses of human umbilical-derived mesenchymal stem cells (hUC-MSCs) were superior to one dose for protecting the brain against intracranial hemorrhage (ICH) induced by intracranial injection collagenase and the capacity of ironic-magnetic-nanoparticles (Ir-MNa) coated hUC-MSCs tracked by MRI.

METHODS AND RESULTS

Adult male SD rats (n = 40) were equally categorized into group 1 (sham-operated-control), group 2 (ICH), group 3 [ICH + Ir-MNa-coated hUC-MSCs/1.2 × 10⁶ cells with an extracorporeal magnet over rat head (eCMag)/administered by left internal carotid artery (LICA) at post-3 h ICH], and group 4 (ICH + Ir-MNa-coated hUC-MSCs/1.2 × 10⁶ cells with an eCMag/administered post-3 h ICH by LICA and 24 h by IV) and euthanized by day 28. The result showed that by day 28 after ICH induction the neurological function was severely impaired in group 2 than in group 1 that was significantly improved in group 3 and further significantly improved in group 4, whereas ICH volume exhibited an opposite pattern of neurological impairment among the groups (all p < 0.0001). Brain MRI demonstrated that by 4 h after ICH, Ir-MNa-coated hUC-MSCs were abundantly identified in ischemic area in group 4. The protein expressions of inflammatory (TNF-α/MMP-9/IL-1ß/iNOS)/oxidative-stress (NOX-1/NOX-2/oxidized protein)/apoptotic (caspase-3/mitochondrial Bax/PARP)/fibrotic (Smad3/TGF-ß)/mitochondrial-damaged (cytosolic-cytochrome-C) biomarkers displayed an identical pattern of neurological impairment among the groups (all p < 0.0001). The cellular expressions of inflammation (CD68+/CD11b+)/brain edema (AQP4+) biomarkers exhibited an identical pattern, whereas the neuronal-myelin (Doublecortin+/NeuN/nestin) biomarkers displayed an opposite pattern of neurological impairment (all p < 0.0001).

CONCLUSION

Two doses of hUC-MSCs were superior to just one dose for protecting the brain against ICH-induced damage and Ir-MNa-coated hUC-MSCs offered a well adopted method for tracking hUC-MSCs homing into the brain.

Developing and validating a mortality prediction model for ICH in ITP: a nationwide representative multicenter study

Intraparenchymal hemorrhage, platelet count, serious infections, severe bleeding events, and Glasgow coma scale predict poor prognosis.

A prognostic model was developed and validated, and an application was established.

Intracranial hemorrhage (ICH) is a rare and life-threatening hemorrhagic event in patients with immune thrombocytopenia (ITP). However, its mortality and related risk factors remain unclear. Herein, we conducted a nationwide multicenter real-world study of ICH in adult ITP patients. According to data from 27 centers in China from 2005 to 2020, the mortality rate from ICH was 33.80% (48/142) in ITP adults. We identified risk factors by logistic univariate and multivariate logistic regression for 30-day mortality in a training cohort of 107 patients as follows: intraparenchymal hemorrhage (IPH), platelet count ≤10 × 10⁹/L at ICH, a combination of serious infections, grade of preceding bleeding events, and Glasgow coma scale (GCS) level on admission. Accordingly, a prognostic model of 30-day mortality was developed based on the regression equation. Then, we evaluated the performance of the prognostic model through a bootstrap procedure for internal validation. Furthermore, an external validation with data from a test cohort with 35 patients from 11 other centers was conducted. The areas under the receiver operating characteristic (ROC) curves for the internal and external validation were 0.954 (95% confidence interval [CI], 0.910-0.998) and 0.942 (95% CI, 0.871-1.014), respectively. Both calibration plots illustrated a high degree of consistency in the estimated and observed risk. In addition, the decision curve analysis showed a considerable net benefit for patients. Thus, an application (47.94.162.105:8080/ich/) was established for users to predict 30-day mortality when ICH occurred in adult patients with ITP.

Ischemic Brain Stroke and Mesenchymal Stem Cells: An Overview of Molecular Mechanisms and Therapeutic Potential

Ischemic brain injury is associated with a high rate of mortality and disability with no effective therapeutic strategy. Recently, a growing number of studies are focusing on mesenchymal stem cell-based therapies for neurodegenerative disorders. However, despite having the promising outcome of preclinical studies, the clinical application of stem cell therapy remained elusive due to little or no progress in clinical trials. The objective of this study was to provide a generalized critique for the role of mesenchymal stem cell therapy in ischemic stroke injury, its underlying mechanisms, and constraints on its preclinical and clinical applications. Thus, we attempted to present an overview of previously published reports to evaluate the progress and provide molecular basis of mesenchymal stem cells (MSCs) therapy and its application in preclinical and clinical settings, which could aid in designing an effective regenerative therapeutic strategy in the future.

Intracerebral Hemorrhage: The Effects of Aging on Brain Injury

Intracerebral hemorrhage (ICH) is a devastating subtype of stroke with high rates of mortality and morbidity. ICH patients often suffer devastating and debilitating neurological impairments, from which the majority of victims are unable to fully recover to functional independence. Unfortunately, there is no established medical therapy for ICH, which is partly attributed to the lack of understanding of the complex pathology of the disorder. Despite advanced age being a major risk factor of ICH, most preclinical studies on ICH employed young animal subjects. Due to this discrepancy, the molecular level changes in the aging brain after ICH are largely unknown, limiting the translation of preclinical studies into potential human treatments. The purpose of this review is to highlight the effects of advanced age on ICH- induced brain injury and recovery and to draw attention to current knowledge gaps, which warrant further investigation.

Prognostic data analysis of surgical treatments for intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is a commonly occurring disease in neurosurgery, yet its surgical treatment is controversial. This paper pertains to the study of the effects of different treatment regimens on the outcome of ICH population. Based on a globally shared third-party MIMIC-III database, the researchers firstly described the dissimilarities in survival probability, mortality, and neurological recovery among mainstream treatments for ICH; secondly, patient classification was determined by important clinical features; and outcome variations among treatment groups were compared. The 28-day, 90-day, and in-hospital mortality in the craniotomy group were significantly lower than minimally invasive surgery (MIS) and non-surgical group patients; and, the medium/long-term mortality in MIS group was significantly lower than the non-surgical group. The craniotomy group positively correlated with short-term GCS recovery compared with the MIS group; no difference existed between the non-surgical and MIS groups. The craniotomy group 90-day survival probability and short-term GCS recovery were superior to the other two treatments in the subgroups of first GCS 3-12; this tendency also presented in the MIS group over non-surgical group. For milder patients (first GCS > 12), the three treatment regimens had a minimal effect on patient survival, but the non-surgical group showed an advantage in short-term GCS recovery. Craniotomy patients have a lower mortality and a better short-term neurological recovery in an ICH population, especially in short-to-medium term mortality and short-term neurological recovery over MIS patients. In addition, surgical treatment is recommendable for patients with a GCS ≤ 12.

Nonhematologic and Hematologic Factors in Spontaneous Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage is defined as nontraumatic bleeding into the brain without vascular malformations or presence of tumor. It occurs in about a third of all strokes and has a high mortality and morbidity. Risk factors that determine the outcome are incompletely understood. Known factors include older age, male gender, Asian ethnicity, hypertension, and comorbidity such as inherited or acquired bleeding diathesis and use of antithrombotic drugs. Likewise, the clinical characteristics of the hematoma such as location and volume of the hematoma and other imaging features are also important. Hematoma extension or expansion is a complication with an unfavorable outcome. Recognition of risk factors for hematoma expansion and measures to prevent it, such as blood pressure lowering, will improve the outcome. Enhanced diagnostic methods, especially in imaging techniques developed over the past decade, have not only led to a better understanding of the pathophysiology of spontaneous intracerebral hemorrhage but also of the factors that influence hematoma expansion. An improved knowledge is essential to better management, minimizing hematoma expansion and leading to a healthier outcome.

The Obesity Paradox in Spontaneous Intracerebral Hemorrhage: Results from a Retrospective Analysis of the Nationwide Inpatient Sample

BACKGROUND/OBJECTIVE

Mild obesity is associated with a survival benefit in cardiovascular and cerebrovascular disease. Only a few studies have analyzed the effect of obesity on outcomes after spontaneous intracerebral hemorrhage (ICH), and none have used a national US database. We sought to determine whether or not obesity was associated with outcomes and in-hospital complications following ICH.

METHODS

The Nationwide Inpatient Sample was used to identify patients with ICH in the USA who were discharged between 2002 and 2011. The presence of obesity (body mass index [BMI] 30-39.9) or morbid obesity (BMI ≥ 40) was noted. The primary outcome of interest was in-hospital mortality, and secondary outcomes included non-routine discharge disposition, tracheostomy or gastrostomy placement, length of stay (LOS), inflation-adjusted hospital charges, and in-hospital complications.

RESULTS

A total of 123,415 patients with ICH met the inclusion criteria, and the 10-year overall incidence of obesity was 4.5%. Between 2002 and 2011, the incidence of obesity increased from 1.9 to 4.4% and the incidence of morbid obesity increased from 0.7 to 3.2%. Both obese (OR 0.62, 95% CI 0.56-0.69) and morbidly obese (OR 0.76, 95% CI 0.66-0.88) patients had lower odds of inpatient mortality. Obese (OR 0.85, 95% CI 0.78-0.93) but not morbidly obese patients had lower odds of non-routine discharge. Morbidly obese patients were twice as likely to require a tracheostomy than non-obese patients (OR 2.07, 95% CI 1.62-2.66). Both obese and morbidly obese patients had higher total hospital charges and rates of pulmonary, renal, and venous thromboembolic complications. There was no difference in LOS according to body habitus.

CONCLUSIONS

In patients with spontaneous ICH, obesity is associated with decreased in-hospital mortality but higher rates of in-hospital complications and greater total hospital charges. Non-morbid obesity carries lower odds of non-routine hospital discharge.

Is the detectability of the spot sign on CT angiography depending on slice thickness and reconstruction type?

OBJECTIVE

The spot sign is a validated imaging marker widely used in CT angiography (CTA) to detect active bleeding and a higher risk of hematoma expansion in patients with intracerebral hemorrhage (ICH). The aim of this study was to investigate the detectability of spot signs on thin multiplanar projection reconstruction (MPR) images compared to thicker maximum intensity projection (MIP) images.

METHODS

In this retrospective analysis, we assessed imaging data of 146 patients with primary hypertensive/microangiopathic ICH who received emergency non-contrast computed tomography (NCCT) and CTA. Two experienced radiologists, blinded to each other, evaluated images of thin (1 mm) MPR images and thick (3 mm) MIP images on the presence of spot signs and performed a consensus reading. Kappa tests were used for data comparison.

RESULTS

In total, spot signs were observed in 27 cases (=18.5 %) in both thin MPR and thick MIP slices. Detectability of the spot sign did not differ in 1 mm MPR images and 3 mm MIP images (Cohen's kappa, 1.0; p = 0.00). Also, when the readings of the two radiologists were analyzed separately, results for MPR and MIP slices were similar (MPR: Cohen's kappa, 0.81, p = 0.00; MIP: Cohen's kappa, 0.74; p = 0.00).

CONCLUSION

No significant difference in the detectability of the spot sign could be demonstrated when comparing 1 mm MPR images with 3 mm MIP images.

Transfer of Patients with Spontaneous Intracranial Hemorrhage who Need External Ventricular Drain: Does Admission Location Matter?

INTRODUCTION

Patients with spontaneous intracranial hemorrhage (sICH) are associated with high mortality and require early neurosurgical interventions. At our academic referral center, the neurocritical care unit (NCCU) receives patients directly from referring facilities. However, when no NCCU bed is immediately available, patients are initially admitted to the critical care resuscitation unit (CCRU). We hypothesized that the CCRU expedites transfer of sICH patients and facilitates timely external ventricular drain (EVD) placement comparable to the NCCU.

METHODS

This is a pre-post study of adult patients transferred with sICH and EVD placement. Patients admitted between January 2011-July 2013 (2011 Control) were compared with patients admitted either to the CCRU or the NCCU (2013 Control) between August 2013-September 2015. The primary outcome was time interval from arrival at any intensive care units (ICU) to time of EVD placement (ARR-EVD). Secondary outcomes included time interval from emergency department transfer request to arrival, and in-hospital mortality. We assessed clinical association by multivariable logistic regressions.

RESULTS

We analyzed 259 sICH patients who received EVDs: 123 (48%) CCRU; 81 (31%) 2011 Control; and 55 (21%) in the 2013 Control. The groups had similar characteristics, age, disease severity, and mortality. Median ARR-EVD time was 170 minutes [106-311] for CCRU patients; 241 minutes [152-490] (p < 0.01) for 2011 Control; and 210 minutes [139-574], p = 0.28) for 2013 Control. Median transfer request-arrival time for CCRU patients was significantly less than both control groups. Multivariable logistic regression showed each minute delay in ARR-EVD was associated with 0.03% increased likelihood of death (odds ratio 1.0003, 95% confidence interval, 1.0001-1.006, p = 0.043).

CONCLUSION

Patients admitted to the CCRU had shorter transfer times when compared to patients admitted directly to other ICUs. Compared to the specialty NCCU, the CCRU had similar time interval from arrival to EVD placement. A resuscitation unit like the CCRU can complement the specialty unit NCCU in caring for patients with sICH who require EVDs.

Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review

Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.

Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review

Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.

Ultra-Early Venous Thromboembolism (VTE) Prophylaxis in Spontaneous Intracerebral Hemorrhage (sICH)

OBJECTIVE

To determine if ultra-early (<24 h) venous thromboembolism (VTE) prophylaxis was associated with hematoma growth in spontaneous intracerebral hemorrhage (ICH).

BACKGROUND

Patients with ICH have a high risk of VTE. Pharmacological prophylaxis such as unfractionated heparin (UFH) have been demonstrated to reduce VTE. However, published datasets exclude patients with recent ICH out of concern for hematoma enlargement. American Heart/Stroke Association guidelines recommend UFH 1-4 days after hematoma stabilization while the European Stroke Organization has no recommendations on when to begin UFH. Our institutional practice is to obtain stability CT scans at 6 to 24 h and to begin UFH following documented clinical and radiologic stability. We examined the impact of this practice on hematoma expansion.

METHODS

We performed a retrospective cohort analysis of consecutive ICH patients treated at a single tertiary academic referral center in the US. Demographic and clinical characteristics were abstracted. ICH volume was measured via 3D volumetrics for a CT head done on admission, follow-up stability, and prior to discharge. The primary outcome was analyzed as ≥3 mL hematoma enlargement. Secondary outcomes include hematoma expansion of ≥6mL and ≥ 33%, length of stay (LOS), discharge disposition and mortality.

RESULTS

A total of 163 ICH patients were analyzed. There were 58 (35.6%) patients in the ultra-early UFH group and UFH was initiated on average at 13.8 h from initial scan. There were 105 (64.6%) patients in the standard group who initiated UFH at an average of 46.6 h. The primary outcome of hematoma enlargement ≥3 mL was observed in 2/58(3.4%) patients with ultra-early initiation of UFH and in 7/105(6.7%) in the standard group (p=0.49). Secondary outcomes were not significant including hematoma expansion in the ultra-early group ≥ 6 mL 3/58 (5.2%) and ≥33% 7/58 (12.1%) (p=0.91, 0.61, respectively) as well as mortality or LOS.

CONCLUSION

Venous thromboembolism prophylaxis started ultra-early (≤24 h) after ICH was not associated with hematoma expansion.

Smoking Status Affects the Association Between Hematoma Heterogeneity and Hematoma Expansion

Objective

The purpose of this study was to verify the relationship between hematoma heterogeneity and hematoma expansion and explore any effect modifiers through subgroup analyses.

Methods

Clinical records of 357 patients with spontaneous cerebral hemorrhage at Shenzhen Second People’s Hospital from March 2016 to October 2018 were included in the study. Hematoma heterogeneity was measured on the first noncontrast computed tomography image according to the Barras scale. Hematoma expansion was defined as an absolute hematoma volume increase of 6 mL, or a 33% increase. We performed univariate and multivariate logistic regression analyses, as well as subgroup analyses, to assess the relationship between the presence of heterogeneity on noncontrast computed tomography and hematoma expansion.

Results

Hematoma expansion occurred in 79 (22.13%) of the 357 patients with intracerebral hemorrhage (ICH). Among the patients with ICH, there were 83 smokers, accounting for 23.24%. The average patient age was 56.21 ± 13.75 years, and 74.51% were male. Compared with the absence of heterogeneity, the risk of hematoma expansion increased by 1.06 times (odds ratio, 2.06; 95% confidence interval, 1.10–3.86). Based on the subgroup analysis, smoking status was found to modify the association between heterogeneity and hematoma expansion; the association was stronger in smokers than in nonsmokers (odds ratio, 10.23; 95% confidence interval, 2.15–48.65).

Conclusions

Heterogeneity independently predicts hematoma expansion, especially in smoking patients.

Minimally invasive puncture versus conventional craniotomy for spontaneous supratentorial hemorrhage: A meta-analysis

BACKGROUND

Minimally invasive puncture and conventional craniotomy are both utilized in the treatment of spontaneous supratentorial hemorrhage. The purpose of this study is to review evidence that compares the safety and effectiveness of these two techniques.

METHODS

We searched EMBASE, Cochrane Library, Web of Science, and PubMed for studies published between 2000 and 2019 that compared the minimally invasive puncture procedure with the conventional craniotomy for the treatment of spontaneous supratentorial hemorrhage.

RESULTS

Seven trials (2 randomized control trials and 5 observational studies) with a total of 970 patients were included. The odds ratio indicated a statistically significant difference between the minimally invasive puncture and conventional craniotomy in terms of good functional outcome (OR 2.36, 90% CI 1.24-4.49). The minimally invasive puncture procedure was associated with lower mortality rates (OR 0.61, 90% CI 0.44-0.85) and rebleeding rates (OR 0.48, 95%CI 0.24-0.99; P=0.003).

CONCLUSIONS

The use of the minimally invasive puncture for the management of spontaneous supratentorial hemorrhage was associated with better functional outcome results, a lower mortality rate, and decreased rebleeding rates. However, because insufficient data has been published thus far, we need more robust evidence to provide a better guide for future management.

Non-Traumatic Intracerebral Hematoma in the Young: Findings from a Tertiary Hospital in the Philippines

BACKGROUND

There is geographic variability in the clinical profile and outcomes of non-traumatic intracerebral hematoma (ICH) in the young, and data for the Philippines is lacking. We aimed to describe this in a cohort from the Philippines, and identify predictors of mortality.

METHODS

We performed a retrospective study of all patients aged 19-49 years with radiographic evidence of non-traumatic ICH admitted in our institution over five years. Data on demographics, risk factors, imaging, etiologies, surgical management, in-hospital mortality, and discharge functional outcomes were collected. Multivariate logistic regression analysis was done to determine factors predictive of mortality.

RESULTS

A total of 185 patients were included, which had a mean age of 40.98 years and a male predilection (71.9%). The most common hematoma location was subcortical, but it was lobar for the subgroup of patients aged 19-29 years. Overall, the most common etiology was hypertension (73.0%), especially in patients aged 40-49. Conversely, the incidence of vascular lesions and thrombocytopenia was higher in patients aged 19-29. Surgery was done in 7.0% of patients. The rates of mortality and favorable functional outcome at discharge were 8.7% and 35.1%, respectively. Younger age (p = 0.004), higher NIHSS score on admission (p=0.01), higher capillary blood glucose on admission (p=0.02), and intraventricular extension of hematoma (p = 0.01) predicted mortality.

CONCLUSIONS

In the Philippines, the most common etiology of ICH in young patients was hypertension, while aneurysms and AVM's were the most common etiology in the subgroup aged 19 - 29 years. Independent predictors of mortality were identified.

Lactoferrin and hematoma detoxification after intracerebral hemorrhage

In this minireview we discuss the role of lactoferrin (LTF) in detoxifying hematoma after intracerebral hemorrhage (ICH). Subsequent to ICH, neutrophils enter the ICH-affected brain, where they release various granule contents, including LTF. LTF is an iron-binding glycoprotein that binds Fe³⁺ with high affinity. Unlike other iron-binding proteins, LTF can retain Fe³⁺ at the low pH associated with inflamed tissue. LTF's ability to sequester Fe³⁺ is of particular importance to ICH pathogenesis, because large quantities of free iron, which is pro-oxidative and pro-inflammatory, are generated in the ICH-affected brain owing to blood hemolysis. LTF delivered to ICH-affected brain, either as a therapeutic agent or through infiltrated polymorphonuclear neutrophils (cells containing high levels of LTF), could limit the pathogenesis of ICH. LTF is a protein with a high isoelectric point (8.7), a property that enables it to bind to negatively-charged apoptotic cells or proteins. Here, LTF could act as a bridging molecule that couples the apoptotic cells to LTF receptors on the cellular membranes of microglia/macrophages to facilitate the efferocytosis/erythrophagocytosis of apoptotic cells and damaged red blood cells. Thus, by virtue of sequestrating iron and facilitating efferocytosis, LTF may contribute to hematoma detoxification and hematoma/inflammation resolution after ICH.

High Mortality Rates Among Patients With Non-Traumatic Intracerebral Hemorrhage and Atrial Fibrillation on Antithrombotic Therapy Are Independent of the Presence of Cerebral Amyloid Angiopathy: Insights From a Population-Based Study

Background Intracerebral hemorrhage (ICH) risk is higher in elderly patients with atrial fibrillation on antithrombotic therapy as well as those with cerebral amyloid angiopathy (CAA). We investigated if mortality among patients with atrial fibrillation on antithrombotic therapy presenting with non-traumatic ICH was influenced by underlying CAA. Methods and Results We used the Rochester Epidemiology Project to identify 6045 patients with atrial fibrillation aged >55 years on anticoagulation or antiplatelet therapy from 1995 to 2016. Seventy-four patients in this cohort presented with non-traumatic ICH. Medical records including imaging data were reviewed to identify those with CAA and record baseline variables and outcomes of interest; 38 of our 74 patients (51.4%) (mean age 81.5 years) met Modified Boston Criteria for possible or probable CAA. Twenty-six of 74 patients (35%) died during the first 30 days while 56 of the 74 (76%) patients died by 10 years follow-up after index ICH. Overall mortality was not significantly different between the CAA and non-CAA groups at any point of time during follow-up (P=0.89) even amongst patients restarted on anticoagulation +/- antiplatelet (n=19) (P=0.46) or those patients restarted only on antiplatelet therapy (n=22) (P=0.66). Three of the 41 patients who restarted on antithrombotic therapy had a recurrent ICH; these 3 patients met criteria for possible or probable CAA. Conclusions Although more than half of our patients with atrial fibrillation on antithrombotic therapy and non-traumatic ICH met Modified Boston Criteria for CAA, CAA did not significantly influence the high mortality seen in this cohort.

Assessment of the Patient With Intracerebral Hemorrhage: A Review of the Literature

Spontaneous nontraumatic intracerebral hemorrhage is associated with high morbidity and mortality. Given the risk of rapid neurological deterioration, early identification with rapid neuroimaging is vital. Predictors of outcome, such as spot sign and intracerebral hemorrhage score, can help guide management goals. Management should be aimed at prevention of hematoma expansion, treatment of increased intracranial pressure, and prevention of secondary brain injury and medical complications.

Sedation Patterns and Hyperosmolar Therapy in Emergency Departments were Associated with Blood Pressure Variability and Outcomes in Patients with Spontaneous Intracranial Hemorrhage

Background

Spontaneous intracranial hemorrhage (sICH) is associated with high mortality. Little information exists to guide initial resuscitation in the emergency department (ED) setting. However, blood pressure variability (BPV) and mechanical ventilation (MV) are known risk factors for poor outcome in sICH.

Objectives

The objective was to examine the associations between BPV and MV in ED (EDMV) and between two ED interventions - post-MV sedation and hyperosmolar therapy for elevated intracranial pressure - and BPV in the ED and in-hospital mortality.

Methods

We retrospectively studied adults with sICH and external ventricular drainage who were transferred to a quaternary academic medical center from other hospitals between January 2011 and September 2015. We used multivariable linear and logistic regressions to measure associations between clinical factors, BPV, and outcomes.

Results

We analyzed ED records from 259 patients. There were 143 (55%) EDMV patients who had more severe clinical factors and significantly higher values of all BPV indices than NoEDMV patients. Two clinical factors and none of the severity scores (i.e., Hunt and Hess, World Federation of Neurological Surgeons Grades, ICH score) correlated with BPV. Hyperosmolarity therapy without fluid resuscitation positively correlated with all BPV indices, whereas propofol infusion plus a narcotic negatively correlated with one of them. Two BPV indices, i.e., successive variation of blood pressure (BP_SV) and absolute difference in blood pressure between ED triage and departure (BP_{Depart - Triage}), were significantly associated with increased mortality rate.

Conclusion

Patients receiving MV had significantly higher BPV, perhaps related to disease severity. Good ED sedation, hyperosmolar therapy, and fluid resuscitation were associated with less BPV and lower likelihood of death.

Relation of Intracerebral Hemorrhage Descriptors with Clinical Factors

The association between intracerebral hemorrhage (ICH) shape and a poor treatment outcome has been established by few authors. We decided to analyze whether computationally assessed hemorrhage shape irregularity is associated with any known predictors of its poor treatment outcome. We retrospectively analyzed 48 patients with spontaneous intracerebral hemorrhage. For each patient we calculated Fractal Dimension, Compactness, Fourier Factor and Circle Factor. Our study showed that patients above 65 years old had significantly higher Compactness (0.70 ± 0.19 vs. 0.56 ± 0.20; p < 0.01), Fractal Dimension (0.46 ± 0.22 vs. 0.32 ± 0.20; p = 0.03) and Circle Factor (0.51 ± 0.25 vs. 0.35 ± 0.17; p < 0.01). Patients with hemorrhage growth had significantly higher Compactness (0.74 ± 0.23 vs. 0.58 ± 0.18; p < 0.01), Circle Factor (0.55 ± 0.27 vs. 0.37 ± 0.18; p < 0.01) and Fourier Factor (0.96 ± 0.06 vs. 0.84 ± 0.19; p = 0.03). In conclusion, irregularity resulting from the number of appendices can be a predictor of ICH growth; however, the size of those appendices is also important. Shape roughness better reflects the severity of brain tissue damage and a patient’s general condition.

Antithrombotics in intracerebral hemorrhage in the era of novel agents and antidotes: A review

BACKGROUND

Intracerebral hemorrhage (ICH)1 is characterized by the pathological accumulation of blood within the brain parenchyma, most commonly associated with hypertension, arteriovenous malformations, or trauma. However, it can also present in patients receiving antithrombotic drugs, either anticoagulants such as acenocoumarol/warfarin-novel oral anticoagulants or antiplatelets, for the prevention and treatment of thromboembolic disease.

OBJECTIVE

The purpose of this review is to present current bibliographic data regarding ICH irrespective of the cause, as well as post-hemorrhage use of antithrombotic agents. Moreover, this review attempts to provide guidelines concerning the termination, inversion, and of course resumption of antithrombotic therapy.

METHODS AND MATERIALS

We reviewed the most recently presented available data for patients who dealt with intracerebral hemorrhagic events while on antithrombotic agents (due to atrial fibrillation, prosthetic mechanical valves or recent/recurrent deep vein thrombosis). Furthermore, we examined and compared the thromboembolic risk, the bleeding risk, as well as the re-bleeding risk in two groups: patients receiving antithrombotic therapy versus patients not on antithrombotic therapy.

CONCLUSION

Antithrombotic therapy is of great importance when indicated, though it does not come without crucial side-effects, such as ICH. Optimal timing of withdrawal, reversal, and resumption of antithrombotic treatment should be determined by a multidisciplinary team consisting of a stroke specialist, a cardiologist, and a neurosurgeon, who will individually approach the needs and risks of each patient.

Risk factors for seizures after intracerebral hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

OBJECTIVE

We aimed to identify risk factors for seizures after intracerebral hemorrhage, and to validate the prognostic value of the previously reported CAVE score (0-4 points: cortical involvement, age <65, volume >10 mL, and early seizures within 7 days of hemorrhage).

PATIENTS AND METHODS

Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) was a prospective study of spontaneous intracerebral hemorrhage. We included patients who did not have a prior history of seizure and survived to discharge. Univariate analysis and multiple logistic regression modeling were used to identify risk factors for seizure.

RESULTS

From 2010-2015, 3000 cases were recruited, and 2507 patients were included in this study. Seizures after hospital discharge developed in 77 patients 3.1 %). Patients with lobar (cortical) hemorrhage (OR 3.0, 95 % CI 1.8-5.0), larger hematoma volume (OR 1.5 per cm³, 95 % CI 1.2-2.0), and surgical evacuation of hematoma (OR 2.6, 95 % CI 1.4-4.8) had a higher risk of late seizure, and older patients had a lower risk (OR 0.88 per 5-year interval increase, 95 % CI 0.81-0.95). The CAVE score was highly associated with seizure development (OR 2.5 per unit score increase, 95 % CI 2.0-3.2, p < 0.0001). The CAVS score, substituting surgical evacuation for early seizure, increased the OR per unit score to 2.8 (95 % CI 2.2-3.5).

CONCLUSIONS

Lobar hemorrhage, larger hematoma volume, younger age, and surgical evacuation are strongly associated with the development of seizures. We validated the CAVE score in a multi-ethnic population, and found the CAVS score to have similar predictive value while representing the current practice of AED use.

Harnessing the anti-inflammatory properties of stem cells for transplant therapy in hemorrhagic stroke

Hemorrhagic stroke is a global health crisis plagued by neuroinflammation in the acute and chronic phases. Neuroinflammation approximates secondary cell death, which in turn robustly contributes to stroke pathology. Both the physiological and behavioral symptoms of stroke correlate with various inflammatory responses in animal and human studies. That slowing the secondary cell death mediated by this inflammation may attenuate stroke pathology presents a novel treatment strategy. To this end, experimental therapies employing stem cell transplants support their potential for neuroprotection and neuroregeneration after hemorrhagic stroke. In this review, we evaluate experiments using different types of stem cell transplants as treatments for stroke-induced neuroinflammation. We also update this emerging area by examining recent preclinical and clinical trials that have deployed these therapies. While further investigations are warranted to solidify their therapeutic profile, the reviewed studies largely posit stem cells as safe and potent biologics for stroke, specifically owing to their mode of action for sequestering neuroinflammation and promoting neuroregenerative processes.

Third Ventricle Obstruction by Thalamic Intracerebral Hemorrhage Predicts Poor Functional Outcome Among Patients Treated with Alteplase in the CLEAR III Trial

INTRODUCTION

The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the ventricular system with alteplase improved functional outcomes in patients with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH). Thalamic ICH location was common and was associated with poor outcome. One possible explanation is thalamic ICH-associated mass effect obstructing the third ventricle. We hypothesized that patients with thalamic ICH obstructing the third ventricle would have worse functional outcomes compared to patients without obstructing lesions.

METHODS

ICH obstruction of third ventricle was defined as third ventricle compression on 1 or more axial computed tomography slices visually impeding cerebral spinal fluid flow. If the third ventricle was casted with IVH, it was scored as such. Multivariable logistic regression analyses were used to determine whether obstruction of the third ventricle predicts poor functional outcomes defined as modified Rankin score (mRS) 4-6, higher mRS, and mortality at 180 days. Models were adjusted for thalamic ICH location, ICH volume, IVH volume, age, hydrocephalus, baseline Glasgow coma scale, and percentage of low cerebral perfusion pressures during treatment.

RESULTS

Among saline-treated patients, obstruction of the third ventricle by IVH was a significant predictor of higher mRS at 180 days (OR 1.87, CI 1.01-3.47) and mortality at 180 days (OR 2.73, CI 1.27-5.87) while obstruction by ICH was not. In contrast, among alteplase-treated patients, obstruction by ICH was a significant predictor of mRS 4-6 (OR 3.20, CI 1.30-7.88) and higher mRS at 180 days (OR 2.33, CI 1.24-4.35), while obstruction by IVH was not.

CONCLUSIONS

Poor outcomes were associated with mass-related obstruction of the third ventricle from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from thalamic ICH might become important in functional recovery.

Intracerebral Hemorrhage: Blood Components and Neurotoxicity

Intracerebral hemorrhage (ICH) is a subtype of stroke which is associated with the highest mortality and morbidity rates of all strokes. Although it is a major public health problem, there is no effective treatment for ICH. As a consequence of ICH, various blood components accumulate in the brain parenchyma and are responsible for much of the secondary brain damage and ICH-induced neurological deficits. Therefore, the strategies that could attenuate the blood component-induced neurotoxicity and improve hematoma resolution are highly needed. The present article provides an overview of blood-induced brain injury after ICH and emphasizes the need to conduct further studies elucidating the mechanisms of hematoma resolution after ICH.

Ruptured aneurysm in the posterior communicating segment of carotid artery presenting with contralateral oculomotor nerve palsy

Background:

Brain aneurysms are mostly discovered during the investigation of subarachnoid hemorrhage (SAH). Some patients present neurological signs that may suggest the aneurysm’s topography, and the oculomotor nerve palsy (ONP) of the same side of the aneurysm is the most common sign. Only one case report of contralateral palsy was previously described in the medical literature.

Case Description:

Authors describe a patient who presented a classic manifestation of SAH associated with complete ONP, whose vascular investigation demonstrated a brain aneurysm located in the contralateral intracranial carotid. The patient was surgically treated with great neurologic outcome, and late angiography did not evidence other vascular abnormalities.

Conclusion:

The ipsilateral ONP is a common sign found in posterior communicating artery aneurysms; however, such aneurysm can have different presentations due to the elevation of intracranial pressure, and, in rarer cases, the ONP cannot be operated as a localizing sign.

A grading scale for surgically treated patients with spontaneous supratentorial intracerebral hemorrhage: the Surgical Swedish ICH Score

OBJECTIVE

The authors aimed to develop the first clinical grading scale for patients with surgically treated spontaneous supratentorial intracerebral hemorrhage (ICH).

METHODS

A nationwide multicenter study including 401 ICH patients surgically treated by craniotomy and evacuation of a spontaneous supratentorial ICH was conducted between January 1, 2011, and December 31, 2015. All neurosurgical centers in Sweden were included. All medical records and neuroimaging studies were retrospectively reviewed. Independent predictors of 30-day mortality were identified by logistic regression. A risk stratification scale (the Surgical Swedish ICH [SwICH] Score) was developed using weighting of independent predictors based on strength of association.

RESULTS

Factors independently associated with 30-day mortality were Glasgow Coma Scale (GCS) score (p = 0.00015), ICH volume ≥ 50 mL (p = 0.031), patient age ≥ 75 years (p = 0.0056), prior myocardial infarction (MI) (p = 0.00081), and type 2 diabetes (p = 0.0093). The Surgical SwICH Score was the sum of individual points assigned as follows: GCS score 15-13 (0 points), 12-5 (1 point), 4-3 (2 points); age ≥ 75 years (1 point); ICH volume ≥ 50 mL (1 point); type 2 diabetes (1 point); prior MI (1 point). Each increase in the Surgical SwICH Score was associated with a progressively increased 30-day mortality (p = 0.0002). No patient with a Surgical SwICH Score of 0 died, whereas the 30-day mortality rates for patients with Surgical SwICH Scores of 1, 2, 3, and 4 were 5%, 12%, 31%, and 58%, respectively.

CONCLUSIONS

The Surgical SwICH Score is a predictor of 30-day mortality in patients treated surgically for spontaneous supratentorial ICH. External validation is needed to assess the predictive value as well as the generalizability of the Surgical SwICH Score.

Surgery for spontaneous intracerebral hemorrhage - A comparative study with medical management in moderate to large sized hematomas

OBJECTIVES

Intracerebral Hemorrhage (ICH) is a devastating form of stroke and accounts for 10-15% of all cases. The management of ICH has predominantly been directed towards medical management. Multiple trials have failed to prove the superiority of surgical evacuation over conservative methods. However, surgery in a carefully selected set of patients is beneficial in reducing mortality and limiting disability. In this article, we retrospectively analysed our ICH register to compare the outcomes of surgical and conservative management of patients <70 years having a clot volume above 30 ml.

PATIENTS AND METHODS

We retrospectively analysed patients with ICH admitted at our centre between January 2015 and December 2017. A total of 119/624 patients with supratentorial hematoma volume >30 ml, GCS ≥ 5 and age less than 70 were included in this study.

RESULTS

The group was dichotomised into two groups A & B based on the management. Seventy-two (60.5%) patients underwent surgical intervention in group A and the remaining 47 (39.5%) were managed by best possible conservative methods in group B. The mean age in Group A was 51.01 years and 55.89 years in group B (P = 0.012). The volume of hematoma in the surgical group was 46.5 ± 14.9 ml in comparison to 38.53 ± 10.84 ml in the medically managed group (p = 0.002). Mortality at 90 days was 27/47 (57.44%) in the medically managed group while 23/72 (31.9%) in the surgical group (p = 0.006). Median mRS at discharge and 90 days were nearly identical and there was no significant difference in the dichotomized outcome among the two different management cohorts (p > 0.05). Mortality was the highest in the 30-50 ml medically managed group and >51 ml surgical group (p = 0.024). Age of the patient, GCS on presentation and medical management were independent predictors of mortality on logistic regression. The Cox Regression survival analysis of the two groups showed a clear survival advantage in the surgically managed group adjusting for age and GCS (p = 0.002) at 90 days.

CONCLUSION

Surgical Evacuation of spontaneous intracerebral haemorrhage has a survival advantage at 90 days in moderate to large sized hematomas. It, however, did not demonstrate any quantifiable improvement in functional outcome. Surgical evacuation of moderate-sized hematomas reduces mortality caused by delayed perihematomal oedema.

Effects of occupation on intracerebral hemorrhage-related deaths in Inner Mongolia

This study assessed the relationship between occupation and Intracerebral Hemorrhage-related deaths and compared the differences in ICH-related deaths rates between the eastern and midwestern regions of Inner Mongolia. We used the case-control method. Cases included Intracerebral Hemorrhage-related deaths that occurred from 2009 to 2012 in Inner Mongolia while controls included non-circulatory system disease deaths that occurred during the same period. Odds ratios (ORs) for Intracerebral Hemorrhage-related deaths were calculated using logistic regression analysis, estimated according to occupation, and adjusted for marital status and age. The Intracerebral Hemorrhage mortality rate in the eastern regions (125.19/100000) was nearly 3 times higher than that in the midwestern regions (45.31/100000). ORs for agriculture-livestock workers, service professionals and general workers, professional workers and senior officials were in descending order. The age-adjusted OR for Intracerebral Hemorrhage-related deaths was lowest in unmarried men senior officials (OR 0.37, 95% CI 0.14-0.99). The Intracerebral Hemorrhage mortality rate in the eastern regions was much higher than that of the midwestern regions, since about 90% of Intracerebral Hemorrhage-related deaths in the eastern regions were those of agriculture-livestock workers who has the largest labor intensity of any other occupation assessed.

Diagnostic value of swirl sign on noncontrast computed tomography and spot sign on computed tomographic angiography to predict intracranial hemorrhage expansion

OBJECTIVE

Intracranial hemorrhage (ICH) expansion is a predictor of poor clinical outcome. ICH expansion can be predicted with a swirl sign on noncontrast computed tomography (NCCT) and/or a spot sign on computed tomographic angiography (CTA). In this study, we aimed to evaluate the diagnostic value of a swirl sign and a spot sign in identifying hematoma expansion.

PATIENTS AND METHODS

Patients with spontaneous ICH between January 2013 and August 2018 who underwent an initial NCCT and CTA, and a subsequent NCCT at a single center were retrospectively identified. Two experienced neuroradiologists reviewed all images for swirl sign and spot sign presence using a 4-point scale for receiver-operative characteristic analysis. ICH expansion was defined as volume growth of >33% or >6 mL.

RESULTS

A total of 227 patients, including 54 with ICH expansion, qualified for analysis. For both observers, the area under the curve (AUC) of spot sign was significantly higher than that of swirl sign (observer 1: 0.748 vs. 0.577, p = .002; observer 2: 0.749 vs. 0.589, p = .004). The sensitivities of ICH expansion in patients with a spot sign was significantly higher than patients with a swirl sign (observer 1: 54.1% vs. 28.0%, p = .002; observer 2: 56.9% vs. 30.3%, p = .002). Patients with a spot sign had the highest risk of ICH expansion (odds ratio: observer 1 = 8.14, observer 2 = 9.30, p < 0.001).

CONCLUSIONS

A spot sign on CTA was identified and associated with ICH expansion. A swirl sign on NCCT had a relatively low sensitivity and AUC, and will not be able to replace spot sign on CTA.

Association between intensive periodontal treatment and spontaneous intracerebral hemorrhage-a nationwide, population-based cohort study

Periodontal disease is a chronic inflammation of periodontium and has a high prevalence. Periodontal disease has been discovered to be a possible risk factor for cerebrovascular diseases. The available evidence are not enough to set up a causal relationship between periodontal disease and cerebrovascular diseases. Patients with spontaneous intracerebral hemorrhage have high mortality rates. The present study investigated whether intensive periodontal treatment is a protective factor of spontaneous intracerebral hemorrhage and can reduce the risk of spontaneous intracerebral hemorrhage.In total, 64,960 patients with a history of periodontal disease were picked out from the National Health Insurance Research Databases as a case-cohort from January 01, 2000 to December 31, 2010. They were divided on the basis of whether periodontal disease patients received intensive surgical treatment (treatment cohort) or not (control cohort). The periodontal disease patients in treatment and control cohorts were selected by propensity score matching at a ratio of 1:1. Incidences of spontaneous intracerebral hemorrhage in both cohorts were analyzed and compared.The total hazard of spontaneous intracerebral hemorrhage was significantly decreased in the treatment cohorts compared with the control cohorts (adjusted hazard ratio = 0.60, 95% confidence interval = 0.45-0.79).Compared with the control cohort, intensive periodontal treatment may reduce the overall incidence of spontaneous intracerebral hemorrhage, particularly in elderly patients, males, and those who received more than 2 intensive treatments.

Acupuncture combined Bobath approach for limbs paralysis after hypertensive intracerebral hemorrhage: A protocol for a systematic review

BACKGROUND

Previous studies have reported that acupuncture combined Bobath approach (BA) can be used to treat limbs paralysis (LP) after hypertensive intracerebral hemorrhage (HICH) effectively. However, no systematic review has explored its effectiveness and safety for LP following HICH. In this systematic review, we aim to assess the effectiveness and safety of acupuncture plus BA for the treatment of LP following HICH.

METHODS

The following 7 databases will be searched from their inception to the February 1, 2019: Cochrane Central Register of Controlled Trials, EMBASE, PUBMED, the Cumulative Index to Nursing and Allied Health Literature, the Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure without any language restrictions. The randomized controlled trials (RCTs) of acupuncture plus BA that evaluate the effectiveness and safety for LP after HICH will be included. The methodological quality of all included studies will be assessed by using Cochrane risk of bias tool. Two authors will independently perform study selection, data extraction, and methodological quality evaluation. Any disagreements occurred between 2 authors will be resolved by a third author involved through discussion. Data will be pooled and analyzed by using RevMan 5.3 Software.

RESULTS

This review will evaluate the effectiveness and safety of acupuncture combined BA for LP following HICH. The primary outcome is limbs function. The secondary outcomes are muscle strength, muscle tone, and quality of life, as well as the adverse events.

CONCLUSION

The results of this study will summarize the latest evidence of acupuncture combined BA for LP following HICH.

Inhibition of EPAC2 Attenuates Intracerebral Hemorrhage-Induced Secondary Brain Injury via the p38/BIM/Caspase-3 Pathway

Exchange proteins directly activated by cAMP (EPACs) are critical cAMP-dependent signaling pathway intermediaries that have been implicated in the pathogenesis of several human diseases, particularly neurological disorders. However, their pathogenic role in secondary brain injury (SBI) induced by intracranial hemorrhage (ICH) is unknown. The aim of this study was to examine the effects of EPAC2 on ICH-induced SBI and its underlying mechanisms. An in vivo ICH model was established in Sprague-Dawley rats by autologous blood injection. In addition, rat primary cortical neuronal cultures were exposed to oxyhemoglobin to simulate ICH in vitro. The function of EPAC2 in SBI induced by ICH was studied using the EPAC2-specific inhibitor ESI-05. In this study, we found that EPAC2 protein expression was significantly increased in the ICH models in vitro and in vivo. Furthermore, EPAC2 activation was inhibited by ESI-05 under ICH conditions. Inhibition of EPAC2 decreased the apoptosis rate of nerve cells in the cortex accompanied by a corresponding decrease in the protein expression of phosphorylated p38, Bcl-2-like protein 11 (BIM), and caspase-3. In summary, this study showed that inhibition of EPAC2 activation by ESI-05 suppressed SBI induced by ICH via the p38/BIM/caspase-3 signaling pathway.

Modifying the Intracerebral Hemorrhage Score to Suit the Needs of the Developing World

Background:

Published literature on intracerebral haemorrhage (ICH) from the Indian subcontinent is very scarce. The study aims to assess the prognostic factors influencing outcome and validating the ICH score which is widely used to prognosticate the disease in this financially constraint population. Prognosticating the outcome at the time of admission is important to customize treatment in a cost-effective manner.

Materials and Methods:

We conducted a prospective study of all Spontaneous ICH patients admitted from February 2015 to May 2016. Data pertaining to patient demographics, clinical findings, biochemical parameters and cranial computed tomography (CT) findings were recorded. mRS (modified Rankin score) was used to assess outcome at discharge and at three month follow up.

Results:

A total of 215 patients with hypertensive haemorrhage were analysed. The mean age of our cohort was 57.64 years and volume of bleed was 24.5ml. 73% pf patients with GCS<8, 46% with Intraventricular extension and 57% with hematoma volume >30 were died at the end of 3 months. Twenty eight patients succumbed during hospitalization while 38 died after their discharge. Mortality rates were 5%,16%, 33%, 54% and 93% for ICH Scores of 0, 1, 2, 3 and 4. The rICH score after modifying the age parameter in the ICH score to 70 years had mortality rates of 6%,15%,25%,51%,75% and 100%.

Conclusion:

ICH Score failed to accurately predict mortality in our cohort. ICH is predominately seen at a younger age group in our country and hence have better outcomes in comparison to the west. We propose a minor modification in the ICH score by reducing the age criteria by 10 years to prognosticate the disease better in our population.

The profile of blunt traumatic supratentorial cranial bleed types

The characteristics of blunt traumatic supratentorial cranial bleed (STCB) types have not been directly compared. The National Trauma Data Bank (NTDB) 2014 was queried for adults with an isolated single STCB n = 57,278. Patients were grouped by STCB categories: subdural (SDH), subarachnoid (SAH), epidural (EDH), intraparenchymal (IPH), and intraventricular hemorrhage (IVH). Frequency, demographics, clinical characteristics, procedures, and outcomes were compared among groups. SDH was the most common STCB (53%) and occurred mostly in elderly patients after a fall (78%), 30% underwent craniotomy and their mortality was 7%. SAH occurred in 32% of patients and carried the lowest mortality (3%). SAH were least likely to have a severe brain injury (7%), and had the lowest Injury Severity Score (ISS, median 8) and complication rate (1%), as well as the shortest hospital length of stay (HLOS, 4.6 ± 6.4 days). EDH was uncommon (2%), occurred in younger patients (median 35 years), and had the highest percentage of traffic related injuries (28%). While EDH patients presented with the poorest neurological status (16% Glasgow Coma Scale ≤ 8, ISS median 18) and were operated on more than any other STCB type (51%), their mortality was lower (4%) and they had the highest discharge to home rate (71%). IVH was the least common (2%), but most lethal (9%) STCB type. These patients had the highest HLOS and intensive care unit LOS, and the lowest craniotomy rate (21%). STCB types have different clinical course, and outcomes. Understanding these differences can be useful in managing patients with STB.

Preconditioned neurons with NaB and nicorandil, a favorable source for stroke cell therapy

Poor survival of stem cells in the harsh microenvironment at the site of stroke, especially during acute phase of injury, remains a serious obstacle to achieve the desired prognosis. We hypothesized that combined treatment of neural stem cells (NSCs) with small molecules would precondition them to become robust and survive better as compared with the native nonpreconditioned cells. Mouse ganglionic NSCs were isolated, cultured, and characterized. The cells were preconditioned by treatment with sodium butyrate (NaB) and nicorandil (Nico) and transplanted in an experimentally induced stroke model. Sham-operated animals without treatment or animals with experimental stroke treated with basal medium, native NSCs, NSCs preconditioned with NaB or Nico alone were used as controls. The tissue samples and cells with different treatments were used to measure brain-tissue-derived neurotrophic factor (BDNF) level and the activity of phosphatidylinositol-3 kinase (PI3K), apurinic/apyrimidinic endonuclease 1 (APE1), and nuclear factor-κB (NF-κB) p50 both in vitro and in vivo, respectively. Additionally, survival of the cells and recovery indices for stroke were studied. The combined treatment with NaB + Nico resulted in increased BDNF level and higher PI3K, APE1, and the downstream NF-κB activation, which were blocked by pretreatment with their respective inhibitors. Donor cell survival increased postengraftment as assessed by 5-bromo-2'-deoxyuridine immunostaining and reduced Terminal deoxynucleotide transferase dUTP Nick End Labeling positivity at the site of engraftment. There was reduction in proinflammatory cytokines and infiltration of both GFAP ⁺ and CD68 ⁺ at the injury site. There was reduction in the infarct size and neurological function was preserved in the preconditioned cell treatment group. Our preconditioning approach with small molecules effectively improved the survival as well as functionality of NSCs.

A Uniaxial Testing Approach for Consistent Failure in Vascular Tissues

Although uniaxial tensile testing is commonly used to evaluate failure properties of vascular tissue, there is no established protocol for specimen shape or gripping method. Large percentages of specimens are reported to fail near the clamp and can potentially confound the studies, or, if discarded will result in sample waste. The objective of this study is to identify sample geometry and clamping conditions that can achieve consistent failure in the midregion of small arterial specimens, even for vessels from older individuals. Failure location was assessed in 17 dogbone specimens from human cerebral and sheep carotid arteries using soft inserts. For comparison with commonly used protocols, an additional 22 rectangular samples were tested using either sandpaper or foam tape inserts. Midsample failure was achieved in 94% of the dogbone specimens, while only 14% of the rectangular samples failed in the midregion, the other 86% failing close to the clamps. Additionally, we found midregion failure was more likely to be abrupt, caused by cracking or necking. In contrast, clamp failure was more likely to be gradual and included a delamination mode not seen in midregion failure. Hence, this work provides an approach that can be used to obtain consistent midspecimen failure, avoiding confounding clamp-related artifacts. Furthermore, with consistent midregion failure, studies can be designed to image the failure process in small vascular samples providing valuable quantitative information about changes to collagen and elastin structure during the failure process.

Packing of metalized polymer nanofibers for aneurysm embolization

Aneurysmal subarachnoid hemorrhage (SAH) is the extravasation of blood into the subarachnoid space and is fatal in most cases. Platinum coils have been used to fill the hemorrhage site and prevent the extravasation of blood. Here we explored the use of Pt-coated polymer nanofibers (NF) to prevent blood extravasation and were able to achieve improved results in vitro. The polymer nanofibers were produced via electrospinning and were subsequently electroplated with Pt, resulting in metalized nanofibers. These nanofibers were installed within a microfluidic channel, and the resulting reduction in the permeability was evaluated using a fluid similar to blood. Based on the obtained results, these newly developed nanofibers are expected to decrease the operation cost for SAH, owing to their reduced size and low material cost. Furthermore, it is expected that these nanofibers will be used in a smaller amount during SAH operation while having the same preventive effect. This should reduce the operational risk associated with the multiple steps required to place the Pt coils at the SAH site. Finally, the underlying hydrodynamic mechanism responsible for the reduced permeability of the synthesized nanofibers is described.

Effect of Hyperosmolar Therapy on Outcome Following Spontaneous Intracerebral Hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

PURPOSE

We aimed to identify the effect of hyperosmolar therapy (mannitol and hypertonic saline) on outcomes after intracerebral hemorrhage (ICH) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study.

METHODS

Comparison of ICH cases treated with hyperosmolar therapy versus untreated cases was performed using a propensity score based on age, initial Glasgow Coma Scale, location of ICH (lobar, deep, brainstem, and cerebellar), log-transformed initial ICH volume, presence of intraventricular hemorrhage, and surgical interventions. ERICH subjects with a pre-ICH modified Rankin Scale (mRS) score of 3 or lower were included. Treated cases were matched 1:1 to untreated cases by the closest propensity score (difference ≤.15), gender, and race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic). The McNemar and the Wilcoxon signed-rank tests were used to compare 3-month mRS outcomes between the 2 groups. Good outcome was defined as a 3-month mRS score of 3 or lower.

RESULTS

As of December 31, 2013, the ERICH study enrolled 2279 cases, of which 304 hyperosmolar-treated cases were matched to 304 untreated cases. Treated cases had worse outcome at 3 months compared with untreated cases (McNemar, P = .0326), and the mean 3-month mRS score was lower in the untreated group (Wilcoxon, P = .0174). Post hoc analysis revealed more brain edema, herniation, and death at discharge for treated cases.

CONCLUSIONS

Hyperosmolar therapy was not associated with better 3-month mRS outcomes for ICH cases in the ERICH study. This finding likely resulted from greater hyperosmolar therapy use in patients with edema and herniation rather than those agents leading to worse outcomes. Further studies should be performed to determine if hyperosmolar agents are effective in preventing poor outcomes.

Pannexin-1 is involved in neuronal apoptosis and degeneration in experimental intracerebral hemorrhage in rats

Pannexins serve an important role in the regulation of extracellular neuronal regenerative currents and cellular signal transduction of glial cells; however, the effects of pannexins in various cerebrovascular diseases have not been reported. The present study focused on the expression and influence of pannexins in a rat model of intracerebral hemorrhage (ICH), and confirmed that pannexins (including Pannexin‑1, Pannexin‑2 and Pannexin‑3) are expressed in rat brain tissues. However, only the expression of Pannexin‑1 was significantly increased and peaked 48 h post‑ICH. Following treatment with carbenoxolone (CBX), which is an inhibitor of Pannexin‑1, apoptosis and neuronal degeneration in the brain tissues around the ICH hematoma decreased. The extent of secondary brain injury due to ICH was also alleviated. Compared with rats in the ICH‑only group, recovery of neurocognitive functions improved significantly in the CBX‑treated groups. Results from the present study suggested that the upregulation of Pannexin‑1 expression may be involved in apoptosis and degeneration of neurons in the rat brain following ICH, and may contribute to subsequent cognitive dysfunction.

Compare the Intracranial Pressure Trend after the Decompressive Craniectomy between Massive Intracerebral Hemorrhagic and Major Ischemic Stroke Patients

Objective

Massive intracerebral hemorrhage (ICH) and major infarction (MI) are devastating cerebral vascular diseases. Decompression craniectomy (DC) is a common treatment approach for these diseases and acceptable clinical results have been reported. Author experienced the postoperative intracranaial pressure (ICP) trend is somewhat different between the ICH and MI patients. In this study, we compare the ICP trend following DC and evaluate the clinical significance.

Methods

One hundred forty-three patients who underwent DC following massive ICH (81 cases) or MI (62 cases) were analyzed retrospectively. The mean age was 56.3±14.3 (median=57, male : female=89 : 54). DC was applied using consistent criteria in both diseases patients; Glasgow coma scale (GCS) score less than 8 and a midline shift more than 6 mm on brain computed tomography. In all patients, ventricular puncture was done before the DC and ICP trends were monitored during and after the surgery. Outcome comparisons included the ictus to operation time (OP-time), postoperative ICP trend, favorable outcomes and mortality.

Results

Initial GCS (p=0.364) and initial ventricular ICP (p=0.783) were similar among the ICH and MI patients. The postoperative ICP of ICH patients were drop rapidly and maintained within physiological range if greater than 80% of the hematoma was removed. While in MI patients, the postoperative ICP were not drop rapidly and maintained above the physiologic range (MI=18.8 vs. ICH=13.6 mmHg, p=0.000). The OP-times were faster in ICH patients (ICH=7.3 vs. MI=40.9 hours, p=0.000) and the mortality rate was higher in MI patients (MI=37.1% vs. ICH=17.3%, p=0.007).

Conclusion

The results of this study suggest that if greater than 80% of the hematoma was removed in ICH patients, the postoperative ICP rarely over the physiologic range. But in MI patients, the postoperative ICP was above the physiologic range for several days after the DC. Authors propose that DC is no need for the massive ICH patient if a significant portion of their hematoma is removed. But DC might be essential to improve the MI patients’ outcome and timely treatment decision.