Hydrocephalus: a previously unrecognized predictor of poor outcome from supratentorial intracerebral hemorrhage

A novel combined model of intracerebral and intraventricular hemorrhage using autologous blood-injection in rats

Intracerebral hemorrhage (ICH) is the least treatable form of stroke and is associated with the worst prognosis. In up to 40% of cases, ICH is further complicated by intraventricular hemorrhage (IVH), which predisposes to hydrocephalus, and increases case-mortality to 80%. However, IVH is not present in widely used preclinical models of ICH. Here, we characterize a novel rat model of combined ICH and IVH. Rats were injected with different volumes of autologous whole blood into the right deep basal ganglia region (100μL, 150μL, 200μL, and 250μL, n=10 per group). MRI was performed immediately, and at 24, 48, 72h, and 1week after blood injection, along with neurological evaluations. Injected blood volume reliably correlated with blood volumes measured from MRI obtained after blood injection. Brain edema was most prominent in the ⩾200μL groups, peaking at 48h in all groups, being statistically different between the ⩾200μL and <200μL groups at all-time points. Presence of hydrocephalus was detected in most of the animals, most clearly in the 200μL and 250μL groups, both being statistically different from the 100μL group at all-time points, with tendency to worsen during the whole follow-up period. Most deteriorating neurological and behavioral outcomes as well as the highest mortality rates were detected in groups injected with 200μL and 250μL of autologous blood, 40% and 70%, respectively. These volumes were most similar to the clinical scenario of combined ICH and IVH, demonstrating that this novel rat model is a promising starting point for future ICH+IVH research.

Interaction between sex and apolipoprotein e genetic background in a murine model of intracerebral hemorrhage

Emerging evidence suggests sex and apolipoprotein E (APOE) genotype separately modify outcomes after intracerebral hemorrhage (ICH). We test the hypothesis that an interaction exists between sex and APOE polymorphism in modifying outcomes after ICH and is altered by administration of exogenous apoE-mimetic peptide. To define the effects of sex and APOE polymorphism in ICH, we created collagenase-induced ICH in male and female APOETR mice (targeted replacement mice homozygous for APOE3 or APOE4 alleles; n=12/group) and assessed performance on Rotarod (RR) and Morris water maze (MWM). To evaluate hematoma formation, we used hematoxylin and eosin staining at 24 h after injury (n=8/group). Using separate cohorts (n=12/group), apoE-mimetic peptide (COG1410 at 2 mg/kg) was administered after ICH, and mice were assessed by RR and MWM. Female mice outperformed male mice via RR and MWM by over 190% improvement through 7 days (RR) and 32 days (MWM) of testing after ICH (p<0.01). Female APOE3TR mice demonstrated improved function compared with all other groups (p<0.05) without any difference in hematoma volume at 24 h after injury in any group. Administration of a therapeutic apoE-mimetic peptide improved RR latencies through 7 days after ICH in male and female APOE4TR mice and MWM latencies over days 28-32 after ICH in male APOE4TR mice (p<0.05). Sex and APOE polymorphism influence functional outcomes in our murine model of ICH. Moreover, administration of exogenous apoE-mimetic peptide after injury differentially modifies the interaction between sex and APOE polymorphism.

Mechanisms of hydrocephalus after neonatal and adult intraventricular hemorrhage

Intraventricular hemorrhage (IVH) is a cause of significant morbidity and mortality and is an independent predictor of a worse outcome in intracerebral hemorrhage (ICH) and germinal matrix hemorrhage (GMH). IVH may result in both injuries to the brain as well as hydrocephalus. This paper reviews evidence on the mechanisms and potential treatments for IVH-induced hydrocephalus. One frequently cited theory to explain hydrocephalus after IVH involves obliteration of the arachnoid villi by microthrombi with subsequent inflammation and fibrosis causing CSF outflow obstruction. Although there is some evidence to support this theory, there may be other mechanisms involved, which contribute to the development of hydrocephalus. It is also unclear whether the causes of acute and chronic hydrocephalus after hemorrhage occur via different mechanisms; mechanical obstruction by blood in the former, and inflammation and fibrosis in the latter. Management of IVH and strategies for prevention of brain injury and hydrocephalus are areas requiring further study. A better understanding of the pathogenesis of hydrocephalus after IVH, may lead to improved strategies to prevent and treat post-hemorrhagic hydrocephalus.

Clotting factors to treat thrombolysis-related symptomatic intracranial hemorrhage in acute ischemic stroke

BACKGROUND

Symptomatic intracranial hemorrhage (sICH) occurs uncommonly after ischemic stroke therapy with tissue plasminogen activator (tPA). Clotting factor administration may be a treatment option.

OBJECTIVE

To determine if treatment with clotting factors (fresh frozen plasma [FFP] or cryoprecipitate) was associated with improved outcomes in sICH.

METHODS

We conducted a retrospective cohort study within University of Texas at Houston Stroke registry involving consecutive patients from February 1, 2007, to June 30, 2011, with tPA-related sICH, including cases with subsequent intra-arterial therapy. Outcomes were Modified Rankin Scale (mRS) score at discharge, death, and hematoma expansion.

RESULTS

Of 921 patients treated with tPA, 48 (5.2%) had sICH and 45 met criteria for the study. Nineteen patients received clotting factors (42.2%; 18 received FFP and 7 received cryoprecipitate), whereas 26 (57.8%) patients received conservative management without clotting factors. None of the patients treated with clotting factors and only 2 of those who did not receive clotting factors had a good outcome, mRS score of 2 or less. All the patients treated with clotting factors and most of those not treated were left bedridden or dead (mRS score 4-6), 19 (100%) versus 22 (85%). Mortality was 9 (47.4%) versus 9 (34.6%), respectively. There was no difference in hematoma expansion between the 2 groups.

CONCLUSIONS

We found no evidence that treatment for sICH with clotting factors has a favorable effect on clinical or radiological outcomes. However, the sample was small because of the low frequency of sICH. New treatments are urgently needed for this uncommon yet serious condition.

Clearing bloody cerebrospinal fluid: clot lysis, neuroendoscopy and lumbar drainage

PURPOSE OF REVIEW

Bloody cerebrospinal fluid (CSF) is a major cause of morbidity and mortality in intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Different treatment strategies aiming at faster clearance of bloody CSF have emerged. The present review focuses on recent developments in the investigation of those treatments.

RECENT FINDINGS

Intraventricular fibrinolysis (IVF) for accelerated IVH-resolution has been clinically tested since the early 1990s. The lately summarized evidence from smaller studies indicates that IVF may result in a benefit in mortality and outcome. Recent investigations have elucidated different aspects of IVF, mainly related to safety. Neuroendoscopy has also emerged as a minimally invasive technique allowing fast removal of IVH. The capability of lumbar drainage to reduce vasospasm after SAH has been tested in a large trial.

SUMMARY

IVF is relatively well tolerated and accelerates clot clearance after IVH. The effect of IVF on clinical outcome and mortality is currently being investigated in a large-scale phase III clinical trial. Neuroendoscopy is feasible for the treatment of IVH, however, larger trials are lacking. Lumbar drainage reduces the incidence of vasospasm after SAH. An ongoing phase III trial has been designed to test its influence on outcome. Lumbar drainage may also reduce shunt-dependency after IVH.

A multicenter, randomized, double-blinded, placebo-controlled phase III study of Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III)

BACKGROUND

In adults, intraventricular thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) facilitates resolution of intraventricular haemorrhage (IVH), reduces intracranial pressure, decreases duration of cerebrospinal fluid diversion, and may ameliorate direct neural injury. We hypothesize that patients with small parenchymal haematoma volumes (<30 cc) and relatively large IVH causing acute obstructive hydrocephalus would have improved clinical outcomes when given injections of low-dose rtPA to accelerate lysis and evacuation of IVH compared with placebo.

METHODS

The Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage III trial is an investigator-initiated, phase III, randomized, multicenter, double-blind, placebo-controlled study comparing the use of external ventricular drainage (EVD) combined with intraventricular injection of rtPA to EVD plus intraventricular injection of normal saline (placebo) for the treatment of IVH. Patients with known symptom onset within 24 h of the computed tomography scan confirmed IVH and third or fourth ventricle obstruction, with or without supratentorial intracerebral haemorrhage volume <30 cc, who require EVD are screened with a computed tomography scan at least six hours after EVD placement and, if necessary, at consecutive 12-h intervals until stabilization of any intracranial bleeding has been established. Patients who meet clinical and imaging criteria (no ongoing coagulopathy and no suspicion of aneurysm, arteriovenous malformation, or any other vascular anomaly) will be randomized to either intraventricular rtPA or placebo.

RESULTS

The primary outcome measure is dichotomized modified Rankin Scale 0-3 vs. 4-6 at 180 days. Clinical secondary outcomes include additional modified Rankin Scale dichotomizations at 180 days (0-4 vs. 5-6), ordinal modified Rankin Scale (0-6), mortality and safety events at 30 days, mortality at 180 days, functional status measures, type and intensity of intensive care unit management, rate and extent of ventricular blood clot removal, and quality of life measures.

Safety of intraventricular hemorrhage (IVH) thrombolysis based on CT localization of external ventricular drain (EVD) fenestrations and analysis of EVD tract hemorrhage

BACKGROUND

The purpose of the study is to review the CT findings associated with ventriculostomy placement in regards to the safety of an EVD plus recombinant tissue plasminogen activator (rt-PA) for IVH.

METHODS

A retrospective review was conducted for patients receiving intraventricular rt-PA for IVH from January 2004 to September 2009. Safety was assessed by the presence of EVD tract hemorrhage by CT at baseline after EVD placement, worsening hemorrhage after rt-PA, and CSF infection. IVH volumetrics were assessed by the Le Roux score and outcomes by Glasgow Outcome Scale and modified Rankin Scale.

RESULTS

Twenty-seven patients received rt-PA for IVH. Median dose was 2 mg (range 0.3-8) and a median of two doses (range 1-17) were given. Worsening EVD catheter tract hemorrhage after rt-PA was 46.7 %, with a significantly higher incidence of worsening tract hemorrhage seen with incorrectly placed EVDs (p = 0.04). IVH hematoma burden decreased by a median Le Roux score of 10 (range 3-16) prior to rt-PA to 4 (range 0-16) after rt-PA. There were no central nervous system bacterial infections.

CONCLUSION

Intraventricular rt-PA appears to be relatively safe especially when all EVD fenestrations are within the ventricle and reduces IVH burden similar to other studies. We describe a CT-based EVD tract hemorrhage grading scale to evaluate EVD tract hemorrhage before and after thrombolysis, and a bone-window technique to evaluate EVD fenestrations prior to IVH thrombolysis. Further research is needed evaluating these imaging techniques in regard to intraventricular thrombolytic safety and EVD tract hemorrhage.

Comparison of ventricular drainage in poor grade patients after intracranial hemorrhage

OBJECTIVES

The selection of patients and treatment criteria for acute hydrocephalus and intracranial pressure (ICP) after intracranial hemorrhage remains unclear. In general neurosurgical practice, there is a tendency to use external ventricular drainage (EVD) for the patients. This study was undertaken to analyse the complications and efficiency of the different treatment modalities.

METHODS

The effects, complications and outcome of ventricular drainage on high ICP and hydrocephalus were analysed retrospectively in 109 patients with intracranial hemorrhage. All the patients were assessed using the Glasgow Coma Scale, computed tomography and ICP monitoring. We excluded patients over the GCS of 8. All patients underwent a procedure for ICP monitoring plus ventricular cerebrospinal fluid (CSF) drainage. Sixty-one patients were managed with one (single) EVD system; 12 patients needed two EVD systems consecutively, while 23 patients underwent an EVD procedure followed by permanent ventriculoperitoneal (VP) shunt insertion. Thirteen patients were treated only by VP shunt for ventricular drainage. The infection rate and outcome 9 months after hemorrhage were analysed.

RESULTS

The infection rates were 8.1% in the one-EVD group, 33.3% in the two-EVD group (one EVD versus two EVD, p<0.05), 8.6% in the EVD-VP group and 7.7% in the VP shunt group. The mortality rates were 73.7% in the one-EVD group, 83.8% in the two-EVD group, 47.8% (p<0.05) in the EVD-VP group and 53.8% (p<0.01) in the VP shunt group.

DISCUSSION

This study indicates that single and short-term use of EVD and/or early VP shunting are associated with a low risk of infection. Furthermore, early VP shunting may protect the brain from the irregular control of intracranial hypertension and may allow more time for resolution of CSF circulation and significantly lowers the mortality rates.

[Management of intracerebral hemorrhage: can we still learn something?]

Intracerebral hemorrhage (ICH) is the most devastating form of stroke. It affects approximately 2 million people worldwide every year and is a major cause of mortality and morbidity. Despite the focus of intensive scientific research on ICH for decades there is still no proven treatment strategy for this disease. Advances in knowledge on the underlying pathomechanisms of ICH and the clinical impact have contributed to the development of novel treatment approaches. Currently, surgical treatment, aggressive blood pressure management and intraventricular fibrinolysis in patients with additional severe intraventricular hemorrhage are being investigated in large scale phase III clinical trials.

Extents of white matter lesions and increased intraventricular extension of intracerebral hemorrhage

OBJECTIVES

To determine whether the extent of white matter lesions on a CT scan of acute intracerebral hemorrhage patients is associated with the prevalence and severity of intraventricular extension of hemorrhage.

DESIGN AND SETTING

A post hoc analysis of Acute Brain Bleeding Analysis-IntraCerebral Hemorrhage cohort, a nationwide prospective cohort of acute intracerebral hemorrhage patients (total number of cohort subjects, 1,604).

PATIENTS

Spontaneous intracerebral hemorrhage patients (n = 1,262).

INTERVENTIONS

None.

MEASUREMENTS

The authors analyzed CT scan images taken within 48 hours after stroke onset. Extent of white matter lesions, volume of intracerebral hemorrhage, presence of intraventricular extension of hemorrhage, and intraventricular extension of hemorrhage score (approximation of intraventricular extension of hemorrhage volume) were measured using CT scans, and demographic, laboratory, clinical, and mortality data were also gathered through review of medical records and retrieval from the governmental statistical archive.

MAIN RESULTS

The frequency of intraventricular extension of hemorrhage in our population was 27.2% (343 subjects). The proportion of extensive white matter lesions in intraventricular extension of hemorrhage subjects (33.8%) was higher than that of non-intraventricular extension of hemorrhage cases (16.3%; p < 0.01). Multivariable analysis showed that mild (odds ratio, 1.48; 95% confidence interval 1.05- 0.09; p < 0.01) and extensive (odds ratio, 2.73; 95% confidence interval 1.88-3.98; p < 0.01) white matter lesions were significantly associated with the presence of intraventricular extension of hemorrhage in spontaneous intracerebral hemorrhage patients. The estimated mean of the intraventricular extension of hemorrhage score from the extensive white matter lesions group (9.09 ± 0.76) was significantly higher than that of the no white matter lesions group (6.72 ± 0.78; p < 0.01 from analyses of covariances) after adjustment for relevant covariates.

CONCLUSIONS

We documented that the severity of white matter lesions is related to the occurrence and amount of intraventricular extension of hemorrhage in spontaneous intracerebral hemorrhage cases.

Seizures and intracranial hemorrhage

Seizures and intracranial hemorrhage are possible medical diseases that any obstetrician may encounter. This article reviews the cause, treatment, and medical management in pregnancy for seizures and intracranial hemorrhage, and how the two can overlap into preeclampsia or eclampsia. This article also highlights some challenging management issues from the obstetrician's perspective.

Management of non-traumatic intraventricular hemorrhage

Intraventricular hemorrhage (IVH) is defined as the eruption of blood in the cerebral ventricular system and is mostly secondary to spontaneous intracerebral hemorrhage and aneurysmal and arteriovenous malformation rupture. IVH is a proven risk factor of increased mortality and poor functional outcome. Its seriousness is correlated not only with the amount of blood but also with the involvement of the third and fourth ventricles. There are four mechanisms that explain the pathophysiology of this event: acute obstructive hydrocephalus, the mass effect exerted by the blood clot, the toxicity of blood-breaking products on the adjacent brain parenchyma, and, lastly, the development of a chronic hydrocephalus. It is thus obvious that the clearance of blood from the ventricles should be a therapeutic goal. In cases of acute hydrocephalus, external ventricular drainage is a mandatory step, but proven often insufficient. The concomitant use of intraventricular fibrinolytics such as recombinant tissue plasminogen activator or urokinase seems to be beneficial at least in the context of spontaneous intracerebral hemorrhage, in which their use is now accepted but not yet validated by a randomized trial. Given the potential neurotoxicity of these agents, further research is needed in order to identify the best treatment for intraventricular fibrinolysis (IVF). The endoscopic retrieval of intraventricular blood was also described recently and seems to be as efficient as IVF, but its use is limited to specialized centers. IVH represents a therapeutic challenge for neurosurgeons, neurologists, and intensivists. Thus, a better understanding of this dramatic event will help in better tailoring the treatment strategies.

Occurrence and impact of intracranial pressure elevation during treatment of severe intraventricular hemorrhage

OBJECTIVES

Elevated intracranial pressure is one of the proposed mechanisms leading to poor outcomes in patients with intraventricular hemorrhage. We sought to characterize the occurrence and significance of intracranial hypertension in severe intraventricular hemorrhage requiring extraventricular drainage.

DESIGN

Prospective analysis from two randomized, multicenter, clinical trials.

SETTING

Intensive care units of 23 academic hospitals.

PATIENTS

One hundred patients with obstructive intraventricular hemorrhage and intracerebral hemorrhage volume <30 mL requiring emergency extraventricular drainage from two randomized multicenter studies comparing intraventricular recombinant tissue plasminogen activator (n=78) to placebo (n=22).

INTERVENTIONS

Intracranial pressure was recorded every 4 hrs in all patients and before and after a 1-hr extraventricular drainage closure period after injection. Intracranial pressure readings were analyzed at predefined thresholds and compared between treatment groups, before and after injection of study agent, and before and after opening of third and fourth ventricles on computed tomography. Impact on 30-day outcomes was assessed.

MEASUREMENTS AND MAIN RESULTS

Initial intracranial pressure ranged from -2 to 60 mm Hg (median; interquartile range, 11;10). Of 2576 intracranial pressure readings, 91.5% (2359) were ≤20 mm Hg, 1.6% were >30, 0.5% were >40, and 0.2% were >50 mm Hg. In a multivariate analysis, threshold events>20 mm Hg and >30 mm Hg were more frequent in placebo vs. recombinant tissue plasminogen activator-treated groups (p=.03 and p=.08, respectively). Intracranial pressure elevation>20 mm Hg occurred during a required 1-hr extraventricular drainage closure interval in 207 of 868 (23.8%) injections of study agent, although early reopening of the extraventricular drainage only occurred in 7.9%. After radiographic opening of the lower ventricular system, intracranial pressure events>20 mm Hg remained significantly associated with initial intraventricular hemorrhage volume (p=.002) and extraventricular drainage placement ipsilateral to the largest intraventricular hemorrhage volume (p=.001), but not with thrombolytic treatment (p=.05) or intracerebral hemorrhage volume (p=.14). Ventriculoperitoneal shunts were required in 13.6% of placebo and 6.4% of recombinant tissue plasminogen activator-treated patients (p=.37). Percentage of intracranial pressure readings per patient>30 mm Hg and initial intracerebral hemorrhage and intraventricular hemorrhage volumes were independent predictors of 30-day mortality after adjustment for other outcome predictors (p=.003, p=.03, and p<.001, respectively). Independent predictors of poor modified Rankin Scale score at 30 days were percent of intracranial pressure events>30 mm Hg per patient (p=.01; but not >20 mm Hg), both intracerebral hemorrhage and intraventricular hemorrhage volume, and pulse pressure.

CONCLUSIONS

Intracranial pressure is not frequently elevated during monitoring and drainage with an extraventricular drainage in patients with severe intraventricular hemorrhage, although intracranial pressure >30 mm Hg predicts higher short-term mortality. Thrombolytic therapy may reduce the frequency of high intracranial pressure events. Intracranial pressure elevation appears to be significantly correlated with extraventricular drainage placement in the ventricle with greatest clot volume.

[New treatment strategies for intraventricular hemorrhage]

The presence of additional intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH) is associated with a much higher mortality and worse functional outcome. Although evidence-based specific treatment options for this entity are still lacking, knowledge about the pathophysiology of IVH has grown in recent decades, leading to the development of promising treatment strategies. Intraventricular fibrinolysis (IVF) accelerates IVH resolution and removal from the ventricular system. The additional usage of lumbar drains probably reduces the incidence of permanent posthemorrhagic hydrocephalus. The influence of these treatment modalities on functional outcome is currently being investigated in ongoing studies. The present article gives an overview of pathophysiological and clinical aspects of IVH, emphasizing novel treatment options.

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

Object

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

Methods

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

Results

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

Conclusions

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

Complications of intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is the most devastating type of stroke and is a leading cause of disability and mortality. By contrast with advances in ischaemic stroke treatment, few evidence-based targeted treatments exist for ICH. Management of ICH is largely supportive, with strategies aimed at the limitation of further brain injury and the prevention of associated complications, which add further detrimental effects to an already lethal disease and jeopardise clinical outcomes. Complications of ICH include haematoma expansion, perihaematomal oedema with increased intracranial pressure, intraventricular extension of haemorrhage with hydrocephalus, seizures, venous thrombotic events, hyperglycaemia, increased blood pressure, fever, and infections. In view of the restricted number of therapeutic options for patients with ICH, improved surveillance is needed for the prevention of these complications, or, when this is not possible, early detection and optimum management, which could be effective in the reduction of adverse effects early in the course of stroke and in the improvement of prognosis. Further studies are needed to enhance the evidence-based recommendations for the management of this important clinical problem.

Intraventricular fibrinolysis for intracerebral hemorrhage with severe ventricular involvement

Intraventricular hemorrhage (IVH) has been associated with poor prognosis in patients with spontaneous intracerebral hemorrhage. Several factors contribute to the deleterious effects of IVH, including direct mass effects of the ventricular blood clot on ependymal and subependymal brain structures, mechanical and inflammatory impairment of the Pacchioni granulations by blood and its breakdown products, and disturbance of physiological cerebrospinal fluid (CSF) circulation. Acute obstructive hydrocephalus represents a major life-threatening complication of IVH and is usually treated with an external ventricular drainage (EVD). However, treatment with EVD alone is frequently not sufficiently effective due to obstruction of the catheter by blood. In the past two decades, intraventricular fibrinolysis (IVF) has been increasingly used for maintenance of EVD functionality and acceleration of ventricular clot resolution in such patients. Unfortunately, there is no prospective, randomized controlled trial addressing the effect of IVF on clinical outcome. The available data on IVF consist of small retrospective case series, case reports, and a few prospective case-control studies, which are the subject of the present review article. All these studies, when considered in their entirety, suggest that IVF has a positive impact on mortality and functional outcome, and could be considered as a treatment option for selected patients.

Evaluation of intraventricular hemorrhage assessment methods for predicting outcome following intracerebral hemorrhage

Object

Intraventricular hemorrhage (IVH) associated with intracerebral hemorrhage (ICH) is an independent predictor of poor outcome. Clinical methods for evaluating IVH, however, are not well established. This study sought to determine the best IVH grading scale by evaluating the predictive accuracies of IVH, Graeb, and LeRoux scores in an independent cohort of ICH patients with IVH. Subacute IVH dynamics as well as the impact of external ventricular drain (EVD) placement on IVH and outcome were also investigated.

Methods

A consecutive cohort of 142 primary ICH patients with IVH was admitted to Columbia University Medical Center between February 2009 and February 2011. Baseline demographics, clinical presentation, and hospital course were prospectively recorded. Admission CT scans performed within 24 hours of onset were reviewed for ICH location, hematoma volume, and presence of IVH. Intraventricular hemorrhage was categorized according to IVH, Graeb, and LeRoux scores. For each patient, the last scan performed within 6 days of ictus was similarly evaluated. Outcomes at discharge were assessed using the modified Rankin Scale (mRS). Receiver operating characteristic analysis was used to determine the predictive accuracies of the grading scales for poor outcome (mRS score ≥ 3).

Results

Seventy-three primary ICH patients (51%) had IVH. Median admission IVH, Graeb, and LeRoux scores were 13, 6, and 8, respectively. Median IVH, Graeb and LeRoux scores decreased to 9 (p = 0.005), 4 (p = 0.002), and 4 (p = 0.003), respectively, within 6 days of ictus. Poor outcome was noted in 55 patients (75%). Areas under the receiver operating characteristic curve were similar among the IVH, Graeb, and LeRoux scores (0.745, 0.743, and 0.744, respectively) and within 6 days postictus (0.765, 0.722, 0.723, respectively). Moreover, the IVH, Graeb, and LeRoux scores had similar maximum Youden Indices both at admission (0.515 vs 0.477 vs 0.440, respectively) and within 6 days postictus (0.515 vs 0.339 vs 0.365, respectively). Patients who received EVDs had higher mean IVH volumes (23 ± 26 ml vs 9 ± 11 ml, p = 0.003) and increased incidence of Glasgow Coma Scale scores < 8 (67% vs 38%, p = 0.015) and hydrocephalus (82% vs 50%, p = 0.004) at admission but had similar outcome as those who did not receive an EVD.

Conclusions

The IVH, Graeb, and LeRoux scores predict outcome well with similarly good accuracy in ICH patients with IVH when assessed at admission and within 6 days after hemorrhage. Therefore, any of one of the scores would be equally useful for assessing IVH severity and risk-stratifying ICH patients with regard to outcome. These results suggest that EVD placement may be beneficial for patients with severe IVH, who have particularly poor prognosis at admission, but a randomized clinical trial is needed to conclusively demonstrate its therapeutic value.

[Intensive care management [corrected] of patients with intracerebral hemorrhage]

Approximately 10-15% of acute strokes are caused by non-aneurysmatic intracerebral hemorrhage (ICH) and incidences are expected to increase due to an aging population. Studies from the 1990s estimated mortality of ICH to be as high as 50%. However, these figures may partly be attributed to the fact that patients suffering from ICH frequently received only supportive therapy and the poor prognosis may therefore be more a self-fulfilling prophecy. Recently it has been shown that treatment in a specialized neurological intensive care unit alone was associated with better outcomes after ICH. In recent years considerable efforts have been undertaken in order to develop new therapies for ICH and to assess them in randomized controlled trials. Apart from admission status, hemorrhage volume is considered to be the main prognostic factor and impeding the spread of the hematoma is thus a basic therapeutic principle. The use of activated factor VIIa (aFVIIa) to stop hematoma enlargement has been assessed in two large randomized controlled trials, however the promising results of the dose-finding study could not be confirmed in a phase III trial. Although hemostatic therapy with aFVIIa reduced growth of the hematoma it failed to improve clinical outcome. Similar results were found in a randomized controlled trial on blood pressure management in acute ICH. The link between reduction of hematoma growth and improved outcome is therefore still lacking. Likewise the value of surgical hematoma evacuation remains uncertain. In the largest randomized controlled trial on surgical treatment in ICH so far, only a small subgroup of patients with superficial hemorrhages seemed to benefit from hematoma evacuation. Whether improved intensive care can contribute to improved outcome after ICH will be shown by data obtained in the coming years.

Reported Antiplatelet Use Influences Long-Term Outcome Independently in Deep Intracerebral Hemorrhage

BACKGROUND:

Recent studies have focused on antiplatelet (AP) use in intracerebral hemorrhage (ICH) patients. Several outcome predictors have been debated, but influences on mortality and outcome still remain controversial, especially for different ICH locations.

OBJECTIVE:

To investigate the characteristics and functional outcome of ICH patients with reported regular AP use according to hemorrhage locations.

METHODS:

This retrospective analysis included 210 consecutive spontaneous ICH patients. Clinical data including the preadmission status, initial presentation, neuroradiological data, treatment, and outcome were evaluated. Analyses were calculated for AP use vs non-AP use according to hematoma locations, and multivariate models were calculated for hematoma expansion and unfavorable (modified Rankin Scale = 4–6) long-term functional outcome (at 1 year).

RESULTS:

For all AP users ICH volume was significantly larger, 27.7 mL (interquartile range 7.4-66.1) vs 16.8 mL (interquartile range 4.2-44.7); (P = .032). Analyses showed an increased mortality for AP users at 90 days and 1 year (P = .036; P = .008). Multivariately, for all ICH patients, prior AP use was independently associated with hematoma expansion (odds ratio [OR] 3.61; P = .026) and poorer functional outcome at 1 year (OR 3.82, P = .035). In deep ICH patients, AP use was an independent predictor of an unfavorable functional outcome at 1 year (OR 4.75, P = .048).

CONCLUSION:

Hematoma expansion and more frequent unfavorable long-term functional outcome were independently associated with prior AP use for all patients, and in deep ICH patients AP use was an independent predictor of an unfavorable long-term functional outcome.

Clinical practice guidelines in intracerebral haemorrhage

Intracerebral haemorrhage accounts for 10%-15% of all strokes; however it has a poor prognosis with higher rates of morbidity and mortality. Neurological deterioration is often observed during the first hours after onset and determines poor prognosis. Intracerebral haemorrhage, therefore, is a neurological emergency which must be diagnosed and treated properly as soon as possible. In this guide we review the diagnostic procedures and factors that influence the prognosis of patients with intracerebral haemorrhage and we establish recommendations for the therapeutic strategy, systematic diagnosis, acute treatment and secondary prevention for this condition.

Spontaneous resolution of obstructive hydrocephalus from blood in the cerebral aqueduct

Obstructive hydrocephalus is a neurological emergency that needs to be immediately identified and treated. It very rarely resolves without treatment. We report about an 86-year-old man with right frontal stroke who developed obstructive hydrocephalus caused by blood in the cerebral aqueduct. The patient had sudden and immediate clinical improvement and a repeated head computed tomography (CT) scan showing spontaneous resolution of hydrocephalus. Spontaneous resolution of obstructive hydrocephalus is possible when the cause is minimal blood in the cerebral aqueduct without any blood in the fourth ventricle.

Novel approaches to the treatment of intracerebral haemorrhage

Intracerebral haemorrhage is the most devastating subtype of stroke. It affects approximately two million patients worldwide every year and is a major cause of morbidity and mortality. After decades of research, we still face the fact that there is no evidence-based treatment strategy for this disease. However, research has contributed to a better understanding of the pathophysiology of intracerebral haemorrhage and also to the identification of new treatment targets. Several novel aspects of treatment of spontaneous intracerebral haemorrhage are reviewed in the present article.

The prediction of 30-day mortality and functional outcome in spontaneous intracerebral hemorrhage with secondary ventricular hemorrhage: a score comparison

The original ICH (oICH) score was tested in different populations and showed good accuracy in the prediction of outcome and 30-day mortality after spontaneous ICH. The oICH was developed to stratify patients with all types of spontaneous intracerebral hemorrhage (SICH). Several modifications of the oICH score exist in the literature.In the current study, we tested the oICH score, two modified ICH scores, and the IVH score on a cohort of 171 patients with SICH and mandatory secondary intraventricular hemorrhage (IVH). Receiver-operating characteristic (ROC) curves were plotted, and the areas under the curves (AUC) were calculated for each score.The calculated AUCs for the prediction of 30-day mortality in the cohort were 0.736, 0.816, 0.805, and 0.836 for the original ICH, the mICH-A, the mICH-B, and the new IVH score, respectively. The best AUC for functional outcome was observed for the mICH-B score (0.823). For the mICH-A and the IVH score, an AUC of 0.811 was calculated.The scores that include the quantification of IVH or the grading of hydrocephalus show good accuracy in the prediction of 30-day mortality and functional outcome at 6 months in SICH with secondary IVH.

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

BACKGROUND:

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

OBJECTIVE:

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

METHODS:

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

RESULTS:

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

CONCLUSION:

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

Intensive care management of acute stroke: surgical treatment

Controversy still exists on surgical management of acute stroke. Even if surgical therapy represents often a life-saving measure, the issue of acceptable outcome remains open. Persuasive evidence for outcome benefit is limited. For large ischaemic strokes, recent convincing data suggest that decompressive surgery significantly reduces mortality and improves outcome quality. On the other hand, despite the long tradition in surgical removal of intracranial haematomas, the recent evidence has not been sufficient to resolve the basic argument whether to operate or not. Most recently, hopeful preliminary data have emerged on new approaches in the treatment of intraventricular haemorrhage. In this article, we review the current neurosurgical options in acute ischaemic and haemorrhagic stroke.

Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations.

CONCLUSIONS

Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

Impact of pattern of admission on ICH outcomes

BACKGROUND

Intracerebral hemorrhage (ICH) is associated with the highest mortality of all strokes. Admission to a Neurosciences Critical Care Unit (NCCU) compared to a general ICU has been associated with reduced mortality following ICH. Such association has led to several hospitals transferring ICH patients to Neuro-ICUs in tertiary care centers. However, delays in optimizing ICH management prior to and during transfer can lead to deleterious consequences. To compare functional outcomes in ICH patients admitted to our NCCU directly from the ED versus inter-hospital transfer admissions.

METHODS

Records of consecutive spontaneous supratentorial ICH patients admitted to The Johns Hopkins Hospital NCCU were reviewed. Patients with ICH related to trauma or underlying lesions (brain tumors, aneurysms, AVM) were excluded. We compared outcomes at discharge in patients admitted directly from the ED and inter-hospital transfers (IHT) using dichotomized modified Rankin Scale (Good outcomes: mRS 0-3). Other factors potentially impacting outcomes such as age, ICH volume, IVH volume, and admission GCS were included in the multiple logistic regression analysis.

RESULTS

125 patients were included in the analysis (ED 61.6%; IHT 38.4%). There were no significant differences between the two groups in mean age (ED 63.4 +/- 13.1; IHT 63.4 +/- 15.2, P = 0.96), ICH volume (ED 31.4 +/- 37.6; IHT 33.5 +/- 42.8, P = 0.76), IVH volume (ED 6.0 +/- 11.2; IHT 8.0 +/- 14.5, P = 0.38), and GCS (ED 11.3 +/- 3.7, IHT 10.9 +/- 3.5; P = 0.44). 57.2% ED patients had good outcomes (mRS 0-3) at discharge compared to 37.5% IHT. This difference was statistically significant following univariate (P = 0.034, 95% CI .2151-.9416) and multivariate analysis (P = 0.028, 95% CI .1338-.8896). Odds (adjusted) of ED admissions having good outcomes was three times higher than IHT. Neurological deterioration (GCS decline 2 or more) was more common in IHT and, in subgroup analysis of IHT patients with warfarin-associated ICH, hematoma enlargement was significantly more likely than in direct ED admissions.

CONCLUSIONS

Patients with ICH brought directly to our ED had significantly better outcomes than IHT; we hypothesize this may be caused by delays in optimizing management prior to arrival at the facility with a dedicated Neuro-ICU. Nevertheless, other equally plausible hypotheses need to be prospectively tested.

Management of intraventricular hemorrhage

Brain hemorrhage is the most fatal form of stroke and has the highest morbidity of any stroke subtype. Intraventricular extension of hemorrhage (IVH) is a particularly poor prognostic sign, with expected mortality between 50% and 80%. IVH is a significant and independent contributor to morbidity and mortality, yet therapy directed at ameliorating intraventricular clot has been limited. Conventional therapy centers on managing hypertension and intracranial pressure while correcting coagulopathy and avoiding complications such as rebleeding and hydrocephalus. Surgical therapy alone has not changed the natural history of the disease significantly. However, fibrinolysis in combination with extraventricular drainage shows promise as a technique to reduce intraventricular clot volume and to manage the concomitant complications of IVH.

Intensive care management of acute stroke: general management

For a long time, patients with severe stroke were facing therapeutic nihilism of the attending physicians. Implementation of do-not-resuscitate-orders may have lead to self-fulfilling prophecies and to a pessimistic overestimation of prognosis of severe stroke syndromes. However, there have been great advances in intensive care management of acute stroke patients and it has been shown that treatment on a specialised neurological intensive care unit improves outcome. In this review, we will present a summary of the current state-of-the-art intensive care management of acute stroke patients. After presenting an overview on general management of stroke intensive care patients, special aspects of neurological intensive care of acute large middle cerebral artery stroke, intracerebral haemorrhage and subarachnoid haemorrhage will be discussed. In part II of the review, surgical management options for acute stroke will be discussed in detail.

The challenge of designing a treatment trial for warfarin-associated intracerebral hemorrhage

BACKGROUND AND PURPOSE

Warfarin-associated intracerebral hemorrhage (WICH) became more frequent in the past 2 decades. Interest in potential WICH treatment trials has grown, but the practicality of such trials has received less attention. We determined the number of patients that would be eligible for enrollment in hypothetical treatment trials for WICH using a population-based study.

METHODS

We identified all patients aged 18 years or older from the Greater Cincinnati/Northern Kentucky region with nontraumatic intracerebral hemorrhage in 2005. Three hypothetical WICH treatment trial criteria sets were used to determine eligibility for enrollment, varying from relatively strict to broadly inclusive. For the hypothetical trials, we assumed the comparison of a standard therapy to an alternative therapy. Sample size calculations assumed different rates of poor outcome depending on the criteria set, various effect sizes, a 2-sided alpha of 0.05, and 80% power. Given 5 years of trial enrollment, the population base needed to enroll the required subjects was then calculated.

RESULTS

Warfarin-associated intracerebral hemorrhage accounted for 54 of 286 (19%) cases of intracerebral hemorrhage within the Greater Cincinnati/Northern Kentucky region in 2005. Eligibility rates ranged from 2 of 54 WICH patients (4% of cases, strictest set) to 11 of 54 WICH patients (20% of cases, most inclusive set). Given these rates, a population base of at least 67 million persons would be required to conduct a 5-year trial for WICH with a 10% effect size using a moderately strict criteria set.

CONCLUSIONS

Any planned treatment trial for WICH should anticipate significant challenges in successfully enrolling adequate numbers of patients.

[Treatment of intraventricular hemorrhage and hydrocephalus]

Most cases of intraventricular hemorrhage (IVH) occur secondary to spontaneous intracerebral or subarachnoid hemorrhage. The main concern is development of hydrocephalus, which is related to a poor prognosis. Over the last years, several treatment options for IVH have been introduced, but prospective data regarding the efficacy of those therapies (external ventricular drainage, intraventricular fibrinolysis, lumbar drainage, endoscopic hematoma evacuation) do not yet exist. This review focuses on combined therapy using an external ventricular drain and intraventricular fibrinolysis with r-TPA for IVH-associated initial occlusive hydrocephalus. Moreover, a continuing treatment strategy for persistent malresorptive communicating hydrocephalus using lumbar drainage is described.

Intraventricular hemorrhage: severity factor and treatment target in spontaneous intracerebral hemorrhage

BACKGROUND AND PURPOSE

This review focuses on the emerging principles of intracerebral hemorrhage (ICH) management, emphasizing the natural history and treatment of intraventricular hemorrhage. The translational and clinical findings from recent randomized clinical trials are defined and discussed. Summary of Review- Brain hemorrhage is the most severe of the major stroke subtypes. Extension of the hemorrhage into the ventricles (a 40% occurrence) can happen early or late in the sequence of events. Epidemiological data demonstrate the amount of blood in the ventricles relates directly to the degree of injury and likelihood of survival. Secondary tissue injury processes related to intraventricular bleeding can be reversed by removal of clot in animals. Specific benefits of removal include limitation of inflammation, edema, and cell death, as well as restoration of cerebral spinal fluid flow, intracranial pressure homeostasis, improved consciousness, and shortening of intensive care unit stay. Limited clinical knowledge exists about the benefits of intraventricular hemorrhage (IVH) removal in humans, because organized attempts to remove blood have not been undertaken in large clinical trials on a generalized scale. New tools to evaluate the volume and location of IVH and to test the benefits/risks of removal have been used in the clinical domain. Initial efforts are encouraging that increased survival and functional improvement can be achieved. Little controversy exists regarding the need to scientifically investigate treatment of this severity factor.

CONCLUSIONS

Animal models demonstrate clot removal can improve the acute and long-term consequences of intraventricular extension from intracerebral hemorrhage by using minimally invasive techniques coupled to recombinant tissue plasminogen activator-mediated clot lysis. The most recent human clinical trials show that severity of initial injury and the long-term consequences of blood extending into the ventricles are clearly related to the amount of bleeding into the ventricular system. The failure of the last 2 pivotal brain hemorrhage randomized control trials may well relate to the consequences of intraventricular bleeding. Small proof of concept studies, meta-analyses, and preliminary pharmacokinetics studies support the idea of positive shifts in mortality and morbidity, if this 1 critical disease severity factor, IVH, is properly addressed. Understanding clinical methods for the removal of IVH is required if survival and long-term functional outcome of brain hemorrhage is to improve worldwide.

Frequency of sustained intracranial pressure elevation during treatment of severe intraventricular hemorrhage

BACKGROUND

Elevated intracranial pressure (ICP) is an important marker of neurological deterioration. The occurrence and significance of elevated ICP and low cerebral perfusion pressure (CPP) in aggressively treated spontaneous intraventricular hemorrhage (IVH) are not defined.

METHODS

We performed a secondary longitudinal exploratory data analysis of a randomized multicenter trial of urokinase (UK) versus placebo (Pcb) as a treatment for IVH. Eleven IVH patients who required an external ventricular drain (EVD) were randomized to receive either intraventricular UK or Pcb every 12 h until clinical response permitted EVD removal. ICP and CPP were recorded every 4 or 6 h, as well as before and 1 h after EVD closure for administration of study agent. ICP, CPP and the proportion of ICP readings above 20, 30, 40 and 50 mm Hg were analyzed.

RESULTS

Six UK and 5 Pcb patients aged 39-74 years (mean +/- standard deviation; 53 +/- 11 years) were enrolled. Initial ICP ranged from 0 to 38 mm Hg (10.9 +/- 11.0), initial CPP from 65 to 133 mm Hg (100.5 +/- 17.7). We recorded 472 ICP readings over the entire monitoring period. Of these 65 (14%) were >20 mm Hg, 23 (5%) >30 mm Hg, 9 (2%) >40 mm Hg and 3 (<1%) >50 mm Hg. Only 2 of 141 intraventricular injections of study agent with EVD closure were not tolerated and required reopening of the EVD.

CONCLUSIONS

In the intensive care unit, initial ICP measured with an EVD was uncommonly elevated (1/11 patients) in this group of severe IVH patients despite acute obstructive hydrocephalus. Frequent monitoring reveals ICP elevation >20 mm Hg in 14% of observations during use of EVD. ICP elevation, though it can occur, is not routinely associated with EVD closure for thrombolytic treatment with UK.

Recent trends in the treatment of spontaneous intracerebral hemorrhage: analysis of a nationwide inpatient database

Object

Recently updated guidelines failed to reflect significant progress in the treatment of intracerebral hemorrhage (ICH). Using data from a nationwide hospital database, the authors identified recent trends in therapy and outcomes for ICH, as well as the effect of associated comorbidities and procedures, including surgery.

Methods

Data from the Nationwide Inpatient Sample hospital discharge database (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality) for the period 1993–2005 was retrospectively reviewed. Multiple variables were categorized and subjected to statistical analysis for codes related to ICH from the International Classification of Diseases, 9th revision, Clinical Modification. Data linked by the Nationwide Inpatient Sample database to associated diagnoses and procedures were also retrieved and analyzed.

Results

The number of discharges remained constant for ICH. The mortality rate remained unchanged at an average of 31.6%, whereas routine discharges (home) steadily declined by 25%, and discharges other than home doubled (p < 0.01). By the end of the study, length of hospital stay decreased by 30% (p < 0.01), and mean hospital charges steadily increased to more than twice the original figures. Arterial hypertension was the most frequently associated comorbidity. Seizures were associated with longer hospital stays and higher mean hospital charges. Craniotomy was associated with decreased mortality rates but also with worse outcomes and lower rates of patients discharged home (p < 0.01). No geographic differences in treatment and outcomes were noted.

Conclusions

From 1993 to 2005, no significant progress in treatment and prevention of ICH was noted. There were no regional differences in the treatment and outcome of ICH. The role of surgery for ICH remains uncertain, and large-scale controlled studies are greatly needed to clarify this role.

Stroke and neurodegenerative disorders: 2. Poststroke medical complications

OBJECTIVE

This self-directed learning module highlights common poststroke medical complaints encountered on an inpatient rehabilitation unit. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette format, this article specifically focuses on the differential diagnosis, evaluation and management of chest pain, mental status changes, weight loss and poor motivation in stroke patients. The goal of this article is to expand the learner's knowledge of how to diagnose and manage common medical complications of stroke patients in rehabilitation.