Acute Management of Hypertension Following Intracerebral Hemorrhage

Is the Effect of Intensive Antihypertensive Treatment in Acute Intracerebral Hemorrhage Dependent on Hematoma Volume? A Traditional Meta-analysis of the Effect of Antihypertensive Regimens, a Bayesian Network Meta-analysis of the Mortality of Antihypertensive Drugs and Systematic Review

BACKGROUND AND OBJECTIVES: Intensive or conventional antihypertensive treatment for acute intracerebral hemorrhage is still controversial. This study aimed to compare those antihypertensive regimens and analyze the efficacy of antihypertensive drugs.

METHODS

Retrieval was conducted through four databases. Meta-analysis and Bayesian network meta-analysis were performed to evaluate the safety of antihypertensive treatments and the efficacy of antihypertensive drugs.

RESULTS

A total of 9271 patients were included. Intensive strategy showed an advantage in 24-h hematoma enlargement (relative risk, RR = 0.76; 95% confidence intervals, CI = 0.67-0.87; P < 0.0001) and 90-day intracranial rebleeding (RR = 0.71, 95% CI = 0.52-0.96, P = 0.03) compared with conventional strategy. Meanwhile, the 90-day renal insufficiency (RR = 2.31, 95% CI = 1.05-5.05, P = 0.04) and renal failure (RR = 2.42, 95% CI = 1.20-4.86, P = 0.01) were increased. When cerebral hematoma volume was less than 15 ml, intensive strategy had a protective effect on 24-h hematoma enlargement (RR = 0.77, 95% CI = 0.67-0.89, P = 0.0003), but it increased 90-day renal failure (RR = 2.33, 95% CI = 1.07-5.04, P = 0.03). For the volume greater than 15 ml, it enhanced 90-day functional independence (RR = 0.78, 95% CI = 0.65-0.94, P = 0.01) and decreased intracranial rebleeding (RR = 0.68, 95% CI = 0.49-0.94, P = 0.02). Labetalol was the best, with the mortality risk probability of 0.09 and the surface under the cumulative ranking curve of 0.33.

CONCLUSIONS

This meta-analysis suggests that for intracerebral hematoma volume greater than 15 ml, intensive antihypertensive treatment can improve functional independence and reduce intracranial bleeding. Labetalol has the best effect among the four antihypertensive regimens studied.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Survival analysis of famotidine administration routes in non-traumatic intracerebral hemorrhage patients: based on the MIMIC-IV database

OBJECTIVE

This study compared the survival outcomes of non-traumatic intracerebral hemorrhage (ICH) patients with different famotidine administration routes and explored related risk factors.

METHODS

Data from ICH patients between 2008-2019 were extracted from the MIMIC-IV database. Survival differences between patients with intravenous (IV) and non-intravenous (Non-IV) famotidine administration were analyzed using Cox analysis and Kaplan-Meier survival curves.

RESULTS

The study included 351 patients, with 109 in the IV group and 84 in the Non-IV group after PSM. Cox analysis revealed that survival was significantly associated with age (HR = 1.031, 95%CI:1.011-1.050, p = 0.002), chloride ions (HR = 1.061, 95%CI:1.027-1.096, p < 0.001), BUN (HR = 1.034, 95%CI:1.007-1.062, p = 0.012), ICP (HR = 1.059, 95%CI:1.027-1.092, p < 0.001), RDW (HR = 1.156, 95%CI:1.030-1.299, p = 0.014), mechanical ventilation (HR = 2.526, 95%CI:1.341-4.760, p = 0.004), antibiotic use (HR = 0.331, 95%CI:0.144-0.759, p = 0.009), and Non-IV route (HR = 0.518, 95%CI:0.283-0.948, p = 0.033). Kaplan-Meier curves showed a significantly higher 30-day survival rate in the Non-IV group (p = 0.011), particularly in patients with normal ICP (HR = 0.518, 95%CI:0.283-0.948, p = 0.033).

CONCLUSION

Non-IV famotidine administration significantly improves 30-day survival of ICH patients, especially for those with normal ICP, compared to IV administration.

Retrospective analysis of prognostic factors in HICH patients after neuroendoscopic hematoma evacuation

The objective of this study is to investigate key prognostic factors of clinical data and prognostic factors in patients with hypertensive intracerebral hemorrhage (HICH) who have undergone neuroendoscopic hematoma evacuation, specifically focusing on those with a hemorrhage volume of 20-40 mL, to identify the determinants influencing their prognosis. In this study, a total of 113 patients were ultimately included in the analysis. Variables such as age, preoperative Glasgow Coma Scale (GCS) scores, and hemorrhage locations were assessed. LASSO logistic regression was employed to select pertinent variables, which were then incorporated into a multivariate logistic regression model. The model's performance was evaluated using ROC and calibration curves, along with clinical utility curves, and the recovery times of patients were analyzed using Kaplan-Meier curves, complemented by COX regression analysis. These three variables-Age (OR: 0.811; 95% CI 0.711-0.925), GCS score (OR: 25.923; 95% CI 4.108-163.598), and ICH location (OR: 7.345; 95% CI 1.811-29.783)-are strong predictors of intracerebral hemorrhage prognosis. Among the patients analyzed, 85.84% experienced a favorable prognosis. Younger age, higher preoperative GCS scores, and hemorrhages located in the basal ganglia and cerebral lobes were associated with better outcomes (mRS score of 0-3) . The nomogram, validated by an ROC curve analysis yielding an AUC of 0.9417 and the Hosmer-Lemeshow test, demonstrated accurate predictive and calibration capabilities for postoperative prognosis in patients with hypertensive intracerebral hemorrhage. Kaplan-Meier intervals and COX regression analysis indicated that age is a significant factor affecting the recovery time of these patients. Age, GCS score, and ICH location are significant prognostic factors for patients undergoing neuroendoscopic hematoma evacuation following hypertensive intracerebral hemorrhage, with age being a particularly important determinant of recovery time. Younger age, higher GCS scores, and lobar hemorrhage are associated with better prognosis.

Effectiveness of bundled care in the management of cerebral hemorrhage complicated by pulmonary infection in China: A systematic review and meta-analysis

OBJECTIVE

Aimed to systematically evaluate the therapeutic and rehabilitative effects of bundled care on patients with cerebral hemorrhage complicated by pulmonary infection in China.

METHODS

Relevant literature was retrieved from multiple databases and original studies investigated the efficacy of bundled care in managing cerebral hemorrhage complicated by pulmonary infection were included. Data analysis was conducted using Meta-analysis software (RevMan 5.3 and Stata 17.0). The Cochrane risk of bias assessment tool was used to evaluate the risk of bias. Sensitivity analysis was performed to evaluate the robustness of the results. Funnel plot, Begg and Egger test were conducted to assess the presence of publication bias. The protocol was registered in PROSPERO (CRD42023475738).

RESULTS

Twelve studies involving 1049 patients were included in this meta-analysis. The results showed that bundled care significantly reduced the duration of antibiotic use and pulmonary infection (SMD = -0.77), reduced the duration of tracheal intubation (MD = -5.35), and shortened hospital stay (MD = -6.30). The effective rate of treatment (OR = 8.39), satisfaction degree (OR = 5.65), anxiety (MD = -4.52) and depression scores (MD = -4.38), and quality of life scores (MD = 11.75) were improved after bundled care intervention compared to routine care. Assessment of publication bias showed no significant evidence of publication bias.

CONCLUSIONS

Bundled care can significantly shorten the duration of illness treatment and hospital stay of patients with cerebral hemorrhage complicated by pulmonary infection, improve treatment effectiveness and satisfaction degree, alleviate anxiety and depression, and promote the improvement of quality of life.

Regulation of interstitial fluid flow in adventitia along vasculature by heartbeat and respiration

Converging studies showed interstitial fluid (ISF) adjacent to blood vessels flows in adventitia along vasculature into heart and lungs. We aim to reveal circulatory pathways and regulatory mechanism of such adventitial ISF flow in rat model. By MRI, real-time fluorescent imaging, micro-CT, and histological analysis, ISF was found to flow in adventitial matrix surrounded by fascia and along systemic vessels into heart, then flow into lungs via pulmonary arteries and back to heart via pulmonary veins, which was neither perivascular tissues nor blood or lymphatic vessels. Under physiological conditions, speckle-like adventitial ISF flow rate was positively correlated with heart rate, increased when holding breath, became pulsative during heavy breathing. During cardiac or respiratory cycle, each dilation or contraction of heart or lungs can generate to-and-fro adventitial ISF flow along femoral veins. Discovered regulatory mechanisms of adventitial ISF flow along vasculature by heart and lungs will revolutionize understanding of cardiovascular system.

Epidemiology of intracerebral hemorrhage: A systematic review and meta-analysis

Background

Intracerebral hemorrhage (ICH) is associated with high mortality and disability rates. This study aimed to investigate the relationship between sex, age, study year, risk factors, bleeding site, median year of study, and the incidence of ICH.

Method

Literature on the incidence of ICH published on 1 January 1980 and 1 January 2020, was systematically retrieved from PubMed and Embase databases. The random-effects model and subgroup analysis were used to explore the relationship between the incidence of ICH and different ages, sex, bleeding sites, and risk factors.

Results

We summarized the epidemiological changes in ICH in the past 40 years according to 52 studies and found that the total incidence of ICH is 29.9 per 100,000 person-years (95% CI: 26.5–33.3), which has not decreased worldwide. The incidence of ICH in the Asian population is much higher than in other continents. In addition, the incidence of ICH increases with age and differs at the 85-year-old boundary. Men are more likely to develop ICH than women, and the basal ganglia region is the most common area for ICH. Of the 10 risk factors examined in this study, those with hypertension had the highest incidence of ICH, followed by those with excessive alcohol consumption and heart disease.

Conclusion

The prevention and treatment of ICH still need to be improved continuously according to age, sex, risk factors, and other factors, and targeted and normative strategies should be gradually developed in the future.

Observation on the Effect of Solution-Focused Approach Combined with Family Involvement in WeChat Platform Management on Inpatients with Intracerebral Hemorrhage

Objective. To explore the effect of the solution-focused approach combined with family involvement in the WeChat platform management on inpatients with intracerebral hemorrhage (ICH). Methods. A total of 80 ICH patients hospitalized in our hospital from June 2018 to June 2021 were split into the control group (CG) and the study group (SG) according to the clinical nursing modes, with 40 cases in each group. Both groups received routine intervention, while SG additionally received the solution-focused approach combined with family involvement in the WeChat platform management to compare the self-care ability, psychological status, and hope levels between the two groups after intervention. Results. No significant differences in general data were observed between the two groups ( $P>0.05$ ). The SAS and SDS scores before intervention showed mild depression and anxiety in both groups, which improved after intervention. In addition, the SAS and SDS scores after intervention were remarkably lower in SG than in CG ( $P<0.05$ ). After intervention, the scores of ICH-related knowledge, self-care skills, self-care responsibility, and rehabilitation knowledge in SG were notably higher compared with CG ( $P<0.05$ ). After intervention, the Herth scores of both groups increased, with a higher score in SG than in CG ( $P<0.05$ ). After intervention, SG had higher quality of life (QOL) scores in general health, physiological function, physiological role, body pain, vitality, social function, emotional role, and physiological health than CG ( $P<0.05$ ). Conclusion. The implementation of the solution-focused approach combined with family involvement in the WeChat platform management for ICH inpatients can effectively improve their psychological status, enhance their self-care ability and hope levels, promote body recovery, and improve their QOL after intervention.

CM-352 EFFICACY IN A MOUSE MODEL OF ANTICOAGULANT-ASSOCIATED INTRACRANIAL HAEMORRHAGE

BACKGROUND

Intracranial haemorrhage (ICH) is one of the major devastating complications of anticoagulation. Matrix metalloproteinases (MMPs) inhibition has been proposed as a novel pharmacological approach for ICH treatment.

OBJECTIVES

We evaluated the effects of CM-352 (MMPs-fibrinolysis inhibitor) in an experimental ICH model associated with oral anticoagulants as compared with clinically used prothrombin concentrate complex (PCC).

METHODS

ICH was induced by collagenase injection into the striatum of WT (C57BL/6J) anticoagulated mice (warfarin or rivaroxaban) and Mmp10 -/- mice. Hematoma volume and neurological deficits were measured 24h later by diaminobenzidine staining and different behavioural test. Circulating plasminogen activator inhibitor-1 (PAI-1) activity and interleukin-6 (IL-6) were measured in plasma samples and local inflammation was assessed by neutrophil infiltration. Finally, fibrinolytic effects of MMP-10 and rivaroxaban were evaluated by thromboelastometry and thrombin-activatable fibrinolysis inhibitor (TAFI) activation assays.

RESULTS

Only PCC reduced haemorrhage volume and improved functional outcome in warfarin-ICH, but both, PCC and CM-352 treatments, diminished haemorrhage volume (46%, p<0.01 and 64%, p<0.001, respectively) and ameliorated functional outcome in rivaroxaban-ICH. We further demonstrated that CM-352, but not PCC decreased neutrophil infiltration in the haemorrhage area at 24h. The effect of CM-352 could be related to MMP-10 inhibition since Mmp10-/- mice showed lower haemorrhage volume, better neurological score, reduced IL-6 levels and neutrophil infiltration, and increased PAI-1 after experimental ICH. Finally, we found that CM-352 reduced MMP-10 and rivaroxaban-related fibrinolytic effects in thromboelastometry and TAFI activation.

CONCLUSIONS

CM-352 treatment, by diminishing MMPs and rivaroxaban-associated fibrinolytic effects, might be a novel antihaemorrhagic strategy for rivaroxaban-associated ICH.

Scalp Acupuncture Protects Against Neuronal Ferroptosis by Activating The p62-Keap1-Nrf2 Pathway in Rat Models of Intracranial Haemorrhage

Intracerebral haemorrhage (ICH) can be a catastrophic event; even if the initial stages of the pathology were well-managed, a number of patients experience varied residual neurological deficits following the insult. Ferroptosis is a recently identified type of cell demise which is tightly linked to the neurological impairment associated with ICH. In the current work, the prophylactic impact of scalp acupuncture (SA) therapy on autologous blood injection murine models of ICH was investigated in order to establish whether SA could mitigate the secondary damage arising following ICH by moderating ferroptosis. The pathophysiological mechanisms associated with this process were also explored. Ludmila Belayev tests were utilised for the characterisation of neurological damage. Haematoxylin–eosin staining was employed in order to determine the cerebral impact of the induced ICH. Malondialdehyde (MDA) and iron titres in peri-haemorrhagic cerebral tissues were appraised using purchased assay kits. Transmission electron microscopy delineated mitochondrial appearances within nerve cell bodies from the area of haemorrhage. Western blotting techniques were utilised to assay the degree of protein expression of NeuN, sequestosome 1 (p62), nuclear factor erythroid 2-related factor 2 (Nrf2), Kelch-like ECH-associated protein 1 (Keap1), glutathione peroxidase 4 (GPX4) and ferritin heavy chain 1 (FTH1). The frequencies of Nrf2, GPX4 and FTH1 positive cells, respectively, were documented with immunohistochemical staining. The results demonstrated that therapy with SA after ICH mitigated MDA and iron sequestration, diminished the appearance of contracted mitochondria with increased outer mitochondrial membrane diameter within the nerve cell bodies, and suppressed neuronal ferroptosis. The pathways responsible for these effects may encompass amplified p62, Nrf2, GPX4 and FTH1 expression, together with decreased Keap1 expression. Application of SA reduced identified neurobehavioural abnormalities after ICH; no disparities were observed between the consequences of SA therapy and deferoxamine delivery. It can be surmised that intervention with SA enhanced recovery after ICH by triggering the antioxidant pathway, p62/Keap1/Nrf2, and causing FTH1 and GPX4 upregulation, factors that participate in diminishing excess iron and thus in mitigating lipid peroxidation insults arising from ferroptosis following ICH.

Clemastine promotes recovery of neural function and suppresses neuronal apoptosis by restoring balance of pro-inflammatory mediators in an experimental model of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) represents a common acute cerebrovascular event that imparts high rates of disability. The microglia-mediated inflammatory response is a critical factor in determining cerebral damage post-ICH. Clemastine (CLM) is a histamine receptor H1 (HRH1) antagonist that has been shown to modulate the inflammatory response. However, the effects of CLM on ICH and the underlying mechanism remain to be determined. This investigation reveals that CLM resulted in reduction of cerebral hematoma volume, decreased cerebral edema and lower rates of neuronal apoptosis as well as improved behavioral scores in an acute ICH murine model. CLM treatment was noted to decrease pro-inflammatory effectors and increased anti-inflammatory effectors post-ICH. In addition, CLM reduced the deleterious effects of activated microglia on neurons in a transwell co-culture system. Our findings show that CLM likely mediates its therapeutic effect through inhibition of microglia-induced inflammatory response and apoptosis, thereby enhancing restoration of neuronal function.

The microsurgical treatment for primary hypertensive brainstem hemorrhage: Experience with 52 patients

OBJECTIVE

This study aims to investigate the effect of minimal invasive microsurgery in treating primary hypertensive brainstem hemorrhage (PHBH).

METHODS

52 patients of PHBH (≥3.5 ml) who have taken the minimal invasive microsurgery with neuronavigation guidance were included between Jan. 2011 and Dec. 2018. The volume/location/type of hematoma, preoperative Glasgow Coma Scale (GCS), postoperative Glasgow Outcome Scale (GOS) and hemorrhagic dilatation of the fourth ventricle were analyzed during the follow-up period ranged from 3 to 57 months.

RESULTS

Among all the patients, 18 achieved complete hematoma evacuation (≥95%), 31 achieved subtotal evacuation (≥90%), 3 achieved premodinantly evacuation (>75%). No rebleeding during or after surgery within 24 h were found. 45 patients survived after 3 months, the mean preoperative hematoma volume decreased from 7.1 ± 2.6 ml-0.9 ml (p < 0.05), 19 patients got GOS Grade V/Ⅳ. It is shown the volume less than 10 ml always led to better outcome while massive and bilateral hematoma were related with poor prognosis.

CONCLUSION

The microsurgical hematoma evacuation under neuronavigation assistance is a rapid, effective, and safe technique for the removal of PHBH, especially for the volume less than 10 ml.

Circulating TIMP-1 is associated with hematoma volume in patients with spontaneous intracranial hemorrhage

Matrix metalloproteinases (MMPs) are proteolytic zinc-endopeptidases regulated by tissue Inhibitors of matrix metalloproteinases (TIMPs). We evaluated the potential of MMPs and TIMPs as clinical tools for Intracranial Haemorrhage (ICH). Spontaneous non-traumatic ICH patients were recruited from two hospitals: Complejo Hospitalario de Navarra (CHN = 29) and Vall d´Hebron (VdH = 76). Plasmatic levels of MMP-1, -2, -7, -9, -10 and TIMP-1 and their relationship with clinical, radiological and functional variables were evaluated. We further studied the effect of TIMP-1 (0.05-0.2 mg/Kg) in an experimental tail-bleeding model. In CHN, TIMP-1 was associated with admission-hematoma volume and MMP-7 was elevated in patients with deep when compared to lobar hematoma. In VdH, admission-hematoma volume was associated with TIMP-1 and MMP-7. When data from both hospitals were combined, we observed that an increase in 1 ng/ml in TIMP-1 was associated with an increase of 0.14 ml in haemorrhage (combined β = 0.14, 95% CI = 0.08-0.21). Likewise, mice receiving TIMP-1 (0.2 mg/Kg) showed a shorter bleeding time (p < 0.01). Therefore, the association of TIMP-1 with hematoma volume in two independent ICH cohorts suggests its potential as ICH biomarker. Moreover, increased TIMP-1 might not be sufficient to counterbalance MMPs upregulation indicating that TIMP-1 administration might be a beneficial strategy for ICH.