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(a) Examples of hematoma and perihematoma edema regions of interest (ROI) on noncontrast CT images (NCCT) and cerebral blood flow (CBF) maps before and after blood pressure (BP) treatment. The ROIs were drawn on the noncontrast CT and transferred to perfusion maps. (b) Time course of systolic BP (SBP) reduction from baseline CT perfusion (CTP). CT, computed tomography.
Source publication
Spontaneous intracerebral hemorrhage (ICH) is associated with high rates of morbidity and mortality. Although treatment options are limited, a potential acute medical intervention is blood pressure (BP) reduction. The review will summarize the current evidence and remaining knowledge gaps with respect to acute BP management in acute ICH.
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Context in source publication
Context 1
... g/min) neither in the perihematoma region nor in the vascular borderzone (watershed) regions [24 & ]. A subgroup analysis of patients undergoing CT perfusion before and after BP treatment showed aggressive antihypertensive therapy did not alter perihematoma or hemispheric CBF, suggesting some preservation of cerebral autoregulation after ICH ( Fig. 1) [25 & ]. Further studies have also shown that perihematoma oxygen delivery (as measured by the maximum oxygen extraction fraction, and the resulting maximum cerebral metabolic rate of oxygen) were unaffected by aggressive BP treatment [26 & ]. Finally, aggressive BP reduction did not result in an increase in the volume of perihematoma ...
Citations
... Bleeding is usually short-lived and is tamponaded by anatomical and physiological means, however, is associated with a 30 days morbidity and mortality of 60% and 30%, respectively. [1] Elevated blood pressure defined as systolic pressure <140 mmHg is seen in 75% of patients with acute ICH, and strict control of blood pressure is paramount in the prevention of delayed rebleeding. [2] The ICH score described by Hemphil in 2001 gives us a good predictive factor for the predicts 30 days mortality. ...
Introduction
Intracranial hemorrhage (ICH) accounts for significant morbidity and mortality in the United States. Many studies have looked at the benefits of surgical intervention for ICH. Recent results for Minimally Invasive Surgery Plus Recombinant Tissue-type Plasminogen Activator for Intracerebral Hemorrhage-II trials have shown promise for a minimally invasive clot evaluation on improving perihematomal edema. Often rural or busy county medical centers may not have the resources available for immediate operative procedures that are nonemergent. In addition, ICH disproportionally affects the elderly which may not be stable for general anesthetics. This study looks at a minimally invasive bedside approach under conscious sedation for evacuation of ICH.
Materials and Methods
Placement of the intraparenchymal hemorrhage drain utilizes bony anatomical landmarks referenced from computed tomography (CT) head to localize the entry point for the trajectory of drain placement. Using the hand twist drill intracranial access is gained the clot accessed with a brain needle. A Frazier suction tip with stylet is inserted along the tract then the stylet is removed. The clot is then aspirated, and suction is then turned off, and Frazier sucker is removed. A trauma style ventricular catheter is then passed down the tract into the center of hematoma and if no active bleeding is noted on postplacement CT and catheter is in an acceptable position then 2 mg recombinant tissue plasminogen activator are administered through the catheter and remaining clot is allowed to drain over days.
Results
A total of 12 patients were treated from October 2014 to December 2017. The average treatment was 6.4 days. The glascow coma scale score improved on an average from 8 to 11 posttreatment with a value of P is 0.094. The average clot size was reduced by 77% with a value of P = 0.0000035. All patients experienced an improvement in expected mortality when compared to the predicted ICH score.
Discussion
The results for our series of 12 patients show a trend toward improvement in Glasgow Coma Scale after treatment with minimally invasive intraparenchymal clot evacuation and drain placement at the bedside; although, it did not reach statistical significance. There was a reduction in clot size after treatment, which was statistically significant. In addition, the 30-day mortality actually observed in our patients was lower than that estimated using ICH score. Based on our experience, this procedure can be safely performed at the bedside and has resulted in better outcomes for these patients.
... This difference between reality and projection may partially explain the absence of proven benefits of intensive treatment. [21] Moreover, BP level is not the only factor that affects prognosis. As recent evidence has accumulated, BP variability has become regarded as another determinant of prognosis. ...
The ideal target blood pressure(BP) has remaining controversial for patients with cerebral haemorrhage, so we performed a meta-analysis to assess the effects of intensive BP lowering therapy. Clinical trials in which acute-phase patients were randomly assigned to an intensive BP lowering group or a standard BP lowering group were included. The primary outcome was mortality and dependency at 90 days. The secondary outcomes were mortality at 90 days, the proportion of cases involving haematoma extension during the acute phase and early neurological deterioration. Although intensive BP lowering was associated with reduced mortality and dependency at 90 days, this result was not statistically significant (OR 0.89, 95% CI 0.77-1.02, P=0.09). No differences between the two groups were found with respect to the secondary outcomes. Significant differences remained absent in sensitivity analyses. The results suggested that intensive BP lowering does not affect 90-day outcomes, but appears to be safe.
... Many predictors of hematoma expansion ( Fig. 1) have been proposed, but some of them e.g., fibrinogen [14,15], blood pressure [6,13,14,[16][17][18], blood glucose [3,13,19,20], and IVH [10,16,21,22] remain controversial. ...
... Higher blood pressures [3,6,14,33,[35][36][37]62] have been recognized to increase hematoma expansion [3,6,14,33,[35][36][37]62], although precise data on the risks and benefits of acute BP lowering remain limited [13,[16][17][18]63]. The INTERACT I and ATACH I pilot studies revealed a safety profile and lower risk of hematoma expansion when aggressive systolic BP lowering to levels between 110-140 mmHg was achieved [62][63][64]. ...
Background:
Hematoma expansion is a detrimental event of intracerebral hemorrhage (ICH) which results in progressive neurologic deteriorations and poor outcomes.
Objective:
To summariz the current understanding of the mechanisms underlying hematoma expansion and discuss the potential approaches of treatment and prevention.
Results:
Although the exact mechanism of hematoma expansion is unclear, accumulating evidences suggest that multiple clinical markers such as coagulation/hemostasis dysfunction, higher blood pressure and BRAIN scores, higher serum glucose and/or glycosylated hemoglobin A1c, serum creatinine, Factor XIII and international normalized ratio (INR), lower serum cholesterol or LDL cholesterol, and fibrinogen, may be correlated with incidents of hematoma expansion. Furthermore, activation of several molecular pathways (i.e. plasma kallikrein, von Willebrand factor, N-methyl-Daspartate and its receptor, cytokines/ adipokines, cellular fibronectin and apolipoprotein Eε2 allele) may lead to hematoma expansion.
Conclusion:
Prospective study for hematoma expansion How to predict the patients Who are at highest risk of hematoma expansion is more challengeable than restricting hematoma expansion itself following acute ICH. Seeking and detecting risk markers in plasma that can be intervened appropriately is meaningful for patients with potential hematoma expansion, which may contribute to improve clinical outcomes in patients suffering from ICH.
... High mortality rates make it the deadliest of stroke subtype. 1,2 Survivors are left with significant disability. 3 Despite the high morbidity and mortality associated with ICH, there is considerably less evidenced-based guidance in the management of ICH 4 when compared with ischemic stroke. ...
... Hypertension is both an etiologic and a poor prognostic factor in ICH. 1,15 Chronic hypertension is the only identifiable risk factor in up to 50% of patients with primary spontaneous ICH. 25 INTERACT2, the largest clinical trial to date examining intensive blood pressure reduction with a goal of systolic blood pressure (SBP) of < 140 mm Hg, showed that this approach is safe as well as modestly beneficial in terms of 90-day functional outcome in surviving patients. The study also showed a modest reduction in hematoma expansion with blood-pressure lowering. ...
Spontaneous intracerebral hemorrhage (ICH), the most devastating and debilitating form of stroke, remains a major healthcare concern all over the world. Intracerebral hemorrhage is frequently managed in critical care settings where intensive monitoring and treatment are employed to prevent and address primary and secondary brain injury as well as other medical complications that may arise. Although there has been increasing data guiding the management of ICH in the past decade, prognosis remains dismal. In this article, the authors discuss the risk factors for ICH, the role of imaging, the major targets of neurocritical care management, the etiology and management of raised intracranial pressure, as well as prevention of and prompt response to the emergence of medical complications. They also discuss the effect of early withdrawal of life-sustaining therapy on prognosis. Finally, we outline several clinical trials that hold promise in improving our management of ICH in the near future.
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
... Initial blood pressure is not considered as a risk factor or prognostic factor of ICHs [13], but there are some reports showing intensive reduction of blood pressure associated with clinical outcomes of ICHs [15][16][17]. In our study, initial blood pressure was not associated with clinical outcomes. ...
Background
Intracerebral hemorrhage (ICH) is a well-known condition, but ICH restricted to the thalamus is less widely studied. We investigated the prognostic factors of thalamic ICHs.
Material/Methods
Seventy patients from January 2009 to November 2014 were retrospectively reviewed. Patients who demonstrated spontaneous ICH primarily affecting the thalamus on initial brain computed tomography (CT) were enrolled. Patients were categorized into 2 groups based on their Glasgow Outcome Scale (GOS) scores. Various presumptive prognostic factors were analyzed to investigate relationships between various clinical characteristics and outcomes.
Results
Of the enrolled patients, 39 showed a GOS of 4–5, and were categorized as the good outcome group, while another 31 patients showed a GOS of 1–3 and were categorized as the poor outcome group. Initial GCS score, calculated volume of hematoma, presence of intraventricular hemorrhage (IVH), coexisting complications, hydrocephalus, performance of external ventricular drainage, and modified Graeb’s scores of patients with IVH were significantly different between the 2 groups. In multivariate analysis, among the factors above, initial GCS score (P=0.002, Odds ratio [OR]=1.761, Confidence interval [CI]=1.223–2.536) and the existence of systemic complications (P=0.015, OR=0.059, CI=0.006–0.573) were independently associated with clinical outcomes. Calculated hematoma volume showed a borderline relationship with outcomes (P=0.079, OR=0.920, CI=0.839–1.010).
Conclusions
Initial GCS score and the existence of systemic complications were strong predictive factors for prognosis of thalamic ICH. Calculated hematoma volume also had predictive value for clinical outcomes.
Stroke is a leading cause of death and disability worldwide. Spontaneous or non-traumatic intracerebral haemorrhage (ICH) is the commonest of all haemorrhagic strokes [1]. It represents the second most common cause of stroke, with an incidence of 8–15% in Australia, the UK and the USA and 25% in Japan [2]. An overall high incidence of ICH is reported in Asians compared with the Caucasian population [3]. Although ICH occurs less frequently than ischaemic stroke, mortality rates are higher—50% for ICH versus 20% for ischaemic strokes. Depending on the aetiology, ICH can be classified as primary or secondary. Primary ICH, which occurs more frequently (78–88%), is caused by the rupture of a vessel usually degenerated by mechanisms such as hypertension [4] or an underlying amyloid angiopathy. Secondary ICH occurs from other disorders that predispose to bleeding. Predilection sites for ICH include the basal ganglia (40–50%), lobar regions (20–50%), thalamus (10–15%), pons (5–12%), cerebellum (5–10%) and other brain stem sites (1–5%). Intraventricular haemorrhage occurs in approximately one-third of cases of ICH from extension of bleeding into the ventricular space and carries a worse prognosis. The 30-day mortality in ICH is high (35–52%) and is associated with a high morbidity, as only 10% of the patients are independent at 30 days and 20% at 6 months.
Background
Studies on isolated primary thalamic hematomas are limited. This study analyses 117 patients with primary thalamic hematomas and attempts to identify the various prognostic factors influencing the outcome.
Materials and Methods
A retrospective analysis of the case records was carried out to analyse the following prognostic parameters - GCS on admission, comorbidities like systemic hypertension and diabetes mellitus, side and site of hematoma, volume of the clot, presence of intraventricular haemorrhage (IVH), development of hydrocephalus, and the role of surgical intervention. A Chi-square test was used to compare categorical variables, and Student t-test and Mann Whitney test were applied to calculate the P-value for continuous variables for univariate statistics. Binary Logistic regression was used for multivariate analysis.
Results and Discussion
This study group comprised 67 men and 50 women with a mean age of 62.05±11.71years. The mean GCS on admission in the study group was 11.56±3.28. The mean clot volume was 13±9.5ml and majority (89.74%) of the patients had clots with a volume of less than 20 ml. An intraventricular extension was noted in 98 patients. Craniotomy and surgical evacuation were performed in only two patients while external ventricular drainage with urokinase instillation was performed in 23 patients. Of the 117 patients, 3 had anterior thalamic clots, 19 had posterior thalamic clots, 13 had medial clots, 53 had lateral thalamic bleeds and 29 had global clots. The overall three-month mortality with thalamic bleeds was 28.2%. At the end of three months, 59 patients (50.42%) had a favourable outcome (mRS < 4). On univariate analysis, male sex, dominant side bleed, preoperative GCS of less than 8 (p < 0.001), presence of hydrocephalus (p< 0.004) and a need for EVD (p<0.012) were found to be significantly associated with mortality and poor outcome. Similarly, clot volume less than 20 ml, right-sided bleed and surgical evacuation were associated with a favourable outcome (p < 0.001). On multiple logistic regression, age, volume of hematoma and GCS on admission were predictors for mortality and volume of hematoma was a significant predictor of poor outcome.
Conclusion
Thalamic hematomas include a spectrum of clots of varying dimensions at different locations and the outcomes need not be uniformly poor. Isolated thalamic hemorrhages are generally small in volume preferentially located in the lateral thalamus. Patients with right-sided bleeds and small clot volume perform well. Male sex, poor GCS on admission, clot volume above 20 ml, intraventricular extension and a need for external ventricular drainage adversely influence the outcome.
Arterial hypertension represents the most important risk factor for ischemic and haemorrhagic stroke, and an acute hypertensive response is often observed in patients with intracranial haemorrhage (ICH). Available data indicate that the vast majority (> 70%) of patient with acute ICH have a systolic BP above 140 mmHg at the time of presentation in the ED; about 20% have SBP values above 180 mmHg. Severe BP elevation in the presence of ICH represents a hypertensive emergency, and worsening of clinical conditions is not infrequent in the first hours after admission; an aggressive early management is therefore required for these patients. Despite this, appropriate management of BP in acute ICH is still controversial, due to the complex issues involved, and the heterogeneous results obtained in clinical trials. This article will review the available evidence supporting acute BP reduction in acute ICH.
Purpose of review:
Severe ischemic or hemorrhagic stroke is a devastating cerebrovascular disease often demanding critical care. Optimal management of blood pressure (BP) in the acute phase is controversial. The purpose of this review is to display insights from recent studies on BP control in both conditions.
Recent findings:
BP control in acute ischemic stroke has recently been investigated with regard to endovascular recanalizing therapies. Decreases from baseline BP and hypotension during the intervention have been found detrimental. Overall, a periinterventional SBP between 140 and 160 mmHg appeared favorable in several studies. In acute hemorrhagic stroke, the recently completed Antihypertensive Treatment of Acute Cerebral Hemorrhage II trial confirmed feasibility of early aggressive BP reduction but failed to demonstrate a reduction in hematoma growth or a clinical benefit.
Summary:
Recent findings do not support benefits of intensive BP lowering in both acute hemorrhagic and ischemic stroke, with the possible exception of the postinterventional phase after successful endovascular recanalization of large-vessel occlusions. Although optimal ranges of BP values remain to be defined, high BP should still be treated according to guidelines. As stroke patients requiring critical care are underrepresented in most studies on BP, caution in transferring these findings is warranted and prospective research in that patient population needed.
