Risk factors for intracerebral hemorrhage in the general population: a systematic review

Effects of Fine Particulate Matter on Cardiovascular Disease Morbidity: A Study on Seven Metropolitan Cities in South Korea

Objectives: The primary purpose of this study is to analyze the relationship between the first occurrence of hospitalization for cardiovascular disease (CVD) and particulate matter less than 2.5 μm in diameter (PM2.5) exposure, considering average PM2.5 concentration and the frequency of high PM2.5 concentration simultaneously.

Methods: We used large-scale cohort data from seven metropolitan cities in South Korea. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) using the Cox proportional-hazards model, including annual average PM2.5 and annual hours of PM2.5 concentration exceeding 55.5 μg/m³ (FH55).

Results: We found that the risk was elevated by 11.6% (95% CI, 9.7–13.6) for all CVD per 2.9 μg/m³ increase of average PM2.5. In addition, a 94-h increase in FH55 increased the risk of all CVD by 3.8% (95% CI, 2.8–4.7). Regarding stroke, we found that people who were older and had a history of hypertension were more vulnerable to PM2.5 exposure.

Conclusion: Based on the findings, we conclude that accurate forecasting, information dissemination, and timely warning of high concentrations of PM2.5 at the national level may reduce the risk of CVD occurrence.

Intracerebral Hemorrhage: The Effects of Aging on Brain Injury

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

Chronic Nicotine Exposure Increases Hematoma Expansion Following Collagenase-Induced Intracerebral Hemorrhage in Rats

Spontaneous intracerebral hemorrhage (sICH) is a deadly stroke subtype, and tobacco use increases sICH risk. However epidemiological studies show that, there are no confirmatory studies showing the effect of tobacco use on sICH outcome. Therefore, we evaluated the effect of chronic nicotine exposure (as a surrogate for tobacco use) on outcomes following sICH. Young male and female rats were randomly assigned to either nicotine (4.5 mg/kg b.w. per day) or vehicle (saline) treatment (2–3 weeks) groups. sICH was induced by injecting collagenase into the right striatum. Neurological score and hematoma volume were determined 24 h post-sICH. The hematoma volumes in nicotine-treated male and female rats were significantly higher by 42% and 48% when compared to vehicle-treated male and female rats, respectively. Neurological deficits measured in terms of neurological score for the nicotine-treated male and female groups were significantly higher when compared to the respective vehicle-treated male and female groups. Our results show that chronic nicotine exposure increases hematoma volume post-sICH in rats of both sexes. Identifying the mechanism of nicotine-dependent increase in hematoma growth post-sICH will be crucial to understanding the detrimental effect of tobacco use on the severity of bleeding following intracerebral hemorrhage.

Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions

Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.

Association of blood eicosapentaenoic acid levels with intracerebral hemorrhage during the COVID-19 pandemic: preliminary experience from a single-center in Japan

Background

The COVID-19 pandemic has forced lockdowns and declarations of states of emergency, resulting in marked changes to daily life such as dietary habits in many countries. Though serum omega-3 polyunsaturated fatty acids levels have been shown to be useful markers for recurrent vascular events or worse prognosis in cardiovascular diseases and ischemic stroke, the relationship between serum omega-3 PUFA levels and the occurrence of intracerebral hemorrhage has essentially been unknown. We explored the association of serum omega-3 polyunsaturated fatty acids with intracerebral hemorrhage during the COVID-19 pandemic.

Methods

Participants comprised patients admitted to Juntendo University Hospital (Tokyo, Japan) with intracerebral hemorrhage between January 1, 2016 and April 30, 2020. Clinical characteristics including serum omega-3 polyunsaturated fatty acid levels were compared between patients developing intracerebral hemorrhage during the period from January 1, 2016 to February 29, 2020, and the subsequent COVID-19 pandemic period (March 1 to April 30, 2020). Clinical characteristics independently related to intracerebral hemorrhage during the COVID-19 pandemic were analyzed by comparing these two cohorts of intracerebral hemorrhage patients in different periods.

Results

A total of 103 patients (age, 67.0 ± 13.9 years; 67 males) with intracerebral hemorrhage were enrolled. Intracerebral hemorrhage developed in 91 patients before and 12 patients during the COVID-19 pandemic. Monthly averages of intracerebral hemorrhage patients admitted to our hospital during and before the COVID-19 pandemic were 6 and 1.82, respectively. Serum eicosapentaenoic acid levels were significantly lower in intracerebral hemorrhage patients during the COVID-19 pandemic than before (31.87 ± 12.93 μg/ml vs. 63.74 ± 43.29 μg/ml, p = 0.007). Multiple logistic regression analysis showed that, compared to before the COVID-19 pandemic, dyslipidemia (odds ratio 0.163, 95% confidence interval 0.031–0.852; p = 0.032) and eicosapentaenoic acid levels (odds ratio 0.947, 95% confidence interval 0.901–0.994; p = 0.029) were associated with intracerebral hemorrhage during the COVID-19 pandemic.

Conclusions

From our preliminary results, low eicosapentaenoic acid levels were linked with intracerebral hemorrhage during the COVID-19 pandemic. Low levels of eicosapentaenoic acid might be an endogenous surrogate marker for intracerebral hemorrhage during the COVID-19 pandemic.

Minimally Invasive Surgery for Intracerebral and Intraventricular Hemorrhage

Spontaneous intracerebral hemorrhage (ICH), especially related to intraventricular hemorrhage (IVH), is the most devastating type of stroke and is associated with high mortality and morbidity. Optimal management of ICH remains one of the most controversial areas of neurosurgery and no effective treatment exists for ICH. Studies comparing conventional surgical interventions with optimal medical management failed to show significant benefit. Recent exploration of minimally invasive surgery for ICH and IVH including catheter- and mechanical-based approaches has shown great promise. Early phase clinical trials have confirmed the safety and preliminary treatment effect of minimally invasive surgery for ICH and IVH. Pending efficacy data from phase III trials dealing with diverse minimally invasive techniques are likely to shape the treatment of ICH.

Controlling blood pressure soon after intracerebral hemorrhage: The SAMURAI-ICH Study and its successors

The impact of acute therapy for intracerebral hemorrhage (ICH) lags far behind that for acute ischemic stroke. Intensive blood pressure lowering is a promising therapeutic strategy for acute ICH, especially for East Asian patients whose etiological mechanism is more commonly hypertension than that of patients in the Western population. A multicenter, prospective, observational study named the Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-IntraCerebral Hemorrhage (SAMURAI-ICH) study, involving 211 patients from ten Japanese stroke centers, was performed to elucidate the safety and feasibility of blood pressure lowering to 160 mmHg or less in acute ICH patients using intravenous nicardipine. When we started the study, intravenous nicardipine was not officially approved for hyperacute ICH patients in Japan. The SAMURAI-ICH study was also a pilot study to judge the feasibility of participation by many Japanese investigators in an international, randomized, controlled trial named the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)−2 trial. The SAMURAI-ICH study, ATACH-2 trial, and their combined individual participant data meta-analysis produced several new interesting findings on how to control blood pressure levels in acute ICH patients. Some of the findings are introduced in the present review article.

Different paradigms of transcranial electrical stimulation improve motor function impairment and striatum tissue injuries in the collagenase-induced intracerebral hemorrhage rat model

Background

In the horizon of therapeutic restrictions in intracerebral hemorrhage (ICH), recently, non-invasive transcranial electrical stimulation (tES) has achieved considerable prosperities. Translational studies have postulated that transcranial direct current stimulation (tDCS) and the other types of tES remain potentially a novel therapeutic option to reverse or stabilize cognitive and motor impairments.

Objective

The aim of this study was to comparatively evaluate the effects of the four main paradigms of tES, including tDCS, transcranial alternating (tACS), pulsed (tPCS), and random noise (tRNS) stimulations on collagenase-induced sensorimotor impairments and striatum tissue damage in male rats.

Methods

To induce ICH, 0.5 μl of collagenase was injected into the right striatum of male Sprague Dawley rats. One day after surgery, tES, was applied to the animals for seven consecutive days. Motor functions were appraised by neurological deficit score, rotarod, and wire hanging tests on the day before surgery and postoperative days 3, 7, and 14. After behavioral tests, brain tissue was prepared appropriately to perform the stereological evaluations.

Results

The results indicated that the application of the four tES paradigms (tDCS, tACS, tRNS, and tPCS) significantly reversed motor disorders in collagenase-induced ICH groups. Further, the motor function improvement of tACS and tRNS receiving rats in wire-hanging and rotarod tests were higher than the other two tES receiving groups. Structural changes and stereological assessments also confirmed the results of behavioral functions.

Conclusion

Our findings suggest that in addition to tDCS application in the treatment of ICH, other tES paradigms, especially tACS and tRNS may be considered as add-on therapeutic strategies in stroke.

The Relative Contribution of Plasma Homocysteine Levels vs. Traditional Risk Factors to the First Stroke: A Nested Case-Control Study in Rural China

Background

Approximately 75% of Chinese hypertensive patients have elevated homocysteine (Hcy). Its implication in risk assessment and prevention of the first stroke remains an important clinical and public health question.

Methods

This study was based on a community cohort recruited from 2016 to 2018 in the rural China. To maximize cost efficiency, we used a nested case-control design, including 3,533 first stroke cases and 3,533 controls matched for age ±1 years, sex, and village. Individual associations of tHcy and traditional risk factors with the first stroke were examined, and their population-attributable risks (PARs) were estimated.

Results

There was a significant dose-response association between first stroke and total Hcy (tHcy) levels, with adjusted odds ratios of 1.11 (95% CI: 0.97, 1.26) for tHcy 10–15 μmol/L and 1.44 (1.22, 1.69) for tHcy ≥ 15 μmol/L, all compared to tHcy < 10 μmol/L. A similar trend was found for ischemic and hemorrhagic stroke. tHcy and systolic blood pressure (SBP) were independently and additively associated with the risk of first stroke (tHcy: 1.06 [1.02, 1.1]; SBP: 1.13 [1.1, 1.16]; P-interaction, 0.889). Among the ten main risk factors examined, the top two contributors to the first stroke were SBP and tHcy, with PARs of 25.73 and 11.24%, respectively.

Conclusions

Elevated tHcy is the second most important contributor and acts additively with SBP to increase the risk of the first stroke. This finding underscores the importance of screening and treating elevated tHcy along with traditional risk factors to further reduce the burden of the first stroke in the high-risk populations.

A minimally invasive strategy to evacuate hematoma by synergy of an improved ultrasonic horn with urokinase: an in-vitro study

OBJECTIVES

In this study, Ultrasound Needle-an improved minimally invasive ultrasonic horn device was used to explore its potential of synergizing with urokinase in enhancing clots lysis in an in-vitro intracranial hematoma model.

MATERIALS AND METHODS

10 ml bovine blood was incubated for 3 h at 37 ℃, and coagulated into clot to mimic intracranial hematoma in-vitro. Ultrasound Needle was an improved ultrasonic horn with a fine tip (1.80 mm) and metallic sheath, and had a frequency of 29.62 kHz. 10000 IU urokinase was injected through the metallic sheath during the vibration of Ultrasound Needle tip to lyse the clots for 8 minutes under different working parameter settings (n = 8) to explore the influence of parameters Amplitude (%) and Duty (%) on clot lysis weight (W₀ ). The maximum temperatures were measured by an infrared thermometer during the treatment process. The W₀ of different treatment groups (US (Ultrasound Needle), US+NS (normal saline), UK (urokinase), US+UK, n = 8) were compared to verify the synergistic lysis effect of Ultrasound Needle combined with urokinase at optimal working parameters (40% Amplitude, 20% Duty; input power 4.20 W; axial tip-vibration amplitude 69.17 μm). Clots samples after treatment were fixed overnight for macroscopic examination. And fluorescent frozen sections and scanning electron microscopy examination were performed to show microscopic changes in clots and evaluate the cavitation effect of Ultrasound Needle on promoting drug diffusion within the clots.

RESULTS

The clot lysis weight W₀ increased with the parameters Amplitude (%) and Duty (%), reached a peak (2.435±0.137 g) at 40% Amplitude and 20% Duty (input power 4.20 W), and then decreased. Higher Amplitude (%) and Duty (%) led to higher maximum temperature, and W₀ was negatively correlated with the maximum temperature after the peak (r = -0.958). At the optimal parameter setting, the maximum temperature was 33.8±0.9 ℃, and the W₀ of the US+UK group was more than 4 times of UK alone group (2.435±0.137 g vs 0.607±0.185 g). Fluorescent frozen sections confirmed that the ultrasound energy of Ultrasound Needle could mechanically damage the clot tissues and promote the intra-clots drug diffusion. Macroscopic examination showed that US+UK group caused larger clots lysis area than UK alone group (2.08 cm² vs 0.65 cm² ). In addition, electron microscopy examination exhibited that the fibrin filaments of the clots in US+UK group were lysed more thoroughly compared to single treatment groups.

CONCLUSIONS

Ultrasound Needle, an improved ultrasonic horn device, can mechanically damage the clot tissues and exhibit an excellent synergistic lysis effect with thrombolytic drugs. Therefore, Ultrasound Needle has great potential in providing a new minimally invasive strategy for rapid intracranial hematoma evacuation. This article is protected by copyright. All rights reserved.

B-Mode Ultrasound, a Reliable Tool for Monitoring Experimental Intracerebral Hemorrhage

Background: Magnetic resonance imaging (MRI) is currently used for the study of intracerebral hemorrhage (ICH) in animal models. However, ultrasound is an inexpensive, non-invasive and rapid technique that could facilitate the diagnosis and follow-up of ICH. This study aimed to evaluate the feasibility and reliability of B-mode ultrasound as an alternative tool for in vivo monitoring of ICH volume and brain structure displacement in an animal model.

Methods: A total of 31 male and female Sprague-Dawley rats were subjected to an ICH model using collagenase-IV in the striatum following stereotaxic references. The animals were randomly allocated into 3 groups: healthy (n = 10), sham (n = 10) and ICH (n = 11). B-mode ultrasound studies with a 13-MHz probe were performed pre-ICH and at 5 h, 48 h, 4 d and 1 mo post-ICH for the assessment of ICH volume and displacement of brain structures, considering the distance between the subarachnoid cisterns and the dura mater. The same variables were studied by MRI at 48 h and 1 mo post-ICH.

Results: Both imaging techniques showed excellent correlation in measuring ICH volume at 48 h (r = 0.905) and good at 1 mo (r = 0.656). An excellent correlation was also observed in the measured distance between the subarachnoid cisterns and the dura mater at 1 mo between B-mode ultrasound and MRI, on both the ipsilateral (r = 0.870) and contralateral (r = 0.906) sides of the lesion.

Conclusion: B-mode ultrasound imaging appears to be a reliable tool for in vivo assessment of ICH volume and displacement of brain structures in animal models.

Clinical profile and role of C-reactive protein and lactate dehydrogenase as prognostic marker and comparative efficacy of different pharmacotherapeutic agents in patients with cerebrovascular accident: An observational study

The current study was conducted to determine the role of C-reactive protein (CRP) and lactate dehydrogenase (LDH) as prognostic-marker and outcomes of different pharmacotherapeutic agents among patients with cerebrovascular accident (CVA). A hospital-based observational study was conducted and patients with CVA admitted were included. Serum-CRP on admission correlated positively with modified Rankin score (mRS) (r = 0.9, P < 0.001) in ischemic stroke, whereas no correlation between serum LDH with mRS (r = 0.1, P = 0.5) was observed. Neither CRP nor LDH was helpful in predicting the outcome in hemorrhagic stroke. The use of Vitamin B12 was associated with favorable outcome in ischemic CVA cases and use of folic acid was associated with favorable outcome among hemorrhagic-CVA patients.

Association between cardiovascular risk factors and intracranial hemorrhage in patients with acute leukemia

BACKGROUND

Intracranial hemorrhage is seen more frequently in acute leukemia patients compared to the general population. Besides leukemia related risk factors, also risk factors that are present in the general population might contribute to hemorrhagic complications in leukemia patients. Of those, cardiovascular risk factors leading to chronic vascular damage could modulate the occurrence of intracranial hemorrhage in these patients, as during their disease and treatment acute endothelial damage occurs due to factors like thrombocytopenia and inflammation.

OBJECTIVES

Our aim was to explore if cardiovascular risk factors can predict intracranial hemorrhage in acute leukemia patients.

METHODS

In a case control study nested in a cohort of acute leukemia patients, including 17 cases with intracranial hemorrhage and 55 matched control patients without intracranial hemorrhage, data on cardiovascular risk factors was collected for all patients. Analyses were performed via conditional logistic regression.

RESULTS

Pre-existing hypertension and ischemic heart disease in the medical history were associated with intracranial hemorrhage, with an incidence rate ratio of 12.9 (95% confidence interval (CI) 1.5 to 109.2) and 12.1 (95% CI 1.3 to110.7), respectively.

CONCLUSION

Both pre-existing hypertension and ischemic heart disease seem to be strong predictors of an increased risk for intracranial hemorrhage in leukemia patients.

Trigger Factors for Spontaneous Intracerebral Hemorrhage: A Case-Crossover Study

BACKGROUND AND PURPOSE

Whether certain activities can trigger spontaneous intracerebral hemorrhage (ICH) remains unknown. Insights into factors that trigger vessel rupture resulting in ICH improves knowledge on the pathophysiology of ICH. We assessed potential trigger factors and their risk for ICH onset.

METHODS

We included consecutive patients diagnosed with ICH between July 1, 2013, and December 31, 2019. We interviewed patients on their exposure to 12 potential trigger factors (eg, Valsalva maneuvers) in the (hazard) period soon before onset of ICH and their normal exposure to these trigger factors in the year before the ICH. We used the case-crossover design to calculate relative risks (RR) for potential trigger factors.

RESULTS

We interviewed 149 patients (mean age 64, 66% male) with ICH. Sixty-seven (45%) had a lobar hemorrhage, 60 (40%) had a deep hemorrhage, 19 (13%) had a cerebellar hemorrhage, and 3 (2%) had an intraventricular hemorrhage. For ICH in general, there was an increased risk within an hour after caffeine consumption (RR=2.5 [95% CI=1.8-3.6]), within an hour after coffee consumption alone (RR=4.8 [95% CI=3.3-6.9]), within an hour after lifting >25 kg (RR=6.6 [95% CI=2.2-19.9]), within an hour after minor head trauma (RR=10.1 [95% CI=1.7-60.2]), within an hour after sexual activity (RR=30.4 [95% CI=16.8-55.0]), within an hour after straining for defecation (RR=37.6 [95% CI=22.4-63.4]), and within an hour after vigorous exercise (RR=21.8 [95% CI=12.6-37.8]). Within 24 hours after flu-like disease or fever, the risk for ICH was also increased (RR=50.7 [95% CI=27.1-95.1]). Within an hour after Valsalva maneuvers, the RR for deep ICH was 3.5 (95% CI=1.7-6.9) and for lobar ICH the RR was 2.0 (95% CI=0.9-4.2).

CONCLUSIONS

We identified one infection and several blood pressure related trigger factors for ICH onset, providing new insights into the pathophysiology of vessel rupture resulting in ICH.

Impact of COVID-19 pandemic on haemorrhagic stroke admissions: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

COVID-19 pandemic, a global health crisis, is disrupting the present medical environment. This systematic review and meta-analysis aimed to evaluate the impact of the COVID-19 pandemic on stroke hospitalisations, especially haemorrhagic stroke.

METHODS

The EMBASE, PubMed, Web of Science, Elsevier, Medline, Cochrane Library and Google Scholar electronic databases were searched for all relevant studies. Two researchers independently screened the studies, extracted data and assessed the quality of the included studies. Odds ratio (OR), total events, OR and 95% CI were considered as the effect size. A fixed-effects model was used to pool the study-specific estimate. The present study was performed by using Review Manager (V.5.3.0) software. We assessed the risk of bias using the Newcastle-Ottawa Scale.

RESULTS

A total of 17 studies with 14 445 cases were included. Overall, the number of stroke admissions is lower in the pandemic period versus the control period (6252 vs 8193). The difference of haemorrhagic stroke is significant, with 1233 of 6252 cases in the pandemic group and 1621 of 8193 cases in the control group. Intracerebral haemorrhage is present in 461 of 1948 cases in the pandemic group and 618 of 2734 cases in the control group. As for subarachnoid haemorrhage, the difference between the two groups is significant, with 70 of 985 cases in the pandemic group and 202 of 1493 cases in the control group.

CONCLUSIONS

The number of stroke admissions is lower in the pandemic period compared with the control period. There is a higher rate of haemorrhagic stroke in the pandemic period. Subgroup analysis identifies a significant increase in the occurrence of intracerebral haemorrhage in the pandemic period. Due to limited data and the impact of a single article, the impact of COVID-19 pandemic on subarachnoid haemorrhage is unclear.

Stroke Risk Due to Smoking Characterized by Sex Differences in Japan: The Jichi Medical School Cohort Study

OBJECTIVES

Smoking is a risk factor for stroke. The relationship between smoking and the risk of different subtypes of stroke has not been fully elucidated. We investigated the relationship between smoking and the incidence of stroke in the Japanese population.

MATERIALS AND METHODS

This prospective, population-based cohort study included 11,324 participants (4447 men; 6877 women) from 12 districts in Japan, between April 1992 and July 1995. Participants were stratified according to smoking status (non-smoker [never smoked]/ex-smoker/current smoker). Male current smokers were further stratified according to the number of cigarettes smoked per day (1-14, 15-29, or ≥ 30). The non-smoking group was used as a reference. Cox proportional hazards analysis was used to determine the risk of stroke due to smoking.

RESULTS

Four hundred and seventeen new stroke events (212 men; 205 women) were recorded during a mean follow-up of 10.7 years, including 95 intracerebral hemorrhages (48 men; 47 women), 267 cerebral infarctions (152 men; 115 women), and 54 subarachnoid hemorrhages (12 men; 42 women). In multivariable analysis, the hazard ratios (95% confidence intervals) for male current smokers (≥ 30 cigarettes/day) were 1.89 (1.08-3.31) and 3.41 (1.22-9.57) for all strokes and intracerebral hemorrhages, respectively; those for female current smokers were 2.78 (1.62-4.74), 3.14 (1.51-6.54), and 4.03 (1.64-9.93) for all strokes, cerebral infarctions, and subarachnoid hemorrhages, respectively.

CONCLUSIONS

Smoking ≥ 30 cigarettes/day is a risk factor for stroke, especially intracerebral hemorrhage in men. Furthermore, smoking increases the risk of cerebral infarction and subarachnoid hemorrhage in women.

Prognostic indicators for the onset of ischaemic versus haemorrhagic stroke in stable coronary artery disease

The incidence of stroke may be increased in patients with coronary artery disease (CAD). We aimed to investigate the specific risk factors for the development of ischaemic and haemorrhagic stroke in stable CAD patients.Patients with stable CAD were prospectively enrolled for future cardiovascular events in Taiwan. All the patients had received coronary interventions and were stable for least 1 month before enrolment. The incidence of ischaemic stroke was identified and confirmed by telephone and hospital records. Baseline characteristics, including demographic data, lipid profiles, medications, and biomarkers for potential inflammatory and atherosclerosis, were analysed.In total, 1428 patients (age, 63.07 ± 11.4 years; 1207 males) were under standard medical treatment and regularly followed-up for at least 4 years. Multivariate logistic regression analysis showed that baseline serum myeloperoxidase (MPO) level (hazard ratio [HR]: 1.89, 95% CI: 1.16-3.10, P = .01) and statin use (HR: 0.37; 95% CI: 0.17-0.79, P = .01) were independently associated with the onset of ischaemic stroke. Age (HR: 1.07, 95% CI: 1.00-1.14, P = .04) and angiotensin receptor blocker (ARB) use (HR: 0.37, 95% CI: 0.17-0.79, P = .01) were independently associated with future onset of intracranial haemorrhage (ICH), implying the different mechanisms of ischaemic stroke and ICH.Age and ARB use were related to ICH onset. Baseline MPO level and statin use were independently associated with longer and shorter future ischaemic stroke onset in stable CAD patients, respectively. Further studies are indicated to confirm the potential mechanisms and advance individual risk stratification for the onset of different types of stroke in clinical CAD.

Risk factors for poor outcomes of spontaneous supratentorial cerebral hemorrhage after surgery

OBJECTIVE

This study aimed to explore the factors affecting the outcomes of spontaneous supratentorial cerebral hemorrhage 90 days after surgery.

METHODS

A total of 256 patients with spontaneous supratentorial intracerebral hemorrhage underwent craniotomy evacuation of hematoma. The control group included 120 patients who received conservative treatment. The patients were divided into two subgroups based on a bifurcation of the modified Rankin Scale (mRS) 90 days after clinical therapeutics: good outcome (mRS score 0-3) and poor outcome (mRS score 4-6). The differences in clinical and imaging data between the two subgroups were analyzed. Based on difference analysis results, a binary logistic regression model was constructed to analyze the influencing factors related to poor outcomes.

RESULTS

The difference analysis results in the surgery group showed statistically significant differences in age, sex, Glasgow Coma Score (GCS) on admission, coronary atherosclerosis, smoking, stroke history, blood glucose, D-dimer, hematoma size, deep cerebral hemorrhage, midline shift, hematoma burst into the ventricle, vortex sign, island sign, and black hole sign. Binary logistic regression analysis showed that deep cerebral hemorrhage, midline shift, and age > 58 years independently correlated with the poor outcomes of patients after surgery. The binary logistic regression results of the control group showed that age > 58 years and GCS ≤ 8 independently correlated with the poor outcomes of patients.

CONCLUSIONS

Deep cerebral hemorrhage, midline shift, and age > 58 years significantly increased the risk of adverse prognosis in patients after surgery. The findings might help select the clinical treatment plan and evaluate the postoperative prognosis of patients.

Long-term exposure to road traffic noise and stroke incidence: a Danish Nurse Cohort study

BACKGROUND

Road traffic noise has been linked to increased risk of ischemic heart disease, yet evidence on stroke shows mixed results. We examine the association between long-term exposure to road traffic noise and incidence of stroke, overall and by subtype (ischemic or hemorrhagic), after adjustment for air pollution.

METHODS

Twenty-five thousand six hundred and sixty female nurses from the Danish Nurse Cohort recruited in 1993 or 1999 were followed for stroke-related first-ever hospital contact until December 31st, 2014. Full residential address histories since 1970 were obtained and annual means of road traffic noise (L_den [dB]) and air pollutants (particulate matter with diameter < 2.5 μm and < 10 μm [PM_2.5 and PM₁₀], nitrogen dioxide [NO₂], nitrogen oxides [NOx]) were determined using validated models. Time-varying Cox regression models were used to estimate hazard ratios (HR) (95% confidence intervals [CI]) for the associations of one-, three-, and 23-year running means of L_den preceding stroke (all, ischemic or hemorrhagic), adjusting for stroke risk factors and air pollutants. The World Health Organization and the Danish government's maximum exposure recommendations of 53 and 58 dB, respectively, were explored as potential L_den thresholds.

RESULTS

Of 25,660 nurses, 1237 developed their first stroke (1089 ischemic, 148 hemorrhagic) during 16 years mean follow-up. For associations between a 1-year mean of L_den and overall stroke incidence, the estimated HR (95% CI) in the fully adjusted model was 1.06 (0.98-1.14) per 10 dB, which attenuated to 1.01 (0.93-1.09) and 1.00 (0.91-1.09) in models further adjusted for PM_2.5 or NO₂, respectively. Associations for other exposure periods or separately for ischemic or hemorrhagic stroke were similar. There was no evidence of a threshold association between L_den and stroke.

CONCLUSIONS

Long-term exposure to road traffic noise was suggestively positively associated with the risk of overall stroke, although not after adjusting for air pollution.

UCATR: Based on CNN and Transformer Encoding and Cross-Attention Decoding for Lesion Segmentation of Acute Ischemic Stroke in Non-contrast Computed Tomography Images

The acute ischemic stroke (AIS) impacts extensively all over the world, the early diagnosis can provide valuable property information of disease. However, it's difficult for our human eyes to distinguish the fine pathological changes. Here we introduce self-attention mechanisms and propose UCATR, an NCCT image segmentation network for AIS lesions. It uses the advantages of Transformer to effectively learn the global context features of the image, and is based on convolutional neural network (CNN) and Transformer as the encoder, adding Multi-Head Cross-Attention (MHCA) modules to the decoder to achieve high-precision spatial information recovery. This method is experimentally verified on the NCCT dataset of AIS provided by Chengdu Medical College in China to obtain that the Dice similarity coefficient of lesion segmentation is 73.58%, which is better than U-Net, Attention U-Net and TransUNet. Furthermore, we conduct ablation study on the MHCA module at three different positions in the decoder to prove its efficiency.

Impact of Pre-Stroke Antiplatelet Use on 3-Month Outcome After Ischemic Stroke

Background

Pre-stroke anti-platelet (PAP) therapy can potentially influence the severity and outcome after ischemic stroke.

Methods

We analyzed data from the prospective multicenter Indo-US collaborative stroke project for the impact of PAP therapy. Outcome measures included the admission National Institute of Health Stroke Scale (NIHSS) score, 3-month modified Rankin scale (mRS) score, and rates of in-hospital mortality and post-ischemic intracerebral hemorrhage.

Results

Among 2048 of 2066 patients (M:F = 2:1) with known pre-stroke medication status, 336 (16.3%) were on PAP therapy. As compared to the non-PAP group, the PAP group had significantly higher mean age (62.2 vs 57.4 years, P < 0.001) and significantly more men, vascular risk factors, cerebral microbleeds (12.8% vs 6.2%, P = 0.001) and intravenous thrombolysis treatment (17% vs. 10.6%, P = 0.001). Cardioembolic strokes were significantly more in the PAP group (P < 0.001), but not large artery atherosclerosis. No significant differences were observed in the median NIHSS score (9 vs. 10, P = 0.274), 3-month mRS (score 0-2,51.4% vs. 49.0%, P = 0.428), in-hospital mortality (8.6% vs. 7.8%, P = 0.592), or symptomatic post ischemic intracerebral haemorrhage (12.2% vs. 10.6%, P = 0.382). The PAP group had more stroke recurrence (6.6% vs. 2.9%, P = 0.002) which was not significant (P = 0.065) after multivariate regression analysis adjusting for age, sex and vascular risk factors. PAP therapy was not an independent predictor of initial stroke severity or stroke outcome.

Conclusion

PAP therapy has no significant effect on initial stroke severity, rates of post-ischemic hemorrhage with or without thrombolysis, in-hospital mortality, stroke recurrence, and 3-month outcome after ischemic stroke.

Anticoagulation after intracerebral hemorrhage in patients with atrial fibrillation: between Scylla and Charybdis

BACKGROUND

Oral anticoagulants (OAC) are indicated in patients with atrial fibrillation (AF) and high risk of ischemic stroke. However, the introduction of anticoagulation in patients with AF and previous intracerebral hemorrhage (ICH) is controversial. We aimed to better understand the efficacy and safety of OAC in this context and to assess the factors that may influence this decision.

METHODS

In a single-center retrospective observational study, patients with AF and ICH who survived hospitalization at a level A Stroke Unit between 2009 and 2018 were included. Patients were followed for two years after discharge. Data were collected regarding the introduction or not of OAC and the occurrence of major thrombotic/hemorrhagic events and death.

RESULTS

Ninety-five patients (75.2 ± 9.9 years) were included and 40 patients (42.1%) started OAC. Patients were more likely to initiate anticoagulation if they had: mechanical prosthetic valves, previous AF (p = 0.005) and previous OAC therapy (p < 0001); and less if they had previous hemorrhagic stroke (p < 0.005). During follow-up, 10.5% had at least one major hemorrhagic event (60% anticoagulated), 20% had at least one major thrombotic event (all non-anticoagulated) and 20% died. The only factor associated with the risk of bleeding was ICH score (OR:2.49 per 1-point increase; 95%CI:1.14-5.46). Patients who initiated anticoagulation had lower mortality than non-anticoagulated (OR:0.296; 95%CI:0.090-0-975). Previous ICH and higher CHA₂DS₂-VASc were associated with higher mortality.

CONCLUSION

In this retrospective series, anticoagulation reduced thrombotic events and overall mortality in patients admitted for ICH and AF, without a significant increase in bleeding risk.

Metabolomic analysis reveals potential biomarkers and serum metabolomic profiling in spontaneous intracerebral hemorrhage patients using UPLC/quadrupole time-of-flight MS

Spontaneous intracerebral hemorrhage (ICH) accounts for 10-20% of all strokes and contributes to higher mortalities and severe disabilities. The aims of this study were, therefore, to characterize novel biomarkers, metabolic disruptions, and mechanisms involving ICH. A total 30 ICH patients and 30 controls were enrolled in the study, and their clinical characteristics were analyzed. Nontargeted metabolomic analysis was conducted using ultra-performance liquid chromatography quadrupole time-of-flight tandem mass spectrometry (UPLC/Q-TOF). Multivariate statistical analysis and receiver operating characteristic curve analysis were used for screening and evaluating the predictive ability of biomarkers. ICH patients showed significantly higher systolic blood pressure, diastolic blood pressure, blood glucose levels, white blood cell counts, neutrophil count, percentage of neutrophils and globulin and a lower albumin/globin ratio when compared with controls. In sum, 11 important metabolites were identified, which were associated with disruption of fatty acid oxidation and sphingolipid and phospholipid metabolism, as well as increased inflammation, oxidative stress, and vascular pathologies. Further multiple logistic regression analyses of these metabolites showed that l-carnitine and phosphatidylcholine (20:3/22:6) have potential as biomarkers of ICH, and the area under the curve, sensitivity, specificity were 0.974, 90%, and 93%, respectively. These findings provide insights into the pathogenesis, early prevention, and diagnosis of ICH.

Prevalence of and factors associated with stroke in hypertensive patients in Thailand from 2014 to 2018: A nationwide cross-sectional study

Stroke is a significant cause of death and disability. In Thailand, it imposes a major health burden, and the prevalence of stroke is increasing, particularly in patients with hypertension (HT), diabetes mellitus (DM), and dyslipidemia (DLP). We aimed to determine the trends in the prevalence of stroke and the associated factors among Thai patients with HT. Nationwide cross-sectional studies were conducted annually in 2014, 2015 and 2018 based on data obtained from the Thailand DM/HT study. Nationally, representative patients with HT in Thailand were sampled with stratified one-stage cluster sampling. A total of 104,028 participants were included in this study. The prevalence of stroke remained constant, with prevalence rates of 4.0%, 3.8%, and 3.9% in 2014, 2015 and 2018, respectively (p for trend = 0.221). Our findings suggested that the management of stroke patients who are covered by the universal coverage scheme should be evaluated. Effective interventions, including promoting smoking cessation, attenuating cholesterol levels, and controlling blood pressure should be provided to hypertensive patients to prevent ischemic stroke. Young adults with HT should be more concerned about the possibility of stroke. The use of prophylactic low-dose aspirin should be carefully monitored to prevent hemorrhagic stroke.

PINK1 antagonize intracerebral hemorrhage by promoting mitochondrial autophagy

BACKGROUND

Intracerebral hemorrhage (ICH) causes neurotransmitter release, oligemia, membrane depolarization, mitochondrial dysfunction, and results in the high rate of mortality and functional disability. Here, we focus on PTEN-induced kinase 1 (PINK1), a mitochondrial-targeted protein kinase, and explore its role in ICH progression.

METHODS

The qPCR and Western blot were performed to examine the expression of PINK1 in ICH patients and mouse model. PINK1 gain- and loss-of-function mice were used to evaluate their protective role on brain injury and behavioral disorders. Flow cytometry was carried out, mitochondrial membrane potential and reactive oxygen species production were detected to explore the distribution and neuroprotective function of PINK1.

RESULTS

PINK1 mRNA was upregulated, however, its protein was downregulated in ICH patients. The reduction of PINK1 was mainly happened in microglial cells in ICH model. Overexpression of PINK1 is able to rescue ICH-induced behavioral disorders. PINK1 protects ICH-induced brain injury by promoting mitochondrial autophagy in microglia.

CONCLUSION

PINK1 possesses a neuroprotective role and antagonizes ICH by promoting mitochondrial autophagy, which may be of value as a therapeutic target for ICH treatment.

Risk of Early Childhood Obesity in Offspring of Women with Preeclampsia: A Population-Based Study

Preeclampsia (PE) is a major disease of pregnancy, with various short- or long-term complications for both the mother and offspring. We focused on the body mass index (BMI) of offspring and compared the incidence of obesity during early childhood between PE- and non-PE-affected pregnancies. Women with singleton births (n = 1,697,432) were identified from the Korea National Health Insurance database. The outcomes of offspring at 30-80 months of age were analyzed. The effects of PE on BMI and the incidence of obesity in the offspring were compared. The incidence of low birth weight (LBW) offspring was higher in the PE group (n = 29,710) than that in the non-PE group (n = 1,533,916) (24.70% vs. 3.33%, p < 0.01). However, BMI was significantly higher in the PE-affected offspring than that in non-PE-affected offspring. After adjusting for various factors, the risk of obesity was higher in the PE-affected offspring (odds ratio = 1.34, 95% confidence interval = 1.30-1.38). The BMI and incidence of obesity were higher during early childhood in the PE-affected offspring, even though the proportion of LBW was higher. These results may support the basic hypotheses for the occurrence of various cardiovascular and metabolic complications in PE-affected offspring. In addition, early-age incidence of obesity could influence PE management and child consultation in clinical applications.

Intracranial Hemorrhage in COVID-19 patients: A Case Series

Background

The coronavirus disease 2019 (COVID-19) pandemic is an ongoing public health emergency. While most cases end in asymptomatic or minor illness, there is growing evidence that some COVID-19 infections result in nonconventional dire consequences. We sought to describe the characteristics of patients with intracranial hemorrhage who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Also, with the existing literature, we raise the idea of a possible association between SARS-CoV-2 infection and intracranial hemorrhage and propose possible pathophysiological mechanisms connecting the two.

Methods

We retrospectively collected and analyzed intracranial hemorrhage cases who were also positive for SARS-CoV-2 from 4 tertiary-care cerebrovascular centers.

Results

We identified a total of 19 patients consisting of 11 males (58%) and 8 females (42%). Mean age was 52.2, with 95% younger than 75 years of age. With respect to COVID-19 illness, 50% had mild-to-moderate disease, 21% had severe disease, and 20% had critical disease requiring intubation. Of the 19 cases, 12 patients had intraparenchymal hemorrhage (63%), 6 had subarachnoid hemorrhage (32%), and 1 patient had a subdural hematoma (5%). A total of 43% had an intracerebral hemorrhage score of 0–2 and 57% a score of 3–6. Modified Rankin Scale cores at discharge were 0–2 in 23% and 3–6 in 77%. The mortality rate was 59%.

Conclusions

Our series sheds light on a distinct pattern of intracerebral hemorrhage in COVID-19–positive cases compared with typical non–COVID-19 cases, namely the severity of hemorrhage, high mortality rate, and the young age of patients. Further research is warranted to delineate a potential association between SARS-CoV-2 infection and intracranial hemorrhage.

Higher cerebral small vessel disease burden is associated with smaller hematoma volume in mixed-location intracerebral hemorrhage

OBJECTIVE

To study the relationship between cerebral small vessel disease (CSVD) and hematoma volume in mixed-location intracerebral hemorrhage (ICH), and non-mixed ICH (hypertensive arteriopathy/cerebral amyloid angiopathy-related ICH).

METHODS

We consecutively collected patients with primary ICH with MRI. Mixed-location ICH was defined as having ICH or cerebral microbleeds (CMBs) in both lobar and deep regions. CSVD markers including lacunes, white matter hyperintensities (WMH), CMBs, and enlarged perivascular spaces (EPVS) were assessed on brain MRI during hospitalization. Multivariable binary logistic regression (≥30 ml vs. <30 ml) and linear regression analyses (log-transformed hematoma volume as dependent variable) were implemented to explore the association between CSVD and hematoma volume.

RESULTS

Of the 167 included patients, 69 (41.3%) had mixed-location ICH, with higher prevalence of lacune, more CMB count, higher WMH score and total CSVD score than those with non-mixed ICH (all p < .001). Higher WMH score was associated with lower risk of hematoma volume ≥30 ml (adjusted OR 0.521, 95% CI 0.299-0.908, p = .021) in patients with mixed-location ICH. Also, multivariable linear regression showed the association of smaller hematoma volume with higher CSVD burden, especially in mixed-location ICH (β = -0.349, p = .019 for CMB ≥ 5; β = -0.183, p < .001 for WMH score; β = -0.456, p = .002 for EPVS>20 in basal ganglia and/or centrum semiovale; β = -0.256, p = .002 for CSVD score), while these relationships were not observed in non-mixed ICH.

CONCLUSIONS

Higher CSVD burden is associated with smaller hematoma volume in mixed-location ICH, but not in non-mixed ICH, which is novel and needs further studies with larger sample size to confirm our results and explore the underlying mechanisms.

Big Data Analysis of the Risk of Intracranial Hemorrhage in Korean Populations Taking Low-Dose Aspirin

OBJECTIVES

Aspirin has traditionally been used as an analgesic and anti-inflammatory drug; however, low-dose aspirin is known to increase the risk of gastrointestinal and intracranial hemorrhage. In this study, the risk of intracranial hemorrhage in patients taking low-dose aspirin was assessed.

MATERIALS AND METHODS

We used the Standard Sample Cohort DB dataset from the National Health Insurance Sharing Service of Korea. This dataset includes details of medical care and prescriptions for patients who used hospital services during a 14-year period throughout Korea. Of approximately 1 million total patients, data from 746,703 adults over the age of 30 years were included for analysis. An Χ² test was performed to assess the effect of low-dose aspirin on intracranial hemorrhage. In addition, the relationship between use of low-dose aspirin and intracranial hemorrhage was analyzed using multiple logistic regression with consideration of all confounding variables.

RESULTS

The results revealed no significant positive correlations between the use of low-dose aspirin and intracranial hemorrhage requiring hospitalization.

CONCLUSIONS

Big data analysis of 746,703 patients in Korea over a period of 14 years showed that serious intracranial hemorrhage requiring hospitalization was unrelated to low-dose aspirin use. Moreover, low-dose aspirin use reduced the risk of intracranial hemorrhage in Korean populations.

Baihui (DU20)-penetrating-Qubin (GB7) acupuncture regulates microglia polarization through miR-34a-5p/Klf4 signaling in intracerebral hemorrhage rats

Intracerebral hemorrhage (ICH) is the most devastating subtype of stroke with high morbidity and mortality. The previous study has confirmed the therapeutic effect of Baihui (DU20)-penetrating-Qubin (GB7) acupuncture on ICH, while the related mechanism is left to be revealed. The aim of this study was to investigate the relevant mechanisms. ICH rat models were established utilizing the autologous blood injection method and the beneficial effect was found after DU20-penetrating-GB7 acupuncture along with decreased miR-34a-5p levels in the perihemorrhagic penumbra. Inversely, upregulating miR-34a-5p expression inhibited microglia M2 polarization while accelerated M1 polarization through targeting Krüppel-like factor 4 (Klf4), and thereby diminished the protective effect of DU20-penetrating-GB7 acupuncture on ICH. The results suggested the therapeutic effect of DU20-penetrating-GB7 acupuncture on ICH might be attributed to its modulation on microglia polarization through miR-34a-5p/Klf4 signaling.

Direct cost of systemic arterial hypertension and its complications in the circulatory system from the perspective of the Brazilian public health system in 2019

INTRODUCTION

Systemic arterial hypertension (SAH), a global public health problem and the primary risk factor for cardiovascular diseases, has a significant financial impact on health systems. In Brazil, the prevalence of SAH is 23.7%, which caused 203,000 deaths and 3.9 million DALYs in 2015.

OBJECTIVE

To estimate the cost of SAH and circulatory system diseases attributable to SAH from the perspective of the Brazilian public health system in 2019.

METHODS

A prevalence-based cost-of-illness was conducted using a top-down approach. The population attributable risk (PAR) was used to estimate the proportion of circulatory system diseases attributable to SAH. The direct medical costs were obtained from official Ministry of Health of Brazil records and literature parameters, including the three levels of care (primary, secondary, and tertiary). Deterministic univariate analyses were also conducted.

RESULTS

The total cost of SAH and the proportion of circulatory system diseases attributable to SAH was Int$ 581,135,374.73, varying between Int$ 501,553,022.21 and Int$ 776,183,338.06. In terms only of SAH costs at all healthcare levels (Int$ 493,776,445.89), 97.3% were incurred in primary care, especially for antihypertensive drugs provided free of charge by the Brazilian public health system (Int$ 363,888,540.14). Stroke accounted for the highest cost attributable to SAH and the third highest PAR, representing 47% of the total cost of circulatory diseases attributable to SAH. Prevalence was the parameter that most affected sensitivity analyses, accounting for 36% of all the cost variation.

CONCLUSION

Our results show that the main Brazilian strategy to combat SAH was implemented in primary care, namely access to free antihypertensive drugs and multiprofessional teams, acting jointly to promote care and prevent and control SAH.

White Matter Injury After Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) accounts for 15% of all stroke cases. ICH is a devastating form of stroke associated with high morbidity, mortality, and disability. Preclinical studies have explored the mechanisms of neuronal death and gray matter damage after ICH. However, few studies have examined the development of white matter injury (WMI) following ICH. Research on WMI indicates that its pathophysiological presentation involves axonal damage, demyelination, and mature oligodendrocyte loss. However, the detailed relationship and mechanism between WMI and ICH remain unclear. Studies of other acute brain insults have indicated that WMI is strongly correlated with cognitive deficits, neurological deficits, and depression. The degree of WMI determines the short- and long-term prognosis of patients with ICH. This review demonstrates the structure and functions of the white matter in the healthy brain and discusses the pathophysiological mechanism of WMI following ICH. Our review reveals that the development of WMI after ICH is complex; therefore, comprehensive treatment is essential. Understanding the relationship between WMI and other brain cells may reveal therapeutic targets for the treatment of ICH.

Association between Angiotensin Converting Enzyme Insertion/Deletion gene polymorphism with the risk of Hemorrhagic Stroke: A systematic review and Meta-Analysis of 53 studies

BACKGROUND AND AIMS

Hemorrhagic stroke (HS) results in significant mortality and disability worldwide. Angiotensin Converting Enzyme (ACE) is responsible for blood pressure regulation and vascular homeostasis. Our objective was to conduct a comprehensive meta-analysis for ascertaining the association of ACE I/D polymorphism with HS since a number of studies depicted inconclusive evidence.

METHODS

Literature search was performed till July 10, 2020 in PubMed, EMBASE, Cochrane, Chinese National Knowledge Information and Google Scholar databases with keywords: ('Angiotensin Converting Enzyme' OR 'ACE') AND ('Single Nucleotide polymorphisms' OR 'SNP') AND ('Hemorrhagic stroke or 'HS'). Pooled Odds Ratio (OR) and 95% Confidence Interval (CI) were determined for gene-disease association using either fixed (when I² < 50%) or random effect (when I² > 50%) models. Risk of bias in studies was assessed using funnel plots and sensitivity analyses. Statistical analysis was performed using STATA version 13.0 software.

RESULTS

A total of 53 studies having 5186 HS and 7347 healthy control subjects were included in our meta-analysis. Pooled analyses showed that ACE I/D gene polymorphism had significant association with risk of HS in overall study population [(dominant model: OR = 1.29, 95% CI = 1.12-1.50 & recessive model: OR = 1.79, 95% CI = 1.46-2.20)]. Population subgroup analyses further revealed significant relationship of ACE I/D polymorphism with ICH in Asians (recessive: OR 1.97, 95% CI = 1.57-2.47) but not in Caucasians (recessive: OR 1.02, 95% CI = 0.76-1.36).

CONCLUSION

This meta-analysis suggests that ACE I/D polymorphism may lead to risk of HS and can be a potential biomarker for HS susceptibility especially in Asian population.

Obstructive Sleep Apnea as a Risk Factor for Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

To determine whether obstructive sleep apnea (OSA) is associated with intracerebral hemorrhage (ICH) risk, we assessed premorbid OSA exposure of patients with nontraumatic ICH and matched controls.

METHODS

Ethnic/Racial Variations of Intracerebral Hemorrhage is a multicenter, case-control study evaluating risk factors for ICH that recruited 3000 cases with ICH and 3000 controls. OSA status was ascertained using the Berlin Questionnaire as a surrogate for premorbid OSA. We performed logistic regression analyses to evaluate the association between OSA and ICH.

RESULTS

Two thousand and sixty-four (71%) cases and 1516 (52%) controls were classified as having OSA by the Berlin Questionnaire. Cases with OSA were significantly more likely to be male and have hypertension, heart disease, hyperlipidemia, and higher body mass index compared with those without OSA. OSA was more common among cases compared with controls (71% versus 52%, odds ratio, 2.28 [95% CI, 2.05-2.55]). In a multivariable logistic regression model, OSA was associated with increased risk for ICH (odds ratio, 1.47 [95% CI, 1.29-1.67]).

CONCLUSIONS

OSA is a risk factor for ICH.

Causality assessment between reported fatal cerebral haemorrhage and suspected drugs: developing a new algorithm based on the analysis of the Japanese Adverse Event Report (JADER) database and literature review

PURPOSE

Cerebral haemorrhage is a life-threatening event with various causes including adverse drug reactions (ADRs). Several methods have been proposed for the causality assessment of ADRs, but none specific for cerebral haemorrhage. The purpose of this study was to develop an algorithm for causality assessment between drugs and fatal cerebral haemorrhage, based on the analysis of data from the Japanese Adverse Drug Event Report (JADER) database and literature review.

METHODS

All fatal ADRs reported in the JADER database between April 2004 and March 2020 were searched, and literature on drug-related cerebral haemorrhage or general causality assessment was reviewed to summarise the information on causality between cerebral haemorrhage and ADRs.

RESULTS

Of the 50,095 cases identified in the JADER database, cerebral haemorrhage was the fifth most reported cause of fatal ADRs, but the causality of >80% of the events was published as 'Unassessable'. The literature review identified articles on drug-related cerebral haemorrhage and causality assessment methods in general. Based on these articles, information on five categories (temporal relationship, previous knowledge about the relationship between drug action and ADRs, alternative aetiological candidate, appropriateness of drug use, and the relationship between death and ADRs) was determined for causality assessment between a suspected drug and fatal cerebral haemorrhage; a new algorithm was created using this information.

CONCLUSION

In this study, the information considered necessary for causality assessment between drugs and fatal cerebral haemorrhage was reviewed and an assessment algorithm was developed. Future studies are needed to validate the usefulness of this method.

Risk of intracerebral haemorrhage from hypertension is greatest at an early age

Introduction

The risk of intracerebral haemorrhage (ICH) associated with hypertension (HTN) is well documented. While the prevalence of HTN increases with age, the greatest odds ratio (OR) for HTN as a risk for ischemic stroke is at an early age. We sought to evaluate if the risk for ICH from HTN was higher in the youngest patients of each race.

Patients and methods

The Ethnic/Racial Variations of ICH (ERICH) study is a prospective multicenter case-control study of ICH among whites, blacks, and Hispanics. Participants were divided into age groups based on race-specific quartiles. Cases in each race/age group were compared to controls using logistic regression (i.e., cases and controls unmatched). The probability of ICH among cases and controls for each race were compared against independent variables of HTN, quartile of age and interaction of quartile and age also using logistic regression.

Results

Overall, 2033 non-lobar ICH cases and 2060 controls, and 913 lobar ICH cases with 927 controls were included. ORs were highest in the youngest age quartile for non-lobar haemorrhage for blacks and Hispanics and highest in the youngest quartile for lobar haemorrhage for all races. The formal test of interaction between age and HTN was significant in all races for all locations with the exception of lobar ICH in whites (p = 0.2935).

Discussion

Hypertension is a strong independent risk factor for ICH irrespective of location among persons of younger age, consistent with the hypothesis that first exposure to HTN is a particularly sensitive time for all locations of ICH.

Rupture Risk of Intracranial Aneurysm and Prediction of Hemorrhagic Stroke after Liver Transplant

Postoperative hemorrhagic stroke (HS) is a rare yet devastating complication after liver transplantation (LT). Unruptured intracranial aneurysm (UIA) may contribute to HS; however, related data are limited. We investigated UIA prevalence and aneurysmal subarachnoid hemorrhage (SAH) and HS incidence post-LT. We identified risk factors for 1-year HS and constructed a prediction model. This study included 3544 patients who underwent LT from January 2008 to February 2019. Primary outcomes were incidence of SAH, HS, and mortality within 1-year post-LT. Propensity score matching (PSM) analysis and Cox proportional hazard analysis were performed. The prevalence of UIAs was 4.63% (n = 164; 95% confidence interval (CI), 3.95–5.39%). The 1-year SAH incidence was 0.68% (95% CI, 0.02–3.79%) in patients with UIA. SAH and HS incidence and mortality were not different between those with and without UIA before and after PSM. Cirrhosis severity, thrombocytopenia, inflammation, and history of SAH were identified as risk factors for 1-year HS. UIA presence was not a risk factor for SAH, HS, or mortality in cirrhotic patients post-LT. Given the fatal impact of HS, a simple scoring system was constructed to predict 1-year HS risk. These results enable clinical risk stratification of LT recipients with UIA and help assess perioperative HS risk before LT.

Deep versus Superficial Spontaneous Cerebellar Hemorrhages: Separated Vascular Etiologies with Different Clinical Consequences

BACKGROUND

Spontaneous cerebellar hemorrhage (CH) is a critical neurosurgical event. It is usually categorized as a homogenous group under the general term of deep/nonlobar intracerebral hemorrhage. However, increasing evidence suggests it is composed of 2 subgroups, separated from each other by their anatomic location (deep vs. superficial), as well as by their vascular etiology (small vessel disease vs. cerebral amyloid angiopathy).

OBJECTIVE

To identify any clinically significant differences between anatomically separated subgroups of CHs: deep versus superficial.

METHODS

This is a retrospective study on patients who were diagnosed with spontaneous CHs at a single tertiary center. On the basis of the radiologic location of the hematoma, patients were divided into 2 groups: deep (group 1) and superficial (group 2). Computerized medical records were extracted for multiple variables.

RESULTS

A total of 69 patients fulfilled the inclusion criteria. Fifty-three (77%) were in group 1, and 16 (23%) were in group 2. Having any vascular risk factor was associated with the highest odds ratio for having a deep CH. Morbid obesity (body mass index ≥30) and the use of antiplatelets were also associated with increased odds ratios. Group 1 is also associated with high prevalence of intraventricular hemorrhage, acute hydrocephalus, and less favorable outcome.

CONCLUSIONS

This study supports the notion that CH is most likely a heterogenous condition, composed of 2 subgroups, separated from each other in terms of anatomic location, vascular etiologies, and clinical consequences. Further studies on large cohort of patients are needed in order to accurately define the subgroups of this life-threatening event.

Restarting Oral Anticoagulation in Patients With Atrial Fibrillation After an Intracranial Hemorrhage

Atrial fibrillation is the most common sustained cardiac arrhythmia in the general population. In western countries with aging populations, atrial fibrillation poses a significant health concern, as it is associated with a high risk of thromboembolism, stroke, congestive heart failure, and myocardial infarction. Thrombi are generated in the left atrial appendage, and subsequent embolism into the cerebral circulation is a major cause of ischemic stroke. Therefore, patients have a lifetime risk of stroke, and those at high risk, defined as a CHA2DS2-VASc2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, age 65-74 yrs, sex category) ≥2, are usually placed on oral anticoagulants. Unfortunately, long-term anticoagulation poses bleeding risks, of which intracranial hemorrhage (ICH) is the most feared and deadly complication.In patients who survive an ICH, the question of oral anticoagulation resumption arises. It is a therapeutic dilemma in which clinicians must decide how to manage the risk of thromboembolism versus recurrent hemorrhage. Although there is a substantial amount of retrospective data on the topic of resumption of anticoagulation, there are, at this time, no randomized controlled trials addressing the issue. We therefore sought to address ICH risk and management, summarize high quality existing evidence on restarting oral anticoagulation, and suggest an approach to clinical decision-making.

Tobacco Use: A Major Risk Factor of Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (sICH) is one of the deadliest subtypes of stroke, and no treatment is currently available. One of the major risk factors is tobacco use. In this article, we review literature on how tobacco use affects the risk of sICH and also summarize the known effects of tobacco use on outcomes following sICH. Several studies demonstrate that the risk of sICH is higher in current cigarette smokers compared to non-smokers. The literature also establishes that cigarette smoking not only increases the risk of sICH but also increases hematoma growth, results in worse outcomes, and increases the risk of death from sICH. This review also discusses potential mechanisms activated by tobacco use which result in an increase in risk and severity of sICH. Exploring the underlying mechanisms may help alleviate the risk of sICH in tobacco users as well as may help better manage tobacco user sICH patients.

Identification of circular RNA expression profiles and potential biomarkers for intracerebral hemorrhage

Aim: To investigate the expression profiles of circRNAs after intracerebral hemorrhage (ICH). Materials & methods: RNA sequencing and qRT-PCR were used to investigate and validate circRNA expression levels. Bioinformatics analysis was performed to explore potential functions of the circRNAs. Results: Expression levels of 15 circRNAs were consistently altered in patients with ICH compared with their expression levels in hypertension. Three circRNAs, hsa_circ_0001240, hsa_circ_0001947 and hsa_circ_0001386, individually or combined, were confirmed as promising biomarkers for predicting and diagnosing ICH. The circRNAs were involved mainly in lysine degradation and the immune system. Conclusion: This is the first study to report expression profiles of circRNAs after ICH and to propose that three circRNAs are potential biomarkers for ICH.

Intracranial Hemorrhage in COVID-19 Patients

Objective

To describe the clinical, laboratory, temporal, radiographic, and outcome features of acute Intracranial Hemorrhage (ICH) in COVID-19 patients.

Methods

Retrospective, observational, consecutive case series of patients admitted with ICH to Maimonides Medical Center from March 1 through July 31, 2020, who had confirmed or highly suspected COVID-19. Demographic, clinical, laboratory, imaging, and outcome data were analyzed. ICH rates among all strokes were compared to the same time period in 2019 in two-week time intervals. Correlation of systolic blood pressure variability (SBPV) and neutrophil-to-lymphocyte ratio (NLR) to clinical outcomes were performed.

Results

Of 324 patients who presented with stroke, 65 (20%) were diagnosed with non-traumatic ICH: 8 had confirmed and 3 had highly suspected COVID-19. Nine (82%) had at least one associated risk factor for ICH. Three ICHs occurred during inpatient anticoagulation. More than half (6) suffered either deep or cerebellar hemorrhages; only 2 were lobar hemorrhages. Two of 8 patients with severe pneumonia survived. During the NYC COVID-19 peak period in April, ICH comprised the highest percentage of all strokes (40%), and then steadily decreased week-after-week (p = 0.02). SBPV and NLR were moderately and weakly positively correlated to discharge modified Rankin Scale, respectively.

Conclusions

COVID-19 associated ICH is often associated with at least one known ICH risk factor and severe pneumonia. There was a suggestive relative surge in ICH among all stroke types during the first peak of the NYC pandemic. It is important to be vigilant of ICH as a possible and important manifestation of COVID-19.