An update on neurocritical care for intracerebral hemorrhage

Ruxolitinib Ameliorates Neuronal Pyroptosis in the Acute Phase of Intracerebral Hemorrhage through Inhibiting the Activation of Caspase-8

Intracerebral hemorrhage (ICH) is a common type of stroke with higher rates of death and neurological dysfunction than ischemic stroke. Based on previous studies, we found that reducing neuronal pyroptosis in the acute phase of ICH improved the neurological dysfunction of mice that suffered from nontraumatic parenchymal hemorrhage. Still, the mechanism must be further explored. In this study, we used ruxolitinib, a selective inhibitor of JAK1/2, to treat CD-1 mice with ICH. We found that inhibition of the JAK1/STAT1 pathway alleviated ICH-induced neuronal pyroptosis and that the activation of caspase-8 was suppressed at the same time. Given that caspase-8 is crosstalk for different types of programmed cell death and its role in the pyroptotic cell death after ICH has not yet been defined, we administered z-IETD-fmk, a selective inhibitor of caspase-8, to treat mice with ICH. We found that the downregulation of caspase-8 reversed ICH-induced neuronal pyroptosis and improved motor and cognitive functions of mice after ICH. Our results show that the JAK1/STAT1/caspase-8 axis is a critical mediator of neuronal pyroptosis in ICH. Inhibiting this axis improved neurological outcomes of mice with ICH, and we propose ruxolitinib as a potential therapeutic approach for post-ICH treatment.

Exogenous mitochondria added on benefits for cellular prion protein overexpression in adipose-derived mesenchymal stem cells treatment on intracranial hemorrhage rat

We examined whether combined exogenous mitochondria (ExMito) and cellular prion protein overexpression (Ove-PrPC) in adipose-derived mesenchymal stem cell (Ove-PrPC in ADMSCs) therapy is superior to a single therapy for protecting the brain against intracranial hemorrhage (ICH) in rats. In vitro, compared with the control group, ExMito transfusion into recipient cells (i.e., N2a cells) significantly increased under hypoxic conditions (P < 0.001) and augmented ρ0 cell proliferation and cell-cycle activation (P < 0.001). PrPC-OE in ADMSCs exhibited higher resistance to H2O2-induced cell senescence and mitochondrial and DNA damage compared to ADMSCs (P < 0.001). Rats were categorized into group 1 (sham-control), 2 (ICH), 3 [ICH + ExMito (350 μg) by intracranial injection at 3 h after ICH], 4 [ICH + PrPC-OE in ADMSCs (6.0 × 105 cells) and intracranial injection and 1.2 × 106 cells by intravenous injection)], and 5 (ICH + combined ExMito + PrPC-OE in ADMSCs). By day 28, the brain infarct volume, brain infarct area, inflammatory cell infiltration, and biomarkers for DNA and mitochondrial damage were highest in group 2, lowest in group 1, and significantly lower in group 5 than in groups 3 and 4. NeuN cells exhibited the opposite pattern for brain infarct volume, and neurological function (corner test) significantly improved in groups 3 and 4, with further improvement in group 5 compared with that in group 2 (P < 0.0001). Combined ExMito + PrPC-OE ADMSCs therapy was superior to either therapy alone in mitigating the ICH-induced brain damage.

[Correction of the effect of vitamin K antagonists and antiplatelet agents in hemorrhagic stroke]

BACKGROUND

Hemorrhagic stroke (HS) is associated with high risk of mortality or disability. To date, up to 25% of HSs are associated with anticoagulants and antiplatelet agents. Early hemostatic therapy and correction of effect of antithrombotic drugs in patients with HS significantly reduce the risk of adverse outcomes. The latest international guidelines on this issue were presented almost 10 years ago.

MATERIAL AND METHODS

In accordance with the PRISMA recommendations, we reviewed the PubMed, eLibrary and UpToDate databases and identified 137 articles. Of these, 52 were enrolled as the most relevant.

RESULTS AND DISCUSSION

Regarding correction of the effect of indirect anticoagulants, various researchers discuss the possibility of either individual dosing or injection of a fixed dose of 4- or 3-factor prothrombin complex (1000-2000 IU regardless of body weight and international normalized ratio). To correct the effect of antiplatelet agents, platelet transfusion and desmopressin are proposed. There is currently no evidence of safety and effectiveness of both methods in patients with HS.

CONCLUSION

The optimal drug for correction of the effect of indirect anticoagulants is 4- or 3-factor prothrombin complex. In the last case, it is necessary to administer factor VIIa or fresh frozen plasma, as well as parenteral form of phytomenadione (vitamin K1) in all cases. The issue of correction of the effects of antiplatelet agents remains open. Regular analysis of available data with updating the guidelines for correction of the effect of anticoagulants and antiplatelet agents in HS is necessary.

Neural network for autonomous segmentation and volumetric assessment of clot and edema in acute and subacute intracerebral hemorrhages

INTRODUCTION

Minimally-invasive surgical techniques for intracerebral hemorrhage (ICH) evacuation use imaging to guide the suction, lysing and/or drainage from the hemorrhage site via various designs. A previous international surgical study has shown that reduction of hematoma volume below 15 ml is indicative of improved long term patient outcomes. The study noted a need for tools to periodically visualize remaining clot during intervention to increase the likelihood of evacuating sufficient clot volumes without endangering rebleeds. Robust segmentation of MRI could guide surgeons and radiologists regarding remaining regions and approaches for prudent evacuation. We thus propose a Convolutional Neural Network (CNN) to identify and autonomously segment clot and peripheral edema in MR images of the brain and generate an estimate of the remaining clot volume.

MATERIALS AND METHODS

We used a retrospective, locally-acquired dataset of ICH patient scans taken on 3 T MRI scanners. Three sets of ground truth manual segmentations were independently generated by two imaging scientists and one radiology fellow. Evaluation of clot age was determined based on relative contrast of hemorrhage components and reviewed by a neurosurgeon. Model accuracy was determined by pixel-wise Dice coefficient (DC) calculations between each ground truth manual segmentation and the machine-derived autonomous segmentations.

RESULTS

The model produced autonomous segmentations of clot core with an average DC of 0.75 ± 0.21 relative to manual segmentations of the same scans. For edema, it produced segmentations with an average DC of 0.68 ± 0.16 relative to manual. From these pixel-wise segmentations, clot volume can be calculated. Model-produced segmentations underestimated clot volumes by an average of 17% relative to ground-truth.

CONCLUSION

The machine learning models were able to identify and segment volumes of ICH components swiftly and accurately.

Association between statin use during hospitalisation and mortality in patients with intracerebral haemorrhage: a propensity score-matched cohort study

OBJECTIVES

We examined the relationship between statin use during hospitalisation and mortality in patients with intracerebral haemorrhage (ICH).

DESIGN

Retrospective propensity-matched cohort study.

SETTING

Patients with ICH (≥18 years old) admitted to Beth Israel Deaconess Medical Center (Boston, Massachusetts, USA) from 2001 to 2012 registered in the Medical Information Mart for Intensive Care III database.

PARTICIPANTS

1043 patients with ICH (≥18 years) were evaluated for the relationship between statin use during hospitalisation and mortality.

INTERVENTIONS

Statin use.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was 90-day mortality. We used multivariable Cox regression analyses to calculate the adjusted HR with 95% CI and used propensity score analysis and an inverse probability weighting (IPW) model to ensure the robustness of our findings.

RESULTS

We included 1043 patients with ICH (362 and 681 were statins and non-statin users, respectively) between 2001 and 2012. The overall 90-day mortality was 29.8% (311/1043); it was 33.3% (227/681) and 23.2% (84/362) for non-statin and statin users, respectively. After adjusted for potential confounders, we found that statin use was associated with 29% lower of 90-day mortality (HR=0.71, 95% CI 0.52 to 0.97, p<0.05). IPW also demonstrated a significantly lower 90-day mortality in statin users. The HR was 0.69 (95% CI 0.54 to 0.88, p<0.01). The results remain stable in subgroup analyses and propensity score matching.

CONCLUSION

Statin use during hospitalisation may be associated with reduced risk-adjusted mortality in patients with ICH. Further randomised controlled trials are needed to clarify this association.

Efficacy and safety of glibenclamide therapy after intracerebral haemorrhage (GATE-ICH): A multicentre, prospective, randomised, controlled, open-label, blinded-endpoint, phase 2 clinical trial

BACKGROUND

Glibenclamide is a promising agent for treating brain oedema, but whether it improves clinical outcomes in patients with intracerebral haemorrhage (ICH) remains unclear. In this study, we aimed to explore the efficacy and safety of glibenclamide treatment in patients with acute ICH.

METHODS

The Glibenclamide Advantage in Treating Oedema after Intracerebral Haemorrhage (GATE-ICH) study was a randomised controlled phase 2 clinical trial conducted in 26 hospitals in the northwest of China, recruiting patients with acute ganglia ICH no more than 72 h after onset from Dec 12, 2018 to Sept 23, 2020. During the first 7 days after enrolment, patients randomly assigned to the glibenclamide group were given glibenclamide orally (1.25 mg, 3/day) and standard care, while patients randomly assigned to the control group were given standard care alone. The computer-generated randomisation sequence was prepared by a statistician not involved in the rest of the study. Randomisation was computer-generated with a block size of four. The allocation results were unblinded to participants and investigators. The primary outcome was the percentage of patients with poor outcome (defined as modified Rankin Scale [mRS] score of ≥3) at day 90. The trial was registered at ClinicalTrials.gov (NCT03741530).

FINDINGS

220 participants were randomised and 200 participants (mean [standard deviation] age, 56 [11] years; sex, 128 [64.0%] male and 72 [36.0%] female) were included in the final analysis, with 101 participants randomly assigned to the control group and 99 to the glibenclamide group. The incidence of poor outcome at day 90 was 20/99 (20.2%) in glibenclamide group and 30/101 (29.7%) in control group (absolute difference, 9.5%; 95% confidence interval [CI], -3.2%-21.8%; P = 0.121) with adjusted odds ratios of 0.54 (95% CI, 0.24-1.20; P = 0.129). No significant difference was found in the overall rates of adverse events or serious adverse events between groups. However, the incidence of asymptomatic hypoglycaemia was significantly higher in glibenclamide group than control group (15/99 [15.2%] vs 0/101 [0.0%]; absolute difference, 15.2%; 95% CI, 7.5%-24.1%; P < 0.001).

INTERPRETATION

Our study provides no evidence that glibenclamide (1.25 mg, 3/day) significantly reduces the proportion of poor outcome at day 90 after ICH. In addition, glibenclamide could result in higher incidence of hypoglycaemia. Larger trials of glibenclamide with optimised medication regimen are warranted.

FUNDING

Shaanxi Province Key Research and Development Project (2017DCXL-SF-02-02) and Shaanxi Province Special Support Program for Leading Talents in Scientific and Technological Innovation (tzjhjw).

Irregular-Shaped Hematoma Predicts Postoperative Rehemorrhage After Stereotactic Minimally Invasive Surgery for Intracerebral Hemorrhage

Background and Purpose

Minimally invasive surgery (MIS) is performed to treat patients with intracerebral hemorrhage (ICH) with favorable results. However, postoperative rehemorrhage is a significant risk. The present study retrospectively analyzed the association of irregular-shaped hematoma with postoperative rehemorrhage following stereotactic MIS (sMIS).

Methods

We enrolled 548 patients with spontaneous ICH who underwent sMIS. Based on the hematoma shape, the patients were assigned to the regular-shaped hematoma group (RSH group; 300 patients) or irregular-shaped hematoma group (ISH group; 248 patients). Logistic regression analysis was performed to identify the predictors of postoperative rehemorrhage after sMIS for ICH evacuation. The functional outcome was assessed using the modified ranking scale (mRS) score at discharge. A receiver operating characteristic (ROC) curve was used to confirm the results.

Results

Among 548 patients with ICH who underwent sMIS, 116 developed postoperative rehemorrhage. Postoperative rehemorrhage occurred in 30.65% of patients with ISH and 13.30% with RSH (P &lt; 0.01), with a significant difference between the ISH and RSH groups. Among 116 patients with postoperative rehemorrhage, 76 (65.52%) showed ISH on CT scan. In 432 patients without postoperative rehemorrhage, only 39.81% displayed ISH. The logistic regression analysis demonstrated that ISH could independently predict postoperative rehemorrhage. The sensitivity, specificity, positive predictive value, and negative predicative value were 0.655, 0.398, 0.655, and 0.602, respectively. The ROC analysis confirmed the value of ISH in predicting postoperative rehemorrhage with an area under the curve of 0.629.

Conclusions

Irregular-shaped hematoma was an independent predictor of postoperative rehemorrhage after sMIS.

MicroNAR-194-5p hinders the activation of NLRP3 inflammasomes and alleviates neuroinflammation during intracerebral hemorrhage by blocking the interaction between TRAF6 and NLRP3

The possible role of miR-194-5p in brain and neurodegenerative diseases has been reported, but its role in intracerebral hemorrhage (ICH) has not been studied. This study estimated the mechanism of miR-194-5p in ICH. ICH rat model was established by injecting collagenase type VII. miR-194-5p expression in brain tissue of ICH rats was overexpressed by injection of miR-194-5p agomir. Then neurological function score and brain water content were measured. The morphological changes of brain tissue and neuronal apoptosis were evaluated by histological staining. Levels of NLRP3 inflammasomes, IL-1β and IL-18 were measured. The target relation between miR-194-5p and TRAF6 was verified and the binding of TRAF6 to NLRP3 was explored. miR-194-5p was decreased in ICH rats. After overexpression of miR-194-5p, the neuropathological injury in ICH rats was significantly reduced, and NLRP3-mediated inflammatory injury was inhibited. miR-194-5p targeted TRAF6. TRAF6 interacted with NLRP3 to promote the activation of NLRP3 inflammasomes. Overexpression of miR-194-5p reduced the interaction between TRAF6 and NLRP3, thereby alleviating the neuroinflammation. Collectively, overexpression of miR-194-5p reduced the TRAF6/NLRP3 interaction, thus inhibiting the activation of NLRP3 inflammasomes and reducing neuroinflammation during ICH. This study may shed new light on ICH treatment.

Regular-Shaped Hematomas Predict a Favorable Outcome in Patients with Hypertensive Intracerebral Hemorrhage Following Stereotactic Minimally Invasive Surgery

BACKGROUND

Stereotactic minimally invasive surgery (sMIS) has been used in the treatment of intracerebral hemorrhage (ICH) in recent years and has obtained promising results. However, the outcomes of patients are associated with many factors. The aim of the present study was to retrospectively observe the relationship between hematoma shape features and the outcome of patients with spontaneous ICH following sMIS.

METHODS

One hundred eighty-three patients with hypertensive ICH who underwent sMIS were enrolled. Based on hematoma shape features, the patients were assigned to a regular-shaped hematoma group (RSH group, including 121 patients) or an irregular-shaped hematoma group (ISH group, including 62 patients). The Glasgow Coma Scale (GCS) score and the National Institutes of Health Stroke Scale (NIHSS) score were assessed on admission and at 1 week and 2 weeks after surgery. The rates of severe pulmonary infection, cardiac complications, and postoperative rebleeding during the hospital stay were also recorded for comparison. The functional outcome assessed by using the modified Rankin scale score was determined at discharge. A multivariate logistic regression analysis was performed for predictors of good outcome in patients with ICH who underwent sMIS. A receiver operating characteristic curve was also used to confirm the results.

RESULTS

Compared to the ISH group, the RSH group showed increased median GCS scores at one week and two weeks after surgery. The RSH group showed significantly decreased NIHSS scores at one week and two weeks after surgery compared with the ISH group at the same time point. Significant differences in the GCS score and the NIHSS score at 1 week (P < 0.05) and 2 weeks (P < 0.05) after surgery were observed between the RSH group and the ISH group. The RSH group showed lower rates of severe pulmonary infection, heart failure, and postoperative rehemorrhage than the ISH group (P < 0.05). Of the total patients with good outcomes, the RSH group accounted for 84.6%, and just 15.4% were from the ISH group. The multivariate logistic regression analysis demonstrated that regular-shaped hematoma (P < 0.0001) was an independent predictor of good outcome. The postoperative residual hematoma volume (P < 0.05) predicted a poor outcome. The sensitivity, specificity, and positive and negative predictive values of regular-shaped hematomas for the prediction of a favorable outcome in patients were 0.667, 0.846, 0.917, and 0.542, respectively. Additionally, the Youden index was 0.513.

CONCLUSIONS

Patients with regular-shaped hematomas exhibited more favorable outcomes. Irregular-shaped hematomas and postoperative residual hematoma volume predicted a poor outcome in patients with ICH following sMIS.