CLINICAL AND NEUROIMAGING STUDIES IN PATIENTS WITH ACUTE SPONTANEOUS INTRACEREBRAL HEMORRHAGE.

Objective: To define the prognostic value of clinical and neuroimaging parameters on the 30-th day mortality and clinical outcome after spontaneous intracerebral hemorrhage (sICH). Materials and methods: we examined 88 patients with sICH admitted to Neurology Clinic, UMHAT Pleven within 48 hours after clinical symptoms onset. Glasgow Coma Scale (GCS) score was used to assess the primary stroke severity; neurological deficit on admission was assessed by National Institute of Health Stroke Scale (NIHSS); clinical outcome at discharge was evaluated by modified Rankin Scale (mRS) and by Glasgow Outcome Scale (GOS) on the 30-th day after sICH onset. Hematoma volume was measured by the formula of Kothari: AxBxC/2 in ml. The statistical analysis was performed by SPSS 19.0 and Statgraphics plus 4.1 for Windows. Results: Initial assessment of primary stroke severity and neurological deficit by GCS и NIHSS, hematoma localization and volume were found strongly correlated with the clinical outcome on the 30-th day after the sICH onset. Age and vascular risk factors did not correlate with the clinical outcome. Male patients had better survival on the 30-th day compared with the female ones. Discussion: Neurological deficit on admission, hematoma localization and volume were found reliable predictors of the 30-th day clinical outcome that could serve for early stratification of patients and optimal choice of therapeutic approach

Seizures and antiepileptic drugs in patients with spontaneous intracerebral hemorrhages

AbstractPurposePatients with intracerebral hemorrhage (ICH) are often initiated on antiepileptic drugs without a clear indication. We compared the percentage of patients with spontaneous ICH who had seizures at onset or during hospitalization, and examined empiric use of antiepileptic drugs (AEDs) in these patients in 2 cohorts 10 years apart.MethodsUsing a clinical data registry at a tertiary care adult hospital, we retrospectively selected admissions for spontaneous ICH between 1/1/99–12/31/00 (Cohort A, n=30) and 1/1/09–12/31/10 (Cohort B, n=108). Clinical, neurophysiological and radiological data were collected in both cohorts.ResultsIn Cohorts A and B respectively, AEDs were started in 53.3% and 50.0%, and continued on discharge in 50.0% and 20.4% of patients; 86.6% and 59.1% of patients discharged on AEDs did not have a clinical/electrographic seizure or epileptiform EEG findings. Seizures occurred in 6.6% and 13.0% in Cohorts A and B respectively. The presence of a seizure at presentation (p=0.01) and during hospitalization (p=0.02) were predictors for continuing AED on discharge.ConclusionIn both cohorts, a significant number of patients were discharged on AEDs without a clear indication, though there is a change in practice between the two cohorts

Improving Acute Stroke Management with CT Perfusion Imaging: Approaches to Treatment Guidance and Brain Tissue Salvage

CT Perfusion (CTP) provides measurement of perfusion at the capillary level which can be used to characterize tissue viability, and blood-brain-barrier (BBB) compromise. Using CTP, the goals of this research are to: 1) select patients that will benefit from acute stroke treatment, and 2) determine if pre-stroke neuroprotection reduces stroke severity. Chapter two investigates the cerebral blood volume (CBV) parameter in a small acute ischemic stroke (AIS) patient set. Overestimation of the acute CBV defect is caused by incomplete wash-out of the CT contrast due to a shortened CTP acquisition time (“truncation artifact”). In chapter three we examine the prognostic reliability of the acute CBV defect to predict infarct core and penumbra in AIS. We determine that hypervolemia, the “truncation artifact” and recanalization are all important variables which affect the relationship between the acute CBV defect volume and the final infarct volume. Chapter four implements a novel porcine model of ischemic stroke using the transient vasoconstrictor, endothelin-1. Using this model, we show that the CTP-cerebral blood flow (CBF) parameter is as good as MR-DWI for acute infarct core delineation, and the CBF/CBV mismatch may not indicate penumbral tissue in the acute stroke setting. In Chapter five, it we show that vascular integrity measured with the CTP-BBB permeability surface area product (PS) is a strong predictor of sub-acute bleeding in the brain (hemorrhagic transformation). Chapter six shows that different rates of CT contrast extravasation exist for primary intracerebral hemorrhage (ICH) patients with/without the CTA-Spot Sign and/or post-contrast leakage. Furthermore, early rates of extravasation are correlated with sub-acute hematoma expansion. Chapter seven describes the development of an improved, reproducible and survivable rabbit large clot embolic model (RLCEM) of cerebral ischemia for testing treatment options for AIS. We demonstrate that pre-stroke treatment with dipyridamole provides a neurovascular advantage post stroke onset. In summary, the current uses of CTP imaging in acute stroke include: 1) quantifying ischemia to define infarct core and penumbra in AIS, 2) predicting hemorrhagic transformation of AIS, 3) predicting hematoma expansion in primary ICH, and 4) assessing treatment response in animal models of stroke to facilitate new drug development

A nested mechanistic sub-study into the effect of tranexamic acid versus placebo on intracranial haemorrhage and cerebral ischaemia in isolated traumatic brain injury: study protocol for a randomised controlled trial (CRASH-3 Trial Intracranial Bleeding Mechanistic Sub-Study [CRASH-3 IBMS]).

BACKGROUND: Tranexamic acid prevents blood clots from breaking down and reduces bleeding. However, it is uncertain whether tranexamic acid is effective in traumatic brain injury. The CRASH-3 trial is a randomised controlled trial that will examine the effect of tranexamic acid (versus placebo) on death and disability in 13,000 patients with traumatic brain injury. The CRASH-3 trial hypothesizes that tranexamic acid will reduce intracranial haemorrhage, which will reduce the risk of death. Although it is possible that tranexamic acid will reduce intracranial bleeding, there is also a potential for harm. In particular, tranexamic acid may increase the risk of cerebral thrombosis and ischaemia. The protocol detailed here is for a mechanistic sub-study nested within the CRASH-3 trial. This mechanistic sub-study aims to examine the effect of tranexamic acid (versus placebo) on intracranial bleeding and cerebral ischaemia. METHODS: The CRASH-3 Intracranial Bleeding Mechanistic Sub-Study (CRASH-3 IBMS) is nested within a prospective, double-blind, multi-centre, parallel-arm randomised trial called the CRASH-3 trial. The CRASH-3 IBMS will be conducted in a cohort of approximately 1000 isolated traumatic brain injury patients enrolled in the CRASH-3 trial. In the CRASH-3 IBMS, brain scans acquired before and after randomisation are examined, using validated methods, for evidence of intracranial bleeding and cerebral ischaemia. The primary outcome is the total volume of intracranial bleeding measured on computed tomography after randomisation, adjusting for baseline bleeding volume. Secondary outcomes include progression of intracranial haemorrhage (from pre- to post-randomisation scans), new intracranial haemorrhage (seen on post- but not pre-randomisation scans), intracranial haemorrhage following neurosurgery, and new focal ischaemic lesions (seen on post-but not pre-randomisation scans). A linear regression model will examine whether receipt of the trial treatment can predict haemorrhage volume. Bleeding volumes and new ischaemic lesions will be compared across treatment groups using relative risks and 95% confidence intervals. DISCUSSION: The CRASH-3 IBMS will provide an insight into the mechanism of action of tranexamic acid in traumatic brain injury, as well as information about the risks and benefits. Evidence from this trial could inform the management of patients with traumatic brain injury. TRIAL REGISTRATION: The CRASH-3 trial was prospectively registered and the CRASH-3 IBMS is an addition to the original protocol registered at the International Standard Randomised Controlled Trials registry ( ISRCTN15088122 ) 19 July 2011, and ClinicalTrials.gov on 25 July 2011 (NCT01402882)

Spontaneous intracerebral supratentorial hemorrhage: general aspects and updates in surgical treatment

Laboratory of Neurosurgery Anesthesia and Reanimation, Institute of Neurology and Neurosurgery, Department of Neurology, Institute of Emergency Medicine, Department of Radiology and Medical Imaging, Nicolae Testemitsanu State University of Medicine and Pharmacy, Chisinau, the Republic of MoldovaBackground: Spontaneous intracerebral hemorrhage (SIH) accounts for 9 to 25% of all strokes and is associated with a high morbidity and mortality, with less than 40% of affected persons surviving 1 year. The condition commonly presents a sudden onset of focal neurological deficits with accompanying headache, nausea, vomiting, elevated blood pressure and altered consciousness. Medical treatment commonly includes airway support, blood pressure control, management of cerebral edema, symptomatic therapy such as anticonvulsive medication, anticoagulation reversal etc. Different surgical options such as open craniotomy, stereotactic aspiration, endoscopic evacuations with or without thrombolysis have also been considered. Most of these techniques have already been implemented successfully in the Republic of Moldova. According to the data of the Institute of Neurology and Neurosurgery and the Institute of Emergency Medicine for the period 2011-2014, just within these two institutions were performed 137 neurosurgical interventions, including 67 interventions involving minimally invasive techniques with local fibrilolysis and 70 interventions involving other minimally invasive surgery or conventional craniotomy. The obtained results are in concordance with those reported by other European institutions. Conclusions: The continuous efforts to improve the outcome of SIH during the recent years have led to the development of a variety of minimally invasive techniques, most of which have already been adopted by the autochthonous surgeons. New randomized controlled trials are required to establish the suitability of these techniques for different clinical situations and SIH localizations

The signs of computer tomography combined with artificial intelligence can indicate the correlation between status of consciousness and primary brainstem hemorrhage of patients

BackgroundFor patients of primary brainstem hemorrhage (PBH), it is crucial to find a method that can quickly and accurately predict the correlation between status of consciousness and PBH.ObjectiveTo analyze the value of computer tomography (CT) signs in combination with artificial intelligence (AI) technique in predicting the correlation between status of consciousness and PBH.MethodsA total of 120 patients with PBH were enrolled from August 2011 to March 2021 according to the criteria. Patients were divided into three groups [consciousness, minimally conscious state (MCS) and coma] based on the status of consciousness. Then, first, Mann–Whitney U test and Spearman rank correlation test were used on the factors: gender, age, stages of intracerebral hemorrhage, CT signs with AI or radiology physicians, hemorrhage involving the midbrain or ventricular system. We collected hemorrhage volumes and mean CT values with AI. Second, those significant factors were screened out by the Mann–Whitney U test and those highly or moderately correlated by Spearman’s rank correlation test, and a further ordinal multinomial logistic regression analysis was performed to find independent predictors of the status of consciousness. At last, receiver operating characteristic (ROC) curves were drawn to calculate the hemorrhage volume for predictively assessing the status of consciousness.ResultsPreliminary meaningful variables include hemorrhage involving the midbrain or ventricular system, hemorrhage volume, grade of hematoma shape and density, and CT value from Mann–Whitney U test and Spearman rank correlation test. It is further shown by ordinal multinomial logistic regression analysis that hemorrhage volume and hemorrhage involving the ventricular system are two major predictors of the status of consciousness. It showed from ROC that the hemorrhage volumes of <3.040 mL, 3.040 ~ 6.225 mL and >6.225 mL correspond to consciousness, MCS or coma, respectively. If the hemorrhage volume is the same, hemorrhage involving the ventricular system should be correlated with more severe disorders of consciousness (DOC).ConclusionCT signs combined with AI can predict the correlation between status of consciousness and PBH. Hemorrhage volume and hemorrhage involving the ventricular system are two independent factors, with hemorrhage volume in particular reaching quantitative predictions