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Nowinski WL. Taxonomy of Acute Stroke: Imaging, Processing, and Treatment. Diagnostics (Basel) 2024; 14:1057. [PMID: 38786355 PMCID: PMC11119045 DOI: 10.3390/diagnostics14101057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/01/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024] Open
Abstract
Stroke management employs a variety of diagnostic imaging modalities, image processing and analysis methods, and treatment procedures. This work categorizes methods for stroke imaging, image processing and analysis, and treatment, and provides their taxonomies illustrated by a state-of-the-art review. Imaging plays a critical role in stroke management, and the most frequently employed modalities are computed tomography (CT) and magnetic resonance (MR). CT includes unenhanced non-contrast CT as the first-line diagnosis, CT angiography, and CT perfusion. MR is the most complete method to examine stroke patients. MR angiography is useful to evaluate the severity of artery stenosis, vascular occlusion, and collateral flow. Diffusion-weighted imaging is the gold standard for evaluating ischemia. MR perfusion-weighted imaging assesses the penumbra. The stroke image processing methods are divided into non-atlas/template-based and atlas/template-based. The non-atlas/template-based methods are subdivided into intensity and contrast transformations, local segmentation-related, anatomy-guided, global density-guided, and artificial intelligence/deep learning-based. The atlas/template-based methods are subdivided into intensity templates and atlases with three atlas types: anatomy atlases, vascular atlases, and lesion-derived atlases. The treatment procedures for arterial and venous strokes include intravenous and intraarterial thrombolysis and mechanical thrombectomy. This work captures the state-of-the-art in stroke management summarized in the form of comprehensive and straightforward taxonomy diagrams. All three introduced taxonomies in diagnostic imaging, image processing and analysis, and treatment are widely illustrated and compared against other state-of-the-art classifications.
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Affiliation(s)
- Wieslaw L Nowinski
- Sano Centre for Computational Personalised Medicine, Czarnowiejska 36, 30-054 Krakow, Poland
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2
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Kaleem S, Zhang C, Gusdon AM, Oh S, Merkler AE, Avadhani R, Awad I, Hanley DF, Kamel H, Ziai WC, Murthy SB. Association Between Neutrophil-Lymphocyte Ratio and 30-Day Infection and Thrombotic Outcomes After Intraventricular Hemorrhage: A CLEAR III Analysis. Neurocrit Care 2024; 40:529-537. [PMID: 37349600 DOI: 10.1007/s12028-023-01774-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Serum neutrophil-lymphocyte ratio (NLR) is a surrogate marker for the inflammatory response after intracerebral hemorrhage (ICH) and is associated with perihematomal edema and long-term functional outcomes. Whether NLR is associated with short-term ICH complications is poorly understood. We hypothesized that NLR is associated with 30-day infection and thrombotic events after ICH. METHODS We performed a post hoc exploratory analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial. The study exposure was the serum NLR obtained at baseline and on days 3 and 5. The coprimary outcomes, ascertained at 30 days, were any infection and a thrombotic event, defined as composite of cerebral infarction, myocardial infarction, or venous thromboembolism; both infection and thrombotic event were determined through adjudicated adverse event reporting. Binary logistic regression was used to study the relationship between NLR and outcomes, after adjustment for demographics, ICH severity and location, and treatment randomization. RESULTS Among the 500 patients enrolled in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial, we included 303 (60.6%) without missing data on differential white blood cell counts at baseline. There were no differences in demographics, comorbidities, or ICH severity between patients with and without data on NLR. In adjusted logistic regression models, NLR ascertained at baseline (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.01-1.07, p = 0.03) and NLR ascertained at day 3 were associated with infection (OR 1.15; 95% CI 1.05-1.20, p = 0.001) but not with thrombotic events. Conversely, NLR at day 5 was associated with thrombotic events (OR 1.07, 95% CI 1.01-1.13, p = 0.03) but not with infection (OR 1.13; 95% CI 0.76-1.70, p = 0.56). NLR at baseline was not associated with either outcome. CONCLUSIONS Serum NLR ascertained at baseline and on day 3 after randomization was associated with 30-day infection, whereas NLR obtained on day 5 was associated with thrombotic events after ICH, suggesting that NLR could be a potential early biomarker for ICH-related complications.
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Affiliation(s)
- Safa Kaleem
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Aaron M Gusdon
- Department of Neurological Surgery, University of Texas Health Science Center, Houston, TX, USA
| | - Stephanie Oh
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Isaam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, IL, USA
| | - Daniel F Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Wendy C Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, IL, USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Chiurillo I, Sha RM, Robertson FC, Liu J, Li J, Le Mau H, Amich JM, Gormley WB, Stolyarov R. High-Accuracy Neuro-Navigation with Computer Vision for Frameless Registration and Real-Time Tracking. Bioengineering (Basel) 2023; 10:1401. [PMID: 38135992 PMCID: PMC10740492 DOI: 10.3390/bioengineering10121401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
For the past three decades, neurosurgeons have utilized cranial neuro-navigation systems, bringing millimetric accuracy to operating rooms worldwide. These systems require an operating room team, anesthesia, and, most critically, cranial fixation. As a result, treatments for acute neurosurgical conditions, performed urgently in emergency rooms or intensive care units on awake and non-immobilized patients, have not benefited from traditional neuro-navigation. These emergent procedures are performed freehand, guided only by anatomical landmarks with no navigation, resulting in inaccurate catheter placement and neurological deficits. A rapidly deployable image-guidance technology that offers highly accurate, real-time registration and is capable of tracking awake, moving patients is needed to improve patient safety. The Zeta Cranial Navigation System is currently the only non-fiducial-based, FDA-approved neuro-navigation device that performs real-time registration and continuous patient tracking. To assess this system's performance, we performed registration and tracking of phantoms and human cadaver heads during controlled motions and various adverse surgical test conditions. As a result, we obtained millimetric or sub-millimetric target and surface registration accuracy. This rapid and accurate frameless neuro-navigation system for mobile subjects can enhance bedside procedure safety and expand the range of interventions performed with high levels of accuracy outside of an operating room.
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Affiliation(s)
- Isabella Chiurillo
- Zeta Surgical Inc., Boston, MA 02111, USA; (I.C.); (R.M.S.); (J.L.); (J.L.); (H.L.M.); (J.M.A.); (R.S.)
| | - Raahil M. Sha
- Zeta Surgical Inc., Boston, MA 02111, USA; (I.C.); (R.M.S.); (J.L.); (J.L.); (H.L.M.); (J.M.A.); (R.S.)
| | - Faith C. Robertson
- Department of Neurological Surgery, Massachusetts General Hospital, Boston, MA 02114, USA;
- Harvard Medical School, Boston, MA 02115, USA
| | - Jian Liu
- Zeta Surgical Inc., Boston, MA 02111, USA; (I.C.); (R.M.S.); (J.L.); (J.L.); (H.L.M.); (J.M.A.); (R.S.)
| | - Jacqueline Li
- Zeta Surgical Inc., Boston, MA 02111, USA; (I.C.); (R.M.S.); (J.L.); (J.L.); (H.L.M.); (J.M.A.); (R.S.)
| | - Hieu Le Mau
- Zeta Surgical Inc., Boston, MA 02111, USA; (I.C.); (R.M.S.); (J.L.); (J.L.); (H.L.M.); (J.M.A.); (R.S.)
| | - Jose M. Amich
- Zeta Surgical Inc., Boston, MA 02111, USA; (I.C.); (R.M.S.); (J.L.); (J.L.); (H.L.M.); (J.M.A.); (R.S.)
| | - William B. Gormley
- Harvard Medical School, Boston, MA 02115, USA
- Computational Neurosurgical Outcomes Center, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Neurological Surgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Roman Stolyarov
- Zeta Surgical Inc., Boston, MA 02111, USA; (I.C.); (R.M.S.); (J.L.); (J.L.); (H.L.M.); (J.M.A.); (R.S.)
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Sanker V, Kundu M, El Kassem S, El Nouiri A, Emara M, Maaz ZA, Nazir A, Bekele BK, Uwishema O. Posttraumatic hydrocephalus: Recent advances and new therapeutic strategies. Health Sci Rep 2023; 6:e1713. [PMID: 38028696 PMCID: PMC10652704 DOI: 10.1002/hsr2.1713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
Background Hydrocephalus or ventriculomegaly is a condition brought on by an overabundance of cerebrospinal fluid (CSF) in the ventricular system. The major contributor to posttraumatic hydrocephalus (PTH) is traumatic brain injuries (TBIs), especially in individuals with occupations set in industrial settings. A variety of criteria have been employed for the diagnosis of PTH, including the combination of neurological symptoms like nerve deficits and headache, as well as an initial improvement followed by a worsened relapse of altered consciousness and neurological deterioration, which is detected by computed tomography-brain imaging that reveals gradual ventriculomegaly. Aim In this article, we discuss and summarize briefly the current understandings and advancements in the management of PTH. Methods The available literature for this review was searched on various bibliographic databases using an individually verified, prespecified approach. The level of evidence of the included studies was considered as per the Centre for Evidence-Based Medicine recommendations. Results The commonly practiced current treatment modality involves shunting CSF but is often associated with complications and recurrence. The lack of a definitive management strategy for PTH warrants the utilization of novel and innovative modalities such as stem cell transplantations and antioxidative stress therapies. Conclusion One of the worst complications of a TBI is PTH, which has a high morbidity and mortality rate. Even though there hasn't been a successful method in stopping PTH from happening, hemorrhage-derived blood, and its metabolic by-products, like iron, hemoglobin, free radicals, thrombin, and red blood cells, may be potential targets for PTH hindrance and management. Also, using stem cell transplantations in animal models and antioxidative stress therapies in future studies can lower PTH occurrence and improve its outcome. Moreover, the integration of clinical trials and theoretical knowledge should be encouraged in future research projects to establish effective and updated management guidelines for PTH.
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Affiliation(s)
- Vivek Sanker
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Society of Brain Mapping and TherapeuticsLos AngelesCaliforniaUSA
| | - Mrinmoy Kundu
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Institute of Medical Sciences and SUM HospitalBhubaneswarIndia
| | - Sarah El Kassem
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Faculty of MedicineBeirut Arab UniversityBeirutLebanon
| | - Ahmad El Nouiri
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Faculty of MedicineBeirut Arab UniversityBeirutLebanon
| | - Mohamed Emara
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- College of MedicineUniversity of SharjahSharjahUnited Arab Emirates
| | - Zeina Al Maaz
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Faculty of MedicineBeirut Arab UniversityBeirutLebanon
| | - Abubakar Nazir
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
| | - Bezawit Kassahun Bekele
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- School of MedicineAddis Ababa UniversityAddis AbabaEthiopia
- Milken Institute of Public HealthGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Olivier Uwishema
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Department of medicineClinton Global Initiative UniversityNew YorkNew YorkUSA
- Faculty of MedicineKaradeniz Technical UniversityTrabzonTurkey
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Wahjoepramono POP, Sasongko AB, Halim D, Aviani JK, Lukito PP, Adam A, Tsai YT, Wahjoepramono EJ, July J, Achmad TH. Hydrocephalus is an independent factor affecting morbidity and mortality of ICH patients: Systematic review and meta-analysis. World Neurosurg X 2023; 19:100194. [PMID: 37359762 PMCID: PMC10288487 DOI: 10.1016/j.wnsx.2023.100194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 04/04/2023] [Indexed: 06/28/2023] Open
Abstract
Background Despite advances in our knowledge of the causes, preventions, and treatments of stroke, it continues to be a leading cause of death and disability. The most common type of stroke-related morbidity and mortality is intracerebral haemorrhage (ICH). Many prognostication scores include an intraventricular extension (IVH) after ICH because it affects mortality independently. Although it is a direct result of IVH and results in significant damage, hydrocephalus (HC) has never been taken into account when calculating prognostication scores. This study aimed to evaluate the significance of hydrocephalus on the outcomes of ICH patients by meta-analysis. Methods Studies that compared the rates of mortality and/or morbidity in patients with ICH, ICH with IVH (ICH + IVH), and ICH with IVH and HC (ICH + IVH + HC) were identified. A meta-analysis was performed by using Mantel-Haezel Risk Ratio at 95% significance. Results This meta-analysis included thirteen studies. The findings indicate that ICH + IVH + HC has higher long-term (90-day) and short-term (30-day) mortality risks than ICH (4.26 and 2.30 higher risks, respectively) and ICH + IVH (1.96 and 1.54 higher risks). Patients with ICH + IVH + HC have lower rates of short-term (3 months) and long-term (6 months) good functional outcomes than those with ICH (0.66 and 0.38 times) or ICH + IVH (0.76 and 0.54 times). Confounding variables included vascular comorbidities, haemorrhage volume, midline shift, and an initial GCS score below 8. Conclusion Hydrocephalus causes a poorer prognosis in ICH patients. Thus, it is reasonable to suggest the inclusion of hydrocephalus in ICH prognostication scoring systems.
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Affiliation(s)
- Petra Octavian Perdana Wahjoepramono
- Department of Neurosurgery, Faculty of Medicine, Pelita Harapan University/Siloam Hospitals, Tangerang, Banten, Indonesia
- Post Graduate Program, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Aloysius Bagus Sasongko
- Department of Neurosurgery, Faculty of Medicine, Pelita Harapan University/Siloam Hospitals, Tangerang, Banten, Indonesia
- Post Graduate Program, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Danny Halim
- Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
- Research Center for Medical Genetics, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Jenifer Kiem Aviani
- Research Center for Medical Genetics, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Patrick Putra Lukito
- Department of Neurosurgery, Faculty of Medicine, Pelita Harapan University/Siloam Hospitals, Tangerang, Banten, Indonesia
| | - Achmad Adam
- Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Yeo Tseng Tsai
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Eka Julianta Wahjoepramono
- Department of Neurosurgery, Faculty of Medicine, Pelita Harapan University/Siloam Hospitals, Tangerang, Banten, Indonesia
| | - Julius July
- Department of Neurosurgery, Faculty of Medicine, Pelita Harapan University/Siloam Hospitals, Tangerang, Banten, Indonesia
| | - Tri Hanggono Achmad
- Research Center for Medical Genetics, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Department of Basic Medical Science, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
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Haldrup M, Miscov R, Mohamad N, Rasmussen M, Dyrskog S, Simonsen CZ, Grønhøj M, Poulsen FR, Bjarkam CR, Debrabant B, Korshøj AR. Treatment of Intraventricular Hemorrhage with External Ventricular Drainage and Fibrinolysis: A Comprehensive Systematic Review and Meta-Analysis of Complications and Outcome. World Neurosurg 2023; 174:183-196.e6. [PMID: 36642373 DOI: 10.1016/j.wneu.2023.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND External ventricular drainage (EVD) is a key factor in the treatment of intraventricular hemorrhage (IVH) but associated with risks and complications. Intraventricular fibrinolysis (IVF) has been proposed to improve clinical outcome and reduce complications of EVD treatment. The following review and metaanalysis provides a comprehensive evaluation of IVH treatment with external ventricular drainage (EVD) and intraventricular fibrinolysis (IVF) with regards to complications and clinical outcomes. METHODS The PRISMA guidelines were followed preparing this review. Studies included in the meta-analysis were compared using forest plots and the related odds ratios. RESULTS After a literature search, 980 articles were identified and 65 and underwent full-text review. Forty-two articles were included in the review and meta-analysis. We found that bolted and antibiotic-coated catheters were superior to tunnelled/uncoated catheters (P < 0.001) and antibiotic- vs. silver-impregnated catheters (P < 0.001]) in preventing infection. Shunt dependency was related to the volume of blood in the ventricles but unaffected by IVF (P = 0.98). IVF promoted hematoma clearance, decreased mortality (22.4% vs. 40.9% with IVF vs. no IVF, respectively, P < 0.00001), improved good functional outcomes (47.2% [IVF] vs. 38.3% [no IVF], P = 0.03), and reduced the rate of catheter occlusion from 37.3% without IVF to 10.6% with IVF (P = 0.0003). CONCLUSIONS We present evidence and best practice recommendations for the treatment of IVH with EVD and intraventricular fibrinolysis. Our analysis further provides a comprehensive quantitative reference of the most relevant clinical endpoints for future studies on novel IVH technologies and treatments.
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Affiliation(s)
- Mette Haldrup
- Department of Neurosurgery, Aarhus University Hospital, Aarhus N, Denmark.
| | - Rares Miscov
- Department of Neurosurgery, Aalborg University Hospital, Aalborg, Denmark
| | - Niwar Mohamad
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Mads Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Stig Dyrskog
- Department of Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Mads Grønhøj
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | | | | | - Birgit Debrabant
- Department of Mathematics and Computer Science, Data Science and Statistics, University of Southern Denmark, Odense M, Denmark
| | - Anders Rosendal Korshøj
- Department of Neurosurgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Hakimi R. Imaging of Central Nervous System Hemorrhage. Continuum (Minneap Minn) 2023; 29:73-103. [PMID: 36795874 DOI: 10.1212/con.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE This article aims to familiarize the reader with the various types of nontraumatic central nervous system (CNS) hemorrhage and the various neuroimaging modalities used to help diagnose and manage them. LATEST DEVELOPMENTS According to the 2019 Global Burden of Diseases, Injuries, and Risk Factors Study, intraparenchymal hemorrhage accounts for 28% of the global stroke burden. In the United States, hemorrhagic stroke makes up 13% of all strokes. The incidence of intraparenchymal hemorrhage increases substantially with age; thus, despite improvements in blood pressure control through various public health measures, the incidence is not decreasing as the population ages. In fact, in the most recent longitudinal study of aging, autopsy findings showed intraparenchymal hemorrhage and cerebral amyloid angiopathy in 30% to 35% of patients. ESSENTIAL POINTS Rapid identification of CNS hemorrhage, which includes intraparenchymal hemorrhage, intraventricular hemorrhage, and subarachnoid hemorrhage, requires either head CT or brain MRI. Once hemorrhage is identified on the screening neuroimaging study, the pattern of blood in conjunction with the history and physical examination can guide subsequent neuroimaging, laboratory, and ancillary tests as part of the etiologic assessment. After determination of the cause, the chief aims of the treatment regimen are reducing hemorrhage expansion and preventing subsequent complications such as cytotoxic cerebral edema, brain compression, and obstructive hydrocephalus. In addition, nontraumatic spinal cord hemorrhage will also be briefly discussed.
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Thermal and Postural Effects on Fluid Mixing and Irrigation Patterns for Intraventricular Hemorrhage Treatment. Ann Biomed Eng 2023; 51:1270-1283. [PMID: 36681748 PMCID: PMC10172237 DOI: 10.1007/s10439-022-03130-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 12/25/2022] [Indexed: 01/22/2023]
Abstract
Intraventricular hemorrhage is characterized by blood leaking into the cerebral ventricles and mixing with cerebrospinal fluid. A standard treatment method involves inserting a passive drainage catheter, known as an external ventricular drain (EVD), into the ventricle. EVDs have common adverse complications, including the occlusion of the catheter, that may lead to permanent neural damage or even mortality. In order to prevent such complications, a novel dual-lumen catheter (IRRAflow®) utilizing an active fluid exchange mechanism has been recently developed. However, the fluid dynamics of the exchange system have not been investigated. In this study, convective flow in a three-dimensional cerebral lateral ventricle with an inserted catheter is evaluated using an in-house lattice-Boltzmann-based fluid-solid interaction solver. Different treatment conditions are simulated, including injection temperature and patient position. Thermal and gravitational effects on medication distribution are studied using a dye simulator based on a recently-introduced (pseudo)spectral convection-diffusion equation solver. The effects of injection temperature and patient position on catheter performance are presented and discussed in terms of hematoma irrigation, vortical structures, mixing, and medication volume distribution. Results suggest that cold-temperature injections can increase catheter efficacy in terms of dye distribution and irrigation potential, both of which can be further guided by patient positioning.
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9
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Liu T, Gao Z, Zhou J, Lai X, Chen X, Rao Q, Guo D, Zheng J, Lin F, Lin Y, Lin Z. Subdural evacuating port system with subdural thrombolysis for the treatment of chronic subdural hematoma in patients older than 80 years. Front Neurol 2023; 14:1068829. [PMID: 36873430 PMCID: PMC9975157 DOI: 10.3389/fneur.2023.1068829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/17/2023] [Indexed: 02/17/2023] Open
Abstract
Objective The subdural evacuating port system (SEPS) is a minimally invasive approach that can be performed under local anesthesia for the treatment of chronic subdural hematoma (CSDH). Subdural thrombolysis has been described as an exhaustive drainage strategy and found to be safe and effective for improving drainage. We aim to analyze the effectiveness of SEPS with subdural thrombolysis in patients older than 80 years. Method Consecutive patients aged ≥80 years old who presented with symptomatic CSDH and underwent SEPS followed by subdural thrombolysis between January 2014 and February 2021 were retrospectively studied. Outcome measures included complications, mortality, recurrence, and modified Rankin Scale (mRS) scores at discharge and 3 months. Results In total, 52 patients with CSDH in 57 hemispheres were operated on, with a mean age of 83.9 ± 3.3 years, and 40 (76.9%) patients were men. The preexisting medical comorbidities were observed in 39 patients (75.0%). Postoperative complications occurred in nine patients (17.3%), with two having significant complications (3.8%). The complications observed included pneumonia (11.5%), acute epidural hematoma (3.8%), and ischemic stroke (3.8%). One patient experienced contralateral malignant middle cerebral artery infarction and died of subsequent severe herniation, contributing to a perioperative mortality rate of 1.9%. Discharge and 3 months of favorable outcomes (mRS score 0-3) were achieved in 86.5% and 92.3% of patients, respectively. CSDH recurrence was observed in five patients (9.6%), and repeat SEPS was performed. Conclusion As an exhaustive drainage strategy, SEPS followed by thrombolysis is safe and effective with excellent outcomes among elderly patients. It is a technically easy and less invasive procedure with similar complications, mortality, and recurrence rates compared with burr-hole drainage in the literature.
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Affiliation(s)
- Tianqing Liu
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Zhenwen Gao
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Jianjun Zhou
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Xiaoyan Lai
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Xiaomei Chen
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Qiong Rao
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Dongbin Guo
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Jinliang Zheng
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Fuxin Lin
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yuanxiang Lin
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zhiqin Lin
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China.,Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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10
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Sun N, Zhang C, Zhang R. Immune activation after intraventricular hemorrhage. J Stroke Cerebrovasc Dis 2022; 31:106696. [PMID: 35963211 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/24/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Intraventricular hemorrhage (IVH) is a subtype of stroke which has high mortality and morbidity, while comprehensive mechanism investigations and effective therapies are still in great need. Plenty of studies have shown that inflammation after stroke plays a critical role in disease outcomes. However, the inflammation after IVH remains unclear. This study aims to observe the immune response after IVH, thus providing therapeutic targets for IVH treatments. MATERIALS AND METHODS IVH was induced by autologous blood infusion model in SD rats. Totally 588 rats were assigned either in the sham or IVH group. T2* lesion and hemoglobin quantities, ventricular volume, brain edema, ventricular wall damage, blood-brain-barrier (BBB) continuity and immune response were observed by magnetic resonance image (MRI), hematoxylin-eosin staining (HE), Evans Blue, flow cytometry (FACS), and enzyme-linked immunosorbent assay (ELISA) at baseline, 6 h, 1 d, 3 d, 7 d, 14 d after surgery. RESULTS We found that ventricular volume enlargement occurred hours after IVH and peaked at 3 d after IVH, then mildly reduced till 14 d. Similar changes happened in brain edema, ventricular wall damage and BBB leakage. Immune cells and cytokines in the central nervous system and peripheral blood also increased after IVH and experienced similar trends as ventricular enlargement. T2* lesion and hemoglobin degradation occurred 6 h after IVH and kept decreasing till 14 d after IVH. CONCLUSIONS Our investigation illustrates that immune response exists after IVH, which may have a close relationship with disease outcomes. These results may provide promising immune related clues for mechanism and intervention studies in IVH.
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Affiliation(s)
- Na Sun
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China.
| | - Chen Zhang
- Department of Neurosurgery, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Rui Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
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11
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Roh DJ, Asonye IS, Carvalho Poyraz F, Magid-Bernstein J, Joiner EF, Avadhani R, Awad I, Hanley D, Ziai WC, Murthy SB. Intraventricular Hemorrhage Expansion in the CLEAR III Trial: A Post Hoc Exploratory Analysis. Stroke 2022; 53:1847-1853. [PMID: 35086362 PMCID: PMC9133068 DOI: 10.1161/strokeaha.121.037438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The objective of this study was to evaluate factors associated with intraventricular hemorrhage (IVH) expansion and its association with long-term outcomes. METHODS We performed a post hoc analysis of the international, multi-center CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) which enrolled IVH patients between September 1, 2009, and January 31, 2015. The exposure was IVH expansion, defined as >1 mL increase in volume between baseline and stability computed tomography scans, before treatment randomization. We assessed factors associated with IVH expansion and secondarily assessed the relationship of IVH expansion with clinical outcomes: composite of death or major disability (modified Rankin Scale score, >3), and mortality alone at 6 months. The relationship of IVH expansion on ventriculoperitoneal shunt placement was additionally explored. Multivariable logistic regression was used for all analyses. RESULTS Of 500 IVH patients analyzed, the mean age was 59 (±11) years old, 44% were female and 135 (27%) had IVH expansion. In multivariable regression models, factors associated with IVH expansion were baseline parenchymal intracerebral hemorrhage (ICH) volume (adjusted odds ratio [OR], 1.04 per 1 mL increase [95% CI, 1.01-1.08]), presence of parenchymal hematoma expansion: >33% (adjusted OR, 6.63 [95% CI, 3.92-11.24]), time to stability head CT (adjusted OR, 0.71 per 1 hour increase [95% CI, 0.54-0.94]), and thalamic hematoma location (adjusted OR, 1.68 [95% CI, 1.01-2.79]) while additionally adjusting for age, sex, and race. In secondary analyses, IVH expansion was associated with higher odds of poor 6-month outcomes (adjusted OR, 1.84 [95% CI, 1.12-3.02]) but not mortality (OR, 1.40 [95% CI, 0.78-2.50]) after adjusting for baseline ICH volume, thalamic ICH location, age, anticoagulant use, Glasgow Coma Scale score, any withdrawal of care order, and treatment randomization arm. However, there were no relationships of IVH expansion on subsequent ventriculoperitoneal shunt placement (adjusted OR, 1.02 [95% CI, 0.58-1.80]) after adjusting for similar covariates. CONCLUSIONS In a clinical trial cohort of patients with large IVH, acute hematoma characteristics, specifically larger parenchymal volume, hematoma expansion, and thalamic ICH location were associated with IVH expansion. Given that IVH expansion resulted in poor functional outcomes, exploration of treatment approaches to optimize hemostasis and prevent IVH expansion, particularly in patients with thalamic ICH, require further study. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT00784134.
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Affiliation(s)
- David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Ifeyinwa S. Asonye
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Fernanda Carvalho Poyraz
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jessica Magid-Bernstein
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY
| | - Evan F. Joiner
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, IL
| | - Daniel Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wendy C. Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY
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12
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Ferreira EF, Portugal D, Silva N, Peixoto C, Matos C, Prates L. Physical and rehabilitation medicine intervention in stroke in the acute hospital setting: A cross-sectional study. Rehabilitacion (Madr) 2022; 56:302-311. [PMID: 35523618 DOI: 10.1016/j.rh.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 09/02/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Stroke represents the main cause of death and disability in Portugal. Resulting functional deficits are widely recognized. This work aims to evaluate the variation in functionality of stroke patients in the acute hospital setting under a rehabilitation program. MATERIAL AND METHODS Cross-sectional study of patients admitted to the Neurology department, from January to June 2019, with acute stroke. The variation in functionality was assessed using the Barthel index. Statistical analysis used Student's t-test and Spearman's correlation coefficient, with a p-value≤0.05 as significant. RESULTS 106 patients with mean age of 63.7±14.2 years and a male predominance (60.4%) were included. Patients started rehabilitation program at 1.37±1.19 days after admission. A gain in functionality between admission and discharge was identified (50.18±32.37 versus 68.73±28.94, p<0.001). A significantly greater increase was observed in patients diagnosed under code stroke protocol (CSP) (p=0.021) and undergoing some type of acute phase treatment (p=0.017). From 90.5% of the patients that pursued rehabilitation after discharge, 40.6% were referred to an inpatient unit on average 12.7±7.0 days after admission. DISCUSSION In this study, Physical and Rehabilitation Medicine (PRM) provided early rehabilitation care to stroke patients. According to international evidence this is associated with greater functional gains. The variation in functionality verified during hospitalization demonstrates the importance of PRM in the acute hospital, assessing the rehabilitation needs after hospital discharge and maximizing outpatient rehabilitation. Diagnosis under CSP and undergoing acute treatment were determinants of greater functional improvement. CONCLUSION PRM plays a central role in the early management of functional impairment resulting from stroke and in the post-discharge guidance of patients.
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Affiliation(s)
- E Freitas Ferreira
- Physical and Rehabilitation Medicine Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal.
| | - D Portugal
- Physical and Rehabilitation Medicine Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - N Silva
- Physical and Rehabilitation Medicine Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - C Peixoto
- Physical and Rehabilitation Medicine Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - C Matos
- Physical and Rehabilitation Medicine Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - L Prates
- Physical and Rehabilitation Medicine Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
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13
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Robertson FC, Sha RM, Amich JM, Essayed WI, Lal A, Lee BH, Calvachi Prieto P, Tokuda J, Weaver JC, Kirollos RW, Chen MW, Gormley WB. Frameless neuronavigation with computer vision and real-time tracking for bedside external ventricular drain placement: a cadaveric study. J Neurosurg 2022; 136:1475-1484. [PMID: 34653985 DOI: 10.3171/2021.5.jns211033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 05/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A major obstacle to improving bedside neurosurgical procedure safety and accuracy with image guidance technologies is the lack of a rapidly deployable, real-time registration and tracking system for a moving patient. This deficiency explains the persistence of freehand placement of external ventricular drains, which has an inherent risk of inaccurate positioning, multiple passes, tract hemorrhage, and injury to adjacent brain parenchyma. Here, the authors introduce and validate a novel image registration and real-time tracking system for frameless stereotactic neuronavigation and catheter placement in the nonimmobilized patient. METHODS Computer vision technology was used to develop an algorithm that performed near-continuous, automatic, and marker-less image registration. The program fuses a subject's preprocedure CT scans to live 3D camera images (Snap-Surface), and patient movement is incorporated by artificial intelligence-driven recalibration (Real-Track). The surface registration error (SRE) and target registration error (TRE) were calculated for 5 cadaveric heads that underwent serial movements (fast and slow velocity roll, pitch, and yaw motions) and several test conditions, such as surgical draping with limited anatomical exposure and differential subject lighting. Six catheters were placed in each cadaveric head (30 total placements) with a simulated sterile technique. Postprocedure CT scans allowed comparison of planned and actual catheter positions for user error calculation. RESULTS Registration was successful for all 5 cadaveric specimens, with an overall mean (± standard deviation) SRE of 0.429 ± 0.108 mm for the catheter placements. Accuracy of TRE was maintained under 1.2 mm throughout specimen movements of low and high velocities of roll, pitch, and yaw, with the slowest recalibration time of 0.23 seconds. There were no statistically significant differences in SRE when the specimens were draped or fully undraped (p = 0.336). Performing registration in a bright versus a dimly lit environment had no statistically significant effect on SRE (p = 0.742 and 0.859, respectively). For the catheter placements, mean TRE was 0.862 ± 0.322 mm and mean user error (difference between target and actual catheter tip) was 1.674 ± 1.195 mm. CONCLUSIONS This computer vision-based registration system provided real-time tracking of cadaveric heads with a recalibration time of less than one-quarter of a second with submillimetric accuracy and enabled catheter placements with millimetric accuracy. Using this approach to guide bedside ventriculostomy could reduce complications, improve safety, and be extrapolated to other frameless stereotactic applications in awake, nonimmobilized patients.
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Affiliation(s)
- Faith C Robertson
- 1Department of Neurosurgery, Massachusetts General Hospital, Boston
- 2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston
- 3Harvard Medical School, Boston
| | - Raahil M Sha
- 4Zeta Surgical Inc., Boston
- 5Harvard Innovation Labs, Boston
| | - Jose M Amich
- 4Zeta Surgical Inc., Boston
- 5Harvard Innovation Labs, Boston
| | - Walid Ibn Essayed
- 3Harvard Medical School, Boston
- 6Department of Neurosurgery, Brigham and Women's Hospital, Boston
| | - Avinash Lal
- 4Zeta Surgical Inc., Boston
- 5Harvard Innovation Labs, Boston
| | - Benjamin H Lee
- 4Zeta Surgical Inc., Boston
- 5Harvard Innovation Labs, Boston
| | - Paola Calvachi Prieto
- 2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston
- 3Harvard Medical School, Boston
| | - Junichi Tokuda
- 7Department of Radiology, Brigham and Women's Hospital, Boston
| | - James C Weaver
- 8Harvard John A. Paulson School of Engineering and Applied Sciences, Cambridge, Massachusetts
| | - Ramez W Kirollos
- 9Department of Neurosurgery, National Neuroscience Institute, Singapore; and
- 10Department of Neurosurgery, SingHealth Duke-NUS, National University of Singapore, Singapore
| | - Min Wei Chen
- 9Department of Neurosurgery, National Neuroscience Institute, Singapore; and
| | - William B Gormley
- 2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston
- 3Harvard Medical School, Boston
- 6Department of Neurosurgery, Brigham and Women's Hospital, Boston
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14
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Holste KG, Xia F, Ye F, Keep RF, Xi G. Mechanisms of neuroinflammation in hydrocephalus after intraventricular hemorrhage: a review. Fluids Barriers CNS 2022; 19:28. [PMID: 35365172 PMCID: PMC8973639 DOI: 10.1186/s12987-022-00324-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/23/2022] [Indexed: 02/08/2023] Open
Abstract
Intraventricular hemorrhage (IVH) is a significant cause of morbidity and mortality in both neonatal and adult populations. IVH not only causes immediate damage to surrounding structures by way of mass effect and elevated intracranial pressure; the subsequent inflammation causes additional brain injury and edema. Of those neonates who experience severe IVH, 25-30% will go on to develop post-hemorrhagic hydrocephalus (PHH). PHH places neonates and adults at risk for white matter injury, seizures, and death. Unfortunately, the molecular determinants of PHH are not well understood. Within the past decade an emphasis has been placed on neuroinflammation in IVH and PHH. More information has come to light regarding inflammation-induced fibrosis and cerebrospinal fluid hypersecretion in response to IVH. The aim of this review is to discuss the role of neuroinflammation involving clot-derived neuroinflammatory factors including hemoglobin/iron, peroxiredoxin-2 and thrombin, as well as macrophages/microglia, cytokines and complement in the development of PHH. Understanding the mechanisms of neuroinflammation after IVH may highlight potential novel therapeutic targets for PHH.
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Affiliation(s)
- Katherine G Holste
- Department of Neurosurgery, University of Michigan, 3470 Taubman Center, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5338, USA.
| | - Fan Xia
- Department of Neurosurgery, University of Michigan, 3470 Taubman Center, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5338, USA
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fenghui Ye
- Department of Neurosurgery, University of Michigan, 3470 Taubman Center, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5338, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, 3470 Taubman Center, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5338, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, 3470 Taubman Center, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5338, USA.
- , 5018 BSRB, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
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15
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Abstract
Intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) carry a very dismal prognosis. Several medical and surgical attempts have been made to reduce mortality and to improve neurological outcomes in survivors. Aggressive surgical treatment of ICH through craniotomy and microsurgical evacuation did not prove to be beneficial to these patients, compared to the best medical treatment. Similarly, the conventional treatment of IVH using an EVD is often effective in controlling ICP only initially, as it is very likely for the EVD to become obstructed by blood clots, requiring frequent replacements with a consequent increase of infection rates.Minimally invasive techniques have been proposed to manage these cases. Some are based on fibrinolytic agents that are infused in the hemorrhagic site through catheters with a single burr hole. Others are possible thanks to the development of neuroendoscopy. Endoscopic removal of ICH through a mini-craniotomy or a single burr hole, and via a parafascicular white matter trajectory, proved to reduce mortality in this population, and further randomized trials are expected to show whether also a better neurological outcome can be obtained in survivors. Moreover, endoscopy offers the opportunity to access the ventricular system to aspirate blood clots in patients with IVH. In such cases, the restoration of patency of the entire CSF pathway has the potential to improve outcome and reduce complications and now it is believed to decrease shunt-dependency.
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Affiliation(s)
- Alberto Feletti
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona, Italy.
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16
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Witsch J, Roh DJ, Avadhani R, Merkler AE, Kamel H, Awad I, Hanley DF, Ziai WC, Murthy SB. Association Between Intraventricular Alteplase Use and Parenchymal Hematoma Volume in Patients With Spontaneous Intracerebral Hemorrhage and Intraventricular Hemorrhage. JAMA Netw Open 2021; 4:e2135773. [PMID: 34860246 PMCID: PMC8642781 DOI: 10.1001/jamanetworkopen.2021.35773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Intraventricular thrombolysis reduces intraventricular hemorrhage (IVH) volume in patients with spontaneous intracerebral hemorrhage (ICH), but it is unclear if a similar association with parenchymal ICH volume exists. OBJECTIVE To evaluate the association between intraventricular alteplase use and ICH volume as well as the association between a change in parenchymal ICH volume and long-term functional outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a post hoc exploratory analysis of data from the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage phase 3 randomized clinical trial with blinded outcome assessments. Between September 1, 2009, and January 31, 2015, patients with ICH and IVH were randomized to receive either intraventricular alteplase or normal saline via an external ventricular drain. Participants with primary IVH were excluded. Data analyses were performed between January 1 and June 30, 2021. EXPOSURE Randomization to receive intraventricular alteplase. MAIN OUTCOMES AND MEASURES The primary outcome was the change in parenchymal ICH volume between the hematoma stability and end-of-treatment computed tomography scans. Secondary outcomes were a modified Rankin Scale score higher than 3 and mortality, both of which were assessed at 6 months. The association between alteplase and change in parenchymal ICH volume was assessed using multiple linear regression, whereas the associations between change in parenchymal ICH volume and 6-month outcomes were assessed using multiple logistic regression. Prespecified subgroup analyses were performed for baseline IVH volume, admission ICH volume, and ICH location. RESULTS A total of 454 patients (254 men [55.9%]; mean [SD] age, 59 [11] years) were included in the study. Of these patients, 230 (50.7%) were randomized to receive alteplase and 224 (49.3%) to receive normal saline. The alteplase group had a greater mean (SD) reduction in parenchymal ICH volume compared with the saline group (1.8 [0.2] mL vs 0.4 [0.1] mL; P < .001). In the primary analysis, alteplase use was associated with a change in the parenchymal ICH volume in the unadjusted analysis per 1-mL change (β, 1.37; 95% CI, 0.92-1.81; P < .001) and in multivariable linear regression analysis that was adjusted for demographic characteristics, stability ICH and IVH volumes, ICH location, and time to first dose of study drug per 1-mL change (β, 1.20; 95% CI, 0.79-1.62; P < .001). In the secondary analyses, no association was found between change in parenchymal ICH volume and poor outcome (odds ratio [OR], 0.97; 95% CI 0.87-1.10; P = .64) or mortality (OR, 0.97; 95% CI 0.99-1.08; P = .59). Similar results were observed in the subgroup analyses. CONCLUSIONS AND RELEVANCE This study found that intraventricular alteplase use in patients with a large IVH was associated with a small reduction in parenchymal ICH volume, but this association did not translate into improved functional outcomes or mortality. Intraventricular thrombolysis should be examined in patients with moderate to large ICH with IVH, especially in a thalamic location.
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Affiliation(s)
- Jens Witsch
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia
| | - David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, Illinois
| | - Daniel F. Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy C. Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
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17
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Stokum JA, Cannarsa GJ, Wessell AP, Shea P, Wenger N, Simard JM. When the Blood Hits Your Brain: The Neurotoxicity of Extravasated Blood. Int J Mol Sci 2021; 22:5132. [PMID: 34066240 PMCID: PMC8151992 DOI: 10.3390/ijms22105132] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 12/15/2022] Open
Abstract
Hemorrhage in the central nervous system (CNS), including intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and aneurysmal subarachnoid hemorrhage (aSAH), remains highly morbid. Trials of medical management for these conditions over recent decades have been largely unsuccessful in improving outcome and reducing mortality. Beyond its role in creating mass effect, the presence of extravasated blood in patients with CNS hemorrhage is generally overlooked. Since trials of surgical intervention to remove CNS hemorrhage have been generally unsuccessful, the potent neurotoxicity of blood is generally viewed as a basic scientific curiosity rather than a clinically meaningful factor. In this review, we evaluate the direct role of blood as a neurotoxin and its subsequent clinical relevance. We first describe the molecular mechanisms of blood neurotoxicity. We then evaluate the clinical literature that directly relates to the evacuation of CNS hemorrhage. We posit that the efficacy of clot removal is a critical factor in outcome following surgical intervention. Future interventions for CNS hemorrhage should be guided by the principle that blood is exquisitely toxic to the brain.
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Affiliation(s)
- Jesse A. Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
| | - Gregory J. Cannarsa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
| | - Aaron P. Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
| | - Phelan Shea
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
| | - Nicole Wenger
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (G.J.C.); (A.P.W.); (P.S.); (N.W.); (J.M.S.)
- Departments of Pathology and Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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18
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Kalisvaart ACJ, Wilkinson CM, Gu S, Kung TFC, Yager J, Winship IR, van Landeghem FKH, Colbourne F. An update to the Monro-Kellie doctrine to reflect tissue compliance after severe ischemic and hemorrhagic stroke. Sci Rep 2020; 10:22013. [PMID: 33328490 PMCID: PMC7745016 DOI: 10.1038/s41598-020-78880-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/01/2020] [Indexed: 02/06/2023] Open
Abstract
High intracranial pressure (ICP) can impede cerebral blood flow resulting in secondary injury or death following severe stroke. Compensatory mechanisms include reduced cerebral blood and cerebrospinal fluid volumes, but these often fail to prevent raised ICP. Serendipitous observations in intracerebral hemorrhage (ICH) suggest that neurons far removed from a hematoma may shrink as an ICP compliance mechanism. Here, we sought to critically test this observation. We tracked the timing of distal tissue shrinkage (e.g. CA1) after collagenase-induced striatal ICH in rat; cell volume and density alterations (42% volume reduction, 34% density increase; p < 0.0001) were highest day one post-stroke, and rebounded over a week across brain regions. Similar effects were seen in the filament model of middle cerebral artery occlusion (22% volume reduction, 22% density increase; p ≤ 0.007), but not with the Vannucci-Rice model of hypoxic-ischemic encephalopathy (2.5% volume increase, 14% density increase; p ≥ 0.05). Concerningly, this 'tissue compliance' appears to cause sub-lethal damage, as revealed by electron microscopy after ICH. Our data challenge the long-held assumption that 'healthy' brain tissue outside the injured area maintains its volume. Given the magnitude of these effects, we posit that 'tissue compliance' is an important mechanism invoked after severe strokes.
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Affiliation(s)
- Anna C J Kalisvaart
- Department of Psychology, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Cassandra M Wilkinson
- Department of Psychology, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Sherry Gu
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Tiffany F C Kung
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Jerome Yager
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Ian R Winship
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Frank K H van Landeghem
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta Hospital, Edmonton, Canada
| | - Frederick Colbourne
- Department of Psychology, Faculty of Science, University of Alberta, Edmonton, AB, Canada.
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada.
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19
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Maas MB, Jahromi BS, Batra A, Potts MB, Naidech AM, Liotta EM. Magnesium and Risk of Bleeding Complications From Ventriculostomy Insertion. Stroke 2020; 51:2795-2800. [PMID: 32772685 DOI: 10.1161/strokeaha.120.030128] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Hemorrhages are a serious complication of brain surgery, and magnesium has shown hemostatic properties in hemorrhagic stroke and non-neurological surgeries. External ventricular drain (EVD) insertion is an advantageous model of emergency neurosurgical hemorrhage risk because it is common, standardized, and the operator is blinded to the outcome during the procedure. We tested the hypothesis that low magnesium is associated with risk of hemorrhagic complications from EVD insertion. METHODS Patients with spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage were enrolled in a prospective, observational study. Demographic and clinical variables were prospectively recorded, including serum magnesium measurements. Catheter tract hemorrhage (CTH) was measured on postoperative head computed tomography within 48 hours of EVD insertion. RESULTS We observed 50 CTH among 327 EVD procedures (15.3%) distributed similarly among intracerebral hemorrhage (21/116 [18.1%]) and subarachnoid hemorrhage (29/211 [13.7%]). Magnesium was lower in patients with CTH compared with those without (median 1.8 versus 2.0 mg/dL, P<0.0001). Higher magnesium was associated with lower odds of CTH (odds ratio 0.67 per 0.1 mg/dL magnesium [95% CI, 0.56-0.78], P<0.0001) after adjustment for other risk factors, with similar effect in the intracerebral hemorrhage and subarachnoid hemorrhage subgroups. Preprocedural increase in magnesium (odds ratio 0.68 [0.52-0.85]) and dose of preprocedural magnesium sulfate (odds ratio 0.67 [0.40-0.97]) were associated with reduced CTH risk after adjustment for initial magnesium and other risk factors. CONCLUSIONS Lower magnesium at the time of EVD insertion was an independent predictor of hemorrhagic complications. Baseline risk was attenuated by preprocedural increases in magnesium, suggesting a therapeutic opportunity.
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Affiliation(s)
- Matthew B Maas
- Department of Neurology (M.B.M., A.B., A.M.N., E.M.L.), Northwestern University, Chicago, IL
| | - Babak S Jahromi
- Department of Neurological Surgery (B.S.J., M.B.P.), Northwestern University, Chicago, IL
| | - Ayush Batra
- Department of Neurology (M.B.M., A.B., A.M.N., E.M.L.), Northwestern University, Chicago, IL
| | - Matthew B Potts
- Department of Neurological Surgery (B.S.J., M.B.P.), Northwestern University, Chicago, IL
| | - Andrew M Naidech
- Department of Neurology (M.B.M., A.B., A.M.N., E.M.L.), Northwestern University, Chicago, IL
| | - Eric M Liotta
- Department of Neurology (M.B.M., A.B., A.M.N., E.M.L.), Northwestern University, Chicago, IL
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20
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Porter AL, Ebot J, Lane K, Mooney LH, Lannen AM, Richie EM, Dlugash R, Mayo S, Brott TG, Ziai W, Freeman WD, Hanley DF. Enhancing the Informed Consent Process Using Shared Decision Making and Consent Refusal Data from the CLEAR III Trial. Neurocrit Care 2020; 32:340-347. [PMID: 31571176 DOI: 10.1007/s12028-019-00860-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The process of informed consent in National Institutes of Health randomized, placebo-controlled trials is poorly studied. There are several issues regarding informed consent in emergency neurologic trials, including a shared decision-making process with the patient or a legally authorized representative about overall risks, benefits, and alternative treatments. METHODS To evaluate the informed consent process, we collected best and worst informed consent practice information from a National Institutes of Health trial and used this in medical simulation videos to educate investigators at multiple sites to improve the consent process. Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) (clinicaltrials.gov, NCT00784134) studied the effect of intraventricular alteplase (n = 251) versus saline (placebo) injections (n = 249) for intraventricular hemorrhage reduction. Reasons for ineligibility (including refusing to consent) for all screen failures were analyzed. The broadcasted presentation outlined best practices for doctor-patient interactions during the consenting process, as well as anecdotal, study-specific reasons for consent refusal. Best and worst consent elements were then incorporated into a simulation video to enhance the informed consent process. This video was disseminated to trial sites as a webinar around the midpoint of the trial to improve the consent process. Pre- and post-intervention consent refusals were compared. RESULTS During the trial, 10,538 patients were screened for eligibility, of which only three were excluded due to trial timing. Pre-intervention, 77 of 5686 (1.40%) screen eligible patients or their proxies refused consent. Post-intervention, 55 of 4849 (1.10%) refused consent, which was not significantly different from pre-intervention (P = 0.312). The incidence of screen failures was significantly lower post-intervention (P = 0.006), possibly due to several factors for patient exclusion. CONCLUSION The informed consent process for prospective randomized trials may be enhanced by studying and refining best practices based on trial-specific plans and patient concerns particular to a study.
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Affiliation(s)
- Amanda L Porter
- Department of Neurology, Mayo Clinic Alix School of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - James Ebot
- Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Karen Lane
- Brain Injury Outcomes (BIOS) Division, Johns Hopkins University, Baltimore, MD, USA
| | - Lesia H Mooney
- Department of Nursing, Mayo Clinic, Jacksonville, FL, USA
| | - Amy M Lannen
- J. Wayne and Delores Barr Weaver Simulation Center, Mayo Clinic, Jacksonville, FL, USA
| | - Eugene M Richie
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Rachel Dlugash
- Brain Injury Outcomes (BIOS) Division, Johns Hopkins University, Baltimore, MD, USA
| | - Steve Mayo
- Brain Injury Outcomes (BIOS) Division, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Wendy Ziai
- Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA.
| | - Daniel F Hanley
- Brain Injury Outcomes (BIOS) Division, Johns Hopkins University, Baltimore, MD, USA
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21
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Miyares LC, Falcone GJ, Leasure A, Adeoye O, Shi FD, Kittner SJ, Langefeld C, Vagal A, Sheth KN, Woo D. Race/ethnicity influences outcomes in young adults with supratentorial intracerebral hemorrhage. Neurology 2020; 94:e1271-e1280. [PMID: 31969467 DOI: 10.1212/wnl.0000000000008930] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 10/02/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES We investigated the predictors of functional outcome in young patients enrolled in a multiethnic study of intracerebral hemorrhage (ICH). METHODS The Ethnic/Racial Variations in Intracerebral Hemorrhage (ERICH) study is a prospective multicenter study of ICH among adult (age ≥18 years) non-Hispanic white, non-Hispanic black, and Hispanic participants. The study recruited 1,000 participants per racial/ethnic group. The present study utilized the subset of ERICH participants aged <50 years with supratentorial ICH. Functional outcome was ascertained using the modified Rankin Scale (mRS) at 3 months. Logistic regression was used to identify factors associated with poor outcome (mRS 4-6), and analyses were compared by race/ethnicity to identify differences across these groups. RESULTS Of the 3,000 patients with ICH enrolled in ERICH, 418 were studied (mean age 43 years, 69% male), of whom 48 (12%) were white, 173 (41%) were black, and 197 (47%) were Hispanic. For supratentorial ICH, black participants (odds ratio [OR], 0.42; p = 0.046) and Hispanic participants (OR, 0.34; p = 0.01) had better outcomes than white participants after adjustment for other factors associated with poor outcome: age, baseline disability, admission blood pressure, admission Glasgow Coma Scale score, ICH volume, deep ICH location, and intraventricular extension. CONCLUSIONS In young patients with supratentorial ICH, black and Hispanic race/ethnicity is associated with better functional outcomes, compared with white race. Additional studies are needed to identify the biological and social mediators of this association.
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Affiliation(s)
- Laura C Miyares
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Guido J Falcone
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Audrey Leasure
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Opeolu Adeoye
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Fu-Dong Shi
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Steven J Kittner
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Carl Langefeld
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Achala Vagal
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Kevin N Sheth
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Daniel Woo
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville.
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22
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Ullman NL, Tahsili-Fahadan P, Thompson CB, Ziai WC, Hanley DF. Third Ventricle Obstruction by Thalamic Intracerebral Hemorrhage Predicts Poor Functional Outcome Among Patients Treated with Alteplase in the CLEAR III Trial. Neurocrit Care 2020; 30:380-386. [PMID: 30251074 DOI: 10.1007/s12028-018-0610-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the ventricular system with alteplase improved functional outcomes in patients with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH). Thalamic ICH location was common and was associated with poor outcome. One possible explanation is thalamic ICH-associated mass effect obstructing the third ventricle. We hypothesized that patients with thalamic ICH obstructing the third ventricle would have worse functional outcomes compared to patients without obstructing lesions. METHODS ICH obstruction of third ventricle was defined as third ventricle compression on 1 or more axial computed tomography slices visually impeding cerebral spinal fluid flow. If the third ventricle was casted with IVH, it was scored as such. Multivariable logistic regression analyses were used to determine whether obstruction of the third ventricle predicts poor functional outcomes defined as modified Rankin score (mRS) 4-6, higher mRS, and mortality at 180 days. Models were adjusted for thalamic ICH location, ICH volume, IVH volume, age, hydrocephalus, baseline Glasgow coma scale, and percentage of low cerebral perfusion pressures during treatment. RESULTS Among saline-treated patients, obstruction of the third ventricle by IVH was a significant predictor of higher mRS at 180 days (OR 1.87, CI 1.01-3.47) and mortality at 180 days (OR 2.73, CI 1.27-5.87) while obstruction by ICH was not. In contrast, among alteplase-treated patients, obstruction by ICH was a significant predictor of mRS 4-6 (OR 3.20, CI 1.30-7.88) and higher mRS at 180 days (OR 2.33, CI 1.24-4.35), while obstruction by IVH was not. CONCLUSIONS Poor outcomes were associated with mass-related obstruction of the third ventricle from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from thalamic ICH might become important in functional recovery.
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Affiliation(s)
- Natalie L Ullman
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Pouya Tahsili-Fahadan
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Neuroscience Intensive Care Unit, Department of Medicine, Virginia Commonwealth University, INOVA campus, Falls Church, VA, USA
| | - Carol B Thompson
- Biotstatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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23
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Venous Thromboembolism After Intraventricular Hemorrhage: Results From the CLEAR III Trial. Neurosurgery 2020; 84:709-716. [PMID: 29788198 DOI: 10.1093/neuros/nyy189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/11/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) after intracerebral hemorrhage is well studied, but data on patients with spontaneous intraventricular hemorrhage (IVH) are limited. OBJECTIVE To study the factors associated with VTE, association between VTE and clinical outcomes in IVH, and safety of VTE chemoprophylaxis in IVH treated with intraventricular catheters and thrombolysis. METHODS Retrospective cohort study of patients enrolled in the CLEAR III trial, a multicenter, randomized trial comparing external ventricular drainage, with administration of intraventricular alteplase vs placebo, for obstructive IVH. Predictor variable was incident VTE in the first 30 d. Outcome measures were factors associated with VTE, and death/severe disability (modified Rankin Score 4-6) at 6 mo. RESULTS Of the 500 patients with IVH, VTE occurred in 59 patients (11.8%) within the first 30 d. VTE chemoprophylaxis was initiated in 412 (82.4%) patients, but before VTE diagnosis in only 401 (80.2%) at median of 4 d (interquartile range, 1-8) from IVH onset, and was not associated with intracranial bleeding or catheter tract hemorrhage. In the multivariate logistic regression analysis, infection within 30 d (odds ratio, 1.80; confidence interval, 1.03-3.17) was significantly associated with higher odds of VTE occurrence. Starting VTE chemoprophylaxis after 72 h was additionally associated with VTE occurrence after the first week. CONCLUSION Infection and delay in timely initiation of VTE chemoprophylaxis were associated with VTE occurrence. VTE chemoprophylaxis in IVH appears safe and should not be delayed beyond standard care policies for ICH including when intraventricular catheter placement and thrombolytic therapy are performed.
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24
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Iliev B, Schlegel A, Mielke D, Rohde V, Malinova V. Intrahematomal catheter placement with connection to the ventricular system allows more effective thrombolysis of combined intracerebral and intraventricular hematomas. Neurosurg Rev 2019; 43:1531-1537. [PMID: 31612335 DOI: 10.1007/s10143-019-01170-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/27/2019] [Accepted: 08/27/2019] [Indexed: 11/24/2022]
Abstract
Intracerebral hematomas (ICH) with intraventricular hemorrhage (IVH) are associated with high morbidity. Catheter-based thrombolysis with recombinant tissue plasminogen activator (rtPA) allows a faster hematoma resolution compared to conservative treatment. However, simultaneous thrombolysis of ICH and IVH is not achievable because the ependyma hinders ICH-lysis if rtPA is given into the ventricles and inversely. We evaluated if the thrombolysis efficacy is enhanced by placing an intrahematomal catheter reaching the ventricle. Patients with ICH plus IVH treated with catheter-based thrombolysis were retrospectively analyzed. Group 1 included patients with an intrahematomal catheter reaching the ventricles and group 2 patients with a catheter placed exclusively in the ICH. The relative hematoma volume reduction (RVR) of ICH and IVH within 3 days was calculated. Furthermore, the patients' outcome, the hydrocephalus incidence, and the infection rate were evaluated. A total of 74 patients were analyzed, of whom 49% had a catheter reaching the ventricle. The mean ICH-RVR (68% vs. 58%, p = 0.0001) and IVH-RVR were significantly higher in group 1 compared to group 2. In group 1, infections occurred more often compared to group 2 (31% vs. 6%, p = 0.005). There was no difference in outcome and in hydrocephalus incidence between both groups. The catheter reaching the ventricles allows simultaneous and more effective thrombolysis of ICH and IVH. We assume that the fibrinolytic property of cerebrospinal fluid itself and a washout effect contribute to these findings. In patients with ICH plus IVH, catheter positioning through the hematoma into the ventricle, and subsequent fibrinolytic therapy should be considered.
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Affiliation(s)
- Bogdan Iliev
- Department of Neurosurgery, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany.,Department of Neurosurgery, Westpfalz-Klinikum, Hellmut-Hartert-Straße 1, 67655, Kaiserslautern, Germany
| | - Anna Schlegel
- Department of Neurosurgery, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Vesna Malinova
- Department of Neurosurgery, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
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25
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Influence of Bleeding Pattern on Ischemic Lesions After Spontaneous Hypertensive Intracerebral Hemorrhage with Intraventricular Hemorrhage. Neurocrit Care 2019; 29:180-188. [PMID: 29589328 DOI: 10.1007/s12028-018-0516-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Concomitant acute ischemic lesions are detected in up to a quarter of patients with spontaneous intracerebral hemorrhage (ICH). Influence of bleeding pattern and intraventricular hemorrhage (IVH) on risk of ischemic lesions has not been investigated. METHODS Retrospective study of all 500 patients enrolled in the CLEAR III randomized controlled trial of thrombolytic removal of obstructive IVH using external ventricular drainage. The primary outcome measure was radiologically confirmed ischemic lesions, as reported by the Safety Event Committee and confirmed by two neurologists. We assessed predictors of ischemic lesions including analysis of bleeding patterns (ICH, IVH and subarachnoid hemorrhage) on computed tomography scans (CT). Secondary outcomes were blinded assessment of mortality and modified Rankin scale (mRS) at 30 and 180 days. RESULTS Ischemic lesions occurred in 23 (4.6%) during first 30 days after ICH. Independent risk factors associated with ischemic lesions in logistic regression models adjusted for confounders were higher IVH volume (p = 0.004) and persistent subarachnoid hemorrhage on CT scan (p = 0.03). Patients with initial IVH volume ≥ 15 ml had five times the odds of concomitant ischemic lesions compared to IVH volume < 15 ml. Patients with ischemic lesions had significantly higher odds of death at 1 and 6 months (but not poor outcome; mRS 4-6) compared to patients without concurrent ischemic lesions. CONCLUSIONS Occurrence of ischemic lesions in the acute phase of IVH is not uncommon and is significantly associated with increased early and late mortality. Extra-parenchymal blood (larger IVH and visible subarachnoid hemorrhage) is a strong predictor for development of concomitant ischemic lesions after ICH.
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Müller A, Mould WA, Freeman WD, McBee N, Lane K, Dlugash R, Thompson R, Nekoovaght-Tak S, Madan V, Ali H, Stadnik A, Awad I, Hanley D, Ziai WC. The Incidence of Catheter Tract Hemorrhage and Catheter Placement Accuracy in the CLEAR III Trial. Neurocrit Care 2019; 29:23-32. [PMID: 29294223 DOI: 10.1007/s12028-017-0492-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Incidence of catheter tract hemorrhage (CTH) after initial ventriculostomy placement ranges from 10 to 34%. We investigated CTH incidence in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III trial. METHODS Prospective observational analysis of 1000 computer tomography (CT) scans from all 500 patients enrolled in the trial. All catheters were evaluated on first CT post-placement and on last CT prior to randomization for placement location and CTH size, location, and severity. Clinical variables were assessed for association with CTH with multivariable logistic regression. RESULTS Of 563 catheters, CTH was detected in 14 and 21% of patients on first and last CT (median 3.7 and 43.4 h after catheter placement, respectively). All, but one were asymptomatic. Majority of CTH (86%) occurred within 24 h after placement, were located within 1 cm of the skull, and had at least one diameter > 5 mm. Most catheters (71%) terminated in the third or lateral ventricle ipsilateral to insertion site. Factors significantly associated with CTH were pre-admission use of antiplatelet drugs, accuracy of catheter placement, non-operating room catheter placement, Asian race, and intraventricular hemorrhage expansion. CONCLUSIONS CTH incidence on initial catheter placement and during stabilization was relatively low, despite emergent placement in a high-risk population. Catheter placement accuracy was similar or better than convenience samples from the published literature. Decreasing risk of CTH may be achieved with attention to catheter placement accuracy and placement in the operating room. Antiplatelet agent use was an independent risk factor for CTH.
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Affiliation(s)
- Achim Müller
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - W Andrew Mould
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - W David Freeman
- Department of Neurology, Neurosurgery, and Critical Care, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Nichol McBee
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Lane
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rick Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Saman Nekoovaght-Tak
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vikram Madan
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hasan Ali
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Agnieszka Stadnik
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Daniel Hanley
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe St./Phipps 455, Baltimore, MD, 21287, USA.
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Bosche B, Mergenthaler P, Doeppner TR, Hescheler J, Molcanyi M. Complex Clearance Mechanisms After Intraventricular Hemorrhage and rt-PA Treatment-a Review on Clinical Trials. Transl Stroke Res 2019; 11:337-344. [PMID: 31522408 DOI: 10.1007/s12975-019-00735-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/29/2019] [Accepted: 09/04/2019] [Indexed: 12/15/2022]
Abstract
Intracerebral hemorrhage in combination with intraventricular hemorrhage (IVH) is a severe type of stroke frequently leading to prolonged clinical care, continuous disability, shunt dependency, and high mortality. The molecular mechanisms induced by IVH are complex and not fully understood. Moreover, the treatment options for IVH are limited. Intraventricular recombinant tissue plasminogen activator (rt-PA) dissolves the blood clot in the ventricular system; however, whether the clinical outcome is thereby positively affected is still being debated. The mechanistic cascade induced by intraventricular rt-PA therapy may cure and harm in parallel. Despite the fact that intraventricular blood clots are thereby dissolved, blood derivatives enter the parenchyma and may still adversely affect functional structures of the brain: Smaller blood clots may obstruct the perivascular (Virchow-Robin) space and thereby the glymphatic system with detrimental consequences for cerebrospinal fluid (CSF)/interstitial fluid (ISF) flow. These clots, blood cells but also blood derivatives in the perivascular space, destabilize the blood-brain barrier from the brain parenchyma side, thereby also functionally weakening the neurovascular unit. This may lead to further accommodation of serum proteins in the ISF and particularly in the perivascular space further contributing to the adverse effects on the neuronal microenvironment. Finally, the arterial (Pacchionian) granulations have to cope with ISF containing this "blood, cell, and protein cocktail," resulting in obstruction and insufficient function of the arterial granulations, followed by a malresorptive hydrocephalus. Particularly in light of currently improved knowledge on the physiologic and pathophysiologic clearance of cerebrospinal fluid and interstitial fluid, a critical discussion and reevaluation of our current therapeutic strategies to treat intraventricular hemorrhages are needed to successfully treat patients suffering from this severe type of stroke. In this review, we therefore summarize and discuss recent clinical trials and future directions for the field of IVH with respect to the currently increased understanding of the glymphatic system and the neurovascular unit pathophysiology.
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Affiliation(s)
- Bert Bosche
- Department of Neurocritical Care, Neurological and Neurosurgical First Stage Rehabilitation and Weaning, MediClin Klinik Reichshof, Berglandstr.1, 51580, Reichshof-Eckenhagen, Germany. .,Faculty of Medicine, Department of Neurology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany. .,Institute of Neurophysiology, Medical Faculty, University of Cologne, Cologne, Germany. .,Department of Surgery, Division of Neurosurgery, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada.
| | - Philipp Mergenthaler
- Departments of Experimental Neurology and Neurology, Center for Stroke Research Berlin, NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Thorsten R Doeppner
- Department of Neurology, University of Göttingen Medical School, Göttingen, Germany.
| | - Jürgen Hescheler
- Institute of Neurophysiology, Medical Faculty, University of Cologne, Cologne, Germany
| | - Marek Molcanyi
- Institute of Neurophysiology, Medical Faculty, University of Cologne, Cologne, Germany.,Department of Neurosurgery, Research Unit for Experimental Neurotraumatology, Medical University Graz, Graz, Austria
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28
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Guo R, Chen R, Yu Z, Zhao X, You C, Li H, Ma L. Primary Intraventricular Hemorrhage in Pediatric Patients: Causes, Characteristics, and Outcomes. World Neurosurg 2019; 133:e121-e128. [PMID: 31476469 DOI: 10.1016/j.wneu.2019.08.145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/17/2019] [Accepted: 08/22/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Primary intraventricular hemorrhage (PIVH) is rare, and causes, characteristics, and outcomes remain unknown in children. METHODS We retrospectively analyzed the clinical characteristics of patients 1 month to 21 years of age who were admitted to the hospital with PIVH over a 7-year period. PIVH was defined as bleeding confined to the ventricular system without parenchymal or subarachnoid hemorrhage involvement. RESULTS Of 18 included patients, 55.6% were female, and mean age was 13.8 ± 6.0 years. The most common presenting symptoms were headache (77.8%) and vomiting (33.3%). In 15 patients (83.3%), known etiologies were diagnosed, including arteriovenous malformations (66.7%), moyamoya disease (11.1%), and aneurysms (5.6%). Idiopathic PIVH was the diagnosis in 3 patients (16.7%). Surgery was performed in 15 patients (83.3%), and 3 patients (16.7%) received conservative treatment. Four patients (28.6%) had an unfavorable outcome at discharge, and 3 patients (16.7%) had an unfavorable outcome at the 3-month follow-up. Higher Graeb score was associated with an unfavorable outcome in both short-term and long-term follow-up. CONCLUSIONS Arteriovenous malformations were diagnosed in most pediatric patients with PIVH. Specific surgical treatment of underlying etiologies should be required to increase clinical improvement. Children with a higher Graeb score at admission tended to have poor early and late outcomes.
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Affiliation(s)
- Rui Guo
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruiqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xin Zhao
- West China School of Clinical Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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29
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Rutkowski M, Song I, Mack W, Zada G. Outcomes After Minimally Invasive Parafascicular Surgery for Intracerebral Hemorrhage: A Single-Center Experience. World Neurosurg 2019; 132:e520-e528. [PMID: 31449997 DOI: 10.1016/j.wneu.2019.08.087] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) comprises 10%-15% of strokes with a high mortality (40%) and low rates of functional independence within 6 months (25%). Minimally invasive parafascicular surgery has emerged as a potentially safer option for ICH management. METHODS Data from 25 patients who underwent channel-based ICH evacuation were retrospectively collected regarding demographics, clinical presentation, neuroimaging characteristics, follow-up modified Rankin Scale (mRS) score, Glasgow Coma Scale (GCS) score, and disposition. RESULTS Sixteen patients were male (64%) and 9 were female (36%), with a mean age of 52 years. There were 4 frontal, 1 occipital, and 20 basal ganglia hemorrhages; 15 (60%) showed intraventricular extension. Seventeen ICHs (68%) and 6 of 7 patient deaths (86%) were left sided. The mean volume was 46 cm3 (range, 13.1-101.2 cm3), and the mean clot reduction was 92%. Left-sided ICH (P = 0.014) and the presence of intraventricular hemorrhage (P = 0.038) were associated with worsened postoperative GCS score. Larger hemorrhages were associated with mortality (66 cm3 vs. 38 cm3; P < 0.005). With a mean follow-up time of 5 months, the median follow-up mRS score was 3.5 (vs. 4 preoperatively), and median follow-up GCS was 15 (vs. 10 preoperatively). Patients with higher postoperative mRS scores and lower postoperative GCS were more likely to die. CONCLUSIONS BrainPath-mediated transsulcal approaches are associated with improved mRS and GCS scores, with low rates of residual hematoma, although further data are needed via controlled studies to determine the importance of hemorrhage location and size, timing of surgical intervention, and long-term patient outcomes.
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Affiliation(s)
- Martin Rutkowski
- Department of Neurosurgery, Keck School of Medicine at University of Southern California, University of Southern California, Los Angeles, California, USA
| | - Ivy Song
- Department of Neurosurgery, Keck School of Medicine at University of Southern California, University of Southern California, Los Angeles, California, USA.
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine at University of Southern California, University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine at University of Southern California, University of Southern California, Los Angeles, California, USA
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Ziai WC, Thompson CB, Mayo S, Nichol M, Freeman WD, Dlugash R, Ullman N, Hao Y, Lane K, Awad I, Hanley DF. Intracranial Hypertension and Cerebral Perfusion Pressure Insults in Adult Hypertensive Intraventricular Hemorrhage: Occurrence and Associations With Outcome. Crit Care Med 2019; 47:1125-1134. [PMID: 31162192 PMCID: PMC7490004 DOI: 10.1097/ccm.0000000000003848] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Elevated intracranial pressure and inadequate cerebral perfusion pressure may contribute to poor outcomes in hypertensive intraventricular hemorrhage. We characterized the occurrence of elevated intracranial pressure and low cerebral perfusion pressure in obstructive intraventricular hemorrhage requiring extraventricular drainage. DESIGN Prospective observational cohort. SETTING ICUs of 73 academic hospitals. PATIENTS Four hundred ninety-nine patients enrolled in the CLEAR III trial, a multicenter, randomized study to determine if extraventricular drainage plus intraventricular alteplase improved outcome versus extraventricular drainage plus saline. INTERVENTIONS Intracranial pressure and cerebral perfusion pressure were recorded every 4 hours, analyzed over a range of thresholds, as single readings or spans (≥ 2) of readings after adjustment for intracerebral hemorrhage severity. Impact on 30- and 180-days modified Rankin Scale scores was assessed, and receiver operating curves were analyzed to identify optimal thresholds. MEASUREMENTS AND MAIN RESULTS Of 21,954 intracranial pressure readings, median interquartile range 12 mm Hg (8-16), 9.7% were greater than 20 mm Hg and 1.8% were greater than 30 mm Hg. Proportion of intracranial pressure readings from greater than 18 to greater than 30 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 70 mm Hg were associated with day-30 mortality and partially mitigated by intraventricular alteplase. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and intracranial pressure greater than 20 mm Hg in spans were associated with both 30-day mortality and 180-day mortality. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 60 mm Hg were associated with poor day-30 modified Rankin Scale, whereas cerebral perfusion pressure less than 65 and less than 75 mm Hg were associated with poor day-180 modified Rankin Scale. CONCLUSIONS Elevated intracranial pressure and inadequate cerebral perfusion pressure are not infrequent during extraventricular drainage for severe intraventricular hemorrhage, and level and duration predict higher short-term mortality and long-term mortality. Burden of low cerebral perfusion pressure was also associated with poor short- and long-term outcomes and may be more significant than intracranial pressure. Adverse consequences of intracranial pressure-time burden and cerebral perfusion pressure-time burden should be tested prospectively as potential thresholds for therapeutic intervention.
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Affiliation(s)
- Wendy C. Ziai
- Departments of Neurology, Anesthesia and Critical Care Medicine, Division of Neurocritical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Carol B. Thompson
- Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - McBee Nichol
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Rachel Dlugash
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Natalie Ullman
- Departments of Neurology, Anesthesia and Critical Care Medicine, Division of Neurocritical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yi Hao
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Issam Awad
- Section of Neurosurgery and the Neurovascular Surgery Program, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD
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31
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Ziai WC, McBee N, Lane K, Lees KR, Dawson J, Vespa P, Thompson RE, Mendelow AD, Kase CS, Carhuapoma JR, Thompson CB, Mayo SW, Reilly P, Janis S, Anderson CS, Harrigan MR, Camarata PJ, Caron JL, Zuccarello M, Awad IA, Hanley DF. A randomized 500-subject open-label phase 3 clinical trial of minimally invasive surgery plus alteplase in intracerebral hemorrhage evacuation (MISTIE III). Int J Stroke 2019; 14:548-554. [PMID: 30943878 PMCID: PMC6706298 DOI: 10.1177/1747493019839280] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
RATIONALE AND HYPOTHESIS Surgical removal of spontaneous intracerebral hemorrhage may reduce secondary destruction of brain tissue. However, large surgical trials of craniotomy have not demonstrated definitive improvement in clinical outcomes. Minimally invasive surgery may limit surgical tissue injury, and recent evidence supports testing these approaches in large clinical trials. METHODS AND DESIGN MISTIE III is an investigator-initiated multicenter, randomized, open-label phase 3 study investigating whether minimally invasive clot evacuation with thrombolysis improves functional outcomes at 365 days compared to conservative management. Patients with supratentorial intracerebral hemorrhage clot volume ≥ 30 mL, confirmed by imaging within 24 h ofknown symptom onset,and intact brainstem reflexes were screened with a stability computed tomography scan at least 6 h after diagnostic scan. Patients who met clinical and imaging criteria (no ongoing coagulopathy; no suspicion of aneurysm, arteriovenous malformation, or any other vascular anomaly; and stable hematoma size on consecutive scans) were randomized to either minimally invasive surgery plus thrombolysis or medical therapy. The sample size of 500 was based on findings of a phase 2 study. STUDY OUTCOMES The primary outcome measure is dichotomized modified Rankin Scale 0-3 vs. 4-6 at 365 days adjusting for severity variables. Clinical secondary outcomes include dichotomized extended Glasgow Outcome Scale and all-cause mortality at 365 days; rate and extent of parenchymal blood clot removal; patient disposition at 365 days; efficacy at 180 days; type and intensity of ICU management; and quality of life measures. Safety was assessed at 30 days and throughout the study.
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Affiliation(s)
- Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Kennedy R Lees
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Paul Vespa
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - A David Mendelow
- Department of Neurosurgery, Newcastle University, Newcastle upon Tyne, UK
| | - Carlos S Kase
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - J Ricardo Carhuapoma
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Carol B Thompson
- Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Pat Reilly
- Genentech Inc., San Francisco, CA, USA (retired)
- Jamison-Reilly LLC, Hummelstown, PA, USA
| | - Scott Janis
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Craig S Anderson
- The George Institute for Global Health China at Peking University Health Science Center, Beijing, China
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas, Kansas City, KS, USA
| | - Jean-Louis Caron
- Department of Neurosurgery, University of Texas, San Antonio, TX, USA
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Issam A Awad
- Section of Neurosurgery, Neurovascular Surgery Program, University of Chicago, Chicago, IL, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
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Eslami V, Tahsili-Fahadan P, Rivera-Lara L, Gandhi D, Ali H, Parry-Jones A, Nelson LS, Thompson RE, Nekoobakht-Tak S, Dlugash R, McBee N, Awad I, Hanley DF, Ziai WC. Influence of Intracerebral Hemorrhage Location on Outcomes in Patients With Severe Intraventricular Hemorrhage. Stroke 2019; 50:1688-1695. [PMID: 31177984 DOI: 10.1161/strokeaha.118.024187] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- We investigated the prognostic significance of spontaneous intracerebral hemorrhage location in presence of severe intraventricular hemorrhage. Methods- We analyzed diagnostic computed tomography scans from 467/500 (excluding primary intraventricular hemorrhage) subjects from the CLEAR (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) III trial. We measured intracerebral hemorrhage engagement with specific anatomic regions, and estimated association of each region with blinded assessment of dichotomized poor stroke outcomes: mortality, modified Rankin Scale score of 4 to 6, National Institutes of Health Stroke Scale score of >4, stroke impact scale score of <60, Barthel Index <86, and EuroQol visual analogue scale score of <50 and <70 at days 30 and 180, respectively, using logistic regression models. Results- Frequency of anatomic region involvement consisted of thalamus (332 lesions, 71.1% of subjects), caudate (219, 46.9%), posterior limb internal capsule (188, 40.3%), globus pallidus/putamen (127, 27.2%), anterior limb internal capsule (108, 23.1%), and lobar (29, 6.2%). Thalamic location was independently associated with mortality (days 30 and 180) and with poor outcomes on most stroke scales at day 180 on adjusted analysis. Posterior limb internal capsule and globus pallidus/putamen involvement was associated with increased odds of worse disability at days 30 and 180. Anterior limb internal capsule and caudate locations were associated with decreased mortality on days 30 and 180. Anterior limb internal capsule lesions were associated with decreased long-term morbidity. Conclusions- Acute intracerebral hemorrhage lesion topography provides important insights into anatomic correlates of mortality and functional outcomes even in severe intraventricular hemorrhage causing obstructive hydrocephalus. Models accounting for intracerebral hemorrhage location in addition to volumes may improve outcome prediction and permit stratification of benefit from aggressive acute interventions. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00784134.
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Affiliation(s)
- Vahid Eslami
- From the Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (V.E., P.T.-F., L.R.-L., D.F.H., W.C.Z.).,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Pouya Tahsili-Fahadan
- From the Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (V.E., P.T.-F., L.R.-L., D.F.H., W.C.Z.).,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.).,Neuroscience Intensive Care Unit, Department of Neurology, Virginia Commonwealth University, Falls Church (P.T.-F.)
| | - Lucia Rivera-Lara
- From the Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (V.E., P.T.-F., L.R.-L., D.F.H., W.C.Z.).,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Dheeraj Gandhi
- Department of Neuroradiology, University of Maryland, Baltimore (D.G.)
| | - Hasan Ali
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Adrian Parry-Jones
- School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Salford Royal NHS Foundation Trust, United Kingdom (A.P.-J., L.S.N.)
| | - Lilli S Nelson
- School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Salford Royal NHS Foundation Trust, United Kingdom (A.P.-J., L.S.N.)
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (R.E.T.)
| | - Saman Nekoobakht-Tak
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Isaam Awad
- Department of Neurological Surgery, University of Chicago Medicine, IL (I.A.)
| | - Daniel F Hanley
- From the Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (V.E., P.T.-F., L.R.-L., D.F.H., W.C.Z.).,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Wendy C Ziai
- From the Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (V.E., P.T.-F., L.R.-L., D.F.H., W.C.Z.).,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
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McNett M, Moran C, Johnson H. Evidence-Based Review of Clinical Trials in Neurocritical Care. AACN Adv Crit Care 2019; 29:195-203. [PMID: 29875116 DOI: 10.4037/aacnacc2018200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Neurocritical care is a rapidly growing specialty of complex care for the critically ill patient with neurological injury. This rapid growth has led to an increase in the number of important clinical trials to guide clinical practice and evidence-based care of the critically ill patient with neurological injury. Specialty-trained critical care nurses and advanced practice providers are integral members of neurocritical care teams and must remain informed about pivotal trials shaping practice recommendations. This article presents a summary of recent trials that have affected current practice and influenced care recommendations in the neurocritical care setting.
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Affiliation(s)
- Molly McNett
- Molly McNett is Director, Nursing Research and Evidence-Based Practice, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Dr, Cleveland, OH 44109 . Cristina Moran is Clinical Nurse, Trauma Surgical Intensive Care Unit, MetroHealth Medical Center, Cleveland, Ohio. Halee Johnson is Advanced Practice Registered Nurse, Department of Neurosurgery, The MetroHealth System, Cleveland, Ohio
| | - Cristina Moran
- Molly McNett is Director, Nursing Research and Evidence-Based Practice, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Dr, Cleveland, OH 44109 . Cristina Moran is Clinical Nurse, Trauma Surgical Intensive Care Unit, MetroHealth Medical Center, Cleveland, Ohio. Halee Johnson is Advanced Practice Registered Nurse, Department of Neurosurgery, The MetroHealth System, Cleveland, Ohio
| | - Halee Johnson
- Molly McNett is Director, Nursing Research and Evidence-Based Practice, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Dr, Cleveland, OH 44109 . Cristina Moran is Clinical Nurse, Trauma Surgical Intensive Care Unit, MetroHealth Medical Center, Cleveland, Ohio. Halee Johnson is Advanced Practice Registered Nurse, Department of Neurosurgery, The MetroHealth System, Cleveland, Ohio
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Thiebaut AM, Gauberti M, Ali C, Martinez De Lizarrondo S, Vivien D, Yepes M, Roussel BD. The role of plasminogen activators in stroke treatment: fibrinolysis and beyond. Lancet Neurol 2018; 17:1121-1132. [PMID: 30507392 DOI: 10.1016/s1474-4422(18)30323-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/25/2018] [Accepted: 08/28/2018] [Indexed: 12/20/2022]
Abstract
Although recent technical advances in thrombectomy have revolutionised acute stroke treatment, prevalence of disability and death related to stroke remain high. Therefore, plasminogen activators-eukaryotic, bacterial, or engineered forms that can promote fibrinolysis by converting plasminogen into active plasmin and facilitate clot breakdown-are still commonly used in the acute treatment of ischaemic stroke. Hence, plasminogen activators have become a crucial area for clinical investigation for their ability to recanalise occluded arteries in ischaemic stroke and to accelerate haematoma clearance in haemorrhagic stroke. However, inconsistent results, insufficient evidence of efficacy, or reports of side-effects in trial settings might reduce the use of plasminogen activators in clinical practice. Additionally, the mechanism of action for plasminogen activators could extend beyond the vessel lumen and involve plasminogen-independent processes, which would suggest that plasminogen activators have also non-fibrinolytic roles. Understanding the complex mechanisms of action of plasminogen activators can guide future directions for therapeutic interventions in patients with stroke.
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Affiliation(s)
- Audrey M Thiebaut
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, Cyceron, Caen, France
| | - Maxime Gauberti
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, Cyceron, Caen, France
| | - Carine Ali
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, Cyceron, Caen, France
| | - Sara Martinez De Lizarrondo
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, Cyceron, Caen, France
| | - Denis Vivien
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, Cyceron, Caen, France; Clinical Research Department, University Hospital Caen-Normandy, Caen, France
| | - Manuel Yepes
- Department of Neurology and Center for Neurodegenerative Disease, Emory University School of Medicine, Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, and Department of Neurology, Veterans Affairs Medical Center, Atlanta, GA, USA
| | - Benoit D Roussel
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, Cyceron, Caen, France.
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Masomi-Bornwassser J, Freguia F, Müller-Werkmeister H, Kempski O, Giese A, Keric N. Effect of irrigation on fibrinolytic rtPA therapy in a clot model of intracerebral haemorrhage: a systematic in vitro study. Acta Neurochir (Wien) 2018; 160:1159-1165. [PMID: 29564653 DOI: 10.1007/s00701-018-3517-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 03/09/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Although fibrinolytic therapy is an upcoming treatment for intracerebral haemorrhage (ICH), standard guidelines are lacking, and some clinical issues persist. Here, we used our recently devised clot model of ICH to systematically analyse effects of irrigation and cerebrospinal fluid (CSF) on fibrinolysis. METHODS In vitro clots of human blood (25 ml) were generated and a catheter irrigation system was applied to deliver fluid/treatment. Clots were weighed before and after treatment and compared to rtPA treatment alone. First various drainage periods (15, 30 and 60 min; n = 3 each) and irrigation rates (0, 15, 90 and 180 ml/h; n = 3-5 each) were tested, followed by rtPA administration (1 mg, 15 min incubation) at each irrigation rate. Potential fibrinolytic effect of CSF was examined by incubation with 5 ml healthy vs. haemorrhagic CSF (n = 3 each). To assess a washout effect treatment with saline (0.9%), rtPA (1 mg) and high-rate irrigation (180 ml/h) were compared with measuring plasminogen level before and after. Furthermore clots were treated with a combination of plasminogen (150% serum concentration) and rtPA (1 mg). RESULTS Relative clot end weights after 60 min irrigation system treatments were 66.3 ± 3.8% (0 ml/h), 46.3 ± 9.5% (15 ml/h), 46.5 ± 7.1% (90 ml/h) and 53.3 ± 4.1% (180 ml/h). At a lower irrigation rate (15 ml/h), relative end weights were lowest (49.5 ± 4.6%) after 60 min (15 min: 62 ± 4.3%, p = 0.016; 30 min: 62.90 ± 1.88%, p = 0.012). The combination of rtPA and irrigation produced following relative end weights: 0 ml/h, 35 ± 3.2%; 15 ml/h, 32.1 ± 5.7%; 90 ml/h, 36.7 ± 6.3% and 180 ml/h, 41.9 ± 7.5%. No irrigation (0 ml/h) versus rtPA alone showed a significant difference (p < 0.0001) in higher clot weight reduction by rtPA. Similar rtPA+15 ml/h irrigation achieved a significant higher weight reduction compared to 15 ml/h irrigation alone (p = 0.0124). No differences were evident at 90 and 180 ml/h irrigation rates with and without rtPA. Healthy (55.1 ± 5%) or haemorrhagic (65.2 ± 6.2%) CSF showed no fibrinolytic activity. Plasminogen levels in clots declined dramatically (> 80% initially to < 10%) after 1 mg single rtPA dosing and high-rate (180 ml/h) irrigation. The fibrinolytic benefit of adding plasminogen to rtPA was marginal. CONCLUSIONS In our in vitro clot model, irrigation combined with rtPA (vs. rtPA alone) conferred no added lytic benefit. Likewise, exposure to haemorrhagic CSF did not increase clot lysis.
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Affiliation(s)
- Julia Masomi-Bornwassser
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Fabio Freguia
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
- Department of Neuropathology, University- and Knappschaft- Hospital Bochum, Bochum, Germany
| | - Hendrik Müller-Werkmeister
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Asklepios Klinikum Harburg, Hamburg, Germany
| | - Oliver Kempski
- Institute of Neurosurgical Pathophysiology, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Alf Giese
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
- OrthoCentrum Hamburg, Hansastr. 1-3, Hamburg, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
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Hammond DA, Baumgartner L, Cooper C, Donahey E, Harris SA, Mercer JM, Morris M, Patel MK, Plewa-Rusiecki AM, Poore AA, Szaniawski R, Horner D. Major publications in the critical care pharmacotherapy literature: January-December 2017. J Crit Care 2018; 45:239-246. [PMID: 29496373 DOI: 10.1016/j.jcrc.2018.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 02/18/2018] [Accepted: 02/20/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2017. The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 32 journals monthly for impactful articles and reviewed 115 during 2017. Two meta-analyses and eight original research trials were reviewed here from those included in the monthly CCPLU. Meta-analyses on early, goal-directed therapy for septic shock and statin therapy for acute respiratory distress syndrome were summarized. Original research trials that were included evaluate thrombolytic therapy in severe stroke, hyperoxia and hypertonic saline in septic shock, intraoperative ketamine for prevention of post-operative delirium, intravenous ketorolac dosing regimens for acute pain, angiotensin II for vasodilatory shock, dabigatran reversal with idarucizumab, bivalirudin versus heparin monotherapy for myocardial infarction, and balanced crystalloids versus saline fluid resuscitation. CONCLUSION This clinical review provides perspectives on impactful critical care pharmacotherapy publications in 2017.
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Affiliation(s)
- Drayton A Hammond
- Rush University Medical Center, 1653 West Congress Parkway, Chicago, IL 60612, United States.
| | - Laura Baumgartner
- Touro University California College of Pharmacy, 1310 Club Drive, Vallejo, CA 94592, United States
| | - Craig Cooper
- Roosevelt University College of Pharmacy, 430 S. Michigan Avenue, Chicago, IL 60605, United States.
| | - Elisabeth Donahey
- Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL 60153, United States.
| | - Serena A Harris
- Eskenazi Health, 720 Eskenazi Avenue, Indianapolis, IN 46202, United States.
| | - Jessica M Mercer
- Roper St Francis Healthcare, 2095 Henry Tecklenburg Drive, Charleston, SC 29414, United States
| | - Mandy Morris
- University of California, San Francisco Medical Center, 533 Parnassus Ave., Box 0622, San Francisco, CA 94143, United States.
| | - Mona K Patel
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, 630 West 168th Street, NY, New York 10032, United States.
| | - Angela M Plewa-Rusiecki
- John H. Stroger, Jr. Hospital of Cook County, 1901 West Harrison Street, LL175, Chicago, IL 60612, United States.
| | - Alia A Poore
- Cleveland Clinic Fairview Hospital, 18101 Lorain Road, Cleveland, OH 44111, United States.
| | - Ryan Szaniawski
- Froedtert & the Medical College of Wisconsin - Community Memorial Hospital, W180 N8085 Town Hall Rd, Menomonee Falls, WI 53226, United States.
| | - Deanna Horner
- United Healthcare Medicare and Retirement - Part D STARs, 2655 Warrenville Road, 3rd floor, Downers Grove, IL 60515, United States.
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Intraventricular hemorrhage related to AVM rupture: Description, outcomes and impact of intraventricular fibrinolysis. Clin Neurol Neurosurg 2017; 164:92-96. [PMID: 29216502 DOI: 10.1016/j.clineuro.2017.11.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/17/2017] [Accepted: 11/29/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Arteriovenous malformation (AVM) rupture could lead to intraventricular hemorrhage (IVH), a particularly severe form of intracranial bleeding. The epidemiology, presentation, management and outcomes of IVH related to AVM rupture have not been clearly addressed yet. The aim of the present study was to investigate the characteristics of IVH related to AVM rupture, with particular attention paid to functional outcomes and to the impact of intraventricular fibrinolysis (IVF). PATIENTS AND METHODS Between 2011 and 2015, all patients suffering from IVH admitted in two tertiary neurosurgical centers were included in a prospective register. Patient with IVH related to AVM rupture were identified (n=29) and their data retrospectively collected. Particular attention was paid on patients who received IVF. We also compared them to 29 apparied aneurysmal IVH. RESULTS IVH related to AVM rupture often occurred in young patients. In most cases, intracerebral hemorrhage was associated to IVH. 17% of the patients died, and functional outcome at 6 months was similar to those with aneurysmal IVH. Interestingly, 5 patients received IVF and none experienced any rebleeding. CONCLUSION IVH related to AVM rupture is a severe form of hemorrhagic stroke, with a poor neurologic prognosis. IVF seems to be safe and may be considered in this particular form of IVH.
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Labib MA, Shah M, Kassam AB, Young R, Zucker L, Maioriello A, Britz G, Agbi C, Day JD, Gallia G, Kerr R, Pradilla G, Rovin R, Kulwin C, Bailes J. The Safety and Feasibility of Image-Guided BrainPath-Mediated Transsulcul Hematoma Evacuation: A Multicenter Study. Neurosurgery 2017; 80:515-524. [PMID: 27322807 DOI: 10.1227/neu.0000000000001316] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 03/02/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Subcortical injury resulting from conventional surgical management of intracranial hemorrhage may counteract the potential benefits of hematoma evacuation. OBJECTIVE To evaluate the safety and potential benefits of a novel, minimally invasive approach for clot evacuation in a multicenter study. METHODS The integrated approach incorporates 5 competencies: (1) image interpretation and trajectory planning, (2) dynamic navigation, (3) atraumatic access system (BrainPath, NICO Corp, Indianapolis, Indiana), (4) extracorporeal optics, and (5) automated atraumatic resection. Twelve neurosurgeons from 11 centers were trained to use this approach through a continuing medical education-accredited course. Demographical, clinical, and radiological data of patients treated over 2 years were analyzed retrospectively. RESULTS Thirty-nine consecutive patients were identified. The median Glasgow Coma Scale (GCS) score at presentation was 10 (range, 5-15). The thalamus/basal ganglion regions were involved in 46% of the cases. The median hematoma volume and depth were 36 mL (interquartile range [IQR], 27-65 mL) and 1.4 cm (IQR, 0.3-2.9 cm), respectively. The median time from ictus to surgery was 24.5 hours (IQR, 16-66 hours). The degree of hematoma evacuation was ≥90%, 75% to 89%, and 50% to 74% in 72%, 23%, and 5.0% of the patients, respectively. The median GCS score at discharge was 14 (range, 8-15). The improvement in GCS score was statistically significant ( P < .001). Modified Rankin Scale data were available for 35 patients. Fifty-two percent of those patients had a modified Rankin Scale score of ≤2. There were no mortalities. CONCLUSION The approach was safely performed in all patients with a relatively high rate of clot evacuation and functional independence.
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Affiliation(s)
- Mohamed A Labib
- Division of Neurosurgery, Department of Surgery,University of Ottawa,Ottawa,On-tario, Canada
| | - Mitesh Shah
- Department of Neurosu-rgery, Goodman Campbell Brain and Spi-ne and Indiana University, Indianapolis, Indiana
| | - Amin B Kassam
- Department of Neurosurg-ery, Aurora Neuroscience and Inn-ovation Institute, Milwaukee, Wisconsin
| | - Ronald Young
- Department of Neurosu-rgery, Goodman Campbell Brain and Spi-ne and Indiana University, Indianapolis, Indiana
| | - Lloyd Zucker
- Department of Neurosurgery, Delray Medical Center, Delray Beach, Florida
| | - Anthony Maioriello
- Department of Neurosurgery, Clear Lake Regional Medical Center, Webster, Texas
| | - Gavin Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Charles Agbi
- Department of Surgery, Otta-wa Civic Hospital, Ottawa, Ontario, Canada
| | - J D Day
- Department of Neurosurgery, University of Arkansas for Medical Sci-ences, Little Rock, Arkansas
| | - Gary Gallia
- Depart-ment of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Robert Kerr
- Depart-ment of Neurosurgery, North Shore-LIJ/Huntington Hospital, Huntington, New York
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Richard Rovin
- Department of Neurosurg-ery, Aurora Neuroscience and Inn-ovation Institute, Milwaukee, Wisconsin
| | - Charles Kulwin
- Department of Neurosu-rgery, Goodman Campbell Brain and Spi-ne and Indiana University, Indianapolis, Indiana
| | - Julian Bailes
- Department of Neuro-surgery, NorthShore University Health-System, Evanston, Illinois
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Dharmadhikari S, Mahapatra A, Tipirneni A, Yavagal D, Malik AM. Safety of Intraventricular rt-PA for Pan-Ventricular IVH Caused by a Ruptured AVM: A Case Report. Neurohospitalist 2017; 7:NP5-NP8. [PMID: 28975005 DOI: 10.1177/1941874416689363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Intraventricular recombinant tissue plasminogen activator (IVT rt-PA) has improved outcomes for intraventricular hemorrhage (IVH). Patients with suspected or untreated arteriovenous malformations (AVMs) have been excluded from clinical trials. We present a patient with IVH secondary to a ruptured AVM safely treated with IVT rt-PA. A 48-year-old Hispanic male with a history of dermatomyositis presented to the emergency department with sudden left-sided weakness. En route to computed tomography (CT), he became lethargic. Computed tomography revealed extensive IVH with acute hydrocephalus, which was treated with the placement of external ventricular drain with clinical improvement. Computed tomography angiogram performed did not reveal AVM. Cerebral digital subtraction angiogram (DSA) was planned due to suspicion of AVM. Prior to DSA, patient became acutely lethargic. Computed tomography imaging revealed worsening hydrocephalus. External ventricular drain was noted to be draining. Repeat CT revealed improved hydrocephalus but with left lateral ventricle dilatation. Risks and benefits of IVT rt-PA were discussed with the family and a decision was made to treat. Three doses of 1 mg IVT rt-PA were administered with resolution of midline blood and lateral ventricular dilatation with clinical improvement. Digital subtraction angiogram revealed early draining vein on right internal carotid artery injection draining into the inferior sagittal sinus representing ruptured AVM without clear nidus. Repeat DSA with possible embolization was planned after discharge. In spite of additional in-hospital complications, the patient gradually improved and was ultimately discharged home. Our case supports the idea that the use of IVT rt-PA following an IVH caused by an underlying AVM could be further explored in carefully designed clinical trials.
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Affiliation(s)
- Sushrut Dharmadhikari
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ashutosh Mahapatra
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Anita Tipirneni
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dileep Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Amer M Malik
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
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Sprügel MI, Kuramatsu JB, Gerner ST, Sembill JA, Hartwich J, Giede-Jeppe A, Madžar D, Beuscher VD, Hoelter P, Lücking H, Struffert T, Schwab S, Huttner HB. Presence of Concomitant Systemic Cancer is Not Associated with Worse Functional Long-Term Outcome in Patients with Intracerebral Hemorrhage. Cerebrovasc Dis 2017; 44:186-194. [PMID: 28768267 DOI: 10.1159/000479075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/27/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Data on clinical characteristics and outcome of patients with intracerebral hemorrhage (ICH) and concomitant systemic cancer disease are very limited. METHODS Nine hundred and seventy three consecutive primary ICH patients were analyzed using our prospective institutional registry over a period of 9 years (2006-2014). We compared clinical and radiological parameters as well as outcome - scored using the modified Rankin Scale (mRS) and analyzed in a dichotomized fashion as favorable outcome (mRS = 0-3) and unfavorable outcome (mRS = 4-6) - of ICH patients with and without cancer. Relevant imbalances in baseline clinical and radiological characteristics were adjusted using propensity score (PS) matching. RESULTS Prevalence of systemic cancer among patients with ICH was 8.5% (83/973). ICH patients with cancer were older (77 [70-82] vs. 72 [63-80] years; p = 0.002), had more often prior renal dysfunction (19/83 [22.9%] vs.107/890 [12.0%]; p = 0.005), and smaller hemorrhage volumes (10.1 [4.8-24.3] vs. 15.3 [5.4-42.9] mL; p = 0.017). After PS-matching there were no significant differences neither in mortality nor in functional outcome both at 3 months (mortality: 33/81 [40.7%] vs. 55/158 [34.8%]; p = 0.368; mRS = 0-3: 28/81 [34.6%] vs. 52/158 [32.9%]; p = 0.797) and 12 months (mortality: 39/78 [50.0%] vs. 70/150 [46.7%]; p = 0.633; mRS = 0-3: 25/78 [32.1%] vs. 53/150 [35.3%]; p = 0.620) among patients with and without concomitant systemic cancer. ICH volume tended to be highest in patients with hematooncologic malignancy and smallest in urothelial cancer. CONCLUSIONS Patients with ICH and concomitant systemic cancer on average are older; however, they show smaller ICH volumes compared to patients without cancer. Yet, mortality and functional outcome is not different in ICH patients with and without cancer. Thus, the clinical history or the de novo diagnosis of concomitant malignancies in ICH patients should not lead to unjustified treatment restrictions.
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Murthy SB, Awad I, Harnof S, Aldrich F, Harrigan M, Jallo J, Caron JL, Huang J, Camarata P, Lara LR, Dlugash R, McBee N, Eslami V, Hanley DF, Ziai WC. Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial. Neurology 2017; 89:355-362. [PMID: 28659429 DOI: 10.1212/wnl.0000000000004155] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 04/11/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To study factors associated with permanent CSF diversion and the relationship between shunting and functional outcomes in spontaneous intraventricular hemorrhage (IVH). METHODS Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III), a randomized, multicenter, double-blind, placebo-controlled trial, was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular alteplase improved outcome, in comparison to EVD plus saline. Outcome measures were predictors of shunting and blinded assessment of mortality and modified Rankin Scale at 180 days. RESULTS Among the 500 patients with IVH, CSF shunting was performed in 90 (18%) patients at a median of 18 (interquartile range [IQR] 13-30) days. Patient demographics and IVH characteristics were similar among patients with and without shunts. In the multivariate analysis, black race (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.18-3.34), duration of EVD (OR 1.10; CI 1.05-1.15), placement of more than one EVD (OR 1.93; CI 1.13-3.31), daily drainage CSF per 10 mL (OR 1.07; CI 1.04-1.10), and intracranial pressure >30 mm Hg (OR 1.70; CI 1.09-2.88) were associated with higher odds of permanent CSF shunting. Patients who had CSF shunts had similar odds of 180-day mortality, while survivors with shunts had increased odds of poor functional outcome, compared to survivors without shunts. CONCLUSIONS Among patients with spontaneous IVH requiring emergency CSF diversion, those with early elevated intracranial pressure, high CSF output, and placement of more than one EVD are at increased odds of permanent ventricular shunting. Administration of intraventricular alteplase, early radiographic findings, and CSF measures were not useful predictors of permanent CSF diversion.
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Affiliation(s)
- Santosh B Murthy
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD.
| | - Issam Awad
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Sagi Harnof
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Francois Aldrich
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Mark Harrigan
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Jack Jallo
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Jean-Louis Caron
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Judy Huang
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Paul Camarata
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Lucia Rivera Lara
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Rachel Dlugash
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Nichol McBee
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Vahid Eslami
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Daniel F Hanley
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Wendy C Ziai
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
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Abstract
Managing acute intracerebral haemorrhage is a challenging task for physicians. Evidence shows that outcome can be improved with admission to an acute stroke unit and active care, including urgent reversal of anticoagulant effects and, potentially, intensive blood pressure reduction. Nevertheless, many management issues remain controversial, including the use of haemostatic therapy, selection of patients for neurosurgery and neurocritical care, the extent of investigations for underlying causes and the benefit versus risk of restarting antithrombotic therapy after an episode of intracerebral haemorrhage.
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Affiliation(s)
- Zhe Kang Law
- University of Nottingham, UK
- National University of Malaysia, Kuala Lumpur, Malaysia
| | | | - Philip M Bath
- University of Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Fam MD, Pang A, Zeineddine HA, Mayo S, Stadnik A, Jesselson M, Zhang L, Dlugash R, Ziai W, Hanley D, Awad IA. Demographic Risk Factors for Vascular Lesions as Etiology of Intraventricular Hemorrhage in Prospectively Screened Cases. Cerebrovasc Dis 2017; 43:223-230. [PMID: 28245439 DOI: 10.1159/000458452] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/28/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Spontaneous intraventricular hemorrhage (IVH) is associated with high rates of morbidity and mortality despite critical care and other advances. An important step in clinical management is to confirm/rule out an underlying vascular lesion, which influences further treatment, potential for further bleeding, and prognosis. Our aim is to compare demographic and clinical characteristics between IVH patients with and without an underlying vascular lesion, and among cohorts with different vascular lesions. METHODS We analyzed prospectively collected data of IVH patients screened for eligibility as part of the Clot Lysis: Evaluation Accelerated Resolution of IVH Phase III (CLEAR III) clinical trial. The trial adopted a structured screening process to systematically exclude patients with an underlying vascular lesion as the etiology of IVH. We collected age, sex, ethnicity, and primary diagnosis on these cases and vascular lesions were categorized prospectively as aneurysm, vascular malformation (arteriovenous malformation, dural arteriovenous fistula, and cavernoma), Moyamoya disease, or other vascular lesion. We excluded cases <18 or >80 years of age. Baseline characteristics were compared between the CLEAR group (IVH screened without vascular lesion) and the group of IVH patients screened and excluded from CLEAR because of an identified vascular lesion. We further analyzed the differential demographic and clinical characteristics among subcohorts with different vascular lesions. RESULTS A total of 10,538 consecutive IVH cases were prospectively screened for the trial between 2011 and 2015. Out of these, 496 cases (4.7%) screened negative for underlying vascular lesion, met the inclusion criteria, and were enrolled in the trial (no vascular etiology group); and 1,205 cases (11.4%) were concurrently screened and excluded from the trial because of a demonstrated underlying vascular lesion (vascular etiology group). Cases with vascular lesion were less likely to be >45 years of age (OR 0.28, 95% CI 0.20-0.40), African-American (OR 0.23, 95% CI 0.18-0.31), or male gender (OR 0.48, 95% CI 0.38-0.60), and more likely to present with primary IVH (OR 1.85, 95% CI 1.37-2.51) compared to those with no vascular etiology (p < 0.001). Other demographic factors were associated with specific vascular lesion etiologies. A combination of demographic features increases the association with the absence of vascular lesion, but not with absolute reliability (OR 0.1, 95% CI 0.06-0.17, p < 0.001). CONCLUSION An underlying vascular lesion as etiology of IVH cannot be excluded solely by demographic parameters in any patient. Some form of vascular imaging is necessary in screening patients before contemplating interventions like intraventricular fibrinolysis, where safety may be impacted by the presence of vascular lesion.
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Affiliation(s)
- Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, IL, USA
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Hanley DF, Lane K, McBee N, Ziai W, Tuhrim S, Lees KR, Dawson J, Gandhi D, Ullman N, Mould WA, Mayo SW, Mendelow AD, Gregson B, Butcher K, Vespa P, Wright DW, Kase CS, Carhuapoma JR, Keyl PM, Diener-West M, Muschelli J, Betz JF, Thompson CB, Sugar EA, Yenokyan G, Janis S, John S, Harnof S, Lopez GA, Aldrich EF, Harrigan MR, Ansari S, Jallo J, Caron JL, LeDoux D, Adeoye O, Zuccarello M, Adams HP, Rosenblum M, Thompson RE, Awad IA. Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet 2017; 389:603-611. [PMID: 28081952 PMCID: PMC6108339 DOI: 10.1016/s0140-6736(16)32410-2] [Citation(s) in RCA: 295] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome. METHODS In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134. FINDINGS Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88-1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90-1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41-0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22-3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31-0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64-0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37-3·91], p=0·771) was similar. INTERPRETATION In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status. FUNDING National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Daniel F Hanley
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA.
| | - Karen Lane
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Nichol McBee
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Wendy Ziai
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Stanley Tuhrim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Natalie Ullman
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - W Andrew Mould
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | | | | | | | | | - Paul Vespa
- University of California, Los Angeles, CA, USA
| | | | | | - J Ricardo Carhuapoma
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Penelope M Keyl
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Marie Diener-West
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - John Muschelli
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Joshua F Betz
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Carol B Thompson
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Elizabeth A Sugar
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Gayane Yenokyan
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Scott Janis
- National Institutes of Health, National institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | | | - Sagi Harnof
- Chaim Sheba Medical Center, Ramat Gan, Israel
| | | | | | | | | | - Jack Jallo
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - David LeDoux
- North Shore Long Island Jewish Medical Center, Manhasset, NY, USA
| | | | | | | | - Michael Rosenblum
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Richard E Thompson
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
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45
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Abstract
In the past decade, the definition of stroke has been revised and major advances have been made for its treatment and prevention. For acute ischaemic stroke, the addition of endovascular thrombectomy of proximal large artery occlusion to intravenous alteplase increases functional independence for a further fifth of patients. The benefits of aspirin in preventing early recurrent ischaemic stroke are greater than previously recognised. Other strategies to prevent recurrent stroke now include direct oral anticoagulants as an alternative to warfarin for atrial fibrillation, and carotid stenting as an alternative to endarterectomy for symptomatic carotid stenosis. For acute intracerebral haemorrhage, trials are ongoing to assess the effectiveness of acute blood pressure lowering, haemostatic therapy, minimally invasive surgery, anti-inflammation therapy, and neuroprotection methods. Pharmacological and stem-cell therapies promise to facilitate brain regeneration, rehabilitation, and functional recovery. Despite declining stroke mortality rates, the global burden of stroke is increasing. A more comprehensive approach to primary prevention of stroke is required that targets people at all levels of risk and is integrated with prevention strategies for other diseases that share common risk factors.
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Affiliation(s)
- Graeme J Hankey
- School of Medicine & Pharmacology, The University of Western Australia, Perth, WA, Australia; Department of Neurology, Sir Charles Gairdner Hospital, Perth, WA, Australia; Western Australian Neuroscience Research Institute (WANRI), Perth, WA, Australia.
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Chen Q, Feng Z, Tan Q, Guo J, Tang J, Tan L, Feng H, Chen Z. Post-hemorrhagic hydrocephalus: Recent advances and new therapeutic insights. J Neurol Sci 2017; 375:220-230. [PMID: 28320134 DOI: 10.1016/j.jns.2017.01.072] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 01/25/2017] [Accepted: 01/30/2017] [Indexed: 02/07/2023]
Abstract
Post-hemorrhagic hydrocephalus (PHH), also referred to as progressive ventricular dilatation, is caused by disturbances in cerebrospinal fluid (CSF) flow or absorption following hemorrhage in the brain. As one of the most serious complications of neonatal/adult intraventricular hemorrhage (IVH), subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI), PHH is associated with increased morbidity and disability of these events. Common sequelae of PHH include neurocognitive impairment, motor dysfunction, and growth impairment. Non-surgical measures to reduce increased intracranial pressure (ICP) in PHH have shown little success and most patients will ultimately require surgical management, such as external ventricular drainage and shunting which mostly by inserting a CSF drainage shunt. Unfortunately, shunt complications are common and the optimum time for intervention is unclear. To date, there remains no comprehensive strategy for PHH management and it becomes imperative that to explore new therapeutic targets and methods for PHH. Over past decades, increasing evidence have indicated that hemorrhage-derived blood and subsequent metabolic products may play a key role in the development of IVH-, SAH- and TBI-associated PHH. Several intervention strategies have recently been evaluated and cross-referenced. In this review, we summarized and discussed the common aspects of hydrocephalus following IVH, SAH and TBI, relevant experimental animal models, clinical translation of in vivo experiments, and potential preventive and therapeutic targets for PHH.
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Affiliation(s)
- Qianwei Chen
- Department of Neurosurgery, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Zhou Feng
- Department of Neurosurgery, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Qiang Tan
- Department of Neurosurgery, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Jing Guo
- Department of Neurosurgery, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China; Department of Neurosurgery, The 211st Hospital of PLA, Harbin 150086, China
| | - Jun Tang
- Department of Neurosurgery, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Liang Tan
- Department of Neurosurgery, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China.
| | - Zhi Chen
- Department of Neurosurgery, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China.
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Improving precision by adjusting for prognostic baseline variables in randomized trials with binary outcomes, without regression model assumptions. Contemp Clin Trials 2017; 54:18-24. [PMID: 28064029 DOI: 10.1016/j.cct.2016.12.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/21/2016] [Accepted: 12/31/2016] [Indexed: 11/24/2022]
Abstract
In randomized clinical trials with baseline variables that are prognostic for the primary outcome, there is potential to improve precision and reduce sample size by appropriately adjusting for these variables. A major challenge is that there are multiple statistical methods to adjust for baseline variables, but little guidance on which is best to use in a given context. The choice of method can have important consequences. For example, one commonly used method leads to uninterpretable estimates if there is any treatment effect heterogeneity, which would jeopardize the validity of trial conclusions. We give practical guidance on how to avoid this problem, while retaining the advantages of covariate adjustment. This can be achieved by using simple (but less well-known) standardization methods from the recent statistics literature. We discuss these methods and give software in R and Stata implementing them. A data example from a recent stroke trial is used to illustrate these methods.
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Prolonged hydrocephalus induced by intraventricular hemorrhage in rats is reduced by curcumin therapy. Neurosci Lett 2017; 637:120-125. [DOI: 10.1016/j.neulet.2016.11.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 11/15/2016] [Accepted: 11/18/2016] [Indexed: 12/12/2022]
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Dos Santos SC, Fortes Lima TT, Lunardi LW, Stefani MA. External Ventricular Drain-Related Infection in Spontaneous Intracerebral Hemorrhage. World Neurosurg 2016; 99:580-583. [PMID: 28024977 DOI: 10.1016/j.wneu.2016.12.071] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We aimed to analyze infection rates in patients with spontaneous intracranial hemorrhage who underwent surgical external ventricular drain (EVD) placement. METHODS This prospective study included 94 consecutive patients who required an EVD for spontaneous intracranial hemorrhage at the Neurosurgery Department of Hospital Cristo Redentor, Porto Alegre, Rio Grande do Sul, Brazil. RESULTS The mean duration of EVD use was 7 days. Overall sample mortality was 45%, and overall infection rate was 36%. Patients who had an EVD in place >10 days had higher odds of infection than patients who had an EVD in place ≤10 days (odds ratio = 3.1, 95% confidence interval, 1.1-8.7). Culture positivity rate was 5.3%. CONCLUSIONS Our findings suggest that EVD infection is a very common complication, occurring in 36.2% of cases. We adopted ventriculitis as the standard diagnosis, as advocated by the U.S. Centers for Disease Control and Prevention. Considering the high lethality associated with intracranial hemorrhage, use of a more aggressive treatment protocol for this patient population might improve morbidity and mortality rates.
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Affiliation(s)
- Samir Cezimbra Dos Santos
- Department of Neurosurgery, Hospital Cristo Redentor, Porto Alegre, Rio Grande do Sul, Brazil; Department of Neurosurgery, Hospital de Pronto Socorro, Porto Alegre, Rio Grande do Sul, Brazil.
| | | | - Luciano Werle Lunardi
- Department of Infectious Diseases, Hospital Cristo Redentor, Porto Alegre, Rio Grande do Sul, Brazil
| | - Marco Antonio Stefani
- Department of Neurosurgery, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Gilard V, Djoubairou BO, Lepetit A, Metayer T, Gakuba C, Gourio C, Derey S, Proust F, Emery E, Gaberel T. Small versus Large Catheters for Ventriculostomy in the Management of Intraventricular Hemorrhage. World Neurosurg 2016; 97:117-122. [PMID: 27729301 DOI: 10.1016/j.wneu.2016.09.105] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/23/2016] [Accepted: 09/26/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Intraventricular hemorrhage (IVH) often requires the insertion of an external ventricular drain (EVD), but blood clots could occlude the catheters. Large EVD catheters may help to reduce the risk of catheter occlusion. Here, we compared small catheters with large catheters for ventriculostomy in patients suffering from IVH. METHODS We conducted a retrospective cohort study. Patients were included if they had IVH requiring EVD insertion. We then compared baseline characteristics and outcomes of patients treated with large catheters with patients treated with small catheters. RESULTS Between 2011 and 2015, 227 IVH patients were admitted to our 2 hospitals. Among the patients, 28 were treated in first intention with large catheters, and 46 controls were identified. Insertion of large catheter decreased the risk of temporary and permanent catheter occlusion without impact on the occurrence of intracerebral hemorrhage (ICH) related to catheter insertion. There was 38.5% more catheter-related infections in the small catheter group when compared with the large catheter group, but this result was not significant. There was no impact on functional outcomes. Surprisingly, the rate of death was higher in the large catheter group. CONCLUSIONS In patients suffering from IVH, the use of large catheters for EVD reduced the risk of catheter occlusion without increasing the risk of ICH related to catheter insertion. The risk of catheter-related infection may subsequently be decreased by using large catheters. A prospective randomized trial would be necessary to seek out any benefits that large catheters may provide for the risk of death and functional outcome.
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Affiliation(s)
- Vianney Gilard
- Department of Neurosurgery, Rouen University Hospital, Rouen, France
| | | | - Arnaud Lepetit
- Department of Anesthesiology and Neurocritical Care, Caen University Hospital, Caen, France
| | - Thomas Metayer
- Department of Neurosurgery, University Hospital of Caen, Caen, France
| | - Clement Gakuba
- Department of Anesthesiology and Neurocritical Care, Caen University Hospital, Caen, France; Normandie University, UNICAEN, INSERM, Serine Proteases and Pathophysiology of the Neurovascular Unit, Caen, France
| | - Charlotte Gourio
- Department of Pharmacy, University Hospital of Caen, Caen, France
| | - Stephane Derey
- Department of Neurosurgery, Rouen University Hospital, Rouen, France
| | - François Proust
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Evelyne Emery
- Department of Neurosurgery, University Hospital of Caen, Caen, France; Normandie University, UNICAEN, INSERM, Serine Proteases and Pathophysiology of the Neurovascular Unit, Caen, France
| | - Thomas Gaberel
- Department of Neurosurgery, University Hospital of Caen, Caen, France; Normandie University, UNICAEN, INSERM, Serine Proteases and Pathophysiology of the Neurovascular Unit, Caen, France.
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