Hematoma Volume Reduction Research Articles

Ultrasound-guided suction using negative pressure, curettage, and percutaneous drainage to treat rectus sheath hematoma

BackgroundThis study aimed to introduce and evaluate a new treatment method for rectus sheath hematoma: ultrasound-guided suction using negative pressure, curettage, and percutaneous drainage. MethodsThis retrospective study involved five patients with rectus sheath hematoma rectus sheath hematoma who had cesarean sections. For all patients, ultrasound revealed that the maximum diameter of their hematoma exceeded 70 mm. We summarized and analyzed the therapeutic effects of five patients and introduced the procedure, technical points, precautions, advantages, and indications of the procedure. ResultsIn all five patients, hematoma area was significantly reduced as confirmed by ultrasound at follow-up, and all patients’ abdominal pain were significantly relieved. No complications, including bleeding or infection, were detected at both the 2-h postoperative and 3-day follow-up assessments. The hematoma volume reduction rates were 90 %, 67 %, 81 %, 68 %, and 70 % at three days re-examinations, and 99 %, 96 %, 98 %, 98 %, and 90 % at the 30-day follow-up. ConclusionThe removal of rectus sheath hematoma by suction using negative pressure can prevent patients from undergoing abdominal wall exploration, offering a less invasive alternative while potentially achieving comparable therapeutic effect to surgical hematoma removal in certain cases. This treatment method shows potential for clinical application, particularly in relatively young and healthy postpartum women, and is expected to be popularized and applied in clinical practice.

Comparison of adjunctive middle meningeal artery embolization using embosphere particles versus surgical drainage alone for the treatment of chronic subdural hematoma: A prospective study

BackgroundMiddle meningeal artery embolization (MMAE) has emerged as a primary and adjunctive therapy for chronic subdural hematoma (CSDH) in addition to conventional treatment. However, there is a scarcity of data that explicitly compares the effectiveness of adjunctive MMAE to surgical drainage alone (SDA), as well as the use of Embosphere particles. The objective of this study was to assess the safety and efficacy of adjunctive MMAE in the treatment of symptomatic CSDH compared to SDA. MethodsThis prospective study included 43 patients with 52 CSDH sides, treated at a single institution between 2022 and 2023. The primary outcome was postoperative hematoma volume at 14, 30, 90, and 180 days after surgical drainage, which was analyzed using the generalized estimating equation. The secondary outcomes were the complications and recurrence/reoperation rate. Adjunctive MMAE was performed within 7 days following the surgery, utilizing Embosphere as the embolic material. ResultsThe patients were assigned to either the adjunctive MMAE group (n = 20, 26 CSDH sides) or the SDA group (n = 23, 26 CSDH sides). The adjunctive MMAE group demonstrated a more significant reduction in hematoma volume (p = 0.007) and maximal hematoma thickness (p = 0.016) at all follow-up intervals. A trend towards lower recurrence and reoperation rates was observed with adjunctive MMAE; particularly, none of the patients in the adjunctive MMAE group experienced a recurrence of CSDH, compared to 19.2 % in the SDA group (p = 0.051). One procedural-related complication (3.8 %) in the adjunctive MMAE group. ConclusionOur results suggested that adjunctive MMAE, compared to SDA, may enhance hematoma resolution and reduce the need for reoperation due to recurrence.

Efficacy and safety of neuroendoscopy surgery versus craniotomy for supratentorial intracerebral hemorrhage: an updated meta-analysis of randomized controlled trials.

Neuroendoscopy (NE) surgery emerged as a promising technique for the treatment of spontaneous intracerebral hemorrhage (ICH). A previous meta-analysis of randomized controlled trials (RCTs) analyzed the efficacy and safety of NE compared to craniotomy, but NE did not present a significant improvement in functional outcomes. However, a new study provided an opportunity to update the current knowledge. We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for RCTs reporting NE evacuation of spontaneous supratentorial ICH compared to craniotomy. The efficacy outcomes of interest were favorable functional outcome, functional disability, hematoma evacuation rate, and residual hematoma volume. The safety outcomes of interest were rebleeding, infection, and mortality. Seven RCTs were included containing 879 patients. The NE approach presented a significantly higher rate of favorable functional outcome compared with craniotomy (RR: 1.42; 95% CI 1.17, 1.73; p < 0.001). The evacuation rate was higher in patients who underwent the NE approach (MD: -8.36; 95% CI -12.66, -4.07; p < 0.001). NE did not show a benefit in improving the mortality rate (RR: 0.81, 95% CI 0.54, 1.22; p = 0.32). NE was associated with more favorable functional outcomes and lower rates of functional disabilities compared to craniotomy. Also, NE was superior regarding evacuation rate, while presenting a reduction in residual hematoma volume. NE might be associated with lower infection rates. Mortality was not improved by NE surgery. Larger, higher-quality randomized studies are needed to adequately evaluate the efficacy and safety of NE compared to craniotomy.

IV Flat Detector CT Angiography in Flat Detector CT Image-Guided Minimally Invasive Surgery for the Treatment of Intracerebral Hypertensive Hemorrhage.

Spontaneous intracerebral hemorrhage is a serious stroke subtype with high mortality and morbidity. Minimally invasive surgery plus thrombolysis is a promising treatment option, but it requires accurate catheter placement and real-time monitoring. The authors introduced IV flat detector CT angiography (ivFDCTA) into the minimally invasive surgery procedure for the first time, to provide vascular information and guidance for hematoma evacuation. Thirty-six patients with hypertensive intracerebral hemorrhage were treated with minimally invasive surgery under the guidance of ivFDCTA and flat detector CT (FDCT) in the angiography suite. The needle path and puncture depth were planned and calculated using software on the DSA workstation. The hematoma volume reduction, operation time, complications, and clinical outcomes were recorded and evaluated. The mean preoperative hematoma volume of 36 patients was 35 (SD, 12) mL, the mean intraoperative volume reduction was 19 (SD, 11) mL, and the mean postoperative residual hematoma volume was 15 (SD, 8) mL. The average operation time was 59 (SD, 22) minutes. One patient had an intraoperative epidural hematoma, which improved after conservative treatment. The mean Glasgow Outcome Scale score at discharge was 4.3 (SD, 0.8), and the mean mRS score at 90 days was 2.4 (SD, 1.1). The use of ivFDCTA in the evacuation of an intracerebral hemorrhage hematoma could improve the safety and efficiency of minimally invasive surgery and has shown great potential in hemorrhagic stroke management in selected patients.

Abstract TP156: The Stereotactic Intracerebral Hemorrhage Underwater Blood Aspiration (SCUBA) Technique for Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation: A Pilot Study

Introduction: Spontaneous intracerebral hemorrhages (ICH) remains the most devastating form of stroke. Only approximately 20% survivors achieve functional independence at six months after ICH. Up to today, there are no medical or surgical treatments with proven functional benefits for this population. The Stereotactic ICH Underwater Blood Aspiration (SCUBA) allows minimally invasive endoscopic hematoma evacuation in basal ganglia. In this pilot study, we tested that early hematoma evacuation by SCUBA may improve functional outcome. Methods: The Study included 10 ICH patients (age 18-85 years, pre-morbid mRS 0-1, hematoma volume 30-90ml) who underwent SCUBA from 2019 to 2022. SCUBA patient was matched with control ICH patient who received standard medical treatment at 1:1 ratio by variables (hematoma volume and laterality, intraventricular hemorrhage [IVH] with hydrocephalus, age, NIHSS, GCS). The comparison between SCUBA and Controls were carried out by T-test, Mann-Whitney U Test or Fisher's Exact Test as appropriate. Results: Of the 10-paired SCUBA patients and controls, the mean age was 66 years, 45.0% were females, pre-op median NIHSS of 18, 45.0% were intubated, and 30.0% had IVH with hydrocephalus and EVD placed. Among SCUBA patients, the median hematoma volume is 34.0 ml; 90.0% of hematoma was located in basal ganglia. The median time from the last known well to SCUBA initiation was 22.3 hours. Hematoma volume reduction by 80% was achieved in 70.0% of SCUBA patients and 100.0% patients with residual hematoma volume less than 15 ml. SCUBA patients had shorter median NeuroICU stay than controls (SCUBA 5 vs. Control 11 days, p=0.029). SCUBA patients tended to have lower hospital mortality rate (SCUBA 10% vs. Control 20%), and a higher proportion of SCUBA patients were discharged to acute rehab (SCUBA 50% vs. Control 10%). At three months of follow-up, none of the patients were functionally independent, but more SCUBA patients achieved mRS 3 (SCUBA 37.5% vs. Control 16.7%). Conclusions: Our pilot study suggests that early SCUBA can efficiently evacuate deep hematoma with potential of improving functional outcome. Further study requires more patients and longer follow-up.

CD22 blockade modulates microglia activity to suppress neuroinflammation following intracerebral hemorrhage

Microglia are first responders to acute brain insults and initiate neuroinflammation to drive secondary tissue injury. Yet the key molecular switches in control of the inflammatory activity of microglia remain poorly understood. Intracerebral hemorrhage (ICH) is a devastating stroke subtype whereby a hematoma is formed within the brain parenchyma and associated with high mortality. Using a mouse model of ICH, we found upregulation of CD22 that predominantly occurred in microglia. Antibody blockade of CD22 led to a reduction in neurological deficits, brain lesion and hematoma volume. This was accompanied by reduced inflammatory activity, increased expression of alternative activation markers (CD206 and IL-10) and enhanced phagocytosis activity in microglia after ICH. CD22 blockade also led to an increase of phosphorylated SYK and AKT after ICH. Notably, the benefits of CD22 blockade were ablated in ICH mice subjected to microglial depletion with a colony-stimulating factor 1 receptor inhibitor PLX5622. Additionally, the protective effects of CD22 blockade was diminished in ICH mice receiving a SYK inhibitor R406. Together, our findings highlight CD22 as a key molecular switch to control the detrimental effects of microglia after acute brain injury, and provide a novel strategy to improve the outcome of ICH injury.

Neural network for autonomous segmentation and volumetric assessment of clot and edema in acute and subacute intracerebral hemorrhages

IntroductionMinimally-invasive surgical techniques for intracerebral hemorrhage (ICH) evacuation use imaging to guide the suction, lysing and/or drainage from the hemorrhage site via various designs. A previous international surgical study has shown that reduction of hematoma volume below 15 ml is indicative of improved long term patient outcomes. The study noted a need for tools to periodically visualize remaining clot during intervention to increase the likelihood of evacuating sufficient clot volumes without endangering rebleeds. Robust segmentation of MRI could guide surgeons and radiologists regarding remaining regions and approaches for prudent evacuation. We thus propose a Convolutional Neural Network (CNN) to identify and autonomously segment clot and peripheral edema in MR images of the brain and generate an estimate of the remaining clot volume. Materials and methodsWe used a retrospective, locally-acquired dataset of ICH patient scans taken on 3 T MRI scanners. Three sets of ground truth manual segmentations were independently generated by two imaging scientists and one radiology fellow. Evaluation of clot age was determined based on relative contrast of hemorrhage components and reviewed by a neurosurgeon. Model accuracy was determined by pixel-wise Dice coefficient (DC) calculations between each ground truth manual segmentation and the machine-derived autonomous segmentations. ResultsThe model produced autonomous segmentations of clot core with an average DC of 0.75 ± 0.21 relative to manual segmentations of the same scans. For edema, it produced segmentations with an average DC of 0.68 ± 0.16 relative to manual. From these pixel-wise segmentations, clot volume can be calculated. Model-produced segmentations underestimated clot volumes by an average of 17% relative to ground-truth. ConclusionThe machine learning models were able to identify and segment volumes of ICH components swiftly and accurately.

Clinical application of 3DSlicer and Sina in minimally invasive puncture drainage of elderly patients with spontaneous intracerebral hemorrhage under local anesthesia

BackgroundDecreased organ function and poor physical compensatory capacity in elderly patients diagnosed with spontaneous intracerebral hemorrhage (ICH) can make surgical treatment procedures challenging and risky. Minimally invasive puncture drainage (MIPD) combined with urokinase infusion therapy is a safe and feasible method of treating ICH. This study aimed to compare the treatment efficacy of MIPD conducted under local anesthesia using either 3DSlicer + Sina application or computer tomography (CT)–guided stereotactic localization of hematomas in elderly patients diagnosed with ICH. MethodsThe study sample included 78 elderly patients (≥ 65 years of age) diagnosed with ICH for the first time. All patients exhibited stable vital signs and underwent surgical treatment. The study sample was randomly divided into two groups, either receiving 3DSlicer+Sina or CT-guided stereotactic assistance. The preoperative preparation time; hematoma localization accuracy rate; satisfactory hematoma puncture rate; hematoma clearance rate; postoperative rebleeding rate; Glasgow Coma Scale (GCS) score after 7 days; and modified Rankin scale (mRS) score 6 months after surgery were compared between the two groups. ResultsNo significant differences in gender, age, preoperative GCS score, preoperative hematoma volume (HV), and surgical duration were observed between the two groups (all p-values > 0.05). However, the preoperative preparation time was shorter in the group receiving 3DSlicer + Sina assistance compared to that receiving CT-guided stereotactic assistance (p-value < 0.001). Both groups exhibited significant improvement in GCS scores and reduction in HV after surgery (all p-values < 0.001). The accuracy of hematoma localization and puncture was 100% in both groups. There were no significant differences in surgical duration, postoperative hematoma clearance rate, rebleeding rate, postoperative GCS and mRS scores between the two groups (all p-values > 0.05). ConclusionsA combination of 3DSlicer and Sina is effective in accurately identifying hematomas in elderly patients with ICH exhibiting stable vital signs, thus simplifying MIPD surgeries conducted under local anesthesia. This procedure may also be preferred over CT-guided stereotactic localization in clinical practice due to its ease of use and accuracy in hematoma localization.

Short-term follow-up pilot study of sole middle meningeal artery embolization for chronic subdural hematoma: influence of internal architecture on the radiological outcomes.

To identify prognostic factors with emphasis on chronic subdural hematoma (CSDH) architecture that determines short-term outcome of middle meningeal artery embolization (MMAE). Consecutive CSDH patients treated by MMAE (November 2019 and March 2022) were retrospectively analyzed. Four architectures were analyzed: homogeneous, laminar, separated, and trabecular types. Predictor variables from baseline CT were correlated with radiological endpoint (≥ 50% of hematoma volume reduction), time to reach the endpoint, and rate of volume reduction. Study included 50 patients with 56 CSDHs (median age [first quartile, Q1; third quartile, Q3] 70.5 [60, 78.3] years; 36 were men). Separated type reached the endpoint at a lower rate on both bivariate (p = 0.02) and multivariate Cox model (0.034). Kaplan-Meier curves demonstrated that the median [Q1, Q3] time for 50% of the hematomas to reach the endpoint was 5 [4, 8], 4 [3, 5], 15 [15, 15], and 11 [4, 19] weeks for homogeneous, laminar, separated, and trabecular types, respectively. Linear mixed-effect model demonstrated a significant variation in the slope of hematoma volume reduction that was - 4.16 (95% confidence interval [CI] - 5.4, - 2.9), - 6.7 (95% CI - 8.35, - 5.1), - 2.03 (95% CI - 4.14, 0.08), and - 5.06 (95% CI - 6.8, - 3.32) ml per week for homogeneous, laminar, separated, and trabecular subtypes, respectively. Separated CSDH is a poor prognostic type in achieving radiological endpoint and a slower rate of volume reduction. While, homogeneous and laminar types reached the endpoint faster than separated and trabecular types on short-term follow-up.

Free-hand bedside catheter evacuation without 3D reconstruction for extensive revascularization-associated hemorrhage after ischemic stroke

ObjectiveTo evaluate the feasibility of free-hand bedside catheterization using axial computed tomography (CT) in patients with brain hemorrhage after ischemic revascularization. MethodsPatients who received revascularization therapy and underwent bedside catheterization were consecutively screened from December 2020 to July 2022. Revascularization included intravenous thrombolysis with or without mechanical thrombectomy, balloon angioplasty, and stenting. The catheter trajectory was designed according to the axial CT along the long axis of the hematoma body and projected onto the scalp at the calculated distance and angle. Urokinase was used locally to drain the hematoma. ResultsIn 12 patients (mean age 66 ± 8 years), an 86% reduction in hematoma volume was found after catheter drainage, from 48.6 ± 20.4 ml to 6.7 ± 5.7 ml (P＜0.001). In accordance with the reduction of the hematoma volume, the Glasgow Coma Scale improved from 7 (6.5–8) to 10 (7–10.5) (P = 0.031). Four patients (33.3%) achieved good outcomes (modified Rankin Scale 0–3) at the 180-day follow-up. All-cause mortality was 25%. One patient experienced active hemorrhage. No bacterial brain infections were observed. ConclusionsFree-hand bedside catheterization according to axial CT localization is feasible for treating extensive revascularization-related hematoma after ischemic stroke.

High-speed drill craniostomy as a minimally invasive method of chronic subdural hematoma management. Preliminary results of a pilot study

Objectives: The objective of this study was to assess the safety and efficiency of minimally invasive high-speed drill craniostomy in the treatment of chronic subduralhematomas.Study design: The study was designed as a retrospective case series study.Patients and Methods: The patients with compressive chronic subdural hematomas were treated by minimally invasive high-speed craniostomy performed underlocal anesthesia or conscious sedation. A minimal skin incision was followed by a single high-speed drill hole placement in the frontal or parietal region, over the area of maximal hematoma thickness. After hematoma aspiration, a 1.9 mm silicone catheter was placed in subdural space and connected to gravity-assisteddrainage. Patients were ambulatory immediately after surgery. Data on clinical course and outcome were recorded and analyzed.Results: There were 23 patients (5 female, 21.7%) included in the study. The median patient age was 77.5 years (interquartile range 67 - 83). Six (26.1%) of the patients had bilateral subdural hematomas. Septated/multiloculated hematomas were observed in 6 (26.1%) patients. Heterodense hematomas denoting more recent bleeding were recorded in 16 (69.5%) patients. The median duration of subdural drainage was 4 days (interquartile range 3 to 5). The median length of hospital stay was 9.5 days (interquartile range 6 - 16). One patient died of sepsis following a nosocomial respiratory infection. One patient developed a wound infection with subdural empyema, requiring subsequent craniotomy. One patient had deep venous thrombosis and pulmonary embolism. In all patients, postoperative CT scans showed a significant reduction of hematoma volume and midline shifting. No postoperative seizures were observed.Conclusion: High-speed drill craniostomy is a safe, simple, straightforward, and effective treatment for the management of chronic subdural hematomas, including multiloculated and heterodense lesions. Elderly patients could most benefit from such a procedure, avoiding general anesthesia, prolonged intracranial procedures, and lengthy hospital stays.

Abstract Number ‐ 97: Middle meningeal artery embolization to treat chronic subdural hematomas – Retrospective study of morphological parameters

Introduction Chronic subdural hematomas are a common neurovascular condition that involve the gradual and continual exudation of fluid from a compromised cell layer lining the dura [1]. Embolization of the middle meningeal artery (MMAE) results in lower recurrence rates as compared to traditional surgical burr hole evacuation [2‐4]. Liquid embolic agents such as cyanoacrylates or ethylene vinyl alcohol copolymers can potentially provide a distinct advantage with greater distal penetration resulting in faster hematoma resolution [5]. Their inherent radiopacity (after pre‐mixing) also allows for accurate visualization and control over embolization. The hypothesis of this study is that liquid embolic surface area would correlate with more effective cSDH volume resolution in patients. Methods Under IRB approval, we retrospectively analyzed non‐contrast head CTs and immediate post‐embolization flat‐detector CTs from 45 patients who underwent first‐line MMAE with a liquid embolic. Patients who received any neurosurgical intervention were excluded. 3D‐Slicer was used to segment and calculate hematoma volumes pre‐embolization, as well as at 1‐month, 3‐months, and 6‐months post‐embolization. The flat‐detector CT scans were also segmented to calculate the surface area of the liquid embolic. Results There was significant reduction in hematoma volume at 1‐, 3‐ and 6‐months with respect to the preoperative cSDH volume (Figure A, Pre: pre‐treatment, mo: month). The liquid embolic surface area significantly correlated with (a) pre‐embolization hematoma volume (R2 = 0.27, p = 0.0002, n = 45), (b) the reduction in volume at 1‐month post‐embolization (R2 = 0.16, p = 0.007, n = 41), (c) volume reduction at 3‐months post‐embolization (R2 = 0.29, p = 0.0015, n = 32), (d) hematoma volume resorption rate (cc/day) calculated at 1‐month post‐embolization (R2 = 0.16, p = 0.011, n = 39), and (e) hematoma volume resorption rate calculated at 3‐months post‐embolization (R2 = 0.34, p = 0.0003, n = 34, Figure B). The liquid embolic surface area was not correlated to the volume reduction at 6‐months (p = 0.3, n = 26). Conclusions The luminal surface area of MMA vasculature embolized with liquid embolics may be correlated to the reduction in cSDH volumes. The liquid embolic segmentation method used here needs further refinement to improve accuracy. Additional data sets are required to confirm the correlations reported here.

Abstract TP130: Effect Of Antifibrinolytic Medication On Hematoma Expansion In Acute Ischemic Stroke Patients With Post Thrombolytic Intracerebral Hemorrhages

Background and Purpose: Antifibrinolytic medications such as the synthetic lysine analogs tranexamic acid and ε-aminocaproic acid inhibit fibrinolysis by attaching to the lysine-binding site of the plasminogen molecule. However, the efficacy of intravenous (IV) antifibrinolytic medication in the prevention of hematoma expansion in acute ischemic stroke patients who develop post thrombolytic intracerebral hemorrhage (ICH) is unclear. Methods: We analyzed the effect of antifibrinolytic medication in acute ischemic stroke patients with post thrombolytic ICH on hematoma expansion over an 8-year period. The Region-of-Interest; method on a Horos Medical Image Viewer (Version 3.3.6) was utilized for hematoma volume measurement on serial computed tomographic scans. We compared changes in hemorrhage volume in patients who did and did not receive IV antifibrinolytic medication. Results: A total of 53 patients (mean age 69.7±14.3, 53% were men) with post thrombolytic ICH were analyzed. Twenty-six patients received antifibrinolytic treatment: 20 and 6 patients received a single IV dose of ε-aminocaproic acid (5 g) or tranexamic acid (1 g), respectively. Ten patients (38%) had a reduction or stabilization in hematoma volume (overall pre and post-treatment volumes were 17.43±16.23 cm3 and 25.14±26.57 cm3 respectively). Mean fibrinogen level in the antifibrinolytic medication group was 277 mg/dL; 3 patients had levels &lt;200 mg/dL. In patients that did not receive antifibrinolytics, 16 (59%) out of 27 patients had a reduction or stabilization in hematoma volume (overall pre and post-treatment volumes were 19.74±32.32 cm3 and 27.15±52.58 cm3 respectively). The mean percent change in hematoma volume with antifibrinolytic medication treatment was 48% and without was 27%. [Figure 1] Conclusion: We did not identify any reduction in any of the measures of hematoma expansion with antifibrinolytic treatment in acute ischemic stroke patients with post thrombolytic ICH.

Middle meningeal artery embolization for chronic subdural hematoma in elderly patients at high risk of surgical treatment.

The purpose of this study was to evaluate the effectiveness of middle meningeal artery embolization (MMAE) in elderly high-risk patients with symptomatic chronic subdural hematoma (CSDH) in terms of reduction in hematoma volume and recurrence rate. We retrospectively reviewed data prospectively collected from nine patients who underwent 13 MMAE for CSDH between June 2017 and May 2022. The volume of the subdural hematoma was measured using a computer-aided volumetric analysis program. Hematoma volume changes during the follow-up period were analyzed and clinical outcomes were evaluated. The mean follow-up period was 160 days (range, 46-311 days). All procedures were technically successful and there were no procedure-related complications. Of the 13 MMAE, 84% (11 out of 13 hemispheres) showed mean 88% of reduction on follow-up volumetric study with eight cases of complete resolution. There was one refractory case with MMAE which had been performed multiple burr-hole trephinations, for which treatment was completed by craniotomy and meticulous resection of multiple pseudomembranes. There was no recurrent case during the follow-up period, except for refractory case. MMAE for CSDH in selected high-risk elderly patients and relapsed patients might be effective. Despite the small cohort, our findings showed a high rate of complete resolution with no complications. Further prospective randomized trials are warranted to evaluate its usefulness as a primary treatment option for CSDH.

Longitudinal Resting-State Functional Magnetic Resonance Imaging Study: A Seed-Based Connectivity Biomarker in Patients with Ischemic and Intracerebral Hemorrhage Stroke.

Objective: The primary aim of the research was to compare the impact of postischemic and hemorrhagic stroke on brain connectivity and recovery using resting-state functional magnetic resonance imaging. Methods and Procedures: We serially imaged 20 stroke patients, 10 with ischemic stroke (IS) and 10 with intracerebral hemorrhage (ICH), at 1, 3, and 12 months (1M, 3M, and 12M) after ictus. Data from 10 healthy volunteers were obtained from a publically available imaging data set. All functional and structural images underwent standard processing for brain extraction, realignment, serial registration, unwrapping, and denoising using SPM12. A seed-based group analysis using CONN software was used to evaluate the default mode network and the sensorimotor network connections by applying bivariate correlation and hemodynamic response function weighting. Results: In comparison with healthy controls, both IS and ICH exhibited disrupted interactions (decreased connectivity) between these two networks at 1M. Interactions then increased by 12M in each group. Temporally, each group exhibited a minimal increase in connectivity at 3M compared with 12M. Overall, the ICH patients exhibited a greater magnitude of connectivity disruption compared with IS patients, despite a significant intrasubject reduction in hematoma volume. We did not observe any significant correlation between change in connectivity and recovery as measured on the National Institutes of Health Stroke Scale (NIHSS) at any time point. Conclusions: These findings demonstrate that the largest changes in functional connectivity occur earlier (3M) rather than later (12M) and show subtle differences between IS and ICH during recovery and should be explored further in larger samples.

Craniocervical Manual Lymphatic Drainage Increases the Efficiency of Atorvastatin-Based Treatment of Chronic Subdural Hematoma.

The objective of this study is to explore whether craniocervical manual lymphatic drainage (cMLD) can promote hematoma absorption and increase the efficiency of atorvastatin-based conservative treatment in chronic subdural hematoma (CSDH) patients. All CSDH patients treated with atorvastatin-based therapy between October 2020 and February 2022 in our department were retrospectively screened for enrollment. The patients were divided into the control and cMLD groups according to whether cMLD was performed. Head CT or MR images in both groups were obtained before the treatment and 2weeks and 4weeks after the treatment. MR images of the deep cervical lymphatic nodes (dCLNs) in 23 patients were obtained in the cMLD group before and approximately 2weeks after treatment. The volumes of the dCLNs and hematoma were calculated. The primary outcomes are the differences in hematoma volume reduction after 4weeks of treatment. The secondary outcomes were (1) the differences in hematoma volume reduction between the patients in these two groups in the 2nd week, (2) the dCLN volume change in the cMLD group before and after 2weeks of treatment, and (3) the percentage of patients who transitioned to surgery because of failure to the conservative treatment. A total of 106 consecutive patients were enrolled in this study for analysis; 54 patients received atorvastatin-based treatment (control group), and 52 were treated with both atorvastatin-based treatment and cMLD (cMLD group). At baseline, the mean hematoma volume was 76.53 ± 42.97ml in the control group and 88.57 ± 49.01ml in the cMLD group (p = 0.181). In the 4th week, the absolute number of hematoma reductions (20.79 ± 34.73ml vs. 37.28 ± 28.24ml, p = 0.009) and percentage of hematoma reductions (22.58% ± 60.01% vs. 46.43% ± 30.12%, p = 0.012) in the cMLD group were greater than those in the control group. After 2weeks of treatment, the absolute number of hematoma reductions showed no difference in the two groups, while the percentage of hematoma reduction was higher in the cMLD group (18.18% ± 24.61% vs. 2.08% ± 25.72%, p = 0.001). One patient in cMLD and 8 patients in the control group were transitioned to receive surgical treatment. The dCLN volumes in 23 experimental patients increased significantly after 2weeks of treatment in the cMLD group (p = 0.032). There were no severe side effects that needed to be reported. Combined with atorvastatin-based therapy, cMLD can promote hematoma absorption and decrease the surgery rate, which provides a new therapeutic strategy for CSDH.

Abstract TP139: Therapeutic Value Of Antifibrinolytic Medication In Acute Ischemic Stroke Patients With Alteplase-associated Intracerebral Hemorrhage

Background and Purpose: Intracerebral hemorrhage can occur in acute ischemic stroke patients receiving alteplase (recombinant tissue plasminogen activator). Antifibrinolytic medications such as the synthetic lysine analogs tranexamic acid and ε;-aminocaproic acid that inhibit fibrinolysis by attaching to the lysine-binding site of the plasminogen molecule have been utilized. However, the efficacy of antifibrinolytic medication in prevention of hematoma expansion is not known. Methods: We analyzed the effect of antifibrinolytic medication in acute ischemic stroke patients with intracerebral hemorrhage associated with Alteplase from 2012 to 2017. The Region-of-Interest method on a Horos Open Source Medical Image Viewer (Version 3.3.6) was utilized for volume measurement. We compared the change in hemorrhage volume in patients who did and did not receive antifibrinolytic medication. Results: A total of 36 patients (mean age 72.7±11.5, 56% were men) who received intravenous alteplase with subsequent intracerebral hemorrhage were identified. Fourteen patients received antifibrinolytic treatment; five patients had reduction or stabilization in hematoma volume (overall pre-treatment volume 13.87±15.74 cm 3 and post-treatment volume 16.74±29.67 cm 3 ). Mean fibrinogen level in the antifibrinolytic medication group was 297 mg/dL; two patients had levels &lt; 200 mg/dL. In the cohort of patients did not receive antifibrinolytics, 15 out of 22 patients had reduction or stabilization in hematoma volume (overall pre-treatment volume 19.25±33.33 cm 3 and post-treatment volume 17.41±26.56 cm 3 ). Mean volume difference in the group that received antifibrinolytic medication was 36% and 9% in the group that did not receive antifibrinolytic medication. [Figure 1] Conclusion: We did not identify any advantage of antifibrinolytic treatment in reduction or stabilization in hematoma volume in patients with Alteplase-associated intracerebral hemorrhages.

Abstract WP141: Effect Of Non-invasive Vagus Nerve Stimulation In Hemorrhagic Brain Injury And Permanent Ischemic Stroke In Rats

Introduction: Non-invasive vagus nerve stimulation (nVNS) reduces infarct volume after transient ischemia in rats. Here, we tested the effect of nVNS in intracerebral hemorrhage (ICH) and permanent ischemic brain injury models. Methods: ICH was induced by whole blood (n=24) or collagenase (n=24) injection into the striatum of adult male and female Wistar rats. 1-hour sham stimulation (n=16) or nVNS (n=32) was initiated 30 minutes after injection. Spontaneous circling, hindlimb retraction, and grasp ability were tested at 24 hours to measure functional deficit. Rats were euthanized 24 hours or one week after injury, and brain tissue was processed for water content analysis (n=24) and histology (n=24), respectively. Permanent ischemia was induced by filament occlusion of the right middle cerebral artery in adult male Wistar rats (n=18). Sham stimulation and nVNS initiated 30 minutes after the induction of ischemia were applied for 1 hour and 3 hours (n=6 per group). Rats were euthanized 24 hours later to measure infarct volume. Results: 1-hour nVNS was associated with a non-significant reduction in hematoma volume in both models of ICH (Fig). Animals treated with nVNS demonstrated better functional outcome at 24 hours after ICH ( p =0.042). There was no difference in brain edema between control and active treatment arms in both models of ICH. 3-hour nVNS reduced infarct volume by 21% in permanent ischemia ( p =0.047, Fig). Conclusion: The results of this study support prior evidence that nVNS may have a therapeutic potential in ischemic stroke. nVNS is currently being evaluated in two clinical studies (NCT03733431 and NCT04050501) for the treatment of acute ischemic stroke. The lack of adverse events in two different models of ICH in this study suggests that nVNS could be safely administered as early as an ambulatory setting before the stroke etiology (ischemic vs. hemorrhagic) has been determined.

Computed Tomography–Guided Catheter Aspiration and Thrombolysis of Hypertensive Basal Ganglionic Hematomas: Technique and Short-Term Outcome Comparison

Minimally invasive techniques of hematoma evacuation with or without the use of thrombolytic agents to lyse the clots have shown promising outcomes compared to open surgical evacuation. However, there is a dearth of literature in developing nations. The objective in this study was to evacuate spontaneous hypertensive basal ganglionic hemorrhages using computed tomography (CT)-guided catheter insertion, hematoma aspiration, and lysis with thrombolytic agents and analyze the efficacy and outcomes. Ten patients with spontaneous basal ganglionic hemorrhage underwent CT-guided clot catheter insertion, followed by aspiration of hematoma and clot lysis using 25,000 IU urokinase instilled every 12 hours. Details including symptoms, clinical and radiologic findings, efficacy of the technique, functional outcomes during follow-up, length of stay, and cost were recorded. Relevant details for 12 age- and sex-matched conservatively treated patients were compared. Functional outcome in the catheter group at 6 months was better than the medically managed group, with improved mean Glasgow Outcome Scale score (0.4 vs. 0.08), reduced modified Rankin scale score (-0.8 vs.-0.25), and reduced National Institutes of Health Stroke Scale score (-6.8 vs.-1.5 points). However, it was not statistically significant. Average hematoma volume reduction in the catheter group was 83.14%. In the medically managed group, 2 of 12 patients (16.6%) had hematoma expansion, 6 patients (50%) developed hydrocephalus, and 2 patients (16.6%) died. In the catheter group, 4 of 10 patients (40%) developed mild pneumocephalus that resolved. The evacuation of hypertensive basal ganglionic hematomas is feasible with basic neurosurgical instruments and existing resources (e.g., CT scan) with improved functional outcome compared with conservative treatment alone.

A propensity-adjusted comparison of middle meningeal artery embolization versus conventional therapy for chronic subdural hematomas.

Middle meningeal artery (MMA) embolization is a promising treatment strategy for chronic subdural hematomas (cSDHs). However, studies comparing MMA embolization and conventional therapy (surgical intervention and conservative management) are limited. The authors aimed to compare MMA embolization versus conventional therapy for cSDHs using a propensity-adjusted analysis. A retrospective study of all patients with cSDH who presented to a large tertiary center over a 2-year period was performed. MMA embolization was compared with surgical intervention and conservative management. Neurological outcome was assessed using the modified Rankin Scale (mRS). A propensity-adjusted analysis compared MMA embolization versus surgery and conservative management for all individual cSDHs. Primary outcomes included change in hematoma diameter, treatment failure, and complete resolution at last follow-up. A total of 231 patients with cSDH met the inclusion criteria. Of these, 35 (15%) were treated using MMA embolization, and 196 (85%) were treated with conventional treatment. On the latest follow-up, there were no statistically significant differences between groups in the percentage of patients with worsening mRS scores. Of the 323 total cSDHs found in 231 patients, 41 (13%) were treated with MMA embolization, 159 (49%) were treated conservatively, and 123 (38%) were treated with surgical evacuation. After propensity adjustment, both surgery (OR 12, 95% CI 1.5-90; p = 0.02) and conservative therapy (OR 13, 95% CI 1.7-99; p = 0.01) were predictors of treatment failure and incomplete resolution on follow-up imaging (OR 6.1, 95% CI 2.8-13; p < 0.001 and OR 5.4, 95% CI 2.5-12; p < 0.001, respectively) when compared with MMA embolization. Additionally, MMA embolization was associated with a significant decrease in cSDH diameter on follow-up relative to conservative management (mean -8.3 mm, 95% CI -10.4 to -6.3 mm, p < 0.001). This propensity-adjusted analysis suggests that MMA embolization for cSDH is associated with a greater extent of hematoma volume reduction with fewer treatment failures than conventional therapy.