Brain edema formation and therapy after intracerebral hemorrhage

Research progress of active compounds from traditional Chinese medicine in the treatment of stroke

Stroke is a serious cerebrovascular disease that is categorized into two types: ischemic and hemorrhagic. The pathological mechanisms of ischemic stroke are complex and diverse, encompassing processes such as neuroinflammation and apoptosis. The pathological processes of hemorrhagic stroke primarily involve the disruption of the blood-brain barrier and cerebral edema. Western medical treatment methods show certain effectiveness during the acute phase of stroke, but they are limited by a narrow therapeutic window and secondary injuries. Traditional Chinese medicine (TCM) has a long history and unique advantages in treating stroke. Studies confirm that active compounds derived from TCM exert multi-pathway, multi-target effects, significantly improving therapeutic outcomes and reducing adverse reactions. However, due to the complexity of the components in TCM, research on monomeric components still faces challenges. This article reviews the relevant research progress published in domestic and international journals over the past twenty years regarding the mechanisms of action of monomeric components of TCM in the treatment of stroke, aiming to provide insights and references for the clinical application of TCM in stroke treatment and further new drug development.

Atorvastatin Protects Against the Macrophage/Microglia-Related Neuroinflammation via Inhibiting Lipocalin-2 in Mouse Experimental Intracerebral Hemorrhage Model

There are few effective pharmacological interventions for intracerebral hemorrhage (ICH). Atorvastatin (Ato) has been shown to exert a substantial protective effect on ischemic stroke and is effective in alleviating neuroinflammation. Lipocalin-2 (LCN2), an important inflammation-regulating protein, has been demonstrated to play pivotal roles in post-ICH neuroinflammation. However, the exact role of Ato and whether LCN2 is involved after ICH remain largely unknown. In the current study, the BV2 (microglia) cell line, which was transfected with or without LCN2 for overexpression/interference, was co-cultured with primary cultured neurons and received blood infusion from C57BL/6 mice in vitro. For the in vivo study, atorvastatin was injected peritoneally into an ICH mouse model, and LCN2 specific knockout using the flox/cre system was performed in mice for mechanism study. Behavioral tests were conducted before ICH and on days 1, 3, and 7 post-ICH, and the brains and cultured cells were collected for protein, histological, and morphological studies. Our results showed that atorvastatin treatment alleviates neural damage and promotes neurological outcomes after ICH. Moreover, M1 activation and pro-inflammatory polarization are inhibited by atorvastatin. In both in vivo and in vitro models, the upregulation of LCN2 after ICH is substantially inhibited by atorvastatin. Studies on LCN2 transgenic mice and LCN2 overexpression/interference cells demonstrated that the suppression of macrophage/microglia (M/M) LCN2 participates in atorvastatin-mediated anti-neuroinflammation and neural protection effects. Therefore, our study suggests that atorvastatin treatment attenuates M/M-related neuroinflammation and protects neural recovery by down-regulating LCN2 after ICH. This study identified a potential novel therapeutic target for ICH treatment.

Role of disturbance coefficient in monitoring and treatment of cerebral edema in patients with cerebral hemorrhage

BACKGROUND

At present, the conventional methods for diagnosing cerebral edema in clinical practice are computed tomography (CT) and magnetic resonance imaging (MRI), which can evaluate the location and degree of peripheral cerebral edema, but cannot realize quantification. When patients have symptoms of diffuse cerebral edema or high cranial pressure, CT or MRI often suggests that cerebral edema is lagging and cannot be dynamically monitored in real time. Intracranial pressure monitoring is the gold standard, but it is an invasive operation with high cost and complications. For clinical purposes, the ideal cerebral edema monitoring should be non-invasive, real-time, bedside, and continuous dynamic monitoring. The disturbance coefficient (DC) was used in this study to dynamically monitor the occurrence, development, and evolution of cerebral edema in patients with cerebral hemorrhage in real time, and review head CT or MRI to evaluate the development of the disease and guide further treatment, so as to improve the prognosis of patients with cerebral hemorrhage.

AIM

To offer a promising new approach for non-invasive adjuvant therapy in cerebral edema treatment.

METHODS

A total of 160 patients with hypertensive cerebral hemorrhage admitted to the Department of Neurosurgery, Second Affiliated Hospital of Xi'an Medical University from September 2018 to September 2019 were recruited. The patients were randomly divided into a control group (n = 80) and an experimental group (n = 80). Patients in the control group received conventional empirical treatment, while those in the experimental group were treated with mannitol dehydration under the guidance of DC. Subsequently, we compared the two groups with regards to the total dosage of mannitol, the total course of treatment, the incidence of complications, and prognosis.

RESULTS

The mean daily consumption of mannitol, the total course of treatment, and the mean hospitalization days were 362.7 ± 117.7 mL, 14.8 ± 5.2 days, and 29.4 ± 7.9 in the control group and 283.1 ± 93.6 mL, 11.8 ± 4.2 days, and 23.9 ± 8.3 in the experimental group (P < 0.05). In the control group, there were 20 patients with pulmonary infection (25%), 30 with electrolyte disturbance (37.5%), 20 with renal impairment (25%), and 16 with stress ulcer (20%). In the experimental group, pulmonary infection occurred in 18 patients (22.5%), electrolyte disturbance in 6 (7.5%), renal impairment in 2 (2.5%), and stress ulcers in 15 (18.8%) (P < 0.05). According to the Glasgow coma scale score 6 months after discharge, the prognosis of the control group was good in 20 patients (25%), fair in 26 (32.5%), and poor in 34 (42.5%); the prognosis of the experimental group was good in 32 (40%), fair in 36 (45%), and poor in 12 (15%) (P < 0.05).

CONCLUSION

Using DC for non-invasive dynamic monitoring of cerebral edema demonstrates considerable clinical potential. It reduces mannitol dosage, treatment duration, complication rates, and hospital stays, ultimately lowering hospitalization costs. Additionally, it improves overall patient prognosis, offering a promising new approach for non-invasive adjuvant therapy in cerebral edema treatment.

Nanobiotechnologies for stroke treatment

Stroke has brought about a poor quality of life for patients and a substantial societal burden with high morbidity and mortality. Thus, the efficient stroke treatment has always been the hot topic in the research of medicine. In the past decades, nanobiotechnologies, including natural exosomes and artificial nanomaterials, have been a focus of attention for stroke treatment due to their inherent advantages, such as facile blood - brain barrier traversal and high drug encapsulation efficiency. Recently, thanks to the rapid development of nanobiotechnologies, more and more efforts have been made to study the therapeutic effects of exosomes and artificial nanomaterials as well as relevant mechanisms in stroke treatment. Herein, from recent studies and articles, the application of natural exosomes and artificial nanomaterials in stroke treatment are summarized. And their prospects of clinical translation and future development are also discussed in further detail.

Development of an Injectable Formulation of a Water-Insoluble Glycyrrhizin Derivative That Potently Inhibits High-Mobility Group Box 1 in Murine Intracerebral Hemorrhage

High-mobility group box (HMGB) 1, a nuclear protein that acts as an inflammatory mediator, exacerbates injury following intracerebral hemorrhage (ICH). Glycyrrhizin, a natural HMGB1 inhibitor derived from licorice, alleviates ICH-induced inflammatory responses, including brain edema formation. In our previous study, inspired by the bioconversion of endophytes living symbiotically in licorice, we discovered a glycyrrhizin derivative with more potent anti-HMGB1 activity than glycyrrhizin. However, this derivative is poorly soluble in water, and some issues remain to be resolved when applying it to treat ICH. The aim of this study was to develop an injectable formulation of a water-insoluble glycyrrhizin derivative (WIGLD) to treat acute ICH. Screening of Pluronic surfactants revealed that Pluronic P103 significantly improved the solubility of WIGLD. The micelles had a particle size of approximately 20 nm; therefore, this formulation was considered suitable for intravenous injection. Thus, we investigated the therapeutic efficacy of an intravenously injected solubilized WIGLD formulation in a murine model of ICH induced by intrastriatal collagenase injection. The injected WIGLD formulation increased brain penetration compared to that after oral administration. Additionally, it inhibited microglial activation by HMGB1, decreased brain edema, and ameliorated neurological deficits. These findings suggested that the injectable WIGLD formulation, with its potent anti-HMGB1 activity, represents a promising therapeutic strategy for managing ICH-related brain edema and associated injuries.

Nomogram Prediction of Prognosis After Surgical Operation for Cerebral Hemorrhage

OBJECTIVE

This study aimed to investigate the risk factors for intensive care unit (ICU) mortality in patients with intracerebral hemorrhage after surgery and to construct a clinical nomogram.

METHODS

The data in this retrospetive analysis were acquired from the Medical Information Mart for Intensive Care IV database, and the study controls were randomly divided into training and validation subsets in a ratio of 7:3. The primary clinical endpoint was all-cause ICU mortality. The prediction model was developed and a nomogram was generated based on findings of the logistic regression and least absolute shrinkage and selection operator regression analyses. Receiver operating characteristic curve was employed to assess model performance, and decision curve analysis was used to assess the clinical utility of the nomogram.

RESULTS

This retrospective study comprised 859 participants, of whom 757 were survivors and 102 were nonsurvivors. The results showed that red cell distribution width (P = 0.014), Glucose (P < 0.001), mechanical ventilation ≥48 hours (P < 0.001), acute respiratory failure (P = 0.019), and Sequential Organ Failure Assessment (P = 0.017) were independent risk factors for death after intracerebral hemorrhage surgery. The results of the nomogram showed that blood glucose and red cell distribution width had the greatest impact on prognosis. The nomogram demonstrated strong discriminating for all-cause mortality in the ICU and showed a positive net benefit across a broad spectrum of threshold probabilities.

CONCLUSIONS

For patients with severe cerebral hemorrhage after craniotomy, we developed a distinctive nomogram model to forecast all-cause mortality in the critical care unit. It can simply and intuitively display the risk of poor prognosis for patients, providing clinicians with an important treatment tool for individualized treatment and outcome forecasting.

Reactive astrocyte-derived exosomes enhance intracranial lymphatic drainage in mice after intracranial hemorrhage

BACKGROUND

After intracranial hemorrhage (ICH), the formation of primary hematoma foci leads to the development of secondary brain injury factors such as perihematomal edema (PHE) and accumulation of toxic metabolites, which severely affect the survival and prognosis of patients. The intracerebral lymphatic system, proposed by Jeffrey J. Iliff et al., plays an important role in central nervous system (CNS) fluid homeostasis and waste removal, while reactive astrocyte-derived exosomes have shown therapeutic potential in CNS disorders. Our study focuses on the effects of hemin-treated reactive astrocyte-derived exosomes on the functional integrity of the glymphatic system (GLS) after ICH and their potential mechanism of action in repairing brain injury.

METHODS

Hemin, an iron-rich porphyrin compound, was used to construct the in vitro model of ICH. Primary astrocytes were treated with complete medium supplemented with different concentrations of hemin to obtain exosomes secreted by them, and mice with ICH induced by the collagenase method were intervened by intranasal administration. Solute clearance efficiency was assessed by intracranial injection of cerebrospinal fluid tracers and fluorescent magnetic beads. Immunofluorescence analysis of Aquaporin 4 (AQP4) polarization and astrocyte proliferation. Magnetic Resonance Imaging was used to visualize and quantify the volume of hematoma foci and PHE, and Western Blot was used to analyze the accumulation of toxic metabolites, while neuronal apoptosis was detected by a combination of TUNEL assay apoptosis detection kit and Nissl staining, and their functional status was analyzed. Gait analysis software was used to detect functional recovery of the affected limb in mice.

RESULTS

Exosomes from hemin treated astrocytes facilitated the recovery of AQP4 polarization and attenuated astrocyte proliferation around hematoma foci in mice with ICH, thereby promoting the recovery of the GLS. Meanwhile, exosomes from hemin treated astrocytes reduced PHE and toxic protein accumulation, decreased apoptosis of cortical neurons on the affected side, and facilitated recovery of motor function of the affected limb, and these effects were blocked by TGN020, an AQP4-specific inhibitor.

CONCLUSIONS

Exosomes from hemin treated astrocytes attenuated secondary brain injury and neurological deficits in mice with ICH by promoting the repair of GLS injury.

Exosomal MicroRNA: an Effective Strategy for the Treatment of Intracerebral Hemorrhage

Intracerebral hemorrhage is a devastating type of stroke, and its pathological mechanism is very complex. Surgical treatment can effectively treat the primary injury caused by mechanical compression of hematoma after intracerebral hemorrhage. However, there is no effective treatment for the secondary injury caused by a series of pathological processes caused by extravasation of blood components, including inflammatory response, oxidative stress, and excitotoxicity. Therefore, there is an urgent need to develop a novel treatment regimen that can reverse the secondary damage of intracerebral hemorrhage. In recent years, as a powerful biomarker, the role of microRNAs (miRNAs) in diseases has been gradually disclosed. As nanocarriers, the miRNAs delivered by exosomes have become a new treatment method and are widely used in the treatment of various diseases. In this paper, the research progress on the mechanism of exosomal miRNAs in intracerebral hemorrhage and its value in prevention, diagnosis, and prognosis is summarized, hoping to provide some reference for the application of exosomal miRNAs in clinical treatment of intracerebral hemorrhage.

Cannabinoid Receptors Reduced Early Brain Damage by Regulating NOX-2 and the NLRP3 Inflammasome in an Animal Model of Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is a leading cause of death and disability worldwide. Following the initial mechanical injury caused by hematoma expansion, a secondary injury occurs, characterized by the production of reactive oxygen species (ROS) generated by NOX-2 and neuroinflammation, which is exacerbated by the upregulation of the NLRP3 inflammasome. These conditions collectively aggravate brain damage. The endocannabinoid system (ECS), through the activation of the cannabinoid receptors, has demonstrated neuroprotective properties in various models of brain injury. However, the role of the ECS during ICH remains poorly understood, particularly regarding the action of the CB1 receptor in the activation of NOX-2 and the inflammasome. The present study investigates the neuroprotective effects of the cannabinoid receptor agonist WIN55,212-2 in an ICH animal model, specifically examining the roles of NLRP3 and NOX-2.

METHODS

Male C57BL/6 mice were subjected to ICH through an intracerebral injection of collagenase, followed by intraperitoneal administration of WIN55,212-2 and/or MCC950, a selective NLRP3 inhibitor. Various outcome measures were employed, including assessments of motor activity, hematoma volume, brain water content, and blood-brain barrier (BBB) permeability, which was evaluated using Evans blue assay. Additionally, the activity of NOX and the protein levels of crucial markers such as CB1, gp91phox, NLRP3, AQP4, and caspase-1 were measured via western blot analysis.

RESULT

The findings demonstrate that ICH induced a significant brain lesion characterized by hematoma formation, edema, BBB disruption, and subsequent motor impairments in the affected mice. Notably, these detrimental effects were markedly reduced in animals treated with WIN55,212-2. The study also revealed an activation of both NOX-2 and NLRP3 in response to ICH, which was reduced by cannabinoid receptor activation. Furthermore, the pharmacological inhibition of NLRP3 using MCC950 also led to a reduction in hematoma size, edema, and motor impairment secondary to ICH.

CONCLUSIONS

These results support a neuroprotective role of the cannabinoid receptor activation during ICH and suggest the involvement of NOX-2 and NLRP3.

miRNA506 Activates Sphk1 Binding with Sirt1 to Inhibit Brain Injury After Intracerebral Hemorrhage via PI3K/AKT Signaling Pathway

Intracerebral hemorrhage (ICH) is an acute neurological disorder characterized by high mortality and disability rates. Previous studies have shown that 75% of patients who survive ICH experience varying degrees of neurological deficits. Sphk1 has been implicated in a multitude of phylogenetic processes, including innate immunity and cell proliferation. An in vivo rat model of ICH and an in vitro model of neuronal oxyhemoglobin (OxyHb) were constructed. The expression level of Sphk1 was assessed using western blotting and immunofluorescence, whereas cell death following ICH was evaluated using fluoro-Jade B and terminal deoxynucleotidyl transferase dUTP nick end labeling staining. Immunofluorescence facilitated the examination of microglial phenotypic alterations, while enzyme-linked immunosorbent assays were used to determine the concentrations of inflammatory markers. Behavioral assays were employed to assess the overall behavioral modifications of animals. Neuronal Sphk1/Sirt1 protein levels gradually increased following the induction of ICH. Elevated Sphk1 expression resulted in increased levels of anti-inflammatory microglia and reduced levels of pro-inflammatory factors. In contrast, suppression of Sphk1 expression resulted in an increased number of dead cells, thereby exacerbating neurological deficits. In vitro findings indicated that the levels of phosphorylated PI3K and AKT proteins increased in conjunction with Sphk1 expression. This study established that after ICH, Sphk1 interacts with Sirt1 to mitigate neuroinflammation, cell death, oxidative stress, and brain edema via the PI3K/AKT signaling pathway. Augmenting expression of Sphk1 significantly can ameliorate neurological impairments induced by ICH, offering novel targets and perspectives for therapeutic interventions in ICH treatment.

Recombinant human heavy-chain ferritin nanoparticles loaded with rosuvastatin attenuates secondary brain injury in intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a severe form of stroke with high mortality and disability rates, largely due to its complex pathology. Currently, no effective therapies exist. Rosuvastatin has shown neuroprotective effects, but its low bioavailability and poor targeting to hemorrhagic sites limit its therapeutic efficacy. To overcome these challenges, this study developed rosuvastatin-loaded human H-ferritin nanoparticles (Rsv@HFn) as a brain-targeting nanoplatform. This nanoplatform enhances the drug's ability to cross the blood-brain barrier, increasing its accumulation at the injury site and improves its therapeutic efficacy. Rsv@HFn also facilitates the translocation of Nrf-2 to the nucleus, increasing HO-1 and CD91 expression and promoting the shift of M1 microglia to the M2 phenotype and reducing neuroinflammation and oxidative stress. Additionally, Rsv@HFn improves blood-brain barrier integrity, reduced brain edema, and alleviated neuropathological damage in ICH mice. Overall, this study introduces a promising therapeutic strategy for ICH by improving drug delivery and targeting, reducing inflammation, and enhancing recovery. These findings provide new avenues for future clinical research in treating ICH.

Association between nutritional status and pneumonia in patients with spontaneous intracerebral hemorrhage

Background

Stroke-associated pneumonia (SAP) is a common and serious complication in patients with spontaneous intracerebral hemorrhage (SICH), contributing to prolonged hospital stays and poor outcomes. Nutritional status has been linked to the development of SAP in patients with ischemic stroke, but its role in SICH patients remains understudied. This study aims to evaluate the predictive value of the Nutritional Risk Screening-2002 (NRS-2002) score for SAP in SICH patients and to compare it with other nutritional assessment tools.

Methods

This retrospective observational study included 404 consecutive SICH patients admitted to Dongyang People's Hospital from January 2023 to May 2024. Nutritional risk was assessed using the NRS-2002 score upon admission, and SAP was diagnosed within the first 7 days of hospitalization. Univariate and multivariate logistic regression analyses identified risk factors for SAP, and receiver operating characteristic (ROC) curves were used to compare the predictive accuracy of the NRS-2002, Controlling Nutritional Status (CONUT) score, and Prognostic Nutritional Index (PNI) for SAP.

Results

Among the 404 patients, 97 developed SAP. A higher NRS-2002 score was significantly associated with an increased risk of SAP (OR: 1.575, 95% CI: 1.134-2.186, p = 0.007). ROC analysis showed that the NRS-2002 score (AUC: 0.768, 95% CI: 0.716-0.820) outperformed the CONUT (AUC: 0.597, 95% CI: 0.530-0.663) and PNI (AUC: 0.588, 95% CI: 0.519-0.657) in predicting SAP (p < 0.05). Subgroup analysis revealed that the NRS-2002 score ≥ 3 was particularly predictive of SAP in patients with weight loss, severe stroke, and those without hypertension or with diabetes.

Conclusion

The NRS-2002 score is a valuable predictor of pneumonia in SICH patients, with higher scores correlating with a significantly increased risk of SAP. This highlights the importance of early nutritional assessment in identifying high-risk patients and potentially guiding clinical interventions to reduce SAP incidence.

Drug delivery strategy of hemostatic drugs for intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is associated with high rates of mortality and disability, underscoring an urgent need for effective therapeutic interventions. The clinical prognosis of ICH remains limited, primarily due to the absence of targeted, precise therapeutic options. Advances in novel drug delivery platforms, including nanotechnology, gel-based systems, and exosome-mediated therapies, have shown potential in enhancing ICH management. This review delves into the pathophysiological mechanisms of ICH and provides a thorough analysis of existing treatment strategies, with an emphasis on innovative drug delivery approaches designed to address critical pathological pathways. We assess the benefits and limitations of these therapies, offering insights into future directions in ICH research and highlighting the transformative potential of next-generation drug delivery systems in improving patient outcomes.

Efficacy and safety of corticosteroids for stroke and traumatic brain injury: a systematic review and meta-analysis

BACKGROUND

Corticosteroids are frequently used in practice to treat patients with neurological disorders. However, its effect for stroke and traumatic brain injury (TBI) remains controversial. This study aimed to systematically review and evaluate efficacy and safety of corticosteroids for the treatment of stroke and TBI.

METHODS

We searched Ovid-Medline and Ovid-Embase databases for randomised controlled trials (RCTs) and cohort studies evaluating the efficacy and safety of corticosteroids in patients with ischaemic stroke, intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH) or TBI. The treatment intervention was corticosteroid, and the control was placebo or routine care. Outcome measures were death, functional outcomes and adverse events. We calculated odds ratio (OR) and 95% confidence interval (CI) for the effect size, pooled the results using random-effects modelling, and assessed heterogeneity by I2 statistic.

RESULTS

We identified 47 studies (41 RCTs and 6 cohort studies). Nine studies enrolled patients with ischaemic stroke (n = 2806), 6 studies for ICH (n = 1229), 1 study recruited both ischaemic stroke (n = 13) and ICH (n = 27), 10 studies for SAH (n = 1318) and 21 studies for TBI (n = 12,414). Dexamethasone was the most used corticosteroid (28 studies). Corticosteroids reduced risk of death at 3 months after ischaemic stroke (n = 1791; 31% vs. 26%, OR 0.77, 95% CI 0.62-0.95; df = 1, I2 = 0%) and after ICH (1 study; n = 850; 44% vs. 27%, OR 0.48, 95% CI 0.35-0.64), had no effect on death at 1 month after SAH (1 study; n = 140; 22% vs. 32%, OR 1.73, 95% CI 0.81-3.68), and increased risk of death at 6 months after TBI (n = 10,755; 23% vs. 27%, OR 1.20, 95% CI 1.10-1.32; df = 6, I2 = 0%). The pooled analyses found no significant effect of corticosteroids on functional outcome after ischaemic stroke, ICH, SAH or TBI, respectively.

CONCLUSION

Corticosteroids reduced the risk of death and in selected patients with stroke, such as those with large artery occlusion after thrombectomy, but increased the risk of death after TBI, had no effect on functional outcomes. Further trials are needed to identify individual stroke patients who may benefit from corticosteroids.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (CRD42023474473).

Quercetin carbon quantum dots: dual-target therapy for intracerebral hemorrhage in mice

Following intracerebral hemorrhage, mitigating oxidative stress and removing excess iron are critical strategies for reducing secondary brain injury and improving neurological outcomes. In vitro, we synthesized quercetin-ethylenediamine carbon quantum dots (QECQDs) with diameters of 2-11 nm and found that QECQDs effectively scavenge ABTS+· and DPPH· free radicals, defending HT22 cells against hemin-induced oxidative stress. In vivo, QECQDs predominantly accumulate in the pia mater, subarachnoid space, and dura mater after intrathecal injection. Compared to the ICH injury group, QECQDs treatment effectively improves cerebral blood flow, inhibits oxidative stress damage, and reduces neuron death. Importantly, QECQDs treatment reduced hemorrhage volume, alleviated edema, and improved neurological function. This lays a foundation for developing multi-target drugs for treating ICH.

Microglial Mechanisms and Therapeutic Potential in Brain Injury Post-Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a particularly common public health problem with a high mortality and disability rate and no effective treatments to enhance clinical prognosis. The increased aging population, improved vascular prevention, and augmented use of antithrombotic agents have collectively contributed to the rise in ICH incidence over the past few decades. The exploration and understanding of mechanisms and intervention strategies has great practical significance for expanding treatments and improving prognosis of ICH. Microglia, as resident macrophages of central nervous system, are responsible for the first immune defense post-ICH. After ICH, M1 microglia is firstly activated by primary injury and thrombin; subsequently, reactive microglia can further amplify the immune response and exert secondary injury (eg, oxidative stress, neuronal damage, and brain edema). The pro-inflammatory phenotype transmits to M2 microglia within 7 days post-ICH, which plays a key role in erythrophagocytosis and limiting the inflammatory secondary injury. Microglial M2 polarization has significant implications for improving prognosis, this process can be mediated through crosstalk with other cells, metabolic changes, and microbiota interaction. Clarifying the effect, timing, and potential downstream effects of multiple mechanisms that synergistically trigger anti-inflammatory responses may be necessary for clinical translation. Analyses of such intricate interaction between microglia cells and brain injury/repair mechanisms will contribute to our understanding of the critical microglial responses to microenvironment and facilitating the discovery of appropriate intervention strategies. Here, we present a comprehensive overview of the latest evidences on microglial dynamics following ICH, their role in driving primary/secondary injury mechanisms as well as neurorepair/plasticity, and possible treatment strategies targeting microglia.

The Inflammasome: A Promising Potential Therapeutic Target for Early Brain Injury Following Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH), a severe cerebrovascular disorder, is principally instigated by the rupture of an aneurysm. Early brain injury (EBI), which gives rise to neuronal demise, microcirculation impairments, disruption of the blood-brain barrier, cerebral edema, and the activation of oxidative cascades, has been established as the predominant cause of mortality among patients with SAH. These pathophysiological processes hinge on the activation of inflammasomes, specifically the nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3)and absent in melanoma 2 (AIM2) inflammasomes. These inflammasomes assume a crucial role in downstream intracellular signaling pathways and hold particular significance within the nervous system. The activation of inflammasomes can be modulated, either by independently regulating these two entities or by influencing their engagement at specific target loci within the pathway, thereby attenuating EBI subsequent to SAH. Although certain clinical instances lend credence to this perspective, more in-depth investigations are essential to ascertain the optimal treatment regimen, encompassing dosage, timing, administration route, and frequency. Consequently, targeting the ensuing early brain injury following SAH represents a potentially efficacious therapeutic approach.

Association between serum total bilirubin levels and 28-day all-cause mortality after intracerebral hemorrhage

Background

Intracerebral hemorrhage (ICH) is associated with high mortality and morbidity rates. Although some studies have indicated a correlation between serum bilirubin levels and ICH severity, evidence of the relationship between serum total bilirubin (TBIL) and ICH outcomes remains lacking.

Methods

A total of 914 patients from the Medical Information Mart for Intensive Care IV database met the eligibility criteria and were included in the study. The patients were categorized into two groups based on whether they survived for 28 days following admission to hospital. The association between serum TBIL levels and 28-day survival in patients with ICH was investigated using Spearman's correlation analysis and restricted cubic splines. The effect of serum TBIL levels on survival time and rate in the 28-day period was analyzed using Kaplan-Meier curves and restricted mean survival times. Univariate Cox regression, least absolute shrinkage and selection operator regression, and multivariate Cox regression were used to identify risk factors associated with 28-day all-cause mortality. Finally, subgroup analysis was performed to verify the stability of the association between serum TBIL levels and 28-day all-cause mortality in patients with ICH.

Results

A negative relationship was revealed between TBIL levels and survival (p < 0.001, correlation = -0.174). Restricted cubic spline analysis revealed a nonlinear link between mean serum TBIL levels and 28-day all-cause mortality (p for nonlinear = 0.001). Patients with ICH and higher serum TBIL levels had significantly reduced survival times and rates compared with those with lower serum TBIL levels (p < 0.001). Serum TBIL level was identified as a significant risk factor for 28-day all-cause mortality in patients with ICH (hazard ratio [95% confidence interval] = 1.121 [1.063-1.182], p < 0.001). Subgroup analyses revealed that the assessed variables had no influence on the association between serum TBIL levels and 28-day all-cause mortality.

Conclusion

Higher serum TBIL levels are associated with a greater risk of mortality within 28 days in patients with ICH, whereas lower serum TBIL levels are associated with prolonged survival.

Causal relations between immune cells and cerebral hemorrhage: a bidirectional Mendelian randomization study

BACKGROUND

Previous studies have shown that an increased number of immune cells is closely associated with the onset and course changes of intracerebral hemorrhage, but the exact causal relationship has not been clarified. The aim of this study was to investigate the causal relationship between immune cells and intracerebral hemorrhage by a two-way Mendelian randomization method.

METHODS

Two sets of SNPs were used as instrumental variables and two-way Mendelian randomization analyses were performed and leave-one-out method were used to assess the validity and heterogeneity of the included genetic variation instruments. The level of multiplicity and heterogeneity of the included genetic variance instruments was assessed.

RESULTS

The results showed a clear causal relationship between three immune cells and intracerebral hemorrhage, and no heterogeneity between SNPs related to intracerebral hemorrhage, while scatterplot and funnel plot confirmed that the causality was less likely to be biased; MR-Egger results suggested that no genetic pleiotropy was found. Leave-one-out analysis was applied to suggest that the MR analysis results for a single SNP were robust; meanwhile, Meta-analysis was applied to combine the two intracerebral hemorrhage datasets, and the analysis results suggested that in the fixed-effects model and random-effects model, the immunocyte CD66b on Granulocytic Myeloid-Derived Suppressor Cells and other three immune cells were significantly causally associated with intracerebral hemorrhage, while the heterogeneity test suggested that there was no significant difference between the different datasets.

CONCLUSIONS

The present study found a significant causal relationship between specific immune cell phenotypes and intracerebral hemorrhage by Mendelian randomization analysis.

HO-1 represses NF-κB signaling pathway to mediate microglia polarization and phagocytosis in intracerebral hemorrhage

BACKGROUND

Microglia polarization plays a crucial role in inflammatory injury of brain following intracerebral hemorrhage (ICH). Heme oxygenase-1 (HO-1) has demonstrated protective properties against inflammation and promote hematoma clearance after ICH. The objective of this study was to explore impacts of HO-1 on microglia polarization and phagocytosis after ICH, along with the underlying mechanism.

METHODS

ICH model was constructed in C57BL/6 mice. Neurological deficit of ICH mice was evaluated. HE detected pathological changes of mouse brain tissue. Immunofluorescence staining tested co-localization between HO-1 or NF-κB p65 and IBA1. The expressions of gene and proteins were detected by RT-qPCR and Western blot, respectively. Flow cytometry determined microglial polarization phenotype and neuron apoptosis. Cell viability of neuron was assessed by CCK-8. Red blood cells labeled by PKH-26 and co-cultured with microglia for examining microglial erythrophagocytosis.

RESULTS

Both HO-1 and NF-κB p65 phosphorylation were elevated in brain tissues of ICH mice. ZnPP, a HO-1 inhibitor, could exacerbate microglial M1 polarization and nerve injury, as well as repress microglial erythrophagocytosis in vitro and hematoma clearance in vivo. On the contrary, Tat-NBD, a NF-κB inhibitor, greatly suppressed microglial M1 polarization, and induced M2 polarization and microglial erythrophagocytosis, thus improving nerve injury and hematoma clearance after ICH. Notably, it was observed that NF-κB p65 could be activated by ZnPP treatment, and the regulatory roles of ZnPP on microglial polarization and erythrophagocytosis after ICH in vivo and in vitro were all diminished by Tat-NBD.

CONCLUSION

Therefore, our data demonstrated that HO-1 alleviated nerve injury and induced M2 polarization and phagocytosis of microglia after ICH via inhibiting NF-κB signaling pathway, which could provide deepen the pathological understanding of ICH and provide potential intervention targets and drug candidate for ICH.

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.

Catechin-Based Polyphenol Nanoparticles Ameliorated Ferroptosis to Alleviate Brain Injury after Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhagic stroke (ICH) is a highly aggressive disease, with a high incidence and mortality rate. Iron deposition following ICH leads to oxidative damage and motor dysfunction, significantly impacting the overall quality of life for those affected. Here, a polyphenolic nanomedicine, catechin-based polyphenol nanoparticles surface-modified by thiol-terminated poly(ethylene glycol) (CNPs@PEG), was developed through the oxidative polymerization and self-assembly of catechin, a natural compound in tea. Due to its potent antioxidant and metal-chelating properties, CNPs@PEG effectively maintained blood-brain barrier integrity, reduced brain edema, significantly increased the survival rate of mice with cerebral hemorrhage and markedly improved neurological deficits after ICH. Mechanistically, CNPs@PEG accomplishes this by chelating iron, enhancing tissue antioxidant capacity, reducing oxidative stress, and inhibiting iron deposition. This approach holds promise as a targeted therapeutic strategy for addressing cerebral hemorrhage and other conditions associated with iron overload.

Prediction of Symptomatic Intracranial Hemorrhage Before Mechanical Thrombectomy Using Machine Learning in Patients with Anterior Circulation Large Vessel Occlusion

BACKGROUND

Symptomatic intracranial hemorrhage (sICH) after mechanical thrombectomy (MT) is associated with worse outcomes. We sought to develop and internally validate a machine learning (ML) model to predict sICH prior to MT in patients with anterior circulation large vessel occlusion.

METHODS

Consecutive adults who underwent MT for internal carotid artery/M1/M2 occlusions at a single institution were reviewed. The data was split into 80% training and 20% hold-out test sets. 9 ML models were screened. The top performing ML model was compared to logistic regression and previously described clinical prediction models. SHapley Additive exPlanations were used to identify the most predictive features in the ML model.

RESULTS

A total of 497 patients met inclusion criteria. The top performing ML model was extreme gradient boosting. The area under the receiver operating characteristics curve for the ML model on the test set was 0.79 (95% confidence interval [CI] 0.67-0.89), which was significantly higher (P < 0.001) than the logistic regression model (0.54 [95% CI 0.33-0.76]). The ML model also performed significantly better than the TAG = TICI-ASPECTS-glucose score (0.69 [95% CI 0.55-0.85], P < 0.001), Systolic blood pressure-Time-Blood glucose-ASPECTS score (0.45 [95% CI 0.30-0.60], P < 0.001), and ChatGPT 4.0 (0.60 [95% CI 0.48-0.68], P < 0.001). Based on SHapley Additive exPlanations values the most predictive features of sICH in the ML model were lower Alberta Stroke Program Early CT score, lower collateral score, and higher presenting National Institutes of Health Stroke Scale.

CONCLUSIONS

An ML model accurately predicted sICH prior to MT. It performed better than a standard statistical model and previously described clinical prediction models.

Melatonin Regulates Glymphatic Function to Affect Cognitive Deficits, Behavioral Issues, and Blood-Brain Barrier Damage in Mice After Intracerebral Hemorrhage: Potential Links to Circadian Rhythms

BACKGROUND

Intracerebral hemorrhage (ICH) is a life-threatening cerebrovascular disorder with no specific pharmacological treatment. ICH causes significant behavioral deficits and cognitive impairments. Recent research suggests that circadian rhythm regulation could be a promising therapeutic strategy for ICH. Melatonin has been shown to alleviate glymphatic system (GS) dysfunction by regulating circadian rhythms, thereby improving depressive-like behaviors and postoperative sleep disorders in mice. However, its application in ICH treatment and specific mechanisms are not well understood.

METHODS

ICH models were created in 8-to-10-week-old mice using collagenase injection. Circadian rhythm modulation was tested with melatonin and luzindole. Behavioral and cognitive impairments were assessed with the modified neurological severity score, corner test, and novel object recognition test. Brain water content was measured by the dry/wet weight method, and cerebral perfusion was assessed by cerebral blood flow measurements. GS function was evaluated using RITC-dextran and Evans blue assays. Immunofluorescence and western blotting were used to analyze GS function and BBB permeability.

RESULTS

Melatonin restored GS transport after ICH, promoting hematoma and edema absorption, reducing BBB damage, and improving cognitive and behavioral outcomes. However, luzindole partially blocked these benefits and reversed the neuroprotective effects.

CONCLUSION

Melatonin and luzindole treatment affect GS function, BBB permeability, and cognitive-behavioral outcomes in mice with ICH. The underlying mechanism may involve the regulation of circadian rhythms.

New targets in spontaneous intracerebral hemorrhage

PURPOSE OF REVIEW

Intracerebral hemorrhage (ICH) is a devastating stroke with limited medical treatments; thus, timely exploration of emerging therapeutic targets is essential. This review focuses on the latest strategies to mitigate secondary brain injury post-ICH other than targeting surgery or hemostasis, addressing a significant gap in clinical practice and highlighting potential improvements in patient outcomes.

RECENT FINDINGS

Promising therapeutic targets to reduce secondary brain injury following ICH have recently been identified, including attenuation of iron toxicity and inhibition of ferroptosis, enhancement of endogenous resorption of hematoma, and modulation of perihematomal inflammatory responses and edema. Additionally, novel insights suggest the lymphatic system of the brain may potentially play a role in hematoma clearance and edema management. Various experimental and early-phase clinical trials have demonstrated these approaches may potentially offer clinical benefits, though most research remains in the preliminary stages.

SUMMARY

Continued research is essential to identify multifaceted treatment strategies for ICH. Clinical translation of these emerging targets could significantly enhance the efficacy of therapeutic interventions and potentially reduce secondary brain damage and improve neurological recovery. Future efforts should focus on large-scale clinical trials to validate these approaches, to pave the way for more effective treatment protocols for spontaneous ICH.

PF4 inhibits ferroptosis-mediated intracerebral hemorrhage through modulating the CXCR3/AKT1/SLC7A11 signaling pathway

Ferroptosis plays a crucial role in the secondary pathophysiological damage to brain tissue surrounding hematomas after intracerebral hemorrhage (ICH). While platelet factor 4 (PF4) is known to promote regeneration following peripheral nerve injury, its role in brain tissue repair after cerebral hemorrhage remains unclear. In this study, Hemin-induced PC12 cells were treated with various inhibitors and assessed for viability, oxidative stress, and ferroptosis using a combination of assays, including CCK-8 (Cell Counting Kit-8), EdU (5-Ethynyl-2'-deoxyuridine), flow cytometry, and immunofluorescence. ICH cells were also treated with recombinant PF4 (Rm-PF4) and a CXCR3 antagonist (AMG487) to investigate the mechanism by which Rm-PF4 influences Hemin-induced PC12 cell injury and inflammation. Subsequently, ICH mouse models were established via collagenase injection. Neurological function in these mice was evaluated using the Cylinder and Corner tests. Histopathological damage to brain tissue was analyzed through HE, TUNEL, and Nissl staining, as well as immunohistochemistry, to further explore the role of Rm-PF4 in controlling neuroinflammation in vivo. Results showed that Rm-PF4 inhibited Hemin-mediated ferroptosis-induced PC12 cell damage and inflammation by activating the CXCR3/AKT1/SLC7A11 signaling pathway. Blocking the CXCR3/AKT1/SLC7A11 pathway partially reversed PF4's protective effects on Hemin-induced PC12 cells.In ICH mice, pro-inflammatory marker CD16 (3rd day) and anti-inflammatory marker Arg1 (7th day) were significantly decreased and increased, respectively (p<0.05). IL-6, TNF-α, and IL-1β levels were down-regulated in brain tissues after Rm-PF4 injection, which was significantly reversed by AMG487. PF4 inhibits ferroptosis after ICH reduced PC12 cell damage and the inflammatory response via activating the CXCR3/AKT1/SLC7A11 pathway.

Association between lactate dehydrogenase and 28-day all-cause mortality in patients with non-traumatic intracerebral hemorrhage: A retrospective analysisof the MIMIC-IV database

Lactate dehydrogenase (LDH), a nonspecific inflammatory biomarker, has been used in the assessment of acute myocardial infarction, acute hepatitis, acute lung injury, and other severe diseases. However, no studies have evaluated the prognostic value of LDH in patients with non-traumatic intracerebral hemorrhage (ICH). This cohort study aims to assess the association between LDH levels and 28-day all-cause mortality in patients with non-traumatic ICH. Data for this retrospective cohort analysis were obtained from the MIMIC-IV (v2.2) database, and the study included patients with non-traumatic ICH as defined by the International Classification of Diseases, 9th and 10th editions. Patients were categorized into four distinct groups based on their LDH levels. The primary outcome of interest was the 28-day mortality rate. To analyze these associations and assess the consistency of interactions, subgroup analyses, Cox regression analysis, Kaplan-Meier (K-M) curves, and nonlinear analysis were conducted. A total of 406 patients with non-traumatic ICH were enrolled in the study and were divided into quartiles based on LDH levels. The K-M curve indicated that the 28-day all-cause mortality rate of patients in the Q4 group (LDH > 287.25) was significantly higher than in the Q1 (LDH < 194.7) (P < 0.001) and Q2 (194.7 < LDH < 233.0) (P < 0.001) groups, though not significantly different from Q3 (P = 0.140). Multivariate Cox proportional hazards analysis revealed that patients in the highest LDH quartile had a significantly increased risk of mortality compared to those in the lowest quartile across three models: unadjusted [HR, 3.401; 95% CI, 1.719-6.731; P < 0.001], partially adjusted [HR, 2.422; 95% CI, 1.211-4.846; P = 0.012], and fully adjusted [HR, 3.054; 95% CI, 1.522-6.126; P = 0.002]. Restricted cubic spline (RCS) models revealed an L-shaped association between LDH levels and the 28-day all-cause mortality rate, indicating a nonlinear relationship (P < 0.001). No significant interactions were observed between LDH levels and other factors in the subgroup analyses (all P for interaction > 0.05). Our findings indicate a significant association between 28-day all-cause mortality and LDH levels in patients with non-traumatic ICH. Specifically, patients with elevated LDH levels within the first 24 h of ICU admission are at a higher risk of mortality.

The critical role of MLKL in hemorrhagic stroke and the therapeutic potential of its associated protein network

Introduction

Mixed Lineage Kinase Domain-Like Protein (MLKL), as the executor of necroptosis and a critical factor in the inflammation, has been shown to be associated with the progression of hemorrhagic stroke. Studies identified MLKL is a promoting factor in this process, suggesting its potential as a therapeutic target to mitigate posthemorrhagic stroke damage. However, the mechanisms by which MLKL functions in the process of intracerebral hemorrhage (ICH)-induced damage remain unclear.

Methods

Here, we explored the correlation between MLKL and pathological damage in ICH patients through histopathological staining and RT-qPCR. Furthermore, we established an intracerebral hemorrhage model by collagenase IV injection in WT and Mlkl-/- mice. Subsequently, we investigated the impact of MLKL knockout on ICH pathological damage through behavioral tests, Western blotting, and RT-qPCR. Finally, we performed a proteomic analysis via LC-MS/MS to explore the potential interacting proteins of MLKL in the progression of ICH.

Results

We found that MLKL is highly expressed in the brain tissue of ICH patients and is positively correlated with the extent of injury. However, we found that Mlkl knockout alone was insufficient to fully reverse neuroinflammation and pathological damage. Although Mlkl knockout has a limited effect on alleviating ICH damage, proteomics results indicate that MLKL can mitigate changes in proteins associated with inflammation, metabolism, and coagulation pathways, suggesting that MLKL may exert its effects through these pathways.

Discussion

In summary, our results suggest that although MLKL is associated with the progression of ICH, single knockout of Mlkl is insufficient to fully reverse the pathological damage of ICH. Proteomic analysis indicates that co-targeting MLKL and its associated protein network may yield better therapeutic outcomes for hemorrhagic stroke.

Targeting mitochondrial dynamics: A promising approach for intracerebral hemorrhage therapy

Intracerebral hemorrhage (ICH) is a major global health issue with high mortality and disability rates. Following ICH, the hematoma exerts direct pressure on brain tissue, and blood entering the brain directly damages neurons and the blood-brain barrier. Subsequently, oxidative stress, inflammatory responses, apoptosis, brain edema, excitotoxicity, iron toxicity, and metabolic dysfunction around the hematoma further exacerbate brain tissue damage, leading to secondary brain injury (SBI). Mitochondria, essential for energy production and the regulation of oxidative stress, are damaged after ICH, resulting in impaired ATP production, excessive reactive oxygen species (ROS) generation, and disrupted calcium homeostasis, all of which contribute to SBI. Therefore, a central factor in SBI is mitochondrial dysfunction. Mitochondrial dynamics regulate the shape, size, distribution, and quantity of mitochondria through fusion and fission, both of which are crucial for maintaining their function. Fusion repairs damaged mitochondria and preserves their health, while fission helps mitochondria adapt to cellular stress and removes damaged mitochondria through mitophagy. When this balance is disrupted following ICH, mitochondrial dysfunction worsens, oxidative stress and metabolic failure are exacerbated, ultimately contributing to SBI. Targeting mitochondrial dynamics offers a promising therapeutic approach to restoring mitochondrial function, reducing cellular damage, and improving recovery. This review explores the latest research on modulating mitochondrial dynamics and highlights its potential to enhance outcomes in ICH patients.

Early decompressive surgery improves long-term prognosis in patients with intracerebral hemorrhage

BACKGROUND

Multiple studies have shown that early decompressive surgery in patients with intracerebral hemorrhage can effectively limit hematoma expansion, reduce perihematomal edema, and improve prognosis. However, these studies are limited by small sample sizes and short follow-up times.

OBJECTIVE

To analyze the effect of early decompressive surgery on the long-term prognosis of patients with cerebral hemorrhage and identify the influencing factors for poor prognosis.

METHODS

A retrospective analysis of 78 patients with cerebral hemorrhage admitted between January 2020 and December 2022 was conducted. Patients were divided into early and delayed surgery groups for comparison of outcomes such as mortality rate, modified Rankin Scale score, and Short Form-36 scores. Additionally, factors influencing long-term prognosis were analyzed through logistic regression based on significant differences observed between groups.

RESULTS

The early decompressive surgery group showed superior outcomes with lower mortality rates, modified Rankin Scale (mRS) scores, hematoma expansion rates, and perihematomal edema volumes compared to the delayed surgery group (P< 0.05). Additionally, age, preoperative Glasgow Coma Scale (GCS) score, preoperative hematoma volume, and a history of hypertension or diabetes were identified as independent prognostic factors for patients with cerebral hemorrhage, with odds ratios (ORs) greater than 1.

CONCLUSIONS

Early decompressive surgery can improve the long-term prognosis and quality of life of patients with cerebral hemorrhage, reduce mortality rates, and decrease hematoma expansion and perihematomal edema. Older patients, those with higher preoperative hematoma volume and GCS score, and those with coexisting hypertension and diabetes should be given special attention to decrease the occurrence of adverse prognosis.

Novel insights into the role of TREM2 in cerebrovascular diseases

Cerebrovascular diseases (CVDs) include conditions such as stroke, cerebral amyloid angiopathy (CAA) and cerebral small vessel disease (CSVD), which contribute significantly to global morbidity and healthcare burden. The pathophysiology of CVD is complex, involving inflammatory, cellular and vascular mechanisms. Recently, research has focused on triggering receptor expressed on myeloid cells 2 (TREM2), an immune receptor predominantly found on microglia. TREM2 interacts with multiple signalling pathways, particularly toll-like receptor 4 (TLR4) and nuclear factor kappa B (NF-κB), inhibiting patients' inflammatory response. This receptor plays an essential role in both immune regulation and neuroprotection. TREM2 deficiency or dysfunction is associated with impaired microglial responses, exacerbated neurodegeneration and neuroinflammation. Up until recently, TREM2 related studies have focused on neurodegenerative diseases (NDs), however a shift in focus towards CVDs is beginning to take place. Advancements in CVD research have focused on developing therapeutic strategies targeting TREM2 to enhance recovery and reduce long-term deficits. These include the exploration of TREM2 agonists and combination therapies with other anti-inflammatory agents, which may synergistically reduce neuroinflammation and promote neuroprotection. The modulation of TREM2 activity holds potential for innovative treatment approaches aimed at improving patient outcomes following cerebrovascular insults. This review compiles current research on TREM2, emphasising its molecular mechanisms, therapeutic potential, and advancements in CNS disease research.

Neutrophil Extracellular Traps Induce Brain Edema Around Intracerebral Hematoma via ERK-Mediated Regulation of MMP9 and AQP4

Perihematomal edema (PHE) significantly aggravates secondary brain injury in patients with intracerebral hemorrhage (ICH), yet its detailed mechanisms remain elusive. Neutrophil extracellular traps (NETs) are known to exacerbate neurological deficits and worsen outcomes after stroke. This study explores the potential role of NETs in the pathogenesis of brain edema following ICH. The rat ICH model was created, immunofluorescence and Western blot were used to examine neutrophil accumulation, NET markers citrullinated histone H3 (CitH3) and myeloperoxidase (MPO), tight junction proteins (ZO-1 and Occludin), Aquaporin-4 (AQP4), matrix metalloproteinase-9 (MMP-9), and ERK phosphorylation (p-ERK) in brain tissues surrounding the hematoma. TUNEL staining and behavioral tests were employed to evaluate neuronal apoptosis and neurological dysfunction, while blood-brain barrier (BBB) permeability and brain edema were also measured by Evans blue and brain water content. Furthermore, the molecular mechanisms related to NETs-induced PHE were investigated using NETs, ERK, MMP-9 and AQP4 regulators, respectively. Ly6G+ neutrophils surrounding the hematoma developed NETs within 3 days post-ICH. NETs decreased tight junction proteins, destroyed BBB integrity, promoted brain edema, increased neuronal apoptosis, and exacerbated neurological deficits. Conversely, inhibition of NETs mitigated PHE, reduced neuronal apoptosis, and improved neurological functions. Mechanistically, NET-induced PHE was originated from impairment of BBB tight junction via ERK/MMP9 pathway, coupled with ERK-mediated AQP4 downregulation in perihematomal regions. These findings elucidated the effects of NETs on PHE, which offered promising insights for targeting NETs to relieve brain edema and secondary brain injury post-ICH.

Sphk1/S1P pathway promotes blood-brain barrier breakdown after intracerebral hemorrhage through inducing Nlrp3-mediated endothelial cell pyroptosis

Intracerebral hemorrhage (ICH) is a severe stroke subtype with high mortality and limited therapeutic options. The blood-brain barrier (BBB) breakdown post-ICH exacerbates secondary brain injury, highlighting the need for targeted therapies to preserve the BBB integrity. We aim to investigate the role of the Sphk1/S1P pathway in BBB breakdown following ICH and to evaluate the therapeutic potential of Sphk1 inhibition in mitigating this breakdown. Using a combination of human patient samples, mouse models of ICH, and in vitro cellular assays, we assessed the expression levels of Sphk1/S1P after ICH and changes of the BBB after ICH. The Sphk1 inhibitor PF543 and siRNAs were utilized to explore the pathway's impact on BBB integrity and the underlying mechanisms. The results indicate significant upregulation of Sphk1/S1P in the peri-hematomal brain tissue after ICH, which correlates with increased BBB leakage. Pharmacological inhibition of Sphk1 with PF543 attenuates BBB leakage, reduces hematoma volume, and improves neurological outcomes in mice. At the molecular and ultrastructural level, Sphk1 inhibition protects the BBB integrity by preserving tight junction proteins and suppressing endothelial transcytosis. Furthermore, mechanistic studies reveal that Sphk1 promotes Nlrp3-mediated pyroptosis of brain endothelial cells through the ERK1/2 signaling pathway. Taken together, the Sphk1/S1P pathway plays a critical role in ICH-induced BBB breakdown, and its inhibition represents a promising therapeutic strategy for ICH management.

Altered brain glymphatic function on diffusion-tensor MRI in patients with spontaneous intracerebral hemorrhage: an exploratory study

Objectives

To investigate the function of the glymphatic system (GS) and its association with neuropsychological tests in spontaneous intracerebral hemorrhage (sICH) by diffusion tensor imaging analysis along the perivascular space (DTI-ALPS).

Methods

This retrospective study included 58 patients with sICH and 63 age- and sex-matched healthy controls (HCs). Partial correlation analyses were performed to examine the relationships between the DTI-ALPS index and radiological as well as clinical data. Mediation analyses were performed to explore the mediating role of the grey matter proportion (GM%) in the relationship between DTI-ALPS index and Montreal Cognitive Assessment (MoCA) score.

Results

Significantly lower DTI-ALPS index values were observed in sICH compared with HCs (FDR-p < 0.001). In the acute-subacute sICH group, the ALPS index was significantly correlated with hematoma volume (r = -0.572, FDR-p = 0.031). In the chronic sICH group, the ALPS index was significantly correlated with MoCA scores (r = 0.425, FDR-p = 0.014). In chronic sICH groups, GM% served as a significant mediator in the relationship between the DTI-ALPS index and MoCA scores (indirect effects β = 4.925, 95%CI: 0.028, 11.841). The ALPS index was identified as an independent prognostic indicator for unfavorable outcomes in sICH (β = -9.851, p = 0.018).

Conclusion

Our study demonstrated that the DTI-ALPS index decreased in sICH patients, suggesting potential functional impairment of the lymphoid system. Additionally, the DTI-ALPS index served as an independent predictor of poor 90-day prognosis. In the acute-subacute stage of sICH, the DTI-ALPS index had negative correlation with hematoma volume. In the chronic sICH group, the GM% partially mediated the relationship between the GS and cognitive function.

Gas6/Axl signaling promotes hematoma resolution and motivates protective microglial responses after intracerebral hemorrhage in mice

BACKGROUND

Intracerebral hemorrhage (ICH) stands out as the most fatal subtype of stroke, currently devoid of effective therapy. Recent research underscores the significance of Axl and its ligand growth arrest-specific 6 (Gas6) in normal brain function and a spectrum of neurological disorders, including ICH. This study is designed to delve into the role of Gas6/Axl signaling in facilitating hematoma clearance and neuroinflammation resolution following ICH.

METHODS

Adult male C57BL/6 mice were randomly assigned to sham and ICH groups. ICH was induced by intrastriatal injection of autologous arterial blood. Recombinant mouse Gas6 (rmGas6) was administered intracerebroventricularly 30 min after ICH. Virus-induced knockdown of Axl or R428 (a selective inhibitor of Axl) treatment was administrated before ICH induction to investigate the protective mechanisms. Molecular changes were assessed using western blot, enzyme-linked immunosorbent assay and immunohistochemistry. Coronal brain slices, brain water content and neurobehavioral tests were employed to evaluate histological and neurofunctional outcomes, respectively. Primary glia cultures and erythrophagocytosis assays were applied for mechanistic studies.

RESULTS

The expression of Axl increased at 12 h after ICH, peaking on day 3. Gas6 expression did not remarkably changed until day 3 post-ICH. Early administration of rmGas6 following ICH significantly reduced hematoma volume, mitigated brain edema, and restored neurological function. Both Axl-knockdown and Axl inhibitor treatment abolished the neuroprotection of exogenous Gas6 in ICH. In vitro studies demonstrated that microglia exhibited higher capacity for phagocytosing eryptotic erythrocytes compared to normal erythrocytes, a process reversed by blocking the externalized phosphatidylserine on eryptotic erythrocytes. The erythrophagocytosis by microglia was Axl-mediated and Gas6-dependent. Augmentation of Gas6/Axl signaling attenuated neuroinflammation and drove microglia towards pro-resolving phenotype.

CONCLUSIONS

This study demonstrated the beneficial effects of recombinant Gas6 on hematoma resolution, alleviation of neuroinflammation, and neurofunctional recovery in an animal model of ICH. These effects were primarily mediated by the phagocytotic role of Axl expressed on microglia.

Traditional Chinese medicine FYTF-919 (Zhongfeng Xingnao oral prescription) for the treatment of acute intracerebral haemorrhage: a multicentre, randomised, placebo-controlled, double-blind, clinical trial

BACKGROUND

There are few proven treatments for acute spontaneous intracerebral haemorrhage, and they all target reducing expansion of the haematoma. The traditional Chinese medicine FYTF-919 (Zhongfeng Xingnao) in an oral solution is comprised of several Chinese herbs that are widely used to treat patients with intracerebral haemorrhage in China on the understanding that they enhance resorption of the haematoma and reduce neuroinflammation. We aimed to provide a reliable assessment of the safety and efficacy of FYTF-919 in patients with moderate to severe acute intracerebral haemorrhage.

METHODS

We did a pragmatic, multicentre, randomised, double-blind, placebo-controlled trial at 26 hospitals in China. We enrolled adults (age ≥18 years) with a diagnosis of symptomatic spontaneous intracerebral haemorrhage (confirmed by brain imaging) within 48 h after the onset of symptoms (or last seen well), which resulted in moderate to severe neurological impairment defined by scores of at least 8 on the National Institute of Health Stroke Scale or between 7 and 14 inclusive on the Glasgow Coma Scale. Randomisation (1:1) was via a central internet-based system with a block grouping method stratified by provincial location of the hospital, severity of neurological impairment, and site of the haematoma in the brain. FYTF-919 and the placebo were masked through consistency in appearance, smell, taste, and other aspects. Participants were allocated to receive 33 mL (or 25 mL via a nasogastric tube if a participant's swallowing was impaired) of either oral liquid FYTF-919 or matching placebo administered at least 30 min after a meal every 8 h (or 6 h via nasogastric tube) over 24 h for 28 days. The primary efficacy outcome was the utility weighted modified Rankin Scale (a seven-level ordinal scale that ranges from 0 [no symptoms] to 6 [death], in which the utility weights of 0·97, 0·88, 0·74, 0·55, 0·20, -0·19, and 0·00 were assigned to the seven levels respectively, with higher scores indicating a better outcome according to the participants' perspective) at 90 days analysed in a general linear model with adjustment for baseline factors. We did several adjusted and sensitivity analyses. Primary analyses were assessed in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT05066620 and is complete.

FINDINGS

Between Nov 24, 2021, and Dec 28, 2023, of 9000 patients screened, 1648 were randomly assigned to treatment, 817 to the FYTF-919 group and 831 to the placebo group. Before receiving any treatment two patients in the FYTF-919 group and five patients in the placebo group immediately withdrew their consent leaving 1641 participants with available primary outcome data in the intention-to-treat population, 815 in the FYTF-919 group and 826 in the placebo group. 1242 (75·7%) participants consumed 80% or more of the study medication and 994 (60·6%) consumed all of it within 28 days. Mean utility weighted modified Rankin Scale scores at 90 days were 0·44 in the FYTF-919 group and 0·44 in the placebo group (difference 0·01, 95% CI -0·02 to 0·04; p=0·63). The neutral result was consistent in adjusted and sensitivity analyses. There was no significant difference in serious adverse events.

INTERPRETATION

This large, randomised, placebo-controlled, double-blind, clinical trial showed no effect of the traditional Chinese medicine herbal compound FYTF-919 on functional recovery, survival, and health-related quality of life in patients with moderate to severe intracerebral haemorrhage. The results reaffirm the need for methodologically rigorous, randomised controlled trials to evaluate the effectiveness of existing therapies, including traditional Chinese medicines that are already in widespread use throughout the world.

FUNDING

Key-Area Research and Development Program of Guangdong Province.

Dual-task vision transformer for rapid and accurate intracerebral hemorrhage CT image classification

Intracerebral hemorrhage (ICH) is a severe and sudden medical condition caused by the rupture of blood vessels in the brain, leading to permanent damage to brain tissue and often resulting in functional disabilities or death in patients. Diagnosis and analysis of ICH typically rely on brain CT imaging. Given the urgency of ICH conditions, early treatment is crucial, necessitating rapid analysis of CT images to formulate tailored treatment plans. However, the complexity of ICH CT images and the frequent scarcity of specialist radiologists pose significant challenges. Therefore, we collect a dataset from the real world for ICH and normal classification and three types of ICH image classification based on the hemorrhage location, i.e., Deep, Subcortical, and Lobar. In addition, we propose a neural network structure, dual-task vision transformer (DTViT), for the automated classification and diagnosis of ICH images. The DTViT deploys the encoder from the Vision Transformer (ViT), employing attention mechanisms for feature extraction from CT images. The proposed DTViT framework also incorporates two multilayer perception (MLP)-based decoders to simultaneously identify the presence of ICH and classify the three types of hemorrhage locations. Experimental results demonstrate that DTViT performs well on the real-world test dataset.

Pterostilbene ameliorates oxidative stress and neuronal apoptosis after intracerebral hemorrhage via the sirtuin 1-mediated Nrf2 pathway in vivo and in vitro

INTRODUCTION

Oxidative stress and neuroapoptosis are significant pathological processes that occur in response to intracerebral hemorrhage (ICH), however, the optimal therapeutic strategy to treat these responses remains unknown. Pterostilbene (PTE) influences neural cell survival in in the pathology of a number of neurological diseases, but the mechanisms underlying this influence at present are not clear. The objective of the present study was to examine the potential impact of PTE on mitigating oxidative stress and neuronal apoptosis following ICH, while also elucidating the potential underlying pathways.

MATERIAL & METHOD

For in vivo experimentation, male C57BL/6 mice were used to establish ICH models. Wet-to-dry weight ratios were utilized to assess the degree of cerebral edema in the context of PTE intervention. Behavioral experiments were conducted to evaluate neurological dysfunction and cognitive impairment, and hematoxylin and eosin staining was employed to observe histopathological changes in the brain. Furthermore, oxidative stress levels in hippocampal tissues were measured, and cell apoptosis was examined using TUNEL staining and western blotting techniques. In vitro experiments were conducted to evaluate the extent of oxidative stress and neural apoptosis after sirtuin 1 (SIRT1) siRNA treatment. Immunofluorescence cytochemistry was used to analyze the immunofluorescence colocalization of SIRT1 and NeuN.

RESULT

Mice that experienced ICH exhibited worsening neurological deterioration, increased oxidative stress and neuronal cell apoptosis. However, the addition of PTE was found to lessen these effects. Furthermore, PTE was found to activate the SIRT1-mediated Nrf2 pathway in mice with ICH. When SIRT1 was inhibited, levels of oxidative stress and neuronal apoptosis increased, even in the presence of PTE.

CONCLUSION

The present study provided evidence to indicate that PTE can suppress oxidative damage and neuronal apoptosis following ICH by activating the SIRT1/Nrf2 pathway.

Development of a risk predication model for critical care needs in patients with intracerebral hemorrhage: a retrospective cohort

BACKGROUND

It is very important to provide the correct nursing care for patients with intracerebral hemorrhage (ICH), but the level of critical care needs in patients with intracerebral hemorrhage is not clear. The purpose of this study is to establish a risk model based on the epidemiological and clinical characteristics of ICH patients, to help identify the critical care needs of ICH patients.

METHODS

The clinical data of ICH patients from January 2018 to September 2023 were analyzed retrospectively. The full cohort was used to derive the clinical prediction model and the model was internally validated with bootstrapping. Discrimination and calibration were assessed using the area under curve (AUC) and the Hosmer-Lemeshow tests, respectively.

RESULTS

611 patients with ICH were included for model development. 61.21% (374/611) ICH patients had received critical care interventions. The influencing factors included in the model were Glasgow Coma Scale (GCS) score, intraventricular hemorrhage, past blood pressure control, systolic blood pressure on admission and bleeding volume. The model's goodness-of-fit was evaluated, which yielded a high area under the curve (AUC) value of 0.943, indicating a good fit. For the purpose of model validation, a cohort of 260 patients with ICH was utilized. The model demonstrated a Youden's index of 0.750, with a sensitivity of 90.56% and a specificity of 78.22%.

CONCLUSION

GCS, systolic blood pressure, intraventricular hemorrhage, bleeding volume and past blood pressure control are the main factors affecting the critical care needs of patients with ICH. This study has deduced a clinical predictive model with good discrimination and calibration to provide scoring criteria for clinical health care providers to accurately evaluate and identify the critical care needs of ICH patients, to improve the rational integration and allocation of medical resources.

A comprehensive prediction model predicts perihematomal edema growth in the acute stage after intracerebral hemorrhage

BACKGROUND

Perihematomal edema (PHE) is regarded as a potential intervention indicator of secondary injury following intracerebral hemorrhage (ICH). But it still lacks a comprehensive prediction model for early PHE formation.

METHODS

The included ICH patients have received an initial Computed Tomography scan within 6 hours of symptom onset. Hematoma volume and PHE volume were computed using semiautomated computer-assisted software. The volume of the hematoma, edema around the hematoma, and surface area of the hematoma were calculated. The platelet-to-lymphocyte ratio (PLR) was calculated by dividing the platelet count by the lymphocyte cell count. All analyses were 2-tailed, and the significance level was determined by P <0.05.

RESULTS

A total of 226 patients were included in the final analysis. The optimal cut-off values for PHE volume increase to predict poor outcomes were determined as 5.5 mL. For clinical applicability, we identified a value of 5.5 mL as the optimal threshold for early PHE growth. In the multivariate logistic regression analyses, we finally found that baseline hematoma surface area (p < 0.001), expansion-prone hematoma (p < 0.001), and PLR (p = 0.033) could independently predict PHE growth. The comprehensive prediction model demonstrated good performance in predicting PHE growth, with an area under the curve of 0.841, sensitivity of 0.807, and specificity of 0.732.

CONCLUSION

In this study, we found that baseline hematoma surface area, expansion-prone hematoma, and PLR were independently associated with PHE growth. Additionally, a risk nomogram model was established to predict the PHE growth in patients with ICH.

Experts consensus on management of tooth luxation and avulsion

Traumatic dental injuries (TDIs) of teeth occur frequently in children and adolescents. TDIs that impact the periodontal tissues and alveolar tissue can be classified into concussion, subluxation, extrusive luxation, intrusive luxation, lateral luxation, and avulsion. In these TDIs, management of injured soft tissue, mainly periodontal ligament, and dental pulp, is crucial in maintaining the function and longevity of the injured teeth. Factors that need to be considered for management in laxation injuries include the maturation stage of the traumatic teeth, mobility, direction of displacement, distance of displacement, and whether there are alveolar fractures. In avulsion, the maturation stage of the permanent tooth, the out-socket time, storage media/condition of the avulsed tooth, and management of the PDL should also be considered. Especially, in this review, we have subdivided the immature tooth into the adolescent tooth (Nolla stage 9) and the very young tooth (Nolla stage 8 and below). This consensus paper aimed to discuss the impacts of those factors on the trauma management and prognosis of TDI to provide a streamlined guide for clinicians from clinical evaluation, diagnostic process, management plan decision, follow-up, and orthodontic treatment for tooth luxation and avulsion injuries.

Protective effects of flavonoids against intracerebral and subarachnoid hemorrhage (Review)

Intracerebral hemorrhage (ICH), known as non-traumatic cerebrovascular rupture and hemorrhage, often occurs in the deep basal brain segment. It is known for its high morbidity and mortality rates. Subarachnoid hemorrhage (SAH) is a clinical syndrome caused by the rupture of blood vessels at the base or surface of the brain that allows blood to flow directly into the subarachnoid space. It progresses quickly and typically manifests at younger ages compared with ICH. ICH and SAH are both devastating events in the category of hemorrhagic strokes and are attracting increasing attention from researchers. Flavonoids, being important natural molecules, have remarkable anti-inflammatory and antioxidant effects. Flavonoids have extensive biological activities in inflammation and oxidative stress (OS), and have protective effects in vascular function associated with cerebrovascular diseases. They have an impact on the onset of ICH and SAH by targeting various pathways, including the suppression of inflammation and OS. Recently, the role of flavonoid compounds in ICH and SAH has also received increasing interest. Thus, to serve as a resource for the prevention and treatment of ICH and SAH, the present review provided an overview of the research on flavonoid compounds in the prevention of brain damage after these two conditions have occurred.

Transient receptor potential vanilloid 1 inhibition reduces brain damage by suppressing neuronal apoptosis after intracerebral hemorrhage

Intracerebral hemorrhage (ICH) induces a complex sequence of apoptotic cascades and inflammatory responses, leading to neurological impairment. Transient receptor potential vanilloid 1 (TRPV1), a nonselective cation channel with high calcium permeability, has been implicated in neuronal apoptosis and inflammatory responses. This study used a mouse ICH model and neuronal cultures to examine whether TRPV1 activation exacerbates brain damage and neurological deficits by promoting neuronal apoptosis and neuroinflammation. ICH was induced by injecting collagenase in both wild-type (WT) C57BL/6 mice and TRPV1-/- mice. Capsaicin (CAP; a TRPV1 agonist) or capsazepine (a TRPV1 antagonist) was administered by intracerebroventricular injection 30 min before ICH induction in WT mice. The effects of genetic deletion or pharmacological inhibition of TRPV1 using CAP or capsazepine on motor deficits, histological damage, apoptotic responses, blood-brain barrier (BBB) permeability, and neuroinflammatory reactions were explored. The antiapoptotic mechanisms and calcium influx induced by TRPV1 inactivation were investigated in cultured hemin-stimulated neurons. TRPV1 expression was upregulated in the hemorrhagic brain, and TRPV1 was expressed in neurons, microglia, and astrocytes after ICH. Genetic deletion of TRPV1 significantly attenuated motor deficits and brain atrophy for up to 28 days. Deletion of TRPV1 also reduced brain damage, neurodegeneration, microglial activation, cytokine expression, and cell apoptosis at 1 day post-ICH. Similarly, the administration of CAP ameliorated brain damage, neurodegeneration, brain edema, BBB permeability, and cytokine expression at 1 day post-ICH. In primary neuronal cultures, pharmacological inactivation of TRPV1 by CAP attenuated neuronal vulnerability to hemin-induced injury, suppressed apoptosis, and preserved mitochondrial integrity in vitro. Mechanistically, CAP reduced hemin-stimulated calcium influx and prevented the phosphorylation of CaMKII in cultured neurons, which was associated with reduced activation of P38 and c-Jun NH2-terminal kinase mitogen-activated protein kinase signaling. Our results suggest that TRPV1 inhibition may be a potential therapy for ICH by suppressing mitochondria-related neuronal apoptosis.

GSTO2 ameliorates human neuroblastoma cell apoptosis, inflammation, ferroptosis, and oxidative stress by upregulating GPX4 expression in intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a severe hemorrhagic stroke and induces severe secondary neurological injury. However, its pathogenesis remains to be explored. The present work investigates the role of glutathione S-transferase omega 2 (GSTO2) in ICH and the underlying mechanism. Human neuroblastoma cells (SK-N-SH) were stimulated using hemin to mimic ICH-like injury. Protein expression levels of GSTO2 and glutathione peroxidase 4 (GPX4) were detected by western blot analysis assay. Cell viability was assessed by cell counting kit-8 assay. Cell proliferation was investigated by 5-ethynyl-2'-deoxyuridine assay. Cell apoptosis was analyzed by flow cytometry. Interleukin-6 and tumor necrosis factor-α levels were quantified by enzyme-linked immunosorbent assays. Fe2+ colorimetric assay kit was used to detect Fe2+ level. A cellular reactive oxygen species (ROS) assay kit was used to detect ROS levels. Malondialdehyde (MDA) level was assessed using the MDA content assay kit. GSH level was quantified using the GSH assay kit. Co-immunoprecipitation assay was performed to identify the association between GSTO2 and GPX4. Hemin stimulation suppressed SK-N-SH cell proliferation and promoted cell apoptosis, cell inflammation, ferroptosis, and oxidative stress. GSTO2 expression was downregulated in hemin-treated SK-N-SH cells in comparison with the control group. In addition, ectopic GSTO2 expression counteracted hemin-induced inhibitory effect on cell proliferation and promoting effects on cell apoptosis, inflammation, ferroptosis, and oxidative stress. Moreover, GSTO2 was associated with GPX4 in SK-N-SH cells. GPX4 silencing attenuated GSTO2 overexpression-induced effects on hemin-stimulated SK-N-SH cell injury. GSTO2 ameliorated SK-N-SH cell apoptosis, inflammation, ferroptosis, and oxidative stress by upregulating GPX4 expression in ICH, providing a therapeutic strategy for ICH.

Based on hematoma and perihematomal tissue NCCT imaging radiomics predicts early clinical outcome of conservatively treated spontaneous cerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is a very serious kind of stroke. If the outcome of patients can be accurately assessed at the early stage of disease occurrence, it will be of great significance to the patients and clinical treatment. The present study was conducted to investigate whether non-contrast computer tomography (NCCT) models of hematoma and perihematomal tissues could improve the accuracy of short-term prognosis prediction in ICH patients with conservative treatment. In this retrospective analysis, a total of 166 ICH patients with conservative treatment during hospitalization were included. Patients were randomized into a training group (N = 132) and a validation group (N = 34) in a ratio of 8:2, and the functional outcome at 90 days after clinical treatment was assessed by the modified Rankin Scale (mRS). Radiomic features of hematoma and perihematomal tissues of 5 mm, 10 mm, 15 mm were extracted from NCCT images. Clinical factors were analyzed by univariate and multivariate logistic regression to identify independent predictive factors. In the validation group, the mean area under the ROC curve (AUC) of the hematoma was 0.830, the AUC of the perihematomal tissue within 5 mm, 10 mm, 15 mm was 0.792, 0.826, 0.774, respectively, and the AUC of the combined model of hematoma and perihematomal tissue within 10 mm was 0.795. The clinical-radiomics nomogram consisting of five independent predictors and radiomics score (Rad-score) of the hematoma model were used to assess 90-day functional outcome in ICH patients with conservative treatment. Our findings found that the hematoma model had better discriminative efficacy in evaluating the early prognosis of conservatively managed ICH patients. The visual clinical-radiomics nomogram provided a more intuitive individualized risk assessment for 90-day functional outcome in ICH patients with conservative treatment. The hematoma could remain the primary therapeutic target for conservatively managed ICH patients, emphasizing the need for future clinical focus on the biological significance of the hematoma itself.

[Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 1 - Primary Treatment Strategies, Haemodynamic Management and Multimodal Monitoring]

This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.

Alterations in brain fluid physiology during the early stages of development of ischaemic oedema

Oedema occurs when higher than normal amounts of solutes and water accumulate in tissues. In brain parenchymal tissue, vasogenic oedema arises from changes in blood-brain barrier permeability, e.g. in peritumoral oedema. Cytotoxic oedema arises from excess accumulation of solutes within cells, e.g. ischaemic oedema following stroke. This type of oedema is initiated when blood flow in the affected core region falls sufficiently to deprive brain cells of the ATP needed to maintain ion gradients. As a consequence, there is: depolarization of neurons; neural uptake of Na+ and Cl- and loss of K+; neuronal swelling; astrocytic uptake of Na+, K+ and anions; swelling of astrocytes; and reduction in ISF volume by fluid uptake into neurons and astrocytes. There is increased parenchymal solute content due to metabolic osmolyte production and solute influx from CSF and blood. The greatly increased [K+]isf triggers spreading depolarizations into the surrounding penumbra increasing metabolic load leading to increased size of the ischaemic core. Water enters the parenchyma primarily from blood, some passing into astrocyte endfeet via AQP4. In the medium term, e.g. after three hours, NaCl permeability and swelling rate increase with partial opening of tight junctions between blood-brain barrier endothelial cells and opening of SUR1-TPRM4 channels. Swelling is then driven by a Donnan-like effect. Longer term, there is gross failure of the blood-brain barrier. Oedema resolution is slower than its formation. Fluids without colloid, e.g. infused mock CSF, can be reabsorbed across the blood-brain barrier by a Starling-like mechanism whereas infused serum with its colloids must be removed by even slower extravascular means. Large scale oedema can increase intracranial pressure (ICP) sufficiently to cause fatal brain herniation. The potentially lethal increase in ICP can be avoided by craniectomy or by aspiration of the osmotically active infarcted region. However, the only satisfactory treatment resulting in retention of function is restoration of blood flow, providing this can be achieved relatively quickly. One important objective of current research is to find treatments that increase the time during which reperfusion is successful. Questions still to be resolved are discussed.

Peripheral cytokine interleukin-10 alleviates perihematomal edema after intracerebral hemorrhage via interleukin-10 receptor/JAK1/STAT3 signaling

AIMS

The extent of perihematomal edema following intracerebral hemorrhage (ICH) significantly impacts patient prognosis, and disruption of the blood-brain barrier (BBB) exacerbates perihematomal edema. However, the role of peripheral IL-10 in mitigating BBB disruption through pathways that link peripheral and central nervous system signals remains poorly understood.

METHODS

Recombinant IL-10 was administered to ICH model mice via caudal vein injection, an IL-10-inhibiting adeno-associated virus and an IL-10 receptor knockout plasmid were delivered intraventricularly, and neurobehavioral deficits, perihematomal edema, BBB disruption, and the expression of JAK1 and STAT3 were evaluated.

RESULTS

Our study demonstrated that the peripheral cytokine IL-10 mitigated BBB breakdown, perihematomal edema, and neurobehavioral deficits after ICH and that IL-10 deficiency reversed these effects, likely through the IL-10R/JAK1/STAT3 signaling pathway.

CONCLUSIONS

Peripheral IL-10 has the potential to reduce BBB damage and perihematomal edema following ICH and improve patient prognosis.

Pre-thrombolysis serum sodium concentration is associated with post-thrombolysis symptomatic intracranial hemorrhage in ischemic stroke patients

Background and aim

Symptomatic intracranial hemorrhage (sICH) was the most serious complication associated with alteplase intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients. However, the relationship between serum sodium levels and post-thrombolysis symptomatic intracranial hemorrhage has not been investigated. Therefore, the aim of this study was to investigate the relationship between pre-thrombolysis serum sodium levels and sICH after IVT, as well as to explore the optimal pre-thrombolysis serum sodium levels for lowering the risk of sICH following IVT.

Methods

From July 1, 2017 to April 30, 2023, out-of-hospital AIS patients who received IVT in the emergency department were enrolled in this study. Serum sodium levels were measured at admission prior to IVT, and National Institutes of Health Stroke Scale scores were continuously assessed during and after thrombolysis. Routine follow-up neuroimaging was performed between 22 to 36 h after IVT. Initially, three logistic regression models and restricted cubic splines (RCS) were established to investigate the relationship between serum sodium levels and post-thrombolysis sICH. Furthermore, to evaluate the predictive value of serum sodium for post-thrombolysis sICH, we compared area under the receiver operating characteristic curve (AUROC) and net reclassification improvement (NRI) before and after incorporating serum sodium into traditional models. Finally, subgroup analysis was conducted to explore interactions between serum sodium levels and other variables.

Results

A total of 784 AIS patients who underwent IVT were enrolled, among whom 47 (6.0%) experienced sICH. The median serum sodium concentration for all patients was 139.10 [interquartile ranges (IQR): 137.40-141.00] mmol/L. Patients who developed sICH had lower serum sodium levels than those without sICH [138.20(IQR:136.00-140.20) vs. 139.20(IQR:137.40-141.00), p = 0.031]. Logistic regression analysis (model 3) revealed a 14% reduction in the risk of post-thrombolysis sICH for every 1 mmol/L increase in serum sodium levels after adjusting for confounding variables (p < 0.001). The risk of post-thrombolysis sICH was minimized within the serum sodium range of 139.1-140.9 mmol/L compared to serum sodium concentration below 137.0 mmol/L [odds ratio (OR) = 0.33, 95% confidence interval (CI): 0.13-0.81] in model3. Furthermore, there was a significant trend of decreasing risk for sICH as serum sodium concentrations increased across the four quartiles (P for trend = 0.036). The RCS analysis indicated a statistically significant reduction in the risk of sICH as serum sodium levels increased when the concentration was below 139.1 mmol/L. Incorporating serum sodium into traditional models improved their predictive performance, resulting in higher AUROC and NRI values. Subgroup analysis suggested that early infarct signs (EIS) appeared to moderate the relationship between serum sodium and sICH (p < 0.05).

Conclusion

Lower serum sodium levels were identified as independent risk factors for post-thrombolysis sICH. Maintaining pre-thrombolysis serum sodium concentrations above 139.1 mmol/L may help reduce the risk of post-thrombolysis sICH.

Jingfang granules protects against intracerebral hemorrhage by inhibiting neuroinflammation and protecting blood-brain barrier damage

Intracerebral hemorrhage (ICH) can induce intensive oxidative stress, neuroinflammation, and brain cell apoptosis. However, conventional methods for ICH treatment have many disadvantages. There is an urgent need for alternative, effective therapies with minimal side effects. Pharmacodynamics experiment, molecular docking, network pharmacology, and metabolomics were adopted to investigate the treatment and its mechanism of Jingfang Granules (JFG) in ICH. In this study, we investigated the therapeutic effects of JFG on ICH using behavioral, brain water content and Magnetic resonance imaging experiments. However, the key active component and targets of JFG remain unknown. Here we verified that JFG was beneficial to improve brain injury after ICH. A network pharmacology analysis revealed that the anti-inflammatory effect of JFG is predominantly mediated by its activation of the phosphatidylinositol 3-kinase (PI3K)/AKT pathway through Luteolin, (+)-Anomalin and Phaseol and their targeting of AKT1, tumor necrosis factorα (TNF-α), and interleukin-1β (IL-1β). Molecular docking analyses revealed an average affinity of -8.633 kcal/mol, indicating a binding strength of less than -5 kcal/mol. Metabolomic analysis showed that JFG exerted its therapeutic effect on ICH by regulating metabolic pathways, such as the metabolism of taurine and hypotaurine, biosynthesis of valine, leucine, and isoleucine. In conclusion, we demonstrated that JFG attenuated neuroinflammation and BBB injury subsequent to ICH by activating the PI3K/Akt signaling pathway.