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Yan Z, Chen S, Xue T, Wu X, Song Z, Wang Z, Chen Z, Wang Z. The Function of Tranexamic Acid to Prevent Hematoma Expansion After Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis From Randomized Controlled Trials. Front Neurol 2021; 12:710568. [PMID: 34630286 PMCID: PMC8498595 DOI: 10.3389/fneur.2021.710568] [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: 05/16/2021] [Accepted: 08/17/2021] [Indexed: 11/20/2022] Open
Abstract
Objectives: The clinical results caused by spontaneous intracerebral hemorrhage (ICH) are disastrous to most patient. As tranexamic acid (TXA) has been proved to decrease the influence of ICH, we conducted this research to explore the function of TXA for the prognosis of ICH compared with placebo. Methods: We searched MEDLINE, Embase, Cochrane Library, and Clinicaltrials.gov for randomized controlled trials (RCTs) that were performed to evaluate TXA vs. placebo for ICH up to February 2021. The data were assessed by Review Manager 5.3 software. The risk ratio (RR) and mean difference were analyzed using dichotomous outcomes and continuous outcomes, respectively, with a fixed effect model. Results: We collected 2,479 patients from four RCTs. Then, we took the change of hematoma volume, modified Rankin Scale (mRS), and adverse events as evaluation standard of the treatment for ICH. Through statistical analysis, we found that there is no obvious hematoma expansion effect after the application of TXA (RR = 1.05), and we proceeded the quantitative analysis of percentage change in hematoma volume from baseline, indicating that TXA could inhibit the expansion of hematoma volume (RR = −2.02) compared with placebo. However, according to the outcomes of mRS (0–1, RR = 1.04; 0–2, RR = 0.96), TXA cannot improve neurological functional prognosis. As for the security outcomes—mortality (RR = 1.02), thromboembolic events (RR = 0.99), neurological deterioration (RR = 0.92), infection (RR = 0.86), and craniotomy (RR = 0.41), there seems exist no statistical difference between TXA and placebo. Conclusions: TXA has an advantage in the aspect of preventing hematoma expansion compared with placebo for ICH, but cannot illustrate the efficacy of TXA in improving neurological functional prognosis, which still needs more researches with large sample sizes. Moreover, for safety, we did not find obvious statistical difference between TXA and placebo.
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Affiliation(s)
- Zeya Yan
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shujun Chen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Tao Xue
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xin Wu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhaoming Song
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zongqi Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
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102
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Li J, Yuan Y, Liao X, Yu Z, Li H, Zheng J. Prognostic Significance of Admission Systemic Inflammation Response Index in Patients With Spontaneous Intracerebral Hemorrhage: A Propensity Score Matching Analysis. Front Neurol 2021; 12:718032. [PMID: 34630289 PMCID: PMC8497988 DOI: 10.3389/fneur.2021.718032] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/13/2021] [Indexed: 02/05/2023] Open
Abstract
Intracerebral hemorrhage (ICH) accounts for ~15% of all strokes and is associated with high mortality and disability rates. The systemic inflammation response index (SIRI) is a novel systemic inflammatory marker based on peripheral neutrophil, monocyte, and lymphocyte counts. This study aimed to evaluate the prognostic significance of admission SIRI in patients with spontaneous ICH and compare its predictive ability with that of the neutrophil-to-lymphocyte ratio (NLR). This retrospective study was conducted based on a prospectively collected database of patients with ICH between June 2016 and January 2019. Propensity score matching (PSM) was conducted to adjust for potential imbalances in the clinical parameters. A total of 403 patients were included in the original cohort. The optimal SIRI cut-off value was 2.76. After 1:1 PSM based on potential confounding variables, a new cohort containing 262 patients was established for further analysis. In the original cohort, SIRI served as an independent predictor of 3-month functional outcome [odds ratio (OR), 1.302; 95% CI, 1.120–1.512; p = 0.001] and 1-month mortality (OR, 1.072; 95% CI, 1.020–1.126; p = 0.006), while NLR was independently associated with only 3-month functional outcomes (OR, 1.051; 95% CI, 1.004–1.100; p = 0.031) and not 1-month mortality. The same applied to the PSM cohort. Receiver operating characteristic analyses and predictive models indicated that in most instances, SIRI was superior to NLR and their components in predicting the outcomes of patients with ICH. Our study found that SIRI is determined to be an independent predictive indicator for ICH patients in 3-month functional outcomes and 1-month mortality. The prognostic predictive ability of SIRI was stronger than that of NLR.
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Affiliation(s)
- Junhong Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Yunbo Yuan
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xiang Liao
- Department of Cardiology, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Zhiyuan Yu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
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103
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He C, Yang G, Zhao M, Wu Q, Wang L, Sharma HS. A clinical study of high-dose urokinase for the treatment of the patients with hypertension induced ventricular hemorrhage. PROGRESS IN BRAIN RESEARCH 2021; 266:349-355. [PMID: 34689863 DOI: 10.1016/bs.pbr.2021.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE This study discusses the therapeutic effect of high-dose urokinase treatment for hypertension ventricular hemorrhage. METHODS A total of 60 patients with hypertension ventricular hemorrhage were randomly assigned to two groups: treatment group (n=30) and control group (n=30). Both groups received bilateral external ventricular drain. The treatment group was injected with 50,000IU urokinase to the lateral ventricle every day; the total injection volume per day was 100,000IU. The control group was injected with 20,000IU urokinase to the lateral ventricle every day with a total injection volume per day of 40,000IU. Lumbar puncture was performed in both groups after the later ventricular drain was removed to release cerebrospinal fluid (CSF). Head Computed tomography(CT) examination was performed regularly to observe changes in the ventricular hematoma as well as the occurrence of complications such as intracranial infection and hydrocephalus. Patient prognosis 6 weeks after surgery was compared between the two groups. RESULTS In the treatment group, the intraventricular hemorrhage clearance time and the number of instances of urokinase treatment were significantly less than those of the control group (P<0.05). The total urokinase dosage of the treatment group was significantly higher than that of the control group (P<0.05). With respect to post-surgery complications, in the treatment group, there were three cases of hydrocephalus and one case of intracranial infection. In the control group, there were four cases of hydrocephalus and three cases of intracranial infection. Intraventricular re-hemorrhage was not observed in either group. Intracranial infection was relieved after strengthened anti-infective therapy and continuous drainage. There was a statistically significant difference in the occurrence of complications between the treatment group and the control group (P<0.05). The rate of good prognosis in the treatment group was higher than that of the control group (P<0.05), and the inefficiency rate was lower (P<0.05). CONCLUSIONS High-dose urokinase treatment produces a significant therapeutic effect in hypertension ventricular hemorrhage. This treatment can quickly eliminate intraventricular hemorrhage, shorten the ventricular drain tube indwelling time, decrease the occurrence of intracranial infection, and increase the likelihood of a good prognosis.
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Affiliation(s)
- Chao He
- Department of Neurosurgery, Zhuji People' Hospital of Zhejiang Province, Zhuji Affiliated Hospital of Shaoxing University, Zhuji, Zhejiang, China
| | - Gang Yang
- Department of Neurosurgery, Zhuji People' Hospital of Zhejiang Province, Zhuji Affiliated Hospital of Shaoxing University, Zhuji, Zhejiang, China.
| | - Ming Zhao
- Department of Neurosurgery, Zhuji People' Hospital of Zhejiang Province, Zhuji Affiliated Hospital of Shaoxing University, Zhuji, Zhejiang, China
| | - Qilin Wu
- Department of Neurosurgery, Zhuji People' Hospital of Zhejiang Province, Zhuji Affiliated Hospital of Shaoxing University, Zhuji, Zhejiang, China
| | - Lin Wang
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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104
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Han HJ, Park KY, Kim J, Lee W, Lee YH, Jang CK, Cho KC, Park SK, Chung J, Kwon YS, Kim YB, Lee JW, Kim SY. Delays in Intracerebral Hemorrhage Management Is Associated with Hematoma Expansion and Worse Outcomes: Changes in COVID-19 Era. Yonsei Med J 2021; 62:911-917. [PMID: 34558870 PMCID: PMC8470569 DOI: 10.3349/ymj.2021.62.10.911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The coronavirus disease 2019 (COVID-19) pandemic disrupted the emergency medical care system worldwide. We analyzed the changes in the management of intracerebral hemorrhage (ICH) and compared the pre-COVID-19 and COVID-19 eras. MATERIALS AND METHODS From March to October of the COVID-19 era (2020), 83 consecutive patients with ICH were admitted to four comprehensive stroke centers. We retrospectively reviewed the data of patients and compared the treatment workflow metrics, treatment modalities, and clinical outcomes with the patients admitted during the same period of pre-COVID-19 era (2017-2019). RESULTS Three hundred thirty-eight patients (83 in COVID-19 era and 255 in pre-COVID-19 era) were included in this study. Symptom onset/detection-to-door time [COVID-19; 56.0 min (34.0-106.0), pre-COVID-19; 40.0 min (27.0-98.0), p=0.016] and median door to-intensive treatment time differed between the two groups [COVID-19; 349.0 min (177.0-560.0), pre-COVID-19; 184.0 min (134.0-271.0), p<0.001]. Hematoma expansion was detected more significantly in the COVID-19 era (39.8% vs. 22.1%, p=0.002). At 3-month follow-up, clinical outcomes of patients were worse in the COVID-19 era (Good modified Rankin Scale; 33.7% in COVID19, 46.7% in pre-COVID-19, p=0.039). CONCLUSION During the COVID-19 era, delays in management of ICH was associated with hematoma expansion and worse outcomes.
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Affiliation(s)
- Hyun Jin Han
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Junhyung Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Woosung Lee
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yun Ho Lee
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Chang Ki Jang
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Kwang-Chun Cho
- Department of Neurosurgery, International St. Mary's Hospital, Catholic Kwandong University, Inchoen, Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Sub Kwon
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Whan Lee
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - So Yeon Kim
- Department of Neurosurgery, International St. Mary's Hospital, Catholic Kwandong University, Inchoen, Korea.
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105
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Park C, Charalambous LT, Yang Z, Adil SM, Hodges SE, Lee HJ, Verbick LZ, McCabe AR, Lad SP. Inpatient mortality and healthcare resource utilization of nontraumatic intracerebral hemorrhage complications in the US. J Neurosurg 2021; 135:1081-1090. [PMID: 33482635 DOI: 10.3171/2020.8.jns201839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nontraumatic, primary intracerebral hemorrhage (ICH) accounts for 2 million strokes worldwide annually and has a 1-year survival rate of 50%. Recent studies examining functional outcomes from ICH evacuation have been performed, but limited work has been done quantifying the incidence of subsequent complications and their healthcare economic impact. The purpose of this study was to quantify the incidence and healthcare resource utilization (HCRU) for major complications that can arise from ICH. METHODS The IBM MarketScan Research databases were used to retrospectively identify patients with ICH from 2010 to 2015. Complications examined included cerebral edema, hydrocephalus, venous thromboembolic events (VTEs), pneumonia, urinary tract infections (UTIs), and seizures. For each complication, inpatient mortality and HCRU were assessed. RESULTS Of 25,322 adult patients included, 10,619 (42%) developed complications during the initial admission of ICH: 22% had cerebral edema, 11% hydrocephalus, 10% pneumonia, 6% UTIs, 5% seizures, and 5% VTEs. The inpatient mortality rates at 7 and 30 days for each complication of ICH ranked from highest to lowest were hydrocephalus (24% and 32%), cerebral edema (15% and 20%), pneumonia (8% and 18%), seizure (7% and 13%), VTE (4% and 11%), and UTI (4% and 8%). Hydrocephalus had the highest total cost (median $92,776, IQR $39,308-$180,716) at 7 days post-ICH diagnosis and the highest cumulative total cost (median $170,839, IQR $91,462-$330,673) at 1 year post-ICH diagnosis. CONCLUSIONS This study characterizes one of the largest cohorts of patients with nontraumatic ICH in the US. More than 42% of the patients with ICH developed complications during initial admission, which resulted in high inpatient mortality and considerable HCRU.
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Affiliation(s)
| | | | - Zidanyue Yang
- 2Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina; and
| | | | | | - Hui-Jie Lee
- 2Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina; and
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106
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Size-Related Differences in Computed Tomography Markers of Hematoma Expansion in Acute Intracerebral Hemorrhage. Neurocrit Care 2021; 36:602-611. [PMID: 34590291 DOI: 10.1007/s12028-021-01347-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Noncontrast computed tomography (NCCT) markers for hematoma expansion (HE) in intracerebral hemorrhage (ICH) are difficult to be found in small ICHs, of which can also expand. We aimed to investigate whether there were size-related differences in the prevalence of NCCT markers and their association with HE. METHODS This retrospective analysis of prospectively collected stroke registry included 267 consecutive patients with ICH who underwent baseline NCCT within 12 h of onset. Qualitative NCCT markers, including heterogeneous density and irregular shape, were assessed. Hematoma density, defined as mean Hounsfield unit of hematoma, and hematoma volume were measured by semiautomated planimetry. Hematoma volume was categorized as small (≤ 10 ml) and large (> 10 ml). Associations of NCCT markers with HE were analyzed using multivariable logistic regression analyses. The model performances of NCCT markers and hematoma density were compared using receiver operating characteristic curves. RESULTS Hematoma expansion occurred in 29.9% of small ICHs and 35.5% of large ICHs. Qualitative NCCT markers were less frequently observed in small ICHs. Heterogeneous density, irregular shape, and hematoma density were associated with HE in small ICH (adjusted odds ratios [95% confidence interval] 3.94 [1.50-10.81], 4.23 [1.73-10.81], and 0.72 [0.60-0.84], respectively), and hematoma density was also related to HE in large ICH (0.84 [0.73-0.97). The model performance was significantly improved in small ICHs when hematoma density was added to the baseline model (DeLong's test, p = 0.02). CONCLUSIONS The prevalence of NCCT markers and their association with HE differed according to hematoma volume. Quantitative hematoma density was associated with HE, regardless of hematoma size.
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107
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Tanaka K, Toyoda K. Clinical Strategies Against Early Hematoma Expansion Following Intracerebral Hemorrhage. Front Neurosci 2021; 15:677744. [PMID: 34526875 PMCID: PMC8435629 DOI: 10.3389/fnins.2021.677744] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/05/2021] [Indexed: 02/01/2023] Open
Abstract
Hematoma volume is the strongest predictor of morbidity and mortality after intracerebral hemorrhage. Protection against early hematoma growth is therefore the mainstay of therapeutic intervention for acute intracerebral hemorrhage, but the current armamentarium is restricted to early blood pressure lowering and emergent reversal for anticoagulant agents. Although intensive lowering of systolic blood pressure to <140 mmHg appears likely to prevent hematoma growth, two recent randomized trials, INTERACT-2 and ATACH-2, demonstrated non-significant trends of reduced hematoma enlargement by intensive blood pressure control, with only a small magnitude of benefit or no benefit for clinical outcomes. While oral anticoagulants can be immediately reversed by prothrombin complex concentrate, or the newly developed idarucizumab for direct thrombin inhibitor or andexanet for factor Xa inhibitors, the situation regarding reversal of antiplatelet agents is not yet quite as advanced. However, considering at most the approximately 10% rate of anticoagulant use among patients with intracerebral hemorrhage, what is most essential for patients with intracerebral hemorrhage in general is early hemostatic therapy. Tranexamic acid may safely reduce hematoma expansion, but its hemostatic effect was insufficient to be translated into improved functional outcomes in the TICH-2 randomized trial with 2,325 participants. In this context, recombinant activated factor VII (rFVIIa) is a candidate to be added to the armory against hematoma enlargement. The FAST, a phase 3 trial that compared doses of 80 and 20 μg/kg rFVIIa with placebo in 841 patients within 4 h after the stroke onset, showed a significant reduction in hematoma growth with rFVIIa treatment, but demonstrated no significant difference in the proportion of patients with severe disability or death. However, a post hoc analysis of the FAST trial suggested a benefit of rFVIIa in a target subgroup of younger patients without extensive bleeding at baseline when treated earlier after stroke onset. The FASTEST trial is now being prepared to determine this potential benefit of rFVIIa, reflecting the pressing need to develop therapeutic strategies against hematoma enlargement, a powerful but modifiable prognostic factor in patients with intracerebral hemorrhage.
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Affiliation(s)
- Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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108
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Mayer SA, Frontera JA, Jankowitz B, Kellner CP, Kuppermann N, Naik BI, Nishijima DK, Steiner T, Goldstein JN. Recommended Primary Outcomes for Clinical Trials Evaluating Hemostatic Agents in Patients With Intracranial Hemorrhage: A Consensus Statement. JAMA Netw Open 2021; 4:e2123629. [PMID: 34473266 DOI: 10.1001/jamanetworkopen.2021.23629] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE In patients with acute spontaneous or traumatic intracranial hemorrhage, early hemostasis is thought to be critical to minimize ongoing bleeding. However, research evaluating hemostatic therapies has been hampered by a lack of standardized clinical trial outcome measures. OBJECTIVE To identify appropriate primary outcomes for phase 2 and 3 clinical trials of therapies aimed at reducing acute intracranial bleeding. EVIDENCE REVIEW A comprehensive review of all previous clinical trials of hemostatic therapy for intracranial bleeding was performed, and studies measuring the frequency, risk factors, and association of intracranial bleeding with outcome of hemorrhage growth were included. FINDINGS A hierarchy of 3 outcome measures is recommended, with the first choice being a global patient-centered clinical outcome scale measured 30 to 180 days after the event; the second, a combined clinical and radiographic end point associating hemorrhage expansion with a poor patient-centered outcome at 24 hours or later; and the third, a radiographic measure of hemorrhage expansion at 24 hours alone. Additional recommendations stress the importance of separating various subtypes of bleeding when possible, early treatment within a standardized treatment window, and the routine use of computerized planimetry comparing continuous measures of absolute and relative hemorrhage growth as either a primary or secondary end point. CONCLUSIONS AND RELEVANCE Standardization of outcome measures in studies of intracranial bleeding and hemostatic therapy will support comparative effectiveness research and meta-analysis, with the goal of accelerating the translation of research into clinical practice. The 3 outcome measures proposed in this consensus statement could help this process.
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Affiliation(s)
- Stephan A Mayer
- Departments of Neurology and Neurosurgery, Westchester Medical Center Health, New York Medical College, Valhalla
| | | | - Brian Jankowitz
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey
| | | | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, UC Davis Health, Sacramento
| | - Bhiken I Naik
- Department of Anesthesiology and Neurological Surgery, University of Virginia, Charlottesville
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, UC Davis Health, Sacramento
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
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109
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Portable, bedside, low-field magnetic resonance imaging for evaluation of intracerebral hemorrhage. Nat Commun 2021; 12:5119. [PMID: 34433813 PMCID: PMC8387402 DOI: 10.1038/s41467-021-25441-6] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/05/2021] [Indexed: 02/07/2023] Open
Abstract
Radiological examination of the brain is a critical determinant of stroke care pathways. Accessible neuroimaging is essential to detect the presence of intracerebral hemorrhage (ICH). Conventional magnetic resonance imaging (MRI) operates at high magnetic field strength (1.5-3 T), which requires an access-controlled environment, rendering MRI often inaccessible. We demonstrate the use of a low-field MRI (0.064 T) for ICH evaluation. Patients were imaged using conventional neuroimaging (non-contrast computerized tomography (CT) or 1.5/3 T MRI) and portable MRI (pMRI) at Yale New Haven Hospital from July 2018 to November 2020. Two board-certified neuroradiologists evaluated a total of 144 pMRI examinations (56 ICH, 48 acute ischemic stroke, 40 healthy controls) and one ICH imaging core lab researcher reviewed the cases of disagreement. Raters correctly detected ICH in 45 of 56 cases (80.4% sensitivity, 95%CI: [0.68-0.90]). Blood-negative cases were correctly identified in 85 of 88 cases (96.6% specificity, 95%CI: [0.90-0.99]). Manually segmented hematoma volumes and ABC/2 estimated volumes on pMRI correlate with conventional imaging volumes (ICC = 0.955, p = 1.69e-30 and ICC = 0.875, p = 1.66e-8, respectively). Hematoma volumes measured on pMRI correlate with NIH stroke scale (NIHSS) and clinical outcome (mRS) at discharge for manual and ABC/2 volumes. Low-field pMRI may be useful in bringing advanced MRI technology to resource-limited settings.
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110
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Yoh N, Sisti J, Connolly ES, Chang TR, Roh D. Can We Utilize Whole Blood Viscoelastic Coagulation Assays to Better Identify and Treat Coagulopathy in Patients With Intracerebral Hemorrhage? World Neurosurg 2021; 147:217-219. [PMID: 33685002 DOI: 10.1016/j.wneu.2021.01.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Nina Yoh
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Jonathan Sisti
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Tiffany R Chang
- Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - David Roh
- Department of Neurology, Columbia University, New York, New York, USA.
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111
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Kellner CP, Schupper AJ, Mocco J. Surgical Evacuation of Intracerebral Hemorrhage: The Potential Importance of Timing. Stroke 2021; 52:3391-3398. [PMID: 34187180 DOI: 10.1161/strokeaha.121.032238] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York
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112
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Li J, Liao X, Yu Z, Li H, Zheng J. Predictive Ability of Ultraearly Hematoma Growth and Spot Sign for Redefined Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105950. [PMID: 34214962 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/03/2021] [Accepted: 06/13/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Redefined hematoma expansion (rHE) including intraventricular hematoma expansion (IVHE) is a new concept in intracerebral hemorrhage (ICH), with better prognostic ability compared to the conventional hematoma expansion. Ultraearly hematoma growth (uHG) and computed tomography angiography (CTA) spot sign are both useful indictors to predict HE and poor clinical outcome. This study aims to explore the clinical characteristics of rHE in retrospective cohort and evaluate the predictive ability of uHG and spot sign in rHE. MATERIALS AND METHODS This study included nontraumatic spontaneous ICH patients from June 1st 2013 and January 1st 2018 in West China Hospital. Multivariate logistic regression was used to determine risk factors for HE/IVHE/rHE and primary outcomes of ICH patients. Receiver operating characteristic (ROC) analysis was performed to assess the accuracy of uHG and spot sign for predicting HE/IVHE/rHE. RESULTS This retrospective cohort included 469 consecutive patients with ICH. rHE was significantly associated with clinical variables including Glasgow coma scale (GCS), time to initial CT, presence of IVH, hematoma volume, presence of spot sign, and uHG. uHG and spot sign were independent risk factors for rHE. ROC analysis indicated that both uHG (AUC 0.726, 95%CI 0.680-0.773) and spot sign (AUC 0.735, 95%CI 0.686-0.785) possessed high predictive accuracy for rHE. HE and rHE were independent risk factors for 1-month mortality and 3-month functional outcome. CONCLUSIONS Both uHG and the spot sign were considered to be good predictors for rHE, and the spot sign appeared to have a better predictive accuracy.
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Affiliation(s)
- Junhong Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, PR China.
| | - Xiang Liao
- Department of Cardiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, PR China..
| | - Zhiyuan Yu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, PR China.
| | - Hao Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, PR China.
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, PR China.
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Lin PBC, Wang PK, Pang CY, Hu WF, Tsai APY, Oblak AL, Liew HK. Moderate Ethanol Pre-treatment Mitigates ICH-Induced Injury via ER Stress Modulation in Rats. Front Mol Neurosci 2021; 14:682775. [PMID: 34248500 PMCID: PMC8267178 DOI: 10.3389/fnmol.2021.682775] [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: 03/19/2021] [Accepted: 05/26/2021] [Indexed: 11/29/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a life-threatening type of stroke that disrupts the normal neurological function of the brain. Clinical studies have reported a non-linear J-shaped association between alcohol consumption levels and the occurrence of cerebral stroke. Specifically, alcohol intoxication increases stroke incidence, while moderate alcohol pre-conditioning decreases stroke frequency and improves outcomes. Although alcohol pre-consumption is likely a crucial player in ICH, the underlying mechanism remains unclear. We performed 1-h alcohol pre-conditioning followed by ICH induction in Sprague-Dawley (SD) rats to investigate the role of alcohol pre-conditioning in ICH. Interestingly, behavioral test analysis found that ethanol intoxication (3 g/kg) aggravated ICH-induced neurological deficits, but moderate ethanol pre-conditioning (0.75 g/kg) ameliorated ICH-induced neurological deficits by reducing the oxidative stress and proinflammatory cytokines release. Moreover, we found that moderate ethanol pretreatment improved the striatal endoplasmic reticulum (ER) homeostasis by increasing the chaperone protein expression and reducing oxidative stress and apoptosis caused by ICH. Our findings show that the mechanism regulated by moderate ethanol pre-conditioning might be beneficial for ICH, indicating the importance of ER homeostasis, oxidative stress, and differential cytokines release in ICH.
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Affiliation(s)
- Peter Bor-Chian Lin
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Po-Kai Wang
- Department of Anesthesiology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Cheng-Yoong Pang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| | - Wei-Fen Hu
- Department of Pharmacology and Toxicology, Tzu Chi University, Hualien, Taiwan
| | - Andy Po-Yi Tsai
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Adrian L Oblak
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Hock-Kean Liew
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,Department of Pharmacology and Toxicology, Tzu Chi University, Hualien, Taiwan.,Neuro-Medical Scientific Center, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
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114
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Helwig SA, Ragoschke-Schumm A, Schwindling L, Kettner M, Roumia S, Kulikovski J, Keller I, Manitz M, Martens D, Grün D, Walter S, Lesmeister M, Ewen K, Brand J, Fousse M, Kauffmann J, Zimmer VC, Mathur S, Bertsch T, Guldner J, Magull-Seltenreich A, Binder A, Spüntrup E, Chatzikonstantinou A, Adam O, Kronfeld K, Liu Y, Ruckes C, Schumacher H, Grunwald IQ, Yilmaz U, Schlechtriemen T, Reith W, Fassbender K. Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke: A Randomized Clinical Trial. JAMA Neurol 2021; 76:1484-1492. [PMID: 31479116 DOI: 10.1001/jamaneurol.2019.2829] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Transferring patients with large-vessel occlusion (LVO) or intracranial hemorrhage (ICH) to hospitals not providing interventional treatment options is an unresolved medical problem. Objective To determine how optimized prehospital management (OPM) based on use of the Los Angeles Motor Scale (LAMS) compares with management in a Mobile Stroke Unit (MSU) in accurately triaging patients to the appropriate hospital with (comprehensive stroke center [CSC]) or without (primary stroke center [PSC]) interventional treatment. Design, Setting, and Participants In this randomized multicenter trial with 3-month follow-up, patients were assigned week-wise to one of the pathways between June 15, 2015, and November 15, 2017, in 2 regions of Saarland, Germany; 708 of 824 suspected stroke patients did not meet inclusion criteria, resulting in a study population of 116 adult patients. Interventions Patients received either OPM based on a standard operating procedure that included the use of the LAMS (cut point ≥4) or management in an MSU (an ambulance with vascular imaging, point-of-care laboratory, and telecommunication capabilities). Main Outcomes and Measures The primary end point was the proportion of patients accurately triaged to either CSCs (LVO, ICH) or PSCs (others). Results A predefined interim analysis was performed after 116 patients of the planned 232 patients had been enrolled. Of these, 53 were included in the OPM group (67.9% women; mean [SD] age, 74 [11] years) and 63 in the MSU group (57.1% women; mean [SD] age, 75 [11] years). The primary end point, an accurate triage decision, was reached for 37 of 53 patients (69.8%) in the OPM group and for 63 of 63 patients (100%) in the MSU group (difference, 30.2%; 95% CI, 17.8%-42.5%; P < .001). Whereas 7 of 17 OPM patients (41.2%) with LVO or ICH required secondary transfers from a PSC to a CSC, none of the 11 MSU patients (0%) required such transfers (difference, 41.2%; 95% CI, 17.8%-64.6%; P = .02). The LAMS at a cut point of 4 or higher led to an accurate diagnosis of LVO or ICH for 13 of 17 patients (76.5%; 6 triaged to a CSC) and of LVO selectively for 7 of 9 patients (77.8%; 2 triaged to a CSC). Stroke management metrics were better in the MSU group, although patient outcomes were not significantly different. Conclusions and Relevance Whereas prehospital management optimized by LAMS allows accurate triage decisions for approximately 70% of patients, MSU-based management enables accurate triage decisions for 100%. Depending on the specific health care environment considered, both approaches are potentially valuable in triaging stroke patients. Trial Registration ClinicalTrials.gov identifier: NCT02465346.
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Affiliation(s)
- Stefan A Helwig
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | | | - Lenka Schwindling
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Michael Kettner
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany.,Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Safwan Roumia
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Johann Kulikovski
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Isabel Keller
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Matthias Manitz
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Daniel Martens
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Daniel Grün
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Silke Walter
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Martin Lesmeister
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Kira Ewen
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Jannik Brand
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Mathias Fousse
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Jil Kauffmann
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Valerie C Zimmer
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Shrey Mathur
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Jürgen Guldner
- Department of Neurology, Knappschaftsklinikum Saar, Püttlingen, Germany
| | | | - Andreas Binder
- Department of Neurology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Elmar Spüntrup
- Department of Radiology, Klinikum Saarbrücken, Saarbrücken, Germany
| | | | - Oliver Adam
- Medizinische Klinik, Kreiskrankenhaus St Ingbert, St Ingbert, Germany
| | - Kai Kronfeld
- Interdisciplinary Centre for Clinical Trials (IZKS), Mainz, Germany
| | - Yang Liu
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Christian Ruckes
- Interdisciplinary Centre for Clinical Trials (IZKS), Mainz, Germany
| | | | - Iris Q Grunwald
- Department of Neuroscience, Faculty of Medical Science, Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, Southend University Hospital, Southend-on-Sea, United Kingdom
| | - Umut Yilmaz
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Thomas Schlechtriemen
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany.,Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany.,Zweckverband für Rettungsdienst und Feuerwehralarmierung, Saar, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
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Gladstone DJ, Aviv RI, Demchuk AM, Hill MD, Thorpe KE, Khoury JC, Sucharew HJ, Al-Ajlan F, Butcher K, Dowlatshahi D, Gubitz G, De Masi S, Hall J, Gregg D, Mamdani M, Shamy M, Swartz RH, Del Campo CM, Cucchiara B, Panagos P, Goldstein JN, Carrozzella J, Jauch EC, Broderick JP, Flaherty ML. Effect of Recombinant Activated Coagulation Factor VII on Hemorrhage Expansion Among Patients With Spot Sign-Positive Acute Intracerebral Hemorrhage: The SPOTLIGHT and STOP-IT Randomized Clinical Trials. JAMA Neurol 2021; 76:1493-1501. [PMID: 31424491 DOI: 10.1001/jamaneurol.2019.2636] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Intracerebral hemorrhage (ICH) is a devastating stroke type that lacks effective treatments. An imaging biomarker of ICH expansion-the computed tomography (CT) angiography spot sign-may identify a subgroup that could benefit from hemostatic therapy. Objective To investigate whether recombinant activated coagulation factor VII (rFVIIa) reduces hemorrhage expansion among patients with spot sign-positive ICH. Design, Setting, and Participants In parallel investigator-initiated, multicenter, double-blind, placebo-controlled randomized clinical trials in Canada ("Spot Sign" Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy [SPOTLIGHT]) and the United States (The Spot Sign for Predicting and Treating ICH Growth Study [STOP-IT]) with harmonized protocols and a preplanned individual patient-level pooled analysis, patients presenting to the emergency department with an acute primary spontaneous ICH and a spot sign on CT angiography were recruited. Data were collected from November 2010 to May 2016. Data were analyzed from November 2016 to May 2017. Interventions Eligible patients were randomly assigned 80 μg/kg of intravenous rFVIIa or placebo as soon as possible within 6.5 hours of stroke onset. Main Outcomes and Measures Head CT at 24 hours assessed parenchymal ICH volume expansion from baseline (primary outcome) and total (ie, parenchymal plus intraventricular) hemorrhage volume expansion (secondary outcome). The pooled analysis compared hemorrhage expansion between groups by analyzing 24-hour volumes in a linear regression model adjusted for baseline volumes, time from stroke onset to treatment, and trial. Results Of the 69 included patients, 35 (51%) were male, and the median (interquartile range [IQR]) age was 70 (59-80) years. Baseline median (IQR) ICH volumes were 16.3 (9.6-39.2) mL in the rFVIIa group and 20.4 (8.6-32.6) mL in the placebo group. Median (IQR) time from CT to treatment was 71 (57-96) minutes, and the median (IQR) time from stroke onset to treatment was 178 (138-197) minutes. The median (IQR) increase in ICH volume from baseline to 24 hours was small in both the rFVIIa group (2.5 [0-10.2] mL) and placebo group (2.6 [0-6.6] mL). After adjustment, there was no difference between groups on measures of ICH or total hemorrhage expansion. At 90 days, 9 of 30 patients in the rFVIIa group and 13 of 34 in the placebo group had died or were severely disabled (P = .60). Conclusions and Relevance Among patients with spot sign-positive ICH treated a median of about 3 hours from stroke onset, rFVIIa did not significantly improve radiographic or clinical outcomes. Trial Registration ClinicalTrials.gov identifier: NCT01359202 and NCT00810888.
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Affiliation(s)
- David J Gladstone
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Richard I Aviv
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences and Medicine, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Heidi J Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Fahad Al-Ajlan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ken Butcher
- University of New South Wales, Prince of Wales Clinical School, Sydney, New South Wales, Australia
| | - Dar Dowlatshahi
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Gord Gubitz
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Stephanie De Masi
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Judith Hall
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - David Gregg
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston
| | - Muhammad Mamdani
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Richard H Swartz
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - C Martin Del Campo
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brett Cucchiara
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Peter Panagos
- Department of Emergency Medicine, Washington University in St Louis, St Louis, Missouri
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Janice Carrozzella
- Department of Radiology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Edward C Jauch
- Mission Research Institute, Mission Health System, Asheville, North Carolina
| | - Joseph P Broderick
- Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Matthew L Flaherty
- Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
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Melmed KR, Carroll E, Lord AS, Boehme AK, Ishida K, Zhang C, Torres JL, Yaghi S, Czeisler BM, Frontera JA, Lewis A. Systemic Inflammatory Response Syndrome is Associated with Hematoma Expansion in Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105870. [PMID: 34077823 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/26/2021] [Accepted: 05/02/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Systemic inflammatory response syndrome (SIRS) and hematoma expansion are independently associated with worse outcomes after intracerebral hemorrhage (ICH), but the relationship between SIRS and hematoma expansion remains unclear. MATERIALS AND METHODS We performed a retrospective review of patients admitted to our hospital from 2013 to 2020 with primary spontaneous ICH with at least two head CTs within the first 24 hours. The relationship between SIRS and hematoma expansion, defined as ≥6 mL or ≥33% growth between the first and second scan, was assessed using univariable and multivariable regression analysis. We assessed the relationship of hematoma expansion and SIRS on discharge mRS using mediation analysis. RESULTS Of 149 patients with ICH, 83 (56%; mean age 67±16; 41% female) met inclusion criteria. Of those, 44 (53%) had SIRS. Admission systolic blood pressure (SBP), temperature, antiplatelet use, platelet count, initial hematoma volume and rates of infection did not differ between groups (all p>0.05). Hematoma expansion occurred in 15/83 (18%) patients, 12 (80%) of whom also had SIRS. SIRS was significantly associated with hematoma expansion (OR 4.5, 95% CI 1.16 - 17.39, p= 0.02) on univariable analysis. The association remained statistically significant after adjusting for admission SBP and initial hematoma volume (OR 5.72, 95% CI 1.40 - 23.41, p= 0.02). There was a significant indirect effect of SIRS on discharge mRS through hematoma expansion. A significantly greater percentage of patients with SIRS had mRS 4-6 at discharge (59 vs 33%, p=0.02). CONCLUSION SIRS is associated with hematoma expansion of ICH within the first 24 hours, and hematoma expansion mediates the effect of SIRS on poor outcome.
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Affiliation(s)
- Kara R Melmed
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA; Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA.
| | - Elizabeth Carroll
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Aaron S Lord
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Amelia K Boehme
- Department of Epidemiology and Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Koto Ishida
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Cen Zhang
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Jose L Torres
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Shadi Yaghi
- Department of Neurology, Brown University School of Medicine, Providence, RI, USA
| | - Barry M Czeisler
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA; Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Jennifer A Frontera
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone University School of Medicine, New York, New York, USA; Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
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Faigle R, Chen BJ, Krieger R, Marsh EB, Alkhachroum A, Xiong W, Urrutia VC, Gottesman RF. Novel Score for Stratifying Risk of Critical Care Needs in Patients With Intracerebral Hemorrhage. Neurology 2021; 96:e2458-e2468. [PMID: 33790039 PMCID: PMC8205477 DOI: 10.1212/wnl.0000000000011927] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/19/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To develop a risk prediction score identifying patients with intracerebral hemorrhage (ICH) at low risk for critical care. METHODS We retrospectively analyzed data of 451 patients with ICH between 2010 and 2018. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting independent predictors of intensive care unit (ICU) needs according to strength of association. The risk score was tested in the validation cohort and externally validated in a dataset from another institution. RESULTS The rate of ICU interventions was 80.3%. Systolic blood pressure (SBP), Glasgow Coma Scale (GCS) score, intraventricular hemorrhage (IVH), and ICH volume were independent predictors of critical care, resulting in the following point assignments for the Intensive Care Triaging in Spontaneous Intracerebral Hemorrhage (INTRINSIC) score: SBP 160 to 190 mm Hg (1 point), SBP >190 mm Hg (3 points); GCS 8 to 13 (1 point), GCS <8 (3 points); ICH volume 16 to 40 cm3 (1 point), ICH volume >40 cm3 (2 points); and presence of IVH (1 point), with values ranging between 0 and 9. Among patients with a score of 0 and no ICU needs during their emergency department stay, 93.6% remained without critical care needs. In an external validation cohort of patients with ICH, the INTRINSIC score achieved an area under the receiver operating characteristic curve of 0.823 (95% confidence interval 0.782-0.863). A score <2 predicted the absence of critical care needs with 48.5% sensitivity and 88.5% specificity, and a score <3 predicted the absence of critical care needs with 61.7% sensitivity and 83.0% specificity. CONCLUSION The INTRINSIC score identifies patients with ICH who are at low risk for critical care interventions. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that the INTRINSIC score identifies patients with ICH at low risk for critical care interventions.
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Affiliation(s)
- Roland Faigle
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH.
| | - Bridget J Chen
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Rachel Krieger
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Elisabeth B Marsh
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Ayham Alkhachroum
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Wei Xiong
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Victor C Urrutia
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Rebecca F Gottesman
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
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Cascone AE, Daley MJ, Pan N, Padilla-Tolentino E, Milling TJ. Low-dose versus standard-dose four-factor prothrombin complex concentrate for factor-Xa inhibitor reversal in spontaneous and traumatic intracranial hemorrhage. Pharmacotherapy 2021; 41:501-507. [PMID: 33866591 DOI: 10.1002/phar.2525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 01/05/2023]
Abstract
STUDY OBJECTIVES Current neurocritical care guidelines recommend 50 IU/kg four-factor prothrombin complex concentrate (4PCC) for factor Xa inhibitor (FXaI) reversal in intracranial hemorrhage (ICH) based on few clinical studies conducted among non-ICH subjects. Two recent studies suggest that low-dose (25 IU/kg) 4PCC may be similar to 50 IU/kg in reversal of FXaI in ICH, and both 25 and 50 IU/kg doses are used in clinical practice for this indication. To our knowledge, no studies have directly compared 25 IU/kg versus 50 IU/kg 4PCC for FXaI reversal in ICH. The purpose of this study is to determine whether there is a difference in hemostatic efficacy between 25 IU/kg versus 50 IU/kg 4PCC for FXaI reversal in ICH. DESIGN This multicenter, retrospective cohort study was performed in five hospitals in central Texas from November 2013 to December 2019. DATA SOURCE Patients were identified with a medication use report of 4PCC and were classified in the low- or standard-dose group based on whether the 25 IU/kg or 50 IU/kg dose was received, respectively. PATIENTS A total of 93 patients were included (25 IU/kg, n = 62; 50 IU/kg, n = 31). MEASUREMENTS AND MAIN RESULTS There was no difference in hemostatic efficacy between groups (82.3% low dose vs. 83.9% standard dose, p = 0.846). No differences were identified in-hospital mortality, length of stay, thrombotic events, or the need for surgery or additional blood products between groups. CONCLUSION For the reversal of FXaI in ICH, a 25 IU/kg dose may be an effective alternative to 50 IU/kg 4PCC dosing.
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Affiliation(s)
- Ava E Cascone
- Department of Pharmacy, Boston Medical Center, Boston, Massachusetts, USA
| | | | - Neil Pan
- Department of Pharmacy, Ascension Seton, Austin, Texas, USA
| | | | - Truman J Milling
- Department of Surgery, Dell Seton Medical Center at the University of Texas, Austin, Texas, USA.,Department of Neurology, Dell Seton Medical Center at the University of Texas, Austin, Texas, USA
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Shi J, Zou X, Jiang K, Tan L, Wang L, Ren S, Mao Y, Yang C, Wang W, Wu G, Tang Z. Intracerebral hemorrhage with tentorial herniation: Conventional open surgery or emergency stereotactic craniopuncture aspiration surgery? Transl Neurosci 2021; 12:198-209. [PMID: 34046216 PMCID: PMC8134800 DOI: 10.1515/tnsci-2020-0173] [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: 12/25/2020] [Revised: 04/02/2021] [Accepted: 04/21/2021] [Indexed: 12/05/2022] Open
Abstract
Background To observe the therapeutic effect of conventional decompressive craniectomy with hematoma evacuation and frame-based stereotactic minimally invasive surgery (MIS) for supratentorial intracranial hematoma with herniation. Methods One hundred forty-nine patients with hypertensive ICH complicated with tentorial herniation were reviewed and analyzed in the present study. The intracranial hematoma was evacuated by emergency surgery within 6 h after admission. According to the authorized representatives’ wishes and consent, 74 of the 149 patients were treated by conventional decompressive craniectomy followed by hematoma removal, defined as the CDC group, and the remaining 75 patients underwent frame-based stereotactic MIS for ICH evacuation, defined as the MIS group. The intervals between the admission to surgery, the duration of surgery, the amount of iatrogenic bleeding, the occurrence of postoperative rebleeding, and the recovery of neurological functions were compared between the two groups. All patients were followed up for 3 months. Secondary epilepsy, survival in a vegetative state, severe pulmonary complications, mortality, and activities of daily living (ADL) classification were also recorded and compared. Results The interval between admission and surgery, the duration of surgery, and intraoperative blood loss in the MIS group were significantly decreased compared to the CDC group. The mortality rate, the rate of rebleeding, prevalence of vegetative state, and severe pulmonary complications in the MIS group were remarkably decreased compared to the CDC group. In the MIS group, the survivors’ (ADL) grade also showed advantages. Conclusions In the surgical treatment of hypertensive ICH complicated with tentorial herniation, frame-based stereotactic MIS for ICH showed advantages compared to conventional open surgery.
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Affiliation(s)
- Jing Shi
- The Affiliated Hospital of Guizhou Medical University, Postal Address: No. 28, Guiyijie Road, Guiyang City, Postal Code 550004, People's Republic of China
| | - Xiaohua Zou
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Postal Address: No. 28, Guiyijie Road, Guiyang City, Postal Code 550004, People's Republic of China
| | - Ke Jiang
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Postal Address: No. 28, Guiyijie Road, Guiyang City, Postal Code 550004, People's Republic of China
| | - Li Tan
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Postal Address: No. 28, Guiyijie Road, Guiyang City, Postal Code 550004, People's Republic of China
| | - Likun Wang
- Emergency Department, The Affiliated Hospital of Guizhou Medical University, Postal Address: No. 28, Guiyijie Road, Guiyang City, Postal Code 550004, People's Republic of China
| | - Siying Ren
- Emergency Department, The Affiliated Hospital of Guizhou Medical University, Postal Address: No. 28, Guiyijie Road, Guiyang City, Postal Code 550004, People's Republic of China
| | - Yuanhong Mao
- Emergency Department, The Affiliated Hospital of Guizhou Medical University, Postal Address: No. 28, Guiyijie Road, Guiyang City, Postal Code 550004, People's Republic of China
| | - Chunguang Yang
- Department of Neurology, Zhengzhou Second People's Hospital, Postal address: No. 90, Hanghai Middle Road, Zhengzhou City, Postal Code 450000, Henan Province, People's Republic of China
| | - Weijun Wang
- Department of Neurosurgery, Qiannan State People's Hospital of Guizhou Province, Duyun City, Postal Code 558000, People's Republic of China
| | - Guofeng Wu
- Emergency Department, The Affiliated Hospital of Guizhou Medical University, Postal Address: No. 28, Guiyijie Road, Guiyang City, Postal Code 550004, People's Republic of China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Sciences and Technology, Postal address: No.1095, Road Jiefang, Wuhan, Postal code 430030, People's Republic of China
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Impacts of ABO-incompatible platelet transfusions on platelet recovery and outcomes after intracerebral hemorrhage. Blood 2021; 137:2699-2703. [PMID: 33649761 DOI: 10.1182/blood.2020008381] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/07/2021] [Indexed: 11/20/2022] Open
Abstract
Acute platelet transfusion after intracerebral hemorrhage (ICH) given in efforts to reverse antiplatelet medication effects and prevent ongoing bleeding does not appear to improve outcome and may be associated with harm. Although the underlying mechanisms are unclear, the influence of ABO-incompatible platelet transfusions on ICH outcomes has not been investigated. We hypothesized that patients with ICH who receive ABO-incompatible platelet transfusions would have worse platelet recovery (using absolute count increment [ACI]) and neurological outcomes (mortality and poor modified Rankin Scale [mRS 4-6]) than those receiving ABO-compatible transfusions. In a single-center cohort of consecutively admitted patients with ICH, we identified 125 patients receiving acute platelet transfusions, of whom 47 (38%) received an ABO-incompatible transfusion. Using quantile regression, we identified an association of ABO-incompatible platelet transfusion with lower platelet recovery (ACI, 2 × 103cells per μL vs 15 × 103cells per μL; adjusted coefficient β, -19; 95% confidence interval [CI], -35.55 to -4.44; P = .01). ABO-incompatible platelet transfusion was also associated with increased odds of mortality (adjusted odds ratio [OR], 2.59; 95% CI, 1.00-6.73; P = .05) and poor mRS (adjusted OR, 3.61; 95% CI, 0.97-13.42; P = .06); however, these estimates were imprecise. Together, these findings suggest the importance of ABO compatibility for platelet transfusions for ICH, but further investigation into the mechanism(s) underlying these observations is required.
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Khan A, Shaikh N, Alvi Y, Gupta P, Mehdi R, Siddiqui A. Blood pressure control measured as "time in range" during initial 24 h for inpatients with spontaneous nontraumatic intracerebral haemorrhage. J Neurol Sci 2021; 426:117480. [PMID: 33984548 DOI: 10.1016/j.jns.2021.117480] [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: 01/14/2021] [Revised: 04/11/2021] [Accepted: 05/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Blood pressure (BP) control is an integral part in the management of spontaneous nontraumatic intracerebral haemorrhage. The aim of this study is to propose a novel concept of blood pressure control measured as 'Time in Range'(TiR) and assess its relationship to neurological deterioration. METHOD Retrospective study of 120 patients with Intracerebral haemorrhage who were admitted within 6 h of the symptom onset. The hourly BP readings for initial 24 h were studied in the form of time in range (TiR). TiR was defined as the percentage of readings with 'in range' systolic BP (SBP 110-140mmHG) during a unit time period. TiR was correlated with mean SBP at 6,12,18 and 24 h. It was categorized dichotomously as controlled (more than 50%) or not controlled (equal to or less than 50%) and analyzed with the change in Glasgow coma scale (drop of ≥2 units) at 24 h. RESULTS Correlation of TiR with mean SBP at 6 and 24 h showed significant negative correlation [r = -0.71 (at 6 h); r = -0.88 (at 24 h); p < 0.001]. The association of TiR with neurological deterioration(ND) was measured by change in GCS; with lower TiR associated with higher chances of neurological deterioration at 12 h interval [OR 4.5(1.2-16.8); p = 0.025], but not at 24 h interval [OR 1.4 (0.34-5.44); p = 0.670]. CONCLUSION Our novel concept of 'Time in Range'(TiR) was found to be relevant in our study. Its association with mean SBP reflect its potential to be a modality of expressing control of SBP in Spontaneous Nontraumatic Intracerebral Haemorrhage.
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Affiliation(s)
- Arshee Khan
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates.
| | - Niaz Shaikh
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
| | - Yasir Alvi
- Department of Community Medicine, Hamdard Institute of Medical Sciences and Research, Hamdard University, New Delhi, India
| | - Priyank Gupta
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
| | - Rommana Mehdi
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
| | - Aisha Siddiqui
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
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Broderick JP, Grotta JC, Naidech AM, Steiner T, Sprigg N, Toyoda K, Dowlatshahi D, Demchuk AM, Selim M, Mocco J, Mayer S. The Story of Intracerebral Hemorrhage: From Recalcitrant to Treatable Disease. Stroke 2021; 52:1905-1914. [PMID: 33827245 PMCID: PMC8085038 DOI: 10.1161/strokeaha.121.033484] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This invited special report is based on an award presentation at the World Stroke Organization/European Stroke Organization Conference in November of 2020 outlining progress in the acute management of intracerebral hemorrhage (ICH) over the past 35 years. ICH is the second most common and the deadliest type of stroke for which there is no scientifically proven medical or surgical treatment. Prospective studies from the 1990s onward have demonstrated that most growth of spontaneous ICH occurs within the first 2 to 3 hours and that growth of ICH and resulting volumes of ICH and intraventricular hemorrhage are modifiable factors that can improve outcome. Trials focusing on early treatment of elevated blood pressure have suggested a target systolic blood pressure of 140 mm Hg, but none of the trials were positive by their primary end point. Hemostatic agents to decrease bleeding in spontaneous ICH have included desmopressin, tranexamic acid, and rFVIIa (recombinant factor VIIa) without clear benefit, and platelet infusions which were associated with harm. Hemostatic agents delivered within the first several hours have the greatest impact on growth of ICH and potentially on outcome. No large Phase III surgical ICH trial has been positive by primary end point, but pooled analyses suggest that earlier ICH removal is more likely to be beneficial. Recent trials emphasize maximization of clot removal and minimizing brain injury from the surgical approach. The future of ICH therapy must focus on delivery of medical and surgical therapies as soon as possible if we are to improve outcomes.
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Affiliation(s)
- Joseph P. Broderick
- University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA
| | - James C. Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston, Texas, USA
| | - Andrew M. Naidech
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany and Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, England
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Dar Dowlatshahi
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada
| | - Andrew M. Demchuk
- Calgary Stroke Program, Depts of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine,, University of Calgary, Calgary, Alberta, Canada
| | - Magdy Selim
- Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Stephan Mayer
- Westchester Medical Center Health Network, Departments of Neurology and Neurosurgery, New York Medical College, Valhalla, New York, USA
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Yang X, Zhu Y, Zhang L, Wang L, Mao Y, Li Y, Luo J, Wu G. The initial CT blend sign is not associated with poor patient outcomes after stereotactic minimally invasive surgery. BMC Neurol 2021; 21:160. [PMID: 33858371 PMCID: PMC8048306 DOI: 10.1186/s12883-021-02181-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 04/02/2021] [Indexed: 11/28/2022] Open
Abstract
Background The initial CT blend sign is an imaging marker that has been used to predict haematoma expansion and poor outcomes in patients with small-volume intracerebral haemorrhage (ICH). However, the association of the blend sign with the outcomes of patients undergoing surgery remains unclear. The present study aimed to retrospectively evaluate the influence of the initial CT blend sign on short-term outcomes in patients with hypertensive ICH after stereotactic minimally invasive surgery (sMIS). Methods We enrolled 242 patients with spontaneous ICH. The patients were assigned to the blend sign group (91 patients) or non-blend sign (control) group (151 patients) based on the initial CT features. The NIHSS, GCS and mRS were used to assess the effects of sMIS. The rates of severe pulmonary infection and cardiac complications were also compared between the two groups. Results Statistically significant differences in the NIHSS and GCS scores were not observed between the blend sign group and the control group. No significant differences in the proportion of patients with good outcomes during the follow-up period were observed between the two groups. A higher rate of re-haemorrhage was noted in the blend sign group. Significant differences in the rates of severe pulmonary infection and cardiac complications were not observed between the two groups. Conclusions The initial CT blend sign is not associated with poor outcomes in patients with hypertensive ICH after sMIS. ICH patients with the CT blend sign should undergo sMIS if they are suitable candidates for surgery.
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Affiliation(s)
- Xu Yang
- Emergency Department of Affiliated Hospital, Guizhou Medical University, No. 28, Guiyijie Road, Guiyang City, 550004, Guizhou Province, People's Republic of China
| | - Yan Zhu
- Department of Neurological Rehabilitation, Shanghai Second Rehabilitation Hospital, No. 25, Lane 860, Changjiang Road, Songnan Town, Baoshan District, Shanghai, 200441, People's Republic of China
| | - Linshan Zhang
- Emergency Department of Affiliated Hospital, Guizhou Medical University, No. 28, Guiyijie Road, Guiyang City, 550004, Guizhou Province, People's Republic of China
| | - Likun Wang
- Emergency Department of Affiliated Hospital, Guizhou Medical University, No. 28, Guiyijie Road, Guiyang City, 550004, Guizhou Province, People's Republic of China.
| | - Yuanhong Mao
- Emergency Department of Affiliated Hospital, Guizhou Medical University, No. 28, Guiyijie Road, Guiyang City, 550004, Guizhou Province, People's Republic of China
| | - Yinghui Li
- Emergency Department of Affiliated Hospital, Guizhou Medical University, No. 28, Guiyijie Road, Guiyang City, 550004, Guizhou Province, People's Republic of China
| | - Jinbiao Luo
- Department of Neurosurgery, Guangzhou First Peoples' Hospital, No. 1, Panfu Road, Guangzhou City, 510000, Guangdong Province, People's Republic of China.
| | - Guofeng Wu
- Department of Neurological Rehabilitation, Shanghai Second Rehabilitation Hospital, No. 25, Lane 860, Changjiang Road, Songnan Town, Baoshan District, Shanghai, 200441, People's Republic of China.
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Fair KA, Farrell DH, McCully BH, Rick EA, Dewey EN, Hilliard C, Dean R, Lin A, Hinson H, Barbosa R, Schreiber MA, Rowell SE. Fibrinolytic Activation in Patients with Progressive Intracranial Hemorrhage after Traumatic Brain Injury. J Neurotrauma 2021; 38:960-966. [PMID: 31382848 DOI: 10.1089/neu.2018.6234] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Progression of intracranial hemorrhage (PICH) is a significant cause of secondary brain injury in patients with traumatic brain injury (TBI). Previous studies have implicated a variety of mediators that contribute to PICH. We hypothesized that patients with PICH would display either a hypocoagulable state, hyperfibrinolysis, or both. We conducted a prospective study of adult trauma patients with isolated TBI. Blood was obtained for routine coagulation assays, platelet count, fibrinogen, thrombelastography, markers of thrombin generation, and markers of fibrinolysis at admission and 6, 12, 24, and 48 h. Univariate analyses were performed to compare baseline characteristics between groups. Linear regression models were created, adjusting for baseline differences, to determine the relationship between individual assays and PICH. One hundred forty-one patients met entry criteria, of whom 71 had hemorrhage progression. Patients with PICH had a higher Injury Severity Score and Abbreviated Injury Scale score (head), a lower Glasgow Coma Scale score, and lower plasma sodium on admission. Patients with PICH had higher D-dimers on admission. After adjusting for baseline differences, elevated D-dimers remained significantly associated with PICH compared to patients without PICH at admission. Hypocoagulation was not significantly associated with PICH in these patients. The association between PICH and elevated D-dimers early after injury suggests that fibrinolytic activation may contribute to PICH in patients with TBI.
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Affiliation(s)
- Kelly A Fair
- Oregon Health & Science University, Portland, Oregon, USA
| | | | | | | | | | - Cole Hilliard
- Oregon Health & Science University, Portland, Oregon, USA
| | - Rondi Dean
- Oregon Health & Science University, Portland, Oregon, USA
| | - Amber Lin
- Oregon Health & Science University, Portland, Oregon, USA
| | - Holly Hinson
- Oregon Health & Science University, Portland, Oregon, USA
| | - Ronald Barbosa
- Legacy Emanuel Hospital and Health Center, Portland, Oregon, USA
| | | | - Susan E Rowell
- Oregon Health & Science University, Portland, Oregon, USA
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Zhu D, Zhang M, Li Q, Liu J, Zhuang Y, Chen Q, Chen C, Xiang Y, Zhang Y, Yang Y. Can perihaematomal radiomics features predict haematoma expansion? Clin Radiol 2021; 76:629.e1-629.e9. [PMID: 33858695 DOI: 10.1016/j.crad.2021.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/02/2021] [Indexed: 12/14/2022]
Abstract
AIM To evaluate the association between perihaematomal radiomics features and haematoma expansion (HE). MATERIALS AND METHODS Clinical and radiological data were collected retrospectively. The 1:1 propensity score matching (PSM) method was used to balance the difference of baseline characteristics between patients with and without HE. Radiomics features were extracted from the intra- and perihaematomal regions. Top HE-associated features were selected using the minimum redundancy, maximum relevancy algorithm. Support vector machine models were used to predict HE. Predictive performance of radiomics features from different regions was evaluated by receiver operating characteristic curve and confusion matrix-derived metrics. RESULTS A total of 1,062 patients were enrolled. After PSM analysis, the propensity score-matched cohort (PSM cohort) included 314 patients (HE: n=157; non-HE: n=157). The PSM cohort was distributed into the training (n=218) and the validation cohorts (n=96). The predictive performance of intra- and perihaematomal features were comparable in the training (area under the receiver operating characteristic curve [AUC], 0.751 versus 0.757; p=0.867) and the validation cohorts (AUC, 0.724 versus 0.671; p=0.454). By incorporating intra- and perihaematomal features, the combined model outperformed the single intrahaematomal model in the training cohort (AUC, 0.872 versus 0.751; p<0.001). Decision curve analysis (DCA) further confirmed the clinical usefulness of the combined model. CONCLUSION Perihaematomal radiomics features can predict HE. The integration of intra- and perihaematomal signatures may provide additional benefit to the prediction of HE.
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Affiliation(s)
- D Zhu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - M Zhang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Q Li
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - J Liu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Y Zhuang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Q Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - C Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Y Xiang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Y Zhang
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Y Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.
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Zhao W, Jiang F, Li S, Liu G, Wu C, Wang Y, Ren C, Zhang J, Gu F, Zhang Q, Gao X, Gao Z, Song H, Ma Q, Ding Y, Ji X. Safety and efficacy of remote ischemic conditioning for the treatment of intracerebral hemorrhage: A proof-of-concept randomized controlled trial. Int J Stroke 2021; 17:425-433. [PMID: 33739197 DOI: 10.1177/17474930211006580] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Remote ischemic conditioning can promote hematoma resolution, attenuate brain edema, and improve neurological recovery in animal models of intracerebral hemorrhage. AIMS This study aimed to evaluate the safety and preliminary efficacy of remote ischemic conditioning in patients with intracerebral hemorrhage. METHODS In this multicenter, randomized, controlled trial, 40 subjects with supratentorial intracerebral hemorrhage presenting within 24-48 h of onset were randomly assigned to receive medical therapy plus remote ischemic conditioning for consecutive seven days or medical therapy alone. The primary safety outcome was neurological deterioration within seven days of enrollment, and the primary efficacy outcome was the changes of hematoma volume on CT images. Other outcomes included hematoma resolution rate at 7 days ([hematoma volume at 7 days - hematoma volume at baseline]/hematoma volume at baseline), perihematomal edema (PHE), and functional outcome at 90 days. RESULTS The mean age was 59.3 ± 11.7 years and hematoma volume was 13.9 ± 4.5 mL. No subjects experienced neurological deterioration within seven days of enrollment, and no subject died or experienced remote ischemic conditioning-associated adverse events during the study period. At baseline, the hematoma volumes were 14.19 ± 5.07 mL in the control group and 13.55 ± 3.99 mL in the remote ischemic conditioning group, and they were 8.54 ± 3.99 mL and 6.95 ± 2.71 mL at seven days after enrollment, respectively, which is not a significant difference (p > 0.05 each). The hematoma resolution rate in the remote ischemic conditioning group (49.25 ± 9.17%) was significantly higher than in the control group (41.92 ± 9.14%; MD, 7.3%; 95% CI, 1.51-13.16%; p = 0.015). The absolute PHE volume was 17.27 ± 8.34 mL in the control group and 12.92 ± 7.30 mL in the remote ischemic conditioning group at seven days after enrollment, which is not a significant between-group difference (p = 0.087), but the relative PHE in the remote ischemic conditioning group (1.77 ± 0.39) was significantly lower than in the control group (2.02 ± 0.27; MD, 0.25; 95% CI, 0.39-0.47; p = 0.023). At 90-day follow-up, 13 subjects (65%) in the remote ischemic conditioning group and 12 subjects (60%) in the control group achieved favorable functional outcomes (modified Rankin Scale score ≤ 3), which is not a significant between-group difference (p = 0.744). CONCLUSIONS Repeated daily remote ischemic conditioning for consecutive seven days was safe and well tolerated in patients with intracerebral hemorrhage, and it may be able to improve hematoma resolution rate and reduce relative PHE. However, the effects of remote ischemic conditioning on the absolute hematoma and PHE volume and functional outcomes in this patient population need further investigations.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03930940.
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Affiliation(s)
- Wenbo Zhao
- Department of Neurology, 71044Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fang Jiang
- Department of Neurology, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sijie Li
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guiyou Liu
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuang Wang
- Department of Neurology, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Changhong Ren
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jing Zhang
- Department of Neurology, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fei Gu
- Department of Neurology, Ningjin County Hospital, Xingtai, China
| | - Quanzhong Zhang
- Department of Neurosurgery, 523110Heze Municipal Hospital, Heze, China
| | - Xinjing Gao
- Department of Neurosurgery, The Sixth Hospital of Hengshui, Hengshui, China
| | - Zongen Gao
- Department of Neurology, 499782Shengli Oilfield Central Hospital, Dongying, China
| | - Haiqing Song
- Department of Neurology, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, 12267Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.,Department of Neurosurgery, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
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Law ZK, Dineen R, England TJ, Cala L, Mistri AK, Appleton JP, Ozturk S, Bereczki D, Ciccone A, Bath PM, Sprigg N. Predictors and Outcomes of Neurological Deterioration in Intracerebral Hemorrhage: Results from the TICH-2 Randomized Controlled Trial. Transl Stroke Res 2021; 12:275-283. [PMID: 32902808 PMCID: PMC7925446 DOI: 10.1007/s12975-020-00845-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/15/2020] [Accepted: 08/25/2020] [Indexed: 12/03/2022]
Abstract
Neurological deterioration is common after intracerebral hemorrhage (ICH). We aimed to identify the predictors and effects of neurological deterioration and whether tranexamic acid reduced the risk of neurological deterioration. Data from the Tranexamic acid in IntraCerebral Hemorrhage-2 (TICH-2) randomized controlled trial were analyzed. Neurological deterioration was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) of ≥ 4 or a decline in Glasgow Coma Scale of ≥ 2. Neurological deterioration was considered to be early if it started ≤ 48 h and late if commenced between 48 h and 7 days after onset. Logistic regression was used to identify predictors and effects of neurological deterioration and the effect of tranexamic acid on neurological deterioration. Of 2325 patients, 735 (31.7%) had neurological deterioration: 590 (80.3%) occurred early and 145 (19.7%) late. Predictors of early neurological deterioration included recruitment from the UK, previous ICH, higher admission systolic blood pressure, higher NIHSS, shorter onset-to-CT time, larger baseline hematoma, intraventricular hemorrhage, subarachnoid extension and antiplatelet therapy. Older age, male sex, higher NIHSS, previous ICH and larger baseline hematoma predicted late neurological deterioration. Neurological deterioration was independently associated with a modified Rankin Scale of > 3 (aOR 4.98, 3.70-6.70; p < 0.001). Tranexamic acid reduced the risk of early (aOR 0.79, 0.63-0.99; p = 0.041) but not late neurological deterioration (aOR 0.76, 0.52-1.11; p = 0.15). Larger hematoma size, intraventricular and subarachnoid extension increased the risk of neurological deterioration. Neurological deterioration increased the risk of death and dependency at day 90. Tranexamic acid reduced the risk of early neurological deterioration and warrants further investigation in ICH. URL: https://www.isrctn.com Unique identifier: ISRCTN93732214.
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Affiliation(s)
- Zhe Kang Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK
- Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Rob Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK
- Vascular Medicine, Division of Medical Sciences and GEM, University of Nottingham, Nottingham, UK
| | - Lesley Cala
- School of Medicine, University of Western Australia, Perth, Australia
| | - Amit K Mistri
- Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK
| | - Serefnur Ozturk
- Department of Neurology, Selcuk University Medical Faculty, Konya, Turkey
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Alfonso Ciccone
- Neurology Unit, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK
- Department of Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK.
- Department of Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.
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128
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Abstract
Intracerebral hemorrhage is a stroke subtype with high mortality and poor functional outcome in survivors. Its main causes are hypertension, cerebral amyloid angiopathy, and anticoagulant treatment. Hematomas have a high frequency of expansion in the first hours after symptom onset, a process associated with neurologic deterioration and poor outcome. Control of severe hypertension, reversal of anticoagulant effect, and management of increased intracranial pressure are the mainstays of management of intracerebral hemorrhage in the acute phase. Surgical evacuation of the hematoma by conventional craniotomy does not improve outcomes, but minimally invasive techniques may be a valuable approach that deserves further evaluation.
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Affiliation(s)
- Carlos S Kase
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
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129
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Hines K, Mouchtouris N, Al Saiegh F, Hafazalla K, Mazza J, Phan P, Gooch MR, Tjoumakaris S, Rosenwasser RH, Jabbour PM. Prediction of hematoma expansion in spontaneous intracerebral hemorrhage: Our institutional experience. J Clin Neurosci 2021; 86:271-275. [PMID: 33775341 DOI: 10.1016/j.jocn.2021.01.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/30/2020] [Accepted: 01/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (sICH) is a disease process with high morbidity and mortality. In particular, hematoma expansion (HE) is a feared complication of sICH. With 15-40% of patients experiencing HE, it has become increasingly important to predict which sICH will remain stable and which will expand. OBJECTIVE With new treatment options being developed, it is becoming increasingly important to be able to predict which hemorrhages are at high versus low risk for expansion. The authors of this study hope to reexamine variables associated with hematoma expansion in hopes of generating newer data on risk factors for expansion. METHODS A retrospective analysis identified 334 patients who presented with sICH. The primary outcome was HE on follow up head CT. HE was defined as a greater than 33% increase or an absolute increase in 6 mL or more in overall volume between the two sets of CT images. Analysis was performed using unpaired t-test, Chi-square, and Fisher's exact tests, as appropriate. RESULTS Of the 334 patients, 247 (74.0%) did not experience an expansion of their ICH while 87 (26.0%) did. Multivariable logistic regression was performed demonstrating ICH score of 3 or greater (4.76 (95% CI 2.60-8.72, p < 0.001) , cortical location of the sICH (1.77 (95% CI 1.03-3.04, p = 0.038), and presence of a fluid level (6.46 (95% CI 2.28-18.3, p < 0.001) as significant predictors of HE. CONCLUSIONS Our study found that fluid-fluid levels on non-contrast CT, an ICH score 3 or greater, and lobar sICH were all more likely to expand.
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Affiliation(s)
- Kevin Hines
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Fadi Al Saiegh
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Karim Hafazalla
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Jacob Mazza
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Phillip Phan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
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130
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Lv XN, Deng L, Yang WS, Wei X, Li Q. Computed Tomography Imaging Predictors of Intracerebral Hemorrhage Expansion. Curr Neurol Neurosci Rep 2021; 21:22. [PMID: 33710468 DOI: 10.1007/s11910-021-01108-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Hematoma expansion (HE) is strongly associated with poor clinical outcome and is a compelling target for improving outcome after intracerebral hemorrhage (ICH). Non-contrast computed tomography (NCCT) is widely used in clinical practice due to its faster acquisition at the presence of acute stroke. Recently, imaging markers on NCCT are increasingly used for predicting HE. We comprehensively review the current evidence on HE prediction using NCCT and provide a summary for assessment of these markers in future research studies. RECENT FINDINGS Predictors of HE on NCCT have been described in reports of several studies. The proposed markers, including swirl sign, blend sign, black hole sign, island sign, satellite sign, and subarachnoid extension, were all significantly associated with HE and poor outcome in their small sample studies after ICH. In summary, the optimal management of ICH remains a therapeutic dilemma. Therefore, using NCCT markers to select patients at high risk of HE is urgently needed. These markers may allow rapid identification and provide potential targets for anti-HE treatments in patients with acute ICH.
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Affiliation(s)
- Xin-Ni Lv
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Lan Deng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Wen-Song Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiao Wei
- Department of Traditional Chinese Medicine, Chongqing Medical and Pharmaceutical College, Chongqing, 401331, China.
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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131
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Leary OP, Merck LH, Yeatts SD, Pan I, Liu DD, Harder TJ, Jung S, Collins S, Braileanu M, Gokaslan ZL, Allen JW, Wright DW, Merck D. Computer-Assisted Measurement of Traumatic Brain Hemorrhage Volume Is More Predictive of Functional Outcome and Mortality than Standard ABC/2 Method: An Analysis of Computed Tomography Imaging Data from the Progesterone for Traumatic Brain Injury Experimental Clinical Treatment Phase-III Trial. J Neurotrauma 2021; 38:604-615. [PMID: 33191851 PMCID: PMC7898408 DOI: 10.1089/neu.2020.7209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hemorrhage volume is an important variable in emergently assessing traumatic brain injury (TBI). The most widely used method for rapid volume estimation is ABC/2, a simple algorithm that approximates lesion geometry as perfectly ellipsoid. The relative prognostic value of volume measurement based on more precise hematoma topology remains unknown. In this study, we compare volume measurements obtained using ABC/2 versus computer-assisted volumetry (CAV) for both intra- and extra-axial traumatic hemorrhages, and then quantify the association of measurements using both methods with patient outcome following moderate to severe TBI. A total of 517 computer tomography (CT) scans acquired during the Progesterone for Traumatic Brain Injury Experimental Clinical Treatment Phase-III (ProTECTIII) multi-center trial were retrospectively reviewed. Lesion volumes were measured using ABC/2 and CAV. Agreement between methods was tested using Bland-Altman analysis. Relationship of volume measurements with 6-month mortality, Extended Glasgow Outcome Scale (GOS-E), and Disability Rating Scale (DRS) were assessed using linear regression and area under the curve (AUC) analysis. In subdural hematoma (SDH) >50cm3, ABC/2 and CAV produce significantly different volume measurements (p < 0.0001), although the difference was not significant for smaller SDH or intra-axial lesions. The disparity between ABC/2 and CAV measurements varied significantly with hematoma size for both intra- and extra-axial lesions (p < 0.0001). Across all lesions, volume was significantly associated with outcome using either method (p < 0.001), but CAV measurement was a significantly better predictor of outcome than ABC/2 estimation for SDH. Among large traumatic SDH, ABC/2 significantly overestimates lesion volume compared with measurement based on precise bleed topology. CAV also offers significantly better prediction of patient functional outcofme and mortality.
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Affiliation(s)
- Owen P. Leary
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Lisa H. Merck
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville Florida, USA
| | - Sharon D. Yeatts
- Department of Health Sciences, Medical University of South Carolina, Charleston South Carolina, USA
| | - Ian Pan
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - David D. Liu
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Tyler J. Harder
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Stefan Jung
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Scott Collins
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Maria Braileanu
- Department of Radiology and Emory University School of Medicine, Atlanta Georgia, USA
| | - Ziya L. Gokaslan
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
| | - Jason W. Allen
- Department of Radiology and Emory University School of Medicine, Atlanta Georgia, USA
| | - David W. Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta Georgia, USA
| | - Derek Merck
- Department of Diagnostic Imaging, and Warren Alpert Medical School of Brown University, Providence Rhode Island, USA
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville Florida, USA
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132
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Hu S, Sheng W, Hu Y, Ma Q, Li B, Han R. A nomogram to predict early hematoma expansion of hypertensive cerebral hemorrhage. Medicine (Baltimore) 2021; 100:e24737. [PMID: 33607818 PMCID: PMC7899817 DOI: 10.1097/md.0000000000024737] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 01/17/2021] [Indexed: 01/05/2023] Open
Abstract
Early hematoma expansion of hypertensive cerebral hemorrhage is affected by various factors. This study aimed to clarify the risk factors and develop a nomogram to predict early hematoma expansion.A retrospective analysis was carried out in patients with hypertensive cerebral hemorrhage admitted to our institution between January 1, 2012 and December 31, 2018; the patients were divided into 2 groups according to the presence of early hematoma expansion. Univariate and multivariate analyses were performed to analyze the risk factors of hematoma expansion. The nomogram was developed based on a multivariate logistic regression model, and the discriminative ability of the model was analyzed.A total of 477 patients with hypertensive cerebral hemorrhage and with a baseline hematoma volume <30 ml were included in our retrospective analysis. The hematoma expansion rate was 34.2% (163/477). After multivariate logistic regression, 9 variables (alcohol history, Glasgow coma scale score, total serum calcium, blood glucose, international normalized ratio, hematoma shape, hematoma density, volume of hematoma on initial computed tomography scan, and presence of intraventricular hemorrhage) identified as independent predictors of hematoma expansion were used to generate the nomogram. The area under the receiver operating characteristic curve of the nomogram was 0.883 (95% confidence interval 0.851-0.914), and the cutoff score was -0.19 with sensitivity of 75.5% and specificity of 87.3%.The nomogram can accurately predict the risk of early hematoma expansion.
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Affiliation(s)
- Si Hu
- Department of Neurosurgery
| | - WenGuo Sheng
- Department of Neurology, Affiliated Huzhou FuYin Hospital of Huzhou University, Huzhou, ZheJiang, China
| | - Yi Hu
- Department of Neurology, Affiliated Huzhou FuYin Hospital of Huzhou University, Huzhou, ZheJiang, China
| | | | - Bin Li
- Department of Neurosurgery
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133
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Is the detectability of the spot sign on CT angiography depending on slice thickness and reconstruction type? Clin Neurol Neurosurg 2021; 203:106559. [PMID: 33618171 DOI: 10.1016/j.clineuro.2021.106559] [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: 01/19/2021] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The spot sign is a validated imaging marker widely used in CT angiography (CTA) to detect active bleeding and a higher risk of hematoma expansion in patients with intracerebral hemorrhage (ICH). The aim of this study was to investigate the detectability of spot signs on thin multiplanar projection reconstruction (MPR) images compared to thicker maximum intensity projection (MIP) images. METHODS In this retrospective analysis, we assessed imaging data of 146 patients with primary hypertensive/microangiopathic ICH who received emergency non-contrast computed tomography (NCCT) and CTA. Two experienced radiologists, blinded to each other, evaluated images of thin (1 mm) MPR images and thick (3 mm) MIP images on the presence of spot signs and performed a consensus reading. Kappa tests were used for data comparison. RESULTS In total, spot signs were observed in 27 cases (=18.5 %) in both thin MPR and thick MIP slices. Detectability of the spot sign did not differ in 1 mm MPR images and 3 mm MIP images (Cohen's kappa, 1.0; p = 0.00). Also, when the readings of the two radiologists were analyzed separately, results for MPR and MIP slices were similar (MPR: Cohen's kappa, 0.81, p = 0.00; MIP: Cohen's kappa, 0.74; p = 0.00). CONCLUSION No significant difference in the detectability of the spot sign could be demonstrated when comparing 1 mm MPR images with 3 mm MIP images.
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134
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Yang Y, Deng G, Wang P, Lv G, Mao R, Sun Y, Wang B, Liu X, Bian L, Zhou D. A Selenium Nanocomposite Protects the Mouse Brain from Oxidative Injury Following Intracerebral Hemorrhage. Int J Nanomedicine 2021; 16:775-788. [PMID: 33574665 PMCID: PMC7871993 DOI: 10.2147/ijn.s293681] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/07/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a common neurological crisis leading to high mortality and morbidity. Oxidative stress-induced secondary injury plays a critical role in neurological deterioration. Previously, we synthesized a porous Se@SiO2 nanocomposite and identified their therapeutic role in osteonecrosis of the femoral head. Whether this nanocomposite is neuroprotective remains to be elucidated. METHODS A porous Se@SiO2 nanocomposite was synthesized, and its biosafety was determined using a CCK-8 assay. The neuroprotective effect was evaluated by TUNEL staining, and intracellular ROS were detected with a DCFH-DA probe in SH-SY5Y cells exposed to hemin. Furthermore, the effect of the nanocomposite on cell apoptosis, brain edema and blood-brain barrier permeability were evaluated in a collagenase-induced ICH mouse model. The potential mechanism was also explored. RESULTS The results demonstrated that Se@SiO2 treatment significantly improved neurological function, increased glutathione peroxidase activity and downregulated malonaldehyde levels. The proportion of apoptotic cells, brain edema and blood-brain barrier permeability were reduced significantly in ICH mice treated with Se@SiO2 compared to vehicle-treated mice. In vitro, Se@SiO2 protected SH-SY5Y cells from hemin-induced apoptosis by preventing intracellular reactive oxygen species accumulation. CONCLUSION These results suggested that the porous Se@SiO2 nanocomposite exerted neuroprotection by suppressing oxidative stress. Se@SiO2 may be a potential candidate for the clinical treatment of ICH and oxidative stress-related brain injuries.
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Affiliation(s)
- Yong Yang
- Department of Neurosurgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Guoying Deng
- Trauma Center, Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 201620, People’s Republic of China
| | - Peng Wang
- Department of Neurosurgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Guangzhao Lv
- Department of Neurosurgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Rui Mao
- Department of Neurosurgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Yuhao Sun
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Baofeng Wang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Xijian Liu
- College of Chemistry and Chemical Engineering, Shanghai University of Engineering Science, Shanghai, 201620, People’s Republic of China
| | - Liuguan Bian
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Dong Zhou
- Department of Neurosurgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
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135
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Hall AN, Weaver B, Liotta E, Maas MB, Faigle R, Mroczek DK, Naidech AM. Identifying Modifiable Predictors of Patient Outcomes After Intracerebral Hemorrhage with Machine Learning. Neurocrit Care 2021; 34:73-84. [PMID: 32385834 PMCID: PMC7648730 DOI: 10.1007/s12028-020-00982-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Demonstrating a benefit of acute treatment to patients with intracerebral hemorrhage (ICH) requires identifying which patients have a potentially modifiable outcome, where treatment could favorably shift a patient's expected outcome. A decision rule for which patients have a modifiable outcome could improve the targeting of treatments. We sought to determine which patients with ICH have a modifiable outcome. METHODS Patients with ICH were prospectively identified at two institutions. Data on hematoma volumes, medication histories, and other variables of interest were collected. ICH outcomes were evaluated using the modified Rankin Scale (mRS), assessed at 14 days and 3 months after ICH, with "good outcome" defined as 0-3 (independence or better) and "poor outcome" defined as 4-6 (dependence or worse). Supervised machine learning models identified the best predictors of good versus poor outcomes at Institution 1. Models were validated using repeated fivefold cross-validation as well as testing on the entirely independent sample at Institution 2. Model fit was assessed with area under the ROC curve (AUC). RESULTS Model performance at Institution 1 was strong for both 14-day (AUC of 0.79 [0.77, 0.81] for decision tree, 0.85 [0.84, 0.87] for random forest) and 3 month (AUC of 0.75 [0.73, 0.77] for decision tree, 0.82 [0.80, 0.84] for random forest) outcomes. Independent predictors of functional outcome selected by the algorithms as important included hematoma volume at hospital admission, hematoma expansion, intraventricular hemorrhage, overall ICH Score, and Glasgow Coma Scale. Hematoma expansion was the only potentially modifiable independent predictor of outcome and was compatible with "good" or "poor" outcome in a subset of patients with low hematoma volumes, good Glasgow Coma scale and premorbid modified Rankin Scale scores. Models trained on harmonized data also predicted patient outcomes well at Institution 2 using decision tree (AUC 0.69 [0.63, 0.75]) and random forests (AUC 0.78 [0.72, 0.84]). CONCLUSIONS Patient outcomes are predictable to a high level in patients with ICH, and hematoma expansion is the sole-modifiable predictor of these outcomes across two outcome types and modeling approaches. According to decision tree analyses predicting outcome at 3 months, patients with a high Glasgow Coma Scale score, less than 44.5 mL hematoma volume at admission, and relatively low premorbid modified Rankin Score in particular have a modifiable outcome and appear to be candidates for future interventions to improve outcomes after ICH.
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Affiliation(s)
- Andrew N Hall
- Department of Psychology, Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL, USA.
| | - Bradley Weaver
- Institute for Public Health and Medicine, Northwestern University Chicago, Chicago, IL, USA
| | - Eric Liotta
- Institute for Public Health and Medicine, Northwestern University Chicago, Chicago, IL, USA
| | - Matthew B Maas
- Institute for Public Health and Medicine, Northwestern University Chicago, Chicago, IL, USA
| | - Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel K Mroczek
- Department of Psychology, Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Andrew M Naidech
- Institute for Public Health and Medicine, Northwestern University Chicago, Chicago, IL, USA
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136
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Shakya MR, Fu F, Zhang M, Shan Y, Yu F, Sun S, Lu J. Comparison of Black Hole Sign, Satellite Sign, and Iodine Sign to Predict Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3919710. [PMID: 33604373 PMCID: PMC7870314 DOI: 10.1155/2021/3919710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/02/2020] [Accepted: 01/21/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To discretely and collectively compare black hole sign (BHS) and satellite sign (SS) with recently introduced gemstone spectral imaging-based iodine sign (IS) for predicting hematoma expansion (HE) in spontaneous intracerebral hemorrhage (SICH). METHODS This retrospective study includes 90 patients from 2017 to 2019 who underwent both spectral computed tomography angiography (CTA) as well as noncontrast computed tomography (NCCT) within 6 hours of SICH onset along with subsequent follow-up NCCT scanned within 24 hours. We named the presence of any of BHS or SS as any NCCT sign. Two independent reviewers analyzed all the HE predicting signs. Receiver-operator characteristic curve analysis and logistic regression were performed to compare the predictive performance of HE. RESULTS A total of 61 patients had HE, out of which IS was seen in 78.7% (48/61) while BHS and SS were seen in 47.5% (29/61) and 41% (25/61), respectively. The area under the curve for BHS, SS, and IS was 63.4%, 67%, and 82.4%, respectively, while for any NCCT sign was 71.5%. There was no significant difference between IS and any NCCT sign (P = 0.108). Multivariate analysis showed IS (odds ratio 68.24; 95% CI 11.76-396.00; P < 0.001) and any NCCT sign (odds ratio 19.49; 95% CI 3.99-95.25; P < 0.001) were independent predictors of HE whereas BHS (odds ratio 0.34; 95% CI 0.01-38.50; P = 0.534) and SS (odds ratio 4.54; 95% CI 0.54-38.50; P = 0.165) had no significance. CONCLUSION The predictive accuracy of any NCCT sign was better than that of sole BHS and SS. Both any NCCT sign and IS were independent predictors of HE. Although IS had higher predictive accuracy, any NCCT sign may still be regarded as a fair predictor of HE when CTA is not available.
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Affiliation(s)
- Milind Ratna Shakya
- Department of Radiology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
| | - Fan Fu
- Department of Radiology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
| | - Miao Zhang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
| | - Yi Shan
- Department of Radiology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
| | - Fan Yu
- Department of Radiology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
| | - Shengjun Sun
- Neuroradiology Department, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, No. 119 Nansihuanxilu, Fengtai District, Beijing, China
| | - Jie Lu
- Department of Radiology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
- Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, China
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137
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Cho S, Rehni AK, Dave KR. Tobacco Use: A Major Risk Factor of Intracerebral Hemorrhage. J Stroke 2021; 23:37-50. [PMID: 33600701 PMCID: PMC7900392 DOI: 10.5853/jos.2020.04770] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/20/2021] [Indexed: 12/23/2022] Open
Abstract
Spontaneous intracerebral hemorrhage (sICH) is one of the deadliest subtypes of stroke, and no treatment is currently available. One of the major risk factors is tobacco use. In this article, we review literature on how tobacco use affects the risk of sICH and also summarize the known effects of tobacco use on outcomes following sICH. Several studies demonstrate that the risk of sICH is higher in current cigarette smokers compared to non-smokers. The literature also establishes that cigarette smoking not only increases the risk of sICH but also increases hematoma growth, results in worse outcomes, and increases the risk of death from sICH. This review also discusses potential mechanisms activated by tobacco use which result in an increase in risk and severity of sICH. Exploring the underlying mechanisms may help alleviate the risk of sICH in tobacco users as well as may help better manage tobacco user sICH patients.
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Affiliation(s)
- Sunjoo Cho
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ashish K Rehni
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kunjan R Dave
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Neuroscience Program, University of Miami Miller School of Medicine, Miami, FL, USA
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138
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Peeters MTJ, Kort KJDD, Houben R, Henneman WJP, Oostenbrugge RJV, Staals J, Postma AA. Dual-Energy CT Angiography Improves Accuracy of Spot Sign for Predicting Hematoma Expansion in Intracerebral Hemorrhage. J Stroke 2021; 23:82-90. [PMID: 33600705 PMCID: PMC7900388 DOI: 10.5853/jos.2020.03531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/22/2020] [Indexed: 12/30/2022] Open
Abstract
Background and Purpose Spot sign (SS) on computed tomography angiography (CTA) is associated with hematoma expansion (HE) and poor outcome after intracerebral hemorrhage (ICH). However, its predictive performance varies across studies, possibly because differentiating hyperdense hemorrhage from contrast media is difficult. We investigated whether dual-energy-CTA (DE-CTA), which can separate hemorrhage from iodinated contrast, improves the diagnostic accuracy of SS for predicting HE.
Methods Primary ICH patients undergoing DE-CTA (both arterial as well as delayed venous phase) and follow-up computed tomography were prospectively included between 2014 and 2019. SS was assessed on both arterial and delayed phase images of the different DE-CTA datasets, i.e., conventional-like mixed images, iodine images, and fusion images. Diagnostic accuracy of SS for prediction of HE was determined on all datasets. The association between SS and HE, and between SS and poor outcome (modified Rankin Scale at 3 months ≥3) was assessed with multivariable logistic regression, using the dataset with highest diagnostic accuracy.
Results Of 139 included patients, 47 showed HE (33.8%). Sensitivity of SS for HE was 32% (accuracy 0.72) on conventional-like mixed arterial images which increased to 76% (accuracy 0.80) on delayed fusion images. Presence of SS on delayed fusion images was independently associated with HE (odds ratio [OR], 17.5; 95% confidence interval [CI], 6.14 to 49.82) and poor outcome (OR, 3.84; 95% CI, 1.16 to 12.73).
Conclusions Presence of SS on DE-CTA, in particular on delayed phase fusion images, demonstrates higher diagnostic performance in predicting HE compared to conventional-like mixed imaging, and it is associated with poor outcome.
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Affiliation(s)
- Michaël T J Peeters
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Kim J D de Kort
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Rik Houben
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Wouter J P Henneman
- Department of Radiology and Nuclear Medicine, MHeNS School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Julie Staals
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, MHeNS School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, Netherlands
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139
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Abstract
Ischemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.
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Affiliation(s)
- Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center-Houston, Houston, Texas
| | - James C Grotta
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
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140
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Kleitsch J, Nistal DA, Romano Spica N, Alkayyali M, Song R, Chada D, Reilly K, Lay C, Reynolds AS, Fifi JT, Bederson JB, Mocco J, Liang JW, Kellner CP, Dangayach NS. Interhospital Transfer of Intracerebral Hemorrhage Patients Undergoing Minimally Invasive Surgery: The Experience of a New York City Hospital System. World Neurosurg 2021; 148:e390-e395. [PMID: 33422715 DOI: 10.1016/j.wneu.2020.12.163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The impact of interhospital transfer (IHT) on outcomes of patients with intracerebral hemorrhage (ICH) has not been well studied. We seek to describe the protocolized IHT and systems of care approach of a New York City hospital system, where ICH patients undergoing minimally invasive surgery (MIS) are transferred to a dedicated ICH center. METHODS We retrospectively reviewed 100 consecutively admitted patients with spontaneous ICH. We gathered information on demographics, variables related to IHT, clinical and radiographic characteristics, and details about the clinical course and outpatient follow-up. We grouped patients into 2 cohorts: those admitted through IHT and those directly admitted through the emergency department. Primary outcome was good functional outcome at 6 months, defined as modified Rankin Scale score 0-3. RESULTS Of 100 patients, 89 underwent IHT and 11 were directly admitted. On multivariable analysis, there were no significant differences in 6-month functional outcome between the 2 cohorts. All transfers were managed by a system-wide transfer center and 24/7 hotline for neuroemergencies. An ICH-specific IHT protocol was followed, in which a neurointensivist provided recommendations for stabilizing patients for transfer. Average transfer time was 199.7 minutes and average distance travelled was 13.6 kilometers. CONCLUSIONS In our hospital system, a centralized approach to ICH management and a dedicated ICH center increased access to specialist services, including MIS. Most patients undergoing MIS were transferred from outside hospitals, which highlights the need for additional studies and descriptions of experiences to further elucidate the impact of and best protocols for the IHT of ICH patients.
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Affiliation(s)
- Julianne Kleitsch
- State University of New York Downstate College of Medicine, Brooklyn, New York, USA; Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Dominic A Nistal
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | | | - Miryam Alkayyali
- Icahn School of Medicine at Mount Sinai (Beth Israel/Mount Sinai West), Department of Neurology, New York, New York, USA
| | - Rui Song
- State University of New York Downstate College of Medicine, Brooklyn, New York, USA
| | - Deeksha Chada
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Kaitlin Reilly
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Cappi Lay
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Alexandra S Reynolds
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Johanna T Fifi
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Joshua B Bederson
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - J Mocco
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - John W Liang
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Christopher P Kellner
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Neha S Dangayach
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA.
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141
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Abstract
Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.
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Affiliation(s)
- Arturo Montaño
- Departments of Neurology and Neurosurgery, University of Colorado, Aurora, CO, United States
| | - Daniel F Hanley
- Departments of Neurology and Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - J Claude Hemphill
- Departments of Neurology and Neurosurgery, University of California San Francisco, San Francisco, CA, United States.
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142
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Oziel M, Rubinsky B, Korenstein R. Detection and estimating the blood accumulation volume of brain hemorrhage in a human anatomical skull using a RF single coil. PeerJ 2020; 8:e10416. [PMID: 33354419 PMCID: PMC7733650 DOI: 10.7717/peerj.10416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/02/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE An experimental study for testing a simple robust algorithm on data derived from an electromagnetic radiation device that can detect small changes in the tissue/fluid ratio in a realistic head configuration. METHODS Changes in the scattering parameters (S21) of an inductive coil resulting from injections of chicken blood in the 0-18 ml range into calf brain tissue in a human anatomical skull were measured over a 100-1,000 MHz frequency range. RESULTS An algorithm that combines amplitude and phase results was found to detect changes in the tissue/fluid ratio with 90% accuracy. An algorithm that estimated the injected blood volume was found to have a 1-4 ml average error. This demonstrates the possibility of the inductive coil-based device to possess a practical ability to detect a change in the tissue/fluid ratio in the head. SIGNIFICANCE This study is an important step towards the goal of building an inexpensive and safe device that can detect an early brain hemorrhagic stroke.
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Affiliation(s)
- Moshe Oziel
- Department of Physiology and Pharmacology, Tel-Aviv University, Tel-Aviv, Israel
| | - Boris Rubinsky
- Department of Mechanical Engineering, University of California, Berkeley, Berkeley, CA, USA
| | - Rafi Korenstein
- Department of Physiology and Pharmacology, Tel-Aviv University, Tel-Aviv, Israel
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143
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McGurgan IJ, Ziai WC, Werring DJ, Al-Shahi Salman R, Parry-Jones AR. Acute intracerebral haemorrhage: diagnosis and management. Pract Neurol 2020; 21:practneurol-2020-002763. [PMID: 33288539 PMCID: PMC7982923 DOI: 10.1136/practneurol-2020-002763] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2020] [Indexed: 12/11/2022]
Abstract
Intracerebral haemorrhage (ICH) accounts for half of the disability-adjusted life years lost due to stroke worldwide. Care pathways for acute stroke result in the rapid identification of ICH, but its acute management can prove challenging because no individual treatment has been shown definitively to improve its outcome. Nonetheless, acute stroke unit care improves outcome after ICH, patients benefit from interventions to prevent complications, acute blood pressure lowering appears safe and might have a modest benefit, and implementing a bundle of high-quality acute care is associated with a greater chance of survival. In this article, we address the important questions that neurologists face in the diagnosis and acute management of ICH, and focus on the supporting evidence and practical delivery for the main acute interventions.
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Affiliation(s)
- Iain J McGurgan
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Wendy C Ziai
- Division of Brain Injury Outcomes, Department of Neurology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, UCL, London, UK
| | | | - Adrian R Parry-Jones
- Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
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144
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Mazhar K, Olson DM, Atem FD, Stutzman SE, Moreno J, Venkatachalam A, Aiyagari V. Supratentorial intracerebral hemorrhage volume and other CT variables predict the neurological pupil index. Clin Neurol Neurosurg 2020; 200:106410. [PMID: 33341651 DOI: 10.1016/j.clineuro.2020.106410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES There is growing interest in the ability of automated infrared pupillometry to assess severity of neurological illness. We studied the correlation between computed tomography (CT) indicators of intracerebral hemorrhage (ICH) severity with objective measures of the pupillary light reflex (PLR), and hypothesized that hemorrhage volume would predict the Neurological Pupil index™ (NPi™), an indicator of pupillary reactivity. METHODS This study examined data from patients with supratentorial ICH who underwent serial pupillometer evaluations. CT images were examined to determine the location and laterality of the hemorrhage, along with hematoma volume (using the simplified ABC/2 method), midline shift, hydrocephalus score, and modified Graeb score (indicating interventricular hemorrhage). Demographics were examined with standard measures of central tendency, hypotheses with logistic regression, categorical data with Fisher's Exact X2, and multivariate modeling with constructed MAX-R models. RESULTS Data were gathered from 44 subjects. ICH volume exhibited the strongest correlation with NPi (ipsilateral [r2 = 0.48, p < 0.0001, contralateral [(r2 = 0.39, p < 0.0001]). Horizontal midline shift of the septum pellucidum also correlated with NPi (ipsilateral [r2 = 0.25, p = 0.0006], contralateral [r2 = 0.15, p = 0.0106]), as did shift of the pineal gland (ipsilateral [r2 = 0.21, p = 0.0017], contralateral[r2 = 0.11, p = 0.0328]). ICH volume was the most predictive of abnormal NPi (AUC = 0.85 for ipsilateral and 0.88 for contralateral NPi), and multivariate modeling identified additional independent predictors of NPi. CONCLUSION ICH volume and shift of midline structures correlate with NPi, and abnormalities in NPi can be predicted by hematoma volume and other CT indicators of ICH severity. Future studies should explore the role of NPi in detecting early hematoma expansion and worsening midline shift.
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Affiliation(s)
- Khadijah Mazhar
- UT Southwestern Medical School, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - DaiWai M Olson
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States; Department of Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - Folefac D Atem
- Department of Biostatistics & Data Sciences, University of Texas Health Science Center, 5161 Harry Hines Blvd. CS5.106 Dallas, TX, 75390, United States
| | - Sonja E Stutzman
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - James Moreno
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - Aardhra Venkatachalam
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - Venkatesh Aiyagari
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States; Department of Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States.
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145
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Toyoda K, Palesch YY, Koga M, Foster L, Yamamoto H, Yoshimura S, Ihara M, Fukuda-Doi M, Okazaki S, Tanaka K, Miwa K, Hasegawa Y, Shiokawa Y, Iwama T, Kamiyama K, Hoshino H, Steiner T, Yoon BW, Wang Y, Hsu CY, Qureshi AI. Regional Differences in the Response to Acute Blood Pressure Lowering After Cerebral Hemorrhage. Neurology 2020; 96:e740-e751. [PMID: 33219136 PMCID: PMC7884997 DOI: 10.1212/wnl.0000000000011229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/25/2020] [Indexed: 01/10/2023] Open
Abstract
Objective To compare the impact of intensive blood pressure (BP) lowering right after intracerebral hemorrhage (ICH) on clinical and hematoma outcomes among patients from different geographic locations, we performed a prespecified subanalysis of a randomized, multinational, 2-group, open-label trial to determine the efficacy of rapidly lowering BP in hyperacute ICH (Antihypertensive Treatment of Acute Cerebral Hemorrhage [ATACH]-2), involving 537 patients from East Asia and 463 recruited outside of Asia. Methods Eligible patients were randomly assigned to a systolic BP target of 110 to 139 mm Hg (intensive treatment) or 140 to 179 mm Hg (standard treatment). Predefined outcomes were poor functional outcome (modified Rankin Scale score 4–6 at 90 days), death within 90 days, hematoma expansion at 24 hours, and cardiorenal adverse events within 7 days. Results Poor functional outcomes (32.0% vs 45.9%), death (1.9% vs 13.3%), and cardiorenal adverse events (3.9% vs 11.2%) occurred significantly less frequently in patients from Asia than those outside of Asia. The treatment-by-cohort interaction was not significant for any outcomes. Only patients from Asia showed a lower incidence of hematoma expansion with intensive treatment (adjusted relative risk [RR] 0.56, 95% confidence interval [CI] 0.38–0.83). Both Asian (RR 3.53, 95% CI 1.28–9.64) and non-Asian (RR 1.71, 95% CI 1.00–2.93) cohorts showed a higher incidence of cardiorenal adverse events with intensive treatment. Conclusions Poor functional outcomes and death 90 days after ICH were less common in patients from East Asia than those outside of Asia. Hematoma expansion, a potential predictor for poor clinical outcome, was attenuated by intensive BP lowering only in the Asian cohort. ClinicalTrials.gov Identifier NCT01176565. Classification of Evidence This study provides Class II evidence that, for patients from East Asia with ICH, intensive blood pressure lowering significantly reduces the risk of hematoma expansion.
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Affiliation(s)
- Kazunori Toyoda
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis.
| | - Yuko Y Palesch
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Masatoshi Koga
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Lydia Foster
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Haruko Yamamoto
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Sohei Yoshimura
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Masafumi Ihara
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Mayumi Fukuda-Doi
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Shuhei Okazaki
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Kanta Tanaka
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Kaori Miwa
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Yasuhiro Hasegawa
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Yoshiaki Shiokawa
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Toru Iwama
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Kenji Kamiyama
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Haruhiko Hoshino
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Thorsten Steiner
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Byung-Woo Yoon
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Yongjun Wang
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Chung Y Hsu
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Adnan I Qureshi
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
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146
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Chu H, Gao Z, Huang C, Dong J, Tang Y, Dong Q. Relationship Between Hematoma Expansion Induced by Hypertension and Hyperglycemia and Blood-brain Barrier Disruption in Mice and Its Possible Mechanism: Role of Aquaporin-4 and Connexin43. Neurosci Bull 2020; 36:1369-1380. [PMID: 32623691 PMCID: PMC7674541 DOI: 10.1007/s12264-020-00540-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/24/2020] [Indexed: 12/24/2022] Open
Abstract
We aimed to select an optimized hematoma expansion (HE) model and investigate the possible mechanism of blood-brain barrier (BBB) damage in mice. The results showed that HE occurred in the group with hypertension combined with hyperglycemia (HH-HE) from 3 to 72 h after intracerebral hemorrhage; this was accompanied by neurological deficits and hardly influenced the survival rate. The receiver operating characteristic curve suggested the criterion for this model was hematoma volume expansion ≥ 45.0%. Meanwhile, HH-HE aggravated BBB disruption. A protector of the BBB reduced HH-HE, while a BBB disruptor induced a further HH-HE. Aquaporin-4 (AQP4) knock-out led to larger hematoma volume and more severe BBB disruption. Furthermore, hematoma volume and BBB disruption were reduced by multiple connexin43 (Cx43) inhibitors in the wild-type group but not in the AQP4 knock-out group. In conclusion, the optimized HE model is induced by hypertension and hyperglycemia with the criterion of hematoma volume expanding ≥ 45.0%. HH-HE leads to BBB disruption, which is dependent on AQP4 and Cx43.
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Affiliation(s)
- Heling Chu
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, 200040, China
- Department of Neurology, North Huashan Hospital, Fudan University, Shanghai, 201907, China
| | - Zidan Gao
- Department of Neurology, Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Chuyi Huang
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Jing Dong
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, 200040, China
| | - Yuping Tang
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, 200040, China.
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, 200040, China.
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147
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Meretoja A, Yassi N, Wu TY, Churilov L, Sibolt G, Jeng JS, Kleinig T, Spratt NJ, Thijs V, Wijeratne T, Cho DY, Shah D, Cloud GC, Phan T, Bladin C, Moey A, Aviv RI, Barras CD, Sharma G, Hsu CY, Ma H, Campbell BCV, Mitchell P, Yan B, Parsons MW, Tiainen M, Curtze S, Strbian D, Tang SC, Harvey J, Levi C, Donnan GA, Davis SM. Tranexamic acid in patients with intracerebral haemorrhage (STOP-AUST): a multicentre, randomised, placebo-controlled, phase 2 trial. Lancet Neurol 2020; 19:980-987. [PMID: 33128912 DOI: 10.1016/s1474-4422(20)30369-0] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/08/2020] [Accepted: 09/22/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Despite intracerebral haemorrhage causing 5% of deaths worldwide, few evidence-based therapeutic strategies other than stroke unit care exist. Tranexamic acid decreases haemorrhage in conditions such as acute trauma and menorrhoea. We aimed to assess whether tranexamic acid reduces intracerebral haemorrhage growth in patients with acute intracerebral haemorrhage. METHODS We did a prospective, double-blind, randomised, placebo-controlled, investigator-led, phase 2 trial at 13 stroke centres in Australia, Finland, and Taiwan. Patients were eligible if they were aged 18 years or older, had an acute intracerebral haemorrhage fulfilling clinical criteria (eg, Glasgow Coma Scale score of >7, intracerebral haemorrhage volume <70 mL, no identified or suspected secondary cause of intracerebral haemorrhage, no thrombotic events within the previous 12 months, no planned surgery in the next 24 h, and no use of anticoagulation), had contrast extravasation on CT angiography (the so-called spot sign), and were treatable within 4·5 h of symptom onset and within 1 h of CT angiography. Patients were randomly assigned (1:1) to receive either 1 g of intravenous tranexamic acid over 10 min followed by 1 g over 8 h or matching placebo, started within 4·5 h of symptom onset. Randomisation was done using a centralised web-based procedure with randomly permuted blocks of varying size. All patients, investigators, and staff involved in patient management were masked to treatment. The primary outcome was intracerebral haemorrhage growth (>33% relative or >6 mL absolute) at 24 h. The primary and safety analyses were done in the intention-to-treat population. The trial is registered at ClinicalTrials.gov (NCT01702636). FINDINGS Between March 1, 2013, and Aug 13, 2019, we enrolled and randomly assigned 100 participants to the tranexamic acid group (n=50) or the placebo group (n=50). Median age was 71 years (IQR 57-79) and median intracerebral haemorrhage volume was 14·6 mL (7·9-32·7) at baseline. The primary outcome was not different between the two groups: 26 (52%) patients in the placebo group and 22 (44%) in the tranexamic acid group had intracerebral haemorrhage growth (odds ratio [OR] 0·72 [95% CI 0·32-1·59], p=0·41). There was no evidence of a difference in the proportions of patients who died or had thromboembolic complications between the groups: eight (16%) in the placebo group vs 13 (26%) in the tranexamic acid group died and two (4%) vs one (2%) had thromboembolic complications. None of the deaths was considered related to study medication. INTERPRETATION Our study does not provide evidence that tranexamic acid prevents intracerebral haemorrhage growth, although the treatment was safe with no increase in thromboembolic complications. Larger trials of tranexamic acid, with simpler recruitment methods and an earlier treatment window, are justified. FUNDING National Health and Medical Research Council, Royal Melbourne Hospital Foundation.
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Affiliation(s)
- Atte Meretoja
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Helsinki University Hospital, Helsinki, Finland.
| | - Nawaf Yassi
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Teddy Y Wu
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Leonid Churilov
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Mathematics and Statistics, University of Melbourne, Melbourne, VIC, Australia
| | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Neil J Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Vincent Thijs
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Department of Neurology, Austin Hospital, Heidelberg, VIC, Australia
| | - Tissa Wijeratne
- Department of Neurology, Western Hospital, Melbourne, VIC, Australia
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Darshan Shah
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Monash University, Melbourne, VIC, Australia; Department of Clinical Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Thanh Phan
- Department of Neurology, Monash Medical Centre, Monash University, Melbourne, VIC, Australia; School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Christopher Bladin
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Department of Neurosciences, Eastern Health Medical School, Monash University, Melbourne, VIC, Australia; Ambulance Victoria, Melbourne, VIC, Australia
| | - Andrew Moey
- Department of Neurology, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Richard I Aviv
- Department of Radiology, Neuroradiology Section, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Christen D Barras
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; South Australian Health and Medical Research Institute, The University of Adelaide, Adelaide, SA, Australia
| | - Gagan Sharma
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Chung Y Hsu
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Henry Ma
- Department of Neurology, Monash Medical Centre, Monash University, Melbourne, VIC, Australia; School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Bruce C V Campbell
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Bernard Yan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Mark W Parsons
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Marjaana Tiainen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Sami Curtze
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jackson Harvey
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia; Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
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148
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Gupta R, Krishnam SP, Schaefer PW, Lev MH, Gilberto Gonzalez R. An East Coast Perspective on Artificial Intelligence and Machine Learning: Part 1: Hemorrhagic Stroke Imaging and Triage. Neuroimaging Clin N Am 2020; 30:459-466. [PMID: 33038996 DOI: 10.1016/j.nic.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hemorrhagic stroke is a medical emergency. Artificial intelligence techniques and algorithms may be used to automatically detect and quantitate intracranial hemorrhage in a semiautomated fashion. This article reviews the use of deep learning convolutional neural networks for managing hemorrhagic stroke. Such a capability may be used to alert appropriate care teams, make decisions about patient transport from a primary care center to a comprehensive stroke center, and assist in treatment selection. This article reviews artificial intelligence algorithms for intracranial hemorrhage detection, quantification, and prognostication. Multiple algorithms currently being explored are described and illustrated with the help of examples.
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Affiliation(s)
- Rajiv Gupta
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA.
| | - Sanjith Prahas Krishnam
- Department of Neurology, University of Alabama at Birmingham, SC 350, 1720 2nd Avenue South, Birmingham, AL 35294, USA
| | - Pamela W Schaefer
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA
| | - Michael H Lev
- Department of Radiology, Division of Emergency Radiology, Massachusetts General Hospital, Harvard Medical School, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA; Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA
| | - R Gilberto Gonzalez
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA
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149
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Sprigg N, Flaherty K, Appleton JP, Al-Shahi Salman R, Bereczki D, Beridze M, Ciccone A, Collins R, Dineen RA, Duley L, Egea-Guerrero JJ, England TJ, Karlinski M, Krishnan K, Laska AC, Law ZK, Ovesen C, Ozturk S, Pocock SJ, Roberts I, Robinson TG, Roffe C, Peters N, Scutt P, Thanabalan J, Werring D, Whynes D, Woodhouse L, Bath PM. Tranexamic acid to improve functional status in adults with spontaneous intracerebral haemorrhage: the TICH-2 RCT. Health Technol Assess 2020; 23:1-48. [PMID: 31322116 DOI: 10.3310/hta23350] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Tranexamic acid reduces death due to bleeding after trauma and postpartum haemorrhage. OBJECTIVE The aim of the study was to assess if tranexamic acid is safe, reduces haematoma expansion and improves outcomes in adults with spontaneous intracerebral haemorrhage (ICH). DESIGN The TICH-2 (Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage) study was a pragmatic, Phase III, prospective, double-blind, randomised placebo-controlled trial. SETTING Acute stroke services at 124 hospitals in 12 countries (Denmark, Georgia, Hungary, Ireland, Italy, Malaysia, Poland, Spain, Sweden, Switzerland, Turkey and the UK). PARTICIPANTS Adult patients (aged ≥ 18 years) with ICH within 8 hours of onset. EXCLUSION CRITERIA Exclusion criteria were ICH secondary to anticoagulation, thrombolysis, trauma or a known underlying structural abnormality; patients for whom tranexamic acid was thought to be contraindicated; prestroke dependence (i.e. patients with a modified Rankin Scale [mRS] score > 4); life expectancy < 3 months; and a Glasgow Coma Scale score of < 5. INTERVENTIONS Participants, allocated by randomisation, received 1 g of an intravenous tranexamic acid bolus followed by an 8-hour 1-g infusion or matching placebo (i.e. 0.9% saline). MAIN OUTCOME MEASURE The primary outcome was functional status (death or dependency) at day 90, which was measured by the shift in the mRS score, using ordinal logistic regression, with adjustment for stratification and minimisation criteria. RESULTS A total of 2325 participants (tranexamic acid, n = 1161; placebo, n = 1164) were recruited from 124 hospitals in 12 countries between 2013 and 2017. Treatment groups were well balanced at baseline. The primary outcome was determined for 2307 participants (tranexamic acid, n = 1152; placebo, n = 1155). There was no statistically significant difference between the treatment groups for the primary outcome of functional status at day 90 [adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.76 to 1.03; p = 0.11]. Although there were fewer deaths by day 7 in the tranexamic acid group (aOR 0.73, 95% CI 0.53 to 0.99; p = 0.041), there was no difference in case fatality at 90 days (adjusted hazard ratio 0.92, 95% CI 0.77 to 1.10; p = 0.37). Fewer patients experienced serious adverse events (SAEs) after treatment with tranexamic acid than with placebo by days 2 (p = 0.027), 7 (p = 0.020) and 90 (p = 0.039). There was no increase in thromboembolic events or seizures. LIMITATIONS Despite attempts to enrol patients rapidly, the majority of participants were enrolled and treated > 4.5 hours after stroke onset. Pragmatic inclusion criteria led to a heterogeneous population of participants, some of whom had very large strokes. Although 12 countries enrolled participants, the majority (82.1%) were from the UK. CONCLUSIONS Tranexamic acid did not affect a patient's functional status at 90 days after ICH, despite there being significant modest reductions in early death (by 7 days), haematoma expansion and SAEs, which is consistent with an antifibrinolytic effect. Tranexamic acid was safe, with no increase in thromboembolic events. FUTURE WORK Future work should focus on enrolling and treating patients early after stroke and identify which participants are most likely to benefit from haemostatic therapy. Large randomised trials are needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN93732214. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 35. See the NIHR Journals Library website for further project information. The project was also funded by the Pragmatic Trials, UK, funding call and the Swiss Heart Foundation in Switzerland.
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Affiliation(s)
- Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Maia Beridze
- The First University Clinic of Tbilisi State Medical University, Tbilisi, Georgia
| | - Alfonso Ciccone
- Neurology Unit, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy
| | - Ronan Collins
- Stroke Service, Adelaide and Meath Hospital, Tallaght, Ireland
| | - Robert A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Juan José Egea-Guerrero
- UGC de Medicina Intensiva, Hospital Universitario Virgen del Rocío, IBiS/CSIC/Universidad de Sevilla, Seville, Spain
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences & GEM, University of Nottingham, Derby, UK
| | - Michal Karlinski
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Zhe Kang Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Christian Ovesen
- Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Department of Neurology, Copenhagen, Denmark
| | - Serefnur Ozturk
- Department of Neurology, Selcuk University Medical Faculty, Konya, Turkey
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Christine Roffe
- Stroke Research, Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jegan Thanabalan
- Division of Neurosurgery, Department of Surgery, National University of Malaysia, Kuala Lumpur, Malaysia
| | - David Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, Faculty of Brain Sciences of University College London, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Whynes
- School of Economics, University of Nottingham, Nottingham, UK
| | - Lisa Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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150
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Rationale and Design of a Randomized, Double-Blind Trial Evaluating the Efficacy of Tranexamic Acid on Hematoma Expansion and Peri-hematomal Edema in Patients with Spontaneous Intracerebral Hemorrhage within 4.5 h after Symptom Onset: The THE-ICH Trial Protocol. J Stroke Cerebrovasc Dis 2020; 29:105136. [PMID: 32912508 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/11/2020] [Accepted: 07/06/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Hematoma expansion (HE) and peri-hematomal edema (PHE) are associated with adverse outcomes of patients with acute spontaneous intracerebral hemorrhage (sICH). Due to a lack of proven treatments, it is critical to explore novel treatments for HE and PHE to improve functional recovery after sICH. METHODS This is a prospective, multicenter, placebo-controlled, double-blind, and randomized clinical study of approximately 2400 patients with sICH. Patients within 4.5 h of sICH onset that fulfilling the clinical criteria for diagnosis (e.g. age more than 18 years old, the Glasgow Coma Scal>7, and no planned surgery) will randomly receive either intravenous tranexamic acid (TXA) 1 g 10-min bolus followed by 1 g eight-hour infusion or placebo (sodium chloride 0.9%). Clinical data including the ICH score and the Glasgow Coma Scale score will be collected on admission. After assessment of HE and PHE expansion, follow-up will be conducted with enrolled patients for 90 days. RESULTS Primary outcome metrics are HE (defined as either >33% or >6 ml increase from baseline) and PHE expansion rate at 24 ± 3 h and 72 ± 3 h post-sICH. Secondary outcome metrics include mortality and the modified Rankin Scale on day 90 after sICH. Appropriate statistic methods will be used to evaluate the efficacy of TXA on patients with sICH within 4.5 h of symptom onset. CONCLUSIONS HE usually occurs within the first few hours after onset of symptoms. It is essential to evaluate the efficacy of TXA on HE within a narrow window of time. This will be the first trial to evaluate the efficacy of TXA on HE and PHE expansion in sICH patients within 4.5 h after symptom onset. This trial is registered as ChiCTR1900027065 at http://www.chictr.org.cn.
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