Peri-Hemorrhagic Edema and Secondary Hematoma Expansion after Intracerebral Hemorrhage: From Benchwork to Practical Aspects

Neuroprotective effect of Naochuxue prescription on intracerebral hemorrhage: inhibition of autophagy downregulating high mobility group box-1

OBJECTIVE

To determine the molecular mechanisms underlying the neuroprotective effects of Naochuxue prescription (,NCXP) in rats with intracerebral hemorrhage (ICH).

METHODS

Sprague-Dawley rats were injected with collagenase to generate ICH models, which were then randomly divided into six groups, including control, sham, model, and three intervention groups. The intervention groups received different doses of NCXP (0.13, 0.26, and 0.52 g/kg) daily for 10 d. High-performance liquid chromatography (HPLC) was used to analyze the chemical characteristics of NCXP. The neurobehavioral outcomes of the rats were evaluated using neurological deficit scores (Zea Longa 5) and the corner turn test. Pathomorphological changes in perihematomal tissues after ICH were observed using hematoxylin and eosin staining. Immunohistochemistry (IHC) was used to detect the inflammation expression of interleukin 6 (IL-6) and toll-like receptor 4 (TLR4). High mobility group box-1 (HMGB1), Beclin1, microtubule-associated protein 1 light chain 3 beta (LC3), and sequestosome 1 (p62) were detected using real-time quantitative polymerase chain reaction and Western blotting in perihematomal tissues.

RESULTS

HPLC showed that the NCXP had good stability. Rats with ICH had severe neurological function deficits compared to the control group. IHC results showed that NCXP significantly downregulated the expression of the inflammatory proteins IL-6 and TLR4. ICH rats treated with NCXP showed less neurological injury than the model group, accompanied by a significantly decreased expression of HMGB1, Beclin1, and LC3 and an increased expression of p62.

CONCLUSIONS

The neuroprotective effect of NCXP alleviated inflammation and autophagy possibly by downregulating HMGB1 expression. However, further research on the signaling pathways is required to verify this hypothesis.

Combination of Hematoma Volume and Perihematoma Radiomics Analysis on Baseline CT Scan Predicts the Growth of Perihematomal Edema

PURPOSE

The aim is to explore the potential value of CT-based radiomics in predicting perihematomal edema (PHE) volumes after acute intracerebral hemorrhage (ICH) from admission to 24 h.

METHODS

A total of 231 patients newly diagnosed with acute ICH at two institutes were analyzed retrospectively. The patients were randomly divided into training (N = 117) and internal validation cohort (N = 45) from institute 1 with a ratio of 7:3. According to radiomics features extracted from baseline CT, the radiomics signatures were constructed. Multiple logistic regression analysis was used for clinical radiological factors and then the nomogram model was generated to predict the extent of PHE according to the optimal radiomics signature and the clinical radiological factors. The receiver operating characteristic (ROC) curve was used to evaluate the discrimination performance. The calibration curve and Hosmer-Lemeshow test were used to evaluate the consistency between the predicted and actual probability. The support vector regression (SVR) model was constructed to predict the overall value of follow-up PHE. The performance of the models was evaluated on the internal and independent validation cohorts.

RESULTS

The perihematoma 5 mm radiomics signature (AUC: 0.875) showed good ability to discriminate the small relative PHE(rPHE) from large rPHE volumes, comparing to intrahematoma radiomics signature (AUC: 0.711) or perihematoma 10 mm radiomics signature (AUC: 0.692) on the training cohort. The AUC of the combined nomogram model was 0.922 for the training cohort, 0.945 and 0.902 for the internal and independent validation cohorts, respectively. The calibration curves and Hosmer-Lemeshow test of the nomogram model suggested that the predictive performance and actual outcome were in favorable agreement. The SVR model also predicted the overall value of follow-up rPHE (root mean squared error, 0.60 and 0.45; Pearson correlation coefficient, 0.73 and 0.68; P < 0.001).

CONCLUSION

Among patients with acute ICH, the established nomogram and SVR model with favorable performance can offer a noninvasive tool for the prediction of PHE after ICH.

Proteomics reveals that Di Dang decoction can regulate the Jak2/Stat5 signaling pathway and inhibit apoptosis by reducing the oxidative stress response in rats with acute intracerebral hemorrhagic stroke

ETHNOPHARMACOLOGICAL RELEVANCE

Di Dang decoction (DDD) is a prescription used for the treatment of cerebral hemorrhage. Its use is derived from the theory of typhoid fever, it has an obvious clinical effect and it has been used in the clinic for a long time. The results of early quantitative proteomics and targeted proteomics studies showed that the administration of high-dose DDD 7 days may regulate the expression of the proteins S100A8, S100A9, Col1a1 and Col1a2. The first 3 days after bleeding begins is the critical period for intervention, what occurs within approximately 3 days after AICH is unclear.

AIM OF THE STUDY

To explore the effects of Di Dang decoction (DDD) on the Jak2/Stat5 signaling pathway and apoptosis-related gene expression in rats with acute hemorrhagic stroke via the oxidative stress response by proteomics to reveal its neuroprotective mechanism.

MATERIALS AND METHODS

Ninety healthy Sprague-Dawley (SD) rats were randomly divided into the control, model, and low-, medium-, and high-dose DDD groups, with 18 rats in each group. An acute intracerebral hemorrhage (AICH) model was established by injecting autologous blood into the caudate nucleus. The low-, medium- and high-dose groups were intragastrically administered 0.15625 g/mL, 0.3125 g/mL and 0.625 g/mL DDD, respectively, for 1 or 3 days. The control and model groups were given the same amount of normal saline. Neurological deficits were evaluated by the modified neurological severity score (mNSS) test, brain water content was measured to assess brain tissue damage, and pathological changes in the lesion site were observed by hematoxylin and eosin (HE) staining. The cerebral cortex was selected for quantitative proteomics, and >1.2/1 and <1/1.2 were used as the thresholds for upregulated and downregulated proteins, respectively. KEGG pathway and Gene Ontology (GO) enrichment analyses of the differentially expressed proteins were conducted. The levels of the oxidative stress markers malondialdehyde (MDA), superoxide dismutase (SOD), and catalase (CAT) were measured by enzyme-linked immunosorbent assay (ELISA). Western blotting was used to assess p-Jak2, Jak2, p-Stat5, Stat5, Bax, Bcl-2, and Caspase-3 protein expression.

RESULTS

Compared with the model group, the group treated with high-dose DDD for 3 days exhibited significant improvements in neurological defects, brain histopathology, and brain edema; reduced the level of MDA and significantly increased the levels of CAT and SOD; significantly decreased p-Jak2 and p-Stat5 protein expression and expression of the pro-apoptotic genes Bax and c-Caspase-3; and significantly increased expression of the anti-apoptotic gene Bcl-2 (all p＜0.05).

CONCLUSIONS

High-dose DDD administration for 3 days reduces the oxidative stress response, regulates the Jak2/Stat5 signaling pathway and inhibits apoptosis to exert a neuroprotective effect in rats with acute hemorrhagic stroke.

Radiomics for prediction of intracerebral hemorrhage outcomes: A retrospective multicenter study

BACKGROUND

Accurate risk stratification of patients with intracerebral hemorrhage (ICH) could help refine adjuvant therapy selection and better understand the clinical course. We aimed to evaluate the value of radiomics features from hematomal and perihematomal edema areas for prognosis prediction and to develop a model combining clinical and radiomic features for accurate outcome prediction of patients with ICH.

METHODS

This multicenter study enrolled patients with ICH from January 2016 to November 2021. Their outcomes at 3 months were recorded based on the modified Rankin Scale (good, 0-3; poor, 4-6). Independent clinical and radiomic risk factors for poor outcome were identified through multivariate logistic regression analysis, and predictive models were developed. Model performance and clinical utility were evaluated in both internal and external cohorts.

RESULTS

Among the 1098 ICH patients evaluated (mean age, 60 ± 13 years), 703 (64 %) had poor outcomes. Age, hemorrhage volume and location, and Glasgow Coma Scale (GCS) were independently associated with outcomes. The area under the receiver operating characteristic curve (AUC) of the clinical model was 0.881 in the external validation cohort. Addition of the Rad-score (combined hematoma and perihematomal edema area) improved predictive accuracy and model performance (AUC, 0.893), net reclassification improvement, 0.140 (P < 0.001), and integrated discrimination improvement, 0.050 (P < 0.001).

CONCLUSIONS

The radiomics features of hematomal and perihematomal edema area have additional value in prognostic prediction; moreover, addition of radiomic features significantly improves model accuracy.

The protective effect of the PDE-4 inhibitor rolipram on intracerebral haemorrhage is associated with the cAMP/AMPK/SIRT1 pathway

Rolipram specifically inhibits phosphodiesterase (PDE) 4, thereby preventing inactivation of the intracellular second messenger cyclic adenosine monophosphate (cAMP). Rolipram has been shown to play a neuroprotective role in some central nervous system (CNS) diseases. However, the role of PDE4 and the potential protective effect of rolipram on the pathophysiological process of intracerebral haemorrhage (ICH) are still not entirely clear. In this study, a mouse model of ICH was established by the collagenase method. Rolipram reduced brain oedema, blood–brain barrier (BBB) leakage, neuronal apoptosis and inflammatory cytokine release and improved neurological function in our mouse model of ICH. Moreover, rolipram increased the levels of cAMP and silent information regulator 1 (SIRT1) and upregulated the phosphorylation of AMP-activated protein kinase (AMPK). Furthermore, these effects of rolipram could be reversed by the SIRT1 inhibitor sirtinol. In conclusion, rolipram can play a neuroprotective role in the pathological process of ICH by activating the cAMP/AMPK/SIRT1 pathway.

Brain injury and repair after intracerebral hemorrhage: The role of microglia and brain-infiltrating macrophages

Intracerebral hemorrhage (ICH) is a major public health problem characterized by cerebral bleeding. Despite recent advances in preclinical studies, there is no effective treatment for ICH making it the deadliest subtype of stroke. The lack of effective treatment options partly attributes to the complexity as well as poorly defined pathophysiology of ICH. The emerging evidence indicates the potential of targeting secondary brain damage and hematoma resolution for improving neurological outcomes after ICH. Herein, we provide an overview of our understanding of the functional roles of activated microglia and brain-infiltrating monocyte-derived macrophages in brain injury and repair after ICH. The clinical and preclinical aspects that we discuss in this manuscript are related to ICH that occurs in adults, but not in infants. Also, we attempt to identify the knowledge gap in the field for future functional studies given the potential of targeting microglia and brain-infiltrating macrophages for therapeutic intervention after ICH.

Rationale and Design of a Randomized, Double-Blind Trial Evaluating the Efficacy of Tranexamic Acid on Hematoma Expansion and Peri-hematomal Edema in Patients with Spontaneous Intracerebral Hemorrhage within 4.5 h after Symptom Onset: The THE-ICH Trial Protocol

BACKGROUND

Hematoma expansion (HE) and peri-hematomal edema (PHE) are associated with adverse outcomes of patients with acute spontaneous intracerebral hemorrhage (sICH). Due to a lack of proven treatments, it is critical to explore novel treatments for HE and PHE to improve functional recovery after sICH.

METHODS

This is a prospective, multicenter, placebo-controlled, double-blind, and randomized clinical study of approximately 2400 patients with sICH. Patients within 4.5 h of sICH onset that fulfilling the clinical criteria for diagnosis (e.g. age more than 18 years old, the Glasgow Coma Scal>7, and no planned surgery) will randomly receive either intravenous tranexamic acid (TXA) 1 g 10-min bolus followed by 1 g eight-hour infusion or placebo (sodium chloride 0.9%). Clinical data including the ICH score and the Glasgow Coma Scale score will be collected on admission. After assessment of HE and PHE expansion, follow-up will be conducted with enrolled patients for 90 days.

RESULTS

Primary outcome metrics are HE (defined as either >33% or >6 ml increase from baseline) and PHE expansion rate at 24 ± 3 h and 72 ± 3 h post-sICH. Secondary outcome metrics include mortality and the modified Rankin Scale on day 90 after sICH. Appropriate statistic methods will be used to evaluate the efficacy of TXA on patients with sICH within 4.5 h of symptom onset.

CONCLUSIONS

HE usually occurs within the first few hours after onset of symptoms. It is essential to evaluate the efficacy of TXA on HE within a narrow window of time. This will be the first trial to evaluate the efficacy of TXA on HE and PHE expansion in sICH patients within 4.5 h after symptom onset. This trial is registered as ChiCTR1900027065 at http://www.chictr.org.cn.

Lesional and perilesional tissue characterization by automated image processing in a novel gyrencephalic animal model of peracute intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is an important stroke subtype, but preclinical research is limited by a lack of translational animal models. Large animal models are useful to comparatively investigate key pathophysiological parameters in human ICH. To (i) establish an acute model of moderate ICH in adult sheep and (ii) an advanced neuroimage processing pipeline for automatic brain tissue and hemorrhagic lesion determination; 14 adult sheep were assigned for stereotactically induced ICH into cerebral white matter under physiological monitoring. Six hours after ICH neuroimaging using 1.5T MRI including structural as well as perfusion and diffusion, weighted imaging was performed before scarification and subsequent neuropathological investigation including immunohistological staining. Controlled, stereotactic application of autologous blood caused a space-occupying intracerebral hematoma of moderate severity, predominantly affecting white matter at 5 h post-injection. Neuroimage post-processing including lesion probability maps enabled automatic quantification of structural alterations including perilesional diffusion and perfusion restrictions. Neuropathological and immunohistological investigation confirmed perilesional vacuolation, axonal damage, and perivascular blood as seen after human ICH. The model and imaging platform reflects key aspects of human ICH and enables future translational research on hematoma expansion/evacuation, white matter changes, hematoma evacuation, and other aspects.

Neuroprotective strategies following intraparenchymal hemorrhage

Intracerebral hemorrhage and, more specifically, intraparenchymal hemorrhage, are devastating disease processes with poor clinical outcomes. Primary injury to the brain results from initial hematoma expansion while secondary hemorrhagic injury occurs from blood-derived products such as hemoglobin, heme, iron, and coagulation factors that overwhelm the brains natural defenses. Novel neuroprotective treatments have emerged that target primary and secondary mechanisms of injury. Nonetheless, translational application of neuroprotectants from preclinical to clinical studies has yet to show beneficial clinical outcomes. This review summarizes therapeutic agents and neuroprotectants in ongoing clinical trials aimed at targeting primary and secondary mechanisms of injury after intraparenchymal hemorrhage.