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Smith CJ, Rossitto CP, Manhart M, Fuhrmann I, DiNitto J, Baker T, Ali M, Sarmiento M, Mocco J, Kellner CP. Minimally Invasive Intracerebral Hemorrhage Evacuation Improves Pericavity Cerebral Blood Volume. Transl Stroke Res 2024; 15:599-605. [PMID: 37195548 DOI: 10.1007/s12975-023-01155-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/18/2023] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
Cerebral blood volume mapping can characterize hemodynamic changes within brain tissue, particularly after stroke. This study aims to quantify blood volume changes in the perihematomal parenchyma and pericavity parenchyma after minimally invasive intracerebral hemorrhage evacuation (MIS for ICH). Thirty-two patients underwent MIS for ICH with pre- and post-operative CT imaging and intraoperative perfusion imaging (DynaCT PBV Neuro, Artis Q, Siemens). The pre-operative and post-operative CT scans were segmented using ITK-SNAP software to calculate hematoma volumes and to delineate the pericavity tissue. Helical CT segmentations were registered to cone beam CT data using elastix software. Mean blood volumes were computed inside subvolumes by dilating the segmentations at increasing distances from the lesion. Pre-operative perihematomal blood volumes and post-operative pericavity blood volumes (PBV) were compared. In 27 patients with complete imaging, post-operative PBV significantly increased within the 6-mm pericavity region after MIS for ICH. The mean relative PBV increased by 21.6 and 9.1% at 3 mm and 6 mm, respectively (P = 0.001 and 0.016, respectively). At the 9-mm pericavity region, there was a 2.83% increase in mean relative PBV, though no longer statistically significant. PBV analysis demonstrated a significant increase in pericavity cerebral blood volume after minimally invasive ICH evacuation to a distance of 6 mm from the border of the lesion.
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Affiliation(s)
- Colton J Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | | | | | | | - Turner Baker
- Sinai BioDesign, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | | | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
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Zompola C, Palaiodimou L, Voumvourakis K, Stefanis L, Katsanos AH, Sandset EC, Boviatsis E, Tsivgoulis G. Blood Pressure Variability in Acute Stroke: A Narrative Review. J Clin Med 2024; 13:1981. [PMID: 38610746 PMCID: PMC11012361 DOI: 10.3390/jcm13071981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
The management of blood pressure variability (BPV) in acute stroke presents a complex challenge with profound implications for patient outcomes. This narrative review examines the role of BPV across various stages of acute stroke care, highlighting its impact on treatment strategies and prognostic considerations. In the prehospital setting, while guidelines lack specific recommendations for BP management, emerging evidence suggests a potential link between BPV and outcomes. Among ischaemic stroke patients who are ineligible for reperfusion therapies, BPV independently influences functional outcomes, emphasising the need for individualised approaches to BP control. During intravenous thrombolysis and endovascular therapy, the intricate interplay between BP levels, recanalisation status, and BPV is evident. Striking a balance between aggressive BP lowering and avoiding hypoperfusion-related complications is essential. Intracerebral haemorrhage management is further complicated by BPV, which emerges as a predictor of mortality and disability, necessitating nuanced BP management strategies. Finally, among patients with acute subarachnoid haemorrhage, increased BPV may be correlated with a rebleeding risk and worse outcomes, emphasizing the need for BPV monitoring in this population. Integration of BPV assessment into clinical practice and research protocols is crucial for refining treatment strategies that are tailored to individual patient needs. Future studies should explore novel interventions targeting BPV modulation to optimise stroke care outcomes.
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Affiliation(s)
- Christina Zompola
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Leonidas Stefanis
- First Department of Neurology, “Aeginition” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON L8L2X2, Canada
| | - Else C. Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, N-0424 Oslo, Norway
| | - Estathios Boviatsis
- Second Department of Neurosurgery, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
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3
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Li N, Guo J, Kang K, Zhang J, Zhang Z, Liu L, Liu X, Du Y, Wang Y, Zhao X. Cytotoxic Edema and Adverse Clinical Outcomes in Patients with Intracerebral Hemorrhage. Neurocrit Care 2023; 38:414-421. [PMID: 36180765 PMCID: PMC10090026 DOI: 10.1007/s12028-022-01603-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Cytotoxic edema (CE) is an important form of perihematomal edema (PHE), which is a surrogate marker of secondary injury after intracerebral hemorrhage (ICH). However, knowledge about CE after ICH is insufficient. Whether CE has adverse effects on clinical outcomes of patients with ICH remains unknown. Therefore, we aimed to investigate the temporal pattern of CE and its association with clinical outcomes in patients with ICH. METHODS Data were derived from a randomized controlled study (comparing the deproteinized calf blood extract with placebo in patients with ICH). Intervention in this original study did not show any impact on hematoma and PHE volume, presence of CE, or clinical outcomes. We conducted our analysis in 20 patients who underwent magnetic resonance imaging with diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) images at day 3 and within 7-12 days after symptom onset. CE was defined as an elevated DWI b1000 signal and an ADC value reduced by > 10% compared with the mirror area of interest in the perihematomal region. The modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), and Barthel Index (BI) were performed face to face at 30-day and 90-day follow-ups after ICH onset to assess the clinical outcomes of the patients. RESULTS CE was detected in nearly two thirds of patients with ICH in our study and seemed to be reversible. CE within 7-12 days, rather than at day 3 after symptom onset, was associated with poor clinical outcome (mRS 3-6) at the 30-day follow-up (P = 0.020). In addition, compared with those without CE, patients with CE within 7-12 days had more severe neurological impairment measured by NIHSS score (P = 0.024) and worse daily life quality measured by BI (P = 0.004) at both the 30- and 90-day follow-ups. CONCLUSIONS CE appears in the acute phase of ICH and might be reversible. CE within 7-12 days post ICH was related to poor outcomes, which provides a novel therapeutic target for ICH intervention.
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Affiliation(s)
- Na Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jiahuan Guo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Kaijiang Kang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jia Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Zhe Zhang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Tiantan Neuroimaging Center of Excellence, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lijun Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xinmin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yang Du
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yu Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
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Zhang X, Zhu HC, Yang D, Zhang FC, Mane R, Sun SJ, Zhao XQ, Zhou J. Association between cerebral blood flow changes and blood-brain barrier compromise in spontaneous intracerebral haemorrhage. Clin Radiol 2022; 77:833-839. [PMID: 35786315 DOI: 10.1016/j.crad.2022.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 12/30/2022]
Abstract
AIM To quantitatively evaluate blood-brain barrier (BBB) permeability in the perihaematomal region of spontaneous intracerebral haemorrhage (ICH) and investigate the association between the alterations in cerebral blood flow and BBB permeability around the haematoma. MATERIALS AND METHODS Spontaneous ICH patients underwent unenhanced computed tomography (CT) and CT perfusion (CTP) simultaneously. Haematoma volume was measured on CT. The values of cerebral haemodynamic parameters including cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), time to peak (TTP), and permeability-surface area product (PS) were measured in the perihaematomal region and the contralateral mirror region, and then relative values were calculated for statistical analysis. Linear regression was used to evaluate associations between BBB permeability and variables. RESULTS A total of 87 ICH patients were included in this study. The focally elevated BBB permeability was observed in the perihaematomal region in ICH patients. Linear regression showed that reduced rCBF (β = -0.379, p=0.001) and increased rCBV (β = 0.412, p=0.000) correlated independently with increased relative PS (rPS) value in deep ICH, while only increased rCBV (β = 0.423, p=0.071) correlated to increased rPS value in patients with lobar ICH. CONCLUSIONS BBB permeability is focally elevated in the region around the haematoma. Cerebral haemodynamic alterations are associated with increased BBB permeability. Cerebral hypoperfusion may aggravate BBB compromise, and a compensatory increase in CBV may lead to reperfusion injury on BBB.
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Affiliation(s)
- X Zhang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - H C Zhu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - D Yang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - F C Zhang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - R Mane
- China National Clinical Research Center-Hanalytics Artificial Intelligence Research Centre for Neurological Disorders, Beijing, China
| | - S J Sun
- Department of Neuroradiology, Beijing Neurosurgical Institute, Affiliated Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - X Q Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - J Zhou
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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The Role of Nondiabetic Hyperglycemia in Critically Ill Patients with Acute Ischemic Stroke. J Clin Med 2022; 11:jcm11175116. [PMID: 36079047 PMCID: PMC9456679 DOI: 10.3390/jcm11175116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 08/18/2022] [Accepted: 08/29/2022] [Indexed: 11/18/2022] Open
Abstract
In this study, we aim to elucidate the association between nondiabetic hyperglycemia and the short-term prognosis of critically ill patients with acute ischemic stroke. We extracted data using the Medical Information Mart for Intensive Care IV from 2008 to 2019. The primary outcomes were set as intensive care units (ICU) and in-hospital mortality. We developed a Cox proportional hazards model to determine the nonlinear association between serum glucose levels and primary outcomes. Of the 1086 patients included, 236 patients had hyperglycemia. Patients with hyperglycemia were associated with higher ages, female gender, higher Charlson Comorbidity Index scores, and higher Acute Physiology Score III scores. After propensity score matching, 222 pairs remained. The hyperglycemia group had a significantly higher ICU mortality (17.6% vs. 10.8%; p = 0.041). Meanwhile, no significant differences in ICU length of stay (5.2 vs. 5.2; p = 0.910), in-hospital mortality (26.6% vs. 18.9%, p = 0.054), and hospital length of stay (10.0 vs. 9.1; p = 0.404) were observed between the two groups. The Kaplan–Meier curves for ICU and in-hospital survival before matching suggested significant differences; however, after matching, they failed to prove any disparity. Non-diabetic patients with acute ischemic stroke have poor clinical characteristic while encountering hyperglycemic events; therefore, careful monitoring in the acute phase is still required.
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Baker TS, Kellner CP, Colbourne F, Rincon F, Kollmar R, Badjatia N, Dangayach N, Mocco J, Selim MH, Lyden P, Polderman K, Mayer S. Consensus recommendations on therapeutic hypothermia after minimally invasive intracerebral hemorrhage evacuation from the hypothermia for intracerebral hemorrhage (HICH) working group. Front Neurol 2022; 13:859894. [PMID: 36062017 PMCID: PMC9428129 DOI: 10.3389/fneur.2022.859894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Therapeutic hypothermia (TH), or targeted temperature management (TTM), is a classic treatment option for reducing inflammation and potentially other destructive processes across a wide range of pathologies, and has been successfully used in numerous disease states. The ability for TH to improve neurological outcomes seems promising for inflammatory injuries but has yet to demonstrate clinical benefit in the intracerebral hemorrhage (ICH) patient population. Minimally invasive ICH evacuation also presents a promising option for ICH treatment with strong preclinical data but has yet to demonstrate functional improvement in large randomized trials. The biochemical mechanisms of action of ICH evacuation and TH appear to be synergistic, and thus combining hematoma evacuation with cooling therapy could provide synergistic benefits. The purpose of this working group was to develop consensus recommendations on optimal clinical trial design and outcomes for the use of therapeutic hypothermia in ICH in conjunction with minimally invasive ICH evacuation. Methods An international panel of experts on the intersection of critical-care TH and ICH was convened to analyze available evidence and form a consensus on critical elements of a focal cooling protocol and clinical trial design. Three focused sessions and three full-group meetings were held virtually from December 2020 to February 2021. Each meeting focused on a specific subtopic, allowing for guided, open discussion. Results These recommendations detail key elements of a clinical cooling protocol and an outline for the roll-out of clinical trials to test and validate the use of TH in conjunction with hematoma evacuation as well as late-stage protocols to improve the cooling approach. The combined use of systemic normothermia and localized moderate (33.5°C) hypothermia was identified as the most promising treatment strategy. Conclusions These recommendations provide a general outline for the use of TH after minimally invasive ICH evacuation. More research is needed to further refine the use and combination of these promising treatment paradigms for this patient population.
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Affiliation(s)
- Turner S. Baker
- Icahn School of Medicine at Mount Sinai, Sinai BioDesign, New York, NY, United States
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Turner S. Baker
| | - Christopher P. Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Fred Rincon
- Department of Neurology, Thomas Jefferson University Hospital, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Neha Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - J. Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Magdy H. Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, United States
| | - Patrick Lyden
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, CA, United States
| | - Kees Polderman
- United Memorial Medical Center, Houston, TX, United States
| | - Stephan Mayer
- Westchester Medical Center Health Network, Valhalla, NY, United States
- Department of Neurology, New York Medical College, Valhalla, NY, United States
- Department of Neurosurgery, New York Medical College, Valhalla, NY, United States
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Mi D, Li Z, Gu H, Jiang Y, Zhao X, Wang Y, Wang Y. Stress hyperglycemia is associated with in-hospital mortality in patients with diabetes and acute ischemic stroke. CNS Neurosci Ther 2022; 28:372-381. [PMID: 35084107 PMCID: PMC8841306 DOI: 10.1111/cns.13764] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/19/2021] [Accepted: 11/05/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Objective Stress hyperglycemia may occur in diabetic patients with acute severe cerebrovascular disease, but the results regarding its association with stroke outcomes are conflicting. This study aimed to examine the association between stress‐induced hyperglycemia and the occurrence of in‐hospital death in patients with diabetes and acute ischemic stroke. Research Design and Methods All data were from the Chinese Stroke Center Alliance (CSCA) database and were collected between 2016 and 2018 from >300 centers across China. Patients’ demographics, clinical presentation, and laboratory data were extracted from the database. The primary endpoint was in‐hospital death. The ratio of fasting blood glucose (FBG) to HbA1c was calculated, that is, the stress‐induced hyperglycemia ratio (SHR), to determine stress hyperglycemia following acute ischemic stroke. Results A total of 168,381 patients were included. The mean age was 66.2 ± 10.7, and 77,688 (43.0%) patients were female. The patients were divided into two groups: survivors (n = 167,499) and non‐survivors (n = 882), as well as into four groups according to their SHR quartiles (n = 42,090–42,099/quartile). There were 109 (0.26%), 142 (0.34%), 196 (0.47%), and 435 (1.03%) patients who died in the Q1, Q2, Q3, and Q4 quartiles, respectively. Compared with Q1 patients, the death risk was higher in Q4 patients (odds ratio (OR) = 4.02) (adjusted OR = 1.80, 95% confidence interval [CI] = 1.10–2.92, p = 0.018 after adjustment for traditional cardiovascular risk factors). The ROC analyses showed that SHR (AUC = 0.667, 95% CI: 0.647–0.686) had a better predictive value for mortality than that of fasting blood glucose (AUC = 0.633, 95% CI: 0.613–0.652) and HbA1c (AUC = 0.523, 95% CI: 0.504–0.543). Conclusions The SHR may serve as an accessory parameter for the prognosis of patients with diabetes after acute ischemic stroke. Hyperglycemia in stroke patients with diabetes mellitus is associated with a higher risk of in‐hospital death.
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Affiliation(s)
- Donghua Mi
- Department of Vascular Neurology, Beijing Tiantan Hospital, Capital, Medical University, Beijing, China
| | - Zixiao Li
- Department of Vascular Neurology, Beijing Tiantan Hospital, Capital, Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongqiu Gu
- Department of Vascular Neurology, Beijing Tiantan Hospital, Capital, Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yingyu Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Vascular Neurology, Beijing Tiantan Hospital, Capital, Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Vascular Neurology, Beijing Tiantan Hospital, Capital, Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Vascular Neurology, Beijing Tiantan Hospital, Capital, Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center for Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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8
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Zarean E, Lattanzi S, Looha MA, Napoli MD, Chou SHY, Jafarli A, Torbey M, Divani AA. Glycemic Gap Predicts in-Hospital Mortality in Diabetic Patients with Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105669. [PMID: 33636475 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105669] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/26/2021] [Accepted: 02/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE The relationship between admission hyperglycemia and intracerebral hemorrhage (ICH) outcome remains controversial. Glycemic gap (GG) is a superior indicator of glucose homeostatic response to physical stress compared to admission glucose levels. We aimed to evaluate the association between GG and in-hospital mortality in ICH. METHODS We retrospectively identified consecutive patients hospitalized for spontaneous ICH at the 2 healthcare systems in the Twin Cities area, MN, between January 2008 and December 2017. Patients without glycosylated hemoglobin (HbA1c) test or those admitted beyond 24 hours post-ICH were excluded. Demographics, medical history, admission tests, and computed tomography data were recorded. GG was computed using admission glucose level minus HbA1c-derived average glucose. The association between GG and time to in-hospital mortality was evaluated by Cox regression analysis. Receiver operating characteristic (ROC) analysis with the DeLong test was used to evaluate the ability of GG to predict in-hospital death. RESULTS Among 345 included subjects, 63 (25.7%) died during the hospital stay. Compared with survivors, non-survivors presented with a lower Glasgow coma scale score, larger hematoma volume, and higher white blood cells count, glucose, and GG levels at admission (p<0.001). GG remained an independent predictor of in-hospital mortality after adjusting for known ICH outcome predictors and potential confounders [adjusted hazard ratio: 1.09, 95% confidence interval (CI): 1.02-1.18, p = 0.018]. GG showed a good discriminative power (area under the ROC curve: 0.75, 95% CI: 0.68-0.82) in predicting in-hospital death and performed better than admission glucose levels in diabetic patients (p = 0.030 for DeLong test). CONCLUSIONS Admission GG is associated with the risk of in-hospital mortality and can potentially represent a useful prognostic biomarker for ICH patients with diabetes.
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Affiliation(s)
- Elaheh Zarean
- Department of Neurology, University of New Mexico, NM, USA; Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Sherry H-Y Chou
- Departments of Critical Care Medicine, Neurology, & Neurosurgery, University of Pittsburgh, PA, USA.
| | - Alibay Jafarli
- Department of Neurology, University of New Mexico, NM, USA.
| | - Michel Torbey
- Department of Neurology, University of New Mexico, NM, USA.
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Peri-hematoma corticospinal tract integrity in intracerebral hemorrhage patients: A diffusion-tensor imaging study. J Neurol Sci 2021; 421:117317. [PMID: 33476986 DOI: 10.1016/j.jns.2021.117317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 12/09/2020] [Accepted: 01/09/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The impact of perihematoma edema in Intracerebral Hemorrhage (ICH) on white matter integrity is uncertain. Fractional Anisotropy (FA), as measured with Diffusion Tensor Imaging (DTI), can be used to assess white matter microstructure. We tested the hypotheses that sections of the Corticospinal Tract (CST) passing through perihematoma edema would 1) have low FA relative to the contralateral CST and 2) would predict NIHSS motor score in ICH patients. METHODS Patients were prospectively imaged with DTI at 48 h and 7 days after onset. Edema volume/extent was measured on CT at baseline and 24 h. FA, mean, axial and radial diffusivity were measured in the perihematoma edema, contralateral CST and sections of CST passing through the edema ('edematous CST'). RESULTS Patients (n = 27, mean age 67 ± 13) were scanned with DTI at a median (IQR) of 42.3 (24.5) hours and 7.7 (1.8) days from onset. Median acute ICH volume was 8.8 (22) ml. FA in edematous CST at 72 h was decreased (0.37 ± 0.03) relative to contralateral CST (0.52 ± 0.06; p < 0.0001). Day 7 FA in edematous CST (0.35 ± 0.08) was also decreased compared to contralateral CST (0.54 ± 0.06; p < 0.0001). FA remained stable between 72 h (0.37 ± 0.03) and day 7 (0.35 ± 0.07; p = 0.350). FA at 72 h (ρ = -0.22, p = 0.420) and day 7 (ρ = -0.14, p = 0.624) was unrelated to 90-day motor score. CONCLUSIONS FA is decreased in the CST where it passes through the edema. Decreased FA in the edematous CST remained stable over time, was unrelated to motor score, and may represent water infiltration into the tracts rather than axonal injury.
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Klahr AC, Kosior JC, Dowlatshahi D, Buck BH, Beaulieu C, Gioia LC, Kalashyan H, Wilman AH, Jeerakathil T, Emery DJ, Shuaib A, Butcher KS. Lower Blood Pressure Is Not Associated With Decreased Arterial Spin Labeling Estimates of Perfusion in Intracerebral Hemorrhage. J Am Heart Assoc 2020; 8:e010904. [PMID: 31131671 PMCID: PMC6585347 DOI: 10.1161/jaha.118.010904] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background Subacute ischemic lesions in intracerebral hemorrhage (ICH) have been hypothesized to result from hypoperfusion. Although studies of cerebral blood flow (CBF) indicate modest hypoperfusion in ICH, these investigations have been limited to early time points. Arterial spin labeling (ASL), a magnetic resonance imaging technique, can be used to measure CBF without a contrast agent. We assessed CBF in patients with ICH using ASL and tested the hypothesis that CBF is related to systolic blood pressure (SBP). Methods and Results In this cross‐sectional study, patients with ICH were assessed with ASL at 48 hours, 7 days, and/or 30 days after onset. Relative CBF (rCBF; ratio of ipsilateral/contralateral perfusion) was measured in the perihematomal regions, hemispheres, border zones, and the perilesional area in patients with diffusion‐weighted imaging hyperintensities. Twenty‐patients (65% men; mean±SD age, 68.5±12.7 years) underwent imaging with ASL at 48 hours (N=12), day 7 (N=6), and day 30 (N=11). Median (interquartile range) hematoma volume was 13.1 (6.3–19.3) mL. Mean±SD baseline SBP was 185.4±25.5 mm Hg. Mean perihematomal rCBF was 0.9±0.2 at 48 hours at all time points. Baseline SBP and other SBP measurements were not associated with a decrease in rCBF in any of the regions of interest (P≥0.111). rCBF did not differ among time points in any of the regions of interest (P≥0.097). Mean perilesional rCBF was 1.04±0.65 and was unrelated to baseline SBP (P=0.105). Conclusions ASL can be used to measure rCBF in patients with acute and subacute ICH. Perihematomal CBF was not associated with SBP changes at any time point. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00963976.
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Affiliation(s)
- Ana C Klahr
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada
| | - Jayme C Kosior
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada
| | | | - Brian H Buck
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada
| | - Christian Beaulieu
- 2 Department of Biomedical Engineering University of Alberta Edmonton Alberta Canada
| | - Laura C Gioia
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada
| | | | - Alan H Wilman
- 2 Department of Biomedical Engineering University of Alberta Edmonton Alberta Canada
| | | | - Derek J Emery
- 3 Department of Radiology and Diagnostic Imaging University of Alberta Edmonton Alberta Canada
| | - Ashfaq Shuaib
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada
| | - Kenneth S Butcher
- 1 Division of Neurology University of Alberta Edmonton Alberta Canada.,5 Prince of Wales Clinical School University of New South Wales Sydney New South Wales Australia
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11
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Blood pressure variability and outcome after acute intracerebral hemorrhage. J Neurol Sci 2020; 413:116766. [PMID: 32151850 DOI: 10.1016/j.jns.2020.116766] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/24/2020] [Accepted: 03/01/2020] [Indexed: 01/12/2023]
Abstract
Intracerebral hemorrhage (ICH) is life threatening neurologic event that results in significant rate of morbidity and mortality. Unfortunately, several randomized clinical trials aiming at limiting the hematoma expansion (HE) in the acute phase of ICH have not shown significant effects in improving the functional outcomes. Blood pressure variability (BPV) is common following ICH. High BPs have been associated with increased risk of bleeding and HE. Conversely, recurrent sudden decrease in BP promote perihematomal ischemia. However, it is still not clear weather BPV causes adverse prognosis following ICH or large ICHs cause fluctuations in BP. In the current review, we will discuss the mechanistic pathophysiology of BPV and the evidence regarding the role of BPV on the ICH outcomes.
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12
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Boltze J, Ferrara F, Hainsworth AH, Bridges LR, Zille M, Lobsien D, Barthel H, McLeod DD, Gräßer F, Pietsch S, Schatzl AK, Dreyer AY, Nitzsche B. Lesional and perilesional tissue characterization by automated image processing in a novel gyrencephalic animal model of peracute intracerebral hemorrhage. J Cereb Blood Flow Metab 2019; 39:2521-2535. [PMID: 30239258 PMCID: PMC6893983 DOI: 10.1177/0271678x18802119] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intracerebral hemorrhage (ICH) is an important stroke subtype, but preclinical research is limited by a lack of translational animal models. Large animal models are useful to comparatively investigate key pathophysiological parameters in human ICH. To (i) establish an acute model of moderate ICH in adult sheep and (ii) an advanced neuroimage processing pipeline for automatic brain tissue and hemorrhagic lesion determination; 14 adult sheep were assigned for stereotactically induced ICH into cerebral white matter under physiological monitoring. Six hours after ICH neuroimaging using 1.5T MRI including structural as well as perfusion and diffusion, weighted imaging was performed before scarification and subsequent neuropathological investigation including immunohistological staining. Controlled, stereotactic application of autologous blood caused a space-occupying intracerebral hematoma of moderate severity, predominantly affecting white matter at 5 h post-injection. Neuroimage post-processing including lesion probability maps enabled automatic quantification of structural alterations including perilesional diffusion and perfusion restrictions. Neuropathological and immunohistological investigation confirmed perilesional vacuolation, axonal damage, and perivascular blood as seen after human ICH. The model and imaging platform reflects key aspects of human ICH and enables future translational research on hematoma expansion/evacuation, white matter changes, hematoma evacuation, and other aspects.
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Affiliation(s)
- Johannes Boltze
- Department of Translational Medicine and Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell Technology, Lübeck, Germany.,Institute for Medical and Marine Biotechnology, University of Lübeck, Lübeck, Germany
| | - Fabienne Ferrara
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Atticus H Hainsworth
- Cell Biology and Genetics Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Leslie R Bridges
- Cell Biology and Genetics Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Department of Cellular Pathology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Marietta Zille
- Department of Translational Medicine and Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell Technology, Lübeck, Germany.,Institute for Medical and Marine Biotechnology, University of Lübeck, Lübeck, Germany.,Institute for Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany
| | - Donald Lobsien
- Department of Neuroradiology, University Hospital of Leipzig, Leipzig, Germany
| | - Henryk Barthel
- Clinic for Nuclear Medicine, University of Leipzig, Leipzig, Germany
| | - Damian D McLeod
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum.,School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, and Hunter Medical Research Institute, The University of Newcastle, Callaghan, Australia
| | - Felix Gräßer
- Institute of Biomedical Engineering, Faculty of Electrical and Computer Engineering, Technical University of Dresden, Dresden, Germany
| | - Sören Pietsch
- Department of Translational Medicine and Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell Technology, Lübeck, Germany
| | - Ann-Kathrin Schatzl
- Department for Cell Therapies, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Antje Y Dreyer
- Department for Cell Therapies, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Björn Nitzsche
- Clinic for Nuclear Medicine, University of Leipzig, Leipzig, Germany.,Department of Pharmacology and Personalised Medicine, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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13
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Peng W, Li Q, Tang J, Reis C, Araujo C, Feng R, Yuan M, Jin L, Cheng Y, Jia Y, Luo Y, Zhang J, Yang J. The risk factors and prognosis of delayed perihematomal edema in patients with spontaneous intracerebral hemorrhage. CNS Neurosci Ther 2019; 25:1189-1194. [PMID: 31542897 PMCID: PMC6776736 DOI: 10.1111/cns.13219] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 08/25/2019] [Accepted: 08/26/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE We hypothesize delayed perihematomal edema (DHE) leads to secondary injury after spontaneous intracerebral hemorrhage (sICH) with a poor prognosis. Hence, we need to investigate the risk factors of DHE and identify whether DHE will predict the poor outcome of sICH. METHODS We retrospectively recruited 121 patients with sICH admitted to the Department of Neurology from January 2014 to August 2018. After dividing all these patients into DHE group and non-DHE group, we analyzed the potential risk factors and outcome of DHE using a multivariate logistic regression model. RESULTS We conclude DHE after sICH associates with age, hospitalization time, hematoma shape, blood pressure upon admission, alcohol consumption, blood sodium level, and baseline hematoma volume within 24 hours after symptom onset, among which differences were statistically significant (P < .05). Logistic regression analysis finally identified that age (OR = 0.958, 95% CI = 0.923-0.995) and the baseline hematoma volume (OR = 1.161, 95% CI = 1.089-1.238) were the most significant risk factors for DHE, and moreover, the DHE (OR = 3.062, 95% CI = 1.196-7.839) was also a risk factor for poor prognosis in sICH patients. CONCLUSION We suggest DHE is a clinical predictor of secondary injury following sICH and poor prognosis. In addition, age and baseline hematoma volume are considered significant high-risk factors for DHE in patients with sICH.
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Affiliation(s)
- Wen‐jie Peng
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Qian Li
- Department of PediatricsThe Third Affiliated Hospital & Field Surgery InstitutionArmy Medical UniversityChongqingChina
| | - Jin‐hua Tang
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Cesar Reis
- Department of Physiology and PharmacologyLoma Linda University School of MedicineLoma LindaCAUSA
| | - Camila Araujo
- Department of Physiology and PharmacologyLoma Linda University School of MedicineLoma LindaCAUSA
| | - Rui Feng
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Ming‐hao Yuan
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Lin‐yan Jin
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Ya‐li Cheng
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Yan‐jie Jia
- Department of NeurologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Ye‐tao Luo
- Department of BiostatisticsSchool of Public Health and ManagementChongqing Medical UniversityChongqingChina
| | - John Zhang
- Department of Physiology and PharmacologyLoma Linda University School of MedicineLoma LindaCAUSA
| | - Jun Yang
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
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14
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Abstract
Central nervous system hemorrhage has multiple pathophysiologic etiologies, including intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI). Given the nuances intrinsic to each of these etiologies and pathophysiologic processes, optimal blood pressure varies significantly and depends on type of hemorrhage and individual characteristics. This article reviews the most current evidence regarding blood pressure targets and provides guidance on reversal of anticoagulation for TBI, ICH, and SAH. It also describes the assessment, optimal therapeutic targets, and interventions to treat intracranial hypertension that can result from TBI, ICH, or SAH.
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Affiliation(s)
- Evie Marcolini
- Department of Surgery, Division of Emergency Medicine, University of Vermont College of Medicine, 111 Colchester Avenue, Burlington, VT 05401, USA; Department of Neurology, Division of Neurocritical Care, University of Vermont College of Medicine, 111 Colchester Avenue, Burlington, VT 05401, USA.
| | - Christoph Stretz
- Division of Vascular Neurology, Yale School of Medicine, 15 York Street, LLCI Building Suite 1004, New Haven, CT 06510, USA
| | - Kyle M DeWitt
- Department of Pharmacy, The University of Vermont Medical Center, 111 Colchester Avenue, Mailstop 272 BA1, Burlington, VT 05401, USA
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15
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Ironside N, Chen CJ, Ding D, Mayer SA, Connolly ES. Perihematomal Edema After Spontaneous Intracerebral Hemorrhage. Stroke 2019; 50:1626-1633. [PMID: 31043154 DOI: 10.1161/strokeaha.119.024965] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Natasha Ironside
- From the Department of Neurological Surgery, Columbia University Medical Center, New York, NY (N.I., E.S.C.)
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville (C.-J.C.)
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville School of Medicine, KY (D.D.)
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Detroit, MI (S.A.M.)
| | - Edward Sander Connolly
- From the Department of Neurological Surgery, Columbia University Medical Center, New York, NY (N.I., E.S.C.)
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16
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Diagnosing Neoplastic Hematoma: Role of MR Perfusion. Clin Neuroradiol 2018; 29:263-268. [PMID: 29417155 DOI: 10.1007/s00062-018-0664-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/10/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND The imaging appearance of neoplastic hematoma can be complicated by the presence of a large hematoma, even on magnetic resonance imaging (MRI). We describe the role of MR perfusion (MRP) in detecting neoplastic hematomas in patients with intraparenchymal hematoma (IPH). MATERIAL AND METHODS A retrospective review was performed for consecutive patients with IPH, where MRP was performed. Routine, post-gadolinium MRI and MRP were analyzed. All patients were either operated on for evacuation of IPH or followed up on imaging. The MRP parameters of cerebral blood volume (CBV) and cerebral blood flow (CBF) and pattern of enhancement (peripheral linear vs. nodular) were recorded. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated for these parameters for diagnosing neoplastic hematoma. RESULTS Of 116 patients with MRP, 16 patients (male 8; mean age-65.5 years) had IPH on their initial MRI. For diagnosing neoplastic hematoma, the sensitivity, specificity, PPV and NPV for increased CBF and CBV were 100%, 88.9%, 87.5%, and 100%; for peripheral linear enhancement were 100%, 28.6%, 50%, 100% and for nodular enhancement were 85.7%, 77.8%, 75% and 12.5%, respectively. The combination of peripheral linear enhancement and increased CBF and CBV showed 100% sensitivity, specificity, PPV and NPV. CONCLUSION In our small series, the combination of peripheral linear enhancement and increased CBF and CBV showed 100% sensitivity, specificity, PPV and NPV for diagnosing a neoplastic hematoma. These findings need to be validated in a larger study.
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17
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Schneider T, Frieling D, Schroeder J, Regelsberger J, Schoen G, Fiehler J, Gellißen S. Perihematomal diffusion restriction as a common finding in large intracerebral hemorrhages in the hyperacute phase. PLoS One 2017; 12:e0184518. [PMID: 28922367 PMCID: PMC5602530 DOI: 10.1371/journal.pone.0184518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/27/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose There is growing evidence that a perihematomal area of restricted diffusion (PDR) exists in intraparenchymal hemorrhages (IPH) within 1 week of symptom onset (SO). Here, we study characteristics and the clinical impact of the PDR in patients with hyperacute (≤ 6 hours from SO) IPH by means of apparent diffusion coefficient (ADC). Methods This monocentric, retrospective study includes 83 patients with first-ever primary IPH from 09/2002-10/2015. 3D volumetric segmentation was performed for the IPH, PDR, and perihematomal edema (PHE) on fluid-attenuated inversion recovery, T2*/susceptibility weighted images, and ADC images. Results A PDR was seen in 56/83 patients (67.5%) presenting with hyperacute IPH. Multivariate logistic regression analysis revealed every 10-year increase of age (HR 1.929, 95% CI 1.047–3.552, P = .035) and male gender (HR 5.672, 95% CI 1.038–30.992, P = .045) as significant predictors of the presence of a PDR, but not IPH size, IPH location, nor National Institutes of Health Stroke Scale Score (NIHSS) at admission. We found no difference in NIHSS at discharge, hematoma removal, or mortality rate in PDR-positive patients. ADC values of the PDR show a step-wise normalization with increasing time from SO. Conclusions Occurrence of a PDR is a common finding in supratentorial hyperacute IPH, but shows no adverse short-term clinical impact. It may represent transient oligemic and metabolic changes.
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Affiliation(s)
- Tanja Schneider
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Diagnostic and Interventional Radiology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
- * E-mail:
| | - David Frieling
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Schroeder
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schoen
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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18
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Jugular Venous Reflux Is Associated with Perihematomal Edema after Intracerebral Hemorrhage. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7514639. [PMID: 28691032 PMCID: PMC5485297 DOI: 10.1155/2017/7514639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 04/01/2017] [Accepted: 05/11/2017] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to determine whether jugular venous reflux (JVR) is associated with perihematomal edema (PHE) in individuals with intracerebral hemorrhage (ICH). Patients with spontaneous supratentorial ICH within 72 h of symptom onset were enrolled. Baseline brain computed tomography (CT) scan was performed, with a follow-up CT examination at 12 ± 3 days after onset. Jugular venous color Doppler ultrasound was performed at 12 ± 3 days after onset to examine the JVR status. A total of 65 patients with ICH were enrolled. In logistic regression analysis, absolute PHE volume was significantly associated with JVR (OR, 5.46; 95% CI, 1.04–28.63; p = 0.044) and baseline hematoma volume (OR, 1.14; 95% CI, 1.03–1.26; p = 0.009) within 72 h of onset. It was also correlated with JVR (OR, 15.32; 95% CI, 2.52–92.99; p = 0.003) and baseline hematoma volume (OR, 1.14; 95% CI, 1.04–1.24; p = 0.006) at 12 ± 3 days after onset. In a similar manner, relative PHE volume was significantly associated with JVR (OR, 14.85; 95% CI, 3.28–67.17; p < 0.001) within 72 h of onset and at 12 ± 3 days after onset (OR, 5.87; 95% CI, 1.94–17.77; p = 0.002). JVR is associated with both absolute and relative PHE volumes after ICH.
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Shimoda Y, Ohtomo S, Arai H, Okada K, Tominaga T. Satellite Sign: A Poor Outcome Predictor in Intracerebral Hemorrhage. Cerebrovasc Dis 2017; 44:105-112. [PMID: 28605739 DOI: 10.1159/000477179] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The presence of high-density starry dots around the intracerebral hemorrhage (ICH), which we termed as a satellite sign, is occasionally observed in CT. The relationship between ICH with a satellite sign and its functional outcome has not been identified. This study aimed to determine whether the presence of a satellite sign could be an independent prognostic factor for patients with ICH. METHODS Patients with acute spontaneous ICH were retrospectively identified and their initial CT scans were reviewed. A satellite sign was defined as scattered high-density lesions completely separate from the main hemorrhage in at least the single axial slice. Functional outcome was evaluated using the modified Rankin Scale (mRS) at discharge. Poor functional outcome was defined as mRS scores of 3-6. Univariate and multivariate logistic regression analyses were applied to assess the presence of a satellite sign and its association with poor functional outcome. RESULTS A total of 241 patients with ICH were enrolled in the study. Of these, 98 (40.7%) had a satellite sign. Patients with a satellite sign had a significantly higher rate of poor functional outcome (95.9%) than those without a satellite sign (55.9%, p < 0.0001). Multivariate logistic regression analysis revealed that higher age (OR 1.06; 95% CI 1.03-1.10; p = 0.00016), large hemorrhage size (OR 1.06; 95% CI 1.03-1.11; p = 0.00015), and ICH with a satellite sign (OR 13.5; 95% CI 4.42-53.4; p < 0.0001) were significantly related to poor outcome. A satellite sign was significantly related with higher systolic blood pressure (p = 0.0014), higher diastolic blood pressure (p = 0.0117), shorter activated partial thromboplastin time (p = 0.0427), higher rate of intraventricular bleeding (p < 0.0001), and larger main hemorrhage (p < 0.0001). CONCLUSIONS The presence of a satellite sign in the initial CT scan is associated with a significantly worse functional outcome in ICH patients.
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Affiliation(s)
- Yoshiteru Shimoda
- Department of Neurosurgery, South Miyagi Medical Center, Miyagi, Japan
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20
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Casolla B, Tortuyaux R, Cordonnier C. Management of spontaneous intracerebral haemorrhages. Presse Med 2016; 45:e419-e428. [DOI: 10.1016/j.lpm.2016.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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21
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Hu X, Bai X, Zai N, Sun X, Zhu L, Li X. Prognostic value of perfusion-weighted magnetic resonance imaging in acute intracerebral hemorrhage. Neurol Res 2016; 38:614-9. [PMID: 27197990 DOI: 10.1080/01616412.2016.1177932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study intends to investigate the prognostic value of perfusion-weighted magnetic resonance imaging in acute intracerebral hemorrhage. METHODS Demographic, clinical and biochemical data between acute intracerebral hemorrhage (AICH) and healthy volunteer groups were assessed in this study, such as rCBV and MTT values. The optimal cutoff values of rCBV and MTT for diagnosing AICH were determined by the ROC curves. Apart from that, we also investigated the association between rCBV/MTT values and cerebral hematoma volumes of AICH patients. The unconditional logistic regression was conducted to determine significant risk factors for AICH. RESULT AICH patients have significantly lower rCBV and higher MTT compared to the control group (all P < 0.05). As suggested by the relatively high sensitivity and specificity, both rCBV and MTT values could be utilized for AICH diagnosis. Moreover, rCBV and MTT were significantly associated with the cerebral hematoma volumes of AICH patients (all P < 0.05). Results from unconditional logistic regression analysis revealed that MTT was a significant risk factor for AICH (P < 0.05 and OR > 1), while rCBV is considered as a protective factor (P < 0.05 and OR < 1). CONCLUSION Perfusion-weighted magnetic resonance imaging produces a high prognostic value for diagnosing AICH.
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Affiliation(s)
- Xibin Hu
- a Department of Radiology , Affiliated Hospital of Jining Medical University , Jining , China
| | - Xueqin Bai
- a Department of Radiology , Affiliated Hospital of Jining Medical University , Jining , China
| | - Ning Zai
- a Department of Radiology , Affiliated Hospital of Jining Medical University , Jining , China
| | - Xinhai Sun
- a Department of Radiology , Affiliated Hospital of Jining Medical University , Jining , China
| | - Laimin Zhu
- a Department of Radiology , Affiliated Hospital of Jining Medical University , Jining , China
| | - Xian Li
- b Department of Medical Imaging , Jining Medical University , Jining , China
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Carcel C, Sato S, Anderson CS. Blood Pressure Management in Intracranial Hemorrhage: Current Challenges and Opportunities. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:22. [PMID: 26909816 DOI: 10.1007/s11936-016-0444-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OPINION STATEMENT Non-traumatic intracranial hemorrhage (i.e. intracerebral hemorrhage [ICH] and subarachnoid hemorrhage [SAH]) are more life threatening and least treatable despite being less common than ischemic stroke. Elevated blood pressure (BP) is a strong predictor of poor outcome in both ICH and SAH. Data from a landmark clinical trial INTERACT 2, wherein 2839 participants enrolled with spontaneous ICH were randomly assigned to receive intensive (target systolic BP <140 mmHg) or guideline recommended BP lowering therapy (target systolic BP <180 mmHg), showed that intensive BP lowering was safe, and more favorable functional outcome and better overall health-related quality of life were seen in survivors in the intensive treatment group. These results contributed to the shift in European and American guidelines towards more aggressive early management of elevated BP in ICH. In contrast, the treatment of BP in SAH is less well defined and more complex. Although there is consensus that hypertension needs to be controlled to prevent rebleeding in the acute setting, induced hypertension in the later stages of SAH has questionable benefits.
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Affiliation(s)
- Cheryl Carcel
- Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Neurology Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Shoichiro Sato
- Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia
| | - Craig S Anderson
- Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia. .,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia. .,Neurology Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. .,The George Institute for Global Health, PO Box M201, Missenden Road, Sydney, NSW, 2050, Australia.
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Abstract
OPINION STATEMENT Cerebral edema (i.e., "brain swelling") is a common complication following intracerebral hemorrhage (ICH) and is associated with worse clinical outcomes. Perihematomal edema (PHE) accumulates during the first 72 h after hemorrhage, and during this period, patients are at risk of clinical deterioration due to the resulting tissue shifts and brain herniation. First-line medical therapies for patients symptomatic of PHE include osmotic agents, such as mannitol in low- or high-dose bolus form, or boluses of hypertonic saline (HTS) at varied concentrations with or without subsequent continuous infusion. Decompressive craniectomy may be required for symptomatic edema refractory to osmotherapy. Other strategies that reduce PHE such as hypothermia and minimally invasive surgery have shown promise in pilot studies and are currently being evaluated in larger clinical trials. Ongoing basic, translational, and clinical research seek to better elucidate the pathophysiology of PHE to identify novel strategies to prevent edema formation as a next major advance in the treatment of ICH.
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Kase CS, Shoamanesh A, Greenberg SM, Caplan LR. Intracerebral Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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Lee AY, Choi BY, Kim SH, Chang CH, Jung YJ, Jang SH. Difference of injury of the corticospinal tract according to surgical or conservative treatment in patients with putaminal hemorrhage. Int J Neurosci 2015; 126:429-35. [PMID: 26000805 DOI: 10.3109/00207454.2015.1026966] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE We investigated difference of injury of the corticospinal tract (CST) according to surgical or conservative treatment in patients with putaminal hemorrhage (PH), using diffusion tensor tractography (DTT). METHODS Forty-six patients with PH (hematoma volume on the brain CT: 20-40 ml) were recruited. Patients were classified as the surgical treatment group and the conservative treatment group. The hematoma volume on the initial brain CT (median 2 hours after onset; range 1-14 hours) and volumes of the hematoma, the total lesion and the peri-hematomal edema volume on the follow-up brain magnetic resonance imaging (MRI) (median 23.5 days after onset; range 12-46 days) were estimated. Diffusion tensor imaging was performed and we defined the injury of the CST in terms of the configuration or abnormal DTT parameters. RESULTS In the conservative treatment group, the total lesion volume on the brain MRI was increased compared with the hematoma volume on the initial brain CT (p < 0.05). On brain MRI, the hematoma volume, peri-hematomal edema volume, and total lesion volume were larger in the conservative treatment group than in the surgical treatment group (p < 0.05). Twelve patients (60%) in the surgical treatment group and 24 patients (92%) in the conservative treatment group had injury of the CST. CONCLUSION Injury of the CST was less prevalent in the surgical treatment group than in the conservative treatment group in patients with PH. Therefore, it appears that surgical treatment could be helpful in prevention of injury of the CST in patients with PH.
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Affiliation(s)
- Ah Young Lee
- a Department of Physical Medicine and Rehabilitation, College of Medicine , Yeungnam University , Daegu , Republic of Korea
| | - Byung Yun Choi
- b Department of Neurosurgery, College of Medicine , Yeungnam University , Daegu , Republic of Korea
| | - Seong Ho Kim
- b Department of Neurosurgery, College of Medicine , Yeungnam University , Daegu , Republic of Korea
| | - Chul Hoon Chang
- b Department of Neurosurgery, College of Medicine , Yeungnam University , Daegu , Republic of Korea
| | - Young Jin Jung
- b Department of Neurosurgery, College of Medicine , Yeungnam University , Daegu , Republic of Korea
| | - Sung Ho Jang
- a Department of Physical Medicine and Rehabilitation, College of Medicine , Yeungnam University , Daegu , Republic of Korea
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Acute Treatment of Blood Pressure After Ischemic Stroke and Intracerebral Hemorrhage. Neurol Clin 2015; 33:361-80. [DOI: 10.1016/j.ncl.2014.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Gioia LC, Kate M, Choi V, Sivakumar L, Jeerakathil T, Kosior J, Emery D, Butcher K. Ischemia in intracerebral hemorrhage is associated with leukoaraiosis and hematoma volume, not blood pressure reduction. Stroke 2015; 46:1541-7. [PMID: 25922504 DOI: 10.1161/strokeaha.114.008304] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/24/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Diffusion-weighted imaging (DWI) lesions have been identified both inside and outside the perihematoma region. We tested the hypotheses that larger hematoma volumes and blood pressure reduction are associated with DWI lesions. METHODS Hematoma and perihematoma edema volumes were measured using planimetric techniques in 117 intracerebral hemorrhage (ICH) patients who underwent DWI. Perihematoma and remote DWI lesion volumes were measured using apparent diffusion coefficient thresholds for moderate (<730×10(-6) mm/s) and severe (<550×10(-6) mm/s) ischemia. Acute blood pressure change over the first 24 hours was calculated. RESULTS The median (interquartile range) time to magnetic resonance imaging was 2 (1-5) days. Median hematoma volume was 9.8 (2.6-23.0) mL, and median perihematoma edema volume was 7.0 (2.9-18.6) mL. A small portion of the perihematoma region contained tissue below the thresholds for moderate (8.0 [2.9-14.5]%) and severe ischemia (1.1 [0.3-3.5]%). Ischemic perihematoma tissue volumes were correlated with hematoma volumes (R=0.52, P<0.001), but not maximal systolic blood pressure drop at 24 hours (R=-0.09, P=0.38). Remote DWI lesions were found in 17 (14.5%) patients (mean volume=0.44±0.3 mL). Patients with remote DWI lesions had higher rates of antiplatelet use (P=0.01), prior ICH (P=0.03), lobar ICH (0.04), and larger leukoaraiosis volumes (P=0.02). Maximal systolic blood pressure drop at 24 hours was similar in patients with (-20.5 [-55, -10] mm Hg) and without remote DWI lesions (-27 [-46, -13] mm Hg, P=0.96). CONCLUSIONS Small DWI lesions within and outside the perihematoma region are common in primary ICH. Perihematoma DWI lesions were independently associated with larger hematoma volumes. Remote DWI lesions may be an epiphenomenon associated with the underlying microvascular pathogenesis. These data do not support a hemodynamic mechanism of ischemic injury after primary ICH.
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Affiliation(s)
- Laura C Gioia
- From the Division of Neurology, Department of Medicine (L.C.G., M.K., V.C., L.S., T.J., J.K., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada
| | - Mahesh Kate
- From the Division of Neurology, Department of Medicine (L.C.G., M.K., V.C., L.S., T.J., J.K., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada
| | - Victor Choi
- From the Division of Neurology, Department of Medicine (L.C.G., M.K., V.C., L.S., T.J., J.K., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada
| | - Leka Sivakumar
- From the Division of Neurology, Department of Medicine (L.C.G., M.K., V.C., L.S., T.J., J.K., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada
| | - Thomas Jeerakathil
- From the Division of Neurology, Department of Medicine (L.C.G., M.K., V.C., L.S., T.J., J.K., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada
| | - Jayme Kosior
- From the Division of Neurology, Department of Medicine (L.C.G., M.K., V.C., L.S., T.J., J.K., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada
| | - Derek Emery
- From the Division of Neurology, Department of Medicine (L.C.G., M.K., V.C., L.S., T.J., J.K., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada
| | - Ken Butcher
- From the Division of Neurology, Department of Medicine (L.C.G., M.K., V.C., L.S., T.J., J.K., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada.
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Blood Pressure Variability and Clinical Outcome in Patients with Acute Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2015; 24:1493-9. [PMID: 25873472 DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.014] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/06/2015] [Accepted: 03/12/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate whether fluctuations of blood pressure (BP) levels occurring in the acute stage of spontaneous intracerebral hemorrhage (ICH) affect the 3-month clinical outcome. METHODS We retrospectively identified consecutive patients hospitalized for acute spontaneous ICH. BP measurements over the first 72 hours from the onset of symptoms were recorded, and standard deviation (SD), coefficient of variation (CV), and maximum-minimum difference (max-min) were determined to characterize both systolic and diastolic BP variability (BPV). The measure of outcome was the 3-month functional status assessed by the modified Rankin Scale following a baseline severity-adjusted analysis. RESULTS Among the 138 enrolled patients with ICH, 67 (48.6%) were classified as having a poor 3-month functional recovery. A dose-response relationship with poor outcome was found for each measure of systolic BPV--adjusted odds ratios (ORs) for the highest thirds of SD 7.95 (95% confidence interval [CI], 2.88-21.90), CV 7.74 (95% CI, 2.88-20.80), and max-min 8.36 (95% CI, 2.72-25.62; P < .001). The strength of association with diastolic BPV turned out to be weaker and significant only for the higher values (adjusted ORs for the highest thirds of SD 6.74 [95% CI, 2.52-18.04], CV 4.57 [95% CI, 1.77-11.81], and max-min 4.34 [95% CI, 1.72-10.93]). CONCLUSIONS In patients with acute ICH, BPV was a strong predictor of the 3-month clinical outcome and may represent a still neglected potential therapeutic target.
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McCourt R, Gould B, Kate M, Asdaghi N, Kosior JC, Coutts S, Hill MD, Demchuk A, Jeerakathil T, Emery D, Butcher KS. Blood-brain barrier compromise does not predict perihematoma edema growth in intracerebral hemorrhage. Stroke 2015; 46:954-60. [PMID: 25700288 DOI: 10.1161/strokeaha.114.007544] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE There are limited data on the extent of blood-brain barrier (BBB) compromise in acute intracerebral hemorrhage patients. We tested the hypotheses that BBB compromise measured with permeability-surface area product (PS) is increased in the perihematoma region and predicts perihematoma edema growth in acute intracerebral hemorrhage patients. METHODS Patients were randomized within 24 hours of symptom onset to a systolic blood pressure (SBP) treatment of <150 (n=26) or <180 mm Hg (n=27). Permeability maps were generated using computed tomographic perfusion source data acquired 2 hours after randomization, and mean PS was measured in the hematoma, perihematoma, and hemispheric regions. Hematoma and edema volumes were measured on noncontrast computed tomographic scans obtained at baseline, 2 hours and 24 hours after randomization. RESULTS Patients were randomized at a median (interquartile range) time of 9.3 hours (14.1) from symptom onset. Treatment groups were balanced with respect to baseline SBP and hematoma volume. Perihematoma PS (5.1±2.4 mL/100 mL per minute) was higher than PS in contralateral regions (3.6±1.7 mL/100 mL per minute; P<0.001). Relative edema growth (0-24 hours) was not predicted by perihematoma PS (β=-0.192 [-0.06 to 0.01]) or SBP change (β=-0.092 [-0.002 to 0.001]). SBP was lower in the <150 target group (139.2±22.1 mm Hg) than in the <180 group (159.7±12.3 mm Hg; P<0.0001). Perihematoma PS was not different between groups (4.9±2.4 mL/100 mL per minute for the <150 group, 5.3±2.4 mL/100 mL per minute for the <180 group; P=0.51). CONCLUSIONS BBB permeability is focally increased in the hematoma and perihematoma regions of acute intracerebral hemorrhage patients. BBB compromise does not predict acute perihematoma edema volume or edema growth. SBP reduction does not affect BBB permeability. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00963976.
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Affiliation(s)
- Rebecca McCourt
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.)
| | - Bronwen Gould
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.)
| | - Mahesh Kate
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.)
| | - Negar Asdaghi
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.)
| | - Jayme C Kosior
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.)
| | - Shelagh Coutts
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.)
| | - Michael D Hill
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.)
| | - Andrew Demchuk
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.)
| | - Thomas Jeerakathil
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.)
| | - Derek Emery
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.)
| | - Kenneth S Butcher
- From the Department of Medicine, Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., K.S.B.) and Department of Radiology and Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.C., M.D.H., A.D.).
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Gould B, McCourt R, Gioia LC, Kate M, Hill MD, Asdaghi N, Dowlatshahi D, Jeerakathil T, Coutts SB, Demchuk AM, Emery D, Shuaib A, Butcher K. Acute blood pressure reduction in patients with intracerebral hemorrhage does not result in borderzone region hypoperfusion. Stroke 2014; 45:2894-9. [PMID: 25147326 DOI: 10.1161/strokeaha.114.005614] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial (ICH ADAPT) demonstrated blood pressure (BP) reduction does not affect mean perihematoma or hemispheric cerebral blood flow. Nonetheless, portions of the perihematoma and borderzones may reach ischemic thresholds after BP reduction. We tested the hypothesis that BP reduction after intracerebral hemorrhage results in increased critically hypoperfused tissue volumes. METHODS Patients with Intracerebral hemorrhage were randomized to a target systolic BP (SBP) of <150 or <180 mm Hg and imaged with computed tomographic perfusion 2 hours later. The volumes of tissue below cerebral blood flow thresholds for ischemia (<18 mL/100 g/min) and infarction (<12 mL/100 g/min) were calculated as a percentage of the total volume within the internal and external borderzones and the perihematoma region. RESULTS Seventy-five patients with intracerebral hemorrhage were randomized a median (interquartile range) of 7.8 (13.3) hours from onset. Acute hematoma volume was 17.8 (27.1) mL and mean SBP was 183±22 mm Hg. At the time of computed tomographic perfusion (2.3 [1.0] hours after randomization), SBP was lower in the <150 mm Hg (n=37; 140±18 mm Hg) than in the <180 mm Hg group (n=36; 162±12 mm Hg; P<0.001). BP treatment did not affect the percentage of total borderzone tissue with cerebral blood flow<18 (14.7±13.6 versus 15.6±13.7%; P=0.78) or <12 mL/100 g/min (5.1±5.1 versus 5.8±6.8%; P=0.62). Similar results were found in the perihematoma region. Low SBP load (fraction of time with SBP<150 mmHg) did not predict borderzone tissue volume with cerebral blood flow<18 mL/100 g/min (β=0.023 [-0.073, 0.119]). CONCLUSIONS BP reduction does not increase the volume of critically hypoperfused borderzone or perihematoma tissue. These data support the safety of early BP reduction in intracerebral hemorrhage. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00963976.
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Affiliation(s)
- Bronwen Gould
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Rebecca McCourt
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Laura C Gioia
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Mahesh Kate
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Michael D Hill
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Negar Asdaghi
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Dariush Dowlatshahi
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Thomas Jeerakathil
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Shelagh B Coutts
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Andrew M Demchuk
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Derek Emery
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Ashfaq Shuaib
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.)
| | - Ken Butcher
- From the Division of Neurology (B.G., R.M., L.C.G., M.K., T.J., A.S., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.D.H., S.B.C., A.M.D.); Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (N.A.); and Division of Neurology, University of British Columbia, Ottawa, Ontario, Canada (D.D.).
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McCourt R, Gould B, Gioia L, Kate M, Coutts SB, Dowlatshahi D, Asdaghi N, Jeerakathil T, Hill MD, Demchuk AM, Buck B, Emery D, Butcher K. Cerebral Perfusion and Blood Pressure Do Not Affect Perihematoma Edema Growth in Acute Intracerebral Hemorrhage. Stroke 2014; 45:1292-8. [DOI: 10.1161/strokeaha.113.003194] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rebecca McCourt
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Bronwen Gould
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Laura Gioia
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Mahesh Kate
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Shelagh B. Coutts
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Dariush Dowlatshahi
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Negar Asdaghi
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Thomas Jeerakathil
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Michael D. Hill
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Andrew M. Demchuk
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Brian Buck
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Derek Emery
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Kenneth Butcher
- From the Division of Neurology (R.M., B.G., L.G., M.K., T.J., B.B., K.B.) and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
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Yaghi S, Dibu J, Achi E, Patel A, Samant R, Hinduja A. Hematoma expansion in spontaneous intracerebral hemorrhage: predictors and outcome. Int J Neurosci 2014; 124:890-3. [DOI: 10.3109/00207454.2014.887716] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Kate MP, Hansen MB, Mouridsen K, Østergaard L, Choi V, Gould BE, McCourt R, Hill MD, Demchuk AM, Coutts SB, Dowlatshahi D, Emery DJ, Buck BH, Butcher KS. Blood pressure reduction does not reduce perihematoma oxygenation: a CT perfusion study. J Cereb Blood Flow Metab 2014; 34:81-6. [PMID: 24045403 PMCID: PMC3887345 DOI: 10.1038/jcbfm.2013.164] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 08/01/2013] [Accepted: 08/22/2013] [Indexed: 11/09/2022]
Abstract
Blood pressure (BP) reduction after intracerebral hemorrhage (ICH) is controversial, because of concerns that this may cause critical reductions in perihematoma perfusion and thereby precipitate tissue damage. We tested the hypothesis that BP reduction reduces perihematoma tissue oxygenation.Acute ICH patients were randomized to a systolic BP target of <150 or <180 mm Hg. Patients underwent CT perfusion (CTP) imaging 2 hours after randomization. Maps of cerebral blood flow (CBF), maximum oxygen extraction fraction (OEF(max)), and the resulting maximum cerebral metabolic rate of oxygen (CMRO2(max)) permitted by local hemodynamics, were calculated from raw CTP data.Sixty-five patients (median (interquartile range) age 70 (20)) were imaged at a median (interquartile range) time from onset to CTP of 9.8 (13.6) hours. Mean OEF(max) was elevated in the perihematoma region (0.44±0.12) relative to contralateral tissue (0.36±0.11; P<0.001). Perihematoma CMRO2(max) (3.40±1.67 mL/100 g per minute) was slightly lower relative to contralateral tissue (3.63±1.66 mL/100 g per minute; P=0.025). Despite a significant difference in systolic BP between the aggressive (140.5±18.7 mm Hg) and conservative (163.0±10.6 mm Hg; P<0.001) treatment groups, perihematoma CBF was unaffected (37.2±11.9 versus 35.8±9.6 mL/100 g per minute; P=0.307). Similarly, aggressive BP treatment did not affect perihematoma OEF(max) (0.43±0.12 versus 0.45±0.11; P=0.232) or CMRO2(max) (3.16±1.66 versus 3.68±1.85 mL/100 g per minute; P=0.857). Blood pressure reduction does not affect perihematoma oxygen delivery. These data support the safety of early aggressive BP treatment in ICH.
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Affiliation(s)
- Mahesh P Kate
- Division of Neurology, Department of Medicine, WMC Health Sciences Centre, Edmonton, Alberta, Canada
| | - Mikkel B Hansen
- Center of Functionally Integrative Neuroscience and MINDLab, Aarhus University, Aarhus, Denmark
| | - Kim Mouridsen
- Center of Functionally Integrative Neuroscience and MINDLab, Aarhus University, Aarhus, Denmark
| | - Leif Østergaard
- Center of Functionally Integrative Neuroscience and MINDLab, Aarhus University, Aarhus, Denmark
| | - Victor Choi
- Division of Neurology, Department of Medicine, WMC Health Sciences Centre, Edmonton, Alberta, Canada
| | - Bronwen E Gould
- Division of Neurology, Department of Medicine, WMC Health Sciences Centre, Edmonton, Alberta, Canada
| | - Rebecca McCourt
- Division of Neurology, Department of Medicine, WMC Health Sciences Centre, Edmonton, Alberta, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences University of Calgary, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences University of Calgary, Calgary, Alberta, Canada
| | - Shelagh B Coutts
- Department of Clinical Neurosciences University of Calgary, Calgary, Alberta, Canada
| | | | - Derek J Emery
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Buck
- Division of Neurology, Department of Medicine, WMC Health Sciences Centre, Edmonton, Alberta, Canada
| | - Kenneth S Butcher
- Division of Neurology, Department of Medicine, WMC Health Sciences Centre, Edmonton, Alberta, Canada
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Sonni S, Lioutas VA, Selim MH. New avenues for treatment of intracranial hemorrhage. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 16:277. [PMID: 24366522 DOI: 10.1007/s11936-013-0277-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OPINION STATEMENT The mortality and morbidity from intracerebral hemorrhage (ICH) remain high despite advances in medical, neurologic, and surgical care during the past decade. The lessons learned from previous therapeutic trials in ICH, improved understanding of the pathophysiology of neuronal injury after ICH, and advances in imaging and pre-hospital assessment technologies provide optimism that more effective therapies for ICH are likely to emerge in the coming years. The potential new avenues for the treatment of ICH include a combination of increased utilization of minimally invasive surgical techniques with or without thrombolytic usage to evacuate or reduce the size of the hematoma; utilization of advanced imaging to improve selection of patients who are likely to benefit from reversal of coagulopathy or hemostatic therapy; ultra-early diagnosis and initiation of therapy in the ambulance; and the use of novel drugs to target the secondary injury mechanisms, including the inflammatory cascade, perihematomal edema reduction, and hemoglobin degradation products-mediated toxicity.
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Affiliation(s)
- Shruti Sonni
- Department of Neurology, Cambridge Hospital, 1493 Cambridge Street, Cambridge, MA, 02139, USA,
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Gaberel T, Gakuba C, Hebert M, Montagne A, Agin V, Rubio M, Emery E, Vivien D, Gauberti M. Intracerebral hematomas disappear on T2*-weighted images during normobaric oxygen therapy. Stroke 2013; 44:3482-9. [PMID: 24105700 DOI: 10.1161/strokeaha.113.002045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The aim of the present study was to investigate the effects of normobaric oxygen (NBO) therapy on T2*-weighted images of intracranial hemorrhages (ICHs). METHODS Two common models of ICH were performed in mice, and longitudinal T2*-weighted images of the hematomas were acquired under normoxia or NBO. The effects of NBO were also investigated on perfusion-weighted imaging, susceptibility-weighted imaging, and molecular imaging of vascular cell adhesion molecule-1 after ICH. Last, we performed neurological testing, including neuroscore, actimetry, and gait analysis (Catwalk), to study the influence of NBO on neurological outcome of mice presenting ICH. RESULTS Our results demonstrated that NBO, even during a short period of time, dramatically reduces the sensitivity of T2*-weighted imaging to detect ICH. Moreover, we provide evidence that the disappearance of ICH on T2*-weighted imaging could be used to improve accuracy of perfusion-weighted imaging and to allow molecular imaging after ICH. Importantly, a 30-minute NBO preparation 24 hours after ICH onset does not influence neurological outcome. CONCLUSIONS We provide an experimental demonstration that NBO significantly affects T2*-weighted imaging in ICH. Although this phenomenon could lead to inaccurate assessment of ICH volume, it could also be safely used to allow perfusion-weighted imaging and molecular imaging.
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Affiliation(s)
- Thomas Gaberel
- From the Inserm, UMR-S U919, Serine Proteases and Pathophysiology of the Neurovascular Unit, GIP Cyceron, University Caen Lower-Normandy, Caen, France (T.G., C.G., A.M., V.A., M.R., E.E., D.V., M.G.); and Department of Neurosurgery (T.G., E.E.), Department of Anesthesiology and Critical Care Medicine (M.H.), and Biostatistics and Clinical Research Unit (M.R.), Caen University Hospital, Caen, France
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Dun Z, Zhu S, Jiang H. Benefits of a frame-based stereotactic surgical planning system for the treatment of spontaneous intracerebral haematomas. J Int Med Res 2013; 41:1550-9. [PMID: 24026775 DOI: 10.1177/0300060513498022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Frame-based stereotactic surgical planning systems (SSPSs) have been used for deep brain stimulation and radioneurosurgery. Here, we evaluated the feasibility, safety and efficacy of using a SSPS to aid spontaneous intracerebral haematoma (ICH) treatment. METHODS Patients with moderate spontaneous putamen haematomas were randomized into two groups: treatment (group A) and control (group B). In group B, the catheter for evacuating haematomas was inserted into a target point, located at the centre of the haematoma, using conventional frame-based stereotactics; urokinase thrombolysis was subsequently delivered through the catheter. In group A, this procedure was assisted by a SSPS, which designed both the target point and trajectory in the haematoma through virtual reality. Duration of evacuating haematomas and number of urokinase injections was compared between groups. RESULTS In total, 65 patients were recruited: in group A (n = 30), the duration of evacuating haematomas (35.27 ± 9.17 h) was shorter than in group B (n = 35; 67.77 ± 13.82 h). There were fewer urokinase injections in group A (3.63 ± 1.16) than in group B (6.40 ± 1.29). CONCLUSIONS The feasibility, efficacy and safety of spontaneous ICH treatment were optimized by the use of a frame-based SSPS.
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Affiliation(s)
- Zhiping Dun
- Department of Neurosurgery, The Second Hospital, Shandong University, Jinan, Shandong Province, China
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Rincon F, Lyden P, Mayer SA. Relationship between temperature, hematoma growth, and functional outcome after intracerebral hemorrhage. Neurocrit Care 2013; 18:45-53. [PMID: 23001769 DOI: 10.1007/s12028-012-9779-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fever and hematoma growth are known to be independent predictors of poor outcome after intracerebral hemorrhage (ICH). We sought to assess the distribution of temperature at different stages in relation to hematoma growth and functional outcome at 90 days in a cohort of ICH patients. METHODS Data of patients registered in the Virtual International Stroke Trials Archive--ICH were analyzed. Temperatures at baseline, 24, 48, 72, and 168 h were assessed in relation to the hematoma growth and functional outcome at 90 days. We calculated the daily linear variation of each subject's temperature by subtracting 37 °C from the maximal daily recorded temperature (delta-temperature). We used logistic regression and mixed-effects models to identify factors associated with hematoma growth, poor outcome, and temperature elevation after ICH. RESULTS 303 patients were included in the analysis. The average age was 66 ± 12 years, 200 (66 %) were males, median admission NIHSS was 13 [Interquartile range (IQR), 9-18), median GCS was 15 (IQR, 14-15). Hematoma growth occurred in 22 % and poor functional outcome at 90-days occurred in 41 % of the patients. Cumulative delta-temperature at 72 h was associated with hematoma growth; age, ICH score, hematoma growth, and cumulative delta-temperature at 168 h were associated with poor outcome at 90 days. Factors associated with fever in mixed-models were day after onset of ICH, hypertension, base hematoma volume, intraventricular-hemorrhage, pneumonia, and hematoma growth. CONCLUSIONS There is a temporal and independent association between fever and hematoma growth. Fever after ICH is associated with poor outcome at 90 days. Future research is needed to study the mechanisms of this phenomenon and if early protocols of temperature modulation would be associated with improved outcomes after ICH.
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Affiliation(s)
- Fred Rincon
- Departments of Neurology and Neurosurgery, Division of Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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El Ahmadieh TY, El Tecle NE, Lall RR, Park AE, Bendok BR. Blood Pressure Control for Spontaneous Intracerebral Hemorrhage. Neurosurgery 2013; 72:N14-6. [DOI: 10.1227/01.neu.0000430734.71114.bc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Gould B, McCourt R, Asdaghi N, Dowlatshahi D, Jeerakathil T, Kate M, Coutts SB, Hill MD, Demchuk AM, Shuaib A, Emery D, Butcher K. Autoregulation of Cerebral Blood Flow is Preserved in Primary Intracerebral Hemorrhage. Stroke 2013; 44:1726-8. [DOI: 10.1161/strokeaha.113.001306] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background and Purpose—
Treatment of acute hypertension after intracerebral hemorrhage (ICH) is controversial. In the context of disrupted cerebral autoregulation, blood pressure (BP) reduction may cause decreased cerebral blood flow (CBF). We used serial computed tomography perfusion to test the hypothesis that CBF remains stable after BP reduction.
Methods—
Patients recruited within 72 hours of ICH were imaged with computed tomography perfusion before and after BP treatment. Change in perihematoma relative (r) CBF after BP treatment was the primary end point.
Results—
Twenty patients were imaged with computed tomography perfusion at a median (interquartile range) time from onset of 20.2 (25.7) hours and reimaged 2.1 (0.5) hours later, after BP reduction. Mean systolic BP in treated patients (n=16; 4 untreated as BP<target at baseline) decreased significantly between the first (168±21 mm Hg) and second (141±19 mm Hg;
P
<0.0001) computed tomography perfusion scans. The primary end point of rCBF was not affected by BP reduction (pretreatment=0.89±0.11; post-treatment=0.87±0.11 mL/100 g per minute;
P
=0.37). Linear regression showed no relationship between changes in systolic BP and perihematoma rCBF (β=0.001 [−0.002 to 0.003];
P
=0.63).
Conclusions—
CBF remained stable after acute BP reduction, suggesting some preservation of cerebral autoregulation.
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Affiliation(s)
- Bronwen Gould
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Rebecca McCourt
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Negar Asdaghi
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Dariush Dowlatshahi
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Thomas Jeerakathil
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Mahesh Kate
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Shelagh B. Coutts
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Michael D. Hill
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Andrew M. Demchuk
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Ashfaq Shuaib
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Derek Emery
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
| | - Kenneth Butcher
- From the Division of Neurology (B.G., R.M., T.J., M.K., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Edmonton, Canada; Division of Neurology, University of British Columbia, Vancouver, Canada (N.A.); Division of Neurology, University of Ottawa, Ottawa, Canada (D.D.); and Department of Clinical Neurosciences, University of Calgary, Calgary, Canada (S.B.C., M.D.H., A.M.D.)
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Chiu CD, Chen CCV, Shen CC, Chin LT, Ma HI, Chuang HY, Cho DY, Chu CH, Chang C. Hyperglycemia exacerbates intracerebral hemorrhage via the downregulation of aquaporin-4: temporal assessment with magnetic resonance imaging. Stroke 2013; 44:1682-9. [PMID: 23592763 DOI: 10.1161/strokeaha.113.675983] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) is associated with high mortality and neurological deficits, and concurrent hyperglycemia usually worsens clinical outcomes. Aquaporin-4 (AQP-4) is important in cerebral water movement. Our aim was to investigate the role of AQP-4 in hyperglycemic ICH. METHODS Hyperglycemia was induced by intraperitoneal injection of streptozotocin (STZ; 60 mg/kg) in adult Sprague-Dawley male rats. ICH was induced by stereotaxic infusion of collagenase/heparin into the right striatum. One set of rats was repeatedly monitored by MRI at 1, 4, and 7 days after ICH induction so as to acquire information on the formation of hematoma and edema. Another set of rats was killed and brains were examined for differences in the degree of hemorrhage and edema, water content, blood-brain barrier destruction, and AQP-4 expression. RESULTS Hyperglycemia ICH rats exhibited increased brain water content, more severe blood-brain barrier destruction, and greater vasogenic edema as seen on diffusion-weighted MRI. Significant downregulation of AQP-4 was observed in STZ-treated rats after ICH as compared with non-STZ-treated rats. Apoptosis was greater on day 1 after ICH in STZ-treated rats. CONCLUSIONS The expression of AQP-4 in the brain is downregulated in hyperglycemic rats as compared with normoglycemic rats after ICH. This change is accompanied by increased vasogenic brain edema and more severe blood-brain barrier destruction.
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Affiliation(s)
- Cheng-Di Chiu
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
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Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, Bistran-Hall AJ, Ullman NL, Vespa P, Martin NA, Awad I, Zuccarello M, Hanley DF. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 2013; 44:627-34. [PMID: 23391763 PMCID: PMC4124642 DOI: 10.1161/strokeaha.111.000411] [Citation(s) in RCA: 233] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Perihematomal edema (PHE) can worsen outcomes after intracerebral hemorrhage (ICH). Reports suggest that blood degradation products lead to PHE. We hypothesized that hematoma evacuation will reduce PHE volume and that treatment with recombinant tissue-type plasminogen activator (rt-PA) will not exacerbate it. METHODS Minimally invasive surgery and rt-PA in ICH evacuation (MISTIE) phase II tested safety and efficacy of hematoma evacuation after ICH. We conducted a semiautomated, computerized volumetric analysis on computed tomography to assess impact of hematoma removal on PHE and effects of rt-PA on PHE. Volumetric analyses were performed on baseline stability and end of treatment scans. RESULTS Seventy-nine surgical and 39 medical patients from minimally invasive surgery and rt-PA in ICH evacuation phase II (MISTIE II) were analyzed. Mean hematoma volume at end of treatment was 19.6±14.5 cm(3) for the surgical cohort and 40.7±13.9 cm(3) for the medical cohort (P<0.001). Edema volume at end of treatment was lower for the surgical cohort: 27.7±13.3 cm(3) than medical cohort: 41.7±14.6 cm(3) (P<0.001). Graded effect of clot removal on PHE was observed when patients with >65%, 20% to 65%, and <20% ICH removed were analyzed (P<0.001). Positive correlation between PHE reduction and percent of ICH removed was identified (ρ=0.658; P<0.001). In the surgical cohort, 69 patients underwent surgical aspiration and rt-PA, whereas 10 underwent surgical aspiration only. Both cohorts achieved similar clot reduction: surgical aspiration and rt-PA, 18.9±14.5 cm(3); and surgical aspiration only, 24.5±14.0 cm(3) (P=0.26). Edema at end of treatment in surgical aspiration and rt-PA was 28.1±13.8 cm(3) and 24.4±8.6 cm(3) in surgical aspiration only (P=0.41). CONCLUSIONS Hematoma evacuation is associated with significant reduction in PHE. Furthermore, PHE does not seem to be exacerbated by rt-PA, making such neurotoxic effects unlikely when the drug is delivered to intracranial clot.
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Affiliation(s)
- W. Andrew Mould
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - J. Ricardo Carhuapoma
- Departments of Neurology, Neurosurgery and Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - John Muschelli
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Karen Lane
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Timothy C Morgan
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Nichol A McBee
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Amanda J Bistran-Hall
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Natalie L Ullman
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Paul Vespa
- Departments of Neurology and Neurosurgery, UCLA School of Medicine, Los Angeles, CA
| | - Neil A Martin
- Departments of Neurology and Neurosurgery, UCLA School of Medicine, Los Angeles, CA
| | - Issam Awad
- Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH
| | - Daniel F. Hanley
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
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Li N, Liu YF, Ma L, Worthmann H, Wang YL, Wang YJ, Gao YP, Raab P, Dengler R, Weissenborn K, Zhao XQ. Association of Molecular Markers With Perihematomal Edema and Clinical Outcome in Intracerebral Hemorrhage. Stroke 2013; 44:658-63. [DOI: 10.1161/strokeaha.112.673590] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Na Li
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
| | - Yan Fang Liu
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
| | - Li Ma
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
| | - Hans Worthmann
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
| | - Yi Long Wang
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
| | - Yong Jun Wang
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
| | - Yi Pei Gao
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
| | - Peter Raab
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
| | - Reinhard Dengler
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
| | - Karin Weissenborn
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
| | - Xing Quan Zhao
- From the Departments of Neurology (N.L., Y.F.L., Y.L.W., Y.J.W., X.Q.Z.) and Neuroradiology (L.M., Y.P.G.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology (N.L., H.W., R.D., K.W.) and Interventional and Diagnostic Neuroradiology (P.R.), Hannover Medical School, Hannover, Germany; and the Center for Systems Neuroscience (ZSN), Hannover, Germany (N.L., R.D., K.W.)
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Li N, Worthmann H, Heeren M, Schuppner R, Deb M, Tryc AB, Bueltmann E, Lanfermann H, Donnerstag F, Weissenborn K, Raab P. Temporal pattern of cytotoxic edema in the perihematomal region after intracerebral hemorrhage: a serial magnetic resonance imaging study. Stroke 2013; 44:1144-6. [PMID: 23391767 DOI: 10.1161/strokeaha.111.000056] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Knowledge about cytotoxic edema (CE) in intracerebral hemorrhage is still limited. We aimed to analyze its presence, temporal pattern, and prognostic meaning. METHODS Twenty-one patients with primary intracerebral hemorrhage underwent magnetic resonance imaging at days 1, 3, and 7 after symptom onset. CE was identified using diffusion-weighted imaging. Hematoma and perihematomal edema volumes were measured on fluid-attenuated inversion recovery images. National Institutes of Health Stroke Scale score was assessed at admission and with each magnetic resonance imaging. Clinical outcome was assessed by modified Rankin scale at 90 days. RESULTS CE appeared in half of the patients within the first 24 hours. The apparent diffusion coefficient values decreased until day 3 and were significantly reversed from days 3 through 7 (P<0.01). Patients with CE showed significantly faster perihematomal edema growth from day 0 to 1 (P=0.036) than those without. Larger 3-day perihematomal edema volume (P=0.02) and presence of CE on day 3 (P=0.07) were associated with poor clinical outcome. CONCLUSIONS CE is associated with stroke severity, perihematomal edema volume, and poor outcome. It is considered to indicate ongoing neuronal injury and, thus, might emerge as new treatment target.
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Affiliation(s)
- Na Li
- Department of Neurology, Hannover Medical School, Hannover, Germany.
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Butcher KS, Jeerakathil T, Hill M, Demchuk AM, Dowlatshahi D, Coutts SB, Gould B, McCourt R, Asdaghi N, Findlay JM, Emery D, Shuaib A. The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial. Stroke 2013; 44:620-6. [PMID: 23391776 DOI: 10.1161/strokeaha.111.000188] [Citation(s) in RCA: 170] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND PURPOSE Acute blood pressure (BP) reduction aimed at attenuation of intracerebral hemorrhage (ICH) expansion might also compromise cerebral blood flow (CBF). We tested the hypothesis that CBF in acute ICH patients is unaffected by BP reduction. METHODS Patients with spontaneous ICH <24 hours after onset and systolic BP > 150 mm Hg were randomly assigned to an intravenous antihypertensive treatment protocol targeting a systolic BP of <150 mm Hg (n=39) or <180 mm Hg (n=36). Patients underwent computed tomography perfusion imaging 2 hours postrandomization. The primary end point was perihematoma relative (relative CBF). RESULTS Treatment groups were balanced with respect to baseline systolic BP: 182±20 mm Hg (<150 mm Hg target group) versus 184±25 mm Hg (<180 mm Hg target group; P=0.60), and for hematoma volume: 25.6±30.8 versus 26.9±25.2 mL (P=0.66). Mean systolic BP 2 hours after randomization was significantly lower in the <150 mm Hg target group (140±19 vs 162±12 mm Hg; P<0.001). Perihematoma CBF (38.7±11.9 mL/100 g per minute) was lower than in contralateral homologous regions (44.1±11.1 mL/100 g per minute; P<0.001) in all patients. The primary end point of perihematoma relative CBF in the <150 mm Hg target group (0.86±0.12) was not significantly lower than that in the <180 mm Hg group (0.89±0.09; P=0.19; absolute difference, 0.03; 95% confidence interval -0.018 to 0.078). There was no relationship between the magnitude of BP change and perihematoma relative CBF in the <150 mm Hg (R=0.00005; 95% confidence interval, -0.001 to 0.001) or <180 mm Hg target groups (R=0.000; 95% confidence interval, -0.001 to 0.001). CONCLUSIONS Rapid BP lowering after a moderate volume of ICH does not reduce perihematoma CBF. These physiological data indicate that acute BP reduction does not precipitate cerebral ischemia in ICH patients. Clinical Trial Registration Information- URL:http://clinicaltrials.gov. Unique Identifier: NCT00963976.
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Tsai YH, Hsu LM, Weng HH, Lee MH, Yang JT, Lin CP. Functional diffusion map as an imaging predictor of functional outcome in patients with primary intracerebral haemorrhage. Br J Radiol 2013; 86:20110644. [PMID: 23255534 DOI: 10.1259/bjr.20110644] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Predicting outcome in patients with primary intracerebral haemorrhage (ICH) in the acute stage can provide information to determine the best therapeutic and rehabilitation strategies. We prospectively investigated the predictive value of the functional diffusion map (fDM) in the acute stage of ICH. METHODS 47 patients with ICH were enrolled for clinical evaluation and MRI within 24 h of symptom onset and 5 days after ICH. Functional diffusion mapping prospectively monitored the apparent diffusion coefficient (ADC) maps of perihaematomal oedema. Consequently, the change in perihaematomal oedema was classified into three categories: increased, decreased, or no significant change. Clinical outcomes were evaluated 6 months after ICH according to the modified Rankin Scale. Correlation between clinical outcome and the fDMs was performed. RESULTS Among the clinical variables, thalamic haematoma, serum glucose level and National Institutes of Health Stroke Scale scores were significantly different between the good- and poor-outcome groups. The percentage of oedematous tissue undergoing significant change between baseline and Day 5 was also significantly different between the groups. CONCLUSION fDMs allow for spatial voxel-by-voxel tracking of changes in ADC values. It may be feasible to use fDMs to predict the functional outcome of patients with ICH during the acute stage. Advances in knowledge The use of fDMs for stroke study is demonstrated. fDMs may be more suitable to reflect the pathophysiological heterogeneity within oedemas and may facilitate another thinking process for imaging study of stroke and other neurological diseases.
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Affiliation(s)
- Y-H Tsai
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
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Kiphuth IC, Huttner HB, Breuer L, Schwab S, Köhrmann M. Sonographic monitoring of midline shift predicts outcome after intracerebral hemorrhage. Cerebrovasc Dis 2012; 34:297-304. [PMID: 23146822 DOI: 10.1159/000343224] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 09/04/2012] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) and the evolution of subsequent perihemorrhagic edema lead to midline shift (MLS), which can be assessed by transcranial duplex sonography (TDS). In this observational study, we monitored MLS with TDS in patients with supratentorial ICH up to day 14 after the ictus, and then correlated MLS with the outcome 6 months after hospital discharge. METHODS Sixty-eight patients with spontaneous ICH (volume >20 cm(3)) were admitted during a 1-year period between April 2009 and April 2010. Sixty-one patients fulfilled the inclusion criteria and were eligible for analysis. TDS to measure MLS was performed upon admission and then subsequently, using serial examinations in 24-hour intervals up to day 14. Statistical tests were used to determine cut-off values for functional outcome and mortality after 6 months. RESULTS The median National Institutes of Health Stroke Scale (NIHSS) score upon admission was 21 and the mean hematoma volume was 52 cm(3). NIHSS score, functional outcome, hematoma volume and MLS were correlated in the examined patient cohort. ICH score upon admission, hematoma volume and the extent of MLS on days 1-14 were predictive of functional outcome and death. Values of MLS showed two peaks, the first between day 2 and day 5 and the second between day 12 and day 14, indicating that edema progresses not only during the acute but also during the subacute phase. Depending on the time point, an MLS of 4.5-7.5 mm or greater indicated an impending failure of conservative therapy. An MLS of 12 mm or greater at any time indicated mortality with a sensitivity of 69%, a specificity of 100% and positive and negative predictive values of 100 and 74%, respectively. CONCLUSIONS MLS seems to be a crucial factor for outcome after ICH. Apart from the hematoma volume itself, edema adds to the intracranial pressure. To monitor MLS in early patient management after ICH, TDS is a useful noninvasive bedside alternative, avoiding increased radiation exposure and repeated transportation of critically ill patients. Cut-off values may help to reliably predict functional outcome and treatment failure in patients undergoing maximal neurointensive therapy.
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Affiliation(s)
- Ines C Kiphuth
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany. ines-christine.kiphuth@uk-erlangen
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Temporal changes in perihematomal apparent diffusion coefficient values during the transition from acute to subacute phases in patients with spontaneous intracerebral hemorrhage. Neuroradiology 2012; 55:145-56. [PMID: 22987060 DOI: 10.1007/s00234-012-1093-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 09/07/2012] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Diffusion-weighted imaging (DWI) studies focusing on apparent diffusion coefficient (ADC) abnormalities have provided conflicting results about the nature and fate of perihematomal edema. METHODS We investigated 35 patients with supratentorial spontaneous intracerebral hemorrhage (SICH) by using DWI scanning obtained at 48 h and 7 days after symptom onset. Regional ADC (rADC) values were measured in three manually outlined regions of interest: (1) the perihematomal hyperintense area, (2) 1 cm of normal appearing brain tissue surrounding the perilesional hyperintense rim, and (3) a mirror area, including the clot and the perihematomal region, located in the contralateral hemisphere. RESULTS rADC mean levels were lower at 7 days than at 48 h in each ROI (p < 0.00001), showing a progressive normalization of initial vasogenic values. Perihematomal vasogenic rADC values were more frequent (p < 0.00001) at 48 h than at 7 days, whereas perihematomal cytotoxic and normal rADC levels were more represented (p < 0.02 and p < 0.001, respectively) at 7 days than at 48 h. A neurological worsening was more frequent (p < 0.02) in patients with than in those without perihematomal cytotoxic rADC values at 7 days. CONCLUSION Our findings suggest that the transition from acute to subacute phases after SICH is characterized by a progressive resolution of perihematomal vasogenic edema associated with an increase in cytotoxic ADC values. In the subset of patients with perihematomal cytotoxic rADC levels in subacute stage after bleeding, irreversible damage development seems to be related to poor clinical outcome.
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Moussouttas M. Challenges and controversies in the medical management of primary and antithrombotic-related intracerebral hemorrhage. Ther Adv Neurol Disord 2012; 5:43-56. [PMID: 22276075 DOI: 10.1177/1756285611422267] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Intracerebral hemorrhage (ICH) represents 10-15% of all cerebrovascular events, and is associated with substantial morbidity and mortality. In contrast to ischemic cerebrovascular disease in which acute therapies have proven beneficial, ICH remains a more elusive condition to treat, and no surgical procedure has proven to be beneficial. Aspects pertinent to medical ICH management include cessation or minimization of hematoma enlargement, prevention of intraventricular extension, and treatment of edema and mass effect. Therapies focusing on these aspects include prothrombotic (hemostatic) agents, antihypertensive strategies, and antiedema therapies. Therapies directed towards the reversal of antithrombosis caused by antiplatelet and anticoagulant agents are frequently based on limited data, allowing for diverse opinions and practice styles. Several newer anticoagulants that act by direct thrombin or factor Xa inhibition have no natural antidote, and are being increasingly used for various prophylactic and therapeutic indications. As such, these new anticoagulants will inevitably pose major challenges in the treatment of patients with ICH. Ongoing issues in the management of patients with ICH include the need for effective treatments that not only limit hematoma expansion but also result in improved clinical outcomes, the identification of patients at greatest risk for continued hemorrhage who may most benefit from treatment, and the initiation of therapies during the hyperacute period of most active hemorrhage. Defining hematoma volume increases at various anatomical locations that translate into clinically meaningful outcomes will also aid in directing future trials for this disease. The focus of this review is to underline and discuss the various controversies and challenges involved in the medical management of patients with primary and antithrombotic-related ICH.
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Zazulia AR, Videen TO, Diringer MN, Powers WJ. Poor correlation between perihematomal MRI hyperintensity and brain swelling after intracerebral hemorrhage. Neurocrit Care 2012; 15:436-41. [PMID: 21725692 DOI: 10.1007/s12028-011-9578-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE The perihematomal hyperintensity (PHH) is commonly interpreted to represent cerebral edema following intracerebral hemorrhage (ICH), but the accuracy of this interpretation is unknown. We therefore investigated the relationship between the changes in PHH and the changes in hemispheric brain volume as a measure of edema during the first week after ICH. METHODS Fifteen individuals aged 66 ± 13 with baseline hematoma size of 13.1 ml (range 3-43) were prospectively studied with sequential MRI 1.0 ± 0.5, 2.6 ± 0.9, and 6.5 ± 1.0 days after spontaneous supratentorial ICH. Changes in hemispheric brain volume were assessed on MPRAGE using the Brain-Boundary Shift Integral (BBSI). Hematoma and PHH volumes were measured on T2-weighted images. RESULTS Brain volume increased a small but statistically significant amount (6.3 ± 8.0 ml, 0.6 ± 0.7%) between the first and second scans relative to 10 normal controls (-0.9 ± 4.1 ml, P = 0.02) and returned toward baseline at the third scan (1.5 ± 9.5 ml vs. controls 0.9 ± 4.0 ml, P = 0.85). There were no significant differences in the volume changes between the two hemispheres at scan 2 or scan 3. At both scan 2 (P = 0.04) and scan 3 (P = 0.004), the change in PHH was significantly greater than and poorly correlated with the change in ipsilateral hemispheric volume. There were no significant correlations between the change in NIH Stroke Scale (NIHSS) and the change in PHH, ipsilateral, or total brain volume at scan 2 or scan 3 (all P > 0.05). CONCLUSIONS In patients with small-to-moderate-sized hematomas, change in PHH was a poor measure of brain edema in the first week following ICH. A small degree of bihemispheric brain swelling occurred, but was of little clinical significance.
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Affiliation(s)
- Allyson R Zazulia
- Department of Neurology and Neurological Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8111, St. Louis, MO 63110, USA.
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Rincon F, Mayer SA. Intracerebral hemorrhage: clinical overview and pathophysiologic concepts. Transl Stroke Res 2012; 3:10-24. [PMID: 24323860 DOI: 10.1007/s12975-012-0175-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/09/2012] [Accepted: 04/11/2012] [Indexed: 10/28/2022]
Abstract
Intracerebral hemorrhage is by far the most destructive form of stroke. Apart from the management in a specialized stroke or neurological intensive care unit (NICU), no specific therapies have been shown to consistently improve outcomes after ICH. Current guidelines endorse early aggressive optimization of physiologic derangements with ventilatory support when indicated, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring for certain cases, osmotherapy, temperature modulation, seizure prophylaxis, treatment of hyerglycemia, and nutritional support in the stroke unit or NICU. Ventriculostomy is the cornerstone of therapy for control of intracranial pressure patients with intraventricular hemorrhage. Surgical hematoma evacuation does not improve outcome for more patients, but is a reasonable option for patients with early worsening due to mass effect due to large cerebellar or lobar hemorrhages. Promising experimental treatments currently include ultra-early hemostatic therapy, intraventricular clot lysis with thrombolytics, pioglitazone, temperature modulation, and deferoxamine to reduce iron-mediated perihematomal inflammation and tissue injury.
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Affiliation(s)
- Fred Rincon
- Department of Neurology and Neurosurgery, Division of Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PA, USA
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