Presence Of Intraventricular Blood Research Articles

Plasma Inflammatory Markers and Ventriculostomy-Related Infection in Patients With Hemorrhagic Stroke: A Retrospective and Descriptive Study.

BackgroundDiagnosis of ventriculostomy-related infection (VRI) remains difficult due to the various existing definitions. In patients with hemorrhagic stroke, its diagnosis might be further complicated by the presence of intraventricular blood. Furthermore, hemorrhagic stroke per se may cause symptoms compatible with VRI. This study aimed to evaluate the benefit of plasma inflammatory markers for the diagnosis of VRI and its differentiation from patients with non-cerebral infection and patients without infection in a cohort of patients with hemorrhagic stroke.MethodsA total of 329 patients with hemorrhagic stroke and an external ventricular drain (EVD) in situ were admitted to the Neurocritical Care Unit, University Hospital Zurich over a period of 6 years. Of those patients, 187 with subarachnoid hemorrhage and 76 with spontaneous intracerebral hemorrhage were included. Patients with VRI were compared to patients without any infection and to patients with non-cerebral infection, with regards to their clinical characteristics, as well as their inflammatory plasma and cerebrospinal fluid (CSF) markers. For the analysis, peak values were considered.ResultsThe VRI was diagnosed in 36% of patients with subarachnoid and in 17% of patients with intracerebral hemorrhage. The VRI was diagnosed on an average day 9±6.2 after EVD insertion, one day after the white blood cell count (WBC) peaked in CSF (8 ± 6.3). Plasma inflammatory markers (WBC, C-reactive protein “CRP” and procalcitonin “PCT”) did not differ among patients with VRI compared to patients without infection. The CRP and PCT, however, were higher in patients with non-cerebral infection than in patients with VRI. The WBC in CSF was generally higher in patients with VRI compared to both patients without any infection and patients with non-cerebral infection.ConclusionsNo differences in plasma inflammatory markers could be found between patients with VRI and patients without any infection. Conversely, CRP/PCT were higher in patients with non-cerebral infection than in patients with VRI. Altogether, CRP, PCT, and WBC are not suitable parameters for VRI diagnosis in neurocritical care unit patients.

Postoperative intraventricular blood: a new modifiable risk factor for early postoperative symptomatic hydrocephalus in children with posterior fossa tumors.

To analyze factors associated with the development of early symptomatic hydrocephalus following posterior fossa tumor (PFT) surgery in children. In this retrospective study, data from 148 children (age < 18years) who underwent primary resection of their PFTs without preoperative permanent CSF diversion procedures were collected. The incidence of symptomatic hydrocephalus within 30days of tumor resection was studied and its association with various demographic, tumor-related, and surgery-related risk factors was analyzed. At presentation, 131 (89%) of the 148 patients had symptomatic hydrocephalus. There were 99 males and 49 females (mean age 8.7years; range 1 to 17years). Postoperatively, 14 (9.4%) patients required shunt placement for symptomatic hydrocephalus. The indications for shunt surgery were persistent symptoms of raised intracranial pressure (n = 6, 43%), CSF leak from the wound (n = 7, 50%), and tense pseudomeningocele (n = 1, 7%). On multivariate analysis, age < 6years (OR 5.9, 95% CI 1.6-22.6, p = 0.009) and the presence of intraventricular blood (IVB) on postoperative CT (OR 6.4, 95% CI 1.7-23.7, p = 0.006) were independent risk factors for developing symptomatic hydrocephalus. The incidence of postoperative symptomatic hydrocephalus in our series (9.4%) is lower than that reported in most previous studies. Age < 6years and the presence of postoperative IVB were independent risk factors for developing symptomatic hydrocephalus. Of these, postoperative IVB is probably the only modifiable risk factor.

Association of Quantified Location-Specific Blood Volumes with Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage.

Delayed cerebral ischemia is a severe complication of aneurysmal SAH and is associated with a high case morbidity and fatality. The total blood volume and the presence of intraventricular blood on CT after aneurysmal SAH are associated with delayed cerebral ischemia. Whether quantified location-specific (cisternal, intraventricular, parenchymal, and subdural) blood volumes are associated with delayed cerebral ischemia has been infrequently researched. This study aimed to associate quantified location-specific blood volumes with delayed cerebral ischemia. Clinical and radiologic data were collected retrospectively from consecutive patients with aneurysmal SAH with available CT scans within 24 hours after ictus admitted to 2 academic centers between January 2009 and December 2011. Total blood volume was quantified using an automatic hemorrhage-segmentation algorithm. Segmented blood was manually classified as cisternal, intraventricular, intraparenchymal, or subdural. Adjusted ORs with 95% confidence intervals for delayed cerebral ischemia per milliliter of location-specific blood were calculated using multivariable logistic regression analysis. We included 282 patients. Per milliliter increase in blood volume, the adjusted OR for delayed cerebral ischemia was 1.02 (95% CI, 1.01-1.04) for cisternal, 1.02 (95% CI, 1.00-1.04) for intraventricular, 0.99 (95% CI, 0.97-1.02) for intraparenchymal, and 0.96 (95% CI, 0.86-1.07) for subdural blood. Our findings suggest that in patients with aneurysmal subarachnoid hemorrhage, the cisternal blood volume has a stronger relation with delayed cerebral ischemia than the blood volumes at other locations in the brain.

Meta-analysis and systematic review of risk factors for shunt dependency after aneurysmal subarachnoid hemorrhage.

OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) may be complicated by hydrocephalus in 6.5%-67% of cases. Some patients with aSAH develop shunt dependency, which is often managed by ventriculoperitoneal shunt placement. The objectives of this study were to review published risk factors for shunt dependency in patients with aSAH, determine the level of evidence for each factor, and calculate the magnitude of each risk factor to better guide patient management. METHODS The authors searched PubMed and MEDLINE databases for Level A and Level B articles published through December 31, 2014, that describe factors affecting shunt dependency after aSAH and performed a systematic review and meta-analysis, stratifying the existing data according to level of evidence. RESULTS On the basis of the results of the meta-analysis, risk factors for shunt dependency included high Fisher grade (OR 7.74, 95% CI 4.47-13.41), acute hydrocephalus (OR 5.67, 95% CI 3.96-8.12), in-hospital complications (OR 4.91, 95% CI 2.79-8.64), presence of intraventricular blood (OR 3.93, 95% CI 2.80-5.52), high Hunt and Hess Scale score (OR 3.25, 95% CI 2.51-4.21), rehemorrhage (OR 2.21, 95% CI 1.24-3.95), posterior circulation location of the aneurysm (OR 1.85, 95% CI 1.35-2.53), and age ≥ 60 years (OR 1.81, 95% CI 1.50-2.19). The only risk factor included in the meta-analysis that did not reach statistical significance was female sex (OR 1.13, 95% CI 0.77-1.65). CONCLUSIONS The authors identified several risk factors for shunt dependency in aSAH patients that help predict which patients are likely to require a permanent shunt. Although some of these risk factors are not independent of each other, this information assists clinicians in identifying at-risk patients and managing their treatment.

Prognostic factors in hypertensive intracerebral hemorrhage - study on a group of 80 patients

Introduction. Hypertensive cerebral hemorrhage remains a severe disease with a high mortality. Current therapeutic options (including surgery) are limited, therefore prognostic elements are important in selecting patients for the testing of more aggressive future therapies. Prognosis depends on the location of the lesion (supratentorial versus infratentorial), size of hematoma, state of the patient at admission (measured by GCS scale), patient age and associated comorbidities. Objective and method. Clinical and imaging correlations of various vital prognostic factors for ICH were evaluated (Glasgow Coma Scale, volume of hemorrhage, presence and volume of ventricular blood, location of bleeding, patient age). The hypothesis of integration of all these prognostic factors was tested and external validation of the ICH prognostic scores was tried. ICH score is one of the predictors for mortality at 30 days due to cerebral hemorrhage. We analyzed 80 patients with cerebral hemorrhage admitted to the National Institute of Neurology and Neurovascular Diseases Bucharest and we evaluated the independent prognostic factors above, but also integrated them into the ICH score which we correlated with the death rate. Results and conclusions. The deaths rate in the study group was 39%. The presence of intraventricular blood was associated with a higher death rate and this rate was directly proportional to the amount of intraventricular blood. ICH score was externally validated in this cohort study as a reliable prognostic method, relatively easy to use and accurate for vital risk assessment in patients with cerebral hemorrhage.

Doctor, I Had a Terrible Headache. What Is My Diagnosis?

A 49-year-old man presented with severe headache and mental confusion of sudden onset. He had a previous history of hypertension, smoking, and alcohol abuse. Neurological examination was normal, except for neck rigidity. Cranial computed tomography (CT) revealed a hyperdense lesion located at the perimesencephalic region suggestive of an aneurysm at the top of the basilar artery (question mark sign). Hydrocephalus and ventricular bleeding were also present. Brain magnetic resonance imaging (MRI) was unrevealing, and cerebral angiography was normal. The patient gradually recovered from headache after analgesia. A cerebral angiography was repeated after 2 weeks and was normal. The final diagnosis was: non-perimesencephalic, nonaneurysmal subarachnoid hemorrhage. Non-aneurysmal subarachnoid hemorrhage (NA-SAH) is divided in 2 different entities: perimesencephalic subarachnoid hemorrhage (PMNSAH) and non-perimesencephalic subarachnoid hemorrhage (n-PMN-SAH). Generally, the 2 patterns of NA-SAH can be reliably distinguished on CT scan. nPMN-SAH is associated with a higher incidence of complications and higher likelihood of finding an underlying cause of bleeding. It is also associated with a first false negative cerebral angiogram in 3% to 15% of cases. Angiography may yield false negative results due to vasospasm, vascular thrombosis, and mass effect by an adjacent hematoma, or a technically inadequate examination. The unfavorable course in patients with nPMN-SAH could be explained by other indicators of poor outcome, such as the amount of subarachnoid blood or the presence of intraventricular blood. Up to 8.5% of nPMN-SAH patients do rebleed, and 2.1 to 3.9% die as the result of a fatal rebleeding. From the Neurology Division, University Hospital, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil (T.C. Vale); Neurosurgery Division, University Hospital, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil (E.G. Morato); Department of Internal Medicine, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil (P. Caramelli). Conflict of Interest: The authors report no conflict of interest. Fig 1.—A non-perimesencephalic, non-aneurysmal subarachnoid hemorrhage peculiarly resembling a question mark sign. ISSN 0017-8748 doi: 10.1111/j.1526-4610.2012.02275.x Published by Wiley Periodicals, Inc. Headache © 2012 American Headache Society

Prevalence and Characterization of ECG Abnormalities After Intracerebral Hemorrhage

Although electrocardiographic (ECG) abnormalities are well known in ischemic stroke and subarachnoid hemorrhage, these changes have only rarely been investigated systematically in patients with intracerebral hemorrhage (ICH). The purpose of this study is to investigate the prevalence and type of ECG abnormalities in a consecutive series of ICH patients, and their possible association with pre-defined neurological and radiological parameters. The study population consisted of all consecutive patients with non-traumatic, intraparenchymal ICH admitted to the Academic Medical Center (AMC) between January 1, 2007 and October 1, 2007. Baseline information was prospectively registered in the AMC Stroke Register. ECGs obtained within 2 days after the initial hemorrhage were analyzed by one blinded observer. Admission cranial CT scans were re-analyzed by two blinded observers. Thirty-one patients were included. Twenty-five patients (81%) had one or more ECG abnormalities. The most frequently observed ECG abnormality was QTc prolongation (36%), followed by ST-T morphologic changes (23%), sinus bradycardia (16%), and inverted T wave (16%). No patient was initially misdiagnosed for having myocardial ischemia. QTc prolongation was associated with ICH involvement of the insular cortex [OR 10.9 (95% CI 1.0-114.6)] and presence of intraventricular blood and hydrocephalus on admission CT scan [OR 10.8 (95% CI 1.6-70.9)]. In ICH patients ECG abnormalities are common. QTc prolongation seems associated with insular cortex involvement, with the presence of intraventricular blood, and with hydrocephalus. A larger cohort of continuously monitored ICH patients is necessary to investigate whether these ECG abnormalities are associated with poor outcome or death.

Prophylactic Antiepileptic Drug Use is Associated with Poor Outcome Following ICH

Intracerebral hemorrhage (ICH) is associated with a risk of early seizure and guidelines recommend consideration of prophylactic antiepileptic drugs (AEDs) for some patients, although the utility is uncertain. We analyzed data from the placebo arm of the Cerebral Hemorrhage and NXY-059 Trial (CHANT), an international multicenter randomized trial of a potential neuroprotectant that enrolled patients within 6 h of the onset of acute ICH. Logistic regression analyses were performed to determine whether early AED use was associated with poor outcome at day 90, defined as a modified Rankin Scale of 5 or 6 (severely disabled or dead). Excluding patients who were previously on AEDs, the primary analysis included 295 patients. The median ICH volume at admission was 14.9 (interquartile range, IQR 7.9-32.7) ml and the mean was 23.3 (+/-SD 22.8) ml. Seizures occurred in 5 patients (1.7%) after enrollment and 82 patients (28%) had a poor outcome at day 90. AEDs were initiated on 23 patients (8%) without documented seizure during the first 10 days of the trial. In logistic regression, initiation of AEDs was robustly associated with poor outcome (OR 6.8; 95% CI: 2.2-21.2, P = 0.001) after adjustment for other known predictors of outcome after ICH (age, initial hematoma volume, presence of intraventricular blood, initial Glasgow coma score, and prior warfarin use). In this clinical trial cohort, seizures were rare after the first few hours following ICH. In addition, prophylactic AED use was associated with poor outcome independent of other established predictors. Given the potential for residual confounding in this cohort, a randomized trial needs to be performed.

Prospective surveillance of drain associated meningitis/ventriculitis in a neurosurgery and neurological intensive care unit

Objectives:There are currently no data available on drain associated infection occurrence related to the number of drainage days (DD), and thus drain associated infection rates. Therefore, a prospective surveillance study...

Impaired baroreflex sensitivity predicts outcome of acute intracerebral hemorrhage

Impaired blood pressure regulation in the acute phase of stroke has been associated with less favorable outcome. Mechanisms and effects of blood pressure dysregulation in stroke are not well understood; however, central autonomic impairment with sympathetic overactivity and baroreflex involvement are discussed. Baroreflex sensitivity (BRS) in spontaneous intracerebral hemorrhage has not been investigated. We sought to examine BRS in patients with intracerebral hemorrhage and evaluate the relationship between BRS and short-term outcome measures. An open, prospective study. Neurocritical care unit and stroke unit in a university hospital. We studied 45 patients with acute intracerebral hemorrhage within 72 hrs from onset of symptoms and 38 control subjects. BRS was measured noninvasively using a hemodynamic monitoring device. Beat-to-beat blood pressure variability was derived. The effects of the BRS, hemorrhage volume, intraventricular blood, and admission scores on outcome at 10 days were studied using a multivariate regression model. Compared with the control group, patients with intracerebral hemorrhage had significantly decreased BRS (p = 0.002) and significantly increased systolic, diastolic, and mean beat-to-beat blood pressure variability (p < 0.0001, p = 0.007, p = 0.015). After adjusting for age, National Institute of Heath Stroke Scale at admission, volume of intracerebral hemorrhage and presence of intraventricular blood in a multivariate regression model, BRS gain was an independent predictor of outcome at 10 days. We found that BRS was decreased in patients with acute intracerebral hemorrhage and correlated with increased beat-to-beat blood pressure variability. BRS independently predicted outcome at 10 days. Modulation of baroreceptor reflex sensitivity may represent a new therapeutic target in acute stroke and warrants future studies.

Hypertensive basal ganglia hemorrhage: a prospective study comparing surgical and nonsurgical management

BACKGROUND The optimal treatment of hypertensive supratentorial intracerebral hemorrhage is still debated. Some studies have shown no improvement in survival or functional outcome after surgery when compared to conservative management while others have shown otherwise. METHODS This study was a prospective trial, matching patients for hematoma volume and Glasgow Coma score on admission. RESULTS There were a total of 34 patients. Seventeen were treated conservatively and 17 surgically. There was no significant difference between the two groups in terms of age, GCS, hematoma volume, or presence of intraventricular blood. At 3, 6, and 12-month follow-up, they were assessed using the Modified Barthel Index by a blinded observer. There was no difference between the two groups at 3, 6, or 12 months follow-up. The mortality rate was similar in the two groups. CONCLUSIONS Based on this study and review of the literature, we cannot recommend routine evacuation of clots to treat these hemorrhages.

Prognostic value of intraventricular blood in perimesencephalic nonaneurysmal subarachnoid hemorrhage.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSH) is a distinct type of subarachnoid hemorrhage with a characteristic bleeding pattern, and an excellent clinical outcome. However, the clinical course of patients presenting with a perimesencephalic nonaneurysmal bleeding pattern and intraventricular blood has not yet been investigated. In this retrospective study we describe the cisternal blood distribution and the clinical course of 34 PNSH patients with (10 patients) and without (24 patients) intraventricular blood. Patients without intraventricular blood were in good clinical condition on admission; the in-hospital course was uneventful except for acute hydrocephalus, which was detected in two cases and improved spontaneously in both patients. All patients resumed their previous lifestyles. In contrast, two patients with PNSH and intraventricular blood were drowsy and had focal neurologic deficits on admission. Four patients developed an acute hydrocephalus, and two of these patients needed ventricular shunting. There was evidence for delayed cerebral ischemia in one of these patients. Outcome was excellent in eight cases, and one patient was moderately and one patient was severely disabled at dismissal from the hospital. Rebleeding did not occur in all patients, and repeated four-vessel angiography did not reveal the source of bleeding in any of our patients. Our data indicate that the presence of intraventricular blood may be a good indicator for the development of acute hydrocephalus in PNSH. Moreover, our results suggest that PNSH patients with ventricular blood may have a higher complication rate and a poorer outcome compared with PNSH patients without intraventricular blood.

The Clomethiazole Acute Stroke Study in hemorrhagic stroke (Class-H): Final results

Background and Purpose: Clomethiazole (CMZ) is a neuroprotectant that may improve outcome in patients with acute major strokes. In a previous study that included 94 hemorrhagic stroke patients (CLASS), a mortality reduction and functional outcome favorable to CMZ was seen. We sought to establish the safety of CMZ in acute hemorrhagic stroke patients and to determine whether a trial of medical therapy for cerebral hemorrhage was feasible. Methods: The safety of CMZ (n = 96) versus a placebo (n = 102) in hemorrhagic stroke patients was evaluated in a randomized, double-blind trial. Treatment began after a computed tomography (CT) scan confirmed the presence of hemorrhage and within 12 hours from symptom onset. Patients received 68 mg/kg of CMZ intravenously over 24 hours. Safety was assessed by collecting serious adverse events (SAE), including deaths up to 90 days after treatment. Functional and neurologic outcome were also monitored. Results: Hemorrhage volumes were found to be similar between groups (26 ± 56 mL CMZ v 26 ± 35 mL placebo). Sedation was reported as an adverse event during therapy in 55% of the CMZ patients versus 13% of the placebo patients. The number of SAE reports was 53 in the CMZ group and 46 in the placebo group. Differences on functional outcome measures were minor. Death within 90 days occurred in 19 CMZ patients versus 11 placebo patients (Odds Ratio [OR] 2.04; 95% confidence interval [CI] 0.92, 4.55; P = .08). After adjusting for baseline covariate imbalances, the mortality difference was less apparent (OR 1.82; 95% CI 0.69, 4.81; P = .23). Conclusions: The feasibility of performing neuroprotectant trials for acute cerebral hemorrhage patients has been established, but requires careful balancing of important predictive indicators, including baseline severity, hematoma location, presence of intraventricular blood, and possibly, coumadin use. The clinical experience to date has identified no specific major safety concerns with the use of CMZ in acute hemorrhagic stroke patients. Additional clinical trials will be required to confirm safety and establish the efficacy of CMZ in acute hemorrhagic stroke patients.

Putaminal and thalamic hemorrhage in ethnic Chinese living in Hong Kong

BACKGROUND Hemorrhagic stroke is very common in the Chinese population, and it is one of the leading causes of mortality in Chinese communities. The risk factors to explain this high incidence are unknown. It is the purpose of this study to look into the features of hemorrhagic stroke in the Hong Kong Chinese. METHODS We conducted a prospective hospital-based study in which 60 consecutive Chinese patients with computed tomography diagnosis of putaminal or thalamic hemorrhage were included. Their demographic and clinical data were collected and analyzed. RESULTS Two major findings evolved from the present study. (1) Unlike the Western studies, the majority of our patients were about a decade younger; (2) 50% of the patients had previously diagnosed hypertension, but only 20% of these patients were compliant with their antihypertensive medication. Our results also suggested that low admission Glasgow Coma Scale scores, large hematoma size, and the presence of intraventricular blood were associated with poor outcomes. CONCLUSIONS This study concludes that hemorrhagic stroke is indeed a serious health problem in Hong Kong. Simple measures, such as improvement of health education and the primary care system in the management of hypertension, would help to reduce the incidence of hemorrhagic stroke.

Asymmetry of intracranial hemodynamics as an indicator of mass effect in acute intracerebral hemorrhage. A transcranial Doppler study.

Hematoma volume is an important determinant of outcome and predictor of clinical deterioration in patients with intracerebral hemorrhage. In many cases, worsening results from herniation due to compartmentalized pressure gradients. We used transcranial Doppler sonography (TCD) to assess the impact of hematoma volume on symmetry of intracranial hemodynamics in patients with acute intracerebral hemorrhage. The goal was to evaluate TCD as a noninvasive method for monitoring compartmentalized mass effect. TCD was performed an average of 1.1 days (range, 0 to 3 days) after onset in 30 patients with supratentorial intracerebral hemorrhage. Hematoma, hematoma + edema, and intraventricular hemorrhage volumes were calculated from admission CT scans using computerized planimetry and were compared with combined TCD values from the middle cerebral and internal carotid arteries. Ipsilateral pulsatility indexes were consistently elevated and mean velocities consistently depressed when intracerebral hemorrhage volumes exceeded 25 mL. Compared with patients with small hemorrhages, those with large hemorrhages (> or = 25 mL, n = 10) had significantly higher ipsilateral pulsatility indexes (1.72 versus 1.13, P < .0001) and higher ratios of ipsilateral-to-contralateral pulsatility (1.29 versus 1.06, P = .001). The ratio of ipsilateral-to-contralateral mean velocity was similarly reduced in patients with large versus small hemorrhages (0.87 versus 1.06, P = .01), but this effect was less pronounced. In a multiple regression analysis, ipsilateral and contralateral pulsatility indexes correlated primarily with intraventricular hemorrhage volume (P < .001), whereas the ratio of ipsilateral-to-contralateral pulsatility correlated with total hemispheric lesion (hematoma + edema) volume (P = .003). Asymmetry of intracranial hemodynamics as assessed by TCD occurs when intracerebral hemorrhage volumes exceed 25 mL. Alterations of pulsatility index reflect intracranial lesion volume more reliably than mean velocity. Although pulsatility is strongly influenced by the presence of intraventricular blood, elevated ratios of ipsilateral-to-contralateral pulsatility correlate primarily with hemispheric lesion volume and may reflect compartmentalized intracranial pressure gradients.