Intracerebral haemorrhage: mechanisms of injury and therapeutic targets

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.

Levels of non-high-density-lipoprotein cholesterol are positively correlated with the risk of cognitive impairment in patients with intracerebral hemorrhage stroke

BACKGROUND

Intracerebral hemorrhage (ICH) is one of the most common strokes, especially in developing countries. Recently, level of non-high-density lipoprotein cholesterol (non-HDL-C) has been implicated to be a better indicator for several lipid-related disorders. However, whether non-HDL-C can be used as an indicator for the risk of cognitive impairment in ICH patients remains to be elucidated.

METHODS

In this study, we performed a retrospective study on patients with ICH treated at our institution to investigate the association between the level of non-HDL-C and various neuropsychological assessments, including mini-mental state examination (MMSE), Montreal cognitive assessment (MoCA), activity of daily living scale (ADL), neuropsychiatric Inventory (NPI) and Hamilton depression rating scale 21 (HAMD21).

RESULTS

We found that all scores of the tested assessments were significantly altered in ICH patients with a high non-HDL-C level. In addition, we revealed that non-HDL-C was negatively correlated with MMSE and MoCA scores and was positively correlated with ADL, NPI and HAMD21 scores.

CONCLUSIONS

Our study suggests that non-HDL-C level can be used as a potential indicator for the risk of cognitive impairment in ICH patients.

Molecular Correlates of Hemorrhage and Edema Volumes Following Human Intracerebral Hemorrhage Implicate Inflammation, Autophagy, mRNA Splicing, and T Cell Receptor Signaling

Intracerebral hemorrhage (ICH) and perihematomal edema (PHE) volumes are major determinants of ICH outcomes as is the immune system which plays a significant role in damage and repair. Thus, we performed whole-transcriptome analyses of 18 ICH patients to delineate peripheral blood genes and networks associated with ICH volume, absolute perihematomal edema (aPHE) volume, and relative PHE (aPHE/ICH; rPHE). We found 440, 266, and 391 genes correlated with ICH and aPHE volumes and rPHE, respectively (p < 0.005, partial-correlation > |0.6|). These mainly represented inflammatory pathways including NF-κB, TREM1, and Neuroinflammation Signaling-most activated with larger volumes. Weighted Gene Co-Expression Network Analysis identified seven modules significantly correlated with these measures (p < 0.05). Most modules were enriched in neutrophil, monocyte, erythroblast, and/or T cell-specific genes. Autophagy, apoptosis, HIF-1α, inflammatory and neuroinflammatory response (including Toll-like receptors), cell adhesion (including MMP9), platelet activation, T cell receptor signaling, and mRNA splicing were represented in these modules (FDR p < 0.05). Module hub genes, potential master regulators, were enriched in neutrophil-specific genes in three modules. Hub genes included NCF2, NCF4, STX3, and CSF3R, and involved immune response, autophagy, and neutrophil chemotaxis. One module that correlated negatively with ICH volume correlated positively with rPHE. Its genes and hubs were enriched in T cell-specific genes including hubs LCK and ITK, Src family tyrosine kinases whose modulation improved outcomes and reduced BBB dysfunction following experimental ICH. This study uncovers molecular underpinnings associated with ICH and PHE volumes and pathophysiology in human ICH, where knowledge is scarce. The identified pathways and hub genes may represent novel therapeutic targets.

Development and validation of a nomogram for predicting hematoma expansion in intracerebral hemorrhage

BACKGROUND AND OBJECTIVE

To develop and validate a clinical nomogram for individualized predicting hematoma expansion (HE) in patients with Intracerebral Hemorrhage (ICH).

METHODS

A total of 1025 patients with ICH were retrospectively enrolled in the development cohort between 2010 and 2016. We identified and integrated significant factors for HE to build a nomogram. The model was subjected to validation with a separate cohort of 397 patients from the 2017-2019. The predictive accuracy and discriminative ability were measured by concordance index (C-index). The primary outcome was HE, defined as hematoma growth more than 6 mL or 33% increase in the volume.

RESULTS

A total of 1025 patients were included for univariable analysis. HE occurred in 180 patients (17.6%). The time to initial CT (≤6h vs. >6 h; p = 0.001), NIHSS score (0-4 vs. 5-14 vs. ≥15; p = 0.031), CTA spot sign (yes vs. no vs. absent; p = 0.018), hypodensities (p = 0.000), blend sign (p = 0.005), and INR (<1.2 vs. ≥1.2; p = 0.009) were identified and entered into the nomogram. The calibration curves for probability of HE showed optimal agreement between nomogram prediction and actual observation. The C-index was 0.751. The validation cohort consisted of 397 patients and HE occurred in 78 patients (19.6%). The C-index was 0.743.

CONCLUSIONS

We developed and validated a nomogram that can individually predict HE for ICH in Chinese populations. This practical prognostic nomogram may help clinicians make decision of clinical practice and design of clinical studies.

A Pooled Analysis of Diffusion-Weighted Imaging Lesions in Patients With Acute Intracerebral Hemorrhage

Importance

The etiology and significance of diffusion-weighted imaging (DWI) lesions in patients with acute intracerebral hemorrhage (ICH) remain unclear.

Objective

To evaluate which factors are associated with DWI lesions, whether associated factors differ by ICH location, and whether DWI lesions are associated with functional outcomes.

Design, Setting, and Participants

This analysis pooled individual patient data from 3 randomized clinical trials (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial, Antihypertensive Treatment of Acute Cerebral Hemorrhage trial, and Intracerebral Hemorrhage Deferoxamine phase 2 trial) and 1 multicenter prospective study (Ethnic/Racial Variations of Intracerebral Hemorrhage). Patients were enrolled from August 1, 2010, to September 30, 2018. Of the 4782 patients, 1788 who underwent magnetic resonance imaging scans of the brain were included. Data were analyzed from July 1 to December 31, 2019.

Main Outcomes and Measures

The primary outcome consisted of factors associated with DWI lesions. Secondary outcomes were poor functional outcome, defined as a modified Rankin score (mRS) of 4 to 6, and mortality, both assessed at 3 months. Mixed-effects logistic regression was used to evaluate the association between exposures and outcomes. Subgroup analyses stratified by hematoma location were performed.

Results

After exclusion of 36 patients with missing data on DWI lesions, 1752 patients were included in the analysis (1019 men [58.2%]; mean [SD] age, 60.8 [13.3] years). Diffusion-weighted imaging lesions occurred in 549 patients (31.3%). In mixed-effects regression models, factors associated with DWI lesions included younger age (odds ratio [OR] per year, 0.98; 95% CI, 0.97-0.99), black race (OR, 1.64; 95% CI, 1.17-2.30), admission systolic blood pressure (OR per 10-mm Hg increase, 1.13; 95% CI, 1.08-1.18), baseline hematoma volume (OR per 10-mL increase, 1.12; 95% CI, 1.02-1.22), cerebral microbleeds (OR, 1.85; 95% CI, 1.39-2.46), and leukoaraiosis (OR, 1.59; 95% CI, 1.67-2.17). Diffusion-weighted imaging lesions were independently associated with poor mRS (OR, 1.50; 95% CI, 1.13-2.00), but not with mortality (OR, 1.11; 95% CI, 0.72-1.71). In subgroup analyses, similar factors were associated with DWI lesions in lobar and deep ICH. Diffusion-weighted imaging lesions were associated with poor mRS in deep but not lobar ICH.

Conclusions and Relevance

In a large, heterogeneous cohort of prospectively identified patients with ICH, results were consistent with the hypothesis that DWI lesions represent acute sequelae of chronic cerebral small vessel disease, particularly hypertensive vasculopathy. Diffusion-weighted imaging lesions portend a worse prognosis after ICH, mainly deep hemorrhages.

In-hospital complications affect short-term and long-term mortality in ICH: a prospective cohort study

Background

Medical complications strongly affected the mortality of patients with stroke. However, only limited research has studied the effect of in-hospital medical complications on the mortality of patients with spontaneous intracerebral haemorrhage (ICH) globally. Using the China National Stroke Registry, the effect was prospectively and systematically investigated in patients with spontaneous ICH during their hospitalisation, at 3, 6 and 12 months after disease onset.

Methods

This study collected data on patients over 18 years old with spontaneous ICH from 132 Chinese clinical centres across 32 provinces and four municipalities (Hong Kong included), from September 2007 to August 2008. Data on patient complications, death and other information were acquired through paper-based registry forms. Using multivariable logistic regression, the association of medical complications with stroke outcomes was evaluated.

Results

Of 3255 patients with spontaneous ICH, 878 (26.97%) had in-hospital medical complications. In-hospital medical complications were independent risk factors for death during the hospitalisation (adjusted OR 4.41, 95% CI 3.18 to 6.12), at 3 months (adjusted OR 2.18, 95% CI 1.70 to 2.80), 6 months (adjusted OR 1.84, 95% CI 1.45 to 2.34) and 12 months (adjusted OR 1.59, 95% CI 1.26 to 2.01) after spontaneous ICH.

Conclusion

The results revealed that the short-term and long-term mortality of patients with spontaneous ICH in China was significantly associated with their in-hospital medical complications.

Effect of Pioglitazone on Perihematomal Edema in Intracerebral Hemorrhage Mouse Model by Regulating NLRP3 Expression and Energy Metabolism

Objective

Cerebral edema is the predominant mechanism of secondary inflammation after intracerebral hemorrhage (ICH). Pioglitazone, peroxisome proliferator-activated receptor gamma agonist has been shown to play a role in regulation of central nervous system inflammation. Here, we examined the pharmacological effects of pioglitazone in an ICH mouse model and investigated its regulation on NLRP3 inflammasome and glucose metabolism.

Methods

The ICH model was established in C57 BL/6 mice by the stereotactical inoculation of blood (30 µL) into the right frontal lobe. The treatment group was administered i.p. pioglitazone (20 mg/kg) for 1, 3, and 6 days. The control group was administered i.p. phosphate-buffered saline for 1, 3, and 6 days. We investigated brain water contents, NLRP3 expression, and changes in the metabolites in the ICH model using liquid chromatography-tandem mass spectrometry.

Results

On day 3, brain edema in the mice treated with pioglitazone was decreased more than that in the control group. Expression levels of NLRP3 in the ICH model treated with pioglitazone were decreased more than those of the control mice on days 3 and 7. The pioglitazone group showed higher levels of glycolytic metabolites than those in the ICH mice. Lactate production was increased in the ICH mice treated with pioglitazone.

Conclusion

Our results demonstrated less brain swelling following ICH in mice treated with pioglitazone. Pioglitazone decreased NLRP3-related brain edema and increased anaerobic glycolysis, resulting in the production of lactate in the ICH mice model. NLRP3 might be a therapeutic target for ICH recovery.

Intra-hematomal White Matter Tracts Act As a Scaffold for Macrophage Infiltration After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a stroke subtype with high mortality and severe morbidity. Hemorrhages frequently develop within the white matter, but whether white matter fibers within the hematoma survive after ICH has not been well studied. The current study examines whether white matter fibers persist in the hematoma after ICH, fibers that might be impacted by evacuation, and their relationship to macrophage infiltration in a porcine model. Male piglets had 2.5 ml blood with or without CD47 blocking antibody injected into the right frontal lobe. Brains were harvested from 3 days to 2 months after ICH for brain histology. White matter fibers were detected within the hematoma 3 and 7 days after hemorrhage by brain histology and myelin basic protein immunohistochemistry. White matter still remained in the hematoma cavity at 2 months after ICH. Macrophage scavenger receptor-1 positive macrophages/microglia and heme oxygenase-1 positive cells infiltrated into the hematoma along the intra-hematomal white matter fibers at 3 and 7 days after ICH. Treatment with CD47 blocking antibody enhanced the infiltration of these cells. In conclusion, white matter fibers exist within the hematoma after ICH and macrophages/microglia may use such fibers as a scaffold to infiltrate into the hematoma and aid in hematoma clearance.

Disruptions of Anaerobic Gut Bacteria Are Associated with Stroke and Post-stroke Infection: a Prospective Case-Control Study

In recent years, preclinical studies have illustrated the potential role of intestinal bacterial composition in the risk of stroke and post-stroke infections. The results of these studies suggest that bacteria capable of producing volatile metabolites, including trimethylamine-N-oxide (TMAO) and butyrate, play opposing, yet important roles in the cascade of events leading to stroke. However, no large-scale studies have been undertaken to determine the abundance of these bacterial communities in stroke patients and to assess the impact of disrupted compositions of the intestinal microbiota on patient outcomes. In this prospective case-control study, rectal swabs from 349 ischemic and hemorrhagic stroke patients (median age, 71 years; IQR: 67-75) were collected within 24 h of hospital admission. Samples were subjected to 16S rRNA amplicon sequencing and subsequently compared with samples obtained from 51 outpatient age- and sex-matched controls (median age, 72 years; IQR, 62-80) with similar cardiovascular risk profiles but without active signs of stroke. Plasma protein biomarkers were analyzed using a combination of nuclear magnetic resonance (NMR) spectroscopy and liquid chromatography-mass spectrometry (LC-MS). Alpha and beta diversity analyses revealed higher disruption of intestinal communities during ischemic and hemorrhagic stroke compared with non-stroke matched control subjects. Additionally, we observed an enrichment of bacteria implicated in TMAO production and a loss of butyrate-producing bacteria. Stroke patients displayed two-fold lower plasma levels of TMAO than controls (median 1.97 vs 4.03 μM, Wilcoxon p < 0.0001). Finally, lower abundance of butyrate-producing bacteria within 24 h of hospital admission was an independent predictor of enhanced risk of post-stroke infection (odds ratio 0.77, p = 0.005), but not of mortality or functional patient outcome. In conclusion, aberrations in trimethylamine- and butyrate-producing gut bacteria are associated with stroke and stroke-associated infections.

The protective effects of prolactin on brain injury

AIMS

Brain injuries based on their causes are divided into two categories, TBI and NTBI. TBI is caused by damages such as head injury, but non-physical injury causes NTBI. Prolactin is one of the blood factors that increase during brain injury. It has been assumed to play a regenerative role in post-injury recovery.

MATERIALS AND METHODS

In this review, various valid papers from electronic sources (including Web of Science, Scopus, PubMed, SID, Google Scholar, and ISI databases) used, which in them the protective effect of prolactin on brain injury investigated.

KEY FINDINGS

Inflammation following brain injury with the production of pro-inflammatory cytokines in the affected area can even lead to excitotoxicity and cell death in the damaged area. Medical brain damage treatments are long-term, and can have several side effects. Therefore, it is better to consider medication treatments that have fewer side effects and greater efficacy. Research suggests that prolactin has numerous regenerative effects on brain injury, and prevents cell death. Prolactin is one of the hormones produced in the body; therefore it has fewer side effects and may be more effective because it increases during brain injury.

SIGNIFICANCE

Prolactin can be used peripherally and centrally, and exerts its neuro regenerative effects against further damage post-TBI and NTBI.

Suppression of microglial activation and monocyte infiltration ameliorates cerebellar hemorrhage induced-brain injury and ataxia

Ataxia, characterized by uncoordinated movement, is often found in patients with cerebellar hemorrhage (CH), leading to long-term disability without effective management. Microglia are among the first responders to CNS insult. Yet the role and mechanism of microglia in cerebellar injury and ataxia after CH are still unknown. Using Ki20227, an inhibitor for colony-stimulating factor 1 receptor which mediates the signaling responsible for the survival of microglia, we determined the impact of microglial depletion on cerebellar injury and ataxia in a murine model of CH. Microglial depletion reduced cerebellar lesion volume and alleviated gait abnormality, motor incoordination, and locomotor dysfunction after CH. Suppression of CH-initiated microglial activation with minocycline ameliorated cerebellum infiltration of monocytes/macrophages, as well as production of proinflammatory cytokines and chemokine C-C motif ligand-2 (CCL-2) that recruits monocytes/macrophages. Furthermore, both minocycline and bindarit, a CCL-2 inhibitor, prevented apoptosis and electrophysiological dysfunction of Purkinje cells, the principal neurons and sole outputs of the cerebellar cortex, and consequently improved ataxia-like motor abnormalities. Our findings suggest a detrimental role of microglia in neuroinflammation and ataxic motor symptoms after CH, and pave a new path to understand the neuroimmune mechanism underlying CH-induced cerebellar ataxia.

Stroke treatment: Is exosome therapy superior to stem cell therapy?

Stroke is one of the most common causes of disability and death, and currently, ideal clinical treatment is lacking. Stem cell transplantation is a widely-used treatment approach for stroke. When compared with other types of stem cells, bone marrow mesenchymal stem cells (BMSCs) have been widely studied because of their many advantages. The paracrine effect is the primary mechanism for stem cells to play their role, and exosomes play an essential role in the paracrine effect. When compared with cell therapy, cell-free exosome therapy can prevent many risks and difficulties, and therefore, represents a promising and novel approach for treatment. In this study, we reviewed the research progress in the application of BMSCs-derived exosomes (BMSCs-exos) and BMSCs in the treatment of stroke. In addition, the advantages and disadvantages of cell therapy and cell-free exosome therapy were described, and the possible factors that hinder the introduction of these two treatments into the clinic were analyzed. Furthermore, we reviewed the current optimization methods of cell therapy and cell-free exosome therapy. Taken together, we hypothesize that cell-free exosome therapy will have excellent research prospects in the future, and therefore, it is worth further exploring. There are still some issues that need to be further addressed. For example, differences between the in vivo microenvironment and in vitro culture conditions will affect the paracrine effect of stem cells. Most importantly, we believe that more preclinical and clinical design studies are required to compare the efficacy of stem cells and exosomes.

Surgical strategy for patients with supratentorial spontaneous intracerebral hemorrhage: minimally invasive surgery and conventional surgery

Objective

The role of surgery in spontaneous intracerebral hemorrhage (sICH) is still controversial. We aimed to investigate the effectiveness of minimally invasive surgery (MIS) compared to conventional surgery (CS) for supratentorial sICH.

Methods

The medical data of 70 patients with surgically treated supratentorial sICH were retrospectively reviewed. MIS was performed in 35 patients, and CS was performed in 35 patients. The surgical technique was selected based on the neurological status and radiological findings, such as hematoma volume, neurological status and spot signs on computed tomographic angiography. Treatment outcomes, prognostic factors and the usefulness of the spot sign were analyzed.

Results

Clinical states in both groups were statistically similar, preoperatively, and in 1 and 3 months after surgery. Both groups showed significant progressive improvement till 3 months after surgery. Better preoperative neurological status, more hematoma removal and intensive care unit (ICU) stay ≤7 days were the significant prognostic factors for favorable 3-month clinical outcomes (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.10–0.96, p=0.04; OR 1.04, 95% CI 1.01–1.08, p=0.02; OR 26.31, 95% CI 2.46–280.95, p=0.01, respectively). Initial hematoma volume and MIS were significant prognostic factors for a short ICU stay (≤7 days; OR 0.95; 95% CI 0.91–0.99; p=0.01; OR 3.91, 95% CI 1.03–14.82, p=0.045, respectively). No patients in the MIS group experienced hematoma expansion before surgery or postoperative rebleeding.

Conclusions

MIS was not inferior to CS in terms of clinical outcomes. The spot sign seems to be an effective radiological marker for predicting hematoma expansion and determining the surgical technique.

Discriminative value of glial fibrillar acidic protein (GFAP) as a diagnostic tool in acute stroke. Individual patient data meta-analysis

Glial fibrillar acidic protein (GFAP) in serum has been evaluated as a promising biomarker to differentiate between intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS). We assessed its value as diagnostic and prognostic tool for ICH through a literature systematic review and individual patient data (IPD) meta-analysis.We performed a systematic search in PubMed database until November 2018 for publications that evaluated GFAP to differentiate AIS and ICH within 4.5 hours after symptoms onset. Thereafter, we invited authors of selected studies to participate in this work by providing IPD from their cohorts. We used standardized individual subject's data to evaluate the association of GFAP concentrations with stroke subtype, demographics, stroke characteristics and factors related with GFAP measurement.From 4 selected studies, we collected data of 340 patients (236 AIS and 104 ICH). Standardized GFAP blood levels were significantly elevated in ICH compared with those with AIS (median and IQR: 0.84 (0.781-1.24), 0.79 (0.74-0.81); p<0.0001). In both stroke types, GFAP concentrations correlated with baseline stroke severity (r=0.27, p<0.0001; r=0.36, p<0.001; for AIS and ICH, respectively) but no correlation was found regarding time to sampling. Limited data precluded the evaluation of GFAP levels and functional outcome.These findings demonstrate substantially different levels of GFAP in the blood of patients with ICH compared with patients with AIS soon after the event, while no association was found with outcome. In summary, GFAP could be a valuable diagnostic tool to assist in medical decision-making and to optimize management of stroke in the acute setting.

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.

Potential therapeutic targets for intracerebral hemorrhage-associated inflammation: An update

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and disability but no specific or effective treatment. In the last two decades, much has been learned about the pathologic mechanisms of ICH. It is now known that after ICH onset, immune and inflammatory responses contribute to blood-brain barrier disruption, edema development, and cell death processes, jointly resulting in secondary brain injury. However, the translation of potential therapies from preclinical to clinical success has been disappointing. With the development of new laboratory technology, recent progress has been made in the understanding of ICH pathomechanisms, and promising therapeutic targets have been identified. This review provides an update of recent progress on ICH and describes the prospects for further preclinical studies in this field. Our goal is to discuss new therapeutic targets and directions for the treatment of ICH and promote the effective transformation from preclinical to clinical trials.

Neuroinflammation Mediated by NLRP3 Inflammasome After Intracerebral Hemorrhage and Potential Therapeutic Targets

Intracerebral hemorrhage (ICH) is the most fatal subtype of stroke; there is still a lack of effective treatment. Microglia are a major component of the innate immune system, and they respond to acute brain injury by activating and forming classic M1-like (pro-inflammatory) or alternative M2-like (anti-inflammatory) phenotype. The existence of the polarization indicates that the role of microglia in disease's progression and recovery after ICH is still unclear, perhaps involving microglial secretion of anti-inflammatory or pro-inflammatory cytokines and chemokines. The NOD-like receptor family, pyrin domain-containing 3 (NLRP3) inflammasome is considered to be the main participant in neuroinflammation. Recent evidence has shown that NLRP3 inflammasome can be activated after ICH, resulting in inflammatory cascade reactions and aggravating brain injury. Furthermore, previous studies have reported that NLRP3 inflammasome is mainly present in microglia, so we speculate that its activation may be strongly associated with microglial polarization. Many scholars have investigated the role of brain injury caused by NLRP3 inflammasome after ICH, but the precise operating mechanisms remain uncertain. This review summarized the activation mechanism of NLRP3 inflammasome after ICH and the possible mechanism of NLRP3 inflammasome promoting neuroinflammation and aggravating nerve injury and discussed the relevant potential therapeutic targets.

Efficacy and safety of edaravone for acute intracerebral haemorrhage: protocol for a systematic review and meta-analysis

INTRODUCTION

Intracerebral haemorrhage (ICH) is a life-threatening condition with no effective internal treatment options. However, edaravone is a promising therapeutic agent, although its beneficial effects are inconclusive based on previous systematic reviews and meta-analyses. While several trials in the last 8 years have reported the favourable long-term functional outcomes, a few reports indicated edaravone to be associated with an increase in adverse events.

METHODS AND ANALYSIS

This protocol was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. We will perform the comprehensive and manual search for published articles, ongoing trials, dissertations and grey literature. The following databases will be searched from inception to 23 April 2020: Medline, Embase, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Chinese scientific periodical database of VIP INFORMATION, Wanfang Data and SinoMed, with no language restrictions. All randomised controlled trials that (1) compared edaravone with placebo or no treatment, and (2) compared edaravone plus routine treatment or cointervention with routine treatment or cointervention for treating acute ICH will be included. Mortality and long-term dependency will be the primary outcomes. The incidence of adverse events will be assessed for safety evaluation. Two reviewers in pairs will independently carry out the article selection, data extraction and quality assessment. Assessment of the risk of bias and data synthesis will be performed using software Review Manager V.5.3. Finally, we will use the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of the overall evidence.

ETHICS AND DISSEMINATION

There are no ethical considerations associated with this updated systematic review and meta-analysis. The findings will be disseminated in peer-reviewed journals or conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42019147801.

Intracerebral hemorrhage alters circular RNA expression profiles in the rat brain

Circular RNAs (circRNAs), formed from pre-messenger RNAs by back-splicing, are a novel class of evolutionarily-conserved endogenous non-coding RNAs. While circRNAs are involved in various diseases, the role of circRNAs in intracerebral hemorrhage (ICH) remains unknown. In the present study, we performed high-throughput sequencing to profile the expression of circRNAs in the rat brain at 24 and 48 hours after ICH onset, and utilized bioinformatics methods to make predictions about the function of dysregulated circRNAs. Compared with the sham group, 346 and 389 circRNAs changed significantly (|log2 (fold change)| > 1 and P < 0.05) at 24 and 48 hours after ICH, respectively. Bioinformatics analyses indicated that parent genes of dysregulated circRNAs were involved in biological processes, cellular component, and molecular function following ICH, and that they were enriched in the dopaminergic synapses, glutamatergic synapses, endocytosis, regulation of actin cytoskeleton, the mitogen-activated protein kinase signaling pathway, and the retrograde endocannabinoid signaling pathway. Enrichment analyses of target mRNAs showed that these mRNAs were enriched in synaptic plasticity, ion channel activity, and pathways including the phospholipase D signaling and the cGMP-PKG signaling. Our study indicates that the expression profile of circRNAs changes significantly after ICH in rat brains, and suggests that circRNAs may be crucial for the pathophysiological process following ICH.

Bedside Catheter Hematoma Evacuation in Vitamin K Antagonist-Related Intracerebral Hemorrhage: A Safe and Feasible Approach

Background and Purpose: Although outcome in intracerebral hemorrhage (ICH) patients is generally not improved by surgical intervention, the use of minimally invasive surgery (MIS) has shown promising results. However, vitamin K antagonist (VKA)-related ICH patients are underrepresented in surgical treatment trials. We therefore assessed the safety and efficacy of a bedside MIS approach including local application of urokinase in VKA-related ICH. Methods: Patients with a VKA-related ICH > 20 ml who received bedside hematoma evacuation treatment (n = 21) at the University Medical Center Freiburg were retrospectively included for analysis and compared to a historical control group (n = 35) selected from an institutional database (University Medical Center Erlangen) according to identical inclusion criteria. Propensity score matching was performed to obtain comparable cohorts. The evolution of hematoma and peri-hemorrhagic edema (PHE) volumes, midline shift, and the occurrence of adverse events were analyzed. Furthermore, we assessed the modified Rankin Scale and NIHSS scores recorded at discharge. Results: Propensity score matching resulted in 16 patients per group with well-balanced characteristics. Median ICH volume at admission was 45.7 (IQR: 24.2-56.7) ml in the control group and 48.4 (IQR: 28.7-59.6) ml in the treatment group (p = 0.327). ICH volume at day 7 was less pronounced in the treatment group [MIS: 23.2 ml (IQR: 15.8-32.3) vs. control: 43.2 ml (IQR: 27.5-52.4); p = 0.013], as was the increase in midline shift up to day 7 [MIS: -3.75 mM (IQR: -4.25 to -2) vs. control: 1 mM (IQR: 0-2); p < 0.001]. No group differences were observed in PHE volume on day 7 [MIS: 42.4 ml (IQR: 25.0-72.3) vs. control: 31.0 ml (IQR: 18.8-53.8); p = 0.274] or mRS at discharge [MIS: 5 (IQR: 4-5) and 5 (IQR: 4-5); p = 0.949]. No hematoma expansion was observed. The catheter had to be replaced in 1 patient (6%). Conclusions: Bedside catheter-based hematoma evacuation followed by local thrombolysis with urokinase appears to be feasible and safe in cases of large VKA-related ICH. Further studies that assess the functional outcome associated with this technique are warranted. Clinical Trial Registration: DRKS00007908 (German Clinical Trial Register; www.drks.de).

Long-Term Effect of Endoscopic Evacuation for Large Basal Ganglia Hemorrhage With GCS Scores ≦ 8

Aims: The surgical evacuation, including stereotactic aspiration, endoscopic evacuation, and craniotomy, is the most effective way to reduce the volume of intracerebral hemorrhage. However, credible evidence for the effects of these techniques is still insufficient. The present study explored the long-term outcomes of these techniques in the treatment of basal ganglia hematoma with low Glasgow Coma Scale (GCS) scores (≤8) and large-volume (≥40 ml), which were predictors of high mortality.

Methods: Two hundred and fifty-eight consecutive patients were reviewed retrospectively. The primary and secondary outcomes were 6-months mortality and 6-months modified Rankin Scale score, which were assessed by a multivariate logistic regression model.

Results: Compared with the endoscopic evacuation group, the mortality was significantly higher in the stereotactic aspiration group (OR 6.858, 95% CI 3.146–14.953) and open craniotomy group (OR 3.315, 95% CI 1.497–7.341). Age (OR = 2.237, 95% CI 1.290–3.877) and herniation (OR = 2.257, 95% CI 1.172–4.348) were independent predictors for mortality. No significant difference in the neurological functional outcome was found in the stereotactic aspiration group (OR 0.501, 95% CI 0.192–1.308) and the craniotomy group (OR 0.774, 95% CI 0.257–2.335) compared with the endoscopic evacuation group.

Conclusion: Endoscopic evacuation significantly decreased the 6-months mortality in patients with hemorrhage ≥40 ml and GCS ≤ 8.

Natural history of recovery after intracerebral haemorrhage: a scoping review protocol

INTRODUCTION

Clinical trials for intracerebral haemorrhage typically measure outcomes in the same way and at the same time points as trials for ischaemic stroke. However, there is growing evidence that the trajectory of recovery following intracerebral haemorrhage may differ significantly from that following ischaemic stroke. A better understanding of current approaches to outcome assessment is essential to ensure that future trials examining treatments for intracerebral haemorrhage are designed appropriately.

OBJECTIVE

To determine when and how outcomes are measured in patients with intracerebral haemorrhage.

METHODS AND ANALYSIS

With the assistance of an information specialist, we will conduct a scoping review by searching MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Web of Science for prospective studies of adults with primary intracerebral haemorrhage and documented outcomes with specified times. Two reviewers will independently collect data on included studies pertaining to publication data, study population information, timing of outcome and details of the outcome measurement tools used. The extracted data will be used to demonstrate the type and timing of outcome measures.

ETHICS AND DISSEMINATION

Primary data will not be collected therefore formal ethics is not required. The findings of this study will be disseminated through peer-reviewed publications and through presentation at academic conferences.

Asymptomatic Striatocapsular slit-like Hemorrhage as a Severity Marker in Patients with Hypertensive Angiopathy

BACKGROUND

Concomitant asymptomatic striatocapsular slit-like hemorrhage (SSH) is occasionally found in patients of spontaneous intracerebral hemorrhage (ICH), but was seldomly described in the literature. In this study, we described the clinico-radiological features of asymptomatic SSH in ICH patients with hypertensive microangiopathy.

METHODS AND RESULTS

246 patients with strictly deep or mixed deep and lobar ICH/microbleeds were included. SSH was defined as hypointense lesions involving the lateral aspect of lentiform nucleus or external capsule in slit shape (>1.5 cm) on susceptibility-weighted imaging without history of associated symptoms. Demographics and neuroimaging markers were compared between patients with SSH and those without. Patients with SSH (n=24, 10%) and without SSH had comparable age (62.0 ± 12.6 vs. 62.3 ± 13.5, p = 0.912) and vascular risk factor profiles including the diagnosis of chronic hypertension, diabetes, and dyslipidemia (all p>0.05). SSH was associated with more common lobar microbleeds (79.2% vs 48.2%, p = 0.005), lacunes (75% vs. 41.4%, p = 0.002) and higher white matter hyperintensity (WMH) volumes (24.1 [10.4-46.3] vs. 13.9 [7.0-24.8] mL, p = 0.012) on MRI, as well as more frequent left ventricular hypertrophy (LVH) (50.0% vs. 20.5%, p = 0.004) and albuminuria (41.7% vs. 19.4%, p = 0.018). In multivariable analyses, SSH remains independently associated with LVH (p = 0.017) and albuminuria (p = 0.032) after adjustment for age, sex, microbleed, lacune and WMH volume.

CONCLUSIONS

Asymptomatic SSH is associated with more severe cerebral small vessel disease-related change on brain MRI, and hypertensive cardiac and renal injury, suggesting a more advanced stage of chronic hypertension.

Recurrent intracerebral hemorrhages due to central nervous system vasculitis: A neuropsychological case report

OBJECTIVE

Primary angiitis of the central nervous system (PACNS) is a rare and devastating form of vasculitis that destroys the vessels of the brain and spinal cord, resulting in progressive and debilitating neurologic symptoms. The objective of the present study was to detail the diagnostic process of a case of a patient with PACNS who suffered from six intracerebral hemorrhages (ICHs).

METHOD

The patient was an African American woman with a history of recurrent ICHs of unclear etiology who received serial neuropsychological evaluations over the course of a 5-year period. Two comprehensive neuropsychological evaluations are included, as well as an overview of her clinical course, including differential diagnostic considerations and treatment planning.

RESULTS

Neuropsychological assessment revealed marked deficits in visuospatial abilities and processing speed associated with her underlying neuropathology. Integrated review of her medical records indicated a probable diagnosis of PACNS as the likely etiology of her recurrent ICHs.

CONCLUSIONS

This study demonstrates the importance of differential diagnosis of low base-rate conditions, functional neuroanatomy and neurobehavioral phenomenology, serial assessment, and cognitive reserve in clinical neuropsychological practice.

Autophagy and Hemorrhagic Stroke

Hemorrhagic stroke includes cerebral hemorrhage and subarachnoid hemorrhage. An increasing number of studies have found that autophagy also occurs in brain tissues after cerebral hemorrhage and subarachnoid hemorrhage. The potential role of selective autophagy in the clinical treatment of hemorrhagic stroke has been recognized, but a consensus on the exact effect and function of autophagy has not been reached, and the mechanism needs to be further studied. In this chapter, the mechanism of brain injury after cerebral hemorrhage and subarachnoid hemorrhage is briefly introduced, and changes in the autophagy pathway and the role of autophagy in the process of brain injury are discussed.

Ferroptosis in Acute Central Nervous System Injuries: The Future Direction?

Acute central nervous system (CNS) injuries, such as stroke, traumatic brain injury (TBI), and spinal cord injury (SCI) present a grave health care challenge worldwide due to high morbidity and mortality, as well as limited clinical therapeutic strategies. Established literature has shown that oxidative stress (OS), inflammation, excitotoxicity, and apoptosis play important roles in the pathophysiological processes of acute CNS injuries. Recently, there have been many studies on the topic of ferroptosis, a form of regulated cell death characterized by the accumulation of iron-dependent lipid peroxidation. Some studies have revealed an emerging connection between acute CNS injuries and ferroptosis. Ferroptosis, induced by the abnormal metabolism of lipids, glutathione (GSH), and iron, can accelerate acute CNS injuries. However, pharmaceutical agents, such as iron chelators, ferrostatin-1 (Fer-1), and liproxstatin-1 (Lip-1), can inhibit ferroptosis and may have neuroprotective effects after acute CNS injuries. However, the specific mechanisms underlying this connection has not yet been clearly elucidated. In this paper, we discuss the general mechanisms of ferroptosis and its role in stroke, TBI, and SCI. We also summarize ferroptosis-related drugs and highlight the potential therapeutic strategies in treating various acute CNS injuries. Additionally, this paper suggests a testable hypothesis that ferroptosis may be a novel direction for further research of acute CNS injuries by providing corresponding evidence.

Insulin-Like Growth Factor 2 (IGF-2) Regulates Neuronal Density and IGF-2 Distribution Following Hippocampal Intracerebral Hemorrhage

BACKGROUND

The insulin-like growth factor 2 (IGF-2) is a growth factor and anti-inflammatory cytokine that plays a crucial role in memory consolidation. However, the precise role of this factor in acute brain damage is still unclear. The present study aimed to evaluate the variations in hippocampal IGF-2 distribution on different days and investigate the effect of recombinant IGF-2 on memory cell density, and IGF-2 distribution following acute hippocampal damage resulting from intracerebral hemorrhage (ICH).

METHODS

ICH was induced by injection of 100 μL of autologous blood into the left hippocampus of 72 male Sprague-Dawley rats. Recombinant IGF-2 was injected into the damaged hippocampus 30 min post-induction of ICH in the ICH-IGF-2 group. Then, on postoperative days 1, 3, 7, and 14, samples of brain tissue were collected to perform histopathological and immunohistochemical examinations.

RESULTS

The stereological study indicated that the volume of the hippocampus and the number of neurons had a significant reduction, and the infarct volume had a significant increase following ICH. Following the injection of IGF-2, a significant improvement was observed in stereological studies. Immunohistochemical data showed that IGF-2 distribution increased in the hippocampus on different days after ICH, and IGF-2 injection led to a dramatic reduction in this distribution.

CONCLUSIONS

In summary, the gradual increase of endogenous IGF-2 as growth and anti-inflammatory factor following hemorrhagic stroke reveals a critical role of this factor in brain recovery after injury. Moreover, the injection of IGF-2 can prevent cell death and alleviate the damage caused by the hemorrhagic stroke.

Different responses after intracerebral hemorrhage between young and early middle-aged mice

Although aging is a major risk factor for intracerebral hemorrhage (ICH), there are very few studies comparing ICH pathology between young and early middle-aged mice. In this study, 8-month old mice (early middle-aged mice) were compared against 2-month old mice (young mice) in neurological and histological changes after ICH induction, such as body weight, lesion volume, astrocytic responses, and motor and cognitive functions. At day 8 after ICH, there was no significant difference in lesion volume between the two groups, and both groups did not exhibit significant cognitive decline, as assessed by spontaneous alternative Y-maze test. On the other hand, 8-month old mice showed delayed recovery from body weight loss, along with reduced astrocytic activation. Interestingly, in the two motor function tests (beam-walking test and corner turn test), 8-month old mice exhibited lower scores only in the beam-walking test, suggesting a partial disturbance in motor recovery after ICH. These results suggest that age-related differences in ICH pathology may already start to appear in early middle-aged brains.

Ferroptosis in Neurological Diseases

Ferroptosis is mechanism for non-apoptotic, iron-dependent, oxidative cell death that is characterized by glutathione consumption and lipid peroxides accumulation. Ferroptosis is crucially involved in neurological diseases, including neurodegeneration, stroke and neurotrauma. This review provides detailed discussions of the ferroptosis mechanisms in these neurological diseases. Moreover, it summarizes recent drugs that target ferroptosis for neurological disease treatment. Furthermore, it compares the differences and relationships among the various cell death mechanisms involved in neurological diseases. Elucidating the ferroptosis role in the brain can improve the understanding of neurological disease mechanism and provide potential prevention and treatment interventions for acute and chronic neurological diseases.

Treatment of intracerebral hemorrhage: Current approaches and future directions

Intracerebral hemorrhage (ICH) stands out among strokes, both for the severely morbid outcomes it routinely produces, and for the striking deficiency of defenses possessed against the same. The brain damage caused by ICH proceeds through multiple pathophysiological mechanisms, broadly differentiated into those considered primary, arising from the hematoma itself, and the secondary consequences of hematoma presence and expansion thereof. A number of interventions against ICH and its sequelae have been investigated (e.g., hemostatic therapies, blood pressure control, hematoma evacuation, and a variety of neuroprotective strategies), but conclusive demonstrations of clinical benefit have remained largely elusive. In this review, we begin with a description of these interventions and the trials in which they have been implemented, coupled with an attempt to account for their failure. Possible causes discussed include iatrogenic injury during hematoma evacuation, secondary injury initiated by hematoma persistence after evacuation, and inadequate therapeutic power arising from an excessively narrow focus on a single component of the complex pathophysiology of ICH injury. To conclude, we propose several strategies, such as enhancing endogenous hematoma resolution, hematoma evacuation-based neuroprotection, and multi-targeted therapy, that hold promise as prospects for the extension of anti-ICH therapy into the domain of clinical significance.

Towards brain-tissue-like biomaterials

Many biomaterials have been developed which aim to match the elastic modulus of the brain for improved interfacing. However, other properties such as ultimate toughness, tensile strength, poroviscoelastic responses, energy dissipation, conductivity, and mass diffusivity also need to be considered.

Pathophysiology of SARS-CoV-2 infection in patients with intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is associated with old age and underlying conditions such as hypertension and diabetes. ICH patients are vulnerable to SARS-CoV-2 infection and develop serious complications as a result of infection. The pathophysiology of ICH patients with SARS-CoV-2 infection includes viral invasion, dysfunction of the ACE2-Ang (1-7)-MasR and ACE-Ang II-AT₁R axes, overactive immune response, cytokine storm, and excessive oxidative stress. These patients have high morbidity and mortality due to hyaline membrane formation, respiratory failure, neurologic deficits, and multiple organ failure.

CCR1 Activation Promotes Neuroinflammation Through CCR1/TPR1/ERK1/2 Signaling Pathway After Intracerebral Hemorrhage in Mice

The activation of C-C chemokine receptor type 1 (CCR1) has been shown to be pro-inflammatory in several animal models of neurological diseases. The objective of this study was to investigate the activation of CCR1 on neuroinflammation in a mouse model of intracerebral hemorrhage (ICH) and the mechanism of CCR1/tetratricopeptide repeat 1 (TPR1)/extracellular signal-regulated kinase 1/2 (ERK1/2) signaling pathway in CCR1-mediated neuroinflammation. Adult male CD1 mice (n = 210) were used in the study. The selective CCR1 antagonist Met-RANTES was administered intranasally at 1 h after autologous blood injection. To elucidate potential mechanism, a specific ERK1/2 activator (ceramide C6) was administered prior to Met-RANTES treatment; CCR1 activator (recombinant CCL5, rCCL5) and TPR1 CRISPR were administered in naïve mouse. Neurobehavioral assessments, brain water content, immunofluorescence staining, and western blot were performed. The endogenous expressions of CCR1, CCL5, TPR1, and p-ERK1/2 were increased in the brain after ICH. CCR1 were expressed on microglia, neurons, and astrocytes. The inhibition of CCR1 with Met-RANTES improved neurologic function, decreased brain edema, and suppressed microglia/macrophage activations and neutrophil infiltration after ICH. Met-RANTES treatment decreased expressions of CCR1, TPR1, p-ERK, TNF-α, and IL-1β, which was reversed by ceramide C6. The brain CCR1 activation by rCCL5 injection in naïve mouse resulted in neurological deficits and increased expressions of CCR1, TPR1, p-ERK, TNF-α, and IL-1β. These detrimental effects of rCCL5 were reversed by TPR1 knockdown using TPR1 CRISPR. Our study demonstrated that CCR1 activation promoted neuroinflammation through CCR1/TPR1/ERK1/2 signaling pathway after ICH in mice. CCR1 inhibition with Met-RANTES attenuated neuroinflammation, thereby reducing brain edema and improving neurobehavioral functions. Targeting CCR1 activation may provide a promising therapeutic approach in the management of ICH patients.

Neurotoxic role of interleukin-17 in neural stem cell differentiation after intracerebral hemorrhage

Interleukin 17 (IL-17) and its main producer, T cell receptor γδ cells, have neurotoxic effects in the pathogenesis of intracerebral hemorrhage (ICH), aggravating brain injuries. To investigate the correlation between IL-17 and ICH, we dynamically screened serum IL-17 concentrations using enzyme-linked immunosorbent assay and explored the clinical values of IL-17 in ICH patients. There was a significant negative correlation between serum IL-17 level and neurological recovery status in ICH patients (r = -0.498, P < 0.01). To study the neurotoxic role of IL-17, C57BL/6 mice were used to establish an ICH model by injecting autologous blood into the caudate nucleus. Subsequently, the mice were treated with mouse neural stem cells (NSCs) and/or IL-17 neutralizing antibody for 72 hours. Flow cytometry, brain water content detection, Nissl staining, and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling results indicated that NSC transplantation significantly reduced IL-17 expression in peri-hematoma tissue, but there was no difference in T cell receptor γδ cells. Compared with the ICH group, there were fewer apoptotic bodies and more Nissl bodies in the ICH + NSC group and the ICH + NSC + IL-17 group. To investigate the potential effect of IL-17 on directional differentiation of NSCs, we cultured mouse NSCs (NE-4C) alone or co-cultured them with T cell receptor γδ cells, which were isolated from mouse peripheral blood mononuclear cells, for 7 days. The results of western blot assays revealed that IL-17 secreted by T cell receptor γδ cells reduced the differentiation of NSCs into astrocytes and neurons, while IL-17 neutralization relieved the inhibition of directional differentiation into astrocytes rather than neurons. In conclusion, serum IL-17 levels were elevated in the early stage of ICH and were negatively correlated with outcome in ICH patients. Animal experiments and cytological investigations therefore demonstrated that IL-17 probably has neurotoxic roles in ICH because of its inhibitory effects on the directional differentiation of NSCs. The application of IL-17 neutralizing antibody may promote the directional differentiation of NSCs into astrocytes. This study was approved by the Clinical Research Ethics Committee of Anhui Medical University of China (For human study: Approval No. 20170135) in December 2016. All animal handling and experimentation were reviewed and approved by the Institutional Animal Care and Use Committee of Anhui Medical University (approval No. 20180248) in December 2017.

miR-183-5p alleviates early injury after intracerebral hemorrhage by inhibiting heme oxygenase-1 expression

Differences in microRNA (miRNA) expression after intracerebral hemorrhage (ICH) have been reported in human and animal models, and miRNAs are being investigated as a new treatment for inflammation and oxidative stress after ICH. In this study, we found that microRNA-183-5p expression was decreased in the mouse brain after ICH. To investigate the effect of miRNA-183-5p on injury and repair of brain tissue after ICH, saline, miRNA-183-5p agomir, or miRNA-183-5p antagomir were injected into the lateral ventricles of 8-week-old mice with collagenase-induced ICH. Three days after ICH, mice treated with exogenous miRNA-183-5p showed less brain edema, neurobehavioral defects, inflammation, oxidative stress, and ferrous deposition than control mice. In addition, by alternately treating mice with a heme oxygenase-1 (HO-1) inducer, a HO-1 inhibitor, a nuclear factor erythroid 2-related factor (Nrf2) activator, and Nrf2 knockout, we demonstrated an indirect, HO-1-dependent regulatory relationship between miRNA-183-5p and Nrf2. Our results indicate that miRNA-183-5p and HO-1 are promising therapeutic targets for controlling inflammation and oxidative damage after hemorrhagic stroke.

Lower total protein and absence of neuronavigation are novel poor prognostic factors of endoscopic hematoma removal for intracerebral hemorrhage

OBJECTIVES

Endoscopic hematoma removal is widely performed for the treatment of intracerebral hemorrhage. We investigated the factors related to the prognosis of intracerebral hemorrhage after endoscopic hematoma removal.

MATERIALS AND METHODS

From 2013 to 2019, we retrospectively analyzed 75 consecutive patients with hypertensive intracerebral hemorrhage who underwent endoscopic hematoma removal. Their characteristics, including neurological symptoms, laboratory data, and radiological findings were investigated using univariate and multivariate analysis. Complications during hospitalization, Glasgow Coma Scale (GCS) score on day 7, and modified Rankin Scale (mRS) score at 6 months were considered as treatment outcomes.

RESULTS

The mean age of the patients (33 women, 42 men) was 71.8 (36-95) years. Mean GCS scores at admission and on day 7 were 10.3 ± 3.2 and 11.7 ± 3.8, respectively. The mean mRS score at 6 months was 3.8 ± 1.6, and poor outcome (mRS score ranging from 3 to 6 at 6 months) in 53 patients. Rebleeding occurred in 4 patients, and other complications in 15 patients. Multivariate analysis revealed that older age, hematoma in the basal ganglia, lower total protein level, higher glucose level, and absence of neuronavigation were associated with poor outcomes. Of the 75 patients, 9 had cerebellar hemorrhages, and they had relatively favorable outcomes compared to those with supratentorial hemorrhages.

CONCLUSION

Several factors were related to the prognosis of intracerebral hemorrhage after endoscopic hematoma removal. Lower total protein level at admission and absence of neuronavigation were novel factors related to poor outcomes of endoscopic hematoma removal for intracerebral hemorrhage.

Systemic Immune-Inflammation (SII) index predicts poor outcome after spontaneous supratentorial intracerebral hemorrhage

BACKGROUND AND AIMS

In experimental models, enhanced inflammation contributes to secondary brain injury in spontaneous intracerebral hemorrhage (ICH). Several inflammatory markers have investigated in humans with inconclusive results. Here, we report the relationship between Systemic Immune-Inflammation (SII) Index and outcome.

METHODS

We reviewed the medical records of 239 supratentorial spontaneous ICH patients. Patients were dichotomized based on modified Rankin Scale (mRS) at discharge in good (mRS 0-3) and poor (mRS 4-6) outcome. Demographic, clinical, laboratory and imaging data at admission were compared for both groups. SII index was calculated as [(Platelet counts x Absolute Neutrophil Counts (ANC)/Absolute Lymphocyte Counts (ALC))/1000]. Logistic regression analyses were performed to determine the association between markers of inflammation (ANC, ALC, Platelets, SII index) and outcome adjusting for baseline differences.

RESULTS

Sixty-two percent of patients had poor outcome (median [IQR] age= 60 [52-71] years). Patients with poor outcome had lower Glasgow coma scale, larger hematoma volumes, and higher incidence of diabetes and intraventricular extension (p<0.05 for each variable). In univariate analysis, ANC and SII index were independently associated with poor outcome (p<0.05). In multivariate analysis, only SII index remained significantly associated with poor outcome (OR=1.34, 95% CI=1.04-1.72, p=0.02). ROC analysis showed that adjusted SII index is a good discriminator for poor outcome (AUC=0.89, 95% CI=0.84-0.93; P <0.0001), with the best cut-off value being 0.73 (Sensitivity 95%, Specificity 71%).

CONCLUSIONS

In patients with supratentorial spontaneous ICH early SII index is an independent predictor of poor outcome at time of hospital discharge.

Endoscopic hematoma removal of supratentorial intracerebral hemorrhage under local anesthesia reduces operative time compared to craniotomy

The surgical efficacy for supratentorial intracerebral hemorrhage (ICH) remains unknown. We compared the advantages of the widely practiced endoscopic hematoma removal under local anesthesia with that of craniotomy under general anesthesia for ICH. We also focused on our novel operative concept of intentional hematoma leaving technique to avoid further damage to the brain. We retrospectively analyzed 134 consecutive patients (66 endoscopies and 68 craniotomies) who were surgically treated for supratentorial ICH. The characteristics of the 134 patients were as follows: The median (interquartile range) age was 73 (61-82) years. The median Glasgow Coma Scale scores at admission, on day 7, and the median modified Rankin Scale (mRS) score at 6 months were 10 (7-13), 13 (10-14), and 4 (3-5) respectively. The statistical comparison revealed there were no differences in GCS score on day seven between the endoscopy 13 (12-14) and craniotomy group 12 (9-14). No differences were observed in mRS scores at 6 months between the endoscopy 4 (2-5) and craniotomy group 4 (3-5). However, the patients treated with our technique tended to have favorable outcomes. Multivariate analysis revealed the operative time was significantly decreased in the endoscopy group compared to the craniotomy group (p < 0.001).

L-3-n-butylphthalide attenuates inflammation response and brain edema in rat intracerebral hemorrhage model

L-3-n-butylphthalide(NBP), a compound found in Apium graveolens Linn seed extracts, has a therapeutic effect on acute ischemic stroke. The pathological inflammatory pathways and consequent brain edema in intracerebral hemorrhage (ICH) share some similar characteristics with ischemic stroke. We hypothesized that NBP has anti-inflammatory and therapeutic effects on rats with ICH. ICH was induced by an infusion of bacterial collagenase type IV into the unilateral striatum of anesthetized rats. The therapeutic effect of NBP was measured by assessing neurological function, brain water content, blood-brain barrier permeability, and expression of tumor necrosis factor-alpha (TNF-α) and matrix metalloproteinase-9 (MMP-9) around the hematoma 48 hours after surgery. Magnetic resonance imaging was performed 4 and 48 hours after ICH induction, and ICH-induced injured area volumes were measured using T2-weighted images. The NBP treatment group performed better in the neurological function test than the vehicle group. Moreover, in comparison with the vehicle group, NBP group showed a lower expanded hematoma volume, brain water content, blood-brain barrier permeability, and TNF-α/ MMP-9 expression level. Our results indicate that NBP attenuates inflammation and brain edema in rat ICH model. Therefore, our findings also provide a potential therapeutic strategy for the treatment of ICH with NBP.

The Potential Value of Targeting Ferroptosis in Early Brain Injury After Acute CNS Disease

Acute central nervous system (CNS) disease is very common and with high mortality. Many basic studies have confirmed the molecular mechanism of early brain injury (EBI) after acute CNS disease. Neuron death and dysfunction are important reasons for the neurological dysfunction in patients with acute CNS disease. Ferroptosis is a nonapoptotic form of cell death, the classical characteristic of which is based on the iron-dependent accumulation of toxic lipid reactive oxygen species. Previous studies have indicated that this mechanism is critical in the cell death events observed in many diseases, including cancer, tumor resistance, Alzheimer’s disease, Parkinson’s disease, stroke, and intracerebral hemorrhage (ICH). Ferroptosis may also play a very important role in EBI after acute CNS disease. Unresolved issues include the relationship between ferroptosis and other forms of cell death after acute CNS disease, the specific molecular mechanisms of EBI, the strategies to activate or inhibit ferroptosis to achieve desirable attenuation of EBI, and the need to find new molecular markers of ferroptosis that can be used to detect and study this process in vivo after acute CNS disease.

Noncoding RNAs and Intracerebral Hemorrhage

BACKGROUND & OBJECTIVE

Intracerebral hemorrhage (ICH) is the most devastating subtype of stroke, for which there are few effective interventions. Computed tomography is accepted as the gold standard for diagnosis, whereas surgical evacuation is the main treatment for ICH. However, in emergency rooms, time is limited and information regarding a patient's clinical status or tolerance is typically not available. Many studies over the last decade have investigated the fundamental mechanisms of ICH and especially hematoma, which not only cause physical damage but also release toxins that have detrimental effects. However, there remain many gaps in our understanding of ICH. Compared to ischemic stroke, there is little known about the ICH pathogenesis and treatment options, and few specific biomarkers are available for monitoring disease progression, which include hematoma enlargement and perihematoma edema. Noncoding RNAs (ncRNAs) are involved in various biological processes and are potential biomarkers and therapeutic tools in central nervous system diseases. Recent studies have examined the role of ncRNAs including microRNAs, long noncoding RNAs, and circular RNAs-the three main subgroups associated with stroke-in ICH models. A deeper understanding of the functions of ncRNAs in different biological processes can provide a basis for developing more effective therapeutic strategies to prevent neuronal damage following ICH. In clinical settings, ncRNAs can serve as biomarkers for predicting the degree of injury resulting from ICH.

CONCLUSION

In this review, we discuss the current state of knowledge of the role of ncRNAs in ICH.

The role of medical gas in stroke: an updated review

Medical gas is a large class of bioactive gases used in clinical medicine and basic scientific research. At present, the role of medical gas in neuroprotection has received growing attention. Stroke is a leading cause of death and disability in adults worldwide, but current treatment is still very limited. The common pathological changes of these two types of stroke may include excitotoxicity, free radical release, inflammation, cell death, mitochondrial disorder, and blood-brain barrier disruption. In this review, we will discuss the pathological mechanisms of stroke and the role of two medical gases (hydrogen and hydrogen sulfide) in stroke, which may potentially provide a new insight into the treatment of stroke.

Long-term Outcomes and Risk Factors Related to Hydrocephalus After Intracerebral Hemorrhage

Hydrocephalus after intracerebral hemorrhage (ICH) is a common and treatable complication. However, the long-term outcomes and factors for predicting hydrocephalus have seldom been studied. The goal of this study was to determine the long-term outcomes and analyze the risk factors of hydrocephalus after ICH. A consecutive series of 1342 patients with ICH were reviewed from 2010 to 2016 to identify significant risk factors for hydrocephalus. Patients with a first-ever ICH without any prior diagnosis of hydrocephalus after ICH were followed up for survival status and cause of death. Risk factors for hydrocephalus were evaluated by using logistic regression analysis. Out of a total of 1342 ICH patients, 120 patients (8.9%) had hydrocephalus. The risk factors for hydrocephalus (≤ 3 days) were infratentorial hemorrhage (p = 0.000), extension to ventricles (p = 0.000), greater ICH volume (p = 0.09), and hematoma expansion (p = 0.01). Extension to ventricles (p = 0.022) was the only independent risk factor for hydrocephalus (4-13 days), while extension to ventricles (p = 0.028), decompressive craniotomy (p = 0.032), and intracranial infection (p = 0.001) were independent predictors of hydrocephalus (≥ 14 days). Patients were followed up for a median of 5.2 years (IQR 3.3-7.3 years). Estimated all-cause mortality was significantly higher in the ICH patients with hydrocephalus than that without hydrocephalus (HR 3.22, 95% CI 2.42-4.28; p = 0.000). Fifty-nine (49.2%) died and 40 (33.3%) had a favorable outcome in patients with hydrocephalus. Of all deaths, 30.5% were from ICH and 64.4% from infection. Hydrocephalus is a frequent complication of ICH and most commonly occurs at the onset of ICH. Patients with hydrocephalus show relatively higher mortality. ClinicalTrials.gov Identifier: NCT02135783 (May 7, 2014).

Brainstem iron overload and injury in a rat model of brainstem hemorrhage

BACKGROUND AND PURPOSE

Brainstem hemorrhage (BSH) is the most devastating subtype of intracerebral hemorrhage (ICH) with the highest mortality ranging from 56 % to 61.2 %. However, there is no effective medical or surgical therapy to improve its outcomes in clinic to date due to lack of understanding of its injury mechanisms. Herein, we explored the brainstem iron overload and injury in a rat model of BSH.

METHODS

Neurological scores were examined on day 1, 3, and 7 after modeling, and mortality of the rats was recorded to draft a survival curve. Rats were monitored by MRI using T2 and susceptibility weighted imaging (SWI) before sacrifice for examination of histology and immunofluorescence on day 1, 3, and 7.

RESULTS

BSH rats had a high mortality of 56 % and demonstrated the severe neurological deficits mimicking the clinical conditions. SWI showed that the same increasing tendency in change of hypointense area with that in iron deposition by Perls staining from day 1 to 7. Expression of heme oxygenase 1 (HO-1) and generation of reactive oxygen species (ROS) had similar tendency and both peaked on day 3. Neuronal degeneration occurred and stayed elevated from day 1 to 7, while myelin sheath injury was initially observed on day 1 but without significant difference within 7 days.

CONCLUSIONS

The time courses of erythrocyte lysis, HO-1 expression, iron deposition and ROS generation are related to each other after BSH. Besides, brainstem injury including neuronal degeneration and myelin damage were observed and discussed.

Intracranial pressure monitoring in patients with spontaneous intracerebral hemorrhage

OBJECTIVE

The utility of ICP monitoring and its benefit with respect to outcomes after ICH is unknown. The aim of this study was to compare intracerebral hemorrhage (ICH) outcomes in patients who underwent intracranial pressure (ICP) monitoring to those who were managed by care-guided imaging and/or clinical examination alone.

METHODS

This was a retrospective analysis of data from the Ethnic/Racial variations of Intracerebral Hemorrhage (ERICH) study between 2010 and 2015. ICH patients who underwent ICP monitoring were propensity-score matched, in a 1:1 ratio, to those who did not undergo ICP monitoring. The primary outcome was 90-day mortality. Secondary outcomes were in-hospital mortality, hyperosmolar therapy use, ICH evacuation, length of hospital stay, and 90-day modified Rankin Scale (mRS) score, excellent outcome (mRS score 0-1), good outcome (mRS score 0-2), Barthel Index, and health-related quality of life (HRQoL; measured by EQ-5D and EQ-5D visual analog scale [VAS] scores). A secondary analysis for patients without intraventricular hemorrhage was performed.

RESULTS

The ICP and no ICP monitoring cohorts comprised 566 and 2434 patients, respectively. The matched cohorts comprised 420 patients each. The 90-day and in-hospital mortality rates were similar between the matched cohorts. Shift analysis of 90-day mRS favored no ICP monitoring (p < 0.001). The rates of excellent (p < 0.001) and good (p < 0.001) outcome, Barthel Index (p < 0.001), EQ-5D score (p = 0.026), and EQ-5D VAS score (p = 0.004) at 90 days were lower in the matched ICP monitoring cohort. Rates of mannitol use (p < 0.001), hypertonic saline use (p < 0.001), ICH evacuation (p < 0.001), and infection (p = 0.001) were higher, and length of hospital stay (p < 0.001) was longer in the matched ICP monitoring cohort. In the secondary analysis, the matched cohorts comprised 111 patients each. ICP monitoring had a lower rate of 90-day mortality (p = 0.041). Shift analysis of 90-day mRS, Barthel Index, and HRQoL metrics were comparable between the matched cohorts.

CONCLUSIONS

The findings of this study do not support the routine utilization of ICP monitoring in patients with ICH.

Arundic Acid (ONO-2506), an Inhibitor of S100B Protein Synthesis, Prevents Neurological Deficits and Brain Tissue Damage Following Intracerebral Hemorrhage in Male Wistar Rats

Stroke is one of the leading causes of mortality and neurological morbidity. Intracerebral hemorrhage (ICH) has the poorest prognosis among all stroke subtypes and no treatment has been effective in improving outcomes. Following ICH, the observed high levels of S100B protein have been associated with worsening of injury and neurological deficits. Arundic acid (AA) exerts neuroprotective effects through inhibition of astrocytic synthesis of S100B in some models of experimental brain injury; however, it has not been studied in ICH. The aim of this study was to evaluate the effects of intracerebroventricular (ICV) administration of AA in male Wistar rats submitted to ICH model assessing the following variables: reactive astrogliosis, S100B levels, antioxidant defenses, cell death, lesion extension and neurological function. Firstly, AA was injected at different doses (0.02, 0.2, 2 and 20 μg/μl) in the left lateral ventricle in order to observe which dose would decrease GFAP and S100B striatal levels in non-injured rats. Following determination of the effective dose, ICH damage was induced by IV-S collagenase intrastrial injection and 2 μg/μl AA was injected through ICV route immediately before injury. AA treatment prevented ICH-induced neurological deficits and tissue damage, inhibited excessive astrocytic activation and cellular apoptosis, reduced peripheral and central S100B levels (in striatum, serum and cerebrospinal fluid), improved neuronal survival and enhanced the antioxidant defences after injury. Altogether, these results suggest that S100B is a viable target for treating ICH and highlight AA as an interesting strategy for improving neurological outcome after experimental brain hemorrhage.

CT-Based Classification of Acute Cerebral Edema: Association with Intracranial Pressure and Outcome

BACKGROUND AND PURPOSE

Brain edema after acute cerebral lesions may lead to raised intracranial pressure (ICP) and worsen outcome. Notwithstanding, no CT-based scoring system to quantify edema formation exists. This retrospective correlative analysis aimed to establish a valid and definite CT score quantifying brain edema after common acute cerebral lesions.

METHODS

A total of 169 CT investigations in 60 patients were analyzed: traumatic brain injury (TBI; n = 47), subarachnoid hemorrhage (SAH; n = 70), intracerebral hemorrhage (ICH; n = 42), and ischemic stroke (n = 10). Edema formation was classified as 0: no edema, 1: focal edema confined to 1 lobe, 2: unilateral edema > 1 lobe, 3: bilateral edema, 4: global edema with disappearance of sulcal relief, and 5: global edema with basal cisterns effacement. ICP and Glasgow Outcome Score (GOS) were correlated to edema formation.

RESULTS

Median ICP values were 12.0, 14.0, 14.9, 18.2, and 25.9 mm Hg in grades 1-5, respectively. Edema grading significantly correlated with ICP (r = .51; P < .0001) in focal and global cerebral edema, particularly in patients with TBI, SAH, and ICH (r = .5, P < .001; r = .5; P < .0001; r = .6, P < .0001, respectively). At discharge, 23.7% of patients achieved a GOS of 5 or 4, 65.0% reached a GOS of 3 or 2, and 11.9% died (GOS 1). CT-score of cerebral edema in all patients correlated with outcome (r = -.3, P = .046).

CONCLUSION

The proposed CT-based grading of extent of cerebral edema significantly correlated with ICP and outcome in TBI, SAH, and ICH patients and might be helpful for standardized description of CT-images and as parameter for clinical studies, for example, measuring effects of antiedematous therapies.