Treatment of intracerebral hemorrhage: What should we do now?

Efficacy of stem cell therapy in animal models of intracerebral hemorrhage: an updated meta-analysis

BACKGROUND

Multiple studies have reported that stem cell therapy has beneficial effects in animal models of intracerebral hemorrhage (ICH). However, this finding remains inconclusive. This study was performed to systematically determine the effect size of stem cell therapy in ICH animal models by pooling and analyzing data from newly published studies.

METHODS

A literature search identified studies of stem cells in animal models of ICH. We searched mainstream databases from inception to November, 2021. And pooled effect size of stem cells was determined for diversified neurobehavioral scales and structural endpoints using random effects models.

RESULTS

The median quality score of 62 included studies was 5.32. Our results revealed an overall positive effect of stem cell therapy. More specifically, the SMD was - 2.27 for mNSS, - 2.14 for rotarod test, - 2.06 for MLPT, - 1.33 for cylinder test, - 1.95 for corner turn test, - 1.42 for tissue loss, and - 1.86 for brain water content. For mNSS, classifying comparisons by quality score showed significant differences in estimates of effect size (p = 0.013), and high-quality comparisons showed a better outcome (SMD = - 2.57) compared with low-quality comparisons (SMD = - 1.59). Besides, different delivery routes also showed a significant difference in the estimates of effect size for mNSS (p = 0.002), and the intraperitoneal route showed the best outcome (SMD = - 4.63). For tissue loss, the autologous blood-induced ICH model showed a better outcome (SMD = - 1.84) compared with the collagenase-induced ICH model (SMD = - 0.94, p = 0.035). Additionally, stem cell therapy initiated within 8 h post-ICH showed the greatest efficacy on tissue loss reduction, followed by initiated with 24 h post-ICH. Finally, stem cells with different sources and types showed similar beneficial effects for mNSS as well as tissue loss.

CONCLUSIONS

Our results suggested that stem cell therapy had remarkable benefits on ICH animals on both the functional and structural outcomes in animal models of ICH, with very large effect size. These findings support the utility of further studies to translate stem cells in the treatment of ICH in humans. Moreover, the results should be interpreted in the light of the limitations in experimental design and the methodological quality of the studies included in the meta-analysis.

Efficacy of melatonin in animal models of intracerebral hemorrhage: a systematic review and meta-analysis

Melatonin is a potent antioxidant and anti-inflammatory agent that is showing promising results in acute brain injury. The aim of this study was to systematically evaluate the pre-clinical evidence on the effectiveness of melatonin in improving outcome after intracerebral hemorrhage (ICH). We searched mainstream databases from the inception to the end of June 2020. Outcomes were measured by neurobehavioral scores or brain water content. Meta-analyses were performed with Stata 12.0 and Review Manager 5.3. Finally, 8 articles published from 2008 to 2019 met the inclusion criteria. Meta-analysis of pre-clinical data revealed an overall positive effect on neurobehavioral outcome with a standardized mean difference (SMD) of -0.81 (95% CI: -1.47, -0.15; p = 0.016) with significant heterogeneity (Q = 41.49, I² = 68.7%; p = 0.000). Further subgroup analysis were performed from methodological differences, especially dose and timing of treatments. Furthermore, melatonin reduced cerebral edema by an SMD of -0.78 (95% CI: -1.23, -0.34; p = 0.001) with low heterogeneity. In conclusion, melatonin treatment significantly improves both behavioral and pathological outcomes in animal models of ICH. In addition, the results should be interpreted in light of the limitations in experimental design and methodological quality of the studies included in the meta-analysis.

Systematic Review and Meta-Analysis of Randomized Controlled Trials of Liangxue Tongyu Formula on Patients With Acute Intracerebral Hemorrhage

BACKGROUND

As a traditional Chinese medicine (TCM) prescription for acute stroke, Liangxue Tongyu formula (LXTYF) was widely used as auxiliary treatment measure in some clinical practice. This study aimed to evaluate the clinical efficacy and safety of LXTYF combined western conventional medicine (WCM) with WCM only for acute intracerebral hemorrhage (ICH).

METHODS

We systematically searched PubMed, Embase, Cochrane Library, CMB (Chinese biomedicine database), CNKI (China National Knowledge Infrastructure), WanFang, and VIP until August 2019 to confirm relevant randomized controlled trials (RCTs) compared the combination of LXTYF and WCM with WCM alone for the treatment of acute ICH. Two investigators independently assessed the risk of bias, and extracted and analyzed the data from the identified studies using RevMan 5.3.0 software following Cochrane's standard and PRISMA guidelines. The herbal compositions of LXTYF were also assessed.

RESULTS

15 RCTs were identified, totally recruiting 1648 patients with acute intracerebral hemorrhage. Compared with the WCM alone, the combination therapy of LXTYF with WCM could improve the clinical effective rate (RR, 1.21; 95% CI, 1.15-1.25, P < 0.05) and ADL score (MD, 18.09; 95% CI, 12.11-24.07; P < 0.05), and reduce syndrome scores of the TCM (MD, -4.11; 95% CI, -4.69 to -3.53; P < 0.05) and the Glasgow outcome score(GOS) (MD=0.43, 95%CI: 0.06 to 0.79, P=0.02) Moreover, there was no sufficient evidence to indicate the adverse effects would increase compared with WCM alone.

CONCLUSION

Based on current evidence, we concluded that the combined therapy had some benefits in treating acute intracerebral hemorrhage. However, considering the potential biases and limitations of our study, additional large, high-quality RCTs are required in the future to confirm or refute the effects of LFTYF combined with WCM in acute stroke.

Electroacupuncture improves neurobehavioral function and brain injury in rat model of intracerebral hemorrhage

Acupuncture has been widely used as a treatment for stroke in China for a long time. Recently, studies have demonstrated that electroacupuncture (EA) can accelerate intracerebral hemorrhage (ICH)-induced angiogenesis in rats. In the present study, we investigated the effect of EA on neurobehavioral function and brain injury in ICH rats. ICH was induced by stereotactic injection of collagenase type I and heparin into the right caudate putamen. Adult ICH rats were randomly divided into the following three groups: model control group (MC), EA at non-acupoint points group (non-acupoint EA) and EA at Baihui and Dazhui acupoints group (EA). The neurobehavioral deficits of ICH rats were assessed by modified neurological severity score (mNSS) and gait analysis. The hemorrhage volume and glucose metabolism of hemorrhagic foci were detected by PET/CT. The expression levels of MBP, NSE and S100-B proteins in serum were tested by ELISA. The histopathological features were examined by haematoxylin-eosin (H&E) staining. Apoptosis-associated proteins in the perihematomal region were observed by immunohistochemistry. EA treatment significantly promoted the recovery of neurobehavioral function in ICH rats. Hemorrhage volume reduced in EA group at day 14 when compared with MC and non-acupoint EA groups. ELISA showed that the levels of MBP, NSE and S100-B in serum were all down-regulated by EA treatment. The brain tissue of ICH rat in the EA group was more intact and compact than that in the MC and non-acupoint groups. In the perihematomal regions, the expression of Bcl-2 protein increased and expressions of Caspase-3 and Bax proteins decreased in the EA group vs MC and non-acupoint EA groups. Our data suggest that EA treatment can improve neurobehavioral function and brain injury, which were likely connected with the absorption of hematoma and regulation of apoptosis-related proteins.

Buyang huanwu decoction promotes angiogenesis via vascular endothelial growth factor receptor-2 activation through the PI3K/Akt pathway in a mouse model of intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is a fatal subtype of stroke that lacks effective treatments. Angiogenesis following ICH is an important response mediating brain recovery and repair. Phosphorylation of vascular endothelial growth factor receptor 2 (pVEGFR2) via PI3K/Akt signaling plays a key role in mediating cellular processes involved in repair, such as mitogenesis, angiogenesis, and vascular permeability. This study aimed to investigate the potential effects of Buyang Huanwu Decoction (BYHWD), a traditional Chinese medicine formula, on angiogenesis by VEGFR2 activation through the phosphatidylinositol 3 kinase (PI3K)/Akt signaling pathway in a mouse model of ICH.

METHODS

Adult male Kunming mice (n = 50) were randomly assigned into sham and ICH-operated groups and treated with one of the followings SU5416 (VEGFR2 inhibitor), BYHWT and BYHWT + SU5416. ICH was induced in mice by injecting collagenase (type VII) into the right globus pallidus of the mouse brain. BYHWD (4.36 g/kg) was administrated in mice by intragastric infusion. Neurological function was evaluated in mice by a modified Neurological Severity Scores (mNSS) as well as corner turn and foot-fault tests. Angiogenesis was examined by intraperitoneal injection of 5-bromodeoxyuridine (BrdU) in mice to quantify new brain vessel growth. SU5416 treatment and assessment of VEGFR2 phosphorylation as well as alterations in PI3K/Akt signaling were performed to determine whether the effect of BYHWD on angiogenesis was partly mediated by phosphorylation of VEGFR2 via the PI3K/Akt signaling pathway.

RESULTS

We show that BYHWD treated mice exhibited (i) significantly better recovery from neurological dysfunction, (ii) increased BrdU(+) nuclei in vWF(+) dilated brain vessels and (iii) higher VEGFR2 phosphorylation immunoreactivity in brain microvessels (P <0.05), (iv) higher expression of PI3K and pAkt at the protein level (P <0.05) when compared to untreated ICH mice. These beneficial effects were reversed by SU5416 (P <0.05).

CONCLUSIONS

BYHWD promoted neurological recovery and angiogenesis after ICH in mice by enhancing VEGFR2 phosphorylation through the PI3K/Akt signaling pathway.

Individual characteristics and management decisions affect outcome of anticoagulated patients with intracranial hemorrhage

BACKGROUND

Anticoagulated patients with intracranial hemorrhage represent a major management challenge. Our goal is to determine how patient characteristics and management decisions influence outcome.

METHODS

A systematic review of the literature identified relevant reported cases. Variables describing patient characteristics, management, and outcome were extracted. Statistical analyses were carried out using analysis of variance and Fisher's exact test.

RESULTS

A total of 242 patients from our updated dataset met inclusion criteria. Tissue plane of the hemorrhage (P < 0.0001), indication for anticoagulation (P < 0.0001), type of anticoagulant (P = 0.0173), and history of hypertension (P = 0.0418) were significantly associated with outcome. Older age (P < 0.0001), supratentorial index hemorrhages (P = 0.0018), failure to restart anticoagulation (P < 0.0001), and larger hematoma volume (P < 0.0001) were associated with worse outcome. Surgical evacuation was associated with improved outcome (P = 0.0011). There was a trend toward an association between the occurrence of a hemorrhagic or thromboembolic complication and risk of death (P = 0.0882). Sex and sidedness of the index hemorrhage were not significantly associated with outcome.

CONCLUSIONS

Our results provide prognostic information that may assist management of these patients. Our results also suggest that it may be unwise to withhold anticoagulation indefinitely after an index hemorrhage. As thromboembolic or hemorrhagic complications may be associated with worse outcome, efforts to avoid them may be wise. The studies that comprise our dataset have important limitations and a prospective study will be required to confirm these results.

Relationship between leukocyte kinetics and behavioral tests changes in the inflammatory process of hemorrhagic stroke recovery

In this study, we investigated the inflammatory response to hemorrhagic stroke (HS) as the main mechanism of brain functional recovery. Sprague-Dawley rats (n = 24) underwent surgery with sterile saline (control group, n = 12) and collagenase IV-S (stroke group, n = 12) being injected into the right striatum. White blood cell analysis, histological and immunohistological examination of the brain slices, as well as densitometric analysis of polymorphonuclear and microglial cells/macrophages were correlated with behavioral tests, and the data were subjected to appropriate statistical processing. The results indicate a strong correlation between polymorphonuclear and mononuclear changes in the blood and the zone of hemorrhagic stroke with behavioral tests of functional brain recovery. We propose that the inflammatory response is determined by kinetics of polymorphonuclear and mononuclear cells in both the blood and the hemorrhagic stroke zone. Kinetics of these cells is followed by the restoration of functions, and the maximum functional recovery is observed by the time polymorphonuclear and mononuclear stages have completed. With the development of inflammation and leukocyte kinetics, it is possible to predict functional recovery of hemorrhagic stroke. Improvement of the degree and rate of hemorrhagic stroke functional recovery may be achieved by therapeutic interventions into the inflammatory mechanisms influencing polymorphonuclear and mononuclear cell kinetics.