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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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Molecular, Pathological, Clinical, and Therapeutic Aspects of Perihematomal Edema in Different Stages of Intracerebral Hemorrhage. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3948921. [PMID: 36164392 PMCID: PMC9509250 DOI: 10.1155/2022/3948921] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/17/2022] [Accepted: 09/03/2022] [Indexed: 02/07/2023]
Abstract
Acute intracerebral hemorrhage (ICH) is a devastating type of stroke worldwide. Neuronal destruction involved in the brain damage process caused by ICH includes a primary injury formed by the mass effect of the hematoma and a secondary injury induced by the degradation products of a blood clot. Additionally, factors in the coagulation cascade and complement activation process also contribute to secondary brain injury by promoting the disruption of the blood-brain barrier and neuronal cell degeneration by enhancing the inflammatory response, oxidative stress, etc. Although treatment options for direct damage are limited, various strategies have been proposed to treat secondary injury post-ICH. Perihematomal edema (PHE) is a potential surrogate marker for secondary injury and may contribute to poor outcomes after ICH. Therefore, it is essential to investigate the underlying pathological mechanism, evolution, and potential therapeutic strategies to treat PHE. Here, we review the pathophysiology and imaging characteristics of PHE at different stages after acute ICH. As illustrated in preclinical and clinical studies, we discussed the merits and limitations of varying PHE quantification protocols, including absolute PHE volume, relative PHE volume, and extension distance calculated with images and other techniques. Importantly, this review summarizes the factors that affect PHE by focusing on traditional variables, the cerebral venous drainage system, and the brain lymphatic drainage system. Finally, to facilitate translational research, we analyze why the relationship between PHE and the functional outcome of ICH is currently controversial. We also emphasize promising therapeutic approaches that modulate multiple targets to alleviate PHE and promote neurologic recovery after acute ICH.
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4
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Lansberg MG, Wintermark M, Kidwell CS, Albers GW. Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00048-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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5
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Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Intrahematomal Ultrasound Enhances RtPA-Fibrinolysis in a Porcine Model of Intracerebral Hemorrhage. J Clin Med 2021; 10:jcm10040563. [PMID: 33546160 PMCID: PMC7913235 DOI: 10.3390/jcm10040563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 11/30/2022] Open
Abstract
Catheter-based ultrasound-thrombolysis has been successfully used in a small clinical trial in order to enhance recombinant tissue plasminogen activator (rtPA)-fibrinolysis, for the treatment of spontaneous intracerebral hemorrhages (ICHs). The aim of this study was to investigate the ultra-early effects of ultrasound on hematoma and the surrounding brain tissue in a porcine ICH-model. To achieve this, 21 pigs with a right frontal ICH were randomly assigned to four groups: (1) drainage (n = 3), (2) drainage + rtPA (n = 6), (3) drainage + ultrasound (n = 6), and (4) drainage + ultrasound + rtPA (n = 6). The hematoma volume assessment was performed using cranial MRI before and after the treatments. Subsequently, the brain sections were analyzed using HE-staining and immunohistochemistry. The combined treatment using rtPA and ultrasound led to a significantly higher hematoma reduction (62 ± 5%) compared to the other groups (Group 1: 2 ± 1%; Group 2: 30 ± 12%; Group 3: 18 ± 8% (p < 0.0001)). In all groups, the MRI revealed an increase in diffusion restriction but neither hyper- or hypoperfusion, nor perihematomal edema. HE stains showed perihematomal microhemorrhages were equally distributed in each group, while edema was more pronounced within the control group. Immunohistochemistry did not reveal any ultra-early side effects. The combined therapy of drainage, rtPA and ultrasound is a safe and effective technique for hematoma-reduction and protection of the perihematomal tissue in regard to ultra-early effects.
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7
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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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8
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Fu F, Sui B, Liu L, Su Y, Sun S, Li Y. Quantitative assessment of local perfusion change in acute intracerebral hemorrhage areas with and without "dynamic spot sign" using CT perfusion imaging. Acta Radiol 2019; 60:367-373. [PMID: 29871494 DOI: 10.1177/0284185118780893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Positive "dynamic spot sign" has been proven to be a potential risk factor for acute intracerebral hemorrhage (ICH) expansion, but local perfusion change has not been quantitatively investigated. PURPOSE To quantitatively evaluate perfusion changes at the ICH area using computed tomography perfusion (CTP) imaging. MATERIAL AND METHODS Fifty-three patients with spontaneous ICH were recruited. Unenhanced computed tomography (NCCT), CTP within 6 h, and follow-up NCCT were performed for 21 patients in the "spot sign"-positive group and 32 patients in the control group. Cerebral perfusion change was quantitatively measured on regional cerebral blood flow/regional cerebral blood volume (rCBF/rCBV) maps. Regions of interest (ROIs) were set at the "spot-sign" region and the whole hematoma area for "spot-sign"-positive cases, and at one of the highest values of three interested areas and the whole hematoma area for the control group. Hematoma expansion was determined by follow-up NCCT. RESULTS For the "spot-sign"-positive group, the average rCBF (rCBV) values at the "spot-sign" region and the whole hematoma area were 21.34 ± 15.24 mL/min/100 g (21.64 ± 21.48 mL/100g) and 5.78 ± 6.32 mL/min/100 g (6.07 ± 5.45 mL/100g); for the control group, the average rCBF (rCBV) values at the interested area and whole hematoma area were 2.50 ± 1.83 mL/min/100 g (3.13 ± 1.96 mL/100g) and 3.02 ± 1.80 mL/min/100 g (3.40 ± 1.44 mL/100g), respectively. Average rCBF and rCBV values of the "spot-sign" region were significantly different from other regions ( P < 0.001; P = 0.004). The average volumes of hematoma expansion in the "spot-sign"-positive and control groups were 25.24 ± 19.38 mL and -0.41 ± 1.34 mL, respectively. CONCLUSION The higher perfusion change at ICH on CTP images may reflect the contrast extravasation and be associated with the hematoma expansion.
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Affiliation(s)
- Fan Fu
- Neuroradiology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Binbin Sui
- Neuroradiology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Liping Liu
- Neuroradiology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Yaping Su
- Neuroradiology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Shengjun Sun
- Neuroradiology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Yingying Li
- Neuroradiology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
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9
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Munakomi S, Agrawal A. Advancements in Managing Intracerebral Hemorrhage: Transition from Nihilism to Optimism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1153:1-9. [PMID: 30888664 DOI: 10.1007/5584_2019_351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There have been significant advancements in the management of intracerebral hemorrhage (ICH) stemming from new knowledge on its pathogenesis. Major clinical trials, such as Surgical Trial in Lobar Intracerebral Hemorrhage (STICH I and II), have shown only a small, albeit clinically relevant, advantage of surgical interventions in specific subsets of patients suffering from ICH. Currently, the aim is to use a minimally invasive and safe trajectory in removing significant brain hematomas with the aid of neuro-endoscopy or precise guidance through neuro-navigation, thereby avoiding a collateral damage to the surrounding normal brain tissue. A fundamental rational to such approach is to safely remove hematoma, preventing the ongoing mass effect resulting in brain herniation, and to minimize deleterious effects of iron released from hematoma to brain cells. The clot lysis process is facilitated with the adjunctive use of recombinant tissue plasminogen activator and sonolysis. Revised recommendations for the management of ICH focus on a holistic approach, with special emphasis on early patient mobilization and graded rehabilitative process. There has been a paradigm shift in the management algorithm, putting emphasis on early and safe removal of brain hematoma and then focusing on the improvement of patients' quality of life. We have made significant progress in transition from nihilism toward optimism, based on evidence-based management of such a severe global health scourge as intracranial hemorrhage.
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Affiliation(s)
- Sunil Munakomi
- Department of Neurosurgery, Nobel Medical College and Teaching Hospital, Biratnagar, Nepal.
| | - Amit Agrawal
- Department of Neurosurgery, Narayana Medical College, Nellore, Andra Pradesh, India
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10
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Heo SH, Lee D, Kwon YC, Kim BJ, Lee KM, Bushnell CD, Chang DI. Cerebral Microbleeds in the Patients With Acute Stroke Symptoms. Front Neurol 2018; 9:988. [PMID: 30519213 PMCID: PMC6258787 DOI: 10.3389/fneur.2018.00988] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 11/02/2018] [Indexed: 11/28/2022] Open
Abstract
Background: Some patients with acute stroke symptoms do not show hyperintensities on diffusion-weighted image (DWI). A few case reports have indicated that acutely developed cerebral microbleeds (CMBs) might cause focal symptoms. This study sought to investigate the incidence and characteristics of symptomatic CMBs in the patients with acute stroke symptoms but without DWI ischemic lesions. Methods: We enrolled the patients with acute stroke symptoms who underwent magnetic resonance imaging including DWI and gradient echo (GRE) sequences within 7 days after symptom onset, at our prospective stroke registry. We then identified patients without DWI-positive ischemic lesions but with CMBs in the relevant brain regions. Results: Between January 2005 and February 2012, we identified 235 DWI-negative transient ischemic attack (n = 221) and stroke (n = 14) patients from 2129 consecutive patients at our registry. In total, 16 patients had CMBs corresponding to the focal symptoms. Among these 16 patients, 12 patients showed a hyperintense rim on DWI around a microbleed suspected to be related to focal symptoms; of the 12 patients, 7 experienced stroke symptoms for more than 24 h. However, the symptoms in the remaining patients (5 patients with the hyperintense rim and 4 patients without the hyperintense rim) improved within 24 h. Conclusion: Symptomatic microbleeds are infrequent but not rare in the patients with acute stroke symptoms. Perihematomal edema around an acute CMB can cause a hyperintense rim on DWI. Our results suggest that a combination of DWI and GRE imaging can help diagnose acute symptomatic CMBs.
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Affiliation(s)
- Sung Hyuk Heo
- Department of Neurology, Kyung Hee University Hospital, Seoul, South Korea
| | - Dongwhane Lee
- Department of Neurology, Kyung Hee University Hospital, Seoul, South Korea
| | - Yong Chul Kwon
- Department of Neurology, Kyung Hee University Hospital, Seoul, South Korea
| | - Bum Joon Kim
- Department of Neurology, Kyung Hee University Hospital, Seoul, South Korea
| | - Kyung Mi Lee
- Department of Radiology, Kyung Hee University Hospital, Seoul, South Korea
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Dae-Il Chang
- Department of Neurology, Kyung Hee University Hospital, Seoul, South Korea
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11
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Li Q, Weiland A, Chen X, Lan X, Han X, Durham F, Liu X, Wan J, Ziai WC, Hanley DF, Wang J. Ultrastructural Characteristics of Neuronal Death and White Matter Injury in Mouse Brain Tissues After Intracerebral Hemorrhage: Coexistence of Ferroptosis, Autophagy, and Necrosis. Front Neurol 2018; 9:581. [PMID: 30065697 PMCID: PMC6056664 DOI: 10.3389/fneur.2018.00581] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/27/2018] [Indexed: 11/24/2022] Open
Abstract
Although intracerebral hemorrhage (ICH) is a devastating disease worldwide, the pathologic changes in ultrastructure during the acute and chronic phases of ICH are poorly described. In this study, transmission electron microscopy was used to examine the ultrastructure of ICH-induced pathology. ICH was induced in mice by an intrastriatal injection of collagenase. Pathologic changes were observed in the acute (3 days), subacute (6 days), and chronic (28 days) phases. Compared with sham animals, we observed various types of cell death in the injured striatum during the acute phase of ICH, including necrosis, ferroptosis, and autophagy. Different degrees of axon degeneration in the striatum were seen in the acute phase, and axonal demyelination was observed in the ipsilateral striatum and corpus callosum at late time points. In addition, phagocytes, resident microglia, and infiltrating monocyte-macrophages were present around red blood cells and degenerating neurons and were observed to engulf red blood cells and other debris. Many synapses appeared abnormal or were lost. This systematic analysis of the pathologic changes in ultrastructure after ICH in mice provides information that will be valuable for future ICH pathology studies.
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Affiliation(s)
- Qian Li
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Beijing, China
| | - Abigail Weiland
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Xuemei Chen
- Department of Human Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Xi Lan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Xiaoning Han
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Frederick Durham
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Xi Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jieru Wan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Wendy C. Ziai
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniel F. Hanley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jian Wang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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12
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Chen-Roetling J, Regan RF. Targeting the Nrf2-Heme Oxygenase-1 Axis after Intracerebral Hemorrhage. Curr Pharm Des 2018; 23:2226-2237. [PMID: 27799046 DOI: 10.2174/1381612822666161027150616] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 10/16/2016] [Accepted: 10/22/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Injury to cells adjacent to an intracerebral hemorrhage (ICH) is likely mediated at least in part by toxins released from the hematoma that initiate complex and interacting injury cascades. Pharmacotherapies targeting a single toxin or pathway, even if consistently effective in controlled experimental models, have a high likelihood of failure in a variable clinical setting. Nuclear factor erythroid-2 related factor 2 (Nrf2) regulates the expression of heme oxygenase-1 (HO-1) and multiple other proteins with antioxidant and antiinflammatory effects, and may be a target of interest after ICH. METHODS Studies that tested the effect of HO and Nrf2 in models relevant to ICH are summarized, with an effort to reconcile conflicting data by consideration of methodological limitations. RESULTS In vitro studies demonstrated that Nrf2 activators rapidly increased HO-1 expression in astrocytes, and reduced their vulnerability to hemoglobin or hemin. Modulating HO-1 expression via genetic approaches yielded similar results. Systemic treatment with small molecule Nrf2 activators increased HO-1 expression in perivascular cells, particularly astrocytes. When tested in mouse or rat ICH models, Nrf2 activators were consistently protective, improving barrier function and attenuating edema, inflammation, neuronal loss and neurological deficits. These effects were mimicked by selective astrocyte HO-1 overexpression in transgenic mice. CONCLUSION Systemic treatment with Nrf2 activators after ICH is protective in rodents. Two compounds, dimethyl fumarate and hemin, are currently approved for treatment of multiple sclerosis and acute porphyria, respectively, and have acceptable safety profiles over years of clinical use. Further development of these drugs as ICH therapeutics seems warranted.
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Affiliation(s)
- Jing Chen-Roetling
- Department of Emergency Medicine, Thomas Jefferson University, 1025 Walnut Street, College Building Room 813, Philadelphia, PA 19107, United States
| | - Raymond F Regan
- Department of Emergency Medicine, Thomas Jefferson University, 1025 Walnut Street, College Building Room 813, Philadelphia, PA 19107, United States
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Dineen RA, Pszczolkowski S, Flaherty K, Law ZK, Morgan PS, Roberts I, Werring DJ, Al-Shahi Salman R, England T, Bath PM, Sprigg N. Does tranexamic acid lead to changes in MRI measures of brain tissue health in patients with spontaneous intracerebral haemorrhage? Protocol for a MRI substudy nested within the double-blind randomised controlled TICH-2 trial. BMJ Open 2018; 8:e019930. [PMID: 29431141 PMCID: PMC5879748 DOI: 10.1136/bmjopen-2017-019930] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/28/2017] [Accepted: 12/12/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To test whether administration of the antifibrinolytic drug tranexamic acid (TXA) in patients with spontaneous intracerebral haemorrhage (SICH) leads to increased prevalence of diffusion-weighted MRI-defined hyperintense ischaemic lesions (primary hypothesis) or reduced perihaematomal oedema volume, perihaematomal diffusion restriction and residual MRI-defined SICH-related tissue damage (secondary hypotheses). DESIGN MRI substudy nested within the double-blind randomised controlled Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage (TICH)-2 trial (ISRCTN93732214). SETTING International multicentre hospital-based study. PARTICIPANTS Eligible adults consented and randomised in the TICH-2 trial who were also able to undergo MRI scanning. To address the primary hypothesis, a sample size of n=280 will allow detection of a 10% relative increase in prevalence of diffusion-weighted imaging (DWI) hyperintense lesions in the TXA group with 5% significance, 80% power and 5% imaging data rejection. INTERVENTIONS TICH-2 MRI substudy participants will undergo MRI scanning using a standardised protocol at day ~5 and day ~90 after randomisation. Clinical assessments, randomisation to TXA or placebo and participant follow-up will be performed as per the TICH-2 trial protocol. CONCLUSION The TICH-2 MRI substudy will test whether TXA increases the incidence of new DWI-defined ischaemic lesions or reduces perihaematomal oedema or final ICH lesion volume in the context of SICH. ETHICS AND DISSEMINATION The TICH-2 trial obtained ethical approval from East Midlands - Nottingham 2 Research Ethics Committee (12/EM/0369) and an amendment to allow the TICH-2 MRI sub study was approved in April 2015 (amendment number SA02/15). All findings will be published in peer-reviewed journals. The primary outcome results will also be presented at a relevant scientific meeting. TRIAL REGISTRATION NUMBER ISRCTN93732214; Pre-results.
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Affiliation(s)
- Rob A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Stefan Pszczolkowski
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Zhe K Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Paul S Morgan
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK
- Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - David J Werring
- Stroke Research Centre, University College London, London, UK
| | | | - Tim England
- Vascular Medicine, Division of Medical Sciences and GEM, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Yin L, Cheng S, Xiao J, Zhu Y, Bu S, Zhang X, Liu R, Huang Y, Xie S. 3D pseudocontinuous arterial spin-labeling perfusion imaging detected crossed cerebellar diaschisis in acute, subacute and chronic intracerebral hemorrhage. Clin Imaging 2017; 50:37-42. [PMID: 29258030 DOI: 10.1016/j.clinimag.2017.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We aimed to evaluate the value of 3D pseudocontinuous arterial spin-labeling (pCASL) perfusion imaging detected crossed cerebellar diaschisis (CCD) at different stages of intracerebral hemorrhage (ICH). MATERIALS AND METHODS We assessed bilateral cerebral blood flow (CBF) values of different brain regions and the relationships between the CCD and clinical status of 16 ICH patients. RESULTS The ICH patients had significantly lower CBF values in the contralateral cerebellum in acute, subacute and chronic stages. The subacute CCD had a significant correlation with clinical status. CONCLUSIONS 3D pCASL may be an ideal tool to study the phenomenon and clinical consequences of ICH with CCD.
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Affiliation(s)
- Liang Yin
- Department of Radiology, Peking University First Hospital, Beijing, China
| | - Shuangjuan Cheng
- Department of Radiology, Peking University First Hospital, Beijing, China
| | - Jiangxi Xiao
- Department of Radiology, Peking University First Hospital, Beijing, China.
| | - Ying Zhu
- Department of Radiology, Peking University First Hospital, Beijing, China
| | - Shanshan Bu
- Department of Radiology, Peking University First Hospital, Beijing, China
| | - Xiaodong Zhang
- Department of Radiology, Peking University First Hospital, Beijing, China
| | - Ran Liu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yining Huang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Sheng Xie
- Department of Radiology, China-Japanese Friendship Hospital, Beijing, China
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Abstract
Intracerebral hemorrhage (ICH) remains a prevalent and severe cause of death and disability worldwide. Control of the hypertensive response in acute ICH has been a mainstay of ICH management, yet the optimal approaches and the yield of recommended strategies have been difficult to establish despite a large body of literature. Over the years, theoretical and observed risks and benefits of intensive blood pressure reduction in ICH have been studied in the form of animal models, radiographic studies, and two recent large, randomized patient trials. In this article, we review the historical and developing data and discuss remaining questions surrounding blood pressure management in acute ICH.
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Affiliation(s)
- Stacy Chu
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Lauren Sansing
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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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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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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Abstract
Intracerebral hemorrhage (ICH) is a potentially devastating neurologic injury representing 10-15% of stroke cases in the USA each year. Numerous risk factors, including age, hypertension, male gender, coagulopathy, genetic susceptibility, and ethnic descent, have been identified. Timely identification, workup, and management of this condition remain a challenge for clinicians as numerous factors can present obstacles to achieving good functional outcomes. Several large clinical trials have been conducted over the prior decade regarding medical and surgical interventions. However, no specific treatment has shown a major impact on clinical outcome. Current management guidelines do exist based on medical evidence and consensus and these provide a framework for care. While management of hypertension and coagulopathy are generally considered basic tenets of ICH management, a variety of measures for surgical hematoma evacuation, intracranial pressure control, and intraventricular hemorrhage can be further pursued in the emergent setting for selected patients. The complexity of management in parenchymal cerebral hemorrhage remains challenging and offers many areas for further investigation. A systematic approach to the background, pathology, and early management of spontaneous parenchymal hemorrhage is provided.
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Malhotra K, Khunger M, Ouyang B, Liebeskind DS, Mohammad YM. Interaction of incidental microbleeds and prior use of antithrombotics with early hemorrhagic transformation: Causative or protective? Ann Indian Acad Neurol 2016; 19:467-471. [PMID: 27994355 PMCID: PMC5144467 DOI: 10.4103/0972-2327.194423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Gradient echo (GRE) sequence of magnetic resonance imaging (MRI) is a sensitive tool to detect hemorrhagic transformation (HT) and old cerebral microbleeds (CMBs). Presence of CMBs and prior use of antithrombotics pose a risk of HT in ischemic stroke. We evaluated the association of CMBs and antithrombotic use with resultant HT in acute ischemic stroke (AIS). METHODS This retrospective study included AIS patients admitted to our center between January 2009 and August 2010 who underwent GRE-weighted MRI within 48 h of admission. Demographic and clinical data including diabetes mellitus, hypertension, hyperlipidemia, prior intake of antiplatelets/anticoagulants/statins, and presence of CMBs at admission were collected and compared between patients who developed HT and those who did not. We did a multivariate analysis using logistic regression to assess the effect of CMBs and prior use of antithrombotic agents on the risk of development for early HT in ischemic stroke. RESULTS Of 529 AIS patients, 81 (15%) were found to have HT during the initial hospital course. CMBs were found in only 9 of 81 patients (11%) with HT and in 40 out of remaining 448 patients (9%) who did not develop HT. The presence of CMBs was not associated with increased risk of HT (P = 0.53). However, prior use of antiplatelets (33% vs. 47% in the patients without HT, P = 0.02) was associated with decreased risk of HT in ischemic stroke. CONCLUSION Presence of incidental CMBs was not associated with increased risk for early HT of an ischemic stroke. Interestingly, the prior intake of antiplatelets was found to be protective against HT of ischemic stroke.
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Affiliation(s)
- Konark Malhotra
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Bichun Ouyang
- Department of Neurology, RUSH University Medical Center, Chicago, IL, USA
| | - David S Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - Yousef M Mohammad
- Department of Internal Medicine, King Saud University, Riyadh, Saudi Arabia
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Younsi A, Scherer M, Unterberg AW, Orakcioglu B. Visualization of pressure related vessel compression in the perihemorrhagic zone during endoscopic ICH evacuation. Clin Neurol Neurosurg 2016; 147:64-70. [DOI: 10.1016/j.clineuro.2016.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/19/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
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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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Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00048-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Sato S, Carcel C, Anderson CS. Blood Pressure Management After Intracerebral Hemorrhage. Curr Treat Options Neurol 2015; 17:49. [PMID: 26478247 DOI: 10.1007/s11940-015-0382-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OPINION STATEMENT Elevated blood pressure (BP), which presents in approximately 80 % of patients with acute intracerebral hemorrhage (ICH), is associated with increased risk of poor outcome. The Second Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT2) study, a multinational, multicenter, randomized controlled trial published in 2013, demonstrated better functional outcomes with no harm for patients with acute spontaneous ICH within 6 h of onset who received target-driven, early intensive BP lowering (systolic BP target <140 mmHg within 1 h, continued for 7 days) and suggested that greater and faster reduction in BP might enhance the treatment effect by limiting hematoma growth. The trial resulted in revisions of guidelines for acute management of ICH, in which intensive BP lowering in patients with acute ICH is recommended as safe and effective treatment for improving functional outcome. BP lowering is also the only intervention that is proven to reduce the risk of recurrent ICH. Current evidences from several randomized trials, including PROGRESS and SPS3, indicate that long-term strict BP control in patients with ICH is safe and could offer additional benefits in major reduction in risk of recurrent ICH. The latest American Heart Association/American Stroke Association (AHA/ASA) guidelines recommended a target BP of <130/80 mmHg after ICH, but supporting evidence is limited. Randomized controlled trials are needed that focus on strict BP control, initiated early after onset of the disease and continued long-term, to demonstrate effective prevention of recurrent stroke and other major vascular events without additional harms in the ICH population.
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Affiliation(s)
- Shoichiro Sato
- Neurological & Mental Health Division, The George Institute for Global Health, Level 10, King George V Building, 83-117 Missenden Rd, Camperdown, Sydney, 2050, NSW, Australia
| | - Cheryl Carcel
- Neurological & Mental Health Division, The George Institute for Global Health, Level 10, King George V Building, 83-117 Missenden Rd, Camperdown, Sydney, 2050, NSW, Australia.,Sydney Medical School, The University of Sydney, Edward Ford Building A27, Sydney, 2006, NSW, Australia.,Royal Prince Alfred Hospital, Level 11, King George V Building, 83-117 Missenden Rd, Camperdown, Sydney, 2050, NSW, Australia
| | - Craig S Anderson
- Neurological & Mental Health Division, The George Institute for Global Health, Level 10, King George V Building, 83-117 Missenden Rd, Camperdown, Sydney, 2050, NSW, Australia. .,Sydney Medical School, The University of Sydney, Edward Ford Building A27, Sydney, 2006, NSW, Australia. .,Royal Prince Alfred Hospital, Level 11, King George V Building, 83-117 Missenden Rd, Camperdown, Sydney, 2050, NSW, Australia.
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Lee EJ, Kang DW, Warach S. Silent New Brain Lesions: Innocent Bystander or Guilty Party? J Stroke 2015; 18:38-49. [PMID: 26467195 PMCID: PMC4747067 DOI: 10.5853/jos.2015.01410] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 09/12/2015] [Accepted: 09/14/2015] [Indexed: 11/17/2022] Open
Abstract
With the advances in magnetic resonance imaging, previously unrecognized small brain lesions, which are mostly asymptomatic, have been increasingly detected. Diffusion-weighted imaging can identify small ischemic strokes, while gradient echo T2* imaging and susceptibility-weighted imaging can reveal tiny hemorrhagic strokes (microbleeds). In this article, we review silent brain lesions appearing soon after acute stroke events, including silent new ischemic lesions and microbleeds appearing 1) after acute ischemic stroke and 2) after acute intracerebral hemorrhage. Moreover, we briefly discuss the clinical implications of these silent new brain lesions.
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Affiliation(s)
- Eun-Jae Lee
- Department of Neurology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Steven Warach
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, USA
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Noguchi T, Nishihara M, Egashira Y, Azama S, Hirai T, Kitano I, Yakushiji Y, Kawashima M, Irie H. Arterial spin-labeling MR imaging of cerebral hemorrhages. Neuroradiology 2015; 57:1135-44. [PMID: 26280515 DOI: 10.1007/s00234-015-1574-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 08/05/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The purpose of this study is to identify the characteristics of brain perfusion measured by arterial spin-labeling magnetic resonance imaging (ASL-MRI) in cerebral hemorrhages. METHODS Brain blood flow values (CBF-ASL values) for cerebral and cerebellar hemispheres and segmented cerebral regions were measured by ASL-MRI in 19 putaminal hemorrhage patients and 20 thalamic hemorrhage patients in acute or subacute stages. We assessed the lateralities of CBF-ASL values and the relationships between CBF-ASL values and other imaging findings and clinical manifestations. RESULTS Both the 19 putaminal hemorrhage patients and the 20 thalamic hemorrhage patients had significantly low CBF-ASL values of the contralateral cerebellum in subacute stage, suggesting that ASL-MRI might delineate crossed cerebellar diaschisis (CCD). Ipsilateral low CBF-ASL values were observed in frontal lobes and thalami with a putaminal hemorrhage and lentiform nuclei, temporal lobes, and parietal lobes with a thalamic hemorrhage, suggesting that ASL-MRI showed the ipsilateral cerebral diaschisis (ICD). In the putaminal hemorrhage patients, the hematoma volume negatively affected both the bilateral cerebellar and cerebral hemispheric CBF-ASL values. In the thalamic hemorrhage patients, a concomitant intraventricular hemorrhage caused low cerebral hemispheric CBF-ASL values. CONCLUSION The use of ASL-MRI is sensitive to the perfusion abnormalities and could thus be helpful to estimate functional abnormalities in cerebral hemorrhage patients.
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Affiliation(s)
- Tomoyuki Noguchi
- Department of Radiology, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan. .,Department of Radiology, Faculty of Medicine and Graduate School of Medicine, Saga University, Saga, Japan.
| | - Masashi Nishihara
- Department of Radiology, Faculty of Medicine and Graduate School of Medicine, Saga University, Saga, Japan
| | - Yoshiaki Egashira
- Department of Radiology, Faculty of Medicine and Graduate School of Medicine, Saga University, Saga, Japan
| | - Shinya Azama
- Department of Radiology, Faculty of Medicine and Graduate School of Medicine, Saga University, Saga, Japan
| | - Tetsuyoshi Hirai
- Department of Radiology, Faculty of Medicine and Graduate School of Medicine, Saga University, Saga, Japan
| | - Isao Kitano
- Department of Radiology, Faculty of Medicine and Graduate School of Medicine, Saga University, Saga, Japan
| | - Yusuke Yakushiji
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Saga University, Saga, Japan
| | - Masatou Kawashima
- Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Saga University, Saga, Japan
| | - Hiroyuki Irie
- Department of Radiology, Faculty of Medicine and Graduate School of Medicine, Saga University, Saga, Japan
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Parody E, Pedraza S, García-Gil MM, Crespo C, Serena J, Dávalos A. Cost-Utility Analysis of Magnetic Resonance Imaging Management of Patients with Acute Ischemic Stroke in a Spanish Hospital. Neurol Ther 2015; 4:25-37. [PMID: 26847673 PMCID: PMC4470974 DOI: 10.1007/s40120-015-0029-x] [Citation(s) in RCA: 7] [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] [Received: 02/17/2015] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Stroke has a high rate of long-term disability and mortality and therefore has a significant economic impact. The objective of this study was to determine from a social perspective, the cost-utility of magnetic resonance imaging (MRI) compared to computed tomography (CT) as the first imaging test in acute ischemic stroke (AIS). METHODS A cost-utility analysis of MRI compared to CT as the first imaging test in AIS was performed. Economic evaluation data were obtained from a prospective study of patients with AIS ≤12 h from onset in one Spanish hospital. The measure of effectiveness was quality-adjusted life-years (QALYs) calculated from utilities of the modified Rankin Scale. Both hospital and post-discharge expenses were included in the costs. The incremental cost-effectiveness ratio (ICER) was calculated and sensitivity analysis was carried out. The costs were expressed in Euros at the 2004 exchange rate. RESULTS A total of 130 patients were analyzed. The first imaging test was CT in 87 patients and MRI in 43 patients. Baseline variables were similar in the two groups. The mean direct cost was €5830.63 for the CT group and €5692.95 for the MRI group (P = not significant). The ICER was €11,868.97/QALY. The results were sensitive when the indirect costs were included in the analysis. CONCLUSION Total direct costs and QALYs were lower in the MRI group; however, this difference was not statistically significant. MRI was shown to be a cost-effective strategy for the first imaging test in AIS in 22% of the iterations according to the efficiency threshold in Spain.
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Affiliation(s)
| | - Salvador Pedraza
- Department of Radiology-IDI, IDIBGI, Hospital Doctor Josep Trueta, UDG, Girona, Spain
| | - María M García-Gil
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalunya, Spain
| | - Carlos Crespo
- Health Economics and Pricing, Boehringer Ingelheim, Sant Cugat del Valles (Barcelona), Spain
| | - Joaquín Serena
- Department of Neurology, Hospital Doctor Josep Trueta, Girona, Spain
| | - Antoni Dávalos
- Department of Neurology, Germans Trias i Pujol Hospital, Badalona, Spain
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Relative systolic blood pressure reduction and clinical outcomes in hyperacute intracerebral hemorrhage. J Hypertens 2015; 33:1069-73. [DOI: 10.1097/hjh.0000000000000512] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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Qureshi AI, Majidi S, Gilani WI, Palesch YY, Martin R, Novitzke J, Cruz-Flores S, Ehtisham A, Goldstein JN, Kirmani JF, Hussein HM, Suri MFK, Tariq N. Increased brain volume among good grade patients with intracerebral hemorrhage. Results from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) study. Neurocrit Care 2015; 20:470-5. [PMID: 23609118 DOI: 10.1007/s12028-013-9842-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND We ascertained the occurrence of global cerebral edema manifesting as increased brain volume in subjects with intracerebral hemorrhage (ICH) and explored the relationship between subject characteristics and three month outcomes. METHODS A post-hoc analysis of a multicenter prospective study that recruited patients with ICH, elevated SBP ≥170 mm Hg, and Glasgow Coma Scale (GCS) score ≥8, who presented within 6 h of symptom onset was performed. Computed tomographic (CT) scans at baseline and 24 h, submitted to a core image laboratory, were analyzed to measure total brain, hematoma, and perihematoma edema volumes from baseline and 24-h CT scans using image analysis software. The increased brain volume was determined by subtracting the hematoma and perihematomal edema volumes from the total brain volume. RESULTS A total of 18 (44 %) of 41 subjects had increased brain volume that developed between initial CT scan and 24-h CT scan. The median increase in brain volume among the 18 subjects was 35 cc ranging from 0.12 to 296 cc. The median baseline GCS score was 15 in both groups of subjects who experienced increased brain volume and those who did not, and the median hematoma volume was 10.18 and 6.73, respectively. Three of the 18 subjects with increased brain volume underwent concurrent neurological deterioration and one subject died during hospitalization. CONCLUSIONS We found preliminary evidence of increased cerebral brain volume in subjects with good grade and small ICHs, which may be suggestive of global cerebral edema.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN, USA,
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Keigler G, Goldberg I, Eichel R, Gomori JM, Cohen JE, Leker RR. Diffusion-weighted imaging at b1000 for identifying intracerebral hemorrhage: preliminary sensitivity, specificity, and inter-rater variability. J Stroke Cerebrovasc Dis 2014; 23:1934-8. [PMID: 24795096 DOI: 10.1016/j.jstrokecerebrovasdis.2014.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 01/06/2014] [Accepted: 02/01/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Noncontrast computed tomography (NCCT) is the gold standard to detect intracerebral hemorrhage (ICH) and ischemic stroke (IS) in patients presenting with acute focal syndromes. Diffusion-weighted magnetic resonance imaging (DW-MRI) obtained at b1000 is highly sensitive to identify acute IS but its sensitivity and specificity to detect ICH has not been systematically studied. METHODS Patients with a diagnosis of ICH on NCCT were prospectively enrolled and underwent DW-MRI at b1000. Patients with suspected ischemia and a negative NCCT served as controls. All diffusion-weighted imaging (DWI) scans were evaluated blindly by 4 experienced raters. Sensitivity, specificity, and inter-rater variability of the DWI b1000 scans for detection of ICH were determined. RESULTS In this preliminary pilot study, 15 patients with ICH and 17 patients with IS were included. All ICH lesions seen on NCCT showed a typical pattern on DW-MRI at b1000 with a hypointense core surrounded by a hyperintense rim. ICH volumes and size were similar on NCCT and MRI. All cases of IS were identified on the DWI scans but none were apparent on NCCT. The mean sensitivity and specificity of DW-MRI at b1000 for ICH were 94% and 93.5%, respectively, and the inter-rater variability for ICH detection on DWI was excellent (κ = .84). CONCLUSIONS DW-MRI at b1000 has a diagnostic yield similar to NCCT for detecting ICH and superior to NCCT for detecting IS. Therefore, DW-MRI may be considered as the initial screening tool for imaging patients presenting with focal neurologic symptoms suggestive of stroke.
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Affiliation(s)
- Galina Keigler
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ilan Goldberg
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Roni Eichel
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - John M Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jose E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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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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Heo SH, Lee D, Lee D, Chang DI. Differentiation of a Symptomatic Cerebral Microbleed from Silent Microbleeds. Int J Stroke 2013; 9:E2. [DOI: 10.1111/ijs.12218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sung Hyuk Heo
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Dongwhane Lee
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Dokyung Lee
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Dae-Il Chang
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
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Hill MD, Muir KW. INTERACT-2: should blood pressure be aggressively lowered acutely after intracerebral hemorrhage? Stroke 2013; 44:2951-2. [PMID: 23988644 DOI: 10.1161/strokeaha.113.002790] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael D Hill
- From the Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Foothills Hospital, University of Calgary, AB, Canada (M.D.H.); and Institute of Neurosciences & Psychology, University of Glasgow, Southern General Hospital, Glasgow, United Kingdom (K.W.M.)
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Abstract
Spontaneous, nontraumatic intracerebral hemorrhage (ICH) is defined as bleeding within the brain parenchyma. Intracranial hemorrhage includes bleeding within the cranial vault and encompasses ICH, subdural hematoma, epidural bleeds, and subarachnoid hemorrhage (SAH). This review will focus only on ICH. This stroke subtype accounts for about 10% of all strokes. The hematoma locations are deep or ganglionic, lobar, cerebellar, and brain stem in descending order of frequency. Intracerebral hemorrhage occurs twice as common as SAH and is equally as deadly. Risk factors for ICH include hypertension, cerebral amyloid angiopathy, advanced age, antithrombotic therapy and history of cerebrovascular disease. The clinical presentation is "stroke like" with sudden onset of focal neurological deficits. Noncontrast head computerized tomography (CT) scan is the standard diagnostic tool. However, newer neuroimaging techniques have improved the diagnostic yield in terms of underlying pathophysiology and may aid in prognosis. Intracerebral hemorrhage is a neurological emergency. Medical care begins with stabilization of airway, breathing function, and circulation (ABCs), followed by specific measures aimed to decrease secondary neurological damage and to prevent both medical and neurological complications. Reversal of coagulopathy when present is of the essence. Blood pressure management can be key and continues as an area of debate and ongoing research. Surgical evacuation of ICH is of unproven benefit though a subset of well-selected patients may have improved outcomes. Ventriculostomy and intracranial pressure (ICP) monitoring are interventions also used in this patient population. To date, hemostatic medications and neuroprotectants have failed to result in clinical improvement. A multidisciplinary approach is recommended, with participation of vascular neurology, vascular neurosurgery, critical care, and rehabilitation medicine as the main players.
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Sakamoto Y, Koga M, Yamagami H, Okuda S, Okada Y, Kimura K, Shiokawa Y, Nakagawara J, Furui E, Hasegawa Y, Kario K, Arihiro S, Sato S, Kobayashi J, Tanaka E, Nagatsuka K, Minematsu K, Toyoda K. Systolic Blood Pressure After Intravenous Antihypertensive Treatment and Clinical Outcomes in Hyperacute Intracerebral Hemorrhage. Stroke 2013; 44:1846-51. [DOI: 10.1161/strokeaha.113.001212] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yuki Sakamoto
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Masatoshi Koga
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Hiroshi Yamagami
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Satoshi Okuda
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Yasushi Okada
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Kazumi Kimura
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Yoshiaki Shiokawa
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Jyoji Nakagawara
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Eisuke Furui
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Yasuhiro Hasegawa
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Kazuomi Kario
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Shoji Arihiro
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Shoichiro Sato
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Junpei Kobayashi
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Eijirou Tanaka
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Kazuyuki Nagatsuka
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Kazuo Minematsu
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
| | - Kazunori Toyoda
- From the Department of Cerebrovascular Medicine (Y.S., S.S., J.K., E.T., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan (H.Y.); Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Cerebrovascular Medicine, National Hospital Organization Kyushu Medical
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Bussière M, Gupta M, Sharma M, Dowlatshahi D, Fang J, Dhar R. Anaemia on Admission is Associated with More Severe Intracerebral Haemorrhage and Worse Outcomes. Int J Stroke 2013; 10:382-7. [DOI: 10.1111/j.1747-4949.2012.00951.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 06/20/2012] [Indexed: 11/29/2022]
Abstract
Background Lower haemoglobin levels may impair cerebral oxygen delivery and threaten tissue viability in the setting of acute brain injury. Few studies have examined the association between haemoglobin levels and outcomes after spontaneous intracerebral haemorrhage. Aims We evaluated whether anaemia on admission was associated with greater intracerebral haemorrhage severity and worse outcome. Methods Consecutive patients with spontaneous intracerebral haemorrhage were analyzed from the Registry of the Canadian Stroke Network. Admission haemoglobin was related to stroke severity (using the Canadian Neurological Scale), modified Rankin score at discharge, and one-year mortality. Adjustment was made for potential confounders including age, gender, medical history, warfarin use, glucose, creatinine, blood pressure, and intraventricular haemorrhage. Results Two thousand four hundred six patients with intracerebral haemorrhage were studied of whom 23% had anaemia (haemoglobin <120 g/l) on admission, including 4% with haemoglobin <100 g/l. Patients with anaemia were more likely to have severe neurological deficits at presentation [haemoglobin ≤100 g/l, adjusted odds ratio 4·04 (95% confidence interval 2·39, 6·84); haemoglobin 101–120 g/l, adjusted odds ratio 1·93 (95% confidence interval 1·43, 2·59), both P < 0·0001]. In nonanticoagulated patients, severe anaemia was also associated with poor outcome (modified Rankin score 4–6) at discharge [haemoglobin ≤100 g/l, adjusted odds ratio 2·42 (95% confidence interval 1·07–5·47), P= 0·034] and increased mortality at one-year [haemoglobin ≤100 g/l, adjusted hazard ratio 1·73 (95% confidence interval 1·22–2·45), P = 0·002]. Conclusions Anaemia on admission is associated with greater intracerebral haemorrhage severity and worse outcomes. The utility of transfusion remains unclear in this setting.
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Affiliation(s)
- Miguel Bussière
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Meera Gupta
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mukul Sharma
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Dar Dowlatshahi
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Rajat Dhar
- Division of Neurocritical Care, Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
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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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Cogez J, Bonnet AL, Touzé E. Pression artérielle: quel objectif à l’occasion d’un accident vasculaire cérébral aigu ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0649-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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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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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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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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Prabhakaran S, Naidech AM. Ischemic brain injury after intracerebral hemorrhage: a critical review. Stroke 2012; 43:2258-63. [PMID: 22821611 DOI: 10.1161/strokeaha.112.655910] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Shyam Prabhakaran
- Department of Neurology, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA.
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d’Esterre CD, Fainardi E, Aviv RI, Lee TY. Improving Acute Stroke Management with Computed Tomography Perfusion: A Review of Imaging Basics and Applications. Transl Stroke Res 2012; 3:205-20. [DOI: 10.1007/s12975-012-0178-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 04/09/2012] [Accepted: 04/12/2012] [Indexed: 10/28/2022]
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Menon RS, Burgess RE, Wing JJ, Gibbons MC, Shara NM, Fernandez S, Jayam-Trouth A, German L, Sobotka I, Edwards D, Kidwell CS. Predictors of highly prevalent brain ischemia in intracerebral hemorrhage. Ann Neurol 2012; 71:199-205. [PMID: 22367992 DOI: 10.1002/ana.22668] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study was undertaken to determine the prevalence, characteristics, risk factors, and temporal profile of concurrent ischemic lesions in patients with acute primary intracerebral hemorrhage (ICH). METHODS Patients were recruited within a prospective, longitudinal, magnetic resonance imaging (MRI)-based study of primary ICH. Clinical, demographic, and MRI data were collected on all subjects at baseline and 1 month. RESULTS Of the 138 patients enrolled, mean age was 59 years, 54% were male, 73% were black, and 84% had a history of hypertension. At baseline, ischemic lesions on diffusion-weighted imaging (DWI) were found in 35% of patients. At 1 month, lesions were present in 27%, and of these lesions, 83% were new and not present at baseline. ICH volume (p = 0.025), intraventricular hemorrhage (p = 0.019), presence of microbleeds (p = 0.024), and large, early reductions in mean arterial pressure (p = 0.003) were independent predictors of baseline DWI lesions. A multivariate logistical model predicting the presence of 1-month DWI lesions included history of any prior stroke (p = 0.012), presence of 1 or more microbleeds (p = 0.04), black race (p = 0.641), and presence of a DWI lesion at baseline (p = 0.007). INTERPRETATION This study demonstrates that >⅓ of patients with primary ICH have active cerebral ischemia at baseline remote from the index hematoma, and ¼ of patients experience ongoing, acute ischemic events at 1 month. Multivariate analyses implicate blood pressure reductions in the setting of an active vasculopathy as a potential underlying mechanism. Further studies are needed to determine the impact of these lesions on outcome and optimal management strategies to arrest vascular damage.
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Affiliation(s)
- Ravi S Menon
- Department of Neurology, Georgetown University, Washington, DC, USA.
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Abstract
Intracerebral hemorrhage is a devastating disease, and no specific therapy has been proven to reduce mortality in a randomized controlled trial. However, management in a neuroscience intensive care unit does appear to improve outcomes, suggesting that many available therapies do in fact provide benefit. In the acute phase of intracerebral hemorrhage care, strategies aimed at minimizing ongoing bleeding include reversal of anticoagulation and modest blood pressure reduction. In addition, the monitoring and regulation of glucose levels, temperature, and, in selected cases, intracranial pressure are recommended by many groups. Selected patients may benefit from hematoma evacuation or external ventricular drainage. Ongoing clinical trials are examining aggressive blood pressure management, hemostatic therapy, platelet transfusion, stereotactic hematoma evacuation, and intraventricular thrombolysis. Finally, preventing recurrence of intracerebral hemorrhage is of pivotal importance, and tight blood pressure management is paramount.
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Affiliation(s)
- H Bart Brouwers
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Tsai YH, Hsu LM, Weng HH, Lee MH, Yang JT, Lin CP. Voxel-based analysis of apparent diffusion coefficient in perihaematomal oedema: associated factors and outcome predictive value for intracerebral haemorrhage. BMJ Open 2011; 1:e000230. [PMID: 22080527 PMCID: PMC3227805 DOI: 10.1136/bmjopen-2011-000230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objectives The pathophysiology of perihaematomal oedema (PO) surrounding a primary intracerebral haemorrhage (ICH) is complicated and incompletely understood. We prospectively investigated the components of PO with voxel-based analysis of the apparent diffusion coefficient (ADC) value and assessed its predictive value for functional outcome. Design Forty-six patients with ICH who were enrolled for clinical evaluation underwent MRI scans within 24 h after ICH. Based on the ADC value of the ipsilateral voxels divided by the mean ADC value of the contralateral mirror region of interest, the voxels with oedema were classified into three categories: cytotoxic, vasogenic and undetermined. The percentages of cytotoxic and vasogenic oedema were then calculated and correlated with clinical outcome according to the modified Rankin Scale (mRS) at 6 months after ICH. The intraobserver and interobserver reliability of this method were examined using intraclass correlation coefficients. Results The intraclass correlation coefficients showed that analysis using the voxel-based method is highly reliable. Among the clinical variables tested, age and serum creatinine levels were positively correlated with percentage of cytotoxic oedema. Age, history of coronary artery disease, National Institutes of Health Stroke Scale score and percentage of cytotoxic oedema were all associated with mRS at 6 months after ICH. Conclusions The pathophysiological processes within PO are complicated. Voxel-based analysis of ADC values may help to identify the components of PO and may be beneficial for decision making and predicting outcome.
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Affiliation(s)
- Yuan-Hsiung Tsai
- Department of Radiology, Chang Gung Memorial Hospital, Chiayi, Taiwan, Republic of China
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming University, Taipei, Taiwan, Republic of China
| | - Li-Ming Hsu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming University, Taipei, Taiwan, Republic of China
| | - Hsu-Huei Weng
- Department of Radiology, Chang Gung Memorial Hospital, Chiayi, Taiwan, Republic of China
| | - Ming-Hsueh Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chiayi, Taiwan, Republic of China
| | - Jen-Tsung Yang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chiayi, Taiwan, Republic of China
| | - Ching-Po Lin
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming University, Taipei, Taiwan, Republic of China
- Institute of Neuroscience, National Yang Ming University, Taiwan, Republic of China
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[Intensive care management [corrected] of patients with intracerebral hemorrhage]. DER NERVENARZT 2011; 82:431-2, 434-6, 438-46. [PMID: 21431439 DOI: 10.1007/s00115-010-3072-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Approximately 10-15% of acute strokes are caused by non-aneurysmatic intracerebral hemorrhage (ICH) and incidences are expected to increase due to an aging population. Studies from the 1990s estimated mortality of ICH to be as high as 50%. However, these figures may partly be attributed to the fact that patients suffering from ICH frequently received only supportive therapy and the poor prognosis may therefore be more a self-fulfilling prophecy. Recently it has been shown that treatment in a specialized neurological intensive care unit alone was associated with better outcomes after ICH. In recent years considerable efforts have been undertaken in order to develop new therapies for ICH and to assess them in randomized controlled trials. Apart from admission status, hemorrhage volume is considered to be the main prognostic factor and impeding the spread of the hematoma is thus a basic therapeutic principle. The use of activated factor VIIa (aFVIIa) to stop hematoma enlargement has been assessed in two large randomized controlled trials, however the promising results of the dose-finding study could not be confirmed in a phase III trial. Although hemostatic therapy with aFVIIa reduced growth of the hematoma it failed to improve clinical outcome. Similar results were found in a randomized controlled trial on blood pressure management in acute ICH. The link between reduction of hematoma growth and improved outcome is therefore still lacking. Likewise the value of surgical hematoma evacuation remains uncertain. In the largest randomized controlled trial on surgical treatment in ICH so far, only a small subgroup of patients with superficial hemorrhages seemed to benefit from hematoma evacuation. Whether improved intensive care can contribute to improved outcome after ICH will be shown by data obtained in the coming years.
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d'Esterre CD, Chia TL, Jairath A, Lee TY, Symons SP, Aviv RI. Early rate of contrast extravasation in patients with intracerebral hemorrhage. AJNR Am J Neuroradiol 2011; 32:1879-84. [PMID: 21885714 DOI: 10.3174/ajnr.a2669] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE For patients with ICH, knowing the rate of CT contrast extravasation may provide insight into the pathophysiology of hematoma expansion. This study assessed whether the PCT-derived PS can measure different rates of CT contrast extravasation for admission CTA spot signs, PCCT, PCL, and regions without extravasation in patients with ICH. MATERIALS AND METHODS CT was performed at admission and at 24 hours for 16 patients with ICH with/without contrast extravasation seen on CTA and PCCT. PCT-PS was measured at admission. The Wilcoxon rank sum test with a Bonferroni correction was used to compare PS values from the following regions of interest: 1) spot sign lesions only (9 foci), 2) PCL lesions only (9 foci), 3) hematoma excluding extravasation, 4) regions contralateral to extravasation, 5) hematoma in patients without extravasation, and 6) an area contralateral to that in 5. Additionally, hematoma expansion was determined at 24 hours defined by NCCT. RESULTS PS was 6.5 ± 1.60 mL · min(-1) × (100 g)(-1), 0.95 ± 0.39 mL · min(-1) × (100 g)(-1), 0.12 ± 0.39 mL · min(-1) × (100 g)(-1), 0.26 ± 0.09 mL · min(-1) × (100 g)(-1), 0.38 ± 0.26 mL · min(-1) × (100 g)(-1), and 0.09 ± 0.32 mL · min(-1) × (100 g)(-1) for the following: 1) spot sign lesions only (9 foci), 2) PCL lesions only (9 foci), 3) hematoma excluding extravasation, 4) regions contralateral to extravasation, 5) hematoma in patients without extravasation, and 6) an area contralateral to that in 5. PS values from spot sign lesions and PCL lesions were significantly different from each other and all other regions, respectively (P < .05). Hematoma volume increased from 34.1 ± 41.0 mL to 40.2 ± 46.1 mL in extravasation-positive patients and decreased from 19.8 ± 31.8 mL to 17.4 ± 27.3 mL in extravasation-negative patients. CONCLUSIONS The PCT-PS parameter measures a higher rate of contrast extravasation for CTA spot sign lesions compared with PCL lesions and hematoma. Early extravasation was associated with hematoma expansion.
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Affiliation(s)
- C D d'Esterre
- Robarts Research Institute and Lawson Health Research Institute, University of Western Ontario, London, Canada
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