Hemorrhagic stroke syndromes: clinical manifestations of intracerebral and subarachnoid hemorrhage

Deciphering changes in the incidence of hemorrhagic stroke and cerebral venous sinus thrombosis during the coronavirus disease 2019 pandemic: A nationwide time-series correlation study

INTRODUCTION

Hemorrhagic stroke and cerebral venous sinus thrombosis (CVST) are associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and vaccination. We aimed to investigate changes in the incidence of hemorrhagic stroke and CVST in South Korea before and during the coronavirus disease 2019 pandemic and the factors associated with these changes.

MATERIALS AND METHODS

We conducted a nationwide time-series study using population-based databases between 2007 and 2022. The real-world and forecasted incidences of acute non-traumatic subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and CVST during the pandemic period (2020-2022) were estimated and compared with the pre-pandemic period (2007-2019). The prevalence of conventional risk factors was measured using time-series data. Finally, a time-series correlation analysis was performed to examine the temporal association between conventional risk factors, SARS-CoV-2 infection, and SARS-CoV-2 vaccination.

RESULTS

The incidence of hemorrhagic stroke (SAH and ICH) was lower during the pandemic than during the pre-pandemic period. This observed decrease was associated with a reduction in the prevalence of conventional risk factors but not with SARS-CoV-2 infection or vaccination. The incidence of CVST was higher during the pandemic than during the pre-pandemic period, which may be temporally related to SARS-CoV-2 vaccination (Pearson correlation coefficient [r] = 0.349, P = 0.031).

CONCLUSION

We report reassuring evidence of hemorrhagic stroke associated with SARS-CoV-2 infection and vaccination. However, awareness of CVST may be required for future vaccine rollouts and SARS-CoV-2 outbreaks.

Analysis of the association between location and patient prognosis in spontaneous intracerebral hemorrhage in the basal ganglia and thalamus: A retrospective single-center study

Spontaneous intracerebral hemorrhage (ICH) causes profound neurological sequelae in survivors. The patient's prognosis is closely linked to the location and amount of hemorrhage. Therefore, we explored the relationship between the hemorrhage location within the basal ganglia, including the thalamus, and its clinical outcomes in patients with spontaneous intracerebral hemorrhage. A retrospective analysis of consecutively enrolled patients with basal ganglia and thalamic intracerebral hemorrhage treated conservatively at a single tertiary neurosurgical center was conducted between January 2014 and December 2020. Patients were divided into 2 groups according to the lateralization of the right or left hemisphere hemorrhage. Furthermore, baseline patient demographics, hematoma volume, location of the hemorrhage (i.e., caudate nucleus, globus palidus, putamen, internal capsule anterior limb, internal capsule posterior limb, thalamus), and clinical outcomes were evaluated. Clinical outcomes were assessed using the modified Rankin scale at the 1-year follow-up. An modified Rankin scale score between 3 and 6 was considered a poor outcome. In the analysis according to location, the prognosis was poor when the ICH was localized to the posterior limb of the internal capsule (P < .000) and globus palidus (P = .001) in the right hemisphere. Similarly, the prognosis was also poor when the ICH was localized to the posterior limb of the internal capsule (P < .000), globus palidus (P < .000), putamen (P = .018), and thalamus (P < .000) of the left hemisphere. In the spontaneous intracerebral hemorrhages of the basal ganglia and thalamus, hemorrhaging within the internal capsule and the left thalamus's bilateral posterior limbs is associated with a poor prognosis. Multivariable logistic analysis showed that hematoma volume (odds ratio [OR] = 70.85, 95% confidence interval [CI]: 1.95-60.53, P = .007) and the posterior limb of the internal capsule (OR = 10.98, 95% CI:1.02-118.49, P = .048) were independent predictors of poor outcomes in the right hemisphere, while hematoma volume (OR = 70.85, 95% CI: 1.95-60.53, P = .007), the posterior limb of the internal capsule (OR = 10.98, 95% CI:1.02-118.49, P = .048) and thalamus (OR = 10.98, 95% CI:1.02-118.49, P = .048) were independent predictors of poor outcomes in the left hemisphere.

Quantifying the Impact of Acute Stroke System of Care Transfer Protocols on Patient Outcomes

BACKGROUND

We quantify the impact of implementing a stroke system of care requiring transport of individuals believed to have stroke to a primary stroke center, in rural and urban settings, based on time from symptom recognition to treatment, probability of receiving treatment within 3 hours of stroke onset, and probability of overcrowding. We use Indiana as an example.

METHODS

We used discrete-event simulation to estimate outcomes for 2 scenarios: stroke system of care with enabling technology (mobile stroke unit, stroke team expansion) and stroke system of care with no enabling technology, as compared with the status quo. We considered patient flow from symptom recognition to treatment. Patient locations and stroke events were generated for the 92 Indiana counties in Indiana, subdivided into 1009 locations. We considered time from emergency medical service (EMS) arrival at onset to treatment, probability of tissue plasminogen activator administered within 3 h of onset, and percentage of patients admitted beyond the occupancy level at the comprehensive stroke center.

RESULTS

Results varied by urbanicity. Under no enabling technology, having a stroke system of care improved outcomes for individuals in urban and suburban settings. However, in rural settings, the implementation of stroke system of care guidelines decreased the average rate of treatment within 3 h of stroke onset and increased the EMS arrival to treatment times compared with sending the individual to the closest provider. Enabling technologies improved outcomes regardless of setting.

DISCUSSION

Geographic disparities tend to increase the number of transfers, decrease the rate of treatment within 3 h of onset, and increase transit time. This could be overcome through federal and state initiatives to reduce quality gaps in stroke care in rural settings and promote care with dedicated stroke wards.

Hydrogen sulfide therapy in brain diseases: from bench to bedside

Hydrogen sulfide (H₂S) has been recognized and studied for nearly 300 years, but past researches mainly focus on its toxicity effect. During the past two decades, the majority of researches have reported that H₂S is a novel endogenous gaseous signal molecule in organisms, and play an important role in various systems and diseases. H₂S is mainly produced by three enzymes, including cystathionine β-synthase, cystathionine γ-lyase and 3-mercaptopyruvate sulfurtransferase along with cysteine aminotransferase. H₂S had been firstly reported as a neuromodulator in the brain, because of its essential role in the facilitating hippocampal long-term potentiation at physiological concentration. It is subsequently reported that H₂S may have relevance to neurologic disorders through antioxidative, anti-inflammatory, anti-apoptotic and additional effects. Recent basic medical studies and preclinical studies on neurologic diseases have demonstrated that the administration of H₂S at physiological or pharmacological levels attenuates brain injury. However, the neuroprotective effect of H₂S is concentration-dependent, only a comparatively low dose of H₂S can provide beneficial effect. Herein, we review the neuroprotevtive role of H₂S therapy in brain diseases from its mechanism to clinical application in animal and human subjects, and therefore provide the potential strategies for further clinical treatment.

Intracranial hemorrhage

Intracranial hemorrhage refers to any bleeding within the intracranial vault, including the brain parenchyma and surrounding meningeal spaces. This article focuses on the acute diagnosis and management of primary nontraumatic intracerebral hemorrhage and subarachnoid hemorrhage in the emergency department.