Emergency Department Hyperglycemia as a Predictor of Early Mortality and Worse Functional Outcome after Intracerebral Hemorrhage

Background

We have previously reported the association of hyperglycemia and mortality after ischemic stroke. This study attempts to answer the hypothesis, if hyperglycemia at arrival, is associated with early mortality and functional outcome in patients with acute non-traumatic intracerebral hemorrhage (ICH).

Methods

The study cohort consisted of 237 patients who presented to the ED with ICH and had blood glucose measured on ED presentation. The presence of hyperglycemia on presentation was correlated with outcome measures including volume of hematoma, intraventricular extension of hematoma (IVE), stroke severity, functional outcome at discharge, and date of death.

Results

Of the cohort of 237 patients, a total of 47 patients had prior history of Diabetes Mellitus (DM). Median blood glucose at presentation was 140 mg/dl (Inter-quartile range 112–181 mg/dl). DM patients had higher glucose levels on arrival (median 202 mg/dl for DM vs. 132.5 mg/dl for non-DM, P < 0.0001). Higher blood glucose at ED arrival was associated with early mortality in both non-diabetics and diabetics (P < 0.0001). Higher blood glucose was associated with poor functional outcome in non-DM patients (P < 0.0001) but not in DM patients (P = 0.268). In the logistic regression model, after adjustment for stroke severity, hematoma volume, and IVE of hemorrhage, higher initial blood glucose was a significant predictor of death (P = 0.0031); as well as bad outcome in non-DM patients (P = 0.004).

Conclusions

Hyperglycemia on presentation in non-diabetic patients is an independent predictor of early mortality and worse functional outcome in patients with intracerebral hemorrhage.     

New methods of intensive therapy in stroke: hemicraniectomy in patients with complete middle cerebral artery infarction and treatment of intracerebral and intraventricular hemorrhage with urokinase

Life-threatening, complete middle cerebral artery infarction occurs in up to 10% of all stroke patients. The "malignant media occlusion" is an infarction occupying more than 50% of middle cerebral artery territory. The malignant, space-occupying supratentorial ischemic stroke is characterised by a mortality rate of up to 80%. Several reports indicate, that hemicraniectomy in this situation can be life-saving. Hemicraniectomy increases cerebral perfusion pressure and optimises retrograde perfusion via the leptomeningeal collateral vessels. A case of a patient is presented, having progressive neurological deterioration due to massive cerebral infarctions. The patient rehabilitation was successful. Decompressive surgery is life saving and can also give acceptable functional recovery. Hemorrhagic stroke is due to stroke in 15% of cases and in 10%, it is "spontaneous" intracerebral hematoma. The intracerebral and intraventricular hemorrhage represents one of the most devastating types of stroke associated with high morbidity and mortality. The 30-day mortality rate is 35% to 50% and most survivors are left with a neurological disability. The value of surgical therapy is debatable. The aspiration and urokinase therapy of the hematoma of intracerebral hemorrhage could improve final neurological outcome. Spontaneous, nontraumatic intraventricular hemorrhage frequently carries a grave prognosis. A large part of morbidity after intraventricular hemorrhage is related to intracranial hypertension from hydrocephalus. One patient presented had intracerebral hemorrhage and another had intraventricular hemorrhage treated with urokinase. Rapid and extensive reduction in the amount of intracerebral and intraventricular blood occurred. Urokinase lysis is safe and can be a potentially beneficial intervention in intracerebral and intraventricular hemorrhage. By performing decompressive craniectomy, the neurologists of stroke departments and intensive care units with the neurosurgeons will have to play major role in the management of stroke patients.     

Effects of Candesartan in the Acute Phase of Intracerebral Hemorrhage

Background and Purpose: Uncertainty persists over the effects of blood pressure-lowering treatment in acute intracerebral hemorrhage (ICH). We assessed the effects of treatment with candesartan in acute ICH and according to different types of hematoma. Methods: Post-hoc analysis of the Scandinavian Candesartan Acute Stroke Trial, a randomized- and placebo-controlled, double-masked trial of candesartan in patients with any stroke within the acute phase (<30 hours) and high systolic blood pressure (≥140 mm Hg). We collected baseline computed tomography scans of participants with ICH, and characterized hematoma volume (planimetric approach), location (deep versus lobar or infratentorial), hemisphere side, and presence of intraventricular hemorrhage. The trial's 2 coprimary effect variables were the composite endpoint of vascular death, stroke or myocardial infarction, and functional outcome at 6 months according to the modified Rankin scale. We used Cox, ordinal, and binary logistic regression for analysis and adjusted for key, predefined prognostic variables. Results: Of 274 participants with ICH, computed tomography scans were available in 205 patients (74.8%). There were no significant differences between the candesartan and placebo groups with respect to hematoma volume (median 15.6 mL versus 13.5 mL, P = .96), deep location (77% versus 72%, P = .64), right hemisphere (49% versus 51%, P = .46), and presence of intraventricular hemorrhage (18% versus 11%, P = .22). Candesartan was associated with a significant increase in poor functional outcome in patients with deep hematoma (adjusted common odds ratio 2.27, 95% confidence interval 1.23-4.18, P = .009, P for interaction .015), but there was no differential effect on functional outcome or vascular events in any of the other imaging subgroups. Conclusions: Candesartan was not associated with any beneficial effect when initiated in the acute phase of ICH, a possible adverse effect on functional outcome in patients with deep hematomas cannot be ruled out by this study alone.     

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.     

常德市城区脑卒中患者预后因素分析

目的调查分析影响常德市城区40岁以上脑卒中患者预后的因素。方法制定统一调查表,由专门培训人员对常德城区40岁以上人群6095人进行脑卒中流行病学调查,并采用改良Rankin量表(mRS)对脑卒中患者的预后进行评定,分为预后良好组和预后不良两组。利用χ2/t检验进行单因素分析,Logistic回归进行多因素分析。结果社区调查发现628例脑卒中患者,其中预后良好者332例(52.87%),预后不良者296例(47.13%)。单因素分析显示,两组在年龄、文化水平、既往脑卒中史、吸烟史、血糖、卒中类型、脑出血按出血部位分型和血肿大小分型,缺血性脑卒中各亚型比较差异具有统计学意义(P0.05)。多因素分析显示预后不良与高龄、低文化程度、既往有脑卒中病史相关(P0.05)。结论年龄、文化水平、脑卒中病史、卒中类型是脑卒中患者预后不良的主要因素,因此要积极采取有效措施改善脑卒中患者预后。     

Clinical discriminators of lobar and deep hemorrhages: the Stroke Data Bank.

Of the 1,805 patients with acute stroke enrolled in the Stroke Data Bank, 237 had parenchymatous hemorrhage. After excluding 34 secondary intracerebral and 31 infratentorial hemorrhage patients, a logistic regression analysis of the 172 patients with primary supratentorial intracerebral hemorrhage (ICH) elucidated clinical factors that distinguished the 65 patients with lobar hemorrhage (LH) from the 107 patients with deep hemorrhage (DH) located in the basal ganglia and thalamus. In LH, severe headache was more common than in DH, while hypertension and motor deficit were significantly less common. Patients with either LH or DH had a similar prognosis and mean Glasgow Coma Scale (GCS) scores, despite the hematoma volume measured on the initial CT being significantly greater for LH than DH. The presence of intraventricular extension (IVH) was more frequent in DH. The frequency of IVH increased with hematoma volume in LH, but remained constant for DH. Two CT variables (IVH and hematoma volume) that differed in these two hemorrhage groups were important predictors of coma (GCS less than or equal to 8) in a logistic regression model. Differences in the frequency of IVH may help explain why the degree of impairment in consciousness was similar in the two groups. Among patients with supratentorial ICH, location of the hematoma is related to both volume and IVH, which are important determinants of the level of consciousness.     

术中超声引导神经内镜手术与脑室外引流术治疗脑室内血肿伴铸型的对比分析研究

目的对比分析术中超声引导神经内镜手术和脑室外引流术治疗脑室血肿伴铸型的安全性及有效性。方法选取我科2016年5月至2018年11月间脑室血肿伴铸型的患者60例,根据脑室血肿伴铸型的类型分为三型,采取分层数字随机法将患者分成两组,对照组(n=30)采取传统的脑室外引流术治疗,实验组(n=30)则采取术中超声引导神经内镜下脑室内血肿清除术,比较两组临床疗效。结果实验组术后24 h血肿清除率、术后24小时GCS评分、术后6月Barthel日常生活能力评分均明显高于对照组(P0.05),实验组引流管带管时间、住院时间较对照组缩短,同时降低死亡率(P0.05);实验组术区再出血、分流依赖性脑积水、颅内感染与对照组比较无统计学差异(P 0.05)。结论术中超声引导下神经内镜手术治疗脑室血肿伴铸型是安全、有效的,该治疗方案优于脑室外引流术。     

阿托伐他汀钙对动脉瘤性蛛网膜下腔出血后脑血管痉挛的作用及机制

目的研究阿托伐他汀钙对动脉瘤性蛛网膜下腔出血(a SAH)后血管痉挛(CVS)的影响及机制。方法连续收集2013年03月至2015年11月收治的动脉瘤性蛛网膜下腔出血患者共62例,随机分为研究组(33例)与对照组(29例)。对照组给予常规治疗,研究组在对照组治疗基础上加服阿托伐他汀钙(20 mg/qn,连服14 d)。于发病后第1天、第3天、第7天和第14天检测分析两组患者大脑中动脉平均血流速度(VMCA)及血清中内皮素血管肽-1(ET-1)、一氧化氮(NO)水平。同时,比较两组患者脑血管痉挛(CVS)的发生率、迟发型脑梗死和复发出血的发生率以及Modified Rankin Scale score量表(mRS)评分。结果在第7天、第14天研究组的VMCA、ET-1均低于对照组,差异有统计学意义(P0.05)。在第3天、第7天、第14天,研究组NO含量高于对照组,差异有统计学意义(P0.05)。研究组脑血管痉挛的发生率较对照组低(36.36%vs.65.52%),差异有统计学意义(P0.05)。研究组mRS评分≤2分所占比例较对照组高(75.76%vs.44.83%),差异有统计学意义(P0.05)。迟发型脑梗死和再发出血的发生率两组差异无统计学意义(P0.05)。结论阿托伐他汀钙能够减少蛛网膜下腔出血后脑血管痉挛的发生,并促进神经功能恢复,其机制可能与改善血管内皮舒缩功能有关。     

急性幕上性脑出血患者脑水肿体积与高迁移率族蛋白B1的关系

目的 探讨脑出血后高迁移率族蛋白B1(high mobility group protein B1,HMGB1)水平的变化及其与脑出血后继发性脑水肿的关系。方法 收集152例幕上性脑出血患者的入院各基线资料及发病24 h时的HMGB1水平和发病后3或4 d复查头颅CT显示的相对水肿体积。结果 初入院的HMGBl水平要显著高于对照组(P<0.05),且24 h患者HMGBl水平与第3或4 d CT复查显示的相对水肿体积呈正相关(r=0.87,P=0.001)。结论 脑出血后HMGBl水平显著升高,且与脑水肿体积进展程度呈正相关。     

自发性脑出血患者血清YKL-40动态变化与预后关系研究

目的观察自发性脑出血(ICH)患者血清YKL-40水平与脑出血量、神经功能损伤的关系,分析影响ICH患者预后的危险因素。方法选择自发性基底节区脑出血患者100例作为实验组,根据神经损伤程度进一步分为轻度损伤30例,中度损伤46例,重度损伤24例,以及根据脑出血量分为小量出血(10 ml)35例,中量出血46例(10~30 ml),大量出血19例(30 ml),另选择同期门诊健康体检者50例作为对照组,分别检测患者第1、3、7和14天血清YKL-40水平。3月后通过mRS评分评价患者预后情况,采用多因素Logistic回归方法分析影响患者预后的独立危险因素。结果实验组患者YKL-40水平明显高于对照组(P0.001)。小量出血、中量出血、大量出血患者的血清YKL-40水平均在7天内逐渐升高,且在第7天达到最大值,随后逐渐下降(P0.05)。重度神经损伤患者的血清YKL-40水平明显高于中度、轻度损伤患者(P0.05)。3月时预后良好组为54例,预后不良组为32例。多因素Logistic回归分析显示,年龄、入院时NIHSS评分、出血破入脑室、YKL-40是影响自发性脑出血患者预后的独立危险因素。结论自发性脑出血患者的血清YKL-40水平与患者的脑出血量及神经功能损伤程度存在相关性,可为自发性脑出血患者临床诊疗及预后判断提供依据。     

显微血管减压术后颅内出血的原因及应对策略

目的 探讨显微血管减压(MVD)术后颅内出血的原因及应对策略.方法 对12例面肌痉挛、三叉神经痛MVD术后颅内出血患者的临床资料进行回顾性分析,并对相关文献进行复习.结果 本组患者中,小脑半球实质内血肿者3例,小脑出血破入脑室3例,蛛网膜下腔出血2例,脑室出血2例,后颅窝硬膜外血肿1例,幕上硬膜下血肿1例.1例脑室出血...     

脑出血应激性高血糖患者血浆内皮素—1变化规律的临床研究

目的 通过对脑出血应激状态下血浆内皮素-1（ET-1）变化规律的研究,为脑出血的治疗提供新方法。方法 对30例脑出血应激性高血糖患者血浆ET-1水平在发病24h、48h、72h及第7d、14d的含量进行测定并与脑出血非高血糖组及正常人组比较。结果 应激性高血糖组血浆ET-1水平明显升高,急性期1-3d维持在较高水平,以后随时间呈下降趋势;ET-1与血糖、血压呈直线正相关;ET-1水平越高,则预后越差。结论 脑出血患者血浆ET-1水平升高与应激反应有关,且对预后产生不利影响。     

自发性脑出血血肿扩大的影响因素与预后分析

目的探讨自发性脑出血血肿扩大的影响因素,并分析其与预后的关系。 方法选取自2013年12月至2018年12月陕西中医药大学附属医院脑外科收治的670例自发性脑出血患者,根据72 h内复查CT的情况分为血肿扩大组（77例）和血肿稳定组（593例）,记录2组患者的临床资料,分析血肿扩大的影响因素,出院后随访3个月,比较2组患者的预后。 结果670例患者中发生血肿扩大77例,发生率11.49%（77/670）,其中预后不良45例,预后良好32例,血肿稳定组593例,其中预后不良261例,预后良好332例,2组患者预后不良率比较差异有统计学意义（P<0.05）。单因素分析显示,血肿扩大组的活化部分凝血活酶时间、首次CT血肿体积、血肿形态、高血压病、卒中病史与血肿稳定组相比差异有统计学意义（P<0.05）。多因素分析显示,高血压病、卒中病史、血肿形态是自发性脑出血血肿扩大的独立危险因素（OR>1,P<0.05）。 结论自发性脑出血患者出现血肿扩大的独立危险因素包括高血压病、卒中病史、不规则血肿形态,血肿扩大可增加不良预后。     

Ventriculomegaly after decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage

Objective

The aim of the present study was to investigate factors associated with the development of ventriculomegaly suggestive of hydrocephalus (VSOH) after decompressive craniectomy with hematoma evacuation for hemispheric hypertensive intracerebral hemorrhage.

Methods

This study focused on 21 patients who underwent decompressive craniectomy with hematoma evacuation for hemispheric hypertensive intracerebral hemorrhage. The patients’ clinical and radiological findings were retrospectively reviewed.

Results

Eleven patients were male and ten were female, with an age range from 22 to 75 years (mean, 56.6 years). The preoperative Glasgow Coma Scale score ranged from 3 to 13 (mean, 6.9). Hematoma volumes ranged from 33.4 to 98.1 ml (mean, 74.2 ml). Hematoma locations were the basal ganglia in 10 patients and the subcortex in 11 patients. The presence of intraventricular hemorrhage was significantly associated with the development of VSOH (P = 0.023). The distance of the decompressive defect to the midline and the presence of meningitis showed a strong trend for association with VSOH (P = 0.051, P = 0.090, respectively).

Conclusion

Careful attention should be paid to the occurrence of VSOH after decompressive craniectomy with hematoma evacuation in intracerebral hemorrhage patients with intraventricular extension, meningitis, and/or a short distance of the decompressive defect to the midline.     

幕上自发性脑出血患者早期预后影响因素的评估

目的 评估影响幕上自发必 出血患者早期预后的临床、实验室和影像学因素。方法 采用ＥＬＩＳＡ法检测５４例自发性幕上出血患者发病第１、２、３、４、７、１４ｄ的血清神经元特异性类醇化酶（ＮＳＰ）水平,计算脑实质内血肿体积,记录脑室出血积分、中线移位、入院时及病程中Ｇｌａｓｇｏｗ昏迷评分（ＧＣＳ）、发病３０ｄ时Ｇｌａｓｇｏｗ预后评分（ＧＯＳ）。检测入院时血压、血糖和周围血白细胞（ＷＢＣ）数。结果 预后恶劣     

偏头痛病人血浆内皮素的变化

目的:探讨各型各期偏头痛病人血浆内皮素的变化。方法:选取82例诊断明确的偏头痛病人,按先兆有无分为有先兆的偏头痛(MWA)组和无先兆的偏头痛(MWO)组,按发病时间分为发作期和间歇期,抽取静脉血用放射免疫分析法测定血浆中的内皮素-1(ET-1)水平,对各型各期的血浆内皮素进行比较。结果:偏头痛病人血浆ET-1水平(80.89±28.70pg/ml)高于正常对照(66.55±14.97pg/ml)(P<0.01);发作期与间歇期的比较发现,发作期(89.83±33.37pg/ml)显著高于间歇期(72.46±20.32pg/ml)(P<0.05);MWA和MWO组的病人的比较发现前者(94.71±29.46pg/ml)显著高于后者(72.46±20.32pg/ml)(P<0.05)。结论:偏头痛病人血浆ET-1增高,增高的血浆ET-1在偏头痛的发病及病理生理进程中起了一定的作用。     

脑血管病患者细胞间粘附分子-l的测定及意义

目的探讨脑血管病患者血清细胞间粘附分子-1(ICAM-1)水平和脑血管病发病与治疗的关系。方法用EUSA法测定脑血管病患者和正常对照组血清可溶性细胞间粘附分子-1(Sicam-1)含量。结果脑血栓形成或脑出血患者血清Sicam-1含量均较对照组显著增高(P<o．01;P<o．01);伴有高血压的脑血栓形成、脑出血患者血清Sicam-1含量较正常血压者显著增高(p<o．05)。结论ICAM-1在高血压引起脑卒中发病及治疗方面具有重要意义。     

Hemorrhage after an acute ischemic stroke.MAST-I Collaborative Group

BACKGROUND AND PURPOSE: Hemorrhagic transformation is frequently seen on CT scans obtained in the subacute phase of ischemic stroke. Its prognostic value is controversial. METHODS: We analyzed 554 patients with acute ischemic stroke enrolled in the Multicenter Acute Stroke Trial-Italy (MAST-I) study in whom a second CT scan was performed on day 5. Presence of 1) intraparenchymal hemorrhages (hematoma or hemorrhagic infarction), 2) extraparenchymal bleeding (intraventricular or subarachnoid) and 3) cerebral edema (shift of midline structure, sulcal effacement or ventricular compression) alone or in association were evaluated. Death or disability at 6 months were considered as "unfavorable outcome." RESULTS: Patients who developed intraparenchymal hemorrhages, extraparenchymal bleeding, or cerebral edema had unfavorable outcome (83%, 100%, and 80%, respectively), but multivariate analysis demonstrated that only extraparenchymal bleeding (collinearity) and cerebral edema (OR=6.8; 95% CI, 4.5 to 10.4) were significant independent prognostic findings. Unfavorable outcome correlated with size of intraparenchymal hemorrhage (chi2 for trend=30.5, P<0.0001). Nevertheless, when a large hematoma was present the negative effect was mostly due to concomitant extraparenchymal bleeding (chi2=51.6, P<0.0001), and when hemorrhagic infarction was detected the negative effect was mostly explained by the association with cerebral edema (chi2=36.6, P<0.0001). CONCLUSIONS: Extraparenchymal bleeding and cerebral edema are the main prognostic CT scan findings in the subacute phase of ischemic stroke. Stroke patients with a high risk for developing these 2 types of brain damage should be identified. Measures to prevent and adequately treat their development should be implemented.     

The relationship between metabolic syndrome (MetS) and spontaneous intracerebral hemorrhage (ICH)

Metabolic syndrome (MetS), well-known risk factor for cardiovascular diseases and ischemic stroke, would be associated with an increased incidence of spontaneous non-lesional intracerebral hemorrhage (ICH) because of some pathophysiologic overlaps between stroke subtypes. The purpose of this study is to identify the associations between MetS components, cerebral infarctions and ICH volume. In this review, demographic and computed tomographic data describing five elements constituting MetS as well as hematoma volume were assessed in 829 spontaneous ICH patients over 10 consecutive years. The same data were also assessed from a control group. The incidence and average numbers of MetS components differed significantly between ICH and control group (p = 0.002, <0.001). When ICH patients were divided into two groups based on whether they had MetS, the average number of MetS components was significantly different (p < 0.001). When the ICH group was divided into two groups based on whether the ICH was accompanied by cerebral infarction, the cerebral infarction group had significantly higher blood pressure, fasting glucose levels and triglyceride levels. When the ICH group was divided based on hematoma volume, there were no significant differences between groups. ICH patients presented more components of MetS than the control group, but detailed relationship between MetS and spontaneous ICH have yet to be completely understood. This study confirmed the association between ICH patients with cerebral infarction and individual MetS components, and therefore the authors strongly suggest controlling hypertension, and maintaining appropriate levels of blood sugar and triglyceride when treating high-risk patients.     

Serum cystatin C and cerebral microbleeds in patients with acute cerebral stroke

Recent studies have shown that kidney dysfunction is associated with cerebral microbleeds (CMB). Cystatin C is a more useful measurement than creatinine-based estimating equations for evaluating kidney function. The purpose of this study was to clarify the relationship between cystatin C levels and CMB in patients with acute cerebral stroke. This cross-sectional study included a total of 485 patients with acute ischemic stroke and 129 patients with cerebral hemorrhage. The serum levels of cystatin C were significantly higher in acute cerebral stroke patients with CMB than in those without (p < 0.001). Multivariate logistic regression analyses showed that for each single standard deviation increase of cystatin C levels, there was a significant increase in the presence of CMB after adjusting for age and sex, and after additional adjustment for cardiovascular risk factors, silent lacunar infarction, and white matter hyperintensity in patients with acute stroke. The odds ratio (95% confidence interval) in patients with acute cerebral infarction and cerebral hemorrhage were 2.92 (1.81–6.93) and 2.98 (1.76–6.97), respectively. The present study suggests that elevated levels of cystatin C are associated with the presence of CMB in acute stroke patients, independent of conventional risk factors.