Autonomic dysreflexia after spinal cord transection or compression in 129Sv,C57BL,and Wallerian degeneration slow mutant mice

To study plasticity of central autonomic circuits that develops after spinal cord injury (SCI), we have characterized a mouse model of autonomic dysreflexia. Autonomic dysreflexia is a condition in which episodic hypertension occurs after injuries above the midthoracic segments of the spinal cord. As synaptic plasticity may be triggered by axonal degeneration, we investigated whether autonomic dysreflexia is reduced in mice when axonal degeneration is delayed after SCI. We subjected three strains of mice, Wld(S), C57BL, and 129Sv, to either spinal cord transection (SCT) or severe clip-compression injury (CCI). The Wld(S) mouse is a well-characterized mutant that exhibits delayed Wallerian degeneration. The CCI model is an injury paradigm in which significant the axonal degeneration is due to secondary events and therefore delayed relative to the time of the initial injury. We herein demonstrate that the incidence of autonomic dysreflexia is reduced in Wld(S) mice after SCT and in all mice after CCI. To determine if differences in afferent arbor sprouting could explain our observations, we assessed changes in the afferent arbor in each mouse strain after both SCT and CCI. We show that independent of the type of injury, 129Sv mice but not C57BL or Wld(S) mice demonstrated an increased small-diameter CGRP-immunoreactive afferent arbor after SCI. Our work thus suggests a role for Wallerian degeneration in the development of autonomic dysreflexia and demonstrates that the choice of mouse strain and injury model has important consequences to the generalizations that may be drawn from studies of SCI in mice.     

Rapid Blood Pressure Reduction in Acute Intracerebral Hemorrhage: Feasibility and Safety

Background  The optimal blood pressure (BP) for treating acute intracerebral hemorrhage remains (ICH) uncertain. High BP may contribute to hematoma growth while excessive BP reduction might precipitate peri-hemorrhage ischemia. We examine here the feasibility and safety of reducing BP to lower than presently recommended levels in patients with acute ICH. Methods  Patients with ICH were prospectively randomized to standard BP treatment (mean arterial BP [MAP] 110–130 mmHg) or aggressive BP lowering (MAP < 110 mmHg) within 8 h of symptom onset. MAP was managed during the 48 h treatment period. NIHSS was obtained at baseline, 24, and 48 h. Brain CT was done 24 h after symptoms. A modified Rankin Scale (mRs) was obtained at 90 days. A clinical decline (NIHSS drop ≥ 2 points) within the first 48 h was the primary endpoint. Hematoma enlargement at 24 h was a secondary endpoint. Results  We enrolled 21 patients into each group. Mean age was 60.6 ± 12.3 years and MAP on presentation was 147.6 ± 18.2 mmHg. Treatment was started on average 3.2 ± 2.2 h after symptom onset. Baseline clinical variables were identical between the 2 treatment groups. Target blood pressure was achieved within 87.1 ± 59.6 min in the standard group and 163.5 ± 163.8 min in the aggressive BP treatment group. There were no significant differences in early neurological deterioration, hematoma and edema growth, and clinical outcome at 90 days. Conclusion  A more aggressive reduction of acute hypertension after ICH does not increase the rate of neurological deterioration even when treatment is initiated within hours of symptom onset. Lowering BP aggressively did not affect hematoma and edema expansion but this possibility deserves further study.     

急性脑出血早期血肿扩大止血治疗研究进展

既往研究证实,脑出血后血肿扩大与早期神经功能恶化密切相关,往往预示着不良临 床结局。血肿扩大是脑出血具有前景的治疗靶点。若不加筛选地对所有脑出血患者进行止血治 疗,不但不能改善功能结局,反而可能增加动脉血栓栓塞不良事件风险。计算机断层扫描血管造影 （computed tomography angiography,CTA）点样征是血肿扩大和不良预后安全有效的预测指标。应用点 样征筛选血肿扩大高风险患者,并选用安全、经济的止血药物进行个体化止血治疗,对于遏制患者 早期病情恶化及改善预后有重要意义。     

Characteristics of Acute Spontaneous Intracerebral Hemorrhage in Patients Receiving Oral Anticoagulants

Objective

We investigated the precise clinical and radiologic characteristics of intracerebral hemorrhage associated with direct oral anticoagulant use.

脑出血后继发性脑损伤的机制与治疗

脑出血具有高发病率和高死亡率的特点。近年研究表明，脑出血产生的继发性脑损伤机 制主要涉及凝血酶诱导、红细胞裂解、毒性反应、氧化损伤和炎症反应等多个方面。根据不同的损 伤机制，应运而生了多种脑出血的治疗策略，但是否能成功应用于临床还有待进一步研究。本文对脑 出血后继发性损伤的潜在机制和新兴治疗方法进行了综述。     

新型脑出血临床评估量表

自2001年首个脑出血（intracerebral hemorrhage,ICH）预后评估量表问世以来,其临床有效性得到了充分的外部验证。但毕竟原始脑出血（original ICH,oICH）评分量表是设计来评价30 d死亡事件的,并没有包括诸多与预后密切相关的因子,因此对功能预后的预测准确率欠佳。为了预测ICH患者的功能预后,一系列新型评测体系被建立起来。本文主要针对现有的新型ICH评估量表从研究背景、方法学、评估指标、外部验证等几个方面进行综述,以期阐明其适用范围和临床效度,为临床医师按需选择提供参考。     

Intracerebral Hemorrhage Following Evacuation of a Chronic Subdural Hematoma

Burr hole drainage has been widely used to treat chronic subdural hematomas (SDH), and most of them are easily treated by simple trephination and drainage. However, various complications, such as, hematoma recurrence, infection, seizure, cerebral edema, tension pneumocephalus and failure of the brain to expand due to cerebro-cranial disproportion may develop after chronic SDH drainage. Among them, intracerebral hemorrhage after evacuation of a recurrent chronic SDH is very rare. Here, we report a fatal case of delayed intracerebral hemorrhage caused by coagulopathy following evacuation of a chronic SDH. Possible pathogenic mechanisms of this unfavorable complication are discussed and a review of pertinent literature is included.     

原发性脑出血超急性期血肿增长速度与临床预后的关系研究

目的 探讨超急性期血肿增长速度（ultraearly hematoma growth，UHG）与急性原发性脑出血 （intracerebral hemorrhage，ICH）血肿扩大及临床预后的关系。 方法 连续收集发病6 h内就诊的ICH患者。患者完成基线及（24±2）h颅脑计算机断层扫描（computed tomography，CT），记录临床信息及结局信息。UHG定义为基线血肿体积除以发病至头CT扫描时间。血 肿扩大定义为发病24 h血肿体积较基线血肿体积增加>33%或者>6 ml。90 d及1年预后不良定义为改 良Rankin量表评分>2分。多元Logistic回归分析UHG与血肿扩大及ICH临床预后的关系。 结果 研究共纳入148例发病6h内到院的ICH患者。所有ICH患者的UHG为5.3（2.3，12.9）ml/h。UHG在 完成头CT较早（P <0.001）、血肿扩大（P =0.019）、90 d预后不良（P <0.001）及1年预后不良（P <0.001） 的患者中数值较大。UHG>4.7 ml/h是1年不良预后的独立危险因素，比值比为17.5，95%可信区间 为1.44～21.23（P =0.025）。其预测1年不良预后的灵敏度为61.5%，特异度为65.1%，阳性预测率为 68.4%，阴性预测率为58%。     

急性期脑出血锥体束损伤的磁共振扩散张量纤维束成像评价

目的 评价扩散张量纤维束成像（Diffusion tensor tractography,DTT）技术观察急性期脑出血锥体束损伤与其功能恢复的关系。方法 对30例发病2周以内的基底节或丘脑出血患者进行磁共振DTT评价锥体束的完整性,发病后6个月应用Barthel指数（Barthel Index,BI）评价其功能恢复。比较各组BI评分以及分析锥体束完整性与BI评分的相关性。结果 除7例资料不完整被剔除外,23例患者资料纳入统计。锥体束完整性不同的各组间BI评分有统计学差异（F =9.693,P＜0.01）。急性期磁共振扩散张量成像（Diffusion tensor imaging,DTI）所显示的锥体束完整性与发病6月后BI评分有良好的相关性,具有统计学差异（r =0.733,P＜0.01）。结论 脑出血急性期应用DTT评价锥体束的完整对患者运动功能的恢复有预测价值。     

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.     

Effect of Treatment of Elevated Blood Pressure on Neurological Deterioration in Patients with Acute Intracerebral Hemorrhage

Introduction  Treatment of elevated blood pressure after acute intracerebral hemorrhage (ICH) is controversial. There is a risk of hematoma expansion with elevated blood pressure, and risk of ischemia with blood pressure control. This study was done to determine the effect of blood pressure control on outcome. Methods  We retrospectively studied 122 patients with ICH. We collected 24-h blood pressure readings on all patients. The Glasgow Coma Score (GCS) at baseline and at 24 h was used to determine neurological deterioration (GCS decline ≥ 2). Baseline computerized tomography (CT) scans were reviewed for hematoma volume, intraventricular hemorrhage, and location of hemorrhage. Drops in systolic blood pressure and mean arterial pressures over 24 h were divided in quartiles to determine the risk of neurological deterioration among quartiles. A logistic regression model was used to determine the association between variables of interest and neurological deterioration. Results  Neurological deterioration was observed in 12 patients (10%). Baseline blood pressure and GCS were only two variables significantly different among quartiles of blood pressure drop. Multivariable adjusted analysis for these variables demonstrated significant trend toward reduced neurological deterioration with maximum blood pressure drop (systolic or mean). The risk of neurological deterioration was significantly lower in the quartile of maximum drop of systolic (odds ratio [OR] 0.02, 95% confidence interval [CI] 0.0–0.68) or mean (OR 0.03, 95% CI 0.0–0.98) blood pressure when compared to the quartile with least drop. Conclusion  This study supports that reduction of blood pressure in patients with acute ICH is safe and suggests that aggressive reduction might reduce the risk of neurological deterioration in first 24 h of admission.     

Improving the Accuracy of Scores to Predict Gastrostomy after Intracerebral Hemorrhage with Machine Learning

Background

Gastrostomy placement after intracerebral hemorrhage indicates the need for continued medical care and predicts patient dependence. Our objective was to determine the optimal machine learning technique to predict gastrostomy.

急性脑出血患者下肢深静脉血栓形成的危险因素分析

目的 分析急性脑出血患者住院期间下肢深静脉血栓形成（deepvenousthrombosis,DVT）发生率、发生时间及危险因素。方法 选取首都医科大学附属北京天坛医院急性卒中入院后并发症队列研究中的脑出血患者,根据患者住院期间是否发生下肢DVT分为DVT组和无DVT组,比较两组患者的临床特征,采用多因素logistic回归分析脑出血患者发生DVT的危险因素。结果 研究最终纳入314例脑出血患者,其中18例（5.7%）住院期间发生了DVT,发生脑出血至DVT确诊的中位时间为7.5(4.0～9.0)d。多因素logistic回归分析结果显示：女性（OR 3.43,95%CI 1.04～11.37,P=0.0436）、既往冠心病病史（OR 6.89,95%CI 1.90～25.04,P=0.0034）、入院NIHSS评分高（OR 1.18,95%CI 1.06～1.23,P=0.0004）、住院时间长（OR 1.07,95%CI 1.01～1.13,P=0.0273）是脑出血患者发生DVT的独立危险因素。结论 急性脑出血患者发生下肢DVT时间在卒中后1周左右,女性、既往冠心病病史、入院时病...     

高血压脑出血卒中后抑郁风险因素相关性研究

目的 探讨高血压脑出血患者卒中后抑郁相关影响因素。方法 前瞻性录入65例急性高血压脑出血患者临床和计算机断层扫描（computer tomography,CT）影像资料,评估患者发病14d和3个月卒中后抑郁发生情况及生存质量状况,对临床资料和CT影像特征与卒中后抑郁的关系进行单因素和多因素分析。结果 65例患者中有57例完成14d随访,53例完成3个月随访。脑出血发病14d和3个月卒中后抑郁的发生率分别为35.1%和38.9％。单因素分析显示入院后首次美国国立卫生研究院卒中量表评分（thenational institutes of health stroke scale, NIHSS）与高血压脑出血发病后14d卒中后抑郁相关（P =0.027）。性别、出血部位和出血量与脑出血发病后3个月卒中后抑郁相关：与非抑郁组比较,抑郁组患者男性比例较低（P =0.038）,基底节出血比例较高（P =0.031）,平均出血量大（P =0.046）。多因素分析显示出血量是高血压脑出血患者发病3个月卒中后抑郁的风险预测因素（P =0.049）。结论 NIHSS评分和CT影像特征可作为高血压脑出血卒中后抑郁的评价指标,将CT影像与神经功能缺损程度评分有机结合可为脑出血综合性治疗策略的建立提供客观依据。