Advances in spontaneous intracerebral haemorrhage

Laser localization with soft‑channel minimally invasive surgery in cerebral hemorrhage

The aim of the present study was to evaluate the efficacy and safety of laser localization combined with soft-channel minimally invasive surgery (MIS) for the treatment of cerebral hemorrhage, and to develop stereotactic alternatives that are cost-effective, safe and precise for underdeveloped regions. To meet this aim, 60 patients with cerebral hemorrhage were randomly assigned to the control group (n=30) or the study group (n=30). The patients in the study group were treated with laser localization combined with soft-channel MIS to remove the hematoma, whereas the control group was treated with YL-1 needle puncture to drain the intracranial hemorrhage. All patients underwent successful surgical treatment. The hematoma clearance rate was revealed to be 88.72±2.82% in the study group and 84.50±4.26% in the control group. Both groups achieved residual hematoma volume <10 ml or a hematoma clearance rate >70%, and the difference in the hematoma clearance rate was found to be statistically significant (P<0.05), with the study group having an improved hematoma clearanc2e rate compared with the control group. The median 7-day postoperative Glasgow Coma Scale score was 13.0 [interquartile range (IQR), 12.0, 14.0] for the study group and 12.0 (IQR, 11.0, 13.0) for the control group, indicating an improved outcome in the study group. The puncture accuracy was 100% (30/30) in the study group compared with 76.66% (23/30) in the control group (P<0.05). The hematoma drainage time was found to be significantly shorter in the study group (40.57±8.24 h) compared with that in the control group (56.80±14.40 h) (P<0.05). At the 6-month follow-up, the median modified Rankin Scale score was found to be 2.0 (IQR, 2.0, 3.0) in both groups. Neither group experienced rebleeding, hydrocephalus or cerebral infarction. No intracranial infections occurred in the treatment group, whereas three cases of intracranial infection were observed in the control group. In conclusion, the findings of the present study have shown that laser localization combined with soft-channel MIS is effective and safe in the treatment of cerebral hemorrhage.

Targeting the neurovascular unit: Therapeutic potential of traditional Chinese medicine for the treatment of stroke

Stroke poses a significant global health challenge due to its elevated disability and mortality rates, particularly affecting developing nations like China. The neurovascular unit (NVU), a new concept encompassing neurons, brain microvascular endothelial cells, pericytes, astrocytes, microglia, and the extracellular matrix, has gained prominence in recent years. Traditional Chinese medicine (TCM), deeply rooted in Chinese history, employs a combination of acupuncture and herbal treatments, demonstrating significant efficacy across all stages of stroke, notably during recovery. The holistic approach of TCM aligns with the NVU's comprehensive view of treating stroke by addressing neurons, surrounding cells, and blood vessels collectively. This review examines the role of NVU in stroke and endeavors to elucidate the mechanisms through which traditional Chinese medicine exerts its anti-stroke effects within the NVU framework. The NVU contributes to neuroinflammation, immune infiltration, blood-brain barrier permeability, oxidative stress, and Ca2+ overload during stroke occurs. Additionally, TCM targeting the NVU facilitates nerve repair post-stroke through various pathways and approaches. Specific herbs, including panax notoginseng, ginseng, and borneol, alleviate brain injury by enhancing brain-derived neurotrophic factor expression and targeting astrocytes and microglia to yield anti-inflammatory and antioxidant effects. Acupuncture, another facet of TCM, promotes brain injury repair by augmenting cerebral blood flow and improving circulation. This exploration aims to assess the viability of stroke treatment by directing TCM interventions toward the NVU, thus paving the way for its broader clinical application.

A Novel Stereotactic Aspiration Technique for Intracerebral Hemorrhage

BACKGROUND

Minimally invasive surgery is effective and recommended for treatment of intracerebral hemorrhage; however, neurosurgeons in grass-root hospitals in underdeveloped countries lack effective and precise minimally invasive surgery techniques. The aim of this study was to present a technique of computed tomography angiography-based three-dimensional-printed navigation mold-guided stereotactic aspiration and demonstrate its clinical application using a hard needle in a series of patients.

METHODS

The novel stereotactic aspiration technique was performed in 18 patients with spontaneous intracerebral hemorrhage at our center, and clinical outcomes were reported. We compared the volume of hematoma measured by 3 different methods: ABC/2 formula, manual segmentation with OsiriX, and manual segmentation with 3D Slicer.

RESULTS

The surgery was completed safely within an average operative time of 15.11 minutes, achieving the goal of <15 mL residual clot volume or >70% clot removal in all patients. No intracranial rebleeding or infection was observed postoperatively. At the end of the 6-month follow-up, 61.11% (11/18) of patients achieved a modified Rankin Scale score <3. There was overall better agreement of hematoma measurement using segmentation with 3D Slicer rather than ABC/2 measurement or hematoma measurement using segmentation with OsiriX.

CONCLUSIONS

Our novel method of stereotactic aspiration benefited patients in this study with good percent clot removal, few surgery-related complications, and a favorable prognosis. Manual segmentation with 3D Slicer could be used to provide the neurosurgeon with dependable information about hematoma volume. This cheap and convenient technique may be applied in grass-root hospitals in underdeveloped countries. Assessment in multicenter prospective clinical trials is needed.

Exploration of Medical Trajectories of Stroke Patients Based on Group-Based Trajectory Modeling

A high mortality rate is an issue with acute cerebrovascular disease (ACVD), as it often leads to a high medical expenditure, and in particular to high costs of treatment for emergency medical conditions and critical care. In this study, we used group-based trajectory modeling (GBTM) to study the characteristics of various groups of patients hospitalized with ACVD. In this research, the patient data were derived from the 1 million sampled cases in the National Health Insurance Research Database (NHIRD) in Taiwan. Cases who had been admitted to hospitals fewer than four times or more than eight times were excluded. Characteristics of the ACVD patients were collected, including age, mortality rate, medical expenditure, and length of hospital stay for each admission. We then performed GBTM to examine hospitalization patterns in patients who had been hospitalized more than four times and fewer than or equal to eight times. The patients were divided into three groups according to medical expenditure: high, medium, and low groups, split at the 33rd and 66th percentiles. After exclusion of unqualified patients, a total of 27,264 cases (male/female = 15,972/11,392) were included. Analysis of the characteristics of the ACVD patients showed that there were significant differences between the two gender groups in terms of age, mortality rate, medical expenditure, and total length of hospital stay. In addition, the data were compared between two admissions, which included interval, outpatient department (OPD) visit after discharge, OPD visit after hospital discharge, and OPD cost. Finally, the differences in medical expenditure between genders and between patients with different types of stroke-ischemic stroke, spontaneous intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH)-were examined using GBTM. Overall, this study employed GBTM to examine the trends in medical expenditure for different groups of stroke patients at different admissions, and some important results were obtained. Our results demonstrated that the time interval between subsequent hospitalizations decreased in the ACVD patients, and there were significant differences between genders and between patients with different types of stroke. It is often difficult to decide when the time has been reached at which further treatment will not improve the condition of ACVD patients, and the findings of our study may be used as a reference for assessing outcomes and quality of care for stroke patients. Because of the characteristics of NHIRD, this study had some limitations; for example, the number of cases for some diseases was not sufficient for effective statistical analysis.

Methylenetetrahydrofolate Reductase Gene Polymorphisms (C677T and A1298C) and Hemorrhagic Stroke in Moroccan Patients

BACKGROUND

The number of deaths from hemorrhagic strokes is about twice as high than the number of deaths from ischemic strokes. Genetic risk assessment could play important roles in preventive and therapeutic strategies. The present study was aimed to evaluate whether the MTHFR gene polymorphisms could increase the risk of cerebral hemorrhage in Moroccan patients.

METHODS

A total of 113 patients with hemorrhagic stroke and 323 healthy controls were included in this case-control study. The C677T (rs1801133) and A1298C (rs1801131) MTHFR gene polymorphisms were genotyped by Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP) method in all patients and controls. The genotype and allele frequencies were compared between groups using appropriate statistical analyses.

RESULTS

Both groups, patients and controls, were in accordance with the Hardy-Weinberg Equilibrium. For the C677T polymorphism, the frequencies of the CC, CT, and TT genotypes were 50.44% versus 46.13%, 39.82% versus 43.03, and 9.73% versus 10.84% in controls versus patients, respectively, whereas for the A1298C polymorphism, the frequencies of the AA, AC, and CC genotypes were 56.64% versus 57.59%, 40.71% versus 37.15, and 2.65% versus 5.26% in controls versus patients, respectively. No statistically significant difference has been proved between patients and controls frequencies (P >.05) for all additive, recessive, and dominant models. Additional analyses including genotypes combination, allelic frequencies, and hemorrhagic stroke patient subtypes did not show any statistically significant difference between controls and patients/subgroup patients.

CONCLUSIONS

Our findings suggested no association between MTHFR gene polymorphisms and susceptibility to hemorrhagic strokes in Moroccan patients. Further investigations should be conducted to elucidate the roles of other gene variants in the pathogenesis of this condition.

P2X7 Receptor-Associated Programmed Cell Death in the Pathophysiology of Hemorrhagic Stroke

Hemorrhagic stroke is a life-threatening disease characterized by a sudden rupture of cerebral blood vessels, and cell death is widely believed to occur after exposure to blood metabolites or subsequently damaged cells. Recently, programmed cell death, such as apoptosis, autophagy, necroptosis, pyroptosis, and ferroptosis, has been demonstrated to play crucial roles in the pathophysiology of stroke. However, the detailed mechanisms of these novel kinds of cell death are still unclear. The P2X7 receptor, previously known for its cytotoxic activity, is an ATP-gated, nonselective cation channel that belongs to the family of ionotropic P2X receptors. Evolving evidence indicates that the P2X7 receptor plays a pivotal role in central nervous system pathology; genetic deletion and pharmacological blockade of the P2X7 receptor provide neuroprotection in various neurological disorders, including intracerebral hemorrhage and subarachnoid hemorrhage. The P2X7 receptor may regulate programmed cell death via (I) exocytosis of secretory lysosomes, (II) exocytosis of autophagosomes or autophagolysosomes during formation of the initial autophagic isolation membrane or omegasome, and (III) direct release of cytosolic IL-1β secondary to regulated cell death by pyroptosis or necroptosis. In this review, we present an overview of P2X7 receptor- associated programmed cell death for further understanding of hemorrhagic stroke pathophysiology, as well as potential therapeutic targets for its treatment.

Differences in Spontaneous Intracerebral Hemorrhage Cases between Urban and Rural Regions of Taiwan: Big Data Analytics of Government Open Data

This study evaluated the differences in spontaneous intracerebral hemorrhage (sICH) between rural and urban areas of Taiwan with big data analysis. We used big data analytics and visualization tools to examine government open data, which included the residents’ health medical administrative data, economic status, educational status, and relevant information. The study subjects included sICH patients of Taipei region (29,741 cases) and Eastern Taiwan (4565 cases). The incidence of sICH per 100,000 population per year in Eastern Taiwan (71.3 cases) was significantly higher than that of the Taipei region (42.3 cases). The mean coverage area per hospital in Eastern Taiwan (452.4 km²) was significantly larger than the Taipei region (24 km²). The residents educational level in the Taipei region was significantly higher than that in Eastern Taiwan. The mean hospital length of stay in the Taipei region (17.9 days) was significantly greater than that in Eastern Taiwan (16.3 days) (p < 0.001). There were no significant differences in other medical profiles between two areas. Distance and educational barriers were two possible reasons for the higher incidence of sICH in the rural area of Eastern Taiwan. Further studies are necessary in order to understand these phenomena in greater depth.

Safety and efficacy of stereotactic aspiration with fibrinolysis for deep-seated spontaneous intracerebral hemorrhages: A single-center experience

OBJECTIVE

The aim of this study was to evaluate feasibility and safety of stereotactic aspiration with fibrinolysis of deep-seated intracerebral hemorrhages (ICH).

MATERIALS AND METHODS

From March 1995 until December 2016, 58 adult patients (34 men and 24 women; mean age of 56.8±11.8 years) presenting with deep-seated spontaneous supratentorial ICH were treated using a minimally invasive technique. Intracerebral hematomas were aspirated until obvious resistance to free-hand suction and subsequent clot fibrinolysis was done using either streptokinase or recombinant tissue-type plasminogen activator. CT scans were performed at intervals ranging from 24 to 72h. At discharge, functional outcomes were evaluated using the Glasgow outcome scale (GOS). The 30-day mortality rate was evaluated in all patients.

RESULTS

The average ICH volume on initial CT scan was 34.7±11.1cm³ (range, 20-90cm³). Mean residual hematoma volume after the treatment was 8.0±5.1cm³ (range, 3-32cm³). There was statistically significant reduction of ICH volume after the treatment (P<0.001). Median ICH reduction rate was 5cm³/d (range, 1.5-16.0cm³/d) and 17.2%/d (range, 5.27-40.0%/d). Median discharge GOS score was 3 (range, 1-4). Six (10.9%) patients died during the 30-day follow-up period. Treatment related complications were observed in three (5.5%) patients. In two patients asymptomatic increase of ICH volume occurred and one patient was diagnosed with CNS infection.

CONCLUSIONS

Stereotactic clot aspiration with subsequent fibrinolytic therapy is safe and feasible treatment procedure associated with significant hematoma resolution rates and acceptable patient outcomes.

Potential role of blood biomarkers in the management of nontraumatic intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH), a subtype of stroke associated with high mortality and disability, accounts for 13% of all strokes. Basic and clinical research has contributed to our understanding of the complex pathophysiology of neuronal injury in ICH. Outcome rates, however, remain stable, and questions regarding acute management of ICH remain unanswered. Newer research is aiming at matching measured levels of serum proteins, enzymes, or cells to different stages of brain damage, suggesting that blood biomarkers may assist in acute diagnosis, therapeutic decisions, and prognostication. This paper provides an overview on the most promising blood biomarkers and their potential role in the diagnosis and management of spontaneous ICH.

SUMMARY

Information was collected from studies, reviews, and guidelines listed in PubMed up to November 2013 on blood biomarkers of nontraumatic ICH in humans. We describe the potential role and limitations of GFAP, S100B/RAGE, and ApoC-III as diagnostic biomarkers, β-​Amyloid as a biomarker for etiological classification, and 27 biomarkers for prognosis of mortality and functional outcome. Within the group of prognostic markers we discuss markers involved in coagulation processes (e.g., D-Dimers), neuroendocrine markers (e.g., copeptin), systemic metabolic markers (e.g., blood glucose levels), markers of inflammation (e.g., IL-6), as well as growth factors (e.g., VEGF), and others (e.g., glutamate). Some of those blood biomarkers are agents of pathologic processes associated with hemorrhagic stroke but also other diseases, whereas others play more distinct pathophysiological roles and help in understanding the basic mechanisms of brain damage and/or recovery in ICH.

KEY MESSAGES

Numerous blood biomarkers are associated with different pathophysiological pathways in ICH, and some of them promise to be useful in the management of ICH, eventually contributing additional information to current tools for diagnosis, therapy monitoring, risk stratification, or intervention. Up to date, however, no blood biomarker of ICH has been studied sufficiently to find its way into clinical routine yet; well-designed, large-scale, clinical studies addressing relevant clinical questions are needed. We suggest that the effectiveness of biomarker research in ICH might be improved by international cooperation and shared resources for large validation studies, such as provided by the consortium on stroke biomarker research (http://stroke-biomarkers.​com/page.php?title=Resources).

siRNA Treatment: "A Sword-in-the-Stone" for Acute Brain Injuries

Ever since the discovery of small interfering ribonucleic acid (siRNA) a little over a decade ago, it has been highly sought after for its potential as a therapeutic agent for many diseases. In this review, we discuss the promising possibility of siRNA to be used as a drug to treat acute brain injuries such as stroke and traumatic brain injury. First, we will give a brief and basic overview of the principle of RNA interference as an effective mechanism to decrease specific protein expression. Then, we will review recent in vivo studies describing siRNA research experiments/treatment options for acute brain diseases. Lastly, we will discuss the future of siRNA as a clinical therapeutic strategy against brain diseases and injuries, while addressing the current obstacles to effective brain delivery.