Prediction of 30-day mortality among patients with thrombolysis-related intracranial hemorrhage

Long-term outcome of stereotactic aspiration, endoscopic evacuation, and open craniotomy for the treatment of spontaneous basal ganglia hemorrhage: a propensity score study of 703 cases

Background

To compare the long-term therapeutic effects of stereotactic aspiration (SA), endoscopic evacuation (EE), and open craniotomy (OC) in the surgical treatment of spontaneous basal ganglia hemorrhage and explore the appropriate clinical indications for each technique.

Methods

Multiple-treatment inverse probability of treatment weighting (IPTW)-adjusted logistic regression analysis was performed to evaluate the therapeutic effects of these techniques. The primary and secondary outcomes were 6-month modified Rankin Scale (mRS) and mortality rates, respectively.

Results

A total of 703 patients were ultimately enrolled. For the entire cohort, the 6-month mortality rate was significantly higher (OR 2.396, 95% CI: 1.865–3.080), and the 6-month functional outcome was significantly worse (OR 1.359, 95% CI: 1.091–1.692) for SA than that of EE. The 6-month mortality rate for OC was significantly higher (OR 1.395, 95% CI: 1.059–1.837) than that of EE. Further subgroup analysis was stratified by initial hematoma volume and Glasgow Coma Scale (GCS) score. The mortality rate for SA was significantly higher for patients with hematoma volume of 20–40 mL (OR 6.226, 95% CI: 3.848–10.075), 40–80 mL (OR 2.121, 95% CI: 1.492–3.016), and ≥80 mL (OR 5.544, 95% CI: 3.315–9.269) than in the same subgroups of EE. The functional outcomes for SA were significantly worse than that of EE for hematoma volume subgroups of 40–80 mL (OR 1.424, 95% CI: 1.039–1.951) and ≥80 mL (OR 4.224, 95% CI: 1.655–10.776). The mortality rate for SA was significantly higher than that of EE for the GCS score subgroups of 6–8 (OR 2.082, 95% CI: 1.410–3.076) and 3–5 (OR 2.985, 95% CI: 1.904–4.678). The mortality rate for OC was significantly higher for the GCS score of 3–5 subgroup (OR 1.718, 95% CI: 1.115–2.648), and a tendency for a higher mortality rate of 6–8 subgroup (OR 1.442, 95% CI: 0.965–2.156) than that of EE.

Conclusions

EE can decrease the 6-month mortality rate and improve the 6-month functional outcomes of spontaneous basal ganglia hemorrhage in patients with a hematoma volume ≥40 mL. EE can decrease the 6-month mortality rate of spontaneous basal ganglia hemorrhage in patients with a GCS score of 3–8.

Incidence, predictors and prognostic impact of intracranial bleeding within the first year after an acute coronary syndrome in patients treated with percutaneous coronary intervention

Background:

The rate of intracranial haemorrhage after an acute coronary syndrome has been studied in detail in the era of thrombolysis; however, in the contemporary era of percutaneous coronary intervention, most of the data have been derived from clinical trials. With this background, we aim to analyse the incidence, timing, predictors and prognostic impact of post-discharge intracranial haemorrhage in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

Methods:

We analysed data from the BleeMACS registry (patients discharged for acute coronary syndrome and undergoing percutaneous coronary intervention from Europe, Asia and America, 2003–2014). Analyses were conducted using a competing risk framework. Uni and multivariate predictors of intracranial haemorrhage were assessed using the Fine–Gray proportional hazards regression analysis. The endpoint was 1-year post-discharge intracranial haemorrhage.

Results:

Of 11,136 patients, 30 presented with intracranial haemorrhage during the first year (0.27%). The median time to intracranial haemorrhage was 150 days (interquartile range 55.7–319.5). The fatality rate of intracranial haemorrhage was very high (30%). After multivariate analysis, only age (subhazard ratio 1.05, 95% confidence interval 1.01–1.07) and prior stroke/transient ischaemic attack (hazard ratio 3.29, 95% confidence interval 1.36–8.00) were independently associated with a higher risk of intracranial haemorrhage. Hypertension showed a trend to associate with higher intracranial haemorrhage rate. The combination of older age (⩾75 years), prior stroke/transient ischaemic attack, and/or hypertension allowed us to identify most of the patients with intracranial haemorrhage (86.7%). The annual rate of intracranial haemorrhage was 0.1% in patients with no risk factors, 0.2% in those with one factor, 0.6% in those with two factors and 1.3% in those with three factors.

Conclusion:

The incidence of intracranial haemorrhage in the first year after an acute coronary syndrome treated with percutaneous coronary intervention is low. Advanced age, previous stroke/transient ischaemic attack, and hypertension are the main predictors of increased intracranial haemorrhage risk.

Hematoma Expansion Following Intracerebral Hemorrhage: Mechanisms Targeting the Coagulation Cascade and Platelet Activation

Hematoma expansion (HE), defined as a greater than 33% increase in intracerebral hemorrhage (ICH) volume within the first 24 hours, results in significant neurological deficits, and enhancement of ICH-induced primary and secondary brain injury. An escalation in the use of oral anticoagulants has led to a surge in the incidences of oral anticoagulation-associated ICH (OAT-ICH), which has been associated with a greater risk for HE and worse functional outcomes following ICH. The oral anticoagulants in use include vitamin K antagonists, and direct thrombin and factor Xa inhibitors. Fibrinolytic agents are also frequently administered. These all act via differing mechanisms and thus have varying degrees of impact on HE and ICH outcome. Additionally, antiplatelet medications have also been increasingly prescribed, and result in increased bleeding risks and worse outcomes after ICH. Aspirin, thienopyridines, and GPIIb/IIIa receptor blockers are some of the most common agents in use clinically, and also have different effects on ICH and hemorrhage growth, based on their mechanisms of action. Recent studies have found that reduced platelet activity may be more effective in predicting ICH risk, hemorrhage expansion, and outcomes, than antiplatelet agents, and activating platelets may thus be a novel target for ICH therapy. This review explores how dysfunctions or alterations in the coagulation and platelet cascades can lead to, and/or exacerbate, hematoma expansion following intracerebral hemorrhage, and describe the mechanisms behind these effects and the drugs that induce them. We also discuss potential future therapy aimed at increasing platelet activity after ICH.

Incidence, Time Trends, and Predictors of Intracranial Hemorrhage During Long-Term Follow-up After Acute Myocardial Infarction

BACKGROUND

To address the lack of knowledge regarding the long-term risk of intracranial hemorrhage (ICH) after acute myocardial infarction (AMI), the aims of this study were to: (1) investigate the incidence, time trends, and predictors of ICH in a large population within 1 year of discharge after AMI; (2) investigate the comparative 1-year risk of ICH in AMI patients and a reference group; and (3) study the impact of previous ischemic stroke on ICH risk in patients treated with various antithrombotic therapies.

METHODS AND RESULTS

Data about patients whose first AMI occurred between 1998 and 2010 were collected from the Swedish Register of Information and Knowledge about Swedish Heart-Intensive-Care Admissions (RIKS-HIA). Patients with an ICH after discharge were identified in the National Patient Register. Risk was compared against a matched reference population. Of 187 386 patients, 590 had an ICH within 1 year. The 1-year cumulative incidence (0.35%) was approximately twice that of the reference group, and it did not change significantly over time. Advanced age, previous ischemic or hemorrhagic stroke, and reduced glomerular filtration rate were associated with increased ICH risk, whereas female sex was associated with a decreased risk. Previous ischemic stroke did not increase risk of ICH associated with single or dual antiplatelet therapy, but increased risk with anticoagulant therapy.

CONCLUSION

The 1-year incidence of ICH after AMI remained stable, at ≈0.35%, over the study period. Advanced age, decreased renal function, and previous ischemic or hemorrhagic stroke are predictive of increased ICH risk.

Use of Recombinant Factor VIIa in Symptomatic Intracerebral Hemorrhage Following Intravenous Thrombolysis

Symptomatic intracerebral hemorrhage (sICH) occurs in up to 7% of stroke patients treated with thrombolytic therapy. There are limited data on the effectiveness of the reversal agents used for intravenous tissue plasminogen activator related intracranial bleeds. We report a patient with sICH following intravenous thrombolysis whose intracerebral hemorrhage continued to expand despite treatment with platelets and cryoprecipitate, needing recombinant factor VIIa use for stabilization before surgical evacuation. Factor VIIa along with routine reversal agents following intravenous thrombolysis related sICH may further enhance clot stability and reduce the risk of hematoma expansion. It could be a bridge to definitive surgical management in those patients.

Meta-analysis of intracranial hemorrhage in acute coronary syndromes: incidence, predictors, and clinical outcomes

BACKGROUND

Little is known about the incidence, predictors, or outcomes of intracranial hemorrhage (ICH) in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). We aimed to determine the incidence and timing of ICH, characterize the location of ICH, and identify independent baseline predictors of ICH in NSTE ACS patients.

METHODS AND RESULTS

We pooled patient-level data from 4 contemporary antithrombotic therapy trials. Multivariable modeling identified independent predictors of ICH. ICHs were adjudicated by a clinical events committee. Of 37 815 patients, 135 (0.4%) had an ICH. The median (25th, 75th percentiles) follow-up was 332 (184, 434) days but differed across trials. Locations of ICH were intracerebral (50%), subdural (31%), subarachnoid (18.5%), and intraventricular (11%). Independent predictors of ICH were older age (HR per 10 years, 1.61; 95% CI, 1.35 to 1.91); prior stroke/transient ischemic attack; HR, 1.95; 95% CI, 1.14 to 3.35), higher systolic blood pressure; HR per 10 mm Hg increase, 1.09; 95% CI, 1.01 to 1.18), and larger number of antithrombotic agents (HR per each additional agent, 2.06; 95% CI, 1.49 to 2.84). Of all ICHs, 45 (33%) were fatal.

CONCLUSIONS

In patients with NSTE ACS enrolled in recent clinical trials of antithrombotic therapies, ICH was uncommon. Patients with older age, prior transient ischemic attack/stroke, higher systolic blood pressure, or larger number of antithrombotic agents were at increased risk. One-third of patients with ICH died. These data may be useful to trialists and data and safety monitoring committees for trial conduct and monitoring.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov/. Unique identifiers: TRACER: NCT00527943, PLATO: NCT00391872, APPRAISE-2: NCT00831441, TRILOGY ACS: NCT00699998.

Thyroid hemorrhage causing airway obstruction after intravenous thrombolysis for acute ischemic stroke

BACKGROUND

There are several life-threatening complications associated with intravenous thrombolysis after acute ischemic stroke such as symptomatic intracerebral hemorrhage, orolingual angioedema, or less frequent, bleedings of the mucosa or ecchymosis. Aside from these known critical incidents, rare and unfamiliar complications may be even more challenging, as they are unexpected and may mimic events that appear more frequently. We report a rare and unusual acute complication of intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) (0.9 mg/kg) administered for acute ischemic stroke.

METHODS

Medical records, radiologic imaging, and pathologic specimens were reviewed.

RESULTS

A 86-year-old woman developed acute respiratory failure 20 h after thrombolysis with suspected angioedema triggered by intravenous rt-PA. The inspiratory stridor and dyspnea were unresponsive to bronchodilators, corticosteroids, and inhaled adrenaline. After endotracheal intubation, laryngoscopy showed no significant supraglottic narrowing. Thyroidal sonography and cervical computed tomography revealed a thyroidal mass causing a tracheal and vascular compression compatible with thyroidal hemorrhage. Sonography showed a nodular goiter of the right thyroid gland. A total thyroidectomy was performed and histologic analysis confirmed a hemorrhage of the right thyroidal lobe.

CONCLUSIONS

Acute airway obstruction with respiratory failure due to thyroidal hemorrhage after intravenous thrombolysis is an important life-threatening complication, mimicking an anaphylactic reaction or a more frequent orolingual angioedema.

Neurologic complications of cardiac tests and procedures

Arterial or central venous vascular access is the cornerstone of invasive cardiac diagnosis, monitoring, and therapeutics. Although procedural safety has significantly improved with protocols perfected over decades of use, their prevalence renders even the uncommon neurologic complication clinically relevant. Serious peripheral nerve complications result from direct or indirect nerve injuries in the setting of a hematoma or compartment syndrome. Functional outcome is dependent upon prompt diagnosis and early treatment, so proceduralists should be aware of the relevant anatomy and early signs of nerve injury. Ischemic stroke is the most common central nervous system complication of diagnostic and therapeutic cardiac catheterization, and is presumed to be due to embolization of atherosclerotic plaque or thrombus dislodged during guiding catheter manipulation, platelet-fibrin thrombus that forms on the catheters, or air that appears during catheter flushing. Acute neurologic deterioration after thrombolysis for acute myocardial infarction should be presumed to be an intracranial hemorrhage until proven otherwise. The ideal angiography suite of the future is patientcentric and multipurpose, coordinating diagnostic and therapeutic strategies for multivascular disease, allowing for multispecialty collaboration, and, in the event of a neurologic complication of a cardiac procedure, facilitating the various treating physicians to converge efficiently upon the patient.

Thrombolysis With Recombinant Tissue Plasminogen Activator in 7 Children

The information about the thromboembolic events, the optimal treatment choice, the dose, and duration of antithrombotic therapy in children are limited. More clinical data are required. Recombinant tissue plasminogen activator (r-tPA) is increasingly used in pediatric thrombosis. We retrospectively analyzed the clinical course of 7 children (9.3 ± 2.1 years; 34 days to 16 years) with arterial thrombosis (n = 1) and intracardiac thrombosis (n = 6). The children were treated with r-tPA. The dose ranged between 0.2 and 0.4 mg/kg per h infused for 3 to 4 hours. This dose was repeated between 2 to 7 times till the thrombolysis was achieved. Treatment side effects were closely monitored. Complete clot lysis was achieved in all cases. None of them had severe bleeding except mild recurrent epistaxis occurring in 2 cases. In conclusion, r-tPA is an effective and safe therapy under close hemostatic control in children.

Uptake, metabolism and toxicity of hemin in cultured neurons

Following hemorrhagic stroke, red blood cells lyse and release neurotoxic hemin into the interstitial space. The present study investigates whether neurons can accumulate and metabolize hemin. We demonstrate that cultured neurons express the heme carrier protein 1 (HCP1), and that this transporter appears to contribute to the time- and concentration-dependent accumulation of hemin by neurons. Although exposure of neurons to hemin stimulates the synthesis of the iron storage protein ferritin, approximately 80% of the hemin accumulated by neurons remains intact. Within 24h of incubation, substantial neurotoxicity was observed that was not attenuated by the cell permeable, selective ferrous iron chelator, 1,10-phenanthroline. These results demonstrate that while neurons efficiently accumulate hemin they slowly degrade it, and they support the conclusion that intact hemin is more neurotoxic than the iron released from the breakdown of hemin. Further investigations are required to determine the basis of this neurotoxicity.

A reversible aptamer improves outcome and safety in murine models of stroke and hemorrhage

Treatment of acute ischemic stroke with intravenous tissue-type plasminogen activator is underutilized partly due to the risk of life-threatening hemorrhage. In response to the clinical need for safer stroke therapy, we explored using an aptamer-based therapeutic strategy to promote cerebral reperfusion in a murine model of ischemic stroke. Aptamers are nucleic acid ligands that bind to their targets with high affinity and specificity, and can be rapidly reversed with an antidote. Here we show that a Factor IXa aptamer administered intravenously after 60 minutes of cerebral ischemia and reperfusion improved neurological function and was associated with reduced thrombin generation and decreased inflammation. Moreover, when the aptamer was administered in the setting of intracranial hemorrhage, treatment with its specific antidote reduced hematoma volume and improved survival. The ability to rapidly reverse a pharmacologic agent that improves neurological function after ischemic stroke should intracranial hemorrhage arise indicates that aptamer-antidote pairs may represent a novel, safer approach to treatment of stroke.

Management of thrombolysis-associated symptomatic intracerebral hemorrhage

BACKGROUND

Symptomatic intracerebral hemorrhage (sICH) is the most devastating complication of thrombolytic therapy for acute stroke. It is not clear whether patients with sICH continue to bleed after diagnosis, nor has the most appropriate treatment been determined.

METHODS

We performed a retrospective analysis of our prospectively collected Get With the Guidelines-Stroke database between April 1, 2003, and December 31, 2007. Radiologic images and all procoagulant agents used were reviewed. Multivariable logistic regression was performed to identify factors associated with in-hospital mortality.

RESULTS

Of 2362 patients with acute ischemic stroke during the study period, sICH occurred in 19 of the 311 patients (6.1%) who received intravenous tissue plasminogen activator and 2 of the 72 (2.8%) who received intra-arterial thrombolysis. In-hospital mortality was significantly higher in patients with sICH than in those without (15 of 20 [75.0]% vs 56 of 332 [16.9%], P < .001). Eleven of 20 patients (55.0%) received therapy for coagulopathy: 7 received fresh frozen plasma; 5, cryoprecipitate; 4, phytonadione (vitamin K(1)); 3, platelets; and 1, aminocaproic acid. Independent predictors of in-hospital mortality included sICH (odds ratio, 32.6; 95% confidence interval, 8.8-120.2), increasing National Institutes of Health Stroke Scale score (1.2; 1.1-1.2), older age (1.3; 1.0-1.7), and intra-arterial thrombolysis (2.9; 1.4-6.0). Treatment for coagulopathy was not associated with outcome. Continued bleeding (>33% increase in intracerebral hemorrhage volume) occurred in 4 of 10 patients with follow-up scans available (40.0%).

CONCLUSIONS

In many patients with sICH after thrombolysis, coagulopathy goes untreated. Our finding of continued bleeding after diagnosis in 40.0% of patients suggests a powerful opportunity for intervention. A multicenter registry to analyze management of thrombolysis-associated intracerebral hemorrhage and outcomes is warranted.

Management of acquired bleeding problems in cancer patients

Cancer patients can have acquired bleeding problems for many reasons. In this review, an approach to the evaluation and management of the bleeding patient is discussed. Specific issues including coagulation defects, thrombocytopenia, platelet dysfunction, and bleeding complications of specific hematological malignancies due to anticoagulation, are discussed.

Hemin toxicity: a preventable source of brain damage following hemorrhagic stroke

Hemorrhagic stroke is a common cause of permanent brain damage, with a significant amount of the damage occurring in the weeks following a stroke. This secondary damage is partly due to the toxic effects of hemin, a breakdown product of hemoglobin. The serum proteins hemopexin and albumin can bind hemin, but these natural defenses are insufficient to cope with the extremely high amounts of hemin (10 mM) that can potentially be liberated from hemoglobin in a hematoma. The present review discusses how hemin gets into brain cells, and examines the multiple routes through which hemin can be toxic. These include the release of redox-active iron, the depletion of cellular stores of NADPH and glutathione, the production of superoxide and hydroxyl radicals, and the peroxidation of membrane lipids. Important gaps are revealed in contemporary knowledge about the metabolism of hemin by brain cells, particularly regarding how hemin interacts with hydrogen peroxide. Strategies currently being developed for the reduction of hemin toxicity after hemorrhagic stroke include chelation therapy, antioxidant therapy and the modulation of heme oxygenase activity. Future strategies may be directed at preventing the uptake of hemin into brain cells to limit the opportunity for toxic interactions.

The putative heme transporter HCP1 is expressed in cultured astrocytes and contributes to the uptake of hemin

Hemin, which is toxic to brain cells, has been reported to be taken up by cultured astrocytes; however, the mechanism of uptake is currently unknown. The present study investigated the mechanism of hemin uptake by rat primary astrocyte cultures. In medium containing 10% fetal calf serum, cultured astrocytes failed to accumulate significant amounts of heme-iron, while in serum-free medium the accumulation of heme-iron was found to be time- and concentration-dependent. After 6 h of incubation with 24 muM hemin, cells contained 36.2 +/- 2.4 nmol heme-iron/mg protein, which was 21% of the applied hemin. These results suggest that the accumulation of hemin in astrocytes does not require serum proteins such as hemopexin. A potential mechanism of hemin uptake in astrocytes involves the heme carrier protein 1 (HCP1), which is reported to mediate hemin uptake into intestinal cells. RT-PCR analysis revealed that astrocyte cultures contained HCP1 mRNA, and immunocytochemical staining and Western blot analysis confirmed the expression of HCP1 protein in cultured astrocytes. The functionality of HCP1 in astrocytes was demonstrated by incubating cells with zinc protoporphyrin IX (ZnPPIX), which is known to be transported into cells via HCP1, and ZnPPIX autofluorescence was detected in HCP1-positive astrocytes. In addition, ZnPPIX was found to attenuate the accumulation of heme-iron by astrocytes. These results are the first to demonstrate that cultured astrocytes contain functional HCP1 and that this transporter contributes to hemin uptake by astrocytes. HCP1 may therefore provide a new target for reducing hemin-related toxicity in brain cells.

Qingkailing injection attenuates apoptosis and neurologic deficits in a rat model of intracerebral hemorrhage

AIM OF THE STUDY

Traditional Chinese herb Angong Niuhuang Pill (AGNHP) is a famous preparation for neurological diseases; Qingkailing injection (QKL), an extract of AGNHP has similar clinical applications. This investigation was designed to further elucidate the neuroprotective effect of QKL on intracerebral hemorrhage (ICH).

MATERIALS AND METHODS

ICH was produced in adult Sprague-Dawley rats by injection of collagenase IV. Three incremental doses of QKL injection including low-(0.5 ml/kg), moderate-(1 ml/kg) and high-dosage (2 ml/kg) were administered twice, 3 and 12h following ICH. TUNEL and caspase-3 activity were measured at 1d after ICH, and apomorphine-induced rotation was evaluated at 1d, 7d, 14 d and 28 d.

RESULTS

Administration of high-dose QKL inhibited TUNEL positive cells (p<0.05) and caspase-3 activity (p<0.05) at 1d following ICH, and reduced apomorphine-induced rotation at 1d (p<0.01), 7d, 14 d and 28 d (p<0.05), compared with the controls. However, QKL in a low or moderate dose had no such effect.

CONCLUSION

QKL reduced brain damage of intracerebral hemorrhage through inhibiting apoptosis, which suggested a potential intervention for ICH patients.

Management of acquired bleeding problems in cancer patients

Cancer patients can have acquired bleeding problems for many reasons. In this review, an approach to the bleeding patient in the Emergency Department is discussed. Specific issue including coagulation defects, thrombocytopenia, platelet dysfunction, bleeding complications of specific hematological malignancies and due to anticoagulation, are discussed.

Outcomes studies in cerebrovascular neurosurgery

✓Successfully measuring cerebrovascular neurosurgery outcomes requires an appreciation of the current state-of-the-art epidemiological instruments, their specific relevance to surgical treatments and the underlying pathological entity, and ultimately the right set of questions for the next generation of studies. In this paper the authors address these questions with specific attention to measurement targets, individual modeling scales, and types of studies, all within a conceptual framework for specific disease models in their current state of outcomes modeling in cerebrovascular neurosurgery.

Venous Thromboembolism in the ICU and Reversal of Bleeding on Anticoagulants

Venous thromboembolic disease is a very common complication in the ICU. This article reviews incidence, prevention, and therapy related to venous thromboembolism, including both deep venous thrombosis and pulmonary embolism. Special diagnostic and treatment considerations in the ICU setting are highlighted. The increased use of antithrombotic agents has led to an increased number of patients who experience bleeding complications on anticoagulant therapy. This review also addresses the methods of reversing various anticoagulants.

Thrombolysis and Adjunctive Therapy in Acute Myocardial Infarction

This chapter about antithrombotic therapy for acute myocardial infarction (MI) is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients with ischemic symptoms characteristic of acute MI of < 12 h in duration, and ST-segment elevation or left bundle-branch block (of unknown duration) on the ECG, we recommend administration of any approved fibrinolytic agent (Grade 1A). We recommend the use of streptokinase, anistreplase, alteplase, reteplase, or tenecteplase over placebo (all Grade 1A). For patients with symptom duration < 6 h, we recommend the administration of alteplase over streptokinase (Grade 1A). For patients with known allergy or sensitivity to streptokinase, we recommend alteplase, reteplase, or tenecteplase (Grade 1A). For patients with acute posterior MI of < 12 h duration, we suggest fibrinolytic therapy (Grade 2C). In patients with any history of intracranial hemorrhage, closed head trauma, or ischemic stroke within past 3 months, we recommend against administration of fibrinolytic therapy (Grade 1C+). For patients with acute ST-segment elevation MI whether or not they receive fibrinolytic therapy, we recommend aspirin, 160 to 325 mg p.o., at initial evaluation by health-care personnel followed by indefinite therapy, 75 to 162 mg/d p.o. (both Grade 1A). In patients allergic to aspirin, we suggest use of clopidogrel as an alternative therapy to aspirin (Grade 2C). For patients receiving streptokinase, we suggest administration of either i.v. unfractionated heparin (UFH) [Grade 2C] or subcutaneous UFH (Grade 2A). For all patients at high risk of systemic or venous thromboembolism (anterior MI, pump failure, previous embolus, atrial fibrillation, or left ventricular thrombus), we recommend administration of IV UFH while receiving streptokinase (Grade 1C+).

Outcomes of thrombolytic therapy for acute myocardial infarction in women

Coronary artery disease is the leading cause of mortality in women older than 50 years of age. Thrombolytic therapy substantially reduces mortality in both women and men with ST-elevation acute myocardial infarction. However, the mortality risk reduction is somewhat lower in women, in spite of similar rates of successful coronary reperfusion after thrombolytic therapy in women and men. Hemorrhagic complications including stroke and other major bleeding appear to be more common in women, particularly elderly women. The risk of reinfarction after thrombolytic therapy also is greater in women compared with men. Because of the higher complication rates, women should be monitored closely after thrombolytic therapy. However, this lifesaving treatment should not be withheld or delayed in women when indicated.

Primary intracerebral haemorrhage--clinical and radiologic predictors of survival and functional outcome

PURPOSE

Primary intracerebral haemorrhage (ICH) is a common and devastating disorder that often results in long-term disability. This review examines the literature on predictors of survival and long-term functional outcome after ICH.

METHOD

Medical literature review.

RESULTS

Numerous clinical and radiologic variables have been shown to be associated with survival and functional recovery following ICH. These include patient age and gender, lesion size and location, initial level of consciousness, presence of intraventricular haemorrhage, hydrocephalus, and mass effect. Studies have employed a variety of outcome measures including survival and functional recovery.

CONCLUSIONS

Clinical and radiologic findings following ICH may assist rehabilitation specialists as they develop treatment goals, anticipate long-term patient care needs, and educate and train caregivers.

Current intracerebral haemorrhage management

Primary intracerebral haemorrhage (ICH) refers to spontaneous bleeding from intraparenchymal vessels. It accounts for 10-20% of all strokes, with higher incidence rates amongst African and Asian populations. The major risk factors are hypertension and age. In addition to focal neurological findings, patients may present with symptoms of elevated intracranial pressure. The diagnosis of ICH can only be made through neuro-imaging. A CT scan is presently standard, although MRI is increasingly important in the evaluation of acute cerebrovascular disease. A significant proportion of intracerebral haematomas expand in the first hours post-ictus and this is often associated with clinical worsening. There is evidence that the peri-haematomal region is compromised in ICH. This tissue is oedematous, although the precise pathogenesis is controversial. An association between elevated arterial pressure and haematoma expansion has been reported. Although current guidelines recommend conservative management of arterial pressure in ICH, an acute blood pressure lowering trial is overdue. ICH is associated with a high early mortality rate, although a significant number of survivors make a functional recovery. Current medical management is primarily aimed at prevention of complications including pneumonia and peripheral venous thromboembolism. Elevated intracranial pressure may be treated medically or surgically. Although the latter definitively lowers elevated intracranial pressure, the optimal patient selection criteria are not clear. Aggressive treatment of hypertension is essential in the primary and secondary prevention of ICH.

Drug-induced iatrogenic intraparenchymal hemorrhage

Intracerebral hemorrhage is bleeding into the brain parenchyma with possible extension into the ventricles and subarachnoid space. Each year, approximately 37,000 to 52,400 people suffer from intraparenchymal hemorrhage (IPH) in the United States. This rate is expected to rise dramatically in the next few decades as a result of the increasing age of the population and a change in racial demographics. IPH accounts for 8% to 13% of all stroke cases and is associated with the highest mortality rate.

Cell death in experimental intracerebral hemorrhage: the "black hole" model of hemorrhagic damage

Intracerebral hemorrhage (ICH) has a poor prognosis that may be the consequence of the hematoma's effect on adjacent and remote brain regions. Little is known about the mechanism, location, and severity of such effects. In this study, rats subjected to intracerebral blood injection were examined at 100 days. Stereology (neuronal count and density) and volume measures in the perihematoma rim, the adjacent and overlying brain, and the substantia nigra pars reticulata (SNr) were compared with contralateral brain regions at 100 days and the perihemorrhage region at 24 hours and 7 days. In addition, cytochrome c release was investigated at 24 hours, 3 days, and 7 days. At 100 days, post-ICH rats showed no difference in neuronal density in the perihemorrhagic scar region or regions of the striatum immediately surrounding and distal to the perihemorrhage scar. The cell density index in the ipsilateral field was 16.2 +/- 3.8 versus the contralateral control field of 15.6 +/- 3.2 (not significant). Volume measurements of the ipsilateral striatum revealed a 20% decrease that was compensated by an increase in ipsilateral ventricular size. The area of the initial ICH as measured by magnetic resonance imaging correlated with the degree of atrophy. In the region immediately surrounding the hematoma, cytochrome c immunoreactivity increased at 24 hours and 3 days, and returned toward baseline by day 7. At 24 hours, stereology in the peri-ICH region showed decreased density in the region where cytochrome c immunoreactivity was the highest. Neuronal density of the ipsilateral SNr was significantly less than the contralateral side (9.6 +/- 1.9 vs 11.6 +/- 2.3). Histologic damage from ICH occurred mainly in the immediate perihemorrhage region. Except for SNr, we found no evidence of neuronal loss in distal regions. We have termed this continued destruction of neurons, which occurs over at least 3 days as the neurons come into proximity to the hematoma, the "black hole" model of hemorrhagic damage.

Intracerebral hemorrhage

Intracerebral hemorrhage (ICH) represents a significant fraction of all strokes and causes a disproportionate amount of stroke related morbidity and mortality, especially in young blacks. While diagnosis of this disorder has greatly improved in the CT era, morbidity and mortality remain essentially unchanged. Not one currently utilized therapeutic modality has been clearly associated with a beneficial effect on long term outcome in small prospective randomized treatment trials for ICH. In spite of the lack of scientific data regarding therapy, patients often require aggressive medical and surgical intervention because of the life-threatening presentation of many patients. Recent clinical and experimental ICH research has identified a number of potentially effective new therapeutic strategies, and time to treatment is likely to be very important as it is for ischemic stroke. Large prospective, randomized, placebo controlled trials to examine the judicious application of current therapeutic modalities, and to investigate the potential benefit of proposed new treatment modalities, are long overdue.

Neurosurgical evacuation of intracranial hemorrhage after thrombolytic therapy for acute myocardial infarction: experience from the GUSTO-I trial. Global Utilization of Streptokinase and tissue-plasminogen activator (tPA) for Occluded Coronary Arteries

BACKGROUND

Intracranial hemorrhage is an uncommon but very dangerous complication in patients receiving thrombolytic therapy for acute myocardial infarction. Neurosurgical evacuation is often an available treatment option. However, the association between neurosurgical evacuation and clinical outcomes in these patients has yet to be determined.

METHODS

The GUSTO-I trial randomly assigned 41,021 patients with acute myocardial infarction to 1 of 4 thrombolytic strategies in 1081 hospitals in 15 countries. A total of 268 patients (0.65%) had an intracranial hemorrhage. We assessed differences in clinical characteristics, neuroimaging features, Glasgow coma scale scores, functional status (disabled: moderate or severe deficit; not disabled: no or minor deficit) and 30-day mortality rate between the 46 patients who underwent neurosurgical evacuation and the 222 patients who did not.

RESULTS

Mortality rate at 30 days for all patients with intracranial hemorrhage was 60%; an additional 27% were disabled. Evacuation was associated with significantly higher 30-day survival (65% versus 35%, P <.001) and a trend toward improved functional status (nondisabling stroke: 20% versus 12%, P =.15).

CONCLUSIONS

Although intracranial hemorrhage is uncommon after thrombolysis for acute myocardial infarction, 87% of patients die or have disabling stroke. Although not definitive, these data indicate that neurosurgical evacuation may be associated with improved clinical outcomes. Physicians treating such patients should consider early neurosurgical consultation and intervention in these patients.

Glycoprotein IIb/IIIa blockade and thrombolytics: early lessons from the SPEED and GUSTO IV trials

Reperfusion with a regimen of thrombolytic therapy, aspirin, and unfractionated heparin is limited by a number of factors. Only 50% to 60% of patients achieve early thrombolysis in myocardial infarction grade-3 flow within 90 minutes with the most effective thrombolytic regimens. Even after initial reperfusion is achieved, transient and permanent reocclusion occurs too often and is associated with high mortality rates. As more older patients are treated, intracranial hemorrhage is becoming more common. Finally, the risk of bleeding and procedural failure has been high in patients who received an acute percutaneous interventional procedure shortly after treatment with thrombolytic therapy. Given the important role of platelets in the thrombotic process and the relatively weak inhibitory effect of aspirin, it is reasonable to seek agents that will provide more profound platelet inhibition. Early studies with full-dose fibrinolytic and glycoprotein IIb/IIIa inhibitors have been promising, but concern about bleeding has hindered this strategy. Several recent trials have evaluated full-dose abciximab with reduced-dose fibrinolytic therapy and have yielded promising results.