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Cheng R, Su K, Zhou X, Jiang X, Luo P, Zhang W, Qian X, Lai L. Does dual antiplatelet therapy increase the risk of haematoma enlargement in the acute stage? A retrospective study of the use of stent-assisted coiling versus coiling alone or balloon-assisted coiling for the treatment of ruptured intracranial aneurysms combined with intracranial haematoma. Neurosurg Rev 2023; 46:133. [PMID: 37266675 DOI: 10.1007/s10143-023-02036-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
This study aims to identify the efficacy and safety of stent-assisted coiling (SAC) treatment of ruptured intracranial aneurysms (RIAs) combined with intracranial haematoma (ICH) compared to coiling alone or balloon-assisted coiling (non-SAC). A retrospective analysis of 54 consecutive patients receiving endovascular therapy from 2014 to 2020 was performed. The data collected included baseline characteristics, angiographic results, perioperative complications, immediate aneurysm occlusion, clinical outcomes, follow-up at discharge and after 6 months, hospitalisation costs, and inpatient length of stay. Patients were categorised into the SAC group and the non-SAC group. Univariate and multivariate logistic regression analyses were used to identify risk factors related to clinical outcomes. Of the 54 patients harbouring RIAs with ICH, 22 (40.74%) and 32 (59.26%) patients were subject to SAC and non-SAC treatments, respectively. Postoperative rebleeding (1 [4.5%] and 3 [9.3%] in SAC and non-SAC groups, respectively, p > 0.05) and Hunt-Hess grade (IV-V) lesions (13.6% vs. 40.6%, p = 0.067) did not differ between the two groups. In total, 10 (45.5%) patients treated with SAC received a Fisher scale score of 0-3 compared with 6 (18.8%) patients treated with non-SAC methods (p = 0.035). Compared with the non-SAC group (7/21.9%), the rate of wide-necked aneurysms was increased in the SAC group (11/50%) (p = 0.031). No differences in poor outcomes (mRS > 2) were noted between the SAC and non-SAC groups (p > 0.05). Multivariate analysis revealed that ischaemic complication events (p = 0.016) represent the only independent risk factor for adverse outcomes, and a trend towards unfavourable clinical outcomes was noted for patients who smoke (p = 0.087). SAC is a safe and efficient treatment for RIAs combined with ICH when dual antiplatelet therapy (DAPT) is used in the perioperative period. In addition, SAC should be preferentially used in wide-neck RIAs. Ischaemic complications are a risk factor for poor clinical outcomes. Given the small sample size and retrospective bias of this study, these findings should be further verified in a study with a larger sample size or a randomised controlled trial (RCT).
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Affiliation(s)
- Ruoxi Cheng
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Kangtai Su
- The First Clinical Medical School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Xiaobing Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xin Jiang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Peiyi Luo
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Weiyun Zhang
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Xiao Qian
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Lingfeng Lai
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.
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Yu L, Zhao M, Lin Y, Zeng J, He Q, Zheng Y, Ma K, Lin F, Kang D. Noncontrast Computed Tomography Markers Associated with Hematoma Expansion: Analysis of a Multicenter Retrospective Study. Brain Sci 2023; 13:brainsci13040608. [PMID: 37190573 DOI: 10.3390/brainsci13040608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/19/2023] [Accepted: 03/24/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Hematoma expansion (HE) is a significant predictor of poor outcomes in patients with intracerebral hemorrhage (ICH). Non-contrast computed tomography (NCCT) markers in ICH are promising predictors of HE. We aimed to determine the association of the NCCT markers with HE by using different temporal HE definitions. METHODS We utilized Risa-MIS-ICH trial data (risk stratification and minimally invasive surgery in acute intracerebral hemorrhage). We defined four HE types based on the time to baseline CT (BCT) and the time to follow-up CT (FCT). Hematoma volume was measured by software with a semi-automatic edge detection tool. HE was defined as a follow-up CT hematoma volume increase of >6 mL or a 33% hematoma volume increase relative to the baseline CT. Multivariable regression analyses were used to determine the HE parameters. The prediction potential of indicators for HE was evaluated using receiver-operating characteristic analysis. RESULTS The study enrolled 158 patients in total. The time to baseline CT was independently associated with HE in one type (odds ratio (OR) 0.234, 95% confidence interval (CI) 0.077-0.712, p = 0.011), and the blend sign was independently associated with HE in two types (OR, 6.203-6.985, both p < 0.05). Heterogeneous density was independently associated with HE in all types (OR, 6.465-88.445, all p < 0.05) and was the optimal type for prediction, with an area under the curve of 0.674 (p = 0.004), a sensitivity of 38.9%, and specificity of 96.0%. CONCLUSION In specific subtypes, the time to baseline CT, blend sign, and heterogeneous density were independently associated with HE. The association between NCCT markers and HE is influenced by the temporal definition of HE. Heterogeneous density is a stable and robust predictor of HE in different subtypes of hematoma expansion.
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Affiliation(s)
- Lianghong Yu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Institute for Brain Disorders and Brain Science, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Mingpei Zhao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Yuanxiang Lin
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Institute for Brain Disorders and Brain Science, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Jiateng Zeng
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Qiu He
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Yan Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Ke Ma
- Clinical Research and Translation Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Fuxin Lin
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Institute for Brain Disorders and Brain Science, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Clinical Research and Translation Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Dezhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Institute for Brain Disorders and Brain Science, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Clinical Research and Translation Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
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Reyes-Esteves S, Nong J, Glassman PM, Omo-Lamai S, Ohashi S, Myerson JW, Zamora ME, Ma X, Kasner SE, Sansing L, Muzykantov VR, Marcos-Contreras OA, Brenner JS. Targeted drug delivery to the brain endothelium dominates over passive delivery via vascular leak in experimental intracerebral hemorrhage. J Control Release 2023; 356:185-195. [PMID: 36868517 PMCID: PMC10519578 DOI: 10.1016/j.jconrel.2023.02.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 02/16/2023] [Accepted: 02/26/2023] [Indexed: 03/05/2023]
Abstract
Intracerebral hemorrhage (ICH) is one of the most common causes of fatal stroke, yet has no specific drug therapies. Many attempts at passive intravenous (IV) delivery in ICH have failed to deliver drugs to the salvageable area around the hemorrhage. The passive delivery method assumes vascular leak through the ruptured blood-brain barrier will allow drug accumulation in the brain. Here we tested this assumption using intrastriatal injection of collagenase, a well-established experimental model of ICH. Fitting with hematoma expansion in clinical ICH, we showed that collagenase-induced blood leak drops significantly by 4 h after ICH onset and is gone by 24 h. We observed passive-leak brain accumulation also declines rapidly over ∼4 h for 3 model IV therapeutics (non-targeted IgG; a protein therapeutic; PEGylated nanoparticles). We compared these passive leak results with targeted brain delivery by IV monoclonal antibodies (mAbs) that actively bind vascular endothelium (anti-VCAM, anti-PECAM, anti-ICAM). Even at early time points after ICH induction, where there is high vascular leak, brain accumulation via passive leak is dwarfed by brain accumulation of endothelial-targeted agents: At 4 h after injury, anti-PECAM mAbs accumulate at 8-fold higher levels in the brain vs. non-immune IgG; anti-VCAM nanoparticles (NPs) deliver a protein therapeutic (superoxide dismutase, SOD) at 4.5-fold higher levels than the carrier-free therapeutic at 24 h after injury. These data suggest that relying on passive vascular leak provides inefficient delivery of therapeutics even at early time points after ICH, and that a better strategy might be targeted delivery to the brain endothelium, which serves as the gateway for the immune attack on the peri-hemorrhage inflamed brain region.
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Affiliation(s)
- Sahily Reyes-Esteves
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jia Nong
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Patrick M Glassman
- Department of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, PA, United States of America
| | - Serena Omo-Lamai
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Sarah Ohashi
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America
| | - Jacob W Myerson
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Marco E Zamora
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Xiaonan Ma
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Lauren Sansing
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America
| | - Vladimir R Muzykantov
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Oscar A Marcos-Contreras
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Jacob S Brenner
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Division of Pulmonary Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States of America.
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Zhang GJ, Wang H, Gao LC, Zhao JY, Zhang T, You C, Wang XY. Constructing and Validating a Nomogram for Survival in Patients without Hypertension in Hypertensive Intracerebral Hemorrhage-Related Locations. World Neurosurg 2023; 172:e256-e266. [PMID: 36627017 DOI: 10.1016/j.wneu.2023.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
OBJECTIVE We aimed to evaluate the risk factors for patients, who had hypertensive intracerebral hemorrhage (ICH)-specific location hemorrhage without hypertensive history, to elucidate a novel and detailed understanding. METHODS We conducted a retrospective review to identify patients diagnosed with hemorrhage in hypertensive ICH-specific locations without hypertensive history between January 2011 and December 2019 from West China Hospital. A least absolute shrinkage and selector operation (LASSO) algorithm was used to select the optimal prognostic factors, and then we performed a multivariable logistic analysis. To verify the accuracy of the nomogram in predicting patient outcome, we used Harrell's statistics, area under the curve, and a calibration as well as decision curves. RESULTS The LASSO method, at a tenfold cross-validation for 7-day mortality, 90-day mortality, and 90-day morbidity, was applied to construct the prognosis-predicting models. Both a higher Glasgow Coma Scale (GCS) score at admission and larger hematoma volume ≥13.64 mL were independently associated with better survival at 7 days and 90 days in multivariate analysis. Lactic dehydrogenase >250 IU/L and neutrophilic granulocyte/lymphocyte ratio in 1 increase were significantly associated with poor outcome at 90 days. Only one factor (GCS score at 7 days) influencing 90-day morbidity remained in a LASSO model. CONCLUSIONS In this study, the GCS score, hematoma volume, and other laboratory factors (Lactic dehydrogenase and neutrophilic granulocyte/lymphocyte ratio) were related to survival. Our current findings of the specific location ICH need to be proven by a large randomized controlled trial study.
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Affiliation(s)
- Gui-Jun Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Wang
- Intensive Care Unit, Qinghai Provincial People's Hospital, Xining, China
| | - Li-Chuan Gao
- Operating Room, West China Hospital, Sichuan University/West China School of Nursing, Chengdu, Sichuan, China
| | - Jie-Yi Zhao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiao-Yu Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Songsaeng D, Peuksiripibul W, Wasinrat J, Boonma C, Wongjaroenkit P. Potential of Satellite Sign for Prediction of Hematoma Expansion in Small Spontaneous Hematoma within 7 Days' Follow-Up. Asian J Neurosurg 2023; 18:45-52. [PMID: 37056899 PMCID: PMC10089762 DOI: 10.1055/s-0043-1764327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Background Hematoma expansion (HE) is the most important modifiable predictor that can change the clinical outcome of intracerebral hemorrhage (ICH) patients. The study aimed to investigate the potential of satellite sign for prediction of HE in spontaneous ICH patients who had follow-up non-contrast computed tomography (NCCT) within 7 days after the initial CT scan.
Methods We retrospectively reviewed data and NCCT from 142 ICH patients who were treated at our hospital at Bangkok, Thailand. All included patients were treated conservatively, had baseline NCCT within 12 hours after symptom onset, and had follow-up NCCT within 168 hours after baseline NCCT. HE was initially estimated by two radiologists, and then by image analysis software. Association between satellite sign and HE was evaluated.
Results HE occurred in 45 patients (31.7%). Patients with HE had significantly higher activated partial thromboplastin time (p = 0.001) and baseline hematoma volume (p = 0.001). The prevalence of satellite sign was 43.7%, and it was significantly independently associated with HE (p = 0.021). The sensitivity, specificity, and accuracy of satellite sign for predicting HE was 57.8, 62.9, and 61.3%, respectively. From image analysis software, the cutoff of greater than 9% relative growth in hematoma volume on follow-up NCCT had the highest association with satellite sign (p = 0.024), with a sensitivity of 55%, specificity of 64.6%, and accuracy of 60.5%.
Conclusion Satellite sign, a new NCCT predictor, was found to be significantly associated with HE in Thai population. With different context of Thai population, HE was found in smaller baseline hematoma volume. Satellite sign was found more common in lobar hematoma. Further studies to validate satellite sign for predicting HE and to identify an optimal cutoff in Thai population that is correlated with clinical outcomes are warranted.
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56
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Gong K, Dai Q, Wang J, Zheng Y, Shi T, Yu J, Chen J, Huang S, Wang Z. Unified ICH quantification and prognosis prediction in NCCT images using a multi-task interpretable network. Front Neurosci 2023; 17:1118340. [PMID: 36998725 PMCID: PMC10043313 DOI: 10.3389/fnins.2023.1118340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/23/2023] [Indexed: 03/15/2023] Open
Abstract
With the recent development of deep learning, the regression, classification, and segmentation tasks of Computer-Aided Diagnosis (CAD) using Non-Contrast head Computed Tomography (NCCT) for spontaneous IntraCerebral Hematoma (ICH) have become popular in the field of emergency medicine. However, a few challenges such as time-consuming of ICH volume manual evaluation, excessive cost demanding patient-level predictions, and the requirement for high performance in both accuracy and interpretability remain. This paper proposes a multi-task framework consisting of upstream and downstream components to overcome these challenges. In the upstream, a weight-shared module is trained as a robust feature extractor that captures global features by performing multi-tasks (regression and classification). In the downstream, two heads are used for two different tasks (regression and classification). The final experimental results show that the multi-task framework has better performance than single-task framework. And it also reflects its good interpretability in the heatmap generated by Gradient-weighted Class Activation Mapping (Grad-CAM), which is a widely used model interpretation method, and will be presented in subsequent sections.
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Affiliation(s)
- Kai Gong
- The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, Fujian, China
| | - Qian Dai
- Department of Computer Science, School of Informatics, Xiamen University, Xiamen, Fujian, China
| | - Jiacheng Wang
- Department of Computer Science, School of Informatics, Xiamen University, Xiamen, Fujian, China
| | - Yingbin Zheng
- The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, Fujian, China
| | - Tao Shi
- Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
| | - Jiaxing Yu
- Department of Computer Science, School of Informatics, Xiamen University, Xiamen, Fujian, China
| | - Jiangwang Chen
- Department of Computer Science, School of Informatics, Xiamen University, Xiamen, Fujian, China
| | - Shaohui Huang
- Department of Computer Science, School of Informatics, Xiamen University, Xiamen, Fujian, China
- *Correspondence: Shaohui Huang
| | - Zhanxiang Wang
- The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, Fujian, China
- Zhanxiang Wang
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Al-Ajlan FS, Gladstone DJ, Song D, Thorpe KE, Swartz RH, Butcher KS, Del Campo M, Dowlatshahi D, Gensicke H, Lee GJ, Flaherty ML, Hill MD, Aviv RI, Demchuk AM. Time Course of Early Hematoma Expansion in Acute Spot-Sign Positive Intracerebral Hemorrhage: Prespecified Analysis of the SPOTLIGHT Randomized Clinical Trial. Stroke 2023; 54:715-721. [PMID: 36756899 DOI: 10.1161/strokeaha.121.038475] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND In the SPOTLIGHT trial (Spot Sign Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy), patients with a computed tomography (CT) angiography spot-sign positive acute intracerebral hemorrhage were randomized to rFVIIa (recombinant activated factor VIIa; 80 μg/kg) or placebo within 6 hours of onset, aiming to limit hematoma expansion. Administration of rFVIIa did not significantly reduce hematoma expansion. In this prespecified analysis, we aimed to investigate the impact of delays from baseline imaging to study drug administration on hematoma expansion. METHODS Hematoma volumes were measured on the baseline CT, early post-dose CT, and 24 hours CT scans. Total hematoma volume (intracerebral hemorrhage+intraventricular hemorrhage) change between the 3 scans was calculated as an estimate of how much hematoma expansion occurred before and after studying drug administration. RESULTS Of the 50 patients included in the trial, 44 had an early post-dose CT scan. Median time (interquartile range) from onset to baseline CT was 1.4 hours (1.2-2.6). Median time from baseline CT to study drug was 62.5 (55-80) minutes, and from study drug to early post-dose CT was 19 (14.5-30) minutes. Median (interquartile range) total hematoma volume increased from baseline CT to early post-dose CT by 10.0 mL (-0.7 to 18.5) in the rFVIIa arm and 5.4 mL (1.8-8.3) in the placebo arm (P=0.96). Median volume change between the early post-dose CT and follow-up scan was 0.6 mL (-2.6 to 8.3) in the rFVIIa arm and 0.7 mL (-1.6 to 2.1) in the placebo arm (P=0.98). Total hematoma volume decreased between the early post-dose CT and 24-hour scan in 44.2% of cases (rFVIIa 38.9% and placebo 48%). The adjusted hematoma growth in volume immediately post dose for FVIIa was 0.998 times that of placebo ([95% CI, 0.71-1.43]; P=0.99). The hourly growth in FFVIIa was 0.998 times that for placebo ([95% CI, 0.994-1.003]; P=0.50; Table 3). CONCLUSIONS In the SPOTLIGHT trial, the adjusted hematoma volume growth was not associated with Factor VIIa treatment. Most hematoma expansion occurred between the baseline CT and the early post-dose CT, limiting any potential treatment effect of hemostatic therapy. Future hemostatic trials must treat intracerebral hemorrhage patients earlier from onset, with minimal delay between baseline CT and drug administration. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01359202.
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Affiliation(s)
- Fahad S Al-Ajlan
- Department of Neurosciences (Neurology), King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia (F.S.A.-A.)
| | - David J Gladstone
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program and Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G., R.H.S.).,Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Dongbeom Song
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Kevin E Thorpe
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Canada (K.E.T.)
| | - Rick H Swartz
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program and Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G., R.H.S.).,Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Kenneth S Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, AustraliaDepartment of Medicine (Neurology), University of Alberta, Edmonton, Canada (K.S.B.)
| | - Martin Del Campo
- Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | - Henrik Gensicke
- Stroke Center and Neurology, University Hospital Basel, Switzerland (H.G.)
| | - Gloria Jooyoung Lee
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Matthew L Flaherty
- Department of Neurology, University of Cincinnati, OH (M.L.F., R.I.A.). Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Richard I Aviv
- Department of Neurology, University of Cincinnati, OH (M.L.F., R.I.A.). Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
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Morotti A, Boulouis G, Dowlatshahi D, Li Q, Shamy M, Al-Shahi Salman R, Rosand J, Cordonnier C, Goldstein JN, Charidimou A. Intracerebral haemorrhage expansion: definitions, predictors, and prevention. Lancet Neurol 2023; 22:159-171. [PMID: 36309041 DOI: 10.1016/s1474-4422(22)00338-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 12/05/2022]
Abstract
Haematoma expansion affects a fifth of patients within 24 h of the onset of acute intracerebral haemorrhage and is associated with death and disability, which makes it an appealing therapeutic target. The time in which active intervention can be done is short as expansion occurs mostly within the first 3 h after onset. Baseline haemorrhage volume, antithrombotic treatment, and CT angiography spot signs are each associated with increased risk of haematoma expansion. Non-contrast CT features are promising predictors of haematoma expansion, but their potential contribution to current models is under investigation. Blood pressure lowering and haemostatic treatment minimise haematoma expansion but have not led to improved functional outcomes in randomised clinical trials. Ultra-early enrolment and selection of participants on the basis of non-contrast CT imaging markers could focus future clinical trials to show clinical benefit in people at high risk of expansion or investigate heterogeneity of treatment effects in clinical trials with broad inclusion criteria.
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Affiliation(s)
- Andrea Morotti
- Neurology Unit, Department of Neurological Sciences and Vision, Azienda Socio Sanitaria Territoriale Spedali Civili, Brescia, Italy.
| | - Gregoire Boulouis
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Dar Dowlatshahi
- Department of Medicine, Division of Neurology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa ON, Canada
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Michel Shamy
- Department of Medicine, Division of Neurology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa ON, Canada
| | | | - Jonathan Rosand
- Division of Neurocritical Care, Massachusetts General Hospital, Boston, MA, USA; Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Charlotte Cordonnier
- Universite Lille, Inserm, CHU Lille, U1172, LilNCog, Lille Neuroscience and Cognition, F-59000 Lille, France
| | - Joshua N Goldstein
- Division of Neurocritical Care, Massachusetts General Hospital, Boston, MA, USA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andreas Charidimou
- Department of Neurology, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
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Hakimi R. Imaging of Central Nervous System Hemorrhage. Continuum (Minneap Minn) 2023; 29:73-103. [PMID: 36795874 DOI: 10.1212/con.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE This article aims to familiarize the reader with the various types of nontraumatic central nervous system (CNS) hemorrhage and the various neuroimaging modalities used to help diagnose and manage them. LATEST DEVELOPMENTS According to the 2019 Global Burden of Diseases, Injuries, and Risk Factors Study, intraparenchymal hemorrhage accounts for 28% of the global stroke burden. In the United States, hemorrhagic stroke makes up 13% of all strokes. The incidence of intraparenchymal hemorrhage increases substantially with age; thus, despite improvements in blood pressure control through various public health measures, the incidence is not decreasing as the population ages. In fact, in the most recent longitudinal study of aging, autopsy findings showed intraparenchymal hemorrhage and cerebral amyloid angiopathy in 30% to 35% of patients. ESSENTIAL POINTS Rapid identification of CNS hemorrhage, which includes intraparenchymal hemorrhage, intraventricular hemorrhage, and subarachnoid hemorrhage, requires either head CT or brain MRI. Once hemorrhage is identified on the screening neuroimaging study, the pattern of blood in conjunction with the history and physical examination can guide subsequent neuroimaging, laboratory, and ancillary tests as part of the etiologic assessment. After determination of the cause, the chief aims of the treatment regimen are reducing hemorrhage expansion and preventing subsequent complications such as cytotoxic cerebral edema, brain compression, and obstructive hydrocephalus. In addition, nontraumatic spinal cord hemorrhage will also be briefly discussed.
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The "SALPARE study" of spontaneous intracerebral haemorrhage-part 2-early CT predictors of outcome in ICH: keeping it simple. Neurol Res Pract 2023; 5:2. [PMID: 36631839 PMCID: PMC9835380 DOI: 10.1186/s42466-022-00228-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate the prognostic role of hematoma characteristics and hematoma expansion (HE) in patients with spontaneous intracerebral hemorrhage (ICH). METHODS This multicenter prospective cohort study enrolled consecutive adult patients with non-traumatic ICH admitted to three Italian academic hospitals (Salerno, Padova, Reggio Emilia) over a 2-year period. Early noncontrast CT (NCCT) features of the hematoma, including markers of HE, and 3-month outcome were recorded. Multivariable logistic regression analysis was performed to identify predictors of poor outcome. RESULTS A total of 682 patients were included in the study [mean age: 73 ± 14 years; 316 (46.3%) females]. Pontine and massive hemorrhage, intraventricular bleeding, baseline hematoma volume > 15 mL, blend sign, swirl sign, margin irregularity ≥ 4, density heterogeneity ≥ 3, hypodensity ≥ 1, island sign, satellite sign, and black hole sign were associated with a higher risk of mortality and disability. However, at multivariate analysis only initial hematoma volume (OR 29.71) proved to be an independent predictor of poor functional outcome at 3 months. CONCLUSION Simple hematoma volume measured on baseline CT best identifies patients with a worse outcome, while early NCCT markers of HE do not seem to add any clinically significant information.
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Paray V. Stroke. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Intravenous nicardipine for Japanese patients with acute intracerebral hemorrhage: an individual participant data analysis. Hypertens Res 2023; 46:75-83. [PMID: 36224285 PMCID: PMC9747609 DOI: 10.1038/s41440-022-01046-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/28/2022] [Accepted: 09/09/2022] [Indexed: 02/03/2023]
Abstract
The effects of acute systolic blood pressure levels achieved with continuous intravenous administration of nicardipine for Japanese patients with acute intracerebral hemorrhage on clinical outcomes were determined. A systematic review and individual participant data analysis of articles were performed based on prospective studies involving adults developing hyperacute intracerebral hemorrhage who were treated with intravenous nicardipine. Outcomes included death or disability at 90 days, defined as the modified Rankin Scale score of 4-6, and hematoma expansion, defined as an increase 6 mL or more from baseline to 24 h computed tomography. Of the total 499 Japanese patients (age 64.9 ± 11.8 years, 183 women, initial BP 203.5 ± 18.3/109.1 ± 17.2 mmHg) studied, death or disability occurred in 35.6%, and hematoma expansion occurred in 15.6%. Mean hourly systolic blood pressure during the initial 24 h was positively associated with death or disability (adjusted odds ratio 1.25, 95% confidence interval 1.03-1.52 per 10 mmHg) and hematoma expansion (1.49, 1.18-1.87). These odds ratios were relatively high as compared to the reported ones for overall global patients of this individual participant data analysis [1.12 (95% confidence interval 1.00-1.26) and 1.16 (1.02-1.32), respectively]. In conclusion, lower levels of systolic blood pressure by continuous intravenous nicardipine were associated with lower risks of hematoma expansion and 90-day death or disability in Japanese patients with hyperacute intracerebral hemorrhage. The impact of systolic blood pressure lowering on better outcome seemed to be stronger in Japanese patients than the global ones.
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Ibrahim A, Arifianto MR, Al Fauzi A. Minimally Invasive Neuroendoscopic Surgery for Spontaneous Intracerebral Hemorrhage: A Review of the Rationale and Associated Complications. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:103-108. [PMID: 37548729 DOI: 10.1007/978-3-030-12887-6_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is associated with a poor prognosis. Its mortality rate exceeds 40%, and 10-15% of survivors remain fully dependent. Considering the limited number of effective therapeutic options in such cases, the possibilities for surgical interventions aimed at removal of a hematoma should always be borne in mind. Although conventional surgery for deep-seated ICH has failed to show an improvement in outcomes, use of minimally invasive techniques-in particular, neuroendoscopic procedures-may be more effective and has demonstrated promising results. Although there are certain risks of morbidities (including rebleeding, epilepsy, meningitis, infection, pneumonia, and digestive tract disorders) and a nonnegligible risk of mortality, their incidence rates after neuroendoscopic evacuation of ICH compare favorably with those after conventional surgery. Prevention of complications requires careful postoperative surveillance of the patient and, preferably, treatment in a neurointensive care unit, as well as early detection and appropriate management of associated comorbidities.
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Affiliation(s)
- Arie Ibrahim
- Department of Neurosurgery, A. Wahab Syahranie Hospital and Faculty of Medicine, Mulawarman University, Kota Samarinda, Kalimantan Timur, Indonesia.
| | - Muhammad Reza Arifianto
- Department of Neurosurgery, Dr. Soetomo General Hospital and Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Asra Al Fauzi
- Department of Neurosurgery, Dr. Soetomo General Hospital and Faculty of Medicine, Airlangga University, Surabaya, Indonesia
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Ratnayake C, Okonkwo DO, Branstetter BF. Hematoma Progression Rates on Head Computed Tomography for Fluid Levels versus Mimics in Patients with Primary Intracerebral Hemorrhage. World Neurosurg 2023; 169:e230-e234. [PMID: 36334718 DOI: 10.1016/j.wneu.2022.10.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Among stroke patients, primary intracerebral hemorrhage has the highest mortality rate. Expansion of hematoma plays a prognostic role in these patients. Although fluid levels have been shown to predict subsequent hematoma expansion, there are mimics of fluid levels that may confuse interpretation. We hypothesized that patients with true fluid levels on head computed tomography (CT) have higher hematoma progression rates and worse outcomes compared with patients who have fluid level mimics on CT. METHODS Adult patients presenting with intracerebral hemorrhage described as a fluid level on initial CT interpretation were included. Medical records were reviewed to extract relevant clinical variables. A CAQ-certified neuroradiologist retrospectively determined whether there was a true fluid level or mimic on CT and then evaluated follow-up CT scans for radiologic progression. We compared radiologic progression, mortality, and anticoagulation status between patients with true fluid levels and fluid level mimics. RESULTS The study included 12 patients, 8 with true fluid levels and 4 with radiologic mimics. The patients with true fluid levels had a significantly higher likelihood of radiographic progression (P = 0.014). Differences in outcome, use of anticoagulation therapy, and average international normalized ratio were not significant. CONCLUSIONS A fluid level within intraparenchymal hemorrhage on head CT scan is associated with higher likelihood of intracerebral hemorrhage progression. However, this applies only to true fluid levels, with mimics having a lower likelihood of progression. A careful analysis of potential fluid levels is necessary before assigning prognostic implications.
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Affiliation(s)
- Charith Ratnayake
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Barton F Branstetter
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Chung GH, Goo JH, Kwak HS, Hwang SB. The comprehensive comparison of imaging sign from CT angiography and noncontrast CT for predicting intracranial hemorrhage expansion: A comparative study. Medicine (Baltimore) 2022; 101:e31914. [PMID: 36626412 PMCID: PMC9750542 DOI: 10.1097/md.0000000000031914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Expansion of intracranial hemorrhage (ICH) is an important predictor of poor clinical outcomes. Various imaging markers on non-contrast computed tomography (NCCT) or computed tomographic angiography (CTA) have been reported as predictors of ICH expansion. We aimed to compare the associations between various CT imaging markers and ICH expansion. Patients with spontaneous ICH who underwent initial NCCT, CTA, and subsequent NCCT between January 2016 and December 2019 were retrospectively identified. ICH expansion was defined as a volume increase of > 33% or > 6 mL. We analyzed the presence of imaging markers such as the black hole sign, blend sign, island sign, or swirl sign on initial NCCT or spot sign on CTA. An alternative free-response receiver operating characteristic curve analysis was performed using a 4-point scoring system based on the consensus of the reviewers. The predictive value of each marker was assessed using univariate and multivariate logistic regression analyses. A total of 250 patients, including 60 (24.0%) with ICH expansion, qualified for the analysis. Among the patients with spontaneous ICH, 118 (47.2%) presented with a black hole sign, 52 (20.8%) with a blend sign, 93 (37.2%) with an island sign, 79 (31.6%) with a swirl sign, and 56 (22.4%) with a spot sign. In univariate logistic regression, the initial ICH volume (P = .038), initial intraventricular hemorrhage (IVH) presence (P < .001), swirl sign (P < .001), and spot sign (P < .001) were associated with ICH expansion. Multivariate analysis confirmed that the presence of initial IVH (odds ratio, 4.111; P = .002) and spot sign (odds ratio, 109.5; P < .001) were independent predictors of ICH expansion. Initial ICH volume, IVH, swirl sign, and spot sign are associated with ICH expansion. The presence of spot signs and IVH were independent predictors of ICH expansion.
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Affiliation(s)
- Gyung Ho Chung
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeollabuk-do, Korea
| | - Ja Hong Goo
- Department of Internal Medicine, Kangbuk Samsung Hospital, Jeollabuk-do, Korea
| | - Hyo Sung Kwak
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeollabuk-do, Korea
- *Correspondence: Hyo Sung Kwak, Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, 567 Baekje-daero, deokjin-gu, Jeonju-si, Jeollabuk-do, 561-756, Republic of Korea (e-mail: )
| | - Seung Bae Hwang
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeollabuk-do, Korea
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Wang Q, Tu Y, Huang Y, Chen L, Lin Y, Zhan L, He J. High fibrinogen to albumin ratio is associated with hematoma enlargement in spontaneous intracerebral hemorrhage. J Clin Neurosci 2022; 106:37-42. [DOI: 10.1016/j.jocn.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 11/15/2022]
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Hillal A, Ullberg T, Ramgren B, Wassélius J. Computed tomography in acute intracerebral hemorrhage: neuroimaging predictors of hematoma expansion and outcome. Insights Imaging 2022; 13:180. [DOI: 10.1186/s13244-022-01309-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/24/2022] [Indexed: 11/24/2022] Open
Abstract
AbstractIntracerebral hemorrhage (ICH) accounts for 10–20% of all strokes worldwide and is associated with serious outcomes, including a 30-day mortality rate of up to 40%. Neuroimaging is pivotal in diagnosing ICH as early detection and determination of underlying cause, and risk for expansion/rebleeding is essential in providing the correct treatment. Non-contrast computed tomography (NCCT) is the most used modality for detection of ICH, identification of prognostic markers and measurements of hematoma volume, all of which are of major importance to predict outcome. The strongest predictors of 30-day mortality and functional outcome for ICH patients are baseline hematoma volume and hematoma expansion. Even so, exact hematoma measurement is rare in clinical routine practice, primarily due to a lack of tools available for fast, effective, and reliable volumetric tools. In this educational review, we discuss neuroimaging findings for ICH from NCCT images, and their prognostic value, as well as the use of semi-automatic and fully automated hematoma volumetric methods and assessment of hematoma expansion in prognostic studies.
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Wu TC, Liu YL, Chen JH, Zhang Y, Chen TY, Ko CC, Su MY. The Added Value of Intraventricular Hemorrhage on the Radiomics Analysis for the Prediction of Hematoma Expansion of Spontaneous Intracerebral Hemorrhage. Diagnostics (Basel) 2022; 12:diagnostics12112755. [PMID: 36428815 PMCID: PMC9689620 DOI: 10.3390/diagnostics12112755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/29/2022] [Accepted: 11/08/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Among patients undergoing head computed tomography (CT) scans within 3 h of spontaneous intracerebral hemorrhage (sICH), 28% to 38% have hematoma expansion (HE) on follow-up CT. This study aimed to predict HE using radiomics analysis and investigate the impact of intraventricular hemorrhage (IVH) compared with the conventional approach based on intraparenchymal hemorrhage (IPH) alone. Methods: This retrospective study enrolled 127 patients with baseline and follow-up non-contrast CT (NCCT) within 4~72 h of sICH. IPH and IVH were outlined separately for performing radiomics analysis. HE was defined as an absolute hematoma growth > 6 mL or percentage growth > 33% of either IPH (HEP) or a combination of IPH and IVH (HEP+V) at follow-up. Radiomic features were extracted using PyRadiomics, and then the support vector machine (SVM) was used to build the classification model. For each case, a radiomics score was generated to indicate the probability of HE. Results: There were 57 (44.9%) HEP and 70 (55.1%) non-HEP based on IPH alone, and 58 (45.7%) HEP+V and 69 (54.3%) non-HEP+V based on IPH + IVH. The majority (>94%) of HE patients had poor early outcomes (death or modified Rankin Scale > 3 at discharge). The radiomics model built using baseline IPH to predict HEP (RMP) showed 76.4% accuracy and 0.73 area under the ROC curve (AUC). The other model using IPH + IVH to predict HEP+V (RMP+V) had higher accuracy (81.9%) with AUC = 0.80, and this model could predict poor outcomes. The sensitivity/specificity of RMP and RMP+V for HE prediction were 71.9%/80.0% and 79.3%/84.1%, respectively. Conclusion: The proposed radiomics approach with additional IVH information can improve the accuracy in prediction of HE, which is associated with poor clinical outcomes. A reliable radiomics model may provide a robust tool to help manage ICH patients and to enroll high-risk ICH cases into anti-expansion or neuroprotection drug trials.
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Affiliation(s)
- Te-Chang Wu
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Department of Medical Sciences Industry, Chang Jung Christian University, Tainan 71101, Taiwan
- Correspondence: (T.-C.W.); (J.-H.C.); Tel.: +886-62812811 (ext. 53752) (T.-C.W.)
| | - Yan-Lin Liu
- Department of Radiological Sciences, University of California, Irvine, CA 92521, USA
| | - Jeon-Hor Chen
- Department of Radiological Sciences, University of California, Irvine, CA 92521, USA
- Department of Radiology, E-DA Hospital, I-Shou University, Kaohsiung 84001, Taiwan
- Correspondence: (T.-C.W.); (J.-H.C.); Tel.: +886-62812811 (ext. 53752) (T.-C.W.)
| | - Yang Zhang
- Department of Radiological Sciences, University of California, Irvine, CA 92521, USA
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Tai-Yuan Chen
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan 71101, Taiwan
| | - Ching-Chung Ko
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Center of General Education, Chia Nan University of Pharmacy and Science, Tainan 71710, Taiwan
| | - Min-Ying Su
- Department of Radiological Sciences, University of California, Irvine, CA 92521, USA
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Rehni AK, Cho S, Quero HN, Shukla V, Zhang Z, Dong C, Zhao W, Perez-Pinzon MA, Koch S, Jy W, Dave KR. Red Blood Cell Microparticles Limit Hematoma Growth in Intracerebral Hemorrhage. Stroke 2022; 53:3182-3191. [PMID: 36069183 PMCID: PMC9529820 DOI: 10.1161/strokeaha.122.039641] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/06/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (sICH) is the deadliest stroke subtype with no effective therapies. Limiting hematoma expansion is a promising therapeutic approach. Red blood cell-derived microparticles (RMPs) are novel hemostatic agents. Therefore, we studied the potential of RMPs in limiting hematoma growth and improving outcomes post-sICH. METHODS sICH was induced in rats by intrastriatal injection of collagenase. RMPs were prepared from human RBCs by high-pressure extrusion. Behavioral and hematoma/lesion volume assessment were done post-sICH. The optimal dose, dosing regimen, and therapeutic time window of RMP therapy required to limit hematoma growth post-sICH were determined. We also evaluated the effect of RMPs on long-term behavioral and histopathologic outcomes post-sICH. RESULTS RMP treatment limited hematoma growth following sICH. Hematoma volume (mm3) for vehicle- and RMP- (2.66×1010 particles/kg) treated group was 143±8 and 86±4, respectively. The optimal RMP dosing regimen that limits hematoma expansion was identified. RMPs limit hematoma volume when administered up to 4.5-hour post-sICH. Hematoma volume in the 4.5-hour post-sICH RMP treatment group was lower by 24% when compared with the control group. RMP treatment also improved long-term histopathologic and behavioral outcomes post-sICH. CONCLUSIONS Our results demonstrate that RMP therapy limits hematoma growth and improves outcomes post-sICH in a rodent model. Therefore, RMPs have the potential to limit hematoma growth in sICH patients.
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Affiliation(s)
- Ashish K. Rehni
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, Florida 33136
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Sunjoo Cho
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, Florida 33136
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Hever Navarro Quero
- The Wallace H Coulter Platelet Laboratory, Division of Hematology/Oncology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Vibha Shukla
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, Florida 33136
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Zhexuan Zhang
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146
| | - Chuanhui Dong
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Weizhao Zhao
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146
| | - Miguel A. Perez-Pinzon
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, Florida 33136
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida 33136
- Neuroscience Program, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Wenche Jy
- The Wallace H Coulter Platelet Laboratory, Division of Hematology/Oncology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Kunjan R. Dave
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, Florida 33136
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida 33136
- Neuroscience Program, University of Miami Miller School of Medicine, Miami, Florida 33136
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Postoperative Hematoma Expansion in Patients Undergoing Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage. Brain Sci 2022; 12:brainsci12101298. [PMID: 36291232 PMCID: PMC9599268 DOI: 10.3390/brainsci12101298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: The aim of the study was to analyze risk factors for hematoma expansion (HE) in patients undergoing decompressive hemicraniectomy (DC) in patients with elevated intracranial pressure due to spontaneous intracerebral hematoma (ICH). Methods: We retrospectively evaluated 72 patients with spontaneous ICH who underwent DC at our institution. We compared the pre- and postoperative volumes of ICH and divided the patients into two groups: first, patients with postoperative HE > 6 cm3 (group 1), and second, patients without HE (group 2). Additionally, we screened the medical history for anticoagulant and antiplatelet medication (AC/AP), bleeding-related comorbidities, age, admission Glasgow coma scale and laboratory parameters. Results: The rate of AC/AP medication was higher in group 1 versus group 2 (15/16 vs. 5/38, p < 0.00001), and patients were significantly older in group 1 versus group 2 (65.1 ± 16.2 years vs. 54.4 ± 14.3 years, p = 0.02). Furthermore, preoperative laboratory tests showed lower rates of hematocrit (34.1 ± 5.4% vs. 38.1 ± 5.1%, p = 0.01) and hemoglobin (11.5 ± 1.6 g/dL vs. 13.13 ± 1.8 g/dL, p = 0.0028) in group 1 versus group 2. In multivariate analysis, the history of AC/AP medication was the only independent predictor of HE (p < 0.0001, OR 0.015, CI 95% 0.001−0.153). Conclusion: We presented a comprehensive evaluation of risk factors for hematoma epansion by patients undergoing DC due to ICH.
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Nehme A, Ducroux C, Panzini MA, Bard C, Bereznyakova O, Boisseau W, Deschaintre Y, Diestro JDB, Guilbert F, Jacquin G, Maallah MT, Nelson K, Padilha IG, Poppe AY, Rioux B, Roy D, Touma L, Weill A, Gioia LC, Létourneau-Guillon L. Non-contrast CT markers of intracerebral hematoma expansion: a reliability study. Eur Radiol 2022; 32:6126-6135. [PMID: 35348859 DOI: 10.1007/s00330-022-08710-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES We evaluated whether clinicians agree in the detection of non-contrast CT markers of intracerebral hemorrhage (ICH) expansion. METHODS From our local dataset, we randomly sampled 60 patients diagnosed with spontaneous ICH. Fifteen physicians and trainees (Stroke Neurology, Interventional and Diagnostic Neuroradiology) were trained to identify six density (Barras density, black hole, blend, hypodensity, fluid level, swirl) and three shape (Barras shape, island, satellite) expansion markers, using standardized definitions. Thirteen raters performed a second assessment. Inter- and intra-rater agreement were measured using Gwet's AC1, with a coefficient > 0.60 indicating substantial to almost perfect agreement. RESULTS Almost perfect inter-rater agreement was observed for the swirl (0.85, 95% CI: 0.78-0.90) and fluid level (0.84, 95% CI: 0.76-0.90) markers, while the hypodensity (0.67, 95% CI: 0.56-0.76) and blend (0.62, 95% CI: 0.51-0.71) markers showed substantial agreement. Inter-rater agreement was otherwise moderate, and comparable between density and shape markers. Inter-rater agreement was lower for the three markers that require the rater to identify one specific axial slice (Barras density, Barras shape, island: 0.46, 95% CI: 0.40-0.52 versus others: 0.60, 95% CI: 0.56-0.63). Inter-observer agreement did not differ when stratified for raters' experience, hematoma location, volume, or anticoagulation status. Intra-rater agreement was substantial to almost perfect for all but the black hole marker. CONCLUSION In a large sample of raters with different backgrounds and expertise levels, only four of nine non-contrast CT markers of ICH expansion showed substantial to almost perfect inter-rater agreement. KEY POINTS • In a sample of 15 raters and 60 patients, only four of nine non-contrast CT markers of ICH expansion showed substantial to almost perfect inter-rater agreement (Gwet's AC1> 0.60). • Intra-rater agreement was substantial to almost perfect for eight of nine hematoma expansion markers. • Only the blend, fluid level, and swirl markers achieved substantial to almost perfect agreement across all three measures of reliability (inter-rater agreement, intra-rater agreement, agreement with the results of a reference reading).
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Affiliation(s)
- Ahmad Nehme
- Neurovascular Health Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
| | - Célina Ducroux
- Neurovascular Health Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Marie-Andrée Panzini
- Neurovascular Health Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Céline Bard
- Département de Radiologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Olena Bereznyakova
- Neurovascular Health Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
- Axe Neurosciences, Centre de Recherche du CHUM (CRCHUM), Montréal, Québec, Canada
- Département de Neurosciences, Université de Montréal, Montréal, Québec, Canada
| | - William Boisseau
- Département de Radiologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Yan Deschaintre
- Neurovascular Health Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
- Axe Neurosciences, Centre de Recherche du CHUM (CRCHUM), Montréal, Québec, Canada
- Département de Neurosciences, Université de Montréal, Montréal, Québec, Canada
| | | | - François Guilbert
- Département de Radiologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Grégory Jacquin
- Neurovascular Health Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
- Axe Neurosciences, Centre de Recherche du CHUM (CRCHUM), Montréal, Québec, Canada
- Département de Neurosciences, Université de Montréal, Montréal, Québec, Canada
| | - Mohamed Taoubane Maallah
- Département de Radiologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Kristoff Nelson
- Département de Radiologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Igor Gomes Padilha
- Département de Radiologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Alexandre Y Poppe
- Neurovascular Health Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
- Axe Neurosciences, Centre de Recherche du CHUM (CRCHUM), Montréal, Québec, Canada
- Département de Neurosciences, Université de Montréal, Montréal, Québec, Canada
| | - Bastien Rioux
- Neurovascular Health Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Daniel Roy
- Département de Radiologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Lahoud Touma
- Neurovascular Health Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Alain Weill
- Département de Radiologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Laura C Gioia
- Neurovascular Health Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
- Axe Neurosciences, Centre de Recherche du CHUM (CRCHUM), Montréal, Québec, Canada
- Département de Neurosciences, Université de Montréal, Montréal, Québec, Canada
| | - Laurent Létourneau-Guillon
- Département de Radiologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
- Imaging and Engineering Axis, Centre de Recherche du CHUM (CRCHUM), Montréal, Québec, Canada
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Lóczi L, Orbán-Kálmándi R, Árokszállási T, Fekete I, Fekete K, Héja M, Tóth J, Csiba L, Bagoly Z. Thrombin generation as a predictor of outcomes in patients with non-traumatic intracerebral hemorrhage. Front Neurol 2022; 13:912664. [PMID: 36061990 PMCID: PMC9436391 DOI: 10.3389/fneur.2022.912664] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background Non-traumatic intracerebral hemorrhage (ICH) accounts for 10–15% of all strokes and leads to a higher rate of mortality as compared to ischemic strokes. We aimed to find out whether the thrombin generation assay (TGA) could predict outcomes in patients with ICH. Patients and methods In this prospective, observational study, 87 consecutive patients with ICH and 164 healthy controls were included. Computed tomography (CT), detailed clinical investigation, and laboratory investigations were performed from patients on admission. TGA was performed using stored platelet poor plasma obtained on admission. Lag time, endogen thrombin potential (ETP), peak thrombin, and time to peak parameters were calculated. Short- and long-term outcomes of ICH were defined at 14 days and 3 months post-event according to the NIHSS and the modified Rankin Scale (mRS), respectively. Results Peak thrombin was significantly higher in patients as compared to controls (397.2 ± 93.9 vs. 306 ± 85.3 nM, p < 0.0001). Lag time, ETP, and time to peak parameters showed a significant positive correlation with CRP in both groups. In patients with worse long-term functional outcomes, peak thrombin was significantly higher as compared to those with favorable outcomes [mRS 2–6 median: 402.5 (IQR:344.8–473.8) vs. mRS 0–1: 326.4 (294.2–416.1) nM, p = 0.0096]. Based on the statistically optimal threshold of 339.1 nM peak thrombin, the sensitivity and specificity of this parameter to determine mRS 2–6 as an outcome were 80.8 and 64.7%, respectively. In a binary logistic regression model including age, sex, BMI, smoking status, NIHSS on admission, D-dimer, and peak thrombin (>339.1 nM), only NIHSS and the peak thrombin parameters remained in the model as significant, independent predictors of poor outcome. Lag time and time to peak showed a modest, significant negative correlation with intracerebral bleeding volume on admission (r = −0.2603, p = 0.0231 and r = −0.3698, p = 0.0010, respectively). During the follow-up of patients, estimated hemorrhage volumes on day 90 showed significant positive association with the ETP and peak thrombin parameters (r = 0.3838, p = 0.0363 and r = 0.5383, p = 0.0021, respectively). Conclusion In patients with ICH, TG was increased as compared to healthy controls, which might be explained by the presence of higher inflammatory parameters in patients. Peak thrombin measured on admission might be a useful tool to predict outcomes in patients with ICH.
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Affiliation(s)
- Linda Lóczi
- Division of Clinical Laboratory Sciences, Department of Laboratory Medicine, Faculty of Medicine, Kálmán Laki Doctoral School, University of Debrecen, Debrecen, Hungary
| | - Rita Orbán-Kálmándi
- Division of Clinical Laboratory Sciences, Department of Laboratory Medicine, Faculty of Medicine, Kálmán Laki Doctoral School, University of Debrecen, Debrecen, Hungary
| | - Tamás Árokszállási
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Klára Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Máté Héja
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Tóth
- Department of Radiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Csiba
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- ELKH-DE Cerebrovascular Research Group, University of Debrecen, Debrecen, Hungary
| | - Zsuzsa Bagoly
- Division of Clinical Laboratory Sciences, Department of Laboratory Medicine, Faculty of Medicine, Kálmán Laki Doctoral School, University of Debrecen, Debrecen, Hungary
- ELKH-DE Cerebrovascular Research Group, University of Debrecen, Debrecen, Hungary
- *Correspondence: Zsuzsa Bagoly
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Baker TS, Kellner CP, Colbourne F, Rincon F, Kollmar R, Badjatia N, Dangayach N, Mocco J, Selim MH, Lyden P, Polderman K, Mayer S. Consensus recommendations on therapeutic hypothermia after minimally invasive intracerebral hemorrhage evacuation from the hypothermia for intracerebral hemorrhage (HICH) working group. Front Neurol 2022; 13:859894. [PMID: 36062017 PMCID: PMC9428129 DOI: 10.3389/fneur.2022.859894] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Therapeutic hypothermia (TH), or targeted temperature management (TTM), is a classic treatment option for reducing inflammation and potentially other destructive processes across a wide range of pathologies, and has been successfully used in numerous disease states. The ability for TH to improve neurological outcomes seems promising for inflammatory injuries but has yet to demonstrate clinical benefit in the intracerebral hemorrhage (ICH) patient population. Minimally invasive ICH evacuation also presents a promising option for ICH treatment with strong preclinical data but has yet to demonstrate functional improvement in large randomized trials. The biochemical mechanisms of action of ICH evacuation and TH appear to be synergistic, and thus combining hematoma evacuation with cooling therapy could provide synergistic benefits. The purpose of this working group was to develop consensus recommendations on optimal clinical trial design and outcomes for the use of therapeutic hypothermia in ICH in conjunction with minimally invasive ICH evacuation. Methods An international panel of experts on the intersection of critical-care TH and ICH was convened to analyze available evidence and form a consensus on critical elements of a focal cooling protocol and clinical trial design. Three focused sessions and three full-group meetings were held virtually from December 2020 to February 2021. Each meeting focused on a specific subtopic, allowing for guided, open discussion. Results These recommendations detail key elements of a clinical cooling protocol and an outline for the roll-out of clinical trials to test and validate the use of TH in conjunction with hematoma evacuation as well as late-stage protocols to improve the cooling approach. The combined use of systemic normothermia and localized moderate (33.5°C) hypothermia was identified as the most promising treatment strategy. Conclusions These recommendations provide a general outline for the use of TH after minimally invasive ICH evacuation. More research is needed to further refine the use and combination of these promising treatment paradigms for this patient population.
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Affiliation(s)
- Turner S. Baker
- Icahn School of Medicine at Mount Sinai, Sinai BioDesign, New York, NY, United States
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Turner S. Baker
| | - Christopher P. Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Fred Rincon
- Department of Neurology, Thomas Jefferson University Hospital, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Neha Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - J. Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Magdy H. Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, United States
| | - Patrick Lyden
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, CA, United States
| | - Kees Polderman
- United Memorial Medical Center, Houston, TX, United States
| | - Stephan Mayer
- Westchester Medical Center Health Network, Valhalla, NY, United States
- Department of Neurology, New York Medical College, Valhalla, NY, United States
- Department of Neurosurgery, New York Medical College, Valhalla, NY, United States
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Jakowenko ND, Kopp BJ, Erstad BL. Appraising the use of tranexamic acid in traumatic and non-traumatic intracranial hemorrhage: A narrative review. J Am Coll Emerg Physicians Open 2022; 3:e12777. [PMID: 35859856 PMCID: PMC9286528 DOI: 10.1002/emp2.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/06/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
Recently there has been increasing interest and debate on the use of tranexamic acid (TXA), an antifibrinolytic drug, in both traumatic and non-traumatic intracranial hemorrhage. In this review we aim to discuss recent investigations looking at TXA in traumatic brain injury (TBI) and different categories of spontaneous intracranial hemorrhage. We also discuss differences between setting (hospital vs pre-hospital), dosing and timing strategies, and other logistical challenges surrounding optimal use of TXA for isolated intracranial hemorrhage. Last, we hope to provide guidance for clinicians when considering the use of TXA in a patient with traumatic or non-traumatic intracranial hemorrhage based on appraisal of the available literature as well as some potential ideas for future research in this area.
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Affiliation(s)
| | - Brian J. Kopp
- Department of PharmacyBanner University Medical Center–TucsonTucsonArizonaUSA
| | - Brian L. Erstad
- Department of Pharmacy Practice and ScienceUniversity of Arizona College of PharmacyTucsonArizonaUSA
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Naidech AM, Grotta J, Elm J, Janis S, Dowlatshahi D, Toyoda K, Steiner T, Mayer SA, Khanolkar P, Denlinger J, Audebert HJ, Molina C, Khatri P, Sprigg N, Vagal A, Broderick JP. Recombinant factor VIIa for hemorrhagic stroke treatment at earliest possible time (FASTEST): Protocol for a phase III, double-blind, randomized, placebo-controlled trial. Int J Stroke 2022; 17:806-809. [PMID: 34427473 PMCID: PMC9933458 DOI: 10.1177/17474930211042700] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Intracerebral hemorrhage is the deadliest form of stroke. Hematoma expansion, growth of the hematoma between the baseline computed tomography scan and a follow-up computed tomography scan at 24 ± 6 h, predicts long-term disability or death. Recombinant factor VIIa (rFVIIa) has reduced hematoma expansion in previous clinical trials with a variable effect on clinical outcomes, with the greatest impact on hematoma expansion and potential benefit when administered within 2 h of symptom onset. METHODS Factor VIIa for Hemorrhagic Stroke Treatment at Earliest Possible Time (FASTEST, NCT03496883) is a randomized controlled trial that will enroll 860 patients at ∼100 emergency departments and mobile stroke units in five countries. Patients are eligible for enrollment if they have acute intracerebral hemorrhage within 2 h of symptom onset confirmed by computed tomography, a hematoma volume of 2 to 60 mL, no or small volumes of intraventricular hemorrhage, do not take anticoagulant medications or concurrent heparin/heparinoids (antiplatelet medications are permissible), and are not deeply comatose. Enrolled patients will receive rFVIIa 80 µg/kg or placebo intravenously over 2 min. The primary outcome measure is the distribution of the ordinal modified Rankin Scale at 180 days. FASTEST is monitored by a Data Safety Monitoring Board. Safety endpoints include thrombotic events (e.g. myocardial infarction). Human subjects research is monitored by an external Institutional Review Board in participating countries. DISCUSSION In the US, FASTEST will be first NIH StrokeNet Trial with an Exception from Informed Consent which allows enrollment of non-communicative patients without an immediately identifiable proxy.
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Affiliation(s)
| | | | - Jordan Elm
- Medical University of South Carolina, Charleston, SC, USA
| | - Scott Janis
- National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA
| | | | - Kazunori Toyoda
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Thorsten Steiner
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Thangameeran SIM, Pang CY, Lee CH, Tsai ST, Hu WF, Liew HK. Experimental animal models and evaluation techniques in intracerebral hemorrhage. Tzu Chi Med J 2022; 35:1-10. [PMID: 36866349 PMCID: PMC9972928 DOI: 10.4103/tcmj.tcmj_119_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/15/2022] [Accepted: 06/10/2022] [Indexed: 11/04/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the most lethal type of cerebral stroke without effective therapy. Although clinical trials with various surgeries have been conducted, none have improved clinical outcomes compared to the current medical management for ICH. Several ICH animal models, including autologous blood injection, collagenase injection, thrombin injection, and microballoon inflation methods, have been developed to elucidate the underlying mechanisms of ICH-induced brain injury. These models could also be used for discovering new therapy for ICH preclinically. We summarize the existing ICH animal models and the evaluation parameters used to measure the disease outcomes. We conclude that these models, resembling the different aspects of ICH pathogenesis, have their advantages and disadvantages. None of the current models closely represent the severity of ICH seen in clinical settings. More appropriate models are needed to streamline ICH's clinical outcomes and be used for validating newly developed treatment protocols.
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Affiliation(s)
| | - Cheng-Yoong Pang
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan,Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Chien-Hui Lee
- Neuro-Medical Scientific Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan,Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Sheng-Tzung Tsai
- Neuro-Medical Scientific Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan,Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Wei-Fen Hu
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan,PhD Program in Pharmacology and Toxicology, Tzu Chi University, Hualien, Taiwan
| | - Hock-Kean Liew
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan,Neuro-Medical Scientific Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan,PhD Program in Pharmacology and Toxicology, Tzu Chi University, Hualien, Taiwan,Address for correspondence: Dr. Hock-Kean Liew, Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 707, Section 3, Chung-Yang Road, Hualien, Taiwan. E-mail:
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Gil-Garcia CA, Alvarez EF, Garcia RC, Mendoza-Lopez AC, Gonzalez-Hermosillo LM, Garcia-Blanco MDC, Valadez ER. Essential topics about the imaging diagnosis and treatment of Hemorrhagic Stroke: a comprehensive review of the 2022 AHA guidelines. Curr Probl Cardiol 2022; 47:101328. [PMID: 35870549 DOI: 10.1016/j.cpcardiol.2022.101328] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/17/2022] [Indexed: 11/03/2022]
Abstract
Intracerebral hemorrhage (ICH) is a severe stroke with a high death rate (40 % mortality). The prevalence of hemorrhagic stroke has increased globally, with changes in the underlying cause over time as anticoagulant use and hypertension treatment have improved. The fundamental etiology of ICH and the mechanisms of harm from ICH, particularly the complex interaction between edema, inflammation, and blood product toxicity, have been thoroughly revised by the American Heart Association (AHA) in 2022. Although numerous trials have investigated the best medicinal and surgical management of ICH, there is still no discernible improvement in survival and functional tests. Small vessel diseases, such as cerebral amyloid angiopathy (CAA) or deep perforator arteriopathy (hypertensive arteriopathy), are the most common causes of spontaneous non-traumatic intracerebral hemorrhage (ICH). Even though ICH only causes 10-15% of all strokes, it contributes significantly to morbidity and mortality, with few acute or preventive treatments proven effective. Current AHA guidelines acknowledge up to 89% sensitivity for unenhanced brain CT and 81% for brain MRI. The imaging findings of both methods are helpful for initial diagnosis and follow-up, sometimes necessary a few hours after admission, especially for detecting hemorrhagic transformation or hematoma expansion. This review summarized the essential topics on hemorrhagic stroke epidemiology, risk factors, physiopathology, mechanisms of injury, current management approaches, findings in neuroimaging, goals and outcomes, recommendations for lifestyle modifications, and future research directions ICH. A list of updated references is included for each topic.
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Affiliation(s)
| | | | | | | | | | | | - Ernesto-Roldan Valadez
- Directorado de investigación, Hospital General de Mexico "Dr. Eduardo Liceaga," 06720, CDMX, Mexico; I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
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Jeon JP, Han SW, Kim TY, Lim SH, Youn DH, Rhim JK, Park JJ, Ahn JH, Kim HC, Yang J. Association of Haptoglobin Phenotypes with Outcomes in Patients with Spontaneous Intracerebral Hemorrhage. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071001. [PMID: 35888091 PMCID: PMC9318044 DOI: 10.3390/life12071001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/25/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022]
Abstract
Object. We aimed to investigate the association of Haptoglobin (Hp) phenotypes with perihematomal edema (PHE) and neurological outcomes after intracerebral hemorrhage (ICH). Methods. This prospective multicenter study enrolled patients that suffered ICH from March 2017 to February 2020. Hp phenotypes were determined using Western blotting; relative α1 intensity was calculated in patients with Hp2-1. A multivariable logistic regression analysis was then conducted to identify risk factors for increased relative PHE at 96 h and 3-month poor outcomes. Results. In total, 120 patients were ultimately enrolled: Hp1-1 (n = 15, 12.5%); Hp2-1 (n = 51, 42.5%); and Hp2-2 (n = 54, 45.0%). Hp phenotype was significantly associated with PHE (p = 0.028). With Hp1-1 as a reference value, Hp2-2 significantly increased the likelihood of increased rPHE (OR = 6.294, 95% CI: 1.283–30.881), while Hp2-1 did not (OR = 2.843, 95% CI: 0.566–14.284). Poor outcomes were found to be closely associated with hematoma volume at admission (OR = 1.057, 95% CI: 1.015–1.101) and surgical treatment (OR = 5.340, 95% CI: 1.665–17.122) but not Hp phenotypes (p = 0.190). Further, a high level of relative α1 intensity was identified to be significantly associated with decreased rPHE (OR = 0.020, 95% CI: 0.001–0.358). However, the relative α1 intensity was not associated with poor outcomes (OR = 0.057, 95% CI: 0.001–11.790). Conclusions: ICH patients with Hp2-2 exhibited a higher likelihood of increased rPHE than those with Hp1-1. Higher relative α1 intensities were identified to be closely associated with rPHE in patients with Hp2-1.
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Affiliation(s)
- Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon 24253, Korea;
| | - Sung Woo Han
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon 24253, Korea; (S.W.H.); (T.Y.K.); (S.H.L.); (D.H.Y.)
| | - Tae Yeon Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon 24253, Korea; (S.W.H.); (T.Y.K.); (S.H.L.); (D.H.Y.)
| | - Seung Hyuk Lim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon 24253, Korea; (S.W.H.); (T.Y.K.); (S.H.L.); (D.H.Y.)
| | - Dong Hyuk Youn
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon 24253, Korea; (S.W.H.); (T.Y.K.); (S.H.L.); (D.H.Y.)
| | - Jong Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju 63243, Korea;
| | - Jeong Jin Park
- Department of Neurology, Konkuk University Medical Center, Seoul 05030, Korea;
| | - Jun Hyong Ahn
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon 24289, Korea;
| | - Heung Cheol Kim
- Department of Radiology, Hallym University College of Medicine, Chuncheon 24253, Korea;
| | - Jinseo Yang
- Department of Neurology, Konkuk University Medical Center, Seoul 05030, Korea;
- Correspondence:
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Naito Y, Morishima N, Oyama H, Iwai K. Inhibitors of early mobilization in the acute phase of intracerebral hemorrhage: A retrospective observational study. J Stroke Cerebrovasc Dis 2022; 31:106592. [PMID: 35780720 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES The association between early mobilization and functional prognosis in the acute phase of intracerebral hemorrhage has been reported, but only a few studies have investigated the inhibitors of early mobilization in the acute phase of intracerebral hemorrhage. This study aimed to investigate the inhibitors of early mobilization. MATERIALS AND METHODS The study enrolled 322 patients with intracerebral hemorrhage. In the early mobilization group, mobilization was started within 72 h from onset, and in the delayed mobilization group, mobilization was started at or after 72 h from onset. The association between the start of mobilization timing and baseline characteristics was investigated using univariate and multivariate analyses to clarify the inhibitors of early mobilization in the acute phase of intracerebral hemorrhage. RESULTS Significant differences between the early mobilization and delayed mobilization groups were observed in the lesion site, leukocyte count at admission, neutrophil count at admission, C-reactive protein level at admission, surgery, use of mechanical ventilation, consciousness level at admission, hematoma volume, and hematoma growth. In the multiple logistic regression analysis, five items were adopted, namely, low consciousness level at admission, lesion below the tent, surgery, C-reactive protein at admission, and hematoma growth. CONCLUSIONS In this study, low consciousness level at admission, lesion below the tent, surgery, C-reactive protein level at admission, and hematoma growth affected delayed mobilization. Therefore, it is recommended to judge the start of mobilization timing by a systematic evidenced-based assessment for each case.
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Affiliation(s)
| | | | - Hirohumi Oyama
- Department of Neurosurgery, Toyohashi Municipal Hospital.
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80
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Li H, Xie Y, Liu H, Wang X. Non-Contrast CT-Based Radiomics Score for Predicting Hematoma Enlargement in Spontaneous Intracerebral Hemorrhage. Clin Neuroradiol 2022; 32:517-528. [PMID: 34324004 DOI: 10.1007/s00062-021-01062-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/28/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To develop a non-contrast computed tomography-(CT)-based radiomics score for predicting the risk of hematoma early enlargement in spontaneous intracerebral hemorrhage. METHODS A total of 258 patients from a single-center database with acute spontaneous intracerebral parenchymal hemorrhage were collected. Radiomics software was explored to segment hematomas on baseline non-contrast CT images, and the texture features were extracted. Minimal Redundancy and Maximal Relevance (mRMR) and Least Absolute Shrinkage and Selection Operator (LASSO), were used to select optimized subset of features and radiomics score was calculated. The radiomics model (radiomics score-based), radiomics nomogram (radiomics score combined with clinical factors-based) and clinical model (clinical factors-based) were built in a training cohort and validated in a test cohort. The discrimination, calibration, and clinical usefulness of the models were evaluated. Finally, a subgroup analysis was performed to assess the predictive value of radiomics score in specific hemorrhage location. RESULTS Radiomics score was composed of 12 radiomics features. The radiomics model and radiomics nomogram both showed good performance in predicting hematoma enlargement (area under the curve, AUC 0.83 [0.71-0.95], AUC 0.82 [0.72, 0.93]), and were both better than clinical model (AUC 0.66 [0.54-0.79]). The radiomics model and radiomics nomogram showed satisfactory calibration and clinical usefulness for detecting hematoma enlargement. For subgroup analysis, radiomics score also showed good predictive value for hematoma enlargement in different locations (AUC were 0.828, 0.940, 0.836 and 0.904, respectively, for supratentorial, subtentorial, deep and lobes). CONCLUSION A radiomics score based on non-contrast CT may be considered as a potential biomarker for prediction of hematoma enlargement in patients with spontaneous intracerebral hemorrhage (SICH), and it presented a high incremental value to clinical factors for hematoma enlargement prediction.
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Affiliation(s)
- Hui Li
- Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, No. 26 Shengli Street, Jiangan District, 430014, Wuhan City, Hubei Province, China
| | - Yuanliang Xie
- Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, No. 26 Shengli Street, Jiangan District, 430014, Wuhan City, Hubei Province, China
| | - Huan Liu
- GE Healthcare, 201203, Shanghai, China
| | - Xiang Wang
- Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, No. 26 Shengli Street, Jiangan District, 430014, Wuhan City, Hubei Province, China.
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Performance of Automated RAPID Intracranial Hemorrhage Detection in Real-World Practice: A Single-Institution Experience. J Comput Assist Tomogr 2022; 46:770-774. [PMID: 35617649 DOI: 10.1097/rct.0000000000001335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial hemorrhage (ICH) is a common finding in patients presenting to the emergency department with acute neurological symptoms. Noncontrast head computed tomography (NCCT) is the primary modality for assessment and detection of ICH in the acute setting. RAPID ICH software aims to automatically detect ICH on NCCT and was previously shown to have high accuracy when applied to a curated test data set. Here, we measured the test performance characteristics of RAPID ICH software in detecting ICH on NCCT performed in patients undergoing emergency stroke evaluation at a tertiary academic comprehensive stroke center. MATERIALS AND METHODS This retrospective study assessed consecutive patients over a 6-month period who presented with acute neurological symptoms suspicious for stroke and underwent NCCT with RAPID ICH postprocessing. RAPID ICH detection was compared with the interpretation of a reference standard comprising a board-certified or board-eligible neuroradiologist, or in cases of discrepancy, adjudicated by a consensus panel of 3 neuroradiologists. Accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RAPID ICH for ICH detection were determined. RESULTS Three hundred seven NCCT scans were included in the study. RAPID ICH correctly identified 34 of 37 cases with ICH and 228 of 270 without ICH. RAPID ICH had a sensitivity of 91.9% (78.1%-98.3%), specificity of 84.4% (79.6%-88.6%), NPV of 98.7% (96.3%-99.6%), PPV of 44.7% (37.6%-52.1%), and overall accuracy of 85.3% (80.9%-89.1%). CONCLUSIONS In a real-world scenario, RAPID ICH software demonstrated high NPV but low PPV for the presence of ICH when evaluating possible stroke patients.
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Irregular shape as an independent predictor of prognosis in patients with primary intracerebral hemorrhage. Sci Rep 2022; 12:8552. [PMID: 35595831 PMCID: PMC9123162 DOI: 10.1038/s41598-022-12536-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 05/12/2022] [Indexed: 11/09/2022] Open
Abstract
The utility of noncontrast computed tomography markers in the prognosis of spontaneous intracerebral hemorrhage has been studied. This study aimed to investigate the predictive value of the computed tomography (CT) irregularity shape for poor functional outcomes in patients with spontaneous intracerebral hemorrhage. We retrospectively reviewed all 782 patients with intracranial hemorrhage in our stroke emergency center from January 2018 to September 2019. Laboratory examination and CT examination were performed within 24 h of admission. After three months, the patient's functional outcome was assessed using the modified Rankin Scale. Multinomial logistic regression analyses were applied to identify independent predictors of functional outcome in patients with intracerebral hemorrhage. Out of the 627 patients included in this study, those with irregular shapes on CT imaging had a higher proportion of poor outcomes and mortality 90 days after discharge (P < 0.001). Irregular shapes were found to be significant independent predictors of poor outcome and mortality on multiple logistic regression analysis. In addition, the increase in plasma D-dimer was associated with the occurrence of irregular shapes (P = 0.0387). Patients with irregular shapes showed worse functional outcomes after intracerebral hemorrhage. The elevated expression level of plasma D-dimers may be directly related to the formation of irregular shapes.
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83
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Blood Pressure and Spot Sign in Spontaneous Supratentorial Subcortical Intracerebral Hemorrhage. Neurocrit Care 2022; 37:246-254. [PMID: 35445934 PMCID: PMC9283165 DOI: 10.1007/s12028-022-01485-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/07/2022] [Indexed: 10/27/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage is a potentially devastating cause of brain injury, often occurring secondary to hypertension. Contrast extravasation on computed tomography angiography (CTA), known as the spot sign, has been shown to predict hematoma expansion and worse outcomes. Although hypertension has been associated with an increased rate of the spot sign being present, the relationship between spot sign and blood pressure has not been fully explored. METHODS We retrospectively analyzed data from 134 patients (40 women and 94 men, mean age 62.3 ± 15.73 years) presenting to a tertiary academic medical center with spontaneous supratentorial subcortical intracerebral hemorrhage from 1/1/2018 to 1/4/2021. RESULTS A spot sign was demonstrated in images of 18 patients (13.43%) and correlated with a higher intracerebral hemorrhage score (2.61 ± 1.42 vs. 1.31 ± 1.25, p = 0.002), larger hematoma volume (53.49cm3 ± 32.08 vs. 23.45cm3 ± 25.65, p = 0.001), lower Glasgow Coma Scale on arrival (9.06 ± 4.56 vs. 11.74 ± 3.65, p = 0.027), increased risk of hematoma expansion (16.67% vs. 5.26%, p = 0.042), and need for surgical intervention (66.67% vs. 15.52%, p < 0.001). We did not see a correlation with age, sex, or underlying comorbidities. The presence of spot sign correlated with higher modified Rankin scores at discharge (4.94 ± 1.00 vs. 3.92 ± 1.64, p < 0.001). We saw significantly higher systolic blood pressure at the time of CTA in patients with a spot sign (184 mm Hg ± 43.11 vs. 153 mm Hg ± 36.99, p = 0.009) and the highest recorded blood pressure (p = 0.019), although not blood pressure on arrival (p = 0.081). Performing CTA early in the process of blood pressure lowering was associated with a spot sign (p < 0.001). CONCLUSIONS The presence of spot sign correlates with larger hematomas, worse outcomes, and increased surgical intervention. There is a significant association between spot sign and systolic blood pressure at the time of CTA, with the highest systolic blood pressure being recorded prior to CTA. Although the role of intensive blood pressure management in spontaneous intracerebral hemorrhage remains a subject of debate, patients with a spot sign may be a subgroup that could benefit from this.
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84
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Ng Y, Qi W, King NKK, Christianson T, Krishnamoorthy V, Shah S, Divani A, Bettin M, Coleman ER, Flaherty ML, Walsh KB, Testai FD, McCauley JL, Gilkerson LA, Langefeld CD, Behymer TP, Woo D, James ML. Initial antihypertensive agent effects on acute blood pressure after intracerebral haemorrhage. Stroke Vasc Neurol 2022; 7:367-374. [PMID: 35443984 PMCID: PMC9614130 DOI: 10.1136/svn-2021-001101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 03/08/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Current guidelines recommend blood pressure (BP) lowering in patients after acute intracerebral haemorrhage (ICH) without guidance on initial choice of antihypertensive class. This study sought to determine if initial antihypertensive class differentially effects acute BP lowering in a large multiethnic ICH cohort. Methods Subjects enrolled in the Ethnic/Racial Variations in ICH study between August 2010 and August 2017 with elevated admission BP and who received labetalol, nicardipine or hydralazine monotherapy as initial antihypertensive were analysed. Primary outcomes were systolic and diastolic BP changes from baseline to first BP measurement after initial antihypertensive treatment. Secondary outcomes included haematoma expansion (HE), hospital length of stay (LOS) and modified Rankin Score (mRS) up to 12 months after ICH. Exploratory outcomes assessed effects of race/ethnicity. Linear and logistic regression analyses, adjusted for relevant covariates, were performed to determine associations of antihypertensive class with outcomes. Results In total, 1156 cases were used in analyses. Antihypertensive class was associated with diastolic BP change (p=0.003), but not systolic BP change (p=0.419). Initial dosing with nicardipine lowered acute diastolic BP than labetalol (least square mean difference (labetalol-nicardipine)=5.47 (2.37, 8.57), p<0.001). Initial antihypertensive class was also found to be associated with LOS (p=0.028), but not with HE (p=0.406), mortality (p=0.118), discharge disposition (p=0.083) or mRS score at discharge, 3, 6 and 12 months follow-up (p=0.262, 0.276, 0.152 and 0.36, respectively). Race/ethnicity variably affected multivariable models. Conclusion In this large acute ICH cohort, initial antihypertensive class was associated with acute diastolic, but not systolic, BP-lowering suggesting differential effects of antihypertensive agents. Trial registration number NCT01202864.
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Affiliation(s)
- Yisi Ng
- Duke-NUS Medical School, SG, Singapore
| | - Wenjing Qi
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Nicolas Kon Kam King
- Duke-NUS Medical School, SG, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Thomas Christianson
- Department of Anesthesiology, University of Tennessee, Knoxville, Tennessee, USA
| | | | - Shreyansh Shah
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Afshin Divani
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Margaret Bettin
- Department of Neurology, University of Virginia, Charlottesville, Virginia, USA
| | - Elisheva R Coleman
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew L Flaherty
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kyle B Walsh
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Fernando D Testai
- Department of Neurology, University of Illinois, Chicago, Illinois, USA
| | - Jacob L McCauley
- Hussman Institute for Human Genomics, University of Miami, Miami, Florida, USA
| | - Lee A Gilkerson
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Carl D Langefeld
- Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Tyler Paul Behymer
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Daniel Woo
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael L James
- Duke-NUS Medical School, SG, Singapore .,Department of Anesthesiology, Duke University, Durham, North Carolina, USA.,Department of Neurology, Duke University, Durham, North Carolina, USA
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Law ZK, Appleton JP, Scutt P, Roberts I, Al-Shahi Salman R, England TJ, Werring DJ, Robinson T, Krishnan K, Dineen RA, Laska AC, Lyrer PA, Egea-Guerrero JJ, Karlinski M, Christensen H, Roffe C, Bereczki D, Ozturk S, Thanabalan J, Collins R, Beridze M, Ciccone A, Duley L, Shone A, Bath PM, Sprigg N. Brief Consent Methods Enable Rapid Enrollment in Acute Stroke Trial: Results From the TICH-2 Randomized Controlled Trial. Stroke 2022; 53:1141-1148. [PMID: 34847710 PMCID: PMC7612544 DOI: 10.1161/strokeaha.121.035191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 08/26/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Seeking consent rapidly in acute stroke trials is crucial as interventions are time sensitive. We explored the association between consent pathways and time to enrollment in the TICH-2 (Tranexamic Acid in Intracerebral Haemorrhage-2) randomized controlled trial. METHODS Consent was provided by patients or by a relative or an independent doctor in incapacitated patients, using a 1-stage (full written consent) or 2-stage (initial brief consent followed by full written consent post-randomization) approach. The computed tomography-to-randomization time according to consent pathways was compared using the Kruskal-Wallis test. Multivariable logistic regression was performed to identify variables associated with onset-to-randomization time of ≤3 hours. RESULTS Of 2325 patients, 817 (35%) gave self-consent using 1-stage (557; 68%) or 2-stage consent (260; 32%). For 1507 (65%), consent was provided by a relative (1 stage, 996 [66%]; 2 stage, 323 [21%]) or a doctor (all 2-stage, 188 [12%]). One patient did not record prerandomization consent, with written consent obtained subsequently. The median (interquartile range) computed tomography-to-randomization time was 55 (38-93) minutes for doctor consent, 55 (37-95) minutes for 2-stage patient, 69 (43-110) minutes for 2-stage relative, 75 (48-124) minutes for 1-stage patient, and 90 (56-155) minutes for 1-stage relative consents (P<0.001). Two-stage consent was associated with onset-to-randomization time of ≤3 hours compared with 1-stage consent (adjusted odds ratio, 1.9 [95% CI, 1.5-2.4]). Doctor consent increased the odds (adjusted odds ratio, 2.3 [1.5-3.5]) while relative consent reduced the odds of randomization ≤3 hours (adjusted odds ratio, 0.10 [0.03-0.34]) compared with patient consent. Only 2 of 771 patients (0.3%) in the 2-stage pathways withdrew consent when full consent was sought later. Two-stage consent process did not result in higher withdrawal rates or loss to follow-up. CONCLUSIONS The use of initial brief consent was associated with shorter times to enrollment, while maintaining good participant retention. Seeking written consent from relatives was associated with significant delays. REGISTRATION URL: https://www.isrctn.com; Unique identifier: ISRCTN93732214.
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Affiliation(s)
- Zhe Kang Law
- Stroke Trials Unit (Z.K.L., J.P.A., P.S., P.M.B., N.S.), University of Nottingham, United Kingdom
- Department of Medicine (Z.K.L.), National University of Malaysia
| | - Jason P. Appleton
- Stroke Trials Unit (Z.K.L., J.P.A., P.S., P.M.B., N.S.), University of Nottingham, United Kingdom
- Stroke, University Hospitals Birmingham NHS Foundation Trust, United Kingdom (J.P.A.)
| | - Polly Scutt
- Stroke Trials Unit (Z.K.L., J.P.A., P.S., P.M.B., N.S.), University of Nottingham, United Kingdom
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, United Kingdom (I.R.)
| | | | - Timothy J. England
- Vascular Medicine, Division of Medical Sciences and GEM, Royal Derby Hospital Centre (T.J.E.), University of Nottingham, United Kingdom
| | - David J. Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom (D.J.W.)
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Biomedical Research Centre, University of Leicester, United Kingdom (T.R.)
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (K.K., P.M.B., N.S.)
| | - Robert A. Dineen
- Radiological Sciences (R.A.D.), University of Nottingham, United Kingdom
- NIHR Nottingham Biomedical Research Centre, United Kingdom (R.A.D.)
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Karolinska Institute Danderyd Hospital, Sweden (A.C.L.)
| | - Philippe A. Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland (P.A.L.)
| | | | | | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Denmark (H.C.)
| | - Christine Roffe
- Stroke Research, School of Medicine, Keele University, Newcastle-Under-Lyme, United Kingdom (C.R.)
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary (D.B.)
| | - Serefnur Ozturk
- Selcuk University Faculty of Medicine, Department of Neurology, Konya, Turkey (S.O.)
| | - Jegan Thanabalan
- Department of Surgery, Division of Neurosurgery (J.T.), National University of Malaysia
| | - Ronan Collins
- Age Related Health Care/Stroke-Service, Tallaght University Hospital, Dublin, Republic of Ireland (R.C.)
| | - Maia Beridze
- The First University Clinic of Tbilisi State Medical University, GA (M.B.)
| | - Alfonso Ciccone
- Neurology and Stroke Unit, Poma Hospital, ASST di Mantova, Mantua, Italy (A.C.)
| | - Lelia Duley
- Nottingham Clinical Trials Unit (L.D.), University of Nottingham, United Kingdom
| | - Angela Shone
- Research and Innovation (A.S.), University of Nottingham, United Kingdom
| | - Philip M. Bath
- Stroke Trials Unit (Z.K.L., J.P.A., P.S., P.M.B., N.S.), University of Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (K.K., P.M.B., N.S.)
| | - Nikola Sprigg
- Stroke Trials Unit (Z.K.L., J.P.A., P.S., P.M.B., N.S.), University of Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (K.K., P.M.B., N.S.)
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Wang L, Luo S, Ren S, Yu H, Shen G, Wu G, Yang Q. Irregular-Shaped Hematoma Predicts Postoperative Rehemorrhage After Stereotactic Minimally Invasive Surgery for Intracerebral Hemorrhage. Front Neurol 2022; 13:727702. [PMID: 35359642 PMCID: PMC8961737 DOI: 10.3389/fneur.2022.727702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background and PurposeMinimally invasive surgery (MIS) is performed to treat patients with intracerebral hemorrhage (ICH) with favorable results. However, postoperative rehemorrhage is a significant risk. The present study retrospectively analyzed the association of irregular-shaped hematoma with postoperative rehemorrhage following stereotactic MIS (sMIS).MethodsWe enrolled 548 patients with spontaneous ICH who underwent sMIS. Based on the hematoma shape, the patients were assigned to the regular-shaped hematoma group (RSH group; 300 patients) or irregular-shaped hematoma group (ISH group; 248 patients). Logistic regression analysis was performed to identify the predictors of postoperative rehemorrhage after sMIS for ICH evacuation. The functional outcome was assessed using the modified ranking scale (mRS) score at discharge. A receiver operating characteristic (ROC) curve was used to confirm the results.ResultsAmong 548 patients with ICH who underwent sMIS, 116 developed postoperative rehemorrhage. Postoperative rehemorrhage occurred in 30.65% of patients with ISH and 13.30% with RSH (P < 0.01), with a significant difference between the ISH and RSH groups. Among 116 patients with postoperative rehemorrhage, 76 (65.52%) showed ISH on CT scan. In 432 patients without postoperative rehemorrhage, only 39.81% displayed ISH. The logistic regression analysis demonstrated that ISH could independently predict postoperative rehemorrhage. The sensitivity, specificity, positive predictive value, and negative predicative value were 0.655, 0.398, 0.655, and 0.602, respectively. The ROC analysis confirmed the value of ISH in predicting postoperative rehemorrhage with an area under the curve of 0.629.ConclusionsIrregular-shaped hematoma was an independent predictor of postoperative rehemorrhage after sMIS.
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Affiliation(s)
- Likun Wang
- Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Sheng Luo
- Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Siying Ren
- Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Hui Yu
- Affiliated Hospital of Guizhou Medical University, Guiyang, China
- *Correspondence: Hui Yu
| | - Guiquan Shen
- Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Guofeng Wu
- Affiliated Hospital of Guizhou Medical University, Guiyang, China
- Guofeng Wu
| | - Qingwu Yang
- Second Affiliated Hospital of Army Military Medical University, Chongqing, China
- Qingwu Yang
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Honig A, Percy J, Sepehry AA, Gomez AG, Field TS, Benavente OR. Hemorrhagic Transformation in Acute Ischemic Stroke: A Quantitative Systematic Review. J Clin Med 2022; 11:jcm11051162. [PMID: 35268253 PMCID: PMC8910828 DOI: 10.3390/jcm11051162] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
The prevalence and risk factors of hemorrhagic transformation (HT) after acute ischemic stroke HT have not been adequately delineated. We performed a systematic review and meta-analysis to identify English-language prospective observational MEDLINE and EMBASE-listed reports of acute ischemic stroke with HT published from 1985–2017. Studies that used the ECASS-2 definitions of hemorrhagic transformation subtypes, hemorrhagic infarction (HI), and parenchymal hematoma (PH) were included. Patients treated with intravenous thrombolysis with tissue plasminogen activator (IV-tPA) were compared with those who did not receive thrombolysis. A total of 65 studies with 17,259 patients met inclusion criteria. Overall, HT prevalence was 27%; 32% in patients receiving IV-tPA vs. 20% in those without. Overall PH prevalence was 9%; 12% in IV-tPA treated patients vs. 5% in those without. HT was associated with a history of atrial fibrillation (OR 2.94) and use of anticoagulants (OR 2.47). HT patients had higher NIHSS (Hedge’s-G 0.96) and larger infarct volume (diffusion-weighted MRI, Hedge’s-G 0.8). In IV-tPA treated patients, PH correlated with antiplatelet (OR 3) and statin treatment (OR 4). HT (OR 3) and PH (OR 8) were associated with a poor outcome at 90-day (mRS 5–6). Hemorrhagic transformation is a frequent complication of acute ischemic stroke and is associated with poor outcome. Recognition of risk factors for HT and PH may reduce their incidence and severity.
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Affiliation(s)
- Asaf Honig
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
- Correspondence:
| | - Jennifer Percy
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Amir A. Sepehry
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
- Clinical Psychology Program, Adler University, Vancouver, BC V6B 3J5, Canada
| | - Alejandra G. Gomez
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Thalia S. Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Oscar R. Benavente
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
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Liu J, Tao W, Wang Z, Chen X, Wu B, Liu M. Radiomics-based prediction of hemorrhage expansion among patients with thrombolysis/thrombectomy related-hemorrhagic transformation using machine learning. Ther Adv Neurol Disord 2022; 14:17562864211060029. [PMID: 35173809 PMCID: PMC8842178 DOI: 10.1177/17562864211060029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/28/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction: Patients with hemorrhagic transformation (HT) were reported to have
hemorrhage expansion. However, identification these patients with high risk
of hemorrhage expansion has not been well studied. Objectives: We aimed to develop a radiomic score to predict hemorrhage expansion after HT
among patients treated with thrombolysis/thrombectomy during acute phase of
ischemic stroke. Methods: A total of 104 patients with HT after reperfusion treatment from the West
China hospital, Sichuan University, were retrospectively included in this
study between 1 January 2012 and 31 December 2020. The preprocessed initial
non-contrast-enhanced computed tomography (NECT) imaging brain images were
used for radiomic feature extraction. A synthetic minority oversampling
technique (SMOTE) was applied to the original data set. The after-SMOTE data
set was randomly split into training and testing cohorts with an 8:2 ratio
by a stratified random sampling method. The least absolute shrinkage and
selection operator (LASSO) regression were applied to identify candidate
radiomic features and construct the radiomic score. The performance of the
score was evaluated by receiver operating characteristic (ROC) analysis and
a calibration curve. Decision curve analysis (DCA) was performed to evaluate
the clinical value of the model. Results: Among the 104 patients, 17 patients were identified with hemorrhage expansion
after HT detection. A total of 154 candidate predictors were extracted from
NECT images and five optimal features were ultimately included in the
development of the radiomic score by using logistic regression
machine-learning approach. The radiomic score showed good performance with
high area under the curves in both the training data set (0.91, sensitivity:
0.83; specificity: 0.89), test data set (0.87, sensitivity: 0.60;
specificity: 0.85), and original data set (0.82, sensitivity: 0.77;
specificity: 0.78). The calibration curve and DCA also indicated that there
was a high accuracy and clinical usefulness of the radiomic score for
hemorrhage expansion prediction after HT. Conclusions: The currently established NECT-based radiomic score is valuable in predicting
hemorrhage expansion after HT among patients treated with reperfusion
treatment after ischemic stroke, which may aid clinicians in determining
patients with HT who are most likely to benefit from anti-expansion
treatment.
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Affiliation(s)
- Junfeng Liu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Wendan Tao
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhetao Wang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xinyue Chen
- CT collaboration, Siemens Healthineers,China
| | - Bo Wu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, China
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89
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Liu J, Zhu Z, Leung GKK. Erythrophagocytosis by Microglia/Macrophage in Intracerebral Hemorrhage: From Mechanisms to Translation. Front Cell Neurosci 2022; 16:818602. [PMID: 35237132 PMCID: PMC8882619 DOI: 10.3389/fncel.2022.818602] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/10/2022] [Indexed: 12/17/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a devastating condition characterized by hematoma related mass effect. Microglia/macrophage (M φ) are rapidly recruited in order to remove the red blood cells through erythrophagocytosis. Efficient erythrophagocytosis can detoxify hemolytic products and facilitate neurological recovery after ICH. The underlying mechanisms include modulation of inflammatory response and oxidative stress, among others. It is a dynamic process mediated by a cascade of signal transduction, including “find-me” signals, “eat-me” signals and a set of phagocytotic receptors-ligand pairs that may be exploited as therapeutic targets. This review summarizes mechanistic signaling pathways of erythrophagocytosis and highlights the potential of harnessing M φ-mediated phagocytosis for ICH treatment.
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Affiliation(s)
- Jiaxin Liu
- Department of Surgery, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
| | - Zhiyuan Zhu
- Department of Surgery, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
- Department of Functional Neurosurgery, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, The Neurosurgery Institute of Guangdong Province, Guangzhou, China
- Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Gilberto Ka-Kit Leung
- Department of Surgery, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
- *Correspondence: Gilberto Ka-Kit Leung,
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90
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Tsai HH, Hsieh YC, Lin JS, Kuo ZT, Ho CY, Chen CH, Chang CF. Functional Investigation of Meningeal Lymphatic System in Experimental Intracerebral Hemorrhage. Stroke 2022; 53:987-998. [DOI: 10.1161/strokeaha.121.037834] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Promotion of hematoma resolution in a timely manner reduces intracerebral hemorrhage (ICH) brain injury induced by toxic blood components and subsequent neuroinflammation. The meningeal lymphatic system is responsible for clearance of macromolecules and pathogenic substances from the central nervous system; however, its role in intraparenchymal hematoma clearance and ICH outcomes is unknown. In the present study, we aimed to understand the contribution of the meningeal lymphatic system to ICH pathologies and to test whether pharmacological enhancement of meningeal lymphatic function promotes hematoma resolution and brain recovery after ICH.
Methods:
Immunofluorescence of whole-mount meninges was used to measure complexity and coverage level of meningeal lymphatic vasculature following ICH induction. Fluorescent microbeads and PKH-26-labeled erythrocytes were used to evaluate drainage function of the meningeal lymphatic system. Visudyne treatment, deep cervical lymph node ligation, and VEGF (vascular endothelial growth factor)-C injection were performed to manipulate meningeal lymphatic function. Neurobehavioral performance and hematoma volume were assayed by the cylinder test and histological measurements. Iron deposition, residual erythrocytes, neuronal loss, and astrogliosis were assessed by immunohistochemistry and antibody-based fluorescence staining.
Results:
Meningeal lymphangiogenesis and enhanced lymphatic drainage occurred during the late phase of ICH. Ablation and blockage of meningeal lymphatic vessels impeded hematoma clearance, whereas pharmacological enhancement of their function reduced hematoma volume, improved behavioral performance, and reduced brain residual erythrocytes, iron deposition, neuronal loss, and astroglial activation.
Conclusions:
Early enhancement of meningeal lymphatic function is beneficial for ICH recovery. Targeting the meningeal lymphatic system is therefore a potential therapeutic approach for treating ICH.
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Affiliation(s)
- Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei (H.-H.T.)
- Department of Neurology, National Taiwan University Hospital, Taipei (H.-H.T.)
| | - Yung-Chia Hsieh
- School of Medicine, National Taiwan University College of Medicine, Taipei. (Y.-C.H.)
- Department and Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei. (Y.-C.H., J.S.L., Z.-T.K., C.-Y.H., C.-H.C., C.-F.C.)
| | - Jhih Syuan Lin
- Department and Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei. (Y.-C.H., J.S.L., Z.-T.K., C.-Y.H., C.-H.C., C.-F.C.)
| | - Zi-Ting Kuo
- Department and Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei. (Y.-C.H., J.S.L., Z.-T.K., C.-Y.H., C.-H.C., C.-F.C.)
| | - Chi-Ying Ho
- Department and Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei. (Y.-C.H., J.S.L., Z.-T.K., C.-Y.H., C.-H.C., C.-F.C.)
| | - Chih-Hung Chen
- Department and Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei. (Y.-C.H., J.S.L., Z.-T.K., C.-Y.H., C.-H.C., C.-F.C.)
| | - Che-Feng Chang
- Department and Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei. (Y.-C.H., J.S.L., Z.-T.K., C.-Y.H., C.-H.C., C.-F.C.)
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91
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Guo Y, Guo XM, Li RL, Zhao K, Bao QJ, Yang JC, Zhang Q, Yang MF. Tranexamic Acid for Acute Spontaneous Intracerebral Hemorrhage: A Meta-Analysis of Randomized Controlled Trials. Front Neurol 2022; 12:761185. [PMID: 34987465 PMCID: PMC8720763 DOI: 10.3389/fneur.2021.761185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The role of tranexamic acid (TXA) in preventing hematoma expansion (HE) in patients with acute spontaneous intracerebral hemorrhage (ICH) remains unclear. We aim to investigate the efficacy and safety of TXA in acute spontaneous ICH with a particular focus on subgroups. Methods: Randomized controlled trials (RCTs) were retrieved from CENTRAL, Clinicaltrials.gov, EMBASE, PubMed, and WHO ICTRP. The primary outcome measurement was HE. The secondary outcome measurements included 3-month poor functional outcome (PFO), 3-month mortality, and major thromboembolic events (MTE). We conducted subgroup analysis according to the CT markers of HE (standard-risk population and high-risk population) and the time from onset to randomization (>4.5 and ≤4.5 h). Results: We identified seven studies (representing five RCTs) involving 2,650 participants. Compared with placebo, TXA may reduce HE on subsequent imaging (odd ratio [OR] 0.825; 95% confidence interval [CI] 0.692–0.984; p = 0.033; I2 = 0%; GRADE: moderate certainty). TXA and placebo arms did not differ in the rates of 3-month PFO, 3-month mortality, and MTE. Subgroup analysis indicated that TXA reduced the risk of HE in the high-risk population with CT markers of HE (OR 0.646; 95% CI 0.503–0.829; p = 0.001; I2 = 0 %) and in patients who were treated within 4.5 h of symptom onset (OR 0.823; 95% CI 0.690–0.980; p = 0.029; I2 = 0%), but this protective effect was not observed in the standard-risk population and patients who were treated over 4.5 h of symptom onset. Conclusions: Tranexamic acid (TXA) may decrease the risk of HE in patients with acute spontaneous ICH. Importantly, the decreased risk was observed in patients who were treatable within 4.5 h and with a high risk of HE, but not in those who were treatable over 4.5 h and in standard-risk population. However, PFO or mortality at 3 months did not significantly differ between patients who received TXA and those who received placebo. TXA is safe for acute spontaneous ICH without increasing MTE.
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Affiliation(s)
- Yu Guo
- Graduate School, Qinghai University, Xining, China
| | - Xin-Mei Guo
- Biomedical Engineering Research Center, Kunming Medical University, Kunming, China
| | - Rui-Li Li
- Neurological Intensive Care Department, Shengli Oilfield Central Hospital, Dongying, China
| | - Kai Zhao
- Graduate School, Qinghai University, Xining, China
| | - Qiang-Ji Bao
- Graduate School, Qinghai University, Xining, China
| | - Jin-Cai Yang
- Graduate School, Qinghai University, Xining, China
| | - Qiang Zhang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, China
| | - Ming-Fei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, China
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92
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Padrick MM, Brown W, Lyden PD. Intravenous Thrombolysis. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00053-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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93
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Dzialowski I, Puetz V, Parsons M, Bivard A, von Kummer R. Computed Tomography-Based Evaluation of Cerebrovascular Disease. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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94
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Berthaud JV, Morgenstern LB, Zahuranec DB. Medical Therapy of Intracerebral and Intraventricular Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00059-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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95
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Kircher CE, Adeoye O. Prehospital and Emergency Department Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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96
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Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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97
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Wang WJ, Lu JJ, Liu LP, Jia JK, Zhao XQ. Ultraearly Hematoma Growth in Acute Spontaneous Intracerebral Hemorrhage Predicts Early and Long-Term Poor Clinical Outcomes: A Prospective, Observational Cohort Study. Front Neurol 2021; 12:747551. [PMID: 34975715 PMCID: PMC8714734 DOI: 10.3389/fneur.2021.747551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/16/2021] [Indexed: 11/26/2022] Open
Abstract
Aims: Although prognostic importance of ultraearly hematoma growth (uHG) in acute, non-traumatic intracerebral hemorrhage (ICH) has been established for early outcomes, longer-term clinical outcomes are lacking. We aimed to determine the association of uHG with early and 1-year clinical outcomes after acute ICH in a larger and broader range of patients. Methods: We studied 589 patients with acute (<6 h) spontaneous ICH. uHG was defined as baseline ICH volume/onset-to-imaging time (OIT) (ml/h). Multivariable logistic regression analyses were performed to determine the association of uHG with in-hospital mortality, 90-day, and 1-year poor outcome [3 ≤ modified Rankin Scale (mRS)] after ICH. Results: The median speed of uHG was 4.8 ml/h. uHG > 9.3 ml/h was independently related to in-hospital mortality [odds ratio (OR) 2.81, 95% CI 1.52–5.23], 90-day poor outcome (OR 3.34, 95% CI 1.87–5.95), and 1-year poor outcome (OR 3.59, 95% CI 2.01–6.40) after ICH. The sensitivity of uHG > 9.3 ml/h in the prediction of in-hospital mortality, 90-day poor outcome, and 1-year poor outcome was 68.8, 48.0, and 51.1%, respectively. Conclusions: Ultraearly hematoma growth was a useful predictor of in-hospital mortality, 90-day, and 1-year poor outcome after acute ICH. The combination of both uHG and baseline ICH volume could allow better selection of patients with ICH at high risk of poorest clinical outcomes for future clinical trials to improve early- and long-term clinical outcomes.
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98
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Wang W, Jin W, Feng H, Wu G, Wang W, Jia J, Ji R, Wang A, Zhao X. Higher Cerebral Blood Flow Predicts Early Hematoma Expansion in Patients With Intracerebral Hemorrhage: A Clinical Study. Front Neurol 2021; 12:735771. [PMID: 34938256 PMCID: PMC8685442 DOI: 10.3389/fneur.2021.735771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 11/03/2021] [Indexed: 12/03/2022] Open
Abstract
The early hematoma expansion of intracerebral hemorrhage (ICH) indicates a poor prognosis. This paper studies the relationship between cerebral blood flow (CBF) around the hematoma and hematoma expansion (HE) in the acute stage of intracerebral hemorrhage. A total of 50 patients with supratentorial cerebral hemorrhage were enrolled in this study. They underwent baseline whole-brain CTP within 6 h after intracerebral hemorrhage, and non-contrast CT within 24 h. Absolute hematoma growth and relative hematoma growth were calculated, respectively. A relative growth of Hematoma volume >33% was considered to be hematoma expansion. The Ipsilateral peri-edema CBF and Ipsilateral edema CBF were calculated by CTP maps in patients with and without hematoma expansion, respectively. In this study the incidence of hematoma expansion in the early stage of supratentorial cerebral hemorrhage was 32%; The CBF of the hematoma expansion group was higher than that of the patients without hematoma expansion (23.5 ± 12.5 vs. 15.1 ± 7.4, P = 0.004). After adjusting for age, gender, Symptom onset to NCCT and Baseline hematoma volume, ipsilateral peri-edema CBF was still an independent risk factor for early HE (or = 1.095, 95% CI = 1.01-1.19, P = 0.024). Here, we concluded that higher cerebral blood flow predicts early hematoma expansion in patients with intracerebral hemorrhage.
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Affiliation(s)
- Weijing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Haidian Hospital, Beijing, China
- Department of Neurology, Haidian Section of Peking University Third Hospital, Beijing, China
| | - Weitao Jin
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Hao Feng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Guoliang Wu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiaokun Jia
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Ruijun Ji
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
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99
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Cai Q, Zhang X, Chen H. Patients with venous thromboembolism after spontaneous intracerebral hemorrhage: a review. Thromb J 2021; 19:93. [PMID: 34838069 PMCID: PMC8626951 DOI: 10.1186/s12959-021-00345-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/14/2021] [Indexed: 01/17/2023] Open
Abstract
Background Patients with spontaneous intracerebral hemorrhage (ICH) have a higher risk of venous thromboembolism (VTE) and in-hospital VTE is independently associated with poor outcomes for this patient population. Methods A comprehensive literature search about patients with VTE after spontaneous ICH was conducted using databases MEDLINE and PubMed. We searched for the following terms and other related terms (in US and UK spelling) to identify relevant studies: intracerebral hemorrhage, ICH, intraparenchymal hemorrhage, IPH, venous thromboembolism, VTE, deep vein thrombosis, DVT, pulmonary embolism, and PE. The search was restricted to human subjects and limited to articles published in English. Abstracts were screened and data from potentially relevant articles was analyzed. Results The prophylaxis and treatment of VTE are of vital importance for patients with spontaneous ICH. Prophylaxis measures can be mainly categorized into mechanical prophylaxis and chemoprophylaxis. Treatment strategies include anticoagulation, vena cava filter, systemic thrombolytic therapy, catheter-based thrombus removal, and surgical embolectomy. We briefly summarized the state of knowledge regarding the prophylaxis measures and treatment strategies of VTE after spontaneous ICH in this review, especially on chemoprophylaxis and anticoagulation therapy. Early mechanical prophylaxis, especially with intermittent pneumatic compression, is recommended by recent guidelines for patients with spontaneous ICH. While decision-making on chemoprophylaxis and anticoagulation therapy evokes debate among clinicians, because of the concern that anticoagulants may increase the risk of recurrent ICH and hematoma expansion. Uncertainty still exists regarding optimal anticoagulants, the timing of initiation, and dosage. Conclusion Based on current evidence, we deem that initiating chemoprophylaxis with UFH/LMWH within 24–48 h of ICH onset could be safe; anticoagulation therapy should depend on individual clinical condition; the role of NOACs in this patient population could be promising.
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Affiliation(s)
- Qiyan Cai
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Xin Zhang
- Respiratory Disease Department, Xinqiao Hospital, Chongqing, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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100
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Tranexamic Acid for Adult Patients with Spontaneous Intracerebral Hemorrhage: A Systematic Review with Meta-analysis. CNS Drugs 2021; 35:1163-1172. [PMID: 34661872 DOI: 10.1007/s40263-021-00865-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The effects of tranexamic acid on spontaneous intracerebral hemorrhage in reducing hematoma expansion and mortality as well as its role in thromboembolic complications and in the improvement of functional outcomes remain substantially uncertain. OBJECTIVE The objective of this systematic review was to evaluate the efficacy and safety of tranexamic acid in patients with spontaneous intracerebral hemorrhage. METHODS Several databases were searched from inception up to 20 June, 2021. We included randomized controlled trials that compared tranexamic acid with placebo or no treatment for the management of intracerebral hemorrhage. The primary outcomes were hematoma expansion and 90-day mortality. The secondary outcomes were hemorrhagic volume change, thromboembolic complications, and functional outcomes. RESULTS Overall, six trials with 2800 patients were included in this meta-analysis. Tranexamic acid was associated with a reduced risk of hematoma expansion (relative risk 0.87, 95% confidence interval [CI] 0.77-0.99, p = 0.03, I2 = 0%, six trials with 2800 participants) and a lessening of hematoma volume change (mean difference - 1.28, 95% CI - 2.44 to - 0.12; p = 0.03; I2 = 0%, four trials with 2626 participants), without a corresponding higher rate of major thromboembolic complications (relative risk 1.20, 95% CI 0.85-1.69; p = 0.80; I2 = 0%, five trials with 2759 participants). The present analysis also demonstrated that tranexamic acid had no effect on reducing 90-day mortality (relative risk 1.02, 95% CI 0.88-1.19; p = 0.80; I2 = 0%, five trials with 2770 participants). CONCLUSIONS In adults with spontaneous intracerebral hemorrhage, tranexamic acid reduced the risk of intracerebral hemorrhage growth compared with the control. The effects on 90-day mortality remained inconclusive. Further studies should report death within 24 h and death due to bleeding whenever possible.
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