Stroke epidemiology studies have underestimated the frequency of intracerebral haemorrhage. A systematic review of imaging in epidemiological studies

Introduction: Small primary intracerebral haemorrhages (PICHs) cause mild stroke symptoms and resolve rapidly on CT. Delays in imaging in stroke incidence studies may therefore have inadvertently led to an underestimate of the frequency of small PICHs. Objective: To determine whether the rate and timing of CT in community-based stroke incidence studies was adequate to determine accurately the proportion of strokes due to PICH. Methods: A systematic review of community-based stroke incidence studies that included details on pathological type of stroke, excluding subarachnoid haemorrhage. We extracted information on the proportions of patients scanned, the timing of scans, characteristics of patients that were less likely to be scanned, and the proportion of ischaemic, or haemorrhagic, or unknown strokes. Results: In the 25 studies identified, scanning methods were poorly documented. When mentioned, the median proportion of patients scanned was 63 % (95 % confidence intervals (CI) 60 to 85 %) and mostly performed outside the time for reliable distinction of PICH from ischaemic stroke (median 18.5 days, 95 % CI 7 to 30 days). Patients particularly likely to miss scanning were older, those not admitted to hospital or who died early after stroke. Conclusion: The scanning strategy documentation, the proportion of patients scanned and the timing of scanning in stroke incidence studies has been suboptimal. The frequency of a primary intracerebral haemorrhage, and its distribution in different age groups of patients or severities of stroke, has been underestimated. Future incidence studies should adopt more rigorous scanning policies and describe these policies more precisely. Received: 8 August 2001, Received in revised form: 14 February 2002, Accepted: 20 February 2002     

Outcome after brain haemorrhage

Between 10 and 20% of strokes are due to intracerebral haemorrhage. The 1-month case fatality is about 42% in unselected cohorts. This relatively low incidence (compared with ischaemic stroke) and high early case fatality means that relatively few patients are available for long-term follow-up and therefore the available data on prognosis are imprecise. Moreover, improvements in diagnostic methods, such as the introduction of gradient echo MRI, which is very sensitive to intracerebral haemorrhage, are altering the types of patients being entered into studies of prognosis. Despite these methodological difficulties, it does appear that the overall prognosis with respect to survival and residual disability is similar to that for ischaemic stroke of equivalent clinical severity. Greater age and stroke severity, whether graded by neurological score or extent of haemorrhage on imaging, are both associated with increased case fatality and poorer functional outcomes. There is no definite evidence of differential recovery between ischaemic and haemorrhagic stroke. Epileptic seizures occur more commonly after haemorrhagic stroke (about 8 per 100 patient-years) compared with ischaemic stroke and more commonly in lobar rather than basal ganglia haemorrhage. There is no reliable evidence to indicate that the risk of recurrent stroke after haemorrhage differs from that after ischaemic stroke. However, strokes due to haemorrhage, like those due to infarction, are heterogeneous not only in terms of severity but also in their causes. The causes (e.g. amyloid angiopathy, hypertension, coagulation deficits) are likely to influence the risk of subsequent stroke. Pooling of data from community-based studies of haemorrhagic stroke that have used consistent definitions and methods represents the only feasible way to obtain more precise data on prognosis after intracerebral haemorrhage.     

Thrombolysis in acute ischaemic stroke within 3 hours of symptom onset: a report of the first 100 cases

BACKGROUND AND PURPOSE: The aim of the study was to present our initial experience with the use of intravenous thrombolytic therapy in patients with acute ischaemic stroke in the 2nd Department of Neurology of the Institute of Psychiatry and Neurology in the years 2003-2007. MATERIAL AND METHODS: The patients were selected and treated with recombinant tissue plasminogen activator (rt-PA, alteplase) according to the SITS-MOST (Safe Implementation of Thrombolysis in Stroke - Monitoring Study) protocol. RESULTS: We present the data on the first 100 patients treated with rt-PA in our department. The mean age of the treated patients was 67 years, the initial neurological deficit measured in the National Institutes of Health Stroke Scale (NIHSS) was 8 pts., the door-to-needle time was 82 minutes. At 3-month follow-up, 61% of patients had achieved modified Rankin scale score of 0-2. Fourteen percent had died within three months of stroke onset. We observed 2 symptomatic intracerebral haemorrhages and there were 17 cases of secondary asymptomatic haemorrhagic transformations (6 cases with haemorrhagic infarct type 2, 11 cases with primary intracerebral haemorrhage, and 6 cases with remote primary intracerebral haemorrhage type 1). CONCLUSIONS: Our results are consistent with the previous experience of other stroke centres and confirm that rt-PA is safe and effective in ischaemic stroke treatment also in the Polish population.     

Incidence of intracerebral and subarachnoid haemorrhage in southern Sweden

OBJECTIVES: Spontaneous intracranial haemorrhage-that is, mainly subarachnoid haemorrhage (SAH) and primary intracerebral haemorrhage (PICH)-constitutes an important part of all strokes. As previous epidemiological studies have demonstrated highly variable incidence rates, we conducted a large prospective investigation of all haemorrhagic strokes during a 1 year period. METHODS: Twelve hospitals serving a defined population of 1.14 million in southern Sweden registered all cases with spontaneous intracranial haemorrhage, including those found dead outside hospitals, during 1996. All patients were examined with CT of the brain or underwent necropsy. Incidence rates adjusted to the Swedish population for age and sex, as well as location of haematoma and prevalence of risk factors were calculated. RESULTS: A total of 106 patients with SAH and 341 patients with PICH were identified. The annual incidence/100 000 was 10.0 (6.4 for men and 13.5 for women) for SAH and 28.4 (32.2 for men and 24.7 for women) for PICH when adjusted to the Swedish population. Subarachnoid haemorrhage affected twice as many women as men. The incidence of both types of haemorrhage increased with advancing age, but in particular, this was the case for supratentorial PICH. Lobar haematomas were the most common (51.6%) type of PICH. Among patients with PICH, 37% had hypertension, 41% other vascular disease, and 12% were on oral anticoagulation. Among patients with SAH, 28% had hypertension and 18% vascular disease before the haemorrhage but no one was on treatment with oral anticoagulation. CONCLUSIONS: The incidence of PICH was high, especially for the older age groups. PICH was, on average, three times as common as SAH. The study underscores the importance of PICH and SAH as significant stroke subgroups.     

Spectrum of primary intracerebral haemorrhage in Perth, Western Australia, 1989-90: incidence and outcome.

In a population based register of stroke (n = 536) compiled in Perth, Western Australia during an 18 month period in 1989-90, 60 cases (11%) of primary intracerebral haemorrhage were identified among 56 persons (52% men). The mean age of these patients was 68 (range 23-93) and 46 (77%) events were first ever strokes. The crude annual incidence was 35 per 100,000, with a peak in the eighth decade, and a male predominance. Deep and lobar haemorrhages each accounted for almost one third of all cases. The clinical presentations included sudden coma (12%), headache (8%), seizures (8%), and pure sensory-motor stroke (3%). Primary intracerebral haemorrhage was the first presentation of leukaemia in two cases (both fatal) and it followed an alcoholic binge in four cases. 55% had a history of hypertension. 16 (27%) patients, half of whom had a history of hypertension, were taking antiplatelet agents, and one patient was taking warfarin. There were only two confirmed cases of amyloid angiopathy. The overall 28 day case fatality was 35%, but this varied from 100% for haemorrhages in the brainstem to 22% for those in the basal ganglionic or thalamic region. Other predictors of early death were intraventricular extension of blood, volume of haematoma, mass effect, and coma and severe paresis at onset. Although based on small numbers, these data confirm the heterogeneous nature of primary intracerebral haemorrhage, but they also suggest a different clinical spectrum of this type of stroke in the community compared with the experience of specialist neurological units.     

Haemorrhagic pure motor stroke

To describe the clinical characteristics of haemorrhagic pure motor stroke (PMS). Twelve patients with haemorrhagic PMS were identified. Haemorrhagic PMS accounted for 3.2% of all cases of pure motor hemiparesis ( n  = 380) and 3.3% of intracerebral haemorrhage ( n  = 364) entered in the database. When compared with PMS of ischaemic origin, patients with haemorrhagic PMS were more likely to be younger (62.2 vs. 75.2 years, P  = 0.003) and to have headache (33% vs. 6.3%, P  =0.007) and thalamus involvement (25% vs. 2.4%, P  = 0.005). Limb weakness (100% vs. 74.1%; P  = 0.03), involvement of the internal capsule (50% vs. 17.3%, P  = 0.012) and symptom free at discharge (25% vs. 3.7%, P  = 0.012) were significantly more frequent in patients with haemorrhagic PMS than in the remaining cases of haemorrhagic stroke, whereas nausea and vomiting (0% vs. 25.9%, P  = 0.03), altered consciousness (0% vs. 42.9%, P  = 0.001), sensory symptoms (8.3% vs. 46.9%, P  =0.007) and ventricular haemorrhage (0% vs. 26.1%, P  = 0.028) were significantly less frequent. Haemorrhagic PMS is a very infrequent stroke subtype. Headache at stroke onset may be useful sign for distinguishing haemorrhagic PMS from other causes of lacunar stroke. There are important differences between haemorrhagic PMS and the remaining intracerebral haemorrhages.     

The morbidity related to atrial fibrillation at a tertiary centre in one year: 9.0% of all strokes are potentially preventable.

Atrial fibrillation is a major risk factor for stroke. Anticoagulant therapy reduces this risk but increases the risk of haemorrhage. We aimed to compare the morbidity related to the treatment of atrial fibrillation with warfarin seen in one year at our hospital, with the morbidity in those patients in whom embolism was potentially preventable. There were 111 patients admitted to our hospital in a 12 month period with nonvalvular atrial fibrillation (NVAF) who had stroke, TIA or peripheral embolism. Atrial fibrillation was identified prior to admission in 87 of these 111 (78%) patients with thromboembolism, yet only 14 of these (16%) were receiving warfarin for stroke prophylaxis. Through chart review, a further 56 (64%) patients with embolism could have been receiving anticoagulant therapy if published clinical guidelines(1) were applied. Therefore, 40 episodes of thromboembolism were potentially preventable. Over the same period, there were 18 patients admitted with haemorrhage related to warfarin therapy for stroke prophylaxis in NVAF, including 10 gastrointestinal, five intracerebral, and three peripheral haemorrhages. Most haemorrhages were associated with a high International Normalized Ratio (INR) and the patients were left less disabled than those with embolism. Only one patient with haemorrhage had an absolute contraindication to warfarin therapy (6%). We conclude that the number of preventable strokes far outweighed the morbidity due to warfarin use in the management of NVAF.     

Intracerebral haemorrhage,microbleeds and antithrombotic drugs

Antithrombotic therapy is a cornerstone for secondary prevention of ischaemic events, cerebral and extra-cerebral. A number of clinical questions remain unanswered concerning the impact of antithrombotic drugs on the risk of first-ever and recurrent macro or micro cerebral haemorrhages, raising the clinical dilemma on the risk/benefit balance of giving antiplatelets and anticoagulants in patients with potential high risk of brain bleeds. High field magnetic resonance imaging (MRI) blood-weighted sequences, including susceptibility weighted imaging (SWI), have expanded the spectrum of these clinical questions, because of their increasing sensitivity in detecting radiological markers of small vessel disease. This review will summarise the literature, focusing on four main clinical questions: how do cerebral microbleeds impact the risk of cerebrovascular events in healthy patients, in patients with previous ischaemic stroke or transient ischaemic attack, and in patients with intracerebral haemorrhage? Is the risk/benefit balance of oral anticoagulants shifted by the presence of microbleeds in patients with atrial fibrillation after recent ischaemic stroke or transient ischaemic attack? Should we restart antiplatelet drugs after symptomatic intracerebral haemorrhage or not? Are oral anticoagulants allowed in patients with a history of atrial fibrillation and previous intracerebral haemorrhage?     

Stroke attack rates and case fatality in the Krakow Stroke Registry

BACKGROUND AND PURPOSE: Previous epidemiological studies of stroke in Poland completed more than 10 years ago reported moderate incidence rates but very high case fatality rates due to stroke. We used the data of the Krakow Stroke Registry to calculate the attack rates as well as short- and long-term case fatality rates from stroke in hospitalized inhabitants of Krakow, Poland. MATERIAL AND METHODS: We prospectively recorded all cases of stroke (defined according to the ICD-10) in adult permanent residents of Krakow, who were admitted to hospitals in that city. The registration took one year (between 1 July 1999 and 30 June 2000). The vital status of participants was established on days 30, 90 and 180 and at one year after their stroke. RESULTS: 1096 strokes occurred in a population of 589,820. Attack rate standardized for the European population was 180.0 per 100,000 (218.3 in men and 151.9 in women). Ischaemic stroke was diagnosed in 532 (48.6%), stroke not specified as haemorrhagic or ischaemic in 406 subjects (37.0%), intracerebral haemorrhage in 86 (7.8%), and subarachnoid haemorrhage in 72 (6.6%). The 30-day, 90-day, 180-day and one-year case fatality rates for all strokes were 17.8%, 28.1%, 30.8% and 39.7%, respectively. Case fatality rates for ischaemic stroke were 9.8%, 19.0%, 21.6% and 31.2%, respectively and for intracerebral haemorrhage 44.2%, 55.8%, 55.8% and 60.5%, respectively. CONCLUSIONS: The attack rates of stroke in urban areas of Poland are similar to the average European rates. Short- and long-term case fatality rates are much lower than previously reported.     

Delirium in the first days of acute stroke

Abstract.Background and Purpose: Delirium is an acute, transient disorder of cognition and consciousness with fluctuating intensity. The aim of this study was to investigate the presence and the risk factors for delirium in the first days after stroke onset.Patients and methods: We assessed delirium prospectively in a sample of 218 consecutive patients (mean age 57 years) with an acute ( 4 days) stroke (28 subarachnoid haemorrhages, 48 intracerebral haemorrhages, 142 cerebral infarcts) and in a control group of 50 patients with acute coronary syndromes with the Delirium Rating Scale (DRS) (cut-off score 10).Results: 29 (13%) acute stroke patients (mean DRS score = 13.2, SD = 2.3) and only one (2 %) acute coronary patient had delirium (² = 5.2, p = 0.02). In nine patients delirium was secondary to stroke without any additional cause, in 10 patients there were also medical complications and in the remaining 10 there were multiple potential causes for delirium. Delirium was more frequent after hemispherical than after brainstem/cerebellum strokes (p = 0.02). No other statistically significant associations with stroke locations were found. Medical complications (OR = 4.3; 95% CI = 1.8 to 10.2), neglect (OR = 3.5; 95% CI = 1.3 to 9.2), intracerebral haemorrhage (OR = 3.1; 95% CI = 1.3 to 7.5) and age 65 (OR = 2.4; 95% CI = 1.0 to 5.8) were independent factors to the development of delirium in stroke patients.Conclusion: Delirium was more frequent in stroke than in coronary acute patients. Among stroke patients, delirium was most frequent in older patients, in those with neglect, with medical complications and with intracerebral haemorrhages. These findings indicated that delirium in acute stroke patients 1) is not a non-specific consequence of acute disease and hospitalisation and 2) is secondary to hemisphere brain damage and to metabolic disturbances due to medical complications.Abbreviations DRS Delirium Rating Scale - GCS Glasgow Coma Scale - NIHSS Neurological Institute Health Stroke Scale - DSM-IV Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Text Reviewed - ICH Intracerebral Haemorrhage - INF Cerebral Infarct - SAH Subarachnoid Haemorrhage - SPSS Statistical Package for Social Sciences - ² Chi-square - OR Odds Ratios - 95% CI 95% Confidence Interval - U Mann-Whitney test - MCA Middle Cerebral Artery - PCA Posterior Cerebral Artery     

Clinical and imaging predictors of intracerebral haemorrhage in stroke patients treated with intravenous tissue plasminogen activator

OBJECTIVE: To evaluate clinical, biological, and pretreatment imaging variables for predictors of tissue plasminogen activator (tPA) related intracerebral haemorrhage (ICH) in stroke patients. METHODS: 48 consecutive patients with hemispheric stroke were given intravenous tPA within seven hours of symptom onset, after computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. Baseline diffusion weighted (DWI) and perfusion weighted (PWI) imaging volumes, time to peak, mean transit time, regional cerebral blood flow index, and regional cerebral blood volume were evaluated. The distribution of apparent diffusion coefficient (ADC) values was determined within each DWI lesion. RESULTS: The symptomatic ICH rate was 8.3% (four of 48); the rate for any ICH was 43.8% (21 of 48). Univariate analysis showed that age, weight, history of hyperlipidaemia, baseline NIHSS score, glucose level, red blood cell count, and lacunar state on MRI were associated with ICH. However, mean 24 hour systolic blood pressure and a hyperdense artery sign on pretreatment CT were the only independent predictors of ICH. Patients with a hyperdense artery sign had larger pretreatment PWI and DWI lesion volumes and a higher NIHSS score. Analysis of the distribution of ADC values within DWI lesions showed that a greater percentage of pixels had lower ADCs (< 400 x 10(-6) mm(2)/s) in patients who experienced ICH than in those who did not. CONCLUSION: Key clinical and biological variables, pretreatment CT signs, and MRI indices are associated with tPA related intracerebral haemorrhage.     

A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project--1981-86. 2. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoid haemorrhage.

The age and sex specific incidence rates for cerebral infarction, primary intracerebral haemorrhage and subarachnoid haemorrhage in a population of approximately 105,000 are presented. Over four years 675 patients with a first-ever stroke were registered with the Oxfordshire Community Stroke Project. The pathological diagnosis was confirmed by computerised tomography (CT) scan, necropsy or lumbar puncture (cases of subarachnoid haemorrhage only) in 78% of cases and a further 17% were diagnosed according to the Guy's Hospital Stroke Diagnostic Score. The proportion of all first-ever strokes by pathological type was: cerebral infarction 81% (95% confidence interval 78-84), primary intracerebral haemorrhage 10% (8-12), subarachnoid haemorrhage 5% (3-7) and uncertain type 5% (3-7). These proportions are similar to other community-based studies. The overall 30 day case fatality rate was 19% (16-22), that for cerebral infarction being 10% (7-13), primary intracerebral haemorrhage 50% (38-62) and subarachnoid haemorrhage 46% (29-63). One year post stroke 23% (19-27) with cerebral infarction were dead and 65% (60-70) of survivors were functionally independent. The figures for primary intracerebral haemorrhage were 62% (43-81) dead and 68% (50-86) of survivors functionally independent and for subarachnoid haemorrhage were 48% (24-72) dead and 76% (56-96) of survivors functionally independent. There are important differences between these rates and those from other sources possibly due to more complete case ascertainment in our study. Nevertheless, the generally more optimistic early prognosis in our study, particularly for cases of cerebral infarction, has important implications for the planning of clinical trials and for the expected impact that any treatment might have on the general population.     

小脑出血与梗死的临床与影像学

目的 探讨小脑出血与梗死的临床与影像学特征及治疗与预后。方法 经CT、MRI及外科手术证实的小脑出血45例，小脑梗死42例，进行临床资料分析。结果 小脑出血45例中，蚓部出血9例，小脑半球出血36例。根据意识障碍程度、脑干受压及影像学所见分为轻型14型、中型20例、重型10例、极重型1例。小脑梗死42例，梗死灶位于小脑半球有55个，蚓部2个，小脑中脚8个。小脑出血无论手术或保守治疗预后均较好。小脑梗死经药物治疗后，大多数近愈，无1例死亡。结论 小脑出血与梗死的预后比幕上出血与梗死要好。     

Change in incidence and aetiology of intracerebral haemorrhage in Oxfordshire, UK, between 1981 and 2006: a population-based study

BACKGROUND: UK stroke mortality data suggest that the incidence of haemorrhagic stroke has fallen in the past 20 years, but these data do not include deaths of individuals aged 75 years or over. Trends in the older population might differ, since cause varies with age. Our aim was to investigate changes in the population-based incidence of intracerebral haemorrhage according to age and likely aetiology. METHODS: We used data from the Oxford Community Stroke Project (OCSP; 1981-86) and the Oxford Vascular Study (OXVASC; 2002-06) to investigate changes in the incidence of intracerebral haemorrhage with time, above and below age 75 years, together with associated risk factors and premorbid medications. Incidences were standardised to the 2001 census population of England and Wales. FINDINGS: In the population aged under 75 years the incidence of intracerebral haemorrhage decreased substantially (rate ratio 0.53, 95% CI 0.29-0.95; p=0.03), but the number of cases of intracerebral haemorrhage at all ages were similar in OXVASC and OCSP (52 vs 55 cases) as the proportion of cases occurring at 75 years and over tended to increase (2.0, 0.8-4.6; p=0.09). The incidence of intracerebral haemorrhage associated with premorbid hypertension (blood pressure >or=160/100 mm Hg) fell overall (0.37, 0.20-0.69; p=0.002), but the incidence of intracerebral haemorrhage associated with antithrombotic use was increased (7.4, 1.7-32; p=0.007). Above age 75 years the proportion of cases who were non-hypertensive with lobar bleeds and presumed to have had mainly amyloid-related haemorrhages, also increased (4.0, 1.1-17; p=0.003). INTERPRETATION: There has been a substantial fall in hypertension-associated intracerebral haemorrhage over the past 25 years, but not in the overall number of cases of intracerebral haemorrhage in older age-groups, in part due to a rise in intracerebral haemorrhage associated with antithrombotic use. These trends, along with the expected increase in prevalence of amyloid angiopathy with the ageing population, suggest that, in contrast to projections based on mortality data below age 75 years, absolute number of cases of intracerebral haemorrhage might increase in future.     

In Which Patients is Diffusion‐Weighted Magnetic Resonance Imaging Most Useful in Routine Stroke Care?

BACKGROUND AND PURPOSE: Magnetic resonance (MR) diffusion-weighted imaging (DWI) has been used extensively in hyperacute cortical ischemic stroke, but its broader role in the assessment of patients presenting at later times after a wider variety of strokes has been less widely studied. METHODS: The authors assessed the clinical usefulness of DWI across a range of patients referred prospectively as either inpatients or outpatients. Detailed clinical information was collected. Diffusion (DWI) and T2-weighted images were read separately and blindly to clinical details. The presence of any infarct and its type were noted. RESULTS: In 153 stroke patients, imaged at a median of 2 days (range, 6 hours to 77 days) after stroke, recent infarcts were identified more often on DWI (70%) than on T2-weighted MRI (32%) in all severities of stroke. The proportion of scans on which relevant lesions were only seen on DWI was greatest among milder strokes due to small cortical or lacunar infarcts and among patients imaged later rather than earlier after the stroke. CONCLUSIONS: DWI is clinically useful up to several weeks after stroke, not just within the first few hours, and especially in patients with minor strokes.     

Significance of white matter high intensity lesions as a predictor of stroke from arteriolosclerosis

OBJECTIVES: To determine whether the extent of white matter high intensity lesions (WML) on magnetic resonance imaging (MRI) is an independent predictor of risk for stroke from arteriolosclerosis, and whether serial evaluation of WML can be used to identify patients who are at risk of strokes. METHODS: Prospective follow up with serial MRI scans was done in 89 patients who were either diagnosed as having symptomatic lacunar infarcts or were stroke-free, neurologically normal individuals with headache or dizziness. None had significant stenosis of major cerebral arteries or atrial fibrillation. Multivariable analysis with the Cox proportional hazards model was used to test the predictive value for subsequent stroke of risk factor status at entry and during follow up, lacunar infarction, and the extent of WML (scored from 0 to 16) on the baseline scans. RESULTS: During follow up (mean (SD), 51 (19) months), seven strokes occurred (five lacunar infarcts and two haemorrhages): four in nine patients with severe WML (score 9-16), and three in 40 patients with mild WML (score 1-8) (log-rank test; p < 0.005). None of 40 patients without WML experienced stroke. The extent of WML was an independent predictor of subsequent stroke (relative risk for a 1 point score increase, 1.60; 95% confidence interval, 1.02 to 2.54; p < 0.05). In three strokes among 80 patients without severe WML, two occurred in four patients with an increase in WML score during follow up, and one occurred in the other 76 patients without an increased score (p < 0.0001). CONCLUSIONS: Severe WML at baseline is an independent predictor of risk for stroke from arteriolosclerosis, while progression of WML during follow up may be associated with subsequent stroke in patients with initially mild WML.     

Intracerebral haemorrhage after thrombolysis for acute ischaemic stroke: an update

Intracerebral haemorrhage (ICH) still represents the most feared complication of thrombolysis. Our aim was to review the literature regarding clinical, biological and imaging predictors of ICH following thrombolysis for acute ischaemic stroke. Relevant studies were identified through a search in Pubmed, using the following key words: "intracerebral", "haemorrhage", "stroke" and "thrombolytic". The query was limited to studies published in the English literature. The reference lists of all relevant articles were reviewed to identify additional studies. The main predictors of clinically significant ICH were age, clinical stroke severity, as assessed by the National Institute of Health Stroke Scale score on admission, high blood pressure, hyperglycaemia, early CT changes, large baseline diffusion lesion volume and leukoaraiosis on MRI. The contribution of biomarkers in the prediction of the ICH risk is currently under evaluation. Available data on patients with limited number of microbleeds on pretreatment gradient echo MRI sequences suggest safe use of thrombolysis. ICH after stroke thrombolysis is a complex and heterogeneous phenomenon, which involves numerous parameters whose knowledge remains partial. To minimise the risk of tissue plasminogen activator (tPA) related symptomatic ICH, careful attention must be given to the pre-therapeutic glycaemia value, and a strict protocol for the control of elevated blood pressure is needed during the first 24 h. Future research should focus on predictors of severe intracerebral haemorrhagic complications (parenchymal haematomas type 2 according to the European Cooperative Acute Stroke Study (ECASS) classification). The input of multimodal MRI and biological predictors of ICH deserves further investigation.     

Citicoline in intracerebral haemorrhage: a double-blind, randomized, placebo-controlled, multi-centre pilot study

BACKGROUND: In experimental models citicoline has shown beneficial effects in intracerebral haemorrhage. Citicoline is a neuroprotectant drug with some beneficial effects in human ischaemic stroke and with an excellent safety profile. We decided to carry out a pilot study to test its safety and efficacy in human intracerebral haemorrhaging. METHODS: In this double-blind, placebo-controlled pilot study, patients had to be previously independent, aged between 40 and 85 years, and had to be admitted within 6 h after onset of symptoms of an acute primary supratentorial hemispheric cerebral haemorrhage diagnosed by neuroimaging (CT or MRI). Baseline severity was defined as patients with a score larger than 8 points on the Glasgow Coma Scale and larger than 7 on the National Institutes of Health Stroke Scale. Patients received either a placebo or 1 g/12 h citicoline for 2 weeks (orally or intravenously). The primary aim was to evaluate safety with respect to the number of adverse events that occurred. The efficacy endpoint was the percentage of patients with a modified Rankin Score (mRS) at 3 months. RESULTS: 19 patients in each group were included in the study. The incidence of serious adverse events was not different among groups (4 patients in each group). One patient in the placebo group was categorised as independent (mRS相似文献   

Cilostazol as an alternative to aspirin after ischaemic stroke: a randomised, double-blind, pilot study

BACKGROUND: Most patients who have had a stroke are given aspirin; however, aspirin-related cerebral haemorrhage is a complication that is currently of concern, particularly in China where there is a high incidence of cerebral haemorrhage in secondary prevention programmes and within the community. Cilostazol, a phosphodiesterase 3 (PDE3) inhibitor, is an alternative to aspirin that works through a different mechanism. This trial aimed to compare the efficacy and safety of cilostazol with that of aspirin for the long-term prevention of the recurrence of ischaemic stroke. METHODS: 720 patients (mean age 60.2 years, SD 9.86) who had had an ischaemic stroke within the previous 1-6 months were enrolled consecutively in a prospective, multicentre, double-blind, randomised trial. 360 patients were randomly assigned to receive cilostazol and 360 patients to receive aspirin. Analysis was by intention to treat. Patients in both groups took the medication for 12-18 months. The primary endpoint was any recurrence of stroke (ischaemic stroke, haemorrhagic stroke, or subarachnoid haemorrhage) during the trial period. All patients had MRI with T1 MRI, T2 MRI, diffusion-weighted imaging (DWI), T2 fluid-attenuated inversion recovery (FLAIR), and T2 gradient echo imaging (T2*) at the beginning and the end of the study. This trial is registered with ClinicalTrials.gov, number NCT00202020. FINDINGS: The average duration of treatment was 740 person-years, and 719 patients were analysed (360 in the cilostazol group and 359 in the aspirin group). The primary endpoint was reported in 12 patients in the cilostazol group and in 20 patients in the aspirin group. The estimated hazard ratio, calculated with Kaplan-Meier curves (risk of primary endpoint in cilostazol group vs aspirin group), was 0.62 (95% CI 0.30-1.26; p=0.185). Symptomatic cerebral haemorrhage was reported in six patients: one in the cilostazol group and five in the aspirin group. Asymptomatic cerebral haematoma was found in four patients in the aspirin group and one patient in the cilostazol group. Brain bleeding events were significantly more common in the aspirin group than in the cilostazol group (7 vs 1, p=0.034). All of the six patients with symptomatic haemorrhage had previous cerebral microbleeds in the area where the haematoma was located. INTERPRETATION: The results of this pilot study showed no significant difference in the rate of recurrence of stroke between patients with ischaemic stroke who were randomly assigned to take either cilostazol or aspirin. The lower rates of ischaemic and haemorrhagic stroke in the cilostazol group suggest that cilostazol might be a more effective and safer alternative to aspirin for Chinese patients with ischaemic stroke; however, a larger phase III trial is required to confirm this. FUNDING: National Health Ministry of the People's Republic of China; Otsuka Pharmaceutical.     

DWI在超急性期脑出血诊断中的临床应用研究

目的:评价磁共振弥散加权成像(DWI)对超急性期脑出血诊断的准确性。方法:对卒中样起病,发病时间在6h以内,因怀疑缺血性脑血管病急诊行头部MRI检查,按文献Schellinger描述的超急性期脑出血MRI特征初步诊断脑出血,并随即行头部CT证实。10例患者均进行DWI、ADC图和常规MRI扫描,测算不同序列血肿体积,并与头部CT进行比较。结果:10例MRI初步诊断脑出血的患者均经CT确诊为脑出血,敏感性和特异性均为100%,超急性期脑出血血肿DWI的特征性表现为高低混杂信号,磁共振T2WI?DWI和ADC图显示血肿体积均大于CT,差异有显著性(P<0.01);而T1WI与CT的血肿体积无显著差异(P>0.05)。结论:DWI对超急性期脑出血诊断准确,有重要临床应用价值。