Supratentorial ICH Research Articles

No association of brain CT blend sign with functional outcomes in patients with spontaneous supratentorial intracerebral hemorrhage after craniotomy

ObjectiveThis study retrospectively analyzed the association of blend sign with long-term outcomes in patients who underwent craniotomy following spontaneous supratentorial intracerebral hemorrhage. MethodsA retrospective analysis was conducted on a cohort comprising 259 patients. Initially, patients were stratified into two groups: the blend sign group and the non-blend sign group. Subsequently, the neurological status of these patients was assessed using the NIHSS, GCS, and mRS following craniotomy. Furthermore, at six months post-craniotomy, patients were categorized into either the “good outcome group” or the “poor outcome group”. A multivariate regression analysis was applied to ascertain the independent correlation between the CT blend sign and prognosis. ResultsNo statistically significant disparities were observed in the proportion of patients experiencing favorable outcomes during the follow-up period between the two groups. Nevertheless, it is noteworthy that the incidence of the blend sign was higher among patients in the good outcome group compared to those in the poor outcome group. Multivariate regression analysis disclosed that poor outcomes following craniotomy was not associated with the blend sign. ConclusionsThe presence of the blend sign may not serve as a reliable predictor of functional outcomes in patients undergoing craniotomy for spontaneous supratentorial ICH.

Minimally invasive surgeries for spontaneous hypertensive intracerebral hemorrhage (MISICH): a multicenter randomized controlled trial

BackgroundIntracerebral hemorrhage (ICH) is a common stroke type with high morbidity and mortality. There are mainly three surgical methods for treating ICH. Unfortunately, thus far, no specific surgical method has been proven to be the most effective. We carried out this study to investigate whether minimally invasive surgeries with endoscopic surgery or stereotactic aspiration (frameless navigated aspiration) will improve functional outcomes in patients with supratentorial ICH compared with small-bone flap craniotomy.MethodsIn this parallel-group multicenter randomized controlled trial conducted at 16 centers, patients with supratentorial hypertensive ICH were randomized to receive endoscopic surgery, stereotactic aspiration, or craniotomy at a 1:1:1 ratio from July 2016 to June 2022. The follow-up duration was 6 months. Patients were randomized to receive endoscopic evacuation, stereotactic aspiration, or small-bone flap craniotomy. The primary outcome was favorable functional outcome, defined as the proportion of patients who achieved a modified Rankin scale (mRS) score of 0–2 at the 6-month follow-up.ResultsA total of 733 patients were randomly allocated to three groups: 243 to the endoscopy group, 247 to the aspiration group, and 243 to the craniotomy group. Finally, 721 patients (239 in the endoscopy group, 246 in the aspiration group, and 236 in the craniotomy group) received treatment and were included in the intention-to-treat analysis. Primary efficacy analysis revealed that 73 of 219 (33.3%) in the endoscopy group, 72 of 220 (32.7%) in the aspiration group, and 47 of 212 (22.2%) in the craniotomy group achieved favorable functional outcome at the 6-month follow-up (P = .017). We got similar results in subgroup analysis of deep hemorrhages, while in lobar hemorrhages the prognostic outcome was similar among three groups. Old age, deep hematoma location, large hematoma volume, low preoperative GCS score, craniotomy, and intracranial infection were associated with greater odds of unfavorable outcomes. The mean hospitalization expenses were ¥92,420 in the endoscopy group, ¥77,351 in the aspiration group, and ¥100,947 in the craniotomy group (P = .000).ConclusionsCompared with small bone flap craniotomy, endoscopic surgery and stereotactic aspiration improved the long-term outcome of hypertensive ICH, especially deep hemorrhages.Trial RegistrationClinicalTrials.gov Identifier: NCT02811614.

Serum cholesterol and interleukin-10 are associated with post-intracerebral hemorrhage depression in patients with acute primary supratentorial intracerebral hemorrhage

ObjectivesThis study explores the correlation between serum cholesterol, interleukin-10 (IL-10), macrophage migration inhibitory factor (MIF), and post-intracerebral hemorrhage (post-ICH) depression in patients with acute ICH. Methods35 patients with acute primary supratentorial ICH were recruited. Serum cholesterol, including total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDLC), and low-density lipoprotein cholesterol (LDLC), IL-10, and MIF were measured in the first morning after admission. Additionally, a 24-item Hamilton Depression Scale (HAMD-24) was used to detect depressive symptoms one week after admission. HAMD scores ≥ 8 indicated a diagnosis of post-ICH depression. ResultsThe levels of TC were significantly lower in ICH patients with depression compared to those without [169.26(139.23–215.67) mg/dL vs. 200.46(182.81–224.74) mg/dL, P = 0.010]. Similarly, levels of LDLC [102.18(78.39–137.28) mg/dL vs. 135.14(120.22–170.63) mg/dL, P = 0.001] and IL-10 [17.56(16.03–22.52) pg/mL vs. 31.17(23.42–37.53) pg/mL, P = 0.001] were also lower in patients with post-ICH depression. Furthermore, the levels of TC (r = -0.433, P = 0.009), TG (r = -0.345, P = 0.043), LDLC (r = -0.549, P = 0.001), and IL-10 levels (r = -0.603, P < 0.001) showed negative correlations with the HAMD scores. Logistic regression analysis indicated that higher IL-10 levels (OR = 0.847, 95 % CI = 0.717–0.999, P = 0.049) were indicative of protection against post-ICH depression in the acute phase. ConclusionLower levels of TC, LDLC, and IL-10 were associated with post-ICH depression during the acute phase. Furthermore, decreased levels of IL-10 may serve as a promising predictor for post-ICH depression.

Predictors of 30-Day Mortality for Surgically Treated Patients with Spontaneous Supratentorial Intracerebral Hemorrhage and Validation of the Surgical Swedish Intracerebral Hemorrhage Score: A Retrospective Single-Center Analysis of 136 Cases

We aimed to: identify independent risk factors of 30-day mortality in patients with surgically treated spontaneous supratentorial ICH, validate the SwICH Score within Polish Healthcare System, and compare the SwICH Score to the ICH Score.We carried out a single-centre retrospective analysis of the medical data juxtaposed with CT scans of 136 ICH patients treated surgically between 2008 and 2022. Statistical analysis was performed using the same characteristics as in the SwICH Score and the ICH Score. Backward stepwise logistic regression with both 5-fold cross-validation and 1000x bootstrap procedure was used to create new scoring system. Finally predictive potential of these scales were compared.The most important predictors of 30-days mortality were: ICH volume (p<0.01), GCS at admission (p<0.01), anticoagulant status (p=0.03), and age (p<0.01). The SwICH score appears to have a better predictive potential than the ICH score, although this did not reach statistical significance [AUC: 0.789 (95% CI: 0.715-0.863) vs. AUC: 0.757 (95% CI: 0.677-0.837)]. Moreover, based on the analysed characteristics, we developed our score (encompassing: age, ICH volume, anticoagulants status, GCS at admission), [AUC of 0.872 (95% CI: 0.815-0.929)]. This score was significantly better than previous ones.Differences in healthcare systems seem to affect the accuracy of prognostic scales for patients with ICH, including possible differences in indications for surgery and postoperative care. Thus, it is important to validate assessment tools before they can be applied in a new setting and develop population-specific scores. This may improve the effectiveness of risk stratification in patients with ICH.

Prediction of functional outcome in supratentorial intracerebral hemorrhage patients treated with stereotactic computed tomographic-guided aspiration and recombinant tissue plasminogen activator (rt-PA)

Background and purposeMinimally invasive surgery for ICH has shown a significantly improved functional outcome for selected ICH patients. This study aimed to evaluate the factors influencing the outcome of supratentorial ICH patients treated with stereotactic computed tomographic (CT) guided recombinant tissue plasminogen activator (rt-PA). MethodsWe retrospectively evaluated data from 80 consecutive supratentorial ICH patients between December 2017 and July 2020, analyzing their 180-day outcomes, and identifying clinical, radiological factors for good prognosis within 180 days. ResultsThe mean age was 55.6 years (SD 11.4). The median preoperative Glasgow Coma Scale (GCS) score was 9 (interquartile range - IQR 6–12). The mean final ICH volume was 26.5 ml (SD 27.5), with ICH volume reduction by an average of 66.7 %. Six months after the procedure, 40 patients (50 %) had favorable outcomes (modified Rankin Scale [mRS]) score 0–3). In multivariate analysis, age (odds ratio [OR] = 0.939, 95 % confidence interval (CI) = 0.894 – 0.986; p = 0.012), the GCS score before operation (OR = 1.525, 95 % CI = 1.008 – 2.309; p = 0.046), the initial midline shift (OR = 0.808, 95 % CI = 0.661 – 0.988; p = 0.038), and the residual volume hematoma (OR = 0.949, 95 % CI = 0.908 – 0.992, p = 0.020) were the significant predictors of a favorable 180-day outcome. Receiver operating characteristic curve analysis confirmed that the best cut-off point for predicting the good functional 180-day outcome was a GCS score of 9 before the procedure [area under the curve: 0.721, 95 % CI = 0.608 – 0.833, p = 0.001]. ConclusionCT-guided thrombolysis and aspiration can be safe and effective in reducing ICH volume. A preoperation GCS score above or equal to 9 and younger age were associated with improved long-term outcomes in patients with supratentorial ICH.

Abstract TMP79: Deep Learning Model For Prediction Of Supratentorial Intracerebral Hemorrhage (ich) Expansion

Purpose: Hematoma expansion (HE) is associated with early clinical deterioration, worse long-term outcome, and higher mortality in ICH. Identification of patients at risk of HE may allow targeted anti-expansion therapies in future trials. We aimed to train and validate a deep learning model for prediction of HE based on admission non-contrast head CT. Methods: We utilized the clinical and imaging information from the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial and Yale ICH registry. All patients with spontaneous supratentorial ICH who had baseline head CT (&lt;24 h from last know well), follow-up scan (within 16-48 h of baseline), axial slice thickness &lt;5.7 mm, and slices numbers &gt;28 were included. The HE was defined as an increase volume &gt;33% or 6 ml. We trained a DenseNet121-based 3D convolutional neural network for prediction of HE (pipeline summarized in the Figure). Results: A total of 749 patients (610 from ATACH-2 and 183 from Yale) were randomly split (4:1) into 634 training/cross-validation (368 (58%) male, mean age of 62.8±13.1 years, median NIHSS 10, and 144 (23%) with HE); and 159 independent test set (92 (58%) male, mean age of 62.5±14.6 years, median NIHSS 12, and 36 (23%) with HE). The average of validation AUC in five-fold training/cross-validation was 0.62, with the best performing model achieving an AUC of 0.71 in validation fold. We then tested this model in the independent validation cohort isolated from training process, achieving an AUC of 0.67 in predicting HE. The attention heatmaps (Figure) confirm that deep learning model predictions were based on head CT regions containing ICH and perilesional edema. Conclusion: We could train, and independently validate a deep learning model for identification of supratentorial ICH patients at risk of impending HE. Compared to visual markers (including CTA spot sign), such model can provide an automated objective tool for future trial enrollment based on readily available non-contrast CT

Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation.

Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation. Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression. A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27-65) ml and the median postoperative volume was 1.2 (0.3-7.5) ml, resulting in a median evacuation percentage of 97% (85%-99%). The median hospital length of stay was 17 (IQR 9-25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67-0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05-0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91-0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90-164, p = 0.01) as compared to those who had undergone evacuation after 48 hours. In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.

Results of endoscopic aspiration of hypertensive intracerebral hematomas depending on the surgery technique

Aim: to conduct a comparative analysis of the invasiveness, radicality of operations and treatment outcomes, depending on the options for the technique of endoscopic aspiration of hypertensive intracerebral hematomas (EA ICH). Material and methods. At the Sklifosovsky Institute for Emergency Medicine, EA ICH was performed in 131 patients with haemorrhagic stroke from 2006 to 2020. There were 89 men (67.9%) and 42 women (32.1%). The mean age of the patients was 55.1±12.5 years (from 20 to 87 years). According to the Glasgow Coma Scale (GCS) [28], the level of consciousness during hospitalization corresponded to 15 points in 42 (32.1%) patients, 11-14 points - in 78 (59.5%), 9-10 points - in 9 (6.9), 6-8 points - in 2 (1.5%) patients. In 124 (94.7%) patients, ICH was supratentorial, in 7 (5.3%) patients - subtentorial. The average volume of supratentorial ICH was 48.3±20.1 cm³ (from 6 to 131 cm³), subtentorial - 14.3±3.5 cm³ (from 9 to 18 cm³). The average term of performing the surgery was 5.5±7.5 days. ICH removal in the aquatic environment was performed through single-channel (6.5 mm) and multi-channel (6.0 mm) trocars of ventriculoscopes; removal of ICH in the air was achieved through a single-channel trocar (6.5 mm), wide (from 12 to 21 mm) and narrow (8.0 mm) transparent ports. CT brain scan was performed during the first day after the operation. The outcomes were assessed on the 30th day according to the modified Rankin scale. Results. The most radical ICH removal was achieved with the use of wide transparent ports, while the least number of recurrences was after operations through narrow transparent ports, and the tendency to achieve better functional outcomes was obtained when the method of ICH removing in the aquatic environment was refused in favor of EA in the air environment. Conclusion. The trend in achieving better functional outcomes can be traced in patients after surgeries in the air environment. Operations through wide ports provide a more radical removal of blood clots, while operations through a trocar and narrow ports in the air allow for the lowest rate of ICH recurrences.

The Role of Risk Factor in the Surgical Treatment of Hemorrhagic Stroke

AIM OF STUDY To identify risk factors for adverse outcomes of surgical treatment of patients with HS.MATERIAL AND METHODS A retrospective analysis of the results of surgical treatment of 500 patients operated on at the N.V. Sklifosovsky Institute from 1997 to 2020 for hypertensive intracerebral hematomas. The mean age of the patients was 53.1±12.2 years. There were 335 (67%) men and 165 (33%) women.The level of consciousness before the operation was clear in 176 (35.2%), stupor (11–14 score, GCS) — in 258 (53.6%), sopor (score 9–10, GCS) — in 38 (7.6 %), moderate coma (7–8 score, GCS) — in 10 (2%) patients, deep coma (score 6) — in 7 (1.4%) patients. ICHs were lobar in 218 (43.6%) patients, lateral in 212 (42.4%) patients, thalamic in 10 (2%) patients, mixed in 10 (2%) patients, cerebellar in 50 (10% ) patients. The average volume of ICH was 46.5±25.1 cm3, supratentorial ICH – 49.6±24.5 cm3 (from 4 to 147 cm3), subtentorial — 18.7±6.4 cm3 (from 5 to 36 cm3). The average duration of the surgical intervention was 3.3±2.6 days. The following types of operations were performed: open removal of the ICH in 271 (54.2%) patients, puncture aspiration and local fibrinolysis of the ICH in 98 (19.6%) cases, endoscopic aspiration of the ICG in 131 (26.2%) patients.RESULTS The risk factors for lethal outcome in HT surgery are the age of patients older than 50 years (χ2=13.9, p&lt;0.04), the volume of cerebral hemispheres more than 50 cm3 (χ2=7.8, p&lt;0.01), the total volume of ICH and perifocal edema more than 100 cm3 (χ2=9.1, p&lt;0.01), transverse dislocation of the median structures of the brain more than 5 mm (χ2=32.2, p&lt;0.0001), axial dislocation of the brain (χ2=16 ,1, p&lt;0.02), BP before surgery higher than 160 mm Hg (χ2=21.9, p&lt;0.002), presence of IVH (χ2=36.9, p&lt;0.00001), AOH (χ2=28.0, p&lt;0.0001), surgery time — the first day after hemorrhage (χ2=64.4, p&lt;0.00001), residual volume of ICH after surgery more than 15 cm3 (χ2=4.0, p&lt;0.05) and recurrence of ICH (χ2=33.1, p&lt;0.00001). The outcomes correlate with the severity of the patient’s condition before surgery (R=0.38, p&lt;0.00001), and the risk factor for death is the depression of consciousness to deep stupor and below (χ2=97.2, p&lt;0.00001).CONCLUSION Assessment of risk factors can help clarify the prognosis of the outcomes of surgical treatment and optimize the treatment tactics of patients.

Automated Pupillometry Identifies Absence of Intracranial Pressure Elevation in Intracerebral Hemorrhage Patients

IntroductionAlthough automated pupillometry is increasingly used in critical care settings, predictive value of automatically assessed pupillary parameters during different intracranial pressure (ICP) levels and possible clinical implications are unestablished.MethodsThis retrospective cohort study at the neurocritical care unit of the University of Erlangen-Nuremberg (2016–2018) included 23 nontraumatic supratentorial (intracerebral hemorrhage) ICH patients without signs of abnormal pupillary function by manual assessment, i.e., absent light reflex. We assessed ICP levels by an external ventricular drain simultaneously with parameters of pupillary reactivity [i.e., maximum and minimum apertures, light reflex latency (Lat), constriction and redilation velocities (CV, DV), and percentage change of apertures (per-change)] using a portable pupillometer (NeurOptics®). Computed tomography (CT) scans were analyzed to determine lesion location, size, intraventricular hemorrhage, hydrocephalus, midline shift, and compression or absence of the basal cisterns. We performed receiver operating characteristics analysis to investigate associations of ICP levels with pupillary parameters and to determine best cutoff values for prediction of ICP elevation. After dichotomization of assessments according to ICP values (normal: < 20 mmHg, elevated: ≥ 20 mmHg), prognostic performance of the determined cutoff parameters of pupillary function versus of CT-imaging findings was analyzed by calculating sensitivity, specificity, positive and negative predictive values (logistic regression, corresponding ORs with 95% CIs).ResultsIn 23 patients (11 women, median age 59.0 (51.0–69.0) years), 1,934 assessments were available for analysis. A total of 74 ICP elevations ≥ 20 mmHg occurred in seven patients. Best discriminative thresholds for ICP elevation were: CV < 0.8 mm/s (AUC 0.740), per-change < 10% (AUC 0.743), DV < 0.2 mm/s (AUC 0.703), and Lat > 0.3 s (AUC 0.616). Positive predictive value of all four parameters to indicate ICP elevation ranged between 7.2 and 8.3% only and was similarly low for CT abnormalities (9.1%). We found high negative predictive values of pupillary parameters [CV: 99.2% (95% CI 98.3–99.6), per-change: 98.7% (95% CI 97.8–99.2), DV: 98.0% (95% CI 97.0–98.7), Lat: 97.0% (95% CI 96.0–97.7)], and CT abnormalities [99.7% (95% CI 99.2–99.9)], providing evidence that both techniques adequately identified ICH patients without ICP elevation.ConclusionsOur data suggest an association between noninvasively detected changes in pupillary reactivity and ICP levels in sedated ICH patients. Although automated pupillometry and neuroimaging seem not sufficient to noninvasively indicate ICP elevation, both techniques, however, adequately identified ICH patients without ICP elevation. This finding may facilitate routine management by saving invasive ICP monitoring or repeated CT controls in patients with specific automated pupillometry readings.

Minimally Invasive Parafascicular Surgery (MIPS) for Spontaneous Intracerebral Hemorrhage Compared to Medical Management: A Case Series Comparison for a Single Institution.

Objective We compared the safety and effectiveness of minimally invasive parafascicular surgery (MIPS) as a frontline treatment for spontaneous supratentorial ICH to medical management. Patients. The sample consisted of 17 patients who underwent MIPS from January 2014 to December 2016 and a comparison group of 23 patients who were medically managed from June 2012 to December 2013. All had an International Classification of Disease (ICD) diagnosis of 431 and were treated at Grady Memorial Hospital, an urban, public, safety-net hospital. Methods The primary endpoint was risk of inpatient mortality. Secondary endpoints were rates of inpatient infection and favorable discharge status, defined as discharge to home or rehabilitation facility. Demographics and pre- and postclinical outcomes were compared using t-tests, the Mann–Whitney test, and chi-squared tests for continuous, ordinal and categorical measures, respectively. Cox proportional hazard models were used to estimate the time to inpatient death. Logistic regression analyses were used to determine treatment effects on secondary outcomes. We also conducted exploratory subgroup analyses which compared MIPS to two medical management subgroups: those who had surgery during their hospitalization and those that did not. Results Two patients (12%) died in the MIPS group compared to three (12%) in the medical management group. MIPS did not increase the risk of inpatient mortality relative to medical management. Rates of inpatient infection did not differ significantly between the two groups; eight MIPS patients (47%) and 13 medically managed patients (50%) contracted infections. MIPS significantly increased the likelihood of favorable discharge status (odds ratio (OR) 1.77; 95% CI, 1.12–21.9) compared to medical management. No outcome measures were significantly different between MIPS and the medical management subgroup without surgery, while rates of favorable discharge were higher among the MIPS patients compared to the medical management group with surgery. Conclusions These data suggest that MIPS, as a frontline treatment for spontaneous ICH, versus medical management for spontaneous ICH warrants further investigation.

Decreased Time to Evacuation Improves Long Term Functional Outcome in Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation

Abstract INTRODUCTION Preclinical and preliminary clinical data suggests that early minimally invasive intracerebral hemorrhage evacuation may convey a functional outcome benefit. Ongoing clinical trials permit an operative window extending out to 72 h. Here we present long term functional outcome after MIS endoscopic ICH evacuation with a focus on time to evacuation. METHODS Minimally invasive endoscopic ICH evacuation was performed on patients with supratentorial ICH who fit previously published clinical criteria including age = 18, National Institutes of Health Stroke Scale (NIHSS) = 6, hematoma volume = 15, and baseline modified Rankin Score (mRS) = 3 with a CTA negative for vascular malformation. Retrospective review was performed on patients who were treated in a single health system from December 2015 to August 2018. Demographic, clinical and radiographic previously demonstrated to impact ICH outcome were included in a multivariate logistic regression to identify factors predicting poor outcome (modified Rankin scale (mRS) 4-6) at 6 mo. RESULTS A total of 97 patients underwent minimally invasive endoscopic ICH evacuation. In a multivariate analysis, factors that predicted poor outcome included age (OR 1.81 (CI 1.15-3.08) P = .016), deep location (OR 11.1 (2.41-67.8) P = .004), presence of intraventricular hemorrhage (OR 5.81 (1.765-22.39) P = .006) and increased time to evacuation measured in hours (OR 1.048 (CI 1.017-1.084) P = .004). CONCLUSION Time to evacuation significantly impacts long term outcome in minimally invasive endoscopic ICH evacuation. Every minute counts.

Basal ganglia hemorrhage in a case report following spinal surgery

BackgroundIntracranial hemorrhage is a rare but potentially severe complication of spinal surgery. Most reported post-operative ICH cases consist of cerebellar hemorrhage. There are fewer reported cases of supratentorial ICH following spinal surgery.Case presentationA 56-year-old woman underwent spinal surgery complicated by bilateral supratentorial intraparenchymal basal ganglia hemorrhage with both intraventricular extension and subarachnoid hemorrhage in both cerebral hemispheres.ConclusionThe occurrence of neurological deterioration post-operatively following spinal surgery should alert physicians to the possibility of intracranial hemorrhage in order to facilitate rapid and optimal management. To our knowledge, this is the first case reporting basal ganglia hemorrhage following spinal surgery. Moreover, consideration should be given to the possibility of this complication prior to recommendation of elective spinal surgery.

Abstract 51: Organ- and Cell-Specific Immune Responses Are Associated With the Outcomes of Intracerebral Hemorrhage

Background: Severe brain injury significantly influences immune responses. However, the levels at which such influence occur and the involvement of neurogenic pathways are not well defined. Methods: 39 eligible patients with supratentorial ICH within 24 hours of onset and 20 matched healthy controls were enrolled. Hematoma sizes at admission were calculated via computed tomography (CT). Perihematomal edema (PHE) and spleen volume at day 3 and 14 were measured via T2-weighted magnetic resonance imaging (MRI), respectively. Tissue diffusion and capillary perfusion of spleen were quantified by Intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) with 9 b values. Peripheral lymphocyte subsets were quantified by flow cytometry. Neurotransmitters and stress hormone were detected by enzyme-linked immunosorbent assay (ELISA). Association of splenic and cellular alterations with progression of PHE and the outcomes of ICH patients were analyzed. Mechanisms governing the spleen and lymphocyte alterations after ICH were investigated in mouse models of ICH. Results: Average spleen shrinkage of 37ml accompanied by splenic capillary perfusion increase occurred in ICH patients at day 3 after disease onset. The magnitude of spleen shrinkage was associated with hematoma size upon admission. Concurrently, patients with severe spleen shrinkage (&gt; 37ml) had less progression of PHE. Lymphopenia was observed in ICH patients after ictus and persisted up to 14 day, which was not parallel with spleen alteration. Patients with infections exhibited poorer functional outcome and significant T and NK cell deficiency. In ICH models, signals derived from adrenergic and hypothalamus-pituitary-adrenal (HPA) axis activation contributed to loss of white blood cells in the white pulp. Conclusions: Spleen shrinkage and lymphopenia reflect the impact of ICH on the immune system at the organ and cellular levels, such impacts are derived from coordinated action of sympathetic innervation and HPA axis. The magnitude of spleen shrinkage might be associative with the progression of PHE and clinical outcome of ICH patients. Additionally specific cellular immunity deficiency was associated with increased infection risk in patients.

Abstract WP357: The Impact of Specific Neuroanatomical Location in Deep Supratentorial Intracerebral Hemorrhage (ICH): Findings From the Ethnic/Racial Variations of ICH Study

Background: Recently early phase clinical trials have targeted individual anatomical locations. However, information regarding ICH characteristics and outcomes of specific deep locations of ICH is limited. Methods: ERICH is a multi-center, prospective, case-control study of a racially mixed population with ICH. ICH locations were systematically designated by a central imaging core. Subjects with supratentorial deep ICH based on initial head CT originating in the caudate, thalamus, or putamen were included. Those with pre-morbid modified Rankin Scale (mRS) &gt; 2, positive drug screen, or missing 3-month mRS were excluded. Differences in baseline characteristics and medical interventions were examined by anatomic location, stratified by intraventricular hemorrhage (IVH) presence. Receiver operating curve analysis was performed to determine ICH volume specificity for poor outcome (mRS 4-6). Results: A total of 945 subjects met inclusion criteria for the analysis: caudate (n=62), putamen (n=394), thalamus (n=489). Significant differences were noted for presence of IVH (caudate 89%, putamen 23%, thalamus 64%, p&lt;.0001), ventriculostomy (caudate 52%, putamen 14%, thalamus 27%; p&lt;.0001), and surgery (caudate 2%, putamen 10%, thalamus 2%, p&lt;.0001). In multivariable analysis, subjects with thalamic ICH without IVH (compared with putaminal ICH without IVH) were more likely to be younger (OR 1.02; 95%CI 1.00-1.04, p=.0130, have history of hypertension (OR 2.82, 95%CI 1.24-6.39), and lower ICH volume (OR 0.28, 95%CI 0.21-0.38, p&lt;.0001). Subjects with thalamic ICH and IVH (compared with putaminal ICH and IVH) were less likely to have surgery for evacuation (OR 0.14, 95%CI 0.04-0.46, p=.0012) and have lower ICH volume (OR 0.13, 95%CI 0.08-0.22, p&lt;.0001). Receiver operating curve analysis identified 5.39 mL volume in thalamic ICH without IVH and 18.68 ml in putaminal ICH without IVH as having 95% specificity for poor outcome. Conclusion: In patients with deep supratentorial ICH, IVH is significantly more common in caudate and thalamic ICH compared with putaminal ICH. ICH volume cut-offs highly specific for poor outcome were identified. These findings may have implications for prognosis and clinical trial design.

Retrospective comparison of decompressive hemicraniectomy and hematoma evacuation for spontaneous supratentorial intracerebral hematoma

Objectives: The aim of this study was to test the hypothesis that decompressive hemicraniectomy (DHC), compared with craniotomy with evacuation of hematoma, and would improve clinical outcomes of patients with supratentorial intracerebral hemorrhage (SICH).Methods: We compared patients (November 2008–February 2014) with supratentorial ICH treated with DHC without hematoma evacuation and craniotomy with hematoma evacuation. DHC measured at least 150 mm and included opening of the dura. We analyzed clinical, radiological, and surgical characteristics. Outcome at 6 months was divided into good (modified Rankin Scale 0–4) and poor (modified Rankin Scale 5–6).Results: Fifteen patients (mean age 58 years) with ICH were treated by DHC. Median hematoma volume was 61 ml and mean preoperative Glasgow Coma Scale (GCS) was 7. Ten patients had good and five had poor outcomes. In hematoma evacuation group 29 patients were treated. Median hematoma volume was 55 ml and mean preoperative Glasgow Coma Scale (GCS) was 8. Seventeen patients had good and twelve had poor outcomes.Conclusions: DHC is more effective than hematoma evacuation in patients with SICH. Based on this small cohort, DHC may reduce mortality. Larger prospective study is warranted to assess safety and efficacy.Pulse Vol.7 January-December 2014 p.16-21

The Impact of Left Ventricular Hypertrophy and Diastolic Dysfunction on Outcome in Intracerebral Hemorrhage Patients

BackgroundThe objective of this study was to determine the prevalence of LVH and DD in patients presenting with supratentorial deep ICH and to determine if the presence of LVH or DD was an independent predictor of initial ICH volume, hematoma expansion, or poor outcome.MethodsA cross-sectional study was performed on ICH patients who presented from 7/2008 to 12/2010. Cases were excluded if ICH was traumatic, lobar, infratentorial, secondary to elevated international normalized ratio, suspicious for underlying structural malformation, or where surgical evacuation was performed. Logistic and linear regressions were used to assess the ability of LVH to predict ICH imaging characteristics and patient outcomes.ResultsAfter adjusting for use of hemostatic agents, LVH was not a significant independent predictor of initial ICH volume (P = 0.344) or 33% volume expansion (P = 0.378). After adjusting for age, infectious complications, and use of hemostatic agents, LVH was not a significant independent predictor of poor functional outcome (P = 0.778). Similar results were seen for DD.ConclusionIn our sample, patients with deep ICH and LVH were more likely to develop IVH, but LVH was not a significant independent predictor of initial ICH volume, hematoma expansion, or poor short-term outcome.

Frequency of Adequate Contrast Opacification of the Major Intracranial Venous Structures with CT Angiography in the Setting of Intracerebral Hemorrhage: Comparison of 16- and 64-Section CT Angiography Techniques

DVST is an important cause of ICH because its treatment may require anticoagulation or mechanical thrombectomy. We aimed to determine the frequency of adequate contrast opacification of the major intracranial venous structures in CTAs performed for ICH evaluation, which is an essential factor in excluding DVST as the ICH etiology. Two readers retrospectively reviewed CTAs performed in 170 consecutive patients with ICH who presented to our emergency department during a 1-year period to determine by consensus whether qualitatively, contrast opacification in each of the major intracranial venous structures was adequate to exclude DVST. "Adequate contrast opacification" was defined as homogeneous opacification of the venous structure examined. "Inadequate contrast opacification" was defined as either inhomogeneous opacification or nonopacification of the venous structure examined. Delayed scans, if obtained, were reviewed by the same readers blinded to the first-pass CTAs to determine the adequacy of contrast opacification in the venous structures according to the same criteria. In patients who did not have an arterial ICH etiology, the same readers determined if thrombosis of an inadequately opacified intracranial venous structure could have potentially explained the ICH by correlating the presumed venous drainage path of the ICH with the presence of inadequate contrast opacification within the venous structure draining the venous territory of the ICH. CTAs were performed in 16- or 64-section CT scanners with bolus-tracking, scanning from C1 to the vertex. Patients with a final diagnosis of DVST were excluded. We used the Pearson χ(2) test to determine the significance of the differences in the frequency of adequate contrast opacification within each of the major intracranial venous structures in scans obtained using either a 16- or 64-section MDCTA technique. Fifty-eight patients were evaluated with a 16-section MDCTA technique (34.1%) and 112 with a 64-section technique (65.9%). Adequate contrast opacification within all major noncavernous intracranial venous structures was significantly less frequent in first-pass CTAs performed with a 64-section technique (33%) than in those performed with a 16-section technique (60%, P value < .0001). Delayed scans were obtained in 50 patients, all of which demonstrated adequate contrast opacification in the major noncavernous intracranial venous structures. In 142 patients with supratentorial or cerebellar ICH without an underlying arterial etiology, we found that thrombosis of an inadequately opacified major intracranial venous structure could have potentially explained the ICH in 38 patients (26.8%), most examined with a 64-section technique (86.8%). Inadequate contrast opacification of the major intracranial venous structures is common in first-pass CTAs performed for ICH evaluation, particularly if performed with a 64-section technique. Acquiring delayed scans appears necessary to confidently exclude DVST when there is strong clinical or radiologic suspicion.

Correlation of age and haematoma volume in patients with spontaneous lobar intracerebral haemorrhage

BackgroundLobar intracerebral haemorrhage (LH) is gaining importance in the ageing population, but there are only limited data regarding specific clinical characteristics and risk factors of older patients with LH.MethodsThis retrospective...

Silent microbleeds are associated with volume of primary intracerebral hemorrhage

The authors performed a correlative radiologic study on the micro-bleeds and volume of intracerebral hemorrhage in the supratentorial ICH patients. In the patients with lobar or putaminal hemorrhage, the hemorrhage volumes increased more than twofold or threefold in the patients with micro-bleeds. Moreover, the presence of microbleeds was an independent risk factor for large-sized hemorrhage. These data show that microbleeds may be associated with a larger ICH volume.