Spontaneous intracerebral hemorrhage

Electroacupuncture reduces oxidative stress response and improves secondary injury of intracerebral hemorrhage in rats by activating the peroxisome proliferator-activated receptor-γ/nuclear factor erythroid2-related factor 2/γ-glutamylcysteine synthetase pathway

Intracerebral hemorrhage (ICH) is a severe stroke subtype. Secondary injury is a key factor leading to neurological deficits after ICH. Electroacupuncture (EA) can improve the neurological function after ICH, however, its internal mechanism is still unclear. The aim of this study is to investigate whether EA could ameliorate secondary injury after ICH through antioxidative stress and its potential regulatory mechanism. A rat model of ICH was established by injecting autologous blood into striatum. After the intervention of EA and EA combined with peroxisome proliferator-activated receptor-γ (PPARγ) blocker, Zea-longa scores, modified neurological severity scores and open field tests were used to evaluate the neurological function of the rats. Flow cytometry detected tissue reactive oxygen species (ROS) levels. Tissue tumor necrosis factor-α (TNF-α) levels were analyzed by enzyme-linked immunosorbent assays. The protein expressions of PPAR γ, nuclear factor erythroid2-related factor 2 (Nrf2) and γ-glutamylcysteine synthetase (γ-GCS) were detected by Western blot. Immunohistochemistry was used to observe the activation of microglia. The demyelination degree of axon myelin was observed by transmission electron microscope. Compared with the model group, EA intervention improved neurological function, decreased ROS and TNF-α levels, increased the protein expression of PPARγ, Nrf2 and γ-GCS, and reduced the activation of microglia, it also alleviated axonal myelin sheath damage. In addition, the neuroprotective effect of EA was partially attenuated by PPARγ blocker. EA ameliorated the neurological function of secondary injury after ICH in rats, possibly by activating the PPARγ/Nrf2/γ-GCS signaling pathway, reducing microglia activation, and inhibiting oxidative stress, thus alleviating the extent of axonal demyelination plays a role.

PHE-SICH-CT-IDS: A benchmark CT image dataset for evaluation semantic segmentation, object detection and radiomic feature extraction of perihematomal edema in spontaneous intracerebral hemorrhage

BACKGROUND AND OBJECTIVE

Intracerebral hemorrhage is one of the diseases with the highest mortality and poorest prognosis worldwide. Spontaneous intracerebral hemorrhage (SICH) typically presents acutely, prompt and expedited radiological examination is crucial for diagnosis, localization, and quantification of the hemorrhage. Early detection and accurate segmentation of perihematomal edema (PHE) play a critical role in guiding appropriate clinical intervention and enhancing patient prognosis. However, the progress and assessment of computer-aided diagnostic methods for PHE segmentation and detection face challenges due to the scarcity of publicly accessible brain CT image datasets.

METHODS

This study establishes a publicly available CT dataset named PHE-SICH-CT-IDS for perihematomal edema in spontaneous intracerebral hemorrhage. The dataset comprises 120 brain CT scans and 7,022 CT images, along with corresponding medical information of the patients. To demonstrate its effectiveness, classical algorithms for semantic segmentation, object detection, and radiomic feature extraction are evaluated. The experimental results confirm the suitability of PHE-SICH-CT-IDS for assessing the performance of segmentation, detection and radiomic feature extraction methods.

RESULTS

This study conducts numerous experiments using classical machine learning and deep learning methods, demonstrating the differences in various segmentation and detection methods on the PHE-SICH-CT-IDS. The highest precision achieved in semantic segmentation is 76.31%, while object detection attains a maximum precision of 97.62%. The experimental results on radiomic feature extraction and analysis prove the suitability of PHE-SICH-CT-IDS for evaluating image features and highlight the predictive value of these features for the prognosis of SICH patients.

CONCLUSION

To the best of our knowledge, this is the first publicly available dataset for PHE in SICH, comprising various data formats suitable for applications across diverse medical scenarios. We believe that PHE-SICH-CT-IDS will allure researchers to explore novel algorithms, providing valuable support for clinicians and patients in the clinical setting. PHE-SICH-CT-IDS is freely published for non-commercial purpose at https://figshare.com/articles/dataset/PHE-SICH-CT-IDS/23957937.

Edaravone dexborneol regulates γ-aminobutyric acid transaminase in rats with acute intracerebral hemorrhage

OBJECTIVES

Edaravone dexborneol is neuroprotective against ischemic stroke, with free radical-scavenging and anti-inflammatory effects, but its effects in hemorrhagic stroke remain unclear. We evaluated whether edaravone dexborneol has a neuroprotective effect in intracerebral hemorrhage, and its underlying mechanisms.

MATERIALS AND METHODS

Bioinformatics were used to predict the pathway of action of edaravone dexborneol. An intracerebral hemorrhage model was established using type IV collagenase in edaravone dexborneol, intracerebral hemorrhage, Sham, adeno-associated virus + edaravone dexborneol, and adeno-associated virus + intracerebral hemorrhage groups. The modified Neurological Severity Score was used to evaluate neurological function in rats. Brain water content was measured using the dry-wet weight method. Tumor necrosis factor-α, interleukin-1β, inducible nitric oxide synthase, and γ-aminobutyric acid levels were determined by enzyme-linked immunosorbent assay. The expression levels of neurofilament light chain and γ-aminobutyric acid transaminase were determined by western blot. Nissl staining was used to examine neuronal morphology. Cognitive behavior was evaluated using a small-animal treadmill.

RESULTS

Edaravone dexborneol alleviated neurological defects, improved cognitive function, and reduced cerebral edema, neuronal degeneration, and necrosis in rats with cerebral hemorrhage. The expression levels of neurofilament light chain, tumor necrosis factor-α, interleukin-1β, inducible nitric oxide synthase, and γ-aminobutyric acid were decreased, while γ-aminobutyric acid transaminase expression was up-regulated.

CONCLUSIONS

Edaravone dexborneol regulates γ-aminobutyric acid content by acting on the γ-aminobutyric acid transaminase signaling pathway, thus alleviating oxidative stress, neuroinflammation, neuronal degeneration, and death caused by excitatory toxic injury of neurons after intracerebral hemorrhage.

Resource utilization in management of spontaneous intracerebral hemorrhage without systemic risk factors. Does early surgical decompression matter?

BACKGROUND

Even though different subtypes of spontaneous ICH are frequently linked to a poor prognosis, their causes, pathological features, and prognoses vary. Atypical intracerebral hemorrhage is the subtype of spontaneous ICH that usually occurs due to an underlying localized vascular lesion. It is unrelated to systemic vascular risk factors, mostly affects children and young adults and is associated with a relatively good outcome. This fact should be considered when planning the evaluation and treatment. Investigating the cause of this subtype is fundamental to providing optimal management. However, if resources do not allow completing the investigations, the cause will be more difficult to discover. Treatment decisions will be made under stress to save the patient's life, especially with rapidly deteriorating patients.

METHODS

We described three cases of spontaneous ICH without systemic risk factors where the bleeding source could not be determined before surgery due to a lack of resources, preventing preoperative vascular investigation. Knowing that the atypical ICH has a distinct identity, regarding etiology and prognosis, encouraged the surgeons to resort to early surgical decompression as an alternative plan. We reviewed the literature searching for supporting evidence.

RESULTS

The results of treatment of the presented cases were satisfactory. The lack of reported similar cases was brought to light by a literature analysis that sought to provide backing for the proposed management strategy. In the end, we supplied two graphic organizers to help readers remember the different types and treatment of hemorrhagic stroke.

CONCLUSION

There isn't enough evidence to show that there are other ways to treat atypical intracerebral haemorrhage when resources are limited. The presented cases highlight the importance of decisionmaking in resource-constrained situations when patient outcomes can be improved.

The Role of Mitochondria-Targeting miRNAs in Intracerebral Hemorrhage

Non-traumatic intracerebral hemorrhage (ICH) is the most common type of hemorrhagic stroke, most often occurring between the ages of 45 and 60. Arterial hypertension (AH) is most often the cause of ICH, followed by atherosclerosis, blood diseases, inflammatory changes in cerebral vessels, intoxication and vitamin deficiencies. Cerebral hemorrhage can occur by diapedesis or as a result of a ruptured vessel. AH is difficult to treat, requires surgery and can lead to disability or death. One of the important directions in the study of the pathogenesis of ICH is mitochondrial dysfunction and its regulation. The key role of mitochondrial dysfunction in AH and atherosclerosis, as well as in the development of brain damage after hemorrhage, has been acknowledged. MicroRNAs (miRNAs) are a class of non-coding RNAs (about 18-22 nucleotides) that regulate a variety of biological processes including cell differentiation, proliferation, apoptosis, etc., primarily through gene repression. There is growing evidence to support dysregulated miRNAs in various cardiovascular diseases, including ICH. Further, the realization of miRNAs within mitochondrial compartment has challenged the traditional knowledge of signaling pathways involved in the regulatory network of cardiovascular diseases. However, the role of miRNAs in mitochondrial dysfunction for ICH is still under-appreciated, with comparatively much lesser studies and investigations reported, than those in other cardiovascular diseases. In this review, we summarize the up-to-date findings on the published role miRNAs in mitochondrial function for ICH, and the potential use of miRNAs in clinical settings, such as potential therapeutic targets and non-invasive diagnostic/prognostic biomarker tools.

Semantic Segmentation of Spontaneous Intracerebral Hemorrhage, Intraventricular Hemorrhage, and Associated Edema on CT Images Using Deep Learning

This study evaluated deep learning algorithms for semantic segmentation and quantification of intracerebral hemorrhage (ICH), perihematomal edema (PHE), and intraventricular hemorrhage (IVH) on noncontrast CT scans of patients with spontaneous ICH. Models were assessed on 1732 annotated baseline noncontrast CT scans obtained from the Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage (ie, TICH-2) international multicenter trial (ISRCTN93732214), and different loss functions using a three-dimensional no-new-U-Net (nnU-Net) were examined to address class imbalance (30% of participants with IVH in dataset). On the test cohort (n = 174, 10% of dataset), the top-performing models achieved median Dice similarity coefficients of 0.92 (IQR, 0.89-0.94), 0.66 (0.58-0.71), and 1.00 (0.87-1.00), respectively, for ICH, PHE, and IVH segmentation. U-Net-based networks showed comparable, satisfactory performances on ICH and PHE segmentations (P > .05), but all nnU-Net variants achieved higher accuracy than the Brain Lesion Analysis and Segmentation Tool for CT (BLAST-CT) and DeepLabv3+ for all labels (P < .05). The Focal model showed improved performance in IVH segmentation compared with the Tversky, two-dimensional nnU-Net, U-Net, BLAST-CT, and DeepLabv3+ models (P < .05). Focal achieved concordance values of 0.98, 0.88, and 0.99 for ICH, PHE, and ICH volumes, respectively. The mean volumetric differences between the ground truth and prediction were 0.32 mL (95% CI: -8.35, 9.00), 1.14 mL (-9.53, 11.8), and 0.06 mL (-1.71, 1.84), respectively. In conclusion, U-Net-based networks provide accurate segmentation on CT images of spontaneous ICH, and Focal loss can address class imbalance. International Clinical Trials Registry Platform (ICTRP) no. ISRCTN93732214 Supplemental material is available for this article. © RSNA, 2022 Keywords: Head/Neck, Brain/Brain Stem, Hemorrhage, Segmentation, Quantification, Convolutional Neural Network (CNN), Deep Learning Algorithms, Machine Learning Algorithms.

Neuroprotective Role of α-Lipoic Acid in Iron-Overload-Mediated Toxicity and Inflammation in In Vitro and In Vivo Models

Hemoglobin and iron overload is considered the major contributor to intracerebral hemorrhage (ICH)-induced brain injury. Accumulation of iron in the brain leads to microglia activation, inflammation and cell loss. Current available treatments for iron overload-mediated disorders are characterized by severe adverse effects, making such conditions an unmet clinical need. We assessed the potential of α-lipoic acid (ALA) as an iron chelator, antioxidant and anti-inflammatory agent in both in vitro and in vivo models of iron overload. ALA was found to revert iron-overload-induced toxicity in HMC3 microglia cell line, preventing cell apoptosis, reactive oxygen species generation and reducing glutathione depletion. Furthermore, ALA regulated gene expression of iron-related markers and inflammatory cytokines, such as IL-6, IL-1β and TNF. Iron toxicity also affects mitochondria fitness and biogenesis, impairments which were prevented by ALA pre-treatment in vitro. Immunocytochemistry assay showed that, although iron treatment caused inflammatory activation of microglia, ALA treatment resulted in increased ARG1 expression, suggesting it promoted an anti-inflammatory phenotype. We also assessed the effects of ALA in an in vivo zebrafish model of iron overload, showing that ALA treatment was able to reduce iron accumulation in the brain and reduced iron-mediated oxidative stress and inflammation. Our data support ALA as a novel approach for iron-overload-induced brain damage.

Curcumin Restrains Oxidative Stress of After Intracerebral Hemorrhage in Rat by Activating the Nrf2/HO-1 Pathway

Intracerebral hemorrhage (ICH), a severe hemorrhagic stroke, induces cerebral oxidative stress and severe secondary neurological injury. Curcumin was demonstrated to inhibit oxidative stress in the brain after ICH. However, the pharmacological mechanism needs further research. We used an intrastriatal injection of autologous blood to make the rat ICH model, and then the rat was treated with curcumin (100 mg/kg/day). Modified Neurological Severity Score (mNSS) and corner test results showed that curcumin could significantly promote the neurological recovery of ICH rats. Meanwhile, curcumin could substantially reduce ROS and MDA in the tissues around intracranial hematoma and prevent GSH depletion. To explore the pharmacological molecular mechanism of curcumin, we used HAPI cells and primary rat cortical microglia for in vitro experiments. In vitro, heme-treated cells were used as the cell model of ICH to explore the molecular mechanism of inhibiting oxidative stress by curcumin treatment. The results showed that curcumin significantly inhibited heme-induced oxidative stress, decreased intracellular ROS and MDA, and promoted Nrf2 and its downstream antioxidant gene (HO-1, NQO1, and Gpx4) expression. These results suggest that curcumin inhibits oxidative stress by activating the Nrf2/HO-1 pathway. Here, our results indicate that curcumin can promote the inhibition of oxidative stress in microglia by activating the Nrf2/HO-1 pathway and promoting neurological recovery after ICH, providing a new therapeutic target for clinical treatment of ICH.

Activation of the PPARγ Prevents Ferroptosis-Induced Neuronal Loss in Response to Intracerebral Hemorrhage Through Synergistic Actions With the Nrf2

Intracerebral hemorrhage (ICH) is a subtype of stroke characterized by high mortality and disability rates. The long-term effects of ICH-induced intracranial hematoma on patients’ neurological function are unclear. Currently, an effective treatment that significantly reduces the rates of death and disability in patients with ICH is not available. Based on accumulating evidence, ferroptosis may be the leading factor contributing to the neurological impairment caused by ICH injury. Peroxisome proliferator-activated receptor γ (PPARγ) is a ligand-activated receptor in the nuclear hormone receptor family that synergistically interacts with the nuclear factor erythrocyte 2-related factor 2 (Nrf2) pathway to promote the expression of related genes and inhibit ferroptosis. Primary rat hippocampal neurons were treated with heme (50 μM) and erastin (50 μM) to induce ferroptosis, followed by the PPARγ agonist pioglitazone (PDZ, 10 μM) to verify the inhibitory effect of PPARγ activation on ferroptosis. ML385 (2 μM), a novel and specific NRF2 inhibitor, was administered to the inhibitor group, followed by an analysis of cellular activity and immunofluorescence staining. In vivo Assays, ICH rats injected with autologous striatum were treated with 30 mg/kg/d pioglitazone, and the inhibitor group was injected with ML385 (30 mg/kg). The results showed that PDZ inhibited ferroptosis in neurons by increasing the expression of PPARγ, Nrf2 and Gpx4 in vitro, while PDZ reduced ferroptosis in neurons after ICH and promoted the recovery of neural function in vivo. Our results suggest that PDZ, a PPARγ agonist, promotes Gpx4 expression through the interaction between PPARγ and the Nrf2 pathway, inhibits ferroptosis of neurons after ICH, and promotes the recovery of neural function.

Serum calcium channel subunit α2δ-1 concentrations and outcomes in patients with acute spontaneous intracerebral hemorrhage

BACKGROUND

Voltage-gated calcium channel subunit α2δ-1 plays an important role in acute brain injury. We attempted to investigate whether serum α2δ-1 subunit concentrations are correlated with severity and prognosis following intracerebral hemorrhage (ICH).

METHODS

Serum α2δ-1 subunit concentrations were quantified in 103 ICH patients and 103 healthy controls. National Institutes of Health Stroke Scale (NIHSS) score and hematoma volume were estimated for assessing illness severity. Modified Rankin scale score of 3-6 at 90 days after stroke onset was defined as a worse outcome.

RESULTS

Serum α2δ-1 subunit concentrations were markedly higher in patients than in controls (median, 875.1 vs. 209.3 pg/ml). Serum α2δ-1 subunit concentrations of patients were tightly correlated with NIHSS score (r = 0.589) and hematoma volume (r = 0.594). Serum α2δ-1 subunit concentrations ≥ 875.1 pg/ml independently discriminated development of 90-day poor outcome with odds ratio of 5.228 (95% CI, 2.201-12.418) and area under the receiver operating characteristic curve of 0.794 (95% CI, 0.703-0.867). Serum α2δ-1 subunit concentrations > 973.4 pg/ml predicted 90-day poor outcome with 64.0% sensitivity and 90.6% specificity. The prognostic predictive ability of serum α2δ-1 concentrations was equivalent to those of NIHSS score and hematoma volume (both P > 0.05), and serum α2δ-1 concentrations also significantly improved the prognostic predictive capabilities of NIHSS score and hematoma volume (both P < 0.05).

CONCLUSIONS

Serum α2δ-1 subunit concentrations are intimately correlated with illness severity and are independently associated with poor 90-day outcome, substantializing serum α2δ-1 subunit as a potential prognostic biomarker for ICH.

Plasma ADAM-10 levels and functional outcome of acute primary basal ganglia hemorrhage

BACKGROUND

The a-secretase A disintegrin and metalloprotease-10 (ADAM-10) may have deleterious effects in acute brain injury. This study was designed to discern if a relationship between plasma ADAM-10 levels and functional outcome exists in patients with intracerebral hemorrhage (ICH).

METHODS

A total of 109 patients with basal ganglia hemorrhage and 100 healthy controls were included. Their plasma ADAM-10 levels were gauged. Ninety-day prognosis was assessed and poor outcome was defined as death or major disability (modified Rankin Scale score of 3 or greater).

RESULTS

Plasma ADAM-10 levels were substantially elevated in patients, as compared to controls. ADAM-10 levels were independently correlated with hematoma size and National Institutes of Health Stroke Scale (NIHSS) score. Plasma ADAM-10, NIHSS score and hematoma size emerged as the independent predictors for 90-day poor outcome. Under receiver operating characteristic curve, plasma ADAM-10 levels exhibited similar prognostic capability, as compared to hematoma size and NIHSS score; moreover, it significantly improved prognostic abilities of NIHSS and hematoma size.

CONCLUSIONS

Rising plasma ADAM-10 levels are independently related to increasing severity and poor long-term functional outcome after hemorrhagic stroke, substantializing serum ADAM-10 as a useful prognostic biomarker of ICH.

Interactions Between Kidney Function and Cerebrovascular Disease: Vessel Pathology That Fires Together Wires Together

The kidney and the brain, as high-flow end organs relying on autoregulatory mechanisms, have unique anatomic and physiological hemodynamic properties. Similarly, the two organs share a common pattern of microvascular dysfunction as a result of aging and exposure to vascular risk factors (e.g., hypertension, diabetes and smoking) and therefore progress in parallel into a systemic condition known as small vessel disease (SVD). Many epidemiological studies have shown that even mild renal dysfunction is robustly associated with acute and chronic forms of cerebrovascular disease. Beyond ischemic SVD, kidney impairment increases the risk of acute cerebrovascular events related to different underlying pathologies, notably large artery stroke and intracerebral hemorrhage. Other chronic cerebral manifestations of SVD are variably associated with kidney disease. Observational data have suggested the hypothesis that kidney function influences cerebrovascular disease independently and adjunctively to the effect of known vascular risk factors, which affect both renal and cerebral microvasculature. In addition to confirming this independent association, recent large-scale human genetic studies have contributed to disentangling potentially causal associations from shared genetic predisposition and resolving the uncertainty around the direction of causality between kidney and cerebrovascular disease. Accelerated atherosclerosis, impaired cerebral autoregulation, remodeling of the cerebral vasculature, chronic inflammation and endothelial dysfunction can be proposed to explain the additive mechanisms through which renal dysfunction leads to cerebral SVD and other cerebrovascular events. Genetic epidemiology also can help identify new pathological pathways which wire kidney dysfunction and cerebral vascular pathology together. The need for identifying additional pathological mechanisms underlying kidney and cerebrovascular disease is attested to by the limited effect of current therapeutic options in preventing cerebrovascular disease in patients with kidney impairment.

Prevalence, Characteristics, and Outcomes of Undetermined Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

There are scarce data regarding the prevalence, characteristics and outcomes of intracerebral hemorrhage (ICH) of undetermined (unknown or cryptogenic) etiology. We sought to determine the prevalence, radiological characteristics, and clinical outcomes of undetermined ICH.

METHODS

Systematic review and meta-analysis of studies involving patients with spontaneous ICH was conducted to primarily assess the prevalence and clinical-radiological characteristics of undetermined ICH. Additionally, we assessed the rates for ICH secondary to hypertensive arteriopathy and cerebral amyloid angiopathy. Subgroup analyses were performed based on the use of (1) etiology-oriented ICH classification, (2) detailed neuroimaging, and (3) Boston criteria among patients with cerebral amyloid angiopathy related ICH. We pooled the prevalence rates using random-effects models, and assessed the heterogeneity using Cochran Q and I² statistics.

RESULTS

We identified 24 studies comprising 15 828 spontaneous ICH patients (mean age, 64.8 years; men, 60.8%). The pooled prevalences of hypertensive arteriopathy ICH, undetermined ICH, and cerebral amyloid angiopathy ICH were 50% (95% CI, 43%-58%), 18% (95% CI, 13%-23%), and 12% (95% CI, 7%-17% [P<0.001 between subgroups]). The volume of ICH was the largest in cerebral amyloid angiopathy ICH (24.7 [95% CI, 19.7-29.8] mL), followed by hypertensive arteriopathy ICH (16.2 [95% CI, 10.9-21.5] mL) and undetermined ICH (15.4 [95% CI, 6.2-24.5] mL). Among patients with undetermined ICH, the rates of short-term mortality (within 3 months) and concomitant intraventricular hemorrhage were 33% (95% CI, 25%-42%) and 38% (95% CI, 28%-48%), respectively. Subgroup analysis demonstrated a higher rate of undetermined ICH among studies that did not use an etiology-oriented classification (22% [95% CI, 15%-29%]). No difference was observed between studies based on the completion of detailed neuroimaging to assess the rates of undetermined ICH (P=0.62).

CONCLUSIONS

The etiology of spontaneous ICH remains unknown or cryptogenic among 1 in 7 patients in studies using etiology-oriented classification and among 1 in 4 patients in studies that avoid using etiology-oriented classification. The short-term mortality in undetermined ICH is high despite the relatively small ICH volume.

Serum Hypoxia-Inducible Factor 1alpha Levels Correlate with Outcomes After Intracerebral Hemorrhage

Background

Serum hypoxia-inducible factor 1alpha (HIF-1α) is a key regulator in hypoxic and ischemic brain injury. We determined the relationship between serum HIF-1α levels and long-term prognosis plus severity of intracerebral hemorrhage (ICH).

Methods

A total of 97 ICH cases and 97 healthy controls were enrolled. Glasgow Coma Scale (GCS) score and hematoma volume were used to assess hemorrhagic severity. Glasgow Outcome Scale (GOS) score of 1–3 at post-stroke 90 days was defined as a poor outcome.

Results

Serum HIF-1α levels of ICH patients were significantly higher than those of healthy controls (median, 218.8 vs 105.4 pg/mL; P<0.001) and were substantially correlated with GCS score (r=−0.485, P<0.001), hematoma volume (r=0.357, P<0.001) and GOS score (r=−0.436, P<0.001). Serum HIF-1α levels >239.4 pg/mL discriminated patients at risk of 90-day poor outcome with sensitivity of 65.9% and specificity of 79.3% (area under the receiver operating characteristic curve, 0.725; 95% confidence interval, 0.625–0.811; P<0.001). Moreover, serum HIF-1α levels >239.4 pg/mL were independently associated with a poor 90-day outcome (odds ratio, 5.133; 95% confidence interval, 1.117–23.593; P=0.036).

Conclusion

Serum HIF-1α, in close correlation with hemorrhagic severity and poor 90-day outcome, may serve as a potential prognostic biomarker for ICH.

Intracerebral Hemorrhage: A Common yet Disproportionately Deadly Stroke Subtype

Spontaneous intracerebral hemorrhage (ICH) is a medical emergency and is disproportionately associated with higher mortality and long-term disability compared with ischemic stroke. The phrase "time is brain" was derived for patients with large vessel occlusion ischemic stroke in which approximately 1.9 million neurons are lost every minute. Similarly, this statement holds true for ICH patients due to a high volume of neurons that are damaged at initial onset and during hematoma expansion. Most cases of spontaneous ICH pathophysiologically stem from chronic hypertension and rupture of small perforating vessels off of larger cerebral arteries supplying deep brain structures, with cerebral amyloid angiopathy being another cause for lobar hemorrhages in older patients. Optimal ICH medical management strategies include timely diagnosis, aggressive blood pressure control, correction of underlying coagulopathy defects if present, treatment of cerebral edema, and continuous assessment for possible surgical intervention. Current strategies in the surgical management of ICH include newly developed minimally invasive techniques for hematoma evacuation, with the goal of mitigating injury to fiber tracts while accessing the clot. We review evidence-based medical and surgical management of spontaneous ICH with the overall goal of reducing neurologic injury and optimizing functional outcome.

Serum glucose and potassium ratio as a predictive factor for prognosis of acute intracerebral hemorrhage

Objective

The serum glucose/potassium ratio (GPR) is a potential prognostic predictor for acute brain injury-related diseases. We calculated the serum GPR in patients with acute intracerebral hemorrhage (ICH) and explored its prognostic value for long-term prognoses and ICH severity.

Methods

This retrospective cohort study consecutively included 92 patients with ICH and 92 healthy controls. The National Institutes of Health Stroke Scale (NIHSS) score, Glasgow coma scale (GCS) score, and hematoma volume were used to assess severity. A modified Rankin Scale score > 2 at 90 days post-stroke was defined as a poor outcome.

Results

The serum GPR was significantly higher in patients than controls. The serum GPR was weakly correlated with the NIHSS score, GCS score, and hematoma volume. The serum GPR, GCS score, and hematoma volume were independently associated with poor outcomes. In the receiver operating characteristic curve analysis, the serum GPR remarkably discriminated patients at risk of poor outcomes at 90 days. The serum GPR significantly improved the prognostic predictive capability of hematoma volume and tended to increase that of the GCS score.

Conclusion

Serum GPR is an easily obtained clinical variable for predicting clinical outcomes after ICH.

Prognostic Value of Various Hemostasis Parameters and Neurophysiological Examinations in Spontaneous Intracerebral Hemorrhage: The IRONHEART Study Protocol

Rationale: Stroke is one of the leading causes of death in all developed countries. In Hungary, more than 10,000 patients die annually due to cerebrovascular diseases according to the WHO Mortality Database. Of these patients, 10–15 % suffer non-traumatic intracerebral hemorrhage (ICH). ICH results in a higher rate of mortality as compared to ischemic stroke and outcomes are difficult to predict. In the IRONHEART study, we aim to test various hemostasis parameters and clinical neurophysiological examinations in evaluating outcome in ICH.

Methods: In this prospective, observational study, we plan to enroll consecutive patients with non-traumatic spontaneous ICH admitted to a single Stroke Center (Department of Neurology, University of Debrecen, Hungary). The protocol of the IRONHEART study includes the investigation of detailed clinical, laboratory investigations, and various neurophysiological examinations. Stroke severity is quantified based on the National Institutes of Health Stroke Scale (NIHSS) on admission and day 7, 14, and 90 after the onset of stroke. Cranial CT is performed on admission, day 14, and 90 to estimate the ICH volume. Modified Rankin Scale (mRS) is used for evaluating the long-term outcome (90 days post-event). Blood is drawn immediately on admission for specific hemostasis tests. Digital and quantitative EEG techniques and motor evoked potential (MEP) are performed to evaluate the prognosis of cerebral hemorrhage on admission (within 24–48 h), immediately before discharge (~10–14 days later), and 3 months after the event.

Outcomes: The following outcomes are investigated: primary outcomes: mortality by day 14 and day 90, secondary long-term outcome at 90 days post-event where mRS 0–2 is defined as favorable long-term outcome.

Discussion: If associations between outcomes and the investigated parameters (hemostasis and neurophysiological examinations) are confirmed, results might aid prognosis assessment in this subtype of stroke with particularly high mortality. Improving clinical grading systems on ICH severity and outcomes by including the investigated parameters could help to better guide the management of these patients in the future.

Entinostat improves acute neurological outcomes and attenuates hematoma volume after Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) or hemorrhagic stroke is a major public health problem with no effective treatment. Given the emerging role of epigenetic mechanisms in the pathophysiology of ICH, we tested the hypothesis that a class 1 histone deacetylase inhibitor (HDACi), Entinostat, attenuates neurodegeneration and improves neurobehavioral outcomes after ICH. To address this, we employed a preclinical mouse model of ICH and Entinostat was administered intraperitoneally one-hour post induction of ICH. Entinostat treatment significantly reduced the number of degenerating neurons and TUNEL-positive cells after ICH in comparison to vehicle-treated controls. Moreover, Entinostat treatment significantly reduced hematoma volume, T2-weighted hemorrhagic lesion volume and improved acute neurological outcomes after ICH. Further, Entinostat significantly reduced the hemin-induced release of proinflammatory cytokines in vitro. Consistently, the expression of proinflammatory microglial/macrophage marker, CD16/32, was remarkably reduced in Entinostat treated group after ICH in comparison to control. Altogether, data implicates the potential of class 1 HDACi, Entinostat, in improving acute neurological function after ICH warranting further investigation.

Brain injury and repair after intracerebral hemorrhage: The role of microglia and brain-infiltrating macrophages

Intracerebral hemorrhage (ICH) is a major public health problem characterized by cerebral bleeding. Despite recent advances in preclinical studies, there is no effective treatment for ICH making it the deadliest subtype of stroke. The lack of effective treatment options partly attributes to the complexity as well as poorly defined pathophysiology of ICH. The emerging evidence indicates the potential of targeting secondary brain damage and hematoma resolution for improving neurological outcomes after ICH. Herein, we provide an overview of our understanding of the functional roles of activated microglia and brain-infiltrating monocyte-derived macrophages in brain injury and repair after ICH. The clinical and preclinical aspects that we discuss in this manuscript are related to ICH that occurs in adults, but not in infants. Also, we attempt to identify the knowledge gap in the field for future functional studies given the potential of targeting microglia and brain-infiltrating macrophages for therapeutic intervention after ICH.

Machine Learning and Improved Quality Metrics in Acute Intracranial Hemorrhage by Noncontrast Computed Tomography

OBJECTIVE

The timely reporting of critical results in radiology is paramount to improved patient outcomes. Artificial intelligence has the ability to improve quality by optimizing clinical radiology workflows. We sought to determine the impact of a United States Food and Drug Administration-approved machine learning (ML) algorithm, meant to mark computed tomography (CT) head examinations pending interpretation as higher probability for intracranial hemorrhage (ICH), on metrics across our healthcare system. We hypothesized that ML is associated with a reduction in report turnaround time (RTAT) and length of stay (LOS) in emergency department (ED) and inpatient populations.

MATERIALS AND METHODS

An ML algorithm was incorporated across CT scanners at imaging sites in January 2018. RTAT and LOS were derived for reports and patients between July 2017 and December 2017 prior to implementation of ML and compared to those between January 2018 and June 2018 after implementation of ML. A total of 25,658 and 24,996 ED and inpatient cases were evaluated across the entire healthcare system before and after ML, respectively.

RESULTS

RTAT decreased from 75 to 69 minutes (P <0.001) at all facilities in the healthcare system. At the level 1 trauma center specifically, RTAT decreased from 67 to 59 minutes (P <0.001). ED LOS decreased from 471 to 425 minutes (P <0.001) for patients without ICH, and from 527 to 491 minutes for those with ICH (P = 0.456). Inpatient LOS decreased from 18.4 to 15.8 days for those without ICH (P = 0.001) and 18.1 to 15.8 days for those with ICH (P = 0.02).

CONCLUSION

We demonstrated that utilization of ML was associated with a statistically significant decrease in RTAT. There was also a significant decrease in LOS for ED patients without ICH, but not for ED patients with ICH. Further evaluation of the impact of such tools on patient care and outcomes is needed.

Acute Ischemic and Hemorrhagic Stroke and COVID-19: Case Series

The coronavirus COVID-19 pandemic is the defining global health crisis of our time and the greatest challenge we have faced since the World Wars; it can attack several systems in the body and has high complications and mortality. COVID-19 can cause venous and arterial thromboembolism due to immobility, high inflammation, extensive intravascular blood coagulation, and hypoxia. In this study, we report 5 cases of adults with COVID-19, hospitalized in Tohid Hospital, Sanandaj, Iran. Three patients were male and two were female. The youngest patient was 20 years old and the oldest was 55 years old. All patients had at least one family member with coronavirus. Fever, chills, muscular pain, cough, and tachypnea were present in all patients. Red blood cell (RBC) was observed in all patients at a low level. Computed tomography (CT) scans of all patients showed abnormal findings in different areas of the brain. These cases indicate that COVID-19 may damage blood vessels in the brain and lead to stroke.

The impact of urgent neurosurgery on the survival of cancer patients

Background:

Patients with cancer are subject to all neurosurgical procedures of the general population, even if they are not directly caused by the tumor or its metastases. We sought to evaluate the impact of urgent neurosurgery on the survival of patients with cancer.

Methods:

We included patients submitted to neurosurgeries not directly related to their tumors in a cancer center from 2009 to 2018. Primary endpoints were mortality in index hospitalization and overall survival.

Results:

We included 410 patients, 144 went through elective procedures, functional (26.4%) and debridement (73.6%) and 276 urgent neurosurgeries were performed: one hundred and sixty-three ventricular shunts (59%), and 113 intracranial hemorrhages (41%). Median age was 56 (IQR = 24), 142 (51.4%) of patients were metastatic, with 101 (36.6%) having brain metastasis. In 82 (33.7%) of the urgent surgeries, the patient died in the same admission. Urgent surgeries were associated with mortality in index hospitalization (OR 3.45, 95% CI 1.93–6.15), as well as non-primary brain tumors (OR 3.13, 95% CI 1.48–6.61). Median survival after urgent surgeries was 102 days, compared to 245 days in the control group (Log rank, P < 0.01). Lower survival probability was associated with metastasis (HR 1.75, 95%CI 1.15–2.66) and urgent surgeries (HR 1.49, 95% CI 1.18–1.89). Within the urgent surgeries alone, metastasis predicted lower survival probability (HR 1.75, 95% CI 1.15–2.67).

Conclusion:

Conditions that require urgent neurosurgery in patients with cancer have a very poor prognosis. We present concrete data on the magnitude of several factors that need to be taken into account when deciding whether or not to recommend surgery.

Utility of serum amyloid A as a potential prognostic biomarker of acute primary basal ganglia hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) can lead to inflammation. Serum amyloid A (SAA) is an acute phase protein, which might be implicated in acute brain injury. We ascertain relationship between serum SAA and inflammation, severity plus outcome after ICH.

METHODS

In this prospective, observational study, serum SAA concentrations were quantified in 159 healthy volunteers and 159 acute primary basal ganglia hemorrhage patients admitted within 24 h after stroke symptom. Prognostic parameters included death and a poor outcome (modified Rankin Scale score > 2) at 90 days after stroke.

RESULTS

Serum SAA concentrations were substantially higher in patients than in controls. Among patients, serum SAA concentrations were strongly correlated with serum C-reactive protein concentrations, hematoma volume and National Institutes of Health Stroke Scale scores. Serum SAA appeared to be an independent predictor for 90-day death, overall survival and poor outcome. Under receiver operating characteristic curve, this protein exhibited similar prognostic capability, as compared to hematoma volume and National Institutes of Health Stroke Scale scores.

CONCLUSIONS

Rising serum SAA concentrations, in close correlation with inflammation and hemorrhagic severity, are independently related to mortality and poor outcome after ICH, indicating that serum SAA might serve as a potential prognostic biomarker for ICH.

Impact of serum omentin-1 concentrations on functional outcome among acute intracerebral hemorrhage patients

BACKGROUND

Reduced serum omentin-1 concentrations might be related to an increased risk for poor functional outcome after acute ischemic stroke. We intended to explore whether serum omentin-1 could be a promising prognostic biomarker for acute intracerebral hemorrhage.

METHODS

A total of 104 consecutive patients with hemorrhagic stroke underwent 90-day follow-up. The modified Rankin scale score >2 was evaluated as worse prognosis. A multivariable logistic model was conFig.d for assessing the relationship between serum omentin-1 concentrations and functional outcome.

RESULTS

Serum omentin-1 concentrations, with the median value of 147.9 ng/ml (interquartile range, 114.7-199.8 ng/ml), were substantially declined with rising modified Rankin scale scores (P < 0.001). Serum omentin-1 concentrations <147.9 ng/ml was independently related to higher risk of 90-day worse prognosis (odds ratio, 3.789; 95% confidence interval, 1.819-8.608; P = 0.018). Under receiver operating characteristic curve, an optimal value of serum omentin-1 concentrations was selected as 179.7 ng/ml, which yielded 0.88 sensitivity value and 0.70 specificity value for discriminating patients at risk of 90-day worse prognosis (area under curve, 0.82; 95% confidence interval, 0.73-0.89).

CONCLUSIONS

Lower serum omentin-1 concentrations are closely associated with poor functional outcome after hemorrhagic stroke, substantializing serum omentin-1 as a potential prognostic biomarker for acute intracerebral hemorrhage.

Genetic risk of Spontaneous intracerebral hemorrhage: Systematic review and future directions

BACKGROUND

Although highly heritable, few genes have been linked to spontaneous intracerebral hemorrhage (SICH), which does not currently have any evidence-based disease-modifying therapy. Individuals of African ancestry are especially susceptible to SICH, even more so for indigenous Africans. We systematically reviewed the genetic variants associated with SICH and examined opportunities for rapidly advancing SICH genomic research for precision medicine.

METHOD

We searched the National Human Genome Research Institute-European Bioinformatics Institute (NHGRI-EBI) Genome Wide Association Study (GWAS) catalog and PubMed for original research articles on genetic variants associated with SICH as of 15 June 2019 using the PRISMA guideline.

RESULTS

Eight hundred and sixty-four articles were identified using pre-specified search criteria, of which 64 met the study inclusion criteria. Among eligible articles, only 9 utilized GWAS approach while the rest were candidate gene studies. Thirty-eight genetic loci were found to be variously associated with the risk of SICH, hematoma volume, functional outcome and mortality, out of which 8 were from GWAS including APOE, CR1, KCNK17, 1q22, CETP, STYK1, COL4A2 and 17p12. None of the studies included indigenous Africans.

CONCLUSION

Given this limited information on the genetic contributors to SICH, more genomic studies are needed to provide additional insights into the pathophysiology of SICH, and develop targeted preventive and therapeutic strategies. This call for additional investigation of the pathogenesis of SICH is likely to yield more discoveries in the unexplored indigenous African populations which also have a greater predilection.

Safety and Efficacy of Transcatheter Administration of Tissue Plasminogen Activating Factor as Adjuvant Therapy for Intraventricular Hemorrhage

Objective

Stroke is the fifth leading cause of death in the United States and the leading cause of disability. Hemorrhagic stroke has higher risks of mortality and neurologic deficit. Higher still, acute intraventricular hemorrhage (IVH) has mortality between 50% and 80% while complicating subarachnoid hemorrhage in 15% of cases and intracerebral hemorrhage in 40% of cases. We sought to demonstrate that early adjuvant intraventricular recombinant tissue plasminogen activating factor (rt-PA) improved outcomes.

Methods

Retrospective chart review was performed on patients aged 18-95 years with external ventricular drain (EVD) and intraventricular rt-PA for clot evacuation in IVH between 2005 and 2015. In total, 22 patients met the inclusion criteria. Generalized linear modeling was performed with factorial analysis using the Glasgow Coma Score (GCS) on arrival, GCS at EVD placement, EVD day of onset of rt-PA administration, GCS at onset of rt-PA administration, total duration of EVD, necessity of ventriculoperitoneal (VP) shunt, occurrence of ventriculitis, day of ventriculitis, GCS after rt-PA, length of stay (LOS) in the intensive care unit (ICU), and hospital disposition.

Results

Presenting GCS affected LOS significantly. Ventriculitis only significantly affected ICU LOS. GCS after rt-PA only significantly affected discharge GCS. EVD day of rt-PA protocol commencement demonstrated significant effects on EVD duration and cerebrospinal fluid (CSF) diversion requirement. Age affected ICU and hospital LOS.

Conclusion

These findings argue for larger prospective trials of EVD day two rt-PA protocol inception in acute IVH. Reported ventriculitis rates with EVDs are 8.8%, while we demonstrated a rate of 18% without significant effects except in ICU LOS. Transcatheter intraventricular rt-PA is safe and effective as an adjuvant in acute spontaneous intraventricular hemorrhage with the greatest benefit of rt-PA protocol at EVD day two.

Serum lipoprotein-associated phospholipase A2 as a promising prognostic biomarker in association with 90-day outcome of acute intracerebral hemorrhage

BACKGROUND

Lipoprotein-associated phospholipase A2 (Lp-PLA2) is reflective of vascular inflammation and plays a role in the pathophysiology of cerebrovascular disease. We determine usefulness of serum Lp-PLA2 as a prognostic biomarker for intracerebral hemorrhage (ICH).

METHODS

In this prospective, observational study, serum Lp-PLA2 concentrations were detected among 164 patients with acute spontaneous basal ganglia hemorrhage and 164 healthy controls. Using multivariate analysis, we analyzed its association with poor outcome (modified Rankin Scale >2) at poststroke 90 days and hemorrhagic severity indicated by National Institutes of Health Stroke Scale (NIHSS) score and hematoma volume.

RESULTS

Serum Lp-PLA2 concentrations were remarkably higher in patients than in controls. Lp-PLA2 concentrations were independently correlated with NIHSS score (t = 5.095, P < .001) and hematoma volume (t = 2.850, P = .005). At 90-day follow-up, 85 patients (51.8%) had poor outcome. Under receiver operating characteristic curve, serum Lp-PLA2 showed a significant prognostic discriminatory capability (AUC, 0.813; 95% CI, 0.744-0.869). Serum Lp-PLA2 concentrations ≥304 ng/ml was an independent predictor associated with poor outcome (OR 7.052; 95% CI 1.971-25.228).

CONCLUSIONS

Rising serum Lp-PLA2 concentrations are closely hemorrhagic severity and clinical outcomes after ICH, substantializing serum Lp-PLA2 as a potential prognostic biomarker of ICH.

Differential Cellular Expression of Galectin-1 and Galectin-3 After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a devastating sub-type of stroke with no proven treatment. Given the emerging role of Galectin-1 and Galectin-3 in neuroimmune responses, the objective of the current manuscript is to elucidate hemorrhagic-injury induced modulation and cellular expression of Galectin-1 and Galectin-3 in the brain in a pre-clinical model of ICH. To address this, ICH was induced in male CD1 mice by collagenase injection method. Western blotting as well as Immunofluorescence staining was performed to characterize the temporal expression pattern as well as cellular localization of Galectin-1 and Galectin-3 after ICH. Further, genetic studies were conducted to assess the functional role of Galectin-1 and Galectin-3 in inflammatory response employing a murine macrophage cell line, RAW 264.7. Galectin-1 and Galectin-3 exhibited very profound and increased expression from day 3 to day 7-post-injury, in the perihematomal brain region after ICH in comparison to Sham. Further, Galectin-1 expression was mostly observed in GFAP-positive astrocytes whereas Galectin-3 expression was observed mostly in Iba1-positive microglia/macrophages as well as CD16/32 (M1 microglial/macrophage marker)-positive cells. Moreover, genetic studies revealed a negative regulatory role of both Galectin-1 and Galectin-3 in the release of a proinflammatory cytokine, IL-6 from RAW 264.7 cells depending on the stimulus. Altogether, the present manuscript demonstrates for the first time, increased expression as well as cellular localization of Galectin-1 and Galectin-3 in the perihematomal brain regions after ICH. In addition, the manuscript raises the potential of Galectin-1 and Galectin-3 in modulating glial responses and thereby brain injury after ICH, warranting further investigation.

Safety and Efficacy of Intraventricular Delivery of Bone Marrow-Derived Mesenchymal Stem Cells in Hemorrhagic Stroke Model

External ventricular drain (EVD) is used clinically to relieve intracranial pressure and occasionally to deliver medications following intracerebral hemorrhage (ICH). Mesenchymal stem cell (MSC) therapy has been shown to be neuroprotective and can induce neuroregeneration in stroke models. We evaluated the safety and efficacy of delivering MSCs intraventricularly in a rat hemorrhagic stroke model. Using autologous blood, hemorrhagic stroke was induced at specific coordinates in the right basal ganglia. After 30 minutes, rats were treated with either bone marrow-derived MSCs or a phosphate-buffered saline placebo via direct intraventricular infusion. Three dosages (2 × 10⁵/kg, 5 × 10⁵/kg, and 1 × 10⁶/kg) of MSCs were administered. Forelimb use asymmetry test was employed to evaluate functional improvement after cell therapy. At the end of the experiment, peripheral blood samples and organs were harvested; biochemistry, cytokine, and growth factor analysis and histology evaluations were performed to explore cell toxicity and cell fate, and the effects of MSC therapy on injury volume, anti-inflammation, and neurogenesis. Intraventricular administration of MSCs in ICH rat model showed improved behavior and alleviated brain damage. Additionally, treated ICH rats showed significantly reduced expression of IL-1α, IL-6, and IFN-γ. No obvious cell toxicity was noticed through blood chemistry and histology evaluation. None of the infused MSCs were detected at the end of the experiment. EVD is safe and effective to use as a method of delivering MSCs to treat ICH. Intraventricularly delivered MSCs have anti-inflammatory properties and a capacity to induce neurogenesis and improve function following ICH injury.

Predicting Intracerebral Hemorrhage Patients' Length-of-Stay Probability Distribution Based on Demographic, Clinical, Admission Diagnosis, and Surgery Information

The vast majority of patients with intracerebral hemorrhage (ICH) suffer from long and uncertain length of stay (LOS). The aim of our study was to provide decision support for discharge and admission plans by predicting ICH patients' LOS probability distribution. The demographics, clinical predictors, admission diagnosis, and surgery information from 3,600 ICH patients were used in this study. We used univariable Cox analysis, multivariable Cox analysis, Cox-variable of importance (Cox-VIMP) analysis, and an intersection analysis to select predictors and used random survival forests (RSF)—a method in survival analysis—to predict LOS probability distribution. The Cox-VIMP method constructed by us effectively selected significant correlation predictors. The Cox-VIMP RSF model can improve prediction performance and is significantly different from the other models. The Cox-VIMP can contribute to the screening of predictors, and the RSF model can be established through those predictors to predict the probability distribution of LOS in each patient.

Determination of serum neutrophil gelatinase-associated lipocalin as a prognostic biomarker of acute spontaneous intracerebral hemorrhage

BACKGROUND

Neutrophil gelatinase-associated lipocalin (NGAL) is currently known as an acute phase protein and implicated in acute brain injury. Herein, we sought to gauge serum NGAL level in patients after acute (<24 h) spontaneous intracerebral hemorrhage (ICH) and to investigate its relation to neurological outcome.

METHODS

Serum NGAL levels were measured in 106 patients and 106 controls. National Institutes of Health Stroke Scale (NIHSS) score, Glasgow coma scale (GCS) score, ICH score and hematoma volume were recorded for assessing hemorrhagic severity. An unfavorable outcome was defined as modified Rankin Scale >2 at 90 days.

RESULTS

As opposed to the controls, the patients had significantly raised serum NGAL levels. Correlations were observed between NGAL levels and serum C-reactive protein levels, blood glucose levels, GCS score, NIHSS score, ICH score and ICH volume. Multivariate analysis identified serum NGAL as a predictor for unfavorable outcome at 90 days. It also showed high prognostic ability under receiver operating characteristic curve.

CONCLUSIONS

Enhanced NGAL level is revealed after acute spontaneous ICH, in association with inflammatory degree and hemorrhagic severity, and intimately correlated with a worse prognosis.

Serum myeloperoxidase concentrations for outcome prediction in acute intracerebral hemorrhage

BACKGROUND

Oxidative stress is related to brain injury after spontaneous intracerebral hemorrhage (ICH). Myeloperoxidase (MPO) is a potent oxidizing enzyme. We tested the hypothesis that serum MPO concentrations are increased after ICH and they correlate with stroke severity and outcome.

METHODS

Serum MPO concentrations were measured in 128 ICH patients and 128 controls. Odds ratios of dependent variables, including early neurological deterioration, hematoma growth, 1-week mortality, 6-month mortality, 6-month unfavorable outcome (modified Rankin Scale score > 2) and 6-month overall survival, were calculated and adjusted for age, sex, hematoma volume, National Institutes of Health Stroke Scale (NIHSS) score and vascular risk factors.

RESULTS

As compared to the controls, the patients had significantly increased serum MPO concentrations. MPO concentrations of the ICH patients were strongly correlated with hematoma volume and NIHSS scores. Serum MPO were independently associated with the above-mentioned study points. Its area under receiver operating characteristic curve was equivalent to those of hematoma volume and NIHSS score. Moreover, serum MPO significantly improved the discriminatory ability of hematoma and NIHSS in predicting 6-month mortality and unfavorable outcome.

CONCLUSIONS

Serum MPO concentrations rise in ICH patients and there is a correlation between MPO concentrations and severity or prognosis.

LncRNA-FENDRR mediates VEGFA to promote the apoptosis of brain microvascular endothelial cells via regulating miR-126 in mice with hypertensive intracerebral hemorrhage

BACKGROUND

LncRNA-FENDRR is a kind of endothelial genes critical for vascular development. Moreover, miR-126 and vascular endothelial growth factor A (VEGFA) are also involved in the physiological process of vascular endothelial cells. This study aimed to the underlying mechanism of FENDRR involving miR-126 and VEGFA in hypertensive intracerebral hemorrhage (HICH).

METHODS

C57BL/6 mice were chosen to establish HICH model. The expression of FENDRR, miR-126, and VEGFA at mRNA level was determined by qRT-PCR. The protein expression of VEGFA was assessed using Western blot. RIP assay and RNA pull-down assay were used to the relationship between FENDRR and miR-126. Flow cytometry was used to analyze cell apoptosis.

RESULTS

The levels of FENDRR and VEGFA were increased, and miR-126 expression was decreased in vascular endothelial cells (VECs) from the right brain of model mice and human brain microvascular endothelial cells (HBMECs) treated by thrombin. Overexpression of FENDRR promoted the apoptosis of HBMECs. FENDRR regulating VEGFA participated in HBMECs apoptosis through targeting miR-126. Downregulation of FENDRR was indicated to relieve the HICH in mice.

CONCLUSIONS

FENDRR could promote the apoptosis of HBMECs via miR-126 regulating VEGFA in HICH.

Genetic testing for Mendelian stroke due to cerebrovascular anomalies and other syndromes

Stroke is defined as a focal or at times global neurological impairment of sudden onset and presumed vascular origin. 85% of strokes are due to cerebral ischemia and the other 15% to primary intracerebral hemorrhage.

Ischemic stroke (IS) is characterized by complete or partial obstruction of a vessel in the brain, resulting in lack of blood supply and death of brain tissue. The most common causes of IS are atherosclerosis, cardioembolism and small-vessel disease (lacunar stroke). Genetic factors play important role. Incidence rates for IS in the 15- to 45-year age range are ≈10 per 100,000 person years.

Hemorrhagic stroke (HS) is the least treatable and the most fatal form of cerebrovascular disease. Genetic mechanisms play a role in its development. Occurrence depends on many risk factors, including hypertension, heavy alcohol intake and anticoagulant treatment. According to the World Health Organization, 15 million people suffer stroke worldwide each year. The overall incidence of spontaneous HS worldwide is 24.6 per 100,000 person years. Strokes are the third most common cause of death and the most common cause of disability in developed countries.

This Utility Gene Test was developed on the basis of an analysis of the literature and existing diagnostic protocols. It is useful for confirming diagnosis, as well as for differential diagnosis, couple risk assessment and access to clinical trials.

Theaflavin alleviates inflammatory response and brain injury induced by cerebral hemorrhage via inhibiting the nuclear transcription factor kappa β-related pathway in rats

OBJECTIVE

Intracerebral hemorrhage (ICH) is one of the most common acute cerebrovascular diseases with high mortality. Numerous studies have shown that inflammatory response played an important role in ICH-induced brain injury. Theaflavin (TF) extracted from black tea has various biological functions including anti-inflammatory activity. In this study, we investigated whether TF could inhibit ICH-induced inflammatory response in rats and explored its mechanism.

MATERIALS AND METHODS

ICH rat models were induced with type VII collagenase and pretreated with TF by gavage in different doses (25 mg/kg-100 mg/kg). Twenty-four hours after ICH attack, we evaluated the rats' behavioral performance, the blood-brain barrier (BBB) integrity, and the formation of cerebral edema. The levels of reactive oxygen species (ROS) and inflammatory cytokines were examined by 2',7'-dichlorofluorescin diacetate and enzyme-linked immunosorbent assay. Nissl staining and transferase dUTP nick end labeling (TUNEL) were aimed to detect the neuron loss and apoptosis, the mechanism of which was explored by Western blot.

RESULTS

It was found that in the pretreated ICH rats TF significantly alleviated the behavioral defects, protected BBB integrity, and decreased the formation of cerebral edema and the levels of ROS as well as inflammatory cytokines (including interleukin-1 beta [IL-1β], IL-18, tumor nectosis factor-alpha, interferon-γ, transforming growth factor beta, and (C-X-C motif) ligand 1 [CXCL1]). Nissl staining and TUNEL displayed TF could protect against the neuron loss and apoptosis via inhibiting the activation of nuclear transcription factor kappa-β-p65 (NF-κβ-p65), caspase-1, and IL-1β. We also found that phorbol 12-myristate 13-acetate, a nonspecific activator of NF-κβ-p65, weakened the positive effect of TF on ICH-induced neural defects and neuron apoptosis by upregulating NF-κβ-related signaling pathway.

CONCLUSION

TF could alleviate ICH-induced inflammatory responses and brain injury in rats via inhibiting NF-κβ-related pathway, which may provide a new way for the therapy of ICH.

The effects of cerebral amyloid angiopathy on integrity of the blood-brain barrier

Cerebral amyloid angiopathy (CAA), in which amyloid accumulates predominantly in the walls of arterioles and capillaries, is seen in most patients with Alzheimer disease (AD) and may contribute to compromise of blood-brain barrier (BBB) function seen in AD. We investigated the effects of CAA on BBB integrity by examining the expression of the endothelial marker CD31, basement membrane protein collagen IV (COL4), tight junction protein claudin-5, and fibrinogen, a marker of BBB leakage, by immunohistochemistry in the occipital cortex of autopsy brains with AD and capillary CAA (CAA type 1; n = 8), AD with noncapillary CAA (CAA type 2; n = 10), and AD without CAA (n = 7) compared with elderly controls (n = 10). Given the difference in pathogenesis of capillary and noncapillary CAA, we hypothesize that features of BBB breakdown are observed only in capillary CAA. We found decreased expression of CD31 in AD subjects with CAA types 1 and 2 compared with AD without CAA and an increase in COL4 in AD without CAA compared with controls. Furthermore, there was increased immunoreactivity for fibrinogen in AD with CAA type 1 compared with controls. These findings suggest that capillary CAA is associated with morphologic and possibly physiologic alterations of the neurovascular unit and increased BBB permeability in AD.

Serum tenascin-C predicts severity and outcome of acute intracerebral hemorrhage

BACKGROUND

Tenascin-C is a matricellular protein related to brain injury. We studied serum tenascin-C in acute intracerebral hemorrhage (ICH) and examined the associations with severity and outcome following the acute event.

METHODS

Tenascin-C samples were obtained from 162 patients with acute hemorrhagic stroke and 162 healthy controls. Poor 90-day functional outcome was defined as modified Rankin Scale score > 2. Early neurological deterioration (END) and hematoma growth (HG) were recorded at 24 h.

RESULTS

Patients had higher tenascin-C levels than controls. Tenascin-C levels were positively correlated with hematoma volume or National Institutes of Health Stroke Scale score at baseline. Elevated tenascin-C levels were independently associated with END, HG, 90-day mortality and poor functional outcome. Moreover, tenascin-C levels significantly predicted END, HG and 90-day outcomes under receiver operating characteristic curves.

CONCLUSIONS

An increase in serum tenascin-C level is associated with an adverse outcome in ICH patients, supporting the potential role of serum tenascin-C as a prognostic biomarker for hemorrhagic stroke.

Macrophage migration inhibitory factor levels in serum from patients with acute intracerebral hemorrhage: Potential contribution to prognosis

BACKGROUND

Intracerebral hemorrhage (ICH) pathophysiology involves inflammation. Macrophage migration inhibition factor (MIF), a pro-inflammatory cytokine, is related to prognosis of ischemic stroke. The aim of this study was to investigate whether serum MIF levels are associated with severity and outcomes in patients with acute ICH.

METHODS

We enrolled a total of 120 consecutive ICH patients and 120 healthy controls and sampled blood on admission and at study entry respectively. Enzyme-linked immunosorbent assay was used to quantify serum MIF levels.

RESULTS

Serum MIF levels were higher in patients compared with controls and correlated with hematoma volume, National Institutes of Health Stroke Scale (NIHSS) scores and plasma C-reactive protein levels. After adjusting for other significant outcome predictors, MIF in serum was an independent predictor of 6-month overall survival and unfavorable outcome (modified Rankin Scale score >2). Areas under receiver-operating characteristic curve (ROC) of serum MIF levels, hematoma volume and NIHSS scores were similar for 6-month unfavorable outcome. Moreover, serum MIF levels significantly improved areas under ROC of hematoma volume and NIHSS scores.

CONCLUSIONS

MIF in serum might be a potential biomarker for reflecting inflammation, severity and prognosis of ICH patients.

Detection of high serum concentration of CXC chemokine ligand-12 in acute intracerebral hemorrhage

BACKGROUND

CXC chemokine ligand-12 (CXCL12), a member of the CXC chemokine subfamily, is involved in both focal angiogenesis and inflammatory reactions. We examined serum CXCL12 concentration in intracerebral hemorrhage (ICH) patients and its correlation to stroke severity and outcome.

METHODS

The study was carried out on 105 ICH patients on 105 healthy controls. Serum samples were at admission obtained to measure CXCL12 concentrations. The National Institutes of Health Stroke Scale (NIHSS) and hematoma volume were recorded to assess stroke severity.

RESULTS

As compared to the controls, CXCL12 concentrations were significantly increased in the patients. Also, non-survivors within 6months and patients with an unfavorable outcome (modified Rankin Scale score>2) at 6months had higher CXCL12 concentrations than other remaining ones. CXCL12 concentrations had positive correlation with NIHSS scores and hematoma volume. Serum CXCL12 significantly discriminated patients at risk of 6-month mortality and 6-month unfavorable outcome under receiver operating characteristic curve. Moreover, serum CXCL12 was independently associated with the mortality, overall survival and unfavorable outcome.

CONCLUSIONS

Serum CXCL12 concentrations are enhanced after ICH and CXCL12 in serum has the potential to reflect severity and prognosis following hemorrhagic stroke.

Role of galectin-3 in plasma as a predictive biomarker of outcome after acute intracerebral hemorrhage

OBJECTIVE

Inflammation is involved in pathophysiological mechanisms underlying secondary brain injury after intracerebral hemorrhage. Enhanced circulating levels of galectin-3, a proinflammatory cytokine, have close relation to poor prognosis of some inflammatory illnesses. This study was designed to investigate whether plasma galectin-3 levels are related to the inflammation, severity and prognosis following intracerebral hemorrhage.

METHODS

In this observational, prospective study, plasma galectin-3 levels of 110 patients and 110 controls were determined. We further assessed the association of galectin-3 levels with inflammation reflected by systemic C-reactive protein levels, severity indicated by hematoma volumes and National Institutes of Health Stroke Scale (NIHSS) scores, and endpoints including 1-week mortality, 6-month mortality, 6-month overall survival and 6-month unfavorable outcome (modified Rankin Scale score>2).

RESULTS

Plasma galectin-3 levels of patients were significantly higher than those of controls. Galectin-3 was identified as an independent prognostic predictor for 1-week mortality, 6-month mortality, 6-month overall survival and 6-month unfavorable outcome, as well as had strong relation to C-reactive protein levels, hematoma volumes and NIHSS scores. Compared with NIHSS scores and hematoma volumes, plasma galectin-3 levels had similar areas under receiver operating characteristic curve (AUC). Moreover, galectin-3 levels significantly improved AUCs of NIHSS scores or hematoma volumes alone for prediction of 6-month mortality and 6-month unfavorable outcome.

CONCLUSIONS

Elevated plasma galectin-3 levels are strongly associated with the inflammation, severity and poor prognosis after intracerebral hemorrhage, indicating galectin-3, involved in brain inflammation, might have the potential to be a prognostic biomarker for hemorrhagic stroke.

Augmented expression of TSPO after intracerebral hemorrhage: a role in inflammation?

Background

Intracerebral hemorrhage (ICH) is a potentially fatal stroke subtype accounting for 10–15 % of all strokes. Despite neurosurgical intervention and supportive care, the 30-day mortality rate remains 30–50 % with ICH survivors frequently displaying neurological impairment and requiring long-term assisted care. Although accumulating evidence demonstrates the role of neuroinflammation in secondary brain injury and delayed fatality after ICH, the molecular regulators of neuroinflammation remain poorly defined after ICH.

Methods

In the present study, ICH was induced in CD1 male mice by collagenase injection method and given the emerging role of TSPO (18-kDa translocator protein) in neuroinflammation, immunofluorescence staining of brain sections was performed to characterize the temporal expression pattern and cellular and subcellular localization of TSPO after ICH. Further, both genetic and pharmacological studies were employed to assess the functional role of TSPO in neuroinflammation.

Results

The expression of TSPO was found to be increased in the peri-hematomal brain region 1 to 7 days post-injury, peaking on day 3 to day 5 in comparison to sham. Further, the TSPO expression was mostly observed in microglia/macrophages, the inflammatory cells of the central nervous system, suggesting an unexplored role of TSPO in neuroinflammatory responses after ICH. Further, the subcellular localization studies revealed prominent perinuclear expression of TSPO after ICH. Moreover, both genetic and pharmacological studies revealed a regulatory role of TSPO in the release of pro-inflammatory cytokines in a macrophage cell line, RAW 264.7.

Conclusions

Altogether, the data suggest that TSPO induction after ICH could be an intrinsic mechanism to prevent an exacerbated inflammatory response and raise the possibility of targeting TSPO for the attenuation of secondary brain injury after ICH.