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Shi H, Tan X, Deng Y, He M, Chen D, Zhou W, Tang X, Liu Y, Cui M. Association between the surgical approach and prognosis of spontaneous supratentorial deep intracerebral hemorrhage. Sci Rep 2024; 14:3994. [PMID: 38369556 PMCID: PMC10874980 DOI: 10.1038/s41598-024-54639-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 02/14/2024] [Indexed: 02/20/2024] Open
Abstract
The association between surgical approach and prognosis in patients with spontaneous supratentorial deep intracerebral hemorrhage is unclear. We aimed to explore the association between surgical approach and prognosis in these patients. A retrospective cohort of 311 patients from 3 centers who were treated with surgery 24 h after ictus was recruited. The surgical procedure involved removing the intracerebral hematoma using an aspirator through either the cortical approach or Sylvian fissure approach, assisted by an endoscope or microscope. The primary outcome was the one-year modified Rankin scale (mRS) score. The association between the surgical approach and the one-year mRS score was explored by using ordinal logistic regression and binary logistic regression. Baseline characteristics were balanced by propensity score matching and inverse propensity score weighting. In the adjusted analysis, compared with the cortex approach group, the Sylvian fissure approach group had better one-year mRS scores when analyzed as an ordinal variable (3.00 [2.00-4.00] vs. 4.00 [3.00-5.00]; adjusted odds ratio, 3.15; 95% CI, 1.78-5.58; p < 0.001) and a dichotomous variable (74.14% vs. 49.01%; adjusted odds ratio, 6.61; 95% CI, 2.75-15.88; p < 0.001). Surgical approach was not significantly associated with rebleeding (p = 0.88) or three-month mortality (p = 0.81). In univariate analysis after propensity score matching, there were significant differences in one-year mRS score between the two groups (p < 0.001), and there were no significant differences in rebleeding (Fisher's exact test, p > 0.999) or three-month mortality (Fisher's exact test, p > 0.999). Inverse probability weighted regression analysis showed better one-year mRS scores when analyzed as an ordinal variable (adjusted odds ratio, 3.03; 95% CI, 2.17-4.17; p < 0.001) and a dichotomous variable (adjusted odds ratio, 3.11; 95% CI, 2.16-4.77; p < 0.001) in the Sylvian fissure approach group; the surgical approach was not significantly associated with rebleeding (p = 0.50) or three-month mortality (p = 0.60). In the surgical treatment of patients with spontaneous supratentorial deep intracerebral hemorrhage, the Sylvian fissure approach may lead to a better functional outcome compared with the cortex approach. Future prospective studies are warranted to confirm this finding.
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Affiliation(s)
- Hui Shi
- Department of Neurosurgery, Yongchuan Hospital of Chongqing Medical University, Chongqing, 402160, China
| | - Xingwei Tan
- Department of Neurology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China
| | - Yongbing Deng
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, 1 Jiankang Road, Yuzhong District, Chongqing, 400010, China
- Chongqing Key Laboratory of Emergency Medicine, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400010, China
| | - Minglian He
- Institute of Hepatopancreatobiliary Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Dongsheng Chen
- Department of Neurosurgery, Yongchuan Hospital of Chongqing Medical University, Chongqing, 402160, China
| | - Weichong Zhou
- Department of Neurosurgery, Yongchuan Hospital of Chongqing Medical University, Chongqing, 402160, China
| | - Xiaoyong Tang
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, 1 Jiankang Road, Yuzhong District, Chongqing, 400010, China
- Chongqing Key Laboratory of Emergency Medicine, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400010, China
| | - Yang Liu
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, 1 Jiankang Road, Yuzhong District, Chongqing, 400010, China
- Chongqing Key Laboratory of Emergency Medicine, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400010, China
| | - Min Cui
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, 1 Jiankang Road, Yuzhong District, Chongqing, 400010, China.
- Chongqing Key Laboratory of Emergency Medicine, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, 400010, China.
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Kleven RT, Huang S, Ford SM, Sakthivel K, Thomas SR, Zuccarello M, Herr AB, Holland CK. Effect of Recombinant Tissue Plasminogen Activator and 120-kHz Ultrasound on Porcine Intracranial Thrombus Density. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:539-548. [PMID: 36336551 DOI: 10.1016/j.ultrasmedbio.2022.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
Surgical intervention for the treatment of intracerebral hemorrhage (ICH) has been limited by inadequate lysis of the target thrombus. Adjuvant transcranial ultrasound exposure is hypothesized to improve thrombolysis, expedite hematoma evacuation and improve clinical outcomes. A juvenile porcine intracerebral hemorrhage model was established by direct infusion of autologous blood into the porcine white matter. Thrombi were either not treated (sham) or treated with recombinant tissue plasminogen activator alone (rt-PA only) or in combination with pulsed transcranial 120-kHz ultrasound (sonothrombolysis). After treatment, pigs were euthanized, the heads frozen and sectioned and the thrombi extracted. D-Dimer and thrombus density assays were used to assess degree of lysis. Both porcine and human D-dimer assays tested did not have sufficient sensitivity to detect porcine D-dimer. Thrombi treated with rt-PA with or without 120-kHz ultrasound had a significantly lower density compared with sham-treated thrombi. No enhancement of rt-PA-mediated thrombolysis was noted with the addition of 120-kHz ultrasound (sonothrombolysis). The thrombus density assay revealed thrombolytic efficacy caused by rt-PA in an in vivo juvenile porcine model of intracerebral hemorrhage. Transcranial sonothrombolysis did not enhance rt-PA-induced thrombolysis, likely because of the lack of exogenous cavitation nuclei.
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Affiliation(s)
- Robert T Kleven
- Department of Biomedical Engineering, College of Engineering and Applied Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Shenwen Huang
- Department of Biomedical Engineering, College of Engineering and Applied Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Samantha M Ford
- Neuroscience Program, College of Arts and Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Karthikeyan Sakthivel
- Medical Sciences Program, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Seth R Thomas
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Andrew B Herr
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christy K Holland
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, Ohio, USA; Department of Biomedical Engineering, College of Engineering and Applied Sciences, University of Cincinnati, Cincinnati, Ohio, USA.
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3
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Paiva WS, Zippo E, Miranda C, Brasil S, Godoy DA, De Andrade AF, Neville I, Patriota GC, Domingues R, Teixeira MJ. Animal models for the study of intracranial hematomas (Review). Exp Ther Med 2022; 25:20. [PMID: 36561628 PMCID: PMC9748783 DOI: 10.3892/etm.2022.11719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022] Open
Abstract
Intracranial hematomas (ICH) are a frequent condition in neurosurgical and neurological practices, with several mechanisms of primary and secondary injury. Experimental research has been fundamental for the understanding of the pathophysiology implicated with ICH and the development of therapeutic interventions. To date, a variety of different animal approaches have been described that consider, for example, the ICH evolutive phase, molecular implications and hemodynamic changes. Therefore, choosing a test protocol should consider the scope of each particular study. The present review summarized investigational protocols in experimental research on the subject of ICH. With this subject, injection of autologous blood or bacterial collagenase, inflation of intracranial balloon and avulsion of cerebral vessels were the models identified. Rodents (mice) and swine were the most frequent species used. These different models allowed improvements on the understanding of intracranial hypertension establishment, neuroinflammation, immunology, brain hemodynamics and served to the development of therapeutic strategies.
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Affiliation(s)
- Wellingson Silva Paiva
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Emanuele Zippo
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Carolina Miranda
- Neurology Center, Samaritan Hospital, 01232010 São Paulo, Brazil
| | - Sérgio Brasil
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Correspondence to: Dr Sérgio Brasil, Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, 05403 São Paulo, Brazil
| | - Daniel Augustin Godoy
- Department of Intensive Care, Neurointensive Care Unit, Pasteur Hospital, 4700 Catamarca, Argentina
| | - Almir Ferreira De Andrade
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Iuri Neville
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | | | - Renan Domingues
- Neurology Center, Samaritan Hospital, 01232010 São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
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Baker TS, Kellner CP, Colbourne F, Rincon F, Kollmar R, Badjatia N, Dangayach N, Mocco J, Selim MH, Lyden P, Polderman K, Mayer S. Consensus recommendations on therapeutic hypothermia after minimally invasive intracerebral hemorrhage evacuation from the hypothermia for intracerebral hemorrhage (HICH) working group. Front Neurol 2022; 13:859894. [PMID: 36062017 PMCID: PMC9428129 DOI: 10.3389/fneur.2022.859894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Therapeutic hypothermia (TH), or targeted temperature management (TTM), is a classic treatment option for reducing inflammation and potentially other destructive processes across a wide range of pathologies, and has been successfully used in numerous disease states. The ability for TH to improve neurological outcomes seems promising for inflammatory injuries but has yet to demonstrate clinical benefit in the intracerebral hemorrhage (ICH) patient population. Minimally invasive ICH evacuation also presents a promising option for ICH treatment with strong preclinical data but has yet to demonstrate functional improvement in large randomized trials. The biochemical mechanisms of action of ICH evacuation and TH appear to be synergistic, and thus combining hematoma evacuation with cooling therapy could provide synergistic benefits. The purpose of this working group was to develop consensus recommendations on optimal clinical trial design and outcomes for the use of therapeutic hypothermia in ICH in conjunction with minimally invasive ICH evacuation. Methods An international panel of experts on the intersection of critical-care TH and ICH was convened to analyze available evidence and form a consensus on critical elements of a focal cooling protocol and clinical trial design. Three focused sessions and three full-group meetings were held virtually from December 2020 to February 2021. Each meeting focused on a specific subtopic, allowing for guided, open discussion. Results These recommendations detail key elements of a clinical cooling protocol and an outline for the roll-out of clinical trials to test and validate the use of TH in conjunction with hematoma evacuation as well as late-stage protocols to improve the cooling approach. The combined use of systemic normothermia and localized moderate (33.5°C) hypothermia was identified as the most promising treatment strategy. Conclusions These recommendations provide a general outline for the use of TH after minimally invasive ICH evacuation. More research is needed to further refine the use and combination of these promising treatment paradigms for this patient population.
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Affiliation(s)
- Turner S. Baker
- Icahn School of Medicine at Mount Sinai, Sinai BioDesign, New York, NY, United States
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Turner S. Baker
| | - Christopher P. Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Fred Rincon
- Department of Neurology, Thomas Jefferson University Hospital, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Neha Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - J. Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Magdy H. Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, United States
| | - Patrick Lyden
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, CA, United States
| | - Kees Polderman
- United Memorial Medical Center, Houston, TX, United States
| | - Stephan Mayer
- Westchester Medical Center Health Network, Valhalla, NY, United States
- Department of Neurology, New York Medical College, Valhalla, NY, United States
- Department of Neurosurgery, New York Medical College, Valhalla, NY, United States
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Zhang R, Yong VW, Xue M. Revisiting Minocycline in Intracerebral Hemorrhage: Mechanisms and Clinical Translation. Front Immunol 2022; 13:844163. [PMID: 35401553 PMCID: PMC8993500 DOI: 10.3389/fimmu.2022.844163] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/24/2022] [Indexed: 01/31/2023] Open
Abstract
Intracerebral hemorrhage (ICH) is an important subtype of stroke with an unsatisfactory prognosis of high mortality and disability. Although many pre-clinical studies and clinical trials have been performed in the past decades, effective therapy that meaningfully improve prognosis and outcomes of ICH patients is still lacking. An active area of research is towards alleviating secondary brain injury after ICH through neuroprotective pharmaceuticals and in which minocycline is a promising candidate. Here, we will first discuss new insights into the protective mechanisms of minocycline for ICH including reducing iron-related toxicity, maintenance of blood-brain barrier, and alleviating different types of cell death from preclinical data, then consider its shortcomings. Finally, we will review clinical trial perspectives for minocycline in ICH. We hope that this summary and discussion about updated information on minocycline as a viable treatment for ICH can facilitate further investigations.
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Affiliation(s)
- Ruiyi Zhang
- The Departments of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - V. Wee Yong
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mengzhou Xue
- The Departments of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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6
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Aronowski J, Sansing LH, Xi G, Zhang JH. Mechanisms of Damage After Cerebral Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kellner CP, Song R, Ali M, Nistal DA, Samarage M, Dangayach NS, Liang J, McNeill I, Zhang X, Bederson JB, Mocco J. Time to Evacuation and Functional Outcome After Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation. Stroke 2021; 52:e536-e539. [PMID: 34424739 DOI: 10.1161/strokeaha.121.034392] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE We present a retrospective analysis of patients who underwent minimally invasive endoscopic intracerebral hemorrhage (ICH) evacuation to identify variables that were associated with long-term outcome. METHODS Minimally invasive endoscopic ICH evacuation was performed on patients with supratentorial ICH who fit prespecified clinical inclusion and exclusion criteria. Demographic, clinical, and radiographic factors previously demonstrated to impact functional outcome in ICH were included in a univariate analysis to identify factors associated with favorable outcome (modified Rankin Scale score, 0-3) at 6 months. Factors associated with a favorable outcome in the univariate analysis (P≤0.20) were included in a multivariate logistic regression analysis with the same dependent variable. RESULTS Ninety patients underwent MIS endoscopic ICH evacuation within 72 hours of ictus. In a multivariate analysis, factors associated with good long-term functional outcome included time to evacuation (per hour; OR, 0.95 [95% CI, 0.92-0.98], P=0.004), age (per decade, odds ratio [OR], 0.49 [95% CI, 0.28-0.77], P=0.005), presence of intraventricular hemorrhage (OR, 0.15 [95% CI, 0.04-0.47], P=0.002), and lobar location (OR, 18.5 [95% CI, 4.5-103], P=0.0005). Early evacuation was not associated with an increased risk of rebleeding. CONCLUSIONS Young age, lack of intraventricular hemorrhage, lobar location, and time to evacuation were independently associated with good long-term functional outcome in patients undergoing minimally invasive endoscopic ICH evacuation. The OR for time to evacuation suggests that for each additional hour, there was a 5% reduction in the odds of achieving a favorable outcome.
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Affiliation(s)
| | - Rui Song
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Dominic A Nistal
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Milan Samarage
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Neha S Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Ian McNeill
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Xiangnan Zhang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
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8
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Kellner CP, Schupper AJ, Mocco J. Surgical Evacuation of Intracerebral Hemorrhage: The Potential Importance of Timing. Stroke 2021; 52:3391-3398. [PMID: 34187180 DOI: 10.1161/strokeaha.121.032238] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York
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9
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Fil JE, Joung S, Hayes CA, Dilger RN. Influence of Rearing Environment on Longitudinal Brain Development, Object Recognition Memory, and Exploratory Behaviors in the Domestic Pig ( Sus scrofa). Front Neurosci 2021; 15:649536. [PMID: 33841090 PMCID: PMC8024486 DOI: 10.3389/fnins.2021.649536] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/04/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Over the last 40 years, the domestic pig has emerged as a prominent preclinical model as this species shares similarities with humans with regard to immunity, gastrointestinal physiology, and neurodevelopment. Artificial rearing of pigs provides a number of advantages over conventional rearing (i.e., true maternal care), including careful control of nutrient intake and environment conditions. Yet there remains a gap in knowledge when comparing brain development between sow-reared and artificially reared domestic pigs. Thus, our research sought to model brain development and assess recognition memory in a longitudinal manner by directly comparing rearing environments. Methods Forty-four intact (i.e., not castrated) male pigs were artificially reared or sow-reared from postnatal day 2 until postnatal week 4. After postnatal week 4, all pigs were housed in a group setting within the same environment until postnatal week 24. Magnetic resonance imaging was conducted on pigs at 8 longitudinal time-points to model developmental trajectories of brain macrostructural and microstructural outcomes. Additionally, pigs behavior were tested using the novel object recognition task at postnatal weeks 4 and 8. Results Throughout the 24-week study, no differences between rearing groups were noted in weekly body weights, average growth and feed intake patterns, or feed efficiency. Whole brain, gray matter, white matter, and cerebrospinal fluid growth patterns also did not differ between pigs assigned to different early-life rearing environments. Moreover, minimal differences in regional absolute volumes and fractional anisotropy developmental trajectories were identified, though artificially reared pigs exhibited higher initial rates of myelination in multiple brain regions compared with sow-reared pigs. Furthermore, behavioral assessment at both PNW 4 and 8 suggested little influence of rearing environment on recognition memory, however, an age-dependent increase in object recognition memory was observed in the sow-reared group. Conclusion Our findings suggest that early-life rearing environment influences the rate of development in some brain regions but has little influence on overall brain growth and object recognition memory and exploratory behaviors in the domestic pig. Artificial rearing may promote maturation in certain brain areas but does not appear to elicit long-term effects in outcomes including brain structure or object recognition memory.
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Affiliation(s)
- Joanne E Fil
- Neuroscience Program, University of Illinois, Urbana, IL, United States
| | - Sangyun Joung
- Neuroscience Program, University of Illinois, Urbana, IL, United States
| | - Courtney A Hayes
- College of Veterinary Medicine, University of Illinois, Urbana, IL, United States
| | - Ryan N Dilger
- Neuroscience Program, University of Illinois, Urbana, IL, United States.,Department of Animal Sciences, University of Illinois, Urbana, IL, United States.,Division of Nutritional Sciences, University of Illinois, Urbana, IL, United States
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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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Withers SE, Parry-Jones AR, Allan SM, Kasher PR. A Multi-Model Pipeline for Translational Intracerebral Haemorrhage Research. Transl Stroke Res 2020; 11:1229-1242. [PMID: 32632777 PMCID: PMC7575484 DOI: 10.1007/s12975-020-00830-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023]
Abstract
Apart from acute and chronic blood pressure lowering, we have no specific medications to prevent intracerebral haemorrhage (ICH) or improve outcomes once bleeding has occurred. One reason for this may be related to particular limitations associated with the current pre-clinical models of ICH, leading to a failure to translate into the clinic. It would seem that a breakdown in the 'drug development pipeline' currently exists for translational ICH research which needs to be urgently addressed. Here, we review the most commonly used pre-clinical models of ICH and discuss their advantages and disadvantages in the context of translational studies. We propose that to increase our chances of successfully identifying new therapeutics for ICH, a bi-directional, 2- or 3-pronged approach using more than one model species/system could be useful for confirming key pre-clinical observations. Furthermore, we highlight that post-mortem/ex-vivo ICH patient material is a precious and underused resource which could play an essential role in the verification of experimental results prior to consideration for further clinical investigation. Embracing multidisciplinary collaboration between pre-clinical and clinical ICH research groups will be essential to ensure the success of this type of approach in the future.
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Affiliation(s)
- Sarah E Withers
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Adrian R Parry-Jones
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Stott Lane, Salford, M6 8HD, UK
| | - Stuart M Allan
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Paul R Kasher
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Oxford Road, Manchester, M13 9PT, UK.
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Bai Q, Sheng Z, Liu Y, Zhang R, Yong VW, Xue M. Intracerebral haemorrhage: from clinical settings to animal models. Stroke Vasc Neurol 2020; 5:388-395. [PMID: 33376200 PMCID: PMC7804065 DOI: 10.1136/svn-2020-000334] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/21/2020] [Accepted: 02/27/2020] [Indexed: 12/13/2022] Open
Abstract
Spontaneous intracerebral haemorrhage (ICH) is a devastating type of stroke with high mortality and morbidity and for which no effective treatments are available to date. Much experimental and clinical research have been performed to explore its mechanisms regard the subsequent inflammatory cascade and to seek the potential therapeutic strategies. The aim of this review is to discuss insights from clinical settings that have led to the development of numerous animal models of ICH. Some of the current and future challenges for clinicians to understand ICH are also surveyed.
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Affiliation(s)
- Qian Bai
- The Departments of Cerebrovascular Diseases; Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhaofu Sheng
- The Departments of Cerebrovascular Diseases; Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yang Liu
- The Departments of Cerebrovascular Diseases; Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruiyi Zhang
- The Departments of Cerebrovascular Diseases; Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Voon Wee Yong
- Hotchkiss Brain Institute and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Mengzhou Xue
- The Departments of Cerebrovascular Diseases; Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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13
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Melià-Sorolla M, Castaño C, DeGregorio-Rocasolano N, Rodríguez-Esparragoza L, Dávalos A, Martí-Sistac O, Gasull T. Relevance of Porcine Stroke Models to Bridge the Gap from Pre-Clinical Findings to Clinical Implementation. Int J Mol Sci 2020; 21:ijms21186568. [PMID: 32911769 PMCID: PMC7555414 DOI: 10.3390/ijms21186568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/03/2020] [Accepted: 09/07/2020] [Indexed: 12/18/2022] Open
Abstract
In the search of animal stroke models providing translational advantages for biomedical research, pigs are large mammals with interesting brain characteristics and wide social acceptance. Compared to rodents, pigs have human-like highly gyrencephalic brains. In addition, increasingly through phylogeny, animals have more sophisticated white matter connectivity; thus, ratios of white-to-gray matter in humans and pigs are higher than in rodents. Swine models provide the opportunity to study the effect of stroke with emphasis on white matter damage and neuroanatomical changes in connectivity, and their pathophysiological correlate. In addition, the subarachnoid space surrounding the swine brain resembles that of humans. This allows the accumulation of blood and clots in subarachnoid hemorrhage models mimicking the clinical condition. The clot accumulation has been reported to mediate pathological mechanisms known to contribute to infarct progression and final damage in stroke patients. Importantly, swine allows trustworthy tracking of brain damage evolution using the same non-invasive multimodal imaging sequences used in the clinical practice. Moreover, several models of comorbidities and pathologies usually found in stroke patients have recently been established in swine. We review here ischemic and hemorrhagic stroke models reported so far in pigs. The advantages and limitations of each model are also discussed.
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Affiliation(s)
- Marc Melià-Sorolla
- Cellular and Molecular Neurobiology Research Group, Department of Neurosciences, Germans Trias i Pujol Research Institute, 08916 Badalona, Catalonia, Spain; (M.M.-S.); (N.D.-R.)
| | - Carlos Castaño
- Neurointerventional Radiology Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, 08916 Badalona, Catalonia, Spain;
| | - Núria DeGregorio-Rocasolano
- Cellular and Molecular Neurobiology Research Group, Department of Neurosciences, Germans Trias i Pujol Research Institute, 08916 Badalona, Catalonia, Spain; (M.M.-S.); (N.D.-R.)
| | - Luis Rodríguez-Esparragoza
- Stroke Unit, Department of Neurology, Hospital Germans Trias i Pujol, 08916 Badalona, Catalonia, Spain; (L.R.-E.); (A.D.)
| | - Antoni Dávalos
- Stroke Unit, Department of Neurology, Hospital Germans Trias i Pujol, 08916 Badalona, Catalonia, Spain; (L.R.-E.); (A.D.)
| | - Octavi Martí-Sistac
- Cellular and Molecular Neurobiology Research Group, Department of Neurosciences, Germans Trias i Pujol Research Institute, 08916 Badalona, Catalonia, Spain; (M.M.-S.); (N.D.-R.)
- Department of Cellular Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, 08916 Bellaterra, Catalonia, Spain
- Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol (IGTP), Carretera del Canyet, Camí de les Escoles s/n, Edifici Mar, 08916 Badalona, Catalonia, Spain
- Correspondence: (O.M.-S.); (T.G.); Tel.: +34-930330531 (O.M.-S.)
| | - Teresa Gasull
- Cellular and Molecular Neurobiology Research Group, Department of Neurosciences, Germans Trias i Pujol Research Institute, 08916 Badalona, Catalonia, Spain; (M.M.-S.); (N.D.-R.)
- Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol (IGTP), Carretera del Canyet, Camí de les Escoles s/n, Edifici Mar, 08916 Badalona, Catalonia, Spain
- Correspondence: (O.M.-S.); (T.G.); Tel.: +34-930330531 (O.M.-S.)
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14
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Bai Q, Xue M, Yong VW. Microglia and macrophage phenotypes in intracerebral haemorrhage injury: therapeutic opportunities. Brain 2020; 143:1297-1314. [PMID: 31919518 DOI: 10.1093/brain/awz393] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/19/2019] [Accepted: 10/20/2019] [Indexed: 01/24/2023] Open
Abstract
Abstract
The prognosis of intracerebral haemorrhage continues to be devastating despite much research into this condition. A prominent feature of intracerebral haemorrhage is neuroinflammation, particularly the excessive representation of pro-inflammatory CNS-intrinsic microglia and monocyte-derived macrophages that infiltrate from the circulation. The pro-inflammatory microglia/macrophages produce injury-enhancing factors, including inflammatory cytokines, matrix metalloproteinases and reactive oxygen species. Conversely, the regulatory microglia/macrophages with potential reparative and anti-inflammatory roles are outcompeted in the early stages after intracerebral haemorrhage, and their beneficial roles appear to be overwhelmed by pro-inflammatory microglia/macrophages. In this review, we describe the activation of microglia/macrophages following intracerebral haemorrhage in animal models and clinical subjects, and consider their multiple mechanisms of cellular injury after haemorrhage. We review strategies and medications aimed at suppressing the pro-inflammatory activities of microglia/macrophages, and those directed at elevating the regulatory properties of these myeloid cells after intracerebral haemorrhage. We consider the translational potential of these medications from preclinical models to clinical use after intracerebral haemorrhage injury, and suggest that several approaches still lack the experimental support necessary for use in humans. Nonetheless, the preclinical data support the use of deactivator or inhibitor of pro-inflammatory microglia/macrophages, whilst enhancing the regulatory phenotype, as part of the therapeutic approach to improve the prognosis of intracerebral haemorrhage.
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Affiliation(s)
- Qian Bai
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Department of Anesthesiology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, Henan, China
| | - Mengzhou Xue
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, Henan, China
| | - V Wee Yong
- Hotchkiss Brain Institute and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Haque ME, Gabr RE, George SD, Zhao X, Boren SB, Zhang X, Ting SM, Sun G, Hasan KM, Savitz S, Aronowski J. Serial Metabolic Evaluation of Perihematomal Tissues in the Intracerebral Hemorrhage Pig Model. Front Neurosci 2019; 13:888. [PMID: 31496934 PMCID: PMC6712426 DOI: 10.3389/fnins.2019.00888] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/07/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose Perihematomal edema (PHE) occurs in patients with intracerebral hemorrhage (ICH) and is often used as surrogate of secondary brain injury. PHE resolves over time, but little is known about the functional integrity of the tissues that recover from edema. In a pig ICH model, we aimed to assess metabolic integrity of perihematoma tissues by using non-invasive magnetic resonance spectroscopy (MRS). Materials and Methods Fourteen male Yorkshire pigs with an average age of 8 weeks were intracerebrally injected with autologous blood to produce ICH. Proton MRS data were obtained at 1, 7, and 14 days after ICH using a whole-body 3.0T MRI system. Point-resolved spectroscopy (PRESS)-localized 2D chemical shift imaging (CSI) was acquired. The concentration of N-Acetylaspartate (NAA), Choline (Cho), and Creatine (Cr) were measured within the area of PHE, tissues adjacent to the injury with no or negligible edema (ATNE), and contralesional brain tissue. A linear mixed model was used to analyze the evolution of metabolites in perihematomal tissues, with p-value < 0.05 indicating statistical significance. Results The perihematoma volume gradually decreased from 2.38 ± 1.23 ml to 0.41 ± 0.780 ml (p < 0.001) over 2 weeks. Significant (p < 0.001) reductions in NAA, Cr, and Cho concentrations were found in the PHE and ATNE regions compared to the contralesional hemisphere at day 1 and 7 after ICH. All three metabolites were significantly (p < 0.001) restored in the PHE tissue on day 14, but remained persistently low in the ATNE area, and unaltered in the contralesional voxel. Conclusion This study highlights the potential of MRS to probe salvageable tissues within the perihematoma in the sub-acute phase of ICH. Altered metabolites within the PHE and ATNE regions in addition to edema and hematoma volumes were explored as possible markers for tissue recovery. Perihematomal tissue with PHE demonstrated a more reversible injury compared to the tissue adjacent to the injury without edema, suggesting a potentially beneficial role of edema.
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Affiliation(s)
- Muhammad E Haque
- Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Refaat E Gabr
- Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sarah D George
- Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Xiurong Zhao
- Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Seth B Boren
- Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Xu Zhang
- Biostatistics, Epidemiology, and Research Design Component, Center for Clinical and Translational Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Shun-Ming Ting
- Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Gunghua Sun
- Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Khader M Hasan
- Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sean Savitz
- Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jaroslaw Aronowski
- Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
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Abstract
PURPOSE OF REVIEW This article describes the advances in the management of spontaneous intracerebral hemorrhage in adults. RECENT FINDINGS Therapeutic intervention in intracerebral hemorrhage has continued to focus on arresting hemorrhage expansion, with large randomized controlled trials addressing the effectiveness of rapidly lowering blood pressure, hemostatic therapy with platelet transfusion, and other clotting complexes and clot volume reduction both of intraventricular and parenchymal hematomas using minimally invasive techniques. Smaller studies targeting perihematomal edema and inflammation may also show promise. SUMMARY The management of spontaneous intracerebral hemorrhage, long relegated to the management and prevention of complications, is undergoing a recent evolution in large part owing to stereotactically guided clot evacuation techniques that have been shown to be safe and that may potentially improve outcomes.
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Jing C, Bian L, Wang M, Keep RF, Xi G, Hua Y. Enhancement of Hematoma Clearance With CD47 Blocking Antibody in Experimental Intracerebral Hemorrhage. Stroke 2019; 50:1539-1547. [PMID: 31084334 DOI: 10.1161/strokeaha.118.024578] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Our previous studies found that erythrocyte CD47 has a role in regulating hematoma resolution following experimental intracerebral hemorrhage (ICH). The current study examined whether or not a CD47 blocking antibody enhances hematoma clearance in a mouse ICH. Methods- ICH was induced by intracaudate injection of autologous blood in adult C57BL/6 mice. Mice had an ICH or ICH with CD47 blocking antibody or IgG coinjection. In subgroups of CD47 blocking antibody-treated mice, clodronate (to deplete microglia/macrophages) or control liposomes were coinjected. The effects of CD47 blocking antibody on ICH-induced brain injury were also tested in both males and females. Mice had magnetic resonance imaging to examine clot volume, iron deposition, brain swelling, and brain tissue loss. Behavioral tests were performed in all mice, and brains were harvested for brain immunohistochemistry. Results- In male mice, CD47 blocking antibody speeded up hematoma/iron clearance by macrophages/microglia and reduced ICH-induced brain swelling, neuronal loss, and neurological deficits. In contrast, clodronate liposome-induced microglia/macrophage depletion caused more severe brain swelling, neuronal loss, and functional deficits. In addition, similar injury severity in males and females was found in IgG control group and CD47 blocking antibody was also effective in females. Conclusions- Blocking CD47 in the hematoma speeded hematoma clearance and reduced brain injury after ICH suggesting it could be a treatment for ICH patients with surgical clot removal.
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Affiliation(s)
- Chaohui Jing
- From the Department of Neurosurgery, University of Michigan, Ann Arbor (C.J., L.B., M.W., R.F.K., G.X., Y.H.).,Department of Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University, China (C.J.)
| | - Liheng Bian
- From the Department of Neurosurgery, University of Michigan, Ann Arbor (C.J., L.B., M.W., R.F.K., G.X., Y.H.)
| | - Ming Wang
- From the Department of Neurosurgery, University of Michigan, Ann Arbor (C.J., L.B., M.W., R.F.K., G.X., Y.H.)
| | - Richard F Keep
- From the Department of Neurosurgery, University of Michigan, Ann Arbor (C.J., L.B., M.W., R.F.K., G.X., Y.H.)
| | - Guohua Xi
- From the Department of Neurosurgery, University of Michigan, Ann Arbor (C.J., L.B., M.W., R.F.K., G.X., Y.H.)
| | - Ya Hua
- From the Department of Neurosurgery, University of Michigan, Ann Arbor (C.J., L.B., M.W., R.F.K., G.X., Y.H.)
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18
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Ziai WC, McBee N, Lane K, Lees KR, Dawson J, Vespa P, Thompson RE, Mendelow AD, Kase CS, Carhuapoma JR, Thompson CB, Mayo SW, Reilly P, Janis S, Anderson CS, Harrigan MR, Camarata PJ, Caron JL, Zuccarello M, Awad IA, Hanley DF. A randomized 500-subject open-label phase 3 clinical trial of minimally invasive surgery plus alteplase in intracerebral hemorrhage evacuation (MISTIE III). Int J Stroke 2019; 14:548-554. [PMID: 30943878 DOI: 10.1177/1747493019839280] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
RATIONALE AND HYPOTHESIS Surgical removal of spontaneous intracerebral hemorrhage may reduce secondary destruction of brain tissue. However, large surgical trials of craniotomy have not demonstrated definitive improvement in clinical outcomes. Minimally invasive surgery may limit surgical tissue injury, and recent evidence supports testing these approaches in large clinical trials. METHODS AND DESIGN MISTIE III is an investigator-initiated multicenter, randomized, open-label phase 3 study investigating whether minimally invasive clot evacuation with thrombolysis improves functional outcomes at 365 days compared to conservative management. Patients with supratentorial intracerebral hemorrhage clot volume ≥ 30 mL, confirmed by imaging within 24 h ofknown symptom onset,and intact brainstem reflexes were screened with a stability computed tomography scan at least 6 h after diagnostic scan. Patients who met clinical and imaging criteria (no ongoing coagulopathy; no suspicion of aneurysm, arteriovenous malformation, or any other vascular anomaly; and stable hematoma size on consecutive scans) were randomized to either minimally invasive surgery plus thrombolysis or medical therapy. The sample size of 500 was based on findings of a phase 2 study. STUDY OUTCOMES The primary outcome measure is dichotomized modified Rankin Scale 0-3 vs. 4-6 at 365 days adjusting for severity variables. Clinical secondary outcomes include dichotomized extended Glasgow Outcome Scale and all-cause mortality at 365 days; rate and extent of parenchymal blood clot removal; patient disposition at 365 days; efficacy at 180 days; type and intensity of ICU management; and quality of life measures. Safety was assessed at 30 days and throughout the study.
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Affiliation(s)
- Wendy C Ziai
- 1 Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Nichol McBee
- 2 Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Karen Lane
- 2 Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Kennedy R Lees
- 3 School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- 4 Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Paul Vespa
- 5 Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Richard E Thompson
- 6 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - A David Mendelow
- 7 Department of Neurosurgery, Newcastle University, Newcastle upon Tyne, UK
| | - Carlos S Kase
- 8 Department of Neurology, Emory University, Atlanta, GA, USA
| | - J Ricardo Carhuapoma
- 1 Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Carol B Thompson
- 9 Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Pat Reilly
- 11 Genentech Inc., San Francisco, CA, USA (retired).,12 Jamison-Reilly LLC, Hummelstown, PA, USA
| | - Scott Janis
- 13 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Craig S Anderson
- 14 The George Institute for Global Health China at Peking University Health Science Center, Beijing, China.,15 The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Mark R Harrigan
- 16 Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - Paul J Camarata
- 17 Department of Neurosurgery, University of Kansas, Kansas City, KS, USA
| | - Jean-Louis Caron
- 18 Department of Neurosurgery, University of Texas, San Antonio, TX, USA
| | - Mario Zuccarello
- 19 Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Issam A Awad
- 20 Section of Neurosurgery, Neurovascular Surgery Program, University of Chicago, Chicago, IL, USA
| | - Daniel F Hanley
- 2 Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
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19
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Hanley DF, Thompson RE, Rosenblum M, Yenokyan G, Lane K, McBee N, Mayo SW, Bistran-Hall AJ, Gandhi D, Mould WA, Ullman N, Ali H, Carhuapoma JR, Kase CS, Lees KR, Dawson J, Wilson A, Betz JF, Sugar EA, Hao Y, Avadhani R, Caron JL, Harrigan MR, Carlson AP, Bulters D, LeDoux D, Huang J, Cobb C, Gupta G, Kitagawa R, Chicoine MR, Patel H, Dodd R, Camarata PJ, Wolfe S, Stadnik A, Money PL, Mitchell P, Sarabia R, Harnof S, Barzo P, Unterberg A, Teitelbaum JS, Wang W, Anderson CS, Mendelow AD, Gregson B, Janis S, Vespa P, Ziai W, Zuccarello M, Awad IA. Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet 2019; 393:1021-1032. [PMID: 30739747 PMCID: PMC6894906 DOI: 10.1016/s0140-6736(19)30195-3] [Citation(s) in RCA: 447] [Impact Index Per Article: 89.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/13/2019] [Accepted: 01/22/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage. METHODS MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0-3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number NCT01827046. FINDINGS Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0-3 at 365 days (adjusted risk difference 4% [95% CI -4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012). INTERPRETATION For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons. FUNDING National Institute of Neurological Disorders and Stroke and Genentech.
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Affiliation(s)
- Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA.
| | - Richard E Thompson
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Rosenblum
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Gayane Yenokyan
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - W Andrew Mould
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | - Hasan Ali
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Kennedy R Lees
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Alastair Wilson
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Joshua F Betz
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth A Sugar
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Yi Hao
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Diederik Bulters
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - David LeDoux
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Judy Huang
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Cully Cobb
- Mercy Neurological Institute Stroke Center, Sacramento, California, USA
| | - Gaurav Gupta
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ryan Kitagawa
- University of Texas, McGovern Medical Center, Houston, TX, USA
| | | | | | - Robert Dodd
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Stacey Wolfe
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | | | | | | | | | - Pal Barzo
- University of Szeged, Szeged, Hungary
| | | | - Jeanne S Teitelbaum
- Montreal Neurological Institute and Hospital at McGill University, Montreal, QC, Canada
| | - Weimin Wang
- Guangzhou Neuroscience Institute, Guangzhou Liuhua Qiao Hospital, Guangzhou, China
| | - Craig S Anderson
- The George Institute for Global Health China at Peking University Health Science Center, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | | | - Scott Janis
- National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Paul Vespa
- University of California, Los Angeles, CA, USA
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
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Zhang X, Gu Y, Li P, Jiang A, Sheng X, Jin X, Shi Y, Li G. Matrix Metalloproteases-Mediated Cleavage on β-Dystroglycan May Play a Key Role in the Blood-Brain Barrier After Intracerebral Hemorrhage in Rats. Med Sci Monit 2019; 25:794-800. [PMID: 30686819 PMCID: PMC6362757 DOI: 10.12659/msm.908500] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND It is well documented that the Blood-Brain barrier (BBB) can be damaged by matrix metalloproteases (MMPs) after intracerebral hemorrhage (ICH), but little is known about the mechanism of this effect. MATERIAL AND METHODS We established an ICH model in rats by injecting collagenase VII into the striatum. Afterwards, intraperitoneal injection of these rats with 40 mg/kg GM6001 (a MMPs inhibitor). The effects of GM6001 on ICH were investigated by neurological severity score, brain water content, Evans blue staining, hematoxylin-eosin staining, immunohistochemical staining, and Western blot assays. RESULTS We demonstrated that the neurological damage caused by ICH was relieved at 5 and 7 days following administration of GM6001. The impaired BBB induced by ICH was improved in response to GM6001 treatment at around 3 days, as evidenced by alleviated cerebral edema, decreased Evans blue extravasation, and a reduction in inflammatory cellular infiltration. Mechanism analysis revealed that ICH induced the generation of β-dystroglycan cleavage, which could be suppressed by GM6001 treatment. Furthermore, we found that recombinant MMP2 and MMP9 triggered the cleavage of β-dystroglycan in vitro, and this action could be inhibited by GM6001 administration. CONCLUSIONS Taken together, our results suggest that MMPs-mediated cleavage on β-dystroglycan may play an important role in BBB after ICH.
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Affiliation(s)
- Xin Zhang
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Yunhe Gu
- Department of Pathology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Peitong Li
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Anqi Jiang
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Xiaomeng Sheng
- Department of Neurology, Harbin Fourth Hospital, Harbin, Heilongjiang, China (mainland)
| | - Xin Jin
- Department of Neurology, Jixi People's Hospital, Jixi, Heilongjiang, China (mainland)
| | - Yue Shi
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Guozhong Li
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
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Masomi-Bornwasser J, Winter P, Neulen A, Kantelhardt SR, König J, Kempski O, Ringel F, Keric N. Doppler sonography enhances rtPA-induced fibrinolysis in an in vitro clot model of spontaneous intracerebral hemorrhages. PLoS One 2019; 14:e0210810. [PMID: 30653589 PMCID: PMC6336417 DOI: 10.1371/journal.pone.0210810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 01/02/2019] [Indexed: 01/25/2023] Open
Abstract
Background Transcranial Doppler (TCD) was shown to enhance intravascular fibrinolysis by rtPA in ischemic stroke. Studies revealed that catheter-based administration of rtPA induces lysis of intracerebral hemorrhages (ICH). However, it is unknown whether TCD would be suitable to enhance rtPA-induced fibrinolysis in patients with ICH. The aim of this study was to assess the potential of TCD to enhance rtPA-induced fibrinolysis in an in vitro clot system. Methods Reproducible human blood clots of 25 ml were incubated in a water bath at 37°C during treatments. They were weighed before and after 6 different treatments: (I) control (incubation only), (II) rtPA only, (III) one Doppler probe, (IV) two Doppler probes placed vis-à-vis, (V) one probe and rtPA and (VI) two probes and rtPA. To quantify lysis of the blood clots and attenuation of the Doppler through a temporal squama acoustic peak rarefaction pressure (APRP) was measured in the field of the probes. Temperature was assessed to evaluate possible side effects. Results Clot weight was reduced in all groups. The control group had the highest relative end weight of 70.2%±7.2% compared to all other groups (p<0,0001). Most efficient lysis was achieved using (VI) 2 probes and rtPA 36.3%±4.4% compared to (II, III, IV) (p<0.0001; p = 0.0002; p = 0.048). APRP was above lysis threshold (535.5±7.2 kPa) using 2 probes even through the temporal squama (731.6±32.5 kPa) (p = 0.0043). There was a maximal temperature elevation of 0.17±0.07°C using both probes. Conclusions TCD significantly enhances rtPA-induced lysis of blood clots, and the effect is amplified by using multiple probes. Our results indicate that bitemporal TCD insonation of hematomas could be a new and safe approach to enhance fibrinolysis of ICH´s treated with intralesional catheter and rtPA.
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Affiliation(s)
- Julia Masomi-Bornwasser
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- * E-mail:
| | - Philipp Winter
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Sven R. Kantelhardt
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Oliver Kempski
- Institute of Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Computed Tomography Angiography Spot Sign as an Indicator for Ultra-Early Stereotactic Aspiration of Intracerebral Hemorrhage. World Neurosurg 2018; 109:e136-e143. [DOI: 10.1016/j.wneu.2017.09.121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 11/19/2022]
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Combination of ultrasound and rtPA enhances fibrinolysis in an In Vitro clot system. PLoS One 2017; 12:e0188131. [PMID: 29145482 PMCID: PMC5690612 DOI: 10.1371/journal.pone.0188131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/01/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Catheter-based lysis with recombinant tissue plasminogen activator (rtPA) is a well-established therapy for spontaneous intracerebral hemorrhage (ICH). The effectiveness of this therapy can be increased with ultrasound, but the optimal conditions are not yet clearly established. Using a novel in vitro system of blood clots previously developed by our group, we investigated various parameters of intralesional sonothrombolysis using an endosonography catheter in combination with rtPA. METHODS Standardized human blood clots were equipped with a drainage catheter and weighed before and after 4 treatments: control (drainage only), rtPA only, ultrasound only and the combination of rtPA+ultrasound. The effectiveness of ultrasound was further analysed in terms of optimal frequency, duration and distance to the probe. Temperature and acoustic peak rarefaction pressure (APRP) were assessed to analyse potential adverse effects and quantify lysis. Histo-morphological analysis of the treated clots was performed by H&E staining and confocal laser scanning microscopy using fluorescent fibrinogen. RESULTS The combined treatment rtPA+ultrasound achieved the highest lysis rates with a relative weight of 30.3%±5.5% (p≤0.0001) compared to all other groups. Similar results were observed when treating aged clots. Confocal fluorescent microscopy of the treated clots revealed a rarefied fibrin mesh without cavitations. No relevant temperature increase occurred (0.53±0.75°C). The optimal insonation treatment time was 1 hour. APRP measurements showed a lysis threshold of 515.5±113.4 kPa. Application of 10 MHz achieved optimal lysis and lysis radius, while simultaneously proving to be the best frequency for morphologic imaging of the clot and surrounding tissue. CONCLUSIONS These promising data provide the basis for an individualized minimal invasive ICH therapy by rtPA and sonothrombolysis independent of ICH age.
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White Matter Injury and Recovery after Hypertensive Intracerebral Hemorrhage. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6138424. [PMID: 28680884 PMCID: PMC5478825 DOI: 10.1155/2017/6138424] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 05/07/2017] [Indexed: 12/26/2022]
Abstract
Hypertensive intracerebral hemorrhage (ICH) could very probably trigger white matter injury in patients. Through the continuous study of white matter injury after hypertensive ICH, we achieve a more profound understanding of the pathophysiological mechanism of its occurrence and development. At the same time, we found a series of drugs and treatment methods for the white matter repair. In the current reality, the research paradigm of white matter injury after hypertensive ICH is relatively obsolete or incomplete, and there are still lots of deficiencies in the research. In the face of the profound changes of stroke research perspective, we believe that the combination of the lenticulostriate artery, nerve nuclei of the hypothalamus-thalamus-basal ganglia, and the white matter fibers located within the capsula interna will be beneficial to the research of white matter injury and repair. This paper has classified and analyzed the study of white matter injury and repair after hypertensive ICH and also rethought the shortcomings of the current research. We hope that it could help researchers further explore and study white matter injury and repair after hypertensive ICH.
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Optimization of Catheter Based rtPA Thrombolysis in a Novel In Vitro Clot Model for Intracerebral Hemorrhage. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5472936. [PMID: 28459065 PMCID: PMC5385248 DOI: 10.1155/2017/5472936] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 03/07/2017] [Indexed: 12/31/2022]
Abstract
Hematoma lysis with recombinant tissue plasminogen activator (rtPA) has emerged as an alternative therapy for spontaneous intracerebral hemorrhage (ICH). Optimal dose and schedule are still unclear. The aim of this study was to create a reliable in vitro blood clot model for investigation of optimal drug dose and timing. An in vitro clot model was established, using 25 mL and 50 mL of human blood. Catheters were placed into the clots and three groups, using intraclot application of rtPA, placebo, and catheter alone, were analyzed. Dose-response relationship, repetition, and duration of rtPA treatment and its effectiveness in aged clots were investigated. A significant relative end weight difference was found in rtPA treated clots compared to catheter alone (p = 0.002) and placebo treated clots (p < 0.001). Dose-response analysis revealed 95% effective dose around 1 mg rtPA in 25 and 50 mL clots. Approximately 80% of relative clot lysis could be achieved after 15 min incubation. Lysis of aged clots was less effective. A new clot model for in vitro investigation was established. Our data suggest that current protocols for rtPA based ICH therapy may be optimized by using less rtPA at shorter incubation times.
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Tan Q, Chen Q, Niu Y, Feng Z, Li L, Tao Y, Tang J, Yang L, Guo J, Feng H, Zhu G, Chen Z. Urokinase, a promising candidate for fibrinolytic therapy for intracerebral hemorrhage. J Neurosurg 2017; 126:548-557. [PMID: 27104852 DOI: 10.3171/2016.1.jns152287] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intracerebral hemorrhage (ICH) is associated with a high rate of mortality and severe disability, while fibrinolysis for ICH evacuation is a possible treatment. However, reported adverse effects can counteract the benefits of fibrinolysis and limit the use of tissue-type plasminogen activator (tPA). Identifying appropriate fibrinolytics is still needed. Therefore, the authors here compared the use of urokinase-type plasminogen activator (uPA), an alternate thrombolytic, with that of tPA in a preclinical study. METHODS Intracerebral hemorrhage was induced in adult male Sprague-Dawley rats by injecting autologous blood into the caudate, followed by intraclot fibrinolysis without drainage. Rats were randomized to receive uPA, tPA, or saline within the clot. Hematoma and perihematomal edema, brain water content, Evans blue fluorescence and neurological scores, matrix metalloproteinases (MMPs), MMP mRNA, blood-brain barrier (BBB) tight junction proteins, and nuclear factor-κB (NF-κB) activation were measured to evaluate the effects of these 2 drugs in ICH. RESULTS In comparison with tPA, uPA better ameliorated brain edema and promoted an improved outcome after ICH. In addition, uPA therapy more effectively upregulated BBB tight junction protein expression, which was partly attributed to the different effects of uPA and tPA on the regulation of MMPs and its related mRNA expression following ICH. CONCLUSIONS This study provided evidence supporting the use of uPA for fibrinolytic therapy after ICH. Large animal experiments and clinical trials are required to further explore the efficacy and safety of uPA in ICH fibrinolysis.
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Affiliation(s)
- Qiang Tan
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
| | - Qianwei Chen
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
| | - Yin Niu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
| | - Zhou Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
| | - Lin Li
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
| | - Yihao Tao
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
| | - Jun Tang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
| | - Liming Yang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
| | - Jing Guo
- Department of Neurosurgery, 211st Hospital of PLA, Harbin, People's Republic of China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
| | - Gang Zhu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
| | - Zhi Chen
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and
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Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol 2016; 15:1228-1237. [PMID: 27751554 PMCID: PMC5154627 DOI: 10.1016/s1474-4422(16)30234-4] [Citation(s) in RCA: 235] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 08/08/2016] [Accepted: 08/31/2016] [Indexed: 12/24/2022]
Abstract
Background Craniotomy, when evaluated in trials, does not improve outcome after intracerebral haemorrhage (ICH). Whether minimally invasive catheter evacuation followed by thrombolysis is safe and can achieve a good functional outcome by removing clot is unknown. We investigated safety and efficacy of alteplase with minimally invasive surgery (MIS) in patients with intracerebral haemorrhage. Methods MISTIE was an international, randomized, open-label study and was done in 26 hospitals in the USA, Canada, the UK, and Germany. Patients (aged 18–80 years), with non-traumatic (spontaneous) ICH ≥20 mL were randomly allocated, centrally, to medical care or image-guided MIS plus rt-PA (0.3 mg or 1.0 mg every 8 hours for up to 9 doses) to remove clot using surgical aspiration followed with alteplase clot irrigation. The primary efficacy outcome was the adjusted dichotomized modified Rankin Scale (mRS) 0–3 vs 4–6 assessed at day 180 after symptom onset. Analysis was by intention to treat. (ClinicalTrials.gov number NCT00224770). Findings Between February 2, 2006 and April 8, 2013, 96 subjects were randomized and completed follow-up: 54 received treatment and 42 medical care. Primary safety outcomes: mortality, symptomatic bleeding, brain infections, as well as withdrawal of care, did not differ between groups. Asymptomatic hemorrhages were more common in the surgical group (3 (7%) vs. 12 (22%) p= 0.05) producing a difference of 15.1% (95% CI: 1.5% to 28.6%). The estimated absolute benefit, i.e., the unadjusted difference in observed proportions of all subjects with mRS 0–3 (33% vs 21%) at 180 days comparing MISPA vs. medical control, is 0.109 [95%CI: −0.088, 0.294; p=0.26], and is 0.162 [95%CI: 0.003, 0.323; p=0.05] after adjustment for potential imbalances in baseline severity between study arms (primary efficacy outcome). Interpretation MIS+rt-PA appears safe with an apparent advantage of better functional outcome at 180 days. Increased asymptomatic bleeding is a major cautionary finding. The MISTIE trial results, if replicable, could produce a meaningful functional benefit adding surgical management as a therapeutic strategy for ICH. Funding National Institute of Neurologic Disorders and Stroke, Genentech, and Codman.
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Mechanisms of Cerebral Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Neuronal tumour necrosis factor-α and interleukin-1β expression in a porcine model of intracerebral haemorrhage: Modulation by U-74389G. Brain Res 2015; 1615:98-105. [PMID: 25916578 DOI: 10.1016/j.brainres.2015.04.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 04/06/2015] [Accepted: 04/17/2015] [Indexed: 12/11/2022]
Abstract
Tumour necrosis factor α (TNF-α) and interleukin 1β (IL-1β) are important mediators of intracerebral haemorrhage (ICH) inflammatory response. Lazaroids, established antioxidants and neuroprotectants, have been studied in several brain pathologies. The present study was designed to investigate: a) TNF-α and IL-1β changes, in neurons and b) U-74389G effects, 4 and 24h after haematoma induction in a porcine model of intracerebral haemorrhage. In twenty male landrace pigs (swines) aged 135-150 days old, autologous whole blood was injected around the right basal ganglia territory; in ten of the pigs the lazaroid compound U-74389G was administered. Brain TNF-α and IL-1β immunopositive neurons were determined by immunoarray techniques at 4 and 24h timepoints. After the haematoma induction the number of TNF-α immunopositive neurons ipsilateral to the haematoma was significantly higher compared to the contralateral site at 4h (p<0.0005), while U-74389G significantly reduced the number of TNF-α immunopositive neurons, ipsilateral to the haematoma, at 4h (p=0.002); at 24h, TNF-α immunopositive neurons were found significantly lower in the control group ipsilateral to the haematoma in comparison to 4h timepoint(p<0.0005). The number of IL-1β immunopositive neurons at 4h after the hematoma induction was significantly higher ipsilateral to the haematoma site (p<0.0005). U-74389G had no statistical significant effect. TNF-α and IL-1β, increase in neurons, 4h after the haematoma induction, ipsilateral to the haematoma site. The administration of the antioxidant compound U-74389G, results in early (at 4h) decrease of TNF-α immunopositive neurons but shows no statistical significant effect to IL-1β immunopossitive neurons.
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Otero-Rodriguez A, Gonçalves-Estella JM, Sanchez-Ledesma MJ, Perez-De la Cruz MA, Munoz-Martin MC. Evacuation of intracerebral hemorrhages by neuroendoscopy with transparent sheath. Experimental study. INTERDISCIPLINARY NEUROSURGERY 2015. [DOI: 10.1016/j.inat.2014.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Keep RF, Zhou N, Xiang J, Andjelkovic AV, Hua Y, Xi G. Vascular disruption and blood-brain barrier dysfunction in intracerebral hemorrhage. Fluids Barriers CNS 2014; 11:18. [PMID: 25120903 PMCID: PMC4130123 DOI: 10.1186/2045-8118-11-18] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 08/07/2014] [Indexed: 12/11/2022] Open
Abstract
This article reviews current knowledge of the mechanisms underlying the initial hemorrhage and secondary blood-brain barrier (BBB) dysfunction in primary spontaneous intracerebral hemorrhage (ICH) in adults. Multiple etiologies are associated with ICH, for example, hypertension, Alzheimer's disease, vascular malformations and coagulopathies (genetic or drug-induced). After the initial bleed, there can be continued bleeding over the first 24 hours, so-called hematoma expansion, which is associated with adverse outcomes. A number of clinical trials are focused on trying to limit such expansion. Significant progress has been made on the causes of BBB dysfunction after ICH at the molecular and cell signaling level. Blood components (e.g. thrombin, hemoglobin, iron) and the inflammatory response to those components play a large role in ICH-induced BBB dysfunction. There are current clinical trials of minimally invasive hematoma removal and iron chelation which may limit such dysfunction. Understanding the mechanisms underlying the initial hemorrhage and secondary BBB dysfunction in ICH is vital for developing methods to prevent and treat this devastating form of stroke.
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Affiliation(s)
- Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA ; Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, USA
| | - Ningna Zhou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA ; Department of Pharmacology, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Jianming Xiang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| | | | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
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Kandadai MA, Korfhagen JJ, Beiler S, Beiler C, Wagner K, Adeoye OM, Shaw GJ. In vivo testing of a non-invasive prototype device for the continuous monitoring of intracerebral hemorrhage. J Neurosci Methods 2014; 235:117-22. [PMID: 24997340 DOI: 10.1016/j.jneumeth.2014.05.025] [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: 03/06/2014] [Revised: 05/18/2014] [Accepted: 05/19/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a stroke subtype with the highest mortality rate. Hematoma expansion and re-bleeding post-ICH are common and exacerbate the initial cerebral insult. There is a need for continuous monitoring of the neurologic status of patients with an ICH injury. NEW METHOD A prototype device for non-invasive continuous monitoring of an ICH was developed and tested in vivo using a porcine ICH model. The device consists of receiving and transmitting antennae in the 400-1000 MHz frequency range, placed directly in line with the site of the ICH. The device exploits the differences in the dielectric properties and geometry of tissue media of a healthy brain and a brain with an ICH injury. The power received by the receiving antenna is measured and the percent change in power received immediately after infusion of blood and 30 min after the infusion, allowing for the blood to clot, is calculated. RESULTS An increase in the received power in the presence of an ICH is observed at 400 MHz, consistent with previous in vitro studies. Frequency sweep experiments show a maximum percent change in received power in the 750-1000 MHz frequency range. COMPARISON WITH EXISTING METHODS Currently, CT, MRI and catheter angiography (CA) are the main clinical neuroimaging modalities. However, these techniques require specialized equipment and personnel, substantial time, and patient-transportation to a radiology suite to obtain results. Moreover, CA is invasive and uses intra-venous dye or vascular catheters to accomplish the imaging. CONCLUSIONS The device has the potential to significantly improve neurologic care in the critically ill brain-injured patient.
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Affiliation(s)
- Madhuvanthi A Kandadai
- Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, Suite 1358, Cincinnati, OH 45267, United States.
| | - Joseph J Korfhagen
- Department of Neuroscience, University of Cincinnati, CARE/Crawley Building Suite E-870, Cincinnati, OH 45267, United States
| | - Shauna Beiler
- Department of Neurology, Stetson Building, 260 Stetson Street, Suite 2300, Cincinnati, OH 45267-0525, United States; Research Service, Veterans Affairs Medical Center, Cincinnati, OH 45220, United States
| | - Chris Beiler
- Department of Neurology, Stetson Building, 260 Stetson Street, Suite 2300, Cincinnati, OH 45267-0525, United States; Research Service, Veterans Affairs Medical Center, Cincinnati, OH 45220, United States
| | - Kenneth Wagner
- Department of Neurology, Stetson Building, 260 Stetson Street, Suite 2300, Cincinnati, OH 45267-0525, United States; Research Service, Veterans Affairs Medical Center, Cincinnati, OH 45220, United States
| | - Opeolu M Adeoye
- Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, Suite 1358, Cincinnati, OH 45267, United States
| | - George J Shaw
- Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, Suite 1358, Cincinnati, OH 45267, United States
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Intraclot recombinant tissue-type plasminogen activator reduces perihematomal edema and mortality in patients with spontaneous intracerebral hemorrhage. ACTA ACUST UNITED AC 2014; 34:165-171. [PMID: 24710926 DOI: 10.1007/s11596-014-1252-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 02/18/2014] [Indexed: 10/25/2022]
Abstract
The study aimed to investigate the impact of intraclot recombinant tissue-type plasminogen activator (rt-PA) on perihematomal edema (PHE) development in patients with intracerebral hemorrhage (ICH) treated with minimally invasive surgery (MIS) and the effects of intraclot rt-PA on the 30-day survival. We reviewed the medical records of ICH patients undergoing MIS between October 2011 and July 2013. A volumetric analysis was done to assess the change in PHE and ICH volumes at pre-MIS (T1), post-MIS (T2) and day 10-16 (T3) following diagnostic computed tomographic scans (T0). Forty-three patients aged 52.8±11.1 years with (n=30) or without rt-PA (n=13) were enrolled from our institutional ICH database. The median rt-PA dose was 1.5 (1) mg, with a maximum dose of 4.0 mg. The ratio of clot evacuation was significantly increased by intraclot rt-PA as compared with controls (77.9%±20.4% vs. 64%±15%; P=0.046). From T1 to T2, reduction in PHE volume was strongly associated with the percentage of clot evacuation (ρ=0.34; P=0.027). In addition, PHE volume was positively correlated with residual ICH volume at the same day (ρ ranging from 0.39-0.56, P<0.01). There was no correlation between the cumulative dose of rt-PA and early (T2) PHE volume (ρ=0.24; P=0.12) or delayed (T3) PHE volume (ρ=0.19; P=0.16). The 30-day mortality was zero in this cohort. In the selected cohort of ICH patients treated with MIS, intraclot rt-PA accelerated clot removal and had no effects on PHE formation. MIS aspiration and low dose of rt-PA seemed to be feasible to reduce the 30-day mortality in patients with severe ICH. A large, randomized study addressing dose titration and long-term outcome is needed.
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Xi G, Strahle J, Hua Y, Keep RF. Progress in translational research on intracerebral hemorrhage: is there an end in sight? Prog Neurobiol 2014; 115:45-63. [PMID: 24139872 PMCID: PMC3961535 DOI: 10.1016/j.pneurobio.2013.09.007] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 09/11/2013] [Accepted: 09/24/2013] [Indexed: 02/08/2023]
Abstract
Intracerebral hemorrhage (ICH) is a common and often fatal stroke subtype for which specific therapies and treatments remain elusive. To address this, many recent experimental and translational studies of ICH have been conducted, and these have led to several ongoing clinical trials. This review focuses on the progress of translational studies of ICH including those of the underlying causes and natural history of ICH, animal models of the condition, and effects of ICH on the immune and cardiac systems, among others. Current and potential clinical trials also are discussed for both ICH alone and with intraventricular extension.
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Affiliation(s)
- Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States.
| | - Jennifer Strahle
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
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Chang YH, Hwang SK. Frameless stereotactic aspiration for spontaneous intracerebral hemorrhage and subsequent fibrinolysis using urokinase. J Cerebrovasc Endovasc Neurosurg 2014; 16:5-10. [PMID: 24765607 PMCID: PMC3997927 DOI: 10.7461/jcen.2014.16.1.5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 01/14/2014] [Accepted: 02/24/2014] [Indexed: 11/23/2022] Open
Abstract
Objectives The optimal management of patients with spontaneous intracerebral hemorrhage (ICH) remains controversial. The aim of this study was to evaluate technical results and clinical outcomes of frameless stereotactic aspiration and fibrinolysis using urokinase performed in a single center. Materials and Methods The subjects of this study were 62 consecutive patients with spontaneous ICH who were treated with frameless stereotactic aspiration and subsequent fibrinolysis using urokinase between February 2009 and June 2010 in our hospital. The surgical results, procedure-related complications, and clinical outcomes were evaluated. Results A total of 62 patients were enrolled in the study. The median age was 54 years (range, 32-86). The mean initial Glasgow coma scale score was 7.7 (range 5-11). The mean initial hemorrhage volume was 43 cm3 (range 30-70). Seven patients (11.2%) died of respiratory failure (four patients), postoperative edema (two patients), and heart disease (one patient). There were seven cases of procedure-related complications (11.2%), including malpositioning of catheters (two patients), pneumocephalus (one patient), and rebleeding (four patients, 6.4%). At the three-month follow-up, a good outcome (three-month Glasgow outcome scale > 3) was noted in 32 patients (51.6%). Conclusions Frameless stereotactic aspiration and subsequent fibrinolytic thearpy using urokinase for spontaneous ICH is a simple and safe procedure with low mortality and rebleeding rate.
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Affiliation(s)
- Youn Hyuk Chang
- Department of Neurosurgery, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Sung-Kyun Hwang
- Department of Neurosurgery, College of Medicine, Ewha Womans University, Seoul, Korea
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A new method for detecting cerebral hemorrhage in rabbits by magnetic inductive phase shift. Biosens Bioelectron 2014; 52:374-8. [DOI: 10.1016/j.bios.2013.09.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 09/05/2013] [Accepted: 09/09/2013] [Indexed: 11/20/2022]
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Affiliation(s)
- Wendy C Ziai
- Johns Hopkins Hospital, Division of Neurosciences Critical Care, 600 N Wolfe St/Meyer 8-140, Baltimore, MD 21287, USA.
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Abstract
Intracranial hemorrhage (ICH) accounts for 10-15 % of all strokes, however it causes 30-50 % of stroke related mortality, disability and cost. The prevalence increases with age with only two cases/100,000/year for age less than 40 years to almost 350 cases/100,000/year for age more than 80 years. Several trials of open surgical evacuation of ICH have failed to show clear benefit over medical management. However, some small trials of minimal invasive hematoma evacuation in combination with thrombolytics have shown encouraging results. Based on these findings larger clinical trials are being undertaken to optimize and define therapeutic benefit of minimally invasive surgery in combination with thrombolytic clearance of hematoma. In this article we will review some of the background of minimally invasive surgery and the use of thrombolytics in the setting of ICH and intraventricular hemorrhage (IVH) and will highlight the early findings of MISTIE and CLEAR trials for these two entities respectively.
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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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Morgan TC, Dawson J, Spengler D, Lees KR, Aldrich C, Mishra NK, Lane K, Quinn TJ, Diener-West M, Weir CJ, Higgins P, Rafferty M, Kinsley K, Ziai W, Awad I, Walters MR, Hanley D. The Modified Graeb Score: an enhanced tool for intraventricular hemorrhage measurement and prediction of functional outcome. Stroke 2013; 44:635-41. [PMID: 23370203 DOI: 10.1161/strokeaha.112.670653] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Simple and rapid measures of intraventricular hemorrhage (IVH) volume are lacking. We developed and validated a modification of the original Graeb scale to facilitate rapid assessment of IVH over time. METHODS We explored the relationship between the modified Graeb scale (mGS), original Graeb scale, measured IVH volume, and outcome using data from the Clot Lysis: Evaluating Accelerated Resolution of Hemorrhage with rtPA B (CLEAR B) study. We also explored its reliability. We then evaluated the relationship between mGS and outcome in a large sample of participants with IVH using data contained within the Virtual International Stroke Trials Archive (VISTA). We defined outcome using the modified Rankin scale (>3 signifying poor outcome). RESULTS The CLEAR B study included 360 scans from 36 subjects. The mGS score and IVH volume were highly correlated (R = 0.80, P<0.0001, R(2) 0.65). Baseline mGS was predictive of poor outcome (area under receiving operating characteristic curve 0.74, 95% confidence interval, 0.57-0.91), whereas the original Graeb scale was not. The VISTA study included 399 participants. Each unit increase in the mGS led to a 12% increase in the odds of a poor outcome (odds ratio, 1.12; 95% confidence interval, 1.05-1.19). Measures of reliability (intra- and inter- reader) were good in both studies. CONCLUSIONS The mGS, a semiquantitative scale for IVH volume measurement, is a reliable measure with prognostic validity suitable for rapid use in clinical practice and in research.
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Affiliation(s)
- Timothy C Morgan
- College of Medical, Veterinary, Life Sciences, University of Glasgow, Glasgow, UK
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Monteith SJ, Harnof S, Medel R, Popp B, Wintermark M, Lopes MBS, Kassell NF, Elias WJ, Snell J, Eames M, Zadicario E, Moldovan K, Sheehan J. Minimally invasive treatment of intracerebral hemorrhage with magnetic resonance-guided focused ultrasound. J Neurosurg 2013; 118:1035-45. [PMID: 23330996 DOI: 10.3171/2012.12.jns121095] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intracerebral hemorrhage (ICH) is a major cause of death and disability throughout the world. Surgical techniques are limited by their invasive nature and the associated disability caused during clot removal. Preliminary data have shown promise for the feasibility of transcranial MR-guided focused ultrasound (MRgFUS) sonothrombolysis in liquefying the clotted blood in ICH and thereby facilitating minimally invasive evacuation of the clot via a twist-drill craniostomy and aspiration tube. METHODS AND RESULTS In an in vitro model, the following optimum transcranial sonothrombolysis parameters were determined: transducer center frequency 230 kHz, power 3950 W, pulse repetition rate 1 kHz, duty cycle 10%, and sonication duration 30 seconds. Safety studies were performed in swine (n = 20). In a swine model of ICH, MRgFUS sonothrombolysis of 4 ml ICH was performed. Magnetic resonance imaging and histological examination demonstrated complete lysis of the ICH without additional brain injury, blood-brain barrier breakdown, or thermal necrosis due to sonothrombolysis. A novel cadaveric model of ICH was developed with 40-ml clots implanted into fresh cadaveric brains (n = 10). Intracerebral hemorrhages were successfully liquefied (> 95%) with transcranial MRgFUS in a highly accurate fashion, permitting minimally invasive aspiration of the lysate under MRI guidance. CONCLUSIONS The feasibility of transcranial MRgFUS sonothrombolysis was demonstrated in in vitro and cadaveric models of ICH. Initial in vivo safety data in a swine model of ICH suggest the process to be safe. Minimally invasive treatment of ICH with MRgFUS warrants evaluation in the setting of a clinical trial.
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Affiliation(s)
- Stephen J Monteith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
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Mohan S, Ahmad AS, Glushakov AV, Chambers C, Doré S. Putative role of prostaglandin receptor in intracerebral hemorrhage. Front Neurol 2012; 3:145. [PMID: 23097645 PMCID: PMC3477820 DOI: 10.3389/fneur.2012.00145] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 09/30/2012] [Indexed: 01/21/2023] Open
Abstract
Each year, approximately 795,000 people experience a new or recurrent stroke. Of all strokes, 84% are ischemic, 13% are intracerebral hemorrhage (ICH) strokes, and 3% are subarachnoid hemorrhage strokes. Despite the decreased incidence of ischemic stroke, there has been no change in the incidence of hemorrhagic stroke in the last decade. ICH is a devastating disease 37–38% of patients between the ages of 45 and 64 die within 30 days. In an effort to prevent ischemic and hemorrhagic strokes we and others have been studying the role of prostaglandins and their receptors. Prostaglandins are bioactive lipids derived from the metabolism of arachidonic acid. They sustain homeostatic functions and mediate pathogenic mechanisms, including the inflammatory response. Most prostaglandins are produced from specific enzymes and act upon cells via distinct G-protein coupled receptors. The presence of multiple prostaglandin receptors cross-reactivity and coupling to different signal transduction pathways allow differentiated cells to respond to prostaglandins in a unique manner. Due to the number of prostaglandin receptors, prostaglandin-dependent signaling can function either to promote neuronal survival or injury following acute excitotoxicity, hypoxia, and stress induced by ICH. To better understand the mechanisms of neuronal survival and neurotoxicity mediated by prostaglandin receptors, it is essential to understand downstream signaling. Several groups including ours have discovered unique roles for prostaglandin receptors in rodent models of ischemic stroke, excitotoxicity, and Alzheimer disease, highlighting the emerging role of prostaglandin receptor signaling in hemorrhagic stroke with a focus on cyclic-adenosine monophosphate and calcium (Ca2+) signaling. We review current ICH data and discuss future directions notably on prostaglandin receptors, which may lead to the development of unique therapeutic targets against hemorrhagic stroke and brain injuries alike.
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Affiliation(s)
- Shekher Mohan
- Department of Anesthesiology, College of Medicine, University of Florida Gainesville, FL, USA
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Enatsu R, Asahi M, Matsumoto M, Hirai O. Prognostic factors of motor recovery after stereotactic evacuation of intracerebral hematoma. TOHOKU J EXP MED 2012; 227:63-7. [PMID: 22688372 DOI: 10.1620/tjem.227.63] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Spontaneous intracerebral hemorrhage represents 20 to 30% of all stroke patients in Japan. However, the treatment strategy of intracerebral hematoma remains controversial. Stereotactic hematoma evacuation is minimally invasive surgery and is beneficial for clot removal with limited tissue damage. The purpose of this study was to investigate the factors affecting motor recovery after stereotactic hematoma evacuation. This retrospective analysis included 30 patients with spontaneous thalamic or putaminal hemorrhage who underwent stereotactic hematoma evacuation. We compared age, presurgical muscle strength, hematoma volume and removal rate between the patients who showed improvement of motor function (improved group) and the patients associated with no motor improvement (unchanged group). Twenty-one patients were classified into the improved group and nine patients into the unchanged group. Statistical analysis revealed that age in the improved group was significantly younger than in the unchanged group (p < 0.01), whereas there was no significant difference in presurgical muscle strength, hematoma volume and removal rate between the two groups. The present results revealed that stereotactic hematoma evacuation is attributable to the improvement of motor function, especially in the younger population, indicating the importance of cortical reorganization during post-surgical rehabilitation. In addition, this procedure could provide functional improvement in severely disabled patients. Proper patient selection to receive this therapy would be beneficial for further advances of this technique. The present result might be useful in elucidating the mechanism of motor recovery and proper patient selection for this technique.
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Affiliation(s)
- Rei Enatsu
- Department of Neurosurgery, Shinko Hospital, Kobe, Japan.
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Keep RF, Hua Y, Xi G. Intracerebral haemorrhage: mechanisms of injury and therapeutic targets. Lancet Neurol 2012; 11:720-31. [PMID: 22698888 DOI: 10.1016/s1474-4422(12)70104-7] [Citation(s) in RCA: 856] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Intracerebral haemorrhage accounts for about 10-15% of all strokes and is associated with high mortality and morbidity. No successful phase 3 clinical trials for this disorder have been completed. In the past 6 years, the number of preclinical and clinical studies focused on intracerebral haemorrhage has risen. Important advances have been made in animal models of this disorder and in our understanding of mechanisms underlying brain injury after haemorrhage. Several therapeutic targets have subsequently been identified that are now being pursued in clinical trials. Many clinical trials have been based on limited preclinical data, and guidelines to justify taking preclinical results to the clinic are needed.
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Affiliation(s)
- Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA.
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Keric N, Maier GS, Samadani U, Kallenberg K, Dechent P, Brueck W, Heuer J, Rohde V. Tissue plasminogen activator induced delayed edema in experimental porcine intracranial hemorrhage: reduction with plasminogen activator inhibitor-1 administration. Transl Stroke Res 2012; 3:88-93. [PMID: 23538320 PMCID: PMC3605490 DOI: 10.1007/s12975-012-0188-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 04/22/2012] [Accepted: 04/26/2012] [Indexed: 11/09/2022]
Abstract
Hematoma puncture and subsequent clot lysis with recombinant tissue plasminogen activator (rtPA) emerged as an alternative therapy for spontaneous intracerebral hemorrhage (ICH) and is associated with delayed edema possibly counteracting the beneficial effects of hematoma volume reduction. We hypothesized that immediate reversal of rtPA activity after clot lysis and hematoma drainage diminishes edema formation. To test this hypothesis, we administered plasminogen activator inhibitor (PAI)-1 after rtPA lysis of experimentally induced ICH. A right frontal ICH was placed through a twist drill burr hole and autologous blood injection. Following creation of the frontal ICH, pigs received no further treatment (n = 5), lysis with rtPA (n = 7), or lysis with rtPA followed by administration of PAI-1 (n = 6). Hematoma and edema volumes were assessed with magnetic resonance imaging on days 0, 4, and 10. The rtPA significantly reduced hematoma volume and contributed to edema on day 10 after experimentally induced ICH. Administration of PAI-1 attenuated the rtPA-induced edema volume on day 10, but the hematoma volume reduction was less pronounced. In conclusion, PAI-1 attenuated delayed cerebral edema after rtPA lysis of experimental ICH but also reduced the lytic activity of rtPA. The combination of rtPA clot lysis with PAI-1 might have the potential to further improve the effect of the lytic therapy of ICH, but additional studies to define the optimum time point for PAI-1 administration are required.
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Affiliation(s)
- Naureen Keric
- Department of Neurosurgery, Georg-August-University, Goettingen, Germany ; Department of Neurosurgery, Johannes-Gutenberg-University, Mainz, Germany
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Hwang BY, Bruce SS, Appelboom G, Piazza MA, Carpenter AM, Gigante PR, Kellner CP, Ducruet AF, Kellner MA, Deb-Sen R, Vaughan KA, Meyers PM, Connolly ES. Evaluation of intraventricular hemorrhage assessment methods for predicting outcome following intracerebral hemorrhage. J Neurosurg 2012; 116:185-92. [DOI: 10.3171/2011.9.jns10850] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intraventricular hemorrhage (IVH) associated with intracerebral hemorrhage (ICH) is an independent predictor of poor outcome. Clinical methods for evaluating IVH, however, are not well established. This study sought to determine the best IVH grading scale by evaluating the predictive accuracies of IVH, Graeb, and LeRoux scores in an independent cohort of ICH patients with IVH. Subacute IVH dynamics as well as the impact of external ventricular drain (EVD) placement on IVH and outcome were also investigated.
Methods
A consecutive cohort of 142 primary ICH patients with IVH was admitted to Columbia University Medical Center between February 2009 and February 2011. Baseline demographics, clinical presentation, and hospital course were prospectively recorded. Admission CT scans performed within 24 hours of onset were reviewed for ICH location, hematoma volume, and presence of IVH. Intraventricular hemorrhage was categorized according to IVH, Graeb, and LeRoux scores. For each patient, the last scan performed within 6 days of ictus was similarly evaluated. Outcomes at discharge were assessed using the modified Rankin Scale (mRS). Receiver operating characteristic analysis was used to determine the predictive accuracies of the grading scales for poor outcome (mRS score ≥ 3).
Results
Seventy-three primary ICH patients (51%) had IVH. Median admission IVH, Graeb, and LeRoux scores were 13, 6, and 8, respectively. Median IVH, Graeb and LeRoux scores decreased to 9 (p = 0.005), 4 (p = 0.002), and 4 (p = 0.003), respectively, within 6 days of ictus. Poor outcome was noted in 55 patients (75%). Areas under the receiver operating characteristic curve were similar among the IVH, Graeb, and LeRoux scores (0.745, 0.743, and 0.744, respectively) and within 6 days postictus (0.765, 0.722, 0.723, respectively). Moreover, the IVH, Graeb, and LeRoux scores had similar maximum Youden Indices both at admission (0.515 vs 0.477 vs 0.440, respectively) and within 6 days postictus (0.515 vs 0.339 vs 0.365, respectively). Patients who received EVDs had higher mean IVH volumes (23 ± 26 ml vs 9 ± 11 ml, p = 0.003) and increased incidence of Glasgow Coma Scale scores < 8 (67% vs 38%, p = 0.015) and hydrocephalus (82% vs 50%, p = 0.004) at admission but had similar outcome as those who did not receive an EVD.
Conclusions
The IVH, Graeb, and LeRoux scores predict outcome well with similarly good accuracy in ICH patients with IVH when assessed at admission and within 6 days after hemorrhage. Therefore, any of one of the scores would be equally useful for assessing IVH severity and risk-stratifying ICH patients with regard to outcome. These results suggest that EVD placement may be beneficial for patients with severe IVH, who have particularly poor prognosis at admission, but a randomized clinical trial is needed to conclusively demonstrate its therapeutic value.
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Kirkman MA, Allan SM, Parry-Jones AR. Experimental intracerebral hemorrhage: avoiding pitfalls in translational research. J Cereb Blood Flow Metab 2011; 31:2135-51. [PMID: 21863040 PMCID: PMC3210340 DOI: 10.1038/jcbfm.2011.124] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 07/20/2011] [Accepted: 07/28/2011] [Indexed: 12/12/2022]
Abstract
Intracerebral hemorrhage (ICH) has the highest mortality of all stroke subtypes, yet treatments are mainly limited to supportive management, and surgery remains controversial. Despite significant advances in our understanding of ICH pathophysiology, we still lack preclinical models that accurately replicate the underlying mechanisms of injury. Current experimental ICH models (including autologous blood and collagenase injection) simulate different aspects of ICH-mediated injury but lack some features of the clinical condition. Newly developed models, notably hypertension- and oral anticoagulant therapy-associated ICH models, offer added benefits but further study is needed to fully validate them. Here, we describe and discuss current approaches to experimental ICH, with suggestions for changes in how this condition is studied in the laboratory. Although advances in imaging over the past few decades have allowed greater insight into clinical ICH, there remains an important role for experimental models in furthering our understanding of the basic pathophysiologic processes underlying ICH, provided limitations of animal models are borne in mind. Owing to differences in existing models and the failed translation of benefits in experimental ICH to clinical practice, putative neuroprotectants should be trialed in multiple models using both histological and functional outcomes until a more accurate model of ICH is developed.
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Affiliation(s)
- Matthew A Kirkman
- Faculty of Life Sciences, The University of Manchester, Manchester, UK
| | - Stuart M Allan
- Faculty of Life Sciences, The University of Manchester, Manchester, UK
| | - Adrian R Parry-Jones
- The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
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Naff N, Williams MA, Keyl PM, Tuhrim S, Bullock MR, Mayer SA, Coplin W, Narayan R, Haines S, Cruz-Flores S, Zuccarello M, Brock D, Awad I, Ziai WC, Marmarou A, Rhoney D, McBee N, Lane K, Hanley DF. Low-dose recombinant tissue-type plasminogen activator enhances clot resolution in brain hemorrhage: the intraventricular hemorrhage thrombolysis trial. Stroke 2011; 42:3009-16. [PMID: 21868730 DOI: 10.1161/strokeaha.110.610949] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Patients with intracerebral hemorrhage and intraventricular hemorrhage have a reported mortality of 50% to 80%. We evaluated a clot lytic treatment strategy for these patients in terms of mortality, ventricular infection, and bleeding safety events, and for its effect on the rate of intraventricular clot lysis. METHODS Forty-eight patients were enrolled at 14 centers and randomized to treatment with 3 mg recombinant tissue-type plasminogen activator (rtPA) or placebo. Demographic characteristics, severity factors, safety outcomes (mortality, infection, bleeding), and clot resolution rates were compared in the 2 groups. RESULTS Severity factors, including admission Glasgow Coma Scale, intracerebral hemorrhage volume, intraventricular hemorrhage volume, and blood pressure were evenly distributed, as were adverse events, except for an increased frequency of respiratory system events in the placebo-treated group. Neither intracranial pressure nor cerebral perfusion pressure differed substantially between treatment groups on presentation, with external ventricular device closure, or during the active treatment phase. Frequency of death and ventriculitis was substantially lower than expected and bleeding events remained below the prespecified threshold for mortality (18% rtPA; 23% placebo), ventriculitis (8% rtPA; 9% placebo), symptomatic bleeding (23% rtPA; 5% placebo, which approached statistical significance; P=0.1). The median duration of dosing was 7.5 days for rtPA and 12 days for placebo. There was a significant beneficial effect of rtPA on rate of clot resolution. CONCLUSIONS Low-dose rtPA for the treatment of intracerebral hemorrhage with intraventricular hemorrhage has an acceptable safety profile compared to placebo and historical controls. Data from a well-designed phase III clinical trial, such as CLEAR III, will be needed to fully evaluate this treatment.
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Affiliation(s)
- Neal Naff
- Sandra and Malcolm Berman Brain & Spine Institute, Department of Neurology, Sinai Hospital of Baltimore, MD, USA
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Zhou H, Zhang Y, Liu L, Han X, Tao Y, Tang Y, Hua W, Xue J, Dong Q. A prospective controlled study: minimally invasive stereotactic puncture therapy versus conventional craniotomy in the treatment of acute intracerebral hemorrhage. BMC Neurol 2011; 11:76. [PMID: 21699716 PMCID: PMC3142495 DOI: 10.1186/1471-2377-11-76] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Accepted: 06/23/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) is a devastating form of stroke with the high mortality twofold to sixfold higher than that for ischemic stroke. But the treatment of haematomas within the basal ganglia continues to be a matter of debate among neurologists and neurosurgeons. The purpose of this study is to judge the clinical value of minimally invasive stereotactic puncture therapy (MISPT) on acute ICH. METHODS A prospective controlled study was undertaken. The clinical trial was in compliance with the WMA Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects. According to the enrollment criterion, there were 168 acute ICH cases analyzed, of which 90 cases were performed by MISPT (MISPT group, MG) and 78 cases by Conventional craniotomy (CC group, CG), by means of compare of Glasgow Coma Scale (GCS) score, postoperative complications (PC) and rebleeding incidence (RI), moreover, long-term outcome of 1 year postoperation judged by Glasgow Outcome Scale (GOS), Barthel Index (BI), modified Rankin Scale (mRS) and case fatality(CF). RESULTS MG patients showed obvious amelioration in GCS score compared with that of CG. The total incidence of PC in MG decreased obviously compared with that of CG. The incidences of rebleeding in MG and CG were 10.0% and 15.4% respectively. There was no obvious difference between CFs of MG and CG. For three parameters representing long-term outcome, the GOS, BI and mRS in MG were ameliorated significantly than that of CG. CONCLUSION These data suggested that the advantage of MISPT was displayed in minute trauma and safety, and seemed to be feasible and to had a trend towards improved long-term outcome. TRIAL REGISTRATION The Australian New Zealand Clinical Trials Registry (ANZCTR), the registration number: ACTRN12610000945022.
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Affiliation(s)
- Houguang Zhou
- Department of Geriatrics, Huashan Hospital, Fudan University, Shanghai, China
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Wu G, Li C, Wang L, Mao Y, Hong Z. Minimally invasive procedures for evacuation of intracerebral hemorrhage reduces perihematomal glutamate content, blood-brain barrier permeability and brain edema in rabbits. Neurocrit Care 2011; 14:118-26. [PMID: 21161434 DOI: 10.1007/s12028-010-9473-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND To observe the effects of the minimally invasive removal of an intracerebral hematoma on the glutamate concentration, blood-brain barrier (BBB) permeability and brain water content in the brain tissue surrounding the hematoma and to provide a theoretical basis for minimally invasive removal of intracerebral hematomas. METHODS Thirty rabbits (2.8-3.4 kg body weight) were selected to establish a model of intracerebral hemorrhage, and they were randomly divided into a model control group and a minimally invasive group after the model was prepared successfully. The intracerebral hematoma was evacuated by stereotactic procedures in minimally invasive group 6 h after the model was established. The glutamate content, the permeability of the BBB and the brain water content in perihematomal brain tissues were determined and compared between the two groups. RESULTS The glutamate content, the permeability of the BBB and the brain water content in the perihematomal brain tissues were significantly decreased compared to the model control group 1, 3, and 7 days after the minimally invasive removal of the intracerebral hematoma. CONCLUSIONS Minimally invasive surgery for removal of an intracerebral hematoma could significantly reduce the glutamate content, BBB permeability and the brain water content in perihematomal brain tissues.
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Affiliation(s)
- Guofeng Wu
- Department of Emergency, Affiliated Hospital, Guiyang Medical College, Guiyang City, Guizhou Province, China.
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