In-Hospital and Long-Term Prognosis after Spontaneous Intracerebral Hemorrhage among Young Adults Aged 18-65 Years

Development and validation of a novel clinical prediction model to predict the 90-day functional outcome of spontaneous intracerebral hemorrhage

Background

Spontaneous intracerebral hemorrhage (SICH) is associated with high mortality and disability. Accurately predicting adverse prognostic risks of SICH is helpful in developing risk stratification and precision medicine strategies for this phenomenon.

Methods

We analyzed 413 patients with SICH admitted to Hefei Second People's Hospital as a training cohort, considering 74 patients from the First Affiliated Hospital of Anhui Medical University for external validation. Univariate and multivariate logistic regression analyses were used to select risk factors for 90-day functional outcomes, and a nomogram was developed to predict their incidence in patients. Discrimination, fitting performance, and clinical utility of the resulting nomogram were evaluated through receiver operating characteristic (ROC) curves, accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), calibration plots, and decision curves analysis (DCA), respectively.

Results

Of the 413 patients, 180 had a poor prognosis. Univariate analysis showed significant variance of age, systolic pressure, intraventricular hemorrhage (IVH), Glasgow Coma Scale (GCS) scores, National Institute of Health Stroke Scale (NIHSS) scores, and hematoma volume between the groups (p < 0.05). Logistic multivariate regression analysis showed that age, IVH, NIHSS, and hematoma volume were associated with unfavorable outcomes. Based on the results, a nomogram model was developed with an area under the ROC curve of 0.91 (95% CI; 0.88-0.94) and 0.89 (95% CI; 0.80-0.95) in the training and validation sets, respectively. In the validation set, the accuracy, sensitivity, specificity, PPV, and NPV of the model were 0.851, 0.923, 0.812, 0.727, and 0.951, respectively. The calibration plot demonstrates the goodness of fit between the nomogram predictions and actual observations. Finally, DCA indicated significant clinical adaptability.

Conclusion

We developed and validated a short-term prognostic nomogram model for patients with SICH including NIHSS scores, age, hematoma volume, and IVH. This model has valuable potential in predicting the prognosis of patients with SICH.

Long-term mortality rates of young stroke in Taiwan: A decade-long epidemiology population-based study

INTRODUCTION

Stroke remains a leading cause of death worldwide. Stroke in young adults is an important issue, gaining extra attention in recent years. This study aims to investigate the mortality after stroke in young adults in Taiwan.

PATIENTS AND METHODS

This is a registry- and population-based study in Taiwan of patients aged 20-50 years with first-ever stroke between 1999 and 2012, with follow-up until January 1, 2022. Patients and mortalities were identified through Taiwan National Health Insurance database.

RESULTS

The study population included 65,097 patients with stroke (mean age, 42.6 ± 6.6 years; 30.5% woman). There were 23,481 (36.1%) intracranial hemorrhage, 37,522 (57.6%) ischemic stroke, and 4094 (6.3%) stroke not otherwise specified. At the end of follow-up, a total of 18,248 deaths (28.0%) occurred during a median follow-up of 9.8 years (interquartile range, 6.4-13.7 years).

CONCLUSION

Taiwan young adults who were 30-day survivors of first-ever stroke have significantly higher long-term mortality rates when compared to other population-based studies.

Analysis of the Failure of Removal of the Urinary Catheter for Patients With Intracerebral Hemorrhage Postoperatively

BACKGROUND

We conducted this study to assess the value of clinically relevant data for predicting the failure of removing urinary catheters among patients with intracerebral hemorrhage postoperatively.

MATERIALS AND METHODS

We retrospectively analyzed the medical records of all patients with intracerebral hemorrhage who underwent surgery for removal of intracerebral hematoma between January 2014 and December 2019, all of whom retained their urinary catheter. The patients were classified into 2 groups. Group A included patients who underwent successful removal of the catheter while group B included patients who underwent a failed removal. Univariate analysis was performed to determine the relationship between the failure of catheter removal and the patients' preoperative clinical characteristics. Independent prognostic predictors were identified using multivariate analyses.

RESULTS

The site of intracerebral hematoma ( P =0.004), volume of hematoma ( P <0.001), intraventricular hemorrhage ( P <0.001), admitted Glasgow Coma Scale (GCS) ( P <0.001), GCS before urinary catheter removal ( P <0.001), smoking ( P =0.011), herniation ( P <0.001), urine protein ( P =0.013), creatinine ( P =0.037), and timing of urinary catheter removal ( P <0.001) were significantly different among the 2 groups. Multiple logistical regression analysis indicated that GCS before urinary catheter removal (odds ratio=1.171; 95% confidence interval=1.050-1.306; P =0.005) and timing for urinary catheter removal (odds ratio=0.962; 95% confidence interval=0.944-0.981; P <0.001) were associated with failure of urinary catheter removal.

CONCLUSIONS

This study demonstrated that GCS before urinary catheter removal and the timing of urinary catheter removal are independent factors associated with failure of urinary catheter removal among patients with intracerebral hemorrhage.

A Contemporary Review of Epidemiology, Risk Factors, Etiology, and Outcomes of Premature Stroke

PURPOSE OF REVIEW

Recent data identifies increases in young ischemic and hemorrhagic strokes. We provide a contemporary overview of current literature on stroke among young patients or premature stroke along with directions for future investigation.

RECENT FINDINGS

Strokes in the young are highly heterogenous and often cryptogenic. Sex distribution and risk factors shift from women among the youngest age groups (< 35) to men over the age of 45, with a coinciding rise in traditional vascular risk factors. Incidence is higher in minority and socioeconomically disadvantaged populations, and the impact of stroke among these communities may be exaggerated by disparities in symptom recognition and access to care. Special diagnostic work-up may be needed, and a lower threshold for diagnosis is warranted as potential misdiagnosis is a concern and may preclude necessary triage and management. Although "premature strokes" form a relatively small proportion of total incidence, they vary greatly across subgroups and present an outsized impact on quality of life and productivity.

Long-term mortality in young patients with spontaneous intracerebral haemorrhage: Predictors and causes of death

INTRODUCTION

Intracerebral haemorrhage (ICH) in young adults is rare but has devastating consequences. We investigated long-term mortality rates, causes of death and predictors of long-term mortality in young spontaneous ICH survivors.

PATIENTS AND METHODS

We included consecutive patients aged 18-55 years from the Prognosis of Intracerebral Haemorrhage cohort (PITCH), a prospective observational cohort of patients admitted to Lille University Hospital (2004-2009), who survived at least 30 days after spontaneous ICH. We studied long-term mortality with Kaplan-Meier analyses, collected causes of death, performed uni-/multivariable Cox-regression analyses for the association of baseline characteristics with long-term mortality.

RESULTS

Of 560 patients enrolled in the PITCH, 75 patients (75% men) met our inclusion criteria (median age 50 years, interquartile range [IQR] 44-53 years). During a median follow-up of 8.2 years (IQR 5.0-10.1), 26 patients died (35%), with a standardized mortality ratio of 13.0 (95% confidence interval [95% CI] 8.5-18.0) compared to peers from the general population. Causes of death were vascular in 7 (27%) patients, non-vascular in 13 (50%) and unknown in 6 (23%). Global cerebral atrophy (hazard ratio [HR] 3.0, 95% CI 1.1-8.6), modified Rankin Score >2 before ICH (HR 3.4, 95% CI 1.0-11.0), and excessive alcohol consumption (HR 3.3, 95% CI 1.1-10.2) were independently associated with long-term mortality.

DISCUSSION

We found a 13-fold higher mortality risk for young ICH survivors compared to the general French population. Predictors of long-term mortality were pre-existing conditions, not ICH-characteristics.

CONCLUSION

Young ICH survivors remain at increased mortality risk of vascular and non-vascular death for years after ICH.

Where to make burr hole for endoscopic hematoma removal against intracerebral hemorrhage at the basal ganglia to increase the hematoma removal rate - Comparison between trans-forehead and along-the-long-axis approaches

Background:

Endoscopic hematoma removal is performed to treat intracerebral hemorrhage (ICH) at the basal ganglia. In our hospital, young neurosurgical trainees perform it for the only 1^st to the 3^rd time. We perform a “trans-forehead approach” and hypothesized that our technique would contribute to higher hematoma removal rate and easiness despite their inexperience. We compared our dataset with an open dataset with along-the-long-axis approaches using pre- and intraoperative neuronavigation by well-trained neurosurgeons and tested the utility of our trans-forehead approach.

Methods:

We retrospectively investigated our 17 consecutive patients with hypertensive ICH who underwent endoscopic hematoma removal using the trans-forehead approach. We obtained the open dataset and compared our data with the 12 patients from the open dataset using the inverse probability weighting method. Operative time, hematoma removal rate, postoperative hematoma volume, Glasgow Coma Scale (GCS) on day 7, and modified Rankin Scale (mRS) at 6 months were assessed as outcomes.

Results:

The median age was 68 (interquartile range; 58–78) years. Median postoperative hematoma volume, removal rate, operative time, GCS on day 7, and mRS at 6 months were 9 (2–24) mL, 90 (79–98)%, 53 (41–80) min, 13 (12–13), and 4 (2–5), respectively. The weighted generalized estimating equations revealed that operative time was shorter in the along-the-long-axis group, but other items were not significantly different between the two approaches.

Conclusion:

The hematoma removal rate of endoscopic hematoma removal with the trans-forehead approach by young trainees was not different from that of the along-the-long-axis approach by well-trained neurosurgeons using neuronavigation.

Hypertension Among Hemorrhagic Stroke Patients in Northeast China: A Population-Based Study 2017-2019

BACKGROUND We aimed to profile the current epidemiology of hypertension among the survivors of hemorrhagic stroke in northeast China. MATERIAL AND METHODS Our cross-sectional study included 18 796 adults aged 40 years or older and residing in northeast China. Hemorrhagic stroke was identified according to the CT and/or MRI results. Hypertension was defined based on the Chinese hypertension guidelines. RESULTS We identified 208 patients with previous hemorrhagic stroke in this population-based study. The overall prevalence of hypertension in the studied population was 88%. Out of all the survivors of hemorrhagic stroke, 80.9% were aware of their hypertensive condition, 70.5% of the patients were in antihypertensive medications treatment, and only 12% of the patients had their blood pressure under control. Furthermore, only 17.10% of the patients who took hypertensive medications achieved appropriate blood pressure. Calcium channel blockers were more commonly used than other medications. Patients with controlled hypertension had significantly higher percentages of comorbidities when compared to those with uncontrolled hypertension. In our patient sample, the rates of stage 2 and stage 3 hypertension in the hemorrhagic stroke population were 28.8% and 15.9%, respectively, and women had a significantly higher prevalence of stage 3 hypertension when compared with men (21.3% vs. 10.0%, P=0.026). CONCLUSIONS The high prevalence of uncontrolled hypertension and high rates of blood pressure at stages 2 and 3 in patients with prior hemorrhagic stroke indicated a considerable stroke burden in northeast China. Therefore, effective and long-time management of hypertension in stroke survivors should be a priority.

Lower total protein and absence of neuronavigation are novel poor prognostic factors of endoscopic hematoma removal for intracerebral hemorrhage

OBJECTIVES

Endoscopic hematoma removal is widely performed for the treatment of intracerebral hemorrhage. We investigated the factors related to the prognosis of intracerebral hemorrhage after endoscopic hematoma removal.

MATERIALS AND METHODS

From 2013 to 2019, we retrospectively analyzed 75 consecutive patients with hypertensive intracerebral hemorrhage who underwent endoscopic hematoma removal. Their characteristics, including neurological symptoms, laboratory data, and radiological findings were investigated using univariate and multivariate analysis. Complications during hospitalization, Glasgow Coma Scale (GCS) score on day 7, and modified Rankin Scale (mRS) score at 6 months were considered as treatment outcomes.

RESULTS

The mean age of the patients (33 women, 42 men) was 71.8 (36-95) years. Mean GCS scores at admission and on day 7 were 10.3 ± 3.2 and 11.7 ± 3.8, respectively. The mean mRS score at 6 months was 3.8 ± 1.6, and poor outcome (mRS score ranging from 3 to 6 at 6 months) in 53 patients. Rebleeding occurred in 4 patients, and other complications in 15 patients. Multivariate analysis revealed that older age, hematoma in the basal ganglia, lower total protein level, higher glucose level, and absence of neuronavigation were associated with poor outcomes. Of the 75 patients, 9 had cerebellar hemorrhages, and they had relatively favorable outcomes compared to those with supratentorial hemorrhages.

CONCLUSION

Several factors were related to the prognosis of intracerebral hemorrhage after endoscopic hematoma removal. Lower total protein level at admission and absence of neuronavigation were novel factors related to poor outcomes of endoscopic hematoma removal for intracerebral hemorrhage.

Endoscopic hematoma removal of supratentorial intracerebral hemorrhage under local anesthesia reduces operative time compared to craniotomy

The surgical efficacy for supratentorial intracerebral hemorrhage (ICH) remains unknown. We compared the advantages of the widely practiced endoscopic hematoma removal under local anesthesia with that of craniotomy under general anesthesia for ICH. We also focused on our novel operative concept of intentional hematoma leaving technique to avoid further damage to the brain. We retrospectively analyzed 134 consecutive patients (66 endoscopies and 68 craniotomies) who were surgically treated for supratentorial ICH. The characteristics of the 134 patients were as follows: The median (interquartile range) age was 73 (61-82) years. The median Glasgow Coma Scale scores at admission, on day 7, and the median modified Rankin Scale (mRS) score at 6 months were 10 (7-13), 13 (10-14), and 4 (3-5) respectively. The statistical comparison revealed there were no differences in GCS score on day seven between the endoscopy 13 (12-14) and craniotomy group 12 (9-14). No differences were observed in mRS scores at 6 months between the endoscopy 4 (2-5) and craniotomy group 4 (3-5). However, the patients treated with our technique tended to have favorable outcomes. Multivariate analysis revealed the operative time was significantly decreased in the endoscopy group compared to the craniotomy group (p < 0.001).

Thrombin-induced miRNA-24-1-5p upregulation promotes angiogenesis by targeting prolyl hydroxylase domain 1 in intracerebral hemorrhagic rats

OBJECTIVE

Thrombin is a unique factor that triggers post-intracerebral hemorrhage (ICH) angiogenesis by increasing hypoxia-inducible factor-1α (HIF-1α) at the protein level. However, HIF-1α mRNA remains unchanged. MicroRNAs (miRNAs) mediate posttranscriptional regulation by suppressing protein translation from mRNAs. This study aimed to determine if miRNAs might be involved in thrombin-induced angiogenesis after ICH by targeting HIF-1α or its upstream prolyl hydroxylase domains (PHDs).

METHODS

The study was divided into two parts. In part 1, rats received an injection of thrombin into the right globus pallidus. An miRNA array combined with miRNA target prediction, luciferase activity assay, and miRNA mimic/inhibitor transfection were used to identify candidate miRNAs and target genes. Part 2 included experiments 1 and 2. In experiment 1, rats were randomly divided into the sham group, ICH group, and ICH+hirudin-treated (thrombin inhibitor) group. In experiment 2, the rats were randomly divided into the sham group, ICH group, ICH+antagomir group, ICH+antagomir-control group, and ICH+vehicle group. Western blotting and quantitative real-time polymerase chain reaction were used to determine the expression of protein and miRNA, respectively. The coexpression of miR-24-1-5p (abbreviated to miR-24) and von Willebrand factor was detected by in situ hybridization and immunohistochemical analysis. The angiogenesis was evaluated by double-labeling immunofluorescence. Neurological function was evaluated by body weight, modified Neurological Severity Scores, and corner turn and foot-fault tests.

RESULTS

In part 1, it was shown that miR-24, which is predicted to target PHD1, was upregulated (fold-change of 1.83) after thrombin infusion, and that the miR-24 mimic transfection decreased luciferase activity and downregulated PHD1 expression (p < 0.05). miR-24 inhibitor transfection increased PHD1 expression (p < 0.05). In part 2, it was shown that miR-24 was expressed in endothelial cells. The HIF-1α protein level and proliferating cell nuclear antigen-positive (PCNA+) nuclei in vessels were increased, while the PHD1 protein level was decreased after ICH, and these effects were reversed by hirudin (p < 0.05). The antagomiR-24-treated rats exhibited a markedly lower body weight and significantly poorer recovery from neurological deficit compared with those in ICH groups (p < 0.05). AntagomiR-24 intervention also led to lower miR-24 expression, a higher PHD1 protein level, and fewer PCNA+ nuclei in vessels compared with those in ICH groups (p < 0.05).

CONCLUSIONS

The present study suggests that thrombin reduces HIF-1α degradation and initiates angiogenesis by increasing miR-24, which targets PHD1 after ICH.

Nontraumatic spontaneous intracerebral hemorrhage: Baseline characteristics and early outcomes

BACKGROUND AND PURPOSE

Hemorrhagic stroke, particularly nontraumatic spontaneous intracerebral hemorrhage (SICH), is a cerebrovascular condition with unfavorable outcomes. The aims of the present study were to evaluate patients who suffered from SICH and investigate the early outcomes in a single-center study.

METHODS

During a study -period of 6 years (2008-2014), 613 consecutive patients (mean age, 72 ± 12.7 years; 51.1% female), who suffered from nontraumatic SICH and were treated at the Department of Neurology at the University Hospital of Schleswig-Holstein, Campus Lübeck, Germany, were included and prospectively analyzed.

RESULTS

During a mean hospitalization time of 12 days, 148 patients (24.1%) died, 47% of those within the first 2 days and 79% within the first week. The patients who died stayed at the hospital for a shorter time (3) than those who survived (p < .001). In the multivariate logistic regression, following parameters were found to be associated with the in-hospital mortality: female sex (OR, 2.0; 95%-CI, 1.2-3.4; p = .009), a NIHSS score> 10 (OR, 10.5; 95%-CI, 5.6-19.5; p < .001), history of hypertension (OR, 0.35; 95%-CI, 0.19-0.64; p = .001), previous oral anticoagulation (OR, 2; 95%-CI, 1.0-3.8; p = .032), and intraventricular extension of hemorrhage (OR, 2.8; 95%-CI, 1.7-4.7; p = .001). At discharge, 192 patients (41.2%) showed favorable outcomes (mRS ≤ 2) whereas the median mRS of patients who survived was 3 (IQR 2-4). The good functional outcome at discharge from the acute hospital was decreased by an age> 70 years (OR, 0.56; 95%-CI, 0.35-0.9; p = .017), NIHSS score> 10 at admission (OR, 0.07; 95%-CI, 0.04-0.13; p < .001), and development of pneumonia during hospitalization (OR, 0.35; 95%-CI, 0.2-0.6; p < .001).

CONCLUSION

The present study showed that SICH is a serious disease causing high mortality and disability, particularly in the early period after event.