血肿扩大是脑出血后死亡和预后不良的决定因素

与缺血性卒中相比,脑出血的预后差、病死率高(接近50％),缺乏有效的治疗方法。最近一项超过1000名患者的大型研究显示,幕上出血患者行早期手术治疗无明显益处,但新的研究显示,脑出血发病4h内应用重组活性Ⅶ因子(rFⅦ_a)能改善患者的预后。     

Hyperglycemia and Short-term Outcome in Patients with Spontaneous Intracerebral Hemorrhage

Background  Hyperglycemia has a detrimental effect in several acute neurological critical illnesses. No consensus exists on the optimal management of hyperglycemia in spontaneous intracerebral hemorrhage (sICH). Our aim was to determine whether blood glucose (BG) would predict 30-day mortality in sICH. Methods  All patients with a well-defined diagnosis of sICH admitted into 24 h in three primary referred centers were included in this prospective observational follow-up study. Patients had extensive monitoring of BG values and those with BG values >8.29 mmol/l (150 mg/dl) received a variable intravenous insulin dose to maintain BG concentrations during the first 72 h after sICH between 3.32 and 8.29 mmol/l (60–150 mg/dl) using pre-specified insulin dosing schedule protocol. Results  Between January 1, 2002, and December 31, 2003, 295 consecutive patients (mean ± SD age 66 ± 12 years) were prospectively included. A 1.0 mmol/l (18 mg/dl) increase in the BG concentration at admission was associated with a 33% mortality increase (OR: 1.33; 95%CI: 1.22–1.46; P < 0.0001). Adjusting for demographics, risk factors, stroke severity, and surgery there was no change in the increased risk. During the first 12 h after sICH, the insulin treatment protocol was enabling to reduce mortality (OR: 1.36, 95%CI: 1.14–1.61; P = 0.0005, per 1 IU increase) while thereafter this association was greatly attenuated and not more significant. Conclusions  Hyperglycemia is a common condition after sICH and may worsen prognosis. Very early insulin therapy apparently does not improve prognosis. These results raise concern about routine clinical practice implementation of this intervention without any evidence from randomized trials.     

Hyperglycemia as An Independent Predictor of Worse Outcome in Non-diabetic Patients Presenting with Acute Ischemic Stroke

Objective  To determine if differences in outcome exist between diabetic and non-diabetic patients who present to the Emergency Department (ED) with acute ischemic stoke (AIS) and elevated blood glucose. Methods  The study population consisted of 447 consecutive patients who presented to the ED with AIS within 24 h of symptom onset and had blood glucose measured on presentation. Hyperglycemia was defined as >130 mg/dl. Outcomes studied included infarct volume, stroke severity (NIH Stroke Scale), functional impairment (modified Rankin Score), and 90-day mortality. Patients with hyperglycemia were then stratified into those with and without a prior history of diabetes mellitus (DM) for the purposes of analysis. Results  Patients with hyperglycemia exhibited significantly greater stroke severity (P = 0.002) and greater functional impairment (P = 0.004) than those with normoglycemia. Patients with hyperglycemia were 2.3 times more likely to be dead at 90 days compared to those with normal glucose (P < 0.001). Stroke severity (P < 0.001) and functional impairment (P < 0.001) were both significantly worse in patients with hyperglycemia and no prior history of DM, when compared to patients with hyperglycemia and previously diagnosed DM. Among the patients without a prior history of DM, patients with hyperglycemia were 3.4 times more likely to die within 90 days (P < 0.001) when compared with patients with normoglycemia. In contrast, the hazard ratio was 1.6 among the patients with DM (P = 0.66). Conclusion  Hyperglycemia on presentation is associated with significantly poorer outcomes following AIS. Patients with hyperglycemia and no prior history of DM have a particularly poor prognosis, worse than that for patients with known diabetes and hyperglycemia. Ethics committee approval: The article is part of the project “Emergency Department Stroke Registry” with the Institutional Review Board approval number 1056-04.     

Prolonged Emergency Department Length of Stay is not Associated with Worse Outcomes in Patients with Intracerebral Hemorrhage

Background

Prolonged emergency department length of stay (EDLOS) has been associated with worse patient outcomes, longer inpatient stays, and failure to meet quality measures in several acute medical conditions, but these findings have not been consistently reproduced. We performed this study to explore the hypothesis that longer EDLOS would be associated with worse outcomes in a large cohort of patients presenting with spontaneous intracerebral hemorrhage (ICH).

Methods

We performed a secondary analysis of a prospective cohort of consecutive patients with spontaneous ICH who presented to a single academic referral center from February 2005 to October 2009. The primary exposure variable was EDLOS, and our primary outcome was neurologic status at hospital discharge, measured with a modified Rankin scale (mRS). Secondary outcomes were ICU length of stay, total hospital length of stay, and total hospital costs.

Results

Our cohort included 616 visits of which 42 were excluded, leaving 574 patient encounters for analysis. Median age was 75?years (IQR 63?C82), median EDLOS 5.1?h (IQR 3.7?C7.1) and median discharge mRS 4 (IQR 3?C6). Thirty percent of the subjects died in-hospital. Multivariable proportional odds logistic regression, controlling for age, initial Glasgow Coma Scale, initial hematoma volume, ED occupancy at registration, and the need for intubation or surgical intervention, demonstrated no association between EDLOS and outcome. Furthermore, multivariable analysis revealed no association of increased EDLOS with ICU or hospital length of stay or hospital costs.

Conclusion

We found no effect of EDLOS on neurologic outcome or resource utilization for patients presenting with spontaneous ICH.     

Hyperglycemia as a Predictor of Poor Outcome at Discharge in Patients with Acute Spontaneous Cerebellar Hemorrhage

Acute stroke patients commonly suffer from hyperglycemia. However, the relationship between hyperglycemia and poor outcome after discharge of patients with acute cerebellar hemorrhage (CH) had not been hitherto investigated.Sixty-two patients with acute spontaneous CH were retrospectively analyzed. The consciousness level, blood glucose/sugar (BS) on arrival and maximum diameter of hematoma, etc., were obtained. Patient prognosis was scored by the Glasgow Outcome Scale (GOS) at discharge and we divided them into good outcome (GOS score of 4 or 5) and poor outcome (GOS score of 1 or 2 or 3) groups. The association between early outcome and clinical characteristics were investigated by multivariate logistic regression. There were 33 (53.4%) patients in the poor outcome group and 29(46.6%) in the good outcome group. The initial BS was significantly higher in the poor outcome group (186.4±57 mg/dl) compared with good outcome group (136.6±31.1 mg/dl)(p<0.001). BS≥140 mg/dl (OR=25.217, p=0.008) and maximum diameter of hematoma ≥3 cm (OR=216.422, p<0.001) were independently correlated with poor outcome. We report the first study that hyperglycemia (BS≥140 mg/dl) on arrival and maximum diameter of hematoma ≥3 cm were found to be strong predictive factors of poor outcome at discharge in patients with acute spontaneous CH.     

Spontaneous Intracerebral Hemorrhage Following a Blood Pressure Surge During Emergency Department Evaluation

Background  

Chronic hypertension and anticoagulation are important risk factors for the development of intracerebral hemorrhage (ICH). Spontaneous ICH occurring in the Emergency Department (ED) following a normal unenhanced computed tomography (CT) scan of the brain and an acute blood pressure (BP) surge is exceedingly rare and has, to our knowledge, never been reported in the literature.     

Initial Troponin Level as a Predictor of Prognosis in Patients with Intracerebral Hemorrhage

Objective

It has been suggested that elevated cardiac troponin T (cTnT) level is a marker of increased risk of mortality in acute ischemic stroke and subarachnoid hemorrhage (SAH). However, the association of serum cTnT level and prognosis of intracerebral hemorrhage (ICH) has been sparsely investigated. The aim of this study was to identify the relationship between cTnT level and the outcome in patients with spontaneous ICH.

Methods

We retrospectively investigated 253 patients identified by a database search from records of patients admitted in our department for ICH between January 1, 2003 and December 31, 2007. The patients were divided into 2 groups; the patients in group 1 (n=225) with serum cTnT values of 0.01 ng/mL or less, and those in group 2 (n=28) with serum cTnT values greater than 0.01 ng/mL.

Results

The serum cTnT level was elevated in 28 patients. There were significant differences in sex, hypertension, creatine kinase-myocardial band, midline shift, side of hematoma, and presence of intraventricular hemorrhage between the 2 groups. Logistic regression analysis identified the level of consciousness on admission, cTnT and midline shift as independent predictors of hospital mortality.

Conclusion

Theses results suggest that increased serum cTnT level at admission is associated with in-hospital mortality and the addition of a serum cTnT assay to routine admission testing should be considered in patients with ICH.     

Early Hypoalbuminemia is an Independent Predictor of Mortality in Aneurysmal Subarachnoid Hemorrhage

Background

Hypoalbuminemia has been identified as a predictor of morbidity and mortality in critically ill patients. There is very little data on the significance and the prognostic value of hypoalbuminemia in patients with aneurysmal subarachnoid hemorrhage (aSAH). This study analyzed the impact of hypoalbuminemia on patient presentation, complications, and outcomes.

Methods

Records of patients admitted with aSAH were examined. Data on baseline characteristics, prevalence of delayed cerebral ischemia, and discharge outcomes were collected. Multivariable logistic regression analysis was performed to assess for associations.

Results

One-hundred and forty-two patients comprised the study cohort (mean age 54.6 ± 13.4), among which 45 (31.5 %) presented with hypoalbuminemia. No difference in baseline characteristics was noted between patients with hypoalbuminemia and those with normal serum albumin. The overall hospital mortality rate was significantly higher in patients with hypoalbuminemia, compared to those with normal albumin (28.9 % vs. 11.3 %; p = 0.04). Hypoalbuminemia was neither associated with delayed cerebral ischemia nor disability at discharge, but independently associated with in-hospital death (odds ratio: 4.26, 95 % confidence interval: 1.09–16.68; p = 0.04).

Conclusion

In patients with aSAH, early hypoalbuminemia is an independent predictor of hospital mortality but not disability at discharge.

     

Early Stroke Recognition and Time-based Emergency Care Performance Metrics for Intracerebral Hemorrhage

Background and Aim: Performance measures have been extensively studied for acute ischemic stroke, leading to guideline-established benchmarks. Factors influencing care efficiency for intracerebral hemorrhage (ICH) are not well delineated. We sought to identify factors associated with early recognition of ICH and to assess the association between early recognition and completion of emergency care tasks. Methods: Consecutive patients with spontaneous ICH were enrolled in an observational cohort study conducted from 2009 to 2017 at an urban comprehensive stroke center, excluding patient transferred from other hospitals. We used stroke team activation as the indicator of early recognition and measured completion times for multiple ICH-relevant performance metrics including door to computed tomography (CT) acquisition and door to hemostatic medication initiation. Results: We studied 204 cases. All stroke-related performance times were faster in patients managed with stroke team activation compared to no activation, including quicker door to CT acquisition (median 24 versus 48 minutes, P < .001) and door to hemostatic medication initiation (63 versus 99 minutes, P = .005). These associations were confirmed in adjusted models. Stroke codes were activated in 43% of cases and were more likely in patients with shorter onset-to-arrival times, higher National Institutes of Health Stroke Scale scores, and higher Glasgow Coma Scale scores. Conclusions: Stroke team activation was associated with more rapid diagnostic and therapeutic interventions for patients with ICH, but activation did not occur in the majority of cases, implying absence of early recognition. A stroke team activation process improves care performance, but leveraging the advantages of existing systems will require improved triage tools to identify ICH in the acute setting.     

Relationship Between Temperature, Hematoma Growth, and Functional Outcome After Intracerebral Hemorrhage

Background

Fever and hematoma growth are known to be independent predictors of poor outcome after intracerebral hemorrhage (ICH). We sought to assess the distribution of temperature at different stages in relation to hematoma growth and functional outcome at 90 days in a cohort of ICH patients.

Methods

Data of patients registered in the Virtual International Stroke Trials Archive—ICH were analyzed. Temperatures at baseline, 24, 48, 72, and 168 h were assessed in relation to the hematoma growth and functional outcome at 90 days. We calculated the daily linear variation of each subject’s temperature by subtracting 37 °C from the maximal daily recorded temperature (delta-temperature). We used logistic regression and mixed-effects models to identify factors associated with hematoma growth, poor outcome, and temperature elevation after ICH.

Results

303 patients were included in the analysis. The average age was 66 ± 12 years, 200 (66 %) were males, median admission NIHSS was 13 [Interquartile range (IQR), 9–18), median GCS was 15 (IQR, 14–15). Hematoma growth occurred in 22 % and poor functional outcome at 90-days occurred in 41 % of the patients. Cumulative delta-temperature at 72 h was associated with hematoma growth; age, ICH score, hematoma growth, and cumulative delta-temperature at 168 h were associated with poor outcome at 90 days. Factors associated with fever in mixed-models were day after onset of ICH, hypertension, base hematoma volume, intraventricular-hemorrhage, pneumonia, and hematoma growth.

Conclusions

There is a temporal and independent association between fever and hematoma growth. Fever after ICH is associated with poor outcome at 90 days. Future research is needed to study the mechanisms of this phenomenon and if early protocols of temperature modulation would be associated with improved outcomes after ICH.     

Neutrophil-to-Lymphocyte Ratio Is an Independent Predictor of 30-Day Mortality of Intracerebral Hemorrhage Patients: a Validation Cohort Study

In a previous study in patients with intracranial hemorrhage (ICH), we found an association between high neutrophil-to-lymphocyte ratio (NLR) with poor short-term mortality. In the current study, this preliminary finding was validated using an independent patient cohort. A total of 181 ICH patients (from January 2016 to December 2017) were included. Diagnosis was confirmed using computed tomography (CT) in all cases. Patient survival (up to 30 days) was compared between subjects with high NLR (above the 7.35 cutoff; n?=?74) versus low NLR (≤?7.35; n?=?107) using Kaplan-Meier analysis. A multivariate logistic regression was performed to identify factors that influenced the 30-day mortality. Correlation between NLR with other relevant factors (e.g., C-reactive protein (CRP) and fibrinogen) was examined using Spearman correlation analysis. The 30-day mortality was 19.3% (35/181) in the entire sample, 37.8% (28/74) in the high-NLR group, and 6.5% (7/107) in the low-NLR group (P?<?0.001). In comparison to the low-NLR group, the high-NLR group had higher rate of intraventricular hemorrhage (29.7 vs. 16.8%), ICH volume (median 23.9 vs. 6.0 cm³) and ICH score (median 1.5 vs. 0), and lower GCS score (9.4?±?4.5 vs. 12.9?±?3.2). An analysis that divided the samples into three equal parts based on NLR also showed increasing 30-day mortality with incremental NLR (1.6, 15.0, and 41.7% from lowest to highest NLR tertile, P for trend <?0.001). Kaplan-Meier curve showed higher 30-day mortality in subjects with high NLR than those with low NLR (P?<?0.001 vs. low-NLR group, log-rank test). High NLR (>?7.35) is associated with poor short-term survival in acute ICH patients.     

Stress-Induced Hyperglycemia and Remote Diffusion-Weighted Imaging Lesions in Primary Intracerebral Hemorrhage

Neurocritical Care - Stress-induced hyperglycemia (SIH) is the relative transient increase in glucose during a critical illness such as intracerebral hemorrhage (ICH) and is likely to play an...     

Impact of Early Enteral Nutrition on In-Hospital Mortality in Patients with Hypertensive Intracerebral Hemorrhage

Objective

We conducted this study to evaluate the clinical impact of early enteral nutrition (EN) on in-hospital mortality and outcome in patients with critical hypertensive intracerebral hemorrhage (ICH).

Methods

We retrospectively analyzed 123 ICH patients with Glasgow Coma Scale (GCS) score of 3-12. We divided the subjects into two groups : early EN group (< 48 hours, n = 89) and delayed EN group (≥ 48 hours, n = 34). Body weight, total intake and output, serum albumin, C-reactive protein, infectious complications, morbidity at discharge and in-hospital mortality were compared with statistical analysis.

Results

The incidence of nosocomial pneumonia and length of intensive care unit stay were significantly lower in the early EN group than in the delayed EN group (p < 0.05). In-hospital mortality was less in the early EN group than in the delayed EN group (10.1% vs. 35.3%, respectively; p = 0.001). By multivariate analysis, early EN [odds ratio (OR) 0.229, 95% CI : 0.066-0.793], nosocomial pneumonia (OR = 5.381, 95% CI : 1.621-17.865) and initial GCS score (OR = 1.482 95% CI : 1.160-1.893) were independent predictors of in-hospital mortality in patients with critical hypertensive ICH.

Conclusion

These findings indicate that early EN is an important predictor of outcome in patients with critical hypertensive ICH.     

自发性脑出血临床试验的结局评价

自发性脑出血(ICH)是一种未得到足够重视的严重疾病,传统治疗包括外科手术治疗或非手术的支持治疗,其住院病死率高。对患者而言,临床结局不仅是生存,更重要的是能保证一定的生存质量。这给临床试验者带来一系列复杂的问题,因为对残疾的评价标准尚不准确。目前普遍使用且得到公认的评分系统不仅考虑卒中的类型