Hypertensive caudate hemorrhage prognostic predictor, outcome, and role of external ventricular drainage

Hydrocephalus is an independent factor affecting morbidity and mortality of ICH patients: Systematic review and meta-analysis

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.

Intracerebral Hemorrhage Models and Behavioral Tests in Rodents

Intracerebral hemorrhage (ICH) is one of the common types of stroke, which can cause neurological dysfunction. In preclinical ICH studies, researchers often established rodent models by donor/autologous whole blood or a collagenase injection. White matter injury (WMI) can result from primary and secondary injuries after ICH. WMI can lead to short- and long-term neurological impairment, and functional recovery can assess the effect of drug therapy after ICH. Therefore, researchers have devised various behavioral tests to assess dysfunction. This review compares the two ICH modeling methods in rodents and summarizes the pathological mechanisms underlying dysfunction after ICH. We also summarize the functions and characteristics of various behavioral methods, including sensation, motion, emotion, and cognition, to assist researchers in selecting the appropriate tests for preclinical ICH research.

Overexpression of NT3P75-2 gene modified bone marrow mesenchymal stem cells supernatant promotes neurological function recovery in ICH rats

Intracerebral hemorrhage (ICH) is an acute cerebrovascular disease with high mortality and long-term disability rates. Stem cell transplantation and neurotrophic factor therapy have shown great potential in ICH. It has been established that mutated NT3 (NT3P75 - 2) can enhance the positive biological functions of NT3 by decreasing its affinity to the P75-2 receptor. The present study aimed to explore whether NT3P75-2 could further improve neurological recovery after ICH. First, we constructed three stable BMSC cell lines (GFP, GFP-NT3 overexpressed and GFP-NT3P75 - 2 overexpressed) by lentivirus infection. Next, rats were injected with fresh supernatants of these three cell lines on days 1 (24 h) and 3 (72 h) post-ICH induction. Behavioral evaluations were conducted to assess the neurological recovery of ICH rats. We further evaluated changes in microglia activation, neuron survival and proliferation of neural stem cells. Compared with the GFP group and the GFP-NT3 group, animals in the GFP-NT3P75 - 2 group exhibited better motor function improvements and milder neuroinflammation response. Meanwhile, overexpression of NT3P75 - 2 significantly decreased neuronal apoptosis and increased number of SOX2 - positive cells. Taken together, our study demonstrated that early administration of NT3P75 - 2 enriched BMMSC supernatants significantly enhanced neuro-functional recovery after ICH by regulating neuroinflammation response, neuronal survival and increasing neural stem cell number, providing a new therapeutic strategy and direction for early treatment of ICH.

Hydrocephalus Growth: Definition, Prevalence, Association with Poor Outcome in Acute Intracerebral Hemorrhage

BACKGROUND/OBJECTIVES

To propose a novel definition for hydrocephalus growth and to further describe the association between hydrocephalus growth and poor outcome among patients with intracerebral hemorrhage (ICH).

METHODS

We analyzed consecutive patients who presented within 6 h after ICH ictus between July 2011 and June 2017. Follow-up CT scans were performed within 36 h after initial CT scans. The degree of hydrocephalus were evaluated by the hydrocephalus score of Diringer et al. The optimal increase of the hydrocephalus scores between initial and follow-up CT scan was estimated to define hydrocephalus growth. Poor long-term outcome was defined as a modified Rankin Scale of 4-6 at 3 months. Multivariate logistic regression analysis was performed to investigate the hydrocephalus growth for predicting 30-day mortality, 90-day mortality, and poor long-term outcome.

RESULTS

A total of 321 patients with ICH were included in the study. Of 64 patients with hydrocephalus growth, 34 (53.1%) patients presented with both concurrent hematoma expansion and intraventricular hemorrhage (IVH) growth. After adjusting for potential confounding factors, hydrocephalus growth independently predicted 30-day mortality, 90-day mortality, and 90-day poor long-term outcome in multivariate logistic regression analysis. Hydrocephalus growth showed higher accuracy for predicting 30-day mortality, 90-day mortality, and poor long-term outcome than IVH growth or hematoma expansion, respectively.

CONCLUSIONS

Hydrocephalus growth is defined by strongly predictive of short- or long-term mortality and poor outcome at 90 days, and might be a potential indicator for assisting clinicians for clinical decision-making.

Natural history and surgical management of spontaneous intracerebral hemorrhage: a systematic review

INTRODUCTION

Management of spontaneous intracerebral hemorrhage (ICH) remains controversial despite efforts to produce high level evidence in the past few years. We systematically examined the pooled literature data on the natural history and surgical management of ICH.

EVIDENCE ACQUISITION

A systematic review was performed using the PubMed and Embase databases, encompassing English, full-text articles, reporting treatment outcomes for the conservative and surgical management of ICH.

EVIDENCE SYNTHESIS

A total of 91 studies met the eligibility criteria (total of 16,411 ICH cases). The most common locations for an ICH were the basal ganglia for both the conservative (68.7%) and surgical cohorts (58.4%). Patients in the non-operative group (40.5%) were older (mean age 62.9 years; range 12.0-94.0), had a higher Glasgow Coma Scale (GCS) score at presentation (mean GCS 10.2; range 3-15) and lower ICH volume (mean 36.9 mL). When managed non-operatively, a favorable functional outcome was encountered in 25.7% (95% CI 16.9-34.5) of patients, with a 22.2% (95% CI 16.6-27.8) mortality rate. Patients who underwent surgery (59.5%) were younger (mean age 58.8 years; range 12.0-94.0), had a lower GCS at presentation (mean GCS 8.2; range 3-15) and larger ICH volume (mean 58.3 mL; range 8.2-140.0). Craniotomy with hematoma evacuation was the preferred surgical technique (38.6%). A favorable functional outcome was encountered in 29.8% (95% CI 23.8-35.8) of operated patients, with a 21.3% (95% CI 16.3-26.3) mortality rate.

CONCLUSIONS

For many ICH cases, the reviewed literature allows to define surgical and conservative candidates. However, there are still some ICH-cases where management remains controversial.

Lithium treatment mitigates white matter injury after intracerebral hemorrhage through brain-derived neurotrophic factor signaling in mice

Intracerebral hemorrhage (ICH), a subtype of stroke with high morbidity and mortality, occurs mainly in the basal ganglia and causes white matter injury (WMI), resulting in severe motor dysfunction and poor prognosis in patients. The preservation of the white matter around the hematoma is crucial for motor function recovery, but there is currently no effective treatment for WMI following ICH. Lithium has been widely used for the treatment of bipolar disorder for decades. Although the protective effects of lithium on neurodegenerative diseases and cerebral trauma have been studied in recent years, whether it can be used to alleviate WMI after ICH remains to be researched. The results of this study revealed that ICH caused significant functional and pathological abnormalities in mice. After LiCl was administered to mice with ICH, behavioural performance and electrophysiological functions were improved and ICH-induced white matter pathological injury, including myelin sheath and axonal degeneration, was ameliorated. Furthermore, LiCl treatment decreased the death of mature oligodendrocytes (OLGs) in ICH mice, which may have been attributed to the enhanced expression of brain-derived neurotrophic factor (BDNF) regulated by the LiCl-induced inhibition of glycogen synthase kinase-3β (GSK-3β). The decreased death of OLGs was closely associated with decreased destruction of the myelin sheath and alleviated degradation of the axons. In summary, this study suggests that the protective effect of lithium on WMI after ICH might be related to an increased level of BDNF and that LiCl treatment may be a potential therapeutic method to palliate WMI after ICH.

Management of Spontaneous Intracerebral Hematoma

The incidence of spontaneous intracerebral hematoma (SICH) is even now high worldwide, especially higher in Japan than in Western countries, despite the development of advances in blood pressure (BP) management and food/alcohol intake education. Although mortality and morbidity for SICH are high, some controversies remain regarding the appropriate acute phase of treatment. Recent studies have revealed that BP lowering treatment than 140 mmHg resulted in better outcomes. However the efficacy of surgical treatment for SICH has not been well established, with the exception of that for cerebellar SICH over 3 cm in diameter and life-saving procedures, although many randomized control studies and systematic reviews focused on surgical treatment have been reported. In this review, we summarize some issues and discuss strategies in development for the treatment of SICH.

[Critical care management of intracerebral hemorrhage]

BACKGROUND

Intracerebral hemorrhage accounts for up to 20 % percent of all ischemic strokes. In addition to a higher mortality, they are often associated with severe neurological impairment for those affected.

OBJECTIVES

Review of the current literature and guidelines addressing the critical care management of spontaneous intracerebral hemorrhage, including treatments to reduce primary and secondary neurological damage.

RESULTS

Acute blood pressure lowering to less than 140 mmHg should be aspired immediately after intensive care admission. During the following days blood pressure variability should be minimized. Preexisting oral anticoagulation should be immediately reversed, while hemostatic therapy not associated with reversal of antithrombotic therapy should not be applied. Surgery for patients with impaired consciousness should be discussed. Use of pneumatic compression in immobile patients is recommended. Developing intracranial hypertension should be treated with combined physical and pharmacological measures in a stepwise approach. Administration of glucocorticoids is currently not recommended.

CONCLUSIONS

Critical care management of spontaneous hemorrhage demands a multimodal, graded approach for reduction of both primary and secondary neurological damage.

Caudate haemorrhage caused by pseudoaneurysm of accessory middle cerebral artery

A 68-year-old man experienced a right caudate haemorrhage with intraventricular haemorrhage. Although a subarachnoid haemorrhage was not shown clearly, our investigation demonstrated an aneurysm-like vascular pouch located in the anomalous vessel arising from the A2 segment of the right anterior cerebral artery. Rupture of the vascular pouch was considered to be the cause of the caudate haemorrhage. Neck clipping was performed. In intraoperative observation, the anomalous vessel was diagnosed as a right accessory middle cerebral artery. Histopathology of the saccular wall showed only an adventitia and a fibrin layer, indicating a pseudoaneurysm. We routinely perform detailed vascular evaluation for any cerebrovascular disease. A meticulous vascular survey makes it possible to obtain valuable clues in cases such as caudate haemorrhage due to pseudoaneurysm of the accessory middle cerebral artery, leading to prevention of rebleeding.

A new choice of minimally invasive surgery for intracerebral hemorrhage in the striatocapsular regions based on computed tomography scans

BACKGROUND

Currently, minimally invasive surgery is considered as a beneficial treatment of supratentorial spontaneous intracerebral hemorrhage (SICH). A new choice of minimally invasive surgery, translower-Rolandic-point approach (TLRPA) with modified craniotomy, is described in this study. A modified classification of striatocapsular SICH based on the computed tomography scans is also described. The surgical strategy of striatocapsular SICH based on the neuroimaging evaluation is proposed.

METHODS

Clinical data from 60 patients with striatocapsular SICH were used in the study. On the basis of the preoperative computed tomography scans, the hematomas were divided into 4 types and 3 subtypes in the axial slices. The surgical approach was used according to the classification. Effect of surgical treatment was evaluated by Glasgow Outcome Scale score.

RESULTS

The mixed type was the most common (31.7%) and was followed by posteromiddle (21.7%), middle (20.0%), posterolateral (11.7%), posteromedial (8.3%), and anterior (6.6%) types in decreasing order of frequency. The transanterior-Sylvian-point approach was used in 25 patients (41.7%), and TLRPA was used in 35 patients (58.3%). Forty-six patients (76.7%) made a relatively good recovery (Glasgow Outcome Scale scores of 4 and 5), and two (3.3%) were dead.

CONCLUSIONS

The modified classification would help to decide the optimal surgical strategy. The TLRPA with modified craniotomy is a minimally invasive, effective, and safe method to remove the hematoma. The choice of the surgical approach should be tailored for each patient based on preoperative neuroimaging evaluation.

Comparison of clinical outcomes of intraventricular hematoma between neuroendoscopic removal and extraventricular drainage

The efficacy of treatment for intraventricular hematoma by neuroendoscopic surgery and extraventricular drainage was compared in 10 patients with intraventricular hematoma and hydrocephalus who underwent neuroendoscopic surgery (endoscopic group), and eight patients with intraventricular hematoma and hydrocephalus treated with extraventricular drainage (EVD group). The outcomes in each group were assessed retrospectively using the Graeb scores on the pre- and postoperative computed tomography (CT), duration of extraventricular drainage, requirement for a shunt operation, and modified Rankin scale score at 12 months. The Graeb scores on the preoperative CT were not significantly different between the two groups, but the duration of catheter placement was significantly shorter (69.3%) in the endoscopic group (2.7 days) than in the EVD group (8.8 days). None of the patients in either group required a shunt procedure for communicating hydrocephalus 12 months after surgery. Neuroendoscopic removal is a safe and effective procedure for intraventricular hematoma. Advantages include rapid removal of hematoma in the ventricular systems and reliable improvement of non-communicating hydrocephalus in the acute phase. The procedure resulted in faster removal of the catheter in the postoperative period and earlier patient ambulation.

MRI-based analysis of intracerebral hemorrhage in mice reveals relationship between hematoma expansion and the severity of symptoms

Intracerebral hemorrhage (ICH) is featured by poor prognosis such as high mortality rate and severe neurological dysfunction. In humans, several valuables including hematoma volume and ventricular expansion of hemorrhage are known to correlate with the extent of mortality and neurological dysfunction. However, relationship between hematoma conditions and the severity of symptoms in animal ICH models has not been clarified. Here we addressed this issue by using 7-tesla magnetic resonance imaging (MRI) on collagenase-induced ICH model in mice. We found that the mortality rate and the performance in behavioral tests did not correlate well with the volume of hematoma. In contrast, when hemorrhage invaded the internal capsule, mice exhibited high mortality and showed poor sensorimotor performance. High mortality rate and poor performance in behavioral tests were also observed when hemorrhage invaded the lateral ventricle, although worsened symptoms associated with ventricular hemorrhage were apparent only during early phase of the disease. These results clearly indicate that invasion of the internal capsule or the lateral ventricle by hematoma is a critical determinant of poor prognosis in experimental ICH model in mice as well as in human ICH patients. MRI assessment may be a powerful tool to refine investigations of pathogenic mechanisms and evaluations of drug effects in animal models of ICH.

Predictors of tracheostomy in patients with spontaneous intracerebral hemorrhage

BACKGROUND

One third of patients with intracerebral hemorrhage (ICH) require mechanical ventilation; in most, tracheostomy may be necessary. Limited data exist about predictors of tracheostomy in ICH. The aim of our study is to identify predictors of tracheostomy in ICH.

METHODS

We reviewed medical records of patients seen in our institution between 2005 and 2009, using ICD-9 codes for ICH, for admission clinical and radiological parameters. A stepwise logistic regression model was used to identify tracheostomy predictors.

RESULTS

Ninety patients with ICH were included in the analysis, eleven of which required tracheostomy. Patients requiring a tracheostomy were more likely to have a large hematoma volume (≥30mL) (63.4% vs. 29.1%, p=0.037), intraventricular hemorrhage (81.8% vs. 27.8%, p<0.0001), hydrocephalus (81.8% vs. 8.8%, p<0.0001), admission GCS<8 (81.8% vs. 5.1%, p<0.0001), intubation≥14 days (54.5% vs. 1.27%, p<0.0001) and pneumonia (63.6% vs. 17.7%, p=0.003). Stepwise logistic regression yielded admission GCS (OR=80.55, p=0.0003) and intubation days (OR=87.49, p<0.006) as most important predictors.

CONCLUSION

We could potentially predict the need for tracheostomy early in the course of ICH based on the admission GCS score; duration of intubation is another predictor for tracheostomy. Early tracheostomy could decrease the time, and therefore risks of prolonged endotracheal intubation and length of hospital stay.

Spontaneous Intracerebral Hemorrhage With Ventricular Extension and the Grading of Obstructive Hydrocephalus: The Prediction of Outcome of a Special Life-Threatening Entity

BACKGROUND:

Primary spontaneous intracerebral hemorrhage (SICH) with secondary intraventricular hemorrhage (IVH) accounts for the highest in-hospital mortality after stroke.

OBJECTIVE:

To analyze predictors and the role of acute hydrocephalus in outcome, especially 30-day mortality or an unfavorable outcome at 6 months. In addition, a new risk stratification tool for SICH- IVH was developed.

METHODS:

Hospital charts of 104 of 110 SICH-IVH patients were retrospectively analyzed. All patients underwent at least 1 external ventricular drainage. Multivariate logistic regression analysis was used to identify independent prognostic predictors for 30-day mortality and outcome. Outcome was determined by the modified Rankin Scale. On the basis of the independent predictors, we developed an IVH scoring system. The IVH score was tested with prospective data from 51 patients and was compared with established intracerebral hemorrhage scoring systems.

RESULTS:

An initial SICH volume of 60 cm3 or greater, severe hydrocephalus, Glasgow Coma Scale score of 8 or less, and age 70 years and older were independent outcome predictors. Different cutoff values for the prediction of 30-day mortality and functional outcome were defined. The IVH score was best for the prediction of 30-day mortality.

CONCLUSION:

Severe hydrocephalus is an independent predictor of 30-day mortality in SICH with ventricular extension. The IVH score is a simple and reliable tool for predicting 30-day mortality.

A priority treatment of the intraventricular hemorrhage (IVH) should be performed in the patients suffering intracerebral hemorrhage with large IVH

BACKGROUND

In patients suffering from intracerebral hemorrhage (ICH) with ventricular hemorrhage (IVH), the IVH severity is thought to be associated with prognosis. Therefore, treating IVH may be a beneficial therapeutic target. In this study, by examining the associations among IVH severity, hydrocephalus, initial level of consciousness and prognosis, we attempted to identify which grade of IVH severity should be considered for surgical treatment.

METHODS

One hundred twenty-nine patients with spontaneous supratentorial ICH treated in our hospital between 2005 and 2006 were screened in this study. Of these patients, 100 with an ICH volume less than 60 ml were categorized into either the ICH patients without IVH (no-IVH) group (n=65) or the ICH patients with IVH (IVH) group (n=35). The Karnofsky Performance Status (KPS) scale assessed at the time of discharge was employed as an outcome index, and a KPS score of <or=40 was defined as the bedridden state. Age, gender, hemorrhage location, volume of ICH, IVH grade (according to the Graeb score), acute hydrocephalus, surgical ICH removal, and ventricular drainage were selected for univariate analyses with logistic regression.

RESULTS

Elderly patients, IVH volume, acute hydrocephalus, and poor initial level of consciousness were significantly associated with an unfavorable prognosis in the IVH group. Poor level of consciousness was significantly dependent on acute hydrocephalus, and significantly more occurrences of acute hydrocephalus were found in patients with a high IVH volume (Graeb score >or=6) than in patients with low to moderate IVH volume (Graeb score <or=6).

CONCLUSIONS

IVH severity influenced the occurrence of acute hydrocephalus and initial level of consciousness, which was significantly associated with prognosis. Our results suggest that priority treatment of the IVH should be given to those ICH patients with IVH admitted with a Graeb score of 6 or more.

Clinical review: Critical care management of spontaneous intracerebral hemorrhage

Intracerebral hemorrhage is by far the most destructive form of stroke. The clinical presentation is characterized by a rapidly deteriorating neurological exam coupled with signs and symptoms of elevated intracranial pressure. The diagnosis is easily established by the use of computed tomography or magnetic resonance imaging. Ventilatory support, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring, osmotherapy, fever control, seizure prophylaxis, treatment of hyerglycemia, and nutritional supplementation are the cornerstones of supportive care in the intensive care unit. Dexamethasone and other glucocorticoids should be avoided. Ventricular drainage should be performed urgently in all stuporous or comatose patients with intraventricular blood and acute hydrocephalus. Emergent surgical evacuation or hemicraniectomy should be considered for patients with large (>3 cm) cerebellar hemorrhages, and in those with large lobar hemorrhages, significant mass effect, and a deteriorating neurological exam. Apart from management in a specialized stroke or neurological intensive care unit, no specific medical therapies have been shown to consistently improve outcome after intracerebral hemorrhage.

Admission microalbuminuria and neurologic outcomes in intensive care unit patients with spontaneous intracerebral hemorrhage

This study was performed to determine the prevalence and the prognostic significance of microalbuminuria in patients admitted to intensive care unit (ICU) after spontaneous intracerebral hemorrhage (ICH). From May 2004 to April 2006, we studied 59 consecutive ICH patients verified using computed tomography and admitted to our ICU within a day after stroke. General clinical, neurologic data, and Glasgow Coma Scale (GCS) were recorded at admission to ICU. Urine was collected at admission to ICU for measuring the urinary microalbumin/creatinine ratio. At hospital discharge, neurologic outcome was assessed using Glasgow Outcome Scale. Among 59 patients, 37 (63%) had unfavorable neurologic outcomes (death, persistent vegetative state, and severe disability). The prevalence rate of microalbuminuria was 85% [95% confidence interval (CI), 76-94]. The areas under the receiver operator characteristic curves showed that the urinary microalbumin/creatinine ratio [0.81 (95% CI, 0.70-0.92)] and the GCS score [0.78 (95% CI, 0.66-0.90)] at admission were significant predictors of unfavorable neurologic outcome at hospital discharge. The threshold value, sensitivity, specificity, and likelihood ratio for the urinary microalbumin/creatinine ratio were 200 mg/g, 51% (95% CI, 39-64), 96% (95% CI, 90-100), and 11.3 (95% CI, 7.9-16.0); and those for the GCS score were 11, 46% (95% CI, 36-61), 96% (95% CI, 90-100), and 10.1 (95% CI, 7.2-14.1), respectively. This study confirmed a high prevalence of microalbuminuria in ICH patients in ICU, and suggested that the urinary microalbumin/creatinine ratio >200 mg/g was comparable to the GCS score <11 at admission to the ICU with regard to its prognostic characteristics after ICH.

Lumbar drainage for communicating hydrocephalus after ICH with ventricular hemorrhage

INTRODUCTION

Our objective was to investigate the feasibility of lumbar drainage (LD) as a new therapeutic approach for the treatment of communicating hydrocephalus in patients with supratentorial intracerebral hemorrhage (ICH) and ventricular extension (IVH) who initially required an external ventricular drain (EVD).

METHODS

Three consecutive patients with ICH and severe IVH were treated with EVD immediately after admission due to acute obstructive hydrocephalus. Each patient received intraventricular fibrinolysis (IVF) starting 12 hours after admission (4 mg rtPA every 12 hours up to a maximum cumulative dose of 20 mg). Although complete clearing from blood of the third and fourth ventricles was achieved in all patients after IVF, branching off the EVD failed because of increasing intracranial pressure (ICP). Assuming a communicating, malresorptive hydrocephalus was present, a lumbar drain was placed (to allow extracorporal CSF drainage through outer CSF space).

RESULTS

In all patients, the EVD could be branched off without raising ICP (while the LD remained open), resulting in the opportunity to remove the EVD in all patients after another 24 hours (mean duration of EVD was 115 +/- 4 hours). Clamping the LD was performed every second day and development of hydrocephalus was monitored by CT. After a mean duration of 6 (5-7) days after placement, the LD could be removed. None of the patients required a VP-Shunt.

CONCLUSION

Our preliminary data suggest that LD is a simple and reasonable alternative for treating communicating hydrocephalus after ICH and IVH. The combination of IVF to enhance clot resolution and to clear the third and fourth ventricle followed by LD may represent a new and promising approach in the therapy of hydrocephalus following severe ventricular hemorrhage.

Coiling and neuroendoscopy: a new perspective in the treatment of intraventricular haemorrhages due to bleeding aneurysms

BACKGROUND

Intraventricular haemorrhages (IVHs) caused by bleeding aneurysms are critical conditions that often carry a severe prognosis. Two main problems must be urgently dealt with: the secondary damage caused by intraventricular clotting and the risk of early rebleeding. A protocol of ultra-early endoscopic ventricular evacuation, after securing the aneurysm with coils, is proposed to solve this challenge in the acute phase and within a few hours of onset.

METHODS

Ten consecutive patients presenting with haematocephalus from aneurysm rupture were treated in our institute with coiling and endoscopic clot aspiration extended to the whole ventricular system. The only inclusion criteria were the presence of a massive IVH and an aneurysm appropriate for coiling. Computed tomography scans obtained before (within 4 h of symptom onset in all patients) and immediately after surgery were compared for Graeb score and ventriculocranial ratio (VCR); the Glasgow Outcome Scale (GOS) was assessed at 1 year.

RESULT

All patients were treated within 2 days of onset. The procedure resulted in a mean 58% removal of ventricular blood and decrease of hydrocephalus; the mean (standard deviation (SD)) Graeb score reduced from 11.5 (0.7) to 4.7 (2.2) (p<0.001) and mean ventriculocranial ratio from 0.26 (0.06) to 0.17 (0.05) (p<0.001). No rebleeding or delayed hydrocephalus needing shunt was observed. Mortality at 1 year was 30%; marked disability (GOS = 3) and good recovery (GOS = 5) were observed in 40% and 30% of patients, respectively.

CONCLUSIONS

Early neuroendoscopic removal of blood casting from the lateral to the fourth ventricle after coiling of bleeding aneurysms is a feasible approach, allowing in most instances the rapid improvement of the IVH.

Influence of intraventricular hemorrhage and occlusive hydrocephalus on the long-term outcome of treated patients with basal ganglia hemorrhage: a case-control study

OBJECT

Only limited data exist addressing the long-term outcome of patients with ganglionic hemorrhage complicated by intraventricular hemorrhage (IVH) and hydrocephalus that requires an external ventricular drain (EVD). The aim of this study was to compare the long-term outcome of patients with pure ganglionic hemorrhage and those requiring an EVD due to additional IVH and hydrocephalus.

METHODS

For this study, 116 patients with supratentorial ganglionic hemorrhage and occlusive hydrocephalus were screened. To avoid any bias the authors excluded all patients with nonprimary intracerebral hemorrhage as well as those who received no treatment. Forty patients with IVH and subsequent hydrocephalus were examined, and 40 more patients with pure ganglionic hematomas were matched with regard to age, sex, Glasgow Coma Scale score, need for mechanical ventilation, and, in particular, hematoma volume. Outcome analysis was performed using the Barthel Index and the modified Rankin Scale (mRS). The mean hematoma volume was 25.3 +/- 15.2 ml. The overall long-term outcome was unfavorable (mRS Score 4-6) in 59% of all patients. Good outcome (mRS score < 4) was observed in 25 (62.5%) of 40 patients with hematoma volumes less than 25 ml, compared with eight (20%) of 40 who had hematoma volumes greater than 25 ml (p < 0.05, chi-square test). The need for an EVD was not associated with a worse long-term outcome in patients with comparable hematoma volumes. In contrast, the duration of treatment in the intensive care unit was longer for patients with EVDs than for those who had pure ganglionic hematomas (16 [range 5-29] days compared with 8 [range 2-19] days; p < 0.05, Mann-Whitney U-test), regardless of hematoma volume.

CONCLUSIONS

The long-term outcome of treated patients with supratentorial ganglionic hemorrhage with ventricular involvement and occlusive hydrocephalus is comparable to that of patients with similar hematoma volumes but no IVH.

Presentation of intracerebral haemorrhage in a community

BACKGROUND

Studies on intracerebral haemorrhage (ICH) from tertiary care centres may not be an accurate representation of the true spectrum of disease presentation.

OBJECTIVE

To describe the clinical and imaging presentation of ICH in a community devoid of the referral bias of an academic medical centre; and to investigate factors associated with lower Glasgow coma scale (GCS) score at presentation, as GCS is crucial to early clinical decision making.

METHODS

The study formed part of the BASIC project (Brain Attack Surveillance in Corpus Christi), a population based stroke surveillance study in a bi-ethnic Texas community. Cases of first non-traumatic ICH were identified from years 2000 to 2003, using active and passive surveillance. Clinical data were collected from medical records by trained abstractors, and all computed tomography (CT) scans were reviewed by a study physician. Multivariable linear regression was used to identify clinical and CT predictors of a lower GCS score.

RESULTS

260 cases of non-traumatic ICH were identified. Median ICH volume was 11 ml (interquartile range 3 to 36) with hydrocephalus noted in 45%. Median initial GCS score was 12.5 (7 to 15). Hydrocephalus score (p = 0.0014), ambient cistern effacement (p = 0.0002), ICH volume (p = 0.014), and female sex (p = 0.024) were independently associated with lower GCS score at presentation, adjusting for other variables.

CONCLUSIONS

ICH has a wide range of severity at presentation. Hydrocephalus is a potentially reversible cause of a lower GCS score. Since early withdrawal of care decisions are often based on initial GCS, recognition of the important influence of hydrocephalus on GCS is warranted before withdrawal of care decisions are made.

Predictive factors for tracheostomy in neurocritical care patients with spontaneous supratentorial hemorrhage

BACKGROUND

Up to 30% of patients with supratentorial intracerebral hemorrhage (ICH) require mechanical ventilation during the course of treatment. For these patients, tracheostomy is necessary in cases of protracted weaning. As only limited data exist about predictors for a tracheostomy in patients with ICH, the aim of this study was to investigate the frequency of tracheostomy and clinical findings that increase the risk for a tracheostomy in patients with supratentorial hemorrhage.

METHODS

A total of 392 patients with supratentorial ICH were analyzed. The parameters age, gender, chronic obstructive pulmonary disease (COPD), Glasgow Coma Scale on admission, ganglionic or non-ganglionic localization, presence of ventricular hemorrhage, hydrocephalus, hematoma volume, and hematoma evacuation were investigated. The effects on the end-point tracheostomy were analyzed using multivariate regression analyses.

RESULTS

The overall need for tracheostomy was 9.9% (16.3% in patients with ganglionic hemorrhage versus 2.8% in patients with non-ganglionic hemorrhages). 31% of the ventilated patients required tracheostomy. The risk for tracheostomy was increased eightfold in patients who developed hydrocephalus. The presence of ventricular blood, in general, showed no significant impact on the need for tracheostomy, whereas hemorrhage extending into the third and fourth ventricles in conjunction with hydrocephalus increased the risk for tracheostomy. The hematoma volume correlated positively with the risk for tracheostomy.

CONCLUSIONS

Our study demonstrates that approximately 10% of patients with ICH require tracheostomy during the course of their disease. Presence of COPD, hematoma volume, ganglionic location of the hematoma, and the development of hydrocephalus are predisposing factors for tracheostomy.

Plasma interleukin 11 levels correlate with outcome of spontaneous intracerebral hemorrhage

BACKGROUND

Interleukin (IL) 11 is a multipotential cytokine with anti-inflammatory and fibrogenic properties. It is released into the peripheral blood from damaged brain tissue. The objective of this study was to determine plasma and cerebral spinal fluid (CSF) levels of IL-11 in patients with spontaneous intracerebral hemorrhage (ICH) and to correlate IL-11 with survival, related edema of the brain, volume of hematoma, and hydrocephalus.

METHODS

Forty-three patients with spontaneous ICH were included. Twenty-three were male, and 20 were female. The mean age of the patients was 64.3 years. Plasma and CSF samples were collected on the first, second, third, and fourth days after spontaneous ICH onset.

RESULTS

The levels of IL-11 in CSF (123.9 +/- 107 pg/mL) were 5 times higher than those in plasma (25.5 +/- 18.0 pg/mL) on the first day (P = .001 by paired t test) in our spontaneous ICH patients, and this significant difference persisted up to the third day of ICH. Plasma IL-11 levels in the nonsurvival group (41.2 +/- 18.9 pg/mL) were significantly higher than those in the survival group (22.2 +/- 15.2 pg/mL) on the second day of ICH onset (P = .024 by Mann-Whitney U test), and the significant difference extended to the fourth day. Plasma IL-11 levels of the hydrocephalus group were higher than those of the nonhydrocephalus group in the first 4 days of ICH, but the difference was not statistically significant.

CONCLUSIONS

IL-11 was highly associated with mortality caused by spontaneous ICH and correlated with the hydrocephalus occurring after ICH onset. It is our belief that IL-11 can be a useful clinical marker for spontaneous ICH patients.

Treatment of intracerebral haemorrhage

Apart from management in a specialised stroke or neurological intensive care unit, until very recently no specific therapies improved outcome after intracerebral haemorrhage (ICH). In a recent phase II trial, recombinant activated factor VII (eptacog alfa) reduced haematoma expansion, mortality, and disability when given within 4 h of ICH onset; a phase III trial (the FAST trial) is now in progress. Ventilatory support, blood-pressure reduction, intracranial-pressure monitoring, osmotherapy, fever control, seizure prophylaxis, and nutritional supplementation are the cornerstones of supportive care in intensive care units. Ventricular drainage should be considered in all stuporous or comatose patients with intraventricular haemorrhage and acute hydrocephalus. Given the lack of benefit seen in a the recent STICH trial, emergency surgical evacuation within 72 h of onset should be reserved for patients with large (>3 cm) cerebellar haemorrhages, or those with large lobar haemorrhages, substantial mass effect, and rapidly deteriorating condition.

Long-term resolution of acute, obstructive, triventricular hydrocephalus by endoscopic removal of a third ventricular hematoma without third ventriculostomy. Case report and review of the literature

The authors describe a new extension of the use of neuroendoscopy beyond that which is ordinarily performed. The authors report on the resolution of acute, obstructive, triventricular hydrocephalus in a 42-year-old woman with hypertensive caudate hemorrhage that migrated into the ventricular system. The patient underwent emergency endoscopic removal of a third ventricular hematoma, which was obstructing the orifice of the aqueduct, and restoration of cerebrospinal fluid (CSF) flow but no third ventriculostomy. The authors believe that this is the first such case to be reported. In selected cases of third ventricular hemorrhage, endoscopic removal of the intraventricular hematoma may represent a useful and effective treatment option even in emergency conditions as well as a better alternative to prolonged CSF external ventricular drainage. A reduction in the duration of hospitalization is a beneficial consequence. The authors assert that third ventriculostomy is not always needed.

Emerging medical and surgical management strategies in the evaluation and treatment of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) accounts for approximately 10% of all strokes and causes high morbidity and mortality. Rupture of the small perforating vessels of the cerebral arteries is caused by chronic hypertension, which induces pathologic changes in the small vessels and accounts for most cases of ICH; however, amyloid angiopathy and other secondary causes are being seen more frequently with the increasing age of the population. Recent computed tomographic studies have revealed that ICH is a dynamic process with up to one third of initial hemorrhages expanding within the first several hours of ictus. Secondary injury is believed to result from the development of cerebral edema and the release of specific neurotoxins associated with the breakdown products of hemoglobin. Treatment is primarily supportive. Surgical evacuation is the treatment of choice for patients with neurologic deterioration from infratentorial hematomas. Randomized trials comparing surgical evacuation to medical management have shown no benefit of surgical removal of supratentorial hemorrhages. New strategies focusing on early hemostasis, improved critical care management, and less invasive surgical techniques for clot evacuation are promising to decrease secondary neurologic injury. We review the pathophysiology of ICH, its medical management, and new treatment strategies for improving patient outcome.

QTc dispersion as a prognostic factor in intracerebral hemorrhage

QTc dispersion in the electrocardiogram (ECG) is a new important prognostic factor for many diseases, but its role in intracerebral hemorrhage (ICH) is not clear. This study was performed to investigate the prognostic significance of QTc dispersion in the acute ICH patients. We studied the differences of QTc dispersion from the initial ECG in the ED between the survival to discharge and nonsurvival patients retrospectively. We found that the patients had lesser chance to survival to discharge if they had increased QTc dispersion, longer maximal QTc interval, lower Glasgow Coma Scale (GCS), and brainstem involvement in the univariate analyses. The QTc dispersion and GCS were the statistically significant independent predictors in the multiple logistic analyses. Increased QTc dispersion in the initial ED electrocardiograph is an important prognostic factor for ICH patients. More attention to the disposition and intensive care should be given for these patients.

Update on management of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a lingering cause of significant mortality and morbidity rates in contemporary society. Despite its established burden, considerably less investigative attention has been devoted to the study of ICH than other forms of stroke. Only a limited number of clinical studies have been performed to examine the surgical (both craniotomy and minimally invasive) and medical management of patients with ICH. No consistently efficacious strategies have been identified through such investigations. Limitations in study design and execution have universally impaired the interpretation and impact of available data. Management of ICH unfortunately remains heterogeneous across institutions, and it continues to suffer from the lack of proven medical and surgical effectiveness. Urgently needed are further prospective randomized controlled trials in which investigators consider the shortcomings of previous endeavors in the management of ICH. In the present article the authors review the current management practices of ICH, discuss the controlled trials, and highlight recent trials and future avenues of further study.

Aspects of stroke management including subarachnoid haemorrhage

The present review focuses on some aspects of stroke management and covers important clinical studies and studies in basic research published during the past year. It is subdivided in three sections. First, we focus on ischaemic stroke and discuss some new insights into the genetics of ischaemic stroke, intensive stroke care including cerebral thrombolysis, and neuroprotective treatment. Secondly, new insights into the risk factors and outcome of primary and iatrogenic intracerebral haemorrhage are discussed. Finally, we review in the section on subarachnoid haemorrhage literature on the further development of endovascular treatment of cerebral aneurysms, and research into the causes of vasospasms and secondary cerebral ischaemia.