Treatment of intracerebral haemorrhage

The role of neurosciences intensive care in trauma and neurosurgical conditions

The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.

Iron and intracerebral hemorrhage: from mechanism to translation

Intracerebral hemorrhage (ICH) is a leading cause of morbidity and mortality around the world. Currently, there is no effective medical treatment available to improve functional outcomes in patients with ICH due to its unknown mechanisms of damage. Increasing evidence has shown that the metabolic products of erythrocytes are the key contributor of ICH-induced secondary brain injury. Iron, an important metabolic product that accumulates in the brain parenchyma, has a detrimental effect on secondary injury following ICH. Because the damage mechanism of iron during ICH-induced secondary injury is clear, iron removal therapy research on animal models is effective. Although many animal and clinical studies have been conducted, the exact metabolic pathways of iron and the mechanisms of iron removal treatments are still not clear. This review summarizes recent progress concerning the iron metabolism mechanisms underlying ICH-induced injury. We focus on iron, brain iron metabolism, the role of iron in oxidative injury, and iron removal therapy following ICH, and we suggest that further studies focus on brain iron metabolism after ICH and the mechanism for iron removal therapy.

Modern intraoperative imaging modalities for the vascular neurosurgeon treating intracerebral hemorrhage

This paper reviews the current intraoperative imaging tools that are available to assist neurosurgeons in the treatment of intracerebral hemorrhage (ICH). This review shares the authors' experience with each modality and discusses the advantages, potential limitations, and disadvantages of each. Surgery for ICH is directed at blood clot removal, reduction of intracranial pressure, and minimization of secondary damage associated with hematoma breakdown products. For effective occlusion and safe obliteration of vascular anomalies associated with ICH, vascular neurosurgeons today require a thorough understanding of the various intraoperative imaging modalities available for obtaining real-time information. Use of one or more of these modalities may improve the surgeon's confidence during the procedure, the patient's safety during surgery, and surgical outcome. The modern techniques discussed include 1) indocyanine green-based video angiography, which provides real-time information based on high-quality images showing the residual filling of vascular pathological entities and the patency of blood vessels of any size in the surgical field; and 2) intraoperative angiography, which remains the gold standard intraoperative diagnostic test in the surgical management of cerebral aneurysms and arteriovenous malformations. Hybrid procedures, providing multimodality image-guided surgeries and combining endovascular with microsurgical strategies within the same surgical session, have become feasible and safe. Microdoppler is a safe, noninvasive, and reliable technique for evaluation of hemodynamics of vessels in the surgical field, with the advantage of ease of use. Intraoperative MRI provides an effective navigation tool for cavernoma surgery, in addition to assessing the extent of resection during the procedure. Intraoperative CT scanning has the advantage of very high sensitivity to acute bleeding, thereby assisting in the confirmation of the extent of hematoma evacuation and the extent of vascular anomaly resection. Intraoperative ultrasound aids navigation and evacuation assessment during intracerebral hematoma evacuation surgeries. It supports the concept of minimally invasive surgery and has undergone extensive development in recent years, with the quality of ultrasound imaging having improved considerably. Image-guided therapy, combined with modern intraoperative imaging modalities, has changed the fundamentals of conventional vascular neurosurgery by presenting real-time visualization of both normal tissue and pathological entities. These imaging techniques are important adjuncts to the surgeon's standard surgical armamentarium. Familiarity with these imaging modalities may help the surgeon complete procedures with improved safety, efficiency, and clinical outcome.

Inflammation in intracerebral hemorrhage: from mechanisms to clinical translation

Intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes and is associated with high mortality and morbidity. Currently, no effective medical treatment is available to improve functional outcomes in patients with ICH. Potential therapies targeting secondary brain injury are arousing a great deal of interest in translational studies. Increasing evidence has shown that inflammation is the key contributor of ICH-induced secondary brain injury. Inflammation progresses in response to various stimuli produced after ICH. Hematoma components initiate inflammatory signaling via activation of microglia, subsequently releasing proinflammatory cytokines and chemokines to attract peripheral inflammatory infiltration. Hemoglobin (Hb), heme, and iron released after red blood cell lysis aggravate ICH-induced inflammatory injury. Danger associated molecular patterns such as high mobility group box 1 protein, released from damaged or dead cells, trigger inflammation in the late stage of ICH. Preclinical studies have identified inflammatory signaling pathways that are involved in microglial activation, leukocyte infiltration, toll-like receptor (TLR) activation, and danger associated molecular pattern regulation in ICH. Recent advances in understanding the pathogenesis of ICH-induced inflammatory injury have facilitated the identification of several novel therapeutic targets for the treatment of ICH. This review summarizes recent progress concerning the mechanisms underlying ICH-induced inflammation. We focus on the inflammatory signaling pathways involved in microglial activation and TLR signaling, and explore potential therapeutic interventions by targeting the removal of hematoma components and inhibition of TLR signaling.

Imaging of contrast medium extravasation in anticoagulation-associated intracerebral hemorrhage with dual-energy computed tomography

BACKGROUND AND PURPOSE

Contrast medium extravasation (CE) in intracerebral hemorrhage (ICH) is a marker of ongoing bleeding and a predictor of hematoma expansion. The aims of the study were to establish an ICH model in which CE can be quantified, characterized in ICH during warfarin and dabigatran anticoagulation, and to evaluate effects of prothrombin complex concentrates on CE in warfarin-associated ICH.

METHODS

CD1-mice were pretreated orally with warfarin, dabigatran, or vehicle. Prothrombin complex concentrates were administered in a subgroup of warfarin-treated mice. ICH was induced by stereotactic injection of collagenase VIIs into the right striatum. Contrast agent (350 μL Isovue 370 mg/mL) was injected intravenously after ICH induction (2-3.5 hours). Thirty minutes later, mice were euthanized, and CE was measured by quantifying the iodine content in the hematoma using dual-energy computed tomography.

RESULTS

The optimal time point for contrast injection was found to be 3 hours after ICH induction, allowing detection of both an increase and a decrease of CE using dual-energy computed tomography. CE was higher in the warfarin group compared with the controls (P=0.002). There was no significant difference in CE between dabigatran-treated mice and controls. CE was higher in the sham-treated warfarin group than in the prothrombin complex concentrates-treated warfarin group (P<0.001).

CONCLUSIONS

Dual-energy computed tomography allows quantifying CE, as a marker of ongoing bleeding, in a model of anticoagulation-associated ICH. Dabigatran induces less CE in ICH than warfarin and consequently reduces risks of hematoma expansion. This constitutes a potential safety advantage of dabigatran over warfarin. Nevertheless, in case of warfarin anticoagulation, prothrombin complex concentrates reduce this side effect.

Ablation of astrocytic laminin impairs vascular smooth muscle cell function and leads to hemorrhagic stroke

Ablation of astrocytic laminin disrupted the interaction between vascular smooth muscle cells and astrocytes, down-regulated contractile protein expression, and weakened vascular integrity in deep brain regions, leading to hemorrhage.

Astrocytes express laminin and assemble basement membranes (BMs) at their endfeet, which ensheath the cerebrovasculature. The function of astrocytic laminin in cerebrovascular integrity is unknown. We show that ablation of astrocytic laminin by tissue-specific Cre-mediated recombination disrupted endfeet BMs and led to hemorrhage in deep brain regions of adult mice, resembling human hypertensive hemorrhage. The lack of astrocytic laminin led to impaired function of vascular smooth muscle cells (VSMCs), where astrocytes have a closer association with VSMCs in small arterioles, and was associated with hemorrhagic vessels, which exhibited VSMC fragmentation and vascular wall disassembly. Acute disruption of astrocytic laminin in the striatum of adult mice also impaired VSMC function, indicating that laminin is necessary for VSMC maintenance. In vitro, both astrocytes and astrocytic laminin promoted brain VSMC differentiation. These results show that astrocytes regulate VSMCs and vascular integrity in small vessels of deep brain regions. Therefore, astrocytes may be a possible target for hemorrhagic stroke prevention and therapy.

Prediction of evolution toward brain death upon admission to ICU in comatose patients with spontaneous intracerebral hemorrhage using simple signs

The aim of the study was to identify the predictors of brain death (BD) upon admission to the intensive care unit (ICU) of comatose patients with spontaneous intracerebral hemorrhage (ICH). Patients admitted in our ICU from 2002 to 2010 for spontaneous ICH and placed under mechanical ventilation were retrospectively analyzed. Of the 72 patients, 49% evolved to BD, 39% died after withdrawal of life support, and 12% were discharged alive. The most discriminating characteristics to predict BD were included in two models; Model 1 contained ≥3 abolished brainstem responses [adjusted odds ratios (OR) = 8.4 (2.4, 29.1)] and the swirl sign on the baseline CT-scan [adjusted OR = 5.0 (1.6, 15.9)] and Model 2 addressed the abolition of corneal reflexes [unilateral/bilateral: adjusted OR = 4.2 (0.9, 20.1)/8.8 (2.4, 32.3)] and the swirl sign on the baseline CT-scan [adjusted OR = 6.2 (1.9, 20.0)]. Two scores predicting BD were created (sensitivity: 0.89 and 0.88, specificity: 0.68 and 0.65). Risk of evolution toward BD was classified as low (corneal reflexes present and no swirl sign), high (≥1 corneal reflexes abolished and swirl sign), and intermediate. Simple signs at ICU admission can predict BD in comatose patients with ICH and could increase the potential for organ donation.

Toll-like receptor 4 signaling in intracerebral hemorrhage-induced inflammation and injury

Intracerebral hemorrhage (ICH) is a common type of fatal stroke, accounting for about 15% to 20% of all strokes. Hemorrhagic strokes are associated with high mortality and morbidity, and increasing evidence shows that innate immune responses and inflammatory injury play a critical role in ICH-induced neurological deficits. However, the signaling pathways involved in ICH-induced inflammatory responses remain elusive. Toll-like receptor 4 (TLR4) belongs to a large family of pattern recognition receptors that play a key role in innate immunity and inflammatory responses. In this review, we summarize recent findings concerning the involvement of TLR4 signaling in ICH-induced inflammation and brain injury. We discuss the key mechanisms associated with TLR4 signaling in ICH and explore the potential for therapeutic intervention by targeting TLR4 signaling.

Artificial neural networks based early clinical prediction of mortality after spontaneous intracerebral hemorrhage

Numerous outcome prediction models have been developed for mortality and functional outcome after spontaneous intracerebral haemorrhage (ICH). However, no outcome prediction model for ICH has considered the impact of care restriction. To develop and compare results of the artificial neural networks (ANN) and logistic regression (LR) models, based on initial clinical parameters, for prediction of mortality after spontaneous ICH. Analysis has been conducted on consecutive dataset of patients with spontaneous ICH, over 5-year period in tertiary care academic hospital. Patients older than 18 years were eligible for inclusion if they had been presented within 6 h from the start of symptoms and had evidence of spontaneous supratentorial ICH on initial brain computed tomography within 24 h. Initial clinical parameters have been used to develop LR and ANN prediction models for hospital mortality as outcome measure. Models have been accessed for discrimination and calibration abilities. We have analyzed 411 patients (199 males and 212 females) with spontaneous ICH, medically treated and not withdrawn from therapy, with average age of 67.35 years. From them, 256 (62.29%) patients died during hospital treatment and 155 (37.71%) patients survived. In the observed dataset, ANN model overall correctly classified outcome in 93.55% of patients, compared with 79.32% of correct classification for the LR model. Discrimination and calibration parameters indicate that both models show an adequate fit of expected and observed values, with superiority of ANN model. Our results favour the ANN model for prediction of mortality after spontaneous ICH. Further studies of the strengths and limitations of this method are needed with larger prospective samples.

Emergency noninvasive angiography for acute intracerebral hemorrhage

Spontaneous ICH is a devastating condition and is associated with significant mortality in the acute phase due to ongoing hemorrhage and hematoma expansion. A growing body of evidence suggests that there may be considerable utility in performing noninvasive vascular imaging during the acute-to-early phase of ICH. CTA has become widely available and is sensitive and specific for detecting vascular causes of secondary ICH such as aneurysms, arteriovenous malformations, dural arteriovenous fistulas, intracranial dissections, and neoplasm. CT venography can also diagnose dural sinus thrombosis presenting as hemorrhagic infarction. Recent data from stroke populations demonstrate a relatively low risk to patients when contrast is administered in the absence of a known serum creatinine. Detection of acute contrast extravasation within the hematoma ("spot sign") with CT angiography is predictive of subsequent hematoma expansion and is associated with increased morbidity and mortality. Risk stratification based on acute CTA can inform and expedite decision-making regarding intensive care unit admission, blood pressure control, correction of coagulopathy, and neurosurgical consultation. Noninvasive vascular imaging should be considered as an important component of the initial diagnostic work-up for patients presenting with acute ICH.

Intracranial hemorrhage in adult patients with hematological malignancies

BACKGROUND

Clinical characteristics and outcomes of intracranial hemorrhage (ICH) among adult patients with various hematological malignancies are limited.

METHODS

A total of 2,574 adult patients diagnosed with hematological malignancies admitted to a single university hospital were enrolled into this study between 2001 and 2010. The clinical characteristics, image reports and outcomes were retrospectively analyzed.

RESULTS

A total of 72 patients (48 men and 24 women) with a median age of 56 (range 18 to 86) had an ICH. The overall ICH incidence was 2.8% among adult patients with hematological malignancies. The incidence of ICH was higher in acute myeloid leukemia (AML) patients than in patients with other hematological malignancies (6.3% vs 1.1%, P = 0.001). ICH was more common among patients with central nervous system (CNS) involvement of lymphoma than among patients with CNS involved acute leukemia (P <0.001). Sites of ICH occurrence included the cerebral cortex (60 patients, 83%), basal ganglia (13 patients, 18%), cerebellum (10 patients, 14%), and brainstem (5 patients, 7%). A total of 33 patients (46%) had multifocal hemorrhages. In all, 56 patients (77%) had intraparenchymal hemorrhage, 22 patients (31%) had subdural hemorrhage, 15 patients (21%) had subarachnoid hemorrhage (SAH), and 3 patients (4%) had epidural hemorrhage. A total of 22 patients had 2 or more types of ICH. In all, 46 (64%) patients died of ICH within 30 days of diagnosis, irrespective of the type of hematological malignancy. Multivariate analysis revealed three independent prognostic factors: prolonged prothrombin time (P = 0.008), SAH (P = 0.021), and multifocal cerebral hemorrhage (P = 0.026).

CONCLUSIONS

The incidence of ICH in patients with AML is higher than patients with other hematological malignancies. But in those with intracranial malignant disease, patients with CNS involved lymphoma were more prone to ICH than patients with CNS involved acute leukemia. Mortality was similar regardless of the type of hematological malignancy. Neuroimaging studies of the location and type of ICH could assist with prognosis prediction for patients with hematological malignancies.

Early do-not-resuscitate orders in intracerebral haemorrhage; frequency and predictive value for death and functional outcome. A retrospective cohort study

Introduction

In former studies from North America early Do-Not–Resuscitate orders (DNR orders) in patients with intracerebral haemorrhage (ICH) had negative prognostic impact on mortality. The influence of DNR orders on functional outcome and whether DNR orders are grounded on relevant patient characteristics is unknown. We aimed to determine the frequency and predictive factors of DNR-orders and its association to prognosis, in ICH patients, in Scandinavia.

Methods

In 197 consecutive ICH patients admitted to Skåne University Hospital, Malmö, Sweden, between January 2007 and June 2009, information of the presence of DNR orders within 48 hours, clinical and radiological characteristics was retrieved by review of patient medical journal and computed tomography scans. Determinants of DNR-orders, one-month case fatality and bad functional outcome (modified Rankin Scale, grade 4–6) were assessed by logistic regression analysis.

Results

DNR orders were made in 41% of the cases. After adjustment for confounding factors, age ≥ 75 years (Odds Ratio (95% confidence interval) 4.2(1.8-9.6)), former stroke (5.1(1.9-3.1)), Reaction Level Scale grade 2–3 and 4 (7.0(2.8-17.5) and (4.1(1.2-13.5), respectively) and intraventricular haemorrhage (3.8(1.6-9.4)) were independent determinants of early DNR orders. Independent predictors of one-month case fatality was age ≥ 75 years (3.7(1.4-9.6)) volume ≥ 30 ml (3.5(1.3-9.6)) and DNR orders (3.5(1.5-8.6)). Seizure (6.0(1.04-34.2) and brain stem hemorrhage (8.0(1.1-58.4)) were related to bad functional outcome, whereas early DNR order was not (3.5(0.99-12.7)).

Conclusions

Well known prognostic factors are determinants for DNR orders, however DNR orders are independently related to one-month case fatality. In addition to improvements of the local routines, we welcome a change of attitude with an enhanced awareness of the definition of, and a more careful approach with respect to DNR orders.

Pharmacological prophylaxis of venous thromboembolism during acute phase of spontaneous intracerebral hemorrhage: what do we know about risks and benefits?

Spontaneous intracerebral hemorrhage (sICH) represents a devastating clinical event with high mortality and morbidity rates. Only few patients with sICH are treated with neurosurgical evacuation of the hematoma, and the majority of them need only a good conservative medical approach. The goal of medical treatment is to avoid secondary neurological and systemic complications. Venous thromboembolism (VTE) represents one of the most feared complications of sICH, and it is a potential cause of death. The balance between the benefit of VTE prevention and the risk of hematoma enlargement and/or rebleeding with the use of pharmacologic thromboprophylaxis remains controversial because of the lack of consistent evidences in the literature. The efficacy of mechanical prophylaxis is also uncertain. Consequently, until now there are no clear guidelines and scientific evidences available for physicians in this field. The aim of this review is to analyze the available literature and guidelines about pharmacological VTE prophylaxis in patients with nonsurgical sICH.

Intracerebral hemorrhage: clinical overview and pathophysiologic concepts

Intracerebral hemorrhage is by far the most destructive form of stroke. Apart from the management in a specialized stroke or neurological intensive care unit (NICU), no specific therapies have been shown to consistently improve outcomes after ICH. Current guidelines endorse early aggressive optimization of physiologic derangements with ventilatory support when indicated, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring for certain cases, osmotherapy, temperature modulation, seizure prophylaxis, treatment of hyerglycemia, and nutritional support in the stroke unit or NICU. Ventriculostomy is the cornerstone of therapy for control of intracranial pressure patients with intraventricular hemorrhage. Surgical hematoma evacuation does not improve outcome for more patients, but is a reasonable option for patients with early worsening due to mass effect due to large cerebellar or lobar hemorrhages. Promising experimental treatments currently include ultra-early hemostatic therapy, intraventricular clot lysis with thrombolytics, pioglitazone, temperature modulation, and deferoxamine to reduce iron-mediated perihematomal inflammation and tissue injury.

Chemokines and their receptors in intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a devastating clinical event which results in a high rate of disability and death. At present, no effective treatment is available for ICH. Accumulating evidence suggests that inflammatory responses contribute significantly to the ICH-induced secondary brain outcomes. During ICH, inflammatory cells accumulate at the ICH site attracted by gradients of chemokines. This review summarizes recent progress in ICH studies and the chemoattractants that act during the injury and focuses on and introduces the basic biology of the chemokine monocyte chemoattractant protein-1 (MCP1) and its role in the progression of ICH. Better understanding of MCP1 signaling cascade and the compensation after its inhibition could shed light on the development of effective treatments for ICH.

Predictors of long-term shunt-dependent hydrocephalus in patients with intracerebral hemorrhage requiring emergency cerebrospinal fluid diversion

Object

Intracerebral hemorrhage (ICH) is frequently complicated by acute hydrocephalus, necessitating emergency CSF diversion with a subset of patients, ultimately requiring long-term treatment via placement of permanent ventricular shunts. It is unclear what factors may predict the need for ventricular shunt placement in this patient population.

Methods

The authors performed a retrospective analysis of a prospective database (ICH Outcomes Project) containing patients with nontraumatic ICH admitted to the neurological ICU at Columbia University Medical Center between January 2009 and September 2011. A multiple logistic regression model was developed to identify independent predictors of shunt-dependent hydrocephalus after ICH. The following variables were included: patient age, admission Glasgow Coma Scale score, temporal horn diameter on admission CT imaging, bicaudate index, admission ICH volume and location, intraventricular hemorrhage volume, Graeb score, LeRoux score, third or fourth ventricle hemorrhage, and intracranial pressure (ICP) and ventriculitis during hospital stay.

Results

Of 210 patients prospectively enrolled in the ICH Outcomes Project, 64 required emergency CSF diversion via placement of an external ventricular drain and were included in the final cohort. Thirteen of these patients underwent permanent ventricular CSF shunting prior to discharge. In univariate analysis, only thalamic hemorrhage and elevated ICP were significantly associated with the requirement for permanent CSF diversion, with p values of 0.008 and 0.033, respectively. Each remained significant in a multiple logistic regression model in which both variables were present.

Conclusions

Of patients with ICH requiring emergency CSF diversion, those with persistently elevated ICP and thalamic location of their hemorrhage are at increased odds of developing persistent hydrocephalus, necessitating permanent ventricular shunt placement. These factors may assist in predicting which patients will require permanent CSF diversion and could ultimately lead to improvements in the management of this disorder and the outcome in patients with ICH.

Age-related comparisons of evolution of the inflammatory response after intracerebral hemorrhage in rats

In the hours to days after intracerebral hemorrhage (ICH), there is an inflammatory response within the brain characterized by the infiltration of peripheral neutrophils and macrophages and the activation of brain-resident microglia and astrocytes. Despite the strong correlation of aging and ICH incidence, and increasing information about cellular responses, little is known about the temporal- and age-related molecular responses of the brain after ICH. Here, we monitored a panel of 27 genes at 6 h and 1, 3, and 7 days after ICH was induced by injecting collagenase into the striatum of young adult and aged rats. Several molecules (CR3, TLR2, TLR4, IL-1β, TNFα, iNOS, IL-6) were selected to reflect the classical activation of innate immune cells (macrophages, microglia) and the potential to exacerbate inflammation and damage brain cells. Most of the others are associated with the resolution of innate inflammation, alternative pathways of macrophage/microglial activation, and the repair phase after acute injury (TGFβ, IL-1ra, IL-1r2, IL-4, IL-13, IL-4Rα, IL-13Rα1, IL-13Rα2, MRC1, ARG1, CD163, CCL22). In young animals, the up-regulation of 26 in 27 genes (not IL-4) was detected within the first week. Differences in timing or levels between young and aged animals were detected for 18 of 27 genes examined (TLR2, GFAP, IL-1β, IL-1ra, IL-1r2, iNOS, IL-6, TGFβ, MMP9, MMP12, IL-13, IL-4Rα, IL-13Rα1, IL-13Rα2, MRC1, ARG1, CD163, CCL22), with a generally less pronounced or delayed inflammatory response in the aged animals. Importantly, within this complex response to experimental ICH, the induction of pro-inflammatory, potentially harmful mediators often coincided with resolving and beneficial molecules.

Design of a prospective, dose-escalation study evaluating the Safety of Pioglitazone for Hematoma Resolution in Intracerebral Hemorrhage (SHRINC)

RATIONALE : Preclinical work demonstrates that the transcription factor peroxisome proliferator-activated receptor gamma plays an important role in augmenting phagocytosis while modulating oxidative stress and inflammation. We propose that targeted stimulation of phagocytosis to promote efficient removal of the hematoma without harming surrounding brain cells may be a therapeutic option for intracerebral hemorrhage. AIMS : The primary objective is to assess the safety of the peroxisome proliferator-activated receptor gamma agonist, pioglitazone, in increasing doses for three-days followed by a maintenance dose, when administered to patients with spontaneous intracerebral hemorrhage within 24 h of symptom onset compared with standard care. We will determine the maximum tolerated dose of pioglitazone. STUDY DESIGN : This is a prospective, randomized, blinded, placebo-controlled, dose-escalation safety trial in which patients with spontaneous intracerebral hemorrhage are randomly allocated to placebo or treatment. The Continual Reassessment Method for dose finding is used to determine the maximum tolerated dose of pioglitazone. Hematoma and edema resolution is evaluated with serial magnetic resonance imaging (MRI) at specified time points. Functional outcome will be evaluated at three- and six-months. OUTCOMES : The primary safety outcome is mortality at discharge. Secondary safety outcomes include mortality at three-months and six-months, symptomatic cerebral edema, clinically significant congestive heart failure, edema, hypoglycemia, anemia, and hepatotoxicity. Radiographic outcomes will explore the time frame for resolution of 25%, 50%, and 75% of the hematoma. Clinical outcomes are measured by the National Institutes of Health Stroke Scale (NIHSS), the Barthel Index, modified Rankin Scale, Stroke Impact Scale-16, and EuroQol at three- and six-months.

Indications for pediatric external ventricular drain placement and risk factors for conversion to a ventriculoperitoneal shunt

BACKGROUND/AIMS

The external ventricular drain (EVD) is commonly used for the treatment of hydrocephalus and intracranial pressure (ICP) monitoring. In this study, we retrospectively reviewed indications for EVD placement over the last 20 years in pediatric patients at our institution. Additionally, we evaluated the rate that an EVD needed to be converted to a ventriculoperitoneal shunt (VPS) and ascertained how hydrocephalus etiology impacted long-term drainage requirements.

METHODS

Patients that received an EVD between 1990 and 2010 at our institution were identified using billing codes. Demographics, etiology of hydrocephalus, length of stay (LOS) and EVD duration were recorded. Only patients receiving their first EVD were included; those with any prior ventricular catheter (including prior shunts) were excluded from this study.

RESULTS

A total of 180 patients underwent first-time placement of an EVD over the 20-year period. Of these, 78.9% were placed on the right side and 81.7% were performed through a frontal burr hole site. The average age of all patients at their initial procedure was 9.3 years (median 9.8; range 0-18), hospital LOS was 22.5 days (median 16; range 1-174) and EVD duration was 7.8 days (median 7; range 1-37). Trauma (43.3%) and neoplasms (32.2%) were the most common indications. Approximately, one quarter of the patients were unable to become EVD independent and, therefore, required a VPS. Only patients receiving an EVD for traumatic brain injury were significantly less likely to be converted to a shunt than other causes of hydrocephalus (relative risk, RR = 0.18, 95% confidence interval, CI = 0.07-0.46). Conversely, patients with neoplasms (RR = 3.56, 95% CI = 1.74-7.31), obstructive hydrocephalus (RR = 5.48, 95% CI = 1.37-22.0) and intraventricular hemorrhage (RR = 9.86, 95% CI = 1.05-92.3) were more likely to need a shunt.

CONCLUSION

Traumatic brain injuries and neoplasms represent the most common indications for EVD placement in the pediatric population. While patients with neoplasm were much more likely to need conversion to a VPS for long-term cerebrospinal fluid diversion, the majority of EVDs in patients with head injuries were successfully weaned.

Management of intracerebral hemorrhage in 2020

Intracerebral hemorrhage (ICH) remains a common and deadly form of stroke, with virtually no greatly effective treatments aside from supportive and stroke unit care. Several surgical and medical therapies have been studied, but nothing has yet been found that greatly changes the pathophysiology. To achieve this, there will need to be substantial changes in treatment strategies. This article will focus on refinements to existing strategies and consider new approaches to the management of ICH. It will draw parallels with ischemic stroke treatments, and define the idea of ‘interventional therapy’ for ICH. It is suggested that reducing hematoma expansion could be compared with salvage of the ischemic penumbra, as a potential target for interventional ICH treatments. The concept of different time windows for the application of therapies according to the pathophysiology will be discussed. Finally, some novel treatment strategies are proposed, including an endovascular approach and ‘external, stereotactic cautery’, as future possibilities.

Ventriculostomy for acute hydrocephalus in critically ill patients on the ICU--outcome analysis of two different procedures

INTRODUCTION

Burr-hole trephine and insertion of an external ventricular drainage (EVD) is a common procedure in neurosurgical practice. In critically ill patients, the transport to the operating room, OR represents a major risk. Thus, the burr-hole trephine and implantation of an EVD is frequently performed on the Intensive Care Unit (ICU). Since 2004, we have applied two different procedures: the conventional method with a mechanical compressed air or an electric drill, and an alternative method with a manual twist drill, including fixation of the EVD in a skull screw (Bolt Kit, Raumedic AG, Germany). This study was designed to evaluate the outcome of both surgical procedures.

PATIENTS AND METHOD

In this retrospective analysis we included 166 consecutive patients with acute hydrocephalus due to intracranial hemorrhage that had been operated at our neurosurgical ICU in a six years interval. We reviewed the charts for gender and age, kind of surgical procedure, cerebrospinal fluid (CSF)-infections, duration of drainage, attempts of insertions, wound infections, misplacement rate, post-surgical hemorrhages, revisions, comorbidities and shunt-dependency.

RESULTS

In 122 patients we applied the Bolt Kit System, in 44 patients the conventional method was performed. We found a significantly lower rate of CSF-infections and significantly fewer attempts of insertions in the Bolt Kit group (p = 0.002 and p = 0.001, respectively). The rate of wound infections, misplacement, revisions, shunt-dependency and the post-surgical hemorrhages did not differ significantly.

DISCUSSION

Our data indicate that the manual drill and the skull screw are safe and feasible tools in the treatment of acute hydrocephalus. Presumably, the direct skin contact is causative for the higher rate of CSF-infections when the conventional method is performed. The skull screw guides the EVD into the ventricle without skin contact. The lower number of insertions needed may be due to the fact that the skull screw allows just one trajectory for the insertion of the EVD.

Tolerated nitrite therapy in experimental intracerebral hemorrhage: Rationale of nitrite therapy in a broad range of hyperacute strokes

Nitrite therapy is more effective in cerebral ischemia when administered earlier. It would be beneficial during the hyperacute stages of stroke if the nitrite effect is demonstrated in intracerebral hemorrhage (ICH). When nitrite is injected intravenously 3h after ICH induction in rats, most doses of nitrite provided no beneficial effects on behavioral deficits, brain edema and hematoma volumes. A high dose of nitrite, however, decreased hematoma volume, but not brain edema. Peri-hematomal apoptosis and inflammation were similar between the control and nitrite groups. Nitrite therapy may be considered a therapeutic option in hyperacute stroke because nitrite therapy is tolerated in ICH as well.

An optimized strategy for real-time hemorrhage monitoring with electrical impedance tomography

Delayed detection of an internal hemorrhage may result in serious disabilities and possibly death for a patient. Currently, there are no portable medical imaging instruments that are suitable for long-term monitoring of patients at risk of internal hemorrhage. Electrical impedance tomography (EIT) has the potential to monitor patients continuously as a novel functional image modality and instantly detect the occurrence of an internal hemorrhage. However, the low spatial resolution and high sensitivity to noise of this technique have limited its application in clinics. In addition, due to the circular boundary display mode used in current EIT images, it is difficult for clinicians to identify precisely which organ is bleeding using this technique. The aim of this study was to propose an optimized strategy for EIT reconstruction to promote the use of EIT for clinical studies, which mainly includes the use of anatomically accurate boundary shapes, rapid selection of optimal regularization parameters and image fusion of EIT and computed tomography images. The method was evaluated on retroperitoneal and intraperitoneal bleeding piglet data. Both traditional backprojection images and optimized images among different boundary shapes were reconstructed and compared. The experimental results demonstrated that EIT images with precise anatomical information can be reconstructed in which the image resolution and resistance to noise can be improved effectively.

Changes of blood-brain barrier permeability following intracerebral hemorrhage and the therapeutic effect of minocycline in rats

OBJECTIVE

to investigate the changes of blood-brain barrier (BBB) permeability and expressions of VEGF, NGF and HPS70 in brain at different time points following intracerebral hemorrhage (ICH) in rats, and observe therapeutic effect of minocycline (MC).

METHODS

rat ICH model was induced with Type IV collagenase. Early MC treatment was administrated via intraperitoneal injection. BBB permeability was evaluated by Evans blue (EB) amount exuded out of cerebral vessels. VEGF, NGF, and HPS70 expressions were determined with immunohistochemical staining.

RESULTS

EB exudation amount in MC treatment group was less than the ICH group (P < 0.05). The former showed a transient EB exudation peak only 1 h after modeling and then gradually decreased, while the latter showed two EB exudation peaks 1 and 4 days after modeling, respectively. The number of VEGF-positive cells in MC treatment group was less than the ICH group (P < 0.05), whereas the number of NGF- and HSP70-positive cells were more than the ICH group (P < 0.05). All three were mainly expressed in neurons and gitter cells, but there were only few expressions in the control group.

CONCLUSION

after ICH, the BBB permeability was destroyed, with neuron function affected. In the early stage, VEGF increased BBB permeability, while NGF and HSP70 showed protective effects on nerve cells. Early intraperitoneal injection with MC could reduce the damage of BBB and increase the protective effect on nerve cells, the mechanism of which may be achieved by reducing VEGF expression and enhancing NGF and HSP70 expressions.

Emerging topics and new perspectives on HLA-G

Following the Fifth International Conference on non-classical HLA-G antigens (HLA-G), held in Paris in July 2009, we selected some topics which focus on emerging aspects in the setting of HLA-G functions. In particular, HLA-G molecules could play a role in: (1) various inflammatory disorders, such as multiple sclerosis, intracerebral hemorrhage, gastrointestinal, skin and rheumatic diseases, and asthma, where they may act as immunoregulatory factors; (2) the mechanisms to escape immune surveillance utilized by several viruses, such as human cytomegalovirus, herpes simplex virus type 1, rabies virus, hepatitis C virus, influenza virus type A and human immunodeficiency virus 1 (HIV-1); and (3) cytokine/chemokine network and stem cell transplantation, since they seem to modulate cell migration by the downregulation of chemokine receptor expression and mesenchymal stem cell activity blocking of effector cell functions and the generation of regulatory T cells. However, the immunomodulatory circuits mediated by HLA-G proteins still remain to be clarified.

Severe depression and behavioral disturbance, an unusual presentation of intracerebral hemorrhage in a 78-year-old man

We describe a case of a 78-year-old man who, on two occasions, had intracerebral hemorrhage with an atypical, predominantly psychiatric presentation: once with major depression without focal neurological signs and the second time with severe behavioral disturbance and only mild facial paralysis.

Prior oral antithrombotic therapy is associated with early death in patients with supratentorial intracerebral hemorrhage

BACKGROUND AND PURPOSE

Although oral antithrombotic therapy (OAT) is a risk factor of intracerebral hemorrhage (ICH), the clinical course of supratentorial ICH with prior OAT is unclear. We therefore assessed the characteristics of supratentorial ICH with OAT to determine whether OAT is independently associated with early death in supratentorial ICH.

METHOD

We retrospectively enrolled consecutive patients with supratentorial ICH admitted to the Stroke Center of Kawasaki Medical School Hospital within 24 hours of onset, from April 2004 to March 2009. The group with OAT therapy (OA group) was compared with the group without (non-OA group).

RESULTS

A total of 389 patients with supratentorial ICH (median age 68 years, 61% males) were enrolled in the present study. OAT was used in 24% of patients. The OA group was older than the non-OA group (median 74 vs. 66 years, p<0.001). In the OA group, Glasgow Coma Scale was less (10 vs. 13, p<0.001), and hematomas were larger (22 mL vs. 14 mL, p<0.001). Early death was more frequently observed in the OA group than in the non-OA group (28% vs. 8.1%, p<0.001). Unadjusted HR of OAT for death within 14 days was 3.62 (95% CI: 2.06-6.33, p<0.001), the age- and sex-adjusted HR was 3.84 (95% CI: 2.12-6.96, p<0.001), and HR adjusted for age, sex, GCS, and hematoma volume was 2.01 (95% CI: 1.11-3.65, p=0.022). HR adjusted for age, sex, GCS, and hematoma volume at day 1 was 2.63 (p=0.34), day 3: 2.35 (p=0.03), day 7: 2.01 (p=0.04), and day 14: 1.90 (p=0.04).

CONCLUSION

The OA group patients were older, their GCS was lower, they had larger hematoma volume, and more frequent occurrence of early death. Prior oral antithrombotic therapy is associated with early death in patients with supratentorial ICH.

Advances in neuroprotective strategies: potential therapies for intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is associated with higher mortality and morbidity than any other form of stroke. However, there currently are no treatments proven to improve outcomes after ICH, and therefore, new effective therapies are urgently needed. Growing insight into ICH pathophysiology has led to the development of neuroprotective strategies that aim to improve the outcome through reduction of secondary pathologic processes. Many neuroprotectants target molecules or pathways involved in hematoma degradation, inflammation or apoptosis, and have demonstrated potential clinical benefits in experimental settings. We extensively reviewed the current understanding of ICH pathophysiology as well as promising experimental neuroprotective agents with particular focus on their mechanisms of action. Continued advances in ICH knowledge, increased understanding of neuroprotective mechanisms, and improvement in the ability to modulate molecular and pathologic events with multitargeting agents will lead to successful clinical trials and bench-to-bedside translation of neuroprotective strategies.

Spontaneous Intracerebral Hemorrhage With Ventricular Extension and the Grading of Obstructive Hydrocephalus: The Prediction of Outcome of a Special Life-Threatening Entity

BACKGROUND:

Primary spontaneous intracerebral hemorrhage (SICH) with secondary intraventricular hemorrhage (IVH) accounts for the highest in-hospital mortality after stroke.

OBJECTIVE:

To analyze predictors and the role of acute hydrocephalus in outcome, especially 30-day mortality or an unfavorable outcome at 6 months. In addition, a new risk stratification tool for SICH- IVH was developed.

METHODS:

Hospital charts of 104 of 110 SICH-IVH patients were retrospectively analyzed. All patients underwent at least 1 external ventricular drainage. Multivariate logistic regression analysis was used to identify independent prognostic predictors for 30-day mortality and outcome. Outcome was determined by the modified Rankin Scale. On the basis of the independent predictors, we developed an IVH scoring system. The IVH score was tested with prospective data from 51 patients and was compared with established intracerebral hemorrhage scoring systems.

RESULTS:

An initial SICH volume of 60 cm3 or greater, severe hydrocephalus, Glasgow Coma Scale score of 8 or less, and age 70 years and older were independent outcome predictors. Different cutoff values for the prediction of 30-day mortality and functional outcome were defined. The IVH score was best for the prediction of 30-day mortality.

CONCLUSION:

Severe hydrocephalus is an independent predictor of 30-day mortality in SICH with ventricular extension. The IVH score is a simple and reliable tool for predicting 30-day mortality.

Efficacy and safety of key hole craniotomy for the evacuation of spontaneous cerebellar hemorrhage

The efficacy and safety of cerebellar hemorrhage evacuation by key hole craniotomy and the importance of thorough evacuation and irrigation of the hematoma in the fourth ventricle to resolve obstructive hydrocephalus were assessed in 23 patients with spontaneous cerebellar hemorrhage (SCH) greater than 3 cm or with brainstem compression and hydrocephalus. A 5-cm elongated S-shaped scalp incision was made, and a 3-cm key hole craniotomy was performed over a cerebellar convexity area. The hematoma was immediately evacuated through a small corticotomy. The hematoma in the fourth ventricle was gently removed through the hematoma cavity, followed by thorough saline irrigation to release obstructive hydrocephalus. Patients classified retrospectively into favorable and poor outcome groups using the Glasgow Outcome Scale (GOS) scores of 4-5 vs. 1-3 showed significant differences with respect to the preoperative Glasgow Coma Scale, hematoma size and volume, and brainstem compression. Only 2 of the 23 patients required ventricular drainage and no postoperative complications were recorded. Patients treated by experienced and inexperienced surgeons showed no significant differences in the hematoma evacuation rate, postoperative GOS, and interval from skin incision to start of hematoma evacuation. Our simplified method of key hole craniotomy to treat SCH was less invasive but easy to perform, as even inexperienced neurosurgeons could obtain good surgical results. Thorough cleaning of the fourth ventricle minimized the necessity for ventricular drainage.

Preclinical and clinical research on inflammation after intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is one of the most lethal stroke subtypes. Despite the high morbidity and mortality associated with ICH, its pathophysiology has not been investigated as well as that of ischemic stroke. Available evidence from preclinical and clinical studies suggests that inflammatory mechanisms are involved in the progression of ICH-induced secondary brain injury. For example, in preclinical ICH models, microglial activation has been shown to occur within 1h, much earlier than neutrophil infiltration. Recent advances in our understanding of neuroinflammatory pathways have revealed several new molecular targets, and related therapeutic strategies have been tested in preclinical ICH models. This review summarizes recent progress made in preclinical models of ICH, surveys preclinical and clinical studies of inflammatory cells (leukocytes, macrophages, microglia, and astrocytes) and inflammatory mediators (matrix metalloproteinases, nuclear factor erythroid 2-related factor 2, heme oxygenase, and iron), and highlights the emerging areas of therapeutic promise.

Management of spontaneous nontraumatic intracranial hemorrhage

Intracerebral hemorrhage (ICH) is one of the most devastating subtypes of stroke and is characterized by spontaneous extravasation into the parenchymal tissue of the brain. Although advances in critical care have improved, there is no intervention currently available that has shown to alter the outcome of patients who have suffered acute ICH. Therefore, management is largely supportive. Treatment strategies are aimed at limiting hematoma enlargement, seizures, and cerebral edema, as well as other ICU-related complications such as deep venous thrombosis, hyperglycemia, and fever. This review will outline the key pharmacological management strategies in patients with ICH and highlight the most current American Heart Association/American Stroke Association (AHA/ASA) guidelines for management published in 2007.