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

Endoscopic Hematoma Evacuation Under Local Anesthesia for Acute Intracerebral Hemorrhage in Older Patients: A Case Series

Intracerebral hemorrhage (ICH) is a severe neurological condition with a poor prognosis, and surgical intervention is often necessary in cases with significant hematoma volume. With the progression of a super-aging society, the incidence of ICH in older patients is increasing. However, traditional craniotomy under general anesthesia poses a high risk to older patients, thereby limiting its use. Recently, minimally invasive techniques have become widely used. Endoscopic hematoma evacuation can be performed under local anesthesia, which may minimize invasiveness and reduce the risk of complications associated with general anesthesia in older patients. However, only a few studies have specifically addressed endoscopic hematoma evacuation under local anesthesia for acute ICH in older patients, and the optimal protocol for surgical procedures and perioperative management remains unclear. The aim of this study is to highlight the technical considerations and potential benefits of endoscopic surgery for ICH in older patients. This study presents a case series of five patients aged ≥ 70 years who underwent endoscopic hematoma evacuation under local anesthesia for acute ICH. The median hematoma removal rate was 95.8%, with no postoperative re-bleeding or mortality. 3D visualization technology using preoperative computed tomography images not only facilitates the initiation of surgery but also assists with intraoperative support for accurate hematoma localization. In older patients, preoperative insertion of a nasogastric tube and the use of a transparent drape were effective in ensuring intraoperative airway management. Our findings suggest that endoscopic hematoma evacuation under local anesthesia is a safe and effective treatment option for older patients, offering reduced surgical invasiveness while maintaining high removal rates.

Early postoperative acetylsalicylic acid administration does not increase the risk of postoperative intracranial bleeding in patients with spontaneous intracerebral hemorrhage

Administration of acetylsalicylic acid (ASA) at early stage after surgery for spontaneous intracerebral hemorrhage (SICH) may increase the risk of postoperative intracranial bleeding (PIB), because of potential inhibition of platelet function. This study aimed to investigate whether early ASA administration after surgery was related to increased risk of PIB. This retrospective study enrolled SICH patients receiving surgery from September 2019 to December 2022 in seven medical institution. Based on postoperative ASA administration, patients who continuously received ASA more than three days within seven days post-surgery were identified as ASA users, otherwise as non-ASA users. The primary outcome was symptomatic PIB events within seven days after surgery. Incidence of PIB was compared between ASA users and non-ASA users using survival analysis. This study included 744 appropriate patients from 794 SICH patients. PIB occurred in 42 patients. Survival analysis showed no statistical difference between ASA users and non-ASA users in incidence of PIB (P = 0.900). Multivariate Cox analysis demonstrated current smoker (hazard ratio [HR], 2.50, 95%CI, 1.33-4.71, P = 0.005), dyslipidemia (HR = 3.03; 95%CI, 1.31-6.99; P = 0.010) and pre-hemorrhagic antiplatelet therapy (HR = 3.05; 95% CI, 1.64-5.68; P < 0.001) were associated with PIB. Subgroup analysis manifested no significant difference in incidence of PIB between ASA users and non-ASA users after controlling the effect from factors of PIB (i.e., sex, age, current smoker, regular drinker, dyslipidemia, pre-hemorrhagic antiplatelet therapy and hematoma location). This study revealed that early ASA administration to SICH patients after surgery was not related to increased risk of PIB.

Minimally invasive craniotomy for putaminal hemorrhage using a tubular retractor: A technical note

Background

Minimally invasive endoscopic and stereotactic surgery have been established as surgical treatments for putaminal hemorrhage. However, facilities that do not have equipment for endoscopic or stereotactic surgery will likely have to perform conventional craniotomy. Using a tubular retractor, we were able to perform minimally invasive surgery, such as endoscopic surgery.

Methods

A craniotomy was performed for left putaminal hemorrhage after cerebral infarction treatment. A 3-4 cm craniotomy centered at Kocher's point was performed under general anesthesia. A 2 cm incision was made in the cortex, and a tubular retractor was inserted under a microscope. The hematoma was reached at a position 4-5 cm from the cortex.

Results

Thanks to the tubular retractor, it was relatively easy to observe the hematoma, and it was possible to remove it and confirm hemostasis without difficulty. Brain injury caused by the retractor insertion cavity was small, and no hemostasis was required. The surgery was completed by dura mater closure, bone flap fixation, and wound closure as per the standard. Most of the putaminal hemorrhage could be removed, and there was no rebleeding after the operation. The patient is still undergoing rehabilitation because of aphasia and muscle weakness. Manual Muscle Testing was at three points in the upper limb, and four points in the lower limb remained.

Conclusion

For putaminal hemorrhage, microscopic craniotomy was performed using a tubular retractor and an approach such as endoscopic surgery. Craniotomy, hematoma removal, and hemostasis operations are also considered to be minimally invasive surgeries.

Comparison of the efficacy of neuronavigation-assisted intracerebral hematoma puncture and drainage with neuroendoscopic hematoma removal in treatment of hypertensive cerebral hemorrhage

OBJECTIVE

To compare neuronavigation-assisted intracerebral hematoma puncture and drainage with neuroendoscopic hematoma removal for treatment of hypertensive cerebral hemorrhage.

METHOD

Ninety-one patients with hypertensive cerebral hemorrhage admitted to our neurosurgery department from June 2022 to May 2023 were selected: 47 patients who underwent endoscopic hematoma removal with the aid of neuronavigation in observation Group A and 44 who underwent intracerebral hematoma puncture and drainage in control Group B. The duration of surgery, intraoperative bleeding, hematoma clearance rate, pre- and postoperative GCS score, National Institutes of Health Stroke Scale (NIHSS) score, mRS score and postoperative complications were compared between the two groups.

RESULTS

The duration of surgery, intraoperative bleeding and hematoma clearance were significantly lower in Group B than in Group A (p < 0.05). Conversely, no significant differences in the preoperative, 7-day postoperative, 14-day postoperative or 1-month postoperative GCS or NIHSS scores or the posthealing mRS score were observed between Groups A and B. However, the incidence of postoperative complications was significantly greater in Group B than in Group A (p < 0.05), with the most significant difference in incidence of intracranial infection (p < 0.05).

CONCLUSION

Both neuronavigation-assisted intracerebral hematoma puncture and drainage and neuroendoscopic hematoma removal are effective at improving the outcome of patients with hypertensive cerebral hemorrhage. The disadvantage of neuronavigation is that the incidence of complications is significantly greater than that of other methods; postoperative care and prevention of complications should be strengthened in clinical practice.

Association between the surgical approach and prognosis of spontaneous supratentorial deep intracerebral hemorrhage

The association between surgical approach and prognosis in patients with spontaneous supratentorial deep intracerebral hemorrhage is unclear. We aimed to explore the association between surgical approach and prognosis in these patients. A retrospective cohort of 311 patients from 3 centers who were treated with surgery 24 h after ictus was recruited. The surgical procedure involved removing the intracerebral hematoma using an aspirator through either the cortical approach or Sylvian fissure approach, assisted by an endoscope or microscope. The primary outcome was the one-year modified Rankin scale (mRS) score. The association between the surgical approach and the one-year mRS score was explored by using ordinal logistic regression and binary logistic regression. Baseline characteristics were balanced by propensity score matching and inverse propensity score weighting. In the adjusted analysis, compared with the cortex approach group, the Sylvian fissure approach group had better one-year mRS scores when analyzed as an ordinal variable (3.00 [2.00-4.00] vs. 4.00 [3.00-5.00]; adjusted odds ratio, 3.15; 95% CI, 1.78-5.58; p < 0.001) and a dichotomous variable (74.14% vs. 49.01%; adjusted odds ratio, 6.61; 95% CI, 2.75-15.88; p < 0.001). Surgical approach was not significantly associated with rebleeding (p = 0.88) or three-month mortality (p = 0.81). In univariate analysis after propensity score matching, there were significant differences in one-year mRS score between the two groups (p < 0.001), and there were no significant differences in rebleeding (Fisher's exact test, p > 0.999) or three-month mortality (Fisher's exact test, p > 0.999). Inverse probability weighted regression analysis showed better one-year mRS scores when analyzed as an ordinal variable (adjusted odds ratio, 3.03; 95% CI, 2.17-4.17; p < 0.001) and a dichotomous variable (adjusted odds ratio, 3.11; 95% CI, 2.16-4.77; p < 0.001) in the Sylvian fissure approach group; the surgical approach was not significantly associated with rebleeding (p = 0.50) or three-month mortality (p = 0.60). In the surgical treatment of patients with spontaneous supratentorial deep intracerebral hemorrhage, the Sylvian fissure approach may lead to a better functional outcome compared with the cortex approach. Future prospective studies are warranted to confirm this finding.

Delayed Postoperative Intracerebral Hemorrhage Associated With Oral Multikinase Inhibitor Therapy for Cancer: A Case Report

Regorafenib is a multikinase inhibitor with anti-vascular endothelial growth factor receptor (VEGF) activity used as an antiangiogenic agent for metastatic colorectal cancer treatment and has been studied as a potential therapeutic agent for several other cancer treatments. Adverse reactions commonly reported with the use of regorafenib and similar oral multikinase inhibitors include hemorrhage, gastrointestinal fistulas, hypertension, and incomplete wound healing. We report a case of a 59-year-old man with metastatic colorectal adenocarcinoma post-colostomy on regorafenib treatment presenting to the emergency department with altered mental status. MRI showed a left frontoparietal mass, which was resected with a left frontal craniotomy. Postoperative MRI showed a resection cavity without significant hemorrhage. He had been prescribed regorafenib preceding his hospitalization, which was continued after admission before surgery and on postoperative day 1. Thirty-two hours after surgery, the patient exhibited sudden right-sided facial droop and right arm weakness. Imaging revealed an acute intraparenchymal hemorrhage within and adjacent to the tumor resection bed, which was managed conservatively. The patient was subsequently discharged to an inpatient rehabilitation facility. The unusual timing of the hemorrhage suggests that the hemorrhage was due to adverse effects of regorafenib. Patients undergoing neurosurgery should have regorafenib discontinued in preparation for surgery. Similar management should be considered for other anti-VEGF medications to avoid serious complications.

Non-Metallic MR-Guided Concentric Tube Robot for Intracerebral Hemorrhage Evacuation

OBJECTIVE

We aim to develop and evaluate an MR-conditional concentric tube robot for intracerebral hemorrhage (ICH) evacuation.

METHODS

We fabricated the concentric tube robot hardware with plastic tubes and customized pneumatic motors. The robot kinematic model was developed using a discretized piece-wise constant curvature (D-PCC) approach to account for variable curvature along the tube shape, and tube mechanics model was used to compensate torsional deflection of the inner tube. The MR-safe pneumatic motors were controlled using a variable gain PID algorithm. The robot hardware was validated in a series of bench-top and MRI experiments, and the robot's evacuation efficacy was tested in MR-guided phantom trials.

RESULTS

The pneumatic motor was able to achieve a rotational accuracy of 0.32°±0.30° with the proposed variable gain PID control algorithm. The kinematic model provided a positional accuracy of the tube tip of 1.39 ± 0.54 mm. The robot was able to evacuate an initial 38.36 mL clot, leaving a residual hematoma of 8.14 mL after 5 minutes, well below the 15 mL guideline suggesting good post-ICH evacuation clinical outcomes.

CONCLUSION

This robotic platform provides an effective method for MR-guided ICH evacuation.

SIGNIFICANCE

ICH evacuation is feasible under MRI guidance using a plastic concentric tube, indicating potential feasibility in future live animal studies.

Using Radiomics and Convolutional Neural Networks for the Prediction of Hematoma Expansion After Intracerebral Hemorrhage

Background

Hematoma enlargement (HE) is a common complication following acute intracerebral hemorrhage (ICH) and is associated with early deterioration and unfavorable clinical outcomes. This study aimed to evaluate the predictive performance of a computed tomography (CT) based model that utilizes deep learning features in identifying HE.

Methods

A total of 408 patients were retrospectively enrolled between January 2015 and December 2020 from our institution. We designed an automatic model that could mask the hematoma area and fusion features of radiomics, clinical data, and convolutional neural network (CNN) in a hybrid model. We assessed the model's performance by using confusion matrix metrics (CM), the area under the receiver operating characteristics curve (AUC), and other statistical indicators.

Results

After automated masking, 408 patients were randomly divided into two cohorts with 204 patients in the training set and 204 patients in the validation set. The first cohort trained the CNN model, from which we then extracted radiomics, clinical data, and CNN features for the second validation cohort. After feature selection by K-highest score, a support vector machines (SVM) model classification was used to predict HE. Our hybrid model exhibited a high AUC of 0.949, and 0.95 of precision, 0.83 of recall, and 0.94 of average precision (AP). The CM found that only 5 cases were misidentified by the model.

Conclusion

The automatic hybrid model we developed is an end-to-end method and can assist in clinical decision-making, thereby facilitating personalized treatment for patients with ICH.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Treatment outcomes between endoscopic surgery and conventional craniotomy for spontaneous supratentorial intracerebral hemorrhage: a randomized controlled trial

Minimally invasive surgery (MIS) has been repeatedly evaluated in patients with ICH as a promising procedure for improved survival and functional outcome. Among MIS techniques, endoscopic surgery (ES) has shown superior efficacy for ICH removal due to rapid clot evacuation and immediate bleeding control. However, the results of ES are still uncertain due to insufficient data. In this study, participants with spontaneous supratentorial ICH who were indicated for surgery were randomly assigned (1:1) to undergo ES or conventional craniotomy (CC) between March 2019 and June 2022. The primary outcome was a difference in favorable modified Rankin Scale (mRS) outcome (0 to 3) at 180-day follow-up evaluated by blind assessors. There were 188 participants, 95 in the ES group and 93 in the CC group, who completed the trial. At 180-day follow-up, 46 (48.4%) participants in the ES group achieved favorable outcomes, compared to 33 (35.5%) in the CC group (risk difference [RD] 12.9, 95% CI - 1.1-27.0, p = 0.07). After covariate adjustment, the difference was slightly higher and significant (adjusted RD 17.3, 95% CI [4.6-30.0], p = 0.01). Moreover, the ES group had less operative duration and less intraoperative blood loss than the CC group. Clot evacuation rate and complications were similar between the two groups. Subgroup analyses showed a potential benefit of ES in age < 60 years, time to surgery ≥ 6 h, and deep ICH. This study showed that ES was safe and effective in ICH removal and provided a better functional outcome compared to CC.

School-Based Stroke Education Through On-Demand E-learning During Coronavirus Disease 2019 Pandemic: Itoigawa Stroke Awareness Campaign

Introduction Raising stroke awareness is important to shorten the interval from onset to consultation. We performed a school-based stroke education by on-demand e-learning during the coronavirus disease 2019 pandemic. Methods We performed on-demand e-learning and distributed the online- and paper-based manga about stroke for students and parental guardians in August 2021. We carried out this in a manner similar to the prior effective online stroke awareness initiatives in Japan. An online post-educational survey in October 2021 was conducted to evaluate the awareness effects by asking participants about their knowledge. We also investigated the modified Rankin Scale (mRS) at the discharge of stroke patients who were treated in our hospital during the before- and after-campaign periods, respectively. Results We distributed the paper-based manga and asked to work on this campaign to all 2,429 students (1,545 elementary school and 884 junior high school students) who lived in Itoigawa. We acquired 261 (10.7%) online responses from the students and 211 (8.7%) responses from their parental guardians. The number of students who chose all correct answers in the survey significantly increased after the campaign (205/261, 78.5%) compared to that before the campaign (135/261, 51.7%) and those of parental guardians showed similar trends (before campaign 93/211, 44.1%; after campaign 198/211, 93.8%). We investigated 282 stroke patients (90 patients before and 192 patients after-campaign period), and their mRS at discharge after-campaign seemed to be improved. Conclusion Only 10.7% of students and 8.7% of the parental guardians worked on the online survey. However, the number of those who chose correct answers about stroke increased after the campaign. After this campaign, the mRS of stroke patients at discharge improved although it was unclear if this is a direct result of this activity.

Machine learning-based CT radiomics model to discriminate the primary and secondary intracranial hemorrhage

It is challenging to distinguish between primary and secondary intracranial hemorrhage (ICH) purely by imaging data, and the two forms of ICHs are treated differently. This study aims to evaluate the potential of CT-based machine learning to identify the etiology of ICHs and compare the effectiveness of two regions of interest (ROI) sketching methods. A total of 1702 radiomic features were extracted from the CT brain images of 238 patients with acute ICH. We used the Select K Best method, least absolute shrinkage, and selection operator logistic regression to select the most discriminable features with a support vector machine to build a classifier model. Then, a ten-fold cross-validation strategy was employed to evaluate the performance of the classifier. From all quantitative CT-based imaging features obtained by two sketch methods, eighteen features were selected respectively. The radiomics model outperformed radiologists in distinguishing between primary and secondary ICH in both the volume of interest and the three-layer ROI sketches. As a result, a machine learning-based CT radiomics model can improve the accuracy of identifying primary and secondary ICH. A three-layer ROI sketch can identify primary versus secondary ICH based on the CT radiomics method.

Neuroprotection by Nrf2 via modulating microglial phenotype and phagocytosis after intracerebral hemorrhage

Activated microglia are divided into pro-inflammatory and anti-inflammatory functional states. In anti-inflammatory state, activated microglia contribute to phagocytosis, neural repair and anti-inflammation. Nrf2 as a major endogenous regulator in hematoma clearance after intracerebral hemorrhage (ICH) has received much attention. This study aims to investigate the mechanism underlying Nrf2-mediated regulation of microglial phenotype and phagocytosis in hematoma clearance after ICH. In vitro experiments, BV-2 cells were assigned to normal group and administration group (Nrf2-siRNA, Nrf2 agonists Monascin and Xuezhikang). In vivo experiments, mice were divided into 5 groups: sham, ICH + vehicle, ICH + Nrf2-/-, ICH + Monascin and ICH + Xuezhikang. In vitro and in vivo, 72 h after administration of Monascin and Xuezhikang, the expression of Nrf2, inflammatory-associated factors such as Trem1, TNF-α and CD80, anti-inflammatory, neural repair and phagocytic associated factors such as Trem2, CD206 and BDNF were analyzed by the Western blot method. In vitro, fluorescent latex beads or erythrocytes were uptaken by BV-2 cells in order to study microglial phagocytic ability. In vivo, hemoglobin levels reflect the hematoma volume. In this study, Nrf2 agonists (Monascin and Xuezhikang) upregulated the expression of Trem2, CD206 and BDNF while decreased the expression of Trem1, TNF-α and CD80 both in vivo and in vitro. At the same time, after Monascin and Xuezhikang treatment, the phagocytic capacity of microglia increased in vitro, neurological deficits improved and hematoma volume lessened in vivo. These results were reversed in the Nrf2-siRNA or the Nrf2-/- mice. All these results indicated that Nrf2 enhanced hematoma clearance and neural repair, improved neurological outcomes through enhancing microglial phagocytosis and alleviating neuroinflammation.

Can Artificial Intelligence Be Applied to Diagnose Intracerebral Hemorrhage under the Background of the Fourth Industrial Revolution? A Novel Systemic Review and Meta-Analysis

Aim

We intended to provide the clinical evidence that artificial intelligence (AI) could be used to assist doctors in the diagnosis of intracerebral hemorrhage (ICH).

Methods

Studies published in 2021 were identified after the literature search of PubMed, Embase, and Cochrane. Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used to perform the quality assessment of studies. Data extraction of diagnosis effect included accuracy (ACC), sensitivity (SEN), specificity (SPE), positive predictive value (PPV), negative predictive value (NPV), area under curve (AUC), and Dice scores (Dices). The pooled effect with its 95% confidence interval (95%CI) was calculated by the random effects model. I-Square (I 2) was used to test heterogeneity. To check the stability of the overall results, sensitivity analysis was conducted by recalculating the pooled effect of the remaining studies after omitting the study with the highest quality or the random effects model was switched to the fixed effects model. Funnel plot was used to evaluate publication bias. To reduce heterogeneity, recalculating the pooled effect of the remaining studies after omitting the study with the lowest quality or perform subgroup analysis.

Results

Twenty-five diagnostic tests of ICH via AI and doctors with overall high quality were included. Pooled ACC, SEN, SPE, PPV, NPV, AUC, and Dices were 0.88 (0.83∼0.93), 0.85 (0.81∼0.89), 0.90 (0.88∼0.92), 0.80 (0.75∼0.85), 0.93 (0.91∼0.95), 0.84 (0.80∼0.89), and 0.90 (0.85∼0.95), respectively. There was no publication bias. All of results were stable as revealed by sensitivity analysis and were accordant as outcomes via subgroups analysis.

Conclusion

Under the background of the fourth industrial revolution, AI might be an effective and efficient tool to assist doctors in the clinical diagnosis of ICH.

Hemorrhagic Stroke: Endoscopic Aspiration

Intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) carry a very dismal prognosis. Several medical and surgical attempts have been made to reduce mortality and to improve neurological outcomes in survivors. Aggressive surgical treatment of ICH through craniotomy and microsurgical evacuation did not prove to be beneficial to these patients, compared to the best medical treatment. Similarly, the conventional treatment of IVH using an EVD is often effective in controlling ICP only initially, as it is very likely for the EVD to become obstructed by blood clots, requiring frequent replacements with a consequent increase of infection rates.Minimally invasive techniques have been proposed to manage these cases. Some are based on fibrinolytic agents that are infused in the hemorrhagic site through catheters with a single burr hole. Others are possible thanks to the development of neuroendoscopy. Endoscopic removal of ICH through a mini-craniotomy or a single burr hole, and via a parafascicular white matter trajectory, proved to reduce mortality in this population, and further randomized trials are expected to show whether also a better neurological outcome can be obtained in survivors. Moreover, endoscopy offers the opportunity to access the ventricular system to aspirate blood clots in patients with IVH. In such cases, the restoration of patency of the entire CSF pathway has the potential to improve outcome and reduce complications and now it is believed to decrease shunt-dependency.

Deep Learning-Based Functional Independence Measure Score Prediction After Stroke in Kaifukuki (Convalescent) Rehabilitation Ward Annexed to Acute Care Hospital

Introduction

Prediction models of functional independent measure (FIM) score after kaifukuki (convalescent) rehabilitation ward (KRW) are needed to decide the treatment strategies and save medical resources. Statistical models were reported, but their accuracies were not satisfactory. We made such prediction models using the deep learning (DL) framework, Prediction One (Sony Network Communications Inc., Tokyo, Japan).

Methods

Of the 559 consecutive stroke patients, 122 patients were transferred to our KRW. We divided our 122 patients’ data randomly into halves of training and validation datasets. Prediction One made three prediction models from the training dataset using (1) variables at the acute care ward admission, (2) those at the KRW admission, and (3) those combined (1) and (2). The models’ determination coefficients (R²), correlation coefficients (rs), and residuals were calculated using the validation dataset.

Results

Of the 122 patients, the median age was 71, length of stay (LOS) in acute care ward 23 (17-30) days, LOS in KRW 53 days, total FIM scores at the admission of KRW 85, those at discharge 108. The mean FIM gain and FIM efficiency were 19 and 0.417. All patients were discharged home. Model (1), (2), and (3)’s R² were 0.794, 0.970, and 0.972. Their mean residuals between the predicted and actual total FIM scores were -1.56±24.6, -4.49±17.1, and -2.69±15.7.

Conclusion

Our FIM gain and efficiency were better than national averages of FIM gain 17.1 and FIM efficiency 0.187. We made DL-based total FIM score prediction models, and their accuracies were superior to those of previous statistically calculated ones. The DL-based FIM score prediction models would save medical costs and perform efficient stroke and rehabilitation medicine.

Easily Created Prediction Model Using Automated Artificial Intelligence Framework (Prediction One, Sony Network Communications Inc., Tokyo, Japan) for Subarachnoid Hemorrhage Outcomes Treated by Coiling and Delayed Cerebral Ischemia

Introduction Reliable prediction models of subarachnoid hemorrhage (SAH) outcomes and delayed cerebral ischemia (DCI) are needed to decide the treatment strategy. Automated artificial intelligence (AutoAI) is attractive, but there are few reports on AutoAI-based models for SAH functional outcomes and DCI. We herein made models using an AutoAI framework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to other previous statistical prediction scores. Methods We used an open dataset of 298 SAH patients, who were with non-severe neurological grade and treated by coiling. Modified Rankin Scale 0-3 at six months was defined as a favorable functional outcome and DCI occurrence as another outcome. We randomly divided them into a 248-patient training dataset and a 50-patient test dataset. Prediction One made the model using training dataset with 5-fold cross-validation. We evaluated the model using the test dataset and compared the area under the curves (AUCs) of the created models. Those of the modified SAFIRE score and the Fisher computed tomography (CT) scale to predict the outcomes. Results The AUCs of the AutoAI-based models for functional outcome in the training and test dataset were 0.994 and 0.801, and those for the DCI occurrence were 0.969 and 0.650. AUCs for functional outcome calculated using modified SAFIRE score were 0.844 and 0.892. Those for the DCI occurrence calculated using the Fisher CT scale were 0.577 and 0.544. Conclusions We easily and quickly made AutoAI-based prediction models. The models' AUCs were not inferior to the previous prediction models despite the easiness.

Postsurgical functional outcome prediction model using deep learning framework (Prediction One, Sony Network Communications Inc.) for hypertensive intracerebral hemorrhage

BACKGROUND

Reliable prediction models of intracerebral hemorrhage (ICH) outcomes are needed for decision-making of the treatment. Statistically making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on DL-based functional outcome prediction models for ICH outcomes after surgery. We herein made a functional outcome prediction model using DLframework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to original ICH score, ICH Grading Scale, and FUNC score.

METHODS

We used 140 consecutive hypertensive ICH patients' data in our hospital between 2012 and 2019. All patients were surgically treated. Modified Rankin Scale 0-3 at 6 months was defined as a favorable outcome. We randomly divided them into 100 patients training dataset and 40 patients validation dataset. Prediction One made the prediction model using the training dataset with 5-fold cross-validation. We calculated area under the curves (AUCs) regarding the outcome using the DL-based model, ICH score, ICH Grading Scale, and FUNC score. The AUCs were compared.

RESULTS

The model made by Prediction One using 64 variables had AUC of 0.997 in the training dataset and that of 0.884 in the validation dataset. These AUCs were superior to those derived from ICH score, ICH Grading Scale, and FUNC score.

CONCLUSION

We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the DL-based model was superior to those of previous statistically calculated models.

Iron Metabolism Disorders for Cognitive Dysfunction After Mild Traumatic Brain Injury

Traumatic brain injury (TBI) is one of the most harmful forms of acute brain injury and predicted to be one of the three major neurological diseases that cause neurological disabilities by 2030. A series of secondary injury cascades often cause cognitive dysfunction of TBI patients leading to poor prognosis. However, there are still no effective intervention measures, which drive us to explore new therapeutic targets. In this process, the most part of mild traumatic brain injury (mTBI) is ignored because its initial symptoms seemed not serious. Unfortunately, the ignored mTBI accounts for 80% of the total TBI, and a large part of the patients have long-term cognitive dysfunction. Iron deposition has been observed in mTBI patients and accompanies the whole pathological process. Iron accumulation may affect long-term cognitive dysfunction from three pathways: local injury, iron deposition induces tau phosphorylation, the formation of neurofibrillary tangles; neural cells death; and neural network damage, iron deposition leads to axonal injury by utilizing the iron sensibility of oligodendrocytes. Thus, iron overload and metabolism dysfunction was thought to play a pivotal role in mTBI pathophysiology. Cerebrospinal fluid-contacting neurons (CSF-cNs) located in the ependyma have bidirectional communication function between cerebral-spinal fluid and brain parenchyma, and may participate in the pathway of iron-induced cognitive dysfunction through projected nerve fibers and transmitted factor, such as 5-hydroxytryptamine, etc. The present review provides an overview of the metabolism and function of iron in mTBI, and to seek a potential new treatment target for mTBI with a novel perspective through combined iron and CSF-cNs.

Standard values for temporal muscle thickness in the Japanese population who undergo brain check-up by magnetic resonance imaging

BACKGROUND

Skeletal muscle mass is an important factor for various diseases' outcomes. The psoas muscle cross-sectional area on the abdominal computed tomography (CT), gait speed, and handgrip strength is used to measure it. However, it is difficult to measure the neurological patients' muscle mass or function because (1) we do not perform abdominal CT. (2) Such patients have impaired consciousness, gait disturbance, paresis, and need of rest. Temporal muscle thickness (TMT) on magnetic resonance imaging (MRI) is now attractive for skeletal muscle volume indicator, but the reference values are not established. We herein investigated the standard value of the Japanese TMT using the brain check-up database by MRI.

METHODS

We retrospectively investigated 360 Japanese individuals from two institutions between 2017 and 2019. We measured TMT on the T1-weighted images in the previously reported way. The associations between TMT and other variables were analyzed.

RESULTS

TMT of 214 women and 146 men, ranging from 35 to 84 years old, was investigated. TMT ranged from 3.69 to 16.90 mm. Mean TMT values were significantly higher in men compared to women except for the over 70-year-old cohort. TMT was correlated to weight and body mass index in both sexes.

CONCLUSION

This is the first retrospective study on the standard TMT values from the Japanese brain check-up database. Our results were just reference values, but these would be useful for further investigation in other neurosurgical and neurological diseases regarding muscle volume or sarcopenia.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Clinical Characteristics and Risk Factors of Cerebral Hemorrhage in Patients with Occult Malignant Tumors

PROPOSE

To investigate the clinical characteristics and potential risk factors of the first onset of cerebral hemorrhage in patients with occult malignant tumors.

PATIENTS AND METHODS

In this retrospective study, 23 patients with occult malignant tumors with the first onset of cerebral hemorrhage were enrolled in the tumor group, and 92 patients without occult tumors in the same period were enrolled in the control group. There were no statistical differences in age and sex between both groups by propensity score matching. Collected clinical data included age, sex, smoking history, drinking history, hypertension history, diabetes history, past medical history, routine blood tests, neutrophil-to-lymphocyte ratio (NLR), liver and kidney function, fasting blood glucose level, coagulation function, tumor markers, imaging examinations, National Institute of Health stroke scale (NIHSS) score on admission, modified Rankin Scale (mRS) score 90 days after intracerebral hemorrhage and final mRS score.

RESULTS

Compared with the control group, the tumor group had fewer patients with hypertension (52.2% vs 81.5%, P<0.05), and the NLR was significantly decreased in the tumor group (2.74 vs 5.46, P<0.05). The tumor group had a greater number of patients with the bleeding sites located in the lobar regions (43.5% vs.19.6%, P<0.05) and a higher coagulation dysfunction (52.2% vs 29.3%, P<0.05) than the control group. Multivariate logistic regression analysis revealed that no history of hypertension (OR: 3.141, 95% CI: 1.107-8.916), lobar cerebral hemorrhage (OR: 3.465 95% CI:1.172-10.243), and coagulation dysfunction (OR: 3.176, 95% CI: 1.131-8.913) were independent predictors of occult tumors, and the receiver operating characteristic (ROC) curve showed that the area under the curve of the three-index combined diagnosis was 0.748, C-statistic analysis also showed the same result.

CONCLUSION

No history of hypertension, lobar cerebral hemorrhage, and coagulation dysfunction may be predictors of the risk of occult malignancies in patients with cerebral hemorrhage.

High Serum S100A12 Levels Predict Poor Outcome After Acute Primary Intracerebral Hemorrhage

OBJECTIVE

Intracerebral hemorrhage (ICH) triggers an inflammatory cascade that damages brain tissues and worsens functional outcome. S100A12 functions to promote brain inflammation. We aimed to investigate the relationship between serum S100A12 levels and functional outcome in ICH patients.

METHODS

Serum S100A12 levels were measured in 101 ICH patients hospitalized within 24 h after symptom onset. Poor functional outcome was defined as a modified Rankin scale of 3 or greater at 3 months after stroke. Early neurologic deterioration was defined as an increase of ≥4 points in the National Institutes of Health Stroke Scale (NIHSS) score or death at 24 hours from symptoms onset.

RESULTS

High serum S100A12 levels were independently correlated with NIHSS score (t = 5.384, P < 0.001), hematoma volume (t = 4.221, P < 0.001) and serum C-reactive protein levels (t = 5.068, P < 0.001). Serum S100A12 levels were substantially higher in patients with a poor outcome (median, 66.5 versus 37.7 ng/mL; P < 0.001) or early neurological deterioration (median, 76.5 versus 40.1 ng/mL; P < 0.001) than in the other remainders, independently predicted a poor outcome (odds ratio, 1.035; 95% confidence interval, 1.007-1.064; P = 0.015) and early neurologic deterioration (odds ratio,1.032; 95% confidence interval, 1.003-1.060; P = 0.027), and significantly discriminated a poor outcome (area under curve, 0.794; 95% confidence interval, 0.702-0.868) and early neurologic deterioration (area under curve, 0.760; 95% confidence interval, 0.664-0.839) under receiver operating characteristic curve.

CONCLUSION

High serum S100A12 levels at admission are highly associated with the extent of inflammatory response, severity, a poor functional outcome and early neurologic deterioration in ICH patients, substantializing serum S100A12 as a promising prognostic biomarker for ICH.

Easily created prediction model using deep learning software (Prediction One, Sony Network Communications Inc.) for subarachnoid hemorrhage outcomes from small dataset at admission

BACKGROUND

Reliable prediction models of subarachnoid hemorrhage (SAH) outcomes are needed for decision-making of the treatment. SAFIRE score using only four variables is a good prediction scoring system. However, making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on prediction models for SAH outcomes using DL. We herein made a prediction model using DL software, Prediction One (Sony Network Communications Inc., Tokyo, Japan) and compared it to SAFIRE score.

METHODS

We used 153 consecutive aneurysmal SAH patients data in our hospital between 2012 and 2019. Modified Rankin Scale (mRS) 0-3 at 6 months was defined as a favorable outcome. We randomly divided them into 102 patients training dataset and 51 patients external validation dataset. Prediction one made the prediction model using the training dataset with internal cross-validation. We used both the created model and SAFIRE score to predict the outcomes using the external validation set. The areas under the curve (AUCs) were compared.

RESULTS

The model made by Prediction One using 28 variables had AUC of 0.848, and its AUC for the validation dataset was 0.953 (95%CI 0.900-1.000). AUCs calculated using SAFIRE score were 0.875 for the training dataset and 0.960 for the validation dataset, respectively.

CONCLUSION

We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the model was not so inferior to those of previous statistically calculated prediction models.

The dataset on the characteristics of the intracerebral hemorrhage patients treated by endoscopic hematoma removal or craniotomy

These data present the characteristics of 148 intracerebral hemorrhage (ICH) patients surgically treated. We retrospectively collected data from the medical records of Suwa Red Cross Hospital, including neurological and physiological symptoms, laboratory data, radiological data on admission, complication rate, Glasgow Coma Scale scores on admission or postoperative day 7, and modified Rankin Scale scores at 6 months. Our two articles on the endoscopic hematoma removal and craniotomy for ICH were based on these data [1,2]. This dataset includes detailed laboratory data and radiological features, and it would be useful for reference value for other neurosurgeons or further analysis.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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