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Rodriguez-Luna D, Silva Y, Prats-Sanchez L, Llull L. Author Response: Effects of Achieving Rapid, Intensive, and Sustained Blood Pressure Reduction in Intracerebral Hemorrhage Expansion and Functional Outcome. Neurology 2025; 104:e209773. [PMID: 39724537 DOI: 10.1212/wnl.0000000000209773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2024] Open
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Saren J, Debain A, Loosveldt F, Petrovic M, Bautmans I. Elevated blood pressure variability is associated with an increased risk of negative health outcomes in adults aged 65 and above-a systematic review and meta-analysis. Age Ageing 2024; 53:afae262. [PMID: 39611353 DOI: 10.1093/ageing/afae262] [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: 02/20/2024] [Accepted: 11/21/2024] [Indexed: 11/30/2024] Open
Abstract
BACKGROUND The clinical relevance of blood pressure variability (BPV) is still unknown, despite increasing evidence associating BPV to negative health outcomes (NHOs). There is currently no gold standard to define high BPV and normal reference values for BPV are lacking. AIM The primary aim was to examine whether high BPV can predict NHO in adults aged ≥65. The predictive value of BPV was compared to mean BP (mBP) when both parameters were available. METHODS PubMed and Web of Science were systematically screened; 49 articles (12 retrospective, 18 prospective and 19 cross-sectional studies) were included and evaluated for methodological quality. Meta-analyses were conducted to examine the association of BPV (and mBP when available) with NHO. RESULTS Systolic BPV and systolic mBP seem to indicate at least comparable odds for cardiovascular disease (BPV: odds ratio (OR) = 1.33 (95% CI: 1.19-1.48, P < .00001) vs mBP: OR = 1.06 (95% CI: 1.03-1.09, P = .0002)) and cerebral deterioration (BPV: OR = 1.28 (95% CI: 1.17-1.41, P < .00001) vs mBP: OR = 1.06 (95% CI: 1.04-1.09, P < .00001)). Increased diastolic BPV was associated with higher odds of cerebral deterioration (OR = 1.18 (95% CI: 1.04-1.35), P = .01). CONCLUSION High systolic BPV and high systolic mBP are associated with 33% and 6% higher odds of cardiovascular disease in adults aged ≥65, respectively. High BPV is also related to an 18%-28% and 11% increased odds of cerebral deterioration and poor stroke recovery. An overview of cut-off values is provided for the most often reported BPV parameters in literature, which can be used as a guideline to identify elevated BPV in clinical practice.
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Affiliation(s)
- Jordy Saren
- Gerontology Department, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Aziz Debain
- Gerontology Department, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
- Frailty & Resilience in Ageing (FRIA) Research Unit, Vitality Research Group, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
- Geriatrics Department, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Fien Loosveldt
- Gerontology Department, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Ivan Bautmans
- Gerontology Department, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
- Frailty & Resilience in Ageing (FRIA) Research Unit, Vitality Research Group, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
- Geriatrics Department, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
- Geriatric Physiotherapy Department, SOMT University of Physiotherapy, Softwareweg 5, 3821 BN Amersfoort, The Netherlands
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Mengel A, Siokas V, Buesink R, Roesch S, Laichinger K, Ferizi R, Dardiotis E, Sartor-Pfeiffer J, Single C, Hauser TK, Krumbholz M, Ziemann U, Feil K. Continuous Blood Pressure Indices During the First 72 Hours and Functional Outcome in Patients with Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2024:10.1007/s12028-024-02146-4. [PMID: 39455525 DOI: 10.1007/s12028-024-02146-4] [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: 06/05/2024] [Accepted: 09/25/2024] [Indexed: 10/28/2024]
Abstract
BACKGROUND Management of intracerebral hemorrhage (ICH) is challenged by limited therapeutic options and a complex relationship between blood pressure (BP) dynamics, especially BP variability (BPV) and ICH outcome. METHODS In an exploratory analysis of prospectively collected data on consecutive patients with nontraumatic ICH between 2015 and 2020, continuous BP accessed via an arterial line extracted from the Intellispace Critical Care and Anesthesia information system (Philips Healthcare) was analyzed over the first 72 h post admission. Arterial lines were used as part of standard clinical practice in the intensive care, ensuring high fidelity and real-time data essential for acute care settings. BPV was assessed through successive variation (SV), standard deviation (SD), and coefficient of variation using all available BP measurements. Multivariate regression models were applied to evaluate the association between BPV indices and functional outcome at 3 months. RESULTS Among 261 patients (mean age 69.6 ± 15.2 years, 47.9% female, median National Institutes of Health Stroke Scale [NIHSS] score 6 [interquartile range 2-12]) analyzed, lower systolic BP upon admission (< 140 mm Hg) and lower systolic BPV were significantly associated with favorable outcome, whereas higher diastolic BPV correlated with improved outcomes. In the multivariate analysis, diastolic BPV (SD, SV) within the first 72 h post admission emerged as an independent predictor of good functional outcome (modified Rankin Scale score < 3; odds ratio 1.123, 95% confidence interval CI 1.008-1.184, p = 0.035), whereas systolic BPV (SD) showed a negative association. Patients with better outcomes also exhibited distinct clinical characteristics, including younger age, lower median NIHSS scores, and less prevalence of anticoagulation therapy upon admission. CONCLUSIONS This study shows the prognostic value of BPV in the acute phase of ICH. Lower systolic BPV (SD) and higher diastolic BPV (SD, SV) were associated with better functional outcomes, challenging traditional BP management strategies. These findings might help to tailor a personalized BP management in ICH.
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Affiliation(s)
- Annerose Mengel
- Department of Neurology and Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany.
| | - Vasileios Siokas
- Department of Neurology and Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Department of Neurology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Rebecca Buesink
- Department of Neurology and Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Sara Roesch
- Department of Neurology and Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Kornelia Laichinger
- Department of Neurology and Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Redina Ferizi
- Department of Neurology and Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Efthimios Dardiotis
- Department of Neurology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Jennifer Sartor-Pfeiffer
- Department of Neurology and Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Constanze Single
- Department of Neurology and Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Till-Karsten Hauser
- Department of Neuroradiology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Markus Krumbholz
- Department of Neurology, University Hospital of the Brandenburg Medical School, Rüdersdorf, Germany
| | - Ulf Ziemann
- Department of Neurology and Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Katharina Feil
- Department of Neurology and Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
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Piqueras-Sanchez C, Esteve-Pastor MA, Moreno-Fernandez J, Soler-Espejo E, Rivera-Caravaca JM, Roldán V, Marín F. Advances in the medical treatment and diagnosis of intracranial hemorrhage associated with oral anticoagulation. Expert Rev Neurother 2024; 24:913-928. [PMID: 39039686 DOI: 10.1080/14737175.2024.2379413] [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: 05/05/2024] [Accepted: 07/09/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION With the increasing prevalence of atrial fibrillation (AF), it entails expanding oral anticoagulants (OACs) use, carrying a higher risk of associated hemorrhagic events, including intracranial hemorrhage (ICH). Despite advances in OACs development with a better safety profile and reversal agent for these anticoagulants, there is still no consensus on the optimal management of patients with OACs-associated ICH. AREAS COVERED In this review, the authors have carried out an exhaustive search on the advances in recent years. The authors provide an update on the management of ICH in anticoagulated patients, as well as an update on the latest evidence on anticoagulation resumption, recent therapeutic strategies, and investigational drugs that could play a role in the future. EXPERT OPINION Following an ICH event in an anticoagulated patient, a comprehensive clinical evaluation is imperative. Anticoagulation should be promptly withdrawn and reversed. Once the patient is stabilized, a reintroduction of anticoagulation should be considered, typically within a timeframe of 4-8 weeks, if feasible. If re-anticoagulation is not possible, alternative options such as Left Atrial Appendage Occlusion are available.
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Affiliation(s)
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- CIBERCV, Murcia, Spain
| | - Jorge Moreno-Fernandez
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Eva Soler-Espejo
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- Department of Hematology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | | | - Vanessa Roldán
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- Department of Hematology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- CIBERCV, Murcia, Spain
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Zhang SY, Li CL, Yin J, Jiang M, Yang XF. Blood pressure variability and prognostic significance in traumatic brain injury: analysis of the eICU-CRD database. BMC Emerg Med 2024; 24:141. [PMID: 39112931 PMCID: PMC11305040 DOI: 10.1186/s12873-024-01054-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/17/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND Preliminary evidence demonstrates that visit-to-visit systolic blood pressure (SBP) variability is a prognostic factor of TBI. However, literature regarding the impact of initial blood pressure management on the outcomes of TBI patients is limited. We aimed to further validate the clinical significance of BPV on the prognostic outcomes of patients with TBI. METHODS We performed the analysis by using individual patient-level data acquired from the eICU-CRD, which collected 200,859 ICU admissions of 139,367 patients in 2014 and 2015 from 208 US hospitals. Adult patients with traumatic intraparenchymal hemorrhage or contusion were included. The primary outcome was in-hospital mortality and the secondary outcome was discharge-home rate. Blood pressure variability (BPV) was calculated according to standard criteria: at least six measurements were taken in the first 24 h (hyperacute group) and 36 over days 2-7 (acute group). We estimated the associations between BPV and outcomes with logistic and proportional odds regression models. The key parameter for BPV was standard deviation (SD) of SBP, categorized into quintiles. We also calculated the average real variability (ARV), as well as maximum, minimum, and mean SBP for comparison in our analysis. RESULTS We studied 1486 patients in the hyperacute group and 857 in the acute group. SD of SBP had a significant association with the in-hospital mortality for both the hyperacute group (highest quintile adjusted OR 2.28 95% CI 1.18-4.42; ptrend<0.001) and the acute group (highest quintile adjusted OR 2.17, 95% CI 1.08-4.36; ptrend<0.001). The strongest predictors of primary outcome were SD of SBP in the hyperacute phase and minimum SBP in the acute phase. Associations were similar for the discharge-home rate (for the hyperacute group, highest quintile adjusted OR 0.58, 95% CI 0.37-0.89; ptrend<0.001; for the acute group OR 0.55, 95% CI 0.32-0.95; ptrend<0.001). CONCLUSION Systolic BPV seems to predict a poor outcome in patients with TBI. The benefits of early treatment to maintain appropriate SBP level might be enhanced by smooth and sustained control.
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Affiliation(s)
- Shao-Yang Zhang
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Chang-Li Li
- Department of FSTC Clinic, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Jian Yin
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Meng Jiang
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China.
| | - Xiao-Feng Yang
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
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Li Y, Du C, Ge S, Zhang R, Shao Y, Chen K, Li Z, Ma F. Hematoma expansion prediction based on SMOTE and XGBoost algorithm. BMC Med Inform Decis Mak 2024; 24:172. [PMID: 38898499 PMCID: PMC11186182 DOI: 10.1186/s12911-024-02561-9] [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: 03/11/2023] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
Hematoma expansion (HE) is a high risky symptom with high rate of occurrence for patients who have undergone spontaneous intracerebral hemorrhage (ICH) after a major accident or illness. Correct prediction of the occurrence of HE in advance is critical to help the doctors to determine the next step medical treatment. Most existing studies focus only on the occurrence of HE within 6 h after the occurrence of ICH, while in reality a considerable number of patients have HE after the first 6 h but within 24 h. In this study, based on the medical doctors recommendation, we focus on prediction of the occurrence of HE within 24 h, as well as the occurrence of HE every 6 h within 24 h. Based on the demographics and computer tomography (CT) image extraction information, we used the XGBoost method to predict the occurrence of HE within 24 h. In this study, to solve the issue of highly imbalanced data set, which is a frequent case in medical data analysis, we used the SMOTE algorithm for data augmentation. To evaluate our method, we used a data set consisting of 582 patients records, and compared the results of proposed method as well as few machine learning methods. Our experiments show that XGBoost achieved the best prediction performance on the balanced dataset processed by the SMOTE algorithm with an accuracy of 0.82 and F1-score of 0.82. Moreover, our proposed method predicts the occurrence of HE within 6, 12, 18 and 24 h at the accuracy of 0.89, 0.82, 0.87 and 0.94, indicating that the HE occurrence within 24 h can be predicted accurately by the proposed method.
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Affiliation(s)
- Yan Li
- Department of Mathematics and Physics, Xi'an Jiaotong-Liverpool University, Suzhou, China
| | - Chaonan Du
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Sikai Ge
- Department of Mathematics and Physics, Xi'an Jiaotong-Liverpool University, Suzhou, China
| | - Ruonan Zhang
- Department of Mathematics and Physics, Xi'an Jiaotong-Liverpool University, Suzhou, China
| | - Yiming Shao
- Department of Mathematics and Physics, Xi'an Jiaotong-Liverpool University, Suzhou, China
| | - Keyu Chen
- Department of Mathematics and Physics, Xi'an Jiaotong-Liverpool University, Suzhou, China
| | - Zhepeng Li
- Department of Mathematics and Physics, Xi'an Jiaotong-Liverpool University, Suzhou, China
| | - Fei Ma
- Department of Mathematics and Physics, Xi'an Jiaotong-Liverpool University, Suzhou, China.
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Kumar A, Witsch J, Frontera J, Qureshi AI, Oermann E, Yaghi S, Melmed KR. Predicting hematoma expansion using machine learning: An exploratory analysis of the ATACH 2 trial. J Neurol Sci 2024; 461:123048. [PMID: 38749281 DOI: 10.1016/j.jns.2024.123048] [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: 12/19/2023] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH) is a key predictor of poor prognosis and potentially amenable to treatment. This study aimed to build a classification model to predict HE in patients with ICH using deep learning algorithms without using advanced radiological features. METHODS Data from the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) was utilized. Variables included in the models were chosen as per literature consensus on salient variables associated with HE. HE was defined as increase in either >33% or 6 mL in hematoma volume in the first 24 h. Multiple machine learning algorithms were employed using iterative feature selection and outcome balancing methods. 70% of patients were used for training and 30% for internal validation. We compared the ML models to a logistic regression model and calculated AUC, accuracy, sensitivity and specificity for the internal validation models respective models. RESULTS Among 1000 patients included in the ATACH-2 trial, 924 had the complete parameters which were included in the analytical cohort. The median [interquartile range (IQR)] initial hematoma volume was 9.93.mm3 [5.03-18.17] and 25.2% had HE. The best performing model across all feature selection groups and sampling cohorts was using an artificial neural network (ANN) for HE in the testing cohort with AUC 0.702 [95% CI, 0.631-0.774] with 8 hidden layer nodes The traditional logistic regression yielded AUC 0.658 [95% CI, 0.641-0.675]. All other models performed with less accuracy and lower AUC. Initial hematoma volume, time to initial CT head, and initial SBP emerged as most relevant variables across all best performing models. CONCLUSION We developed multiple ML algorithms to predict HE with the ANN classifying the best without advanced radiographic features, although the AUC was only modestly better than other models. A larger, more heterogenous dataset is needed to further build and better generalize the models.
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Affiliation(s)
- Arooshi Kumar
- Rush University Medical Center, Department of Neurology, Chicago, IL 60612, United States of America.
| | - Jens Witsch
- Hospital of the University of Pennsylvania, Department of Neurology, Philadelphia, PA 19104, United States of America
| | - Jennifer Frontera
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO 65201, United States of America
| | - Eric Oermann
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Shadi Yaghi
- Warren Alpert Medical School of Brown University, Department of Neurology, Providence, RI 02903, United States of America
| | - Kara R Melmed
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Neurosurgery, New York, NY 10016, United States of America
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Zhu W, Zhou J, Ma B, Fan C. Predictors of early neurological deterioration in patients with intracerebral hemorrhage: a systematic review and meta-analysis. J Neurol 2024; 271:2980-2991. [PMID: 38507074 DOI: 10.1007/s00415-024-12230-6] [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: 01/06/2024] [Revised: 01/26/2024] [Accepted: 01/27/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Early neurological deterioration, a common complication in patients with intracerebral hemorrhage, is associated with poor outcomes. Despite the fact that the prevalence and predictors of early neurological impairment are widely addressed, few studies have consolidated these findings. This study aimed to systematically investigate the prevalence and predictors of early neurological deterioration. METHODS The PubMed, Embase, Cochrane Library, CIHNAL, and Web of Science databases were systematically searched for relevant studies from the inception to December 2023. The data were extracted using a predefined worksheet. Quality assessment was conducted using the Newcastle-Ottawa Scale. Two reviewers independently performed the study selection, data extraction, and quality appraisal. The pooled effect size and 95% confidence intervals were calculated using the STATA 17.0 software package. RESULTS In total, 32 studies and 5,014 patients were included in this meta-analysis. The prevalence of early neurological deterioration was 23% (95% CI 21-26%, p < 0.01). The initial NIHSS score (OR = 1.24, 95% CI 1.17, 1.30, p < 0.01), hematoma volume (OR = 1.07, 95% CI 1.06, 1.09, p < 0.01), intraventricular hemorrhage (OR = 3.50, 95% CI 1.64, 7.47, p < 0.01), intraventricular extension (OR = 3.95, 95% CI 1.96, 7.99, p < 0.01), hematoma expansion (OR = 9.77, 95% CI 4.43, 17.40, p < 0.01), and computed tomographic angiography spot sign (OR = 5.77, 95% CI 1.53, 20.23, p = 0.01) were predictors of early neurological deterioration. The funnel plot and Egger's test revealed significant publication bias (p < 0.001). CONCLUSIONS This meta-analysis revealed a pooled prevalence of early neurological deterioration of 23% in patients with intracerebral hemorrhage. The initial NIHSS score, hematoma volume, intraventricular hemorrhage, intraventricular expansion, hematoma expansion, and spot sign enhanced the probability of early neurological deterioration. These findings provide healthcare providers with an evidence-based basis for detecting and managing early neurological deterioration in patients with intracerebral hemorrhage.
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Affiliation(s)
- Wei Zhu
- Department of Neurosurgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Jiehong Zhou
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Buyun Ma
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Chaofeng Fan
- Department of Neurosurgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China.
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Rodriguez-Luna D, Pancorbo O, Llull L, Silva Y, Prats-Sanchez L, Muchada M, Rudilosso S, Terceño M, Ramos-Pachón A, Hernandez Guillamon M, Coscojuela P, Blasco J, Perez-Hoyos S, Chamorro A, Molina CA. Effects of Achieving Rapid, Intensive, and Sustained Blood Pressure Reduction in Intracerebral Hemorrhage Expansion and Functional Outcome. Neurology 2024; 102:e209244. [PMID: 38598746 DOI: 10.1212/wnl.0000000000209244] [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: 04/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The time taken to achieve blood pressure (BP) control could be pivotal in the benefits of reducing BP in acute intracerebral hemorrhage (ICH). We aimed to assess the relationship between the rapid achievement and sustained maintenance of an intensive systolic BP (SBP) target with radiologic, clinical, and functional outcomes. METHODS Rapid, Intensive, and Sustained BP lowering in Acute ICH (RAINS) was a multicenter, prospective, observational cohort study of adult patients with ICH <6 hours and SBP ≥150 mm Hg at 4 Comprehensive Stroke Centers during a 4.5-year period. Patients underwent baseline and 24-hour CT scans and 24-hour noninvasive BP monitoring. BP was managed under a rapid (target achievement ≤60 minutes), intensive (target SBP <140 mm Hg), and sustained (target stability for 24 hours) BP protocol. SBP target achievement ≤60 minutes and 24-hour SBP variability were recorded. Outcomes included hematoma expansion (>6 mL or >33%) at 24 hours (primary outcome), early neurologic deterioration (END, 24-hour increase in NIH Stroke Scale score ≥4), and 90-day ordinal modified Rankin scale (mRS) score. Analyses were adjusted by age, sex, anticoagulation, onset-to-imaging time, ICH volume, and intraventricular extension. RESULTS We included 312 patients (mean age 70.2 ± 13.3 years, 202 [64.7%] male). Hematoma expansion occurred in 70/274 (25.6%) patients, END in 58/291 (19.9%), and the median 90-day mRS score was 4 (interquartile range, 2-5). SBP target achievement ≤60 minutes (178/312 [57.1%]) associated with a lower risk of hematoma expansion (adjusted odds ratio [aOR] 0.43, 95% confidence interval [CI] 0.23-0.77), lower END rate (aOR 0.43, 95% CI 0.23-0.80), and lower 90-day mRS scores (aOR 0.48, 95% CI 0.32-0.74). The mean 24-hour SBP variability was 21.0 ± 7.6 mm Hg. Higher 24-hour SBP variability was not related to expansion (aOR 0.99, 95% CI 0.95-1.04) but associated with higher END rate (aOR 1.15, 95% CI 1.09-1.21) and 90-day mRS scores (aOR 1.06, 95% CI 1.04-1.10). DISCUSSION Among patients with acute ICH, achieving an intensive SBP target within 60 minutes was associated with lower hematoma expansion risk. Rapid SBP reduction and stable sustention within 24 hours were related to improved clinical and functional outcomes. These findings warrant the design of randomized clinical trials examining the impact of effectively achieving rapid, intensive, and sustained BP control on hematoma expansion. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that in adults with spontaneous ICH and initial SBP ≥150 mm Hg, lowering SBP to <140 mm Hg within the first hour and maintaining this for 24 hours is associated with decreased hematoma expansion.
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Affiliation(s)
- David Rodriguez-Luna
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Olalla Pancorbo
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Laura Llull
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Yolanda Silva
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Luis Prats-Sanchez
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Marián Muchada
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Salvatore Rudilosso
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Mikel Terceño
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Anna Ramos-Pachón
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Mar Hernandez Guillamon
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Pilar Coscojuela
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Jordi Blasco
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Santiago Perez-Hoyos
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Angel Chamorro
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
| | - Carlos A Molina
- From the Department of Neurology (D.R.-L., M.M., C.A.M.), Vall d'Hebron University Hospital; Stroke Research Group (D.R.-L., O.P., M.M., C.A.M.), Vall d'Hebron Research Institute; Department of Medicine (D.R.-L., O.P.), Autonomous University of Barcelona; Department of Neuroscience (L.L., S.R., A.C.), Comprehensive Stroke Center, Hospital Clinic, Barcelona; Department of Neurology (Y.S., M.T.), Hospital Universitari Dr. Josep Trueta, Girona; Department of Neurology (L.P.-S., A.R.-P.), Hospital de la Santa Creu i Sant Pau; Neurovascular Research Group (M.H.G.), Vall d'Hebron Research Institute; Department of Neuroradiology (P.C.), Vall d'Hebron University Hospital; Department of Interventional Neuroradiology (J.B.), CDI, Hospital Clínic; and Statistics and Bioinformatics Unit (S.P.-H.), Vall d'Hebron Research Institute, Barcelona, Spain
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10
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Pancorbo O, Sanjuan E, Rodríguez-Samaniego MT, Miñarro O, Simonetti R, Olivé-Gadea M, García-Tornel Á, Rodriguez-Villatoro N, Muchada M, Rubiera M, Álvarez-Sabin J, Molina CA, Rodriguez-Luna D. Enhancing blood pressure management protocol implementation in patients with acute intracerebral haemorrhage through a nursing-led approach: A retrospective cohort study. J Clin Nurs 2024; 33:1398-1408. [PMID: 38379362 DOI: 10.1111/jocn.17080] [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: 11/30/2023] [Revised: 01/03/2024] [Accepted: 02/07/2024] [Indexed: 02/22/2024]
Abstract
AIM To evaluate the impact of nurse care changes in implementing a blood pressure management protocol on achieving rapid, intensive and sustained blood pressure reduction in acute intracerebral haemorrhage patients. DESIGN Retrospective cohort study of prospectively collected data over 6 years. METHODS Intracerebral haemorrhage patients within 6 h and systolic blood pressure ≥ 150 mmHg followed a rapid (starting treatment at computed tomography suite with a target achievement goal of ≤60 min), intensive (target systolic blood pressure < 140 mmHg) and sustained (maintaining target stability for 24 h) blood pressure management plan. We differentiated six periods: P1, stroke nurse at computed tomography suite (baseline period); P2, antihypertensive titration by stroke nurse; P3, retraining by neurologists; P4, integration of a stroke advanced practice nurse; P5, after COVID-19 impact; and P6, retraining by stroke advanced practice nurse. Outcomes included first-hour target achievement (primary outcome), tomography-to-treatment and treatment-to-target times, first-hour maximum dose of antihypertensive treatment and 6-h and 24-h systolic blood pressure variability. RESULTS Compared to P1, antihypertensive titration by stroke nurses (P2) reduced treatment-to-target time and increased the rate of first-hour target achievement, retraining of stroke nurses by neurologists (P3) maintained a higher rate of first-hour target achievement and the integration of a stroke advanced practice nurse (P4) reduced both 6-h and 24-h systolic blood pressure variability. However, 6-h systolic blood pressure variability increased from P4 to P5 following the impact of the COVID-19 pandemic. Finally, compared to P1, retraining of stroke nurses by stroke advanced practice nurse (P6) reduced tomography-to-treatment time and increased the first-hour maximum dose of antihypertensive treatment. CONCLUSION Changes in nursing care and continuous education can significantly enhance the time metrics and blood pressure outcomes in acute intracerebral haemorrhage patients. REPORTING METHOD STROBE guidelines. PATIENT AND PUBLIC CONTRIBUTION No Patient or Public Contribution.
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Affiliation(s)
- Olalla Pancorbo
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Estela Sanjuan
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | | | - Olga Miñarro
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Renato Simonetti
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Marta Olivé-Gadea
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Álvaro García-Tornel
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Noelia Rodriguez-Villatoro
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marián Muchada
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marta Rubiera
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - José Álvarez-Sabin
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Carlos A Molina
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David Rodriguez-Luna
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
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11
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Drapkina OM, Kontsevaya AV, Kalinina AM, Avdeev SN, Agaltsov MV, Alekseeva LI, Almazova II, Andreenko EY, Antipushina DN, Balanova YA, Berns SA, Budnevsky AV, Gainitdinova VV, Garanin AA, Gorbunov VM, Gorshkov AY, Grigorenko EA, Jonova BY, Drozdova LY, Druk IV, Eliashevich SO, Eliseev MS, Zharylkasynova GZ, Zabrovskaya SA, Imaeva AE, Kamilova UK, Kaprin AD, Kobalava ZD, Korsunsky DV, Kulikova OV, Kurekhyan AS, Kutishenko NP, Lavrenova EA, Lopatina MV, Lukina YV, Lukyanov MM, Lyusina EO, Mamedov MN, Mardanov BU, Mareev YV, Martsevich SY, Mitkovskaya NP, Myasnikov RP, Nebieridze DV, Orlov SA, Pereverzeva KG, Popovkina OE, Potievskaya VI, Skripnikova IA, Smirnova MI, Sooronbaev TM, Toroptsova NV, Khailova ZV, Khoronenko VE, Chashchin MG, Chernik TA, Shalnova SA, Shapovalova MM, Shepel RN, Sheptulina AF, Shishkova VN, Yuldashova RU, Yavelov IS, Yakushin SS. Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2024; 23:3696. [DOI: 10.15829/1728-8800-2024-3996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2024] Open
Abstract
Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.
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12
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Zompola C, Palaiodimou L, Voumvourakis K, Stefanis L, Katsanos AH, Sandset EC, Boviatsis E, Tsivgoulis G. Blood Pressure Variability in Acute Stroke: A Narrative Review. J Clin Med 2024; 13:1981. [PMID: 38610746 PMCID: PMC11012361 DOI: 10.3390/jcm13071981] [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: 03/12/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
The management of blood pressure variability (BPV) in acute stroke presents a complex challenge with profound implications for patient outcomes. This narrative review examines the role of BPV across various stages of acute stroke care, highlighting its impact on treatment strategies and prognostic considerations. In the prehospital setting, while guidelines lack specific recommendations for BP management, emerging evidence suggests a potential link between BPV and outcomes. Among ischaemic stroke patients who are ineligible for reperfusion therapies, BPV independently influences functional outcomes, emphasising the need for individualised approaches to BP control. During intravenous thrombolysis and endovascular therapy, the intricate interplay between BP levels, recanalisation status, and BPV is evident. Striking a balance between aggressive BP lowering and avoiding hypoperfusion-related complications is essential. Intracerebral haemorrhage management is further complicated by BPV, which emerges as a predictor of mortality and disability, necessitating nuanced BP management strategies. Finally, among patients with acute subarachnoid haemorrhage, increased BPV may be correlated with a rebleeding risk and worse outcomes, emphasizing the need for BPV monitoring in this population. Integration of BPV assessment into clinical practice and research protocols is crucial for refining treatment strategies that are tailored to individual patient needs. Future studies should explore novel interventions targeting BPV modulation to optimise stroke care outcomes.
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Affiliation(s)
- Christina Zompola
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Leonidas Stefanis
- First Department of Neurology, “Aeginition” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON L8L2X2, Canada
| | - Else C. Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, N-0424 Oslo, Norway
| | - Estathios Boviatsis
- Second Department of Neurosurgery, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
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13
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Manolis AJ, Kallistratos MS, Koutsaki M, Doumas M, Poulimenos LE, Parissis J, Polyzogopoulou E, Pittaras A, Muiesan ML, Mancia G. The diagnostic approach and management of hypertension in the emergency department. Eur J Intern Med 2024; 121:17-24. [PMID: 38087668 DOI: 10.1016/j.ejim.2023.11.028] [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: 01/26/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 03/08/2024]
Abstract
Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment.
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Affiliation(s)
- A J Manolis
- Metropolitan Hospital, 2nd Department of Cardiology, Ethnarchou Makariou 9, Praeus, Greece
| | - M S Kallistratos
- Metropolitan Hospital, 2nd Department of Cardiology, Ethnarchou Makariou 9, Praeus, Greece.
| | - M Koutsaki
- Asklepeion General Hospital, Cardiology Department, Vasileos Pavlou 1 street, Voula Greece
| | - M Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - L E Poulimenos
- Asklepeion General Hospital, Cardiology Department, Vasileos Pavlou 1 street, Voula Greece
| | - J Parissis
- Second Department of Cardiology, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - E Polyzogopoulou
- Second Department of Cardiology, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - A Pittaras
- Metropolitan Hospital, 2nd Department of Cardiology, Ethnarchou Makariou 9, Praeus, Greece
| | - M L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia & 2a Medicina ASST Spedali Civili di Brescia, 25121 Brescia, Italy
| | - G Mancia
- University of Milano-Bicocca (Emeritus Professor), Milan, Italy
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14
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Lin V, Souter MJ. Intracerebral hemorrhage. NEUROLOGICAL AND NEUROSURGICAL EMERGENCIES 2024:213-227. [DOI: 10.1016/b978-0-443-19132-9.00018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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15
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Stretz C, Mahta A, Witsch J, Burton T, Yaghi S, Furie KL, Reznik ME. A reassessment of hemoglobin and hematoma expansion in intracerebral hemorrhage. J Stroke Cerebrovasc Dis 2023; 32:107339. [PMID: 37683527 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107339] [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: 04/01/2023] [Revised: 08/14/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND In patients with spontaneous intracerebral hemorrhage (ICH), prior studies identified an increased risk of hematoma expansion (HE) in those with lower admission hemoglobin (Hgb) levels. We aimed to reproduce these findings in an independent cohort. METHODS We conducted a cohort study of patients admitted to a Comprehensive Stroke Center for acute ICH within 24 hours of onset. Admission laboratory and CT imaging data on ICH characteristics including HE (defined as >33% or >6 mL), and 3-month outcomes were collected. We compared laboratory data between patients with and without HE and used multivariable logistic regression to determine associations between Hgb, HE, and unfavorable 3-month outcomes (modified Rankin Scale 4-6) while adjusting for confounders including anticoagulant use, and laboratory markers of coagulopathy. RESULTS Among 345 patients in our cohort (mean [SD] age 72.9 [13.7], 49% male), 71 (21%) had HE. Patients with HE had similar Hgb versus those without HE (mean [SD] 13.1 [1.8] g/dl vs. 13.1 [1.9] g/dl, p=0.92). In fully adjusted multivariable models, Hgb was not associated with HE (OR per 1g/dl 1.01, 95% CI 0.86 -1.17, p = 0.94), however higher admission Hgb levels were associated with lower odds of unfavorable 3-month outcome (OR 0.83 per 1 g/dl Hgb, 95% CI 0.72-0.96, p=0.01). CONCLUSION We did not confirm a previously reported association between admission Hgb and HE in patients with ICH, although Hgb and HE were both associated with poor outcome. These findings suggest that the association between Hgb and poor outcome is mediated by other factors.
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Affiliation(s)
- Christoph Stretz
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI.
| | - Ali Mahta
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI; Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Jens Witsch
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Tina Burton
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Karen L Furie
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Michael E Reznik
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI; Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI
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16
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Leshko NA, Lamore RF, Zielke MK, Sandsmark DK, Schmidt LE. Adherence to Established Blood Pressure Targets and Associated Complications in Patients Presenting with Acute Intracerebral Hemorrhage. Neurocrit Care 2023; 39:378-385. [PMID: 36788180 DOI: 10.1007/s12028-023-01679-4] [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: 08/10/2022] [Accepted: 01/19/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Conflicting evidence exists surrounding systolic blood pressure (SBP) control in patients with acute intracerebral hemorrhage (ICH). The 2022 American Heart Association and American Stroke Association guidelines recommend targeting a SBP of 140 mm Hg while maintaining the range of 130-150 mm Hg. The current practice at our health system is to titrate antihypertensives to a SBP goal of < 160 mm Hg, which aligns with previous recommendations. We hypothesized that the prior lack of guidance to a specific SBP target range predisposed patients to hypotension leading to an increased risk of brain and renal adverse events. METHODS This retrospective, multicenter, single health system cohort study included adults admitted to the neurointensive care unit or intermediate unit with acute ICH from June 2019 to June 2021. The primary objective evaluated the frequency of time within SBP range (140-160 mm Hg) in the first 48 h. Secondary and safety end points included the frequency of time above and below the established SBP range, episodes of hypotension (defined as a decrease in SBP < 140 mm Hg prompting discontinuation in antihypertensive[s] or the initiation of vasopressor[s]), the incidence of new brain or renal adverse events within 7 days, and modified Rankin Scale at discharge. RESULTS A total of 80 patients (59% men; median age 62 years) were included. The majority of ICHs in this cohort were intraparenchymal (70%). Nearly one third were attributed to systemic hypertension (31%). During the first 48 h of admission, the frequency of time spent above, within, and below the target SBP range were 6 h (12%), 16 h (34%), and 26 h (54%), respectively. Hypotension was associated with renal adverse events (odds ratio [OR] 3.36, 95% confidence interval [CI] 1.10-11.44, p = 0.023). A relative SBP reduction > 20% in the first 48 h was associated with renal adverse events (OR 8.99, 95% CI 2.57-35.25, p < 0.001), brain ischemia (OR 22.5, 95% CI 1.92-300.11, p = 0.005), and an increased odd of a modified Rankin Scale of 4-6 at discharge (OR 11.79, 95% CI 2.79-57.02, p < 0.001). CONCLUSIONS In individuals with nontraumatic/nonaneurysmal ICH, SBP measurements were observed to be < 140 mm Hg for > 50% of the initial 48 h following admission. Hypotension and relative SBP reduction > 20% were also independent predictors of renal adverse events. SBP reduction > 20% was also an independent predictor of brain ischemia. These data indicate that intensive SBP reduction following ICH predispose patients to secondary organ injury that may impact long-term outcomes. Our data suggest that a more modest lowering of the SBP within 48 h, as recommended in the most recent guidelines, may minimize the risk of further adverse events.
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Affiliation(s)
- Nicole A Leshko
- Department of Pharmacy, Northwestern Memorial Hospital, 251 E. Huron St., Chicago, IL, 60611, USA.
| | - Raymond F Lamore
- Department of Pharmacy, Penn Presbyterian Medical Center, 51 N. 39th St, Philadelphia, PA, 19104, USA
| | - Megan K Zielke
- Department of Pharmacy, Penn Presbyterian Medical Center, 51 N. 39th St, Philadelphia, PA, 19104, USA
| | - Danielle K Sandsmark
- Department of Neurology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Lauren E Schmidt
- Department of Pharmacy, Penn Presbyterian Medical Center, 51 N. 39th St, Philadelphia, PA, 19104, USA
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17
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Xu J, Xie Z, Chen K, Lan S, Liao G, Xu S, Yang X, Luo H. The L-shaped correlation between systolic blood pressure and short-term and long-term mortality in patients with cerebral hemorrhage. BMC Neurol 2023; 23:230. [PMID: 37316781 DOI: 10.1186/s12883-023-03271-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 06/01/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND A large amount of evidence has shown the necessity of lowering blood pressure (BP) in patients with acute cerebral hemorrhage, but whether reducing BP contributes to lower short-term and long-term mortality in these patients remains uncertain. AIMS We aimed to explore the association between BP, including systolic and diastolic BP, during intensive care unit (ICU) admission and 1-month and 1-year mortality after discharge of patients with cerebral hemorrhage. METHODS A total of 1085 patients with cerebral hemorrhage were obtained from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Maximum and minimum values of systolic and diastolic BP in these patients during their ICU stay were recorded, and endpoint events were defined as the 1-month mortality and 1-year mortality after the first admission. Multivariable adjusted models were performed for the association of BP with the endpoint events. RESULTS We observed that patients with hypertension were likely to be older, Asian or Black and had worse health insurance and higher systolic BP than those without hypertension. The logistic regression analysis showed inverse relationships between systolic BP-min (odds ratio (OR) = 0.986, 95% CI 0.983-0.989, P < 0.001) and diastolic BP-min (OR = 0.975, 95% CI 0.968-0.981, P < 0.001) and risks of 1-month, as well as 1-year mortality when controlling for confounders including age, sex, race, insurance, heart failure, myocardial infarct, malignancy, cerebral infarction, diabetes and chronic kidney disease. Furthermore, smooth curve analysis suggested an approximate L-shaped association of systolic BP with the risk of 1-month mortality and 1-year mortality. Reducing systolic BP in the range of 100-150 mmHg has a lower death risk in these patients with cerebral hemorrhage. CONCLUSION We observed an L-shaped association between systolic BP levels and the risks of 1-month and 1-year mortality in patients with cerebral hemorrhage, which supported that lowering BP when treating an acute hypertensive response could reduce short-term and long-term mortality.
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Affiliation(s)
- Jiang Xu
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Zhiping Xie
- Department of Neurosurgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, China
| | - Kang Chen
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Shihai Lan
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Gang Liao
- Institute of Medicine, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Shan Xu
- Department of Pathology, The First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Xuanyong Yang
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China.
| | - Hai Luo
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China.
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18
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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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19
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El-Sherif AM, Rashad A, Rabie MM, Hegazy M, Adel M, Albialy M, El-Shandawely M, Mahmoud EA. Resource utilization in management of spontaneous intracerebral hemorrhage without systemic risk factors. Does early surgical decompression matter? Clin Neurol Neurosurg 2023; 231:107829. [PMID: 37331206 DOI: 10.1016/j.clineuro.2023.107829] [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: 02/13/2023] [Revised: 06/03/2023] [Accepted: 06/05/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Even though different subtypes of spontaneous ICH are frequently linked to a poor prognosis, their causes, pathological features, and prognoses vary. Atypical intracerebral hemorrhage is the subtype of spontaneous ICH that usually occurs due to an underlying localized vascular lesion. It is unrelated to systemic vascular risk factors, mostly affects children and young adults and is associated with a relatively good outcome. This fact should be considered when planning the evaluation and treatment. Investigating the cause of this subtype is fundamental to providing optimal management. However, if resources do not allow completing the investigations, the cause will be more difficult to discover. Treatment decisions will be made under stress to save the patient's life, especially with rapidly deteriorating patients. METHODS We described three cases of spontaneous ICH without systemic risk factors where the bleeding source could not be determined before surgery due to a lack of resources, preventing preoperative vascular investigation. Knowing that the atypical ICH has a distinct identity, regarding etiology and prognosis, encouraged the surgeons to resort to early surgical decompression as an alternative plan. We reviewed the literature searching for supporting evidence. RESULTS The results of treatment of the presented cases were satisfactory. The lack of reported similar cases was brought to light by a literature analysis that sought to provide backing for the proposed management strategy. In the end, we supplied two graphic organizers to help readers remember the different types and treatment of hemorrhagic stroke. CONCLUSION There isn't enough evidence to show that there are other ways to treat atypical intracerebral haemorrhage when resources are limited. The presented cases highlight the importance of decisionmaking in resource-constrained situations when patient outcomes can be improved.
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Affiliation(s)
- Ahmed M El-Sherif
- Al-Azhar University, Faculty of Medicine, Nasr City, 11651 Cairo, Egypt.
| | - Alaa Rashad
- Al-Azhar University, Faculty of Medicine, Nasr City, 11651 Cairo, Egypt
| | | | | | - Mostafa Adel
- Al-Azhar University, Faculty of Medicine, Al-Hussein Hospital, Egypt
| | - Mohammad Albialy
- Al-Azhar University, Faculty of Medicine, Nasr City, 11651 Cairo, Egypt
| | | | - Ehab Adel Mahmoud
- Uppsala University Hospital, Radiology Department, Neurointervention Unit, Sweden
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20
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Amer HA, El-Jaafary SIM, Sadek HMAEA, Fouad AM, Mohammed SS. Clinical and paraclinical predictors of early neurological deterioration and poor outcome in spontaneous intracerebral hemorrhage. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2023; 59:74. [PMID: 37305215 PMCID: PMC10242586 DOI: 10.1186/s41983-023-00675-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/28/2023] [Indexed: 06/13/2023] Open
Abstract
Background Spontaneous intracerebral hemorrhage (sICH) is the second most common form of stroke. It is a major cause of morbidity and mortality. Several clinical and radiological parameters are related to its poor outcome. The aim of this study is to elucidate the clinical, laboratory, and radiological factors associated with early neurological deterioration and poor outcome in patients with ICH. Results seventy patients diagnosed with sICH were evaluated within the first 72 h from the onset of symptoms by Clinical, radiological, and laboratory parameters. Patients were assessed for early neurological deterioration (END) during the hospital stay (up to 7 days from admission) using Glasgow coma scale (GSC), and the National Institutes of Health Stroke Scale (NIHSS), and within 3 months from stroke onset using modified Rankin scale (mRS). ICH score and Functional Outcome in Patients with Primary Intracerebral Hemorrhage (FUNC) Score were calculated for prognostication. 27.1% and 71.42% of patients had END and showed unfavorable outcome, respectively. Clinical indices, as NIHSS > 7 on admission and age > 51 years, radiological characteristics, as large hematoma size, leukoaraiosis, and mass effect detected on CT scan, as well as serum biomarkers; serum urea level > 50 mg/dL, high neutrophil:lymphocyte ratio on admission, high ALT and AST, as well as low total, LDL, and HDL cholesterol levels, all were significantly associated with poor outcome in the patients. Stepwise multivariate logistic regression analysis found the presence of aspiration to be an independent predictor of END, and the scores of NIHSS > 7 on admission, age > 51 years, and urea level > 50 mg/dL were independent predictors of poor outcome. Conclusions There are several predictors for END as well as poor outcome in ICH. Some are clinical, others are radiological and laboratory. Aspiration was an independent predictor of END during hospital stay (3-7 days) in patients with ICH, while older age, high NIHSS and urea level on admission were independent predictors of poor outcome.
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Affiliation(s)
| | | | | | - Amr Mohamed Fouad
- Neurology Department, Faculty of Medicine, Cairo University, Giza, Egypt
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21
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Yu K, Sun Y, Guo K, Peng J, Jiang Y. Early blood pressure management in hemorrhagic stroke: a meta-analysis. J Neurol 2023:10.1007/s00415-023-11654-w. [PMID: 36884070 DOI: 10.1007/s00415-023-11654-w] [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: 11/29/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023]
Abstract
The aim of the present meta-analysis was to evaluate the outcomes and effects of different systolic blood pressure (SBP) lowering in patients with hemorrhagic stroke using data from randomized controlled trials. A total of 2592 records were identified for this meta-analysis. We finally included 8 studies (6119 patients; mean age 62.8 ± 13.0, 62.7% men). No evidence of heterogeneity between estimates (I2 = 0% < 50%, P = 0.26), or publication bias in the funnel plots (P = 0.065, Egger statistical test) was detected. Death or major disability rates were similar between patients with intensive BP-lowering treatment (SBP < 140 mmHg) and those receiving guideline BP-lowering treatment (SBP < 180 mmHg). Intensive BP-lowering treatment may have a better functional outcome, but the results were not significantly different (log RR = - 0.03, 95% CI: - 0.09 to 0.02; P = 0.55). Intensive BP-lowering treatment tended to be associated with lower early hematoma growth compared with guideline treatment (log RR = - 0.24, 95% CI - 0.38, - 0.11; P < 0.001). Intensive BP-lowering helps reduce hematoma enlargement in the early stage of acute hemorrhagic stroke. However, this observation did not translate into functional outcomes. Further research is needed to clarify the specific scope and time of blood pressure reduction.
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Affiliation(s)
- Kuangyang Yu
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, No. 25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Yuxuan Sun
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, No. 25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Kecheng Guo
- Laboratory of Neurological Diseases and Brain Function, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
| | - Jianhua Peng
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, No. 25 of Taiping Street, Luzhou, 646000, Sichuan, China. .,Laboratory of Neurological Diseases and Brain Function, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China. .,Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou, 646000, China. .,Sichuan Clinical Research Center for Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China.
| | - Yong Jiang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, No. 25 of Taiping Street, Luzhou, 646000, Sichuan, China. .,Laboratory of Neurological Diseases and Brain Function, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China. .,Institute of Epigenetics and Brain Science, Southwest Medical University, Luzhou, 646000, China. .,Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China.
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22
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [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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23
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Kim HL, Lee EM, Ahn SY, Kim KI, Kim HC, Kim JH, Lee HY, Lee JH, Park JM, Cho EJ, Park S, Shin J, Kim YK. The 2022 focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension. Clin Hypertens 2023; 29:11. [PMID: 36788612 PMCID: PMC9930285 DOI: 10.1186/s40885-023-00234-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023] Open
Abstract
Hypertension is the leading cause of death in human being, which shows high prevalence and associated complications that increase the mortality and morbidity. Controlling blood pressure (BP) is very important because it is well known that lowering high BP effectively improves patients' prognosis. This review aims to provide a focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension. The importance of ambulatory BP and home BP monitoring was further emphasized not only for the diagnosis but also for treatment target. By adopting corresponding BPs, the updated guideline recommended out-of-office BP targets for both standard and intensive treatment. Based on the consensus on corresponding BPs and Systolic Blood Pressure Intervention Trial (SPRINT) revisit, the updated guidelines recommended target BP in high-risk patients below 130/80 mmHg and it applies to hypertensive patients with three or more additional cardiovascular risk factors, one or more risk factors with diabetes, or hypertensive patients with subclinical organ damages, coronary or vascular diseases, heart failure, chronic kidney disease with proteinuria, and cerebral lacunar infarction. Cerebral infarction and chronic kidney disease are also high-risk factors for cardiovascular disease. However, due to lack of evidence, the target BP was generally determined at < 140/90 mmHg in patients with those conditions as well as in the elderly. Updated contents regarding the management of hypertension in special situations are also discussed.
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Affiliation(s)
- Hack-Lyoung Kim
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Mi Lee
- grid.410899.d0000 0004 0533 4755Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Republic of Korea
| | - Shin Young Ahn
- grid.411134.20000 0004 0474 0479Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kwang-il Kim
- grid.412480.b0000 0004 0647 3378Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hyeon Chang Kim
- grid.15444.300000 0004 0470 5454Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ju Han Kim
- grid.411597.f0000 0004 0647 2471Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Hae-Young Lee
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jang Hoon Lee
- grid.258803.40000 0001 0661 1556Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | - Jong-Moo Park
- grid.255588.70000 0004 1798 4296Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Republic of Korea
| | - Eun Joo Cho
- grid.488414.50000 0004 0621 6849Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungha Park
- grid.15444.300000 0004 0470 5454Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinho Shin
- grid.49606.3d0000 0001 1364 9317Department of Internal Medicine, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Young-Kwon Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Seoul, Republic of Korea.
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Deng L, Li ZQ, Yang WS, Li R, Lv XN, Li YL, Wang ZJ, Hu X, Zhao LB, Lv FJ, Yao ST, Cao F, Xie P, Li Q. Prehospital Ultra-Early Neurological Deterioration in Intracerebral Hemorrhage: Definition, Prevalence, and Association with Outcomes. Cerebrovasc Dis 2022; 52:471-479. [PMID: 36509082 DOI: 10.1159/000527545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/07/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The objective of this study was to define prehospital ultra-early neurological deterioration (UND) and to investigate the association with functional outcomes in patients with intracerebral hemorrhage (ICH). METHODS We conducted a prospective cohort study of consecutive acute ICH patients. The stroke severity at onset and hospital admission was assessed using the Chongqing Stroke Scale (CQSS), and prehospital UND was defined as a CQSS increase of ≥2 points between symptoms onset and admission. Early neurological deterioration (END) was defined as the increase of ≥4 points in NIHSS score within the first 24 h after admission. Poor outcome was defined as a modified Rankin Scale (mRS) of 4-6 at 3 months. RESULTS Prehospital UND occurred in 29 of 169 patients (17.2%). Patients with prehospital UND had a median admission NIHSS score of 17.0 as opposed to those without prehospital UND with a median NIHSS score of 8.5. There were three patterns of neurological deterioration: prehospital UND only in 21 of 169 patients (12.4%), END but without prehospital UND in 20 of 169 patients (11.8%), and continuous neurological deterioration in both phases in 8 patients (4.7%). Prehospital UND was associated with worse 3-month outcomes (median mRS score, 4.0 vs. 2.0, p = 0.002). After adjusting for age, time from onset to admission, END, and systolic blood pressure, prehospital UND was an independent predictor of poor outcome (odds ratio [OR] 3.27, 95% confidence interval [CI] 1.26-8.48, p = 0.015). CONCLUSION Prehospital UND occurs in approximately 1 in 7 patients between symptom onset and admission and is associated with poor functional outcome in patients with ICH. Further research is needed to investigate the prehospital UND in the prehospital phase in the triage of patients with ICH.
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Affiliation(s)
- Lan Deng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zuo-Qiao Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wen-Song Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin-Ni Lv
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu-Lun Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zi-Jie Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Hu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li-Bo Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Fa-Jin Lv
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Sheng-Tao Yao
- Department of Neurosurgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fang Cao
- Department of Neurosurgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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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: 0] [Impact Index Per Article: 0] [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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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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Zhao J, Song C, Li D, Yang X, Yu L, Wang K, Wu J, Wang X, Li D, Zhang B, Li B, Guo J, Feng W, Fu F, Gu X, Qian J, Li J, Yuan X, Liu Q, Chen J, Wang X, Liu Y, Wei D, Wang L, Shang L, Yang F, Jiang W. Efficacy and safety of glibenclamide therapy after intracerebral haemorrhage (GATE-ICH): A multicentre, prospective, randomised, controlled, open-label, blinded-endpoint, phase 2 clinical trial. EClinicalMedicine 2022; 53:101666. [PMID: 36177443 PMCID: PMC9513728 DOI: 10.1016/j.eclinm.2022.101666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/30/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Glibenclamide is a promising agent for treating brain oedema, but whether it improves clinical outcomes in patients with intracerebral haemorrhage (ICH) remains unclear. In this study, we aimed to explore the efficacy and safety of glibenclamide treatment in patients with acute ICH. METHODS The Glibenclamide Advantage in Treating Oedema after Intracerebral Haemorrhage (GATE-ICH) study was a randomised controlled phase 2 clinical trial conducted in 26 hospitals in the northwest of China, recruiting patients with acute ganglia ICH no more than 72 h after onset from Dec 12, 2018 to Sept 23, 2020. During the first 7 days after enrolment, patients randomly assigned to the glibenclamide group were given glibenclamide orally (1.25 mg, 3/day) and standard care, while patients randomly assigned to the control group were given standard care alone. The computer-generated randomisation sequence was prepared by a statistician not involved in the rest of the study. Randomisation was computer-generated with a block size of four. The allocation results were unblinded to participants and investigators. The primary outcome was the percentage of patients with poor outcome (defined as modified Rankin Scale [mRS] score of ≥3) at day 90. The trial was registered at ClinicalTrials.gov (NCT03741530). FINDINGS 220 participants were randomised and 200 participants (mean [standard deviation] age, 56 [11] years; sex, 128 [64.0%] male and 72 [36.0%] female) were included in the final analysis, with 101 participants randomly assigned to the control group and 99 to the glibenclamide group. The incidence of poor outcome at day 90 was 20/99 (20.2%) in glibenclamide group and 30/101 (29.7%) in control group (absolute difference, 9.5%; 95% confidence interval [CI], -3.2%-21.8%; P = 0.121) with adjusted odds ratios of 0.54 (95% CI, 0.24-1.20; P = 0.129). No significant difference was found in the overall rates of adverse events or serious adverse events between groups. However, the incidence of asymptomatic hypoglycaemia was significantly higher in glibenclamide group than control group (15/99 [15.2%] vs 0/101 [0.0%]; absolute difference, 15.2%; 95% CI, 7.5%-24.1%; P < 0.001). INTERPRETATION Our study provides no evidence that glibenclamide (1.25 mg, 3/day) significantly reduces the proportion of poor outcome at day 90 after ICH. In addition, glibenclamide could result in higher incidence of hypoglycaemia. Larger trials of glibenclamide with optimised medication regimen are warranted. FUNDING Shaanxi Province Key Research and Development Project (2017DCXL-SF-02-02) and Shaanxi Province Special Support Program for Leading Talents in Scientific and Technological Innovation (tzjhjw).
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Affiliation(s)
- Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Changgeng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Deshuai Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xiai Yang
- Department of Neurology, Ankang Central Hospital, Ankang 725000, China
| | - Liping Yu
- Department of Neurology, The First People's Hospital of Xianyang, Xianyang 712000, China
| | - Kangjun Wang
- Department of Neurology, Hanzhong Central Hospital, Hanzhong 723000, China
| | - Jun Wu
- Department of Neurology, Xianyang Central Hospital, Xianyang 712000, China
| | - Xiaofeng Wang
- Department of Neurosurgery, The PLA 987 Hospital, Baoji 721000, China
| | - Dongsong Li
- Department of Neurology, Ankang People's Hospital, Ankang 725000, China
| | - Bo Zhang
- Department of Neurology, Shangluo Central Hospital, Shangluo 726000, China
| | - Binyong Li
- Department of Neurology, Xixiang Hospital, Hanzhong 723000, China
| | - Jun Guo
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Weikui Feng
- Department of Neurology, Shaanxi Province Mianxian Hospital, Hanzhong 723000, China
| | - Feng Fu
- Department of Neurology, 215 Hospital of Shaanxi NI, Xianyang 712021, China
| | - Xinrong Gu
- Department of Neurology, Tianjin Hospital of Ningqiang, Hanzhong 723000, China
| | - Jian Qian
- Department of Neurology, Xi'an No.4 Hospital, Xi'an 710004, China
| | - Jialong Li
- Department of Neurology, Baoji No.3 Hospital, Baoji 721000, China
| | - Xiangjun Yuan
- Department of Neurology, Weinan Central Hospital, Weinan 714000, China
| | - Qiuwu Liu
- Department of Neurology, Xi'an 141 Hospital, Xi'an 710499, China
| | - Jiang Chen
- Department of Neurology, Shaanxi Aerospace Hospital, Xi'an 710025, China
| | - Xiaocheng Wang
- Department of Neurology, Yulin No.2 Hospital, Yulin 719000, China
| | - Yi Liu
- Department of Neurology, Ankang Central Hospital, Ankang 725000, China
| | - Dong Wei
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Ling Wang
- Department of Health Statistics, Fourth Military Medical University, Xi'an, China
| | - Lei Shang
- Department of Health Statistics, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
- The Shaanxi Cerebrovascular Disease Clinical Research Centre, Xi'an 710032, China
- Corresponding authors at: Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
- The Shaanxi Cerebrovascular Disease Clinical Research Centre, Xi'an 710032, China
- Corresponding authors at: Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
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Yang J, Jing J, Chen S, Liu X, Tang Y, Pan C, Tang Z. Changes in Cerebral Blood Flow and Diffusion-Weighted Imaging Lesions After Intracerebral Hemorrhage. Transl Stroke Res 2022; 13:686-706. [PMID: 35305264 DOI: 10.1007/s12975-022-00998-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/25/2022]
Abstract
Intracerebral hemorrhage (ICH) is a common subtype of stroke and places a great burden on the family and society with a high mortality and disability rate and a poor prognosis. Many findings from imaging and pathologic studies have suggested that cerebral ischemic lesions visualized on diffusion-weighted imaging (DWI) in patients with ICH are not rare and are generally considered to be associated with poor outcome, increased risk of recurrent (ischemic and hemorrhagic) stroke, cognitive impairment, and death. In this review, we describe the changes in cerebral blood flow (CBF) and DWI lesions after ICH and discuss the risk factors and possible mechanisms related to the occurrence of DWI lesions, such as cerebral microangiopathy, cerebral atherosclerosis, aggressive early blood pressure lowering, hyperglycemia, and inflammatory response. We also point out that a better understanding of cerebral DWI lesions will be a key step toward potential therapeutic interventions to improve long-term recovery for patients with ICH.
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Affiliation(s)
- Jingfei Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China
| | - Jie Jing
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China
| | - Xia Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China
| | - Yingxin Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China.
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, NO, China.
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29
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Postoperative Hematoma Expansion in Patients Undergoing Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage. Brain Sci 2022; 12:brainsci12101298. [PMID: 36291232 PMCID: PMC9599268 DOI: 10.3390/brainsci12101298] [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: 08/15/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: The aim of the study was to analyze risk factors for hematoma expansion (HE) in patients undergoing decompressive hemicraniectomy (DC) in patients with elevated intracranial pressure due to spontaneous intracerebral hematoma (ICH). Methods: We retrospectively evaluated 72 patients with spontaneous ICH who underwent DC at our institution. We compared the pre- and postoperative volumes of ICH and divided the patients into two groups: first, patients with postoperative HE > 6 cm3 (group 1), and second, patients without HE (group 2). Additionally, we screened the medical history for anticoagulant and antiplatelet medication (AC/AP), bleeding-related comorbidities, age, admission Glasgow coma scale and laboratory parameters. Results: The rate of AC/AP medication was higher in group 1 versus group 2 (15/16 vs. 5/38, p < 0.00001), and patients were significantly older in group 1 versus group 2 (65.1 ± 16.2 years vs. 54.4 ± 14.3 years, p = 0.02). Furthermore, preoperative laboratory tests showed lower rates of hematocrit (34.1 ± 5.4% vs. 38.1 ± 5.1%, p = 0.01) and hemoglobin (11.5 ± 1.6 g/dL vs. 13.13 ± 1.8 g/dL, p = 0.0028) in group 1 versus group 2. In multivariate analysis, the history of AC/AP medication was the only independent predictor of HE (p < 0.0001, OR 0.015, CI 95% 0.001−0.153). Conclusion: We presented a comprehensive evaluation of risk factors for hematoma epansion by patients undergoing DC due to ICH.
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Xu X, Peng S, Zhou Y, Li J, Tong L, Gao F. Remote diffusion-weighted imaging lesions and blood pressure variability in primary intracerebral hemorrhage. Front Neurol 2022; 13:950056. [PMID: 36203972 PMCID: PMC9530136 DOI: 10.3389/fneur.2022.950056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe aim of this study was to examine the association between remote diffusion-weighted imaging lesions (R-DWILs) and blood pressure variability (BPV) in patients with primary intracerebral hemorrhage (ICH).MethodsWe conducted a retrospective review of a consecutive cohort of 375 patients with primary ICH within 24 h onset. R-DWILs were defined as hyperintensity lesions in DWI remote from the hematoma. Blood pressure recordings were extracted up to 24 h post-admission. BPV was measured using SD, coefficient of variation (CV), and successive variation (SV).ResultsRemote DWI lesions were detected in 65 (17.3%) primary ICH patients. In multivariable logistic regression analysis, parameters of BPV were independently associated with R-DWILs, and the results remained consistent after being adjusted with mean SBP. SD, CV, and SV values in the highest quintile, showed 3- to 8-fold increased risk of R-DWILs, compared with the lowest quintile. ΔSBP demonstrated a significant difference in 2 different predictive models. Max SBP only dictated a significant difference in model 1. Mean SBP, admission SBP, and min SBP, failed to present an association with R-DWILs in model 1 or model 2.ConclusionOur results provided additional evidence that BPV is associated with the development of R-DWILs in primary ICH.
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Affiliation(s)
- Xuhua Xu
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Neurology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Shuangshuang Peng
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Neurology, Taizhou First People's Hospital, Taizhou, China
| | - Yanli Zhou
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Neurology, Taizhou First People's Hospital, Taizhou, China
| | - Jiawen Li
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lusha Tong
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Lusha Tong
| | - Feng Gao
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Feng Gao
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31
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Time course of beat-to-beat blood pressure variability and outcome in patients with spontaneous intracerebral haemorrhage. J Hypertens 2022; 40:1744-1750. [PMID: 35943102 DOI: 10.1097/hjh.0000000000003206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Increased blood pressure variability (BPV) over 24 h or longer was associated with poor clinical outcomes in patients with intracerebral haemorrhage (ICH). However, the characteristics of beat-to-beat BPV, a rapid assessment of BPV and its association with outcome in ICH patients remain unknown. METHODS We consecutively and prospectively recruited patients with ICH between June 2014 and December 2020. Five-minute noninvasive beat-to-beat recordings were measured serially at three time points, 1-2, 4-6 and 10-12 days after ICH onset. BPV was calculated using standard deviation (SD) and variation independent of mean (VIM). Favourable outcome was defined as modified Rankin Scale score of less than 2 at 90 days. RESULTS The analysis included 66 participants (54.12 ± 10.79 years; 71.2% men) and 66 age and sex-matched healthy controls. Compared with that in healthy adults, beat-to-beat BPV was significantly increased 1-2 days after ICH and was completely recovered 10-12 days later. BPV recorded 1-2 days after ICH onset was higher among patients with unfavourable outcomes than among those with favourable outcomes (all P < 0.05) and higher BPV on days 1-2 was independently associated with a 3-month unfavourable outcome after adjustment for major covariates. CONCLUSION Beat-to-beat BPV was significantly increased among patients with ICH and could be completely recovered 10-12 days later. In addition, beat-to-beat BPV 1-2 days after ICH was independently associated with prognosis and could be regarded as a potential prognostic predictor and effective therapeutic target in the future.
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32
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Tran Q, Frederick H, Tran C, Baqai H, Lurie T, Solomon J, Aligabi A, Olexa J, Cardona S, Bodanapally U, Schwartzbauer G, Downing J. Blood Pressure Variability and Outcome in Traumatic Brain Injury: A Propensity Score Matching Study. West J Emerg Med 2022; 23:769-780. [PMID: 36205663 PMCID: PMC9541979 DOI: 10.5811/westjem.2022.6.55549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/27/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Patients with tIPH (used here to refer to traumatic intraparenchymal hemorrhagic contusion) or intraparenchymal hemorrhage face high rates of mortality and persistent functional deficits. Prior studies have found an association between blood pressure variability (BPV) and neurologic outcomes in patients with spontaneous IPH. Our study investigated the association between BPV and discharge destination (a proxy for functional outcome) in patients with tIPH. Methods We retrospectively reviewed the charts of patients admitted to a Level I trauma center for ≥ 24 hours with tIPH. We examined variability in hourly BP measurements over the first 24 hours of hospitalization. Our outcome of interest was discharge destination (home vs facility). We performed 1:1 propensity score matching and multivariate regressions to identify demographic and clinical factors predictive of discharge home. Results We included 354 patients; 91 were discharged home and 263 to a location other than home. The mean age was 56 (SD 21), 260 (73%) were male, 22 (6%) were on anticoagulation, and 54 (15%) on antiplatelet therapy. Our propensity-matched cohorts included 76 patients who were discharged home and 76 who were discharged to a location other than home. One measure of BPV (successive variation in systolic BP) was identified as an independent predictor of discharge location in our propensity-matched cohorts (odds ratio 0.89, 95% confidence interval 0.8–0.98; P = 0.02). Our model demonstrated good goodness of fit (P-value for Hosmer-Lemeshow test = 0.88) and very good discriminatory capability (AUROC = 0.81). High Glasgow Coma Scale score at 24 hours and treatment with fresh frozen plasma were also associated with discharge home. Conclusion Our study suggests that increased BPV is associated with lower rates of discharge home after initial hospitalization among patients with tIPH. Additional research is needed to evaluate the impact of BP control on patient outcomes.
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Affiliation(s)
- Quincy Tran
- University of Maryland School of Medicine, Baltimore, Maryland; University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland; The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Hannah Frederick
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Cecilia Tran
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Hammad Baqai
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Tucker Lurie
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland; Wellspan York Hospital, Department of Emergency Medicine, York, Pennsylvania
| | - Julianna Solomon
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Ayah Aligabi
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Joshua Olexa
- University of Maryland School of Medicine, Department of Neurosurgery, Baltimore, Maryland
| | - Stephanie Cardona
- Mount Sinai Hospital, Department of Critical Care Medicine, York, New York
| | - Uttam Bodanapally
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gary Schwartzbauer
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; University of Maryland School of Medicine, Department of Neurosurgery, Baltimore, Maryland
| | - Jessica Downing
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Program in Trauma/Surgical Critical Care, Baltimore, Maryland
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Kim HJ, Kim BS, Shin JH. Clinical characteristics and prognosis of patients with very severe acute hypertension visiting the emergency department. Clin Hypertens 2022; 28:23. [PMID: 35965337 PMCID: PMC9377086 DOI: 10.1186/s40885-022-00208-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Data regarding very severe acute hypertension, a serious problem in emergency departments (EDs), are scarce. We investigated the clinical characteristics, practice patterns, and long-term prognoses of patients presenting to the ED with very severe acute hypertension. Methods Cross-sectional study data were obtained from a single regional emergency medical center, including patients aged ≥ 18 years who were admitted to the ED between January 2016 and December 2019 for very severe acute hypertension, which was defined as systolic blood pressure of > 220 mmHg and/or diastolic blood pressure of > 120 mmHg. The patients were classified into two groups based on the presence or absence of hypertension-mediated organ damage (HMOD). Results Among 1,391 patients with very severe acute hypertension in the ED, half of the them (50.2%) had a previous medical history of hypertension, and 547 (39.3%) had acute HMOD. The overall 3-month, 1-year, and 3-year mortality rates were 5.2%, 11.9%, and 17.3%, respectively. In particular, patients with HMOD had a significantly higher mortality rate at each time point than those without HMOD. Among patients with HMOD, acute ischemic stroke was the most common (28.7%). Moreover, intravenous antihypertensive drugs were significantly more prescribed in patients with HMOD than in those without HMOD (79.0% vs. 22.2%, P < 0.001), but there were no differences in oral antihypertensive drugs between the two groups. Conclusions Patients with very severe acute hypertension had poor long-term clinical prognoses. Clinicians should be continuously monitoring and providing appropriate treatment and close follow-up for patients with very severe acute hypertension. Supplementary Information The online version contains supplementary material available at 10.1186/s40885-022-00208-3.
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Gao D, Zhang X, Zhang Y, Zhang R, Qiao Y. A Prediction Model for Neurological Deterioration in Patients with Acute Spontaneous Intracerebral Hemorrhage. Front Surg 2022; 9:886856. [PMID: 35722524 PMCID: PMC9198834 DOI: 10.3389/fsurg.2022.886856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
Aim The aim of this study was to explore factors related to neurological deterioration (ND) after spontaneous intracerebral hemorrhage (sICH) and establish a prediction model based on random forest analysis in evaluating the risk of ND. Methods The clinical data of 411 patients with acute sICH at the Affiliated Hospital of Jining Medical University and Xuanwu Hospital of Capital Medical University between January 2018 and December 2020 were collected. After adjusting for variables, multivariate logistic regression was performed to investigate the factors related to the ND in patients with acute ICH. Then, based on the related factors in the multivariate logistic regression and four variables that have been identified as contributing to ND in the literature, we established a random forest model. The receiver operating characteristic curve was used to evaluate the prediction performance of this model. Results The result of multivariate logistic regression analysis indicated that time of onset to the emergency department (ED), baseline hematoma volume, serum sodium, and serum calcium were independently associated with the risk of ND. Simultaneously, the random forest model was developed and included eight predictors: serum calcium, time of onset to ED, serum sodium, baseline hematoma volume, systolic blood pressure change in 24 h, age, intraventricular hemorrhage expansion, and gender. The area under the curve value of the prediction model reached 0.795 in the training set and 0.713 in the testing set, which suggested the good predicting performance of the model. Conclusion Some factors related to the risk of ND were explored. Additionally, a prediction model for ND of acute sICH patients was developed based on random forest analysis, and the developed model may have a good predictive value through the internal validation.
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Affiliation(s)
- Daiquan Gao
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xiaojuan Zhang
- Emergency Department, Affiliated Hospital of Jining Medical University, Jining, China
| | - Yunzhou Zhang
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Rujiang Zhang
- Department of Internal Medicine, Ruili People’s Hospital, Ruili, China
| | - Yuanyuan Qiao
- Intensive Care Unit, Affiliated Hospital of Jining Medical University, Jining, China
- Correspondence: Yuanyuan Qiao
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 576] [Impact Index Per Article: 192.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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Blood Pressure and Spot Sign in Spontaneous Supratentorial Subcortical Intracerebral Hemorrhage. Neurocrit Care 2022; 37:246-254. [PMID: 35445934 PMCID: PMC9283165 DOI: 10.1007/s12028-022-01485-4] [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: 09/24/2021] [Accepted: 03/07/2022] [Indexed: 10/27/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage is a potentially devastating cause of brain injury, often occurring secondary to hypertension. Contrast extravasation on computed tomography angiography (CTA), known as the spot sign, has been shown to predict hematoma expansion and worse outcomes. Although hypertension has been associated with an increased rate of the spot sign being present, the relationship between spot sign and blood pressure has not been fully explored. METHODS We retrospectively analyzed data from 134 patients (40 women and 94 men, mean age 62.3 ± 15.73 years) presenting to a tertiary academic medical center with spontaneous supratentorial subcortical intracerebral hemorrhage from 1/1/2018 to 1/4/2021. RESULTS A spot sign was demonstrated in images of 18 patients (13.43%) and correlated with a higher intracerebral hemorrhage score (2.61 ± 1.42 vs. 1.31 ± 1.25, p = 0.002), larger hematoma volume (53.49cm3 ± 32.08 vs. 23.45cm3 ± 25.65, p = 0.001), lower Glasgow Coma Scale on arrival (9.06 ± 4.56 vs. 11.74 ± 3.65, p = 0.027), increased risk of hematoma expansion (16.67% vs. 5.26%, p = 0.042), and need for surgical intervention (66.67% vs. 15.52%, p < 0.001). We did not see a correlation with age, sex, or underlying comorbidities. The presence of spot sign correlated with higher modified Rankin scores at discharge (4.94 ± 1.00 vs. 3.92 ± 1.64, p < 0.001). We saw significantly higher systolic blood pressure at the time of CTA in patients with a spot sign (184 mm Hg ± 43.11 vs. 153 mm Hg ± 36.99, p = 0.009) and the highest recorded blood pressure (p = 0.019), although not blood pressure on arrival (p = 0.081). Performing CTA early in the process of blood pressure lowering was associated with a spot sign (p < 0.001). CONCLUSIONS The presence of spot sign correlates with larger hematomas, worse outcomes, and increased surgical intervention. There is a significant association between spot sign and systolic blood pressure at the time of CTA, with the highest systolic blood pressure being recorded prior to CTA. Although the role of intensive blood pressure management in spontaneous intracerebral hemorrhage remains a subject of debate, patients with a spot sign may be a subgroup that could benefit from this.
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Ng Y, Qi W, King NKK, Christianson T, Krishnamoorthy V, Shah S, Divani A, Bettin M, Coleman ER, Flaherty ML, Walsh KB, Testai FD, McCauley JL, Gilkerson LA, Langefeld CD, Behymer TP, Woo D, James ML. Initial antihypertensive agent effects on acute blood pressure after intracerebral haemorrhage. Stroke Vasc Neurol 2022; 7:367-374. [PMID: 35443984 PMCID: PMC9614130 DOI: 10.1136/svn-2021-001101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 03/08/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Current guidelines recommend blood pressure (BP) lowering in patients after acute intracerebral haemorrhage (ICH) without guidance on initial choice of antihypertensive class. This study sought to determine if initial antihypertensive class differentially effects acute BP lowering in a large multiethnic ICH cohort. Methods Subjects enrolled in the Ethnic/Racial Variations in ICH study between August 2010 and August 2017 with elevated admission BP and who received labetalol, nicardipine or hydralazine monotherapy as initial antihypertensive were analysed. Primary outcomes were systolic and diastolic BP changes from baseline to first BP measurement after initial antihypertensive treatment. Secondary outcomes included haematoma expansion (HE), hospital length of stay (LOS) and modified Rankin Score (mRS) up to 12 months after ICH. Exploratory outcomes assessed effects of race/ethnicity. Linear and logistic regression analyses, adjusted for relevant covariates, were performed to determine associations of antihypertensive class with outcomes. Results In total, 1156 cases were used in analyses. Antihypertensive class was associated with diastolic BP change (p=0.003), but not systolic BP change (p=0.419). Initial dosing with nicardipine lowered acute diastolic BP than labetalol (least square mean difference (labetalol-nicardipine)=5.47 (2.37, 8.57), p<0.001). Initial antihypertensive class was also found to be associated with LOS (p=0.028), but not with HE (p=0.406), mortality (p=0.118), discharge disposition (p=0.083) or mRS score at discharge, 3, 6 and 12 months follow-up (p=0.262, 0.276, 0.152 and 0.36, respectively). Race/ethnicity variably affected multivariable models. Conclusion In this large acute ICH cohort, initial antihypertensive class was associated with acute diastolic, but not systolic, BP-lowering suggesting differential effects of antihypertensive agents. Trial registration number NCT01202864.
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Affiliation(s)
- Yisi Ng
- Duke-NUS Medical School, SG, Singapore
| | - Wenjing Qi
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Nicolas Kon Kam King
- Duke-NUS Medical School, SG, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Thomas Christianson
- Department of Anesthesiology, University of Tennessee, Knoxville, Tennessee, USA
| | | | - Shreyansh Shah
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Afshin Divani
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Margaret Bettin
- Department of Neurology, University of Virginia, Charlottesville, Virginia, USA
| | - Elisheva R Coleman
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew L Flaherty
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kyle B Walsh
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Fernando D Testai
- Department of Neurology, University of Illinois, Chicago, Illinois, USA
| | - Jacob L McCauley
- Hussman Institute for Human Genomics, University of Miami, Miami, Florida, USA
| | - Lee A Gilkerson
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Carl D Langefeld
- Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Tyler Paul Behymer
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Daniel Woo
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael L James
- Duke-NUS Medical School, SG, Singapore .,Department of Anesthesiology, Duke University, Durham, North Carolina, USA.,Department of Neurology, Duke University, Durham, North Carolina, USA
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Challenges in the hemodynamic management of acute nontraumatic neurological injuries. Curr Opin Crit Care 2022; 28:138-144. [PMID: 35102071 DOI: 10.1097/mcc.0000000000000925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To appraise the evidence from the literature and suggest an integrated hemodynamic approach of early and delayed phases of acute ischemic stroke (AIS), subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH). RECENT FINDINGS In AIS, the research aims to evaluate the optimal pressure control before, during and after the revascularization, to optimize the perfusion in the ischemic areas, minimizing the risk of hemorrhage or secondary damage to already infarcted areas. In the early phase of SAH, systemic pressure should be controlled to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure. The late phase aims to minimize the risk of cerebral vasospasm by adapting systemic pressure and volemia to cerebral and systemic physiological hemodynamic targets. In the mild-to-moderate ICH, achieving SAP of less than 140 mmHg and greater than 110 mmHg may be considered as a beneficial target. Caution should be considered in lowering intensively SAP in severe ICH. SUMMARY In nontraumatic brain injuries, the hemodynamic management is strictly related to fluctuating physiology of these diseases, needing a strict control of pressure and flow variable to ensure both cerebral and systemic homeostasis.
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Surgical Indications and Options for Hypertensive Hemorrhages. Neurol Clin 2022; 40:337-353. [DOI: 10.1016/j.ncl.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Beucler N, Sellier A, Dagain A. Letter to the Editor. Individualized blood pressure targets in the postoperative care of patients with ICH. J Neurosurg 2022; 136:314-315. [PMID: 34560631 DOI: 10.3171/2021.4.jns211038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nathan Beucler
- 1Sainte-Anne Military Teaching Hospital, Toulon, France
- 2Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
| | | | - Arnaud Dagain
- 1Sainte-Anne Military Teaching Hospital, Toulon, France
- 3Val-de-Grâce Military Academy, Paris, France
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Zhang Q, Ding Q, Yan S, Yue QY. Fatal Adverse Events of Dabigatran Combined With Aspirin in Elderly Patients: An Analysis Using Data From VigiBase. Front Pharmacol 2021; 12:769251. [PMID: 35002709 PMCID: PMC8727914 DOI: 10.3389/fphar.2021.769251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The elderly are vulnerable to cardiovascular diseases and the incidence of atrial fibrillation (AF) and venous thromboembolism (VTE) increases significantly with age. Dabigatran is a commonly used new oral anticoagulant approved by the FDA for stroke prevention in patients with non-valvular AF and VTE treatment and prevention. Aspirin is commonly used as a preventive drug for cardiovascular diseases. AF and coronary heart disease share many risk factors, so these two diseases often coexist and thus dabigatran and aspirin are often combined in those people. The aim of this study was to analyze the clinical characteristics of fatal adverse events of dabigatran combined with aspirin in elderly patients, and to provide references for clinical rational use of drugs.Materials and Methods: Fatal adverse events related to the combined use of dabigatran and aspirin in elderly patients aged over 75 were extracted from the WHO global database of individual case safety reports (VigiBase). Well-documented reports, vigiGrade completeness score ≥0.80, or with an informative narrative, were analyzed with a focus on the clinical features of the cases.Results: From 1968 up to January 19, 2020, there were 112 eligible reports in VigiBase from 13 countries, of which 33 were identified as well-documented. Of these 33, 19 were male (58%) and 14 were female (42%), the average age of the patients was 84 (75–95 years), with five cases of extreme weights (>100 kg in one case, <50 kg in four cases). There were 31 cases of death by internal bleeding (mainly 15 of gastrointestinal hemorrhage and 12 of intracranial hemorrhage) and two cases of the sudden death of unknown cause. Medication errors existed in 15 patients. The times to onset (TTO) was provided in 24 cases, ranging from 2 days to 4 years, and in 12 patients occurred within a month. Of the 31 patients with fatal bleeding events, 29 were associated with other factors that increase the risk of bleeding, such as diseases (hypertension, renal impairment, stroke, gastrointestinal related diseases, hypothyroidism, and cancer), drugs (antiplatelets, anticoagulants, thrombolytics, P glycoprotein substrates, non-steroidal anti-inflammatory drugs, hormones, selective serotonin reuptake inhibitors, and acetaminophen) and other factors (low body weights and alcohol consumption), and 21 of these contained two or more risk factors.Conclusion: The fatal adverse events associated with the combined use of dabigatran and aspirin in elderly patients were mainly serious bleeding events, which often occurred within 1 month. Most of these cases had medication errors and most of the patients had multiple diseases, medications, or other conditions at the same time that increase the risk of bleeding. It is suggested that prescription of dabigatran and aspirin in elderly patients should go along with alertness for medication errors, care for correct dose or control of other bleeding risk factors, and the combined medication time should be as short as possible to minimise serious adverse events.
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Affiliation(s)
- Qingxia Zhang
- Department of Pharmacy, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Disease, Beijing, China
- *Correspondence: Qingxia Zhang, ; Qun-Ying Yue,
| | - Qian Ding
- School of Pharmaceutical Science, Capital Medical University, Beijing, China
| | - Suying Yan
- Department of Pharmacy, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Qun-Ying Yue
- Uppsala Monitoring Centre, Uppsala, Sweden
- *Correspondence: Qingxia Zhang, ; Qun-Ying Yue,
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Lindner A, Rass V, Ianosi BA, Schiefecker AJ, Kofler M, Gaasch M, Addis A, Rhomberg P, Pfausler B, Beer R, Schmutzhard E, Thomé C, Helbok R. Individualized blood pressure targets in the postoperative care of patients with intracerebral hemorrhage. J Neurosurg 2021; 135:1656-1665. [PMID: 33836501 DOI: 10.3171/2020.9.jns201024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recent guidelines recommend targeting a systolic blood pressure (SBP) < 140 mm Hg in the early management of patients with spontaneous intracerebral hemorrhage (ICH). The optimal SBP targets for ICH patients after hematoma evacuation (HE) remain unclear. Here, the authors aimed to define the optimal SBP range based on multimodal neuromonitoring data. METHODS Forty poor-grade ICH patients who had undergone HE and then monitoring of intracerebral pressure, brain tissue oxygen tension (PbtO2), and cerebral metabolism (via cerebral microdialysis [CMD]) were prospectively included. Episodes of brain tissue hypoxia (BTH) (1-hour averaged PbtO2 < 20 mm Hg) and metabolic distress (CMD-lactate/pyruvate ratio [LPR] ≥ 40) were identified and linked to corresponding parameters of hemodynamic monitoring (SBP and cerebral perfusion pressure [CPP]). Multivariable regression analysis was performed using generalized estimating equations to identify associations between SBP levels, PbtO2, and brain metabolism. RESULTS The mean patient age was 60 (range 51-66) years and the median [IQR] initial ICH volume was 47 [29-60] ml. In multivariable models adjusted for Glasgow Coma Scale score, probe location, ICH volume, and age, lower SBP was independently associated with a higher risk of BTH (≤ 120 mm Hg: adjusted OR 2.9, p = 0.007; 120-130 mm Hg: adj OR 2.4, p = 0.002; 130-140 mm Hg: adj OR 1.6, p = 0.017) compared to a reference range of 140-150 mm Hg at the level of the foramen interventriculare Monroi, which corresponded to a CPP of 70-80 mm Hg and SBP levels between 150 and 160 mm Hg at the heart level. After exclusion of episodes with mitochondrial dysfunction, SBP targets < 140 mm Hg were associated with higher odds of cerebral metabolic distress (≤ 130 mm Hg: OR 2.5, p = 0.041; 130-140 mm Hg: OR 2.3, p = 0.033). Patients with a modified Rankin Scale score ≥ 5 at neurological ICU discharge more often exhibited BTH than patients with better outcomes (51% vs 10%, p = 0.003). CONCLUSIONS These data suggest that lower SPB and CPP levels are associated with a higher risk for BTH. Further studies are needed to evaluate whether a higher SPB target may prevent BTH and improve outcomes.
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Affiliation(s)
- Anna Lindner
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Verena Rass
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Bogdan-Andrei Ianosi
- 1Neurological Intensive Care Unit, Department of Neurology, and
- 2Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Tyrol, Austria; and
| | | | - Mario Kofler
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Max Gaasch
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Alberto Addis
- 3School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | | | | | - Ronny Beer
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | | | | | - Raimund Helbok
- 1Neurological Intensive Care Unit, Department of Neurology, and
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Hong JM, Kim DS, Kim M. Hemorrhagic Transformation After Ischemic Stroke: Mechanisms and Management. Front Neurol 2021; 12:703258. [PMID: 34917010 PMCID: PMC8669478 DOI: 10.3389/fneur.2021.703258] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/21/2021] [Indexed: 01/01/2023] Open
Abstract
Symptomatic hemorrhagic transformation (HT) is one of the complications most likely to lead to death in patients with acute ischemic stroke. HT after acute ischemic stroke is diagnosed when certain areas of cerebral infarction appear as cerebral hemorrhage on radiological images. Its mechanisms are usually explained by disruption of the blood-brain barrier and reperfusion injury that causes leakage of peripheral blood cells. In ischemic infarction, HT may be a natural progression of acute ischemic stroke and can be facilitated or enhanced by reperfusion therapy. Therefore, to balance risks and benefits, HT occurrence in acute stroke settings is an important factor to be considered by physicians to determine whether recanalization therapy should be performed. This review aims to illustrate the pathophysiological mechanisms of HT, outline most HT-related factors after reperfusion therapy, and describe prevention strategies for the occurrence and enlargement of HT, such as blood pressure control. Finally, we propose a promising therapeutic approach based on biological research studies that would help clinicians treat such catastrophic complications.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Da Sol Kim
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Min Kim
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
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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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Zhu Z, Bower M, Stern-Nezer S, Atallah S, Stradling D, Groysman L, Dastur CK, Akbari Y, Yu W. Early Initiation of Oral Antihypertensives Reduces Intensive Care Unit Stay and Hospital Cost for Patients with Hypertensive Intracerebral Hemorrhage. Neurocrit Care 2021; 32:707-714. [PMID: 32253732 DOI: 10.1007/s12028-020-00951-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVE Intravenous nicardipine infusion is effective for rapid blood pressure control. However, its use requires hemodynamic monitoring in the intensive care unit (ICU) and is associated with high hospital cost. This study aimed to examine the effect of early versus late initiation of oral antihypertensives on ICU length of stay (LOS) and cost of hospitalization in patients with hypertensive intracerebral hemorrhage (ICH). METHODS This is a single-center retrospective study of patients with hypertensive ICH treated with nicardipine infusion from January 1, 2013, to December 31, 2017. Patients were dichotomized into study and control groups, based on receiving oral antihypertensives within 24 h versus after 24 h of emergency department arrival. Baseline characteristics, duration of nicardipine infusion, LOS in the ICU and hospital, functional outcome at discharge, and hospital cost were compared between the two groups using univariate and multivariate analysis. RESULTS A total of 90 patients in the study group and 76 in the control group were identified. There was no significant difference in demographics, past medical history, and initial SBP between the two groups. After adjusting for confounding factors with multivariate regression models, early initiation of oral antihypertensives was associated with significant reductions in duration of nicardipine infusion (55.5 ± 60.1 vs 121.6 ± 141.3 h, p <0.005), nicardipine cost ($14,207 vs $29,299, p < 0.01), ICU LOS (2 vs 5 days, p < 0.005), and cost of hospitalization ($24,564 vs $47,366, p < 0.01). There was no significant difference in adversary renal events, favorable outcomes, and mortality between the two groups. CONCLUSIONS Early initiation of oral antihypertensives is safe and may have a significant financial impact on patients with hypertensive ICH.
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Affiliation(s)
- Zhu Zhu
- Department of Neurology, University of California, Irvine, 200 S. Manchester Ave., Suite 206E, Orange, CA, 92868, USA
| | - Matthew Bower
- Department of Neurology, University of California, Irvine, 200 S. Manchester Ave., Suite 206E, Orange, CA, 92868, USA
| | - Sara Stern-Nezer
- Department of Neurology, University of California, Irvine, 200 S. Manchester Ave., Suite 206E, Orange, CA, 92868, USA
| | - Steven Atallah
- Departments of Pharmacy, University of California, Irvine, Orange, CA, USA
| | - Dana Stradling
- Department of Neurology, University of California, Irvine, 200 S. Manchester Ave., Suite 206E, Orange, CA, 92868, USA
| | - Leonid Groysman
- Department of Neurology, University of California, Irvine, 200 S. Manchester Ave., Suite 206E, Orange, CA, 92868, USA
| | - Cyrus K Dastur
- Department of Neurology, University of California, Irvine, 200 S. Manchester Ave., Suite 206E, Orange, CA, 92868, USA
| | - Yama Akbari
- Department of Neurology, University of California, Irvine, 200 S. Manchester Ave., Suite 206E, Orange, CA, 92868, USA
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, 200 S. Manchester Ave., Suite 206E, Orange, CA, 92868, USA.
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Hawkes MA, Rabinstein AA. Acute Hypertensive Response in Patients With Acute Intracerebral Hemorrhage: A Narrative Review. Neurology 2021; 97:316-329. [PMID: 34031208 DOI: 10.1212/wnl.0000000000012276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/23/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review the role of the acute hypertensive response in patients with intracerebral hemorrhage, current treatment options, and areas for further research. METHODS Review of the literature to assess 1) frequency of acute hypertensive response in intracerebral hemorrhage; 2) consequences of acute hypertensive response in clinical outcomes; 3) acute hypertensive response and secondary brain injury: hematoma expansion and perihematomal edema; 4) vascular autoregulation, safety data side effects of acute antihypertensive treatment; and 5) randomized clinical trials and meta-analyses. RESULTS An acute hypertensive response is frequent in patients with acute intracerebral hemorrhage and is associated with poor clinical outcomes. However, it is not clear whether high blood pressure is a cause of poor clinical outcome or solely represents a marker of severity. Although current guidelines recommend intensive blood pressure treatment (<140 mm Hg) in patients with intracerebral hemorrhage, 2 randomized clinical trials have failed to demonstrate a consistent clinical benefit from this approach, and new data suggest that intensive blood pressure treatment could be beneficial for some patients but detrimental for others. CONCLUSIONS Intracerebral hemorrhage is a heterogenous disease, thus, a one-fit-all approach for blood pressure treatment may be suboptimal. Further research should concentrate on finding subgroups of patients more likely to benefit from aggressive blood pressure lowering, considering intracerebral hemorrhage etiology, ultra-early randomization, and risk markers of hematoma expansion on brain imaging.
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Affiliation(s)
- Maximiliano A Hawkes
- From the Department of Neurological Sciences (M.A.H.), University of Nebraska Medical Center, Omaha; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN.
| | - Alejandro A Rabinstein
- From the Department of Neurological Sciences (M.A.H.), University of Nebraska Medical Center, Omaha; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
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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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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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Cantone M, Lanza G, Puglisi V, Vinciguerra L, Mandelli J, Fisicaro F, Pennisi M, Bella R, Ciurleo R, Bramanti A. Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021; 11:70. [PMID: 33430236 PMCID: PMC7825668 DOI: 10.3390/brainsci11010070] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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Affiliation(s)
- Mariagiovanna Cantone
- Department of Neurology, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy
- Department of Neurology IC, Oasi Research Institute—IRCCS, Via Conte Ruggero, 73, 94018 Troina, Italy
| | - Valentina Puglisi
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Jaime Mandelli
- Department of Neurosurgery, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Manuela Pennisi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy;
| | - Rosella Ciurleo
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
| | - Alessia Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
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Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021. [PMID: 33430236 DOI: 10.3390/brainsci11010070.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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