Cortical Intracerebral Hemorrhage Research Articles

Abstract TP157: Utility of CT Angiography in Patients With Intracerebral Hemorrhage

Introduction: Patients with intracerebral hemorrhage (ICH) often undergo CT and CT angiography with the latter being done to identify vascular abnormalities for ICH etiology. It is unclear whether CTA yields are high enough to warrant routine use particularly for subcortical ICH, however. Methods: Retrospective chart review was done on the Loyola Stroke Database of ICH patients over the last 10 years. Data from CT, CTA (and other imaging modalities) regarding ICH size and location, as well as vascular abnormalities, were collected. Demographics, comorbidities, and clinical outcomes were also recorded. Frequencies and percentages are reported to describe overall sample and bivariate associations. Univariate logistic regression estimated unadjusted effects of ICH type, age, hypertension (HTN), and other predictors on the logit of vascular abnormalities. Chi square values are reported for overall interaction effects. Stratified odds ratios (OR) are reported with 95% confidence intervals and p-values. Multivariable binary logistic regression estimated adjusted effects of ICH type on the logit of vascular abnormalities, after adjusting for covariates; OR are reported for adjusted effects. Results: Of 744 ICH cases analyzed, 376 were subcortical (50.54%) and 368 cortical (49.46%). Eighty-one had vascular abnormalities (10.89%); 46 of those being lesion-related (6.18%). Unadjusted odds of lesion-related vascular abnormalities were higher for cortical versus subcortical ICH (OR: 7.04; 95% CI: 3.09, 16.04; p < 0.01). Two-way interaction was non-significant for effects of ICH type and age (p = 0.76), ICH type and HTN (p = 0.68), age and hypertension (p = 0.09), and ICH type and ICH size (p = 0.93) on the logit of lesion-related vascular abnormalities. Thus, these effects did not co-vary significantly with respect to lesion-related vascular abnormalities. Odds of lesion-related vascular abnormalities are significantly higher for cortical versus subcortical ICH, after adjusting for age, HTN ICH size, and CTA (OR: 6.91; 95% CI: 2.93, 16.30; p < 0.01). Conclusion: Our analysis suggests there is decreased utility for CTA in subcortical compared to cortical ICH and CTA should probably not be performed routinely on subcortical ICH.

Surgical hematoma evacuation of cortical intracerebral hemorrhage ≥10ml reduces risk of subsequent epilepsy by more than 70%: A retrospective monocenter study.

The aim of this study was to re-evaluate risk factors for post-ICH epilepsy (PICHE) and examine the impact of surgical hematoma evacuation on epilepsy development afterICH. Epilepsy is a common complication after intracerebral hemorrhage (ICH). Information on risk factors is still scarce and the role of ICH evacuation remains uncertain. We retrospectively included patients with spontaneous ICH treated in our hospital in 2006-2019. Patients' medical records were analyzed. In addition, mailed questionnaires and telephone interviews were used to complete the dataset. Uni- and multivariable hazard ratios (HRs) were applied to investigate risk factors for PICHE and the impact of surgical ICH evacuation. Among 587 ICH patients available for analyses, 139 (23.7%) developed PICHE (mean follow-up 1795 ± 1378 days). The median time of epilepsy onset was 7months after ICH (range 1-132 months). Risk factors associated with PICHE were cortical hemorrhage (multivariable HR 1.65 [95% CI 1.14-2.37]; p=0.008), ICH volume > 10ml (multivariable HR 1.91 [95% CI 1.33-2.73]; p < 0.001) and acute symptomatic seizures (multivariable HR 1.81 [95% CI 1.20-2.75]; p=0.005). Patients with cortical ICH > 10ml who underwent surgical hematoma evacuation were less likely to develop epilepsy than those with conservative treatment alone (multivariable HR 0.26 [95% CI 0.08-0.84]; p=0.025). Post-ICH epilepsy is frequent and predicted by large cortical ICH and acute symptomatic seizures. Hematoma evacuation reduced the risk of PICHE by more than 70% in patients with large cortical ICH. This finding could be considered in the clinical decision making on the acute treatment of ICH.

Nrf2-BDNF-TrkB pathway contributes to cortical hemorrhage-induced depression, but not sex differences

Post-stroke depression, observed in 30-50% of stroke patients, negatively affects quality of life and mortality. The pathogenesis of post-stroke depression is complex, but heightened reactive oxygen species production and inflammation might be two key factors. We have reported that intracerebral hemorrhage (ICH) in cerebral cortex produces depression-like behavior in young male mice. Here, we found that mice lacking nuclear factor erythroid-derived 2-related factor 2 (Nrf2), a transcription factor that upregulates antioxidant proteins and trophic factors such as brain-derived neurotrophic factor (BDNF), had more severe depression-like behavior than wild-type mice at days 21 to 28 after cortical ICH (c-ICH). Moreover, the expression of Nrf2, heme oxygenase-1, BDNF, and TrkB were significantly decreased in wild-type mice after c-ICH. Interestingly, TP-500 (2 mg/kg), a potent Nrf2 inducer, decreased the inflammatory response and reactive oxygen species production on day 28 after c-ICH and improved depression-like behaviors. TrkB receptor antagonist ANA-12 abolished this anti-depression effect. Depression was more severe in female than in male wild-type mice after ICH, but TP-500 improved depression-like behavior in females. These results suggest that downregulation of Nrf2-BDNF-TrkB signaling contributes to development of post-stroke depression, and that Nrf2 inducer TP-500 might improve depression after c-ICH.

Changes in motor function, cognition, and emotion-related behavior after right hemispheric intracerebral hemorrhage in various brain regions of mouse

Intracerebral hemorrhage (ICH) is a detrimental type of stroke. Mouse models of ICH, induced by collagenase or blood infusion, commonly target striatum, but not other brain sites such as ventricular system, cortex, and hippocampus. Few studies have systemically investigated brain damage and neurobehavioral deficits that develop in animal models of ICH in these areas of the right hemisphere. Therefore, we evaluated the brain damage and neurobehavioral dysfunction associated with right hemispheric ICH in ventricle, cortex, hippocampus, and striatum. The ICH model was induced by autologous whole blood or collagenase VII-S (0.075 units in 0.5 µl saline) injection. At different time points after ICH induction, mice were assessed for brain tissue damage and neurobehavioral deficits. Sham control mice were used for comparison. We found that ICH location influenced features of brain damage, microglia/macrophage activation, and behavioral deficits. Furthermore, the 24-point neurologic deficit scoring system was most sensitive for evaluating locomotor abnormalities in all four models, especially on days 1, 3, and 7 post-ICH. The wire-hanging test was useful for evaluating locomotor abnormalities in models of striatal, intraventricular, and cortical ICH. The cylinder test identified locomotor abnormalities only in the striatal ICH model. The novel object recognition test was effective for evaluating recognition memory dysfunction in all models except for striatal ICH. The tail suspension test, forced swim test, and sucrose preference test were effective for evaluating emotional abnormality in all four models but did not correlate with severity of brain damage. These results will help to inform future preclinical studies of ICH outcomes.

Drops in Barometric Pressure Are Associated with Deep Intracerebral Hemorrhage

The objective of this study is to assess the effects of changes in barometric pressure and outdoor temperature on the incidence of different subtypes of intracerebral hemorrhage (ICH). Consecutive patients with primary supratentorial ICH were included. All patients resided in the same geographic area. We compared patients with subcortical ICH to those with cortical ICH. Meteorological data were continuously accrued. High-risk ICH days were defined as those on which 1 or more patients with ICH were admitted and compared to non-high-risk days. We analyzed the relationship between spontaneous ICH location and averaged daily atmospheric pressures and temperatures. We included 206 patients (147 with deep ICH and 59 with lobar ICH). Patients with deep ICH were younger (P < .001), more often had histories of diabetes, smoking and previous lacunar strokes, and were more often male (P < .01 for all). Drops in mean air pressure 2 days prior to the ictus were associated with deep but not lobar ICH (P = .006). Deep ICH clustered during February months in parallel with larger changes in barometric pressures (P < .001). Drops in daily atmospheric pressures were associated with deep but not cortical ICH, suggesting a link to hypertensive etiology. Changes in barometric pressures were also associated with higher monthly frequencies of ICH.

Mouse models of intracerebral hemorrhage in ventricle, cortex, and hippocampus by injections of autologous blood or collagenase.

Intracerebral hemorrhage (ICH) is a devastating condition. Existing preclinical ICH models focus largely on striatum but neglect other brain areas such as ventricle, cortex, and hippocampus. Clinically, however, hemorrhagic strokes do occur in these other brain regions. In this study, we established mouse hemorrhagic models that utilize stereotactic injections of autologous whole blood or collagenase to produce ventricular, cortical, and hippocampal injury. We validated and characterized these models by histology, immunohistochemistry, and neurobehavioral tests. In the intraventricular hemorrhage (IVH) model, C57BL/6 mice that received unilateral ventricular injections of whole blood demonstrated bilateral ventricular hematomas, ventricular enlargement, and brain edema in the ipsilateral cortex and basal ganglia at 72 h. Unilateral injections of collagenase (150 U/ml) caused reproducible hematomas and brain edema in the frontal cortex in the cortical ICH (c-ICH) model and in the hippocampus in the hippocampal ICH (h-ICH) model. Immunostaining revealed cellular inflammation and neuronal death in the periventricular regions in the IVH brain and in the perihematomal regions in the c-ICH and h-ICH brains. Locomotor abnormalities measured with a 24-point scoring system were present in all three models, especially on days 1, 3, and 7 post-ICH. Locomotor deficits measured by the wire-hanging test were present in models of IVH and c-ICH, but not h-ICH. Interestingly, mice in the c-ICH model demonstrated emotional abnormality, as measured by the tail suspension test and forced swim test, whereas h-ICH mice exhibited memory abnormality, as measured by the novel object recognition test. All three ICH models generated reproducible brain damage, brain edema, inflammation, and consistent locomotor deficits. Additionally, the c-ICH model produced emotional deficits and the h-ICH model produced cognitive deficits. These three models closely mimic human ICH and should be useful for investigating the pathophysiology of ICH in ventricle, cortex, and hippocampus and for evaluating potential therapeutic strategies.

Stroke : Highlights of Selected Articles

HomeStrokeVol. 44, No. 6Stroke: Highlights of Selected Articles Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBStroke: Highlights of Selected Articles Scott B. Silverman, MD Scott B. SilvermanScott B. Silverman Search for more papers by this author Originally published1 Jun 2013https://doi.org/10.1161/STROKEAHA.113.002000Stroke. 2013;44:1499Paroxysmal Supraventricular Tachycardia and the Risk of Ischemic StrokeAtrial fibrillation and atrial flutter are currently the only cardiac arrhythmias known to be risk factors for ischemic stroke. Patients with cardioembolic-appearing stroke have supraventricular arrhythmias more often than patients with other types of stroke. Multiple studies have also shown a link between frequent supraventricular ectopy and stroke in the absence of atrial fibrillation. Paroxysmal supraventricular tachycardia (PSVT) affects mostly older patients who have a high burden of cardiovascular disease. Atrial fibrillation is associated with PSVT. The current retrospective study by Kamel et al sought to demonstrate a possible association between PSVT and stroke. They reviewed ≈4.8 million patients from emergency room visits and hospitalizations at California’s nonfederal acute care hospitals in 2009. Of these patients, >14 000 (0.29%) were diagnosed with PSVT, and >14 000 (0.30%) had a diagnosis of ischemic stroke. Patients with PSVT were older and had significantly more cardiovascular risk factors than patients without PSVT. The cumulative stroke rate after the diagnosis of PSVT (0.94%) significantly exceeded the rate among patients without PSVT (0.21%; P<0.001). Stroke occurred a median of 70 days after index visit. PSVT was independently associated with a higher risk of subsequent stroke (hazard ratio, 2.10). An age cutoff existed such that PSVT was associated with a higher risk of stroke in patients ≥65 years old. This is an important work, for PSVT may be an independent risk factor for ischemic stroke and thus accounts for a proportion of stroke currently classified as cryptogenic. Further prospective studies are needed. See p 1550.Incidence and Predictors of Late Seizures in Intracerebral HemorrhagesThe Prognosis of InTra-Cerebral Hemorrhage cohort is an observational cohort at the Lille University Hospital in France. Early seizures were classified as ≤7 days and late seizures (LSs) as >7 days after stroke onset. The authors previously reported an early seizure incidence of 14%. Early seizures in this cohort were associated with cortical intracerebral hemorrhage and did not influence in-hospital mortality or 6-month outcome. The current study population consisted of 324 patients. During 778 person-years of follow-up, 31 patients developed ≥1 LS, resulting in an incidence rate of 4 new cases/100 person-years. Nine months were the median delay between intracerebral hemorrhage and LS. Cortical involvement of the intracerebral hemorrhage was the only factor independently associated with LS. Lobar microbleeds were predictors of LS as well. Early seizures were not predictive of LSs. Interestingly, LSs were associated with a worse functional outcome after 3 years of follow-up. Further prospective studies are needed to confirm these findings. It would be interesting to know as well whether location of the cortical hemorrhage and microbleed differed significantly with the risk of LS. See p 1723. Previous Back to top Next FiguresReferencesRelatedDetails June 2013Vol 44, Issue 6 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.113.002000 Originally publishedJune 1, 2013 PDF download Advertisement

Intra-Arterial Iodinated Radiographic Contrast Material Injection Administration in a Rat Middle Cerebral Artery Occlusion and Reperfusion Model

Observations in human interventional stroke treatment led us to hypothesize that iodinated radiographic contrast material use may contribute to intracerebral hemorrhage. Effects of intra-arterial iodinated radiographic contrast material on hemorrhagic transformation after middle cerebral artery occlusion and reperfusion were studied in a placebo-controlled, blinded preclinical study in rats. Four groups of male Sprague-Dawley rats were studied: saline group (n=8), contrast group (n=12), heparin group (n=9), and contrast+heparin group (n=9). The middle cerebral artery was occluded for 5 hours using suture placement. Heparin was infused before suture removal and reperfusion. Saline and/or contrast were infused immediately during reperfusion. Incidence, location, and size of hemorrhage were determined by brain necropsy inspection at 24 hours. There was a significant increase in incidence of cortical hemorrhage from control (37.5%), contrast (75.0%), heparin (77.8%) to contrast+heparin (100%; Cochran-Mantel-Haenszel correlation, P<0.01). Both pooled contrast groups (85.7%) and pooled heparin groups (88.9%) had higher rates of cortical intracerebral hemorrhage compared with the control group (P<0.05). Similar trends for increased cortical intracerebral hemorrhage were seen in the contrast-only (P=0.18) and heparin-only (P=0.18) groups. There was a trend for decreased infarct edema in rats receiving contrast versus those without (P=0.06). Intraarterial iodinated radiographic contrast material may increase cortical intracerebral hemorrhage, similar to heparin. Iodinated radiographic contrast material effect may be additive to heparin effect on the incidence of cortical intracerebral hemorrhage.

Electrographic seizures and periodic discharges after intracerebral hemorrhage

To determine the frequency and significance of electrographic seizures and other EEG findings in patients with intracerebral hemorrhage (ICH). We reviewed 102 consecutive patients with ICH who underwent continuous electroencephalographic monitoring (cEEG). Demographic, clinical, radiographic, and cEEG findings were recorded. Using multivariate logistic regression analysis, we determined factors associated with 1) electrographic seizures, 2) periodic epileptiform discharges (PEDs), and 3) poor outcome (death, vegetative or minimally conscious state) at hospital discharge. Seizures occurred in 31% (n = 32) of patients with ICH, prior to cEEG in 19 patients. Eighteen percent (n = 18) of patients had electrographic seizures; only one of these patients also had clinical seizures while on cEEG. After controlling for demographic and clinical predictors, only an increase in ICH volume of 30% or more between admission and 24-hour follow-up CT scan was associated with electrographic seizures (33% vs 15%; OR 9.5, 95% CI 1.7 to 53.8). PEDs were less frequently seen in those with hemorrhages located at least 1 mm from the cortex (8% vs 29%; OR 0.2, 95% CI 0.1 to 0.7). PEDs were independently associated with poor outcome (65% vs 17%; OR 7.6, 95% CI 2.1 to 27.3). In patients with electrographic seizures, the first seizure was detected within the first hour of cEEG monitoring in 56% and within 48 hours in 94%. Seizures occurred in one third of patients with intracerebral hemorrhage (ICH) and over half were purely electrographic. Electrographic seizures were associated with expanding hemorrhages, and periodic discharges with cortical ICH and poor outcome. Further research is needed to determine if treating or preventing seizures or PEDs might lead to improved outcome after ICH.