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Intracerebral Hemorrhage (intracerebral + hemorrhage)
Kinds of Intracerebral Hemorrhage Selected AbstractsContinuous Mean Arterial Pressure Estimation in the Setting of Intracerebral HemorrhageACADEMIC EMERGENCY MEDICINE, Issue 8 2007Gene R. Pesola MD No abstract is available for this article. [source] Intracerebral hemorrhage and COL4A1 mutations, from preterm infants to adult patients,ANNALS OF NEUROLOGY, Issue 1 2009Manuele Mine Pharm D No abstract is available for this article. [source] Therapeutic Yield and Outcomes of a Community Teaching Hospital Code Stroke ProtocolACADEMIC EMERGENCY MEDICINE, Issue 4 2004Andrew W. Asimos MD Objectives: To describe the experience of a community teaching hospital emergency department (ED) Code Stroke Protocol (CSP) for identifying acute ischemic stroke (AIS) patients and treating them with tissue plasminogen activator (tPA) and to compare outcome measures with those achieved in the National Institute of Neurological Disorders and Stroke (NINDS) trial. Methods: This study was a retrospective review from a hospital CSP registry. Results: Over a 56-month period, CSP activation occurred 255 times, with 24% (n= 60) of patients treated with intravenous (IV) tPA. The most common reasons for thrombolytic therapy exclusion were mild or rapidly improving symptoms in 37% (n= 64), intracerebral hemorrhage (ICH) in 23% (n= 39), and unconfirmed symptom onset time for 14% (n= 24) of patients. Within 36 hours of IV tPA treatment, 10% (NINDS = 6%) of patients (n= 6) sustained a symptomatic ICH (SICH). Three months after IV tPA treatment, 60% of patients had achieved an excellent neurologic outcome, based on a Barthel Index of ,95 (NINDS = 52%), while mortality measured 12% (NINDS = 17%). Among IV tPA-treated patients, those developing SICH were significantly older and had a significantly higher mean initial glucose value. Treatment protocol violations occurred in 32% of IV tPA-treated patients but were not significantly associated with SICH (Fisher's exact test). Conclusions: Over the study period, the CSP yielded approximately one IV tPA-treated patient for every four screened and, despite prevalent protocol violations, attained three-month functional outcomes equal to those achieved in the NINDS trial. For community teaching hospitals, ED-directed CSPs are a feasible and effective means to screen AIS patients for treatment with thrombolysis. [source] Epileptogenicity of Supratentorial Medullary Venous MalformationEPILEPSIA, Issue 2 2006Takato Morioka Summary:,Purpose: The purpose of this study was to evaluate the epileptogenicity of supratentorial medullary venous malformation (MVM). Special consideration was given to any associations with intracerebral hemorrhage with or without other vascular malformations, including cavernous angioma (CA). Methods: In total, 10 patients with angiographically or histologically verified MVMs were examined. The patients were divided into two groups with or without intracerebral hemorrhage, and their clinical, neuroradiologic, and interictal and ictal EEG findings were reviewed retrospectively. Results: Although three of five patients in the nonhemorrhagic group had epilepsy, no topographic concordance was found between the MVM location and the EEG focus. On the contrary, in four of five patients in the hemorrhagic group, epilepsy developed, and topographic concordance between the hemorrhagic MVM location and the EEG focus was noted. One patient with a hemorrhagic MVM and an associated CA in the hippocampus had electroclinical pictures of intractable medial temporal lobe epilepsy on this side. Conclusions: Although a supratentorial MVM itself is not epileptogenic, the development of an intracerebral hemorrhage may cause epilepsy. In particular, an associated CA may be highly epileptogenic. [source] Random forest can predict 30-day mortality of spontaneous intracerebral hemorrhage with remarkable discriminationEUROPEAN JOURNAL OF NEUROLOGY, Issue 7 2010S. -Y. Background and purpose:, Risk-stratification models based on patient and disease characteristics are useful for aiding clinical decisions and for comparing the quality of care between different physicians or hospitals. In addition, prediction of mortality is beneficial for optimizing resource utilization. We evaluated the accuracy and discriminating power of the random forest (RF) to predict 30-day mortality of spontaneous intracerebral hemorrhage (SICH). Methods:, We retrospectively studied 423 patients admitted to the Taichung Veterans General Hospital who were diagnosed with spontaneous SICH within 24 h of stroke onset. The initial evaluation data of the patients were used to train the RF model. Areas under the receiver operating characteristic curves (AUC) were used to quantify the predictive performance. The performance of the RF model was compared to that of an artificial neural network (ANN), support vector machine (SVM), logistic regression model, and the ICH score. Results:, The RF had an overall accuracy of 78.5% for predicting the mortality of patients with SICH. The sensitivity was 79.0%, and the specificity was 78.4%. The AUCs were as follows: RF, 0.87 (0.84,0.90); ANN, 0.81 (0.77,0.85); SVM, 0.79 (0.75,0.83); logistic regression, 0.78 (0.74,0.82); and ICH score, 0.72 (0.68,0.76). The discriminatory power of RF was superior to that of the other prediction models. Conclusions:, The RF provided the best predictive performance amongst all of the tested models. We believe that the RF is a suitable tool for clinicians to use in predicting the 30-day mortality of patients after SICH. [source] Clinical features of non-hypertensive lobar intracerebral hemorrhage related to cerebral amyloid angiopathyEUROPEAN JOURNAL OF NEUROLOGY, Issue 6 2010M. Hirohata Background and purpose: The present study aims to clarify the clinical features of non-hypertensive cerebral amyloid angiopathy-related lobar intracerebral hemorrhage (CAA-L-ICH). Methods: We investigated clinical, laboratory, and neuroimaging findings in 41 patients (30, women; 11, men) with pathologically supported CAA-L-ICH from 303 non-hypertensive Japanese patients aged ,55, identified via a nationwide survey as symptomatic CAA-L-ICH. Results: The mean age of patients at onset of CAA-L-ICH was 73.2 ± 7.4 years; the number of patients increased with age. The corrected female-to-male ratio for the population was 2.2, with significant female predominance. At onset, 7.3% of patients received anti-platelet therapy. In brain imaging studies, the actual frequency of CAA-L-ICHs was higher in the frontal and parietal lobes; however, after correcting for the estimated cortical volume, the parietal lobe was found to be the most frequently affected. CAA-L-ICH recurred in 31.7% of patients during the average 35.3-month follow-up period. The mean interval between intracerebral hemorrhages (ICHs) was 11.3 months. The case fatality rate was 12.2% at 1 month and 19.5% at 12 months after initial ICH. In 97.1% of patients, neurosurgical procedures were performed without uncontrollable intraoperative or post-operative hemorrhage. Conclusions: Our study revealed the clinical features of non-hypertensive CAA-L-ICH, including its parietal predilection, which will require further study with a larger number of patients with different ethnic backgrounds. [source] High prevalence of unrecognized cerebral infarcts in first-ever stroke patients with cardioembolic sourcesEUROPEAN JOURNAL OF NEUROLOGY, Issue 7 2009A.-H. Cho Background:, With magnetic resonance imaging (MRI) analysis, we investigated the prevalence, clinical significance, and factors related to the presence of unrecognized cerebral infarcts in patients with first-ever ischaemic stroke. Methods:, We consecutively included patients who were admitted with first-ever stroke. Unrecognized cerebral infarct was defined as an ischaemic infarction or primary intracerebral hemorrhage on MRI irrelevant to the index stroke, without acute lesions on diffusion-weighted image. Results:, Of the total 203 patients, 78 (39.4%) patients were observed as having unrecognized cerebral infarct. Patients with high-risk cardioembolic sources (e.g., atrial fibrillation) more frequently had unrecognized stroke than those without (P = 0.008, 21/36 [58.3%] vs. 57/167 [34.1%]). On univariate analysis, male sex (P = 0.027) and cardioembolic source (P = 0.008) were associated with the presence of unrecognized cerebral infarcts. After adjustment for gender, age and risk factors, the presence of cardioembolic sources independently increased the risk of unrecognized cerebral infarct (P = 0.002, odds ratio 3.56, 95% confidence interval 1.58,8.02). Regarding clinical outcome at 3 months, the presence of unrecognized cerebral infarct was not associated with the poor clinical outcome. Conclusion:, In our study, the presence of cardioembolic sources was an independent risk factor for the unrecognized cerebral infarct in patients with first-ever stroke. [source] Angiotensin-converting enzyme polymorphisms and risk of spontaneous deep intracranial hemorrhage in TaiwanEUROPEAN JOURNAL OF NEUROLOGY, Issue 11 2008C.-M. Chen Background and purpose:, This study examines whether angiotensin-converting enzyme (ACE) gene polymorphisms are associated with the risk of spontaneous deep intracerebral hemorrhage (SDICH) in Taiwan using a case,control study. Methods:, Totally, 217 SDICH patients and 283 controls were recruited. Associations of ACE A-240T and ACE I/D polymorphisms with SDICH were examined under the additive model and adjusted for gender, age, body mass index, total cholesterol level, smoking history, alcohol use, hypertension, and use of ACE inhibitors. Results:, Hypertension, diabetes mellitus, family history of spontaneous intracerebral hemorrhage (SICH), and low cholesterol level increase risk of female SDICH, whereas hypertension, alcohol use, smoking history, family history of SICH, and low cholesterol level are an important risk factor for male SDICH. After adjusting for covariates, only haplotype ACE T-D (OR = 2.7, 95% CI, 1.1,6.5, P = 0.02) was associated with female SDICH. Conclusions:, This study demonstrates that environmental risk factors play a major role and ACE polymorphisms play a minor role in contributing risk of SDICH in Taiwan. [source] EFNS guideline on neuroimaging in acute stroke.EUROPEAN JOURNAL OF NEUROLOGY, Issue 12 2006Report of an EFNS task force Neuroimaging techniques are necessary for the evaluation of stroke, one of the leading causes of death and neurological impairment in developed countries. The multiplicity of techniques available has increased the complexity of decision making for physicians. We performed a comprehensive review of the literature in English for the period 1965,2005 and critically assessed the relevant publications. The members of the panel reviewed and corrected an initial draft, until a consensus was reached on recommendations stratified according to the European Federation of Neurological Societies (EFNS) criteria. Non-contrast computed tomography (CT) scan is the established imaging procedure for the initial evaluation of stroke patients. However, magnetic resonance imaging (MRI) has a higher sensitivity than CT for the demonstration of infarcted or ischemic areas and depicts well acute and chronic intracerebral hemorrhage. Perfusion and diffusion MRI together with MR angiography (MRA) are very helpful for the acute evaluation of patients with ischemic stroke. MRI and MRA are the recommended techniques for screening cerebral aneurysms and for the diagnosis of cerebral venous thrombosis and arterial dissection. For the non-invasive study of extracranial vessels, MRA is less portable and more expensive than ultrasonography but it has higher sensitivity and specificity for carotid stenosis. Transcranial Doppler is very useful for monitoring arterial reperfusion after thrombolysis, for the diagnosis of intracranial stenosis and of right-to-left shunts, and for monitoring vasospasm after subarachnoid hemorrhage. Currently, single photon emission computed tomography and positron emission tomography have a more limited role in the evaluation of the acute stroke patient. [source] Spontaneous intracerebral hemorrhage in young adultsEUROPEAN JOURNAL OF NEUROLOGY, Issue 4 2005S.-L. Lai Few studies have addressed intracerebral hemorrhage (ICH) in younger adults. We studied spontaneous ICH in adults ,45 years of age. We retrospectively reviewed patients hospitalized with ICH between 2000 and 2001 to investigate incidence, etiology, risk factors, bleeding sites, management, and prognosis. Patients (224 men, 72 women; 37.0 ± 7.7 years) had a mortality rate of 24%. The most common risk factor for mortality was hypertension (HTN) (48.7%). Bleeding was most common in the ganglion (49.0%). Multiple hemorrhages (83.3%) caused the highest mortality, with the most common cause of mortality being HTN (46.6%). Coagulopathy (62.5%) caused the highest mortality based on etiologic classification. Recurrent HTN-induced hemorrhage rate was 3.6%. In Taiwanese adults ,45 years of age, ICHs mainly involve the ganglion and result from HTN. Rates of HTN-induced hemorrhage are higher in Taiwan (46.6%) than elsewhere. Differences between races or countries should be investigated further. [source] Hematology and coagulation parameters predict outcome in Taiwanese patients with spontaneous intracerebral hemorrhageEUROPEAN JOURNAL OF NEUROLOGY, Issue 3 2005H.-Y. Fang Volume of intracerebral hemorrhage (ICH), Glasgow Coma Scale (GCS) score, peripheral edema around the hematoma, and hydrocephalus are good predictors of mortality in patients with spontaneous ICH from western countries. However, the significance of hematologic and biochemical parameters associated with spontaneous ICH has not been extensively studied. This study was designed to determine prognostic factors for spontaneous ICH in Taiwanese patients. We prospectively studied 109 consecutive patients with spontaneous ICH admitted to Changhua Christian Medical Center. Clinical and laboratory data were collected and analyzed. Mean age was 62.3 years. There were 63 men (58%) and 46 women (42%). Differences in GCS score, ICH score, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score between the survival and non-survival groups were statistically significant. Laboratory data were statistically different using multivariate analysis for platelet count, prothrombin time, and white cell count. This is the first study providing information on predictors of spontaneous ICH mortality in Taiwanese patients. The prothrombin time and platelet count on the first day were good early predictors of mortality. This finding in ethnically Chinese patients appears to be different from the profile for patients from western countries. [source] Antiplatelet drug use preceding the onset of intracerebral hemorrhage is associated with increased mortalityFUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 3 2007Karine Lacut Abstract Recent studies highlight the contribution of antiplatelet therapy to clinical severity and increased mortality of intracerebral hemorrhage (ICH) but results are discrepant. The aim of this report was to evaluate the association between antiplatelet drug use preceding the onset of ICH and the mortality, assessed at regular intervals, among patients with acute ICH. We analyzed data from a randomized study which enrolled consecutive patients with a documented acute ICH to evaluate the efficacy of intermittent pneumatic compression of the legs in venous thrombosis prevention. Clinical characteristics and treatment used before the onset of ICH were checked at the time of inclusion. Mortality was assessed at regular intervals until 3 months after ICH diagnosis. Among 138 patients included in this report, 30 were current users of antiplatelet therapy at the time of ICH; they were significantly older and less frequently heavy drinkers than non-users of antiplatelet drugs. Mortality rates were 20% at 8 days, 40% at 1 month, and 47% at 3 months among antiplatelet drug users compared with 6.5%, 13% and 19% among non-users. The corresponding estimated risks for mortality related to antiplatelet drug use were 3.6 (95% CI 1.1,12), 4.5 (95% CI 1.8,11), and 3.6 (95% CI 1.5,8.6). Adjusted for age, hypertension and alcohol over use, antiplatelet therapy remained significantly associated with an increased mortality rate of acute ICH. Current antiplatelet drug use preceding the onset of ICH is associated with increased short-term ICH mortality, independently of age. [source] Patterns of stroke recurrence according to subtype of first stroke event: the North East Melbourne Stroke Incidence Study (NEMESIS)INTERNATIONAL JOURNAL OF STROKE, Issue 3 2008Mahmoud Reza Azarpazhooh Background Specific information about the nature of recurrent events that occur after each subtype of index stroke may be useful for refining preventive therapies. We aimed to determine whether stroke recurrence rates, the pattern of subtype recurrence, and prescription of secondary prevention agents differed according to initial stroke subtype. Methods Multiple overlapping sources were used to recruit all first-ever stroke patients from a geographically defined region of Melbourne, Australia over a 3-year period from 1996 to 1999. Potential stroke recurrences (fatal and nonfatal) occurring within 2 years of the initial event were identified following patient interview and follow up of death records. Subjects were classified into the different Oxfordshire groups and the type of first-ever stroke was compared with recurrent stroke events. Results One thousand, three hundred and sixteen first-ever strokes were registered during the 3-year period (mean age 74.4 years). A total of 103 first recurrent stroke events (fatal and nonfatal) occurred among those with a first-ever ischemic stroke or intracerebral hemorrhage (ICH) during the 2-year follow-up period. The recurrent stroke subtype was different to the index stroke subtype in most (78%) patients. People with partial anterior circulation infarct had the greatest proportion of recurrences (13%), with a third of these being the more severe total anterior circulation infarct subgroup. The relative risk of ICH after an index lacunar infarct (LACI) compared with an index non-LACI was 4.06 (95% CI 1.10,14.97, P=0.038). Prescription of secondary prevention agents was greater at 2 years after stroke than at hospital discharge, and was similar between ischemic stroke subtypes. Conclusion Approximately 9% of people with first-ever stroke suffered a recurrent event, despite many being prescribed secondary prevention agents. This has implications for the uptake of current preventive strategies and the development of new strategies. The possibility that ICH is greater among index LACI cases needs to be confirmed. [source] The STRokE DOC trial technique: ,video clip, drip, and/or ship'INTERNATIONAL JOURNAL OF STROKE, Issue 4 2007B. C. Meyer Rationale To describe the clinical trial methods of a site-independent telemedicine system used in stroke. Aims A lack of readily available stroke expertise may partly explain the low rate of rt-PA use in acute stroke. Although telemedicine systems can reliably augment expertise available to rural settings, and may increase rt-PA use, point-to-point systems do require fixed base stations. Site-independent systems may minimize delay. The STRokE DOC trial assesses whether site-independent telemedicine effectively and efficiently brings rt-PA to a remote population. Design STRokE DOC is a 5-year, 400-participant, noninvasive trial, comparing two consultative techniques at four remote sites. Participants are randomized to acute ,STRokE DOC telemedicine' or ,telephone' consultations. Treatment decision accuracy is adjudicated at two time points, using three levels of data availability and an independent auditor. Study outcomes The primary outcome measure is whether there was a ,correct decision to treat or not to treat using rt-PA' at each of three adjudication levels (primarily at Level #2). Secondary outcomes include the number of thrombolytic recommendations, intracerebral hemorrhage, and 90-day outcomes. Using the STRokE DOC system (or telephone evaluation), medical history, neurologic scales, CT interpretations, and recommendations have been completed on over 200 participants to date. Of the initial 11, nonrandomized, ,run-in' patients, six (65%) were evaluated wirelessly, and five (45%) were evaluated with a site-independent LAN or cable modem. Three (27%) received rt-PA. The adjudication methodology was able to show both agreements and disagreements in these 11 cases. It is feasible to perform site-independent stroke consultations, and adjudicate those cases, using the STRokE DOC system and trial design. Telemedicine efficacy remains to be proven. [source] The role of thrombin and thrombin receptors in ischemic, hemorrhagic and traumatic brain injury: deleterious or protective?JOURNAL OF NEUROCHEMISTRY, Issue 1 2003Guohua Xi Abstract In the last two decades it has become apparent that thrombin has many extravascular effects that are mediated by a family of protease-activated receptors (PARs). PAR-1, -3 and -4 are activated via cleavage by thrombin. The importance of extravascular thrombin in modulating ischemic, hemorrhagic and traumatic injury in brain has recently become clear. Thus, in vitro, thrombin at low concentration protects neurons and astrocytes from cell death caused by a number of different insults. In vivo, pretreating the brain with a low dose of thrombin (thrombin preconditioning), attenuates the brain injury induced by a large dose of thrombin, an intracerebral hemorrhage or by focal cerebral ischemia. Thrombin may also be an important mediator of ischemic preconditioning. In contrast, high doses of thrombin kill neurons and astrocytes in vitro and cause disruption of the blood,brain barrier, brain edema and seizures in vivo. This review examines the role of thrombin in brain injury and the molecular mechanisms and signaling cascades involved. [source] Neuroimaging and Neurologic Complications after Organ TransplantationJOURNAL OF NEUROIMAGING, Issue 2 2007ivkovi ABSTRACT Neurologic complications are common after transplantation and affect 30-60% of transplant recipients. The etiology of most of the posttransplant neurologic disorders is related to the opportunistic infections, both systemic and involving central nervous system (CNS), toxicity of immunosuppressive medications, and the metabolic insult created by the underlying primary disease and the transplant procedure. Neuroimaging studies are one of the key tools in the evaluation and enable early diagnosis of neurologic complications in transplant patients, especially posterior reversible leukoencephalopathy syndrome, central pontine myelinolysis, intracerebral hemorrhage, and fungal and bacterial abscesses. Magnetic resonance imaging (MRI) is the preferred technique, but each of the available neuroimaging techniques offers a unique insight into the pathophysiologic mechanisms underlying neurologic complications of transplantation. The role of neuroimaging in this population includes early detection of calcineurin inhibitor neurotoxicity, opportunistic infections, neoplasia, metabolic disorders, or cerebrovascular diseases. In addition, we can monitor longitudinal progression of disease and treatment response. [source] ORIGINAL ARTICLE: Venous thromboembolism and subsequent diagnosis of subarachnoid hemorrhage: a 20-year cohort studyJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 8 2010H. T. SØRENSEN Summary.,Background:,Venous thromboembolism is a predictor of subsequent risk of ischemic stroke and intracerebral hemorrhage, but no data are available regarding its association with risk of subarachnoid hemorrhage. Objectives:,To examine this issue, we conducted a nationwide cohort study in Denmark. Patients and methods: Between 1977 and 2007, we identified 97 558 patients with a hospital diagnosis of venous thromboembolism and obtained information on risk of subsequent subarachnoid hemorrhage during follow-up in the Danish Registry of Patients. The incidence of subarachnoid hemorrhage in the venous thromboembolism cohort was compared with that of 453 406 population control cohort members. Results:,For patients with pulmonary embolism (PE), there was clearly an increased risk of subarachnoid hemorrhage, both during the first year of follow-up [relative risk 2.69; 95% confidence interval (CI), 1.32,5.48] and during later follow-up of 2,20 years (relative risk 1.40; 95% CI, 1.05,1.87). For patients with deep venous thrombosis (DVT) the risk was likewise clearly increased during the first year of follow-up (relative risk 1.91; 95% CI, 1.13,3.22), but not during later follow-up (relative risk 1.04; 95% CI, 0.81,1.32). Conclusions:,We found evidence that PE is associated with an increased long-term risk of subarachnoid hemorrhage. The two diseases might share etiologic pathways affecting the vessel wall or share unknown risk factors. [source] Spontaneous splenic rupture in a patient with factor XIII deficiency and a novel mutationPEDIATRIC BLOOD & CANCER, Issue 1 2008Hassan Khalife MD Abstract We report a novel mutation in factor XIIIA gene that caused severe congenital factor XIII deficiency in a 6 year and 8 month old male. The mutation is a GA deletion in the core domain leading to a premature stop at codon 502. The child had severe deficiency with two episodes of intracerebral hemorrhage. He also developed spontaneous splenic rupture, an unusual complication of this disorder. Pediatr Blood Cancer 2008;50:113,114. © 2006 Wiley-Liss, Inc. [source] Nonmyeloablative allogeneic bone marrow transplantation for treatment of myelodysplastic syndrome complicated by recent intracerebral hemorrhageAMERICAN JOURNAL OF HEMATOLOGY, Issue 4 2004Korenori Ohtsubo Abstract A patient with intracerebral hemorrhage is considered ineligible for hematopoietic stem cell transplantation (HSCT). We report a 49-year-old woman with myelodysplastic syndrome (MDS) complicated by refractoriness to platelet transfusion and intracerebral hemorrhage, who underwent allogeneic bone marrow transplantation from an HLA-identical unrelated male donor. Nine days before the scheduled transplantation, she developed dysarthria and right hemiparesis; computed tomography (CT) of the brain disclosed an acute hematoma in the left parietal lobe exceeding 3 cm in diameter. She underwent conditioning with reduced-intensity, including fludarabine (30 mg/m2/day on days ,8 to ,3), busulfan (4 mg/kg/day on days ,6 and ,5), and total body irradiation (4 Gy on day ,2). Two weeks after transplantation, dysarthria and right hemiparesis began to resolve, and CT showed spontaneous resolution of the hematoma. Simultaneously, engraftment was confirmed. Thus, recent stroke may be not an absolute contraindication for HSCT. Am. J. Hematol. 77:400,404, 2004. © 2004 Wiley-Liss, Inc. [source] Point-of-care reversal treatment in phenprocoumon-related intracerebral hemorrhageANNALS OF NEUROLOGY, Issue 6 2010Timolaos Rizos MD Objective Rapid reversal of the anticoagulatory effect of vitamin K antagonists represents the primary emergency treatment for oral anticoagulant-related intracerebral hemorrhage (OAC-ICH). Predicting the amount of prothrombin complex concentrate (PCC) needed to reverse OAC in individual patients is difficult, and repeated international normalized ratio (INR) measurements in central laboratories (CLs) are time-consuming. Accuracy and effectiveness of point-of-care INR coagulometers (POCs) for INR reversal in OAC-ICH have not been evaluated. Methods In phase 1, the agreement of emergency POC and CL INR measurements was determined. In phase 2, stepwise OAC reversal was performed with PCC using a predetermined dosing schedule. Concordance of POC and CL INR measurements during reversal and time gain due to POC were determined. Results In phase 1 (n = 165), Bland-Altman analysis showed close agreement between POCs and CLs (mean INR deviation 0.04). In phase 2 (n = 26), POCs caused a median initial net time gain of 24 minutes for the start of treatment with PCC. Median time for POC-documented complete OAC reversal was 28 minutes, compared with 120 minutes for CLs. Bland-Altman analysis between POCs and CLs revealed a mean INR deviation of 0.13 during stepwise PCC administration. POCs tended to slightly overestimate the INR, especially at higher INR levels. Remarkably, POC-guided reversal led to a median reduction of 30.5% of PCC dose compared with the a priori dose calculation. Hematomas enlarged in 20% of patients. Interpretation POC INR monitoring is a fast, effective, and economic means of PCC dose-titration in OAC-ICH. Larger studies examining the clinical efficacy of this procedure are warranted. ANN NEUROL 2010;67:788,793 [source] Blood,brain barrier breakdown and repair by Src after thrombin-induced injuryANNALS OF NEUROLOGY, Issue 4 2010Da-Zhi Liu PhD Objective Thrombin mediates the life-threatening cerebral edema that occurs after intracerebral hemorrhage. Therefore, we examined the mechanisms of thrombin-induced injury to the blood,brain barrier (BBB) and subsequent mechanisms of BBB repair. Methods Intracerebroventricular injection of thrombin (20U) was used to model intraventricular hemorrhage in adult rats. Results Thrombin reduced brain microvascular endothelial cell (BMVEC) and perivascular astrocyte immunoreactivity,indicating either cell injury or death,and functionally disrupted the BBB as measured by increased water content and extravasation of sodium fluorescein and Evans blue dyes 24 hours later. Administration of nonspecific Src family kinase inhibitor (PP2) immediately after thrombin injections blocked brain edema and BBB disruption. At 7 to 14 days after thrombin injections, newborn endothelial cells and astrocytes were observed around cerebral vessels at the time when BBB permeability and cerebral water content resolved. Delayed administration of PP2 on days 2 through 6 after thrombin injections prevented resolution of the edema and abnormal BBB permeability. Interpretation Thrombin, via its protease-activated receptors, is postulated to activate Src kinase phosphorylation of molecules that acutely injure the BBB and produce edema. Thus, acute administration of Src antagonists blocks edema. In contrast, Src blockade for 2 to 6 days after thrombin injections is postulated to prevent resolution of edema and abnormal BBB permeability in part because Src kinase proto-oncogene members stimulate proliferation of newborn BMVECs and perivascular astrocytes in the neurovascular niche that repair the damaged BBB. Thus, Src kinases not only mediate acute BBB injury but also mediate chronic BBB repair after thrombin-induced injury. ANN NEUROL 2010;67:526,533 [source] Transcranial ultrasound in clinical sonothrombolysis (TUCSON) trial,ANNALS OF NEUROLOGY, Issue 1 2009Carlos A. Molina MD Objective Microspheres (,S) reach intracranial occlusions and transmit energy momentum from an ultrasound wave to residual flow to promote recanalization. We report a randomized multicenter phase II trial of ,S dose escalation with systemic thrombolysis. Methods Stroke patients receiving 0.9mg/kg tissue plasminogen activator (tPA) with pretreatment proximal intracranial occlusions on transcranial Doppler (TCD) were randomized (2:1 ratio) to ,S (MRX-801) infusion over 90 minutes (Cohort 1, 1.4ml; Cohort 2, 2.8ml) with continuous TCD insonation, whereas controls received tPA and brief TCD assessments. The primary endpoint was symptomatic intracerebral hemorrhage (sICH) within 36 hours after tPA. Results Among 35 patients (Cohort 1 = 12, Cohort 2 = 11, controls = 12) no sICH occurred in Cohort 1 and controls, whereas 3 (27%, 2 fatal) sICHs occurred in Cohort 2 (p = 0.028). Sustained complete recanalization/clinical recovery rates (end of TCD monitoring/3 month) were 67%/75% for Cohort 1, 46%/50% for Cohort 2, and 33%/36% for controls (p = 0.255/0.167). The median time to any recanalization tended to be shorter in Cohort 1 (30 min; interquartile range [IQR], 6) and Cohort 2 (30 min; IQR, 69) compared to controls (60 min; IQR, 5; p = 0.054). Although patients with sICH had similar screening and pretreatment systolic blood pressure (SBP) levels in comparison to the rest, higher SBP levels were documented in sICH+ patients at 30 minutes, 60 minutes, 90 minutes, and 24,36 hours following tPA bolus. Interpretation Perflutren lipid ,S can be safely combined with systemic tPA and ultrasound at a dose of 1.4ml. Safety concerns in the second dose tier may necessitate extended enrollment and further experiments to determine the mechanisms by which microspheres interact with tissues. In both dose tiers, sonothrombolysis with ,S and tPA shows a trend toward higher early recanalization and clinical recovery rates compared to standard intravenous tPA therapy. Ann Neurol 2009;66:28,38 [source] Platelet activity and outcome after intracerebral hemorrhage,ANNALS OF NEUROLOGY, Issue 3 2009Andrew M. Naidech MD, MSPH There are few data on platelet function in intracerebral hemorrhage (ICH). We prospectively enrolled 69 patients with ICH and measured platelet function on admission. Aspirin use before ICH was associated with reduced platelet activity. Less platelet activity was associated with intraventricular hemorrhage (516.5 [interquartile range (IQR), 454,629.25] vs 637 [IQR, 493,654] aspirin reaction units; p = 0.04) and death at 14 days (480.5 [IQR, 444.5,632.5] vs 626 [IQR, 494,652] aspirin reaction units; p = 0.04). Objective measures of platelet function on admission are associated with intraventricular hemorrhage and death after ICH. Ann Neurol 2009;65:352,356 [source] COL4A1 mutation in two preterm siblings with antenatal onset of parenchymal hemorrhage,ANNALS OF NEUROLOGY, Issue 1 2009Linda S. de Vries MD Objective To report the presence of intracerebral hemorrhage and porencephaly, both present at birth, in two preterm infants with a mutation in the collagen 4 A1 gene. Methods Two preterm infants with antenatal intracerebral hemorrhage and established porencephaly, as well as their affected mother and grandfather, underwent neurological and ophthalmological examination and magnetic resonance imaging of the brain. Mutation analysis of the COL4A1 gene was performed in the infants and in their mother. Results Both infants had a novel G1580R mutation in the COL4A1 gene, encoding procollagen type IV ,1. A history of mild antenatal trauma was present in the first but not in the second infant. Both preterm infants were asymptomatic at birth. The intracerebral hemorrhage and porencephaly were diagnosed with cranial ultrasound examination and were subsequently confirmed with magnetic resonance imaging. Leukoencephalopathy was present in the mother and in her father. Interpretation Mutation of the COL4A1 gene appears to be a risk factor of antenatal intracerebral hemorrhage followed by porencephaly in the preterm newborn. Ann Neurol 2009;65:12,18 [source] Injections of Blood, Thrombin, and Plasminogen More Severely Damage Neonatal Mouse Brain Than Mature Mouse BrainBRAIN PATHOLOGY, Issue 4 2005Mengzhou Xue MD The mechanism of brain cell injury associated with intracerebral hemorrhage may be in part related to proteolytic enzymes in blood, some of which are also functional in the developing brain. We hypothesized that there would be an age-dependent brain response following intracerebral injection of blood, thrombin, and plasminogen. Mice at 3 ages (neonatal, 10-day-old, and young adult) received autologous blood (15, 25, and 50 ,l respectively), thrombin (3, 5, and 10 units respectively), plasminogen (0.03, 0.05, and 0.1 units respectively) (the doses expected in same volume blood), or saline injection into lateral striatum. Forty-eight hours later they were perfusion fixed. Hematoxylin and eosin, lectin histochemistry, Fluoro-Jade, and TUNEL staining were used to quantify changes related to the hemorrhagic lesion. Damage volume, dying neurons, neutrophils, and microglial reaction were significantly greater following injections of blood, plasminogen, and thrombin compared to saline in all three ages of mice. Plasminogen and thrombin associated brain damage was greatest in neonatal mice and, in that group unlike the other 2, greater than the damage caused by whole blood. These results suggest that the neonatal brain is relatively more sensitive to proteolytic plasma enzymes than the mature brain. [source] Hyperdense middle cerebral artery sign is an ominous prognostic marker despite optimal workflowACTA NEUROLOGICA SCANDINAVICA, Issue 2 2010K. Abul-Kasim Abul-Kasim K, Brizzi M, Petersson J. Hyperdense middle cerebral artery sign is an ominous prognostic marker despite optimal workflow. Acta Neurol Scand: DOI: 2010: 122: 132,139. © 2009 The Authors Journal compilation © 2009 Blackwell Munksgaard. Objectives,,, To evaluate the association between the hyperdense middle cerebral artery sign (HMCAS) and the functional outcome on one hand, and different predictors such as the National Institutes of Health Stroke Scale (NIHSS), infarct size, ASPECTS Score, intracerebral hemorrhage, and mortality on the other hand. Material and methods,,, Retrospective analysis of 120 patients with MCA-stroke treated with intravenous thrombolysis. We tested the association between HMCAS and NIHSS, infarct volume, ASPECTS, outcome, level of consciousness, different recorded time intervals, and the day/time of admission. Results,,, Seventy-four percentage of patients treated with thrombolysis developed cerebral infarction. All patients with HMCAS (n = 39) sustained infarction and only 31% showed favorable outcome compared with 62% and 60%, respectively among patients without HMCAS (P < 0.001 and P = 0.002). There was statistically significant association between functional outcome and HMCAS (P = 0.002), infarct volume, NIHSS, and ASPECTS (P < 0.001). The time to treatment was 12 min shorter in patients who developed infarction (P = 0.037). Independent predictors for outcome were NIHSS and the occurrence of cerebral infarction on computed tomography for the whole study population, and infarct volume for patients who sustained cerebral infarction. Conclusions,,, Despite optimal workflow, patients with HMCAS showed poor outcome after intravenous thrombolysis. The results emphasize the urgent need for more effective revascularization therapies and neuroprotective treatment in this subgroup of stroke patients. [source] Combined thrombolysis with abciximab and rtPA in patients with middle cerebral artery occlusionACTA NEUROLOGICA SCANDINAVICA, Issue 1 2010G. Gahn Background,,, In patients with acute middle cerebral artery (MCA) occlusion, recanalization rates with intravenous (IV) recombinant tissue plasminogen activator (rtPA) are limited. Aim, We evaluated the feasibility and safety of combined IV thrombolysis with abciximab and reduced dose rtPA in a 3- to 6-h time window. Methods,,, We prospectively (March 2002 to February 2005) studied patients with symptomatic MCA occlusion on computed tomography (CT) angiography and absence of major early ischemic changes (EIC) on non-contrast CT (NCCT) within 3,6 h from symptom onset. Patients were treated with IV abciximab and half-standard dose rtPA. Outcome parameters were symptomatic intracerebral hemorrhage (sICH), early clinical improvement and functional independence at discharge (modified Rankin Scale score , 2). Results,,, Of 13 patients, mean age was 62 ± 11 years, onset-to-treatment time 4.8 ± 0.9 h and median baseline National Institutes of Health Stroke Scale score 11 (interquartile range 6.5,13.5). sICH occurred in one patient (8%). We observed early clinical improvement in four patients (31%). Six patients (46%) were functionally independent at discharge. Conclusions,,, In patients with acute symptomatic MCA occlusion and absence of major EIC on NCCT, combined IV thrombolysis with abciximab and half-standard dose rtPA was feasible and seemed to be safe if applied within 3,6 h from symptom onset. [source] Acute treatment costs of intracerebral hemorrhage and ischemic stroke in ArgentinaACTA NEUROLOGICA SCANDINAVICA, Issue 4 2009M. C. Christensen Background and purpose,,, Stroke is the third leading cause of death in Argentina, yet little information exists on the acute treatment provided for stroke or its costs. This study estimates the national costs of the acute treatment of first-ever intracerebral hemorrhage (ICH) and ischemic stroke (IS) in Argentina. Methods,,, Retrospective hospital-based inception study design using data on resource use and costs from high-volume stroke centers in Argentina, and published population-based incidence data. Treatment provided at two large urban hospitals were evaluated in all patients admitted with a first-ever stroke between 1 January 2004 and 31 August 2006, and costs were assigned using appropriate unit cost data for all resource use. Cost estimates in Argentinian pesos were converted to US dollars ($) using the 2005 purchasing power parity index. National costs of acute treatment for incident strokes were estimated by extrapolation of average costs estimates to national incidence data. Assumptions of the average cost of stroke treatment on a national scale were examined in sensitivity analysis. Results,,, The acute care of 167 patients with stroke was thoroughly evaluated from hospital admission to hospital discharge. Mean length of hospital stay was 35.4 days for ICH and 13.0 days for IS. Ninety-one percent of the patients with ICH and 68% of the patients with IS were admitted to an ICU for a mean length of stay (LOS) of 12.9 ± 20.3 and 3.6 ± 5.9 days respectively. Mean total costs of initial hospitalization were $12,285 (SD ±14,336) for ICH and $3888 (SD ±4018) for IS. Costs differed significantly by Glasgow Coma Scale (GCS) score at admission, development of pneumonia and infections during hospitalization, and functional outcome at hospital discharge. Aggregate national healthcare expenditures for acute treatment of incident ICH were $194.2m (range 97.1,388.4) and $239.9m for IS (range 119.9,479.7). Conclusion,,, The direct hospital costs of incident ICH and IS in Argentina are substantial and primarily driven by stroke severity, in-hospital complications and clinical outcomes. With the expected increase in the incidence of stroke over the coming decades, these results emphasize the need for effective preventive and acute medical care. [source] Brain herniations in patients with intracerebral hemorrhageACTA NEUROLOGICA SCANDINAVICA, Issue 4 2009J. Kalita Objectives,,, To study the types, frequency and clinical correlates of brain herniations in patients with intracerebral hemorrhage (ICH). Methods,,, In 24 patients with ICH (putaminal 22 and thalamic 2) features of raised intracranial pressure (ICP), such as hyperventilation, extensor rigidity, pupillary asymmetry and pyramidal signs on the non-hemiplegic side, were recorded. Depth of coma was assessed by using the Glasgow Coma Scale (GCS) and severity of stroke by using the Canadian Neurological Scale (CNS). On MRI, evidence of herniation, horizontal and vertical shifts and the edema,hematoma complex were measured and compared with that of 15 matched controls. The clinical signs of herniation correlated with radiological parameters. Results,,, The mean age of the patients was 57.7 years, six of them were women. Cerebral herniations were present in 11 (46%) patients. Subfalcian herniation (in six) was the commonest followed by uncal (in three). Combination of subfalcian and uncal herniations was present in one and subfalcian, uncal and tonsillar herniations in another. Herniations had significant correlation with the GCS, pupillary abnormalities, cortical atrophy, hematoma size and the edema,hematoma complex. One-month mortality was related to the GCS score, pupillary abnormalities and the edema,hematoma complex. Horizontal shift was related to the GCS score. Conclusion,,, In patients with ganglionic ICH, subfalcian herniation was the commonest. Herniation was associated with increased mortality. Horizontal shift correlated with clinical features of raised ICP and outcome. [source] Is D-dimer helpful in evaluating stroke patients?ACTA NEUROLOGICA SCANDINAVICA, Issue 3 2009A systematic review D-dimer (DD) is a fibrin degradation product present in negligible amounts in healthy individuals, but in thrombotic/fibrinolytic conditions substantially increases in plasma. Over the last two decades numerous studies have explored whether DD measurements would help stroke clinicians. An easy, reliable, and inexpensive test for stroke diagnosis, determination of stroke subtype, severity, prognosis, and recurrence risk is being sought. We searched the database, of studies indexed in English on MEDLINE, using the keywords ,cerebral venous thrombosis, D-dimer, deep vein thrombosis, intracerebral hemorrhage, ischemic stroke, outcome, prognosis, and subarachnoid hemorrhage' for relevant studies. Here, we systematically review current evidence on plasma DD levels in patients with ischemic and hemorrhagic strokes, transient ischemic attacks, and cerebral venous thrombosis. Numerous studies showed that patients with various strokes and stroke-related diseases had acutely increased plasma DD levels. Plasma DD levels, however, are neither sensitive nor specific enough to be utilized in stroke diagnostics and cannot replace either clinical or radiological evaluation. Regarding prediction of patient outcome, good clinical evaluation is clearly superior to DD testing. [source] | ||||||||||