A population based study of outcomes after evacuation of primary supratentorial intracerebral hemorrhage

Background and Purpose

The role of surgery after primary intracerebral hemorrhage (ICH) is controversial. To explore whether hematoma evacuation after ICH had improved short-term survival or functional outcome we conducted a retrospective observational population-based study.

Methods

We identified all subjects with primary ICH between 1993 and 2008 among the population of Northern Ostrobothnia, Finland. Hematoma evacuation was carried out by using standard craniotomy or through a burr hole. We compared mortality rates and functional outcomes of patients with hematoma evacuation with those treated conservatively.

Results

Of 982 patients with verified ICH during the study period, 127 (13%) underwent hematoma evacuation. Surgically treated patients were significantly younger (mean ± SD, 63 ± 11 vs. 70 ± 12 years; p < 0.001), had larger hematomas (66 ± 36 vs. 28 ± 40 ml; p < 0.001), lower Glasgow Coma Scale scores (median, 11 vs. 14; p < 0.001) and more frequently subcortical hematomas (68% vs. 24%; p < 0.001) than those treated conservatively. In multivariable analysis, hematoma evacuation independently lowered 3-month mortality (adjusted hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.43–0.88; p < 0.03), particularly among patients aged ≤70 years with ≥30 ml supratentorial hematomas (adjusted HR, 0.26; 95% CI, 0.14–0.49; p < 0.001). However, poor outcome was not improved by surgery (adjusted odds ratio 0.71; 95% CI 0.29–1.70).

Conclusions

Improved 3-month survival was observed in patients who had undergone hematoma evacuation relative to patients not undergoing evacuation particularly in the subgroup of patients aged ≤70 years with ≥30 ml supratentorial hematomas. Surgery might improve outcome if cases could be selected more precisely and if performed before deterioration.     

Surgical hematoma evacuation of cortical intracerebral hemorrhage ≥10 ml reduces risk of subsequent epilepsy by more than 70%: A retrospective monocenter study

Aim

The aim of this study was to re-evaluate risk factors for post-ICH epilepsy (PICHE) and examine the impact of surgical hematoma evacuation on epilepsy development after ICH.

Background and purpose

Epilepsy is a common complication after intracerebral hemorrhage (ICH). Information on risk factors is still scarce and the role of ICH evacuation remains uncertain.

Methods

We retrospectively included patients with spontaneous ICH treated in our hospital in 2006–2019. Patients' medical records were analyzed. In addition, mailed questionnaires and telephone interviews were used to complete the dataset. Uni- and multivariable hazard ratios (HRs) were applied to investigate risk factors for PICHE and the impact of surgical ICH evacuation.

Results

Among 587 ICH patients available for analyses, 139 (23.7%) developed PICHE (mean follow-up 1795 ± 1378 days). The median time of epilepsy onset was 7 months after ICH (range 1–132 months). Risk factors associated with PICHE were cortical hemorrhage (multivariable HR 1.65 [95% CI 1.14–2.37]; p = 0.008), ICH volume > 10 ml (multivariable HR 1.91 [95% CI 1.33–2.73]; p < 0.001) and acute symptomatic seizures (multivariable HR 1.81 [95% CI 1.20–2.75]; p = 0.005). Patients with cortical ICH > 10 ml who underwent surgical hematoma evacuation were less likely to develop epilepsy than those with conservative treatment alone (multivariable HR 0.26 [95% CI 0.08–0.84]; p = 0.025).

Conclusions

Post-ICH epilepsy is frequent and predicted by large cortical ICH and acute symptomatic seizures. Hematoma evacuation reduced the risk of PICHE by more than 70% in patients with large cortical ICH. This finding could be considered in the clinical decision making on the acute treatment of ICH.     

Surgical treatment of spasticity in children: comparison of selective dorsal rhizotomy and intrathecal baclofen pump implantation

Introduction Neurosurgical treatments for spasticity in children include the traditional selective dorsal rhizotomy (SDR) and intrathecal baclofen pumps (ITBPs), which have been widely used in the past decade as an attractive alternative. The purpose of the study was to examine and compare the outcomes of these two procedures in the treatment of children with severe spasticity. Materials and methods A consecutive series of 71 children who underwent SDR for treatment of spasticity was compared with a group of 71 children matched by age and preoperative score on the Gross Motor Function Classification System (GMFCS) who underwent ITBP placement. Change in GMFCS score, lower-extremity tone (based on the Modified Ashworth–Bohannon Scale), and lower-extremity passive range of movement (PROM) at 1 year as well as the need for subsequent orthopedic procedures and parents’ satisfaction were selected as outcome measures. Results At 1 year, both SDR and ITBP decreased tone, increased PROM, and improved function. Both procedures resulted in a high degree of patient satisfaction. Compared with ITBP, SDR provided a larger magnitude of improvement in tone (−2.52 vs −1.23, p < 0.0001), PROM (−0.77 vs −0.39, p = 0.0138), and gross motor function (−0.66 vs −0.08, p < 0.0001). In addition, fewer patients in the SDR group required subsequent orthopedic procedures (19.1 vs 40.8%, p = 0.0106). Conclusions For children with moderate to severe spasticity, SDR and ITBP are both effective surgical treatments. Our results indicate SDR is more effective in reducing the degree of spasticity and improving function than ITBP is in this group of patients.     

MRI of the Perihemorrhagic Zone in a Rat ICH Model: Effect of Hematoma Evacuation

Background  Perihemorrhagic pathophysiology of spontaneous intracerebral hemorrhages (ICH) remains unclear. Recently, ischemic changes in the perihemorrhagic zone (PHZ) have been discussed as a potential source of secondary damage. In this study, we focussed on diffusion and perfusion characteristics of experimental ICH. Methods  Experimental ICH was induced with a double injection model in rats. In total, 49 animals were examined at three timepoints within 3.5 h after ICH with a 2.35T animal scanner. We investigated perihemorrhagic relative apparent diffusion coefficients (rADC) and relative mean transit time (rMTT). Animals were divided into 2 groups; controls (gr1, n = 27) and facilitated hematoma evacuation with recombinant tissue plasminogen activator (rt-PA) after the first of 3 imaging time points (gr2, n = 22). Diffusion (rADC) and perfusion (rMTT) characteristics were analyzed in 3 regions of interest surrounding the hematoma (ROI1–3). Results  Overall rADC and rMTT values in ROI3 (normal tissue) did not show any changes. There was mild edema—not ischemia—in ROIs1 and 2 at TP1 with rADC of 1.05–1.18 in both groups indicating vasogenic edema (not ischemia). This did not change with hematoma evacuation. There was mild (non-critical) perfusion reduction in ROIs1 and 2 at TP1, which disappeared after clot evacuation in group 2 (P < 0.05 for TP3). Multifactorial ANOVA showed a solid trend (0.06 < P < 0.1) for clot evacuation associated normalization of perfusion in ROIs 1 and 2 within and in between groups 1 and 2. Conclusions  We demonstrated vasogenic edema and mild perfusion reduction in the PHZ above the ischemic threshold. The existence of a perihemorrhagic “penumbra” indicating critically ischemic tissue analogous to ischemic stroke is unlikely.     

Phencyclidine (PCP)-Induced Disruption in Cognitive Performance is Gender-Specific and Associated with a Reduction in Brain-Derived Neurotrophic Factor (BDNF) in Specific Regions of the Female Rat Brain

Phencyclidine (PCP), used to mimic certain aspects of schizophrenia, induces sexually dimorphic, cognitive deficits in rats. In this study, the effects of sub-chronic PCP on expression of brain-derived neurotrophic factor (BDNF), a neurotrophic factor implicated in the pathogenesis of schizophrenia, have been evaluated in male and female rats. Male and female hooded-Lister rats received vehicle or PCP (n = 8 per group; 2 mg/kg i.p. twice daily for 7 days) and were tested in the attentional set shifting task prior to being sacrificed (6 weeks post-treatment). Levels of BDNF mRNA were measured in specific brain regions using in situ hybridisation. Male rats were less sensitive to PCP-induced deficits in the extra-dimensional shift stage of the attentional set shifting task compared to female rats. Quantitative analysis of brain regions demonstrated reduced BDNF levels in the medial prefrontal cortex (p < 0.05), motor cortex (p < 0.01), orbital cortex (p < 0.01), olfactory bulb (p < 0.05), retrosplenial cortex (p < 0.001), frontal cortex (p < 0.01), parietal cortex (p < 0.01), CA1 (p < 0.05) and polymorphic layer of dentate gyrus (p < 0.05) of the hippocampus and the central (p < 0.01), lateral (p < 0.05) and basolateral (p < 0.05) regions of the amygdaloid nucleus in female PCP-treated rats compared with controls. In contrast, BDNF was significantly reduced only in the orbital cortex and central amygdaloid region of male rats (p < 0.05). Results suggest that blockade of NMDA receptors by sub-chronic PCP administration has a long-lasting down-regulatory effect on BDNF mRNA expression in the female rat brain which may underlie some of the behavioural deficits observed post PCP administration.     

Outcome of teenagers and young adults with ependymoma: The Royal Marsden experience

Background  The outcome and clinical characteristics of teenagers and young adults (TYA) with ependymoma have not been well documented. We report the Royal Marsden Hospital experience treating TYA with ependymoma. Materials and methods  Sixteen TYA were treated for ependymoma from 1971 to 2004 and are compared to 24 children (not infants) treated in the same period. Results  Twelve TYA (75%) received treatment in a neuro-oncology unit. Average time from symptoms to diagnosis was 183 days for TYA vs. 61.2 for children (p = 0.005). Two TYA (12.5% vs. 41.6% for children, p = 0.08) were enrolled in a clinical trial. Only 25% of TYA achieved gross total resection, all of them received radiotherapy and five of them received chemotherapy. There were five relapses; all of them were local. Five-year overall survival was 84.6% ± 10 for TYA vs. 78.1% ± 8.7 for children (p = 0.15), and 5-year progression-free survival was 66.6% ± 12.3 for TYA vs. 44.4% ± 10.3 for children (p = 0.08). Up to 56% of patients treated in the paediatric unit received psychosocial support vs. 42.9% of patients treated in the adult unit. Discussion  Ependymoma in adolescents and young adults is an infrequent entity, with perhaps better outcome compared to children. The extent of surgical resection as seen in children is an important prognostic factor. Providing adolescents with ependymoma the appropriate neuro-oncologic care, including access to multidisciplinary teams, full access to clinical trials and age-appropriate neuro-oncologic ancillary support services, remains a challenge.     

The Effect of Blood Glutamate Scavengers Oxaloacetate and Pyruvate on Neurological Outcome in a Rat Model of Subarachnoid Hemorrhage

Blood glutamate scavengers have been shown to effectively reduce blood glutamate concentrations and improve neurological outcome after traumatic brain injury and stroke in rats. This study investigates the efficacy of blood glutamate scavengers oxaloacetate and pyruvate in the treatment of subarachnoid hemorrhage (SAH) in rats. Isotonic saline, 250 mg/kg oxaloacetate, or 125 mg/kg pyruvate was injected intravenously in 60 rats, 60 minutes after induction of SAH at a rate of 0.1 ml/100 g/min for 30 minutes. There were 20 additional rats that were used as a sham-operated group. Blood samples were collected at baseline and 90 minutes after SAH. Neurological performance was assessed at 24 h after SAH. In half of the rats, glutamate concentrations in the cerebrospinal fluid were measured 24 h after SAH. For the remaining half, the blood brain barrier permeability in the frontal and parieto-occipital lobes was measured 48 h after SAH. Blood glutamate levels were reduced in rats treated with oxaloacetate or pyruvate at 90 minutes after SAH (p < 0.001). Cerebrospinal fluid glutamate was reduced in rats treated with pyruvate (p < 0.05). Neurological performance was significantly improved in rats treated with oxaloacetate (p < 0.05) or pyruvate (p < 0.01). The breakdown of the blood brain barrier was reduced in the frontal lobe in rats treated with pyruvate (p < 0.05) and in the parieto-occipital lobes in rats treated with either pyruvate (p < 0.01) or oxaloacetate (p < 0.01). This study demonstrates the effectiveness of blood glutamate scavengers oxaloacetate and pyruvate as a therapeutic neuroprotective strategy in a rat model of SAH.     

Effectiveness of a limited invasive scalp approach in the correction of sagittal craniosynostosis

Background Several surgical techniques have been proposed for the correction of sagittal craniosynostosis. Extensive procedures seem to ensure the most stable long-term results and are more indicated in the older age group. Mini-invasive approaches are particularly useful in the very young infant as they are associated with a minor surgical risk. Furthermore, they are weighted by a minor cosmetic impact related to a less extended surgical scar. Materials and methods Data of the last 94 consecutively operated on scaphocephalic patients have been reviewed to verify the effectiveness of a personal limited-invasive approach based on four to six short linear scalp incisions vs the traditional bicoronal skin flap. The patients have been divided in two groups: (1) the control group (2000–2002): 45 children, operated on by means of a traditional bicoronal skin incision, and (2) the study group (2002–2004): 49 children, treated through four to six linear scalp incisions. The patients’ variables were comparable. The results were evaluated in terms of duration of the surgical procedure, estimated blood loss (EBL), transfusion risk, postoperative complication rate, length of hospital stay, and postoperative cephalic index and cosmetic outcome as perceived by the patients’ families. Results No significant differences between the two groups were found about the early and the long-term surgical results; however, about one third of the subjects of the control group complained about the visibility of the surgical scar. In the study group, a significant reduction in the duration of the operation (p < 0.0001), postoperative hospital stay (p < 0.0001), EBL (p = 0.011), transfusion risk (p = 0.018), and complication rate (p = 0.016) was observed. Conclusion The current trend in the management of scaphocephaly is to favor simplified surgical procedures to be performed in the younger ages prevalently. The technique here presented allows achieving a stable long-term cranial reshaping, even when performed in the very young patient. The technique can be utilized also in older subjects with results comparable to those of more extensive surgical procedures. This less invasive technique is weighted by minor complication rates and minor impact of the surgical scar. Presented at the Consensus Conference on Pediatric Neurosurgery, Rome, 1–2 December 2006.     

Intensive care management [corrected] of patients with intracerebral hemorrhage

Approximately 10-15% of acute strokes are caused by non-aneurysmatic intracerebral hemorrhage (ICH) and incidences are expected to increase due to an aging population. Studies from the 1990s estimated mortality of ICH to be as high as 50%. However, these figures may partly be attributed to the fact that patients suffering from ICH frequently received only supportive therapy and the poor prognosis may therefore be more a self-fulfilling prophecy. Recently it has been shown that treatment in a specialized neurological intensive care unit alone was associated with better outcomes after ICH. In recent years considerable efforts have been undertaken in order to develop new therapies for ICH and to assess them in randomized controlled trials. Apart from admission status, hemorrhage volume is considered to be the main prognostic factor and impeding the spread of the hematoma is thus a basic therapeutic principle. The use of activated factor VIIa (aFVIIa) to stop hematoma enlargement has been assessed in two large randomized controlled trials, however the promising results of the dose-finding study could not be confirmed in a phase III trial. Although hemostatic therapy with aFVIIa reduced growth of the hematoma it failed to improve clinical outcome. Similar results were found in a randomized controlled trial on blood pressure management in acute ICH. The link between reduction of hematoma growth and improved outcome is therefore still lacking. Likewise the value of surgical hematoma evacuation remains uncertain. In the largest randomized controlled trial on surgical treatment in ICH so far, only a small subgroup of patients with superficial hemorrhages seemed to benefit from hematoma evacuation. Whether improved intensive care can contribute to improved outcome after ICH will be shown by data obtained in the coming years.     

Association of Toll-like Receptor 2 Polymorphisms with National Institute of Health Stroke Scale Scores of Ischemic Stroke Patients

Toll-like receptor 2 (TLR2) has been shown to have an important role in the postischemic inflammatory response and to contribute to ischemic brain damage. In this study, we investigated whether coding region single nucleotide polymorphisms (SNPs) of the TLR2 gene were associated with ischemic stroke (IS) and with clinical phenotypes in IS patients. We genotyped two SNPs (rs3804099 [Asn199Asn] and rs3804100 [Ser450Ser]) using direct sequencing in 202 IS patients and 291 control subjects. No SNPs of the TLR2 gene were found to be associated with IS. However, in analysis of clinical phenotypes, we found that rs3804099 was associated with the National Institute of Health Stroke Scale (NIHSS) scores of IS patients in codominant (TC vs. TT, p = 0.0005; CC vs. TT, p = 0.0007) and dominant models (TC/CC vs. TT, p = 0.0001). Also, rs3804100 revealed significant association in codominant (TC vs. TT, p = 0.0002; CC vs. TT, p = 0.008) and dominant models (TC/CC vs. TT, p < 0.0001). In allele frequency analysis, we also found that the C alleles of rs3804099 and rs3804100 were associated with higher NIHSS scores (p = 0.0003 in rs3804099; p = 0.0001 in rs3804100). Our results suggest that TLR2 may be related to severe IS.     

Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage

Introduction: Decompressive hemicraniectomy in large hemispheric infarctions has been reported to lower mortality and improve the unfavorable outcomes. Hematoma volume is a powerful predictor of 30-day mortality in patients with intracerebral hemorrhage (ICH). Hematoma volume adds to intracranial volume and may lead to life-threatening elevation of intracranial pressure. Methods: Records of 12 consecutive patients with hypertensive ICH treated with decompressive hemicraniectomy were reviewed. The data collected included Glasgow Coma Scale (GCS) score at admission and before surgery, ICH volume, ICH score, and a clinical grading scale for ICH that accurately risk-stratifies patients regarding 30-day mortality. Outcome was assessed as immediate mortality and modified Rankin Score (mRS) at the last follow-up. Results: Of the 12 patients with decompressive hemicraniectomy, 11 (92%) survived to discharge; of those 11, 6 (54.5%) had good functional outcome, defined as a mRS of 0 to 3 (mean follow-up: 17.13 months; range: 2–39 months). The mean age was 49.8 years (range: 19–76 years). Three of the 7 patients with pupillary abnormalities made a good recovery; of the 11 patients with intraventricular extensions (IVEs), 7 made a good recovery. The clinical finding (which was present in all 3 patients with mRS equal to 5 and which was not present in patients with mRS less than 5) was abnormal occulocephalic reflex. Of the 10 patients with an ICH score of 3,9 (90%) survived to discharge, 4 (44%) had good functional outcome (mRS: 1–3). Hematoma volume was 60 cm³ or greater in eight patients, four (50%) of whom had good functional outcome (mRS: 0–3). Conclusion: Decompressive hemicraniectomy with hematoma evacuation is life-saving and improves unfavorable outcomes in a select group of young patients with large right hemispherical ICH.     

Incidence of symptomatic retethering after surgical management of pediatric tethered cord syndrome with or without duraplasty

Background  Cord retethering and other postoperative complications can occur after the surgical untethering of a first-time symptomatic tethered cord. It is unclear if using duraplasty vs. primary dural closure in the initial operation is associated with decreased incidence of either immediate postoperative complications or subsequent symptomatic retethering. It is also unclear if different etiologies are associated with different outcomes after each method of closure. We reviewed our pediatric experience in first-time surgical untethering of symptomatic tethered cord syndrome (TCS) to identify the incidence of postoperative complications and symptomatic retethering after duraplasty vs. primary closure. Materials and methods  We retrospectively reviewed 110 consecutive pediatric (<18 years old) cases of first-time symptomatic spinal cord untethering at our institution over a 10-year period. Incidence of postoperative complications and symptomatic retethering were compared in cases with duraplasty vs. primary dural closure use. Results  Mean age was 5.7 ± 4.8 years old. “Complex” etiologies included lipomyelomeningocele or prior lipomyelomeningocele repair in 22 (20%) patients, prior myelomeningocele repair in 35 (32%), and concurrent lumbosacral lipoma in 18 (16%). “Noncomplex etiologies” included fatty filum in 26 (24%) and split cord malformation in five (4%). Seventy-five (68%) cases underwent primary dural closure vs. 35 (32%) with duraplasty. Twenty-nine (26%) patients experienced symptomatic retethering at a median [interquartile range (IQR)] of 30.5 [20.75–41.75] months postoperatively. There was no difference in incidence of postoperative cerebrospinal fluid leak, surgical site infection, or median [IQR] length of stay in patients receiving primary dural closure [4 (5%), 7 (9%), and 5 (4–6) days, respectively] vs. duraplasty [3 (9%), 3 (9%), and 6 [5–8] days, respectively], p > 0.05. Complex etiologies were more likely to retether than noncomplex etiologies after primary closure (33.6% vs. 6.6%, p = 0.05) but not after duraplasty (13.7% vs. 5.4%, p = 0.33). Duraplasty graft type (polytetrafluoroethylene vs. bovine pericardium) was not associated with pseudomeningocele or retethering. Conclusion  In our experience, the increased rate of symptomatic retethering observed with complex pediatric TCS (pTCS) etiologies after primary dural closures was not observed when duraplasty was instituted. Expansile duraplasty may be valuable specifically in the management of patient subgroups with complex pTCS etiologies.     

The prognostic value of the CT scan in conservatively treated patients with intracerebral hematoma

Prognostic factors for survival and neurological recovery were assessed in 42 patients with nontraumatic intracerebral hematoma (ICH) diagnosed by CT scan. None underwent surgical evacuation of hematoma. CT scans were used to determine location and volume of ICH and presence or absence of intraventricular hemorrhage (IVH). Only 11 patients (26%) died and 17 patients (40.5%) recovered fully. Mortality was associated with: 1) loss of consciousness as a presenting symptom (63.5% mortality rate versus 13% when there was no loss of consciousness at the onset; p less than 0.01). 2) extension of the bleeding into the ventricular system (45% mortality rate versus 9% when hemorrhages were confined to brain parenchyma; p less than 0.01). 3) location of hematoma in the posterior fossa (mortality rate of 43% versus 23% for intrahemispheric hematomas). Mortality was unaffected by age of patients and size of ICH. Full neurological and functional recovery occurred mainly when estimated volume of hematomas was less than 15 cc and with lobar hematomas regardless of size. In survivors there is CT evidence of complete resolution of ICH. Our data indicates a favourable outcome in a relatively large percentage of patients with ICH treated conservatively and therefore questions the need for surgical evacuation of hematoma.     

Analysis of thrombin‐antithrombin complex contents in plasma and hematoma fluid of hypertensive intracerebral hemorrhage patients after clot removal

Background and purpose: Animal experiments indicate that the cerebral thrombin is associated with secondary brain damage after intracerebral hemorrhage (ICH). This study was aimed to investigate the concentrations of thrombin‐antithrombin complex (TAT) in hematoma fluid and plasma of the patients with ICH after surgery and analyze the correlation between TAT complex levels and severity of ICH. Methods: Sixty patients with ICH were enrolled. Craniotomy for removal of intracranial blood clot was performed within 24 h after ICH. Hematoma fluid and plasma were collected on postoperative days 1, 2, and 4. The plasma obtained from healthy subjects and cerebrospinal fluid from patients without cerebrovascular diseases served as controls, respectively. Enzyme‐linked immunosorbent assay was used to determine the concentrations of TAT complex in the patients and controls. Results: TAT complex concentrations in both postoperative plasma and hematoma fluid of patients with ICH were significantly higher than those of the controls (P < 0.01). In patients with ICH, hematoma fluid had a higher TAT complex level than plasma (P < 0.01). The preoperative hemorrhage volume and postoperative TAT complex levels in plasma and hematoma fluid correlated positively with National Institutes of Health stroke scale and negatively with Glasgow coma score (P < 0.01). Conclusion: This study indicates that TAT complex levels of plasma and hematoma fluid correlate positively with the severity of ICH. Determination of the plasma TAT complex concentration is helpful for the evaluation of the severity of post‐ICH brain injury.     

Effects of statin and deferoxamine administration on neurological outcomes in a rat model of intracerebral hemorrhage

Deferoxamine (DFX), a potent iron-chelating agent, reduces brain edema and neuronal cell injury that develop due to the hemolysis cascade. Statins have neuroprotective effects via anti-inflammatory action and increment of cerebral blood flow after intracerebral hemorrhage (ICH). The purpose of this study was to identify the effects of combined DFX and statins treatment in an experimental ICH rat model. The treatments were: intraperitoneal (i.p.) injection of DFX (group I), combined treatment of i.p. DFX and oral statins (group II), statins only (group III) and treatment with vehicle (group IV). Induction of ICH was performed with injection of bacterial collagenase type IV into the left striatum. After removal of the brain, hematoma volume, water content and brain atrophy were measured. Immunohistochemistry in the perihematomal region was performed for identification of microglial infiltration, astrocyte expression and apoptotic cell presence. Statistical analysis was performed using the non-parametric Kruskal–Wallis test and significance was evaluated when the p value was less than 0.05. According to behavioral tests, significant differences among treatment groups were noted 4 weeks after ICH induction (p < 0.05). However, there were no significant differences among treatment groups in hematoma volume, brain water content or brain atrophy. In the perihematomal area, the activated microglial cells were reduced in the combined treatment group. Among the four groups, a significant difference in immunohistochemical staining was identified (p < 0.05). These results suggest that combined treatment with DFX and statins improves neurologic outcomes after ICH through reduction of microglial infiltration, apoptosis, inflammation and brain edema.     

Emergent Clipping without Prophylactic Decompressive Craniectomy in Patients with a Large Aneurysmal Intracerebral Hematoma

Objective

Many vascular neurosurgeons tend to remove bone flap in patients with large aneurysmal intracerebral hematomas (ICH). However, relatively little work has been done regarding the effectiveness of prophylactic decompressive craniectomy in a patient with a large aneurysmal ICH.

Methods

Large ICH was defined as hematoma when its volume exceeded 25 mL, ipsilateral to aneurysms. The patients were divided into two groups; aneurysmal subarachnoid hemorrhage (SAH) associated with large ICH, January, 1994 - December, 1999 (Group A, 41 patients), aneurysmal SAH associated with large ICH, January, 2000 - May, 2005 (Group B, 27 patients). Demographic and clinical variables including age, sex, hypertension, vasospasm, rebleeding, Hunt-Hess grade, aneurysm location, aneurysm size, and outcome were compared between two groups, and also compared between craniotomy and craniectomy patients in Group A.

Results

In Group A, 21 of 41 patients underwent prophylactic decompressive craniectomy. In Group B, only two patients underwent craniectomy. Surgical outcome in Group A (good 23, poor 18) was statistically not different from Group B (good 15, poor 12). Surgical outcomes between craniectomy (good 12, poor 9) and craniotomy cases (good 11, poor 9) in Group A were also comparable.

Conclusion

We recommend that a craniotomy can be carried out safely without prophylactic craniectomy in patients with a large aneurysmal ICH if intracranial pressure is controllable with hematoma evacuation.     

Alteration of serum semicarbazide-sensitive amine oxidase activity in chronic renal failure

Summary Despite recent intensive investigations, physiological and pathological role of semicarbazide-sensitive amine oxidase (SSAO) is far from clear. In this study, serum SSAO activity was determined, radiochemically, in various groups of uremic patients: haemodialysed (HD), peritoneally dialysed (PD) and those receiving conservative treatment but still not dialysed (ND), as well as in controls. Reduced enzyme activity was found in HD uremic patients before and after dialysis treatment, compared to controls (5260 ± 862 and 6011 ± 958 pmol/h/ml vs. 8601 ± 283 pmol/h/ml, p < 0.01 and p < 0.05, respectively). The activity was slightly lower in PD, and normal in ND patients. In HD patients SSAO activity was also determined by an assay based on the formation of hydrogen peroxide, and was found to be elevated compared to controls (2384 ± 323 pmol/h/ml vs. 1437 ± 72 pmol/h/ml, p < 0.05). The elevated serum SSAO activity measured through the detection of the enzyme-generated hydrogen peroxide in HD patients might indicate its contribution to the accelerated atherosclerotic disease observed in uremia.     

Initial experience with minimally invasive endoscopic evacuation of intracerebral hemorrhage in the setting of radiographic herniation

BackgroundSpontaneous intracerebral hemorrhage (ICH) can rapidly result in cerebral herniation, leading to poor neurologic outcomes or mortality. To date, neither decompressive hemicraniectomy (DH) nor hematoma evacuation have been conclusively shown to improve outcomes for comatose ICH patients presenting with cerebral herniation, with these patients largely excluded from clinical trials. Here we present the outcomes of a series of patients presenting with ICH and radiographic herniation who underwent emergent minimally invasive (MIS) ICH evacuation.MethodsWe reviewed our prospectively collected registry of patients undergoing MIS ICH evacuation at a single institution from 01/01/2017 to 10/01/2021. We selected all consecutive patients with Glasgow coma scale (GCS) ≤ 8 and radiographic herniation for this case series. Clinical and radiographic variables were collected, including admission GCS score, preoperative and postoperative hematoma volumes, National Institute of Health stroke scale (NIHSS) scores, and modified Rankin scale (mRS) scores at last follow-up.ResultsOf 176 patients with spontaneous supratentorial ICH who underwent minimally invasive endoscopic evacuation during the study time period, a total of 9 patients presented with GCS ≤ 8 and evidence of radiographic herniation. Among these patients, the mean age was 62 ± 12 years, the median GCS at presentation was 5 [IQR 4-6], the mean preoperative hematoma volume was 94 ± 44 mL, the mean time from ictus to evacuation was 12 ± 5 h, and the mean postoperative hematoma volume was 11 ± 16 mL, for a median evacuation percentage of 97% [83-99]. Three patients (33%) died, four (44%) survived with mRS 5 and two (22%) with mRS 4. Patients had a median NIHSS improvement of 5 compared to their initial NIHSS. Age was very strongly correlate to improvements in NIHSS (r² = 0.90).ConclusionData from this initial experience suggest emergent MIS hematoma evacuation in the setting of ICH with radiographic herniation is feasible and technically effective. Further randomized studies are required to determine if such an intervention offers overall benefits to patients and their families.     

Neurological outcome after resection of intramedullary spinal cord tumors in children

Objective With modern surgical advances, radical resection of pediatric intramedullary spinal cord tumors (IMSCT) can be achieved with preservation of long-term neurological function. Clinical and radiographic risk factors predictive of postoperative neurological outcome may serve as a guide for surgical risk stratification. Materials and methods We prospectively reviewed the outcomes of 16 consecutive cases of pediatric IMSCT resection at a single institution. Clinical, radiographic, and operative variables were analyzed as predictors of postoperative neurological function defined by the modified McCormick score (MMS). Results Sixteen children 10 ± 5 years old presented with median (interquartile range) MMS score of 2 (1–2) with IMSCTs (eight cervical, eight thoracic) involving 4 ± 2 levels. Pathology revealed astrocytoma in 12 cases (three pilocytic, four grade II, three gradeIII, two GBM), gangliogliomas in two, ependymoma in one, and gliosis in one case. At median follow-up of 7 months, six (38%) patients experienced improved neurological function, eight (50%) remained stable, one (6%) experienced a delayed decrease in neurological function (GBM progression), and one (6%) died (GBM progression). Five (31%) patients developed persistent dysesthetic symptoms. Four (80%) patients with cystic tumors experienced neurological improvement compared to only two (18%) patients with noncystic tumors, p < 0.05. Preoperative steroid use (odds ratio, OR [95% confidence interval, CI] = 18.0 [1.24–260.1], p = 0.03) and cystic tumor (OR [95%CI] = 18.0 [1.24–260.1], p = 0.03) predicted neurological improvement after surgery. Conclusion Radical resection of pediatric IMSCTs can be achieved with low incidence of neurological injury. Sensory syndromes frequently occur after pediatric IMSCT resection and frequently affect patient’s quality of life. Tumors with compressive cysts may identify patients more likely to experience improved neurological function after surgical resection.     

A double-injection model of intracerebral hemorrhage in rabbits

We aimed to develop a double-injection model of intracerebral hemorrhage (ICH) in rabbits and to evaluate it as a tool for investigating post-ICH brain injury. Rabbits were injected with 300 μL fresh autologous whole blood into the right basal ganglia. Behavioral changes were rated, brain water content (BWC) was measured and brain tissue morphology was also examined. ICH was established in 93.5% of the blood injection group. At 1, 3 and 7 days after ICH, there were significant differences in the total neurological scores (p < 0.01) and BWC (p < 0.01) between a sham-operated group and the ICH group. These findings suggest that the model produces a persistent neurological deficit, hematoma volume and perihematomal edema and closely mimics human hypertensive basal ganglia ICH; it is a controllable and reproducible hematoma that lends itself to quantitative investigation.