Treatment of intracerebral haemorrhage

Combined neuroprotective effects of celecoxib and memantine in experimental intracerebral hemorrhage

Memantine, a N-methyl-D-aspartate (NMDA) receptor antagonist, inhibits hematoma expansion and celecoxib, a selective cyclooxygenase-2 (COX-2) inhibitor, reduces perihematomal inflammation in intracerebral hemorrhage. We examined whether the combination treatment has additive effects in experimental intracerebral hemorrhage (ICH). ICH was induced using stereotaxic infusion of collagenase into brains of adult rats. After the induction of ICH, rats were treated with intraperitoneal injection of memantine (20 mg/kg), celecoxib (20 mg/kg) or both agents. Only vehicles were administrated in rats of the control group. Results showed that the combination treatment of memantine and celecoxib reduced both hematoma volume and brain edema. Combination treatment also induced the better functional recovery with further attenuation of cerebral inflammation and apoptosis compared to the control group. When compared to the single agent groups, the combination treatment showed better effects in neuroprotection and anti-inflammation. These results suggest the feasible combined application of memantine and celecoxib in ICH treatment.

Traitement des hémorragies cérébrales

The incidence of cerebral hemorrhage in France is 25000 new cases per year. Their prognosis is especially grim: six months afterward, 30-50% of these patients have died and only 20% are able to live independently. Management of acute forms requires, above all, hospitalization in a specialized neurovascular unit of proven quality. Initial treatment includes general measures to avoid possible early aggravation and the prevention and treatment of some complications. Specific treatment by recombinant factor VII can be effective in the first 4 hours after symptoms begin. A phase III study is under way to confirm its efficacy against hematoma growth in the first 24 hours and prognosis at 3 months. According to the recent STICH study, surgery is indicated in the case of hydrocephaly, for large cerebellar hematomas and for cortical supratentorial hematomas located less than 1 cm from the cortical surface. Beyond these situations, surgery must be considered on a case-by-case basis, until other studies more clearly specify indications and techniques. The pathophysiology of cerebral hemorrhage remains poorly understood but numerous research pathways are being explored and should make it possible to identify new treatment targets to combat, in particular, cerebral edema and neuronal lesions.

Pharmacological induction of heat shock protein exerts neuroprotective effects in experimental intracerebral hemorrhage

Heat shock proteins (HSPs) are reported to reduce inflammation and apoptosis in a variety of brain insults. Geranylgeranylacetone (GGA), developed as an antiulcer in Japan, has been known to induce HSP70 and to exert cytoprotective effects. In this study, we investigated whether GGA, as a specific HSP inducer, exerts therapeutic effects in experimentally induced intracerebral hemorrhage (ICH). ICH was induced with male Sprague-Dawley rats via the collagenase infusion. GGA (800 mg/kg) was administered via oral tube according to various schedules of treatment. The treatment with GGA, beginning before the induction of ICH and continuing until day 3, showed the reduction of brain water content and the increased level of HSP70 protein, as compared to the treatment with vehicle, although GGA started after the induction of ICH or administered as a single dose before ICH failed to up-regulate HSP70 and to reduce brain edema. The rats treated with GGA exhibited better functional recovery than those treated with vehicle. In the pre- and post- treatment group, inflammatory cells and cell death in the perihematomal regions were found to have been decreased. The treatment of GGA inhibited the mRNA expression of MMP-9, uPA, IL-6 and MIP-1, with concomitant increment of eNOS and phosphorylated STAT3 and Akt after ICH. We demonstrated that GGA induced a reduction in the brain edema along with marked inhibitory effects on inflammation and cell death after ICH.

[Recommendations of the European Stroke Initiative for the diagnosis and treatment of spontaneous intracerebral haemorrhage]

This article summarises the recommendations for the management of managing patients with intracerebral haemorrhage published in 2006 by the European Stroke Initiative (EUSI) on behalf of the European Stroke Council (ESC), the European Neurological Society (ENS), and the European Federation of Neurological Societies (EFNS).

Trends in Hospitalization Rate, Hospital Case Fatality, and Mortality Rate of Stroke by Subtype in Minneapolis-St. Paul, 1980–2002

BACKGROUND

The stroke mortality rates have been declining in the USA for decades. Less is known about trends in stroke incidence rates, but some studies indicate they have declined. The stroke case fatality has also been declining. Little information exists on trends in stroke subtypes. We examined trends in mortality, hospitalization rate, and hospital case fatality of stroke by subtype in the Minneapolis-St. Paul area from 1980 to 2002.

METHODS

We estimated hospitalization rates and case fatality for > or =30-year-olds with data from the Minnesota Hospital Association. We estimated mortality rates with counts from the Minnesota Department of Health. Rates were age adjusted to the US 2000 standard by the direct method using census estimates. We tested for significant trends using linear regression.

RESULTS

Total stroke mortality and hospital case fatality both declined by almost 50% over the study period, while the rate of stroke hospitalization was relatively stable. Ischemic stroke hospitalization rates increased, while hospital case fatality and mortality rates decreased. Subarachnoid hemorrhage in-hospital case fatality and mortality rates declined, while the hospitalization rate was stable. Intracerebral hemorrhage hospitalization rates increased minimally, hospital case fatality declined, and the mortality rate was stable.

CONCLUSION

These data suggest that declines in total stroke case fatality are contributing most to declining mortality rates in the presence of stable total stroke attack rates.

Primary hemorrhagic stroke in children with sickle cell disease is associated with recent transfusion and use of corticosteroids

OBJECTIVES

Primary hemorrhagic stroke is an uncommon complication of sickle cell disease, with reported mortality rates of 24% to 65%. Most reported cases are in adults; little is known about its occurrence in children. Proposed risk factors include previous ischemic stroke, aneurysms, low steady-state hemoglobin, high steady-state leukocyte count, acute chest syndrome, and hypertransfusion. We performed a retrospective case-control study to evaluate risk and prognostic factors for primary hemorrhagic stroke among children with sickle cell disease.

PATIENTS AND METHODS

Case subjects (sickle cell disease and primary hemorrhagic stroke) and control subjects (sickle cell disease and ischemic stroke) were identified at 2 children's hospitals from January 1979 to December 2004 by reviewing divisional records and the discharge databases.

RESULTS

We identified 15 case subjects (mean age: 10.4 +/- 1.3 years) and 29 control subjects (mean age: 5.2 +/- 0.4 years). An increased risk of hemorrhagic stroke was associated with a history of hypertension and recent (in the last 14 days) transfusion, treatment with corticosteroids, and possibly nonsteroidal antiinflammatory drugs. Average blood pressures at well visits (adjusted for age and gender) were similar between the 2 groups, suggesting that hypertension was intermittent.

CONCLUSIONS

In this group of children with sickle cell disease, hemorrhagic stroke was associated with a history of hypertension or antecedent events including transfusion or treatment with corticosteroids. Improved understanding of risk and prognostic factors, especially those that are modifiable, may help prevent this devastating complication in children with sickle cell disease.

Current Updates in Perioperative Management of Intracerebral Hemorrhage

Spontaneous ICH remains a formidable disease that continues to disable and kill the majority of its victims. Treatment of the disease continues to be controversial and without any proved success, such as improvement in the disease mortality or the resulting disability in survivors. Primary prevention is the most effective medical intervention. Nevertheless, as the population continues to age and patients remain undertreated for hypertension, the incidence of ICH likely will increase, resulting in significant socioeconomic impact on society in the coming years. It is imperative that more research be conducted to improve treatment and outcomes of patients who have ICH. Unlike ischemic stokes or other causes of hemorrhagic stroke, such as SAH, where major advancement of treatment has led to improved outcomes, the increased incidence of ICH has not been matched with any considerable improvement in treatment. This burden to improve therapeutic interventions for patients who have ICH should be shared by all neurosurgeons, stroke neurologists, and critical care physicians who care for these patients on a regular basis. It is hoped that early diagnosis and resuscitation, prevention of hematoma growth, selective surgery or minimally invasive clot evacuation, and judicious critical care and rehabilitation will combine to lessen the burden of this disease.

[Therapy for spontaneous intracerebral haemorrhage]

Spontaneous intracerebral haemorrhage (ICH) is a common and serious disease. It is responsible for 10-17% of all strokes, and mortality exceeds 50%. A variety of underlying causes exist for ICH, advancing age and hypertension being the most important risk factors. Other causes of ICH include vascular malformations, coagulation disorders, and use of anticoagulants and thrombolytic agents. Treatment options comprise conservative as well as surgical management. In addition, a recently published clinical trial evaluating the use of activated recombinant Factor VII allows specific haemostatic therapies to be used in ICH treatment. That and other studies have significantly added to the understanding of the disease. The European Stroke Initiative, which represents the European Stroke Council, European Neurological Society, and European Federation of Neurological Societies, will soon publish recommendations for the management of spontaneous intracerebral haemorrhages. Those recommendations form the basis of this article.

Recommendations for the Management of Intracranial Haemorrhage – Part I: Spontaneous Intracerebral Haemorrhage

This article represents the recommendations for the management of spontaneous intracerebral haemorrhage of the European Stroke Initiative (EUSI). These recommendations are endorsed by the 3 European societies which are represented in the EUSI: the European Stroke Council, the European Neurological Society and the European Federation of Neurological Societies.

Accident vasculaire cérébral hémorragique : nouveautés sur la prise en charge

Haemorrhagic stroke is frequent and associated with a high mortality and morbidity. Less than 30% of patients are still alive five years after onset and few patients regain functional independence. The worsening effect of anticoagulation has been demonstrated and the failure to rapidly normalize coagulation further increases haematoma expansion. In a recent phase II trial, recombinant activated factor VII given within 4 hours of stroke onset, reduced haematoma growth, mortality and disability. An aggressive blood pressure and intracranial pressure control early after the haemorrhage seems beneficial. A large prospective randomized study (the STICH trial) did not demonstrate any beneficial effect of surgery.

Hemostatic therapy for intracerebral hemorrhage

Despite the highest mortality and morbidity of all forms of stroke, few advances have been made in the management of intracerebral hemorrhage (ICH). Besides specialized care in the stroke or neurologic intensive care unit, until very recently no specific therapies have been shown to improve outcome after ICH. Ventilatory support, blood pressure reduction, intracranial pressure monitoring, osmotherapy, fever control, seizure prophylaxis, and nutritional supplementation are the cornerstones of supportive care in the intensive care unit. Recently, a phase II trial of recombinant activated factor VII (NovoSeven; Novo Nordisk, Bagsvaerd, Denmark) reduced hematoma expansion, mortality, and disability when given within 3 hours of ICH onset. A phase III trial to confirm these results is now in progress.