Female gender remains an independent risk factor for poor outcome after acute nontraumatic intracerebral hemorrhage

The impact of sex on epidemiology, management, and outcome of spontaneous intracerebral hemorrhage (sICH)

OBJECTIVE

Data on sex differences in spontaneous intracerebral hemorrhages are limited.

METHODS

An automated comprehensive scoping literature review was performed using PubMed and Scopus. Articles written in English about spontaneous intracerebral hemorrhage and sex were reviewed.

RESULTS

Males experience spontaneous intracerebral hemorrhage more frequently than females, at younger ages, and have a higher prevalence of deep bleeds compared to females. Risk factors between sexes vary and may contribute to differing incidences and locations of spontaneous intracranial hemorrhage. Globally, females receive less aggressive care than males, likely impacting survival.

CONCLUSIONS

Epidemiology, risk factors, and treatment of spontaneous intracranial hemorrhage vary by sex, with limited and oftentimes conflicting data available. Further research into the sex-based differences of spontaneous intracranial hemorrhage is necessary for clinicians to better understand how to evaluate and guide treatment in the future.

Sex Differences in the Epidemiology of Intracerebral Hemorrhage Over 10 Years in a Population-Based Stroke Registry

BACKGROUND

We investigated incidence and outcome of spontaneous intracerebral hemorrhage (ICH) in a population-based stroke registry and provided data to inform on the figures of the disease in women and in men.

METHODS AND RESULTS

Our prospective population-based registry included patients with first-ever ICH occurring from January 2011 to December 2020. Incidence rates were standardized to the 2011 Italian and European population, and incidence rate ratios were calculated. Multivariate hazard ratios for 30-day and 1-year fatality were estimated with Cox regression, including components of the ICH score and sex. We included 748 first-ever ICHs (41.3% women). Women were significantly older than men at ICH onset (78.9±12.6 versus 73.2±13.6 years; P<0.001) and showed higher clinical severity on presentation (median National Institutes of Health Stroke Scale score, 11 [interquartile range, 6-20] versus 9 [interquartile range, 4-15], respectively; P=0.016). The crude annual incidence rate was 20.2 (95% CI, 18.0-22.6) per 100 000 person-years in women and 30.2 (95% CI, 27.4-33.2) per 100 000 person-years in men); incidence was lower in women versus men (incidence rate ratio, 0.67 [95% CI, 0.58-0.78]; P<0.001) and did not change over time in both sexes (P for trend=0.073 and 0.904, respectively). Unadjusted comparison showed higher 1-year case-fatality rates in women versus men (48.5% versus 40.1%; P=0.026). After adjusting for components of the ICH score, female sex lost significance as a predictor of mortality.

CONCLUSIONS

We found lower ICH incidence in women than in men. However, women showed a higher 1-year case-fatality rate versus men, which was likely related to older age at ICH onset and higher clinical severity. Identification of factors explaining the reported differences is important to develop targeted interventions.

Gender Differences in Intracerebral Hemorrhage

Differences exist between genders in intracerebral hemorrhage cause, epidemiology, and outcomes. These gender differences are in part attributable to physiologic differences; however, demographic, social/behavioral risk factors, along with health care system variation and potential family and/or clinician bias play a role as well. These factors vary from region to region and interact, making comprehensive and definitive conclusions regarding sex differences a challenging task. Differences between the genders in intracerebral hemorrhage epidemiology and extensive differences in underlying pathophysiology, intervention, risk factors, and outcome are all discussed.

Gender disparity in stoke: Women have higher ICH scores than men at initial ED presentation for intracerebral hemorrhage

OBJECTIVE

To determine what if any differences in presentation exist between men and women who present with acute intracerebral hemorrhage (ICH) to the emergency department (ED).

METHODS

This was an IRB approved prospective cohort study of ED patients presenting with acute intracerebral hemorrhage. Statistical analyses were performed in JMP 14.1. Non parametric methods were used for skewed variables. The study was conducted in a comprehensive stroke center. The independent variable was the ICH score, and the dependent variable of interest was ultimate disposition (death or hospice vs. home or skilled nursing facility).

RESULTS

The cohort consisted of 129 patients (54 women and 75 men). The median age was 71 years (IQR 58-81). The baseline co-morbidities were similar between both men and women and whether or not they were independent in their activities of daily living prior to experiencing their ICH. The overall median ICH score for women was 2, IQR 1-4, and 1 for men, IQR 1-2 (P = 0.0369) . A higher ICH score was significantly associated with in-hospital death and or hospice status (P = .0095, 95% CI 0.6340 - 0.4825). Conversely, a lower ICH score was significantly associated with being discharged home (P< 0.001, 95% CI -0.1694 to -0.0759).

CONCLUSION

Women have higher ICH scores than men at initial ED presentation for intracerebral hemorrhage. A higher ICH score is significantly associated with the worse outcomes of death and/or hospice.

Sex Differences in Treatment and Prognosis of Acute Intracerebral Hemorrhage

Background: Intracerebral hemorrhage (ICH) accounts for 10%-15% of all stroke cases and is associated with a high risk of death and disability. Prior studies in ischemic stroke have demonstrated a less favorable outcome in women compared with men, but there is a paucity of data regarding differences in outcome by sex in ICH. The aim of the present study was to investigate possible sex differences in acute care and the 3-months follow-up of patients with ICH. Methods: Data were collected from the Swedish National Stroke Registry (Riksstroke). Demographic and baseline characteristics were collected, based on in-hospital data and data from 3-months follow-up. Results: Variables of interest were collected from 1,403 patients. Women (45.1%) were significantly older than men, with a mean age ± standard deviation of 77 ± 13years, versus 71 ± 14 years, p < 0.01. On admission, the ICH severity was similar in men and women. There was no significant association between sex and reception of neuroimaging or neurosurgery. Women were less likely to be treated in a stroke unit (80.8% vs. 85.3%, p = 0.03), or discharged to home (51.5% vs. 63.4%, p < 0.01). At 3-months follow-up, there were no sex-related differences regarding dependence, post-ICH self-reported depression, or case fatality. Conclusions: Women were less likely to be treated in a stroke unit, and were less often discharged to home. However, no significant differences in 3-month functional outcome or survival between men and women with ICH were found in this study.

Association of sex and age with in-hospital mortality and complications of patients with intracerebral hemorrhage: A study from the Chinese Stroke Center Alliance

BACKGROUND AND PURPOSE

The impact of sex and age on prognosis in patients with intracerebral hemorrhage (ICH) in the Chinese population remains unclear. Our study aimed to investigate the relationship between sex and age of Chinese ICH patients and adverse prognosis.

METHODS

We used the Chinese Stroke Center Alliance database with in-hospital mortality as the primary outcome and hospital complications as the secondary outcome. Patients were divided into four groups by sex and age. Logistic regression analyses were performed to assess the association between sex and age and the prognosis of ICH patients.

RESULTS

We enrolled 60,911 ICH patients, including 22,284 young and middle-aged males, 15,651 older males, 11,948 young and middle-aged females, and 11,028 older females. After adjusting for variables, older male patients had a higher mortality rate (OR = 1.21, 95% CI 1.01-1.45), combined with more frequent hematoma expansion (OR = 1.14, 95% CI 1.03-1.26), pneumonia (OR = 1.91, 95% CI 1.81-2.03), and hydrocephalus (OR = 1.28, 95% CI 1.04-1.59). Young and middle-aged female patients had a lower mortality rate (OR = 0.74, 95% CI 0.58-0.95) and less frequent combined pneumonia (OR = 0.81, 95% CI 0.75-0.87). In-hospital mortality was not significantly different in older females compared with young and middle-aged males, but the odds of deep vein thrombosis, swallowing disorders, urinary tract infections, and gastrointestinal bleeding were significantly higher.

CONCLUSION

Among young and middle-aged patients, females are related to a lower in-hospital mortality rate from ICH. Older patients are at an increased risk of ICH complications, with higher in-hospital mortality in older men.

Red Cell Microparticles Suppress Hematoma Growth Following Intracerebral Hemorrhage in Chronic Nicotine-Exposed Rats

Spontaneous intracerebral hemorrhage (sICH) is a disabling stroke sub-type, and tobacco use is a prominent risk factor for sICH. We showed that chronic nicotine exposure enhances bleeding post-sICH. Reduction of hematoma growth is a promising effective therapy for sICH in smoking subjects. Red-blood-cell-derived microparticles (RMPs) are hemostatic agents that limit hematoma expansion following sICH in naïve rats. Considering the importance of testing the efficacy of experimental drugs in animal models with a risk factor for a disease, we tested RMP efficacy and the therapeutic time window in limiting hematoma growth post-sICH in rats exposed to nicotine. Young rats were chronically treated with nicotine using osmotic pumps. sICH was induced in rats using an injection of collagenase in the right striatum. Vehicle/RMPs were administered intravenously. Hematoma volume and neurological impairment were quantified ≈24 h after sICH. Hematoma volumes in male and female nicotine-exposed rats that were treated with RMPs at 2 h post-sICH were significantly lower by 26 and 31% when compared to their respective control groups. RMP therapy was able to limit hematoma volume when administered up to 4.5 h post-sICH in animals of both sexes. Therefore, RMPs may limit hematoma growth in sICH patients exposed to tobacco use.

Gene expression changes implicate specific peripheral immune responses to Deep and Lobar Intracerebral Hemorrhages in humans

The peripheral immune system response to Intracerebral Hemorrhage (ICH) may differ with ICH in different brain locations. Thus, we investigated peripheral blood mRNA expression of Deep ICH, Lobar ICH, and vascular risk factor-matched control subjects (n = 59). Deep ICH subjects usually had hypertension. Some Lobar ICH subjects had cerebral amyloid angiopathy (CAA). Genes and gene networks in Deep ICH and Lobar ICH were compared to controls. We found 774 differentially expressed genes (DEGs) and 2 co-expressed gene modules associated with Deep ICH, and 441 DEGs and 5 modules associated with Lobar ICH. Pathway enrichment showed some common immune/inflammatory responses between locations including Autophagy, T Cell Receptor, Inflammasome, and Neuroinflammation Signaling. Th2, Interferon, GP6, and BEX2 Signaling were unique to Deep ICH. Necroptosis Signaling, Protein Ubiquitination, Amyloid Processing, and various RNA Processing terms were unique to Lobar ICH. Finding amyloid processing pathways in blood of Lobar ICH patients suggests peripheral immune cells may participate in processes leading to perivascular/vascular amyloid in CAA vessels and/or are involved in its removal. This study identifies distinct peripheral blood transcriptome architectures in Deep and Lobar ICH, emphasizes the need for considering location in ICH studies/clinical trials, and presents potential location-specific treatment targets.

Frontal Lobe Hemorrhage With Surrounding Edema and Subarachnoid Hemorrhage

We report the case of an 81-year-old woman who presented with a left hemineglect, a rightward gaze preference, and baseline disorientation. Her National Institutes of Health Stroke Score was 4. Her medical history was significant for dementia, osteoporosis, dyslipidemia, and a previous stroke. CT revealed a right-sided frontal lobe hemorrhage with surrounding edema and subarachnoid hemorrhage. Laboratory evaluation was significant for leukocytosis. The etiologies, clinical presentation, and diagnosis of this often devastating type of stroke are presented. While she did have a significant neurologic deficit (neglect), she was able to remain alert and protect her airway. Her hospital course consisted of observation in the ICU and blood pressure management. The case illustrates that intracerebral hemorrhage (ICH) can sometimes present indolently and does not always require surgical intervention.

Sex-related differences in spontaneous intracerebral hemorrhage outcomes: A prognostic study based on 111,112 medical records

Objective

To identify sex-related differences in the outcome of hospitalized patients with spontaneous intracerebral hemorrhage (SICH), and to identify potential causal pathways between sex and SICH outcome.

Methods

A total of 111,112 medical records of in-hospital patients with SICH were collected. Data- and expert-driven techniques were applied, such as a multivariate logistic regression model and causal mediation analysis. These analyses were used to determine the confounders and mediators, estimate the true effect of sex on the SICH outcome, and estimate the average causal mediation effect for each mediator.

Results

(1) Failure (disability or death) rates in women with SICH were significantly lower than in men with SICH. On the day of discharge, the odds ratio (OR) of failure between women and men was 0.9137 [95% confidence interval (CI), 0.8879–0.9402], while the odds ratio at 90 days post-discharge was 0.9353 (95% confidence interval, 0.9121–0.9591). (2) The sex-related difference in SICH outcome decreased with increasing age and disappeared after 75 years. (3) Deep coma, brainstem hemorrhage, and an infratentorial hemorrhage volume of >10 ml accounted for 62.76% (p < 0.001), 33.46% (p < 0.001), and 11.56% (p < 0.001) of the overall effect on the day of discharge, and for 52.28% (p < 0.001), 27.65% (p < 0.001), and 10.86% (p < 0.001) of the overall effect at the 90-day post-discharge.

Conclusion

Men have a higher failure risk than women, which may be partially mediated by a higher risk for deep coma, brainstem hemorrhage, and an infratentorial hemorrhage volume of >10 ml. Future work should explore the biological mechanisms underlying this difference.

Gender differences in mortality of hospitalised stroke patients. Systematic review and meta-analysis

OBJECTIVE

Gender differences in mortality after stroke remains unclear in the current literature. We therefore aimed to systematically review the gender differences in mortality up to five years after ischaemic (IS) or haemorrhagic stroke (HS) to address this evidence gap.

METHODS

The literature was systematically searched using Ovid EMBASE, Ovid Medline, and Web of Science databases, from inception-November 2021. The quality of evidence was appraised using the CASP Cohort-study checklist. Unadjusted and adjusted odds and hazard ratios were meta-analysed, separately for IS and HS and a subgroup analysis of age-stratified mortality data was conducted.

RESULTS

Forty-one studies were included (n = 8,128,700; mean-age 68.5 yrs; 47.1% female). 37 studies were included in meta-analysis (n = 8, 8008, 110). Compared to men, women who had an IS had lower mortality risk in-hospital (0.94; 95%CI 0.91-0.97), at one-month (0.87; 95%CI 0.77-0.98), 12-months (0.94; 95%CI 0.91-0.98) and five-years (0.93 95%CI 0.90-0.96). The subgroup analysis showed that this gender difference in mortality was present in women ≥ 70 years up to one-month post-IS (in-hospital: 0.94; 95%CI 0.91-0.97; one-month: 0.87; 95% CI 0.77-0.98), however, in women < 70 years this difference was no longer present. Nevertheless, analysis of crude data showed women were at higher risk of mortality in-hospital, at 12-months and five-years (in-hospital: 1.05; 95%CI 1.03-1.07, 12-months: 1.10; 95%CI 1.06-1.14, five-years: 1.06; 95%CI 1.02-1.10). After HS, women had higher mortality risk in-hospital (1.03; 95%CI 1.01-1.04) however, no gender differences were found post-discharge.

CONCLUSION

The gender differences in post-stroke mortality differ by stroke type, age group and follow-up. Crude stroke mortality in women is higher than in men and this appears to be driven by pre-existing comorbidities. In adjusted models, women have a lower mortality risk following IS, independent of duration of follow-up. After HS, women had higher mortality in hospital however, no gender differences after hospital discharge were found.

Gender Disparities in Stroke Code Activation in Patients with Intracerebral Hemorrhage

OBJECTIVES

Routine implementation of protocol-driven stroke "codes" results in timelier and more effective acute stroke management. However, it is unclear if patient demographics contribute to disparities in stroke code activation. We aimed to explore these demographic factors in a retrospective cohort study of patients with intracerebral hemorrhage (ICH).

MATERIALS AND METHODS

We identified consecutive patients with non-traumatic ICH who presented directly to our Comprehensive Stroke Center over 2 years and collected data on demographics, clinical features, and stroke code activation. We used multivariable logistic regression to examine differences in stroke code activation based on patient demographics while adjusting for initial clinical features (NIH Stroke Scale, FAST [facial drooping, arm weakness, speech difficulties] vs. non-FAST symptoms, time from last-known-well [LKW], and systolic blood pressure [SBP]).

RESULTS

Among 265 patients, 68% (n=179) had a stroke code activation. Stroke codes occurred less frequently in women (62%) than men (72%) and in non-white (57%) vs. white patients (70%). Non-stroke code patients were less likely to have FAST symptoms (37% vs. 87%) and had lower initial SBP (mean±SD 159.3±34.2 vs. 176.0±31.9 mmHg) than stroke code patients. In our primary multivariable models, neither age nor race were associated with stroke code activation. However, women were significantly less likely to have stroke codes than men (OR 0.49 [95% CI 0.24-0.98]), as were non-FAST symptoms (OR 0.11 [95% CI 0.05-0.22]).

CONCLUSIONS

Our data suggest gender disparities in emergency stroke care that should prompt further investigations into potential systemic biases. Increased awareness of atypical stroke symptoms is also warranted.

Gender differences in long-term mortality after spontaneous intracerebral hemorrhage in southern Portugal

Introduction:

the prognosis of spontaneous intracerebral hemorrhage (SICH) remains poor. Understanding gender differences can clarify the clinico-epidemiological and process of care related factors that influence SICH prognosis. We analyzed the long-term gender differences of mortality after SICH in Algarve, southern Portugal.

Patients and Methods:

analysis of consecutive community representative of SICH survivors (2009–2015). Logistic regression analysis and Kaplan–Meier method was used to assess gender differences on 1-year mortality and survival. We further analyzed if differences exist between 4 age and gender based subgroups (women <75 years, women ≥75 years, men <75 years, men ≥75 years).

Results:

a total of 285 survivors were analyzed; majority men (66.3%). Women were 2 years older on average. Overall case fatality was 11.6% [CI: 8.3–15.8]. A non-statistically significant (P = .094) higher case-fatality rate was observed in women; men were more frequently admitted to stroke unit; women had more often poor functional outcome or modified Rankin scale (mRS) ≥3. Predictors of death were: being women with ≥ 75 years, in-hospital pneumonia and hospital discharge mRS ≥3. The likelihood of death was higher in women ≥75 years (OR = 2.91 [1.23–8.1], P = .035) in comparison to women <75 years and men ≥75 years. Women <75 years had the longest survivor time, whereas women ≥75 years the shortest survivor time (P < .001).

Conclusion:

gender and age interact to influence long-term mortality after SICH. Women ≥75 years are at increased risk of death and have reduced survival after SICH in southern Portugal. Further studies are needed to clarify the biological or social factors contributing for the poor prognosis in the very old women in the region.

Sex Differences in Outcomes After Spontaneous Intracerebral Hemorrhage Among Patients With Low Total Cholesterol Levels

BACKGROUND

Low total cholesterol (TC) levels were shown to be an independent predictor of intracerebral hemorrhagic stroke in previous studies. However, the role of sex in risk and outcome of patients with ICH and low TC levels is unclear. Therefore, the objective of our study was to assess the sex differences in the risk factors and outcomes after spontaneous intracerebral hemorrhage (ICH) in patients with low TC levels in China.

METHODS

This study recruited consecutive patients diagnosed with ICH who were admitted to the Stroke Registry System in Tianjin between May 2005 and May 2018. Patients with low TC levels (defined as TC<200mg/dl) were analyzed in this study. Sex differences in clinical features, risk factors, and outcomes at hospital discharge, 3 months, and 12 months after ICH were evaluated.

RESULTS

Of the 824 patients with low TC levels, 610 men (74%) and 214 women (26%). The mean age at ICH onset was younger in men than in women (60.93±12.54 vs. 64.5±12.28, P<0.001), and men were more likely to have higher educational levels than women. There were higher prevalence rates of hypertension, current smoking status, and alcohol consumption in men. Urinary tract infections were more prevalent in women, and hepatic/renal dysfunctions were more prevalent in men. Women had significantly higher neurological function deficits. With lower Barthel indices (BIs) and higher modified Rankin scale (mRS) scores at admission; but there was no significant difference between men and women in National Institutes of Health Stroke Scale (NIHSS) scores. The study showed that there was no significant difference in mortality and dependency rates at hospital discharge, 3 months, and 12 months after ICH.

CONCLUSIONS

Our study showed that there were no sex differences in clinical outcomes of patients with ICH and low TC levels, which suggests that the effect of low cholesterol as a risk factor for cerebral hemorrhage is the same on patients of different sexs. The possible mechanisms need larger, prospective, multicenter studies to further research.

Why Are Women Less Represented in Intracerebral Hemorrhage Trials?

BACKGROUND AND PURPOSE

Fewer women than men tend to be enrolled in clinical trials of intracerebral hemorrhage. It is unclear whether this reflects lower prevalence of intracerebral hemorrhage in women, selection bias, or poor recruitment efforts. We undertook this study to examine differences between men and women in the reasons for exclusion from the iDEF trial (Intracerebral Hemorrhage Deferoxamine).

METHODS

The screen failure log included 29 different reasons for exclusion. Chi-square statistics were used to evaluate the differences in reasons for exclusion between men and women.

RESULTS

A total of 38.2% of participants in iDEF were women. Three thousand nine hundred eighty-two women (45.7%) and 4736 men (54.3%) were screen failures (P<0.0001). Similar proportions of women (1.28%) and men (1.73%) were excluded due to inability to obtain consent (P=0.1). Patients or families declined participation in 1.26% of women versus 1.31% of men (P=0.9). More women than men failed screening because of age>80 (22.40% versus 12.61%; adjusted P=0.0007) and preexisting do-not-resuscitate/do-not-intubate (3.69% versus 2.83%; adjusted P=0.067).

CONCLUSIONS

Lower rates of women enrollment in the iDEF trial may be attributed to older age. Inability to obtain consent or declining participation was similar between women and men, arguing against selection bias. Our findings should be confirmed in other intracerebral hemorrhage trials to determine best strategies to improve women's representation in future trials.

Acute Treatment With Fingolimod Does Not Confer Long-Term Benefit in a Mouse Model of Intracerebral Haemorrhage

Intracerebral haemorrhage (ICH) has no specific treatment, but accounts for up to 15% of all strokes and has the highest mortality. Fingolimod (FTY720) is an immunomodulator approved for the management of multiple sclerosis, with abundant evidence of efficacy in experimental ischemic stroke, and more limited evidence in experimental ICH. The goal of this study was to confirm the efficacy of fingolimod in experimental ICH using rigorous and statistically well-powered studies. ICH was induced in C57BL/6JOlaHsd male and female mice by intrastriatal bacterial collagenase injection. Fingolimod (0.5 mg/kg) or saline was administered intraperitoneally after 0.5, 24 and 72 h, in a randomized and blinded manner. Functional improvement with cylinder, wire hanging, and foot fault tests was evaluated one and two weeks later. Lesion volume and hemispheric atrophy were quantified at the 14-day endpoint. There was a higher mortality in saline-treated females compared to fingolimod-treated females and saline-treated males. There was no treatment- or gender-related difference in the behavioural tests. Histological outcome measures did not differ between any of the groups. These results, contrasting with those of previous studies of fingolimod in experimental ICH, emphasize the importance of rigorous testing of this agent in models more representative of the clinical situation.

Molecular Correlates of Hemorrhage and Edema Volumes Following Human Intracerebral Hemorrhage Implicate Inflammation, Autophagy, mRNA Splicing, and T Cell Receptor Signaling

Intracerebral hemorrhage (ICH) and perihematomal edema (PHE) volumes are major determinants of ICH outcomes as is the immune system which plays a significant role in damage and repair. Thus, we performed whole-transcriptome analyses of 18 ICH patients to delineate peripheral blood genes and networks associated with ICH volume, absolute perihematomal edema (aPHE) volume, and relative PHE (aPHE/ICH; rPHE). We found 440, 266, and 391 genes correlated with ICH and aPHE volumes and rPHE, respectively (p < 0.005, partial-correlation > |0.6|). These mainly represented inflammatory pathways including NF-κB, TREM1, and Neuroinflammation Signaling-most activated with larger volumes. Weighted Gene Co-Expression Network Analysis identified seven modules significantly correlated with these measures (p < 0.05). Most modules were enriched in neutrophil, monocyte, erythroblast, and/or T cell-specific genes. Autophagy, apoptosis, HIF-1α, inflammatory and neuroinflammatory response (including Toll-like receptors), cell adhesion (including MMP9), platelet activation, T cell receptor signaling, and mRNA splicing were represented in these modules (FDR p < 0.05). Module hub genes, potential master regulators, were enriched in neutrophil-specific genes in three modules. Hub genes included NCF2, NCF4, STX3, and CSF3R, and involved immune response, autophagy, and neutrophil chemotaxis. One module that correlated negatively with ICH volume correlated positively with rPHE. Its genes and hubs were enriched in T cell-specific genes including hubs LCK and ITK, Src family tyrosine kinases whose modulation improved outcomes and reduced BBB dysfunction following experimental ICH. This study uncovers molecular underpinnings associated with ICH and PHE volumes and pathophysiology in human ICH, where knowledge is scarce. The identified pathways and hub genes may represent novel therapeutic targets.

Clinical Characteristics and Outcomes of Patients with Intracerebral Hemorrhage - A Feasibility Study on Romanian Patients

Intracerebral hemorrhage is a significant public health problem, as it is a disease associated with overwhelming mortality and disability. We performed a retrospective feasibility study of patients admitted with acute intracerebral hemorrhage in our department for four months. Our aims were to identify peculiarities of the risk factors, demographic and clinical characteristics of intracerebral hemorrhage patients from our population, to estimate a feasible recruitment rate for a larger prospective study of patients with intracerebral hemorrhage and to analyze and correct potential drawbacks in the methodology of a more extensive prospective study of patients with intracerebral hemorrhage hospitalized in our department. During the study period, we admitted 53 patients with intracerebral hemorrhage in our department. The mean age of the patients was 69.1 years, and 53% were men. Arterial hypertension was the most common etiologic factor leading to intracerebral hemorrhage. 50.01% of patients died during hospitalization, 31.19% were discharged with significant disability, and 18.8% had a favorable short-term outcome. Higher hematoma volumes, male sex, deep location of the hemorrhage, and age between 51 and 60 years were factors associated with an unfavorable short-term outcome.

Intracerebral Hemorrhage: Blood Components and Neurotoxicity

Intracerebral hemorrhage (ICH) is a subtype of stroke which is associated with the highest mortality and morbidity rates of all strokes. Although it is a major public health problem, there is no effective treatment for ICH. As a consequence of ICH, various blood components accumulate in the brain parenchyma and are responsible for much of the secondary brain damage and ICH-induced neurological deficits. Therefore, the strategies that could attenuate the blood component-induced neurotoxicity and improve hematoma resolution are highly needed. The present article provides an overview of blood-induced brain injury after ICH and emphasizes the need to conduct further studies elucidating the mechanisms of hematoma resolution after ICH.

Gender Differences in Outcomes after Non-traumatic Intracerebral Hemorrhage

Background

Nontraumatic intracranial hemorrhages (ICH) are serious cerebrovascular events with high morbidity and mortality. They occur in about two million people a year worldwide. While ICH continues to be a focus of research in the medical community, there is little data on the differences in outcomes by gender. We aimed to further investigate these differences in our study.

Methods

This analysis involves a de-identified dataset of all adult patients who presented to one of our hospital system's emergency departments with ICHs as one of the top three discharge diagnoses. This study was considered exempt by our medical school's Institutional Review Board (IRB). Our hospital system comprises over 176 hospitals in the United States with over 8.6 million emergency department visits annually. Logistic regression analyses were performed using JMP 14.1. Outcome variables included the length of stay, mortality, and disposition.

Results

The cohort (n = 8069) comprised 68% Caucasians, 17% Blacks, 5% Asians, and 1% Hispanic. Forty-eight percent of patients were females with a median age of 71 years. Fifty-two percent of patients were males with a median age of 65 years. One-fifth of the cohort (20%) died while another fifth (21%) were discharged home. Thirteen percent joined hospice. Women were significantly more likely to die or join hospice (p <0.0001, OR 1.304, 95% CI: 1.183-1.440) even after controlling for age. Women also had a significantly shorter length of stay even when controlled for age (P = 0.0002, 95% CI: -1.58 to -0.489, R² = 1.5%) with a median of four days for men and three days for women.

Conclusion

The median age for women with nontraumatic ICH is older than men, which could explain their increased rates of mortality and discharge to hospice. However, even after controlling for age, women were significantly more likely to die or be discharged to hospice. Conversely, men and younger patients had a longer hospital stay and a higher likelihood of being discharged home.

Impact of a routine neurosurgical dispatch on emergency air medical transport and outcome of patients with intracranial hemorrhage

BACKGROUND/PURPOSE

Emergency air medical transport (EAMT) of patients in remote areas with neurological emergencies to higher-level facilities is an integral part of the regionalized healthcare system. EAMT is safe and feasible for head injuries. Debates persist on the high cost, safety, and risk of EAMT, thereby calling for alternatives.

METHODS

We conducted a retrospective cohort study by including all patients with intracranial hemorrhage (ICH) who visited the Kinmen Hospital from January 2006 to December 2016. Routine neurosurgical dispatch (RNSD) implemented since 2009, dispatches neurosurgeons to Kinmen. EAMT and 90-day mortality were assessed.

RESULTS

We enrolled 560 patients: 173 pre-stage and 387 post-stage. RNSD resulted in less EAMT deployment ([adjusted odds ratio AOR] = 0·23, p < 0·001) and lower 90-day mortality ([adjusted hazard ratio AHR] 0·66, p = 0·043). RNSD resulted in decreased EAMT among all subgroups, especially in age ≥81 years (AOR 0.03, p < 0.001), age 41-60 years (AOR 0.10, p < 0.001), traumatic intracranial hemorrhage (TICH) (AOR 0·11, p < 0·001), and Glasgow Coma Scale (GCS) 9-12 (AOR 0.14, p 0.001). The risk of 90-day mortality was higher in male (AHR 1.81, p = 0·006), GCS 3-8 (AHR 35.52, p < 0·001) and GCS 9-12 (AHR 7.46, p < 0·01) and lower in age 21-40 years (AHR 0.46, p = 0.034).

CONCLUSION

Incorporating RNSD with EAMT is a plausible alternative to EAMT with a significant decrease in EAMT and decreased 90-day mortality in patients with ICH compared with non-neurosurgical care with EAMT. Despite a 34% decrease in 90-day mortality after RNSD, patient characteristics such as disease severity, age, and sex still dictated patient outcomes.

Sex differences in blood pressure after stroke: a systematic review and meta-analysis

OBJECTIVES

Evidence about sex differences in blood pressure (BP) at the time of acute stroke presentation is scarce. We aimed to summarize available data on sex differences in BP at the time of acute stroke presentation, including stratification by prior history of hypertension and stroke subtype.

METHODS

We performed a systematic literature search across MEDLINE and Embase, from inception to 21 December 2018, to identify all population-based observational studies that reported BP at the time of acute stroke presentation. We extracted data on patient demographics, stroke-type (ischaemic or haemorrhagic), stroke severity, vascular risk factors, and SBP and DBP at the time of stroke presentation. Wherever possible, data were pooled for meta-analysis with weighted mean difference (WMD) and corresponding 95% confidence intervals (CI) using random effects meta-analysis.

RESULTS

We included 128 138 stroke patients from 43 studies. Women had higher SBP at presentation than men (WMD, 1.46; 95% CI, 0.65-2.26); this difference was significant in ischaemic stroke (1.49; 0.25-2.72 mmHg), but not in intracerebral haemorrhage (0.19; -4.21 to 4.59 mmHg). Meta regression show that sex differences in SBP were consistent with increasing age, stroke severity, other comorbidities and medication history.

CONCLUSION

This systematic review and meta-analysis indicates that women have higher SBP at the time of presentation with acute stroke. These differences are consistent with sex differences in hypertension patterns in older age, and may be explained by the fact that women are more likely to have a premorbid hypertension. This highlights the need for effective sex-specific blood pressure control in patients at high risk for stroke.

Effect of Gender on Postoperative Morbidity and Mortality Outcomes: A Retrospective Cohort Study

Full extent of gender differences on postoperative outcomes has never been studied on large scale, specifically postoperative complications. This study aims to assess the effect of gender on 30-day morbidity and mortality after major surgery. A retrospective cohort study was carried out using data of patients undergoing major surgeries from the American College of Surgeons’ National Surgical Quality Improvement Program database between 2008 and 2011. Demographics, pre- and perioperative risk factors, as well as 30-day morbidities, both overall and specific, were reviewed. The 30-day mortality data were also assessed. Multivariate logistic regression analyses, basic (Adj1) and extended (Adj2), were used to assess the association between gender and outcomes. Out of 1,409,131 patients, 57.2 per cent were females. Females had lower prevalence of most system-specific risk variables. Overall morbidities were also lower in females versus males, even after adjustment for variables [total overall morbidity: ORadj2 = 0.9 (0.89–0.92), P < 0.0001] except in some cases such as after cardiac surgeries [ORadj2 = 1.29 (1.14–1.44), P < 0.0001] and vascular surgeries [ORadj2 = 1.14 (1.10–1.18), P < 0.0001], where overall morbidities of females were higher. Specific morbidities were also lower in females than in males in all types of complications except central nervous system-related postoperative complications [ORadj2 = 1.15 (1.08–1.22), P < 0.0001] and return to the operating room [ORadj2 = 1.06 (1.04–1.08), P < 0.0001]. The 30-day mortality rate for females was lower than males [ORadj2 = 0.99 (0.96–1.03), P = 0.94]. Female gender was associated with less perioperative morbidity and mortality versus males, but they did worse after cardiovascular procedures and had more central nervous system-related complications. These outcomes should be taken into consideration by surgeons and should be evaluated further in future studies.

Cerebrovascular Hemodynamics in Women

Sex and gender, as biological and social factors, significantly influence health outcomes. Among the biological factors, sex differences in vascular physiology may be one specific mechanism contributing to the observed differences in clinical presentation, response to treatment, and clinical outcomes in several vascular disorders. This review focuses on the cerebrovascular bed and summarizes the existing literature on sex differences in cerebrovascular hemodynamics to highlight the knowledge deficit that exists in this domain. The available evidence is used to generate mechanistically plausible and testable hypotheses to underscore the unmet need in understanding sex-specific mechanisms as targets for more effective therapeutic and preventive strategies.

Sex differences in intracerebral hemorrhage expansion and mortality

BACKGROUND AND OBJECTIVE

Due to conflicting results in multiple studies, uncertainty remains regarding sex differences in severity and mortality after intracerebral hemorrhage (ICH). We investigated the impact of sex on ICH severity, expansion, and mortality.

METHODS

We analyzed prospectively collected ICH patients and assessed clinical variables and mortality rate. Mediation analyses were used to examine associations between sex and mortality and sex and hematoma expansion.

RESULTS

2212 patients were investigated, 53.5% male. Men with ICH were younger (72 vs. 77years), had greater smoking and alcohol use, and were more likely to have hypertension, diabetes, hypercholesterolemia and coronary artery disease (all p<0.05). Lobar hemorrhages were more frequent in women (47.6% vs 38.4%, p<0.001). Male sex was a risk factor for hematoma expansion (Odd Ratio (OR) 1.7, 95% confidence interval (CI) 1.15-2.50, p=0.007). Multivariable analysis found that male sex was independently associated with 90-day mortality (OR 2.15 (95% CI 1.46-3.19), p<0.001), and one-year mortality (Hazard Ratio 1.28 (95% CI: 1.09-1.50), p=0.003). Early hematoma expansion mediated a portion of the association between sex and mortality (mediation p=0.02).

CONCLUSIONS

Men with ICH experience a higher risk of both expansion and early and late mortality, even after controlling for known risk factors. Further research is needed to explore the biological mechanisms underlying these observed differences.

Assessment of the interaction of age and sex on 90-day outcome after intracerebral hemorrhage

OBJECTIVE

Because age affects hormonal production differently in women compared with men, we sought to define sex and age interactions across a multiracial/ethnic population after intracerebral hemorrhage (ICH) to uncover evidence that loss of gonadal hormone production would result in loss of the known neuroprotective effects of gonadal hormones.

METHODS

Clinical and radiographic data from participants in the Ethnic/Racial Variations of Intracerebral Hemorrhage study and the Genetic and Environmental Risk Factors for Hemorrhagic Stroke study prior to December 2013 were used. Relationships among sex, age, and outcome after ICH in 616 non-Hispanic black, 590 Hispanic, and 868 non-Hispanic white participants were evaluated using multivariable logistic regression analysis. Poor outcome was defined as modified Rankin Scale score ≥3 at 90 days after ICH.

RESULTS

Sex differences were found in multiple variables among the racial/ethnic groups, including age at onset, premorbid neurologic status, and neurologic outcome after ICH. Overall, no sex-age interaction effect was found for mortality (p = 0.183) or modified Rankin Scale score (p = 0.378) at 90 days after ICH. In racial/ethnic subgroups, only the non-Hispanic black cohort provided possible evidence of a sex-age interaction on 90-day modified Rankin Scale score (p = 0.003).

CONCLUSION

Unlike in ischemic stroke, there was no evidence that patient sex modified the effect of age on 90-day outcomes after ICH in a large multiracial/ethnic population. Future studies should evaluate biological reasons for these differences between stroke subtypes.

CLINICALTRIALSGOV IDENTIFIER

NCT01202864.

Sex Differences in the Clinical Features, Risk Factors, and Outcomes of Intracerebral Hemorrhage: a Large Hospital-based Stroke Registry in China

Intracerebral hemorrhage (ICH) is common in China. However, the sex differences in clinical features, risk factors, and outcomes of ICH remain controversial. Between 2005 and 2014, we recruited patients with primary ICH in Tianjin, China, and evaluated sex differences in clinical features, risk factors, and outcomes at 3, 12, and 36 months after ICH. The 1,325 patients included 897 men (67.7%) and 428 women (32.3%). The mean age at ICH onset was younger among men (59.14 years) than among women (63.12 years, P < 0.001). Men were more likely to have a hematoma in the basal ganglia, while women were more likely to have one in the thalamus. Women had higher frequencies of urinary tract infections, diabetes mellitus, cardiovascular diseases, and obesity. Men had a greater risk of death at 3 months after ICH. However, no sex differences were observed for mortality at 12 and 36 months after ICH or for recurrence and dependency at 3, 12, and 36 months after ICH. These findings suggested that it crucial to strengthen management of AF and complications in patients with ICH, especially management of blood pressure in men for reducing the mortality rates and the burden of ICH in China.

MMP-9, brain edema, and length of hospital stay of patients with spontaneous supratentorial intracerebral hemorrhage after hematoma evacuation along with the administration of tigecycline

Background: The high plasma level of matrix metalloproteinses–9 (MMP-9) is believed to disrupt the blood-brain barrier (BBB) and cause brain edema, as well as increase patient’s length of hospital stay (LOS). Tigecycline showed ability to reduce the MMP-9 level on study in animals. This study aimed to evaluate whether tigecycline can reduce the plasma levels of MMP-9; brain edema; and LOS of patients with supratentorial spontaneous intracerebral hemorrhage (SSICH).Methods: A randomized clinical trial (RCT) was conducted on 72 SSICH patients who underwent hematoma evacuation in eleven hospitals in Jakarta; 100 mg tigecycline (n=35) or 2 g fosfomycine (n=37) administered intravenously before skin incision as an prophylactic antibiotics to avoid post-operative infections. Plasma levels of MMP-9 were measured in all subjects before and on the first and seventh day after the surgery. Reduction of brain edema was assessed by comparing the extent of brain edema on computed tomography scan (CT scan) before and CT scan after surgery. The length of stay (LOS) was recorded at the time of hospital discharge either survive or death. Data were analyzed using Mann-Whitney and Chi-Square test.Results: There were non-significant statistical differences between two groups in the proportion of subjects with reduced MMP-9 levels on the first day (48% vs 50%; p=0.902; OR=1.1) and seventh day after the surgery (33% vs 48%; p=0.296; OR=1.9); proportion of the subjects with brain edema reduction (86% vs 80%, p=0.58); LOS (median 12 days vs 13 days, p=0.256; LOS ≥15 days 40% vs 27%; p=0.243; OR=1.81; NNT=8).Conclusion: On SSICH patients who underwent hematoma evacuation, tigecycline did not either reduce MMP-9 levels and brain edema or shorthen LOS.

A Pilot Study Exploring the Plasma Potassium Variation in Dogs Undergoing Steroid Therapy and Its Clinical Importance

In most situations in veterinary medicine, glucocorticoids are the drugs of choice used, that is, to reduce the inflammatory response or limit an inappropriate immune response. Their use in long-term therapy may cause side effects that may weaken the patient. The aim of the study was to evaluate possible variations in the plasma potassium concentrations and their clinical relevance in dogs undergoing steroid therapy with methylprednisolone in anti-inflammatory doses. The study used a sample of 21 dogs (n = 21) presented for consultation, with a clinical condition requiring a corticosteroid therapeutic protocol with an anti-inflammatory dose of methylprednisolone. All the individuals were submitted to a corticosteroid therapeutic protocol administered orally during 18 days. During this period, 3 time points were considered: T0 (the day the prescription was first given), T1 (3 days later), and T2 (8 days later). Blood samples were collected from a peripheral vein to measure plasma potassium concentrations in T0, T1, and T2. Corticosteroid therapy on an outpatient basis statistically significantly decreased plasma potassium levels, especially between T1 and T2 (P = .03). The plasma potassium levels decreased in 12.5% of the males, compared with a decrease of 23.1% in the females. No statistically significant relationships were observe between the decreased plasma potassium levels and age, clinical condition, and patient׳s body weight. However, we found a statistically significant association between decreased plasma potassium levels and sex. The study results may justify the need for the systematic prescription of potassium supplements in patients undergoing steroid therapy, similar to what already occurs in human medicine.

No sex differences in long-term functional outcome after intracerebral hemorrhage

Background There is conflicting evidence about the influence of sex on outcome after spontaneous intracerebral hemorrhage (sICH) and the majority of the research focused on mortality and short-term outcome only. We investigated sex differences in long-term functional outcome after sICH. Methods We used data from a prospective hospital registry and included all consecutive patients with ICH admitted to our institution between January 2006 and July 2014. Functional outcome was assessed by modified Rankin Scale evaluated 3 and 12 months after ICH. We explored the influence of sex on long-term functional outcome using multivariable regression models and additionally by means of propensity score matching. Results We analyzed 823 patients, of whom 380 (46%) women. Women were on average three years older (p < 0.001), men had more often deep hematomas (p = 0.01). Unadjusted mortality rates were significantly increased in women at three months (42% vs. 35%; odds ratio (OR): 1.35; 95% confidence interval (CI): 1.02-1.80). After adjusting for baseline prognostic factors there were no differences between men and women in short- and long-term mortality (OR = 1.01; 95% CI = 0.66-1.54 and OR = 1.04; 95%CI = 0.69-1.57, respectively) and short- and long-term unfavorable outcome (OR = 1.02; 95%CI = 0.67-1.55 and OR = 0.96; 95% CI = 0.62-1.48, respectively). Conclusion We found no sex-related differences in long-term functional outcome in patients with sICH. The apparently worse functional outcome in women can be explained by differences in age.

Sex and Age Interactions and Differences in Outcomes After Intracerebral Hemorrhage

BACKGROUND

Compared to ischemic stroke, sex differences in response to intracerebral hemorrhage (ICH) are largely unexplored, and their potential interactions with patient age have not been examined. This study hypothesized that risk for poor outcome is greater in women with increasing age.

METHODS AND RESULTS

The Get With The Guidelines^®-Stroke database was used to assess differences between men and women with ICH. Data from 192,826 ICH patients admitted from January 1, 2009 through March 31, 2014 to 1,728 fully participating sites were analyzed using logistic regression to test interactions between age/sex and outcome.

RESULTS

In the total study population, 48.9% were women (median age 75; male median age 67). On admission, women over 65 years were less likely to have atrial fibrillation or dyslipidemia, or use antiplatelet therapy or cholesterol reducers, but more likely to suffer worse neurological deficit than men over 65. As age increased, odds of in-hospital mortality increased in both men and women, although the relationship was stronger in men. Odds of combined mortality and discharge to hospice were similar in men and women with increasing age, but odds for discharge to home and independent ambulation at discharge decreased more in women with increasing age.

CONCLUSIONS

After adjusting for covariates, modest sex differences in early outcomes after ICH were linked to age. While statistically significant, detected interactions should be considered in context. Future study may examine whether sex-based interactions represent biologic or treatment differences, unmeasured covariates, or some combination thereof.

Tigecycline reduced tumor necrosis factor alpha level and inhospital mortality in spontaneous supratentorial intracerebral hemorrhage

Background: The outcome of patients with spontaneous supratentorial intracerebral hemorrhage (SSICH) is unsatisfactory. Inflammatory response secondary to brain injury as well as those resulted from surgical procedure were considered responsible of this outcome. This study was intended to elucidate the anti-inflammatory activity of tigecycline by measuring TNF-α level and its neuroprotective effect as represented by inhospital mortality rate.Methods: Patients with SSICH who were prepared for hematoma evacuation were randomized to receive either tigecycline (n=35) or fosfomycine (n=37) as prophylactic antibiotic. TNF-α level was measured in all subjects before surgery and postoperatively on day-1 and day-7. A repeated brain CT Scan was performed on postoperative day-7. The Glasgow outcome scale (GOS) and length of stay (LOS) were recorded at the time of hospital discharge. Data were analyzed using Mann-Whitney and Chi square test. Relative clinical effectiveness was measured by calculating the number needed to treat (NNT).Results: There was a significant difference regarding the proportion of subject who had  reduced TNF-α level on postoperative day-7 between the groups receiving tigecycline and fosfomycine (62% vs 29%, p=0.022). Decrease brain edema on CT control (86% vs 80%, p=0.580). Tigecycline administration showed a tendency of better clinical effectiveness in lowering inhospital mortality (17% vs 35%; p=0.083; OR=0.49; NNT=5) and worse clinical outcome / GOS ≤ 2 (20% vs 38% ; p=0.096; OR=0.41; NNT=6). LOS ≥ 15 hari ( 40% vs 27%; p=0.243; OR=1.81; NNT=8).Conclusion: Tigecycline showed anti-inflammatory and neuroprotective activities. These activities were associated with improved clinical outcome in patients with SSICH after hematoma evacuation.

Sex-related differences in primary intracerebral hemorrhage

OBJECTIVE

Little information is available about sex-related differences in intracerebral hemorrhage (ICH). This is a prospective observational study to describe the sex differences in demographics, vascular risk factors, stroke care, and outcomes in primary ICH.

METHODS

BasicMar is a hospital-based registry of all stroke patients admitted to a single public hospital that covers a population of 330,000. From 2005 to 2015, there were 515 consecutive acute primary ICH patients. Outcome data were obtained at 3 months.

RESULTS

More men than women had ICH (52.4% vs 47.6%); the women were older and had worse previous functional status than men, who were more likely to drink alcohol and smoke and to have ischemic heart disease and peripheral arterial disease. There were no sex differences in etiology, severity, or hemorrhage volume. ICH score was greater in women than in men (p = 0.018). Women had more lobar ICH than men (odds ratio adjusted by age was 1.75 [95% confidence interval 1.18-2.58], p = 0.005). The quality of stroke care was similar in both sexes. Mortality at 3 months was 44.1% in women and 41.1% in men (p = 0.656), and 3-month poor outcome among survivors (modified Rankin Scale [mRS] score 3-5) 58.4% in women and 45.3% in men (p = 0.027). After adjustment for previous mRS and ICH score, there were no differences in 3-month mortality or poor outcome at 3 months between sexes.

CONCLUSIONS

Patients with ICH showed sex-related differences in demographic characteristics, ICH location, and vascular risk factors, but not in stroke care, 3-month mortality, or adjusted poor outcome.

Comparison of Gender Differences in Intracerebral Hemorrhage in a Multi-Ethnic Asian Population

BACKGROUND

Intracerebral hemorrhage (ICH) accounts for 10-15% of all first time strokes and with incidence twice as high in the Asian compared to Western population. This study aims to investigate gender differences in ICH patient outcomes in a multi-ethnic Asian population.

METHOD

Data for 1,192 patients admitted for ICH were collected over a four-year period. Multivariate logistic regression was used to identify independent predictors and odds ratios were computed for 30-day mortality and Glasgow Outcome Scale (GOS) comparing males and females.

RESULT

Males suffered ICH at a younger age than females (62.2 ± 13.2 years vs. 66.3 ± 15.3 years; P<0.001). The occurrence of ICH was higher among males than females at all ages until 80 years old, beyond which the trend was reversed. Females exhibited increased severity on admission as measured by Glasgow Coma Scale compared to males (10.9 ± 4.03 vs. 11.4 ± 4.04; P = 0.030). No difference was found in 30-day mortality between females and males (F: 30.5% [155/508] vs. M: 27.0% [186/688]), with unadjusted and adjusted odds ratio (F/M) of 1.19 (P = 0.188) and 1.21 (P = 0.300). At discharge, there was a non-statistically significant but potentially clinically relevant morbidity difference between the genders as measured by GOS (dichotomized GOS of 4-5: F: 23.7% [119/503] vs. M: 28.7% [194/677]), with unadjusted and adjusted odds ratio (F/M) of 0.77 (P = 0.055) and 0.87 (P = 0.434).

CONCLUSION

In our multi-ethnic Asian population, males developed ICH at a younger age and were more susceptible to ICH than women at all ages other than the beyond 80-year old age group. In contrast to the Western population, neurological status of female ICH patients at admission was poorer and their 30-day mortality was not reduced. Although the study was not powered to detect significance, female showed a trend toward worse 30-day morbidity at discharge.

"Timing" of arrival and in-hospital mortality in a cohort of patients under anticoagulant therapy presenting to the emergency departments with cerebral hemorrhage: A multicenter chronobiological study in Italy

Therapy with oral anticoagulants (OACs) is a risk factor for cerebral hemorrhage (CH). Although different studies have been undertaken to investigate the timing of the onset of major cardiovascular events, no data exist on temporal patterns of the onset of CH in subjects treated with OACs. The aim of this study is to evaluate the timing of CH in patients treated with OACs. All patients who developed CH under OACs therapy and admitted to 28 Italian Emergency Departments (EDs) between September 2011 and July 2013 were enrolled. Age, sex, time and location of the hemorrhagic lesion, type of the bleeding events (idiopathic or post-traumatic), anticoagulant therapy (warfarin or new oral anticoagulants - NOAs) and time of ED admission (i.e., hour, day, month and season) were recorded. Five hundred and seventeen patients (63.2% male aged 80 ± 7.9 yrs) with CH were involved. Warfarin was taken by 494 patients (95.6%), and NOAs by 23 (4.4%). In-hospital mortality (IHM) was recorded in 208 cases (40.2%). Cosinor analysis showed a peak of CH arrival between 12:00 and 14:00 h both in the whole population (PR 73.9%, p = 0.002) and the male subgroup (PR 65.2%, p = 0.009), whereas females showed an anticipated morning peak between 08:00 and 10:00 h (PR 65.7%, p = 0.008). A further analysis between idiopathic and post-traumatic CH confirmed the presence of a 24 h pattern with a peak between 12:00 and 14:00 h (PR 58.5%, p = 0.019) and between 08:00 and 10:00 h (PR80.1%, p < 0.001) for idiopathic events and post-traumatic hemorrhages, respectively. Moreover, a seasonal winter peak was identified for idiopathic forms (PR 74%, p = 0.035), and a summer peak for post-traumatic forms (PR 77%, p = 0.025). The present study suggests the presence of a temporal pattern of ED arrivals in CH patients treated with OACs.

Progesterone Improves Neurobehavioral Outcome in Models of Intracerebral Hemorrhage

In models of acute brain injury, progesterone improves recovery through several mechanisms including modulation of neuroinflammation. Secondary injury from neuroinflammation is a potential therapeutic target after intracerebral hemorrhage (ICH). For potential translation of progesterone as a clinical acute ICH therapeutic, the present study sought to define efficacy of exogenous progesterone administration in ICH-relevant experimental paradigms. Young and aged C57BL/6 male, female, and ovariectomized (OVX) mice underwent left intrastriatal collagenase (0.05-0.075 U) or autologous whole blood (35 μl) injection. Progesterone at varying doses (4-16 mg/kg) was administered at 2, 5, 24, 48, and 72 h after injury. Rotarod and Morris water maze latencies were measured on days 1-7 and days 28-31 after injury, respectively. Hematoma volume, brain water content (cerebral edema), complementary immunohistochemistry, multiplex cytokine arrays, and inflammatory proteins were assessed at prespecified time points after injury. Progesterone (4 mg/kg) administration improved rotarod and water maze latencies (p < 0.01), and decreased cerebral edema (p < 0.05), microglial proliferation, and neuronal loss (p < 0.01) in young and aged male, young OVX, and aged female mice. Brain concentration of proinflammatory cytokines and Toll-like receptor-associated proteins were also decreased after progesterone (4 mg/kg) treatment (p < 0.01). Progesterone-treated young female mice showed no detectable effects. Exogenous progesterone improved short- and long-term neurobehavioral recovery and modulated neuroinflammation in male and OVX mice after ICH. Future studies should validate these findings, and address timing and length of administration before translation to clinical trial.

Nuclear factor-κB activation in perihematomal brain tissue correlates with outcome in patients with intracerebral hemorrhage

Background

Nuclear factor-κB (NF-κB) plays an important role in the inflammatory response after intracerebral hemorrhage (ICH). We therefore proposed that NF-κB activation in perihematomal brain tissue might correlate with clinical outcome in patients with ICH. To confirm this, we studied clinical data of 45 patients with ICH and NF-κB activation in perihematomal brain tissue and analyzed predictors of clinical outcome as well as the predictive value of NF-κB activation.

Methods

Forty-five patients with spontaneous basal ganglia hemorrhage were prospectively investigated. The clinical data were collected, which include demographics, alcohol and tobacco abuse, stroke risk factors, neuroimaging variables at presentation, Glasgow Coma Scale (GCS) at admission, number of days in hospital, mechanical ventilation, pneumonia, and outcome. Clinical outcome was assessed by the modified Rankin Scale at 6 months after ICH. Perihematomal brain tissue was collected, and NF-κB activation was detected using immunohistochemistry. Univariate analysis and multivariate logistic regression analysis were performed to determine predictors of the poor outcome.

Results

Immunohistochemical detection showed that NF-κB p65 was expressed in the nuclei of neurons and glial cells in all patients. The number of nuclear NF-κB p65-positive cells was 54 ± 21. Six months after ICH, 18 (40%) patients achieved a favorable functional outcome (mRS ≤ 3) while 27 (60%) had a poor functional outcome (mRS 4 to 6). In univariate analysis, predictors of poor functional outcome were lower GCS score on admission (P = 0.004), larger hematoma volume (P = 0.004), intraventricular extension (P = 0.047), midline shift (P = 0.005), NF-κB activation (P < 0.0001), mechanical ventilation (P = 0.018), and co-morbidity with pneumonia (P = 0.002). In multivariate logistic regression analysis, NF-κB activation was the only independent predictor of poor outcome at 6 months after ICH.

Conclusions

NF-κB activation is closely related to clinical outcome 6 months after ICH in humans. Therefore, it could be useful to predict prognosis of ICH accurately and should be further evaluated as a target for therapeutic strategies of ICH in the future.

Gender differences in neurologic emergencies part I: a consensus summary and research agenda on cerebrovascular disease

Cerebrovascular neurologic emergencies including ischemic and hemorrhagic stroke, subarachnoid hemorrhage (SAH), and migraine are leading causes of death and disability that are frequently diagnosed and treated in the emergency department (ED). Although sex and gender differences in neurologic emergencies are beginning to become clearer, there are many unanswered questions about how emergency physicians should incorporate sex and gender into their research initiatives, patient evaluations, and overall management plans for these conditions. After evaluating the existing gaps in the literature, a core group of ED researchers developed a draft of future research priorities. Participants in the 2014 Academic Emergency Medicine consensus conference neurologic emergencies working group then discussed and approved the recommended research agenda using a standardized nominal group technique. Recommendations for future research on the role of sex and gender in the diagnosis, treatment, and outcomes pertinent to ED providers are described for each of three diagnoses: stroke, SAH, and migraine. Recommended future research also includes investigation of the biologic and pathophysiologic differences between men and women with neurologic emergencies as they pertain to ED diagnoses and treatments.

Subarachnoid hemorrhage and the female sex: analysis of risk factors, aneurysm characteristics, and outcomes

OBJECT

The pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH) is unclear. Sex may play a role in the outcome of patients with aSAH.

METHODS

The authors retrospectively identified 617 patients with aSAH (April 2005 to February 2010) and analyzed sex differences in risk factors (age, hypertension, smoking, alcohol consumption, and family history), admission-related factors (World Federation of Neurosurgical Societies grade and admission delay), aneurysm characteristics (site, side, location, and multiplicity), and outcomes (treatment modalities [coiling/clipping/both/conservative], complications [vasospasm and hydrocephalus], length of stay, and modified Rankin Scale score at 3 months).

RESULTS

The female patients with aSAH were older than the male patients (mean age 56.6 vs 51.9 years, respectively, p < 0.001), and more women than men were ≥ 55 years old (56.2% vs 40.4%, respectively, p < 0.001). Women exhibited higher rates of bilateral (6.8% vs 2.6%, respectively, p < 0.05), multiple (11.5% vs 5.2%, respectively, p < 0.05), and internal carotid artery (ICA) (36.9% vs 17.5%, respectively, p < 0.001) aneurysms and a lower rate of anterior cerebral artery aneurysms (26.3% vs 44.8%, respectively, p < 0.001) than the men, but no side differences were noted. There were no sex differences in risk factors, admission-related factors, or outcome measures. For both sexes, outcomes varied according to aneurysm location, with odds ratios for a poor outcome of 1.62 (95% CI 0.91-2.86, p = 0.1) for middle cerebral artery, 2.41 (95% CI 1.29-4.51, p = 0.01) for ICA, and 2.41 (95% CI 1.29-4.51, p = 0.006) for posterior circulation aneurysms compared with those for anterior cerebral artery aneurysms. The odds ratio for poor outcome (modified Rankin Scale score of 4-6) in women compared with men after adjusting for significant prognostic factors was 0.71 (95% CI 0.45-1.11, p > 0.05).

CONCLUSIONS

The overall outcomes after aSAH between women and men are similar.

Sex differences in clinical characteristics and outcomes after intracerebral haemorrhage: results from a 12-month prospective stroke registry in Nanjing, China

Background

There is uncertainty surrounding the differences in outcomes after intracerebral haemorrhage (ICH) between men and women. This study aimed to investigate the sex differences in clinical characteristics, severity and outcomes of Chinese ICH patients.

Methods

The Nanjing First Hospital stroke registry was a hospital-based registry of stroke patients with 1-year prospective follow-up. From 2004 to 2008, a total of 651 consecutively recruited patients with acute ICH were enrolled. Primary outcome was death or dependency defined as a modified Rankin Scale score of 3–6 at 12 months. Multivariable logistic regression analyses were performed to determine whether there were sex differences in clinical outcomes after ICH. Clinically important and biologically plausible risk factors of death or dependency were selected from available variables.

Results

A total of 615 ICH patients were enrolled. There was no significant difference in age (63.5 ± 14.0 vs. 62.7 ± 12.7, p = 0.500) between women and men. At baseline, men were more likely to be current smokers (46.1% vs. 3.6%, P < 0.001) or current drinkers (35.4% vs. 3.6%, P < 0.001), but women had higher admission National Institute of Health Stroke Scale (NIHSS) scores than men (10 vs. 8, P = 0.039). Women also had higher rates of death or dependency at 3, 6, and 12 months (61.2% vs. 46.8%, P = 0.001; 56.7% vs. 45.3%, P = 0.009; and 51.8% vs. 44.1%, P = 0.065; respectively). After adjustment for age, existing hypertension and diabetes, prior stroke, previous ischemic heart disease, previous atrial fibrillation, current smoking and alcohol consumption status, pre-stroke dependency, onset-to-door time, admission NIHSS score, admission systolic blood pressure and location of bleeding, the association between the female gender and death or dependency remained statistical significant at 3 months [odds ratio (OR): 1.76; 95% confidence interval (CI): 1.07-2.89], but did not reach statistical significance at 6 months (OR: 1.59; 95% CI: 0.99-2.54) and 12 months (OR: 1.22; 95% CI: 0.77-1.95).

Conclusions

In a Chinese population, women are more likely to be dead or dependent early after ICH than men. However, this gender difference gradually attenuates over the period of 12 months.