Putaminal hemorrhage and outcome

Mechanism of cognitive impairment in chronic patients with putaminal hemorrhage: A diffusion tensor tractography

It is not clear whether the fornix and cingulum are involved in cognition after putaminal hemorrhage (PH). We investigated structural changes and differences of the neural tracts, and the relationship between the integrity of the neural tracts and cognition not only at the affected but also at the unaffected side.Sixteen patients with left chronic putaminal hemorrhage and 20 healthy volunteers were enrolled. Using diffusion tensor tractography (DTT), we compared fiber number (FN), fractional anisotropy (FA), and apparent diffusion coefficient (ADC) of the neural tracts between patient and control groups. The relationship between the neural tract parameters and neuropsychological results was also analyzed.The left fornix FN was significantly lower than the right fornix FN in the patient group. Except for the cingulum FA, the neural tracts parameters for both the affected and unaffected hemispheres differed significantly between the groups. The fornix FA and ADC at the affected side were significantly correlated with intelligence quotient (IQ), mini-mental status examination (MMSE), and short-term memory. Interestingly, the fornix ADC at the unaffected side was significantly correlated with MMSE. However, none of the cingulum parameters was correlated with neuropsychological results.The fornix integrity is critical for cognitive impairment after putaminal hemorrhage.

Clinico-radiological Characteristics of Spontaneous Basal Ganglia Hemorrhage, According to Regional Classification

OBJECTIVE

The clinico-radiologic features of the spontaneous basal ganglia hemorrhage (BGH) may often differ one from another, according to its regional location. Therefore, we attempted to classify the BGH into regional subgroups, and to extrapolate the distinct characteristics of each group of BGH.

MATERIALS AND METHODS

A total of 103 BGHs were analyzed by retrospective review of medical records. BGH was classified according to four subgroups; anterior BGH; posterior BGH; lateral BGH; massive BGH.

RESULTS

The most common BGH was the posterior BGH (56, 54.4%), followed by the lateral BGH (26, 25.2%), the massive BGH (12, 11.7%), and the anterior BGH (9, 8.7%). The shape of hemorrhage tended to be round in anterior, irregular in posterior, and ovoid in lateral BGH. A layered density of hematoma on initial computed tomography showed correlation with hematoma expansion (p = 0.016), which was observed more often in the postero-lateral group of BGH than in the anterior BGH group. Relatively better recovery from the initial insult was observed in the lateral BGH group than in the other regional BGH groups. The proportion of poor outcome (modified Rankin scale 4, 5, 6) was 100% in the massive, 41.1% in the posterior, 34.6% in the lateral, and 0% in the anterior BGH group.

CONCLUSION

We observed that BGH can be grouped according to its regional location and each group may have distinct characteristics. Thus, a more sophisticated clinical strategy tailored to each group of BGHs can be implemented.

Swirl sign in intracerebral haemorrhage: definition, prevalence, reliability and prognostic value

Background

Swirl sign has previously been described in epidural hematomas as areas of low attenuation, radiolucency or irregular density. The aims of this study were to describe swirl sign in ICH, study its prevalence, study the reliability of the subjective evaluation on computed tomography (CT), and to explore its prognostic value.

Methods

CTs of 203 patients with ICH were retrospectively evaluated for the presence of swirl sign. Association between swirl sign and different clinical and radiological variables was studied.

Results

Inter- and intraobserver agreement with regard to the occurrence of swirl sign was substantial (К 0.80) and almost perfect (К 0.87), respectively. Swirl sign was found in 30% of the study population. 61% of patients with swirl sign were dead at one month compared with 21% of those with no swirl sign (p < 0.001). Only 19% of patients with swirl sign exhibited favorable outcome at three months compared with 53% of those with no swirl sign (p < 0.001). Patients with swirl sign exhibited larger ICHs with average ICH-volume 52 ± 50 ml (median 42 ml) compared with 15 ± 25 ml (median 6) in patients whose CT did not show swirl sign (p < 0.001). Swirl sign was independent predictor of death at one month (p = 0.03; adjusted odds ratio 2.6, 95% CI 1.1 – 6), and functional outcome at three months (p = 0.045; adjusted odds ratio 2.6, 95% CI 1.02 – 6.5).

Conclusions

As swirl sign showed to be an ominous sign, we recommend identification of this sign in cases of ICHs.

Rehabilitation promotes recovery after whole blood-induced intracerebral hemorrhage in rats

BACKGROUND

Rehabilitation improves recovery after intracerebral hemorrhage (ICH) caused by collagenase infusion into the striatum of rats by promoting dendritic growth and reducing brain injury in this model.

OBJECTIVE

Effective preclinical testing requires multiple models because none, including the collagenase model, perfectly mimics human ICH. Thus, the authors assessed enhanced rehabilitation (ER), a combination of environmental enrichment and task-specific motor training, on skilled reaching, lesion size, and dendritic plasticity after whole blood-induced, striatal ICH.

METHODS

Three groups of rats were trained to retrieve food in a reaching task prior to ICH. One group was euthanized at 7 days, whereas 2 groups survived 7 weeks post-ICH. Of the latter, 1 group received 2 weeks of ER starting at 7 days, whereas controls did not. Reaching success was assessed 6 weeks after ICH. Lesion volume and dendritic length and complexity (contralateral striatum) were assessed.

RESULTS

The ICH caused reaching deficits that were markedly attenuated by ER as observed previously in the collagenase model. In contrast to that model, there was a time-dependent decline in dendritic length after untreated, whole blood-induced ICH. Furthermore, behavioral recovery was not accompanied by changes in lesion volume or contralateral dendritic morphology.

CONCLUSIONS

Converging data from animal models support the use of rehabilitation for ICH patients. However, although rehabilitation effectively promotes behavioral recovery, the mechanisms of action vary by model making it difficult to predict clinical effects.

Three-dimensional reconstruction and volumetry of intracranial haemorrhage and its mass effect

Intracerebral haemorrhage still causes considerable disability and mortality. The studies on conservative and operative management are inconclusive, probably due to inexact volumetry of the haemorrhage. We investigated whether three-dimensional (3-D), voxel-based volumetry of the haemorrhage and its mass effect is feasible with routine computed tomography (CT) scans. The volumes of the haemorrhage, ventricles, midline shift, the intracranial volume and ventricular compression in CT scans of 12 patients with basal ganglia haemorrhage were determined with the 3-D slicer software. Indices of haemorrhage and intracranial or ventricular volume were calculated and correlated with the clinical data. The intended measures could be determined with an acceptable intra-individual variability. The 3-D volumetric data tended to correlate better with the clinical course than the conventionally assessed distance of midline shift and volume of haemorrhage. 3-D volumetry of intracranial haemorrhage and its mass effect is feasible with routine CT examination. Prospective studies should assess its value for clinical studies on intracranial space-occupying diseases.

International Variations in Surgical Practice for Spontaneous Intracerebral Hemorrhage

Background and Purpose— Spontaneous intracerebral hemorrhage is a major cause of death and disability, yet there is no convincing evidence of the benefit of any medical treatment and the role of surgery remains controversial. The international randomized Surgical Trial in Intracerebral Hemorrhage (STICH) provided an opportunity to assess the role of surgery within the centers taking part.

Methods— Screening logs were completed to record details of all patients assessed by the department, whether they were included in the trial, the reasons if they were not included, and whether they underwent surgery.

Results— Logs were returned by 42 centers and cover 704 months. They include details on 1578 patients with characteristics comparable to STICH inclusion criteria. Neurosurgeons were more likely to express clinical certainty about treatment for older patients, patients with a higher Glasgow Coma Score scale, and patients in whom the hematoma was located on the right or in the basal ganglia or thalamus. Patients for whom the neurosurgeon was certain about treatment were more likely to have the hematoma removed if they were younger (62 versus 68 years of age), had a lower Glasgow Coma Scale score (10 versus 13), and had a lobar hematoma (49% versus 40%). The operation rate varied between 74% in Lithuania and 2% in Hungary.

Conclusions— The difference in operation rates could not be explained by differences in patient characteristics alone. This finding demonstrates the need for further evidence to ensure that treatment for intracerebral hemorrhage is not governed by local custom.