Effects of plasma D-dimer levels on early mortality and long-term functional outcome after spontaneous intracerebral hemorrhage

The activation of hemostatic systems has been detected in spontaneous intracerebral hemorrhage (ICH) patients. The influence of plasma D-dimer levels on clinical outcome remains unclear. This study aimed to investigate the impact of elevated plasma D-dimer levels on early mortality and long-term functional outcome in spontaneous ICH. A total of 259 spontaneous ICH patients (<24 hours from ictus) between November 2010 and October 2011 were included. Clinical information and radiological findings were collected at admission. Spearman correlation analyses revealed that D-dimer concentrations were correlated with midline shift, hematoma volume, intraventricular hemorrhage (IVH) score and Glasgow Coma Scale score. Patients with subarachnoid extension had significantly higher D-dimer levels than those without SAH extension. Comparison of patients with IVH and those without yielded a similar result. Multivariate stepwise backward logistic analysis identified plasma D-dimer levels as an independent risk factor for 7 day mortality (adjusted odds ratio [OR] = 1.237, 95% confidence interval [CI] 1.017–1.504, p = 0.033) and 3 month poor functional outcome (modified Rankin Scale score ⩾3) (adjusted OR = 2.279, 95% CI 1.130–6.595, p = 0.026). The mechanisms by which elevated D-dimer affects the prognoses of spontaneous ICH patients remain unclear and require clarification in future studies.     

Minimally invasive evacuation of intraventricular hemorrhage with the Apollo vibration/suction device

Intraventricular hemorrhages (IVH) can occur as a consequence of spontaneous intracerebral hemorrhage, aneurysm rupture, arteriovenous malformation hemorrhage, trauma, or coagulopathy. IVH is a known risk factor for poor clinical outcome with up to 80% mortality. The current standard treatment strategy for IVH consists of the placement of an external ventricular drain. We report our early experience with using the Apollo suction/vibration aspiration system (Penumbra, Alameda, CA, USA) for minimally invasive evacuation of IVH with a review of the pertinent literature. Medical records of patients with IVH who were admitted to Rush University Medical Center, USA, from July to November 2014 were queried from the electronic database. Patients with Graeb Scores (GS) >6 were selected for minimally invasive IVH evacuation with the Apollo aspiration system. Patient demographics, pre- and post-operative GS, pre- and post-operative modified Graeb Score (mGS), as well procedure related complications were analyzed and recorded. A total of eight patients (five men) were identified during the study period. The average age was 55.5 years. The mean GS was 9.6 pre-operatively and decreased to 4.9 post-operatively (p = 0.0002). The mean mGS was 22.9 pre-operatively and decreased to 11.4 post-operatively (p = 0.0001). Most of the IVH reduction occurred in the frontal horn and atrium of the lateral ventricle, as well the third ventricle. One (1/8) procedure-related complication occurred consisted of a tract hemorrhage. The Apollo system can be used for minimally invasive IVH evacuation to achieve significant blood clot volume reduction with minimal procedure-related complication.     

A priority treatment of the intraventricular hemorrhage (IVH) should be performed in the patients suffering intracerebral hemorrhage with large IVH

Background

In patients suffering from intracerebral hemorrhage (ICH) with ventricular hemorrhage (IVH), the IVH severity is thought to be associated with prognosis. Therefore, treating IVH may be a beneficial therapeutic target. In this study, by examining the associations among IVH severity, hydrocephalus, initial level of consciousness and prognosis, we attempted to identify which grade of IVH severity should be considered for surgical treatment.

Methods

One hundred twenty-nine patients with spontaneous supratentorial ICH treated in our hospital between 2005 and 2006 were screened in this study. Of these patients, 100 with an ICH volume less than 60 ml were categorized into either the ICH patients without IVH (no-IVH) group (n = 65) or the ICH patients with IVH (IVH) group (n = 35). The Karnofsky Performance Status (KPS) scale assessed at the time of discharge was employed as an outcome index, and a KPS score of ≤40 was defined as the bedridden state. Age, gender, hemorrhage location, volume of ICH, IVH grade (according to the Graeb score), acute hydrocephalus, surgical ICH removal, and ventricular drainage were selected for univariate analyses with logistic regression.

Results

Elderly patients, IVH volume, acute hydrocephalus, and poor initial level of consciousness were significantly associated with an unfavorable prognosis in the IVH group. Poor level of consciousness was significantly dependent on acute hydrocephalus, and significantly more occurrences of acute hydrocephalus were found in patients with a high IVH volume (Graeb score ≥6) than in patients with low to moderate IVH volume (Graeb score ≤6).

Conclusions

IVH severity influenced the occurrence of acute hydrocephalus and initial level of consciousness, which was significantly associated with prognosis. Our results suggest that priority treatment of the IVH should be given to those ICH patients with IVH admitted with a Graeb score of 6 or more.     

Safety and feasibility of combined coiling and neuroendoscopy for better outcomes in the treatment of severe subarachnoid hemorrhage accompanied by massive intraventricular hemorrhage

Subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) is associated with poor outcomes. The aim of this study was to evaluate the safety and feasibility of combined coiling and neuroendoscopy for treating severe SAH with massive IVH. Between April 2008 and June 2011, 49 patients with a severe SAH were treated at the Department of Neurosurgery, Fukuoka University, Japan; 10 of these patients had a massive IVH with a ruptured aneurysm. All 10 patients (three men and seven women; mean age, 63.1 ± 8.5 years) were treated with coiling and neuroendoscopic removal of the IVH within 2 days of onset. Coiling was successfully performed at a mean volume embolization ratio of 21.8 ± 5.5%. Neuroendoscopic removal of the IVH reduced the mean Graeb score from 10.5 ± 2.0 to 4.8 ± 2.5 (p = 0.005). All external drains were removed on day 3. No rebleeding or acute hydrocephalus was noted. The Glasgow Outcome Scale scores at discharge indicated two patients with good recovery, three with moderate disability, four in a vegetative state, and one dead. A good modified Rankin Scale (mRS) score (0–2) at least 6 months later (mean follow-up period, 15.4 ± 9.2 months) was observed for five patients (50%), and a poor mRS score (3–6) was observed for the remaining four patients. Neuroendoscopically removing the IVH from all of the ventricles between the lateral and the fourth ventricle and coiling the ruptured aneurysm is a safe, feasible approach for treating severe SAH with massive IVH.     

Intracerebral hemorrhage with intraventricular extension and no hydrocephalus may not increase mortality or severe disability

This paper aimed to test the hypothesis that intraventricular extension of spontaneous intracerebral hemorrhage (ICH) in the absence of hydrocephalus is not associated with increased mortality or severe disability. We performed a retrospective consecutive cohort study of patients with primary spontaneous ICH who were admitted to a single institution. Multivariate logistic regression analysis was used to assess the association of each variable with functional outcome as measured by the modified Rankin Scale (mRS). A total of 164 patients met our inclusion criteria and were included in the study. Only hydrocephalus (p = 0.002) and hematoma volume (p = 0.006) were significantly associated with mortality or poor functional outcome (mRS of 3 to 6). In contrast, the presence of intraventricular hematoma was not independently associated with poor functional outcome. The presence of intraventricular extension of ICH in the absence of hydrocephalus may not increase mortality or disability.     

Increased cerebrospinal fluid concentrations of asymmetric dimethylarginine correlate with adverse clinical outcome in subarachnoid hemorrhage patients

Elevated cerebrospinal fluid (CSF) concentrations of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, have been found in patients with subarachnoid hemorrhage (SAH). In addition, CSF levels of ADMA are associated with the severity of vasospasm. However, the relation between CSF ADMA levels and the clinical outcome of SAH patients is still unclear. We hypothesized that elevated ADMA levels in CSF might be related to the clinical outcome of SAH patients. CSF ADMA levels were measured in 20 SAH patients at days 3–5, days 7–9 and days 12–14 after SAH onset using high-performance liquid chromatography. Cerebral vasospasm was assessed by transcranial Doppler ultra sonography. Clinical outcome at 2 year follow-up was evaluated using the Karnofsky Performance Status scale (KPS). CSF ADMA concentrations in all SAH patients were significantly increased at days 3–5 (p = 0.002) after SAH, peaked on days 7–9 (p < 0.001) and remained elevated until days 12–14 (p < 0.001). In subgroup analysis, significant increases of CSF ADMA levels were found in patients both with and without vasospasm. The KPS scores significantly correlated with CSF levels of ADMA at days 7–9 (correlation coefficient = −0.55, p = 0.012; 95% confidence interval −0.80 to −0.14). Binary logistic regression analysis indicated that higher ADMA level at days 7–9 predicted a poor clinical outcome at 2 year follow-up after SAH (odds ratio = 1.722, p = 0.039, 95% confidence interval 1.029 to 2.882). ADMA may be directly involved in the pathological process and future adverse prognosis of SAH.     

Risk factors and clinical characteristics of non-promyelocytic acute myeloid leukemia of intracerebral hemorrhage: A single center study in China

BackgroundAlthough high mortality in patients with acute leukemia (AL) is associated with intracranial hemorrhage (ICH), the clinical features and pathogenesis of AL patients with cerebral hemorrhage are not well known.MethodsWe diagnosed 90 patients with ICH from a total of 1467 patients with non-promyelocytic AL who had been hospitalized in the First Affiliated Hospital of Medical School of Zhejiang University from January 2010 to October 2015. Moreover, the risk factors of ICH death were evaluated.ResultMedian age at ICH was 51 years old, in which men accounted for 52.2%. They also accounted for 85.6% of acute myeloid leukemia. The relative incidence of ICH was the highest in M2 and M5 (60.1%). ICH presented with higher peripheral blood white blood cell count (WBC) (P < 0.001), lower peripheral platelet counts (P < 0.001), lower albumin (P < 0.001), lower fibrous protein (P < 0.001) and prolongation of prothrombin time (P < 0.001) compared to those observed in the patients of NICH group; multivariate analysis, independent risk factors for death in patients with ICH include: WBC ≥ 30.00 × 109/l and prothrombin time ≥ 12.91 s.ConclusionsLeukocytosis and coagulation dysfunctions might be the main pathogenesis of acute leukemia complicated with cerebral hemorrhage.     

Intracerebral hemorrhage due to developmental venous anomalies

Developmental venous anomalies (DVA) and cavernous malformations (CM) are a common form of mixed vascular malformation. The relationship between DVA, CM and hemorrhage is complicated. It is important to differentiate hemorrhagic CM and hemorrhagic DVA. A retrospective review of all patients with acute spontaneous intracerebral hemorrhages (ICH) between 1 May 2008 and 1 May 2013 was performed. ICH due to DVA or CM were identified and compared for demographic features, clinical symptoms, neurological deficits, and radiological findings. A total of 1706 patients with acute spontaneous ICH were admitted to our hospital during the study period. Among these, 10 (0.59%) were caused by DVA and 42 (2.47%) were caused by CM. No significant differences were found in age (p = 0.252) or sex ratio (p = 1.000) between the two groups. Compared with CM-induced ICH, DVA-induced ICH were characterized by cerebellar predominance (p = 0.000) and less severe neurological deficits (p = 0.008). Infratentorial hemorrhagic DVA are characterized by cerebellar predominance and benign clinical course. Infratentorial hemorrhagic CM are mainly located in the brainstem. DVA should be given suspected rather than CM when considering the etiology of a cerebellar hemorrhage, especially in young adults.     

Intracerebral hemorrhage in young from a tertiary neurology center in North India

ObjectiveThere is paucity of information on the etiology and predictors of outcome of intracerebral hemorrhage (ICH) in young which may have regional and ethnic differences. In this study, we report the etiology and predictors of outcome of ICH in young patients from North India.Methods404 patients with ICH in young (16–50 years) were retrospectively reviewed who were admitted in neurology service of a tertiary care teaching hospital in North India. The data were retrieved from the computerized hospital information service. The information about the demography, risk factors, clinical status, laboratory findings, CT/MRI features and angiography (CT, MRI or digital substraction) were noted. The etiology of ICH was ascertained based on clinical, laboratory and radiological findings. Outcome at 1 month was assessed using Glasgow Outcome Scale (GOS).ResultsThe mean age of the patients was 41.6 years and 23.8% were females. Hypertension (57.2%), hypocholesterolemia (33.7%), alcohol (15.8%) and anticoagulant (3.5%) were the important risk factors. The etiology of ICH was hypertension in 320 (79.2%), vascular malformation in 17 (4.2%), coagulopathy in 16 (4%), cerebral venous sinus thrombosis (CVST) in 9 (2.2%), thrombocytopenia in 3 (0.7%), vasculitis in 2 (0.5%) and cryptogenic in 37 (9.2%) patients. The patients with cryptogenic ICH were younger, had better Glasgow coma scale (GCS) on admission and good outcome compared those with known etiology. The most common location of ICH was basal ganglion and thalamus (71.3%). 102 (25%) patients died, 161 (39.9%) had poor and 141 (34.9%) had good outcome. Hypertensive ICH patients had frequent death or disability (P < 0.001). On multivariate analysis, low GCS score (P < 0.001), large ICH (P = 0.01) and high leukocyte count on admission (P = 0.03) were significantly related to the 1 month mortality.ConclusionHypertension is the commonest cause of ICH in young Indian adults and its outcome is related to volume of ICH, GCS score and admission leukocyte count.     

Plasma brain natriuretic peptide is elevated in the acute phase of intracerebral hemorrhage

Previous reports have shown that plasma brain natriuretic peptide (BNP) levels are increased in patients with subarachnoid hemorrhage and ischemic stroke. We examined BNP in patients with intracerebral hemorrhage (ICH). Between June 2006 and February 2010, we prospectively enrolled consecutive patients with acute ICH within 24 hours of onset. The plasma BNP level was measured twice, on admission and 4 weeks after onset or at discharge. We investigated whether plasma BNP was elevated in the acute phase of ICH and associated factors. The mean ± standard deviation (SD) plasma BNP level of all patients was 71.1 ± 104.1 pg/mL. The log BNP level positively correlated with the cardio–thoracic ratio (r = 0.240, p = 0.0001). Moreover, BNP was significantly associated with intraventricular extension (p = 0.0039) and hydrocephalus (p = 0.0046). The mean ± SD BNP level of patients with cerebellar hemorrhage was the highest (130.2 ± 152.0 pg/mL), followed by brainstem (84.5 ± 170.6 pg/mL), lobar (72.4 ± 148.1 pg/mL), thalamus (64.8 ± 72.1 pg/mL), and putamen (59.9 ± 62.6 pg/mL) hemorrhages. In 185 patients, BNP was measured in the subacute phase of ICH. The BNP level in the acute phase of ICH was significantly higher than that in the subacute phase of ICH (69.3 ± 108.1 versus 21.7 ± 23.5 pg/mL, p < 0.0001). In conclusion, plasma BNP appears to be elevated in the acute phase of ICH, particularly in those with cerebellar lesions.     

Increased levels of soluble triggering receptor expressed on myeloid cells-1 in cerebrospinal fluid of subarachnoid hemorrhage patients

Triggering receptor expressed on myeloid cells-1 (TREM-1) has been highlighted as a key amplifier of inflammatory response in various diseases. To determine the contribution of TREM-1 in the inflammatory cascade after subarachnoid hemorrhage (SAH), concentrations of soluble TREM-1 (sTREM-1) in cerebrospinal fluid (CSF) from 30 SAH patients and 9 healthy volunteers were measured by enzyme-linked immunosorbent assay. It was shown that the CSF sTREM-1 levels of SAH patients increased significantly than that of the volunteers (P < 0.05). Interestingly, the levels were up-regulated dynamically over time with an early increase within 2 days and a late peak at day 6 after SAH onset. In addition, it was found that the early sTREM-1 levels (within 3 days post-SAH) were negatively correlated with Glasgow Coma Scale (r = −0.550, P = 0.022) and positively correlated with the Hunt and Hess scale (r = 0.603, P = 0.010) respectively conducted on admission, also the early sTREM-1 levels were negatively correlated with Glasgow Outcome Scale (r = −0.505, P = 0.039) and positively correlated with modified Rankin Scale (r = 0.557, P = 0.020) respectively conducted one month after SAH. Altogether, this is the first study showing CSF sTREM-1 dynamics in SAH patients, and exploring the correlations of early CSF sTREM-1 levels to patients’ severity and prognosis, which suggests that TREM-1 may play an important role in the inflammatory cascade after SAH and act as a monitoring biomarker facilitated to assess the severity and prognosis of SAH patients.     

Prediction,clinical characteristics and prognosis of intracerebral hemorrhage in hepatocellular carcinoma patients with intracerebral metastasis

The clinical characteristics of intracerebral hemorrhage (ICH) in hepatocellular carcinoma (HCC) patients with intracerebral metastasis (IcM) have not been reported on extensively. We compared the clinical characteristics between patients with ICH (w-ICH, 18 patients) and without ICH (wo-ICH, 24 patients) in HCC patients with IcM. Using multivariate logistic regression, only habitual alcohol consumption is a significant predictor of ICH in HCC patients with IcM (adjusted odds ratio [OR] = 4.7, 95% CI = 1.26–17.71, p = 0.022). Patients with ICH also had lower Glasgow Coma Scale scores at the time of admission (p = 0.032) and lower incidence of infratentorial metastasis (p = 0.014). Using correlation analysis, only blood platelet count on admission was positively correlated with survival duration after the diagnosis of IcM in the wo-ICH group (p = 0.000) but not in the w-ICH group.     

Diagnostic accuracy of flair in detection of acute subarachnoid hemorrhage in patients presenting with severe headache

BackgroundFluid attenuation inversion recovery (FLAIR) magnetic resonance imaging (MRI) sequences are previously described for the evaluation of acute subarachnoid hemorrhage (SAH) and demonstrated good sensitivity. This study was designed to find the diagnostic accuracy of FLAIR in detection of acute SAH in patients presenting with severe headache considering the fact that controversy has been observed in previous studies.ObjectiveTo determine diagnostic accuracy of FLAIR in detection of acute subarachnoid hemorrhage in patients presenting with severe headache using lumber puncture as gold standard.MethodologyA total of 245 patients fulfilling selection criteria were enrolled in the study through the emergency department of Combined Military Hospital, Lahore. MRI was performed by Philips Intera Achieva 1.5 T super conducting MR unit (Philips Medical Systems, the Netherlands), with the use of a head coil. FLAIR examination was performed at 6700/150 (TR/TE) with an inversion time (TI) of 2200 ms, a field of view 230 mm, matrix 189 × 256, scan time of 3 min 50s and section thickness 5 mm in axial plane. Following MRI, patients underwent lumbar puncture for cerebrospinal fluid (CSF) examination after 8–12 h from the onset of event. MRI and CSF analysis results were then compared.ResultsOut of 245 cases, 49.39% (n = 121) were between 20–55 years of age while 50.61% (n = 124) were between 56–70 years of age, mean ± sd was calculated as 52.13 ± 10.45 years, 53.88% (n = 132) were male while 46.12% (n = 113) were females, frequency of acute subarachnoid hemorrhage in patients presenting with severe headache was recorded as 5.71%(n = 14), diagnostic accuracy of FLAIR in detection of acute subarachnoid hemorrhage in patients presenting with severe headache taking lumbar puncture as gold standard as 78.57% sensitivity, 96.53% specificity, 57.89% positive predictive value, 98.67% negative predictive value and accuracy rate was calculated as 95.29%.ConclusionDiagnostic accuracy of FLAIR in detection of acute subarachnoid hemorrhage in patients presenting with severe headache taking lumbar puncture as gold standard is higher and reliable.     

In-hospital outcomes of aneurysmal subarachnoid hemorrhage associated with cocaine use in the USA

Cocaine use is associated with higher mortality in small retrospective studies of brain-injured patients. We aimed to explore in-hospital outcomes in a large population based study of aneurysmal subarachnoid hemorrhage (aSAH) with cocaine use. aSAH patients were identified from the 2007–2010 USA Nationwide Inpatient Sample using International Classification of Disease, Ninth Revision codes. Demographics, comorbidities and surgical procedures were compared between cocaine users and non-users. The primary outcomes were in-hospital mortality and home discharge/self-care. Secondary outcomes were vasospasm treated with angioplasty, hydrocephalus, gastrostomy and tracheostomy. There were 103,876 patients with aSAH. The cocaine group were younger (45.8 ± 9.8 versus 58.4 ± 15.8, p < 0.001), predominantly male (53.3% versus 38.5%, p < 0.001) and had a higher proportion of black patients (36.9% versus 11.5%, p < 0.001). The incidence of seizures was higher among cocaine users (16.2% versus 11.1%, p < 0.001). Endovascular coiling of intracranial aneurysms (24% versus 18.5%, p < 0.001) was more frequent in cocaine users. The univariate analysis showed higher rates of in-hospital mortality and vasospasm treated with angioplasty, but lower home discharge in the cocaine group. In the multivariate analysis, the cocaine cohort had higher in-hospital mortality (odds ratio [OR] 1.43, 95% confidence interval [CI] 1.27–1.61, p < 0.001) and lower home discharge rates (OR 0.79, 95% CI 0.69–0.87, p < 0.001) after adjusting for confounders. Rates of vasospasm treated with angioplasty however were similar between the two groups. Cocaine use was found to be independently associated with poor outcomes, particularly higher mortality and lower home discharge rates. Cocaine use however, was not associated with vasospasm that required treatment with angioplasty. Prospective confirmation is warranted.     

Seizures and antiepileptic drugs in patients with spontaneous intracerebral hemorrhages

PurposePatients with intracerebral hemorrhage (ICH) are often initiated on antiepileptic drugs without a clear indication. We compared the percentage of patients with spontaneous ICH who had seizures at onset or during hospitalization, and examined empiric use of antiepileptic drugs (AEDs) in these patients in 2 cohorts 10 years apart.MethodsUsing a clinical data registry at a tertiary care adult hospital, we retrospectively selected admissions for spontaneous ICH between 1/1/99–12/31/00 (Cohort A, n = 30) and 1/1/09–12/31/10 (Cohort B, n = 108). Clinical, neurophysiological and radiological data were collected in both cohorts.ResultsIn Cohorts A and B respectively, AEDs were started in 53.3% and 50.0%, and continued on discharge in 50.0% and 20.4% of patients; 86.6% and 59.1% of patients discharged on AEDs did not have a clinical/electrographic seizure or epileptiform EEG findings. Seizures occurred in 6.6% and 13.0% in Cohorts A and B respectively. The presence of a seizure at presentation (p = 0.01) and during hospitalization (p = 0.02) were predictors for continuing AED on discharge.ConclusionIn both cohorts, a significant number of patients were discharged on AEDs without a clear indication, though there is a change in practice between the two cohorts.     

The rs9509 polymorphism of MMP-9 is associated with risk of hemorrhage in brain arteriovenous malformations

We examined whether single nucleotide polymorphisms (SNP) of the matrix metalloproteinase 9 (MMP-9) and tissue inhibitor of metalloproteinase 4 (TIMP-4) genes are associated with risk of intracranial hemorrhage (ICH) among patients with brain arteriovenous malformation (BAVM). For 311 Chinese patients with BAVM, we performed genotyping analysis for 11 selected SNP of MMP-9 and TIMP-4 using the MassARRAY genotyping system (Sequenom, San Diego, CA, USA). Associations between each genotype and risk of hemorrhage were evaluated using logistic regression analysis. Multivariate logistic regression analysis revealed that MMP-9_rs9509 was significantly associated with ICH among patients with BAVM with adjustments for BAVM size, venous drainage type, age and sex (adjusted odds ratio [OR] = 0.19; 95% confidence interval [CI] = 0.05–0.66; p = 0.009 for CC compared with TT genotype). However, the association was not significant (p = 0.072) after Bonferroni correction and was not significant (p = 0.064) in the univariate model. The TIMP-4_rs3755724 polymorphism did not have a statistically significant effect in the multivariate model (adjusted OR = 0.57; 95% CI = 0.32–1.01; p = 0.055 for CT compared with TT genotype). The global score test did not reveal any statistically significant differences in haplotype frequency distributions for these two genes. Our findings suggest that the MMP-9_rs9509 polymorphism may be associated with ICH in patients with BAVM.     

The incidence,hospital expenditure,and, 30 day and 1 year mortality rates of spontaneous intracerebral hemorrhage in Taiwan

The risks of morbidity and mortality are high in patients with spontaneous intracerebral hemorrhage (sICH). The medical care resources associated with sICH are also substantial. This study aimed to evaluate the medical expenditure for sICH patients in Taiwan. We analyzed the National Health Insurance Research Database from 2005 to 2010. The inclusion criterion was first-event sICH; traumatic ICH patients were excluded. Student’s t-test, multiple linear regression and the chi-squared test were employed as the statistical methods. Our results showed that the incidence of sICH was 40.77 patients per 100,000 of population per year in Taiwan. The incidence increased with age and was greater in men than women. The mean hospital length of stay (LOS) of first-event sICH patients was 31.8 days; the mean LOS in the intensive care unit was 7.9 days; and the mean survival time was 60.4 months. The mortality rate within 30 days and within 1 year was 19.8 and 29.6%, respectively. The mean hospital expenditure of first-event sICH patients was USD$7572, and was highly correlated with LOS. In conclusion, the incidence of sICH in Taiwan is higher than that in white and black populations of northern America and some European countries and lower than that in the Asian populations of Japan and China. The features of male and female sICH patients differ. Our findings suggest that the hospital expenditure and mortality rate of sICH patients in Taiwan are comparable with those of other countries.     

Noninvasive assessment of the intracranial pressure in non-traumatic intracranial hemorrhage

The article describes the modified technique of measuring the diameters of the optic nerve sheath (ONSD) for assessment of the intracranial pressure (ICP) in patients with intracerebral or subarachnoid hemorrhage (SAH). The CT scans of 443 patients were analyzed retrospectively. The ONSDs were measured at 3 mm behind the globe and at the point where the ophthalmic artery crosses the optic nerve. The ONSD/eyeball transverse diameter (ETD) ratio was calculated. The correlation analysis was performed with the Glasgow Coma Scale score, Hemispheric Stroke Scale score, Glasgow Outcome Score, and invasive ICP readings. ONSD was enlarged in 95% of patients with intracerebral hemorrhage or SAH. Pathological ONSDs were 6.6 ± 0.8 mm (cut-off value >5.5 mm; p < 0.05). ONSD/ETD ratio was 0.29 ± 0.05 against normative 0.19 ± 0.02 (p < 0.01) with no correlation with initial Glasgow Coma Scale score or Hemispheric Stroke Scale score. There was an inverse correlation between ONSD/ETD ratio and Glasgow Outcome Score (r = −0.7) and direct correlation with invasive ICP readings. This study provides further evidence that in patients with intracranial hemorrhage and SAH, the presence of ONSD greater than a threshold of 5.5 mm is significantly predictive of invasively measured elevated ICP. The prediction of raised ICP can be further refined by measuring ONSD at the point where the optic nerve and the ophthalmic artery cross, and by determining the ratio between the ONSD and ETD.     

Pituitary dysfunction after aneurysmal subarachnoid hemorrhage in Japanese patients

To elucidate the pituitary function of Japanese patients after aneurysmal subarachnoid hemorrhage (aSAH) and implicative factors related to growth hormone deficiency (GHD) after aSAH. We evaluated basal pituitary hormone levels among 59 consecutive aSAH patients with a modified Rankin Scale (mRS) ⩽4 at 3 months after aSAH onset. Patients with low insulin-like growth factor 1 (IGF-1) SD score (SDS) or who seemed to develop pituitary dysfunction underwent provocative endocrine testing during a period of 3–36 months after SAH onset. The relationship between IGF-1 SDS and clinical factors of the patients such as severity of SAH, aneurysm location, and treatment modalities, were assessed. Six patients (10.2%) demonstrated their IGF-1 SDS less than −2. Multiple logistic regression analyses revealed that patients who underwent surgical clipping had a significantly lower IGF-1 SDS (<−1 SD) than patients who underwent endovascular embolization with an odds ratio of 5.83 (p = 0.032). Thirty-three patients took provocative tests and five (15.6%) patients were identified as having GHD. The mean IGF-1 SDS of these five GHD patients was 0.08 SD. The aneurysms in all GHD patients were located in internal carotid artery (ICA) or anterior cerebral artery (ACA). To the best of our knowledge, this is the first report describing the prevalence of GHD in Japanese patients after aSAH, and it was not as high as that of previous European studies. We recommend that screening pituitary dysfunction for aSAH survivors with their aneurysms located in ICA or ACA.     

Risk of hemorrhage in patients over age 60 with arteriovenous malformations (AVMs)

Treatment selection for patients 60 years of age and older with intracranial arteriovenous malformations (AVMs), requires careful consideration of the natural history and post-treatment hemorrhagic risk. We aimed to directly compare the natural history of AVMs with post-treatment hemorrhagic risk in this population. We retrospectively reviewed our AVM database of 683 patients. Patients ⩾60 years at diagnosis were included. Treatment modality was divided into four groups: surgery ± embolization (SE), radiosurgery ± embolization (RE), embolization only (Emb), and observation (Obs). The natural history of the AVM was defined as the annual risk of hemorrhage under observation. Risk of hemorrhage after treatment was also calculated. Sixty-one patients with complete data were included. Average age was 68.4 ± 7.5 years, with 55.7% (n = 34) being male. Twenty-seven (44.3%) patients presented with intracerebral hemorrhage (ICH). At last follow-up, modified Rankin Scale was higher in patients with subsequent hemorrhages (p = 0.023). Overall, obliteration was 65.5%, with 100.0% in the SE group and 43.8% in the RE group (p <0.001). During an average follow-up period of 2.8 ± 3.2 years, six patients (9.8%) experienced hemorrhage, with two (12.5%) in the RE group, three (9.4%) in the Obs group and one (9.1%) in the SE group, corresponding to a natural history of 3.5% annual hemorrhage rate and a post-treatment hemorrhagic risk of 3.6%. This post-treatment hemorrhage risk was 2.4% in the SE group and 4.9% in the RE group. Presenting with ICH (p = 0.042) and race (p = 0.014) were associated with a higher risk of follow-up hemorrhage. Definitive treatment for AVM patients ⩾60 years should be cautiously considered. Despite higher post-treatment obliteration rates, the subsequent hemorrhagic risk may exceed that of its natural history. For AVMs with a high risk for hemorrhage, surgery reduces hemorrhagic risk and achieves the highest rate of obliteration.