Intracerebral Hematoma Volume Research Articles

Endovascular Treatment for Ruptured Intracranial Aneurysms with Intracerebral Hematoma—Clinical Propriety of Less Invasive Treatment

Endovascular treatment of ruptured intracranial aneurysms (rIAs) accompanied by intracerebral hematoma (ICH) can be challenging because the ICH can be enlarged due to intraoperative anticoagulation during the endovascular procedure. This retrospective study aimed to compare the outcomes of aneurysmal subarachnoid hemorrhage with and without ICH treated by endovascular procedures. We reviewed 62 patients who underwent endovascular treatment of rIAs between January 2015 and April 2023. The patients were divided into 2 groups: those with ICH (group H; n= 13) and those without ICH (group N; n= 49). The patient demographics, aneurysm characteristics, World Federation of Neurosurgical Societies (WFNS) grade, complications (e.g., symptomatic vasospasm, hydrocephalus), and outcomes were assessed stratified by the presence of ICH. In group H, age, sex, complications, WFNS grade, and hematoma volume were also analyzed in relation to the outcomes at discharge. None of these patients required removal of ICH after endovascular treatment of the rIA. We found no significant differences in patient characteristics, aneurysm morphologies, WFNS grade, or overall outcomes between the 2 groups. In contrast, only a poor WFNS grade was significantly associated with poor outcomes (modified Rankin scale score ≥3) in group H (P= 0.04), and the ICH volume was not significantly different between those with good (6.2 ± 5.8 mL) and poor (14.6 ± 10.4 mL) outcomes in group H (P= 0.20). Endovascular treatment without hematoma evacuation did not adversely affect the outcomes of rIAs with ICH when the clinical condition and aneurysm morphology permitted. Surgical invasion might be avoidable with this less-invasive strategy without worsening the outcomes.

Unified ICH quantification and prognosis prediction in NCCT images using a multi-task interpretable network.

With the recent development of deep learning, the regression, classification, and segmentation tasks of Computer-Aided Diagnosis (CAD) using Non-Contrast head Computed Tomography (NCCT) for spontaneous IntraCerebral Hematoma (ICH) have become popular in the field of emergency medicine. However, a few challenges such as time-consuming of ICH volume manual evaluation, excessive cost demanding patient-level predictions, and the requirement for high performance in both accuracy and interpretability remain. This paper proposes a multi-task framework consisting of upstream and downstream components to overcome these challenges. In the upstream, a weight-shared module is trained as a robust feature extractor that captures global features by performing multi-tasks (regression and classification). In the downstream, two heads are used for two different tasks (regression and classification). The final experimental results show that the multi-task framework has better performance than single-task framework. And it also reflects its good interpretability in the heatmap generated by Gradient-weighted Class Activation Mapping (Grad-CAM), which is a widely used model interpretation method, and will be presented in subsequent sections.

Supraorbital approach in surgery for lateral intracerebral hematoma

Aim: to present the experience of using the technique of endoscopic aspiration (EA) of lateral intracerebral hematomas (ICH) through the mini-supraorbital approach. Material and methods. From 2019 to 2021 at the Sklifosovsky Institute for Emergency Medicine, 12 patients with lateral ICH underwent EA of the ICH using a mini-supraorbital approach. There were 7 men (58.3 %) and 5 women (41.7 %). The mean age of the patients was 53.2±6.8 years. According to the Glasgow Coma Scale (GCS), the level of consciousness during hospitalization corresponded to 15 points in 4 (33.3 %) patients, and 11‑14 points — in 8 (66.7 %) patients. The average volume of lateral ICH was 45.3±17.4 cm3 (from 28 to 84 cm3). The average duration of the surgical intervention was within 4.2±2.1 days. The operations were performed using STORZ endoscopic equipment. Ventriculoscopes and Gaab trocars were used in 3 cases, and transparent endoscopic ports with a diameter of 8 mm and 4 mm endoscopes were applied in 9 cases. The operations were performed under the control of BrainLab frameless neuronavigation. Results. The average duration of operations was 93±18 minutes. EA through the mini-supraorbital approach provides the removal from 51 to 91 % of the intracerebral hematoma volume, 73.3±16.6 % on average. There were no complications during the operation associated with the use of the approach. The outcomes were of 0‑2 in 2 (16.7 %) patients, 3‑5 — in 8 (66.7 %), and 6 — in 2 (16.7 %) patients according to the modified Rankin Scale. Conclusion. Supraorbital approach allows efficient removal of lateral ICH. The close passage of the access trajectory to the base of the anterior cranial fossa is not an obstacle and does not reduce the radicality of blood clots removal from the ICH cavity. However, the lateral ICH removal through the supraorbital approach requires the use of frameless navigation during the entire main stage of the operation, and instead of a metal trocar, it is recommended to use a transparent endoscopic port.

Association between kidney function and intracerebral hematoma volume

Renal dysfunction has been reported to be associated with larger hematoma volume in intracerebral hemorrhage (ICH) due to concomitant nutritional imbalances and platelet dysfunction; however, this association remains controversial. This study analyzed the association between potential risk factors and hematoma volume in patients with ICH. This retrospective cohort study used data from 456 patients with ICH at a single comprehensive stroke center. We assessed the association of estimated glomerular filtration rate (eGFR) and Controlling Nutritional Status score with hematoma volume using multivariable non-linear regression models. The effect of the use of antithrombotic agents on hematoma volume was analyzed using outcome-adaptive double/debiased machine learning approach, considering many covariates. The median and interquartile range of age and eGFR were 64 (54–75) years and 56.1 (39.3–66.7) mL/min/1.73 m2, respectively. The multivariable non-linear regression model showed that (1) eGFR and hematoma volume had a positive linear association, which was not statistically significant, and (2) nutritional status was positively associated with hematoma volume, although not significantly. Outcome-adaptive double/debiased machine learning revealed that patients receiving antithrombotic agents did not present with significantly larger hematoma volume than those who were not receiving antithrombotic agents (estimated mean difference of hematoma volume [95% confidence interval] = 15.32 [−6.02 to 36.65]). Our analysis shows no statistically or clinically significant relationship between renal function and hematoma volume; however, nutritional status and the use of antithrombotic agents showed an increasing tendency of the degree of hematoma in patients with ICH.

Surgery of hypertensive intracranial hematomas using one-portal mini-access and video endoscopic assistance

Background. Hypertensive intracranial hemorrhage is an extremely serious complication of hypertension, which accounts for 10 % to 20 % of all cerebral strokes. About 50 % patients die within the next year, and their 5-year survival rate does not exceed 30 %. Objective. To study the effectiveness of surgical treatment of hypertensive intracranial hematomas using one-portal mini-access and video endoscopic assistance. Design and methods. The study included 23 patients with supratentorial intracerebral hypertensive hematomas aged 26 to 70 years (median age 55 (50; 61) years). All patients underwent one-portal endoscopic surgery. The median volume of intracerebral hematoma, calculated according to the Tada formula, was 50 (40; 60) ml. The comparison group included 28 patients who received conservative treatment. The dynamics of the severity was assessed using the Glasgow Coma Scale (GCS), NIHSS, Rankin, Rivermead scales upon admission to the hospital, on days 3 and 7 of treatment, at discharge for outpatient treatment, and after 6 months.Results. There were no lethal outcomes in either the main group or the comparison group. The hematoma was removed totally in all patients, which was accompanied by a rapid improvement of general cerebral symptoms and, as a consequence, an increase in GCS values from 13 (12; 14) to 13 (12; 15) points by 3rd day after the disease onset. By the 7th day, there was a slow positive dynamic in both groups, however, all patients still had a pronounced or severe disability according to the Rankin scale. After 6 months, patients who underwent surgical treatment showed faster and more complete recovery. Conclusions. The results of the study are consistent with current worldwide data on the effectiveness of modern endoscopic technologies in patients with hypertensive intracerebral hemorrhage in relation to the rate and degree of regression of neurological loss.

Minimally Invasive Intracerebral Hematoma Evacuation Using a Novel Cost-Effective Tubular Retractor: Single-Center Experience

Spontaneous intracerebral hematoma (ICH) is a common disease with a dismal overall prognosis. Recent development of minimally invasive ICH evacuation techniques has shown promising results. Commercially available tubular retractors are commonly used for minimally invasive ICH evacuation yet are globally unavailable. A novel U.S. $7 cost-effective, off-the-shelf, atraumatic tubular retractor for minimally invasive intracranial surgery is described. Patients with acute spontaneous ICH underwent microsurgical tubular retractor-assisted minimally invasive ICH evacuation using the novel retractor. Patient outcome was retrospectively analyzed and compared with open surgery and with commercial tubular retractors. Ten adult patients with spontaneous supratentorial ICH and median preoperative Glasgow Coma Scale score of 10 were included. ICH involved the frontal lobe, parietal lobe, occipitotemporal region, and solely basal ganglia in 3, 3, 2, and 2 patients, respectively. Mean preoperative ICH volume was 80 mL. Mean residual hematoma volume was 8.7 mL and mean volumetric hematoma reduction was 91% (median, 94%). Seven patients (70%) underwent >90% volumetric hematoma reduction. The total median length of hospitalization was 26 days. On discharge, the median Glasgow Coma Scale score was 12.5 (mean, 11.7). Thirty to 90 days' follow-up data were available for 9 patients (90%). The mean follow-up modified Rankin Scale score was 3.7 and 5 patients (56%) had a modified Rankin Scale score of3. The novel cost-effective tubular retractor and microsurgical technique offer a safe and effective method for minimally invasive ICH evacuation. Cost-effective tubular retractors may continue to present a valid alternative to commercial tubular retractors.

An 18-month single-center observational study of real-world use of andexanet alfa in patients with factor Xa inhibitor associated intracranial hemorrhage

ObjectiveIntracranial hemorrhage is a life threatening complication of factor Xa inhibitors. Except for results of the open-label, single-arm ANNEXA-4 study, published real-world utilization of andexanet alfa is limited. We present our experience with andexanet alfa use in factor Xa inhibitor associated intracranial hemorrhage. The objective of this study was to assess the hemostatic efficacy and safety following early implementation of andexanet alfa use in factor Xa inhibitor associated intracranial hemorrhage. MethodsSingle center, retrospective, observational study at a large community teaching hospital and Comprehensive Stroke Center. Consecutive patients with factor Xa inhibitor associated intracranial hemorrhage, spontaneous or traumatic, treated with andexanet alfa. Primary outcome was hemostatic efficacy established by categories of hematoma growth between baseline and follow-up head computerized tomography after andexanet alfa treatment. Safety outcomes included inpatient mortality and 30-day readmission due to a thromboembolic event. Consecutive factor Xa inhibitor associated intracranial hemorrhage treated with andexanet alfa presenting between June 2018 and December 2019 were included. ResultsThirty-nine patients with mean age of 81.9 years and median baseline Glasgow Coma Score of 14 were evaluated. Median (IQR) baseline intracerebral hematoma volume was 7.1 mL (2.3-28.5), while baseline thickness for subdural hemorrhage was 12.5 mm (8.0-19.3). In 35 of 39 patients with repeat computerized tomography prior to surgical intervention, excellent/good hemostatic efficacy was seen in 29 (82.9%). Excluded from the hemostatic efficacy estimate were four trauma patients who underwent hematoma evacuation prior to repeat head computerized tomography, nevertheless they had excellent hemostatic effectiveness without perioperative complications or rebleeding. Four (10.3%) patients died during hospitalization and two (5.1%) thrombotic events were observed. ConclusionsIn this cohort of a real-world utilization of andexanet alfa for reversal of factor Xa inhibitors in patients presenting with intracranial hemorrhage, we observed a high excellent/good hemostatic efficacy rate and lower than reported inpatient mortality and 30-day readmission due to thromboembolism consistent with the findings reported in ANNEXA-4 study. Despite the lack of comparative group, our outcomes, most noticeably hemostatic efficacy and inpatient mortality are consistent with those reported in the literature.

In Reply: Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure.

To the Editor: We are grateful for the opportunity to respond to the thoughtful commentary1 stemming from our publication, “Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure.”2 We would like to first highlight that the efficacy of intracerebral hematoma (ICH) evacuation in the MISTIE III (Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation) clinical trial was high, achieving a mean end of treatment hematoma volume of 12.6 mL (compared to a mean initial ICH volume of 48.7 mL), and a mean 73.9% hematoma evacuation in surgical cases. A greater evacuation efficacy was achieved when protocol adherence was optimal, and this translated into improved mortality and functional outcomes. New devices have emerged, some gaining Food and Drug Administration (FDA) approval recently, to improve fibrinolytic activity, such as ultrasonic tipped, endoscopic or aspiration catheters. These new and additional adjuncts or drugs have not been subjected to the same rigorous safety and protocol performance testing as was done with the MISTIE procedure. Progress in ICH treatment will likely be incremental, including patient selection, optimized intensive care unit (ICU) care, optimized timing of intervention, novel techniques/technology with precision execution, and ultimately a platform with wide generalizability. A key lesson of the MISTIE trial should highlight that MISTIE is much more than just a catheter and recombinant tissue plasminogen activator (rtPA). It includes careful patient selection with etiology screening, bleeding stabilization, surgeon training and experience, state-of-the-art ICU care, and enforced protocol adherence.3 It is difficult to assess the contribution of any single element of this intricate process. It will be equally challenging to evaluate pharmacological adjuncts, unless all other elements are standardized and controlled. Neutrophil extracellular traps (NETs) present a biologically plausible and interesting avenue to enhance clot lysis, or to target those clots that present a challenge to lyse. Preclinical data are needed to confirm this, and prospective clinical data will be needed to understand their potential role in ICH/intraventricular hemorrhage (IVH)/subarachnoid hemorrhage (SAH), and different impacts with those various bleeds. Hypotheses must be clearly articulated about the specific bleed type, potential hematologic criteria of resistance to fibrinolysis, goals of maintaining catheter patency versus enhancement of ICH/IVH/SAH thrombolytic clearance, and criteria for superiority in comparative effectiveness. We remain enthusiastic that many investigators are eager to expand the armamentarium for the treatment of ICH with improvements in current treatment paradigms at all levels. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

1/2SH

Background and Purpose- 1/2ABC has been used widely for assessing the volume of intracerebral hematoma. However, it is only suitable for calculating regular and small volume hematomas. Therefore, we re-explored the formula of hematoma volume to find a method that can calculate hematoma volumes accurately, reliably, and quickly. Methods- Computed tomography imaging data of 257 patients with intracerebral hemorrhage were collected. Hematoma volumes were estimated using 3-dimensional Slicer and 7 formulas (π/6ABC, 1/2ABC, 1/3ABC, 2/3SH, 1/2SH, π/6SH, and 2.5/6ABC). Taking the hematoma volumes measured by 3-dimensional Slicer as the reference standard, the accuracy and reliability of the 7 formulas were evaluated. Furthermore, the time needed to calculate hematoma volumes by the 1/2SH method was noted for further analysis. Results- (1) The accuracy of the 7 formulas based on the error analysis from the highest to the lowest was: π/6SH, 1/2SH, 2.5/6ABC, 1/3ABC, 1/2ABC, and π/6ABC or 2/3SH. According to concordance analysis and receiver operating characteristic curve analysis, the results from the highest to lowest were as follows: 1/2SH, π/6SH, 2.5/6ABC, 1/3ABC, 1/2ABC, 2/3SH, and π/6ABC. After categorizing cases according to size, shape, and location of hematoma, the results were almost the same as the results for overall accuracy evaluation in any subgroup. (2) Intraclass correlation coefficient (ICC) of 1/2SH in intra and inter-researcher were 0.998 and 0.989, respectively. For the formula π/6SH, intraclass correlation coefficient was the same as that of 1/2ABC. Kappa values of 1/2SH for intra- and inter-observer were 0.992 and 0.913, respectively. For π/6SH, kappa values of within- and between-reader were 0.984 and 0.904, respectively. (3) The average time taken to calculate hematoma volumes by 1/2SH was 74 seconds. Conclusions- The 1/2SH and π/6SH are accurate, reliable, and rapid methods for calculating hematoma volumes. The accuracy and reliability of 1/2SH were slightly higher than those of π/6SH.

Treatment allocation of ruptured anterior communicating artery aneurysms: The influence of aneurysm morphology

ObjectivesSince publication of the ISAT study, the majority of neurovascular centers adhere to “coil first” policy for patients with subarachnoid hemorrhage (SAH). However, final allocation in favor of coiling or clipping is based on anatomic features of ruptured intracranial aneurysms with respect to clinical characteristics of SAH. In this study, we analyzed the parameters relevant for treatment allocation of ruptured anterior communicating artery aneurysms (AComAA). Patients and methodsFrom our institutional SAH database, all cases with ruptured AComAA, which underwent diagnostic subtraction angiography (DSA) with subsequent treatment allocation, were included. The radiographic features of AComAA were collected from pre-treatment DSA. In addition, demographic, clinical and radiographic parameters of SAH were recorded. The variables selected through univariate analyses were subsequently evaluated using multivariate regression analysis. ResultsOf 300 SAH patients in the final analysis, the majority of the cases underwent endovascular coiling (n = 221, 73.7%). The following aneurysm features were associated with treatment modality in the univariate analysis: maximal sack size (p = 0.034), perpendicular height (p = 0.007), aspect ratio (p < 0.001) and sack/neck-ratio (p = 0.001). Accordingly, the following cutoffs for these variables were defined upon the receiver operating characteristics curves: 5 mm for sack size, 6 mm for perpendicular height, 1.6 for aspect ratio and sack/neck-ratio. In the multivariate analysis, aspect ratio of 1.6 was the only independent predictor of treatment allocation (p = 0.005; aOR = 2.57; 95% CI 1.33–4.96), which remained significant (p = 0.003; aOR = 2.77; 95% CI 1.41–5.45) after adjusting for patients’ age, WFNS & Fisher grades, as well as intracerebral hematoma volume. ConclusionAlthough not-routinely assessed during initial allocation treatment, our retrospective analysis proved that aspect ratio is a reliable predictor of treatment allocation of ruptured AComAA. Except for large space-occupying ICH commonly obligating the microsurgical treatment, other clinical and radiographic characteristics of SAH do not seem to be of clinical relevance for the selection of treatment modality.

The NIHSS score can predict the outcome of patients with primary intracerebral hemorrhage

IntroductionIntracerebral hemorrhage (ICH) is characterized to be the most lethal form of stroke, with high rates of mortality, not only during the acute phase (39%), but also 3 months later (33.5%) with a significant long-term disability. The National Institutes of Health Stroke Scale (NIHSS) score is a purely clinical scale, is easily administrable, and does not require the use of any additional diagnostic procedure.ObjectivesTo evaluate if the admission NIHSS score in acute primary ICH patients can be a predictive tool for their short-term outcome.Patient and methodsWe included 120 patients diagnosed with spontaneous ICH. All patients were subjected to full history taking, general, and neurological examination with assessment of neurological function on admission using the NIHSS. Laboratory assessment on admission including complete blood count, routine liver and kidney functions, and coagulation profile. Radiological investigations included computerized tomography (CT). The patients were followed, both clinically using the NIHSS score, radiologically with CT brain after 1 week and 4 weeks from the onset to assess the hematoma growth, its complications, and or resolution. Modified Rankin score (mRS) was done after 30 days of onset to assess patient’s disability.ResultsThe 30-day mortality was about one third of the patients. The intracerebral hematoma volume on admission has a significant positive correlation with the NIHSS, and ICH score significantly correlates with the 30-day outcome.ConclusionAdmission NIHSS has an independent predictive value of the 30-day outcome in cases of primary ICH as regards mortality and disability.

Modification of apparent intracerebral hematoma volume on T2∗-weighted images during normobaric oxygen therapy may contribute to false diagnosis

It was previously reported that normobaric oxygen therapy (NBO) significantly affected T2∗-weighted imaging in a mouse model of intracerebral hemorrhage (ICH). However, it is unclear whether a similar phenomenon exists in large volume ICH as seen in human pathology. We investigated the effects of NBO on T2∗-weighted images in a pig model of ICH. Our data show that NBO makes disappear a peripheral crown of the hematoma, which in turn decreases the apparent volume of ICH by 18%. We hypothesized that this result could be translated to ICH in human, and subsequently could lead to inaccurate diagnostic.

Curative effect comparison of endoscopic surgery and craniotomic hematoma evacuation in management of hypertensive intracerebral hemorrhage

Objective To investigate and compare the curative effect of endoscopic management and craniotomic hematoma evacuation in hypertensive intracerebral hemorrhage (HICH). Methods Seventy cases of HICH were randomly divided into 2 groups: endoscopy group (30 cases) and craniotomy group (40 cases). In the patients with intracerebral hematoma volume of 30-40 ml, the therapeutic effect was compared between two groups: incision of scalp, bone window, cortical incision, blood loss, operating duration, rate of hematoma evacuation, rate of rehemorrhage, rate of intracranial infection, mortality and Barthel index. Results The length of scalp incision in endoscopy group and craniotomy group was (5.40±0.97) cm and (24.50±3.88) cm, comparison between the two groups was statistically significant (t=26.310, P=0.000). The area of bone window in endoscopy group and craniotomy group was (12.5±2.2) cm2 and (63.3±12.3) cm2 respectively, comparison between the two groups was statistically significant (t=22.320, P=0.000). The length of cortical incision in endoscopy group and craniotomy group was (1.05±0.45) cm and (2.40±0.52) cm respectively, comparison between the two groups was statistically significant (t=11.385, P=0.000). The blood loss in endoscopy group and craniotomy group was (80.0±18.3) ml and (339.0±90.3) ml respectively, comparison between the two groups was statistically significant (t=15.450, P=0.000). The time of operating duration in endoscopy group and craniotomy group was (0.96±0.31) h and (4.35±0.57) h respectively, comparison between the two groups was statistically significant (t=24.440, P=0.001). The rates of hematoma evacuation in endoscopy group and craniotomy group was (81.00±7.93)% and (92.40±6.15)% respectively, comparison between the two groups was not statistically significant (χ2=6.777, P=0.138). Rates of rehemorrhage in endoscopy group and craniotomy group was 7.5% and 6.7% respectively, comparison between the two groups was not statistically significant (χ2=0.018, P=1.000). The rates of intracranial infection in endoscopy group and craniotomy group was 10% and 15%, comparison between the two groups was not statistically significant (χ2=1.350, P=0.723). Death rates in endoscopy group and craniotomy group was 5% and 6% respectively, comparison between the two groups was not statistically significant (χ2=0.088, P=1.000). Barthel index in endoscopy group (75.34±20.51) was higher compared with craniotomy group (55.30±10.20). Comparison between the two groups was statistically significant (t=1.350, P=0.000). Conclusion For the patients with intracerebral hematoma volume 30-40 ml, endoscopic surgery has the advantages including minimally invasive、short operating duration and good prognosis, but it has lower hematoma evacuation than craniotomic hematoma evacuation. Key words: Hypertension intracerebral hemorrhage; Endoscope; Craniotomic hematoma evacuation; The rate of hematoma evacuation

Surgical Outcome of Spontaneous Supra Tentorial Intracerebral Hemorrhage.

Objective:To assess the risks and benefits of surgical treatment (Open Craniotomy) of Intra-cerebral hematoma (ICH).Methods:Twenty seven patients of ICH who underwent surgical treatment at Neurosurgical department of Sheikh Zayed Hospital, Rahim Yar Khan, from 1st January 2015 to 31st December 2015 were included in this study. The primary outcome measured was death and improvement in GCS Status among survivor’s at three months.Results:Mean age of the patients was 58.4±10.7 and majority of patients (48.1%) were in the age range of 60-70 years. There were22.2% patients with ICH volume of >50 ml. Six (6) patients had 8 GCS with 50ml volume, who later died in ICU. Three of the patients who expired developed post-operative pneumothorax. These patients also acquired RTI resulting in deterioration of GCS. The rest of the expired patients showed deterioration in their GCS associated with oedma on brain CT scan. One patient died as a result of re-bleed. Twenty one (21) patients were discharged from hospital, two of these patients were lost in second follow up. Rest of the patients showed a gradual improvement in GCS touching 15/15 by 2nd follow up visit.Conclusion:Surgical prognosis of ICH depends on the patients GCS received and size of hemorrhage at the time of presentation. Urgent surgical evacuation in patients with rapid deterioration carries good outcome, hence should be considered.

Ultra-early microsurgical treatment within 24 h of SAH improves prognosis of poor-grade aneurysm combined with intracerebral hematoma.

Spontaneous subarachnoid hemorrhage (SAH) is the most common cerebrovascular disease. The conventional treatment for SAH is usually associated with high mortality. The present study aims to assess the prognosis of microsurgical treatment for patients with poor-grade aneurysm (Hunt and Hess grades IV-V) associated with intracerebral hematoma. A total of 18 consecutive patients who were diagnosed with poor-grade aneurysm accompanied with intracerebral hematoma were retrospectively recruited. All patients underwent microsurgical treatment between April 2010 and June 2013 at The 101st Hospital of Chinese People's Liberation Army (Wuxi, China). Among them, 15 cases underwent microsurgery within 24 h of SAH, and 3 cases underwent microsurgery 24 h following SAH. All 18 cases were examined by computed tomography angiography (CTA). The outcome was assessed during a follow-up time of 6-36 months. According to the Glasgow Outcome Scale, 4 patients experienced a good recovery, 6 were dissatisfied with the outcome, 4 were in vegetative state and 4 succumbed to disease. Poor outcome occurred in patients with an aneurysm diameter >10 mm, exhibited >50 ml volume of intracerebral hematoma or presented cerebral hernia prior to the surgical operation. The outcome of ultra-early surgery (within 24 h of SAH) was improved, compared with that of surgery following 24 h of SAH (P=0.005). Among 7 patients who accepted extraventricular drainage, good outcomes were achieved in 4 of them, whereas dissatisfaction and mortality occurred in 2 and 1 patients, respectively. Therefore, ultra-early microsurgery (within 24 h of SAH) combined with extraventricular drainage may improve the prognosis of patients with poor-grade aneurysm.

Intracerebral Hematoma Due to Aneurysm Rupture

Along with subarachnoid hemorrhage (SAH), a ruptured aneurysm may also cause an intracerebral hematoma (ICH), which negatively impacts the functional outcome of SAH. To identify independent risk factors of aneurysmal ICH. Six hundred thirty-two consecutive patients with aneurysmal SAH treated at our institution from January 2005 to December 2012 were eligible for this study. Demographic parameters and preexisting comorbidities of patients, as well as various clinical and radiographic characteristics of SAH were correlated with the incidence and volume of aneurysmal ICH. One hundred fifty-five patients (25%) had ICH on initial computed tomography with a mean volume of 26.7 mL (±26.8 mL). Occurrence and volume of ICH were associated with the location (distal anterior or middle cerebral artery >proximal anterior cerebral or internal carotid artery >posterior circulation, P < .001/P < .001) and size (>12 mm, P = .026/P < .001) of the ruptured aneurysm. Vascular risk factors independently increased the risk of ICH as well (arterial hypertension: odds ratio [OR] = 1.62, P = .032; diabetes mellitus: OR = 3.06, P = .009), while the use of aspirin (P = .037) correlated with the volume of ICH. The predictors of ICH were included into a risk score (0-9 points) that strongly predicted the occurrence of ICH (P = .01). Poor functional outcome after SAH was independently associated with the occurrence of ICH (P = .003, OR = 2.77) and its volume (P = .001, OR = 1.07 per-mL-increase). Aneurysmal ICH is strongly associated with poorer functional outcome and seems to be predictable even before the bleeding event. The proposed risk factors for aneurysmal ICH require further validation and may be considered for treatment decisions regarding unruptured intracranial aneurysms. ACA, anterior cerebral arteryDHC, decompressive hemicraniectomyEVD, external ventricular drainageICA, internal carotid arteryICH, intracerebral hematomaMCA, middle cerebral arterymRS, modified Rankin scalePC, posterior circulationSAH, subarachnoid hemorrhageSIRS, systemic inflammatory response syndromeTCD, transcranial Doppler sonography.

Idarucizumab Improves Outcome in Murine Brain Hemorrhage Related to Dabigatran.

Lack of specific antidotes is a major concern in intracerebral hemorrhage (ICH) related to direct anticoagulants including dabigatran (OAC-ICH). We examined the efficacy of idarucizumab, an antibody fragment binding to dabigatran, in a mouse model of OAC-ICH. Dabigatran etexilate (DE) dose-dependently prolonged diluted thrombin time and tail-vein bleeding time, which were reversed by idarucizumab. Pretreatment with DE increased intracerebral hematoma volume and cerebral hemoglobin content. Idarucizumab in equimolar dose prevented excess hematoma expansion for both DE doses. In more extensive ICH, idarucizumab significantly reduced mortality. Thus, idarucizumab prevents excess intracerebral hematoma formation in mice anticoagulated with dabigatran and reduces mortality.

New Measuring Method for the Volume of Intracerebral Hematoma

For the measurement of intracerebral hematoma volume, the medical staff prefers to use Dotian formula to estimate the volume for convenience. Dotian technique is a method that considers hematoma as a solid to measure, although the majority of hematomas are not in the form of regular solids, and different hematoma forms are seen when computed tomography (CT) scans are taken at different baseline, thickness, or layers. Hence, the Dotian formula cannot fully meet the clinical requirements .The author has written a VB program based on a polygon formula method, which depicts points through the CT images. Each CT is approximated as a polygon by us, and then we can use this program to calculate each CT image’s area and each layer’s volume according to the area multiplied by the thickness. We could use the hematoma volume measured by computer software as relatively accurate standard, and compare with hematoma volume calculated by the polygon formula to verify the accuracy of this method. It has important clinical significance and practical value.

Analysis the prognostic factors of microsurgical treatment for poor-grade aneurysms associated with hematoma

Objective To study the of microsurgical treatment for patients with poor-grade aneurysms (Hunt-Hess Ⅳ-Ⅴ) associated with hematoma and to explore the best therapeutic opportunity. Methods A retrospective analysis of 18 consecutive patients who were diagnosed as poor-grade aneurysms combined with hematoma and underwent microsurgical treatment in Wuxi Clinical Medical School of Anhui Medical University between April 2010 and June 2013 was performed. Fifteen cases underwent microsurgical treatment within 24 hours, and 3 more than 72 hours. Results All the aneurysms were occluded completely by CTA . The outcome was assessed by follow-up for 6-36 months. According to the Glasgow Outcome Scale, good recovery was observed in 4 patients, dissatisfied in 6, vegetative state in 4 and dead in 4. A poor outcome occurred in patients whose aneurysm diameter was more than 10 mm(P=0.035), intracerebral hematoma volume more than 50 ml(P=0.046) and with cerebral hernia(P=0.038) before operation. The outcome of ultra-early (within 24 hours) surgery patients was better than those received surgery over 72 hours. In 7 patients who accepted extraventricular drainage after the aneurysm was occluded, good outcome was achieved in 4, dissatisfied in 2 and 1 dead. The efficacy was better than those patients not accepted extraventricular drainage (P=0.034). Conclusions Poor-grade aneurysm was a critical condition and the prognosis weas poor. The outcome had close relationship with the size of aneurysm, volume of hematoma and cerebral hernia before operation. The ultra-early (within 24 hours) surgery combined with extraventricular drainage could improve the prognosis of patients. Key words: Intracranial aneurysm; Cranial hematoma; Microsurgery; Prognosis

Perioperative Management of Coagulation in Nontraumatic Intracerebral Hemorrhage

Approximately 70,000 new cases of spontaneous, nontraumatic intracerebral hemorrhage (ICH) occur annually in the United States.1 ICH is a significant cause of mortality throughout the Western world, with an estimated 30-day fatality rate of 30-50%. Surgical treatment is indicated for patients meeting specific criteria2 and coagulation management is a crucial aspect of perioperative strategy. Antithrombotic therapies are split into three categories: antiplatelet agents (e.g., aspirin, clopidogrel), anticoagulant agents (e.g., warfarin, heparins) and fibrinolytic agents (e.g., recombinant tissue plasminogen activator). ICH can occur in the absence or the presence of any of antithrombotic therapies. All antithrombotic agents have been associated with an increased risk of ICH in specific settings. Even though antiplatelet agents are the most commonly prescribed agents in the population, oral vitamin-K antagonists (VKAs) are a predominant cause of antithrombotic-associated ICH. With the increased use of antithrombotic therapies, the incidence of antithrombotic-associated ICH appears to be increasing.3 Moreover, new antithrombotic agents, such as the direct thrombin inhibitors and the oral Factor Xa antagonists, are on the rise.4 Specific strategies are recommended to reverse most antithrombotic treatments in the context of ICH.2,5 Disagreements regarding the use of these reversal strategies will be discussed in this article. Intracranial hemorrhage in the presence of underlying antithrombotic treatment is thought to have a worse prognosis due to prolonged bleeding.6 Thus, anticoagulation reversal may provide a therapeutic opportunity. Though evidence for anticoagulation reversal directly impacting outcomes is scarce,7,8 this approach, a common element of care in neurological ICUs, is known to have improved outcomes and is a part of the current ICH guidelines from the American Heart Association and the American Stroke Association with a Class 1 (level of evidence C).2 Even without any antithrombotic agent, it is now clearly established that intracerebral hematoma volume frequently increases during the initial phase of bleeding, contributing to neurological deterioration.9 The ICH Score identifies independent risk factors for poor neurological outcome,10 including hematoma volume. Consequently, there has been interest in the use of hemostatic agents to potentially limit hematoma expansion. The high prevalence of antithrombotic-associated ICH and the potentially protective strategy of improving hemostasis in ICH highlight the pivotal role of coagulation in perioperative management. The critical nature of this disease demands complex management and close collaboration among intensivists, hematologists, neurologists, neurosurgeons, and anesthesiologists. In this nonsystematic review article, we will summarize and clarify therapeutic recommendations for intracranial hemorrhage in the presence or absence of antithrombotic treatments, and highlight the debate about new therapeutic strategies in perioperative coagulation management in ICH.