Clinical Characteristics and Outcomes of Intracerebral Hemorrhage in Very Elderly

A nomogram based on systemic inflammation response index and clinical risk factors for prediction of short-term prognosis of very elderly patients with hypertensive intracerebral hemorrhage

Objective

To develop and validate a nomogram based on systemic inflammation response index (SIRI) and clinical risk factors to predict short-term prognosis in very elderly patients with hypertensive intracerebral hemorrhage (HICH).

Methods

A total of 324 very elderly HICH patients from January 2017 to June 2024 were retrospectively enrolled and randomly divided into two cohorts for training (n = 227) and validation (n = 97) according to the ratio of 7:3. Independent predictors of poor prognosis were analyzed using univariate and multivariate logistic regression analyses. Furthermore, a nomogram prediction model was built. The area under the receiver operating characteristic curves (AUC), calibration plots and decision curve analysis (DCA) were used to evaluate the performance of the nomogram in predicting the prognosis of very elderly HICH.

Results

By univariate and stepwise multivariate logistic regression analyses, GCS score (p < 0.001), hematoma expansion (p = 0.049), chronic obstructive pulmonary disease (p = 0.010), and SIRI (p = 0.005) were independent predictors for the prognosis in very elderly patients with HICH. The nomogram showed the highest predictive efficiency in the training cohort (AUC = 0.940, 95% CI: 0.909 to 0.971) and the validation cohort (AUC = 0.884, 95% CI: 0.813 to 0.954). The calibration curve indicated that the nomogram had good calibration. DCA showed that the nomogram had high applicability in clinical practice.

Conclusion

The nomogram incorporated with the SIRI and clinical risk factors has good potential in predicting the short-term prognosis of very elderly HICH.

Exploring Metabolic Aberrations after Intracerebral Hemorrhage In Vivo with Deuterium Metabolic Spectroscopy Imaging

Aberrations in metabolism after intracerebral hemorrhage (ICH), particularly lactate metabolism, play a crucial role in the pathophysiology and patient outcome. To date, the evaluation of metabolism relies heavily on invasive methods such as microdialysis, restricting a comprehensive understanding of the metabolic mechanisms associated with ICH. This study proposes a noninvasive metabolic imaging method based on 2H magnetic resonance spectroscopy and imaging (2H-MRS/MRSI) to detect metabolic changes after ICH in vivo. To overcome the low-sensitivity limitation of 2H, we designed a new 1H-2H double-resonance coil with 2H-channel active detuning and proposed chemical shift imaging based on the balanced steady-state free precession method (CSI-bSSFP). Compared with the volume coil, the signal-to-noise ratio (SNR) of the new coil was increased by 4.5 times. In addition, the SNR of CSI-bSSFP was 1.5 times higher than that of conventional CSI. These two technologies were applied to measure lactate metabolic flux at different phases of ICH. The results show a higher lactate concentration in ICH rats than in control rats, which is in line with the increased expression of lactate dehydrogenase measured via immunohistochemistry staining (AUCLac_area/Glc_area: control, 0.08 ± 0.02 vs ICH-3d, 0.39 ± 0.05 vs ICH-7d, 0.18 ± 0.02, P < 0.01; H-score: control, 126.4 ± 5.03 vs ICH-3d, 168.4 ± 5.71 vs ICH-7d,133.6 ± 7.70, P < 0.05). A higher lactate signal also appeared near the ICH region than in normal brain tissue. In conclusion, 2H-MRS/MRSI shows potential as a useful method for in vivo metabolic imaging and noninvasive assessment of ICH.

The Role of Aging in Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the cerebrovascular disease with the highest disability and mortality rates, causing severe damage to the health of patients and imposing a significant socioeconomic burden. Aging stands as a foremost risk factor for ICH, with a significant escalation in ICH incidence within the elderly demographic, highlighting a close association between ICH and aging. In recent years, with the acceleration of the "aging society" trend, exploring the intricate relationship between aging and ICH has become increasingly urgent and worthy of in-depth attention. We have summarized the characteristics of ICH in the elderly, reviewing how aging influences the onset and development of ICH by examining its etiology and the mechanisms of damage via ICH. Additionally, we explored the potential impacts of ICH on accelerated aging, including its effects on cognitive abilities, quality of life, and lifespan. This review aims to reveal the connection between aging and ICH, providing new ideas and insights for future ICH research.

Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage

BACKGROUND

The objective of this document is to provide recommendations on the formal reliability of major clinical predictors often associated with intracerebral hemorrhage (ICH) neuroprognostication.

METHODS

A narrative systematic review was completed using the Grading of Recommendations Assessment, Development, and Evaluation methodology and the Population, Intervention, Comparator, Outcome, Timing, Setting questions. Predictors, which included both individual clinical variables and prediction models, were selected based on clinical relevance and attention in the literature. Following construction of the evidence profile and summary of findings, recommendations were based on Grading of Recommendations Assessment, Development, and Evaluation criteria. Good practice statements addressed essential principles of neuroprognostication that could not be framed in the Population, Intervention, Comparator, Outcome, Timing, Setting format.

RESULTS

Six candidate clinical variables and two clinical grading scales (the original ICH score and maximally treated ICH score) were selected for recommendation creation. A total of 347 articles out of 10,751 articles screened met our eligibility criteria. Consensus statements of good practice included deferring neuroprognostication-aside from the most clinically devastated patients-for at least the first 48-72 h of intensive care unit admission; understanding what outcomes would have been most valued by the patient; and counseling of patients and surrogates whose ultimate neurological recovery may occur over a variable period of time. Although many clinical variables and grading scales are associated with ICH poor outcome, no clinical variable alone or sole clinical grading scale was suggested by the panel as currently being reliable by itself for use in counseling patients with ICH and their surrogates, regarding functional outcome at 3 months and beyond or 30-day mortality.

CONCLUSIONS

These guidelines provide recommendations on the formal reliability of predictors of poor outcome in the context of counseling patients with ICH and surrogates and suggest broad principles of neuroprognostication. Clinicians formulating their judgments of prognosis for patients with ICH should avoid anchoring bias based solely on any one clinical variable or published clinical grading scale.

Endoscopic surgery versus craniotomy for spontaneous intracerebral hemorrhage in the late elderly patients

OBJECTIVES

To compare the prognosis of late elderly patients with spontaneous intracerebral hemorrhage (ICH) treated by endoscopic evacuation and craniotomy MATERIALS AND METHODS: Using the Diagnosis Procedure Combination database, we identified patients aged ≥ 75 years who underwent surgery for spontaneous ICH within 48 hours after admission between April 2014 and March 2018. Eligible patients were classified into two groups according to the type of surgery (endoscopic surgery and craniotomy). Propensity-score matching weight analysis was conducted to compare the good neurological outcome modified Rankin Scale (mRS) score (0-4) at discharge as the primary endpoint between the two groups. Secondary endpoints were postoperative meningitis, tracheostomy, reoperation within 3 days and total hospitalization costs.

RESULTS

Among the 5,396 eligible patients, endoscopic surgery and craniotomy were performed in 895 and 4,501 patients, respectively. In the propensity-score matching weight analysis, all covariates were well balanced. The proportions of patients with a good prognosis (mRS score at discharge: 0-4) did not significantly differ between the surgical procedures (42.1% vs. 42.8%, p = 0.828). The proportions of meningitis, tracheostomy and reoperation were not significantly different between the two groups. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (25,536 vs. 29,603 US dollars, p = 0.012).

CONCLUSIONS

Inhospital outcomes did not differ between endoscopic and open surgeries for spontaneous ICH in the late-stage elderly patients aged ≥75 years. Hospitalization costs were significantly higher in the craniotomy group, suggesting that endoscopic surgery may be more acceptable.

Determinants of acute and subacute case-fatality in elderly patients with hypertensive intracerebral hemorrhage

Background

Given that limited reports have described the survival and risk factors for elderly patients with hypertensive intracerebral hemorrhage (HICH), we aimed to develop a valid but simple prediction nomogram for the survival of HICH patients.

Methods

All elderly patients ≥65 years old who were diagnosed with HICH between January 2011 and December 2019 were identified. We performed the least absolute shrinkage and selection operator (Lasso) on the Cox regression model with the R package glmnet. A concordance index was performed to calculate the nomogram discrimination; and calibration curves and decision curves were graphically evaluated by depicting the observed rates against the probabilities predicted by the nomogram.

Results

A total of 204 eligible patients were analyzed, and over 20 % of the population was above the age of 80 (65-79 years old, n = 161; 80+ years old, n = 43). A hematoma volume ≥13.64 cm3 was associated with higher 7-day mortality (OR = 6.773, 95 % CI = 2.622-19.481; p < 0.001) and higher 90-day mortality (OR = 3.955, 95 % CI = 1.611-10.090, p = 0.003). A GCS score between 13 and 15 at admission was associated with a 7-day favorable outcome (OR = 0.025, 95 % CI = 0.005-0.086; p < 0.001) and a 90-day favorable outcome (OR = 0.033, 95 % CI = 0.010-0.099; p < 0.001).

Conclusions

Our nomogram models were visualized and accurate. Neurosurgeons could use them to assess the prognostic factors and provide advice to patients and their relatives.

Clinical application of 3DSlicer and Sina in minimally invasive puncture drainage of elderly patients with spontaneous intracerebral hemorrhage under local anesthesia

BACKGROUND

Decreased organ function and poor physical compensatory capacity in elderly patients diagnosed with spontaneous intracerebral hemorrhage (ICH) can make surgical treatment procedures challenging and risky. Minimally invasive puncture drainage (MIPD) combined with urokinase infusion therapy is a safe and feasible method of treating ICH. This study aimed to compare the treatment efficacy of MIPD conducted under local anesthesia using either 3DSlicer + Sina application or computer tomography (CT)-guided stereotactic localization of hematomas in elderly patients diagnosed with ICH.

METHODS

The study sample included 78 elderly patients (≥ 65 years of age) diagnosed with ICH for the first time. All patients exhibited stable vital signs and underwent surgical treatment. The study sample was randomly divided into two groups, either receiving 3DSlicer+Sina or CT-guided stereotactic assistance. The preoperative preparation time; hematoma localization accuracy rate; satisfactory hematoma puncture rate; hematoma clearance rate; postoperative rebleeding rate; Glasgow Coma Scale (GCS) score after 7 days; and modified Rankin scale (mRS) score 6 months after surgery were compared between the two groups.

RESULTS

No significant differences in gender, age, preoperative GCS score, preoperative hematoma volume (HV), and surgical duration were observed between the two groups (all p-values > 0.05). However, the preoperative preparation time was shorter in the group receiving 3DSlicer + Sina assistance compared to that receiving CT-guided stereotactic assistance (p-value < 0.001). Both groups exhibited significant improvement in GCS scores and reduction in HV after surgery (all p-values < 0.001). The accuracy of hematoma localization and puncture was 100% in both groups. There were no significant differences in surgical duration, postoperative hematoma clearance rate, rebleeding rate, postoperative GCS and mRS scores between the two groups (all p-values > 0.05).

CONCLUSIONS

A combination of 3DSlicer and Sina is effective in accurately identifying hematomas in elderly patients with ICH exhibiting stable vital signs, thus simplifying MIPD surgeries conducted under local anesthesia. This procedure may also be preferred over CT-guided stereotactic localization in clinical practice due to its ease of use and accuracy in hematoma localization.

The prognostic value of the Charlson comorbidity index in aged patients with intracerebral hemorrhage

BACKGROUND

Comorbidities are common in aged intracerebral hemorrhage patients. The purpose of this study was to assess whether the Charlson Comorbidity Index (CCI) was associated with in-hospital death and short-term functional outcome in elderly patients (age ≥ 70) with intracerebral hemorrhage (ICH).

METHODS

This was a retrospective cohort of aged ICH patients (≥70 years old) admitted within 24 hours of ICH onset. The CCI was derived using hospital discharge ICD-9 CM codes and patient history obtained from standardized case report forms. Multivariable logistic regression was used to determine the independent effect of the CCI score on clinical outcomes.

RESULTS

In this cohort of 248 aged ICH patients, comorbid conditions were common, with CCI scores ranging from 2 to 12. Logistic regression showed that the CCI score was independently predictive of 1-month functional outcome (OR = 1.642, P < 0.001) and in-hospital death (OR = 1.480, P = 0.003). Neither ICH volume nor the presence of IVH was an independent predictive factor for 1-month functional outcome or in-hospital mortality (P < 0.05).

CONCLUSION

Comorbid medical conditions as assessed by the CCI independently influence short-term outcomes in aged ICH patients. The characteristics of the hematoma itself, such as ICH volume and the presence of IVH, seem to have a reduced effect on it.

Development and validation of a nomogram to predict the 30-day mortality risk of patients with intracerebral hemorrhage

Background

Intracerebral hemorrhage (ICH) is a stroke syndrome with an unfavorable prognosis. Currently, there is no comprehensive clinical indicator for mortality prediction of ICH patients. The purpose of our study was to construct and evaluate a nomogram for predicting the 30-day mortality risk of ICH patients.

Methods

ICH patients were extracted from the MIMIC-III database according to the ICD-9 code and randomly divided into training and verification cohorts. The least absolute shrinkage and selection operator (LASSO) method and multivariate logistic regression were applied to determine independent risk factors. These risk factors were used to construct a nomogram model for predicting the 30-day mortality risk of ICH patients. The nomogram was verified by the area under the receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision curve analysis (DCA).

Results

A total of 890 ICH patients were included in the study. Logistic regression analysis revealed that age (OR = 1.05, P < 0.001), Glasgow Coma Scale score (OR = 0.91, P < 0.001), creatinine (OR = 1.30, P < 0.001), white blood cell count (OR = 1.10, P < 0.001), temperature (OR = 1.73, P < 0.001), glucose (OR = 1.01, P < 0.001), urine output (OR = 1.00, P = 0.020), and bleeding volume (OR = 1.02, P < 0.001) were independent risk factors for 30-day mortality of ICH patients. The calibration curve indicated that the nomogram was well calibrated. When predicting the 30-day mortality risk, the nomogram exhibited good discrimination in the training and validation cohorts (C-index: 0.782 and 0.778, respectively). The AUCs were 0.778, 0.733, and 0.728 for the nomogram, Simplified Acute Physiology Score II (SAPSII), and Oxford Acute Severity of Illness Score (OASIS), respectively, in the validation cohort. The IDI and NRI calculations and DCA analysis revealed that the nomogram model had a greater net benefit than the SAPSII and OASIS scoring systems.

Conclusion

This study identified independent risk factors for 30-day mortality of ICH patients and constructed a predictive nomogram model, which may help to improve the prognosis of ICH patients.

Machine learning model prediction of 6-month functional outcome in elderly patients with intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) has an increasing incidence and a worse outcome in elderly patients. The ability to predict the functional outcome in these patients can be helpful in supporting treatment decisions and establishing prognostic expectations. We evaluated the performance of a machine learning (ML) model to predict the 6-month functional status in elderly patients with ICH leveraging the predictive value of the clinical characteristics at hospital admission. Data were extracted by a retrospective multicentric database of patients ≥ 70 years of age consecutively admitted for the management of spontaneous ICH between January 1, 2014 and December 31, 2019. Relevant demographic, clinical, and radiological variables were selected by a feature selection algorithm (Boruta) and used to build a ML model. Outcome was determined according to the Glasgow Outcome Scale (GOS) at 6 months from ICH: dead (GOS 1), poor outcome (GOS 2–3: vegetative status/severe disability), and good outcome (GOS 4–5: moderate disability/good recovery). Ten features were selected by Boruta with the following relative importance order in the ML model: Glasgow Coma Scale, Charlson Comorbidity Index, ICH score, ICH volume, pupillary status, brainstem location, age, anticoagulant/antiplatelet agents, intraventricular hemorrhage, and cerebellar location. Random forest prediction model, evaluated on the hold-out test set, achieved an AUC of 0.96 (0.94–0.98), 0.89 (0.86–0.93), and 0.93 (0.90–0.95) for dead, poor, and good outcome classes, respectively, demonstrating high discriminative ability. A random forest classifier was successfully trained and internally validated to stratify elderly patients with spontaneous ICH into prognostic subclasses. The predictive value is enhanced by the ability of ML model to identify synergy among variables.

Intracerebral Hemorrhage: The Effects of Aging on Brain Injury

Intracerebral hemorrhage (ICH) is a devastating subtype of stroke with high rates of mortality and morbidity. ICH patients often suffer devastating and debilitating neurological impairments, from which the majority of victims are unable to fully recover to functional independence. Unfortunately, there is no established medical therapy for ICH, which is partly attributed to the lack of understanding of the complex pathology of the disorder. Despite advanced age being a major risk factor of ICH, most preclinical studies on ICH employed young animal subjects. Due to this discrepancy, the molecular level changes in the aging brain after ICH are largely unknown, limiting the translation of preclinical studies into potential human treatments. The purpose of this review is to highlight the effects of advanced age on ICH- induced brain injury and recovery and to draw attention to current knowledge gaps, which warrant further investigation.

Simultaneous presentation of subcortical hemorrhage, subdural hemorrhage, and cerebral infarct in a hemiplegic patient

A 90-year-old, non-hypertensive woman presented gait disturbance followed by falls. She had developed a lacunar infarction in the right frontal lobe 1 month previously that subsequently resulted in subtle motor weakness in the left lower extremity. At presentation, the patient showed motor weakness in the left upper and lower extremities with normal findings on blood test. Cranial computed tomography (CT) revealed a subcortical hemorrhage in the anterior part of the right frontal lobe that was accompanied by perilesional edema. In addition, two small subdural hematomas, apparently in the acute phase, were found. Magnetic resonance imaging performed immediately after the CT revealed hyperacute infarct in the right precentral gyrus adjacent to the previous infarct. It was hyperintense on the diffusion-weighted imaging but indistinct on the fluid-attenuated inversion recovery sequence. In addition, findings suggesting cerebral contusions were not observed. Based on these, we assumed that the patient's symptoms were mainly derived from the infarct and the subdural hemorrhages had developed in association with falls. However, it was unclear whether the infarct had developed before or after the formation of subcortical hemorrhage. Traumatic and non-traumatic intracranial hemorrhage and cerebral infarcts may present simultaneously. When intracranial hemorrhages appearing on CT do not adequately explain the patient's neurological findings, undetected cerebral ischemia should be assumed.

Cerebral Microangiopathy Mimicking a High-Grade Glioma in Old Age: A Case Report

Cerebral microangiopathy (CM) has become a common disease related to improved neuroimaging modalities and an increased life expectancy. Intracerebral tumor-like mass lesions have rarely been reported in cases of cerebral amyloid angiopathy (CAA) in elderly patients. However, tumor-like mass lesions from CM without amyloid deposits have rarely been reported. These two angiopathies may have different pathogeneses and neuroimaging characteristics. Herein, we present the case of an 83-year-old man with CM mimicking a high-grade glioma. We described the possible pathogenesis and different neuroimaging features of CM compared to CAA.

The Effect of Aging and Small-Vessel Disease Burden on Hematoma Location in Patients with Acute Intracerebral Hemorrhage

INTRODUCTION

Intracerebral hemorrhage (ICH) is a devastating hemorrhagic event and is associated with high mortality or severe neurological sequelae. Age-associated differences in hematoma location for nonlobar ICH are not well known. The aims of the present study were to elucidate the relationship between age and hematoma location and to assess the differences in small-vessel disease (SVD) burden as a potential surrogate marker for longstanding hypertension among various hematoma locations.

METHODS

From September 2014 through July 2019, consecutive patients with acute, spontaneous ICH were retrospectively enrolled from a prospective registry. Magnetic resonance imaging was performed during admission, and the total SVD burden score (including microbleeds, lacunes, enlarged perivascular spaces, and white matter hyperintensities) was calculated. The relationships of hematoma location with aging and SVD burden were assessed by using multivariate logistic regression analyses.

RESULTS

A total of 444 patients (156 women [35%]; median age 69 [interquartile range 59-79] years; National Institutes of Health Stroke Scale score 9 [17][3-17]) were enrolled in the present study. Multivariate logistic regression analyses showed that advanced age was independently associated with thalamic (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.19-1.84, p < 0.001 for 10-year increment) and lobar hemorrhage (OR: 1.58, 95% CI: 1.19-2.09, p = 0.002) and was independently and negatively related to putaminal hemorrhage (OR: 0.55, 95% CI: 0.44-0.68, p < 0.001). The total SVD burden score was independently and positively associated with thalamic hemorrhage (OR: 1.27, 95% CI: 1.01-1.59, p = 0.045) and negatively with lobar hemorrhage (OR: 0.74, 95% CI: 0.55-0.99, p = 0.042), even after adjusting by age, but not with putaminal hemorrhage (OR: 0.91, 95% CI: 0.73-1.14, p = 0.395).

CONCLUSION

Putaminal, thalamic, and lobar hemorrhages are prone to occur in specific ages and SVD states: putaminal in young patients, thalamic in old and high SVD burden patients, and lobar hemorrhages in old and low SVD burden patients. Susceptibility to bleeding with aging or severe SVD accumulation seems to differ considerably among brain locations.

Current Management and Therapeutic Strategies for Cerebral Amyloid Angiopathy

Cerebral amyloid angiopathy (CAA) is characterized by accumulation of amyloid β (Aβ) in walls of leptomeningeal vessels and cortical capillaries in the brain. The loss of integrity of these vessels caused by cerebrovascular Aβ deposits results in fragile vessels and lobar intracerebral hemorrhages. CAA also manifests with progressive cognitive impairment or transient focal neurological symptoms. Although development of therapeutics for CAA is urgently needed, the pathogenesis of CAA remains to be fully elucidated. In this review, we summarize the epidemiology, pathology, clinical and radiological features, and perspectives for future research directions in CAA therapeutics. Recent advances in mass spectrometric methodology combined with vascular isolation techniques have aided understanding of the cerebrovascular proteome. In this paper, we describe several potential key CAA-associated molecules that have been identified by proteomic analyses (apolipoprotein E, clusterin, SRPX1 (sushi repeat-containing protein X-linked 1), TIMP3 (tissue inhibitor of metalloproteinases 3), and HTRA1 (HtrA serine peptidase 1)), and their pivotal roles in Aβ cytotoxicity, Aβ fibril formation, and vessel wall remodeling. Understanding the interactions between cerebrovascular Aβ deposits and molecules that accumulate with Aβ may lead to discovery of effective CAA therapeutics and to the identification of biomarkers for early diagnosis.

[Acute stroke treatment in old age]

In patients over 80 years old, 4 of the 5 evidence-based acute treatments of ischemic stroke, i.e. stroke unit treatment, antiplatelet therapy, intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are effective but with a higher morbidity than in younger patients. The indications for the more invasive forms of treatment, such as IVT and MT are given in principle but have to be oriented to the individual patient comorbidities. In the case of failure of these procedures a consistent therapeutic target change to palliative measures is appropriate. Decompressive craniotomy in space-occupying media infarction can be indicated up to the relative age limit of 60 years and absolute age limit of 70 years. Patients over 80 years often do not undergo IVT or MT. Although the German approval for alteplase within the framework of IVT over the age of 80 years suggests a careful and critical review of the indications, its use is generally recommended.

[Acute stroke treatment in old age]

In patients over 80 years old, 4 of the 5 evidence-based acute treatments of ischemic stroke, i.e. stroke unit treatment, antiplatelet therapy, intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are effective but with a higher morbidity than in younger patients. The indications for the more invasive forms of treatment, such as IVT and MT are given in principle but have to be oriented to the individual patient comorbidities. In the case of failure of these procedures a consistent therapeutic target change to palliative measures is appropriate. Decompressive craniotomy in space-occupying media infarction can be indicated up to the relative age limit of 60 years and absolute age limit of 70 years. Patients over 80 years often do not undergo IVT or MT. Although the German approval for alteplase within the framework of IVT over the age of 80 years suggests a careful and critical review of the indications, its use is generally recommended.

Prevention and Treatment of Acute Stroke in the Nonagenarians and Beyond: Medical and Ethical Issues

PURPOSE OF REVIEW

As one of the fastest growing portions of the population, nonagenarians will constitute a significant percentage of the stroke patient population in the near future. Nonagenarians are nevertheless not specifically targeted by most clinical guidelines. In this review, we aimed to summarise the available evidence guiding stroke prevention and treatment in this age group.

RECENT FINDINGS

Several recent observational studies have shown that the benefits of anticoagulation for the oldest old patients with atrial fibrillation may outweigh the bleeding risk. A sub-analysis of the IST-3 trial has shown for the first time that thrombolysis treatment in acute ischaemic stroke may be beneficial and safe even in octogenarian patients and older. Several recent observational studies have assessed thrombolysis in nonagenarians. The latest of these has shown better disability outcomes without increased rates of symptomatic intracerebral haemorrhage with thrombolysis. Nonagenarian stroke patients may benefit from similar preventative and therapeutic strategies as their younger counterparts. A few important exceptions include primary prevention using aspirin or statins. Patient selection is nevertheless essential given the increased adverse event rates. Patient preference should play a key role in the decision-making process. Clinical trials including more nonagenarian patients are required to yield more robust evidence.

Clinical Features and Prognosis of Primary Intraventricular Hemorrhage in Elderly: Single-Center Experience

OBJECTIVE

Primary intraventricular hemorrhage (PIVH) is rare in the aging population and remains a challenge for cerebrovascular surgeons. In the present study, the authors reviewed the patient characteristics, angiographic results, and treatments and determined clinical outcomes in 34 patients older than 60 years of age who were treated at West China Hospital between 2010 and 2014.

METHODS

The medical records of elderly patients were queried. The parameters regarding patient demographics, presenting symptoms, treatment modalities, angiographic results, and clinical outcomes were assessed and analyzed.

RESULTS

There were 19 male (55.9%) and 15 female (44.1%) patients, with an average age (±SD) of 67.9 ± 7.7 years in our study. The most common symptoms on presentation were headache (50%), followed by disturbance of consciousness (26.5%). Only 5 patients (14.3%) were diagnosed with underlying cerebrovascular etiologies including Moyamoya disease (5.9%), arteriovenous malformations (2.9%), and aneurysms (5.9%). Idiopathic PIVH was diagnosed in 29 patients (85.7%). Thirteen patients (38.2%) underwent surgical intervention, while 21 patients (61.8%) received conservative treatment. Twelve patients (35.3%) had an unfavorable outcome at discharge, and an unfavorable outcome was observed in 14 patients (41.2%) at the 3-month follow-up. Patients with higher Graeb score might be associated with an unfavorable outcome both in short-term and long-term follow-up.

CONCLUSIONS

Most PIVH patients were diagnosed with idiopathic PIVH in the elderly. Surgical treatment of aging patients should be optimized to improve clinical outcomes. The admission Graeb scores were considered to be the independent prognostic factors for both short-term and long-term outcomes.