Acute Spontaneous Lobar Cerebral Hemorrhages Present a Different Clinical Profile and a More Severe Early Prognosis than Deep Subcortical Intracerebral Hemorrhages-A Hospital-Based Stroke Registry Study

The clinical value of triglyceride to high-density lipoprotein cholesterol ratio for predicting stroke-associated pneumonia after spontaneous intracerebral hemorrhage

OBJECTIVE

Stroke-associated pneumonia (SAP) is relevant to the poor functional outcomes of patients with spontaneous intracerebral hemorrhage (SICH). It is unclear if the triglyceride (TG) to high-density lipoprotein cholesterol (HDL-C) ratio (TG/HDL-C) is related to the risk of SAP in SICH patients. This study aimed to investigate the association between TG/HDL-C and SAP in SICH patients.

METHODS

Consecutive patients with SICH were enrolled in this retrospective study. Relevant clinical variables were extracted from electronic medical records. All enrolled participants were divided into SAP (n = 71) and non-SAP (n = 187) groups. Multivariate binary logistic regression analysis was used to explore the association between TG/HDL-C and SAP. The optimal cutoff value of TG/HDL-C was defined by the receiver operating characteristic (ROC).

RESULTS

Among 258 patients, 71 (27.5%) had SAP. Patients with SAP were older (72.75 ± 11.10 vs. 64.81 ± 12.70 years), with a lower TG, higher HDL-C, and lower TG/HDL-C than participants in the non-SAP group. TG/HDL-C was an independent protective factor for SAP (adjusted OR 0.516, 95% CI 0.339-0.784) after adjusting for relevant risk factors. According to ROC analysis, the optimal cutoff value was a TG/HDL-C > 1.09 for decreased SAP [area under the ROC curve (AUC) 0.705; sensitivity 76.1% and specificity 59.4%]. Patients with a TG/HDL-C of > 1.09 were independently associated with decreased SAP (adjusted OR 0.285, 95% CI 0.138-0.591 ) after adjustment.

CONCLUSION

This study suggests that a lower TG/HDL-C is independently associated with increased SAP after SICH.

Risk factors of posthemorrhagic seizure in spontaneous intracerebral hemorrhage

Seizure is a relatively common neurological consequence after spontaneous intracerebral hemorrhage (SICH). This study aimed to investigate risk factors of early, late, and overall seizures in patients with SICH. Retrospective analysis was performed on all patients with SICH who completed two years of follow-up. The variables collected were obtained from demographic, clinical, radiographic and treatment data, in-hospital complications, and follow-up results. Univariate and multivariate analyzes were used to identify risk factors for post-hemorrhagic stroke seizure. Of 400 SICH patients recruited, 30 (7.5%) and 40 (10%) developed early and late seizures during the 2-year follow-up period, respectively. In the final result of the multivariate analysis, factors associated with the occurrence of the early seizure included lobar location of hematoma (p = 0.018), and GCS ≤ 12 on initial clinical presentation (p = 0.007). Factors associated with the occurrence of the late seizure included lobar location of hematoma (p = 0.001), volume of hematoma greater than 10 ml (p = 0.009), and midline shift on initial cranial CT (p = 0.036). Risk factors of the overall seizure after SICH included lobar location of hematoma (p < 0.001), volume of hematoma greater than 10 ml (p < 0.001), and craniotomy with evacuation of hematoma (p = 0.007). Furthermore, seizure was also associated with a poor functional outcome 2 years after the onset of SICH. Several factors associated with the appearance of post-ICH seizures were revealed. In patients with increased risk of post-SICH seizures, appropriate surveillance and management of seizures should be carried out.

Predictors and lesion patterns of dysphagia and swallowing outcomes after acute intracerebral hemorrhage

BACKGROUND

Dysphagia is a common complication following intracerebral hemorrhage (ICH) and is associated with an increased risk of aspiration pneumonia and poor outcomes.

OBJECTIVES

This study aimed to explore associated lesion patterns and contributing factors of post-ICH dysphagia, and predict dysphagia outcomes following ICH.

DESIGN

A multicenter, prospective study.

METHODS

Patients with ICH from two stroke centers within 72 h of symptom onset received baseline bedside swallowing evaluations. Dysphagia-related lesion patterns were identified using support-vector regression-based lesion-symptom mapping. Predictors of swallowing impairment on the 7th and 30th day, as well as stroke-associated pneumonia (SAP), were determined through multiple logistic regression analyses, and nomograms were developed.

RESULTS

A total of 153 patients were included in the final analysis. Of those, 28 had dysphagia. Dysphagia-related lesions predominantly affected bilateral subcortical and adjacent cortical regions. Stroke severity, hematoma expansion, and basal ganglia hemorrhage were significantly associated with initial dysphagia. Baseline aspiration risk and age were identified as independent predictors of impaired swallowing function on days 7 and 30, and SAP. Moreover, ICH volume was significantly correlated with swallowing impairment on day 7 and SAP occurrence. Midline shift and basal ganglia hematoma remained independent predictors of impaired swallowing on day 30. Predictive models for swallowing impairment on days 7 and 30, as well as SAP, demonstrated strong calibration and discriminatory ability, with C indices of 0.867, 0.895, and 0.773, respectively.

CONCLUSION

Post-ICH dysphagia can be predicted based on stroke severity, hematoma expansion, and basal ganglia hemorrhage. Incorporating aspiration risk and imaging evaluation can further improve the identification of patients at high risk for swallowing impairment at both 1 week and 1 month after ICH.

Association between apolipoprotein E gene polymorphism and early MR findings in individuals with acute intracerebral hemorrhage: A retrospective cohort analysis

OBJECTIVE

The Apolipoprotein E (APOE) gene plays a significant role in the development and prognosis of intracerebral hemorrhage (ICH). Imaging features identified within 48 h of ICH onset, particularly on magnetic resonance imaging (MRI), are indicative of cerebral small vessel diseases (CSVD). Our study aimed to assess these imaging characteristics and investigate their association with the APOE gene among ICH patients.

METHODS

Clinical and imaging data from patients meeting specific inclusion and exclusion criteria from October 2021 to March 2022 were collected. MR signs or scores were evaluated following international accreditation standards and then analyzed in connection with the APOE allele genes.

RESULTS

In a cohort of 220 patients, ε2 was identified as an independent risk factor for the "multiple subcortical spots" sign (OR = 13.29, 95% CI 1.88-22.59). Furthermore, ε4 emerged as an independent risk factor for the presence of perivascular space (PVS) in the centrum semiovale (OR = 2.46, 95% CI 1.03-5.89) and basal ganglia (OR = 2.64, 95% CI 1.10-6.35), as well as for cerebral microbleeds (CMB) across all locations (OR = 2.38, 95% CI 1.15-6.97), lobar CMB (OR = 2.92, 95% CI 1.11-7.65), and deep CMB (OR = 2.29, 95% CI 1.12-8.67).

CONCLUSION

The association between APOE ɛ2 and ɛ4 alleles and the presence of "subcortical multiple spots," "PVS," and "CMB" indirectly implies the potential role of APOE gene-related pathological changes in the progression of ICH and small vessel pathology.

Brain structural-functional coupling mechanism in mild subcortical stroke and its relationship with cognition

OBJECTIVES

Stroke can lead to significant restructuring of brain structure and function. However, the precise changes in the coordination between brain structure and function in subcortical stroke patients remain unclear. We investigated alterations in brain structural-functional coupling (SC-FC coupling) and their impact on cognitive function in subcortical basal ganglia infarction patients.

METHODS

The study comprised 40 patients with mild stroke with basal ganglia region infarcts and 29 healthy controls (HC) who underwent multidimensional neuroimaging examination and neuropsychological testing. The subcortical stroke patients were divided into post-stroke cognitive impairment (PSCI) and stroke with no cognitive impairment (NPSCI) groups based on cognitive performance, with 22 individuals undergoing follow-up examination after three months. We investigated differences in brain structural-functional coupling across three groups, and their associations with cognitive functions.

RESULTS

Compared to both HC participants and NPSCI, PSCI exhibited significantly reduced structural-functional coupling strength in specific brain regions. After a three-month period, there was observed an increase in structural-functional coupling strength within the frontal lobe (precentral gyrus and paracentral lobule). The strength of SC-FC coupling within the precentral gyrus, precuneus, and paracentral lobule regions demonstrated a decline correlating with the deterioration of cognitive function (MoCA, memory and visual motor speed functions).

CONCLUSIONS

After subcortical basal ganglia stroke, PSCI patients demonstrated decreased SC-FC coupling in the frontal lobe region, correlating with multidimensional cognitive impairment. Three months later, there was an increase in SC-FC coupling in the frontal lobe, suggesting a compensatory mechanism during the recovery phase of cognitive impairment following stroke.

Joint association of METS-IR and uric acid with stoke, mediated by C-reactive protein

Objectives

To explore the dose-response relationship between the Metabolic Score of Insulin Resistance (METS-IR), uric acid (UA) and the risk of stroke incidence, the mediating role of C-reactive protein (CRP) in the above relationship, as well as the joint effect of METS-IR and UA on the risk of stroke incidence.

Methods

Participants from the CHARLS study were included in this cohort study. Logistic regression models were used to estimate the odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for the associations of METS-IR and UA with the risk of incident stroke. The dose-response relationships of METS-IR and UA with stroke risk were assessed by restricted cubic spline regression. The mediation models were employed to estimate the potential mediating effects of CRP on the associations of METS-IR and UA with stroke risk. Logistic regression analysis was carried out to analyse the association of stroke and MRTS-IR combined with UA.

Result

During a 9-year follow-up from 2011 to 2018, 570 incident cases of stroke were documented among 7,343 total participants. Per interquartile range increases in METS-IR and UA were associated with the increased risk of incident stroke, with the OR (95% CI) of 1.61 (1.44, 1.80) and 1.18 (1.05, 1.32) respectively. A dose-response function showed that METS-IR had a nonlinear relationship (P for nonlinear=0.047) and UA had a linear relationship (P for nonlinear=0.247) with the stroke risk. CRP had significant mediated effects on the associations of METS-IR and UA with stroke risk, and the proportion of mediation was 9.01% and 26.34% respectively (all P < 0.05). The results of joint effect showed that participants with high levels of METS-IR and UA had the highest increased risk of stroke compared to the participants with low levels of METS-IR and UA.

Conclusion

METS-IR and UA levels were positively associated with an increased risk of stroke onset, and CRP mediated these relationships. Improving insulin sensitivity and regulating CRP and uric acid levels may be important for preventing the risk of stroke occurrence.

NU7441, a selective inhibitor of DNA-PKcs, alleviates intracerebral hemorrhage injury with suppression of ferroptosis in brain

Neuronal apoptosis, oxidative stress, and ferroptosis play a crucial role in the progression of secondary brain injury following intracerebral hemorrhage (ICH). Although studies have highlighted the important functions of DNA-dependent protein kinase catalytic subunit (DNA-PKcs) in various experimental models, its precise role and mechanism in ICH remain unclear. In this study, we investigated the effects of DNA-PKcs on N2A cells under a hemin-induced hemorrhagic state in vitro and a rat model of collagenase-induced ICH in vivo. The results revealed a notable increase in DNA-PKcs levels during the acute phase of ICH. As anticipated, DNA-PKcs and γ-H2AX had consistent upregulations after ICH. Administration of NU7441, a selective inhibitor of DNA-PKcs, alleviated neurological impairment, histological damage, and ipsilateral brain edema in vivo. Mechanistically, NU7441 attenuated neuronal apoptosis both in vivo and in vitro, alleviated oxidative stress by decreasing ROS levels, and suppressed ferroptosis by enhancing GPX4 activity. These results suggest that inhibition of DNA-PKcs is a promising therapeutic target for ICH.

Intracerebral hemorrhage complicated by alcohol use disorder in young males in Chongqing China: Characteristics and long-term outcome

BACKGROUND

The characteristics of patients with intracerebral hemorrhage (ICH) complicated by alcohol use disorders (AUD) are not well understood. Investigating the clinical characteristics and prognosis of this subgroup (AUD-ICH) is necessary.

METHODS

This study involved young males with ICH who were admitted to our hospital between January 2013 and March 2022. Based on drinking patterns, the included cases were divided into three groups: AUD, occasional drinking, and non-drinking. We compared the clinical characteristics and prognosis of patients in the three groups. The effect of AUD on hematoma expansion and long-term dysfunction was explored by developing regression models. The potential mediating role of hematoma density heterogeneity within the relationship between AUD and hematoma expansion was examined through mediation analysis.

RESULTS

This study included 222 cases of male patients with ICH, with a mean age of 54.16. AUD patients had a higher risk of hematoma expansion and dysfunction compared to occasional drinkers (odds ratio [OR] 2.966, p=0.028 for hematoma expansion; hazard ratio [HR] 2.620, p=0.006 for dysfunction) and non-drinkers (OR 3.505, p=0.011 for hematoma expansion; HR 2.795, P=0.003 for dysfunction). The mediation analysis showed that the indirect effect through hematoma density heterogeneity on the relationship between AUD and hematoma expansion was significant, with a mediated proportion of 19.3%.

CONCLUSIONS

AUD was an independent risk factor for hematoma expansion and long-term dysfunction in young male patients with ICH. Hematoma density heterogeneity partially mediated the relationship between AUD and hematoma expansion.

A Mendelian Randomization Study about Causal Associations between Tofu Consumption and Stroke as well as Related Subtypes

OBJECTIVE

Consuming soy in the diet is beneficial for health, and tofu possess the richest source of dietary soy. However, the specific association with stroke and related subtypes remains controversial. In this study, the genetic causal relationship among tofu and stroke as well as the subtypes was investigated by utilizing the data in a number of genome-wide association study (GWAS) based on population.

METHODS

The tofu intake GWAS analysis is derived from the Medical Research Council (MRC) Integrative Epidemiology Unit at the University of Bristol (MRC-IEU) Consortium. The two-sample Mendelian randomization (MR) study was carried out, utilizing multiple analysis methods to analyze the associations with stroke and related subtypes. The sensitivity, heterogeneity, and potential pleiotropy could be investigated by multiple analysis method.

RESULTS

We found that tofu intake had no causal relationship with stroke. However, in stroke subtype, there is a causal relationship among tofu intake with the risk of intracerebral hemorrhage (ICH) (odds ratio, OR = 1.24 × 10-5, 95% CI: 1.54 × 10-8-9.95 × 10-3, p = 9.300 × 10-4), while tofu intake does not affect the risk of ischemic stroke (OR = 1.07 × 10-1, 95% CI: 3.84 × 10-4-2.97 × 101, p = 4.362 × 10-1) and subarachnoid hemorrhage (SAH) (OR = 3.33 × 10-3, 95% CI: 1.79 × 10-6-6.18, p = 1.373 × 10-1). Both the Mendelian randomization PRESSO (MR-PRESSO) global test and Cochran's Q test did not detect any sensitivity and heterogeneity.

CONCLUSIONS

While tofu consumption is associated with a higher risk of ICH, it does not show a significant relationship with ischemic stroke or SAH. The varying effects of tofu on different stroke subtypes underscore the need for considering potential confounding dietary and lifestyle factors in future studies.

Targeting the neurovascular unit: Therapeutic potential of traditional Chinese medicine for the treatment of stroke

Stroke poses a significant global health challenge due to its elevated disability and mortality rates, particularly affecting developing nations like China. The neurovascular unit (NVU), a new concept encompassing neurons, brain microvascular endothelial cells, pericytes, astrocytes, microglia, and the extracellular matrix, has gained prominence in recent years. Traditional Chinese medicine (TCM), deeply rooted in Chinese history, employs a combination of acupuncture and herbal treatments, demonstrating significant efficacy across all stages of stroke, notably during recovery. The holistic approach of TCM aligns with the NVU's comprehensive view of treating stroke by addressing neurons, surrounding cells, and blood vessels collectively. This review examines the role of NVU in stroke and endeavors to elucidate the mechanisms through which traditional Chinese medicine exerts its anti-stroke effects within the NVU framework. The NVU contributes to neuroinflammation, immune infiltration, blood-brain barrier permeability, oxidative stress, and Ca2+ overload during stroke occurs. Additionally, TCM targeting the NVU facilitates nerve repair post-stroke through various pathways and approaches. Specific herbs, including panax notoginseng, ginseng, and borneol, alleviate brain injury by enhancing brain-derived neurotrophic factor expression and targeting astrocytes and microglia to yield anti-inflammatory and antioxidant effects. Acupuncture, another facet of TCM, promotes brain injury repair by augmenting cerebral blood flow and improving circulation. This exploration aims to assess the viability of stroke treatment by directing TCM interventions toward the NVU, thus paving the way for its broader clinical application.

Comprehensive Stroke Management: a Guide for Hospitalists

Stroke is a devastating clinical condition characterized by an acute neurological impairment secondary to cerebrovascular disease. Globally, stroke is the second leading cause of mortality and disability, with prominent risk factors including age, hypertension, hyperlipidemia, atrial fibrillation, diabetes, smoking, preexisting vascular anomalies and obesity. Acute neurological deficits are commonly encountered in the inpatient wards. Heightened clinical suspicion and prompt evaluation involving neurological examination and imaging are crucial for effective management. At many hospitals, hospitalists are tasked with managing stroke patients with consultation from neurologists. The management of stroke is constantly evolving as new and advanced therapies emerge. This review of the literature seeks to summarize current practice in stroke management in hopes it is helpful to those hospitalists who care for this patient population frequently. A search of the literature was performed to summarize current research as well as management and therapeutic strategies.

Neuroendoscopic Parafascicular Evacuation of Spontaneous Intracerebral Hemorrhage (NESICH Technique): A Multicenter Technical Experience with Preliminary Findings

INTRODUCTION

Intracerebral hemorrhage (ICH) is a severe manifestation of stroke, demonstrating notably elevated global mortality and morbidity. Thus far, effective therapeutic strategies for ICH have proven elusive. Currently, minimally invasive techniques are widely employed for ICH management, particularly using endoscopic hematoma evacuation in cases of deep ICH. Exploration of strategies to achieve meticulous surgery and diminish iatrogenic harm, especially to the corticospinal tract, with the objective of enhancing the neurological prognosis of patients, needs further efforts.

METHODS

We comprehensively collected detailed demographic, clinical, radiographic, surgical, and postoperative treatment and recovery data for patients who underwent endoscopic hematoma removal. This thorough inclusion of data intends to offer a comprehensive overview of our technical experience in this study.

RESULTS

One hundred fifty-four eligible patients with deep supratentorial intracerebral hemorrhage who underwent endoscopic hematoma removal were included in this study. The mean hematoma volume was 42 ml, with 74 instances of left-sided hematoma and 80 cases of right-sided hematoma. The median Glasgow Coma Scale (GCS) score at admission was 10 (range from 4 to 15), and the median time from symptom onset to surgery was 18 (range 2 to 96) h. The mean hematoma clearance rate was 89%. The rebleeding and mortality rates within 1 month after surgery were 3.2% and 7.8%, respectively. At the 6-month mark, the proportion of patients with modified Rankin Scale (mRS) scores of 0-3 was 58.4%.

CONCLUSION

Both the reduction of surgery-related injury and the protection of the residual corticospinal tract through endoscopic hematoma removal may potentially enhance neurological functional outcomes in patients with deep ICH, warranting validation in a forthcoming multicenter clinical study.

Etiology, Risk Factors and Outcome of Spontaneous Intracerebral Hemorrhage in Young Adults Admitted to Tertiary Care Hospital in Mogadishu, Somalia

Introduction

Spontaneous Intracerebral hemorrhage (ICH) in young patients is less common and not well studied compared to ICH in older patients. The etiology, risk factors and outcome of ICH in young patients may have regional and ethnic differences. The study aims to investigate the clinical characteristics, risk factors, etiology and outcome of spontaneous intracerebral hemorrhage in young adults in Somalia.

Methods

The study enrolled 168 young patients with ICH (16-50 years) admitted to the neurology department of a tertiary hospital from 2019 to 2022. The information about the demographic details, documented ICH risk factors, etiology and patients' clinical status were retrieved. The etiology of ICH was determined based on clinical, laboratory and radiological findings. Intra-hospital survival status and associated factors were assessed.

Results

The mean age of the patients was 35±8.6 years. 99 (59%) of patients were male while 69 (41%) were females. Hypertension 48 (29%) was the most common risk factor, followed by substance abuse. Hypertensive hemorrhage was the most common etiology of ICH 60 (35.7%), followed by cerebral venous thrombosis (CVT) 5(15%), substance abuse 23 (13.7%) and arteriovenous malformation (AVM) in 10 (6%). AVM, CVT, cavernoma, eclampsia, substance abuse and cryptogenic etiology were more common in the 2nd and 3rd decades whereas hypertension was more common in the 4th and 5th decade. Intrahospital mortality was 28% in this study. Factors predicting intrahospital mortality were hematoma volume of greater than 30mL, thrombolytic etiology, brainstem ICH location, substance abuse related etiology, presence of associated mass effect, low GCS score on admission, high systolic blood pressure on admission, and the presence of chronic renal failure.

Conclusion

In this study, hypertension, substance abuse, CVT and vascular malformation are the leading causes of ICH in young adults. Intracerebral hemorrhage in the young has different spectrum of etiologies and factors associated with short-term mortality compared to older patients.

Predicting the recurrence of spontaneous intracerebral hemorrhage using a machine learning model

Background

Recurrence can worsen conditions and increase mortality in ICH patients. Predicting the recurrence risk and preventing or treating these patients is a rational strategy to improve outcomes potentially. A machine learning model with improved performance is necessary to predict recurrence.

Methods

We collected data from ICH patients in two hospitals for our retrospective training cohort and prospective testing cohort. The outcome was the recurrence within one year. We constructed logistic regression, support vector machine (SVM), decision trees, Voting Classifier, random forest, and XGBoost models for prediction.

Results

The model included age, NIHSS score at discharge, hematoma volume at admission and discharge, PLT, AST, and CRP levels at admission, use of hypotensive drugs and history of stroke. In internal validation, logistic regression demonstrated an AUC of 0.89 and precision of 0.81, SVM showed an AUC of 0.93 and precision of 0.90, the random forest achieved an AUC of 0.95 and precision of 0.93, and XGBoost scored an AUC of 0.95 and precision of 0.92. In external validation, logistic regression achieved an AUC of 0.81 and precision of 0.79, SVM obtained an AUC of 0.87 and precision of 0.76, the random forest reached an AUC of 0.92 and precision of 0.86, and XGBoost recorded an AUC of 0.93 and precision of 0.91.

Conclusion

The machine learning models performed better in predicting ICH recurrence than traditional statistical models. The XGBoost model demonstrated the best comprehensive performance for predicting ICH recurrence in the external testing cohort.

Managing Post-Stroke Fatigue Using a Mobile Health Called iHealth After Intracerebral Hemorrhage

Background

Post-stroke Fatigue (PSF) after Intracerebral Hemorrhage (ICH) is a long-term symptom in stroke survivors. However, the pathogenesis of PSF remains inadequately understood and sufficient evidence-based treatments are lacking. Mobile health (mHealth) technology offers a promising approach to expanding access to high-quality and culturally tailored evidence-based mental care.

Aim

This study examined the role of mHealth called iHealth in the management of PSF after ICH.

Methods

A total of 225 patients diagnosed with intracerebral hemorrhage (ICH) were included in the study and randomly assigned to either the Mobile Health Intervention Group (mHI Group) or the non-Mobile Health Intervention Group (non-mHI). The management involved the utilization of a digital healthcare application named iHealth, which incorporated digital questionnaires, fatigue scale tests, and online videos for the purpose of administering the Patient Fatigue Reporting Measurement Information System (PFRMIS) short form as part of the initial patient assessment following ICH. The study was conducted remotely via video conferencing over a 12-week period in mHI Group, with fatigue assessments being conducted 3 months post-ICH onset in two groups.

Results

Following the administration of PSF by iHealth, Univariate Logistic analyses indicated a significant association between fatigue and the type of activity, with patients who were sedentary or did nothing experiencing higher levels of fatigue (β=2.332, p<0.001; β=2.517, p<0.001). Multivariate Logistic analyses demonstrated a positive association between the intensity of physical activity and decreased emotional well-being and family support, as well as increased fatigue. (p=0.001, p=0.002, p=0.001). The FSS results demonstrated a significantly reduced incidence of PSF in the MHI group in comparison to non-mHI group following the conclusion of the programme. (13.1% vs 40%, p<0.001).

Conclusion

This study explored the effectiveness of the iHealth app for PSF following ICH, indicating that iHealth is a clinically valuable tool that warrants further dissemination.

Remote Ischemic Conditioning to Reduce Perihematoma Edema in Patients with Intracerebral Hemorrhage (RICOCHET): A Randomized Control Trial

Background: Early perihematomal edema (PHE) growth is associated with worse functional outcomes at 90 days. Remote Ischemic conditioning (RIC) may reduce perihematomal inflammation if applied early to patients with intracerebral hemorrhage (ICH). We hypothesize that early RIC, delivered for seven days in patients with spontaneous ICH, may reduce PHE growth. Methods: ICH patients presenting within 6 h of symptom onset and hematoma volume < 60 milliliters (mL) were randomized to an RIC + standard care or standard care (SC) group. The primary outcome measure was calculated edema extension distance (EED), with the cm assessed on day seven. Results: Sixty patients were randomized with a mean  ±  SD age of 57.5  ±  10.8 years, and twenty-two (36.7%) were female. The relative baseline median PHE were similar (RIC group 0.75 (0.5-0.9) mL vs. SC group 0.91 (0.5-1.2) mL, p  =  0.30). The median EEDs at baseline were similar (RIC group 0.58 (0.3-0.8) cm vs. SC group 0.51 (0.3-0.8) cm, p  =  0.76). There was no difference in the median day 7 EED (RIC group 1.1 (0.6-1.2) cm vs. SC group 1 (0.9-1.2) cm, p  =  0.75). Conclusions: Early RIC therapy delivered daily for seven days was feasible. However, no decrease in EED was noted with the intervention.

A Prospective Cohort Study of Elevated Serum NLRP1 Levels to Prognosticate Neurological Outcome After Acute Intracerebral Hemorrhage at a Single Academic Institution

Background

Nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 1 (NLRP1) participates in neuroinflammation. This study aimed to identify serum NLRP as a potential prognostic biomarker of acute intracerebral hemorrhage (ICH).

Methods

This prospective cohort study enrolled 145 patients with supratentorial ICH and 51 healthy controls. Serum NLRP1 levels were quantified on admission of all 145 patients, on days 1, 3, 5, 7, and 10 after stroke in 51 of 145 patients and at entry into the study of controls. Poststroke 6-month modified Rankin Scale (mRS) scores of 3-6 signified a poor prognosis.

Results

Compared to controls, patients had prominently increased serum NLRP1 levels until day 10 after ICH, with the highest levels at days 1 and 3. Serum NLRP1 levels were independently correlated with National Institutes of Health Stroke Scale (NIHSS) scores, hematoma volume and six-month mRS scores, and independently predicted six-month bad prognosis. A linear relationship was observed between serum NLRP1 levels and the risk of poor prognosis in a restricted cubic spline. Under the receiver operating characteristic (ROC) curve, serum NLRP levels efficiently discriminated poor prognosis. Serum NLRP1, NIHSS, and hematoma volume were merged into a prognosis prediction model, which was portrayed using a nomogram. Good performance of the model was verified using calibration curve, decision curve, and ROC curve.

Conclusion

Serum NLRP1 levels are elevated during the early period following ICH and are independently related to hemorrhagic severity and poor prognosis, suggesting that serum NLRP1 may represent a promising prognostic biomarker of ICH.

More severe initial manifestations and worse short-term functional outcome of intracerebral hemorrhage in the plateau than in the plain

Intracerebral hemorrhage (ICH) is one of the most devastating forms of stroke. However, studies on ICH at high altitude are insufficient. We aimed to compare the initial manifestations, imaging features and short-term functional outcomes of ICH at different altitudes, and further explore the effect of altitude on the severity and prognosis of ICH. We retrospectively recruited ICH patients from January 2018 to July 2021 from two centers at different altitudes in China. Information regarding to clinical manifestations, neuroimages, and functional outcomes at discharge were collected and analyzed. Association between altitude and initial severity, neuroimages, and short-term prognosis of ICH were also investigated. A total of 724 patients with 400 lowlanders and 324 highlanders were enrolled. Compared with patients from the plain, those at high altitude were characterized by more severe preliminary manifestations (P < 0.0001), larger hematoma volume (P < 0.001) and poorer short-term functional outcome (P < 0.0001). High altitude was independently associated with dependency at discharge (adjusted P = 0.024), in-hospital mortality (adjusted P = 0.049) and gastrointestinal hemorrhage incidence (adjusted P = 0.017). ICH patients from high altitude suffered from more serious initial manifestations and worse short-term functional outcome than lowlanders. Control of blood pressure, oxygen supplementation and inhibition of inflammation may be critical for ICH at high altitude.

Serum Secreted Protein Acidic and Rich in Cysteine-Like 1 as a Biochemical Predictor for Prognosticating Clinical Outcomes After Acute Supratentorial Intracerebral Hemorrhage: A Prospective Cohort Study

Background

Secreted protein acidic and rich in cysteine-like 1 (SPARCL1) regulates synaptic stability and is up-regulated during axonal regeneration. Here, serum SPARCL1 was determined for estimating severity and prognosticating early neurological deterioration (END) and functional outcomes of acute intracerebral hemorrhage (ICH).

Methods

In this prospective observational cohort study of 156 patients with supratentorial ICH, blood samples of 53 were acquired not only at admission but also ad days 1, 3, 5, 7 and 10. Another group of 53 healthy controls were recruited. The modified Rankin Scale (mRS) scores of 3-6 at poststroke six months were regarded as poor prognosis.

Results

As opposed to controls, serum SPARCL1 levels were markedly elevated during the early ten days after ICH, with the highest levels at days 1 and 3. Admission serum SPARCL1 levels were independently correlated with National Institutes of Health Stroke Scale scores and hematoma volume, were significantly increased in the order of six-month mRS scores from 0 to 6 and were independently correlated with six-month mRS scores. Serum SPARCL1 levels were linearly related to risks of poor six-month prognosis and END under restricted cubic spline, had significant efficiency under receiver operating characteristic (ROC) curve and were independently associated with END and poor prognosis. Subgroup analysis confirmed that no interactions existed for associations of serum SPARCL1 levels with other variables, such as age, gender and some specific vascular risk factors. END and poor prognosis prediction models integrating serum SPARCL1 were displayed using the two nomograms. The poor prognosis prediction model, but END prediction model not, performed well under calibration curve, decision curve and ROC curve.

Conclusion

A substantial elevation of serum SPARCL1 levels during the early period after ICH is independently related to illness severity and poor neurological outcomes, thus signifying that serum SPARCL1 may appear as a prognostic biomarker of ICH.

A Prospective Cohort Study of Inter-Alpha-Trypsin Inhibitor Heavy Chain 4 as a Serologic Marker in Relation to Severity and Functional Outcome of Acute Intracerebral Hemorrhage

Background

The inter-alpha-trypsin inhibitor heavy chain 4 (ITIH4) may regulate immunity and inflammation. The current study was conducted to determine its role as a biomarker for reflecting the severity and predicting outcomes of intracerebral hemorrhage (ICH).

Methods

In this prospective cohort study, 185 patients with supratentorial ICH were enrolled, among whom 62 had blood obtained not only at admission but also on days 1, 3, 5, 7, 10, and 14. In addition, 62 healthy controls underwent blood collection at the start of the study. The serum ITIH4 levels were then quantified. We recorded early neurological deterioration (END) and poor prognosis (modified Rankin Scale [mRS] scores of 3-6]) six months after ICH.

Results

Serum ITIH4 levels decreased prominently in the early phase after ICH, continued to decline until day 5, then gradually increased until day 14, and were significantly lower during 14 days in patients than in controls. Serum ITIH4 levels on admission were independently associated with serum C-reactive protein levels, National Institutes of Health Stroke Scale (NIHSS) scores and hematoma volume. Admission serum ITIH4 levels were independently associated with mRS scores, END, and poor prognosis. No substantial differences existed in the areas under the receiver operating characteristic curve of END and poor prognosis prediction between the serum ITIH4 levels, NIHSS scores, and hematoma volume. Prediction models, in which serum ITIH4 levels, NIHSS scores, and hematoma volume were integrated, were relatively reliable and stable using a series of statistical methods. In addition, the prediction model of poor prognosis had a higher discriminatory ability than the NIHSS scores and hematoma volume alone.

Conclusion

A dramatic decline in serum ITIH4 levels during the early period following ICH is independently related to the inflammatory response, stroke severity, and poor neurologic outcomes, suggesting that serum ITIH4 may be a useful prognostic biomarker of ICH.

The Venular Side of Cerebral Amyloid Angiopathy: Proof of Concept of a Neglected Issue

Small vessel diseases (SVD) is an umbrella term including several entities affecting small arteries, arterioles, capillaries, and venules in the brain. One of the most relevant and prevalent SVDs is cerebral amyloid angiopathy (CAA), whose pathological hallmark is the deposition of amyloid fragments in the walls of small cortical and leptomeningeal vessels. CAA frequently coexists with Alzheimer's Disease (AD), and both are associated with cerebrovascular events, cognitive impairment, and dementia. CAA and AD share pathophysiological, histopathological and neuroimaging issues. The venular involvement in both diseases has been neglected, although both animal models and human histopathological studies found a deposition of amyloid beta in cortical venules. This review aimed to summarize the available information about venular involvement in CAA, starting from the biological level with the putative pathomechanisms of cerebral damage, passing through the definition of the peculiar angioarchitecture of the human cortex with the functional organization and consequences of cortical arteriolar and venular occlusion, and ending to the hypothesized links between cortical venular involvement and the main neuroimaging markers of the disease.