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Chen W, Li W, Xun W, Wang J, Zhang X, Hou Z, Zhang X, Yang Y, Zhang T. Hemodynamic criteria for intimal tear in Type-B intramural hematoma of aorta based on patient-specific geometry. J Biomech 2025; 187:112739. [PMID: 40409119 DOI: 10.1016/j.jbiomech.2025.112739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2025] [Revised: 03/27/2025] [Accepted: 04/30/2025] [Indexed: 05/25/2025]
Abstract
This study conducts hemodynamic simulations for a total of 20 patients with Type B aortic intramural hematoma (TBIMH) and aims to develop hemodynamic criteria for possible development of intimal tear and indicator for tearing location. The patients are divided into Group A without intimal tear and Group B with progression into tear. The mean oscillatory shear index OSI¯ is calculated based on the wall shear stress (WSS¯) distribution. The blood pressure drop along the main aortic vessel is calculated and the high pressure drop time fraction over one cardiac cycle Td/T is determined, with high pressure drop being defined as the pressure drop larger than half the maximal value. By combining OSI¯ and Td/T at low heart rates 60bpm and 75bpm, we reveal statistically significant correlation between no progression to tear and both low OSI¯<0.121 and low Td/T<0.067, with a pvalue of p=8.7e-5. We also propose a new parameter, namely the magnitude of tangential pressure gradient at aortic wall |∇τp| at the time when the pressure drop is maximal during one cardiac cycle. Comparison with CT imaging reveals that nine out of ten patients in Group B develop intimal tear at the location with elevated |∇τp|. Therefore, the current study provides a two-step procedure for the hemodynamic diagnosis of TBIMH. First, by combining OSI¯ and Td/T those patients with low risk of intimal tear can be excluded. Then, the location of elevated |∇τp| can be adopted as the indicator for possible intimal tear locations.
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Affiliation(s)
- Wenyuan Chen
- State Key Laboratory for Turbulence and Complex Systems, and Department of Mechanics and Engineering Science, College of Engineering, Peking University, Beijing, China.
| | - Weihao Li
- Vascular Surgery Department, Peking University People's Hospital, Beijing, China.
| | - Weikang Xun
- State Key Laboratory for Turbulence and Complex Systems, and Department of Mechanics and Engineering Science, College of Engineering, Peking University, Beijing, China.
| | - Jing Wang
- Vascular Surgery Department, Peking University People's Hospital, Beijing, China.
| | - Xuemin Zhang
- Vascular Surgery Department, Peking University People's Hospital, Beijing, China.
| | - Zhenchen Hou
- School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China.
| | - Xiaoming Zhang
- Vascular Surgery Department, Peking University People's Hospital, Beijing, China.
| | - Yantao Yang
- State Key Laboratory for Turbulence and Complex Systems, and Department of Mechanics and Engineering Science, College of Engineering, Peking University, Beijing, China.
| | - Tao Zhang
- Vascular Surgery Department, Peking University People's Hospital, Beijing, China.
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Qureshi AI, Baskett W, Martin RH, Lakhani P, Bhatti IA, El Sabae H, Al-Mufti F, Gomes JA, Seifi A, Rabinstein AA, Suarez JI, Steiner T, Shyu CR, Anderson CS. Systolic Blood Pressure Reduction with Stability as a New Therapeutic Goal in Patients with Intracerebral Hemorrhage: Results of the Pooled Analysis of ATACH 2 and INTERACT 2 Trials. Neurocrit Care 2025:10.1007/s12028-025-02277-2. [PMID: 40394357 DOI: 10.1007/s12028-025-02277-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2024] [Accepted: 04/08/2025] [Indexed: 05/22/2025]
Abstract
BACKGROUND The American Heart Association/American Stroke Association recommends achieving systolic blood pressure (SBP) therapeutic targets within 60 min of initiating treatment for intracerebral hemorrhage (ICH), emphasizing avoidance of "overshoot" correction and SBP fluctuations. We evaluated the prognostic value of "SBP reduction with stability," a novel end point combining controlled blood pressure reduction and maintenance, using data from two large multinational clinical trials. METHODS We analyzed patients with ICH from Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 and Intensive BP Reduction in Acute Cerebral Hemorrhage Trial 2 trials presenting with initial SBP 150-220 mm Hg. SBP reduction with stability was defined as achieving and maintaining SBP between 130 and 150 mm Hg within the first hour after randomization based on consecutive recordings. Outcomes included functional independence (modified Rankin scale 0-2) at 90 days and neurological deterioration within 24 h, adjusted for potential confounders. RESULTS Among 3,694 patients with ICH (2,781 patients from Intensive BP Reduction in Acute Cerebral Hemorrhage Trial 2 and 913 patients from Antihypertensive Treatment of Acute Cerebral Hemorrhage 2), 1,061 patients (28.7%) achieved SBP reduction with stability within 1 h. Patients had mean age 63.3 ± 12.9 years, baseline SBP 177.14 ± 18.28 mm Hg, and median hematoma volume of 10.78 mL (interquartile range 5.5-19.16). Achieving SBP reduction with stability significantly improved functional independence odds (odds ratio 1.38, 95% confidence interval 1.16-1.64) and reduced neurological deterioration odds (odds ratio 0.68, 95% confidence interval 0.53-0.88) after adjusting for initial SBP, Glasgow Coma Scale, age, sex, stroke history, hypertension, diabetes mellitus, study, ICH location, hematoma volume, and intraventricular hemorrhage presence. CONCLUSIONS Only 30% of patients with mild-to-moderate ICH achieved SBP reduction with stability within the first hour. This achievement was associated with improved functional outcomes and reduced early neurological deterioration. These findings suggest that SBP reduction with stability represents a valuable therapeutic target for future clinical trials in ICH management.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, Columbia, MO, USA
- Department of Neurology, University of Missouri, Columbia, MO, USA
| | - William Baskett
- Institute for Data Science and Informatics, University of Missouri, Columbia, MO, USA
| | - Renee H Martin
- Department of Public Health Sciences College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Pashmeen Lakhani
- Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Ibrahim A Bhatti
- Zeenat Qureshi Stroke Institute, Columbia, MO, USA.
- Department of Neurology, University of Missouri, Columbia, MO, USA.
| | | | - Fawaz Al-Mufti
- New York Medical College, Westchester Medical Center at New York Medical College, New York, NY, USA
| | - Joao A Gomes
- Lerner College of Medicine Cleveland Clinic, Cleveland, OH, USA
| | - Ali Seifi
- University of Texas Health at San Antonio, San Antonio, TX, USA
| | | | - Jose I Suarez
- Division of Neurosciences Critical Care, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Thorsten Steiner
- Department of Neurology, Varsisano Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Chi-Ren Shyu
- Institute for Data Science and Informatics, University of Missouri, Columbia, MO, USA
| | - Craig S Anderson
- George Institute for Global Health, Australia, University of New South Wales, Sydney, NSW, Australia
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
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Selph L, Allison TA, Samuel S. Blood pressure management in the first 24 hours for intracerebral hemorrhage patients on oral anticoagulant therapy. Curr Med Res Opin 2025; 41:733-740. [PMID: 40257438 DOI: 10.1080/03007995.2025.2495853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 04/15/2025] [Accepted: 04/16/2025] [Indexed: 04/22/2025]
Abstract
OBJECTIVE To investigate the differences in blood pressure (BP) management and outcomes between intracerebral hemorrhage (ICH) patients on oral anticoagulant (OAC) therapy compared to those not on OAC therapy within the first 24 h of hospital admission. METHODS This retrospective cohort study included 165 ICH patients admitted to a comprehensive stroke center between July 1, 2014 and June 30, 2021. Patients were divided into two groups: those on OAC therapy (n = 55) and those not on OAC therapy (n = 110). BP measurements, including systolic BP (SBP) within 24 h of post-admission, were recorded. Clinical outcomes, such as mortality, modified Rankin Scale (mRS) scores, and length of hospital stay, were assessed. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to evaluate the impact of BP management on patient outcomes. RESULTS No significant differences in overall survival were observed between the OAC and non-OAC groups. Although the mean SBP at 24 h was slightly higher in the OAC group (142 mmHg) compared to the non-OAC group (136 mmHg; p = 0.032), this did not translate into differences in mortality or functional outcomes. Higher ICH scores were associated with increased mortality risk (HR 2.01, 95% CI 1.29-3.12, p = 0.002). Higher GCS scores were associated with better functional outcomes (HR 0.92, 95% CI 0.85-0.99, p = 0.035), while BP management strategies did not show a significant impact. CONCLUSION BP management in the first 24 h for ICH patients on OAC may not significantly affect mortality or functional outcomes. Current BP management strategies may be applicable to both OAC and non-OAC patients, though further research is needed to explore tailored approaches.
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Affiliation(s)
- Lindsey Selph
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Teresa A Allison
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Sophie Samuel
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA
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Lu P, Cui L, Gu H, Li Z, Wang Y, Zhao X. Safety Study of Anticoagulants for Preventing Deep Venous Thrombosis after Intracerebral Hemorrhage: Data from the Chinese Stroke Center Alliance. Drugs Aging 2025; 42:329-337. [PMID: 39979772 DOI: 10.1007/s40266-025-01187-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2025] [Indexed: 02/22/2025]
Abstract
OBJECTIVE The use of anticoagulants to prevent deep vein thrombosis (DVT) after intracerebral hemorrhage (ICH) remains controversial. This study aims to evaluate the safety of anticoagulants in preventing DVT in patients with ICH. METHODS Data were sourced from the Chinese Stroke Center Alliance. The primary outcomes include in-hospital mortality, intracranial hematoma evacuation, and hematoma expansion. Absolute standardized differences (ASD) are used to assess differences between groups, and multivariate logistic regression analysis is employed to analyze correlations. Platelet counts and international normalized ratio (INR) were examined within subgroups. Propensity score matching (PSM) is used for sensitivity analysis. RESULTS A total of 56,633 patients with ICH were finally enrolled. Multivariate logistic regression analysis revealed that anticoagulant use correlated with reduced in-hospital mortality and hematoma expansion (OR: 0.59, 95% CI: 0.50-0.69, p < 0.001 and OR: 0.55, 95% CI: 0.41-0.73, p < 0.001), while no association was observed with intracranial hematoma evacuation clearance (OR: 1.00, 95% CI: 0.93-1.08, p = 0.941). Subgroup analysis revealed an increased risk of intracranial hematoma evacuation with anticoagulant use when INR >1.7 (OR: 1.47, 95% CI: 1.15-1.89, p = 0.002), but not of in-hospital mortality (OR: 1.20, 95% CI: 0.78-1.85, p = 0.409) or hematoma expansion (OR: 0.66, 95% CI: 0.19-2.25, p = 0.503). PSM yielded consistent outcomes. CONCLUSIONS Post-ICH anticoagulant therapy to prevent DVT is safe, posing no heightened risk of in-hospital mortality, intracranial hematoma evacuation, or hematoma expansion. However, caution is warranted in patients with coagulopathies.
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Affiliation(s)
- Ping Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119# Nan Si Huan Xi Lu, Beijing, 100070, People's Republic of China
| | - Lingyun Cui
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119# Nan Si Huan Xi Lu, Beijing, 100070, People's Republic of China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119# Nan Si Huan Xi Lu, Beijing, 100070, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119# Nan Si Huan Xi Lu, Beijing, 100070, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119# Nan Si Huan Xi Lu, Beijing, 100070, People's Republic of China.
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China.
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.
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Li Q, Lv X, Morotti A, Qureshi AI, Dowlatshahi D, Falcone GJ, Sheth KN, Shoamanesh A, Murthy SB, Viswanathan A, Goldstein JN. Optimal Magnitude of Blood Pressure Reduction and Hematoma Growth and Functional Outcomes in Intracerebral Hemorrhage. Neurology 2025; 104:e213412. [PMID: 39913881 PMCID: PMC11803522 DOI: 10.1212/wnl.0000000000213412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Accepted: 01/02/2025] [Indexed: 02/09/2025] Open
Abstract
BACKGROUND AND OBJECTIVES Early intensive systolic blood pressure (SBP) reduction is a promising strategy for intracerebral hemorrhage (ICH), but the optimal magnitude of reduction in the first 2 hours remains uncertain. This study aimed to determine the optimal SBP reduction magnitude to maximize benefit in patients enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial. METHODS We performed a post hoc analysis of the ATACH-2 trial. Participants with baseline SBP ≥180 mm Hg were randomized within 4.5 hours from onset and assigned to the intensive or standard group. The magnitude of SBP reduction was calculated as admission SBP minus minimum SBP at 2 hours. Eligible participants were divided into 5 groups by 15 mm Hg stratum: <40, 40-55, 55-70, 70-85, and ≥85 mm Hg. Poor functional outcome was defined as the modified Rankin Scale score at 3-6 and hematoma expansion (HE) as a relative increase of >33% from baseline to 24 hours. Multivariable logistic regression assessed associations between SBP reduction and outcomes. RESULTS Our study included 925 patients, of whom 360 (38.9%) were female. The median age was 62 years (IQR: 53-71). The median hematoma volume was 10.2 mL (IQR: 5.1-18.4), and the median magnitude of SBP reduction was 68 mm Hg (IQR: 48-88). Of those, 209 (22.6%) experienced HE, 122 (13.2%) experienced acute kidney injury (AKI), and 516 (55.8%) had poor outcome. Hematoma expansion decreased linearly as the magnitude of blood pressure reduction increased in 5 SBP reduction groups (p < 0.001). After multivariable adjustment, patients with a greater degree of SBP reduction (≥70 mm Hg) were less likely to experience HE and a SBP reduction ≥55 mm Hg was associated with a lower risk of poor outcomes (odds ratio [OR] 0.49, 95% CI 0.28-0.85). However, a SBP reduction ≥85 mm Hg increased AKI risk compared with <40 mm Hg (OR, 2.00; 95% CI 1.01-3.94). DISCUSSION Targeting a SBP reduction within the range of 55-85 mm Hg during the first 2 hours seems to be associated with optimal outcomes in patients with mild-to-moderate ICH, balancing the need to limit hematoma growth while avoiding adverse effect. Further study focusing on severe ICH is warranted. TRIAL REGISTRATION INFORMATION Clinical trial registration number: NCT01176565. CLASSIFICATION OF EVIDENCE This post hoc analysis of the ATACH-2 trial provides Class III evidence that SBP reduction of 55-85 mm Hg during the initial 2 hours is associated with lower frequency of HE and better functional outcomes in patients with acute cerebral hemorrhage.
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Affiliation(s)
- Qi Li
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xinni Lv
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Dar Dowlatshahi
- Department of Medicine, Division of Neurology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Kevin Navin Sheth
- Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, and the Yale Center for Brain and Mind Health, Yale School of Medicine, New Haven, CT
| | - Ashkan Shoamanesh
- Division of Neurology, Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Anand Viswanathan
- Department of Neurology, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, MA; and
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
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Huo G, Lan Y, Feng Y, Gao X, Chen C. The Efficacy for Hypertensive Intracerebral Hemorrhage Between Neuroendoscopic Surgery and Conservative Treatment: A Retrospective Observational Study. Neurologist 2025; 30:109-115. [PMID: 39575625 DOI: 10.1097/nrl.0000000000000597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2025]
Abstract
OBJECTIVES This study aims to investigate the efficacy of neuroendoscopic surgery in the treatment of hypertensive intracerebral hemorrhage (HICH). METHODS A total of 193 patients diagnosed with HICH were divided into 2 groups in this study: the observation group (n=101) received neuroendoscopic surgery, whereas the control group (n=92) underwent conservative treatment. Then, the outcomes between these 2 groups were compared and assessed. RESULTS In the pretreatment phase, there were no significant differences in the levels of inflammation and neurological function scores between these 2 groups ( P >0.05). After 3 months of treatment, the observation group displayed significantly shorter median hospital stay, lower average hospital costs, and faster hematoma resorption time, along with reduced levels of tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP), interleukin (IL)-6 and IL-8, aquaporin-4 (AQP4), macrophage migration inhibitory factor (MIF), matrix metalloproteinase-9 (MMP-9), granulocyte macrophage colony stimulating factor (GM-CSF), Nerve Deficiency Scale (NDS), Graeb score, and national institute of health stroke scale (NIHSS) compared with the control group ( P <0.05). In addition, the observation group exhibited higher rate of hematoma clearance and better glasgow outcome scale (GOS) score compared with the control group ( P <0.05). The effective treatment rate in the observation group was notably superior to that in the control group (89.11% vs. 73.91%, P <0.05). CONCLUSIONS Neuroendoscopic surgery is an effective treatment for HICH, with alleviating the inflammatory response and enhancing the neurological function. The treatment shows promising outcomes and justifies extensive implementation.
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Affiliation(s)
- Guojin Huo
- Department of Neurosurgery, Yulin No. 1 Hospital, Yulin City, Shaanxi
| | - Yanping Lan
- Department of Neurosurgery, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan City, Ningxia, China
| | - Yi Feng
- Department of Neurosurgery, Yulin No. 1 Hospital, Yulin City, Shaanxi
| | - Xiang Gao
- Department of Neurosurgery, Yulin No. 1 Hospital, Yulin City, Shaanxi
| | - Chen Chen
- Department of Neurosurgery, Yulin No. 1 Hospital, Yulin City, Shaanxi
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Gomez JR, Bhende BU, Mathur R, Gonzalez LF, Shah VA. Individualized autoregulation-guided arterial blood pressure management in neurocritical care. Neurotherapeutics 2025; 22:e00526. [PMID: 39828496 PMCID: PMC11840358 DOI: 10.1016/j.neurot.2025.e00526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2024] [Revised: 01/07/2025] [Accepted: 01/08/2025] [Indexed: 01/22/2025] Open
Abstract
Cerebral autoregulation (CA) is the physiological process by which cerebral blood flow is maintained during fluctuations in arterial blood pressure (ABP). There are various validated methods to measure CA, either invasively, with intracranial pressure or brain tissue oxygenation monitors, or noninvasively, with transcranial Doppler ultrasound or near-infrared spectroscopy. Utilizing these monitors, researchers have been able to discern CA patterns in several pathological states, such as but not limited to acute ischemic stroke, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, sepsis, and post-cardiac arrest, and they have found CA to be altered in these patients. CA disturbances predispose patients suffering from these ailments to worse outcomes. Much focus has been placed on CA monitoring in these populations, with an emphasis on arterial blood pressure optimization. Many guidelines recommend universal static ABP targets; however, in patients with altered CA, these targets may make them susceptible to hypoperfusion and further neurological injury. Based on this observation, there has been much investigation on individualized ABP goals and their effect on clinical outcomes. The scope of this review includes (1) a summary of the physiology of CA in healthy adults; (2) a review of the evidence on CA monitoring in healthy individuals; (3) a summary of CA changes and its effect on outcomes in various diseased states including acute ischemic stroke, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, sepsis and meningitis, post-cardiac arrest, hypoxic-ischemic encephalopathy, surgery, and moyamoya disease; and (4) a review of the current evidence on individualized ABP changes in various patient populations.
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Affiliation(s)
- Jonathan R Gomez
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, USA; Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, USA
| | - Bhagyashri U Bhende
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, USA; Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, USA
| | - Rohan Mathur
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, USA; Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, USA; Division of Vascular and Endovascular Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vishank A Shah
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, USA; Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, USA.
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Li N, Ding S, Liu Z, Ye W, Liu P, Jing J, Jiang Y, Zhao X, Liu T. A Deep Learning-Based Framework for Predicting Intracerebral Hematoma Expansion Using Head Non-contrast CT Scan. Acad Radiol 2025; 32:347-358. [PMID: 39107191 DOI: 10.1016/j.acra.2024.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/11/2024] [Accepted: 07/21/2024] [Indexed: 08/09/2024]
Abstract
RATIONALE AND OBJECTIVES Hematoma expansion (HE) in intracerebral hemorrhage (ICH) is a critical factor affecting patient outcomes, yet effective clinical tools for predicting HE are currently lacking. We aim to develop a fully automated framework based on deep learning for predicting HE using only clinical non-contrast CT (NCCT) scans. MATERIALS AND METHODS A large retrospective dataset (n = 2484) was collected from 84 centers, while a prospective dataset (n = 500) was obtained from 26 additional centers. Baseline NCCT scans and follow-up NCCT scans were conducted within 6 h and 48 h from symptom onset, respectively. HE was defined as a volume increase of more than 6 mL on the follow-up NCCT. The retrospective dataset was divided into a training set (n = 1876) and a validation set (n = 608) by patient inclusion time. A two-stage framework was trained to predict HE, and its performance was evaluated on both the validation and prospective sets. Receiver operating characteristics area under the curve (AUC), sensitivity, and specificity were leveraged. RESULTS Our two-stage framework achieved an AUC of 0.760 (95% CI 0.724-0.799) on the retrospective validation set and 0.806 (95% CI 0.750-0.859) on the prospective set, outperforming the commonly used BAT score, which had AUCs of 0.582 and 0.699, respectively. CONCLUSION Our framework can automatically and robustly identify ICH patients at high risk of HE using admission head NCCT scans, providing more accurate predictions than the BAT score.
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Affiliation(s)
- Na Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (N.L., J.J., X.Z.); China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (N.L., W.Y., J.J., Y.J., X.Z.)
| | - Shaodong Ding
- Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China (S.D., Z.L., T.L.)
| | - Ziyang Liu
- Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China (S.D., Z.L., T.L.)
| | - Wanxing Ye
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (N.L., W.Y., J.J., Y.J., X.Z.)
| | - Pan Liu
- Medical Big Data Research Center, Chinese PLA General Hospital, Beijing 100853, China (P.L.)
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (N.L., J.J., X.Z.); China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (N.L., W.Y., J.J., Y.J., X.Z.)
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (N.L., W.Y., J.J., Y.J., X.Z.)
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (N.L., J.J., X.Z.); China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (N.L., W.Y., J.J., Y.J., X.Z.)
| | - Tao Liu
- Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China (S.D., Z.L., T.L.).
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9
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Bower MM, Giles JA, Sansing LH, Carhuapoma JR, Woo D. Stroke Controversies and Debates: Imaging in Intracerebral Hemorrhage. Stroke 2024; 55:2765-2771. [PMID: 39355925 PMCID: PMC11536919 DOI: 10.1161/strokeaha.123.043480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 08/13/2024] [Accepted: 09/06/2024] [Indexed: 10/03/2024]
Affiliation(s)
- Matthew M. Bower
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
| | - James A. Giles
- Yale University School of Medicine, Department of Neurology; New Haven, CT
| | - Lauren H. Sansing
- Yale University School of Medicine, Department of Neurology; New Haven, CT
| | | | - Daniel Woo
- University of Cincinnati College of Medicine, Department of Neurology; Cincinnati, OH
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Cho H, Kim T, Lee Y, Kim D, Bae H. Overall and linked blood pressure variabilities in the first 24 hours and mortality after spontaneous intracerebral hemorrhage: a retrospective study of 1,036 patients. Anesth Pain Med (Seoul) 2024; 19:302-309. [PMID: 39512052 PMCID: PMC11558055 DOI: 10.17085/apm.24039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 08/08/2024] [Accepted: 08/12/2024] [Indexed: 11/15/2024] Open
Abstract
BACKGROUND This study aims to establish the individual contributions of blood pressure variability (BPV) indexes, categorized into overall and linked variability, to mortality following intracerebral hemorrhage (ICH) by examining the risk factors. METHODS Patients with spontaneous ICH (n = 1,036) were identified with valid blood pressures (BP) from the first 24-h systolic BP records in the Medical Information Mart for Intensive Care IV version 2.2 database (MIMIC IV). Information on the baseline characteristics, including age, sex, initial Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) scores, ICH location, Charlson comorbidity index score, and presence of diabetes with or without complications, were collected. Three indexes of BPV-range, standard deviation (SD), and generalized BPV (GBPV)-were calculated using the first 24-h systolic BPs. An automated stepwise variable-selection procedure was used to develop the final logistic model for predicting in-hospital mortality. RESULTS Out of 1,036 patients, 802 (77.4%) survived and were discharged after spontaneous ICH. Factors associated with mortality included age; male sex; ICH in the brainstem, ventricle, or multiple locations; low GCS score (< 9); high NIHSS score (> 20); and diabetes with complications. Mean systolic BP, SD, and GBPV were also linked to mortality. Higher GBPV notably increased the risk of in-hospital death, with an odds ratio of 3.21 (95% confidence interval, 2.10 to 4.97) for every + 10 mmHg/h change in GBPV. CONCLUSIONS This study underscores the additional impact of GBPV, herein linked to BPV, on mortality following ICH, providing further insights into the management of blood pressure in the early stages of ICH treatment.
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Affiliation(s)
- Hangyul Cho
- Department of Anesthesiology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Taehoon Kim
- Department of Anesthesiology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Younsuk Lee
- Department of Anesthesiology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Dawoon Kim
- Department of Anesthesiology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Hansu Bae
- Department of Anesthesiology, Dongguk University Ilsan Hospital, Goyang, Korea
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11
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Fu J, Xu Y, Chen X, Li J, Peng L. Monocyte-to-Albumin Ratio Is Associated With Hematoma Expansion in Spontaneous Intracerebral Hemorrhage. Brain Behav 2024; 14:e70059. [PMID: 39344372 PMCID: PMC11440023 DOI: 10.1002/brb3.70059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 08/19/2024] [Accepted: 08/31/2024] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND Hematoma expansion (HE) after spontaneous intracerebral hemorrhage (ICH) is a severe complication that independently predicts poor prognosis. In this study, we aimed to investigate whether monocyte-to-albumin ratio (MAR), a novel marker of systemic inflammation, could predict HE in patients with ICH. METHODS We retrospectively assessed the data of patients with ICH. The clinical, imaging, and laboratory test data including, the MAR on admission, were analyzed. A multivariate logistic regression analysis was carried out to explore the relationship between MAR and hematoma growth. The receiver operating characteristic (ROC) curve was employed to investigate the predictive value of MAR for HE after ICH. RESULTS A total of 246 patients were included in the present study. Multivariate logistic regression analysis demonstrated that the MAR was associated with HE (odds ratio [OR] = 1.179; 95% confidence interval, 1.093-1.272; p = 0.000). ROC curve analysis showed that MAR could predict HE, with an area under the curve of 0.802 (95% CI: 0.744-0.859, p < 0.001). The optimal predictive cutoff value of MAR for HE was 10.01 (sensitivity: 72.43%, specificity: 77.05%). CONCLUSIONS Our results suggested that a high MAR on admission was associated with an increased risk of HE in ICH patients, and MAR can become an independent predictor of HE in ICH patients.
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Affiliation(s)
- Jie Fu
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yilin Xu
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiu Chen
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jinglun Li
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Lilei Peng
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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Kucukceylan M, Gulen M, Satar S, Acehan S, Gezercan Y, Acik V, Boga Z, Gorur M, Pehlivan M, Dengiz I. The Relationship Between Ionized Calcium Levels and Prognosis in Patients with Spontaneous Subarachnoid Hemorrhage. World Neurosurg 2024; 189:e467-e475. [PMID: 38909751 DOI: 10.1016/j.wneu.2024.06.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND The serum calcium plays a role as a cofactor in critical steps such as cardiac contractility, vascular tone, and the coagulation cascade. This study aimed to determine if the level of ionized calcium can predict outcomes in patients with spontaneous subarachnoid hemorrhage (SAH) in the emergency department. METHODS The study was a retrospective cross-sectional case series. Patients aged 18 and over diagnosed with spontaneous SAH in the emergency department were included in the study. Patients' demographic characteristics, comorbidities, vital signs, laboratory parameters, World Federation of Neurosurgical Societies score, SAH grading according to the Fisher scale, needs of mechanical ventilation and inotropic treatment, administered treatments, complications, Rankin scores at discharge, and outcome were recorded in a standard data form. RESULTS A total of 267 patients were studied, with a mean age of 55.5 ± 13.4 years, and 53.9% (n = 144) were female. Hydrocephalus was present in 16.5% of patients. The average hospital stay was 20.4 ± 19.8 days. Mortality rate was 34.8% (n = 93). Mortality was significantly higher in patients with low calcium levels upon admission (P = 0.024). Ionized calcium levels during complication development independently predicted mortality (OR: 0.945, 95% CI: 0.898-0.996, P = 0.034). Patients with poor neurologic outcomes (Rankin: 3-6) had significantly lower initial ionized calcium levels (P = 0.002). CONCLUSIONS The ionized calcium level is a readily accessible blood gas parameter that assists clinicians in predicting functional independence and mortality at discharge in patients presenting to the emergency department with spontaneous SAH.
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Affiliation(s)
- Melike Kucukceylan
- Department of Emergency Medicine, Health Science University, Adana City Training and Research Hospital, Adana, Turkey
| | - Muge Gulen
- Department of Emergency Medicine, Health Science University, Adana City Training and Research Hospital, Adana, Turkey.
| | - Salim Satar
- Department of Emergency Medicine, Health Science University, Adana City Training and Research Hospital, Adana, Turkey
| | - Selen Acehan
- Department of Emergency Medicine, Health Science University, Adana City Training and Research Hospital, Adana, Turkey
| | - Yurdal Gezercan
- Department of Neurosurgery, Health Science University, Adana City Training and Research Hospital, Adana, Turkey
| | - Vedat Acik
- Department of Neurosurgery, Health Science University, Adana City Training and Research Hospital, Adana, Turkey
| | - Zeki Boga
- Department of Neurosurgery, Health Science University, Adana City Training and Research Hospital, Adana, Turkey
| | - Mehmet Gorur
- Department of Emergency Medicine, Health Science University, Adana City Training and Research Hospital, Adana, Turkey
| | - Mert Pehlivan
- Department of Emergency Medicine, Health Science University, Adana City Training and Research Hospital, Adana, Turkey
| | - Ihsan Dengiz
- Department of Emergency Medicine, Health Science University, Adana City Training and Research Hospital, Adana, Turkey
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13
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Dong R, Li F, Li B, Chen Q, Huang X, Zhang J, Huang Q, Zhang Z, Cao Y, Yang M, Li J, Li Z, Li C, Liu G, Zhong S, Feng G, Zhang M, Xiao Y, Lin K, Shen Y, Shao H, Shi Y, Yu X, Li X, Yao L, Du X, Xu Y, Kang P, Gao G, Ouyang B, Chen W, Zeng Z, Chen P, Chen C, Yang H. Effects of an Early Intensive Blood Pressure-lowering Strategy Using Remifentanil and Dexmedetomidine in Patients with Spontaneous Intracerebral Hemorrhage: A Multicenter, Prospective, Superiority, Randomized Controlled Trial. Anesthesiology 2024; 141:100-115. [PMID: 38537025 DOI: 10.1097/aln.0000000000004986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
BACKGROUND Although it has been established that elevated blood pressure and its variability worsen outcomes in spontaneous intracerebral hemorrhage, antihypertensives use during the acute phase still lacks robust evidence. A blood pressure-lowering regimen using remifentanil and dexmedetomidine might be a reasonable therapeutic option given their analgesic and antisympathetic effects. The objective of this superiority trial was to validate the efficacy and safety of this blood pressure-lowering strategy that uses remifentanil and dexmedetomidine in patients with acute intracerebral hemorrhage. METHODS In this multicenter, prospective, single-blinded, superiority randomized controlled trial, patients with intracerebral hemorrhage and systolic blood pressure (SBP) 150 mmHg or greater were randomly allocated to the intervention group (a preset protocol with a standard guideline management using remifentanil and dexmedetomidine) or the control group (standard guideline-based management) to receive blood pressure-lowering treatment. The primary outcome was the SBP control rate (less than 140 mmHg) at 1 h posttreatment initiation. Secondary outcomes included blood pressure variability, neurologic function, and clinical outcomes. RESULTS A total of 338 patients were allocated to the intervention (n = 167) or control group (n = 171). The SBP control rate at 1 h posttreatment initiation in the intervention group was higher than that in controls (101 of 161, 62.7% vs. 66 of 166, 39.8%; difference, 23.2%; 95% CI, 12.4 to 34.1%; P < 0.001). Analysis of secondary outcomes indicated that patients in the intervention group could effectively reduce agitation while achieving lighter sedation, but no improvement in clinical outcomes was observed. Regarding safety, the incidence of bradycardia and respiratory depression was higher in the intervention group. CONCLUSIONS Among intracerebral hemorrhage patients with a SBP 150 mmHg or greater, a preset protocol using a remifentanil and dexmedetomidine-based standard guideline management significantly increased the SBP control rate at 1 h posttreatment compared with the standard guideline-based management. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Rui Dong
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Fen Li
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Bin Li
- Department of Intensive Care Unit, The First Hospital of Lanzhou University, Lanzhou, China
| | - Qiming Chen
- Department of Intensive Care Unit, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xianjian Huang
- Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Jiehua Zhang
- Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Qibing Huang
- Department of Emergency Neurosurgical Intensive Care Unit, Qilu Hospital of Shandong University and Brain Science Research Institute of Shandong University, Jinan, China
| | - Zeli Zhang
- Department of Emergency Neurosurgical Intensive Care Unit, Qilu Hospital of Shandong University and Brain Science Research Institute of Shandong University, Jinan, China
| | - Yunxing Cao
- Department of Intensive Care Unit, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mingbiao Yang
- Neurosurgery Department, The First Affiliated Hospital of Hunan University of Medicine, Huaihua, China
| | - Jianwei Li
- Department of Critical Care Medicine, Zhongshan People's Hospital, Zhongshan, China
| | - Zhanfu Li
- Department of Intensive Care Unit, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Cuiyu Li
- Department of Intensive Care Unit, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Guohua Liu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Shu Zhong
- Department of Neurosurgery, Guangxi Hospital Division of the First Affiliated Hospital, Sun Yat-sen University, Nanning, China
| | - Guang Feng
- Department of Neurosurgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Ming Zhang
- Department of Neurosurgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yumei Xiao
- Neurological Intensive Medicine Department, Maoming People's Hospital, Maoming, China
| | - Kangyue Lin
- Neurological Intensive Medicine Department, Maoming People's Hospital, Maoming, China
| | - Yunlong Shen
- Department of Neurosurgery, The Fifth Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Huanzhang Shao
- Department of Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuan Shi
- Department of Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiangyou Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaopeng Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Lan Yao
- Department of Emergency Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Xinyu Du
- Department of Emergency Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Ying Xu
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Pei Kang
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Guoyi Gao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wenjin Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Pingyan Chen
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Chunbo Chen
- Department of Critical Care Medicine, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Hong Yang
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
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14
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Schwabauer E, Piccininni M, Freitag E, Ebinger M, Geisler F, Harmel P, Hille A, Lorenz-Meyer I, Rohrpasser-Napierkowski I, Kurth T, Rohmann JL, Endres M, Schlunk F, Weber J, Wendt M, Audebert HJ. Effects of Mobile Stroke Unit dispatch on blood pressure management and outcomes in patients with intracerebral haematoma: Results from the Berlin_Prehospital Or Usual Care Delivery in acute Stroke (B_PROUD) controlled intervention study. Eur Stroke J 2024; 9:366-375. [PMID: 38014623 PMCID: PMC11318420 DOI: 10.1177/23969873231213156] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/11/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION In patients with acute intracerebral haemorrhage (ICH) and elevated systolic blood pressure (BP), guidelines suggest that systolic BP reduction to <140 mmHg should be rapidly initiated. Compared with conventional care, Mobile Stroke Units (MSUs) allow for earlier ICH diagnosis through prehospital imaging and earlier BP lowering. PATIENTS AND METHODS ICH patients were prospectively evaluated as a cohort of the controlled B_PROUD-study in which MSU availability alone determined MSU dispatch in addition to conventional ambulance. We used inverse probability of treatment weighting to adjust for confounding to estimate the effect of additional MSU dispatch in ICH patients. Outcomes of interest were 7-day mortality (primary), systolic BP (sBP) at hospital arrival, dispatch-to-imaging time, largest haematoma volume, anticoagulation reversal, length of in-hospital stay, 3-month functional outcome. RESULTS Between February 2017 and May 2019, MSUs were dispatched to 95 (mean age: 72 ± 13 years, 45% female) and only conventional ambulances to 78 ICH patients (mean age: 71 ± 12 years, 44% female). After adjusting for confounding, we found shorter dispatch-to-imaging time (mean difference: -17.75 min, 95% CI: -27.16 to -8.21 min) and lower sBP at hospital arrival (mean difference = -16.31 mmHg, 95% CI: -30.64 to -6.19 mmHg) in the MSU group. We found no statistically significant difference for the other outcomes, including 7-day mortality (adjusted odds ratio: 1.43, 95% CI: 0.68 to 3.31) or favourable outcome (adjusted odds ratio = 0.67, 95% CI: 0.27 to 1.67). CONCLUSIONS Although MSU dispatch led to sBP reduction and lower dispatch-to-imaging time compared to conventional ambulance care, we found no evidence of better outcomes in the MSU dispatch group.
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Affiliation(s)
- Eugen Schwabauer
- Klinik für Neurologie mit Stroke Unit; Vivantes Klinikum Neukölln, Berlin, Germany
| | - Marco Piccininni
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Erik Freitag
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Frederik Geisler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Harmel
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Annegret Hille
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Tobias Kurth
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica L Rohmann
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | - Frieder Schlunk
- Berlin Institute of Health (BIH), Berlin, Germany
- Institut für Neuroradiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Weber
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | | | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
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15
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Almubayyidh M, Alghamdi I, Parry-Jones AR, Jenkins D. Prehospital identification of intracerebral haemorrhage: a scoping review of early clinical features and portable devices. BMJ Open 2024; 14:e079316. [PMID: 38643005 PMCID: PMC11033659 DOI: 10.1136/bmjopen-2023-079316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 03/26/2024] [Indexed: 04/22/2024] Open
Abstract
INTRODUCTION Prehospital identification of intracerebral haemorrhage (ICH) in suspected stroke cases may enable the initiation of appropriate treatments and facilitate better-informed transport decisions. This scoping review aims to examine the literature to identify early clinical features and portable devices for the detection of ICH in the prehospital setting. METHODS Three databases were searched via Ovid (MEDLINE, EMBASE and CENTRAL) from inception to August 2022 using prespecified search strategies. One reviewer screened all titles, abstracts and full-text articles for eligibility, while a second reviewer independently screened 20% of the literature during each screening stage. Data extracted were tabulated to summarise the key findings. RESULTS A total of 6803 articles were screened for eligibility, of which 22 studies were included for analysis. Among them, 15 studies reported on early clinical features, while 7 considered portable devices. Associations between age, sex and comorbidities with the presence of ICH varied across studies. However, most studies reported that patients with ICH exhibited more severe neurological deficits (n=6) and higher blood pressure levels (n=11) at onset compared with other stroke and non-stroke diagnoses. Four technologies were identified for ICH detection: microwave imaging technology, volumetric impedance phase shift spectroscopy, transcranial ultrasound and electroencephalography. Microwave and ultrasound imaging techniques showed promise in distinguishing ICH from other diagnoses. CONCLUSION This scoping review has identified potential clinical features for the identification of ICH in suspected stroke patients. However, the considerable heterogeneity among the included studies precludes meta-analysis of available data. Moreover, we have explored portable devices to enhance ICH identification. While these devices have shown promise in detecting ICH, further technological development is required to distinguish between stroke subtypes (ICH vs ischaemic stroke) and non-stroke diagnoses.
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Affiliation(s)
- Mohammed Almubayyidh
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Department of Aviation and Marine, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Ibrahim Alghamdi
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Department of Emergency Medical Services, College of Applied Medical Sciences, Khamis Mushait Campus, King Khalid University, Abha, Saudi Arabia
| | - Adrian Robert Parry-Jones
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - David Jenkins
- Division of Informatics, Imaging and Data Science, The University of Manchester, Manchester, UK
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Lv X, Liu X, Hu Z, Deng L, Li Z, Cheng J, Pu M, Li Q. Early blood pressure lowering therapy is associated with good functional outcome in patients with intracerebral hemorrhage. BMC Neurol 2024; 24:63. [PMID: 38355479 PMCID: PMC10865678 DOI: 10.1186/s12883-024-03561-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/01/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The implementation of a care bundle might improve functional outcome for patients with intracerebral hemorrhage (ICH). However, the impact of anti-hypertensive treatment on ICH outcomes remains uncertain. Our objective is to examine whether early blood pressure (BP) lowering therapy within first 12 h is associated with good outcome in ICH patients. METHODS We included acute ICH patients who had baseline computed tomography (CT) scans within 6 h after onset of symptoms between October 2013 and December 2021. Early BP reduction was defined as use of anti-hypertensive agents within 12 h after onset of symptom. The clinical characteristics were compared between patients who received early BP lowering therapy and those without. The associations between early BP lowering and good outcome and functional independence at 3 months were assessed by using multivariable logistic regression analyses. RESULTS A total of 377 patients were finally included in this study for outcome analysis. Of those, 212 patients received early BP reduction within 12 h after ICH. A total of 251 (66.6%) patients had good outcome. After adjustment for age, admission systolic BP, admission GCS score, baseline hematoma volume, hematoma expansion, and presence of intraventricular hemorrhage, early BP lowering therapy was associated with functional independence (adjusted odd ratio:1.72, 95% confidence interval:1.03-2.87; P = 0.039) and good outcome (adjusted odd ratio: 2.02, 95% confidence interval:1.08-3.76; P = 0.027). CONCLUSIONS In ICH patients presenting within 6 h after symptom onset, early BP reduction within first 12 h is associated with good outcome and functional independence when compared to those who do not undergo such early intervention. Implementation of quality measures to ensure early BP reduction is crucial for management of ICH.
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Affiliation(s)
- Xinni Lv
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xueyun Liu
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zicheng Hu
- Department of Neurology, People's Hospital of Chongqing Hechuan (PHHC), Chongqing, China
| | - Lan Deng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zuoqiao Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Jing Cheng
- Department of Neurology and Neurosurgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mingjun Pu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China.
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17
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Kamabu LK, Bbosa GS, Lekuya HM, Cho EJ, Kyaruzi VM, Nyalundja AD, Deng D, Sekabunga JN, Kataka LM, Obiga DOD, Kiryabwire J, Kaddumukasa MN, Kaddumukasa M, Fuller AT, Galukande M. Burden, risk factors, neurosurgical evacuation outcomes, and predictors of mortality among traumatic brain injury patients with expansive intracranial hematomas in Uganda: a mixed methods study design. BMC Surg 2023; 23:326. [PMID: 37880635 PMCID: PMC10601114 DOI: 10.1186/s12893-023-02227-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Expansive intracranial hematomas (EIH) following traumatic brain injury (TBI) continue to be a public health problem in Uganda. Data is limited regarding the neurosurgical outcomes of TBI patients. This study investigated the neurosurgical outcomes and associated risk factors of EIH among TBI patients at Mulago National Referral Hospital (MNRH). METHODS A total of 324 subjects were enrolled using a prospective cohort study. Socio-demographic, risk factors and complications were collected using a study questionnaire. Study participants were followed up for 180 days. Univariate, multivariable, Cox regression analyses, Kaplan Meir survival curves, and log rank tests were sequentially conducted. P-values of < 0.05 at 95% Confidence interval (CI) were considered to be statistically significant. RESULTS Of the 324 patients with intracranial hematomas, 80.6% were male. The mean age of the study participants was 37.5 ± 17.4 years. Prevalence of EIH was 59.3% (0.59 (95% CI: 0.54 to 0.65)). Participants who were aged 39 years and above; PR = 1.54 (95% CI: 1.20 to 1.97; P = 0.001), and those who smoke PR = 1.21 (95% CI: 1.00 to 1.47; P = 0.048), and presence of swirl sign PR = 2.26 (95% CI: 1.29 to 3.95; P = 0.004) were found to be at higher risk for EIH. Kaplan Meier survival curve indicated that mortality at the 16-month follow-up was 53.4% (95% CI: 28.1 to 85.0). Multivariate Cox regression indicated that the predictors of mortality were old age, MAP above 95 mmHg, low GCS, complications such as infection, spasticity, wound dehiscence, CSF leaks, having GOS < 3, QoLIBRI < 50, SDH, contusion, and EIH. CONCLUSION EIH is common in Uganda following RTA with an occurrence of 59.3% and a 16-month higher mortality rate. An increased age above 39 years, smoking, having severe systemic disease, and the presence of swirl sign are independent risk factors. Old age, MAP above 95 mmHg, low GCS, complications such as infection, spasticity, wound dehiscence, CSF leaks, having a GOS < 3, QoLIBRI < 50, ASDH, and contusion are predictors of mortality. These findings imply that all patients with intracranial hematomas (IH) need to be monitored closely and a repeat CT scan to be done within a specific period following their initial CT scan. We recommend the development of a protocol for specific surgical and medical interventions that can be implemented for patients at moderate and severe risk for EIH.
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Affiliation(s)
- Larrey Kasereka Kamabu
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda.
- Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo.
- Department of Surgery, Makerere University College of Health Medicine, Mulago Upper Hill, Kampala, Uganda.
| | - Godfrey S Bbosa
- Department of Pharmacology & Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Hervé Monka Lekuya
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
- Department of Human Structure & Repair/ Neurosurgery, Faculty of Medicine, Ghent University, Ghent, Belgium
| | | | - Victor Meza Kyaruzi
- Department of Surgery, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Arsene Daniel Nyalundja
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu, South Kivu, Democratic Republic of the Congo
| | - Daniel Deng
- Duke Global Neurosurgery, Neurology and Health System, Duke University, Durham, NC, USA
| | - Juliet Nalwanga Sekabunga
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Louange Maha Kataka
- Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo
| | - Doomwin Oscar Deogratius Obiga
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Joel Kiryabwire
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Martin N Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Mark Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Anthony T Fuller
- Duke University, Durham, NC, USA
- Duke Global Neurosurgery, Neurology and Health System, Duke University, Durham, NC, USA
| | - Moses Galukande
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
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Gkantzios A, Kokkotis C, Tsiptsios D, Moustakidis S, Gkartzonika E, Avramidis T, Tripsianis G, Iliopoulos I, Aggelousis N, Vadikolias K. From Admission to Discharge: Predicting National Institutes of Health Stroke Scale Progression in Stroke Patients Using Biomarkers and Explainable Machine Learning. J Pers Med 2023; 13:1375. [PMID: 37763143 PMCID: PMC10532952 DOI: 10.3390/jpm13091375] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/03/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
As a result of social progress and improved living conditions, which have contributed to a prolonged life expectancy, the prevalence of strokes has increased and has become a significant phenomenon. Despite the available stroke treatment options, patients frequently suffer from significant disability after a stroke. Initial stroke severity is a significant predictor of functional dependence and mortality following an acute stroke. The current study aims to collect and analyze data from the hyperacute and acute phases of stroke, as well as from the medical history of the patients, in order to develop an explainable machine learning model for predicting stroke-related neurological deficits at discharge, as measured by the National Institutes of Health Stroke Scale (NIHSS). More specifically, we approached the data as a binary task problem: improvement of NIHSS progression vs. worsening of NIHSS progression at discharge, using baseline data within the first 72 h. For feature selection, a genetic algorithm was applied. Using various classifiers, we found that the best scores were achieved from the Random Forest (RF) classifier at the 15 most informative biomarkers and parameters for the binary task of the prediction of NIHSS score progression. RF achieved 91.13% accuracy, 91.13% recall, 90.89% precision, 91.00% f1-score, 8.87% FNrate and 4.59% FPrate. Those biomarkers are: age, gender, NIHSS upon admission, intubation, history of hypertension and smoking, the initial diagnosis of hypertension, diabetes, dyslipidemia and atrial fibrillation, high-density lipoprotein (HDL) levels, stroke localization, systolic blood pressure levels, as well as erythrocyte sedimentation rate (ESR) levels upon admission and the onset of respiratory infection. The SHapley Additive exPlanations (SHAP) model interpreted the impact of the selected features on the model output. Our findings suggest that the aforementioned variables may play a significant role in determining stroke patients' NIHSS progression from the time of admission until their discharge.
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Affiliation(s)
- Aimilios Gkantzios
- Department of Neurology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (D.T.); (I.I.); (K.V.)
- Department of Neurology, Korgialeneio—Benakeio “Hellenic Red Cross” General Hospital of Athens, 11526 Athens, Greece;
| | - Christos Kokkotis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (S.M.); (N.A.)
| | - Dimitrios Tsiptsios
- Department of Neurology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (D.T.); (I.I.); (K.V.)
| | - Serafeim Moustakidis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (S.M.); (N.A.)
| | - Elena Gkartzonika
- School of Philosophy, University of Ioannina, 45110 Ioannina, Greece;
| | - Theodoros Avramidis
- Department of Neurology, Korgialeneio—Benakeio “Hellenic Red Cross” General Hospital of Athens, 11526 Athens, Greece;
| | - Gregory Tripsianis
- Laboratory of Medical Statistics, Democritus University of Thrace, 68100 Alexandroupolis, Greece;
| | - Ioannis Iliopoulos
- Department of Neurology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (D.T.); (I.I.); (K.V.)
| | - Nikolaos Aggelousis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (S.M.); (N.A.)
| | - Konstantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (D.T.); (I.I.); (K.V.)
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19
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Appleton JP, Law ZK, Woodhouse LJ, Al-Shahi Salman R, Beridze M, Christensen H, Dineen RA, Guerrero JJE, England TJ, Karlinski M, Krishnan K, Laska AC, Lyrer P, Ozturk S, Roffe C, Roberts I, Robinson TG, Scutt P, Werring DJ, Bath PM, Sprigg N. Effects of blood pressure and tranexamic acid in spontaneous intracerebral haemorrhage: a secondary analysis of a large randomised controlled trial. BMJ Neurol Open 2023; 5:e000423. [PMID: 37337529 PMCID: PMC10277112 DOI: 10.1136/bmjno-2023-000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/06/2023] [Indexed: 06/21/2023] Open
Abstract
Background Tranexamic acid reduced haematoma expansion and early death, but did not improve functional outcome in the tranexamic acid for hyperacute spontaneous intracerebral haemorrhage-2 (TICH-2) trial. In a predefined subgroup, there was a statistically significant interaction between prerandomisation baseline systolic blood pressure (SBP) and the effect of tranexamic acid on functional outcome (p=0.019). Methods TICH-2 was an international prospective double-blind placebo-controlled randomised trial evaluating intravenous tranexamic acid in patients with acute spontaneous intracerebral haemorrhage (ICH). Prerandomisation baseline SBP was split into predefined ≤170 and >170 mm Hg groups. The primary outcome at day 90 was the modified Rankin Scale (mRS), a measure of dependency, analysed using ordinal logistic regression. Haematoma expansion was defined as an increase in haematoma volume of >33% or >6 mL from baseline to 24 hours. Data are OR or common OR (cOR) with 95% CIs, with significance at p<0.05. Results Of 2325 participants in TICH-2, 1152 had baseline SBP≤170 mm Hg and were older, had larger lobar haematomas and were randomised later than 1173 with baseline SBP>170 mm Hg. Tranexamic acid was associated with a favourable shift in mRS at day 90 in those with baseline SBP≤170 mm Hg (cOR 0.73, 95% CI 0.59 to 0.91, p=0.005), but not in those with baseline SBP>170 mm Hg (cOR 1.05, 95% CI 0.85 to 1.30, p=0.63). In those with baseline SBP≤170 mm Hg, tranexamic acid reduced haematoma expansion (OR 0.62, 95% CI 0.47 to 0.82, p=0.001), but not in those with baseline SBP>170 mm Hg (OR 1.02, 95% CI 0.77 to 1.35, p=0.90). Conclusions Tranexamic acid was associated with improved clinical and radiological outcomes in ICH patients with baseline SBP≤170 mm Hg. Further research is needed to establish whether certain subgroups may benefit from tranexamic acid in acute ICH. Trial registration number ISRCTN93732214.
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Affiliation(s)
- Jason Philip Appleton
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Zhe Kang Law
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Neurology Unit, Department of Medicine, National University of Malaysia Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Lisa Jane Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | | | - Maia Beridze
- The First University Clinic, Tbilisi State Medical University, Tbilisi, Georgia
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Robert A Dineen
- Radiological Sciences, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Juan José Egea Guerrero
- Neurocritical Care Unit, Virgen del Rocio University Hospital, Sevilla, Spain
- IbiS, CSIC, University of Seville, Sevilla, Spain
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Michal Karlinski
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Philippe Lyrer
- Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Serefnur Ozturk
- Neurology, Faculty of Medicine, Selcuk Universitesi, Konya, Turkey
| | - Christine Roffe
- Stroke Research, School of Medicine, University of Keele, Stoke-on-Trent, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Polly Scutt
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Philip M Bath
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
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20
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Sotoudeh H, Rezaei A, Godwin R, Prattipati V, Singhal A, Sotoudeh M, Tanwar M. Radiomics Outperforms Clinical and Radiologic Signs in Predicting Spontaneous Basal Ganglia Hematoma Expansion: A Pilot Study. Cureus 2023; 15:e37162. [PMID: 37153238 PMCID: PMC10162352 DOI: 10.7759/cureus.37162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 04/09/2023] Open
Abstract
Prediction of the hematoma expansion (HE) of spontaneous basal ganglia hematoma (SBH) from the first non-contrast CT can result in better management, which has the potential of improving outcomes. This study has been designed to compare the performance of "Radiomics analysis," "radiology signs," and "clinical-laboratory data" for this task. We retrospectively reviewed the electronic medical records for clinical, demographic, and laboratory data in patients with SBH. CT images were reviewed for the presence of radiologic signs, including black-hole, blend, swirl, satellite, and island signs. Radiomic features from the SBH on the first brain CT were extracted, and the most predictive features were selected. Different machine learning models were developed based on clinical, laboratory, and radiology signs and selected Radiomic features to predict hematoma expansion (HE). The dataset used for this analysis included 116 patients with SBH. Among different models and different thresholds to define hematoma expansion (10%, 20%, 25%, 33%, 40%, and 50% volume enlargement thresholds), the Random Forest based on 10 selected Radiomic features achieved the best performance (for 25% hematoma enlargement) with an area under the curve (AUC) of 0.9 on the training dataset and 0.89 on the test dataset. The models based on clinical-laboratory and radiology signs had low performance (AUCs about 0.5-0.6).
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21
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Larsen KT, Sandset EC, Selseth MN, Jahr SH, Koubaa N, Hillestad V, Kristoffersen ES, Rønning OM. Antithrombotic Treatment, Prehospital Blood Pressure, and Outcomes in Spontaneous Intracerebral Hemorrhage. J Am Heart Assoc 2023; 12:e028336. [PMID: 36870965 PMCID: PMC10111438 DOI: 10.1161/jaha.122.028336] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Background In acute intracerebral hemorrhage, both elevated blood pressure (BP) and antithrombotic treatment are associated with poor outcome. Our aim was to explore interactions between antithrombotic treatment and prehospital BP. Methods and Results This observational, retrospective study included adult patients with spontaneous intracerebral hemorrhage diagnosed by computed tomography within 24 hours, admitted to a primary stroke center during 2012 to 2019. The first recorded prehospital/ambulance systolic and diastolic BP were analyzed per 5 mm Hg increment. Clinical outcomes were in-hospital mortality, shift on the modified Rankin Scale at discharge, and mortality at 90 days. Radiological outcomes were initial hematoma volume and hematoma expansion. Antithrombotic (antiplatelet and/or anticoagulant) treatment was analyzed both together and separately. Modification of associations between prehospital BP and outcomes by antithrombotic treatment was explored by multivariable regression with interaction terms. The study included 200 women and 220 men, median age 76 (interquartile range, 68-85) years. Antithrombotic drugs were used by 252 of 420 (60%) patients. Compared with patients without, patients with antithrombotic treatment had significantly stronger associations between high prehospital systolic BP and in-hospital mortality (odds ratio [OR], 1.14 versus 0.99, P for interaction 0.021), shift on the modified Rankin Scale (common OR, 1.08 versus 0.96, P for interaction 0.001), and hematoma volume (coef. 0.03 versus -0.03, P for interaction 0.011). Conclusions In patients with acute, spontaneous intracerebral hemorrhage, antithrombotic treatment modifies effects of prehospital BP. Compared with patients without, patients with antithrombotic treatment have poorer outcomes with higher prehospital BP. These findings may have implications for future studies on early BP lowering in intracerebral hemorrhage.
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Affiliation(s)
- Kristin Tveitan Larsen
- Department of Neurology Akershus University Hospital Lørenskog Norway.,Department of Geriatric Medicine Oslo University Hospital Oslo Norway.,University of Oslo, Institute of Clinical Medicine Oslo Norway
| | - Else Charlotte Sandset
- Department of Neurology Oslo University Hospital Oslo Norway.,The Norwegian Air Ambulance Foundation Oslo Norway
| | | | - Silje Holt Jahr
- Department of Neurology Akershus University Hospital Lørenskog Norway.,University of Oslo, Institute of Clinical Medicine Oslo Norway
| | - Nojoud Koubaa
- Department of Neurology Akershus University Hospital Lørenskog Norway
| | - Vigdis Hillestad
- Department of Diagnostic Imaging Akershus University Hospital Lørenskog Norway
| | - Espen Saxhaug Kristoffersen
- Department of Neurology Akershus University Hospital Lørenskog Norway.,Department of General Practice University of Oslo, Institute of Health and Society Oslo Norway
| | - Ole Morten Rønning
- Department of Neurology Akershus University Hospital Lørenskog Norway.,University of Oslo, Institute of Clinical Medicine Oslo Norway
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22
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Association Between Hyperacute Blood Pressure Variability and Hematoma Expansion After Intracerebral Hemorrhage: Secondary Analysis of the FAST-MAG Database. Neurocrit Care 2022; 38:356-364. [PMID: 36471183 DOI: 10.1007/s12028-022-01657-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Blood pressure variability (BPV) has emerged as a significant factor associated with clinical outcomes after intracerebral hemorrhage (ICH). Although hematoma expansion (HE) is associated with clinical outcomes, the relationship between BPV that encompasses prehospital data and HE is unknown. We hypothesized that BPV was positively associated with HE. METHODS We analyzed 268 patients with primary ICH enrolled in the National Institutes of Health-funded Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study who received head computed tomography or magnetic resonance imaging on arrival to the emergency department (ED) and repeat imaging within 6-48 h. BPV was calculated by standard deviation (SD) and coefficient of variation (CV) from prehospital data as well as systolic blood pressure (SBP) measurements taken on ED arrival, 15 min post antihypertensive infusion start, 1 h post maintenance infusion start, and 4 h after ED arrival. HE was defined by hematoma volume expansion increase > 6 mL or by 33%. Univariate logistic regression was used for presence of HE in quintiles of SD and CV of SBP for demographics and clinical characteristics. RESULTS Of the 268 patients analyzed from the FAST-MAG study, 116 (43%) had HE. Proportions of patients with HE were not statistically significant in the higher quintiles of the SD and CV of SBP for either the hyperacute or the acute period. Presence of HE was significantly more common in patients on anticoagulation. CONCLUSIONS Higher BPV was not found to be associated with occurrence of HE in the hyperacute or the acute period of spontaneous ICH. Further study is needed to determine the relationship.
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23
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Li Z, Hui Y, Sha Z, Liu B, Wang C, Yang F, Zhang W, Gao C, Jiang R. Association between preadmission low‐density lipoprotein cholesterol concentration and risk of large intracerebral hemorrhage: Results from the Kailuan study. J Clin Lab Anal 2022; 36:e24787. [DOI: 10.1002/jcla.24787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/24/2022] [Accepted: 11/13/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Zhanying Li
- Department of Neurosurgery Tianjin Medical University General Hospital Tianjin China
- Tianjin Neurological Institute, Key Laboratory of Post‐Neuroinjury Neuro‐Repair and Regeneration in Central Nervous System Tianjin Medical University General Hospital, Ministry of Education Tianjin China
- Department of Neurosurgery Kailuan General Hospital Tangshan China
| | - Ying Hui
- Department of Radiology, Beijing Friendship Hospital Capital Medical University Beijing China
| | - Zhuang Sha
- Department of Neurosurgery Tianjin Medical University General Hospital Tianjin China
- Tianjin Neurological Institute, Key Laboratory of Post‐Neuroinjury Neuro‐Repair and Regeneration in Central Nervous System Tianjin Medical University General Hospital, Ministry of Education Tianjin China
| | - Bailu Liu
- Department of Rheumatology Kailuan General Hospital Tangshan China
| | - Chengbo Wang
- Department of Medical Imaging Kailuan General Hospital Linxi Hospital Tangshan China
| | - Feng Yang
- Department of neurosurgery North China University of Science and Technology Affiliated Hospital Tangshan China
| | - Wenfei Zhang
- Department of Medical Imaging Kailuan General Hospital Tangshan China
| | - Chuang Gao
- Department of Neurosurgery Tianjin Medical University General Hospital Tianjin China
- Tianjin Neurological Institute, Key Laboratory of Post‐Neuroinjury Neuro‐Repair and Regeneration in Central Nervous System Tianjin Medical University General Hospital, Ministry of Education Tianjin China
| | - Rongcai Jiang
- Department of Neurosurgery Tianjin Medical University General Hospital Tianjin China
- Tianjin Neurological Institute, Key Laboratory of Post‐Neuroinjury Neuro‐Repair and Regeneration in Central Nervous System Tianjin Medical University General Hospital, Ministry of Education Tianjin China
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Hillal A, Ullberg T, Ramgren B, Wassélius J. Computed tomography in acute intracerebral hemorrhage: neuroimaging predictors of hematoma expansion and outcome. Insights Imaging 2022; 13:180. [DOI: 10.1186/s13244-022-01309-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/24/2022] [Indexed: 11/24/2022] Open
Abstract
AbstractIntracerebral hemorrhage (ICH) accounts for 10–20% of all strokes worldwide and is associated with serious outcomes, including a 30-day mortality rate of up to 40%. Neuroimaging is pivotal in diagnosing ICH as early detection and determination of underlying cause, and risk for expansion/rebleeding is essential in providing the correct treatment. Non-contrast computed tomography (NCCT) is the most used modality for detection of ICH, identification of prognostic markers and measurements of hematoma volume, all of which are of major importance to predict outcome. The strongest predictors of 30-day mortality and functional outcome for ICH patients are baseline hematoma volume and hematoma expansion. Even so, exact hematoma measurement is rare in clinical routine practice, primarily due to a lack of tools available for fast, effective, and reliable volumetric tools. In this educational review, we discuss neuroimaging findings for ICH from NCCT images, and their prognostic value, as well as the use of semi-automatic and fully automated hematoma volumetric methods and assessment of hematoma expansion in prognostic studies.
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25
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Emergency department and transport predictors of neurological deterioration in patients with spontaneous intracranial hemorrhage. Am J Emerg Med 2022; 53:154-160. [DOI: 10.1016/j.ajem.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/25/2021] [Accepted: 01/02/2022] [Indexed: 11/20/2022] Open
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Brown CS, Oliveira J E Silva L, Mattson AE, Cabrera D, Farrell K, Gerberi DJ, Rabinstein AA. Comparison of Intravenous Antihypertensives on Blood Pressure Control in Acute Neurovascular Emergencies: A Systematic Review. Neurocrit Care 2022; 37:435-446. [PMID: 34993849 DOI: 10.1007/s12028-021-01417-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Acute blood pressure (BP) management in neurologic patients is paramount. Different neurologic emergencies dictate various BP goals. There remains a lack of literature determining the optimal BP regimen regarding safety and efficacy. The objective of this study was to identify which intravenous antihypertensive is the most effective and safest for acute BP management in neurologic emergencies. METHODS Ovid EBM (Evidence Based Medicine) Reviews, Ovid Embase, Ovid Medline, Scopus, and Web of Science Core Collection were searched from inception to August 2020. Randomized controlled trials or comparative observational studies that evaluated clevidipine, nicardipine, labetalol, esmolol, or nitroprusside for acute neurologic emergencies were included. Outcomes of interest included mortality, functional outcome, BP variability, time to goal BP, time within goal BP, incidence of hypotension, and need for rescue antihypertensives. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the degree of certainty in the evidence available. RESULTS A total of 3878 titles and abstracts were screened, and 183 articles were selected for full-text review. Ten studies met the inclusion criteria; however, the significant heterogeneity and very low quality of studies precluded a meta-analysis. All studies included nicardipine. Five studies compared nicardipine with labetalol, three studies compared nicardipine with clevidipine, and two studies compared nicardipine with nitroprusside. Compared with labetalol, nicardipine appears to reach goal BP faster, have less BP variability, and need less rescue antihypertensives. Compared with clevidipine, nicardipine appears to reach goal BP goal slower. Lastly, nicardipine appears to be similar for BP-related outcomes when compared with nitroprusside; however, nitroprusside may be associated with increased mortality. The confidence in the evidence available for all the outcomes was deemed very low. CONCLUSIONS Because of the very low quality of evidence, an optimal BP agent for the treatment of patients with neurologic emergencies was unable to be determined. Future randomized controlled trials are needed to compare the most promising agents.
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Affiliation(s)
- Caitlin S Brown
- Department of Pharmacy Services, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | | | - Alicia E Mattson
- Department of Pharmacy Services, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kyle Farrell
- Creighton University School of Medicine, Creighton University, Omaha, NE, USA
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Cai Q, Zhang X, Chen H. Patients with venous thromboembolism after spontaneous intracerebral hemorrhage: a review. Thromb J 2021; 19:93. [PMID: 34838069 PMCID: PMC8626951 DOI: 10.1186/s12959-021-00345-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/14/2021] [Indexed: 01/17/2023] Open
Abstract
Background Patients with spontaneous intracerebral hemorrhage (ICH) have a higher risk of venous thromboembolism (VTE) and in-hospital VTE is independently associated with poor outcomes for this patient population. Methods A comprehensive literature search about patients with VTE after spontaneous ICH was conducted using databases MEDLINE and PubMed. We searched for the following terms and other related terms (in US and UK spelling) to identify relevant studies: intracerebral hemorrhage, ICH, intraparenchymal hemorrhage, IPH, venous thromboembolism, VTE, deep vein thrombosis, DVT, pulmonary embolism, and PE. The search was restricted to human subjects and limited to articles published in English. Abstracts were screened and data from potentially relevant articles was analyzed. Results The prophylaxis and treatment of VTE are of vital importance for patients with spontaneous ICH. Prophylaxis measures can be mainly categorized into mechanical prophylaxis and chemoprophylaxis. Treatment strategies include anticoagulation, vena cava filter, systemic thrombolytic therapy, catheter-based thrombus removal, and surgical embolectomy. We briefly summarized the state of knowledge regarding the prophylaxis measures and treatment strategies of VTE after spontaneous ICH in this review, especially on chemoprophylaxis and anticoagulation therapy. Early mechanical prophylaxis, especially with intermittent pneumatic compression, is recommended by recent guidelines for patients with spontaneous ICH. While decision-making on chemoprophylaxis and anticoagulation therapy evokes debate among clinicians, because of the concern that anticoagulants may increase the risk of recurrent ICH and hematoma expansion. Uncertainty still exists regarding optimal anticoagulants, the timing of initiation, and dosage. Conclusion Based on current evidence, we deem that initiating chemoprophylaxis with UFH/LMWH within 24–48 h of ICH onset could be safe; anticoagulation therapy should depend on individual clinical condition; the role of NOACs in this patient population could be promising.
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Affiliation(s)
- Qiyan Cai
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Xin Zhang
- Respiratory Disease Department, Xinqiao Hospital, Chongqing, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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Kumar S, Andoniadis M, Solhpour A, Asghar S, Fangman M, Ashouri R, Doré S. Contribution of Various Types of Transfusion to Acute and Delayed Intracerebral Hemorrhage Injury. Front Neurol 2021; 12:727569. [PMID: 34777198 PMCID: PMC8586553 DOI: 10.3389/fneur.2021.727569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/28/2021] [Indexed: 11/17/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the second most prevalent type of stroke, after ischemic stroke, and has exceptionally high morbidity and mortality rates. After spontaneous ICH, one primary goal is to restrict hematoma expansion, and the second is to limit brain edema and secondary injury. Various types of transfusion therapies have been studied as treatment options to alleviate the adverse effects of ICH etiopathology. The objective of this work is to review transfusions with platelets, fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), and red blood cells (RBCs) in patients with ICH. Furthermore, tranexamic acid infusion studies have been included due to its connection to ICH and hematoma expansion. As stated, the first line of therapy is limiting bleeding in the brain and hematoma expansion. Platelet transfusion is used to promote recovery and mitigate brain damage, notably in patients with severe thrombocytopenia. Additionally, tranexamic acid infusion, FFP, and PCC transfusion have been shown to affect hematoma expansion rate and volume. Although there is limited available research, RBC transfusions have been shown to cause higher tissue oxygenation and lower mortality, notably after brain edema, increases in intracranial pressure, and hypoxia. However, these types of transfusion have varied results depending on the patient, hemostasis status/blood thinner, hemolysis, anemia, and complications, among other variables. Inconsistencies in published results on various transfusion therapies led us to review the data and discuss issues that need to be considered when establishing future guidelines for patients with ICH.
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Affiliation(s)
- Siddharth Kumar
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Matthew Andoniadis
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Ali Solhpour
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Salman Asghar
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Madison Fangman
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Rani Ashouri
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Sylvain Doré
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, United States.,Departments of Psychiatry, Pharmaceutics, Psychology, and Neuroscience, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, FL, United States
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Sadaf H, Desai VR, Misra V, Golanov E, Hegde ML, Villapol S, Karmonik C, Regnier‐Golanov A, Sayenko D, Horner PJ, Krencik R, Weng YL, Vahidy FS, Britz GW. A contemporary review of therapeutic and regenerative management of intracerebral hemorrhage. Ann Clin Transl Neurol 2021; 8:2211-2221. [PMID: 34647437 PMCID: PMC8607450 DOI: 10.1002/acn3.51443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 06/25/2021] [Accepted: 08/03/2021] [Indexed: 11/27/2022] Open
Abstract
Intracerebral hemorrhage (ICH) remains a common and debilitating form of stroke. This neurological emergency must be diagnosed and treated rapidly yet effectively. In this article, we review the medical, surgical, repair, and regenerative treatment options for managing ICH. Topics of focus include the management of blood pressure, intracranial pressure, coagulopathy, and intraventricular hemorrhage, as well as the role of surgery, regeneration, rehabilitation, and secondary prevention. Results of various phase II and III trials are incorporated. In summary, ICH patients should undergo rapid evaluation with neuroimaging, and early interventions should include systolic blood pressure control in the range of 140 mmHg, correction of coagulopathy if indicated, and assessment for surgical intervention. ICH patients should be managed in dedicated neurosurgical intensive care or stroke units where continuous monitoring of neurological status and evaluation for neurological deterioration is rapidly possible. Extravasation of hematoma may be helpful in patients with intraventricular extension of ICH. The goal of care is to reduce mortality and enable multimodal rehabilitative therapy.
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Affiliation(s)
- Humaira Sadaf
- Punjab Medical CollegeUniversity of Health ScienceFaisalabadPakistan
| | - Virendra R. Desai
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
| | - Vivek Misra
- Department of NeurologyHouston Methodist Neurological InstituteHoustonTexasUSA
| | - Eugene Golanov
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
| | - Muralidhar L. Hegde
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Sonia Villapol
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Christof Karmonik
- Translational Imaging CenterHouston Methodist Research InstituteHoustonTexasUSA
| | | | - Dimitri Sayenko
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Philip J. Horner
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Robert Krencik
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Yi Lan Weng
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
| | - Farhaan S. Vahidy
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for Outcomes ResearchHouston Methodist Research InstituteHoustonTexasUSA
| | - Gavin W. Britz
- Department of NeurosurgeryHouston Methodist Neurological InstituteHoustonTexasUSA
- Center for NeuroregenerationHouston Methodist Research InstituteHoustonTexasUSA
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30
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Park J, Hwang SK. Transcranial Doppler study in acute spontaneous intracerebral hemorrhage: The role of pulsatility index. J Cerebrovasc Endovasc Neurosurg 2021; 23:334-342. [PMID: 34579508 PMCID: PMC8743820 DOI: 10.7461/jcen.2021.e2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Pulsatility index (PI) is a parameter calculated by transcranial Doppler sonography (TCD), which is commonly used for patients with subarachnoid hemorrhage or ischemic stroke. However, we performed a retrospective analysis of patients with acute spontaneous intracerebral hemorrhage (ICH) to assess the function of TCD, particularly the PI. Methods This study involved a total of 46 patients with acute ICH who received treatment at a single center between May 2013 and December 2014. Medical records of baseline characteristics, except for the modified Rankin scale, were obtained at initial evaluation in the emergency room, and TCD was used to calculate middle cerebral artery flow velocity (MFV) and PI at admission (baseline), 24 h, and 7 days. The PI and MFV values on the affected middle cerebral artery were compared with those on the contralateral side. Linear regression analysis was used for statistical analyses (SPSS 21.0, IBM Corp., Armonk, NY, USA). Results Statistical analysis indicated that sex, age, Glasgow coma scale, intraventricular hemorrhage, and hematoma size were not correlated with PI (p＞0.05); however, only PI was positively correlated with functional outcome at 6 months after treatment (R=0.846, p=0.002). Conclusions These results provide evidence that the parameter of PI is an independent determinant prognostic factor in acute spontaneous ICH. Further research is needed to investigate the influence of cerebral blood flow dynamics on a larger, more controlled, and more randomized basis.
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Affiliation(s)
- Jiyong Park
- Department of Neurosurgery, College of Medicine, Ewha Womans University, Mokdong Hospital, Seoul, Korea
| | - Sung-Kyun Hwang
- Department of Neurosurgery, College of Medicine, Ewha Womans University, Mokdong Hospital, Seoul, Korea
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31
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Lu Y, Jin H, Zhao Y, Li Y, Xu J, Tian J, Luan X, Chen S, Sun W, Zhang S, Xu S, Zhu F, Chen L, Mima D, Sun Y, Zhuoga C. Impact of Increased Hemoglobin on Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2021; 36:395-403. [PMID: 34313936 PMCID: PMC8964592 DOI: 10.1007/s12028-021-01305-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Abstract
Background Studies of the impact of increased hemoglobin on spontaneous intracerebral hemorrhage (ICH) are limited. The present study aimed to explore the effect of increased hemoglobin on ICH. Methods A retrospective single-center study using medical records from a database processed by univariate and multivariate analyses was performed in the People’s Hospital of Tibet Autonomous Region in Lhasa, Tibet, China. Results The mean hemoglobin level in 211 patients with ICH was 165.03 ± 34.12 g/l, and a median hematoma volume was 18.5 ml. Eighty-eight (41.7%) patients had large hematomas (supratentorial hematoma ≥ 30 ml; infratentorial hematoma ≥ 10 ml). No differences in ICH risk factors between the groups with different hemoglobin levels were detected. Increased hemoglobin was independently associated with large hematomas [odds ratio (OR) 1.013, P = 0.023]. Increased hemoglobin was independently associated with ICH with subarachnoid hemorrhage (OR 1.014, P = 0.016), which was more pronounced in men (OR 1.027, P = 0.002). Increased hemoglobin was independently associated with basal ganglia hemorrhage and lobar hemorrhage in men (OR 0.986, P = 0.022; OR 1.013, P = 0.044, respectively) but not in women (P > 0.1). Conclusions Increased hemoglobin was independently associated with large hemorrhage volume. Increased hemoglobin was independently associated with lobar hemorrhage in men and ICH with subarachnoid hemorrhage, which was more pronounced in men. Additional studies are needed to confirm our findings and explore potential mechanisms.
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Affiliation(s)
- Yuxuan Lu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Haiqiang Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yuhua Zhao
- Department of Neurology, People's Hospital of Tibet Autonomous Region, Lhasa, Tibet, China
| | - Yuxian Li
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Jun Xu
- Department of Cognitive Neurology, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiayu Tian
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Xiaoting Luan
- Department of Neurology, The First Hospital of Tsinghua University, Beijing, China
| | - Siwei Chen
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Wei Sun
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Shouzi Zhang
- Department of Psychiatry, Beijing Geriatric Hospital, Beijing, China
| | - Shunliang Xu
- Department of Neurology, the Second Hospital, Shandong University, Jinan, Shandong Province, China
| | - Feiqi Zhu
- Cognitive Impairment Ward of Neurology Department, the Third Affiliated Hospital of Shenzhen University Medical College, Shenzhen, China
| | - Luzeng Chen
- Department of Ultrasound, Peking University First Hospital, Beijing, China
| | - Dunzhu Mima
- Department of Neurology, People's Hospital of Tibet Autonomous Region, Lhasa, Tibet, China
| | - Yongan Sun
- Department of Neurology, Peking University First Hospital, Beijing, China.
| | - Cidan Zhuoga
- Department of Neurology, People's Hospital of Tibet Autonomous Region, Lhasa, Tibet, China.
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Yen HC, Jeng JS, Cheng CH, Pan GS, Chen WS. Effects of early mobilization on short-term blood pressure variability in acute intracerebral hemorrhage patients: A protocol for randomized controlled non-inferiority trial. Medicine (Baltimore) 2021; 100:e26128. [PMID: 34032760 PMCID: PMC8154506 DOI: 10.1097/md.0000000000026128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 03/14/2021] [Accepted: 05/07/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Early out-of-bed mobilization may improve acute post-intracerebral hemorrhage (ICH) outcomes, but hemodynamic instability may be a concern. Some recent studies have showed that an increase in mean systolic blood pressure (SBP) and high blood pressure variability (BPV), high standard deviation of SBP, may lead to negative ICH outcomes. Therefore, we investigated the impact of an early mobilization (EM) protocol on mean SBP and BPV during the acute phase. METHODS The study was an assessor-blinded, randomized controlled non-inferiority study. The participants were in An Early Mobilization for Acute Cerebral Hemorrhage trial and were randomly assigned to undergo EM or a standard early rehabilitation (SER) protocol within 24 to 72 hour after ICH onset at the stroke center. The EM and SER groups each had 30 patients. 24-measurement SBP were recorded on days 2 and 3 after onset, and SBP were recorded three times daily and during rehabilitation on days 4 through 7. The two groups' mean SBP and BPV under three different time frames (days 2 and 3 during the acute phase, and days 4 through 7 during the late acute phase) were calculated and compared. RESULTS At baseline, the two groups' results were similar, with the exception being that the mean time to first out-of-bed mobilization after symptom onset was 51.60 hours (SD 14.15) and 135.02 hours (SD 33.05) for the EM group and SER group, respectively (P < .001). There were no significant differences in mean SBP and BPV during the acute and late acute phase between the two groups for the three analyses (days 2, 3, and 4 through 7) (P > .05). CONCLUSIONS It is safe to implement the EM protocol within 24 to 72 hour of onset for mild-moderate ICH patients during the acute phase.
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Affiliation(s)
- Hsiao-Ching Yen
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation
| | | | | | - Guan-Shuo Pan
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation
| | - Wen-Shiang Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
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33
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Ovesen C, Jakobsen JC, Gluud C, Steiner T, Law Z, Flaherty K, Dineen RA, Christensen LM, Overgaard K, Rasmussen RS, Bath PM, Sprigg N, Christensen H. Tranexamic Acid for Prevention of Hematoma Expansion in Intracerebral Hemorrhage Patients With or Without Spot Sign. Stroke 2021; 52:2629-2636. [PMID: 34000834 DOI: 10.1161/strokeaha.120.032426] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE The computed tomography angiography or contrast-enhanced computed tomography based spot sign has been proposed as a biomarker for identifying on-going hematoma expansion in patients with acute intracerebral hemorrhage. We investigated, if spot-sign positive participants benefit more from tranexamic acid versus placebo as compared to spot-sign negative participants. METHODS TICH-2 trial (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) was a randomized, placebo-controlled clinical trial recruiting acutely hospitalized participants with intracerebral hemorrhage within 8 hours after symptom onset. Local investigators randomized participants to 2 grams of intravenous tranexamic acid or matching placebo (1:1). All participants underwent computed tomography scan on admission and on day 2 (24±12 hours) after randomization. In this sub group analysis, we included all participants from the main trial population with imaging allowing adjudication of spot sign status. RESULTS Of the 2325 TICH-2 participants, 254 (10.9%) had imaging allowing for spot-sign adjudication. Of these participants, 64 (25.2%) were spot-sign positive. Median (interquartile range) time from symptom onset to administration of the intervention was 225.0 (169.0 to 310.0) minutes. The adjusted percent difference in absolute day-2 hematoma volume between participants allocated to tranexamic versus placebo was 3.7% (95% CI, -12.8% to 23.4%) for spot-sign positive and 1.7% (95% CI, -8.4% to 12.8%) for spot-sign negative participants (Pheterogenity=0.85). No difference was observed in significant hematoma progression (dichotomous composite outcome) between participants allocated to tranexamic versus placebo among spot-sign positive (odds ratio, 0.85 [95% CI, 0.29 to 2.46]) and negative (odds ratio, 0.77 [95% CI, 0.41 to 1.45]) participants (Pheterogenity=0.88). CONCLUSIONS Data from the TICH-2 trial do not support that admission spot sign status modifies the treatment effect of tranexamic acid versus placebo in patients with acute intracerebral hemorrhage. The results might have been affected by low statistical power as well as treatment delay. Registration: URL: http://www.controlled-trials.com; Unique identifier: ISRCTN93732214.
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Affiliation(s)
- Christian Ovesen
- Department of Neurology, Bispebjerg Hospital (C.O., L.M.C., H.C.), Copenhagen University Hospital, Copenhagen, Denmark.,The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet (C.O., J.C.J., C.G.), Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet (C.O., J.C.J., C.G.), Copenhagen University Hospital, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense (J.C.J.)
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet (C.O., J.C.J., C.G.), Copenhagen University Hospital, Copenhagen, Denmark
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Germany (T.S.).,Department of Neurology, Heidelberg University Hospital, Germany (T.S.)
| | - Zhe Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, United Kingdom (Z.L., K.F., P.M.B., N.S.).,Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.L., P.M.B., N.S.).,Department of Medicine, National University of Malaysia, Malaysia (Z.L.)
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, United Kingdom (Z.L., K.F., P.M.B., N.S.)
| | - Rob A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Queen's Medical Centre, United Kingdom (R.A.D.).,Sir Peter Mansfield Imaging Centre, University of Nottingham, United Kingdom (R.A.D.).,NIHR Nottingham Biomedical Research Centre, United Kingdom (R.A.D.)
| | - Louisa M Christensen
- Department of Neurology, Bispebjerg Hospital (C.O., L.M.C., H.C.), Copenhagen University Hospital, Copenhagen, Denmark
| | - Karsten Overgaard
- Department of Neurology, Herlev Hospital (K.O., R.S.R.), Copenhagen University Hospital, Copenhagen, Denmark
| | - Rune S Rasmussen
- Department of Neurology, Herlev Hospital (K.O., R.S.R.), Copenhagen University Hospital, Copenhagen, Denmark
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, United Kingdom (Z.L., K.F., P.M.B., N.S.).,Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.L., P.M.B., N.S.)
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, United Kingdom (Z.L., K.F., P.M.B., N.S.).,Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.L., P.M.B., N.S.)
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital (C.O., L.M.C., H.C.), Copenhagen University Hospital, Copenhagen, Denmark
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Khan A, Shaikh N, Alvi Y, Gupta P, Mehdi R, Siddiqui A. Blood pressure control measured as "time in range" during initial 24 h for inpatients with spontaneous nontraumatic intracerebral haemorrhage. J Neurol Sci 2021; 426:117480. [PMID: 33984548 DOI: 10.1016/j.jns.2021.117480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/11/2021] [Accepted: 05/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Blood pressure (BP) control is an integral part in the management of spontaneous nontraumatic intracerebral haemorrhage. The aim of this study is to propose a novel concept of blood pressure control measured as 'Time in Range'(TiR) and assess its relationship to neurological deterioration. METHOD Retrospective study of 120 patients with Intracerebral haemorrhage who were admitted within 6 h of the symptom onset. The hourly BP readings for initial 24 h were studied in the form of time in range (TiR). TiR was defined as the percentage of readings with 'in range' systolic BP (SBP 110-140mmHG) during a unit time period. TiR was correlated with mean SBP at 6,12,18 and 24 h. It was categorized dichotomously as controlled (more than 50%) or not controlled (equal to or less than 50%) and analyzed with the change in Glasgow coma scale (drop of ≥2 units) at 24 h. RESULTS Correlation of TiR with mean SBP at 6 and 24 h showed significant negative correlation [r = -0.71 (at 6 h); r = -0.88 (at 24 h); p < 0.001]. The association of TiR with neurological deterioration(ND) was measured by change in GCS; with lower TiR associated with higher chances of neurological deterioration at 12 h interval [OR 4.5(1.2-16.8); p = 0.025], but not at 24 h interval [OR 1.4 (0.34-5.44); p = 0.670]. CONCLUSION Our novel concept of 'Time in Range'(TiR) was found to be relevant in our study. Its association with mean SBP reflect its potential to be a modality of expressing control of SBP in Spontaneous Nontraumatic Intracerebral Haemorrhage.
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Affiliation(s)
- Arshee Khan
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates.
| | - Niaz Shaikh
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
| | - Yasir Alvi
- Department of Community Medicine, Hamdard Institute of Medical Sciences and Research, Hamdard University, New Delhi, India
| | - Priyank Gupta
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
| | - Rommana Mehdi
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
| | - Aisha Siddiqui
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
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35
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Epstein D, Freund Y, Marcusohn E, Diab T, Klein E, Raz A, Neuberger A, Miller A. Association Between Ionized Calcium Level and Neurological Outcome in Endovascularly Treated Patients with Spontaneous Subarachnoid Hemorrhage: A Retrospective Cohort Study. Neurocrit Care 2021; 35:723-737. [PMID: 33829378 DOI: 10.1007/s12028-021-01214-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Spontaneous subarachnoid hemorrhage (SSAH) is associated with significant morbidity and mortality. Pathophysiological processes following initial bleeding are complex and not fully understood. In this study, we aimed to determine whether a low level of ionized calcium (Ca++), an essential cofactor in the coagulation cascade and other cellular processes, is associated with adverse neurological outcome, development of early hydrocephalus, and symptomatic vasospasm among patients with SSAH. METHODS This was a retrospective single-center cohort study of all patients admitted for SSAH between January 1, 2009, and April 31, 2020. The primary outcome was an unfavorable neurological status at discharge, defined as a modified Rankin Scale score greater than or equal to 3. Secondary outcomes were the development of early hydrocephalus and symptomatic vasospasm. Multivariable logistic regression was performed to determine whether Ca++ was an independent predictor of these outcomes. RESULTS A total of 255 patients were included in the final analysis. Hypocalcemia, older age, admission Glasgow Coma Scale (GCS) score, and admission Hunt-Hess classification scale (H&H) grades IV and V were independently associated with unfavorable neurological outcome, with adjusted odds ratios (ORs) of 1.93 (95% confidence interval [CI] 1.1-3.4; p = 0.02) for each 0.1 mmol L-1 decrease in the Ca++ level, 1.04 (95% CI 1.01-1.08; p = 0.02) for each year increase, 0.82 (95% CI 0.68-0.99; p = 0.04), and 6.29 (95% CI 1.14-34.6; p = 0.03), respectively. Risk factors for the development of hydrocephalus were hypocalcemia and GCS score, with ORs of 1.85 (95% CI 1.26-2.71; p = 0.002) for each 0.1 mmol L-1 decrease in the Ca++ level and 0.83 (95% CI 0.73-0.94; p = 0.005), respectively. Ca++ was not associated with symptomatic vasospasm (OR 1.04 [95% CI 0.76-1.41]; p = 0.81). Among patients with admission H&H grade I-III bleeding, hypocalcemia was independently associated with unfavorable neurological outcome at discharge, with an adjusted OR of 1.99 (95% CI 1.03-3.84; p = 0.04) for each 0.1 mmol L-1 decrease in the Ca++ level. Hypocalcemia was also an independent risk factor for the development of early hydrocephalus, with an adjusted OR of 2.95 (95% CI 1.49-5.84; p = 0.002) for each 0.1 mmol L-1 decrease in the Ca++ level. Ca++ was not associated with symptomatic vasospasm. No association was found between Ca++ and predefined outcomes among patients with admission H&H grade IV and V bleeding. CONCLUSIONS Our study shows that hypocalcemia is associated with worse neurological outcome at discharge and development of early hydrocephalus in endovascularly treated patients with SSAH. Potential mechanisms include calcium-induced coagulopathy and higher blood pressure. Trials are needed to assess whether correction of hypocalcemia will lead to improved outcomes.
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Affiliation(s)
- Danny Epstein
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Yaacov Freund
- Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Efron St 1, Haifa, 35254, Israel.
| | - Erez Marcusohn
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Tarek Diab
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel.,Department of Neurosurgery, Rambam Health Care Campus, Haifa, Israel
| | - Erez Klein
- Department of Diagnostic Imaging, Rambam Health Care Campus, Haifa, Israel
| | - Aeyal Raz
- Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Efron St 1, Haifa, 35254, Israel.,Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel
| | - Ami Neuberger
- Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Efron St 1, Haifa, 35254, Israel.,Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel.,Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel
| | - Asaf Miller
- Medical Intensive Care Unit, Rambam Health Care Campus, Haifa, Israel
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Liu W, Zhuang X, Zhang L. Prognostic Value of Blood Pressure Variability for Patients With Acute or Subacute Intracerebral Hemorrhage: A Meta-Analysis of Prospective Studies. Front Neurol 2021; 12:606594. [PMID: 33776881 PMCID: PMC7991598 DOI: 10.3389/fneur.2021.606594] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 01/15/2021] [Indexed: 11/29/2022] Open
Abstract
The results on the role of systolic blood pressure (SBP) variability in the functional outcome for patients with intracerebral hemorrhage (ICH) have been inconsistent. Hence, this meta-analysis of prospective studies was conducted to assess the association between SBP variability and poor outcomes in patients with acute or subacute ICH. PubMed, Embase, and the Cochrane Library were electronically searched for eligible studies from their inception to July 2020. The role of SBP variability assessed using standard deviation (SD), coefficient of variation (CV), successive variation (SV), average real variability (ARV), and residual standard deviation (RSD) in the risk of poor functional outcomes were assessed using odds ratio (OR) with 95% confidence interval (CI) through the random-effects model. Seven prospective studies involving 5,201 patients with ICH were selected for the final meta-analysis. Increased SBP variability was associated with an increased risk of poor functional outcomes, regardless of its assessment using SD (OR: 1.38; 95% CI: 1.14–1.68; P = 0.001), CV (OR: 1.98; 95% CI: 1.13–3.47; P = 0.017), SV (OR: 1.30; 95% CI: 1.08–1.58; P = 0.006), ARV (OR: 1.13; 95% CI: 1.03–1.24; P = 0.010), or RSD (OR: 1.22; 95% CI: 1.00–1.50; P = 0.049). Moreover, the role of SBP variability in the risk of poor functional outcomes for patients with ICH was affected by country, study design, mean age, stroke type, outcome definition, and study quality. This study indicated that SBP variability was a predictor of poor outcomes for patients with ICH.
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Affiliation(s)
- Weidong Liu
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Xianbo Zhuang
- Department of Neurology, Liaocheng People's Hospital, Liaocheng, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
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Hu S, Sheng W, Hu Y, Ma Q, Li B, Han R. A nomogram to predict early hematoma expansion of hypertensive cerebral hemorrhage. Medicine (Baltimore) 2021; 100:e24737. [PMID: 33607818 PMCID: PMC7899817 DOI: 10.1097/md.0000000000024737] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 01/17/2021] [Indexed: 01/05/2023] Open
Abstract
Early hematoma expansion of hypertensive cerebral hemorrhage is affected by various factors. This study aimed to clarify the risk factors and develop a nomogram to predict early hematoma expansion.A retrospective analysis was carried out in patients with hypertensive cerebral hemorrhage admitted to our institution between January 1, 2012 and December 31, 2018; the patients were divided into 2 groups according to the presence of early hematoma expansion. Univariate and multivariate analyses were performed to analyze the risk factors of hematoma expansion. The nomogram was developed based on a multivariate logistic regression model, and the discriminative ability of the model was analyzed.A total of 477 patients with hypertensive cerebral hemorrhage and with a baseline hematoma volume <30 ml were included in our retrospective analysis. The hematoma expansion rate was 34.2% (163/477). After multivariate logistic regression, 9 variables (alcohol history, Glasgow coma scale score, total serum calcium, blood glucose, international normalized ratio, hematoma shape, hematoma density, volume of hematoma on initial computed tomography scan, and presence of intraventricular hemorrhage) identified as independent predictors of hematoma expansion were used to generate the nomogram. The area under the receiver operating characteristic curve of the nomogram was 0.883 (95% confidence interval 0.851-0.914), and the cutoff score was -0.19 with sensitivity of 75.5% and specificity of 87.3%.The nomogram can accurately predict the risk of early hematoma expansion.
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Affiliation(s)
- Si Hu
- Department of Neurosurgery
| | - WenGuo Sheng
- Department of Neurology, Affiliated Huzhou FuYin Hospital of Huzhou University, Huzhou, ZheJiang, China
| | - Yi Hu
- Department of Neurology, Affiliated Huzhou FuYin Hospital of Huzhou University, Huzhou, ZheJiang, China
| | | | - Bin Li
- Department of Neurosurgery
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Optimal Hemodynamic Parameters for Brain-injured Patients in the Clinical Setting: A Narrative Review of the Evidence. J Neurosurg Anesthesiol 2021; 34:288-299. [PMID: 33443353 DOI: 10.1097/ana.0000000000000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/07/2020] [Indexed: 11/25/2022]
Abstract
Defining optimal hemodynamic targets for brain-injured patients is a challenging undertaking. The physiological interference observed in various intracranial pathologies can have varying effects on cerebral physiology at different time points. This narrative review provides an overview of cerebral autoregulatory physiology and common misconceptions, and examines the physiological considerations and clinical evidence for determining optimal hemodynamic parameters in acutely brain-injured patients with relevance to modern neuroanesthesia and neurocritical care practice.
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Andalib S, Lattanzi S, Di Napoli M, Petersen A, Biller J, Kulik T, Macri E, Girotra T, Torbey MT, Divani AA. Blood Pressure Variability: A New Predicting Factor for Clinical Outcomes of Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:105340. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105340] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/10/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023] Open
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Zhang G, Pan C, Zhang P, McBride DW, Tang Y, Wu G, Tang Z. Precision of minimally invasive surgery for intracerebral hemorrhage treatment. BRAIN HEMORRHAGES 2020. [DOI: 10.1016/j.hest.2020.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Huang H, Huang G, Gu J, Chen K, Huang Y, Xu H. Relationship of Serum Uric Acid to Hematoma Volume and Prognosis in Patients with Acute Supratentorial Intracerebral Hemorrhage. World Neurosurg 2020; 143:e604-e612. [PMID: 32781152 DOI: 10.1016/j.wneu.2020.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 08/02/2020] [Accepted: 08/03/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Oxidative stress and inflammation play important roles in the neuronal injury caused by intracerebral hemorrhage (ICH). Uric acid (UA), an important natural antioxidant, might reduce the neuronal injury caused by ICH. Delineating the relationship between UA and ICH will enhance our understanding of antioxidative mechanisms in recovery from ICH. METHODS We conducted a retrospective study of 325 patients with acute supratentorial ICH to investigate the relationship between serum UA levels and hematoma volumes and prognosis. A hematoma volume of ≥30 mL was defined as a large hematoma. An unfavorable outcome was defined as a modified Rankin scale score of 4-6 on day 30. RESULTS The serum UA level was significantly lower in the patients with a large hematoma volume (median, 306 μmol/L; 25th to 75th percentile, 243-411 μmol/L) than in those with a small hematoma volume (median, 357 μmol/L; 25th to 75th percentile, 271-442 μmol/L; P = 0.012). Similarly, the unfavorable outcome group had had lower serum UA levels (median, 309 vs. 363 μmol/L; P = 0.009) compared with the favorable outcome group. The results of the multivariate logistic analysis indicated that a lower serum UA level was associated with a larger hematoma volume (odds ratio, 0.996; P = 0.006) and an unfavorable outcome (odds ratio, 0.997; P = 0.030). CONCLUSIONS The results from the present study have indicated that in patients with acute supratentorial ICH, a low serum UA level might indicate that the patient has a large hematoma volume and might be a risk factor for a poor day 30 functional prognosis.
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Affiliation(s)
- Haoping Huang
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College, Shantou, China; Shantou University Medical College, Shantou, China
| | - Guanhua Huang
- Shantou University Medical College, Shantou, China; Department of Anthropotomy/Clinically Oriented Anatomy, Shantou University Medical College, Shantou, China
| | - Jiajie Gu
- Department of Neurosurgery, Yinzhou people's Hospital, Ningbo, Zhejiang, China
| | - Kehua Chen
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College, Shantou, China; Shantou University Medical College, Shantou, China
| | - Yuejun Huang
- Department of Pediatrics, Second Affiliated Hospital of Medical College of Shantou University, Shantou, China
| | - Hongwu Xu
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College, Shantou, China; Department of Anthropotomy/Clinically Oriented Anatomy, Shantou University Medical College, Shantou, China.
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Zhang S, Wang Z, Zheng A, Yuan R, Shu Y, Zhang S, Lei P, Wu B, Liu M. Blood Pressure and Outcomes in Patients With Different Etiologies of Intracerebral Hemorrhage: A Multicenter Cohort Study. J Am Heart Assoc 2020; 9:e016766. [PMID: 32924756 PMCID: PMC7792400 DOI: 10.1161/jaha.120.016766] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/30/2020] [Indexed: 02/05/2023]
Abstract
Background We aimed to investigate the association between blood pressure (BP) and outcomes in intracerebral hemorrhage (ICH) subtypes with different etiologies. Methods and Results A total of 5656 in-hospital patients with spontaneous ICH were included between January 2012 and December 2016 in a prospective multicenter cohort study. Etiological subtypes of ICH were assigned using SMASH-U (structural lesion, medication, amyloid angiopathy, systemic/other disease, hypertension, undetermined) classification. Elevated systolic BP was defined as ≥140 mm Hg. Hypertension was defined as elevated BP for >1 month before the onset of ICH. The primary outcomes were measured as 1-month survival rate and 3-month mortality. A total of 5380 patients with ICH were analyzed, of whom 4052 (75.3%) had elevated systolic BP on admission and 3015 (56.0%) had hypertension. In multinomial analysis of patients who passed away by 3 months, systolic BP on admission was significantly different in cerebral amyloid angiopathy (P<0.001), structural lesion (P<0.001), and undetermined subtypes (P=0.003), compared with the hypertensive angiopathy subtype. Elevated systolic BP was dose-responsively associated with higher 3-month mortality in hypertensive angiopathy (Ptrend=0.013) and undetermined (Ptrend=0.005) subtypes. In cerebral amyloid angiopathy, hypertension history had significant inverse association with 3-month mortality (adjusted odds ratio, 0.37, 95% CI, 0.20-0.65; P<0.001). Similarly, adjusted Cox regression indicated decreased risk of 1-month survival rate in the presence of hypertension in patients with cerebral amyloid angiopathy (adjusted hazard ratio, 0.47; 95% CI, 0.24-0.92; P=0.027). Conclusions This study suggests that the association between BP and ICH outcomes might specifically depend on its subtypes, and cerebral amyloid angiopathy might be pathologically distinctive from the others. Future studies of individualized BP-lowering strategy are needed to validate our findings.
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Affiliation(s)
- Shuting Zhang
- Department of NeurologyWest China Hospital of Sichuan UniversityChengduSichuan ProvinceP.R. China
| | - Zhihao Wang
- West China School of MedicineSichuan UniversityChengduSichuan ProvinceP.R. China
| | - Aiping Zheng
- West China School of MedicineSichuan UniversityChengduSichuan ProvinceP.R. China
| | - Ruozhen Yuan
- Department of NeurologyWest China Hospital of Sichuan UniversityChengduSichuan ProvinceP.R. China
| | - Yang Shu
- State Key Laboratory of BiotherapyWest China Hospital of Sichuan UniversityChengduSichuan ProvinceP.R. China
| | - Shihong Zhang
- Department of NeurologyWest China Hospital of Sichuan UniversityChengduSichuan ProvinceP.R. China
| | - Peng Lei
- State Key Laboratory of BiotherapyWest China Hospital of Sichuan UniversityChengduSichuan ProvinceP.R. China
| | - Bo Wu
- Department of NeurologyWest China Hospital of Sichuan UniversityChengduSichuan ProvinceP.R. China
| | - Ming Liu
- Department of NeurologyWest China Hospital of Sichuan UniversityChengduSichuan ProvinceP.R. China
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Kuriakose D, Xiao Z. Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. Int J Mol Sci 2020; 21:E7609. [PMID: 33076218 PMCID: PMC7589849 DOI: 10.3390/ijms21207609] [Citation(s) in RCA: 586] [Impact Index Per Article: 117.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 12/14/2022] Open
Abstract
Stroke is the second leading cause of death and a major contributor to disability worldwide. The prevalence of stroke is highest in developing countries, with ischemic stroke being the most common type. Considerable progress has been made in our understanding of the pathophysiology of stroke and the underlying mechanisms leading to ischemic insult. Stroke therapy primarily focuses on restoring blood flow to the brain and treating stroke-induced neurological damage. Lack of success in recent clinical trials has led to significant refinement of animal models, focus-driven study design and use of new technologies in stroke research. Simultaneously, despite progress in stroke management, post-stroke care exerts a substantial impact on families, the healthcare system and the economy. Improvements in pre-clinical and clinical care are likely to underpin successful stroke treatment, recovery, rehabilitation and prevention. In this review, we focus on the pathophysiology of stroke, major advances in the identification of therapeutic targets and recent trends in stroke research.
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Affiliation(s)
| | - Zhicheng Xiao
- Development and Stem Cells Program, Monash Biomedicine Discovery Institute and Department of Anatomy and Developmental Biology, Monash University, Melbourne, VIC 3800, Australia;
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44
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Li Z, You M, Long C, Bi R, Xu H, He Q, Hu B. Hematoma Expansion in Intracerebral Hemorrhage: An Update on Prediction and Treatment. Front Neurol 2020; 11:702. [PMID: 32765408 PMCID: PMC7380105 DOI: 10.3389/fneur.2020.00702] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the most lethal type of stroke, but there is no specific treatment. After years of effort, neurologists have found that hematoma expansion (HE) is a vital predictor of poor prognosis in ICH patients, with a not uncommon incidence ranging widely from 13 to 38%. Herein, the progress of studies on HE after ICH in recent years is updated, and the topics of definition, prevalence, risk factors, prediction score models, mechanisms, treatment, and prospects of HE are covered in this review. The risk factors and prediction score models, including clinical, imaging, and laboratory characteristics, are elaborated in detail, but limited by sensitivity, specificity, and inconvenience to clinical practice. The management of HE is also discussed from bench work to bed practice. However, the upmost problem at present is that there is no treatment for HE proven to definitely improve clinical outcomes. Further studies are needed to identify more accurate predictors and effective treatment to reduce HE.
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Affiliation(s)
- Zhifang Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mingfeng You
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunnan Long
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rentang Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haoqiang Xu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Quanwei He
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Blood pressure variability and outcome after acute intracerebral hemorrhage. J Neurol Sci 2020; 413:116766. [PMID: 32151850 DOI: 10.1016/j.jns.2020.116766] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/24/2020] [Accepted: 03/01/2020] [Indexed: 01/12/2023]
Abstract
Intracerebral hemorrhage (ICH) is life threatening neurologic event that results in significant rate of morbidity and mortality. Unfortunately, several randomized clinical trials aiming at limiting the hematoma expansion (HE) in the acute phase of ICH have not shown significant effects in improving the functional outcomes. Blood pressure variability (BPV) is common following ICH. High BPs have been associated with increased risk of bleeding and HE. Conversely, recurrent sudden decrease in BP promote perihematomal ischemia. However, it is still not clear weather BPV causes adverse prognosis following ICH or large ICHs cause fluctuations in BP. In the current review, we will discuss the mechanistic pathophysiology of BPV and the evidence regarding the role of BPV on the ICH outcomes.
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Xu W, Ding Z, Shan Y, Chen W, Feng Z, Pang P, Shen Q. A Nomogram Model of Radiomics and Satellite Sign Number as Imaging Predictor for Intracranial Hematoma Expansion. Front Neurosci 2020; 14:491. [PMID: 32581674 PMCID: PMC7287169 DOI: 10.3389/fnins.2020.00491] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 04/20/2020] [Indexed: 12/21/2022] Open
Abstract
Background We aimed to construct and validate a nomogram model based on the combination of radiomic features and satellite sign number for predicting intracerebral hematoma expansion. Methods A total of 129 patients from two institutions were enrolled in this study. The preprocessed initial CT images were used for radiomic feature extraction. The ANOVA-Kruskal–Wallis test and least absolute shrinkage and selection operator regression were applied to identify candidate radiomic features and construct the Radscore. A nomogram model was developed by integrating the Radscore with a satellite sign number. The discrimination performance of the proposed model was evaluated by receiver operating characteristic (ROC) analysis, and the predictive accuracy was assessed via a calibration curve. Decision curve analysis (DCA) and Kaplan–Meier (KM) survival analysis were performed to evaluate the clinical value of the model. Results Four optimal features were ultimately selected and contributed to the Radscore construction. A positive correlation was observed between the satellite sign number and Radscore (Pearson’s r: 0.451). The nomogram model showed the best performance with high area under the curves in both training cohort (0.881, sensitivity: 0.973; specificity: 0.787) and external validation cohort (0.857, sensitivity: 0.950; specificity: 0.766). The calibration curve, DCA, and KM analysis indicated the high accuracy and clinical usefulness of the nomogram model for hematoma expansion prediction. Conclusion A nomogram model of integrated radiomic signature and satellite sign number based on noncontrast CT images could serve as a reliable and convenient measurement of hematoma expansion prediction.
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Affiliation(s)
- Wen Xu
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhongxiang Ding
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yanna Shan
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenhui Chen
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhan Feng
- Department of Radiology, The First Hospital of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Peipei Pang
- Department of Pharmaceuticals Diagnosis, GE Healthcare, Hangzhou, China
| | - Qijun Shen
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Zhang M, Chen J, Zhan C, Liu J, Chen Q, Xia T, Zhang T, Zhu D, Chen C, Yang Y. Blend Sign Is a Strong Predictor of the Extent of Early Hematoma Expansion in Spontaneous Intracerebral Hemorrhage. Front Neurol 2020; 11:334. [PMID: 32508731 PMCID: PMC7248383 DOI: 10.3389/fneur.2020.00334] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/07/2020] [Indexed: 01/18/2023] Open
Abstract
Background and Purpose: It is unclear which imaging marker is optimal for predicting the extent of hematoma expansion (EHE). We aimed to compare the usefulness of the blend sign (BS) with that of other non-contrast computed tomography (NCCT) markers for predicting the EHE in patients with spontaneous intracerebral hemorrhage (sICH). Methods: Patients with sICH admitted to our Neurology Emergency Department between September 2013 and January 2019 were enrolled. The EHE was calculated as the absolute increase in hematoma volume between baseline and follow-up CT (within 72 h). The EHE was categorized into four groups: "no growth," "minimal change" (≤5.1 ml), "moderate change" (5.1-12.5 ml), and "massive change" (>12.5 ml). Univariate and multivariate analyses were performed to investigate the relationship between the NCCT markers [BS, black hole sign (BHS), satellite sign, and island sign] and the EHE. Results: A total of 1,111 sICH patients were included (median age: 60 years; 66.5% males). Multiple linear regression analysis showed that the presence of the BS and BHS was independently associated with the EHE, after adjusting for confounders (P < 0.001 and P = 0.003, respectively). The presence of the BS and BHS was positively correlated with growth category (r = 0.285 and r = 0.199, both Ps < 0.001). The BS demonstrated a better predictive performance for the EHE than did the BHS [area under the curve (AUC): 0.67 vs. 0.57; both Ps < 0.001]. Conclusions: In patients with acute sICH, the BS showed a better performance in predicting the EHE compared with other NCCT markers. This imaging marker may help identify patients at a high risk of significant hematoma expansion and may facilitate its early management.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Wei L, Lin C, Zhou Z, Zhang J, Tan Q, Zhang Y, Zhang B, Ye D, Wu L, Liu Q, Xian J, Chen Z, Feng H, Zhu G. Analysis of different hematoma expansion shapes caused by different risk factors in patients with hypertensive intracerebral hemorrhage. Clin Neurol Neurosurg 2020; 194:105820. [PMID: 32315941 DOI: 10.1016/j.clineuro.2020.105820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 03/27/2020] [Accepted: 03/28/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To elucidate the relationship between the risk factors and hematoma expansion(HE)shapes. PATIENTS AND METHODS From February 2013 to November 2018, 60 patients diagnosed as basal ganglia ICH were divided into the filled type hematoma expansion group (FTE group) and the expanded type hematoma expansion group (ETE group). we performed follow-up CT and three-dimensional reconstruction for the patients and compared the hematoma before and after the expansion of size and extent. RESULTS The regression analysis showed that the irregular sign (odds ratio, 3.64; 95 % CI, 1.46-9.12), black hole sign (odds ratio, 3.85; 95 % CI, 1.40-10.60), blend sign (odds ratio, 2.86; 95 % CI, 1.03-7.95), and early use of dehydration (odds ratio, 4.59; 95 % CI, 1.59-13.19) were possible risk factors for the ETE group, while the high systolic blood pressure (odds ratio, 1.51; 95 % CI, 1.04-2.30), early use of dehydration (odds ratio, 3.27; 95 % CI, 1.10-9.69) and low density low-density band (odds ratio, 4.52; 95 % CI, 1.54-13.28) were possible risk factors for the FTE group. CONCLUSIONS The irregular sign, black hole sign, blend sign and early use of dehydration may be the main risk factors for ETE, whereas early use of dehydration, high systolic blood pressure, and low density low-density band may be the main risk factors for FTE.
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Affiliation(s)
- Linjie Wei
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China; Department of Neurosurgery, PLA 956th Hospital, Linzhi, Tibet, People's Republic of China
| | - Chi Lin
- Department of Neurosurgery, First People's Hospital of Honghe City, Yunnan, People's Republic of China
| | - Zhihong Zhou
- Department of Clinical Laboratory, The People's Hospital of Weiyuan County, Sichuan, People's Republic of China
| | - Jianbo Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Qiang Tan
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Yu Zhang
- Department of Neurosurgery, PLA 956th Hospital, Linzhi, Tibet, People's Republic of China
| | - Bo Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Dongping Ye
- Department of Neurosurgery, PLA 956th Hospital, Linzhi, Tibet, People's Republic of China
| | - Lixia Wu
- Department of Neurosurgery, First People's Hospital of Honghe City, Yunnan, People's Republic of China
| | - Qianling Liu
- Department of Neurosurgery, First People's Hospital of Honghe City, Yunnan, People's Republic of China
| | - Jishu Xian
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Zhi Chen
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Gang Zhu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China.
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Yogendrakumar V, Ramsay T, Fergusson DA, Demchuk AM, Aviv RI, Rodriguez-Luna D, Molina CA, Silva Y, Dzialowski I, Kobayashi A, Boulanger JM, Gubitz G, Srivastava P, Roy J, Kase CS, Bhatia R, Hill MD, Goldstein JN, Dowlatshahi D. Redefining Hematoma Expansion With the Inclusion of Intraventricular Hemorrhage Growth. Stroke 2020; 51:1120-1127. [PMID: 32078498 DOI: 10.1161/strokeaha.119.027451] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background and Purpose- Definitions of significant hematoma expansion traditionally focus on changes in intraparenchymal volume. The presence of intraventricular hemorrhage (IVH) is a predictor of poor outcome, but current definitions of hematoma expansion do not include IVH expansion. We evaluated whether including IVH expansion to current definitions of hematoma expansion improves the ability to predict 90-day outcome. Methods- Using data from the PREDICT-ICH study (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT), we compared a standard definition of hematoma expansion (≥6 mL or ≥33%) to revised definitions that includes new IVH development or expansion (≥6 mL or ≥33% or any IVH; ≥6 mL or ≥33% or IVH expansion ≥1 mL). The primary outcome was poor clinical outcome (modified Rankin Scale score, 4-6) at 90 days. Diagnostic accuracy measures were calculated for each definition, and C statistics for each definition were compared using nonparametric methods. Results- Of the 256 patients eligible for primary analysis, 127 (49.6%) had a modified Rankin Scale score of 4 to 6. Sensitivity and specificity for the standard definition (n=80) were 45.7% (95% CI, 36.8-54.7) and 82.9% (95% CI, 75.3-88.9), respectively. The revised definition, ≥6 mL or ≥33% or any IVH (n=113), possessed a sensitivity of 63.8% (95% CI, 54.8-72.1) and specificity of 75.2% (95% CI, 66.8-82.4). Overall accuracy was significantly improved with the revised definition (P=0.013) and after adjusting for relevant covariates, was associated with a 2.55-fold increased odds (95% CI, 1.31-4.94) of poor outcome at 90 days. A second revised definition, ≥6 mL or ≥33% or IVH expansion ≥1 mL, performed similarly (sensitivity, 56.7% [95% CI, 47.6-65.5]; specificity, 78.3% [95% CI, 40.2-85.1]; aOR, 2.40 [95% CI, 1.23-4.69]). Conclusions- In patients with mild-to-moderate ICH, including IVH expansion to the definition of hematoma expansion improves sensitivity with only minimal decreases to specificity and improves overall prediction of 90-day outcome.
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Affiliation(s)
- Vignan Yogendrakumar
- From the Ottawa Stroke Program, Department of Medicine, Division of Neurology, (V.Y., D.D.), University of Ottawa, Canada
| | - Tim Ramsay
- Ottawa Methods Center (T.R., D.A.F.), University of Ottawa, Canada.,Ottawa Hospital Research Institute (T.R., D.A.F., D.D.), University of Ottawa, Canada
| | - Dean A Fergusson
- Ottawa Methods Center (T.R., D.A.F.), University of Ottawa, Canada.,Ottawa Hospital Research Institute (T.R., D.A.F., D.D.), University of Ottawa, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Departments of Clinical Neurosciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Canada.,Radiology (A.M.D., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Canada
| | - Richard I Aviv
- Department of Radiology (R.I.A.), University of Ottawa, Canada
| | - David Rodriguez-Luna
- Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.)
| | - Carlos A Molina
- Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.)
| | - Yolanda Silva
- Department of Neurology, Dr. Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.)
| | - Imanuel Dzialowski
- Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.)
| | - Adam Kobayashi
- Interventional Stroke and Cerebrovascular Treatment Center and 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.).,Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.)
| | - Jean-Martin Boulanger
- Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Longueuil, Canada (J.-M.B.)
| | - Gord Gubitz
- Department of Neurology, Dalhousie University, Halifax, Canada (G.G.)
| | - Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi (P.S., R.B.)
| | | | - Carlos S Kase
- Department of Neurology, Boston Medical Center, MA (C.S.K.)
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi (P.S., R.B.)
| | - Michael D Hill
- Calgary Stroke Program, Departments of Clinical Neurosciences (A.M.D., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Canada.,Radiology (A.M.D., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Canada
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Dar Dowlatshahi
- From the Ottawa Stroke Program, Department of Medicine, Division of Neurology, (V.Y., D.D.), University of Ottawa, Canada.,Ottawa Hospital Research Institute (T.R., D.A.F., D.D.), University of Ottawa, Canada
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Miyares LC, Falcone GJ, Leasure A, Adeoye O, Shi FD, Kittner SJ, Langefeld C, Vagal A, Sheth KN, Woo D. Race/ethnicity influences outcomes in young adults with supratentorial intracerebral hemorrhage. Neurology 2020; 94:e1271-e1280. [PMID: 31969467 DOI: 10.1212/wnl.0000000000008930] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 10/02/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES We investigated the predictors of functional outcome in young patients enrolled in a multiethnic study of intracerebral hemorrhage (ICH). METHODS The Ethnic/Racial Variations in Intracerebral Hemorrhage (ERICH) study is a prospective multicenter study of ICH among adult (age ≥18 years) non-Hispanic white, non-Hispanic black, and Hispanic participants. The study recruited 1,000 participants per racial/ethnic group. The present study utilized the subset of ERICH participants aged <50 years with supratentorial ICH. Functional outcome was ascertained using the modified Rankin Scale (mRS) at 3 months. Logistic regression was used to identify factors associated with poor outcome (mRS 4-6), and analyses were compared by race/ethnicity to identify differences across these groups. RESULTS Of the 3,000 patients with ICH enrolled in ERICH, 418 were studied (mean age 43 years, 69% male), of whom 48 (12%) were white, 173 (41%) were black, and 197 (47%) were Hispanic. For supratentorial ICH, black participants (odds ratio [OR], 0.42; p = 0.046) and Hispanic participants (OR, 0.34; p = 0.01) had better outcomes than white participants after adjustment for other factors associated with poor outcome: age, baseline disability, admission blood pressure, admission Glasgow Coma Scale score, ICH volume, deep ICH location, and intraventricular extension. CONCLUSIONS In young patients with supratentorial ICH, black and Hispanic race/ethnicity is associated with better functional outcomes, compared with white race. Additional studies are needed to identify the biological and social mediators of this association.
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Affiliation(s)
- Laura C Miyares
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Guido J Falcone
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Audrey Leasure
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Opeolu Adeoye
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Fu-Dong Shi
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Steven J Kittner
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Carl Langefeld
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Achala Vagal
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Kevin N Sheth
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Daniel Woo
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville.
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