Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

How far are we from bringing intensive care bundle for intracerebral hemorrhage into the real-world setting? A 5-year population based-study

INTRODUCTION

Comprehensive care bundles including rapid blood pressure management, anticoagulation reversal, neurosurgical consultation, control of blood glucose and body temperature, can improve short- and medium-term outcomes in patients with intracerebral hemorrhage (ICH). This study assessed how the acute management of ICH practices evolved in a real-world setting over five years characterized by global changes in ICH care.

METHODS

This study analysed ICH cases from a population-based stroke registry between 2018 and 2022. We collected demographic and clinical data, focusing on key parameters of ICH management, such as systolic blood pressure, anticoagulation reversal, neurosurgical referrals, blood glucose, and body temperature. We also examined yearly trends in control of parameters over time.

RESULTS

We included 460 patients with ICH (55.4% male, median age 79 years, interquartile range 69-85). At onset, 266 patients (57.8%) had high SBP (SBP ≥ 140 mmHg), 286 (70.3%) hyperglycemia (blood glucose ≥ 108 mg/dL), and 63 (17.3%) hyperpyrexia (body temperature ≥ 37.0*C). Anticoagulation was reversed in 21.4% of anticoagulated patients within 24 h. Neurosurgical referrals were made for 84.6% of patients while only 12.4% underwent surgery. From 2018 to 2022, anticoagulation reversal rates increased from 0 to 88.9% (p < 0.001), while neurosurgical referrals not followed by surgery decreased from 79.5 to 55.7% (p < 0.001).

CONCLUSIONS

This real-world study demonstrates suboptimal management of key factors associated with ICH prognosis; nevertheless, it highlights improvement over time. There is a need for structured interventions to improve the timely and consistent application of simple yet effective measures yielding the potential to improve patients' outcomes.

Outcomes Following Minimally Invasive Surgery for Intracerebral Hemorrhage in the AHA Get With The Guidelines-Stroke Registry

BACKGROUND

The efficacy of minimally invasive surgery (MIS) in improving outcomes after nontraumatic intracerebral hemorrhage (ICH) remains uncertain, with inconsistent findings from randomized clinical trials. Our objective was to evaluate the real-world impact of MIS on ICH outcomes using a nationally representative cohort.

METHODS

We performed a retrospective cohort study of patients with a nontraumatic ICH enrolled in the American Heart Association Get With The Guidelines-Stroke Registry between January 1, 2011, and December 31, 2021. We excluded patients with a diagnosis of ischemic stroke or other intracranial hemorrhage subtypes, those who underwent open craniotomy or craniectomy, and patients transferred to another hospital. The exposure was MIS, defined as a composite of stereotactic surgical evacuation and endoscopic surgical evacuation. The primary outcome was in-hospital mortality, while secondary outcomes included functional outcomes at discharge (discharge disposition, ambulatory status, and modified Rankin Scale score). We matched patients who underwent MIS with nonsurgical patients using overlap propensity matching and used multiple logistic regression to study the association between MIS and outcomes.

RESULTS

Among 684 467 patients with ICH, 555 964 were included; the mean age was 68 (SD, 15.3) years, and 262 999 (47.3%) were female. MIS was performed in 703 patients of whom 312 had stereotactic surgery and 391 had endoscopic surgery. In the matched cohort, in-hospital deaths occurred in 60 of 446 (13.5%) with MIS and 8321 of 35 361 patients (23.5%) without surgery. In regression analyses, MIS was associated with lower in-hospital mortality (adjusted odds ratio, 0.50 [95% CI, 0.39-0.65]) and favorable discharge disposition (adjusted odds ratio, 1.93 [95% CI, 1.61-2.32]) but not with ambulatory status or functional outcomes. In additional analyses, stereotactic surgery and endoscopic surgery were independently associated with lower mortality.

CONCLUSIONS

In a large diverse cohort of patients with ICH, MIS was associated with lower in-hospital mortality and favorable discharge disposition. These findings support efforts to understand the durable impact of MIS in patients with ICH.

Clinical impact of gradient echo MRI versus CT in detecting hemorrhagic transformation after mechanical thrombectomy

PURPOSE

Hemorrhagic transformation (HT) following mechanical thrombectomy (MT) is a critical concern in the management of ischemic stroke patients. While both CT and MRI are used to detect HT, the clinical implications of discrepancies between these modalities remain unclear. This study aims to investigate the clinical implications of discordant findings between gradient echo MRI and CT in detecting HT after MT.

METHODS

In this retrospective study, patients who underwent MT for ischemic stroke between 2016 and 2023 were analyzed. Patients were categorized into two groups based on imaging results: CT negative and MRI positive versus CT positive and MRI positive.

RESULTS

A total of 286 patients were included in the study, with 104 in the CT negative and MRI positive group and 182 in the CT positive and MRI positive group. More patients in the CT negative and MRI positive group were started on antithrombotic medications in less than 2 days compared to the patients in the CT positive and MRI positive group (47.3% vs. 34.5%; OR: 1.94, 95% CI: 0.88-4.27, p = 0.09) and still exhibited significantly higher rates of good functional outcomes (mRS 0-2) at discharge (OR: 3.27, 95% CI: 1.03-10.36, p = 0.04). Additionally, the CT negative and MRI positive group had a lower, though not statistically significant, likelihood of readmission for diagnosis of intracranial hemorrhage (ICH) within 30 days (0% vs. 2.7%, p = 0.16).

CONCLUSION

Gradient echo MRI can detect subtle hemorrhages not seen on CT, and both modalities offer complementary insights. In our cohort of MRI-positive patients, those with CT-negative findings had better functional outcomes and earlier antithrombotic resumption without increased risk of ICH readmission. These results suggest that in select scenarios, a negative CT may help inform safe antithrombotic management, though this does not diminish the diagnostic value of MRI. Further prospective studies are warranted to establish thresholds for MRI findings and refine clinical protocols post-MT.

Two decades of trends in nontraumatic intracerebral hemorrhage care: A nationwide analysis

PURPOSE

This study aims to analyze the temporal trends of comorbidities, complications, and in-hospital mortality of non-traumatic intracerebral hemorrhages (ICH) over the past two decades using a nationwide inpatient sample.

METHODS

The National Inpatient Sample database was screened to identify patients hospitalized with ICH from 2002 to 2022. Socio-demographic characteristics, comorbidities, complications (including ischemic stroke, seizures, aspiration pneumonia, and deep vein thrombosis/pulmonary embolism DVT/PE), neurosurgical procedures, tracheostomy, and percutaneous gastrostomy placement were reviewed. Length of hospital stay and in-hospital mortality were analyzed. Temporal trends were determined using linear logistic regression models for each predetermined variable. For dichotomous variables, the natural logarithm was calculated to achieve a harmonic linear trend. Pairwise comparison was used for subgroup analyses.

RESULTS

A total of 467,117 patients with ICH were included in the study. From 2002 to 2022, there was a significant increase in comorbidities, including hypertension, diabetes, chronic kidney disease, obesity, and anticoagulant use, p < 0.01 for all. Patients' age progressively decreased over time (β:-0.104, 95 %CI: -0.124-0.085, p < 0.01). Notably, a temporal increase in ischemic stroke (β:0.081, 95 %CI: 0.069-0.092, p < 0.01) and seizures (β:0.012, 95 %CI: 0.001-0.008, p < 0.01) was noted. Clot removal/decompression declined over the years (β:-0.039, 95 %CI: -0.057-0.022, p < 0.01) while EVD/VPS placement increased (β:, 95 %CI: -0.057-0.022, p < 0.01). Length of hospital stay increased yearly by 0.07 days (95 %CI: 0.04-0.08, p < 0.01). The average annual mortality rate significantly decreased by 2.43 % per year (95 %CI: -2.21 %-2.65 %, p < 0.01). In-hospital mortality rates declined more rapidly in urban areas compared to rural areas (0.99 % difference, 95 %CI: 0.5 %-1.48 %, p < 0.01). No statistical difference was observed among sex, racial or income groups; however, there was a trend toward a slower decline in in-hospital mortality among lower-income compared to higher-income groups.

CONCLUSION

Despite increasing patient complexity, in-hospital mortality has steadily decreased in ICH patients over the last two decades. These improvements have come at the cost of longer hospital stays. Profound inequities remain in the mortality rate in rural areas.

Volume Tolerance and Prognostic Impact of Hematoma Expansion in Deep and Lobar Intracerebral Hemorrhage

BACKGROUND

The prognostic impact of intracerebral hemorrhage (ICH) volume varies according to location, with smaller volume tolerance in deep ICH, and hematoma expansion (HE) contributes to final ICH volume. We tested the hypothesis that HE influences outcome only when the final ICH volume achieves a critical threshold that differs according to ICH location.

METHODS

Retrospective analysis of patients with supratentorial ICH admitted at 10 centers in North America and China (development cohort) and Europe (replication cohort). HE was defined as growth >33% and/or >6 mL. Location-specific (lobar versus deep) volume cutoffs for the prediction of poor outcomes were derived using receiver operating characteristic curves and the Youden index. The prognostic impact of HE stratified by location and final volume was explored with logistic regression (poor outcome: 90-day modified Rankin Scale score of 4-6), accounting for age, Glasgow Coma Scale, baseline volume, intraventricular hemorrhage, and admission center.

RESULTS

We identified 1774 patients with ICH in the development cohort and 1746 in the replication cohort. A total of 1058 (mean age, 68 years; 47.8% men) and 1423 (mean age, 71 years; 44.7% men) subjects met the inclusion criteria, respectively. The optimal final ICH volume cutoff for poor outcome differed by location: ≥36 mL for lobar and ≥17 mL for deep ICH. HE with final volume below the cutoff was not associated with higher odds of poor outcome compared with patients without HE (adjusted odds ratio, 1.85 [95% CI, 0.78-4.38]; P=0.163 in lobar ICH; adjusted odds ratio, 0.85 [95% CI, 0.38-1.89]; P=0.685 in deep ICH). The combination of HE and final volume over the critical threshold was, however, significantly associated with poor prognosis, and the magnitude of this effect was substantial (adjusted odds ratio, 8.55 [95% CI, 2.87-25.48]; P<0.001 in lobar ICH; adjusted odds ratio, 10.34 [95% CI, 2.86-37.44]; P<0.001 in deep ICH). These findings were confirmed in the replication cohort.

CONCLUSIONS

HE significantly impacts severe outcomes only when the final ICH volume exceeds a critical target threshold, and this threshold is lower in deep versus lobar ICH. These findings might inform clinical practice and future trials.

Triad of Cerebellar Hematoma, Obstructive Hydrocephalus and Non-Traumatic Subarachnoid Hemorrhage in a Hypertensive Patient: A Case Report and Literature Review

We are reporting the case of a hypertensive middle-aged adult with a triad of right cerebellar hematoma, acute obstructive tri-ventricular hydrocephalus, and spontaneous subarachnoid hemorrhage. A 45-year-old male with a 3-year history of uncontrolled hypertension presented with a severe thunderclap headache, left lower facial weakness, left symmetrical hemiparesis, ataxia, dysdiadochokinesis, signs of intracranial hypertension, grade III hypertension, and a Glasgow coma score (GCS) of 13/15 with a loss of spatial and temporal orientation. A non-contrast-enhanced cerebral CT scan showed a right cerebellar hematoma complicated by a diffuse cerebral edema, a tri-ventricular obstructive hydrocephalus from compression of the fourth ventricle, and a subarachnoid hemorrhage. A conservative management approach was adopted by the neurosurgeon based on the high GCS on entry, slight improvement in the signs of intracranial hypertension and blood pressure, and the lack of a neurosurgical technical platform to manage the case surgically. On his fifth day of admission, he was transferred to the intensive care unit (ICU) following a significant deterioration in his GCS (8/15), despite improvement in his blood pressure (BP) and intracranial pressure. He unfortunately passed away in the ICU 24 h later following a cardiorespiratory arrest. The exact etiology of this extremely rare occurrence remains obscure, and the management is all the more challenging, especially in a setting like ours where neurosurgical services are still underdeveloped. This case highlights the need not only for the establishment of proper neurosurgical services in our setting but also for standardized guidelines for the management of these cases.

Application of promoting blood circulation and resolving blood stasis in intracerebral hemorrhage: a traditional method gradually being reconsidered

Intracerebral hemorrhage (ICH) is a significant and growing threat to human health, with increasing incidence. Promoting blood circulation and removing blood stasis therapy (PBCRBS), a Traditional Chinese Medicine therapy, can be an adjuvant therapy to benefit patients with ICH by improving clinical efficacy. However, in theory, using PBCRBS to treat ICH carries the risk of hematoma enlargement and rebleeding, which has led to controversy over its application in ICH treatment. To demonstrate the effectiveness and safety of PBCRBS in treating ICH, this review first analyzes the pathological and physiological basis of ICH and secondly, the cascade of response after ICH and the involvement of cytokines and signaling pathways in this process. Finally, experimental and clinical studies on the treatment of ICH with PBCRBS over the past decade were retrieved from the PubMed and China National Knowledge Infrastructure databases, and the content of these studies was used to summarize commonly used herbs with PBCRBS effects and their mechanisms of action. Through analysis, hypertension has been identified as the most common cause of ICH. Heme, interleukin, reactive oxygen species, coagulation promoting particles and other induced mass effects, inflammation, oxidative stress, and coagulation cascade reactions lead to brain damage following ICH. This review includes 56 experimental studies and 83 clinical studies summarizing 28 commonly used herbs, demonstrating the positive impact of PBCRBS as an adjuvant therapy for ICH. In summary, PBCRBS appears effective and safe for treating ICH.

Ultra-Early Blood Pressure Control in Acute Intracerebral Hemorrhage

Acute intracerebral hemorrhage (ICH) remains one of the most devastating neurological emergencies, with blood pressure (BP) management in the early hours playing a pivotal role in determining patient outcomes. Emerging evidence suggests that ultra-early BP control-intervening within minutes to 2 hours of symptom onset-has the potential to reduce secondary brain injury and improve survival. Yet, despite this evidence, current clinical practice is often inconsistent, and there is no universally agreed-upon approach for managing BP in the acute phase of ICH. We advocate for ultra-early BP intervention as a standard of care in ICH, as it offers a clear opportunity to mitigate damage and to enhance recovery. We contend that current BP management protocols are often too conservative and fail to recognize the critical importance of acting swiftly. The first few hours represent a unique window in which targeted interventions, such as continuous infusion intravenous antihypertensives, may limit hematoma expansion and stabilize cerebral perfusion pressure. However, achieving optimal outcomes requires more than just aggressive treatment-it demands a tailored approach to BP control, accounting for individual patient factors, evolving clinical conditions, and operational aspects of care. We advocate for a paradigm shift toward prioritizing ultra-early intervention, supported by clear, evidence-based protocols and real-time decision-making.

Perihematomal oligemia is associated with progression to ischemia and poor outcome in a subset of patients with intracerebral hemorrhage

OBJECTIVES

We aimed to characterize the longitudinal evolution of perihematomal oligemia in acute intracerebral hemorrhage (ICH).

MATERIALS AND METHODS

A single center prospectively collected cohort of 150 patients with primary spontaneous ICH were imaged with computed tomography perfusion within 6 h from onset (T0), at 24 h (T1) and at 7 days (T7). Perihematomal cerebral blood flow (pCBF) was measured in the manually outlined perihematomal low-density area and categorized into ischemic (< 20 mL/100 g/min), oligemic (20-39.9 mL/100 g/min), normal (40-55 mL/100 g/min) and hyperemic (> 55 mL/100 g/min).

RESULTS

pCBF values were ischemic in 20.7%, oligemic 47.3%, normal in 17.3%, and hyperemic in 14.7% of patients at T0. All patients with T0 ischemia remained ischemic at T7, normal and hyperemic patients at T0 maintained good perfusion values at T7, whereas 46.5% of oligemic patients at T0 developed delayed perihematomal ischemia. In patients with T0 perihematomal oligemia, the risk of conversion into delayed ischemia at T7 was higher in those with pCBF < 30 mL/100 g/min (p < 0.001). A total of 42.7% patients had perihematomal ischemia at T7 and this profile correlated with poor outcome, regardless of baseline perfusion status.

CONCLUSION

Our findings suggest that perihematomal oligemia may not represent a benign entity and indicate that delayed perihematomal ischemia is common and associated with unfavorable outcome.

KEY POINTS

Question The natural history and longitudinal evolution of perihematomal oligemia over time in patients with intracerebral hemorrhage (ICH) remains to be established. Findings Conversion of baseline perihematomal oligemia into ischemia occurs in 46.5% of oligemic ICH patients at 7 days, where a total of 42.7% patients were ischemic. Clinical relevance Evolution of perihematomal oligemia into ischemia during the transition from hyperacute to subacute phases is common. ICH patients with perihemorrhagic cerebral blood flow values < 30 mL/100 g/min are at high risk of ischemic progression, which in turn contributes to poor outcome.

Association of ICH Score with Withdrawal of Life-Sustaining Treatment: A Decade from the Florida Stroke Registry

Background and Purpose

The intracerebral hemorrhage (ICH) score was created as a tool improve communication and consistency among providers, and authors initially cautioned against its use as a predictor of outcomes. We aimed to investigate the association of ICH score with mortality and withdrawal of life-sustaining treatment (WLST).

Methods

Patients with a diagnosis of ICH were identified using data from Florida Stroke Registry (FSR) hospitals participating in the American Heart Association (AHA) Get with the Guidelines-Stroke (GWTG-S) from 2013-2022. Outcomes of WLST and in-hospital mortality were collected. ICH score was stratified into three groups: ICH score 0-2; 3-4; 5-6. Importance plots were generated to identify the most predictive factors associated with WLST. AUC-ROC curves were generated for logistic regression (LR) and random forest (RF) models, adjusted for relevant confounders. Secondary outcome analyses were performed using stratified univariate logistic regression to assess changes between 2015-2018 and 2019-2022.

Results

A total of 12,426 (26%) patients had documented ICH scores (mean age 69, 55% male, 56% white). The most predictive factors associated with WLST were ICH score, age, state region, presenting level of consciousness, insurance status and race (RF AUC=.94, LR AUC=.82). Mortality was 6.6%, 41.5% and 66% for ICH score 0-2, 3-4 and 5-6. Decision to WLST occurred more for ICH scores 3-4 (OR 9.35, 95% CI: 8.5-10.3) and ICH scores 5-6 (15.43, 95% CI: 15.28-22.74). Early WLST (< 2 days) was more likely for ICH score 3-4 (OR 2.97, 95% CI: 2.48-3.55) and score 5-6 groups (OR 9.51, 95% CI: 7.33-12.35).

Conclusion

Among ICH patients admitted across Florida, we noted a significant association between ICH score and likelihood of mortality, decision to WLST, and specifically WLST within two days of presentation. We identified the most predictive variable associated with WLST to be the ICH score. These findings suggest a continued influence of the self-fulfilling prophecy in ICH.

Hemoglobin Decrements are Associated with Ischemic Brain Lesions and Poor Outcomes in Patients with Intracerebral Hemorrhage

BACKGROUND

Acute ischemic lesions seen on brain magnetic resonance imaging (MRI) are associated with poor intracerebral hemorrhage (ICH) outcomes, but drivers for these lesions are unknown. Rapid hemoglobin decrements occur in the initial days after ICH and may impair brain oxygen delivery. We investigated whether acute hemoglobin decrements after ICH are associated with MRI ischemic lesions and poor long-term ICH outcomes.

METHODS

Consecutive patients with acute spontaneous ICH enrolled into a single-center prospective cohort study were assessed. Change in hemoglobin levels from admission to brain MRI was defined as the exposure variable. The presence of MRI ischemic lesions on diffusion-weighted imaging was the primary radiographic outcome. Poor 6-month modified Rankin Scale score (4-6) was assessed as our clinical outcome. Separate regression models assessed relationships between exposure and outcomes adjusting for relevant confounders. These relationships were also assessed in a separate prospective single-center cohort of patients with ICH receiving minimally invasive hematoma evacuation.

RESULTS

Of 190 patients analyzed in our primary cohort, the mean age was 66.7 years, the baseline hemoglobin level was 13.4 g/dL, and 32% had MRI ischemic lesions. Greater hemoglobin decrements were associated with MRI ischemic lesions (adjusted odds ratio [OR] 0.77 for every 1 g/dL change, 95% confidence interval [CI] 0.60-0.99) and with poor 6-month outcomes (adjusted OR 0.73, 95% CI 0.55-0.98) after adjusting for demographics, ICH and medical disease severity, and antithrombotic use. In our separate cohort of 172 surgical patients with ICH, greater hemoglobin concentration decrements similarly associated with MRI ischemic lesions (adjusted OR 0.74, 95% CI 0.56-0.97) and poor 6-month outcomes (adjusted OR 0.69, 95% CI 0.48-0.98).

CONCLUSIONS

Greater hemoglobin decrements after acute ICH are associated with ischemic lesions on brain MRI and poor long-term outcomes. Further work is required to clarify drivers for these relationships and whether anemia treatment and prevention can be used to improve ICH outcomes.

Early Postoperative Changes in Von Willebrand Factor Activity Are Associated With Future Bleeding and Stroke in HeartMate 3 Patients

Hemocompatibility-related adverse events (HRAEs), particularly gastrointestinal bleeding, remain a frequent complication after left ventricular assist device (LVAD) implantation. The current study sought to describe and analyze whether early (<60 days) postoperative von Willebrand factor (VWF) activity assays predict the risk of gastrointestinal bleeding and stroke. A prospective single-center study including 74 HeartMate 3 device recipients between 2016 and 2023 was undertaken. The postoperative trajectory of the VWF profile was analyzed using linear mixed-effect models and Cox models were used to quantify associations between an early postoperative dip (≤0.7) in VWF activity assay measurements and late outcomes. Preoperatively, the mean VWF:Activity (Act)/Antigen (Ag) and VWF:Collagen Binding (CB)/Ag ratios were 0.94 (95% confidence interval [CI] = 0.81-1.02) and 0.95 (95% CI = 0.80-1.03), respectively, decreasing to 0.66 (95% CI = 0.57-0.73) and 0.67 (95% CI = 0.58-0.74) within 40 days ( p < 0.05). In patients with VWF:CB/Ag and VWF:Act/Ag ratios ≤0.7 significantly more gastrointestinal bleeding (hazard ratio [HR]: 2.53; 95% CI = 1.1-5.8, and HR: 3.7; 95% CI = 1.5-9.2, respectively) and hemorrhagic stroke events (HR: 3.5; 95% CI = 1.6-7.6 and HR: 4.9; 95% CI = 2.1-11.7, respectively) were observed throughout the entire late (>60 days) postoperative period. In patients with VWF:Act/Ag ratio ≤0.7 less ischemic stroke events were observed (HR: 0.11; 95% CI = 0.01-0.85). In conclusion, VWF:Act/Ag and VWF:CB/Ag ratios ≤0.7 in the early postoperative phase can be used as biomarkers to predict HRAEs during long-term LVAD support.

Etiology and characteristics of non-aneurysmal thunderclap headache presenting to an acute setting

OBJECTIVES

To describe the characteristics and causes of non-aneurysmal thunderclap headache (TCH) and compare serious from benign underlying causes.

METHODS

Retrospective cohort study of consecutive adult patients with TCH presenting to a tertiary care academic medical center between 2010 and 2020. Aneurysmal subarachnoid hemorrhage cases were excluded. Cases were categorized into serious or benign; serious TCH was defined as any condition in which delayed diagnosis and treatment could result in neurological disability or death. Risk factors for serious TCH were analyzed. We adhere to standardized guidelines for reporting observational studies.

RESULTS

A total of 932 patients presented with TCH. After exclusion of 393 patients with aneurysmal-type subarachnoid hemorrhage, 539 were included in the analysis. One-half (n = 275, 51.0 %) had a serious cause. Median age was 51 years, 69.0 % were female. Most frequent diagnoses were intracranial hemorrhage (n = 102, 18.9 %), reversible cerebral vasoconstriction syndrome (n = 97, 18.0 %), and idiopathic TCH (n = 102, 38.6 %). A multivariable logistic regression model for prediction of serious TCH included age, hypertension, migraines, recurrent TCH, level of consciousness and other clinical exam findings, and achieved an AUROC of 0.732. This score had a sensitivity of 79.9 % (95 % CI 73.5-83.5 %) for the identification of serious TCH. A 0.5-point increase in the risk score was associated with a 73 % increase in the odds of serious TCH (odds ratio 1.73, 95 % CI 1.53-1.95, p < 0.001).

CONCLUSION

Our study describes the relative frequency of presentation and etiologies among patients with TCH This score can aide clinicians in recognising patients with potentially serious cause of TCH, for whom additional imaging and neurological consultation is necessary.

Evaluating the strength and quality of evidence in American heart association/American stroke association's guidelines for aneurysmal subarachnoid hemorrhage and spontaneous intracerebral hemorrhage

BACKGROUND

Clinical practice recommendations guide healthcare decisions. This study aims to evaluate the strength and quality of evidence supporting the American Heart Association (AHA)/American Stroke Association (ASA) guidelines for aneurysmal subarachnoid hemorrhage (aSAH) and spontaneous intracerebral hemorrhage (ICH).

METHODS

We reviewed the current AHA/ASA guidelines for aSAH and spontaneous ICH and compared with previous guidelines. Guidelines were classified based on the Class of recommendation (COR) and Level of evidence (LOE). COR signifies recommendation strength (COR 1: Strong; COR 2a: Moderate; COR 2b: Weak; COR 3: No Benefit/Harm), while LOE denotes evidence quality (LOE A: High-Quality; LOE B-NR: Moderate-Quality, Not Randomized; LOE B-R: Moderate-Quality, Randomized; LOE C-EO: Expert Opinion; LOE C-LD: Limited Data).

RESULTS

For aSAH, we identified 84 recommendations across 15 guideline categories. Of these, 31% were classified as COR I, 30% as COR 2a, 17% as COR 2b, and 18% as COR 3. In terms of LOE, 7% were based on LOE A, 10% on LOE B-R, 65% on LOE B-NR, 14% on LOE C-LD, and 5% on LOE C-EO. Compared to previous guidelines, there was a 46% decrease in LOE A, a 45% increase in LOE B, and an 11% decrease in LOE C. For spontaneous ICH, 124 guidelines were identified across 31 guideline categories. Of these, 28% were COR I, 32% COR 2b, and 9% COR 3. For LOE, 4% were based on LOE A, 35% on LOE B-NR, and 42% on LOE C-LD. Compared to previous guidelines, there was a 78% decrease in LOE A, an 82% increase in LOE B, and a 14% increase in LOE C. This analysis highlights that less than a third of AHA/ASA guidelines are classified as the highest class of recommendation, with less than 10% based on the highest LOE.

CONCLUSION

Less than a third of AHA/ASA guidelines on aSAH and spontaneous ICH are classified as the highest class of recommendation with less than 10% based on highest LOE. There appears to be a decrease in proportion of guidelines based on highest LOE in most recent guidelines.

Imaging of Hemorrhagic Stroke in Children

Hemorrhagic stroke (HS) is an important cause of neurologic morbidity and mortality in children and is more common than ischemic stroke between the ages of 1 and 14 years, a notable contradistinction relative to adult stroke epidemiology. Rapid neuroimaging is of the utmost importance in making the diagnosis of HS, identifying a likely etiology, and directing acute care. Computed tomography and MR imaging with flow-sensitive MR imaging and other noninvasive vascular imaging studies play a primary role in the initial diagnostic evaluation. Catheter-directed digital subtraction angiography is critical for definitive diagnosis and treatment planning.

Mortality, Functional Status, and Quality of Life after 5 Years of Patients Admitted to Critical Care for Spontaneous Intracerebral Hemorrhage

BACKGROUND

The objective of this study was to assess long-term outcome in patients with spontaneous intracerebral hemorrhage admitted to the intensive care unit.

METHODS

Mortality and Glasgow Outcome Scale, Barthel Index, and 5-level EQ-5D version (EQ-5D-5L) scores were analyzed in a multicenter cohort study of three Spanish hospitals (336 patients). Mortality was also analyzed in the Medical Information Mart for Intensive Care III (MIMIC-III) database.

RESULTS

The median (25th percentile-75th percentile) age was 62 (50-70) years, the median Glasgow Coma Score was 7 (4-11) points, and the median Acute Physiology and Chronic Health disease Classification System II (APACHE-II) score was 21 (15-26) points. Hospital mortality was 54.17%, mortality at 90 days was 56%, mortality at 1 year was 59.2%, and mortality at 5 years was 66.4%. In the Glasgow Outcome Scale, a normal or disabled self-sufficient situation was recorded in 21.5% of patients at 6 months, in 25.5% of patients after 1 year, and in 22.1% of patients after 5 years of follow-up (4.5% missing). The Barthel Index score of survivors improved over time: 50 (25-80) points at 6 months, 70 (35-95) points at 1 year, and 90 (40-100) points at 5 years (p < 0.001). Quality of life evaluated with the EQ-5D-5L at 1 year and 5 years indicated that greater than 50% of patients had no problems or slight problems in all items (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). In the MIMIC-III study (N = 1354), hospital mortality was 31.83% and was 40.5% at 90 days and 56.2% after 5 years.

CONCLUSIONS

In patients admitted to the intensive care unit with a diagnosis of nontraumatic intracerebral hemorrhage, hospital mortality up to 90 days after admission is very high. Between 90 days and 5 years after admission, mortality is not high. A large percentage of survivors presented a significant deficit in quality of life and functional status, although with progressive improvement over time. Five years after the hemorrhagic stroke, a survival of 30% was observed, with a good functional status seen in 20% of patients who had been admitted to the hospital.

Efficacy study of neuronavigation-assisted stereotactic drilling of urokinase drainage versus craniotomy in the treatment of massive intracerebral haemorrhage in elderly patientsa

To evaluate the efficacy of neuronavigation-assisted stereotactic drilling drainage compared with that of craniotomy in the treatment of massive intracerebral haemorrhage (ICH) in elderly patients. This was a randomized, controlled, blind endpoint clinical study. Elderly patients with massive ICH treated at our neurosurgery department, without the formation of brain herniation preoperatively, all underwent neurosurgical intervention. Patients were randomly assigned to two groups: the minimally invasive surgery (MIS) group, which received neuronavigation-assisted stereotactic drilling drainage, and the craniotomy haematoma removal surgery (CHRS) group. Patient characteristics, surgical anaesthesia methods, surgery duration, intraoperative bleeding volume, duration of ICU stay duration of hospital stay, complications, and modified Rankin scale (mRS) scores at 90 days posttreatment were compared between the two groups. Statistical analysis was performed on the collected data. A total of 67 patients were randomly assigned, with 33 (49.25%) in the MIS group and 34 (50.75%) in the CHRS group. Compared with the CHRS group, the MIS group had advantages, including the use of local anaesthesia, shorter surgery duration, less intraoperative bleeding, shorter ICU stay, and fewer complications (P < 0.05). The MIS group had a significantly improved patient prognosis at 90 days (mRS 0-3). However, there were no significant differences in hospital stay or 90-day survival rate between the two groups (P > 0.05). For elderly patients with massive ICH without brain herniation, stereotactic drilling drainage is a simple surgical procedure that can be performed under local anaesthesia. Patients treated with this approach seem to have better outcomes than those treated with craniotomy. In clinical practice, neuronavigation-assisted stereotactic drilling drainage is recommended for surgical treatment in elderly patients with massive ICH without brain herniation.Clinical trial registration number: NCT04686877.

The Effect of Tranexamic Acid on Neurosurgical Intervention in Spontaneous Intracerebral Hematoma: Data From 121 Surgically Treated Participants From the Tranexamic Acid in IntraCerebral Hemorrhage-2 Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

An important proportion of patients with spontaneous intracerebral hemorrhage (ICH) undergo neurosurgical intervention to reduce mass effect from large hematomas and control the complications of bleeding, including hematoma expansion and hydrocephalus. The Tranexamic acid (TXA) for hyperacute primary IntraCerebral Hemorrhage (TICH-2) trial demonstrated that tranexamic acid (TXA) reduces the risk of hematoma expansion. We hypothesized that TXA would reduce the frequency of surgery (primary outcome) and improve functional outcome at 90 days in surgically treated patients in the TICH-2 data set.

METHODS

Participants enrolled in TICH-2 were randomized to placebo or TXA. Participants randomized to either TXA or placebo were analyzed for whether they received neurosurgery within 7 days and their characteristics, outcomes, hematoma volumes (HVs) were compared. Characteristics and outcomes of participants who received surgery were also compared with those who did not.

RESULTS

Neurosurgery was performed in 5.2% of participants (121/2325), including craniotomy (57%), hematoma drainage (33%), and external ventricular drainage (21%). The number of patients receiving surgery who received TXA vs placebo were similar at 4.9% (57/1153) and 5.5% (64/1163), respectively (odds ratio [OR] 0.893; 95% CI 0.619-1.289; P -value = .545). TXA did not improve outcome compared with placebo in either surgically treated participants (OR 0.79; 95% CI 0.30-2.09; P = .64) or those undergoing hematoma evacuation by drainage or craniotomy (OR 1.19 95% 0.51-2.78; P -value = .69). Postoperative HV was not reduced by TXA (mean difference -8.97 95% CI -23.77, 5.82; P -value = .45).

CONCLUSION

TXA was not associated with less neurosurgical intervention, reduced HV, or improved outcomes after surgery.

Swiss trial of decompressive craniectomy versus best medical treatment of spontaneous supratentorial intracerebral haemorrhage (SWITCH): an international, multicentre, randomised-controlled, two-arm, assessor-blinded trial

RATIONALE

Decompressive craniectomy (DC) is beneficial in people with malignant middle cerebral artery infarction. Whether DC improves outcome in spontaneous intracerebral haemorrhage (ICH) is unknown.

AIM

To determine whether DC without haematoma evacuation plus best medical treatment (BMT) in people with ICH decreases the risk of death or dependence at 6 months compared to BMT alone.

METHODS AND DESIGN

SWITCH is an international, multicentre, randomised (1:1), two-arm, open-label, assessor-blinded trial. Key inclusion criteria are age ⩽75 years, stroke due to basal ganglia or thalamic ICH that may extend into cerebral lobes, ventricles or subarachnoid space, Glasgow coma scale of 8-13, NIHSS score of 10-30 and ICH volume of 30-100 mL. Randomisation must be performed <66 h after onset and DC <6 h after randomisation. Both groups will receive BMT. Participants randomised to the treatment group will receive DC of at least 12 cm in diameter according to institutional standards.

SAMPLE SIZE

A sample of 300 participants randomised 1:1 to DC plus BMT versus BMT alone provides over 85% power at a two-sided alpha-level of 0.05 to detect a relative risk reduction of 33% using a chi-squared test.

OUTCOMES

The primary outcome is the composite of death or dependence, defined as modified Rankin scale score 5-6 at 6 months. Secondary outcomes include death, functional status, quality of life and complications at 180 days and 12 months.

DISCUSSION

SWITCH will inform physicians about the outcomes of DC plus BMT in people with spontaneous deep ICH, compared to BMT alone.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02258919.

Efficacy of neuroendoscopic and small-bone-window craniotomy microsurgery for hypertensive cerebral hemorrhage: a meta-analysis of Chinese RCT studies

Objective

To compare the clinical efficacy of neuroendoscopy and small-bone-window craniotomy microsurgery in the treatment of supratentorial hypertensive intracerebral hemorrhage.

Methods

A search was conducted for Chinese randomized controlled trials on neuroendoscopy and small-bone-window craniotomy microsurgery treatment of hypertensive intracerebral hemorrhage published before February 1, 2024, in PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data, and China Science and Technology Journal Database. Meta-analysis was performed using Review Manager 5.4 software.

Results

We included 9 randomized controlled trials, with 391 cases in the neuroendoscopy group and 403 cases in the craniotomy group. The meta-analysis results showed that compared to the small-bone-window craniotomy group, the neuroendoscopy group had a higher rate of hematoma clearance (95% CI [6.65, 18.52], p < 0.00001), less intraoperative bleeding (95% CI [-294.83, -284.75], p < 0.00001), shorter operation time (95% CI [-138.65, -63.04], p < 0.00001), fewer days in the ICU (95% CI [-8.56, -4.04], p < 0.00001), lower rate of postoperative complications (95% CI [0.15, 0.50], p < 0.0001), lower NIHSS score at 3 months postoperatively (95% CI [-6.82, -5.36], p < 0.00001), and higher ADL score (95% CI [16.5, 20.07], p < 0.00001). All comparison results were statistically significant.

Conclusion

Compared with small-bone-window craniotomy microsurgery, neuroendoscopic surgery for episodic hypertensive cerebral hemorrhage resulted in a higher rate of hematoma clearance, less intraoperative bleeding, shorter operative time, fewer days in the ICU, a lower rate of postoperative complications and a lower 3-month postoperative NIHSS score, and a higher ADL score.

Decompressive Hemicraniectomy without Evacuation of Acute Intraparenchymal Hemorrhage

BACKGROUND

Intracerebral hemorrhages (ICHs) are prevalent, with high morbidity and mortality. We analyzed whether decompressive craniectomy (DC) without evacuation of the acute intraparenchymal hematoma could produce better functional outcomes than treatment with evacuation.

METHODS

Patients with acute ICH treated with DC without clot evacuation, or evacuation with or without associated craniectomy were included. Matched univariate analyses were performed, and a binary logistic regression model was constructed using the Glasgow Outcome Scale (GOS) and modified Rankin scale (mRS) as dependent variables.

RESULTS

27 patients treated with DC without clot evacuation were compared to 36 patients with clot evacuation; eleven of the first group were matched with 18 patients with evacuation. A significantly better functional prognosis in the group treated with DC without clot evacuation was found. Patients aged < 55 years and treated with DC without clot evacuation had a significantly better functional prognosis (p = 0.008 and p = 0.039, respectively). In multivariate analysis, the intervention performed was the greatest predictor of functional status at the end of follow-up.

CONCLUSIONS

DC without clot evacuation improves the functional prognosis of patients with acute intraparenchymal hematomas. Larger multicenter studies are warranted to determine whether a change in the management of acute ICH should be recommended.

Telemedicine Protocols for the Management of Patients with Acute Spontaneous Intracerebral Hemorrhage in Rural and Medically Underserved Areas in Gangwon State : Recommendations for Doctors with Less Expertise at Local Emergency Rooms

Previously, we reported the concept of a cloud-based telemedicine platform for patients with intracerebral hemorrhage (ICH) at local emergency rooms in rural and medically underserved areas in Gangwon state by combining artificial intelligence and remote consultation with a neurosurgeon. Developing a telemedicine ICH treatment protocol exclusively for doctors with less ICH expertise working in emergency rooms should be part of establishing this system. Difficulties arise in providing appropriate early treatment for ICH in rural and underserved areas before the patient is transferred to a nearby hub hospital with stroke specialists. This has been an unmet medical need for decade. The available reporting ICH guidelines are realistically possible in university hospitals with a well-equipped infrastructure. However, it is very difficult for doctors inexperienced with ICH treatment to appropriately select and deliver ICH treatment based on the guidelines. To address these issues, we developed an ICH telemedicine protocol. Neurosurgeons from four university hospitals in Gangwon state first wrote the guidelines, and professors with extensive ICH expertise across the country revised them. Guidelines and recommendations for ICH management were described as simply as possible to allow more doctors to use them easily. We hope that our effort in developing the telemedicine protocols will ultimately improve the quality of ICH treatment in local emergency rooms in rural and underserved areas in Gangwon state.

CT-based deep learning model for predicting hospital discharge outcome in spontaneous intracerebral hemorrhage

OBJECTIVES

To predict the functional outcome of patients with intracerebral hemorrhage (ICH) using deep learning models based on computed tomography (CT) images.

METHODS

A retrospective, bi-center study of ICH patients was conducted. Firstly, a custom 3D convolutional model was built for predicting the functional outcome of ICH patients based on CT scans from randomly selected ICH patients in H training dataset collected from H hospital. Secondly, clinical data and radiological features were collected at admission and the Extreme Gradient Boosting (XGBoost) algorithm was used to establish a second model, named the XGBoost model. Finally, the Convolution model and XGBoost model were fused to build the third "Fusion model." Favorable outcome was defined as modified Rankin Scale score of 0-3 at discharge. The prognostic predictive accuracy of the three models was evaluated using an H test dataset and an external Y dataset, and compared with the performance of ICH score and ICH grading scale (ICH-GS).

RESULTS

A total of 604 patients with ICH were included in this study, of which 450 patients were in the H training dataset, 50 patients in the H test dataset, and 104 patients in the Y dataset. In the Y dataset, the areas under the curve (AUCs) of the Convolution model, XGBoost model, and Fusion model were 0.829, 0.871, and 0.905, respectively. The Fusion model prognostic performance exceeded that of ICH score and ICH-GS (p = 0.043 and p = 0.045, respectively).

CONCLUSIONS

Deep learning models have good accuracy for predicting functional outcome of patients with spontaneous intracerebral hemorrhage.

CLINICAL RELEVANCE STATEMENT

The proposed deep learning Fusion model may assist clinicians in predicting functional outcome and developing treatment strategies, thereby improving the survival and quality of life of patients with spontaneous intracerebral hemorrhage.

KEY POINTS

• Integrating clinical presentations, CT images, and radiological features to establish deep learning model for functional outcome prediction of patients with intracerebral hemorrhage. • Deep learning applied to CT images provides great help in prognosing functional outcome of intracerebral hemorrhage patients. • The developed deep learning model performs better than clinical prognostic scores in predicting functional outcome of patients with intracerebral hemorrhage.

Intracranial Hemorrhage-Is Very Early Rehabilitation Safe? A Narrative Review

Intracerebral hemorrhage (ICH) is a serious neurological disease with a 30-day mortality rate of 34-50%. Rehabilitation can reduce disability and improve recovery from a stroke; however, it is uncertain whether early rehabilitation is safe. There are many studies and reviews on rehabilitation for chronic conditions, but there is not enough information on the details of rehabilitation in the acute and subacute phases of ICH. We analyzed clinical trials from the electronic databases PubMed, PubMedCentral, Medline, Cochrane Library, Embase, Scopus and PEDro. Based on the data, we determined that early rehabilitation of patients with ICH has beneficial effects on improving ADL scores, motor function, functional independence, quality of life, improved gait, improved trunk control and reduced mortality. Varying the duration and intensity of rehabilitation in patients with ICH may improve health status, functional outcomes and reduce the length of stay in the hospital. The earliest protocol for initiating rehabilitation after ICH included up to 24 h after stroke onset. The medical literature indicates the need for more randomized controlled group trials of early rehabilitation in patients with acute and subacute ICH with a precise timing of rehabilitation initiation. This narrative review aims to summarize the existing evidence and provide insights into the current state of knowledge regarding the safety of early rehabilitation. There is a need for a clear definition of "early rehabilitation" when determining the most appropriate time to begin rehabilitation therapy.

Endoscopic Evacuation Versus Open Craniotomy and Evacuation of Non-traumatic Intracerebral Bleed: A Comparative Study

Objective In patients with intracerebral hemorrhage (ICH), the usage of microsurgical instrumentation and techniques can reduce traction-related injuries and enhance postoperative outcomes compared with traditional hematoma evacuation. The purpose of this study was to compare the results of endoscopic evacuation of spontaneous non-traumatic ICH with conventional open craniotomies and evacuations of ICH in terms of safety, feasibility, and neurological outcomes. Methods This was a prospective study that included 21 patients with spontaneous intracerebral hematomas managed by surgical evacuation endoscopically and another 24 patients with spontaneous supratentorial ICH who underwent hematoma evacuation by open craniotomy. Primary outcomes included operation duration, operative blood loss, hematoma evacuation rate, re-bleeding rate, and postoperative Glasgow Coma Scale (GCS) score. Results The median operation durations were 110 (90-200) and 230 (120-460) minutes in the endoscopic and open procedure groups, respectively (p = 0.00001). The median operative blood loss was 160 (80-300) and 530 (100-2000) mL in the endoscopic and open procedure groups, respectively (p < 0.00001). The median hematoma removal rates were 90% (60%-99%) and 85% (60%-100%) in the endoscopic and open procedure groups, respectively (p = 0.0348). Re-bleeding rates were higher in the endoscopic group (p = 0.46). Postoperative Glasgow Outcome Scale scores at two-month and six-month intervals were similar between the groups (p = 0.87). Conclusion Endoscopic hematoma evacuation for spontaneous supratentorial hemorrhage is becoming a standard surgical procedure, and promising clinical results can be expected. In addition, an endoscope can enhance time efficiency, hematoma evacuation rates, and reduce bleeding. Although endoscopic surgeries have higher re-bleeding rates, the difference is not significant when compared to open craniotomies with similar postoperative GCS scores. It is therefore important to be familiar with the endoscope and its associated equipment in order to achieve better results and reduce complications.

Suboptimal Cerebral Perfusion is Associated with Ischemia After Intracerebral Hemorrhage

BACKGROUND

Remote ischemic lesions on diffusion-weighted imaging (DWI) occur in one third of patients with intracerebral hemorrhage (ICH) and are associated with worse outcomes. The etiology is unclear and not solely due to blood pressure reduction. We hypothesized that impaired cerebrovascular autoregulation and hypoperfusion below individualized lower limits of autoregulation are associated with the presence of DWI lesions.

METHODS

This was a retrospective, single-center study of all primary ICH with intraparenchymal pressure monitoring within 10 days from onset and subsequent magnetic resonance imaging. Pressure reactivity index was calculated as the correlation coefficient between mean arterial pressure and intracranial pressure. Optimal cerebral perfusion pressure (CPPopt) is the cerebral perfusion pressure (CPP) with the lowest corresponding pressure reactivity index. The difference between CPP and CPPopt, time spent below the lower limit of autoregulation (LLA), and time spent above the upper limit of autoregulation (ULA) were calculated by using mean hourly physiologic data. Univariate associations between physiologic parameters and DWI lesions were analyzed by using binary logistic regression.

RESULTS

A total of 505 h of artifact-free data from seven patients without DWI lesions and 479 h from six patients with DWI lesions were analyzed. Patients with DWI lesions had higher intracranial pressure (17.50 vs. 10.92 mm Hg; odds ratio 1.14, confidence interval 1.01-1.29) but no difference in mean arterial pressure or CPP compared with patients without DWI lesions. The presence of DWI lesions was significantly associated with a greater percentage of time spent below the LLA (49.85% vs. 14.70%, odds ratio 5.77, confidence interval 1.88-17.75). No significant association was demonstrated between CPPopt, the difference between CPP and CPPopt, ULA, LLA, or time spent above the ULA between groups.

CONCLUSIONS

Blood pressure reduction below the LLA is associated with ischemia after acute ICH. Individualized, autoregulation-informed targets for blood pressure reduction may provide a novel paradigm in acute management of ICH and require further study.

The Neurocritical Care Examination and Workup

OBJECTIVE

This article provides an overview of the evaluation of patients in neurocritical care settings and a structured approach to recognizing and localizing acute neurologic emergencies, performing a focused examination, and pursuing workup to identify critical findings requiring urgent management.

LATEST DEVELOPMENTS

After identifying and stabilizing imminent threats to survival, including respiratory and hemodynamic compromise, the initial differential diagnosis for patients in neurocritical care is built on a focused history and clinical examination, always keeping in mind critical "must-not-miss" pathologies. A key priority is to identify processes warranting time-sensitive therapeutic interventions, including signs of elevated intracranial pressure and herniation, acute neurovascular emergencies, clinical or subclinical seizures, infections of the central nervous system, spinal cord compression, and acute neuromuscular respiratory failure. Prompt neuroimaging to identify structural abnormalities should be obtained, complemented by laboratory findings to assess for underlying systemic causes. The indication for EEG and lumbar puncture should be considered early based on clinical suspicion.

ESSENTIAL POINTS

In neurocritical care, the initial evaluation is often fast paced, requiring assessment and management to happen in parallel. History, clinical examination, and workup should be obtained while considering therapeutic implications and the need for lifesaving interventions.

Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial

BACKGROUND

It is unknown whether decompressive craniectomy improves clinical outcome for people with spontaneous severe deep intracerebral haemorrhage. The SWITCH trial aimed to assess whether decompressive craniectomy plus best medical treatment in these patients improves outcome at 6 months compared to best medical treatment alone.

METHODS

In this multicentre, randomised, open-label, assessor-blinded trial conducted in 42 stroke centres in Austria, Belgium, Finland, France, Germany, the Netherlands, Spain, Sweden, and Switzerland, adults (18-75 years) with a severe intracerebral haemorrhage involving the basal ganglia or thalamus were randomly assigned to receive either decompressive craniectomy plus best medical treatment or best medical treatment alone. The primary outcome was a score of 5-6 on the modified Rankin Scale (mRS) at 180 days, analysed in the intention-to-treat population. This trial is registered with ClincalTrials.gov, NCT02258919, and is completed.

FINDINGS

SWITCH had to be stopped early due to lack of funding. Between Oct 6, 2014, and April 4, 2023, 201 individuals were randomly assigned and 197 gave delayed informed consent (96 decompressive craniectomy plus best medical treatment, 101 best medical treatment). 63 (32%) were women and 134 (68%) men, the median age was 61 years (IQR 51-68), and the median haematoma volume 57 mL (IQR 44-74). 42 (44%) of 95 participants assigned to decompressive craniectomy plus best medical treatment and 55 (58%) assigned to best medical treatment alone had an mRS of 5-6 at 180 days (adjusted risk ratio [aRR] 0·77, 95% CI 0·59 to 1·01, adjusted risk difference [aRD] -13%, 95% CI -26 to 0, p=0·057). In the per-protocol analysis, 36 (47%) of 77 participants in the decompressive craniectomy plus best medical treatment group and 44 (60%) of 73 in the best medical treatment alone group had an mRS of 5-6 (aRR 0·76, 95% CI 0·58 to 1·00, aRD -15%, 95% CI -28 to 0). Severe adverse events occurred in 42 (41%) of 103 participants receiving decompressive craniectomy plus best medical treatment and 41 (44%) of 94 receiving best medical treatment.

INTERPRETATION

SWITCH provides weak evidence that decompressive craniectomy plus best medical treatment might be superior to best medical treatment alone in people with severe deep intracerebral haemorrhage. The results do not apply to intracerebral haemorrhage in other locations, and survival is associated with severe disability in both groups.

FUNDING

Swiss National Science Foundation, Swiss Heart Foundation, Inselspital Stiftung, and Boehringer Ingelheim.

Mechanistic Evaluation of Diffusion Weighted Hyperintense Lesions After Large Spontaneous Intracerebral Hemorrhage: A Subgroup Analysis of MISTIE III

BACKGROUND

Ischemic lesions on diffusion weighted imaging (DWI) are common after acute spontaneous intracerebral hemorrhage (ICH) but are poorly understood for large ICH volumes (> 30 mL). We hypothesized that large blood pressure drops and effect modification by cerebral small vessel disease markers on magnetic resonance imaging (MRI) are associated with DWI lesions.

METHODS

This was an exploratory analysis of participants in the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial with protocolized brain MRI scans within 7 days from ICH. Multivariable logistic regression analysis was performed to assess biologically relevant factors associated with DWI lesions, and relationships between DWI lesions and favorable ICH outcomes (modified Rankin Scale 0-3).

RESULTS

Of 499 enrolled patients, 300 had MRI at median 7.5 days (interquartile range 7-8), and 178 (59%) had DWI lesions. The incidence of DWI lesions was higher in patients with systolic blood pressure (SBP) reduction ≥ 80 mm Hg in first 24 h (76%). In adjusted models, factors associated with DWI lesions were as follows: admission intraventricular hematoma volume (p = 0.03), decrease in SBP ≥ 80 mm Hg from admission to day 1 (p = 0.03), and moderate-to-severe white matter disease (p = 0.01). Patients with DWI lesions had higher odds of severe disability at 1 month (p = 0.04), 6 months (p = 0.036), and 12 months (p < 0.01). No evidence of effect modification by cerebral small vessel disease on blood pressure was found.

CONCLUSIONS

In patients with large hypertensive ICH, white matter disease, intraventricular hemorrhage volume, and large reductions in SBP over the first 24 h were independently associated with DWI lesions. Further investigation of potential hemodynamic mechanisms of ischemic injury after large ICH is warranted.

Early Cardiac Evaluation, Abnormal Test Results, and Associations with Outcomes in Patients with Acute Brain Injury Admitted to a Neurocritical Care Unit

Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF < 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p < 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th-50th quartile (aOR 1.65 [1.10-2.47]), troponin 50th-75th quartile (aOR 1.79 [1.22-2.63]), troponin >75th quartile (aOR 2.18 [1.49-3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28-6.40]), BNP >75th quartile (aOR 4.54 [2.09-9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF < 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th-75th quartile (aOR 1.77 [1.14-2.73]), troponin >75th quartile (aOR 1.81 [1.18-2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort.

Predictors and Prognostic Impact of Hematoma Expansion in Infratentorial Cerebral Hemorrhage

BACKGROUND

Hematoma expansion (HE) is common and predicts poor outcome in patients with supratentorial intracerebral hemorrhage (ICH). We investigated the predictors and prognostic impact of HE in infratentorial ICH.

METHODS

We conducted a retrospective analysis of patients with brainstem and cerebellar ICH admitted at seven sites. Noncontrast computed tomography images were analyzed for the presence of hypodensities according to validated criteria, defined as any hypodense region strictly encapsulated within the hemorrhage with any shape, size, and density. Occurrence of HE (defined as > 33% and/or > 6-mL growth) and mortality at 90 days were the outcomes of interest. Their predictors were investigated using logistic regression with backward elimination at p < 0.1. Logistic regression models for HE were adjusted for baseline ICH volume, antiplatelet and anticoagulant treatment, onset to computed tomography time, and presence of hypodensities. The logistic regression model for mortality accounted for the ICH score and HE.

RESULTS

A total of 175 patients were included (median age 75 years, 40.0% male), of whom 38 (21.7%) had HE and 43 (24.6%) died within 90 days. Study participants with HE had a higher frequency of hypodensities (44.7 vs. 24.1%, p = 0.013), presentation within 3 h from onset (39.5 vs. 24.8%, p = 0.029), and 90-day mortality (44.7 vs. 19.0%, p = 0.001). Hypodensities remained independently associated with HE after adjustment for confounders (odds ratio 2.44, 95% confidence interval 1.13-5.25, p = 0.023). The association between HE and mortality remained significant in logistic regression (odds ratio 3.68, 95% confidence interval 1.65-8.23, p = 0.001).

CONCLUSION

Early presentation and presence of noncontrast computed tomography hypodensities were independent predictors of HE in infratentorial ICH, and the occurrence of HE had an independent prognostic impact in this population.

Meta-analysis of stereotactic hematoma removal and craniotomy hematoma removal in the treatment of hypertensive intracerebral hemorrhage in the elderly

BACKGROUND

A large number of clinical studies suggested that surgery might be a better choice than conservative treatment for treating hypertensive intracerebral hemorrhage in the middle-aged and elderly. Stereotactic puncture can reduce the mass effect caused by hematoma, reduce the intervention of body homeostasis, reduce brain tissue damage, and improve the prognosis of patients with cerebral hemorrhage. This meta-analysis aims to evaluate the efficacy of stereotactic puncture and craniotomy in elderly patients with hypertensive intracerebral hemorrhage.

METHODS

A search strategy was designed to search in databases, including PubMed, Embase, Cochrane Central Register of Controlled Trials, CNKI, Wanfang database and relevant references. Literature on the efficacy and safety of different surgical methods for hypertensive cerebral hemorrhage in the middle-aged and elderly were retrieved. The search time was until August 17, 2022. Keywords included "hypertensive intracerebral hemorrhage," "stereotactic hematoma removal," "craniotomy." After the literature search, 2 researchers independently conducted literature screening, quality evaluation of included trials and data extraction. RevMan5.4 software was used to perform a Meta-analysis on the operation time, hospital stay, postoperative Glasgow Coma Scale (GCS) score, postoperative daily activity ability, postoperative complications and neurological prognosis scores included in the included studies.

RESULTS

A total of 1988 samples were included in 9 studies. 1022 patients underwent stereotactic hematoma removal, and 968 patients underwent craniotomy hematoma removal. The orientation group had more advantages in the length of hospital stay, postoperative disability, pulmonary infection, intracranial infection and digestive tract ulcer, and the difference was statistically significant (P < .05). In addition, the length of stay (I²= 83%) of the included articles had good homogeneity (I²< 50%), and there was no significant difference between the 2 groups in operation time, postoperative GCS score, postoperative daily activity ability, and neurological prognosis score (P > .05).

CONCLUSION

The meta-analysis indicate that compared to craniotomy for hematoma removal, stereotactic hematoma removal can reduce the postoperative disability rate, intracranial infection rate, lung infection rate, and digestive tract ulcer rate in middle-aged and elderly patients with hypertensive intracerebral hemorrhage.

Statins Effects on Blood Clotting: A Review

Statins are powerful lipid-lowering drugs that inhibit cholesterol biosynthesis via downregulation of hydroxymethylglutaryl coenzyme-A reductase, which are largely used in patients with or at risk of cardiovascular disease. Available data on thromboembolic disease include primary and secondary prevention as well as bleeding and mortality rates in statin users during anticoagulation for VTE. Experimental studies indicate that statins alter blood clotting at various levels. Statins produce anticoagulant effects via downregulation of tissue factor expression and enhanced endothelial thrombomodulin expression resulting in reduced thrombin generation. Statins impair fibrinogen cleavage and reduce thrombin generation. A reduction of factor V and factor XIII activation has been observed in patients treated with statins. It is postulated that the mechanisms involved are downregulation of factor V and activated factor V, modulation of the protein C pathway and alteration of the tissue factor pathway inhibitor. Clinical and experimental studies have shown that statins exert antiplatelet effects through early and delayed inhibition of platelet activation, adhesion and aggregation. It has been postulated that statin-induced anticoagulant effects can explain, at least partially, a reduction in primary and secondary VTE and death. Evidence supporting the use of statins for prevention of arterial thrombosis-related cardiovascular events is robust, but their role in VTE remains to be further elucidated. In this review, we present biological evidence and experimental data supporting the ability of statins to directly interfere with the clotting system.

Association Between Hematoma Expansion Severity and Outcome and Its Interaction With Baseline Intracerebral Hemorrhage Volume

BACKGROUND AND OBJECTIVES

Hematoma expansion (HE) is a major determinant of neurologic deterioration and poor outcome in intracerebral hemorrhage (ICH) and represents an appealing therapeutic target. We analyzed the prognostic effect of different degrees of HE.

METHODS

This was a retrospective analysis of patients with ICH admitted at 8 academic institutions in Italy, Germany, Canada, China, and the United States. All patients underwent baseline and follow-up imaging for HE assessment. Relative HE (rHE) was classified as follows: none (<0%), mild (0%-33%), moderate (33.1%-66%), and severe (>66%). Absolute HE (aHE) was classified as none (<0 mL), mild (0-6.0 mL), moderate (6.1-12.5 mL), and severe (>12.5 mL). Predictors of poor functional outcome (90 days modified Rankin Scale 4-6) were explored with logistic regression.

RESULTS

We included 2,163 patients, of whom 1,211 (56.0%) had poor outcome. The occurrence of severe aHE or rHE was more common in patients with unfavorable outcome (13.9% vs 6.5%, p < 0.001 and 18.3% vs 7.2%, p < 0.001 respectively). This association was confirmed in logistic regression (rHE odds ratio [OR] 1.98, 95% CI 1.38-2.82, p < 0.001; aHE OR 1.73, 95% CI 1.23-2.45, p = 0.002) while there was no association between mild or moderate HE and poor outcome. The association between severe HE and poor outcome was significant only in patients with baseline ICH volume below 30 mL.

DISCUSSION

The strongest association between HE and outcome was observed in patients with smaller initial volume experiencing severe HE. These findings may inform clinical trial design and guide clinicians in selecting patients for antiexpansion therapies.

Using Radiomics and Convolutional Neural Networks for the Prediction of Hematoma Expansion After Intracerebral Hemorrhage

Background

Hematoma enlargement (HE) is a common complication following acute intracerebral hemorrhage (ICH) and is associated with early deterioration and unfavorable clinical outcomes. This study aimed to evaluate the predictive performance of a computed tomography (CT) based model that utilizes deep learning features in identifying HE.

Methods

A total of 408 patients were retrospectively enrolled between January 2015 and December 2020 from our institution. We designed an automatic model that could mask the hematoma area and fusion features of radiomics, clinical data, and convolutional neural network (CNN) in a hybrid model. We assessed the model's performance by using confusion matrix metrics (CM), the area under the receiver operating characteristics curve (AUC), and other statistical indicators.

Results

After automated masking, 408 patients were randomly divided into two cohorts with 204 patients in the training set and 204 patients in the validation set. The first cohort trained the CNN model, from which we then extracted radiomics, clinical data, and CNN features for the second validation cohort. After feature selection by K-highest score, a support vector machines (SVM) model classification was used to predict HE. Our hybrid model exhibited a high AUC of 0.949, and 0.95 of precision, 0.83 of recall, and 0.94 of average precision (AP). The CM found that only 5 cases were misidentified by the model.

Conclusion

The automatic hybrid model we developed is an end-to-end method and can assist in clinical decision-making, thereby facilitating personalized treatment for patients with ICH.

Prophylactic antiseizure drugs for spontaneous intracerebral hemorrhage: An updated systematic review and meta-analysis

BACKGROUND

There is concern that recommendations on prophylactic antiseizure drugs (PASDs) for patients with spontaneous intracerebral hemorrhage (sICH) are biased by studies using older drugs and no electrographic monitoring.

AIMS

We performed a systematic review and meta-analysis to determine whether PASDs in patients with sICH reduced seizure occurrence and improved functional outcomes. We included analyses of newer trials, newer antiseizure drugs, and effectiveness in patients with consistent electrographic monitoring.

METHODS

Medline, Embase, and Cochrane were searched from inception until 12 August 2022, to identify studies with patients with sICH treated with PASDs, regardless of study design. The studied outcomes were functional status and occurrence of seizures.

RESULTS

Fourteen studies were included, including 6742 patients. Risk of bias was low overall. There was no effect of PASD on seizure occurrence overall (odds ratio (OR) 0.73, 95% confidence interval (CI) 0.47-1.15), but they were associated with reduced occurrence in studies with electrographic monitoring (OR 0.36, 95% CI 0.18-0.70). There was no effect of PASDs on functional outcomes (OR 1.15; 95% CI 0.91-1.47) or mortality (OR 0.85, 95% CI 0.65-1.11).

CONCLUSION

Prophylactic antiseizure medications after sICH reduce seizures in studies with electroencephalogram monitoring in high-risk patients. However, this benefit did not reflect in the improvement of functional outcomes, even in studies with newer, less toxic, antiseizure drugs.

Hyperglycemia, Ischemic Lesions, and Functional Outcomes After Intracerebral Hemorrhage

Background Ischemic lesions observed on diffusion-weighted imaging (DWI) magnetic resonance imaging are associated with poor outcomes after intracerebral hemorrhage (ICH). We evaluated the association between hyperglycemia, ischemic lesions, and functional outcomes after ICH. Methods and Results This was a retrospective observational analysis of 1167 patients who received magnetic resonance imaging in the ERICH (Ethnic and Racial Variations in Intracerebral Hemorrhage) study. A machine learning strategy using the elastic net regularization and selection procedure was used to perform automated variable selection to identify final multivariable logistic regression models. Sensitivity analyses with alternative model development strategies were performed, and predictive performance was compared. After covariate adjustment, white matter hyperintensity score, leukocyte count on admission, and non-Hispanic Black race (compared with non-Hispanic White race) were associated with the presence of DWI lesions. History of ICH and ischemic stroke, presence of DWI lesions, deep ICH location (versus lobar), ICH volume, age, lower Glasgow Coma Score on admission, and medical history of diabetes were associated with poor 6-month modified Rankin Scale outcome (4-6) after covariate adjustment. Inclusion of interactions between race and ethnicity and variables included in the final multivariable model for functional outcome improved model performance; a significant interaction between race and ethnicity and medical history of diabetes and serum blood glucose on admission was observed. Conclusions No measure of hyperglycemia or diabetes was associated with presence of DWI lesions. However, both medical history of diabetes and presence of DWI lesions were independently associated with poor functional outcomes after ICH.

Clinical Practice Guideline for Stroke Rehabilitation in Korea-Part 1: Rehabilitation for Motor Function (2022)

This clinical practice guideline (CPG) is the fourth edition of the Korean guideline for stroke rehabilitation, which was last updated in 2016. The development approach has been changed from a consensus-based approach to an evidence-based approach using the Grading of Recommendations Assessment Development and Evaluation (GRADE) method. This change ensures that the guidelines are based on the latest and strongest evidence available. The aim is to provide the most accurate and effective guidance to stroke rehabilitation teams, and to improve the outcomes for stroke patients in Korea. Fifty-five specialists in stroke rehabilitation and one CPG development methodology expert participated in this development. The scope of the previous clinical guidelines was very extensive, making it difficult to revise at once. Therefore, it was decided that the scope of this revised CPG would be limited to Part 1: Rehabilitation for Motor Function. The key questions were selected by considering the preferences of the target population and referring to foreign guidelines for stroke rehabilitation, and the recommendations were completed through systematic literature review and the GRADE method. The draft recommendations, which were agreed upon through an official consensus process, were refined after evaluation by a public hearing and external expert evaluation.

Resource utilization in management of spontaneous intracerebral hemorrhage without systemic risk factors. Does early surgical decompression matter?

BACKGROUND

Even though different subtypes of spontaneous ICH are frequently linked to a poor prognosis, their causes, pathological features, and prognoses vary. Atypical intracerebral hemorrhage is the subtype of spontaneous ICH that usually occurs due to an underlying localized vascular lesion. It is unrelated to systemic vascular risk factors, mostly affects children and young adults and is associated with a relatively good outcome. This fact should be considered when planning the evaluation and treatment. Investigating the cause of this subtype is fundamental to providing optimal management. However, if resources do not allow completing the investigations, the cause will be more difficult to discover. Treatment decisions will be made under stress to save the patient's life, especially with rapidly deteriorating patients.

METHODS

We described three cases of spontaneous ICH without systemic risk factors where the bleeding source could not be determined before surgery due to a lack of resources, preventing preoperative vascular investigation. Knowing that the atypical ICH has a distinct identity, regarding etiology and prognosis, encouraged the surgeons to resort to early surgical decompression as an alternative plan. We reviewed the literature searching for supporting evidence.

RESULTS

The results of treatment of the presented cases were satisfactory. The lack of reported similar cases was brought to light by a literature analysis that sought to provide backing for the proposed management strategy. In the end, we supplied two graphic organizers to help readers remember the different types and treatment of hemorrhagic stroke.

CONCLUSION

There isn't enough evidence to show that there are other ways to treat atypical intracerebral haemorrhage when resources are limited. The presented cases highlight the importance of decisionmaking in resource-constrained situations when patient outcomes can be improved.

Location-Specific Hematoma Volume Cutoff and Clinical Outcomes in Intracerebral Hemorrhage

BACKGROUND

Major intracerebral hemorrhage (ICH) trials have largely been unable to demonstrate therapeutic benefit in improving functional outcomes. This may be partly due to the heterogeneity of ICH outcomes based on their location, where a small strategic ICH could be debilitating, thus confounding therapeutic effects. We aimed to determine the ideal hematoma volume cutoff for different ICH locations in predicting ICH outcomes.

METHODS

We retrospectively analyzed consecutive ICH patients enrolled in the University of Hong Kong prospective stroke registry from January 2011 to December 2018. Patients with premorbid modified Rankin Scale score >2 or who underwent neurosurgical intervention were excluded. ICH volume cutoff, sensitivity, and specificity in predicting respective 6-month neurological outcomes (good [modified Rankin Scale score 0-2], poor [modified Rankin Scale score 4-6], and mortality) for specific ICH locations were determined using receiver operating characteristic curves. Separate multivariate logistic regression models were also conducted for each location-specific volume cutoff to determine whether these cutoffs were independently associated with respective outcomes.

RESULTS

Among 533 ICHs, the volume cutoff for good outcome according to ICH location was 40.5 mL for lobar, 32.5 mL for putamen/external capsule, 5.5 mL for internal capsule/globus pallidus, 6.5 mL for thalamus, 17 mL for cerebellum, and 3 mL for brainstem. ICH smaller than the cutoff for all supratentorial sites had higher odds of good outcomes (all P<0.05). Volumes exceeding 48 mL for lobar, 41 mL for putamen/external capsule, 6 mL for internal capsule/globus pallidus, 9.5 mL for thalamus, 22 mL for cerebellum, and 7.5 mL for brainstem were at greater risk of poor outcomes (all P<0.05). Mortality risks were significantly higher for volumes that exceeded 89.5 mL for lobar, 42 mL for putamen/external capsule, and 21 mL for internal capsule/globus pallidus (all P<0.001). All receiver operating characteristic models for location-specific cutoffs had good discriminant values (area under the curve >0.8), except in predicting good outcome for cerebellum.

CONCLUSIONS

ICH outcomes differed with location-specific hematoma size. Location-specific volume cutoff should be considered in patient selection for ICH trials.

Presumed pituitary apoplexy in 26 dogs: Clinical findings, treatments, and outcomes

BACKGROUND

Pituitary apoplexy refers to hemorrhage or infarction within the pituitary gland resulting in acute neurological abnormalities. This condition is poorly described in dogs.

OBJECTIVES

To document presenting complaints, examination findings, endocrinopathies, magnetic resonance imaging (MRI), treatments, and outcomes of dogs with pituitary apoplexy.

ANIMALS

Twenty-six client-owned dogs with acute onset of neurological dysfunction.

METHODS

Retrospective case series. Dogs were diagnosed with pituitary apoplexy if MRI or histopathology documented an intrasellar or suprasellar mass with evidence of hemorrhage or infarction in conjunction with acute neurological dysfunction. Clinical information was obtained from medical records and imaging reports.

RESULTS

Common presenting complaints included altered mentation (16/26, 62%) and gastrointestinal dysfunction (14/26, 54%). Gait or posture changes (22/26, 85%), mentation changes (18/26, 69%), cranial neuropathies (17/26, 65%), cervical or head hyperpathia (12/26, 46%), and hyperthermia (8/26, 31%) were the most frequent exam findings. Ten dogs (38%) lacked evidence of an endocrinopathy before presentation. Common MRI findings included T1-weighted hypo- to isointensity of the hemorrhagic lesion (21/25, 84%), peripheral enhancement of the pituitary mass lesion (15/25, 60%), brain herniation (14/25, 56%), and obstructive hydrocephalus (13/25, 52%). Fifteen dogs (58%) survived to hospital discharge. Seven of these dogs received medical management alone (median survival 143 days; range, 7-641 days) and 8 received medications and radiation therapy (median survival 973 days; range, 41-1719 days).

CONCLUSIONS AND CLINICAL IMPORTANCE

Dogs with pituitary apoplexy present with a variety of acute signs of neurological disease and inconsistent endocrine dysfunction. Dogs that survive to discharge can have a favorable outcome.

ZJUSAH Classification: A New Classification for Primary Brainstem Hemorrhage

To analyze and improve ZJUSAH classification for primary brainstem hematoma, we retrospectively reviewed 211 patients with primary brainstem hemorrhage who were admitted to our institution between January 2014 and October 2020. The primary clinical outcomes were the 30-day survival rate and 90-day consciousness recovery rate, which were evaluated using the National Institutes of Health Stroke Scale score. Univariate logistic regression and multivariate Cox regression analyses were performed to evaluate the prognostic model. The overall 30-day survival rate of the 211 patients was 69.7%. The 30-day survival rate was 95% among Type 1 patients, 77.8% among Type 2 patients, and 63.2% among Type 3 patients. The 90-day consciousness recovery rate was 63.2% among Type 1 patients, 61.9% among Type 2 patients, and 30.2% among Type 3 patients. Our findings suggest that ZJUSAH classification can be optimized according to hematoma volume, with Type 3 patients with a hematoma larger than 12.4 mL tending to have a worse state of consciousness. Additionally, we discovered that ZJUSAH classification is valuable in predicting 30-day survival rates in conservative treatment patients. In conclusion, our study established and optimized a new CT-based hematoma classification system for primary brainstem hematoma, which facilitates treatment selection and prognostic prediction.

Early blood pressure management in hemorrhagic stroke: a meta-analysis

The aim of the present meta-analysis was to evaluate the outcomes and effects of different systolic blood pressure (SBP) lowering in patients with hemorrhagic stroke using data from randomized controlled trials. A total of 2592 records were identified for this meta-analysis. We finally included 8 studies (6119 patients; mean age 62.8 ± 13.0, 62.7% men). No evidence of heterogeneity between estimates (I² = 0% < 50%, P = 0.26), or publication bias in the funnel plots (P = 0.065, Egger statistical test) was detected. Death or major disability rates were similar between patients with intensive BP-lowering treatment (SBP < 140 mmHg) and those receiving guideline BP-lowering treatment (SBP < 180 mmHg). Intensive BP-lowering treatment may have a better functional outcome, but the results were not significantly different (log RR = - 0.03, 95% CI: - 0.09 to 0.02; P = 0.55). Intensive BP-lowering treatment tended to be associated with lower early hematoma growth compared with guideline treatment (log RR = - 0.24, 95% CI - 0.38, - 0.11; P < 0.001). Intensive BP-lowering helps reduce hematoma enlargement in the early stage of acute hemorrhagic stroke. However, this observation did not translate into functional outcomes. Further research is needed to clarify the specific scope and time of blood pressure reduction.

Hemorrhagic Stroke in Pregnancy

Hemorrhagic stroke carries a high risk of disability and mortality. The obstetrical population is at increased risk. Prompt diagnosis and maternal stabilization with a multidisciplinary approach are the mainstays in management. Computed tomography head is the diagnostic imaging of choice and is considered safe in pregnancy. Fetal status optimization before neurosurgery and delivery should be considered if the fetus is viable or if worsening maternal condition. Obstetric indications guide the mode of delivery. Cesarean delivery may be indicated to reduce increasing intracranial pressure. Neuraxial anesthesia should be considered to minimize catecholamine surges, reduce sedation, and control blood pressures.

Association of Cardiovascular Disease Risk and Health-Related Behaviors in Stroke Patients

Brain stroke continues to be a leading cause of mortality and disability in both developed and developing countries, with higher healthcare costs due to the long-term care and rehabilitation that it incurs. The purpose of the current study was to assess the association between brain stroke patients' health-related behaviors and their risk for cardiovascular disease.

METHODS

A cross-sectional study was carried out from March to August 2022 in the Vlora district regional hospital in Albania. The study included 150 out of 170 participants who met the necessary criteria, achieving an 88% response rate. Measurement tools included the Framingham Cardiovascular Risk Scale (FRS) and the Lifestyle Health Promotion Profile II (HPLP II).

RESULTS

The patients' average age was 65.9 ± 9.04 years. Over 65% of the stroke patients suffer from diabetes, and 47% from hypertension. About 31% of them have a high risk of hyperlipidemia (mean TC = 179 ± 28.5). About 32% of the brain stroke patients manifested unhealthy behaviors, while 84% of them had a high risk of cardiovascular disease (FRS = 19.5 ± 0.53). Cardiovascular disease (CVD) risk was statistically associated with stress management behaviors (p = 0.008; OR = 0.20; CI = 95%). This risk was highest in the over-70 age group as well as in men.

CONCLUSION

Brain stroke patients had a high probability of developing CVD. For better health among stroke patients, new evidence-based behavior change approaches must be introduced into preventative and management programs.

Using Noncontrast Computed Tomography to Improve Prediction of Intracerebral Hemorrhage Expansion

BACKGROUND

Noncontrast computed tomography hypodensities are a validated predictor of hematoma expansion (HE) in intracerebral hemorrhage and a possible alternative to the computed tomography angiography (CTA) spot sign but their added value to available prediction models remains unclear. We investigated whether the inclusion of hypodensities improves prediction of HE and compared their added value over the spot sign.

METHODS

Retrospective analysis of patients admitted for primary spontaneous intracerebral hemorrhage at the following 8 university hospitals in Boston, US (1994-2015, prospective), Hamilton, Canada (2010-2016, retrospective), Berlin, Germany (2014-2019, retrospective), Chongqing, China (2011-2015, retrospective), Pavia, Italy (2017-2019, prospective), Ferrara, Italy (2010-2019, retrospective), Brescia, Italy (2020-2021, retrospective), and Bologna, Italy (2015-2019, retrospective). Predictors of HE (hematoma growth >6 mL and/or >33% from baseline to follow-up imaging) were explored with logistic regression. We compared the discrimination of a simple prediction model for HE based on 4 predictors (antitplatelet and anticoagulant treatment, baseline intracerebral hemorrhage volume, and onset-to-imaging time) before and after the inclusion of noncontrast computed tomography hypodensities, using receiver operating characteristic curve and De Long test for area under the curve comparison.

RESULTS

A total of 2465 subjects were included, of whom 664 (26.9%) had HE and 1085 (44.0%) had hypodensities. Hypodensities were independently associated with HE after adjustment for confounders in logistic regression (odds ratio, 3.11 [95% CI, 2.55-3.80]; P<0.001). The inclusion of noncontrast computed tomography hypodensities improved the discrimination of the 4 predictors model (area under the curve, 0.67 [95% CI, 0.64-0.69] versus 0.71 [95% CI, 0.69-0.74]; P=0.025). In the subgroup of patients with a CTA available (n=895, 36.3%), the added value of hypodensities remained statistically significant (area under the curve, 0.68 [95% CI, 0.64-0.73] versus 0.74 [95% CI, 0.70-0.78]; P=0.041) whereas the addition of the CTA spot sign did not provide significant discrimination improvement (area under the curve, 0.74 [95% CI, 0.70-0.78]).

CONCLUSIONS

Noncontrast computed tomography hypodensities provided a significant added value in the prediction of HE and appear a valuable alternative to the CTA spot sign. Our findings might inform future studies and suggest the possibility to stratify the risk of HE with good discrimination without CTA.

Survival benefits of oral anticoagulation therapy in acute kidney injury patients with atrial fibrillation: a retrospective study from the MIMIC-IV database

OBJECTIVE

To find out the effect of different oral anticoagulation therapies (OAC) on mortality rate in patients with acute kidney injury (AKI) and atrial fibrillation (AF).DesignA retrospective study.

SETTING

This study was conducted in the Medical Information Mart for Intensive Care IV database.

PARTICIPANTS

A total of 19 672 patients diagnosed with AKI.

MAIN OUTCOME MEASURES

Patients were categorised into three groups: (1) AF; (2) AKI and AF, OAC-; (3) AKI and AF, OAC+. The primary endpoint was 30-day mortality. Secondary endpoints were the length of stay (LOS) in the intensive care unit (ICU) and hospital. Propensity score matching (PSM) and Cox proportional hazards model adjusted confounding factors. Linear regression was applied to assess the associations between OAC treatment and LOS.

RESULTS

After PSM, 2042 pairs of AKI and AF patients were matched between the patients who received OAC and those without anticoagulant treatment. Cox regression analysis showed that, OAC significantly reduce 30-day mortality compared with non-OAC (HR 0.30; 95% CI 0.25 to 0.35; p<0.001). Linear regression analysis revealed that OAC prolong LOS in hospital (11.3 days vs 10.0 days; p=0.013) and ICU (4.9 days vs 4.4 days; p<0.001). OAC did not improve survival in patients with haemorrhage (HR 0.67; 95% CI 0.34 to 1.29; p=0.23). Novel OAC did not reduce mortality in acute-on-chronic renal injury (HR 2.03; 95% CI 1.09 to 3.78; p=0.025) patients compared with warfarin.

CONCLUSION

OAC administration was associated with improved short-term survival in AKI patients concomitant with AF.

Direct implantation of hair-follicle-associated pluripotent (HAP) stem cells repairs intracerebral hemorrhage and reduces neuroinflammation in mouse model

Intracerebral hemorrhage (ICH) is a leading cause of mortality with ineffective treatment. Hair-follicle-associated pluripotent (HAP) stem cells can differentiate into neurons, glial cells and many other types of cells. HAP stem cells have been shown to repair peripheral-nerve and spinal-cord injury in mouse models. In the present study, HAP stem cells from C57BL/6J mice were implanted into the injured brain of C57BL/6J or nude mice with induced ICH. After allo transplantation, HAP stem cells differentiated to neurons, astrocytes, oligodendrocytes, and microglia in the ICH site of nude mice. After autologous transplantation in C57BL/6J mice, HAP stem cells suppressed astrocyte and microglia infiltration in the injured brain. The mRNA expression levels of IL-10 and TGF-β1, measured by quantitative Real-Time RT-PCR, in the brain of C57BL/6J mice with ICH was increased by HAP-stem-cell implantation compared to the non-implanted mice. Quantitative sensorimotor function analysis, with modified limb-placing test and the cylinder test, demonstrated a significant functional improvement in the HAP-stem-cell-implanted C57BL/6J mice, compared to non-implanted mice. HAP stem cells have critical advantages over induced pluripotent stem cells, embryonic stem cells as they do not develop tumors, are autologous, and do not require genetic manipulation. The present study demonstrates future clinical potential of HAP-stem-cell repair of ICH, currently a recalcitrant disease.

Perfusion gradients promote delayed perihaematomal oedema in intracerebral haemorrhage

Perihaematomal oedema is a potential therapeutic target to improve outcome of patients with intracerebral haemorrhage, but its pathophysiology remains poorly elucidated. We investigated the longitudinal changes of cerebral perfusion and their influence on perihaematomal oedema development in 150 patients with intracerebral haemorrhage who underwent computed tomography perfusion within 6 h from onset, at 24 h and at 7 days. Perfusion parameters were measured in haemorrhagic core, perihaematomal rim, surrounding normal appearing and contralateral brain tissue. Computed tomography perfusion parameters gradually improved from the core to the periphery in each time interval with an early increase at 24 h followed by a delayed decline at 7 days compared with admission values (P < 0.001). Multivariable linear regression analysis showed that haematoma volume and cerebral blood flow gradient between normal appearing and perihaematomal rim were independently associated with absolute perihaematomal oedema volume in the different time points (within 6 h, B = 0.128, P = 0.032; at 24 h, B = 0.133, P = 0.016; at 7 days, B = 0.218, P < 0.001). In a secondary analysis with relative perihaematomal oedema as the outcome of interest, cerebral blood flow gradient between normal appearing and perihaematomal rim was an independent predictor of perihaematomal oedema only at 7 days (B = 0.239, P = 0.002). Our findings raise the intriguing hypothesis that perfusion gradients promote perihaematomal oedema development in the subacute phase after intracerebral haemorrhage.