Effect of BMI on Central Arterial Reflected Wave Augmentation Index, Toe-Brachial Index, Brachial-Ankle Pulse Wave Velocity and Ankle-Brachial Index in Chinese Elderly Hypertensive Patients with Hemorrhagic Stroke

BACKGROUND

Hypertensive cerebral hemorrhage seriously endangers the health of the elderly. However, the relationship between obesity and arterial elasticity in hypertensive cerebral hemorrhage remains to be clarified. The purpose of our study is to explore the associations between body mass index (BMI) and central arterial reflected wave augmentation index (cAIx), toe-brachial index (TBI), brachial-ankle pulse wave velocity (baPWV), and ankle-brachial index (ABI) in the elderly hypertensive patients with hemorrhagic stroke.

MATERIALS AND METHODS

A total of 502 elderly hypertensive patients with hemorrhagic stroke and 100 healthy controls were collected. According to the BMI, patients were divided into normal BMI, overweight, obesity, and obese groups. The multivariate logistic regression model was used to establish a risk model for elderly hypertensive hemorrhagic stroke.

RESULTS

Compared with the normal BMI group, systolic blood pressure (SBP), diastolic blood pressure (DBP), cAIx, and baPWV in the abnormal BMI group were significantly increased (P < 0.05), while TBI and ABI were significantly decreased (P < 0.05). Logistic regression showed that BMI (OR = 1.031, 95%CI: 1.009-1.262), cAIx (OR = 1.214, 95%CI: 1.105-1.964), TBI (OR = 0.913, 95%CI: 0.885-0.967), baPWV (OR = 1.344, 95%CI: 1.142-2.147), and ABI (OR = 0.896, 95%CI: 0.811-0.989) are important factors for the occurrence of hemorrhagic stroke in the elderly hypertensive patients. ROC curve analysis showed that the AUC of cAIx, TBI, baPWV, ABI, and BMI were 0.914, 0.797, 0.934, 0.833, and 0.608, respectively. The final prediction model of hemorrhagic stroke elderly hypertensive patients was Y_(P)= 65.424 + 0.307(cAIx) - 13.831(TBI) + 0.012(baPWV) - 0.110(ABI) + 0.339(BMI).

CONCLUSIONS

Obesity is associated with decreased arterial elasticity. Therefore, reasonable weight management of the elderly may be of great significance for reducing the risk of hemorrhagic stroke in patients with hypertension.

Intensive blood pressure control reduces the risk of progressive hemorrhage in patients with acute hypertensive intracerebral hemorrhage: A retrospective observational study

OBJECTIVE

To investigate the impact of intensive blood pressure control on progressive intracerebral hemorrhage and outcome in patients with high blood pressure and intracerebral hemorrhage.

PATIENTS AND METHODS

A retrospective study was conducted recruiting 659 patients with acute hemorrhagic stroke between Jan. 2012 and May 2018. Patients recruited before May 2015 were treated with a target systolic level of <180 mm Hg, while those recruited after May 2015 received intensive blood pressure control treatment with a target systolic level of <140 mm Hg within 1 h. Uni- and multi-variate analysis were conducted to illustrate the association between intensive blood pressure control and progressive intracerebral hemorrhage. Mortality, rates of operation, length of ICU stay, modified Rankin scores at 90 days, and the rate of serious adverse events were also compared between the two groups.

RESULTS

A total of 351 and 308 patients with acute hypertensive intracerebral hemorrhage were recruited before and after May 2015, respectively. Progressive intracerebral hemorrhage was identified among 111 out of 659 patients. Patients who received intensive blood pressure control showed a statistically lower rate of hematoma enlarging (43 of 308, 13.9% vs. 74 of 351, 21.1%, p = 0.018). The rates of operation and modified Rankin scores at 90 days were statistically lower with intensive blood control, while the mortality, length of ICU stay and rate of serious adverse events were similar between the two groups. Intensive BP control is an independent factor in predicting hematoma growing, with a more favorable discrimination (AUC = 0.889; 95%CI, 0.859-0.917) than other two models (AUC = 0.821; 95%CI, 0.791-0.852; and AUC = 0.635; 95%CI, 0.588-0.682).

CONCLUSION

Intensive blood pressure control reduce the risk of progressive intracerebral hemorrhage and improved functional outcomes in patients with acute hemorrhagic stroke.

Suspected brain metastasis from lung cancer mimicking intracerebral hemorrhage: A case report

RATIONALE

Hemorrhage rarely occurs in a solitary brain metastasis from lung carcinoma.

PATIENT CONCERNS

We report on a 54-year-old man who presented with a severe headache for 4 days.

DIAGNOSES

Based on computed tomography and magnetic resonance imaging enhancement, the patient was diagnosed with a suspected hemorrhagic brain metastasis from lung carcinoma.

INTERVENTIONS

The patient's family rejected a pathological examination.

OUTCOMES

The patient's family requested discharge after diagnosis.

LESSONS

The present case emphasizes the need to consider hemorrhagic metastasis as a differential diagnosis in patients presenting with solitary intracerebral hemorrhage whose location is uncommon, especially when the poor general state of the patient cannot be attributed to hypertensive intracerebral hemorrhage.

Comparison of endoscopic evacuation, stereotactic aspiration and craniotomy for the treatment of supratentorial hypertensive intracerebral haemorrhage: study protocol for a randomised controlled trial

BACKGROUND

Hypertensive intracerebral haemorrhage (HICH) is the most common form of haemorrhagic stroke with the highest morbidity and mortality of all stroke types. The choice of surgical or conservative treatment for patients with HICH remains controversial. In recent years, minimally invasive surgeries, such as endoscopic evacuation and stereotactic aspiration, have been attempted for haematoma removal and offer promise. However, research evidence on the benefits of endoscopic evacuation or stereotactic aspiration is still insufficient.

METHODS/DESIGN

A multicentre, randomised controlled trial will be conducted to compare the efficacy of endoscopic evacuation, stereotactic aspiration and craniotomy in the treatment of supratentorial HICH. About 1350 eligible patients from 10 neurosurgical centres will be randomly assigned to an endoscopic group, a stereotactic group and a craniotomy group at a 1:1:1 ratio. Randomisation is undertaken using a 24-h randomisation service accessed by telephone or the Internet. All patients will receive the corresponding surgery based on their grouping. They will be followed-up at 1, 3 and 6 months after surgery. The primary outcome is the modified Rankin Scale at 6-month follow-up. Secondary outcomes include: haematoma clearance rate; Glasgow Coma Scale 7 days after surgery; rebleeding rate; intracranial infection rate; hospitalisation time; mortality at 1 month and 3 months after surgery; the Barthel Index and the WHO quality of life at 3 months and 6 months after surgery.

DISCUSSION

The trial aims to investigate whether endoscopic evacuation and stereotactic aspiration could improve the outcome of supratentorial HICH compared with craniotomy. The trial will help to determine the best surgical method for the treatment of supratentorial HICH.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02811614 . Registered on 20 June 2016.

Performance characteristics of methods for quantifying spontaneous intracerebral haemorrhage: data from the Efficacy of Nitric Oxide in Stroke (ENOS) trial

BACKGROUND

Poor prognosis after intracerebral haemorrhage (ICH) is related to haemorrhage characteristics. Along with developing therapeutic interventions, we sought to understand the performance of haemorrhage descriptors in large clinical trials.

METHODS

Clinical and neuroimaging data were obtained for 548 participants with ICH from the Efficacy of Nitric Oxide in Stroke (ENOS) trial. Independent observers performed visual categorisation of the largest diameter, measured volume using ABC/2, modified ABC/2, semiautomated segmentation (SAS), fully automatic measurement methods; shape, density and intraventricular haemorrhage were also assessed. Intraobserver and interobserver reliability were determined for these measures.

RESULTS

ICH volume was significantly different among standard ABC/2, modified ABC/2 and SAS: (mean) 12.8 (SD 16.3), 8.9 (9.2), 12.8 (13.1) cm(3), respectively (p<0.0001). There was excellent agreement for haemorrhage volume (n=193): ABC/2 intraobserver intraclass correlation coefficient (ICC) 0.96-0.97, interobserver ICC 0.88; modified ABC/2 intraobserver ICC 0.95-0.97, interobserver ICC 0.91; SAS intraobserver ICC 0.95-0.99, interobserver ICC 0.93; largest diameter: (visual) interadjudicator ICC 0.82, (visual vs measured) adjudicator vs observer ICC 0.71; shape intraobserver ICC 0.88 interobserver ICC 0.75; density intraobserver ICC 0.86, interobserver ICC 0.73. Graeb score (mean 3.53) and modified Graeb (5.22) scores were highly correlated. Using modified ABC/2, ICH volume was underestimated in regular (by 2.2-2.5 cm(3), p<0.0001) and irregular-shaped haemorrhages (by 4.8-4.9 cm(3), p<0.0001). Fully automated measurement of haemorrhage volume was possible in only 5% of cases.

CONCLUSIONS

Formal measurement of haemorrhage characteristics and visual estimates are reproducible. The standard ABC/2 method is superior to the modified ABC/2 method for quantifying ICH volume.

CLINICAL TRIAL REGISTRATION

ISRCTN9941422.

Associations between biomarkers of renal function with cerebral microbleeds in hypertensive patients

BACKGROUND

Cerebral microbleeds (CMBs) have been observed in the elderly and have been regarded as a manifestation of small vessel disease (SVD). Cerebral and glomerular SVD may have a common source of pathogenesis because these organs are closely connected through anatomic and hemodynamic similarities. The purpose of this study was to clarify the associations between kidney biomarker levels and CMBs in hypertensive patients.

METHODS

The presence and number of CMBs were assessed on susceptibility-weighted imaging. We calculated the urinary albumin/creatinine ratio (UACR) from morning spot urine and the estimated glomerular filtration rate (eGFR) in serum samples. Serum cystatin C (CysC) was measured with an automated particle-enhanced turbidimetric immunoassay.

RESULTS

UACR and CysC levels were higher in the patients with CMBs than those without, and the eGFR was lower in the patients with CMBs than those without. A logistic regression analysis indicates that eGFR and UACR were independently associated with the prevalence of deep or infratentorial CMBs. The odds ratio (OR) (95% confidence interval (CI)) of eGFR and UACR was 1.95 (1.37-3.27) and 2.25 (1.66-4.46), respectively. CysC was independently associated with CMBs in both deep or infratentorial and lobar locations. The ORs (95% CI) were 2.59 (1.57-6.22) and 1.57 (1.15-4.85), respectively. Furthermore, CysC exhibited fair diagnostic value for CMBs, with an area under the curve of 0.80.

CONCLUSIONS

Kidney biomarker levels are associated with the presence of CMB in hypertensive patients without a history of transient ischemic attack (TIA) or stroke, independent of conventional risk factors, and CysC was a better marker for CMBs than eGFR and UACR.

Sequential therapy for non-thalamus supratentorial hypertensive intracerebral hemorrhages

OBJECTIVE

We sought to assess the effectiveness of sequential therapy for non-thalamus supratentorial hypertensive intracerebral hemorrhage (NTS-HICH).

PATIENTS AND METHODS

We retrospectively analyzed clinical data of 110 patients with HICH. The patients were admitted 72 hours after disease onset, and 43 patients received sequential therapy. The length of hospital stay, treatment costs, incidence of pulmonary infections, mortality rates and Modified Rankin Score (mRS) 1 and 3 months after NTS-HICH were compared between patients who received sequential or non-sequential therapies.

RESULTS

The length of hospital stay, treatment costs, and 1-month mortality rates were not significantly different between both groups. However, mortality rates at 3 months, incidence of pulmonary infection, and mRS at both 1 and 3 months were significantly better in patients who received sequential therapy.

CONCLUSIONS

Sequential therapy significantly improves the prognosis for patients with NTS-HICH.

Hold the heparin

Dynamic ischemic-type electrocardiographic T-wave inversions raise the possibility of myocardial ischemia or infarction but are actually a nonspecific finding. We present a case of a young man presenting with headache and dizziness found to have marked hypertension, deepening T-wave inversions, and troponin elevation. Initial concerns were for acute coronary syndrome (ACS); however, before anticoagulant and antithrombotic therapy was instituted, further evaluation with noncontrast computed tomography of the head showed intraventricular hemorrhage. Electrocardiographic T-wave inversions are nonspecific and have a broad differential diagnosis, but ACS is of the highest concern especially in the setting of elevated troponin. However, as in this case, T-wave inversion and troponin elevation have been well described in intracranial bleeds as well, and full evaluation is required for such findings before initiation of therapy for presumed ACS to avoid a potentially catastrophic outcome.

The diagnosis and management of cerebrovascular disease in diabetes

Cerebrovascular disease is a leading cause of morbidity and mortality in diabetes. Compared with nondiabetic patients, diabetic patients have at least twice the risk for stroke, earlier onset of symptoms, and worse functional outcomes. Approximately 20 % of diabetic patients will die from stroke, making it one of the leading causes of death in this population. Effective strategies for primary and secondary prevention of stroke have been developed in research cohorts that included both diabetic and nondiabetic patients. Nevertheless, prevention in diabetes has some specific considerations. In this paper, we summarize evidence to guide the diagnosis and management of stroke in diabetic patients. We propose that diabetic stroke patients should have a robust risk assessment to target interventions, like other patients with cerebrovascular disease, but with special attention to glycemic control and lifestyle modification.

[Case of postpartum intracerebral hemorrhage due to pregnancy induced hypertension]

A 32-year-old woman, gravida 0, para 0, was admitted to the obstetrics department of our hospital after a cesarean section at 35 weeks of gestation. The cesarean section was performed because pregnancy induced hypertension (PIH) had worsened. The next day, she suddenly became drowsy and developed right hemiparesis and anisocoria. Computed tomography of the brain showed intracerebral hemorrhage in the parietal lobe with uncal herniation. She underwent an urgent craniotomy and removal of the hematoma. Five days later, magnetic resonance angiography (MRA) of the brain showed vasospasm of the bilateral intracranial internal carotid arteries, middle cerebral arteries, and anterior cerebral arteries. Thirteen days later, cerebral angiography showed cessation of vasospasm and vascular abnormalities such as moyamoya disease, arteriovenous malformation and cerebral aneurysm were not observed. Twenty-one days later, MRA showed the absence of vasospasm in those arteries, but her right hemiparesis and sensory aphasia persisted. Twenty-six days later, she was transferred to another hospital for further rehabilitation. Neurosurgeons should be aware of the possibility of intracerebral hemorrhage caused by PIH. In this manuscript, we provide a case presentation and review of the literature.

[Initial experience of using XperCT in neurosurgery]

Modern angiographic complexes allow performing emulation of computed tomography (CT). Comparison of the resolving power of XperCT and CT indicated sufficient sensitivity of the new technology in detection of focal lesions of the brain, the possibility of its application in interventional neuroradiology. The application of XperGuide allows control the position of the instrument during operation directly without using additional equipment of moving the patient. The application of XperGuide decreases the risk of intra- and early postoperative complications.

[Mortality after surgical treatment of patients with hypertensive intracerebral hematomas]

Authors summarized the experience of specialized neurosurgical clinic for treatment of patients with stroke. From 1998 till 2008 1035 patients with hypertensive intracerebral hematomas were examined and treated in the clinic. 635 patients were operated, 400 received conservative treatment. Volumes of hematomas varied from 3 to 130 ml. Mean volume of hematoma in the "surgical" group was 52.9 ml (SD = 23.1), in the "conservative" group -- 37.2 ml (SD = 22.9). Two types of indications for surgery were defined: a) indications for life-saving surgery; b) indications for surgical treatment, implying achievement of good functional result. Hematomas were removed using different techniques: craniectomy or craniotomy -- 123 patients; minimally-invasive craniotomy and limited encephalotomy -- 78; puncture aspiration -- 65; puncture aspiration combined with local fibrinolysis (prourokinase) -- 291; combined procedures (including endoscopic) -- 49; external ventricular drainage -- 29. 30-days mortality in the "surgical" group was 29%, in the "conservative" group -- 38.7%. Critical volumes of hematomas of different localization with maximal effect on mortality were distinguished. Main causes of lethal outcome in the "surgical" group were the following: pulmonary artery thomboembolism -- 21.5%, pneumonia -- 29%, recurrent hemorrhage -- 19.5%. Therefore, surgical management of hypertensive intracerebral hematomas in selected groups of patients is associated with lower rate of mortality, in comparison with conservative management. Basically, it refers to the patients in severe condition, with volumes of hematoma above critical limits specific for certain localization.

[Effectiveness of cerebrolysin in hypertensive supratentorial intracranial hemorrhages: results of a randomized triple blind placebo-controled study]

Cerebrolysin was administered to 38 patients with small hypertensive supratentorial intracranial hemorrhages. Cerebrolysin was used intravenous in drops in dosage of 30 ml during 14 days. High effectiveness and good tolerability of the treatment was shown. In the end of treatment, groups receiving cerebrolysin or placebo were statistically significant differed by the total NIHSS score, Bartel index and the Rankin's modified scale. Moreover, a trend to the decrease of intracranial hemorrhage volume was observed in patients treated with cerebrolysin.

Circadian effects on outcome following surgery for intracerebral hemorrhage in humans?

Previous studies indicated that recovery of brain injury involves in circadian system and circadian system also modulates cardiovascular function. The present study was focused on the circadian characteristic of blood pressure (BP) and heart rate (HR) of patients with hypertensive intracerebral hemorrhage (HICH) after neurosurgical operation at the first 24-hour and its relationship to prognosis of HICH. This retrospective study was based on the analysis of circadian rhythm of postoperative patients with HICH who received no anti-hypertensive treatment before operation and during the first 24-hour after operation. Series data of BP and HR after operation were analyzed with cosinor method to determine whether circadian rhythms were present or absent. The patients were divided into two groups, including presence of circadian rhythm group and absence of circadian rhythm group. The basic clinical characteristics of two groups were analyzed with Student's t-test. The percentage of good prognosis in two groups was analyzed with Pearson's Chi-squared test. Statistical results indicated that the percentage of good prognosis was significantly different between the presence and absence group. More cases of good prognosis in presence group of Systolic Blood Pressure (SBP) was discovered than in absence group (p=0.032). The results of Diastolic Blood Pressure (DBP) and HR were similar as SBP was observed in presence group for DBP (p=0.002) and for HR (p=0.001), respectively. We conclude that the presence or absence of circadian rhythm after operation would be an early predictor of the postoperative prognosis from hypertensive intracerebral hemorrhage.

Aspects of intracerebral hematomas--an update

BACKGROUND

In Norway, there are approximately 16000 strokes each year and 15% of these are caused by intracerebral hematomas. Intracerebral hemorrhage (ICH) results from the rupture of blood vessels within the brain parenchyma. ICH occurs as a complication of several diseases, the most prevalent of which is chronic hypertension. When hemorrhage develops in the absence of a pre-existing vascular malformation or brain parenchymal lesion, it is denoted primary ICH. Secondary ICH refers to hemorrhage complicating a pre-existing lesion. Primary ICH is the most common type of hemorrhagic stroke, accounting for approximately 10% of all strokes. Despite aggressive management strategies, the 30-day mortality remains high, at almost 50%, with the majority of deaths occurring within the first 2 days. At 6 months, only 20-30% achieve independent status.

MATERIAL AND METHODS

This article is based on clinical experience, modern therapeutic guidelines for the treatment of intracerebral hematomas and up-to-date medical literature found in Medline. The article discusses the pathophysiology, clinical aspects, treatment, and the prognosis of intracerebral hematomas.

RESULTS AND DISCUSSION

Advances in diagnosis, prognosis, pathophysiology, and treatment over the past few decades have significantly advanced our knowledge of ICH; however, much work still needs to be carried out. Future genetic and epidemiologic studies will help identify at-risk populations and hopefully allow for primary prevention. Randomized controlled studies focusing on novel therapeutics should help to minimize secondary injury and hopefully improve morbidity and mortality.

[Local fibrinolysis of hypertensive intracerebral hematomas]

Authors presented the results of experimental and clinical studies of effects of recombinant prourokinase on brain tissue, its toxicity and safety in intracerebral administration for lysis of hypertensive intracerebral hematomas. Experiments were performed in 64 rabbits. Histological specimens were examined in different periods after injection of prourokinase into white matter and into experimental hematoma. It is revealed that dose of 615 mg/kg causes minimal changes in cerebral tissue. Clinical study was based on analysis of puncture aspiration of intracerebral hematomas with local fibrinolysis performed in 275 patients with hemorrhagic stroke. Dynamics of MRI, clinical and laboratory parameters, coagulation, analysis of aspirated products of lysis were assessed. Authors showed that recombinant prourokinase and the drug "Puroplazan" are effective for local fibrinolysis. The drugs are non-toxic and non-allergenic and do not cause cerebral edema.

Neisseria sicca meningitis following intracranial hemorrhage and ventriculostomy tube placement

A normal component of the flora of the oropharynx, Neisseria sicca was first isolated in 1906 and has since been reported as a rare cause of various human infections including endocarditis, pneumonia, sinusitis, sepsis, and urethritis. We report the case of a 44-year-old African-American female with a history of hypertension who presented with complaints of right frontal headache, nausea, photophobia, and vomiting. A computed tomography scan of the patient's brain showed a large subarachnoid hemorrhage, and an arteriogram confirmed a large posterior communicating artery aneurysm. A ventriculostomy tube was placed, and the patient subsequently developed an elevated temperature and elevated white blood cell count. Cerebrospinal fluid studies showed elevated protein and glucose levels and cultures positive for N. sicca. This is only the seventh reported case of culture-proven meningitis related to N. sicca, and the first reported case associated with intracranial hemorrhage and ventriculostomy tube placement.

[Spontaneous intracerebral hemorrhage]

BACKGROUND

Cerebral stroke caused by intracerebral hemorrhage is serious. This review presents updated knowledge about the condition.

MATERIAL AND METHODS

The review is based on pivotal articles published during recent years, identified through a PubMed search applying the key words "intracerebral haemorrhage", and our own clinical experience.

RESULTS AND INTERPRETATION

Intracerebral hemorrhage strikes about 1,000 persons in Norway annually. Hypertension is the single most important risk factor. Cerebral CT confirms the diagnosis. Almost half of the patients die during the first month after the hemorrhage, many during the first two days. About 20% of the patients can manage without help after the first six months. Treatment includes measures against increased intracranial pressure and in selected cases surgical evacuation of the haematoma, especially in cases of bleeding into the cerebellum. Recombinant factor VIIa infused within the first three hours to stop the bleeding can play an important role in the acute phase. Patients below the age of 45, patients without hypertension, and patients with lobar haemorrhage and signs of clinical deterioration should be thoroughly investigated to disclose a potential arteriovenous malformation or an aneurysm. Neurointensive care may give better clinical results and the condition should ideally be treated in an intensive care unit.

Hypertensive intracerebral hemorrhage in young people: previously unnoticed age-related clinical differences

BACKGROUND AND PURPOSE

Hypertensive intracerebral hemorrhage (ICH) in young people has been the object of only succinct analyses. Therefore, it is unclear whether extrapolation of the information obtained from older patients is also valid for the young. Here we describe young persons with hypertensive ICH and compare them with their older counterparts to determine whether age-related clinical differences exist.

METHODS

From 1988 to 2004, we studied 35 consecutive young patients with ICH (60% men; mean age, 33 years; range, 15 to 40 years) for whom the etiology of the brain hemorrhage was hypertension. For clinical comparisons, sex-matched persons with hypertensive ICH, aged >40 years, were randomly selected by a factor of 3:1 (n=105).

RESULTS

Essential hypertension was present in 26 (74%) young patients and secondary hypertension in 9 (26%), with renovascular hypertension being the most common cause (n=5, 55%). Compared with older patients, the young had higher blood pressures, smaller hemorrhage volumes, lower rates of ventricular extensions (for all, P<0.05), and different distribution pattern of ICHs (P=0.05), without cerebellar and lobar locations. Thirty-day mortality was markedly lower in the young than in older persons (P=0.001), nevertheless at the expense of more incapacitating disabilities.

CONCLUSIONS

Young people presenting with hypertensive ICH differ in clinical characteristics and have a different prognosis when compared with their older counterparts. These findings suggest underlying age-related differences in disease pathogenesis.

Dural arteriovenous fistulas of the cavernous sinus with onset of intracerebral haemorrhage mimicking hypertensive putaminal hemorrhage

We describe a patient with dural arteriovenous fistulas of the cavernous sinus (CS-dAVFs) who developed an intracerebral haemorrhage (ICH) mimicking hypertensive putaminal haemorrhage. Drainage into the superior ophthalmic vein (SOV) and inferior petrosal sinus (IPS) was not demonstrated on cerebral angiography, and only cortical venous reflux into the Sylvian vein was observed. In cases of venous drainage concentrated on the Sylvian vein, CS-dAVFs could indicate ICH with radiological appearance resembling putaminal haemorrhage.

New era for management of primary hypertensive intracerebral hemorrhage

This discussion focuses on recent reports relevant to improved understanding and future directions in the management of intracerebral hemorrhage (ICH). Prevention is possible with adequate treatment of hypertension; microbleeds, apolipoprotein genotype, and cholesterol treatment have been examined in relation to ICH risk. Hematoma products, matrix metalloproteinases, inflammatory markers, and means to attenuate injury have also received attention. The multifaceted character of perihematomal edema has been further defined but evidence for perihematomal ischemia remains elusive. New data on acute blood pressure reinforces the need for a clinical trial. With the lack of efficacy found in the International Surgical Trial in Intracerebral Hemorrhage (ISTICH), a landmark surgical trial, emphasis is shifting to minimally invasive and catheter/thrombolytic-based technologies for clot evacuation. On the medical side, activated factor VII has been shown to control hemorrhage growth. Looking forward, stem cell therapies for ICH are under investigation and some outcome studies are shedding new rays of hope.

[Study of regional cerebral blood flow around hematoma in acute intracerebral hemorrhage by xenon-CT]

OBJECTIVE

To study the change of regional cerebral blood flow (rCBF) around hematoma in acute intracerebral hemorrhage.

METHODS

Xenon-CT was performed on 5 patients of basal ganglia hemorrhage with the hematoma volume less than 30 ml, 3 males and 2 females, aged 56.8 +/- 5.6. within 36 hours of the onset and 13 days after to measure the rCBF was measured by 27 pixel rings respectively in the core of hematoma, edema region around the hematoma and compared with rCBF in the uninvolved hemisphere.

RESULTS

(1) all the 5 patients had a history of hypertension, the mean intracerebral hemorrhage volume was 13 ml +/- 7 ml (6.4 approximately 23.7 ml). The first examination was conducted 23 h +/- 6 h (19 approximately 34 h) after the onset and the second examination was conducted 13.0 d +/- 0.7 d (12 approximately 14 d) after the onset. (2) Within 36 hours of the onset, the mean rCBF in the core of hematoma was 15 ml.100 g(-1).min(-1) +/- 8 ml.100 g(-1).min(-1), and the mean rCBF in edema region around the hematoma was 30 ml.100 g(-1).min(-1) +/- 8 ml.100 g(-1).min(-1). Thirteen days after the onset the mean rCBF in the core of hematoma was 9 ml.100 g(-1).min(-1) +/- 4 ml.100 g(-1).min(-1), significantly reduced in comparison with that measured in the first examination (P = 0.014), and the mean rCBF in the edema region around the hematoma was 23 ml.100 g(-1).min(-1) +/- 13 ml.100 g(-1).min(-1), reduced in comparison with those measured in the first examination too, however, not significantly (P = 0.055). The rCBF reduction was more significant in the edema region adjacent to the hematoma (P = 0.004), but not in the distant edema region. During the first examination the rCBF in the edema region around the hematoma was lower than the enantiomorph rCBF by 20.9%. Thirteen days after, the rCBF in the edema region around the hematoma was lower than the enantiomorph rCBF by 46.3%, significantly greater than the reduction during the first examination (P = 0.324). There was no difference between the values of enantiomorph rCBF during the first and second examinations (P = 0.038).

CONCLUSION

There exists reduced perihematoma rCBF after intracerebral hemorrhage by xenon-CT examination, this phenomenon lasts 14 days and have the tendency of further reduced.

[Simultaneous multiple hypertensive intracerebral hematoma]

Hypertensive intracerebral hemorrhage (HIH) occurring simultaneously in different locations is rare. We encountered 11 such cases between January 1990 and November 2002. The diagnosis of all 11 cases was established by computed tomography, and the location of the hematomas was: cerebellum and basal ganglia in 5 cases, pons and basal ganglia in 4, and subcortex and basal ganglia in 2. Our patients were analyzed with respect to clinical characteristics, pathogenesis of multiple hematomas, and indication of operation. These patients represented 1% of all 1,069 patients we encountered with HIH. As past history, there were no characteristic disorders except hypertension. There were no characteristic initial symptoms suggesting that hemorrhage had occurred simultaneously. Both supra- and infra-tentorial hematomas were observed in 80% of the patients, and the size of the multiple hematomas was proportional in principle. Cerebellar hematomas were often mild, and pontine hematomas were often severe. The outcome in those patients whose neurological grading was 1 to 3 was good with conservative therapy or surgical treatment. The severity, treatment methods, and outcomes in these patients were similar to those in patients with single HIH, which suggests only a slight influence of multiple lesions on outcome. As for the possible mechanism of simultaneous multiple hemorrhages, we speculated that bleeding occurred simultaneously in the different regions, or that the initial bleeding was followed after a short time by secondary bleeding due to high intracranial pressure and circulatory disturbance. In patients with cerebellar hematoma, initial symptoms suggested the development of secondary hemorrhage after primary hemorrhage. The surgical treatment for multiple hematomas should be determined by the location and maximum axis of the hematoma. We proposed that cerebellar hematomas should be removed if the supra-tentorial hematoma is small.

Clinical and radiographic features of lobar cerebral hemorrhage: hypertensive versus non-hypertensive cases

OBJECTIVES

The underlying cause of lobar intracerebral hemorrhage (ICH) is often difficult to determine, since these vascular abnormalities are not necessarily visualized in radiographic studies. We sought to determine the clinical features of hypertensive and nonhypertensive lobar ICH, and further predict the presence or absence of vascular abnormalities in terms of clinical features and radiographic abnormalities.

PATIENTS AND METHODS

Eighty-one patients with lobar ICH were retrospectively assigned to either hypertensive or non-hypertensive groups based on their blood pressure levels during the chronic phase or a history of antihypertensive medication. The clinical and radiographic features of these two groups were compared.

RESULTS

Forty-nine patients (60%) were hypertensive, and the other thirty-two (40%) were non-hypertensive. In the non-hypertensive group, amyloid angiopathy (n = 6), aneurysms (n = 5), arteriovenous malformation (n = 4), use of anticoagulants (n = 2), liver cirrhosis (n = 2) and thrombasthenia (n = 1) were found as underlying causes. There were no significant differences between these two groups in the frequencies of stroke risk factors except for hypertension, clinical features and initial neurological findings. On the contrary, subarachnoid extension of the hematoma on CT was significantly more frequent in the non-hypertensive lobar ICH group than in the hypertensive group (p < 0.001). The patients with subarachnoid extension were more likely to have vascular abnormality than those without subarachnoid extension (p < 0.01).

CONCLUSION

Subarachnoid extension of the hematoma on CT strongly indicates a non-hypertensive cause, and more specifically, it suggests lobar ICH caused by vascular abnormalities.

Cortical auditory disorder caused by bilateral strategic cerebral bleedings. Analysis of two cases

The authors present the anatomical and clinical features of cortical auditory dysfunction in two patients, in whom hypertensive bleedings destroyed the cortical auditory centres in both hemispheres. The second haemorrhage occurred four years after the first bleeding in both cases. The bleedings isolated the cortical hearing centres due to the destruction of the right and left temporal white matter. During the clinical course the symptomatology has changed in both patients: pure word deafness has transformed to cortical deafness and generalised auditory agnosia. Normal pattern of brain stem auditory evoked potentials suggested intact auditory pathways. Authors conclude that transformation of clinical forms of cortical auditory disorder can be explained by the tissue reaction to the subcortical bleeding in the cortical auditory centres.

[Noninvasive monitoring of hypertensive intracerebral hemorrhage and perihematomal tissue edema]

OBJECTIVE

To investigate the dynamic change regularity of intracerebral hemorrhage and perihematomal tissue edema.

METHODS

The cerebral electric impedance (CEI) of 100 normal volunteers and 24 patients with hypertensive intracerebral hemorrhage was measured, and the results of measurement were compared with the volumes of hematoma detected by CT.

RESULTS

In the normal persons, the CEI values in the left and right sides of cerebral hemispheres were 11.5 +/- 1.3 k(Omega) vs 11.4 +/- 1.8 k(Omega) at the frequency of 20 kHz, 10.2 +/- 1.0 k(Omega) vs 10.3 +/- 1.1 k(Omega) at the frequency of 50 kHz, and 9.1 +/- 0.8 k(Omega) vs 9.2 +/- 0.8 k(Omega) at the frequency of 100 kHz (all P > 0.05). Age, sex and measuring time did not obviously affect the CEI values. In the patients with hypertensive intracerebral hemorrhage the CEI of hematoma side was significantly decreased within 2 days after onset and then increased significantly for more than 10 days. The rate of EI change in the hematoma side within 24 h had a negative correlation with the volume of hematoma (r = -0.895 3, P < 0.01). however, the rate of CEI change in the hematoma side had a positive correlation with the volume of perihematomal edema (r = 0.881 1, P < 0.01).

CONCLUSION

CEI is a stable physical parameter reflecting the electrical character of human brain tissue. CEI sensitively reflects the change of hematoma and perihematomal edema, and guides the clinical treatment of cerebral hemorrhage.

Stereotactic fibrinolysis of spontaneous intracerebral hematoma using infusion of recombinant tissue plasminogen activator

PURPOSE

The authors present a prospective study on 10 patients with stereotactic infusion of tissue plasminogen activator (rtPA) intraparenchimal hemorrhage.

METHODS

Between 1999 and 2000, 10 patients with deep seated hematomas in the basal ganglia were selected for stereotactic infusion of rtPA and spontaneous clot drainage.

RESULTS

All cases had about 80% reduction of the hematoma volume in the CT scan at the third day. The intracranial pressure was normalized by the third day too. There were no local or systemic complications with the use of this thrombolytic. The results were shown by the Glasgow Outcome Scale with six patients in V, three in IV and one in III after 3 months.

CONCLUSION

Early treatment and drainage with minimally invasive neurosurgery, can make these patients with deep-seated hematomas recover the consciousness and they can be rehabilitated earlier avoiding secondary complications.

[Diagnostic image (55). Thalamus hemorrhage with intraventricular invasion]

A 54-year-old man presented with headache and cognitive deterioration without other neurological signs, caused by intraventricular, thalamic, and caudate nucleus haemorrhage. He had longstanding hypertension, a known risk factor.

Stroke pattern interpretation: the variability of hypertensive versus amyloid angiopathy hemorrhage

INTRODUCTION

It is commonly felt that cerebral amyloid angiopathy (CAA) related intracerebral hemorrhage (ICH) can be distinguished from hypertension (HTN)-related ICH by certain typical features on computerized tomography (CT) and magnetic resonance imaging (MRI). The purpose of this study was to investigate the performance of clinicians who were asked to differentiate between CAA and HTN based on hemorrhage pattern interpretation and to assess the feasibility of such classification.

METHODS

The admission scans from 83 patients who were admitted to our service with an acute ICH were presented to 5 clinicians in a randomized and blinded fashion (1 junior, and 1 senior neurosurgical resident, 1 attending neurosurgeon, and 2 neurosurgeon-neuroradiologists). There were no patients who received oral anticoagulants other than low-dose aspirin, or who suffered from vascular malformations or tumors. Scans from 41 patients with a histologically proven diagnosis of CAA and from 42 patients with a clear history of HTN were investigated. Hematoma evacuation was done in all CAA patients and in 59% of HTN patients (n = 25).

RESULTS

The overall average classification accuracy was 66.8% (range: 62.7-69.9). For correct HTN classification it was 69.5% (range: 64.3-81), and 63.9% for CAA, respectively (range: 48.9-75.6). There were negligible differences in classification accuracy among all observers. Patients with a CAA-related ICH were significantly older than patients with a HTN-related ICH (74 vs. 66.5 years, p < 0.05). There was a significantly higher number of hematomas >30 ml in CAA (85.3%) when compared with HTN (59.5%). No basal ganglionic hemorrhage was seen in CAA, but in 40.5% in HTN. Intraventricular hemorrhage was seen in 24.4% in CAA, and in 26.2% in HTN. Two patients (4.9%) with CAA, and 7 patients with HTN (16.7%) presented with cerebellar hematomas.

CONCLUSIONS

Three of 10 scans were not correctly diagnosed regardless of the examiner's level of training. This calls into question the reliability of classifying the underlying pathological condition based on hemorrhage pattern interpretation on CT or MRI. The definite diagnosis of CAA- versus HTN-related hemorrhage requires a histopathological confirmation and should not be based solely on hemorrhage pattern interpretation.

Relationship between stroke and asymptomatic minute hemorrhages in hypertensive patients

Asymptomatic small hemorrhages were identified in hypertensive patients by T2*-weighted gradient echo magnetic resonance (MR) imaging to investigate the relationship between hypertensive intracerebral hemorrhage and asymptomatic minute hemorrhages. Forty-eight patients with hypertensive intracerebral hemorrhage or cerebral infarction with hypertension (these diseases were defined as stroke) were treated in National Defense Medical College from April 1998 to February 2000. All patients had no past history of stroke or head injury, underwent MR imaging within 6 months of the stroke attack, were aged from 40 to 80 years, and had no diagnosis of aneurysm, angioma, or moyamoya disease. Patients were divided into the infarction group and hemorrhage group. All foci over 2 mm in size appearing as hypointense on T2*-weighted MR imaging and unrelated to stroke areas were defined as minute hemorrhages. There were no significant differences between the two groups with respect to sex, age, and history of diabetes mellitus. The incidence of minute hemorrhages in the hemorrhage group (21/26) was greater than in the infarction group (9/22, p < 0.01). The incidence of minute hemorrhages in the basal ganglia (18/26) was greater in the hemorrhage group than in the infarction group (4/22, p < 0.001). Symptomatic intracerebral hemorrhage may be preceded by asymptomatic minute hemorrhage.

Dynamic contrast-enhanced subtraction MR angiography in intracranial vascular abnormalities

We present our clinical experience with dynamic contrast-enhanced MR angiography (MRA) with subtraction for assessing intracranial vascular abnormalities. Ten patients with various cerebrovascular disorders underwent dynamic contrast-enhanced MRA on a 1.0-T system. Thirty sections (2 mm) were acquired in 29-30 s. Maximum intensity projection images and subtracted source images were compared with those obtained by conventional angiography. In all cases, the presence or absence of abnormalities in the targeted vessels, as well as the morphology of the sagittal sinuses, was clearly visualized as in conventional angiography, without any obstructions such as hyperintense hematomas or thrombi, or intraluminal turbulence. Although the temporal and spatial resolutions with current hardware are insufficient, these preliminary results suggest that dynamic contrast-enhanced MRA with subtraction may be useful for assessing vascular lesions with hemorrhage or thrombus, and the dural sinuses.

Lenticulocapsular hemorrhages presenting as pure sensory stroke

Pure sensory stroke (PSS) syndrome is most often produced by a small infarct involving the lateral thalamus. Larger than lacune-sized putaminal hemorrhages have not been considered as a cause of this syndrome. The author describes 3 patients with hypertensive lenticulocapsular hemorrhage presenting with hemisensory symptoms without any other neurological deficits. In these patients, the sensory symptoms were more marked and persistent in the legs than in the other body parts. Neuroradiological data suggested that thalamocortical sensory pathways were exclusively involved. These patients highlight the heterogeneity of the vascular lesion producing PSS syndrome and illustrate that a putaminal hemorrhage should be included in the differential diagnosis of this clinical syndrome.