Long-term Outcomes and Risk Factors Related to Hydrocephalus After Intracerebral Hemorrhage

Short-term prognostic value of cranial volume in patients with cerebral hemorrhage based on propensity score matching

OBJECTIVES

The purpose of this study was to investigate whether cranial volume can improve the accuracy of prognosis, and to explore the relationship between the prognosis of patients with cerebral hemorrhage and the cranial volume and anterior and posterior diameter.

METHODS

We obtained data from patients diagnosed with spontaneous cerebral hemorrhage between 2018 and 2020 at the First Hospital of Harbin Medical University. The hematoma volume to cranial volume ratio (HVCVR) was calculated as the ratio of hematoma volume to cranial volume. Multivariate logistic regression models were developed to assess the predictive power of hematoma volume and HVCVR. Propensity score matching was employed to adjust for baseline differences in cranial volume. Multiple logistic regression models were used to explore the relationship between cranial diameter and prognosis.

RESULTS

Among 3494 patients, 1,796 (51.4%) had poor outcomes. Poor outcomes were associated with larger HVCVR values, and multivariate analysis confirmed HVCVR as an independent predictor (OR 1.722, 95 % CI 1.471-2.206, P < 0.001), outperforming hematoma volume alone (AUC 0.774 vs. 0.761, P < 0.001). Propensity-matched cohorts (n = 1199 each) revealed that larger intracranial volume correlated with better prognosis (OR 0.802, 95 % CI 0.683-0.942, P = 0.002).

CONCLUSION

Our study suggests that HVCVR provides a more accurate prediction of prognosis in spontaneous cerebral hemorrhage patients. Greater cranial volume and a more flattened cranial cavity may potentially influence positive prognoses in patients with cerebral hemorrhage.

Acetylation of α-tubulin restores endothelial cell injury and blood-brain barrier disruption after intracerebral hemorrhage in mice

Damage to endothelial cells (ECs) is a key factor in blood-brain barrier (BBB) disruption after intracerebral hemorrhage (ICH). While microtubules are essential for EC structure, their role in BBB injury remains unclear. Here we investigated the role of acetylated α-tubulin (α-Ac-Tub) in BBB integration after ICH. Using an autologous blood injection model in the striatum, we showed that the expression of α-Ac-Tub and MEC17, an α-tubulin acetyltransferase, significantly decreased along the vessels around the hematoma after ICH. Conditional MEC17 knockout in ECs further reduced α-Ac-Tub levels and exacerbated BBB leakage, brain edema, hematoma expansion, inflammation and motor dysfunction. Conversely, selective α-Ac-Tub upregulation in ECs via intravenous delivery of AAV-BI30-MEC17-GFP alleviated BBB dysfunction and improved motor recovery. Similarly, the HDAC6 inhibitor tubastatin A enhanced α-Ac-Tub levels, mitigating BBB damage and neurological deficits. Mechanistically, α-Ac-Tub deficiency in ECs reduced tight junction proteins (ZO-1 and Claudin5) and increased F-actin stress fibers through RhoA activation. Together, our findings highlighted α-Ac-Tub as a therapeutic target for restoring BBB function and reducing brain injury after ICH.

Estimation of Ventricular and Intracranial Hemorrhage Volumes and Midline Shift on an External Validation Data Set Using a Convolutional Neural Network Algorithm

BACKGROUND AND OBJECTIVES

Noncontrast head computed tomography is the mainstay imaging modality to guide the management of intracranial hemorrhage (ICH); however, manual measurements can be time-consuming. In our study, we evaluate the performance of an artificial intelligence (AI) machine learning algorithm, Viz ICH-Plus, to automatically quantify ICH and bilateral lateral ventricular (BLV) volumes as well as midline shift (MLS).

METHODS

ICH patients considered for external ventricular drain with an initial noncontrast head computed tomography, and at least 1 follow-up scan within 48 hours was identified from a single center. Viz ICH-Plus estimations of ICH volume, BLV volume, and MLS were generated for each scan and compared with manually contoured and measured values. Median absolute errors and the ability of Viz ICH-Plus to detect clinically meaningful change from initial to follow-up scans (ICH volume growth ≥10 mL, BLV volume change ≥10 mL, or MLS increase ≥4 mm) were assessed.

RESULTS

Thirty patients were included for a total of 78 scans. The median absolute error was 2.9 mL (IQR 1.2 to 5.8) for ICH, 5.3 mL (IQR 2.5 to 7.9) for BLV volume, and 1.1 mm (IQR 0.7 to 2.0) for MLS. The ability of Viz ICH-Plus to detect a clinically significant change between scans was robust with sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of 91.7%, 92.6%, 84.6%, 96.2%, and 92.3%, respectively.

CONCLUSION

The described Viz ICH-Plus algorithm performed moderately well at quantifying ICH, BLV volume, and MLS with satisfying spatial overlap of artificial intelligence and manual segmentations. The system demonstrated good predictive power when using predetermined thresholds to estimate clinically significant changes.

Development and validation of a nomogram for predicting early neurological deterioration in patients with moderate traumatic brain injury: a retrospective analysis

Objective

Early neurological deterioration (END) greatly affects prognosis of moderate traumatic brain injury (TBI). This study aimed to develop and validate a nomogram to predict the occurrence of END in patients with moderate TBI.

Methods

A total of 371 patients with moderate TBI were enrolled and divided into the training (n = 260) and validation (n = 111) groups at a ratio of 7:3. Univariate and multivariate logistic regression analyses were used to identify the significant factors for END, which were used to develop a nomogram. The discrimination of the nomogram was evaluated using area under the receiver operating characteristic curves (AUC), the calibration was evaluated using calibration curves and Hosmer-Lemeshow tests. Decision curve analysis (DCA) was used to evaluate the net benefit of the model for patients.

Results

In the training group, multivariate logistic regression demonstrated that GCS score, epidural hematoma, intracerebral hemorrhage, fibrinogen, and D-dimer were independent risk factors for END in patients with moderate TBI. A nomogram was constructed using the logistic regression prediction model. The AUCs of the nomogram in the training and validation groups were 0.901 and 0.927, respectively. The calibration curves showed that the predicted probability was consistent with the actual situation in both the training and validation sets. DCA curves demonstrated significantly better net benefit with the model. Then a web-based calculator was generated to facilitate clinical application.

Conclusion

The present study developed and validated a model to predict END in patients with moderate TBI. The nomogram that had good discrimination, calibration, and clinical utility can provide clinicians with an effective and accurate tool for evaluating the occurrence of END after moderate TBI.

Classification Prediction of Hydrocephalus After Intercerebral Haemorrhage Based on Machine Learning Approach

In order to construct a clinical classification prediction model for hydrocephalus after intercerebral haemorrhage(ICH) to guide clinical treatment decisions, this paper retrospectively analyses the clinical data of 844 cases of ICH and hydrocephalus inpatients admitted to Yueyang People's Hospital from May 2019 to October 2022, of which 95 cases of hydrocephalus occurred after ICH and no hydrocephalus in 749 cases. The following indicators were compared between the two groups of patients: gender, age, Glasgow Coma Scale(GCS)score, whether the amount of bleeding was greater than 30 ml, whether it broke into the ventricle or not, modified Graeb score(MGS), modified Rankin Scale (MRS) score, whether surgery was performed or not, red blood cells, white blood cells, and platelets. After variable screening, the following six variables were selected: GCS score, MGS, MRS score, whether the bleeding volume was greater than 30 ml, whether it broke into the ventricle or not, and whether surgery was performed or not were modelled and analysed using logistic regression model and support vector machine model in machine learning. The results showed that under the same conditions, the accuracy of the support vector machine model was 0.89 and F1 was 0.838 ,the value of the AUC of the support vector machine model is 0.888; the accuracy of the logistic regression model was 0.902 and F1 was 0.89, the value of the AUC of the support vector machine model is 0.903. Compared with the group without hydrocephalus, patients in the group with hydrocephalus had bleeding volume greater than 30 ml, haemorrhage into the ventricles of the brain, and had undergone surgery in the brain, and the difference was statistically significant (P 0.001). Statistical analysis showed that GCS score ≤ 8.8, modified Graeb score (MGS) ≥ 10 and MRS score ≥ 3 were independent risk factors for the development of hydrocephalus after spontaneous ventricular haemorrhage. Therefore, patients with lower GCS score, higher modified Graeb score, higher MRS score, bleeding volume > 30 ml, haemorrhage into the ventricles of the brain, and experience of having undergone surgery in the brain should be operated on early to remove the intraventricular haematoma in order to reduce the incidence of hydrocephalus.

Clinical characteristics and prognostic analysis of patients with hydrocephalus after hypertensive cerebral haemorrhage: a retrospective case-control study

To investigate the clinical characteristics of patients with hydrocephalus after hypertensive cerebral haemorrhage (HICH) and to analyse the relevant factors affecting the prognosis. A total of 500 patients with HICH admitted to the neurosurgery department of The First Hospital of Hebei Medical University between January 2020 and July 2024 were retrospectively analysed. The clinical data of the patients were collected, the occurrence of hydrocephalus within 3 months after discharge was followed up, and the patients were divided into the occurrence group and the non-occurrence group. Logistic regression analysis was applied to identify risk factors for hydrocephalus, and receiver operating characteristic (ROC) curves were used to evaluate the predictive value of these factors. Among 500 patients, 45 (9%) developed hydrocephalus, with an average age of 59.93 ± 14.20 years in the occurrence group and 61.76 ± 12.28 years in the non-occurrence group. Logistics univariate analysis showed that the brain haemorrhage location, cerebral hernia, haematoma volume and the Glasgow Coma Scale (GCS) score were the influencing factors for hydrocephalus after HICH (P < 0.05). The results of logistics multivariate analysis showed that cerebral hernia (odds ratio [OR] = 3.102, 95% CI: 1.315-7.204) and the GCS score (OR = 1.732. 95% CI: 1.102-2.401) were risk factors for the development of hydrocephalus after HICH (P < 0.05). The ROC curve analysis showed an area under the curve of 0.639 for cerebral hernia, 0.713 for the GCS score and 0.794 for their combination in predicting hydrocephalus. Cerebral hernia and the GCS score are independent influencing factors of hydrocephalus after HICH, and the combination of the two can better predict the formation of hydrocephalus.

Hydrocephalus in primary brainstem hemorrhage risk predictors and management

This study explored the risk factors associated with hydrocephalus incidence and evaluated the effectiveness of surgical treatments in managing this condition. Patients with PBSH were retrospectively evaluated, identifying clinical and radiological characteristics. A multivariate logistic regression model was used for analyses. Of the 169 patients studied, 77 developed hydrocephalus. Midbrain hemorrhage, tegmental pons hemorrhage, disappearance of annular cisterna, combined cerebellar and intraventricular hematoma increased the risk of hydrocephalus (p < 0.05). A linear relationship was found between hematoma volume and hydrocephalus, with a volume > 6.1 mL associated with a higher risk. Patients with ≥ 2 the following factors: multiple hematoma sites, intraventricular hematoma, or hematoma volume > 6.1 mL, had a significantly increased risk of hydrocephalus. Forty-seven patients received surgical treatments including stereotactic puncture drainage of hematoma (SPDH) or external ventricular drainage (EVD). Both SPDH and EVD were effective in treating hydrocephalus (p < 0.001). The combination of SPDH and EVD showed the greatest benefit (p < 0.001); 30-day mortality and de-ventilator rates in the surgical group were significantly different from the non-surgical group. This finding provides valuable insights for early surgical intervention in patients with PBSH.

Development and validation of a nomogram for predicting early acute hydrocephalus after spontaneous intracerebral hemorrhage: a single-center retrospective study

Acute hydrocephalus is a severe complication that may occur early after an intracerebral hemorrhage (ICH). However, clinical factors predicting the occurrence of acute hydrocephalus have rarely been studied. This study aimed to establish a nomogram model to predict early acute hydrocephalus after ICH. We retrospectively analyzed the data of 930 patients with ICH who were treated at our hospital between January 2017 and May 2024. Least absolute shrinkage and selection operator (LASSO) regression analysis was used to screen for risk factors for acute hydrocephalus, and stepwise logistic regression analysis was used to construct the prediction model, which was visualized using a nomogram. Data were randomly divided into training (n = 652) and test (n = 278) sets at a 7:3 ratio. A total of 930 patients were included, of whom 123 (13.2%) developed acute hydrocephalus within 6 h of being diagnosed with ICH. Univariate analysis revealed that 11 indicators were associated with acute hydrocephalus. In the training set, LASSO and stepwise logistic regression analyses identified four independent risk factors that were used to establish a prediction model. These were the modified Graeb score, age, infratentorial hemorrhage > 15 mL, and thalamic hemorrhage > 15 mL. A graphical nomogram was then developed. The area under the receiver operating characteristic (ROC) curve was 0.974 (95% confidence interval 0.961-0.987). In the Hosmer-Lemeshow test, the p-value was 0.887. The mean absolute error of the calibration plot was 0.012. The decision curve analysis (DCA) validated the fitness and clinical application value of this nomogram. Internal validation showed the test set was in good accordance with the training set. The nomogram prediction model showed good accuracy and could be used to predict the risk of early acute hydrocephalus after ICH, thereby aiding neurologist in making rapid clinical decisions.

Development of a model to predict the risk of multi-drug resistant organism infections in ruptured intracranial aneurysms patients with hospital-acquired pneumonia in the neurological intensive care unit

OBJECTIVE

This study was developed to explore the incidence of multi-drug resistant organism (MDRO) infections among ruptured intracranial aneurysms(RIA) patient with hospital-acquired pneumonia(HAP) in the neurological intensive care unit (NICU), and to establish risk factors related to the development of these infections.

METHODS

We collected clinical and laboratory data from 328 eligible patients from January 2018 to December 2022. Bacterial culture results were used to assess MDRO strain distributions, and risk factors related to MDRO infection incidence were identified through logistic regression analyses. These risk factors were further used to establish a predictive model for the incidence of MDRO infections, after which this model underwent internal validation.

RESULTS

In this study cohort, 26.5 % of RIA patients with HAP developed MDRO infections (87/328). The most common MDRO pathogens in these patients included Multidrug-resistant Klebsiella pneumoniae (34.31 %) and Multidrug-resistant Acinetobacter baumannii (27.45 %). Six MDRO risk factors, namely, diabetes (P = 0.032), tracheotomy (P = 0.004), history of mechanical ventilation (P = 0.033), lower albumin levels (P < 0.001), hydrocephalus (P < 0.001) and Glasgow Coma Scale (GCS) score ≤8 (P = 0.032) were all independently correlated with MDRO infection incidence. The prediction model exhibited satisfactory discrimination (area under the curve [AUC], 0.842) and calibration (slope, 1.000), with a decision curve analysis further supporting the clinical utility of this model.

CONCLUSIONS

In summary, risk factors and bacterial distributions associated with MDRO infections among RIA patients with HAP in the NICU were herein assessed. The developed predictive model can aid clinicians to identify and screen high-risk patients for preventing MDRO infections.

Intracranial Pressure Monitoring in Patients with Spontaneous Intracerebral Hemorrhage: A Systematic Review with Meta-Analysis

OBJECTIVE

To describe the potential effects of Intracranial pressure monitoring on the outcome of patients with spontaneous intracerebral hemorrhage (ICH).

METHODS

This study is a systematic review with meta-analysis. Patients with spontaneous ICH treated with intracranial pressure monitoring were included. The primary outcome was mortality at 6 months and in-hospital mortality. The secondary outcome was poor neurological function outcome at 6 months.

RESULTS

This analysis compares in-hospital and 6-month mortality rates between patients with intracranial pressure monitoring (ICPm) and those without (no ICPm). Although the ICPm group had a lower in-hospital mortality rate, it was not statistically significant (24.9% vs. 34.1%; OR 0.51, 95% CI 0.20 to 1.31, P = 0.16). Excluding patients with intraventricular hemorrhage revealed a significant reduction in in-hospital mortality for the ICPm group (23.5% vs. 43%; OR 0.39, 95% CI 0.29 to 0.53, P < 0.00001). For 6-month mortality, the ICPm group showed a significant reduction (32% vs. 39.6%; OR 0.76, 95% CI 0.61 to 0.94, P = 0.01), with the effect being more pronounced after excluding intraventricular hemorrhage patients (29.1% vs. 47.2%; OR 0.45, 95% CI 0.34 to 0.60, P < 0.0001). However, there were no statistically significant differences in 6-month functional outcomes between the groups. Increased ICP was associated with higher 3-month mortality (OR 1.12, 95% CI 1.07 to 1.18, P < 0.00001) and lower likelihood of good functional outcomes (OR 1.11, 95% CI 1.04 to 1.18, P < 0.00001).

CONCLUSIONS

Elevated ICP is associated with increased mortality and poor prognosis in ICH patients. Although continuous intracranial pressure monitoring may reduce short-term mortality rates in specific subgroups of ICH patients, it does not improve neurological functional outcomes. While potential patient populations may benefit from ICP monitoring, more research is needed to screen suitable populations for ICP monitoring.

Development and validation of a machine learning-based predictive model for assessing the 90-day prognostic outcome of patients with spontaneous intracerebral hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (sICH) is associated with significant mortality and morbidity. Predicting the prognosis of patients with sICH remains an important issue, which significantly affects treatment decisions. Utilizing readily available clinical parameters to anticipate the unfavorable prognosis of sICH patients holds notable clinical significance. This study employs five machine learning algorithms to establish a practical platform for the prediction of short-term prognostic outcomes in individuals afflicted with sICH.

METHODS

Within the framework of this retrospective analysis, the model underwent training utilizing data gleaned from 413 cases from the training center, with subsequent validation employing data from external validation center. Comprehensive clinical information, laboratory analysis results, and imaging features pertaining to sICH patients were harnessed as training features for machine learning. We developed and validated the model efficacy using all the selected features of the patients using five models: Support Vector Machine (SVM), Logistic Regression (LR), Random Forest (RF), XGboost and LightGBM, respectively. The process of Recursive Feature Elimination (RFE) was executed for optimal feature screening. An internal five-fold cross-validation was employed to pinpoint the most suitable hyperparameters for the model, while an external five-fold cross-validation was implemented to discern the machine learning model demonstrating the superior average performance. Finally, the machine learning model with the best average performance is selected as our final model while using it for external validation. Evaluation of the machine learning model's performance was comprehensively conducted through the utilization of the ROC curve, accuracy, and other relevant indicators. The SHAP diagram was utilized to elucidate the variable importance within the model, culminating in the amalgamation of the above metrics to discern the most succinct features and establish a practical prognostic prediction platform.

RESULTS

A total of 413 patients with sICH patients were collected in the training center, of which 180 were patients with poor prognosis. A total of 74 patients with sICH were collected in the external validation center, of which 26 were patients with poor prognosis. Within the training set, the test set AUC values for SVM, LR, RF, XGBoost, and LightGBM models were recorded as 0.87, 0.896, 0.916, 0.885, and 0.912, respectively. The best average performance of the machine learning models in the training set was the RF model (average AUC: 0.906 ± 0.029, P < 0.01). The model still maintains a good performance in the external validation center, with an AUC of 0.817 (95% CI 0.705-0.928). Pertaining to feature importance for short-term prognostic attributes of sICH patients, the NIHSS score reigned supreme, succeeded by AST, Age, white blood cell, and hematoma volume, among others. In culmination, guided by the RF model's variable importance weight and the model's ROC curve insights, the NIHSS score, AST, Age, white blood cell, and hematoma volume were integrated to forge a short-term prognostic prediction platform tailored for sICH patients.

CONCLUSION

We constructed a prediction model based on the results of the RF model incorporating five clinically accessible predictors with reliable predictive efficacy for the short-term prognosis of sICH patients. Meanwhile, the performance of the external validation set was also more stable, which can be used for accurate prediction of short-term prognosis of sICH patients.

Predicting ICU readmission risks in intracerebral hemorrhage patients: Insights from machine learning models using MIMIC databases

BACKGROUND

Intracerebral hemorrhage (ICH) is a stroke subtype characterized by high mortality and complex post-event complications. Research has extensively covered the acute phase of ICH; however, ICU readmission determinants remain less explored. Utilizing the MIMIC-III and MIMIC-IV databases, this investigation develops machine learning (ML) models to anticipate ICU readmissions in ICH patients.

METHODS

Retrospective data from 2242 ICH patients were evaluated using ICD-9 codes. Recursive feature elimination with cross-validation (RFECV) discerned significant predictors of ICU readmissions. Four ML models-AdaBoost, RandomForest, LightGBM, and XGBoost-underwent development and rigorous validation. SHapley Additive exPlanations (SHAP) elucidated the effect of distinct features on model outcomes.

RESULTS

ICU readmission rates were 9.6% for MIMIC-III and 10.6% for MIMIC-IV. The LightGBM model, with an AUC of 0.736 (95% CI: 0.668-0.801), surpassed other models in validation datasets. SHAP analysis revealed hydrocephalus, sex, neutrophils, Glasgow Coma Scale (GCS), specific oxygen saturation (SpO2) levels, and creatinine as significant predictors of readmission.

CONCLUSION

The LightGBM model demonstrates considerable potential in predicting ICU readmissions for ICH patients, highlighting the importance of certain clinical predictors. This research contributes to optimizing patient care and ICU resource management. Further prospective studies are warranted to corroborate and enhance these predictive insights for clinical utilization.

Predicting the need for cerebrospinal fluid shunt implantation after spontaneous intracerebral hemorrhage: a challenging task

Objectives

The development of persistent hydrocephalus in patients after spontaneous intracerebral hemorrhage (ICH) is still poorly understood, and many variables predicting the need for a cerebrospinal fluid (CSF)-shunt have been described in the literature with varying results. The aim of this study is to find predictive factors for shunt dependency.

Methods

We performed a retrospective, single-center study of 99 neurosurgically treated patients with spontaneous ICH. Variables, including age, Glasgow Coma Scale (GCS), intraventricular hemorrhage (IVH), location of hemorrhage, acute hydrocephalus, and volumetric analysis of IVH, ICH, and intraventricular CSF were compared between patients with and without CSF-shunt implantation. Furthermore, receiver operating characteristics (ROC) for ICH, IVH, and intraventricular CSF volume parameters were calculated.

Results

CSF-shunt implantation was performed significantly more often in patients after thalamic (p = 0.03) and cerebellar ICH (p = 0.04). Moreover, a lower ratio between the total hemorrhage volume and intraventricular CSF volume (p = 0.007), a higher IVH distribution in the third ventricle, and an acute hydrocephalus (p < 0.001) with an increased intraventricular CSF volume (p < 0.001) were associated with shunt dependency. Our ROC model demonstrated a sensitivity of 82% and a specificity of 65% to predict the necessity for a shunt at a cutoff value of 1.9 with an AUC of 0.835.

Conclusion

Volumetric analysis of ICH, IVH, and intraventricular CSF may improve the prediction of CSF shunt implantation in patients with spontaneous ICH.

Retrospective comparison of long-term functionality and revision rate of two different shunt valves in pediatric and adult patients

PURPOSE

The most frequent therapy of hydrocephalus is implantation of ventriculoperitoneal shunts for diverting cerebrospinal into the peritoneal cavity. We compared two adjustable valves, proGAV and proGAV 2.0, for complications resulting in revision surgery.

METHODS

Four hundred patients undergoing primary shunt implantation between 2014 and 2020 were analyzed for overall revision rate, 1-year revision rate, and revision-free survival observing patient age, sex, etiology of hydrocephalus, implantation site, prior diversion of cerebrospinal fluid, and cause of revision.

RESULTS

All data were available of all 400 patients (female/male 208/192). Overall, 99 patients underwent revision surgery after primary implantation. proGAV valve was implanted in 283 patients, and proGAV 2.0 valves were implanted in 117 patients. There was no significant difference between the two shunt valves concerning revision rate (p = 0.8069), 1-year revision rate (p = 0.9077), revision-free survival (p = 0.6921), and overall survival (p = 0.3232). Regarding 1-year revision rate, we observed no significant difference between the two shunt valves in pediatric patients (40.7% vs 27.6%; p = 0.2247). Revision operation had to be performed more frequently in pediatric patients (46.6% vs 24.8%; p = 0.0093) with a significant higher number of total revisions with proGAV than proGAV 2.0 (33 of 59 implanted shunts [55.9%] vs. 8 of 29 implanted shunts [27.6%]; p = 0.0110) most likely due to longer follow-up in the proGAV-group. For this reason, we clearly put emphasis on analyzing results regarding 1-year revision rate.

CONCLUSION

According to the target variables we analyzed, aside from lifetime revision rate in pediatric patients, there is no significant difference between the two shunt valves.

Exosomes from young healthy human plasma promote functional recovery from intracerebral hemorrhage via counteracting ferroptotic injury

Intracerebral hemorrhage (ICH), as a type of life-threatening and highly disabled disease, has limited therapeutic approaches. Here, we show that exosomes derived from young healthy human plasma exhibiting typical exosomes features could facilitate functional recovery of ICH mice. When these exosomes are intraventricularly delivered into the brain after ICH, they mainly distribute around the hematoma and could be internalized by neuronal cells. Strikingly, exosomes administration markedly enhanced the behavioral recovery of ICH mice through reducing brain injury and cell ferroptosis. MiRNA sequencing revealed that microRNA-25-3p (miR-25-3p) was differentially expressed miRNA in the exosomes from young healthy human plasma, compared with exosomes from the old control. Importantly, miR-25-3p mimicked the treatment effect of exosomes on behavioral improvement, and mediated the neuroprotective effect of exosomes against ferroptosis in ICH. Furthermore, luciferase assay and western blotting data illustrated that P53 as assumed the role of a downstream effector of miR-25-3p, thereby regulating SLC7A11/GPX4 pathway to counteract ferroptosis. Taken together, these findings firstly reveal that exosomes from young healthy human plasma improve functional recovery through counteracting ferroptotic injury by regulating P53/SLC7A11/GPX4 axis after ICH. Given the easy availability of plasma exosomes, our study provides a potent therapeutic strategy for ICH patients with quick clinical translation in the near future.

Neuroendoscopic Evacuation Improves Outcomes Compared with External Ventricular Drainage in Patients with Spontaneous Intraventricular Hemorrhage: A Systematic Review with Meta-Analyses

BACKGROUND

Spontaneous intraventricular hemorrhage (IVH) is a cause of significant morbidity and mortality. Treatment for resulting obstructive hydrocephalus has traditionally been via an external ventricular drain (EVD). We aimed to compare patient outcomes after neuroendoscopic surgery (NES) evacuation of IVH versus EVD management.

METHODS

MEDLINE, Embase, and Cochrane Library databases were searched on October 8, 2022. Of the 252 records remaining after removal of duplicates, 12 met study inclusion criteria. After extraction of outcomes data, fixed-effect and random-effects models were used to establish odds ratios (ORs) with 95% confidence intervals (CIs) for intensive care unit length of stay, rate of permanent cerebrospinal fluid diversion, Glasgow Outcome Scale score, and mortality rate.

RESULTS

The results of the pooled analysis showed that intensive care unit length of stay was shorter (OR -2.61 [95% CI -5.02, -0.19]; I2 = 97.76%; P = 0.034), permanent cerebrospinal fluid diversion was less likely (OR -0.79, 95% CI [-1.17, -0.41], I2 = 46.96%, P < 0.001), higher Glasgow Outcome Scale score was more likely (OR 0.48, 95% CI [0.04, 0.93], I2 = 60.12%, P = 0.032), and all-cause mortality was less likely (OR -1.11, 95% CI [-1.79, -0.44], I2 = 0%, P = 0.001) in the NES evacuation group compared with the EVD group.

CONCLUSIONS

NES for evacuation of spontaneous IVH results in reduced intensive care unit length of stay, reduced permanent cerebrospinal fluid diversion rates, improved Glasgow Outcome Scale score, and reduced mortality when compared with EVD. More robust prospective, randomized studies are necessary to help inform the safety and utility of NES for IVH.

Intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is a dramatic condition caused by the rupture of a cerebral vessel and the entry of blood into the brain parenchyma. ICH is a major contributor to stroke-related mortality and dependency: only half of patients survive for 1 year after ICH, and patients who survive have sequelae that affect their quality of life. The incidence of ICH has increased in the past few decades with shifts in the underlying vessel disease over time as vascular prevention has improved and use of antithrombotic agents has increased. The pathophysiology of ICH is complex and encompasses mechanical mass effect, haematoma expansion and secondary injury. Identifying the causes of ICH and predicting the vital and functional outcome of patients and their long-term vascular risk have improved in the past decade; however, no specific treatment is available for ICH. ICH remains a medical emergency, with prevention of haematoma expansion as the key therapeutic target. After discharge, secondary prevention and management of vascular risk factors in patients remains challenging and is based on an individual benefit-risk balance evaluation.

Risk factors of postoperative hydrocephalus following decompressive craniectomy for spontaneous intracranial hemorrhages and intraventricular hemorrhage

INTRODUCTION

Hydrocephalus is a complication of spontaneous intracerebral hemorrhage; however, its predictive relationship with hydrocephalus in this patient cohort is not understood. Here, we evaluated the incidence and risk factors of hydrocephalus after craniectomy.

METHODS

Retrospectively studied data from 39 patients in the same hospital from 2016/01 to 2020/12 and analyzed risk factors for hydrocephalus. The clinical data recorded included patient age, sex, timing of surgery, initial Glasgow Coma Scale score, intracerebral hemorrhage (ICH) score, alcohol consumption, cigarette smoking, medical comorbidity, and blood data. Predictors of patient outcomes were determined using Student t test, chi-square test, and logistic regression.

RESULTS

We recruited 39 patients with cerebral herniation who underwent craniectomy for spontaneous supratentorial hemorrhage. Persistent hydrocephalus was observed in 17 patients. The development of hydrocephalus was significantly associated with the timing of operation, cigarette smoking, and alcohol consumption according to the Student t test and chi-square test. Univariate and multivariate analyses suggested that postoperative hydrocephalus was significantly associated with the timing of surgery (P = .031) and cigarette smoking (P = .041).

DISCUSSION

The incidence of hydrocephalus in patients who underwent delayed operation (more than 4 hours) was lower than that in patients who underwent an operation after less than 4 hours. nonsmoking groups also have lower incidence of hydrocephalus. Among patients who suffered from spontaneous supratentorial hemorrhage and need to receive emergent craniectomy, physicians should be reminded that postoperative hydrocephalus followed by ventriculoperitoneal shunting may be necessary in the future.

Dexpramipexole Attenuates White Matter Injury to Facilitate Locomotion and Motor Coordination Recovery via Reducing Ferroptosis after Intracerebral Hemorrhage

Deciphering the factors causing damage to white matter fiber bundles and exploring new strategies to alleviate white matter injury (WMI) is a promising treatment to improve neurological impairments after intracerebral hemorrhage (ICH). Ferroptosis usually occurs at perihematomal region and contributes to neuronal death due to reactive oxygen species (ROS) production. Dexpramipexole (DPX) easily crosses the blood brain barrier (BBB) and exerts antioxidative properties by reducing ROS production, while the role of DPX in ferroptosis after ICH remains elusive. Here, our results indicated that ferroptosis played a significant role in WMI resulting from iron and ROS accumulation around hematoma. Further evidence demonstrated that the administration of DPX decreased iron and ROS deposition to inhibit ferroptosis at perihematomal site. With the inhibition of ferroptosis, WMI was alleviated at perihematomal site, thereafter promoting locomotion and motor coordination recovery in mice after ICH. Subsequently, the results showcased that the expression of glutathione peroxidase 4 (GPX4) and ferroptosis suppressing protein 1 (FSP1) was upregulated with the administration of DPX. Collectively, the present study uncovers the underlying mechanism and elucidates the therapeutic effect of DPX on ICH, and even in other central nervous system (CNS) diseases with the presence of ferroptosis.

Prediction of adult post-hemorrhagic hydrocephalus: a risk score based on clinical data

There is lacking research on risk factors and prediction models associated with Post-hemorrhagic hydrocephalus (PHH). Thus, this present study aimed to analyze the risk factors of PHH and establish a risk-scoring system through a large-scale study. A retrospective study of 382 patients with intracranial hemorrhage assessed age, history and diagnosis, Glasgow coma score (GCS), and fever time. After univariate and logistic regression analysis, a risk scoring system was established according to independent risk factors and evaluated using the area under the curve (AUC). Of the 382 patients, 133 (34.8%) had PHH, 43 (11.3%) received surgical treatment. Factor classification showed that age > 60 years old [odds ratio (OR): 0.347, II = 5 points], GCS < 5 (OR: 0.09, IV = 10 points), GCS 6‒8 (OR = 0.232, III = 6 points), fever time > 9 (OR: 0.202, III = 7 points), fever time 5-9 (OR: 0.341, II = 5 points), CSF-TP x time > 14,4000 group (OR: 0.267, IV = 6 points), and CSF-TP x time 9,601‒14,400 group (OR: 0.502, III = 3 points) were independent risk factors. The result of the receiver operating characteristic (ROC) prediction showed that AUC = 0.790 (0.744‒0.836). Low-risk (IV-VII), moderate (VIII-X), and high-risk group (XI-XIII) incidence of PHH were 11.76%, 50.55%, and 70.00% (p < 0.001), respectively. The coincidence rates in the validation cohort were 26.00%, 74.07%, and 100.0% (p < 0.001), respectively. AUC value was 0.860 (0.780‒0.941). The predictive model was conducive to determining the occurrence of PHH and facilitating early intervention.

NLRP3 inflammasome-mediated choroid plexus hypersecretion contributes to hydrocephalus after intraventricular hemorrhage via phosphorylated NKCC1 channels

Background

Hydrocephalus is a severe complication of intracerebral hemorrhage with ventricular extension (ICH-IVH) and causes cerebrospinal fluid (CSF) accumulation. The choroid plexus epithelium plays an important role in CSF secretion and constitutes the blood–CSF barrier within the brain–immune system interface. Although the NLRP3 inflammasome, as a key component of the innate immune system, promotes neuroinflammation, its role in the pathogenesis of hydrocephalus after hemorrhage has not been investigated. Therefore, this study aimed to investigate the potential mechanism of NLRP3 in hydrocephalus to discover a potential marker for targeted therapy.

Methods

A rat model of hydrocephalus after ICH-IVH was developed through autologous blood infusion in wild-type and Nlrp3^−/− rats. By studying the features and processes of the model, we investigated the relationship between the NLRP3 inflammasome and CSF hypersecretion in the choroid plexus.

Results

The ICH-IVH model rats showed ventricular dilation accompanied by CSF hypersecretion for 3 days. Based on the choroid plexus RNA-seq and proteomics results, we found that an inflammatory response was activated. The NLRP3 inflammasome was investigated, and the expression levels of NLRP3 inflammasome components reached a peak at 3 days after ICH-IVH. Inhibition of NLRP3 by an MCC950 inflammasome inhibitor or Nlrp3 knockout decreased CSF secretion and ventricular dilation and attenuated neurological deficits after ICH-IVH. The mechanism underlying the neuroprotective effects of NLRP3 inhibition involved decreased phosphorylation of NKCC1, which is a major protein that regulates CSF secretion by altering Na⁺- and K⁺-coupled water transport, via MCC950 or Nlrp3 knockout. In combination with the in vitro experiments, this experiment confirmed the involvement of the NLRP3/p-NKCC1 pathway and Na⁺ and K⁺ flux.

Conclusions

This study demonstrates that NKCC1 phosphorylation in the choroid plexus epithelium promotes NLRP3 inflammasome-mediated CSF hypersecretion and that NLRP3 plays an important role in the pathogenesis of hydrocephalus after hemorrhage. These findings provide a new therapeutic strategy for treating hydrocephalus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-022-02530-x.

Risk Factor of Posthemorrhagic Hydrocephalus: Cerebrospinal Fluid Total Protein

Objective

Cerebrospinal fluid total protein (CSF-TP) levels in adults with posthemorrhagic hydrocephalus (PHH) are poorly studied. The objective of this study was to explore the characteristics of CSF-TP levels in patients with PHH.

Methods

The clinical data of 156 patients with hemorrhagic brain disease were retrospectively studied and divided into PHH and NPHH groups. Single-factor and multi-factor analyses were performed, and the key role of CSF-TP was evaluated using linear analysis.

Results

Among the 156 patients, 85 (54.5%) had PHH and 34 (21.8%) underwent surgeries. Hypertension (p = 0.017), days [total fever time when body temperature ≥ 38.5°C (p = 0.04)], Glasgow Coma Scale (GCS) score (p < 0.001), and time (from the onset of the disease to the obtainment of CSF-TP after lumbar puncture (p < 0.001) were important factors for PHH. Logistic regression analysis revealed that GCS score < 8 [odds ratio (OR) = 2.943 (1.421–6.097), p = 0.004] and CSF-TP × time ≥ 9,600 [OR = 2.317 (1.108–4.849), p = 0.026] were independent risk factors for PHH. All CSF-TP values were averaged every 2 days. CSF-TP was negatively correlated with time. Linear analysis showed that CSF-TP in the PHH group was higher than that in the NPHH group at the same onset time, and that the duration of detectionin the CSF was longer.

Conclusion

Cerebrospinal fluid total protein (CSF-TP) × time ≥ 9,600 and GCS score <8 were independent risk factors for PHH. CSF-TP was higher in the PHH group than in the NPHH group.

Cerebrospinal fluid predictors of shunt-dependent hydrocephalus after hemorrhagic stroke: a systematic review and meta-analysis

Hydrocephalus is a common complication of hemorrhagic stroke and has been reported to contribute to poor neurological outcomes. Herein, we aimed to investigate the validity of cerebrospinal fluid (CSF) data in predicting shunt-dependent hydrocephalus (SDHC) in patients with hemorrhagic stroke. PubMed, CENTRAL, and Embase databases were searched for relevant studies published through July 31, 2021. The 16 studies with 1505 patient included those in which CSF data predicted risk for SDHC and reports on CSF parameters in patients in whom SDHC or hydrocephalus that was not shunt-dependent developed following hemorrhagic stroke. We appraised the study quality using Newcastle-Ottawa Scale and conducted a meta-analysis of the pooled estimates of the CSF predictors. The meta-analysis revealed three significant CSF predictors for shunt dependency, i.e., higher protein levels (mean difference [MD] = 32.09 mg/dL, 95% confidence interval [CI] = 25.48-38.70, I² = 0%), higher levels of transforming growth factor β1 (TGF-β1; MD = 0.52 ng/mL, 95% CI = 0.42-0.62, I² = 0%), and higher ferritin levels (MD = 108.87 µg/dL, 95% CI = 56.68-161.16, I² = 36%). The red blood cell count, lactate level, and glucose level in CSF were not significant in predicting SDHC in patients with hemorrhagic stroke. Therefore, higher protein, TGF-β1, and ferritin levels in CSF are significant predictors for SDHC in patients with hemorrhagic stroke. Measuring these CSF parameters would help in the early recognition of SDHC risk in clinical care.

Neurokinin Receptor 1 (NK1R) Antagonist Aprepitant Enhances Hematoma Clearance by Regulating Microglial Polarization via PKC/p38MAPK/NFκB Pathway After Experimental Intracerebral Hemorrhage in Mice

Hematoma clearance is an important therapeutic target to improve outcome following intracerebral hemorrhage (ICH). Recent studies showed that Neurokinin receptor-1 (NK1R) inhibition exerts protective effects in various neurological disease models, but its role in ICH has not been explored. The objective of this study was to investigate the role of NK1R and its relation to hematoma clearance after ICH using an autologous blood injection mouse model. A total of 332 adult male CD1 mice were used. We found that the expression levels of NK1R and its endogenous ligand, substance P (SP), were significantly upregulated after ICH. Intraperitoneal administration of the NK1R selective antagonist, Aprepitant, significantly improved neurobehavior, reduced hematoma volume and hemoglobin levels after ICH, and promoted microglia polarization towards M2 phenotype. Aprepitant decreased phosphorylated PKC, p38MAPK, and NFκB p65, and downregulated M1 markers while upregulating M2 markers after ICH. Intracerebroventricular administration of the NK1R agonist, GR73632 or PKC agonist, phorbol 12-myristate 13-acetate (PMA) reversed the effects of Aprepitant. To demonstrate the upstream mediator of NK1R activation, we performed thrombin injection and found that it increased SP. Inhibiting thrombin suppressed SP and decreased M1 markers while increasing M2 microglia polarization. Thus, NK1R inhibition promoted hematoma clearance after ICH by increasing M2 microglial polarization via downregulating PKC/p38MAPK/NFκB signaling pathway, and thrombin may be a key upstream mediator of NK1R activation. Therapeutic interventions inhibiting NK1R signaling may be a new target for the treatment of ICH.

Prognostication after intracerebral hemorrhage: a review

Background

Approximately half of patients with spontaneous intracerebral hemorrhage (ICH) die within 1 year. Prognostication in this context is of great importance, to guide goals of care discussions, clinical decision-making, and risk stratification. However, available prognostic scores are hardly used in clinical practice. The purpose of this review article is to identify existing outcome prediction scores for spontaneous intracerebral hemorrhage (ICH) discuss their shortcomings, and to suggest how to create and validate more useful scores.

Main text

Through a literature review this article identifies existing ICH outcome prediction models. Using the Essen-ICH-score as an example, we demonstrate a complete score validation including discrimination, calibration and net benefit calculations. Score performance is illustrated in the Erlangen UKER-ICH-cohort (NCT03183167). We identified 19 prediction scores, half of which used mortality as endpoint, the remainder used disability, typically the dichotomized modified Rankin score assessed at variable time points after the index ICH. Complete score validation by our criteria was only available for the max-ICH score. Our validation of the Essen-ICH-score regarding prediction of unfavorable outcome showed good discrimination (area under the curve 0.87), fair calibration (calibration intercept 1.0, slope 0.84), and an overall net benefit of using the score as a decision tool. We discuss methodological pitfalls of prediction scores, e.g. the withdrawal of care (WOC) bias, physiological predictor variables that are often neglected by authors of clinical scores, and incomplete score validation. Future scores need to integrate new predictor variables, patient-reported outcome measures, and reduce the WOC bias. Validation needs to be standardized and thorough. Lastly, we discuss the integration of current ICH scoring systems in clinical practice with the awareness of their shortcomings.

Conclusion

Presently available prognostic scores for ICH do not fulfill essential quality standards. Novel prognostic scores need to be developed to inform the design of research studies and improve clinical care in patients with ICH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-021-00120-5.

Neurovascular Units and Neural-Glia Networks in Intracerebral Hemorrhage: from Mechanisms to Translation

Intracerebral hemorrhage (ICH), the most lethal type of stroke, often leads to poor outcomes in the clinic. Due to the complex mechanisms and cell-cell crosstalk during ICH, the neurovascular unit (NVU) was proposed to serve as a promising therapeutic target for ICH research. This review aims to summarize the development of pathophysiological shifts in the NVU and neural-glia networks after ICH. In addition, potential targets for ICH therapy are discussed in this review. Beyond cerebral blood flow, the NVU also plays an important role in protecting neurons, maintaining central nervous system (CNS) homeostasis, coordinating neuronal activity among supporting cells, forming and maintaining the blood-brain barrier (BBB), and regulating neuroimmune responses. During ICH, NVU dysfunction is induced, along with neuronal cell death, microglia and astrocyte activation, endothelial cell (EC) and tight junction (TJ) protein damage, and BBB disruption. In addition, it has been shown that certain targets and candidates can improve ICH-induced secondary brain injury based on an NVU and neural-glia framework. Moreover, therapeutic approaches and strategies for ICH are discussed.