Comparison of Spontaneous Intracerebral Hemorrhage Treatment in Germany Between 1999 and 2009

A Novel Stereotactic Aspiration Technique for Intracerebral Hemorrhage

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Alpha-asarone ameliorates neurological deterioration of intracerebral hemorrhagic rats by alleviating secondary brain injury via anti-excitotoxicity pathways

BACKGROUND

Secondary brain injury (SBI) has been confirmed as a leading cause for the poor prognosis of patients suffering from intracerebral hemorrhage (ICH). SBI co-exists in ischemia and hemorrhagic stroke. Neuro-excitotoxicity is considered the initiating factor of ICH-induced SBI. Our previous research has revealed alpha-asarone (ASA)'s efficacy against cerebral ischemia-reperfusion stroke by mitigating neuro-excitotoxicity. It is not yet known if ASA exhibit neuroprotection against ICH.

PURPOSE

This work aimed to investigate ASA's therapeutic effects and potential mechanisms of action against ICH in a classic rat model induced by collagenase Ⅶ injection.

METHODS

An in vivo ICH model of Sprague-Dawley rats was established by collagenase Ⅶ injection. We administrated different ASA doses (10, 20, or 40 mg/kg, i.p.) at 2 h post-ICH. Then, rats' short- and long-term neurobehavioral function, bodyweight change, and learning and memory ability were blindly evaluated. Histological, Nissl, and flow cytometry were applied to assess the neuronal damage post-ICH. The wet/dry method and Evans blue extravasation estimated brain edema and blood-brain barrier function. Pathway-related proteins were investigated by immunofluorescence staining, enzyme-linked immunosorbent assay, and Western-blot analysis.

RESULTS

The results demonstrated that ASA ameliorated neurological deterioration, bodyweight loss, and learning and memory ability of ICH rats. Histological, Nissl, and flow cytometry analyses showed that ASA reduced neuronal damage and apoptosis post-ICH. Besides, ASA probably mitigated brain edema and blood-brain barrier dysfunction via inhibiting astrocyte activation and consequent pro-inflammatory response. The mechanism investigation attributed ASA's efficacy to the following aspects: 1) promoting sodium ion excretion, thus blocking excitatory signal transduction along the axon; 2) preventing glutamate-involved pathways, i.e., decrease of N-methyl-d-aspartic acid receptor subunit 2B, increase of glutamate transporter-1, and alleviation of calcium-related cascades, mitochondrion-associated apoptosis, and neuronal autophagy; 3) enhancing the expression of GABA_ARs, thus abating neuronal excitotoxicity.

CONCLUSION

Our study first confirmed the effect of ASA on ameliorating the neurobehavioral deterioration of ICH rats, possibly via alleviation of glutamate-involved neuro-excitotoxicity, i.e., calcium cascades, mitochondrion-involved apoptosis, neuronal autophagy, and astrocyte-related inflammation. These findings not only provided a promising drug candidate for clinical treatment of ICH but also shed light on the future drug discovery against ICH.

Five psychological mechanisms that might bias learning from neurosurgical complications: case discussions and a narrative review

PURPOSE

The ability of neurosurgeons to analyze and reflect on their complications in a constructive way is important both for professional development and for patient safety. The purpose of the present paper is to highlight some psychological factors that might impair or bias the ability of the neurosurgeon to do this successfully.

METHODS

Five fictitious cases, loosely inspired by real events and situations, are used as a basis for a discussion of some of the most important potential sources of psychological bias in the context of understanding neurosurgical complications.

RESULTS

The issues of a) self-serving bias and the actor-observer effect; b) heuristics and biases in interpreting probabilistic events; c) emotional avoidance and denial; d) limitations of attention (dual systems theory) and e) errors of memory, are discussed.

CONCLUSION

There are a number of psychological factors, that are well known to science that may be ubiquitous sources of influence on the ability of neurosurgeons to grow by reflection on their own complications. Exactly how these factors can and should be efficiently adressed by the individual neurosurgeon and/or the organisation and team in which the neurosurgeon works may vary according to type of bias, context and circumstances. However, being aware of these issues and addressing them on an individual and organizational level remains important to the quality of our craft.

Comparison of epidemiological and clinical features between two chronological cohorts of patients with intracerebral hemorrhage

To investigate the differences in the epidemiological and clinical characteristics of patients with intracerebral hemorrhage (ICH) treated at our institution over the last few decades. Two chronological cohorts with ten-year-interval were established and epidemiological and clinical data were retrospectively collected from patients with ICH, and data were analyzed using SPSS 13.0. The time windows for the two cohorts were from January 1, 2010 to December 31, 2014 (2010-2014 cohort) and January 1, 2000 to December 31, 2004 (2000-2004 cohort). 1598 patients with ICH were enrolled: 360 patients in the 2000-2004 cohort and 1238 patients in the 2010-2014 cohort. ICH often occurred in patients aged from 45 to 75 years, without a sex bias, accounting for 69.6% of patients. Hypertension (60.7%) was still the main risk factors. Meanwhile, the risk factors of smoking (28.9%) and drinking (23.3%) were often present in male patients but not female patients (p ≤ 0.001). The incidence of pulmonary infection, the main complication during hospitalization, was 40.8% in the 2000-2004 cohort and 61.8% in the 2010-2014 cohort (p ≤ 0.001). Moreover, the incidence of gastrointestinal hemorrhage was 12.5% in the 2000-2004 cohort and 6.0% in the 2010-2014 cohort (p ≤ 0.001). The epidemiological and clinical features have changed over the past 10 years. The mortality was reduced but still high, as evidenced by the increased hospitalization rate of patients with ICH. Current preventions and therapeutic strategies for ICH are effective, but more strategies must be developed to improve the outcome of ICH and decrease the incidence of pulmonary infection.

Conservative versus operative treatment in supratentorial intracerebral hemorrhage - A survey among neurosurgeons and neurologists in Germany

OBJECTIVES

Decision making for surgical therapy in patients with intracerebral hemorrhage is still controversial among neurologists and neurosurgeons. Whereas neurologists may favor conservative treatments, surgeons may opt for operations. This might lead to different therapy decisions.

PATIENTS AND METHODS

Between 2017 and 2018, we conducted a survey among the neurological and neurosurgical societies in Germany. An online questionnaire consisting of 10 fictive patients with spontaneous supratentorial intracerebral hemorrhage (including CT scans and brief case descriptions) was administered to the members of the societies. The participants were asked to decide whether conservative or surgical treatment would be preferred. Furthermore, the results from the neurosurgeons were compared to the results of our previous surveys in 1999 and 2009.

RESULTS

A total of 157 answers were collected (response rate of 16.2%). Nineteen had to be excluded, leaving 138 for analysis (84 neurosurgeons and 54 neurologists). There were no significant differences in therapy decisions between neurologists and neurosurgeons in all ten cases. Comparing the answers from neurosurgeons with our previous results, there were no significant differences between the results from 1999, 2009 and 2017.

CONCLUSIONS

Against common prejudices, the process of decision making for or against surgery in patients with spontaneous intracerebral hemorrhage is comparable among conservative physicians (neurologists) and neurosurgeons in Germany. This might be the result of joint efforts in spontaneous intracerebral hemorrhage (ICH) therapy, such as joint guidelines or a society of neurointensive care medicine.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Stereotactic Administration of Edaravone Ameliorates Collagenase-Induced Intracerebral Hemorrhage in Rat

Background

Edaravone is widely used for treating ischemic stroke, but it is not still confirmed in intracerebral hemorrhage (ICH) as an ideal medication targeting the brain parenchyma. We aimed to investigate the neuroprotective effects of stereotactic administration of edaravone (SI) into the brain parenchyma.

Methods

Intracerebral hemorrhage rat models were established by infusion of collagenase into the caudate nucleus. Neural functional recovery was assessed using modified neurological severity scores (mNSS). A comparative study of therapeutic effects between SI and intraperitoneal injection of edaravone (IP) involved in cerebral edema, blood–brain barrier (BBB) permeability, hematoma absorption, inflammatory response and neuronal apoptosis.

Results

Compared with IP, the mNSS was significantly (P < 0.05) improved by SI; cerebral edema and BBB permeability were dramatically ameliorated (P < 0.05); IL‐4 and IL‐10 levels increased, but IL‐1β and TNF‐α levels significantly decreased; neuron apoptosis decreased markedly (P < 0.05); and caspase‐3 and Bax expression significantly dropped, but Bcl‐2 increased in SI group (P < 0.05).

Conclusion

SI markedly improved neurological deficits in ICH rat models via antiinflammatory and antiapoptosis mechanisms and promoted M2‐type microglia differentiation. SI was effective in rats with collagenase‐induced ICH.

Regulatory T cells inhibit microglia activation and protect against inflammatory injury in intracerebral hemorrhage

Numerous evidence demonstrate that microglia mediated inflammatory injury plays a critical role in intracerebral hemorrhage (ICH). Therefore, the way to inhibit the inflammatory response is greatly needed. Treg cells have been shown to play a critical role in immunologic self-tolerance as well as anti-tumor immune responses and transplantation. In the current study, we transfered Treg cells in the ICH model, and investigated the effect. The cytokines of microglia were measured by ELISA, JNK/ERK and NF-κB were measured by Western blot and EMSA (Electrophoretic Mobility Shift Assay), animal behavior was evaluated by animal behavioristics. We found that Treg cells could inhibit microglia mediated inflammatory response through NF-κB activation via the JNK/ERK pathway in vitro, and improve neurological function in vivo. Our findings suggest that Treg cells could suppress inflammatory injury and represent a novel cell-based therapeutical strategy in ICH.

Spontaneous intracerebral hemorrhage and the challenge of surgical decision making: a review

Decision making for patients with spontaneous intracerebral hemorrhage (ICH) poses several challenges. Outcomes in this patient population are generally poor, prognostication is often uncertain, and treatment strategies offer limited benefits. Studies demonstrate variability in the type and intensity of treatment offered, which is attributed to clinical uncertainty and habits of training. Research has focused on new techniques and more stringent evidence-based selection criteria to improve outcomes and produce consensus around treatment strategies for patients with ICH. Such focus, however, offers little description of how ICH treatment decisions are made and how such decisions reflect patient preferences regarding medical care. A growing body of literature suggests that the process of decision making in ICH is laden with bias, value assumptions, and subjective impressions. Factors such as geography, cognitive biases, patient perceptions, and physician characteristics can all shape decision making and the selection of treatment. Such factors often serve as a barrier to providing patient-centered medical care. In this article, the authors review how surgical decision making for patients with ICH is shaped by these decisional factors and suggest future research pathways to study decision making in ICH. Such research efforts are important for establishing quality guidelines and pay-for-performance measures that reflect the preferences of individual patients and the contextual nature of medical decision making.