Hemorrhage Status Research Articles

Establishment of a risk prediction model for cerebrogenic multiple organ dysfunction syndrome in patients with acute cerebral hemorrhage

To construct and validate a predictive model for the risk of cerebrogenic multiple organ dysfunction syndrome (CMODS) in patients with acute cerebral hemorrhage. Clinical data of 93 patients with acute cerebral hemorrhage admitted to Wannan Rehabilitation Hospital from January 2019 to June 2023 were retrospectively analyzed. Data included baseline information, disease severity score, laboratory examination indicators, cerebral hemorrhage status, treatment status, etc. Patients were divided into CMODS group and non-CMODS group according to whether CMODS occurred during hospitalization. The clinical data of the two groups were compared. Multivariate Logistic regression was used to analyze the risk factors of CMODS in patients with acute cerebral hemorrhage. A nomogram model was constructed to predict the risk of CMODS in patients with acute cerebral hemorrhage, and the model was validated. Receiver operator characteristic curve (ROC curve) was used to evaluate the predictive efficiency of nomogram model for CMODS in patients with acute cerebral hemorrhage. A total of 93 patients with acute cerebral hemorrhage were enrolled, including 26 patients in CMODS group and 67 patients in non-CMODS group. Compared with the non-CMODS group, the ratio of diabetes, acute physiological and chronic health evaluation II (APACHE II)≥35 score, cerebral hemorrhage volume ≥30 mL, endotoxemia, and national institutes of health stroke scale (NIHSS) and intracranial pressure of patients in the CMODS group were significantly higher, while the Glasgow coma score (GCS) was significantly lower and the length of hospital stay was significantly longer, with statistically significant differences (all P < 0.05). Multivariate Logistic regression analysis showed that diabetes mellitus [odds ratio (OR) = 3.615, 95% confidence interval (95%CI) was 1.487-8.785, P = 0.000], APACHE II score (OR = 4.697, 95%CI was 1.933-11.416, P = 0.000), endotoxemia (OR = 4.577, 95%CI was 1.883-11.123, P = 0.000), and cerebral hemorrhage volume (OR = 4.039, 95%CI was 1.662-9.816, P = 0.000) were the risk factors for CMODS in patients with acute cerebral hemorrhage. Taking the above risk factors as predictive variables, a nomogram prediction model was established. The verification results of the nomogram model showed that the C index was 0.804 (95%CI was 0.768-0.841), and the calibration curve was close to the ideal curve with good fit (P > 0.05). ROC curve results showed that the sensitivity and specificity of the nomogram model in predicting CMODS in patients with acute cerebral hemorrhage were 76.92%, 86.57%, respectively, and the area under the ROC curve (AUC) was 0.855 (95%CI was 0.776-0.935). Diabetes mellitus, APACHE II score, endotoxemia and intracerebral hemorrhage are risk factors for CMODS in patients with acute cerebral hemorrhage. The risk prediction model based on these risk factors is effective in evaluating the risk of CMODS in patients with acute cerebral hemorrhage.

The Effect of Out-of-Hours Admission on Mortality in Patients Who Underwent Thrombectomy Due to Ischemic Stroke.

It is important to investigate the factors that may delay the diagnosis and treatment process of ischemic stroke. The aim of this study was to investigate whether in-hospital mortality increased in patients who presented to the emergency department out-of-hours and underwent thrombectomy. A total of 59 patients who applied to the emergency department between January 1, 2018 and November 1, 2021 and underwent thrombectomy due to ischemic stroke were included in the study. Patient age, gender, thrombectomy success (successful recanalization), in-hospital mortality status, intracranial hemorrhage status after thrombectomy, and out-of-hours admission status were recorded and compared according to out-of-hours admission status. Twenty-seven (45.8%) patients were male, and the median age was 74 (61-81) years. Forty-two (71.2%) patients applied to the emergency department out-of-hours. In-hospital mortality occurred in 27 (45.8%) patients. There was no statistically significant difference in out-of-hours admission status between the non-survivor group and the survivor group (non-survivor: 24 [75%]; survivor: 18 [66.7%], p = 0.481). Nor was a statistically significant difference found in the intracranial hemorrhage complication rate of the patients admitted out-of-hours compared to the patients admitted during working hours (out-of-hours: 17 [40.5%]; during working hours: 6 [35.3%], p = 0.712). No statistically significant difference was found in the rate of in-hospital mortality and intracranial bleeding complications in patients who underwent thrombectomy out of working hours compared to during working hours.

Examination of Treatment Options According to Clinical Features and Radiological Findings in Wake-up Stroke

Aim: Wake-up stroke patients account for one-fifth of all ischemic stroke patients and they have been deprived of recanalization treatment as the onset of the stroke is not known. It has come into the focus of recent research that this treatment could be applied to particularly patients who are selected on a radiological basis. We aimed to examine clinical and demographic characteristics of wake-up strokes.&#x0D; Material and Methods: All ischemic stroke patients who presented to the emergency service throughout the night were analyzed. Patients with wake up stroke were recorded. The time of finding these patients, clinical features, treatment options and mortality status of these patients were examined. It was examined whether they received intravenous thrombolysis (IVT), endovascular therapy (EVT), or both as acute reperfusion therapy.&#x0D; Results: Age, gender, the last time when they were seen healthy, treatment start time, treatment types, clinical classification, comorbid diseases, and discharge status of 72 wake-up stroke patients were analyzed. It was found that the time of discovery of 51.4% (n=37) of the wake-up stroke patients was 06.00 am and afterwards. Of these patients, 15.3% (n=11) received intravenous tissue plasminogen activator and/or endovascular treatment. These patients’ hospital stay durations, intracerebral hemorrhage status following the procedure, NIHSS scores, angiography findings, and mortality rates were examined. Here, mortality rate was found to be significantly high especially in patients with high NIHSS score.&#x0D; Conclusion: Wake-up stroke is more common in the period close to the time of waking up in the morning. Recanylazation therapy should always be considered as an option in these patients.

İkinci basamak devlet hastanesinde laparoskopik adrenalektomi uygulanabilirliği ve deneyimlerimiz

Objective: Since the laparoscopy education had became widespread, the advance laparoscopic procedures can be performed even at secondary public hospitals. In this study, we aimed to present our experience of the first seven years of laparoscopic transperitoneal adrenalectomy. Material And Methods: the study included 30 patients with laparoscopic transperitoneal adrenalectomy (LA) performed from October 2012 to April 2019. The retrospective assessment investigated age, sex, body mass index, adrenal mass characteristics, hormonal activity, operation duration, hemorrhage status, transfusion requirements, final pathology and complication rates. Results: Mean age was 54.3±11.5 years and mean body mass index was 25.6±2.7 kg/m2. Mean mass size was 48.5±23 mm and mean operation duration was 70.2±21.6 minutes. Mean peroperative hemorrhage amount was 41±48.8 cc, while only 2 patients required transfusion. Mean hospitalization duration was 1.3±0.88 days. None of the laparoscopic cases was converted to open surgery, and no major complications such as death recorded. Conclusion: Transperitoneal laparoscopic adrenalectomy (LA) surgery may be performed safely after adequate training for appropriate patients with low morbidity and mortality. Keywords: laparoscopy, adrenalectomy, experience, open surgery, transperitoneal

MRI Detection of Carotid Intraplaque Hemorrhage and Postintervention Cognition.

Cognitive improvement has been reported after carotid revascularization and attributed to treating stenosis and correcting hypoperfusion. This study investigated the effect of carotid intraplaque hemorrhage on postintervention cognition. In this institutional review board-approved single-center study, consecutive patients scheduled for carotid surgery were recruited for preoperative carotid MR imaging (MPRAGE) and pre- and postintervention cognitive testing using the Repeatable Battery for the Assessment of Neuropsychological Status. Pre- and postintervention scores were compared using t tests and multivariable linear regression. Twenty-three participants were included, with endarterectomy performed in 20 (87%) and angioplasty/stent placement, in 3 (13%). Overall, statistically significant improvements occurred in the pre- versus postintervention mean Total Scale score (92.1 [SD, 15.5] versus 96.1 [SD, 15.8], P = .04), immediate memory index (89.4 [SD, 18.2] versus 97.7 [SD, 14.9], P < .001), and verbal index (96.1 [SD, 14.1] versus 103.0 [SD, 12.0], P = .002). Intraplaque hemorrhage (+) participants (n = 11) had no significant improvement in any category, and the attention index significantly decreased (99.4 [SD, 18.0] versus 93.5 [SD, 19.4], P = .045). Intraplaque hemorrhage (-) participants (n = 12) significantly improved in the Total Scale score (86.4 [SD, 11.8] versus 95.5 [SD, 12.4], P = .004), immediate memory index (82.3 [SD, 14.6] versus 96.2 [SD, 14.1], P = .002), delayed memory index (94.3 [SD, 14.9] versus 102.4 [SD, 8.0], P = .03), and verbal index (94.3 [SD, 13.2] versus 101.5 [SD, 107.4], P = .009). Postintervention minus preintervention scores for intraplaque hemorrhage (+) versus (-) groups showed statistically significant differences in the Total Scale score (-0.4 [SD, 6.8] versus 8.0 [SD, 8.5], P = .02), attention index (-5.9 [SD, 8.5] versus 4.3 [SD, 11.9], P = .03), and immediate memory index (4.2 [SD, 6.7] versus 12.2 [SD, 10.2], P = .04). Cognitive improvement was observed after carotid intervention, and this was attributable to intraplaque hemorrhage (-) plaque. MR imaging detection of intraplaque hemorrhage status may be an important determinant of cognitive change after intervention.

Prognosis Prediction in Severe Traumatic Brain Injury According to Initial Time of Brain Computed Tomography Scan Using the Rotterdam Scoring System

The Rotterdam scoring system (RSS) is useful for prognosis prediction in patients with severe traumatic brain injury (sTBI). It comprises basal cistern, midline shifting (MLS), epidural hematoma (EDH), and subarachnoid hemorrhage (SAH)/intraventricular hemorrhage (IVH) status. Brain computed tomography (CT) is important to assessing patients with sTBI; however, results often change over time. We aimed to determine whether RSS outcome prediction differs by initial brain CT scan time after the trauma in patients with sTBI. We used data from the second Korea Neurotrauma Data Bank, and analyzed 455 patients; RSS, Glasgow Outcome Scale Extended (GOSE) on 6-months, and the CT scan time were obtained. Unfavorable outcomes were defined as a GOSE score of 1-4. Participants were divided into 2 groups according to when brain CT scan was performed (> or ≤ 2 hours after trauma). The relationship between the prognosis of patients with sTBI and RSS score was examined by calculating the odds ratios. Univariate and multivariate analyses were performed. In both univariate and multivariate analysis, the total RSS and basal cistern status were statistically correlated with prognosis in both groups. EDH and SAH/IVH showed statistically significant difference according to CT scan time. MLS was associated with prognosis in both groups in univariate analysis although not in multivariate analysis. The total RSS score predicted prognosis 6 months after trauma in patients with sTBI, regardless of CT scan time. However, the prognostic predictive power of each item constituting the RSS varied according to CT scan time.

A study on the proper catheter position in minimally invasive surgery using stereotactic aspiration plus urokinase for intracerebral hemorrhage.

ObjectiveThe surgical method for treating spontaneous intracranial hemorrhage (ICH) is not well established despite ICH’s high prevalence and poor prognosis. Minimally invasive surgery has recently received attention; however, literature on this method is scarce. In particular, the appropriate location of the catheter in the hematoma has not been described. We examined whether the catheter position affects the hematoma reduction in a hematoma ＞50 cc.MethodsWe investigated the prognoses of 36 patients with ICH who underwent stereotactic aspiration and hematoma drainage using urokinase from January 2010 to December 2018 and the hematoma reduction rates according to the tube position. Two methods evaluated the position of the catheter. In the first method, the hematoma was an imaginary sphere. The center point was set as the operation target. We evaluated the catheter position by determining whether it was in the deep part or the outer part of the half point from that location to the hematoma margin. In the second method, we evaluated whether the catheter was located 1 cm inside the hematoma margin.ResultsIn both the first and second evaluations, there were no differences in age, midline shift, intraventricular hemorrhage status, hematoma volume on admission, Glasgow Coma Scale score on admission, time to operation after symptom onset, and systolic blood pressure. The rates of decrease in bleeding and the prognoses were also not significantly different.ConclusionsIf the catheter is in the hematoma, the rate of hematoma reduction at any position is similar.

Factors Impacting Hydrocephalus Incidence in Intracerebral Hemorrhage: A Retrospective Analysis

To test which intracerebral hemorrhage (ICH) characteristics impact incidence of hydrocephalus and characterize subsequent impact on outcomes. A search of the electronic medical record of Sinai Grace Hospital between January 2009 and April 2018 using International Classification of Diseases, Ninth Revision and Tenth Revision codes for ICH identified 847 patients. After excluding patients with hemorrhagic conversion of stroke, subarachnoid hemorrhage, and traumatic hemorrhage, 560 patients remained for analysis. Generalized linear modeling was used to assess variance in modified Rankin Scale (mRS) score and length of stay. Incidence of hydrocephalus on arrival varied with ICH volume (P < 0.001), intraventricular hemorrhage (IVH) status (P < 0.001), bleed location (P < 0.001), and external ventricular drain (EVD) status (P < 0.001). An EVD was inserted in 47% of patients presenting with IVH (n= 102/217), while 4% of patients without IVH received an EVD (n= 14/343) (P < 0.001). Hemorrhage locations had different rates of EVD placement: thalamic 43%, basal ganglia 22%, cerebellar 28%, brainstem 21%, lobar 7% (P < 0.001). Shunt dependency did not vary between bleed locations (P= 0.072). Variance in mRS score was explained by IVH, bleed location, hydrocephalus on arrival, and ICH volumes. In particular, cerebellar hemorrhage location was associated with better outcomes (mean discharge mRS score of 3.3 vs. 3.9, P < 0.001). Bleed characteristics affect incidence of hydrocephalus on admission, rates of long-term shunt dependency, and outcomes. Hemorrhage location did not predict shunt dependency; however, it did predict outcomes. Specifically, cerebellar ICH was associated with a better discharge mRS score.

Mortality Outcomes of Endovascular Treatment and Surgical Clipping in Patients with Cerebral Aneurysms: A Single-Center Study.

To compare endovascular and surgical treatment methods for cerebral aneurysms focusing on mortality. The study included 187 patients who had undergone aneurysm treatment. The patients were divided into four groups according to their treatment modality and subarachnoid hemorrhage status: patients with endovascular treatment and bleeding aneurysms (EVG-b), patients with endovascular treatment and non-bleeding aneurysms (EVG-nb), patients with surgical clipping and bleeding aneurysms (SCG-b), and patients with surgical clipping and non-bleeding aneurysms (SCG-nb). The Hunt?Hess scores, Fisher grade, aneurysm morphology, and length of stay (LOS) were compared between groups. There was no significant difference in the mortality rate between EVG-b and SCG-b at the end of the first year (23.5% and 39.7%, respectively; p > 0.05). A significantly shorter LOS was observed in EVG-b than in SCG-b (11.5 days and 15 days, respectively; p=0.027). Fusiform aneurysms were associated with higher patient mortality, whereas saccular aneurysms were associated with a 1.9-fold higher survival (p=0.037; 95% confidence interval: 0.83?4.74). The rate of closure of non-bleeding aneurysms was 93.4%. Complete embolization was verified in all bleeding aneurysms. In EVG-nb, the morbidity rate was 5%, the mortality rate was 3%, and the mean LOS was 2.86 days. Both treatment methods showed similar mortality rates, but hospital stays were shorter after endovascular treatment.

Subcallosal haemorrhage as a sign of diffuse axonal injury in patients with traumatic brain injury

To identify the relationship between subcallosal haemorrhage and diffuse axonal injury (DAI) grading. Computed tomography (CT) and magnetic resonance imaging (MRI) images of all patients with traumatic brain injury over the past 5 years were reviewed. Subcallosal haemorrhage was defined as the presence of haemorrhage on admission CT underneath the corpus callosum. Grading of DAI was performed using MRI or CT exclusive of subcallosal haemorrhage status. The association of demographic factors, mechanism of injury, Glasgow Coma Scale (GCS) on admission, and positive subcallosal haemorrhage status with the presence of moderate-severe DAI was assessed. Receiver operating characteristic (ROC) curve analysis was used to evaluate the performance of subcallosal haemorrhage status in predicting DAI severity. Median modified Rankin Scale (mRS) scores were compared between subcallosal haemorrhage positive and negative cases. The images of 1,150 patients were reviewed with 301 patients showing DAI. Of those, 64 patients (21.2%) and 237 patients (78.7%) were positive and negative for subcallosal haemorrhage, respectively. Isolated subcallosal haemorrhage was noted in 15 patients (23.4%). A subcallosal haemorrhage positive status (OR=5.16, p<0.001) was statistically significantly associated with moderate-severe DAI. The ROC curve for predicting moderate-severe DAI with subcallosal haemorrhage status showed an area under the curve of 0.625 (95% confidence interval [CI]: 0.561-0.688, p<0.001). The median mRS score was significantly higher (p<0.001) in the subcallosal haemorrhage positive group (median 4.5, interquartile range [IQR] 2-6) versus the negative group (median 2, IQR 2-3). Isolated subcallosal haemorrhage group showed moderate-severe DAI in 80% (12/15) of cases. Subcallosal haemorrhage is a highly specific radiographic predictor of moderate-severe DAI (grade 2-3).

S2332 Complete Occlusion of the Common Bile Duct Due to Erosion of a Gastroduodenal Artery Coil

INTRODUCTION: Endoscopic intervention remains the first-line method for treating upper gastrointestinal bleeding. In the case of bleeding duodenal ulcers and failed endoscopic hemostasis, visceral artery embolization has become standard of care at many centers because of its high efficacy and minimal side-effect profile. We present a patient who presented with ascending cholangitis due to complete occlusion of the CBD after migration of a gastroduodenal (GDA) coil. CASE DESCRIPTION/METHODS: 53-year-old male with history of duodenal ulceration and massive hemorrhage status post graham patch repair and suture ligation of the GDA followed by elective embolization of the GDA, complicated by disruption of the common bile duct (CBD) and hepatic artery hemorrhage status post stenting, presented 30 months after GDA embolization with transaminitis and recent hospitalization with Klebsiella bacteremia of unclear etiology. Subsequent outpatient ERCP revealed complete obstruction of the CBD at the level of the GDA coils. Manipulation of wires allowed for passage through a fistula that ended on the bulb side of the pylorus. Cholangioscopy revealed erosion of nearly the entire GDA coil into the bile duct entrapping multiple portions of the biliary wall. Various sites were probed with wire but without ability to pass. Patient was referred for percutaneous biliary tube placement and initial plan was to repeat ERCP after PTC to try to pull coils out of the duct with forceps. However, subsequent cholangiogram and intervention resulted in successful recanalization of distal CBD obstruction and placement of internal/external biliary drain. Intraluminal portion of the coil pack had migrated into the duodenum and was removed. A 10 mm × 60 mm covered stent was positioned under fluoroscopic guidance to reconnect the ducts. DISCUSSION: Percutaneous endovascular embolization is generally safe and capable of achieving hemostasis in 93% of emergent cases of GI bleeding nonamenable to endoscopic therapy. Coil migration causing biliary obstruction, although rare, has been previously reported including a few case reports involving the embolization of the hepatic arteries and one case in the English literature involving the GDA. ERCP with removal of the coils is the best management. When ERCP fails, as in our case, decompression of the biliary system by PTC or surgery should be considered.Figure 1.: ERCP showing GDA coils in the CBD.Figure 2.: ERCP cholangiogram showing complete obstruction of the CBD.Figure 3.: IR Cholangiogram showing recanalization of CBD.

Delta Systolic Blood Pressure (SBP) Can be a Stronger Predictor of Mortality Than Pre-Aortic Occlusion SBP in Non-Compressible Torso Hemorrhage: An Abotrauma and Aorta Analysis.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is becoming a standardized adjunct for the management in patients with severe non-compressible torso hemorrhage (NCTH). Although guidelines have been developed to help with the best indications for REBOA utilization, no studies have addressed the significance of change in systolic blood pressure (ΔSBP) after REBOA insufflation. We hypothesized that ΔSBP would predict mortality in patients with NCTH and have utility as a surrogate marker for hemorrhage status. This was an international, multicenter retrospective review of all patients managed with REBOA from the ABOTrauma Registry and the AORTA database. ΔSBP was defined as the difference between pre- and post-REBOA insertion SBP. Based on post-insertion SBP, patient hemorrhage status was categorized as responder or non-responder. A non-responder was defined as a hypotensive patient with systolic blood pressure < 90 mm Hg after REBOA placement with full aortic occlusion. Significance was set at P < 0.05. A total of 524 patients with NCTH were included. Most (74%) were male, 77% blunt injured with a median age of 40 (27-58) years and Injury Severity Score 34 (25-45). Overall mortality was 51.0%. Twenty percent of patients were classified as non-responders. Demographic and injury descriptors did not differ between groups. Mortality was significantly higher in non-responders versus responders (64% versus 46%, respectively; P = 0.001). Non-responders had lower median pre-insertion SBP (50 mm Hg vs. 67 mm Hg; P < 0.001) and lower ΔSBP (20 mm Hg vs. 48 mm Hg; P < 0.001). REBOA non-responders present and remain persistently hypotensive and are more likely to die than responders, indicating a potential direct correlation between ΔSBP as a surrogate marker of hemorrhage volume status and mortality. Future prospective studies will need to further elucidate the impact of Damage Control Resuscitation efforts on ΔSBP and mortality.

The Combination of Astragalus membranaceus and Ligustrazine Protects Against Thrombolysis-Induced Hemorrhagic Transformation Through PKCδ/Marcks Pathway in Cerebral Ischemia Rats

Astragalus membranaceus (Ast) and ligustrazine (Lig) have a protective effect on lower hemorrhagic transformation induced by pharmaceutical thrombolysis. The cerebral ischemia rat model was induced with autologous blood clot injections. A combination of Ast and Lig, or a protein kinase C delta (PKCδ) inhibitor—rottlerin, or a combination of Ast, Lig, and rottlerin was administered immediately after recombinant tissue plasminogen activator injection. The cerebral infarct area, neurological deficits, cerebral hemorrhage status, neuronal damage and tight junctions’ changes in cerebral vessels, and the messenger RNA and protein levels of PKCδ, myristoylated alanine-rich C kinase substrate (Marcks), and matrix metallopeptidase 9 (MMP9) were determined after 3 h and 24 h of thrombolysis. The ultrastructure of the neuronal damage and tight junctions was examined under a transmission electron microscope. The expression levels of PKCδ, Marcks, and MMP9 were assessed by immunohistochemistry, western blot, and quantitative real-time polymerase chain reaction . Administration of Ast and Lig not only significantly decreased neurological deficit scores, infarct volumes, and cerebral hemorrhage but also inhibited the disruption due to neuronal dysfunction and the tight junction integrity in the cerebral vessel. Treatment with a combination of Ast and Lig effectively protected ischemia-induced microhemorrhage transformation through PKCδ/Marcks pathway suppression.

Comparison of Bronchoscopy-Guided and Real-Time Ultrasound-Guided Percutaneous Dilatational Tracheostomy: Safety, Complications, and Effectiveness in Critically Ill Patients.

To compare the efficacy, safety, and incidence of complications between fiber-optic bronchoscopy-guided percutaneous dilatational tracheostomy (FOB-PDT) and ultrasound-guided percutaneous dilatational tracheostomy (US-PDT) and to determine whether US-PDT is a viable alternative to FOB-PDT. This randomized prospective study was carried out in 80 patients who were randomly divided into US-PDT and FOB-PDT groups. Demographic data and Acute Physiology and Chronic Health Evaluation II (APACHE II), procedure duration, hemorrhage status, complications, procedure difficulty, displacement of entry location after US, and hemodynamic data were evaluated in both groups. Tracheal incision was performed with real-time US and a transverse probe position in the out-of-plane mode. No significant differences were observed between the 2 groups in terms of demographic data, oral intubation time, APACHE II values, difficulty of the procedure, or the number of needle interventions (P > .05). The mean hemorrhage ratio of the FOB-PDT group was significantly higher than that of the US-PDT group (P < .05). The entry location was changed in 6 patients in the US-PDT group following neck examination with US. The mean duration of the procedure for the FOB-PDT group was significantly longer than that for the US-PDT group (P < .05). Ultrasound-guided percutaneous dilatational tracheostomy is a safe procedure for critically ill patients and has the advantages of a low complication rate, short duration of procedure, being informative with regard to neck anatomy, and facilitating prevention of vascular puncture. Thus, US-PDT can be used as an alternative to FOB-PDT.

Increased prevalence and rupture status of feeder vessel aneurysms in posterior fossa arteriovenous malformations

BackgroundPosterior fossa arteriovenous malformations (AVMs) are considered to have a higher risk of poor outcome, as are AVMs with associated aneurysms. We postulated that posterior fossa malformations may be more...

Mesenchymal stem cell therapy in a rat model of birth-trauma injury: functional improvements and biodistribution.

We evaluated the potential role of human mesenchymal stem cells (hMSCs) in improvement of urinary continence following birth-trauma injury. Human MSCs were injected periurethrally or systemically into rats immediately after vaginal distention (VD) (n = 90). Control groups were non-VD (uninjured/untreated, n = 15), local or systemic saline (injection/control, n = 90), and dermofibroblast (cell therapy/control, n = 90). Leak-point pressure (LPP) was measured 4, 10, and 14 days later. Urethras were morphometrically evaluated. In another sets of VD and non-VD rats, the fate of periurethrally injected hMSC, biodistribution, and in vivo viability was studied using human Alu genomic repeat staining, PKH26 labeling, and luciferase-expression labeling, respectively. Saline- and dermofibroblast-treated control rats demonstrated lower LPP than non-VD controls at days 4 and 14 (P < 0.01). LPP after systemic hMSC and periurethral hMSC treatment were comparable with non-VD controls at 4, 10, and 14 days (P > 0.05). Local saline controls demonstrated extensive urethral tissue bleeding. The connective tissue area/urethral section area proportion and vascular density were higher in the local hMSC- versus the saline-treated group at 4 and 14 days, respectively. No positive Alu-stained nuclei were observed in urethras at 4, 10, and 14 days. PKH26-labelled cells were found in all urethras at 2 and 24 h. Bioluminescence study showed increased luciferase expression from day 0 to 1 following hMSC injection. Human MSCs restored the continence mechanism with an immediate and sustained effect in the VD model, while saline and dermofibroblast therapy did not. Human MSCs remained at the site of periurethral injection for <7 days. We hypothesize that periurethral hMSC treatment improves vascular, connective tissue, and hemorrhage status of urethral tissues after acute VD injury.

Aneurysmal Subarachnoid Hemorrhage—Status Quo and Perspective

Aneurysmal subarachnoid hemorrhage (SAH) accounts for about 5 % of all strokes and continues to be a major cause of morbidity and mortality, especially in younger patients (mean age of 52). The global incidence of SAH is 9 per 100, 000 per year with some regional variations [1]. Data from population-based studies suggests a distinct decrease in case fatality (0.9 % per year) over the past four decades to about 30 %, which is likely originated in earlier and more advanced aneurysm repair as well as improved neurocritical care of SAH patients following aneurysm repair [2]. Nevertheless, the incidence of poor functional outcome in SAH patients remains high (about one third of patients). The main determinants for poor outcome after SAH are the degree of early brain injury (EBI) and the incidence of delayed cerebral ischemia (DCI) (see below) [3, 4]. The clinical course of SAH is complex and can be divided into an acute stage (the initial 72 h after SAH ictus) and a subacute stage, which lasts up until 20 days after SAH ictus. The potential main complications in the acute phase are EBI, rebleeding from the ruptured aneurysms, with a frequency of up to 23 % within the first 72 h, and acute hydrocephalus, occurring in about 20 % of the patients, whereas the main complications occurring in the subacute phase are DCI (formerly referred to as Bvasospasm,^ see below), cardiopulmonary or other medical complications, as well as permanent hydrocephalus [5–7]. The term EBI refers not only to direct mechanical damage to the brain tissue due to the hemorrhage but also to a cascade of different pathomechanisms, incl. a temporary increase of intracranial pressure, consecutive reduction of cerebral blood flow and/or microcirculatory spasm, transient global ischemia, neuronal injury or apoptosis, and edema formation [8]. The degree of EBI is a strong and independent predictor for clinical outcome after SAH [9, 3, 4]. The term DCI describes a complex phenomenon as a consequence of several pathomechanisms, incl. (1) macrovascular or angiographic vasospasm, i.e., narrowing of proximal cerebral arteries, (2) microvascular spasm, (3) microthromboembolism, (4) cortical spreading depolarization/ischemia, (5) autoregulatory dysfunction, and (6) inflammation [10–13, 7, 14–17]. The radiological term vasospasm has been widely replaced with the clinical term DCI, which describes a secondary neurological deterioration in the course SAH, excluding other causes of neurological deterioration; an explicit definition for DCI has been proposed by a multidisciplinary research group [16]. This Bparadigm shift^ came along with the insight that angiographic vasospasm occurs in up to 70 % of SAH patients, whereas only 30 % of SAH patients develop clinical features of DCI and, moreover, because pharmaceutical treatments exclusively targeting of angiographic vasospasm failed to improve neurological outcome after SAH [18–20]. However, in those clinical studies where cerebral infarction due to DCI was effectively reduced by experimental pharmaceutical treatments, a significant improvement of clinical outcome was also seen. These data further underlined the concept that DCI comprises several, pro-ischemic pathomechanisms, which ultimately result in cerebral infarction, but the individual importance of each of these pro-ischemic pathomechanisms remains to elucidated [21, 22]. The general shift in scientific focus, i.e., away from ‘vasospasm’ towards DCI and EBI, can also be * Nima Etminan etminan@uni-duesseldorf.de

The impact of inspiratory pressure on stroke volume variation and the evaluation of indexing stroke volume variation to inspiratory pressure under various preload conditions in experimental animals.

PurposeStroke volume variation (SVV) measures fluid responsiveness, enabling optimal fluid management under positive pressure ventilation. We aimed to investigate the effect of peak inspiratory pressure (PIP) on SVV under various preload conditions in experimental animals and to ascertain whether SVV indexed to PIP decreases the effect.MethodsMild and moderate hemorrhage models were created in nine anesthetized, mechanically ventilated beagle dogs by sequentially removing 10 and then an additional 10 ml/kg of blood, respectively. In all the animals, PIP was incrementally increased by 4 cmH2O, from 5 to 21 cmH2O. SVV was measured by arterial pulse contour analysis. Stroke volume was derived using a thermodilution method, and central venous pressure and mean arterial pressure were also measured.ResultsSVV increased according to PIP with significant correlation at baseline, with mild hemorrhage and moderate hemorrhage. PIP regression coefficients at baseline and in the mild and moderate hemorrhage models were 0.59, 0.86, and 1.4, respectively. Two-way repeated-measures analysis of variance showed that PIP and the degree of hemorrhage had a significant interaction effect on SVV (p = 0.0016). SVV indexed to PIP reflected the hemorrhage status regardless of PIP changes ≥9 cmH2O.ConclusionsPIP is significantly correlated with SVV, even under hypovolemia, and the effect is enhanced with decreasing preload volumes. Compared with SVV, the indexed SVV was less susceptible to higher inspiratory pressures.

MR imaging-detected carotid plaque hemorrhage is stable for 2 years and a marker for stenosis progression.

MR imaging-detected carotid plaque hemorrhage is associated with an increased risk of recurrent ischemic cerebrovascular events and could be an indicator of disease progression; however, there are limited data regarding the dynamics of the MR imaging-detected carotid plaque hemorrhage signal. We assessed the temporal change of this signal and its impact on carotid disease progression. Thirty-seven symptomatic patients with 54 carotid stenoses of >30% on sonography underwent serial MR imaging during 24 months. A signal-intensity ratio of >1.5 between the carotid plaque and adjacent muscle was defined as plaque hemorrhage, and a change in signal-intensity ratio of >0.31 between time points was considered significant. Sixteen patients underwent ≥2 carotid sonography scans to determine the peak systolic velocities and degree of stenosis with time. Of the 54 carotids, 28 had the presence of hyperintense signal on an MR imaging sequence (PH+) and 26 had the absence of hyperintense signal on an MR imaging sequence (PH-) at baseline. The signal-intensity ratio was stable in 33/54 carotid plaques, but 39% showed a change. Plaque hemorrhage classification did not change in 87% of carotid plaques, but 4 became PH+, and 3, PH-. As a group, PH+ carotids did not change significantly in signal-intensity ratio (P = .585), whereas PH- showed an increased signal-intensity ratio at 24.5 months (P = .02). In PH+ plaques, peak systolic velocities significantly increased by 22 ± 39.8 cm/s from baseline to last follow-up sonography (Z = 2.427, P = .013). During 2 years, MR imaging-detected carotid plaque hemorrhage status remained stable in most (87%) cases with 4 (7%) incident plaque hemorrhages. PH+ plaques were associated with increased flow velocity during the follow-up period.

Silent arteriovenous malformation hemorrhage and the recognition of "unruptured" arteriovenous malformation patients who benefit from surgical intervention.

Arteriovenous malformation (AVM) patients present in 4 ways relative to hemorrhage: (1) unruptured, without a history or radiographic evidence of old hemorrhage (EOOH); (2) silent hemorrhage, without a bleeding history but with EOOH; (3) ruptured, with acute bleeding but without EOOH; and (4) reruptured, with acute bleeding and EOOH. We hypothesized that characteristics and outcomes in the unrecognized group of silent hemorrhage patients may differ from those of unruptured patients. Two hundred forty-two patients operated-on since 1997 were categorized by hemorrhage status and hemosiderin positivity in this cohort study: unruptured (group 1), silent hemorrhage (group 2), and ruptured/reruptured (group 3/4). Group 3/4 was combined because hemosiderin cannot distinguish acute hemorrhage from older silent hemorrhage. Hemosiderin was found in 45% of specimens. Seventy-five patients (31.0%) had unruptured AVMs, 30 (12.4%) had silent hemorrhage, and 137 (56.6%) had ruptured/reruptured AVMs. Deep drainage, posterior fossa location, preoperative modified Rankin Scale (mRS) score, outcome, and macrophage score were different across groups. Only the macrophage score was different between the groups without clinical hemorrhage. Outcomes were better in silent hemorrhage patients than in those with frank rupture (mean mRS scores of 1.2 and 1.7, respectively). One-third of patients present with silent AVM hemorrhage. No clinical or anatomic features differentiate these patients from unruptured patients, except the presence of hemosiderin and macrophages. Silent hemorrhage can be diagnosed using magnetic resonance imaging with iron-sensitive imaging. Silent hemorrhage portends an aggressive natural history, and surgery halts progression to rerupture. Good final mRS outcomes and better outcomes than in those with frank rupture support surgery for silent hemorrhage patients, despite the findings of ARUBA.