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Abstract
IMPORTANCE Although spontaneous intraparenchymal hemorrhage (IPH) accounts for less than 20% of cases of stroke, it continues to be associated with the highest mortality of all forms of stroke and substantial morbidity rates. OBSERVATIONS Early identification and management of IPH is crucial. Blood pressure control, reversal of associated coagulopathy, care in a dedicated stroke unit, and identification of secondary etiologies are essential to optimizing outcomes. Surgical management of hydrocephalus and space occupying hemorrhage in the posterior fossa are accepted forms of treatment. Modern advances in minimally invasive surgical management of primary, supratentorial IPH are being explored in randomized trials. Hemorrhagic arteriovenous malformations and cavernous malformations are surgically excised if accessible, while hemorrhagic dural arteriovenous fistulas and distal/mycotic aneurysms are often managed with embolization if feasible. CONCLUSIONS AND RELEVANCE IPH remains a considerable source of neurological morbidity and mortality. Rapid identification, medical management, and neurosurgical management, when indicated, are essential to facilitate recovery. There is ongoing evaluation of minimally invasive approaches for evacuation of primary IPH and evolution of surgical and endovascular techniques in the management of lesions leading to secondary IPH.
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Affiliation(s)
- Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian T Jankowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert M Friedlander
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Sun S, Li Y, Zhang H, Wang X, She L, Yan Z, Lu G. The Effect of Mannitol in the Early Stage of Supratentorial Hypertensive Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 124:386-396. [PMID: 30576817 DOI: 10.1016/j.wneu.2018.11.249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/28/2018] [Accepted: 11/30/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mannitol has been widely applied as a priority drug in the clinical treatment for brain edema and increased intracranial pressure after intracerebral hemorrhage. However, no consensus on the efficacy and safety of mannitol has been achieved. Our meta-analysis was conducted to assess the effect of mannitol in the early stage of supratentorial hypertensive intracerebral hemorrhage (HICH) and provided a treatment reference for clinicians. METHODS All relevant studies on mannitol treatment of supratentorial HICH were identified from the databases including PubMed, EMBASE, Cochrane Library, VIP, CNKI, and Wan Fang. Our outcome measures included the incidence of hematoma enlargement, the neurologic function improvement rate, mortality, and the incidence of aggravated brain edema. The subgroup analysis was performed to explore the impact of study type, year of publication, intervention time, and dose on the outcome measures. Publication bias was assessed by the funnel plot. RESULTS Thirty-four studies consisting of 3627 patients with supratentorial HICH were included in this study (from 2000 to 2018). Significant statistical difference was found between the mannitol and nonmannitol group in terms of all the outcome measures, including the incidence of hematoma enlargement (P < 0.00001), the neurologic function improvement rate (P < 0.00001), mortality (P < 0.00001), and the incidence of aggravated cerebral edema (P = 0.0002). In subgroup analysis, the results showed that study type and intervention time did not significantly affect the outcome measures. No significant statistical difference was found in the subgroups of publication time (after 2010) (P = 0.08) and half-dose of mannitol (P = 0.20) on mortality. In addition, the further analysis showed that whatever the dose (250 mL or 125 mL) and intervention time (<24, <12, or <6 hours), mannitol could lead to hematoma enlargement. CONCLUSIONS For patients without obvious symptoms of intracranial hypertension or cerebral palsy, it is not recommended to use mannitol routinely in the early stage of supratentorial HICH. More high-quality trials should be included to confirm our conclusion and to ascertain the best time and dose of mannitol to use.
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Affiliation(s)
- Shuwen Sun
- Department of Neurosurgery, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yuping Li
- Department of Neurosurgery, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Hengzhu Zhang
- Department of Neurosurgery, The Clinical Medical College of Yangzhou University, Yangzhou, China.
| | - Xiaodong Wang
- Department of Neurosurgery, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Lei She
- Department of Neurosurgery, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Zhengcun Yan
- Department of Neurosurgery, The Clinical Medical College of Yangzhou University, Yangzhou, China
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203
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Zhu H, Wang Z, Yu J, Yang X, He F, Liu Z, Che F, Chen X, Ren H, Hong M, Wang J. Role and mechanisms of cytokines in the secondary brain injury after intracerebral hemorrhage. Prog Neurobiol 2019; 178:101610. [PMID: 30923023 DOI: 10.1016/j.pneurobio.2019.03.003] [Citation(s) in RCA: 218] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 03/07/2019] [Accepted: 03/16/2019] [Indexed: 12/18/2022]
Abstract
Intracerebral hemorrhage (ICH) is a common and severe cerebrovascular disease that has high mortality. Few survivors achieve self-care. Currently, patients receive only symptomatic treatment for ICH and benefit poorly from this regimen. Inflammatory cytokines are important participants in secondary injury after ICH. Increases in proinflammatory cytokines may aggravate the tissue injury, whereas increases in anti-inflammatory cytokines might be protective in the ICH brain. Inflammatory cytokines have been studied as therapeutic targets in a variety of acute and chronic brain diseases; however, studies on ICH are limited. This review summarizes the roles and functions of various pro- and anti-inflammatory cytokines in secondary brain injury after ICH and discusses pathogenic mechanisms and emerging therapeutic strategies and directions for treatment of ICH.
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Affiliation(s)
- Huimin Zhu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong 276003, China
| | - Zhiqiang Wang
- Central laboratory, Linyi People's Hospital, Linyi, Shandong 276003, China
| | - Jixu Yu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong 276003, China; Central laboratory, Linyi People's Hospital, Linyi, Shandong 276003, China; Genetics and Aging Research Unit, Department of Neurology, Massachusetts General Hospital, Boston, MA 02129, USA
| | - Xiuli Yang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Feng He
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong 276003, China
| | - Zhenchuan Liu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong 276003, China.
| | - Fengyuan Che
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong 276003, China; Central laboratory, Linyi People's Hospital, Linyi, Shandong 276003, China.
| | - Xuemei Chen
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou 450000, Henan, China
| | - Honglei Ren
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Michael Hong
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jian Wang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Abstract
Intracerebral hemorrhage (ICH) is responsible for approximately 15% of strokes annually in the United States, with nearly 1 in 3 of these patients dying without ever leaving the hospital. Because this disproportionate mortality risk has been stagnant for nearly 3 decades, a main area of research has been focused on the optimal strategies to reduce mortality and improve functional outcomes. The acute hypertensive response following ICH has been shown to facilitate ICH expansion and is a strong predictor of mortality. Rapidly reducing blood pressure was once thought to induce cerebral ischemia, though has been found to be safe in certain patient populations. Clinicians must work quickly to determine whether specific patient populations may benefit from acute lowering of systolic blood pressure (SBP) following ICH. This review provides nurses with a summary of the available literature on blood pressure control following ICH. It focuses on intravenous and oral antihypertensive medications available in the United States that may be utilized to acutely lower SBP, as well as medications outside of the antihypertensive class used during the acute setting that may reduce SBP.
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205
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Zhang X, Zhou S, Zhang Q, Fu X, Wu Y, Liu J, Liang B, Yang Z, Wang X. Stereotactic aspiration for hypertensive intracerebral haemorrhage in a Chinese population: a retrospective cohort study. Stroke Vasc Neurol 2019; 4:14-21. [PMID: 31105974 PMCID: PMC6475080 DOI: 10.1136/svn-2018-000200] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/09/2019] [Accepted: 02/13/2019] [Indexed: 12/31/2022] Open
Abstract
Objective We aimed to compare the therapeutic effects of stereotactic aspiration and best medical management in patients who developed supratentorial hypertensive intracerebral haemorrhage (HICH) with a volume of haemorrhage between 20 and 40 mL. Methods The clinical data of 220 patients with supratentorial HICH with a volume between 20 and 40 mL were retrospectively analysed. Among them, 142 received stereotactic aspiration surgery (stereotactic aspiration group) and 78 received best medical management (conservative group). All were followed up for 6 months. Multivariate logistic regression and Kaplan-Meier survival curves were used to compare the outcome between the two groups. Results The rebleeding rate was lower in the group that had stereotactic aspiration when compared with the group with medical treatment (6 [4.2%] vs 9 [11.5%], χ2=4.364, p=0.037). After 6 months, although the mortality rate did not differ significantly between the two groups (8 cases [5.6%] vs 10 cases [12.8%], χ2=3.461, p=0.063), the rate of a favourable outcome was higher in the group who received stereotactic aspiration (χ2=15.870, p=0.000). Logistic regression identified that medical treatment (OR=1.64, p=0.000) was an independent risk factor for an unfavourable outcome. The Kaplan-Meier curves indicated that the median favourable outcome time in the stereotactic aspiration group was 59.5 days compared with that in the medically treated group (87.0 days). The log-rank test indicated that the prognosis at 6 months was better for those treated with stereotactic haematoma aspiration (χ2=29.866, p=0.000). However, the 6-month survival rate was similar between the two groups (χ2=3.253, p=0.068). Conclusions Stereotactic haematoma aspiration significantly improved the quality of life, although did not effectively reduce the rate of mortality. When selected appropriately, patients with HICH may benefit from this type of surgical intervention.
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Affiliation(s)
- Xuyang Zhang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shaolong Zhou
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiang Zhang
- Department of Radiation Oncology and Comprehensive Cancer Center, The University of Michigan, Ann Arbor, Michigan, USA
| | - Xudong Fu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuehui Wu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiasheng Liu
- Department of Neurosurgery, Neihuang People’s Hospital, Neihuang, China
| | - Bo Liang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhuo Yang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinjun Wang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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206
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Determination of serum neutrophil gelatinase-associated lipocalin as a prognostic biomarker of acute spontaneous intracerebral hemorrhage. Clin Chim Acta 2019; 492:72-77. [PMID: 30771300 DOI: 10.1016/j.cca.2019.02.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/02/2019] [Accepted: 02/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neutrophil gelatinase-associated lipocalin (NGAL) is currently known as an acute phase protein and implicated in acute brain injury. Herein, we sought to gauge serum NGAL level in patients after acute (<24 h) spontaneous intracerebral hemorrhage (ICH) and to investigate its relation to neurological outcome. METHODS Serum NGAL levels were measured in 106 patients and 106 controls. National Institutes of Health Stroke Scale (NIHSS) score, Glasgow coma scale (GCS) score, ICH score and hematoma volume were recorded for assessing hemorrhagic severity. An unfavorable outcome was defined as modified Rankin Scale >2 at 90 days. RESULTS As opposed to the controls, the patients had significantly raised serum NGAL levels. Correlations were observed between NGAL levels and serum C-reactive protein levels, blood glucose levels, GCS score, NIHSS score, ICH score and ICH volume. Multivariate analysis identified serum NGAL as a predictor for unfavorable outcome at 90 days. It also showed high prognostic ability under receiver operating characteristic curve. CONCLUSIONS Enhanced NGAL level is revealed after acute spontaneous ICH, in association with inflammatory degree and hemorrhagic severity, and intimately correlated with a worse prognosis.
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207
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Tan Q, Li Y, Guo P, Zhou J, Jiang Z, Liu X, Chen Z, Feng H. Tolvaptan attenuated brain edema in experimental intracerebral hemorrhage. Brain Res 2019; 1715:41-46. [PMID: 30703371 DOI: 10.1016/j.brainres.2019.01.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/05/2019] [Accepted: 01/26/2019] [Indexed: 12/25/2022]
Abstract
Arginine-vasopressin (AVP) is believed to be positively correlated with the brain edema formation, but the underlying mechanism is still unclear. In this study, we explored the role of the V2 receptors antagonist tolvaptan on brain edema following intracerebral hemorrhage (ICH) with a rat model. Animals were randomly given tolvaptan or vehicle through oral gavage at 12 h, 36 h, and 60 h after ICH surgery. Brain swelling (%), brain water content(BWC), neurological scores, Evans blue fluorescence and blood-brain barrier (BBB) tight junction proteins were measured to evaluate the effect of tolvaptan in ICH. We found that tolvaptan alleviated the brain swelling (%), decreased the BWC growth, and attenuated the neurological deficits after ICH (p < 0.05, vs vehicle). What's more, tolvaptan increased the expression of ZO-1 and occludin (p < 0.05, vs vehicle), which might be attributed to the down-regulated effects of tolvaptan on MMP-9. These results provided evidence supporting the use of tolvaptan for ICH-induced brain edema. Large animal experiments are required to further explore the efficacy and mechanism of tolvaptan in ICH treatment.
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Affiliation(s)
- Qiang Tan
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing 400038, China
| | - Yuhan Li
- State Key Laboratory Of Silkworm Genome Biology, Southwest University, No. 2 Rd Tiansheng, Beibei District of Chongqing, 400715, China
| | - Peiwen Guo
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing 400038, China
| | - Jiru Zhou
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing 400038, China
| | - Zhouyang Jiang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing 400038, China
| | - Xin Liu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing 400038, China
| | - Zhi Chen
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing 400038, China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing 400038, China.
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208
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Gerner ST, Kuramatsu JB, Sembill JA, Sprügel MI, Endres M, Haeusler KG, Vajkoczy P, Ringleb PA, Purrucker J, Rizos T, Erbguth F, Schellinger PD, Fink GR, Stetefeld H, Schneider H, Neugebauer H, Röther J, Claßen J, Michalski D, Dörfler A, Schwab S, Huttner HB. Association of prothrombin complex concentrate administration and hematoma enlargement in non-vitamin K antagonist oral anticoagulant-related intracerebral hemorrhage. Ann Neurol 2019; 83:186-196. [PMID: 29314216 DOI: 10.1002/ana.25134] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 12/29/2017] [Accepted: 12/29/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate parameters associated with hematoma enlargement in non-vitamin K antagonist oral anticoagulant (NOAC)-related intracerebral hemorrhage (ICH). METHODS This retrospective cohort study includes individual patient data for 190 patients with NOAC-associated ICH over a 5-year period (2011-2015) at 19 departments of neurology across Germany. Primary outcome was the association of prothrombin complex concentrate (PCC) administration with hematoma enlargement. Subanalyses were calculated for blood pressure management and its association with the primary outcome. Secondary outcomes include associations with in-hospital mortality and functional outcome at 3 months assessed using the modified Rankin Scale. RESULTS The study population for analysis of primary and secondary outcomes consisted of 146 NOAC-ICH patients with available follow-up imaging. Hematoma enlargement occurred in 49/146 (33.6%) patients with NOAC-related ICH. Parameters associated with hematoma enlargement were blood pressure ≥ 160mmHg within 4 hours and-in the case of factor Xa inhibitor ICH-anti-Xa levels on admission. PCC administration prior to follow-up imaging was not significantly associated with a reduced rate of hematoma enlargement either in overall NOAC-related ICH or in patients with factor Xa inhibitor intake (NOAC: risk ratio [RR] = 1.150, 95% confidence interval [CI] = 0.632-2.090; factor Xa inhibitor: RR = 1.057, 95% CI = 0.565-1.977), regardless of PCC dosage given or time interval until imaging or treatment. Systolic blood pressure levels < 160mmHg within 4 hours after admission were significantly associated with a reduction in the proportion of patients with hematoma enlargement (RR = 0.598, 95% CI = 0.365-0.978). PCC administration had no effect on mortality and functional outcome either at discharge or at 3 months. INTERPRETATION In contrast to blood pressure control, PCC administration was not associated with a reduced rate of hematoma enlargement in NOAC-related ICH. Our findings support the need of further investigations exploring new hemostatic reversal strategies for patients with factor Xa inhibitor-related ICH. Ann Neurol 2018;83:186-196.
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Affiliation(s)
- Stefan T Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen
| | - Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen
| | - Jochen A Sembill
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen
| | | | - Matthias Endres
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin.,Center for Stroke Research Berlin, Berlin.,German Center for Cardiovascular Research, Berlin.,German Center for Neurodegenerative Diseases, Berlin
| | - Karl Georg Haeusler
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin.,Center for Stroke Research Berlin, Berlin
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg
| | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Nuremberg
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, Minden
| | - Gereon R Fink
- Department of Neurology, University of Cologne, Cologne
| | | | | | | | - Joachim Röther
- Department of Neurology, Asklepios Clinic Altona, Hamburg
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Leipzig
| | | | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen
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Toyoda K, Koga M, Yamamoto H, Foster L, Palesch YY, Wang Y, Sakai N, Hara T, Hsu CY, Itabashi R, Sato S, Fukuda-Doi M, Steiner T, Yoon BW, Hanley DF, Qureshi AI. Clinical Outcomes Depending on Acute Blood Pressure After Cerebral Hemorrhage. Ann Neurol 2019; 85:105-113. [PMID: 30421455 DOI: 10.1002/ana.25379] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 11/03/2018] [Accepted: 11/06/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the association between clinical outcomes and acute systolic blood pressure (SBP) levels achieved after intracerebral hemorrhage (ICH). METHODS Eligible patients who were randomized to the ATACH-2 (Antihypertensive Treatment in Intracerebral Hemorrhage 2) trial (ClinicalTrials.gov: NCT01176565) were divided into 5 groups by 10-mmHg strata of average hourly minimum SBP (<120, 120-130, 130-140, 140-150, and ≥ 150 mmHg) during 2 to 24 hours after randomization. Outcomes included: 90-day modified Rankin Scale (mRS) 4 to 6; hematoma expansion, defined as an increase ≥6 ml from baseline to 24-hour computed tomography; and cardiorenal adverse events within 7 days. RESULTS Of the 1,000 subjects in ATACH-2, 995 with available SBP data were included in the analyses. The proportion of mRS 4 to 6 was 37.5, 36.0, 42.8, 38.6, and 38.0%, respectively. For the "140 to 150" group relative to the "120 to 130," the odds ratio (OR), adjusting for sex, race, age, onset-to-randomization time, baseline National Institutes of Health Stroke Scale score, hematoma volume, and hematoma location, was 1.62 (95% confidence interval [CI], 1.02-2.58). Hematoma expansion was identified in 16.9, 13.7, 21.4, 18.5, and 26.4%, respectively. The 140 to 150 (OR, 1.80; 95% CI, 1.05-3.09) and "≥150" (1.98; 1.12-3.51) showed a higher frequency of expansion than the 120 to 130 group. Cardiorenal events occurred in 13.6, 16.6, 11.5, 8.1, and 8.2%, respectively. The 140 to 150 (0.43; 0.19-0.88) and ≥ 150 (0.44; 0.18-0.96) showed a lower frequency of the events than the 120 to 130. INTERPRETATION Beneficial effects of lowering and maintaining SBP at 120 to 130 mmHg during the first 24 hours on clinical outcomes by suppressing hematoma expansion was somewhat offset by cardiorenal complications. ANN NEUROL 2019;85:105-113.
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Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruko Yamamoto
- Department of Advanced Medical Technology Development, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Lydia Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Yuko Y Palesch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | | | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | | | - Ryo Itabashi
- Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Shoichiro Sato
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN
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210
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Chang JJ, Armonda R, Goyal N, Arthur AS. Magnesium: Pathophysiological mechanisms and potential therapeutic roles in intracerebral hemorrhage. Neural Regen Res 2019; 14:1116-1121. [PMID: 30804233 PMCID: PMC6425828 DOI: 10.4103/1673-5374.251189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Intracerebral hemorrhage (ICH) remains the second-most common form of stroke with high morbidity and mortality. ICH can be divided into two pathophysiological stages: an acute primary phase, including hematoma volume expansion, and a subacute secondary phase consisting of blood-brain barrier disruption and perihematomal edema expansion. To date, all major trials for ICH have targeted the primary phase with therapies designed to reduce hematoma expansion through blood pressure control, surgical evacuation, and hemostasis. However, none of these trials has resulted in improved clinical outcomes. Magnesium is a ubiquitous element that also plays roles in vasodilation, hemostasis, and blood-brain barrier preservation. Animal models have highlighted potential therapeutic roles for magnesium in neurological diseases specifically targeting these pathophysiological mechanisms. Retrospective studies have also demonstrated inverse associations between admission magnesium levels and hematoma volume, hematoma expansion, and clinical outcome in patients with ICH. These associations, coupled with the multifactorial role of magnesium that targets both primary and secondary phases of ICH, suggest that magnesium may be a viable target of study in future ICH studies.
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Affiliation(s)
- Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center; Department of Neurology, Georgetown University School of Medicine, Washington, DC, USA
| | - Rocco Armonda
- Department of Neurosurgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center; Semmes Murphey Clinic, Memphis, TN, USA
| | - Adam S Arthur
- Semmes Murphey Clinic; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
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211
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Chen X, Jin Y, Chen J, Chen X, Cao X, Yu L, Xu Y. Relationship between White Matter Hyperintensities and Hematoma Volume in Patients with Intracerebral Hematoma. Aging Dis 2018; 9:999-1009. [PMID: 30574413 PMCID: PMC6284763 DOI: 10.14336/ad.2018.0108] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/08/2018] [Indexed: 12/13/2022] Open
Abstract
The relationship of white-matter hyperintensity (WMH) to intracerebral hemorrhage (ICH) remains unclear. In this retrospective study, we investigated whether the severity and progression of WMH could be related to the hematoma volume and absorption in ICH. 2338 WMH patients with ICH aged≥40 years receiving brain computed tomography (CT) imaging within 12 hours of ICH symptom onset were screened, and 227 patients were included in the final study. The severity and progression of WMH were assessed using the software programs MRICRON and ITK-SNAP on brain magnetic resonance imaging (MRI) and the hematoma volumes and absorption with ITK-SNAP software on CT. We assessed the association of WMH severity with ICH volume in 227 patients at baseline. Totally 183 of 227 patients underwent repeated CT within 14 days of ICH onset. The relationship of WMH severity to ICH absorption was analyzed in 183 patients. Additionally, among all 227 patients, 37 subjected to another MRI before ICH onset were divided into two groups according to WMH progression: non-progression and progression groups. The link between WMH progression and hematoma volume was examined. The ICH volume was significantly larger in patients with the highest WMH scores than in those with the lowest WMH scores. Larger WMH volume was independently associated with larger ICH volume (odds ratio 1.00; 95% CI, 1.00 to 1.00; P = 0.049). There was a trend towards WMH progression being related to ICH volume (P =0.049). Contrastingly, the WMH volume was not linked with hematoma absorption (P = 0.79). In conclusion, we found that greater severity and progression of WMH were associated with larger ICH volume. Our findings suggest that WMH might provide important prognostic information about patients with ICH and may have implications for treatment stratification.
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Affiliation(s)
- Xuemei Chen
- 1Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China.,3Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,4Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
| | - Yuexinzi Jin
- 1Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Jian Chen
- 1Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Xin Chen
- 1Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Xiang Cao
- 2Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China.,3Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,4Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
| | - Linjie Yu
- 2Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China
| | - Yun Xu
- 1Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China.,2Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China.,3Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,4Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
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Thomas R, Sudlow M. Update on the management of acute stroke. Br J Hosp Med (Lond) 2018; 79:C178-C182. [PMID: 30526104 DOI: 10.12968/hmed.2018.79.12.c178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Revin Thomas
- Specialty Trainee in Stroke Medicine, Department of Geriatric Medicine, North Tyneside General Hospital, Tyne and Wear NE29 8NH
| | - Mark Sudlow
- Consultant Stroke Physician, Department of Geriatric Medicine, North Tyneside General Hospital, Tyne and Wear, and Honorary Senior Lecturer, Newcastle University, Newcastle Upon Tyne
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Buonacera A, Stancanelli B, Malatino L. Stroke and Hypertension: An Appraisal from Pathophysiology to Clinical Practice. Curr Vasc Pharmacol 2018; 17:72-84. [DOI: 10.2174/1570161115666171116151051] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/25/2017] [Accepted: 10/05/2017] [Indexed: 01/04/2023]
Abstract
Stroke as a cause of long-term disability is a growing public health burden. Therefore, focusing
on prevention is important. The most prominent aim of this strategy is to treat modifiable risk factors,
such as arterial hypertension, the leading modifiable contributor to stroke. Thus, efforts to adequately
reduce Blood Pressure (BP) among hypertensives are mandatory. In this respect, although safety
and benefits of BP control related to long-term outcome have been largely demonstrated, there are open
questions that remain to be addressed, such as optimal timing to initiate BP reduction and BP goals to be
targeted. Moreover, evidence on antihypertensive treatment during the acute phase of stroke or BP management
in specific categories (i.e. patients with carotid stenosis and post-acute stroke) remain controversial.
</P><P>
This review provides a critical update on the current knowledge concerning BP management and stroke
pathophysiology in patients who are either at risk for stroke or who experienced stroke.
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Affiliation(s)
- Agata Buonacera
- Academic Unit of Internal Medicine and Hypertension Centre, Department of Clinical and Experimental Medicine, University of Catania, c/o Cannizzaro Hospital, Catania, Italy
| | - Benedetta Stancanelli
- Academic Unit of Internal Medicine and Hypertension Centre, Department of Clinical and Experimental Medicine, University of Catania, c/o Cannizzaro Hospital, Catania, Italy
| | - Lorenzo Malatino
- Academic Unit of Internal Medicine and Hypertension Centre, Department of Clinical and Experimental Medicine, University of Catania, c/o Cannizzaro Hospital, Catania, Italy
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Dong R, Li F, Xu Y, Chen P, Maegele M, Yang H, Chen W. Safety and efficacy of applying sufficient analgesia combined with a minimal sedation program as an early antihypertensive treatment for spontaneous intracerebral hemorrhage: a randomized controlled trial. Trials 2018; 19:607. [PMID: 30400977 PMCID: PMC6219080 DOI: 10.1186/s13063-018-2943-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 09/26/2018] [Indexed: 01/09/2023] Open
Abstract
Background Spontaneous intracerebral hemorrhage (ICH) is a serious threat to human health. Although early blood pressure (BP) elevation is closely associated with a poor prognosis, the optimal antihypertensive regimen for acute-phase ICH remains controversial. In ICH, pain, sleep deprivation, and stress are usually the main causes of dramatic BP increases. While traditional antihypertensive treatment resolves the increased BP, it does not address the root cause of the disease. Remifentanil relieves pain and, when combined with dexmedetomidine’s antisympathetic action, can restore elevated BP to normal levels. Here, we seek to validate the efficacy and safety of applying sufficient analgesia in combination with a minimal sedation program versus antihypertensive drug therapy for the early and rapid stabilization of BP in ICH patients. Methods/design We are conducting a multicenter, prospective, randomized controlled, single-blinded, superiority clinical trial across 15 hospitals. We will enroll 354 subjects in mainland China, and all subjects will be randomized into experimental and control groups in which they will be given remifentanil combined with dexmedetomidine or antihypertensive drugs (urapidil, nicardipine, and labetalol). The primary endpoint will be the systolic BP control rate within 1 h of treatment initiation, and the efficacy and safety of the antihypertensive regimens will be compared between the two groups. Secondary endpoints include the incidence rate of early hemorrhage growth, neurological function, duration of intensive care unit (ICU) stay, and staff satisfaction with the treatment process. Discussion We hypothesize that applying sufficient analgesia in combination with minimal sedation will act as an effective and safe antihypertensive strategy in ICH and that this treatment strategy could, therefore, be widely used as an ICH acute-phase therapy. Trial registration ClinicalTrials.gov, ID: NCT03207100. Registered on 22 July 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2943-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rui Dong
- Department of Intensive Care Unit, The Third Affiliated Hospital of Southern Medical University, No.183 West Zhongshan Ave, Tianhe District, Guangzhou, 510630, Guangdong, China
| | - Fen Li
- Department of Intensive Care Unit, The Third Affiliated Hospital of Southern Medical University, No.183 West Zhongshan Ave, Tianhe District, Guangzhou, 510630, Guangdong, China
| | - Ying Xu
- Department of Biostatistics, School of Public Health, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Pingyan Chen
- Department of Biostatistics, School of Public Health, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Marc Maegele
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr. 200, 51109, Cologne, Germany
| | - Hong Yang
- Department of Intensive Care Unit, The Third Affiliated Hospital of Southern Medical University, No.183 West Zhongshan Ave, Tianhe District, Guangzhou, 510630, Guangdong, China.
| | - Wenjin Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.
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Serum cyclophilin A concentrations and prognosis of acute intracerebral hemorrhage. Clin Chim Acta 2018; 486:162-167. [DOI: 10.1016/j.cca.2018.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 07/30/2018] [Accepted: 08/01/2018] [Indexed: 11/22/2022]
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Tan CO, Lam S, Kuppens D, Bergmans RHJ, Parameswaran BK, Forghani R, Hu R, Daftari Besheli L, Goldstein JN, Thrall J, Lev M, Romero JM, Gupta R. Spot and Diffuse Signs: Quantitative Markers of Intracranial Hematoma Expansion at Dual-Energy CT. Radiology 2018; 290:179-186. [PMID: 30375929 DOI: 10.1148/radiol.2018180322] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To compare dual-energy CT with iodine quantification to single-energy CT for evaluation of the spot sign for intracranial hematoma expansion. Materials and Methods In this retrospective study, 42 patients (mean age, 66 years ± 15 [standard deviation]; 19 women) were referred for dual-energy CT assessment of intracranial hemorrhage from October 2014 to January 2017. A machine learning approach (naive Bayes classifier) was used to identify iodine markers of extravasation for risk of hematoma expansion. Specificity and sensitivity of these markers were then independently validated in 65 new patients from February 2017 to February 2018. Results Analysis of dual-energy CT images identified two features of iodine extravasation: total iodine concentration within the hematoma (Ih) and focal iodine concentration in the brightest spot in the hematoma (Ibs) as predictors of expansion. The I2 score derived from these features provided a measure of expansion probability. Optimal classification threshold was an I2 score of 20 (95% confidence interval [CI]: 18, 23), leading to correct identification of 39 of 46 (85%; 95% CI: 71%, 94%) of the hematomas on the training set (sensitivity of 79% [11 of 14; 95% CI: 57%, 100%] and specificity of 88% [28 of 32; 95% CI: 76%, 99%]), and 62 of 70 (89%; 95% CI: 79%, 95%) of the hematomas on the validation set (sensitivity of 71% [10 of 14; 95% CI: 48%, 95%] and specificity of 93% [52 of 56; 95% CI: 86%, 100%]). Sensitivity, specificity, and accuracy of conventional spot sign were, respectively, 57% (eight of 14), 90% (29 of 32), and 80% (37 of 46) on the training set and 57% (eight of 14), 83% (47 of 56), and 75% (53 of 70) on the validation set. Conclusion This study identified two quantitative markers of intracranial hemorrhage expansion at dual-energy CT of the brain. The I2 score derived from these markers highlights the utility of dual-energy CT measurements of iodine content for high sensitivity risk assessment. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Can Ozan Tan
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Stephanie Lam
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Daan Kuppens
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Rick H J Bergmans
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Bimal Kumar Parameswaran
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Reza Forghani
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Ranliang Hu
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Laleh Daftari Besheli
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Joshua N Goldstein
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - James Thrall
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Michael Lev
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Javier M Romero
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Rajiv Gupta
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
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Zheng GR, Chen B, Shen J, Qiu SZ, Yin HM, Mao W, Wang HX, Gao JB. Serum myeloperoxidase concentrations for outcome prediction in acute intracerebral hemorrhage. Clin Chim Acta 2018; 487:330-336. [PMID: 30347182 DOI: 10.1016/j.cca.2018.10.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Oxidative stress is related to brain injury after spontaneous intracerebral hemorrhage (ICH). Myeloperoxidase (MPO) is a potent oxidizing enzyme. We tested the hypothesis that serum MPO concentrations are increased after ICH and they correlate with stroke severity and outcome. METHODS Serum MPO concentrations were measured in 128 ICH patients and 128 controls. Odds ratios of dependent variables, including early neurological deterioration, hematoma growth, 1-week mortality, 6-month mortality, 6-month unfavorable outcome (modified Rankin Scale score > 2) and 6-month overall survival, were calculated and adjusted for age, sex, hematoma volume, National Institutes of Health Stroke Scale (NIHSS) score and vascular risk factors. RESULTS As compared to the controls, the patients had significantly increased serum MPO concentrations. MPO concentrations of the ICH patients were strongly correlated with hematoma volume and NIHSS scores. Serum MPO were independently associated with the above-mentioned study points. Its area under receiver operating characteristic curve was equivalent to those of hematoma volume and NIHSS score. Moreover, serum MPO significantly improved the discriminatory ability of hematoma and NIHSS in predicting 6-month mortality and unfavorable outcome. CONCLUSIONS Serum MPO concentrations rise in ICH patients and there is a correlation between MPO concentrations and severity or prognosis.
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Affiliation(s)
- Guan-Rong Zheng
- Department of Neurosurgery, The First People's Hospital of Fuyang District of Hangzhou City, 429 Beihuan Road, Fuyang District, Hangzhou 311400, China
| | - Bin Chen
- Department of Neurosurgery, The First People's Hospital of Fuyang District of Hangzhou City, 429 Beihuan Road, Fuyang District, Hangzhou 311400, China
| | - Jia Shen
- Department of Neurosurgery, The First People's Hospital of Fuyang District of Hangzhou City, 429 Beihuan Road, Fuyang District, Hangzhou 311400, China
| | - Shen-Zhong Qiu
- Department of Neurosurgery, The First People's Hospital of Fuyang District of Hangzhou City, 429 Beihuan Road, Fuyang District, Hangzhou 311400, China.
| | - Huai-Ming Yin
- Department of Neurosurgery, The First People's Hospital of Fuyang District of Hangzhou City, 429 Beihuan Road, Fuyang District, Hangzhou 311400, China
| | - Wei Mao
- Department of Neurosurgery, The First People's Hospital of Fuyang District of Hangzhou City, 429 Beihuan Road, Fuyang District, Hangzhou 311400, China
| | - Hong-Xiang Wang
- Department of Neurology, The First People's Hospital of Fuyang District of Hangzhou City, 429 Beihuan Road, Fuyang District, Hangzhou 311400, China
| | - Jian-Bo Gao
- Department of Emergency Medicine, The First People's Hospital of Fuyang District of Hangzhou City, 429 Beihuan Road, Fuyang District, Hangzhou 311400, China
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The profile of blunt traumatic infratentorial cranial bleed types. J Clin Neurosci 2018; 60:58-62. [PMID: 30342807 DOI: 10.1016/j.jocn.2018.10.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 10/05/2018] [Indexed: 11/20/2022]
Abstract
Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ± 6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.
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Brenner A, Arribas M, Cuzick J, Jairath V, Stanworth S, Ker K, Shakur-Still H, Roberts I. Outcome measures in clinical trials of treatments for acute severe haemorrhage. Trials 2018; 19:533. [PMID: 30285839 PMCID: PMC6167881 DOI: 10.1186/s13063-018-2900-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/03/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acute severe haemorrhage is a common complication of injury, childbirth, surgery, gastrointestinal pathologies and other medical conditions. Bleeding is a major cause of death, but patients also die from non-bleeding causes, the frequency of which varies by the site of haemorrhage and between populations. Because patients can bleed to death within hours, established interventions inevitably take priority over randomisation into a trial. These circumstances raise challenges in selecting appropriate outcome measures for clinical trials of haemostatic interventions. MAIN BODY We use data from three large randomised controlled trials in acute severe haemorrhage (CRASH-2, WOMAN and HALT-IT) to explore the strengths and limitations of outcome measures commonly used in trials of haemostatic treatments, including all-cause and cause-specific mortality, blood transfusion and surgical interventions. Many deaths following acute severe haemorrhage are due to patient comorbidities or complications rather than bleeding. If non-bleeding deaths are unaffected by a haemostatic intervention, even large trials will have low power to detect an effect on all-cause mortality. Due to the dilution from deaths unaffected or reduced by the trial treatment, all-cause mortality can also obscure important harmful effects. Additionally, because the relative contributions of different causes of death vary within and between patient populations, all-cause mortality is not generalisable. Different causes of death occur at different time intervals from bleeding onset, with bleeding deaths generally occurring early. Time-specific mortality can therefore be used as a proxy for cause in un-blinded trials where bias is a concern or in situations where cause of death cannot be assessed. Urgent treatment is critical, and so post-randomisation blood transfusion and surgery are often planned before or at the time of randomisation and therefore cannot be influenced by the trial treatment. CONCLUSIONS All-cause mortality has low power, lacks generalisability and can obscure harmful effects. Cause-specific mortality, such as death due to bleeding or thrombosis, avoids these drawbacks. In certain scenarios, time-specific mortality can be used as a proxy for cause-specific mortality. Blood transfusion and surgical procedures have limited utility as outcome measures in trials of haemostatic treatments.
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Affiliation(s)
- Amy Brenner
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Monica Arribas
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, EC1M 6BQ UK
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, University Hospital, Western University, London, ON Canada
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, Oxford, UK
| | - Katharine Ker
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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220
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Zhang F, Li H, Qian J, Tao C, Zheng J, You C, Yang M. Hyperglycemia Predicts Blend Sign in Patients with Intracerebral Hemorrhage. Med Sci Monit 2018; 24:6237-6244. [PMID: 30191900 PMCID: PMC6139114 DOI: 10.12659/msm.910024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Predictive values of admission blood glucose for early hematoma expansion in patients with intracranial hemorrhage (ICH) remain controversial. Blend sign is a novel image predictor for early hematoma growth that suggests presence of active bleeding. We investigated the association between hyperglycemia and blend sign in predicting early hematoma growth in ICH patients. Material/Methods All patients with intracranial hemorrhage were retrospectively reviewed. Clinical characteristics and radiological parameters were collected. Blood glucose was measured within 24 h after onset. CT scan results for hematoma expansion and blend sign were evaluated by 2 readers. Multivariate logistic regression analyses were applied to reveal the associations between hematoma growth and blend sign, as well as other variables. Results Out of 164 patients with ICH, 52 exhibited early hematoma growth and 18 of these were diagnosed with blend sign. Average blood glucose was 7.53 mmol/L among all patients. By using multivariate analyses, the time of CT scan baseline, GCS score, hematoma size, blend sign, and blood glucose were associated with hematoma expansion, whereas only hyperglycemia was associated with blend sign. Conclusions Admission hyperglycemia is associated with hematoma expansion in the presence of blend sign. These findings suggest that elevated blood glucose is a possible factor predicting continuous bleeding. Strategies to control blood glucose and ameliorate hematoma growth are urgently needed and will be investigated in our future studies.
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Affiliation(s)
- Fan Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Department of Pathology, Case Western Reserve University, Cleveland, OH, USA
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Juan Qian
- Department of Population and Quantitative Health, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Chuanyuan Tao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Mu Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada.,Alan Edwards Centre for Research on Pain, McGill University, Montreal, QC, Canada
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The application of point-of-care platelet function assay in guiding platelet transfusion in aspirin-users with intracranial haemorrhages. J Clin Neurosci 2018; 55:52-56. [DOI: 10.1016/j.jocn.2018.06.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 06/25/2018] [Indexed: 11/19/2022]
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Qureshi AI, Qureshi MH. Acute hypertensive response in patients with intracerebral hemorrhage pathophysiology and treatment. J Cereb Blood Flow Metab 2018; 38:1551-1563. [PMID: 28812942 PMCID: PMC6125978 DOI: 10.1177/0271678x17725431] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute hypertensive response is a common systemic response to occurrence of intracerebral hemorrhage which has gained unique prominence due to high prevalence and association with hematoma expansion and increased mortality. Presumably, the higher systemic blood pressure predisposes to continued intraparenchymal hemorrhage by transmission of higher pressure to the damaged small arteries and may interact with hemostatic and inflammatory pathways. Therefore, intensive reduction of systolic blood pressure has been evaluated in several clinical trials as a strategy to reduce hematoma expansion and subsequent death and disability. These trials have demonstrated either a small magnitude benefit (second intensive blood pressure reduction in acute cerebral hemorrhage trial and efficacy of nitric oxide in stroke trial) or no benefit (antihypertensive treatment of acute cerebral hemorrhage 2 trial) with intensive systolic blood pressure reduction compared with modest or standard blood pressure reduction. The differences may be explained by the variation in intensity of systolic blood pressure reduction between trials. A treatment threshold of systolic blood pressure of ≥180 mm with the target goal of systolic blood pressure reduction to values between 130 and 150 mm Hg within 6 h of symptom onset may be best supported by current evidence.
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Cavallo C, Zhao X, Abou-Al-Shaar H, Weiss M, Gandhi S, Belykh E, Tayebi-Meybodi A, Labib MA, Preul MC, Nakaji P. Minimally invasive approaches for the evacuation of intracerebral hemorrhage: a systematic review. J Neurosurg Sci 2018; 62:718-733. [PMID: 30160081 DOI: 10.23736/s0390-5616.18.04557-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) is associated with a high rate of morbidity and mortality. Minimally-invasive surgery (MIS) has been increasingly used in recent years. We systematically reviewed the role of MIS in the acute management of ICH using various techniques. EVIDENCE ACQUISITION A comprehensive electronic search for relevant articles was conducted on several relevant international databases, including PUBMED (Medline), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL). EVIDENCE SYNTHESIS Our primary literature research resulted in 1134 articles. In total, 116 publications finally met the eligibility criteria to be included in our systematic review. Five major MIS categories for the evacuation of ICH were identified, respectively: minimally invasive direct aspiration with or without thrombolytics, endoscope assisted technique, sonothrombolysis, aspiration-irrigation device and endoport-assisted evacuation. CONCLUSIONS The role of minimally invasive techniques in the management of ICH remains under dispute. However, a mounting evidence in the literature demonstrates that MIS is associated with significantly improved outcomes when compared with conservative treatment and conventional surgical evacuation strategy.
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Affiliation(s)
- Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA -
| | - Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, North Shore University Hospital, Hempstead, New York, NY, USA
| | - Miriam Weiss
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.,Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ali Tayebi-Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Absolute risk and predictors of the growth of acute spontaneous intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data. Lancet Neurol 2018; 17:885-894. [PMID: 30120039 PMCID: PMC6143589 DOI: 10.1016/s1474-4422(18)30253-9] [Citation(s) in RCA: 263] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/26/2018] [Accepted: 06/26/2018] [Indexed: 12/13/2022]
Abstract
Background Intracerebral haemorrhage growth is associated with poor clinical outcome and is a therapeutic target for improving outcome. We aimed to determine the absolute risk and predictors of intracerebral haemorrhage growth, develop and validate prediction models, and evaluate the added value of CT angiography. Methods In a systematic review of OVID MEDLINE—with additional hand-searching of relevant studies' bibliographies— from Jan 1, 1970, to Dec 31, 2015, we identified observational cohorts and randomised trials with repeat scanning protocols that included at least ten patients with acute intracerebral haemorrhage. We sought individual patient-level data from corresponding authors for patients aged 18 years or older with data available from brain imaging initially done 0·5–24 h and repeated fewer than 6 days after symptom onset, who had baseline intracerebral haemorrhage volume of less than 150 mL, and did not undergo acute treatment that might reduce intracerebral haemorrhage volume. We estimated the absolute risk and predictors of the primary outcome of intracerebral haemorrhage growth (defined as >6 mL increase in intracerebral haemorrhage volume on repeat imaging) using multivariable logistic regression models in development and validation cohorts in four subgroups of patients, using a hierarchical approach: patients not taking anticoagulant therapy at intracerebral haemorrhage onset (who constituted the largest subgroup), patients taking anticoagulant therapy at intracerebral haemorrhage onset, patients from cohorts that included at least some patients taking anticoagulant therapy at intracerebral haemorrhage onset, and patients for whom both information about anticoagulant therapy at intracerebral haemorrhage onset and spot sign on acute CT angiography were known. Findings Of 4191 studies identified, 77 were eligible for inclusion. Overall, 36 (47%) cohorts provided data on 5435 eligible patients. 5076 of these patients were not taking anticoagulant therapy at symptom onset (median age 67 years, IQR 56–76), of whom 1009 (20%) had intracerebral haemorrhage growth. Multivariable models of patients with data on antiplatelet therapy use, data on anticoagulant therapy use, and assessment of CT angiography spot sign at symptom onset showed that time from symptom onset to baseline imaging (odds ratio 0·50, 95% CI 0·36–0·70; p<0·0001), intracerebral haemorrhage volume on baseline imaging (7·18, 4·46–11·60; p<0·0001), antiplatelet use (1·68, 1·06–2·66; p=0·026), and anticoagulant use (3·48, 1·96–6·16; p<0·0001) were independent predictors of intracerebral haemorrhage growth (C-index 0·78, 95% CI 0·75–0·82). Addition of CT angiography spot sign (odds ratio 4·46, 95% CI 2·95–6·75; p<0·0001) to the model increased the C-index by 0·05 (95% CI 0·03–0·07). Interpretation In this large patient-level meta-analysis, models using four or five predictors had acceptable to good discrimination. These models could inform the location and frequency of observations on patients in clinical practice, explain treatment effects in prior randomised trials, and guide the design of future trials. Funding UK Medical Research Council and British Heart Foundation.
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225
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Computed Tomographic Black Hole Sign Predicts Postoperative Rehemorrhage in Patients with Spontaneous Intracranial Hemorrhage Following Stereotactic Minimally Invasive Surgery. World Neurosurg 2018; 120:e153-e160. [PMID: 30092481 DOI: 10.1016/j.wneu.2018.07.256] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Determining the value of the computed tomographic black hole sign in predicting postoperative rehemorrhage in patients with intracranial hemorrhage (ICH) underwent minimally invasive surgery (MIS). METHODS Two hundred ninety-five patients with spontaneous ICH underwent stereotactic MIS within 24 hours after admission. Ninety-eight patients (33%) demonstrated a black hole sign on initial computed tomography (CT). Postoperative rehemorrhage occurred in 68 patients (named the rehemorrhage group, including patients with and without black hole sign) and the other 227 patients (non-rehemorrhage group) did not show rehemorrhage. Multivariable logistic regression analyses were performed to assess the values of the black hole sign. RESULTS Postoperative rehemorrhage occurred in 57 of the 98 (58.2%) patients with the black hole sign, and in 11 of the 197 (5.58%) patients without the black hole sign. In the rehemorrhage group, 39 patients (57.4%) were found to have the black hole sign. However, only 59 patients (25.99%) from the non-rehemorrhage group showed the black hole sign. The sensitivity, specificity, and positive and negative predictive values of the black hole sign for predicting postoperative rehemorrhage were 57.4%, 74%, 39.8%, and 85.3%, respectively. The odd ratio for the black hole sign, the hematoma irregularity, and the CT value for predicting the postoperative rehemorrhage were 10.501, 9.631, and 4.750, respectively. CONCLUSIONS The black hole sign on initial CT could predict the postoperative rehemorrhage following the minimally invasive procedures.
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226
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Sporns PB, Kemmling A, Minnerup J, Hanning U, Heindel W. Imaging-based outcome prediction in patients with intracerebral hemorrhage. Acta Neurochir (Wien) 2018; 160:1663-1670. [PMID: 29943191 DOI: 10.1007/s00701-018-3605-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
Abstract
Besides the established spot sign in computed tomography angiography (CTA), recently investigated imaging predictors of hematoma growth in noncontrast computed tomography (NCCT) suggest great potential for outcome prediction in patients with intracerebral hemorrhage (ICH). Secondary hematoma growth is an appealing target for therapeutic interventions because in contrast to other determined factors, it is potentially modifiable. Even more initial therapy studies failed to demonstrate clear therapeutic benefits, there is a need for an effective patient selection using imaging markers to identify patients at risk for poor outcome and thereby tailor individual treatments for every patient. Hence, this review gives an overview about the current literature on NCCT imaging markers for neurological outcome prediction and aims to clarify the association with the established spot sign. Moreover, it demonstrates the clinical impact of these parameters and gives a roadmap for future imaging research in patients with intracerebral hemorrhage.
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227
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Lauridsen SV, Hvas AM, Sandgaard E, Gyldenholm T, Rahbek C, Hjort N, Tønnesen EK, Hvas CL. Coagulation Profile after Spontaneous Intracerebral Hemorrhage: A Cohort Study. J Stroke Cerebrovasc Dis 2018; 27:2951-2961. [PMID: 30072172 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/14/2018] [Accepted: 06/17/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) causes death or disability and the incidence increases with age. Knowledge of acute hemostatic function in patients with ICH without anticoagulant and antiplatelet therapy is sparse. Increased knowledge of the coagulation profile in the acute phase of ICH could improve acute treatment and recovery. We investigated coagulation at admission and changes in coagulation during the first 24hours after symptom onset. METHODS Enrolled were 41 ICH patients without anticoagulant or antiplatelet therapy admitted to Aarhus University Hospital, Denmark. Blood samples were collected at admission, 6, and 24hours after symptom onset. Thromboelastometry (ROTEM), thrombin generation, and thrombin-antithrombin (TAT) complex were analyzed. Clinical outcome was evaluated using the National Institute of Health Stroke Scale, the Modified Rankin Score, and mortality. RESULTS At admission, compared with healthy individuals, ICH patients had increased maximum clot firmness (EXTEM P < .0001; INTEM P < .0001; FIBTEM P < .0001), increased platelet maximum clot elasticity (P < .0001) in ROTEM, higher peak thrombin (P < .0001) and endogenous thrombin potential (P = .01) in thrombin generation, and elevated TAT complex levels. During 24hours after significantly, while thrombin generation showed decreased peak thrombin (P < .0001) and endogenous thrombin potential (P < .0001). Coagulation test results did not differ between patients when stratified according to clinical outcome. CONCLUSIONS ICH patients without anticoagulant or antiplatelet therapy demonstrated activated coagulation at admission and within 24hours after symptom onset.
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Affiliation(s)
| | - Anne-Mette Hvas
- Center for Hemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University, Hospital, Aarhus, Denmark
| | - Emilie Sandgaard
- Center for Hemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University, Hospital, Aarhus, Denmark
| | - Tua Gyldenholm
- Center for Hemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University, Hospital, Aarhus, Denmark
| | - Christian Rahbek
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Hjort
- Department of Neurology, Danish Stroke Center, Aarhus University Hospital, Aarhus, Denmark
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Abstract
Intracerebral hemorrhage (ICH) is a subset of stroke due to spontaneous bleeding within the parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, proper diagnosis, and early management of several specific issues such as blood pressure, coagulopathy reversal, and surgical hematoma evacuation for appropriate patients. ICH was chosen as an Emergency Neurological Life Support (ENLS) protocol because intervention within the first hours may improve outcome, and it is critical to have site-specific protocols to drive care quickly and efficiently.
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229
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Burchell SR, Tang J, Zhang JH. Hematoma Expansion Following Intracerebral Hemorrhage: Mechanisms Targeting the Coagulation Cascade and Platelet Activation. Curr Drug Targets 2018; 18:1329-1344. [PMID: 28378693 DOI: 10.2174/1389450118666170329152305] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/20/2016] [Accepted: 03/14/2017] [Indexed: 01/04/2023]
Abstract
Hematoma expansion (HE), defined as a greater than 33% increase in intracerebral hemorrhage (ICH) volume within the first 24 hours, results in significant neurological deficits, and enhancement of ICH-induced primary and secondary brain injury. An escalation in the use of oral anticoagulants has led to a surge in the incidences of oral anticoagulation-associated ICH (OAT-ICH), which has been associated with a greater risk for HE and worse functional outcomes following ICH. The oral anticoagulants in use include vitamin K antagonists, and direct thrombin and factor Xa inhibitors. Fibrinolytic agents are also frequently administered. These all act via differing mechanisms and thus have varying degrees of impact on HE and ICH outcome. Additionally, antiplatelet medications have also been increasingly prescribed, and result in increased bleeding risks and worse outcomes after ICH. Aspirin, thienopyridines, and GPIIb/IIIa receptor blockers are some of the most common agents in use clinically, and also have different effects on ICH and hemorrhage growth, based on their mechanisms of action. Recent studies have found that reduced platelet activity may be more effective in predicting ICH risk, hemorrhage expansion, and outcomes, than antiplatelet agents, and activating platelets may thus be a novel target for ICH therapy. This review explores how dysfunctions or alterations in the coagulation and platelet cascades can lead to, and/or exacerbate, hematoma expansion following intracerebral hemorrhage, and describe the mechanisms behind these effects and the drugs that induce them. We also discuss potential future therapy aimed at increasing platelet activity after ICH.
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Affiliation(s)
- Sherrefa R Burchell
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jiping Tang
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA.,Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda CA, USA
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230
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Akhter M, Morotti A, Cohen AS, Chang Y, Ayres AM, Schwab K, Viswanathan A, Gurol ME, Anderson CD, Greenberg SM, Rosand J, Goldstein JN. Timing of INR reversal using fresh-frozen plasma in warfarin-associated intracerebral hemorrhage. Intern Emerg Med 2018; 13:557-565. [PMID: 28573379 DOI: 10.1007/s11739-017-1680-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
Abstract
Rapid reversal of coagulopathy is recommended in warfarin-associated intracerebral hemorrhage (WAICH). However, rapid correction of the INR has not yet been proven to improve clinical outcomes, and the rate of correction with fresh-frozen plasma (FFP) can be variable. We sought to determine whether faster INR reversal with FFP is associated with decreased hematoma expansion and improved outcome. We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with WAICH presenting to an urban tertiary care hospital from 2000 to 2013. Patients with baseline INR > 1.4 treated with FFP and vitamin K were included. The primary outcomes are occurrence of hematoma expansion, discharge modified Rankin Scale (mRS), and 30-day mortality. The association between timing of INR reversal, ICH expansion, and outcome was investigated with logistic regression analysis. 120 subjects met inclusion criteria (mean age 76.9, 57.5% males). Median presenting INR was 2.8 (IQR 2.3-3.4). Hematoma expansion is not associated with slower INR reversal [median time to INR reversal 9 (IQR 5-14) h vs. 10 (IQR 7-16) h, p = 0.61]. Patients with ultimately poor outcome received more rapid INR reversal than those with favorable outcome [9 (IQR 6-14) h vs. 12 (8-19) h, p = 0.064). We find no evidence of an association between faster INR reversal and either reduced hematoma expansion or better outcome.
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Affiliation(s)
- Murtaza Akhter
- Department of Emergency Medicine, University of Arizona College of Medicine-Phoenix and Maricopa Integrated Health System, Phoenix, AZ, USA.
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Andrea Morotti
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Abigail Sara Cohen
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yuchiao Chang
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alison M Ayres
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin Schwab
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Viswanathan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mahmut Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Steven Mark Greenberg
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua Norkin Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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231
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Affiliation(s)
- Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH 45219-0525, USA.
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Sprigg N, Flaherty K, Appleton JP, Al-Shahi Salman R, Bereczki D, Beridze M, Christensen H, Ciccone A, Collins R, Czlonkowska A, Dineen RA, Duley L, Egea-Guerrero JJ, England TJ, Krishnan K, Laska AC, Law ZK, Ozturk S, Pocock SJ, Roberts I, Robinson TG, Roffe C, Seiffge D, Scutt P, Thanabalan J, Werring D, Whynes D, Bath PM. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet 2018; 391:2107-2115. [PMID: 29778325 PMCID: PMC5976950 DOI: 10.1016/s0140-6736(18)31033-x] [Citation(s) in RCA: 318] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 04/19/2018] [Accepted: 04/30/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Tranexamic acid can prevent death due to bleeding after trauma and post-partum haemorrhage. We aimed to assess whether tranexamic acid reduces haematoma expansion and improves outcome in adults with stroke due to intracerebral haemorrhage. METHODS We did an international, randomised placebo-controlled trial in adults with intracerebral haemorrhage from acute stroke units at 124 hospital sites in 12 countries. Participants were randomly assigned (1:1) to receive 1 g intravenous tranexamic acid bolus followed by an 8 h infusion of 1 g tranexamic acid or a matching placebo, within 8 h of symptom onset. Randomisation was done centrally in real time via a secure website, with stratification by country and minimisation on key prognostic factors. Treatment allocation was concealed from patients, outcome assessors, and all other health-care workers involved in the trial. The primary outcome was functional status at day 90, measured by shift in the modified Rankin Scale, using ordinal logistic regression with adjustment for stratification and minimisation criteria. All analyses were done on an intention-to-treat basis. This trial is registered with the ISRCTN registry, number ISRCTN93732214. FINDINGS We recruited 2325 participants between March 1, 2013, and Sept 30, 2017. 1161 patients received tranexamic acid and 1164 received placebo; the treatment groups were well balanced at baseline. The primary outcome was assessed for 2307 (99%) participants. The primary outcome, functional status at day 90, did not differ significantly between the groups (adjusted odds ratio [aOR] 0·88, 95% CI 0·76-1·03, p=0·11). Although there were fewer deaths by day 7 in the tranexamic acid group (101 [9%] deaths in the tranexamic acid group vs 123 [11%] deaths in the placebo group; aOR 0·73, 0·53-0·99, p=0·0406), there was no difference in case fatality at 90 days (250 [22%] vs 249 [21%]; adjusted hazard ratio 0·92, 95% CI 0·77-1·10, p=0·37). Fewer patients had serious adverse events after tranexamic acid than after placebo by days 2 (379 [33%] patients vs 417 [36%] patients), 7 (456 [39%] vs 497 [43%]), and 90 (521 [45%] vs 556 [48%]). INTERPRETATION Functional status 90 days after intracerebral haemorrhage did not differ significantly between patients who received tranexamic acid and those who received placebo, despite a reduction in early deaths and serious adverse events. Larger randomised trials are needed to confirm or refute a clinically significant treatment effect. FUNDING National Institute of Health Research Health Technology Assessment Programme and Swiss Heart Foundation.
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Affiliation(s)
- Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK.
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, UK
| | | | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Maia Beridze
- The First University Clinic of Tbilisi State Medical University, Tbilisi, Georgia
| | - Hanne Christensen
- Department of Neurology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Alfonso Ciccone
- Neurology Unit, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy
| | - Ronan Collins
- Stroke Service, Adelaide and Meath Hospital, Tallaght, Ireland
| | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Robert A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, UK; NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Juan Jose Egea-Guerrero
- UGC de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, Consejo Superior de Investigaciones Científicas, Universidad de Sevilla, Seville, Spain
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, 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, City Hospital Campus, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK; Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - 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, Staffordshire, UK
| | - David Seiffge
- Stroke Center, Neurology and Department of Clinical Research, University Hospital, University Basel, Basel, Switzerland
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Jegan Thanabalan
- Division of Neurosurgery, Department of Surgery, National University of Malaysia, Kuala Lumpur, Malaysia
| | - David Werring
- Stroke Research Centre, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, University College London, London, UK
| | - David Whynes
- School of Economics, University of Nottingham, University Park, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
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Forlivesi S, Turcato G, Zivelonghi C, Zannoni M, Ricci G, Cervellin G, Lippi G, Bovi P, Bonetti B, Cappellari M. Association of Short- and Medium-Term Particulate Matter Exposure with Risk of Mortality after Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2018; 27:2519-2523. [PMID: 29803602 DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 03/05/2018] [Accepted: 05/07/2018] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE We investigated the association of short- and medium-term particulate matter (PM) exposure with risk of mortality in patients with spontaneous intracerebral hemorrhage (ICH) identified according to strict etiologic criteria. METHODS We conducted a retrospective analysis of prospectively collected data from consecutive patients with spontaneous ICH admitted to the emergency department of the University Hospital of Verona from March 2011 to December 2014. Outcome measures were mortality within 1 month after ICH and significant hematoma expansion (HE) defined as an absolute growth of more than 12.5 mL or a relative increase of more than 50% from baseline to follow-up computed tomography scan. RESULTS A final number of 308 patients were included. In the adjusted model, higher PM2.5 and PM10 values in the last 3 days (odds ratio [OR] 1.827, 95% confidence interval [CI] 1.057-3.159, P = .031 and OR 1.949, 95% CI 1.025-3.704, P = .042, respectively) and in the last 4 weeks (OR 4.975, 95% CI 2.174-11.381, P < .001 and OR 9.781, 95% CI 3.425-27.932, P < .001, respectively) before ICH were associated with higher mortality rate. No association was found between PM exposure and significant HE. CONCLUSIONS PM exposure in the short- and medium-term before spontaneous ICH was associated with risk of 1-month mortality, independent of predictors such as age, sex, stroke severity, intraventricular hemorrhage, ICH volume, ICH location, ICH etiologic subtype, significant HE, antithrombotic therapy, atrial fibrillation, and blood glucose levels.
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Affiliation(s)
- Stefano Forlivesi
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
| | - Gianni Turcato
- Emergency Department, Girolamo Fracastoro Hospital, Verona, Italy
| | - Cecilia Zivelonghi
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Massimo Zannoni
- Department of Emergency and Intensive Care, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giorgio Ricci
- Department of Emergency and Intensive Care, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | | | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Paolo Bovi
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Bruno Bonetti
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Manuel Cappellari
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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Akhter M, Qin T, Fischer P, Sadeghian H, Kim HH, Whalen MJ, Goldstein JN, Ayata C. Rho-kinase inhibitors do not expand hematoma volume in acute experimental intracerebral hemorrhage. Ann Clin Transl Neurol 2018; 5:769-776. [PMID: 29928660 PMCID: PMC5989779 DOI: 10.1002/acn3.569] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 03/23/2018] [Accepted: 03/26/2018] [Indexed: 01/13/2023] Open
Abstract
Rho‐associated kinase (ROCK) is an emerging target in acute ischemic stroke. Early pre‐hospital treatment with ROCK inhibitors may improve their efficacy, but their antithrombotic effects raise safety concerns in hemorrhagic stroke, precluding use prior to neuroimaging. Therefore, we tested whether ROCK inhibition affects the bleeding times, and worsens hematoma volume in a model of intracerebral hemorrhage (ICH) induced by intrastriatal collagenase injection in mice. Tail bleeding time was measured 1 h after treatment with isoform‐nonselective inhibitor fasudil, or ROCK2‐selective inhibitor KD025, or their vehicles. In the ICH model, treatments were administered 1 h after collagenase injection. Although KD025 but not fasudil prolonged the tail bleeding times, neither drug expanded the volume of ICH or worsened neurological deficits at 48 h compared with vehicle. Although more testing is needed in aged animals and comorbid models such as diabetes, these results suggest ROCK inhibitors may be safe for pre‐hospital administration in acute stroke.
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Affiliation(s)
- Murtaza Akhter
- Department of Emergency Medicine University of Arizona College of Medicine- Phoenix Maricopa Medical Center Phoenix Arizona.,Neurovascular Research Laboratory Department of Radiology Massachusetts General Hospital Harvard Medical School Charlestown Massachusetts.,Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston Massachusetts
| | - Tom Qin
- Neurovascular Research Laboratory Department of Radiology Massachusetts General Hospital Harvard Medical School Charlestown Massachusetts
| | - Paul Fischer
- Neurovascular Research Laboratory Department of Radiology Massachusetts General Hospital Harvard Medical School Charlestown Massachusetts
| | - Homa Sadeghian
- Neurovascular Research Laboratory Department of Radiology Massachusetts General Hospital Harvard Medical School Charlestown Massachusetts
| | - Hyung Hwan Kim
- Neurovascular Research Laboratory Department of Radiology Massachusetts General Hospital Harvard Medical School Charlestown Massachusetts
| | - Michael J Whalen
- Department of Pediatrics Pediatric Critical Care Medicine Massachusetts General Hospital Harvard Medical School Charlestown Massachusetts
| | - Joshua N Goldstein
- Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston Massachusetts
| | - Cenk Ayata
- Neurovascular Research Laboratory Department of Radiology Massachusetts General Hospital Harvard Medical School Charlestown Massachusetts.,Stroke Service and Neuroscience Intensive Care Unit Department of Neurology Massachusetts General Hospital Harvard Medical School Boston Massachusetts
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Shen Q, Shan Y, Hu Z, Chen W, Yang B, Han J, Huang Y, Xu W, Feng Z. Quantitative parameters of CT texture analysis as potential markersfor early prediction of spontaneous intracranial hemorrhage enlargement. Eur Radiol 2018; 28:4389-4396. [PMID: 29713780 DOI: 10.1007/s00330-018-5364-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/15/2018] [Accepted: 02/01/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To objectively quantify intracranial hematoma (ICH) enlargement by analysing the image texture of head CT scans and to provide objective and quantitative imaging parameters for predicting early hematoma enlargement. METHODS We retrospectively studied 108 ICH patients with baseline non-contrast computed tomography (NCCT) and 24-h follow-up CT available. Image data were assessed by a chief radiologist and a resident radiologist. Consistency analysis between observers was tested. The patients were divided into training set (75%) and validation set (25%) by stratified sampling. Patients in the training set were dichotomized according to 24-h hematoma expansion ≥ 33%. Using the Laplacian of Gaussian bandpass filter, we chose different anatomical spatial domains ranging from fine texture to coarse texture to obtain a series of derived parameters (mean grayscale intensity, variance, uniformity) in order to quantify and evaluate all data. The parameters were externally validated on validation set. RESULTS Significant differences were found between the two groups of patients within variance at V1.0 and in uniformity at U1.0, U1.8 and U2.5. The intraclass correlation coefficients for the texture parameters were between 0.67 and 0.99. The area under the ROC curve between the two groups of ICH cases was between 0.77 and 0.92. The accuracy of validation set by CTTA was 0.59-0.85. CONCLUSION NCCT texture analysis can objectively quantify the heterogeneity of ICH and independently predict early hematoma enlargement. KEY POINTS • Heterogeneity is helpful in predicting ICH enlargement. • CTTA could play an important role in predicting early ICH enlargement. • After filtering, fine texture had the best diagnostic performance. • The histogram-based uniformity parameters can independently predict ICH enlargement. • CTTA is more objective, more comprehensive, more independently operable, than previous methods.
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Affiliation(s)
- Qijun Shen
- Department of Radiology, Hangzhou First People's Hospital, 261 Huansha Road, Hangzhou, 310003, China
| | - Yanna Shan
- Department of Radiology, Hangzhou First People's Hospital, 261 Huansha Road, Hangzhou, 310003, China
| | - Zhengyu Hu
- Department of Radiology, Second People's Hospital of Yuhang District, 80 Anle Road, Hangzhou, 311121, China
| | - Wenhui Chen
- Department of Radiology, Hangzhou First People's Hospital, 261 Huansha Road, Hangzhou, 310003, China
| | - Bing Yang
- Department of Radiology, Hangzhou First People's Hospital, 261 Huansha Road, Hangzhou, 310003, China
| | - Jing Han
- Department of Radiology, Hangzhou First People's Hospital, 261 Huansha Road, Hangzhou, 310003, China
| | - Yanfang Huang
- Department of Radiology, Hangzhou First People's Hospital, 261 Huansha Road, Hangzhou, 310003, China
| | - Wen Xu
- Department of Radiology, Hangzhou First People's Hospital, 261 Huansha Road, Hangzhou, 310003, China
| | - Zhan Feng
- Department of Radiology, First Affiliated Hospital of College of Medical Science, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China.
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Al‐Shahi Salman R, Law ZK, Bath PM, Steiner T, Sprigg N, Cochrane Stroke Group. Haemostatic therapies for acute spontaneous intracerebral haemorrhage. Cochrane Database Syst Rev 2018; 4:CD005951. [PMID: 29664991 PMCID: PMC6494564 DOI: 10.1002/14651858.cd005951.pub4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Outcome after spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is influenced by haematoma volume; up to one-third of ICHs enlarge within 24 hours of onset. Early haemostatic therapy might improve outcome by limiting haematoma growth. This is an update of a Cochrane Review first published in 2006, and last updated in 2009. OBJECTIVES To examine 1) the effectiveness and safety of individual classes of haemostatic therapies, compared against placebo or open control, in adults with acute spontaneous intracerebral haemorrhage, and 2) the effects of each class of haemostatic therapy according to the type of antithrombotic drug taken immediately before ICH onset (i.e. anticoagulant, antiplatelet, or none). SEARCH METHODS We searched the Cochrane Stroke Trials Register, CENTRAL; 2017, Issue 11, MEDLINE Ovid, and Embase Ovid on 27 November 2017. In an effort to identify further published, ongoing, and unpublished randomised controlled trials (RCT), we scanned bibliographies of relevant articles and searched international registers of RCTs in November 2017. SELECTION CRITERIA We sought randomised controlled trials (RCTs) of any haemostatic intervention (i.e. pro-coagulant treatments such as coagulation factors, antifibrinolytic drugs, or platelet transfusion) for acute spontaneous ICH, compared with placebo, open control, or an active comparator, reporting relevant clinical outcome measures. DATA COLLECTION AND ANALYSIS Two authors independently extracted data, assessed risk of bias, and contacted corresponding authors of eligible RCTs for specific data if they were not provided in the published report of an RCT. MAIN RESULTS We included 12 RCTs involving 1732 participants. There were seven RCTs of blood clotting factors versus placebo or open control involving 1480 participants, three RCTs of antifibrinolytic drugs versus placebo or open control involving 57 participants, one RCT of platelet transfusion versus open control involving 190 participants, and one RCT of blood clotting factors versus fresh frozen plasma involving five participants. We were unable to include two eligible RCTs because they presented aggregate data for adults with ICH and other types of intracranial haemorrhage. We identified 10 ongoing RCTs. Across all seven criteria in the 12 included RCTs, the risk of bias was unclear in 37 (44%), high in 16 (19%), and low in 31 (37%). Only one RCT was at low risk of bias in all criteria.In one RCT of platelet transfusion versus open control for acute spontaneous ICH associated with antiplatelet drug use, there was a significant increase in death or dependence (modified Rankin Scale score 4 to 6) at day 90 (70/97 versus 52/93; risk ratio (RR) 1.29, 95% confidence interval (CI) 1.04 to 1.61, one trial, 190 participants, moderate-quality evidence). All findings were non-significant for blood clotting factors versus placebo or open control for acute spontaneous ICH with or without surgery (moderate-quality evidence), for antifibrinolytic drugs versus placebo (moderate-quality evidence) or open control for acute spontaneous ICH (moderate-quality evidence), and for clotting factors versus fresh frozen plasma for acute spontaneous ICH associated with anticoagulant drug use (no evidence). AUTHORS' CONCLUSIONS Based on moderate-quality evidence from one trial, platelet transfusion seems hazardous in comparison to standard care for adults with antiplatelet-associated ICH.We were unable to draw firm conclusions about the efficacy and safety of blood clotting factors for acute spontaneous ICH with or without surgery, antifibrinolytic drugs for acute spontaneous ICH, and clotting factors versus fresh frozen plasma for acute spontaneous ICH associated with anticoagulant drug use.Further RCTs are warranted, and we await the results of the 10 ongoing RCTs with interest.
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Affiliation(s)
- Rustam Al‐Shahi Salman
- University of EdinburghCentre for Clinical Brain SciencesFU303i, First floor, Chancellor's Building49 Little France CrescentEdinburghMidlothianUKEH16 4SB
| | - Zhe Kang Law
- Universiti Kebangsaan Malaysia Medical CentreDepartment of MedicineJalan Yaacob LatifBandar Tun RazakKuala LumpurCherasMalaysia56000
- University of Nottingham, City HospitalStroke Trials Unit, Division of Clinical NeuroscienceRoom B56, Clinical Sciences Building, City Hospital Campus,NottinghamUKNG5 1PB
| | - Philip M Bath
- University of Nottingham, City HospitalStroke Trials Unit, Division of Clinical NeuroscienceRoom B56, Clinical Sciences Building, City Hospital Campus,NottinghamUKNG5 1PB
| | - Thorsten Steiner
- Klinikum Frankfurt HöchstGotenstr 6‐8FrankfurtGermany65929
- Heidelberg University HospitalDepartment of NeurologyHeidelbergGermany
| | - Nikola Sprigg
- University of Nottingham, City HospitalStroke Trials Unit, Division of Clinical NeuroscienceRoom B56, Clinical Sciences Building, City Hospital Campus,NottinghamUKNG5 1PB
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Abstract
PURPOSE OF REVIEW Elevations in systolic blood pressure (BP) greater than 140 mmHg are reported in the majority (75%) of patients with acute ischemic stroke and in 80% of patients with acute intracerebral hemorrhages (ICH). This paper summarizes and updates the current knowledge regarding the proper management strategy for elevated BP in patients with acute stroke. Recent studies have generally showed a neutral effect of BP reduction on clinical outcomes among acute ischemic stroke patients. Thus, because of the lack of convincing evidence from clinical trials, aggressive BP reduction in patients presenting with acute ischemic stroke is currently not recommended. Although in patients treated with intravenous tissue plasminogen activator, guidelines are recommending BP < 180/105 mmHg but currently, the optimal BP management after reperfusion therapy still remains unclear. In acute ICH, the evidence from randomized clinical trials supports the immediate BP lowering targeting systolic BP to 140 mmHg, which is now recommended by guidelines.
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Unmet Needs and Challenges in Clinical Research of Intracerebral Hemorrhage. Stroke 2018; 49:1299-1307. [PMID: 29618558 DOI: 10.1161/strokeaha.117.019541] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/12/2018] [Accepted: 02/23/2018] [Indexed: 11/16/2022]
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Ge C, Zhao W, Guo H, Sun Z, Zhang W, Li X, Yang X, Zhang J, Wang D, Xiang Y, Mao J, Zhang W, Guo H, Zhang Y, Chen J. Comparison of the clinical efficacy of craniotomy and craniopuncture therapy for the early stage of moderate volume spontaneous intracerebral haemorrhage in basal ganglia: Using the CTA spot sign as an entry criterion. Clin Neurol Neurosurg 2018; 169:41-48. [PMID: 29625339 DOI: 10.1016/j.clineuro.2018.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/21/2018] [Accepted: 04/01/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Surgical treatment is widely used for haematoma removal in spontaneous intracerebral haemorrhage (ICH) patients, but there is controversy about the selection of surgical methods. The CT angiography (CTA) spot sign has been proven to be a promising factor predicting haematoma expansion and is recommended as an entry criterion for haemostatic therapy in patients with ICH. This trial was designed to evaluate the clinical efficacy of two surgical methods (haematoma removal by craniotomy and craniopuncture combined with urokinase infusion) for patients in the early stage (≤6h from symptom onset) of spontaneous ICH with a moderate haematoma volume (30 ml - 60 ml). PATIENTS AND METHODS From January 2012 to July 2017, 196 eligible patients treated in our institution were enrolled according to the inclusion criteria. The patients were divided into the CTA spot sign positive type and CTA spot sign negative type according to the presence or absence of the CTA spot sign. For each type, the patients were randomly assigned to two groups, i.e., the craniotomy group, in which patients underwent craniotomy with haematoma removal, and the craniopuncture group, in which patients underwent minimally invasive craniopuncture combined with urokinase infusion therapy. Neurological function was evaluated with the Scandinavian Stroke Scale (SSS) at day 14. The disability level and the activities of daily living were assessed using a modified Rankin Scale (mRS) and Barthel Index (BI) at day 90. Case fatalities were recorded at day 14 and 90. Complications were recorded during hospitalization. RESULTS For the CTA spot sign positive type, the craniotomy group had a higher SSS than that in the craniopuncture group (P < 0.05) at day 14. The rebleeding rate was higher in the craniopuncture group than that in the craniotomy group (P < 0.05) during hospitalization. The craniotomy group had a lower mRS than that in the craniopuncture group (P < 0.01) and had a higher BI than that in the craniopuncture group (P < 0.05) at day 90. There was no statistically significant difference in the fatality rate between the two groups. For the CTA spot sign negative type, there were no significant differences in the SSS, mRS, BI, fatality rate and complication rate between the two groups. CONCLUSION ICH can be divided into the CTA spot sign positive and negative type according to the presence or absence of the CTA spot sign. For the CTA spot sign positive type, patients can benefit from craniotomy with haematoma removal, which can reduce the postoperative rebleeding rate and improve the prognosis. For the CTA spot sign negative type, both craniotomy and craniopuncture are applicable. Considering simple procedure and minor surgical injury, craniopuncture can be a more reasonable choice.
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Affiliation(s)
- Chunyan Ge
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Wangmiao Zhao
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Hong Guo
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Zhaosheng Sun
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Wanzeng Zhang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Xiaowei Li
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Xuehui Yang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Jinrong Zhang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Dongxin Wang
- Department of Radiology, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Yi Xiang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Jianhui Mao
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Wenchao Zhang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Hao Guo
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Yazhao Zhang
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
| | - Jianchao Chen
- Department of Neurosurgery, Harrison International Peace Hospital (Hengshui People's Hospital) Affiliated to Hebei Medical University, Postal address: No. 180, East Renmin Road, Hengshui City, Hebei Province, China.
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Suo Y, Chen W, Pan Y, Peng Y, Yan H, Li W, Liu G, Wang Y. Magnetic Resonance Imaging Markers of Cerebral Small Vessel Disease in Hematoma Expansion of Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2018; 27:2006-2013. [PMID: 29605289 DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/19/2018] [Accepted: 02/28/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Hematoma expansion is an independent risk factor of unfavorable outcome after intracerebral hemorrhage (ICH), which always occurs in the early phase after symptoms onset. The relationship between underlying small vessel disease (SVD) and hematoma expansion was inconsistent in patients with ICH. We aimed to investigate the relationship between magnetic resonance (MR) characteristics of SVD and hematoma expansion in patients with ICH within 72 hours after symptoms onset. METHODS Data were derived from a cohort of biological sample collection from April 2014 to April 2016. We recruited patients aged 18 years or older with a baseline and follow-up computed tomography within 72 hours after symptom onset, as well as an MR imaging within 3 months before or after ICH. Hematoma expansion was defined as an increase in volume between baseline and final hematoma volume exceeding 6 mL or 33% of the baseline volume. Multivariate logistic regression was used to explore the association between clinical characteristics, imaging markers, total SVD score, and hematoma expansion in patients with ICH. RESULTS A total of 103 patients experienced hematoma expansion among the 263 enrolled patients (mean age 53.4 ± 14.0 years, 76.4% male). Electrocardiogram abnormal rhythm, fewer non-lobar microbleeds, lower plasma homocysteine concentration, and smaller baseline hematoma volume independently predicted the risk of hematoma expansion (P = .004, .021, .001, and .024, respectively). Odds ratios ranged from 1.02 to 3.72. CONCLUSIONS Our study suggested that the use of MR markers revealing underlying SVD may help to identify patients with ICH with potential hematoma expansion.
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Affiliation(s)
- Yue Suo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Weiqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Yujing Peng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wei Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; Monogenic Disease Research Center for Neurological Disorders, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Intensive Care Unit Admission for Patients in the INTERACT2 ICH Blood Pressure Treatment Trial: Characteristics, Predictors, and Outcomes. Neurocrit Care 2018; 26:371-378. [PMID: 28000127 DOI: 10.1007/s12028-016-0365-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Wide variation exists in criteria for accessing intensive care unit (ICU) facilities for managing patients with critical illnesses such as acute intracerebral hemorrhage (ICH). We aimed to determine the predictors of admission, length of stay, and outcome for ICU among participants of the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). METHODS INTERACT2 was an international, open, blinded endpoint, randomized controlled trial of 2839 ICH patients (<6 h) and elevated systolic blood pressure (SBP) allocated to receive intensive (target SBP <140 mmHg within 1 h) or guideline-recommended (target SBP <180 mmHg) BP-lowering treatment. The primary outcome was death or major disability, defined by modified Rankin scale scores 3-6 at 90 days. Logistic regression and propensity score analyses were used to determine independent associations. MAIN RESULTS Predictors of ICU admission included younger age, recruitment in China, prior ischemic/undetermined stroke, high SBP, severe stroke [National Institute of Health stroke scale (NIHSS) score ≥15], large ICH volume (≥15 mL), intraventricular hemorrhage (IVH) extension, early neurological deterioration, intubation and surgery. Determinants of prolonged ICU stay (≥5 days) were prior antihypertensive use, NIHSS ≥15, large ICH volume, lobar ICH location, IVH, early neurological deterioration, intubation and surgery. ICU admission was associated with higher-risk major disability at 90-day assessment compared to those without ICU admission. CONCLUSIONS This study presents prognostic variables for ICU management and outcome of ICH patients included in a large international cohort. These data may assist in the selection and counseling of patients and families concerning ICU admission.
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Wang LG, Huangfu XQ, Tao B, Zhong GJ, Le ZD. Serum tenascin-C predicts severity and outcome of acute intracerebral hemorrhage. Clin Chim Acta 2018; 481:69-74. [PMID: 29499198 DOI: 10.1016/j.cca.2018.02.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/22/2018] [Accepted: 02/25/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Tenascin-C is a matricellular protein related to brain injury. We studied serum tenascin-C in acute intracerebral hemorrhage (ICH) and examined the associations with severity and outcome following the acute event. METHODS Tenascin-C samples were obtained from 162 patients with acute hemorrhagic stroke and 162 healthy controls. Poor 90-day functional outcome was defined as modified Rankin Scale score > 2. Early neurological deterioration (END) and hematoma growth (HG) were recorded at 24 h. RESULTS Patients had higher tenascin-C levels than controls. Tenascin-C levels were positively correlated with hematoma volume or National Institutes of Health Stroke Scale score at baseline. Elevated tenascin-C levels were independently associated with END, HG, 90-day mortality and poor functional outcome. Moreover, tenascin-C levels significantly predicted END, HG and 90-day outcomes under receiver operating characteristic curves. CONCLUSIONS An increase in serum tenascin-C level is associated with an adverse outcome in ICH patients, supporting the potential role of serum tenascin-C as a prognostic biomarker for hemorrhagic stroke.
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Affiliation(s)
- Lin-Guo Wang
- Department of Neurosurgery, The First People's Hospital of Tonglu County, 338 Xuesheng Road, Tonglu 311500, China.
| | - Xue-Qin Huangfu
- Department of Neurosurgery, The First People's Hospital of Tonglu County, 338 Xuesheng Road, Tonglu 311500, China
| | - Bo Tao
- Department of Neurosurgery, The First People's Hospital of Tonglu County, 338 Xuesheng Road, Tonglu 311500, China
| | - Guan-Jin Zhong
- Department of Neurosurgery, The First People's Hospital of Tonglu County, 338 Xuesheng Road, Tonglu 311500, China
| | - Zhou-Di Le
- Department of Neurosurgery, The First People's Hospital of Tonglu County, 338 Xuesheng Road, Tonglu 311500, China
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243
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Ker K, Prieto-Merino D, Sprigg N, Mahmood A, Bath P, Kang Law Z, Flaherty K, Roberts I. The effectiveness and safety of antifibrinolytics in patients with acute intracranial haemorrhage: statistical analysis plan for an individual patient data meta-analysis. Wellcome Open Res 2018; 2:120. [DOI: 10.12688/wellcomeopenres.13262.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2017] [Indexed: 11/20/2022] Open
Abstract
Introduction: The Antifibrinolytic Trialists Collaboration aims to increase knowledge about the effectiveness and safety of antifibrinolytic treatment by conducting individual patient data (IPD) meta-analyses of randomised trials. This article presents the statistical analysis plan for an IPD meta-analysis of the effects of antifibrinolytics for acute intracranial haemorrhage. Methods: The protocol for the IPD meta-analysis has been registered with PROSPERO (CRD42016052155). We will conduct an individual patient data meta-analysis of randomised controlled trials with 1000 patients or more assessing the effects of antifibrinolytics in acute intracranial haemorrhage. We will assess the effect on two co-primary outcomes: 1) Death in hospital within 30 days of randomisation, and 2) Death or dependency at final follow-up within 90 days of randomisation. The co-primary outcomes will be limited to patients treated within three hours of injury or stroke onset. We will report treatment effects using odds ratios and 95% confidence intervals. We use logistic regression models to examine how the effect of antifibrinolytics vary by time to treatment, severity of intracranial bleeding, and age. We will also examine the effect of antifibrinolytics on secondary outcomes including death, dependency, vascular occlusive events, seizures, and neurological outcomes. Secondary outcomes will be assessed in all patients irrespective of time of treatment. All analyses will be conducted on an intention-to-treat basis. Conclusions: This IPD meta-analysis will examine important clinical questions about the effects of antifibrinolytic treatment in patients with intracranial haemorrhage that cannot be answered using aggregate data. With IPD we can examine how effects vary by time to treatment, bleeding severity, and age, to gain better understanding of the balance of benefit and harms on which to base recommendations for practice.
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van Ginneken V, Engel P, Fiebach JB, Audebert HJ, Nolte CH, Rocco A. Prior antiplatelet therapy is not associated with larger hematoma volume or hematoma growth in intracerebral hemorrhage. Neurol Sci 2018; 39:745-748. [DOI: 10.1007/s10072-018-3255-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/13/2018] [Indexed: 11/28/2022]
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Combination of Intra-Hematomal Hypodensity on CT and BRAIN Scoring Improves Prediction of Hemorrhage Expansion in ICH. Neurocrit Care 2018; 29:40-46. [DOI: 10.1007/s12028-018-0507-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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246
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Cusack TJ, Carhuapoma JR, Ziai WC. Update on the Treatment of Spontaneous Intraparenchymal Hemorrhage: Medical and Interventional Management. Curr Treat Options Neurol 2018; 20:1. [PMID: 29397452 DOI: 10.1007/s11940-018-0486-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Spontaneous intraparenchymal hemorrhage (IPH) is a prominent challenge faced globally by neurosurgeons, neurologists, and intensivists. Over the past few decades, basic and clinical research efforts have been undertaken with the goal of delineating biologically and evidence-based practices aimed at decreasing mortality and optimizing the likelihood of meaningful functional outcome for patients afflicted with this devastating condition. Here, the authors review the medical and surgical approaches available for the treatment of spontaneous intraparenchymal hemorrhage, identifying areas of recent progress and ongoing research to delineate the scope and scale of IPH as it is currently understood and treated. RECENT FINDINGS The approaches to IPH have broadly focused on arresting expansion of hemorrhage using a number of approaches. Recent trials have addressed the effectiveness of rapid blood pressure lowering in hypertensive patients with IPH, with rapid lowering demonstrated to be safe and at least partially effective in preventing hematoma expansion. Hemostatic therapy with platelet transfusion in patients on anti-platelet medications has been recently demonstrated to have no benefit and may be harmful. Hemostasis with administration of clotting complexes has not been shown to be effective in reducing hematoma expansion or improving outcomes although correcting these abnormalities as soon as possible remains good practice until further data are available. Stereotactically guided drainage of IPH with intraventricular hemorrhage (IVH) has been shown to be safe and to improve outcomes. Research on new stereotactic surgical methods has begun to show promise. Patients with IPH should have rapid and accurate diagnosis with neuroimaging with computed tomography (CT) and computed tomography angiography (CTA). Early interventions should include control of hypertension to a systolic BP in the range of 140 mmHg for small hemorrhages without intracranial hypertension with beta blockers or calcium channel blockers, correction of any coagulopathy if present, and assessment of the need for surgical intervention. IPH and FUNC (Functional Outcome in Patients with Primary Intracerebral Hemorrhage) scores should be assessed. Patients should be dispositioned to a dedicated neurologic ICU if available. Patients should be monitored for seizures and intracranial pressure issues. Select patients, particularly those with intraventricular extension, may benefit from evacuation of hematoma with a ventriculostomy or stereotactically guided catheter. Once stabilized, patients should be reassessed with CT imaging and receive ongoing management of blood pressure, cerebral edema, ICP issues, and seizures as they arise. The goal of care for most patients is to regain capacity to receive multidisciplinary rehabilitation to optimize functional outcome.
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Affiliation(s)
- Thomas J Cusack
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology/Critical Care Medicine, The Johns Hopkins Hospital, 1800 Orleans Street/Phipps 455, Baltimore, MD, 21287, USA
| | - J Ricardo Carhuapoma
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology/Critical Care Medicine, The Johns Hopkins Hospital, 1800 Orleans Street/Phipps 455, Baltimore, MD, 21287, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology/Critical Care Medicine, The Johns Hopkins Hospital, 1800 Orleans Street/Phipps 455, Baltimore, MD, 21287, USA.
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247
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Al-Mufti F, Thabet AM, Singh T, El-Ghanem M, Amuluru K, Gandhi CD. Clinical and Radiographic Predictors of Intracerebral Hemorrhage Outcome. INTERVENTIONAL NEUROLOGY 2018; 7:118-136. [PMID: 29628951 PMCID: PMC5881146 DOI: 10.1159/000484571] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) represents 10-15% of all stroke cases in the US annually. Fewer than 40% of these patients ever reach long-term functional independence, and mortality rate is roughly 40% at 1 month. Due to the high morbidity and mortality rates after ICH, early detection of high-risk patients would be beneficial in directing the management course and goals of care. This review aims to discuss relevant clinical and radiographic characteristics that can serve as predictors of poor prognosis and examine their efficacy in predicting patient outcomes after ICH. SUMMARY A literature review was conducted on various clinical and radiographic factors. They were examined for their predictive value in relation to ICH outcome. Studies that focused on each of these factors were included, and their results analyzed for trends with regard to incidence, patient outcome, and mortality rate. KEY MESSAGE In this review, we examined clinical and radiographic characteristics that have been found to be significantly associated to a varying degree with poor outcome. Clinical and radiographic predictors of poor patient outcome are invaluable when it comes to identifying high-risk patients and triaging accordingly as well as guiding decision-making.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Neurosurgery, and Radiology, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
| | - Ahmad M. Thabet
- Department of Neurology, Neurosurgery, and Radiology, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Tarundeep Singh
- Department of Neurology, Neurosurgery, and Radiology, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery, and Radiology, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
| | - Krishna Amuluru
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
- Department of Interventional Neuroradiology, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania, USA
| | - Chirag D. Gandhi
- Westchester Medical Center, New York College of Medicine, Valhalla, New York, USA
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248
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Serum S100A12 and 30-day mortality after acute intracerebral hemorrhage. Clin Chim Acta 2018; 477:1-6. [DOI: 10.1016/j.cca.2017.11.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 11/24/2017] [Accepted: 11/27/2017] [Indexed: 11/18/2022]
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249
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Xiong X, Li Q, Yang WS, Wei X, Hu X, Wang XC, Zhu D, Li R, Cao D, Xie P. Comparison of Swirl Sign and Black Hole Sign in Predicting Early Hematoma Growth in Patients with Spontaneous Intracerebral Hemorrhage. Med Sci Monit 2018; 24:567-573. [PMID: 29375118 PMCID: PMC5800320 DOI: 10.12659/msm.906708] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Early hematoma growth is associated with poor outcome in patients with spontaneous intracerebral hemorrhage (ICH). The swirl sign (SS) and the black hole sign (BHS) are imaging markers in ICH patients. The aim of this study was to compare the predictive value of these 2 signs for early hematoma growth. Material/Methods ICH patients were screened for the appearance of the 2 signs within 6 h after onset of symptoms. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the 2 signs in predicting early hematoma growth were assessed. The accuracy of the 2 signs in predicting early hematoma growth was analyzed by receiver-operator analysis. Results A total of 200 patients were enrolled in this study. BHS was found in 30 (15%) patients, and SS was found in 70 (35%) patients. Of the 71 patients with early hematoma growth, BHS was found on initial computed tomography scans in 24 (33.8%) and SS in 33 (46.5%). The sensitivity, specificity, PPV, and NPV of BHS for predicting early hematoma growth were 33.8%, 95.3%, 80.0%, and 72.0%, respectively. The sensitivity, specificity, PPV, and NPV of SS were 46.5%, 71.3%, 47.0%, and 71.0%, respectively. The area under the curve was 0.646 for BHS and 0.589 for SS (P=0.08). Multivariate logistic regression showed that presence of BHS is an independent predictor of early hematoma growth. Conclusions The Black hole sign seems to be good predictor for hematoma growth. The presence of swirl sign on admission CT does not independently predict hematoma growth in patients with ICH.
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Affiliation(s)
- Xin Xiong
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland).,Department of Neurology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China (mainland)
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Wen-Song Yang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Xiao Wei
- Department of Medical Technology, Chongqing Medical and Pharmaceutical College, Chongqing, China (mainland)
| | - Xi Hu
- Department of Neurosurgery, The Fourth People's Hospital of Chongqing, Chongqing, China (mainland)
| | - Xing-Chen Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Dan Zhu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Rui Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Du Cao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
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250
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Huh J, Yang SY, Huh HY, Ahn JK, Cho KW, Kim YW, Kim SL, Kim JT, Yoo DS, Park HK, Ji C. Compare the Intracranial Pressure Trend after the Decompressive Craniectomy between Massive Intracerebral Hemorrhagic and Major Ischemic Stroke Patients. J Korean Neurosurg Soc 2018; 61:42-50. [PMID: 29354235 PMCID: PMC5769847 DOI: 10.3340/jkns.2017.0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/03/2017] [Accepted: 09/06/2017] [Indexed: 11/27/2022] Open
Abstract
Objective Massive intracerebral hemorrhage (ICH) and major infarction (MI) are devastating cerebral vascular diseases. Decompression craniectomy (DC) is a common treatment approach for these diseases and acceptable clinical results have been reported. Author experienced the postoperative intracranaial pressure (ICP) trend is somewhat different between the ICH and MI patients. In this study, we compare the ICP trend following DC and evaluate the clinical significance. Methods One hundred forty-three patients who underwent DC following massive ICH (81 cases) or MI (62 cases) were analyzed retrospectively. The mean age was 56.3±14.3 (median=57, male : female=89 : 54). DC was applied using consistent criteria in both diseases patients; Glasgow coma scale (GCS) score less than 8 and a midline shift more than 6 mm on brain computed tomography. In all patients, ventricular puncture was done before the DC and ICP trends were monitored during and after the surgery. Outcome comparisons included the ictus to operation time (OP-time), postoperative ICP trend, favorable outcomes and mortality. Results Initial GCS (p=0.364) and initial ventricular ICP (p=0.783) were similar among the ICH and MI patients. The postoperative ICP of ICH patients were drop rapidly and maintained within physiological range if greater than 80% of the hematoma was removed. While in MI patients, the postoperative ICP were not drop rapidly and maintained above the physiologic range (MI=18.8 vs. ICH=13.6 mmHg, p=0.000). The OP-times were faster in ICH patients (ICH=7.3 vs. MI=40.9 hours, p=0.000) and the mortality rate was higher in MI patients (MI=37.1% vs. ICH=17.3%, p=0.007). Conclusion The results of this study suggest that if greater than 80% of the hematoma was removed in ICH patients, the postoperative ICP rarely over the physiologic range. But in MI patients, the postoperative ICP was above the physiologic range for several days after the DC. Authors propose that DC is no need for the massive ICH patient if a significant portion of their hematoma is removed. But DC might be essential to improve the MI patients’ outcome and timely treatment decision.
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Affiliation(s)
- Joon Huh
- Department of Neurosurgery, Myungji St. Mary's Hospital, Seoul, Korea
| | - Seo-Yeon Yang
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Han-Yong Huh
- Department of Neurosurgery, St. Paul's Hospital, Seoul, Korea
| | - Jae-Kun Ahn
- Department of Neurosurgery, St. Paul's Hospital, Seoul, Korea
| | - Kwang-Wook Cho
- Department of Neurosurgery, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Young-Woo Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Sung-Lim Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Jong-Tae Kim
- Department of Neurosurgery, Incheon St. Mary's Hospital, Incheon, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea.,Department of Neurosurgery, St. Paul's Hospital, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Cheol Ji
- Department of Neurosurgery, St. Paul's Hospital, Seoul, Korea
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