Endovascular management of intracerebral and subarachnoid hemorrhage

Opinion statement Significant advances in neuroendovascular devices and techniques are changing the approach to the management of acute hemorrhagic stroke. Greater numbers of aneurysms can now be treated using a wide array of platinum coils. Intracranial stents and balloon remodeling have made possible the treatment of wide-necked aneurysms. Microcatheters have been developed with better tractability to traverse tortuous vessels and access vascular lesions. With more than an estimated 100,000 patients with aneurysms treated worldwide, coil embolization has an excellent safety profile and level of outcome, with similar or better results compared with surgical clipping in select patient populations. Arteriovenous malformations and fistulae may also benefit from endovascular treatment by embolization using n-butyl cyanoacrylate or coils. In this article, we describe the endovascular role for the most common causes of intracerebral and subarachnoid hemorrhages, with special attention toward ruptured aneurysms and vascular malformations.     

Direct, progressive association of cardiovascular risk factors with incident proteinuria: results from the Korea Medical Insurance Corporation (KMIC) study

BACKGROUND: Proteinuria is a major risk factor for the progression of kidney disease and the development of cardiovascular disease. Little is known, however, about risk factors for incident proteinuria. METHODS: We conducted a 10-year prospective cohort study of 104,523 Korean men and 52,854 women, aged 35 to 59 years, who attended Korea Medical Insurance Corporation health examinations and who did not have proteinuria at baseline. Incident proteinuria was assessed at biennial examinations during the next 10 years. We performed Cox proportional hazards analyses. RESULTS: During 10 years of follow-up, proteinuria developed in 3951 men (3.8%) and 1527 women (2.9%). The adjusted relative risk (RR) of proteinuria associated with diabetes was 3.27 (95% confidence interval [CI], 2.98-3.58) in men and 2.60 (95% CI, 1.98-3.43) in women; with body mass index (calculated as weight in kilograms divided by the square of height in meters), it was 1.43 (95% CI, 1.35-1.50) in men and 1.45 (95% CI, 1.35-1.55) in women per 5-U increment. Compared with subjects with serum cholesterol levels of less than 200 mg/dL (< 5.18 mmol/L), the adjusted RRs associated with serum cholesterol levels of 200 to 239 mg/dL (5.18-6.19 mmol/L) and 240 mg/dL or more (> or = 6.22 mmol/L) were 1.13 (95% CI, 1.05-1.21) and 1.40 (95% CI, 1.27-1.54), respectively, in men and 1.14 (95% CI, 1.01-1.28) and 1.22 (95% CI, 1.00-1.37), respectively, in women. Persons with stages 1 and 2 hypertension had a greater adjusted RR of incident proteinuria compared with those with normal blood pressure (1.62 [95% CI, 1.47-1.79] and 2.06 [95% CI, 1.81-2.34], respectively, in men and 1.37 [95% CI, 1.14-1.65] and 2.10 [95% CI, 1.59-2.76], respectively, in women). CONCLUSIONS: Fasting glucose and cholesterol levels, body mass index, and blood pressure were direct and independent predictors of incident proteinuria in Korean adults. These associations were present even at low levels of exposure, emphasizing the importance of early detection and management of these modifiable risk factors.     

Older age and elevated blood pressure are risk factors for intracerebral hemorrhage after thrombolysis

Intracerebral hemorrhage is an important concern after thrombolytic therapy for acute myocardial infarction, but risk factors are controversial. Accordingly, we assessed risk factors in 107 treated patients of whom 4 had intracerebral hemorrhage. Intracerebral hemorrhage occurred at a mean of 25 hours (range 3.5 to 48) after therapy and was fatal in 2 patients. Significant differences were found between patients with and without intracerebral hemorrhage for age (77 +/- 7 vs 62 +/- 11 years, p less than or equal to 0.01), and initial (161 +/- 23 vs 135 +/- 23 mm Hg, p less than or equal to 0.03) and maximal (171 +/- 30 vs 146 +/- 20, p less than or equal to 0.02) systolic blood pressures. Initial and maximal diastolic blood pressures also tended to be higher (101 +/- 25 vs 86 +/- 16, p less than or equal to 0.07; 104 +/- 24 vs 90 +/- 13, p less than or equal to 0.06). Differences did not achieve significance for comparisons of gender, height, weight, site of infarction, time to therapy, specific thrombolytic agent used, concomitant therapy, interventions and partial thromboplastin time. It is concluded that age (greater than or equal to 70 years) and elevated blood pressure (greater than or equal to 150/95 mm Hg) are important risk factors for intracerebral hemorrhage. The overall balance of benefit and risk of thrombolysis should continue to be assessed by large mortality trials.     

Nonalcoholic fatty liver disease and risk of intracerebral hemorrhage

Background and aimsThis study aimed to investigate the association between the steatosis severity of nonalcoholic fatty liver disease (NAFLD) and future intracerebral hemorrhage (ICH) risk.Methods and resultsWe used data from the Kailuan study. Participants without a history of stroke, myocardial infarction, cancer, other liver diseases or alcohol abuse were enrolled. NAFLD and the severity of liver steatosis were assessed by abdominal ultrasonography. We stratified the participants into different groups according to the severity changes in liver steatosis status across the first 4-year follow-up period. The outcome was the first occurrence of ICH during the next 6-year follow-up period. Hazard ratios (HRs) and 95% CI of ICH were estimated using Cox models adjusted for potential risk factors. A total of 49,906 participants were enrolled in this study. During a median of 6.79 years of follow-up, 193 incident ICH cases were identified. Compared with persistent nonfatty liver participants, the hazard ratios (HRs) for participants with persistent mild steatosis, persistent moderate steatosis, persistent severe steatosis, alleviating steatosis, and aggravating steatosis were 1.28 (95% CI, 0.75–2.18), 2.33 (95% CI, 1.24–4.38), 1.63 (95% CI, 0.22–12.11), 1.41 (95% CI, 0.91–2.18), and 1.37 (95% CI, 0.94–2.00), respectively, in the fully adjusted model.ConclusionsNAFLD with persistent moderate steatosis was significantly related to an increased risk of future ICH, independent of other conventional risk factors.     

脑出血再发危险因素的分析

目的研究脑出血患者再发脑出血的相关因素,为临床预防和治疗再出血提供参考。方法回顾性分析3672例脑mm上患者中再发脑出血的临床资料,分为再次出血组239例,初次出血组3433例。先经单因素分析,筛选出差异有统计学意义的危险因素,再经多元Logistic回归分析,确定再发脑出血的独立危险因素。结果①3672例患者再发脑出血的发生率为6．5％（239／3672）,脑出血再发的病死率为19．2％（46／239）。②单因素分析显示,脑出血再发与高血压、服用抗血小板聚集药物、糖尿病、长期吸烟及酗酒等相关;两组比较,再出血组患者糖尿病史、长期吸烟、口服抗凝药、平均收缩脉升高、平均舒张压升高的比例均高于初次出血组;出血部位中,基底核区比例亦较高,年龄较大,两组比较均P〈0．01。③Logistic多元回归分析筛选出平均舒张压（OR=8．7893,95％CI：5．0162～18．9358）、抗凝药的应用（OR=3．7273,95％CI：1．8245～5．7806）、长期吸炯（OR=3．1654,95％CI：1．6124～5．4528）、平均收缩压（OR=2．9463,95％CI：1．4596～4．9753）及糖尿病（OR=2．4689,95％CI：1．1807～4．7650）是脑出血再发的独立危险因素,均P〈0．05。结论脑出血患者的再发出血与平均舒张压升高、抗凝药的应用、长期吸烟、平均收缩压升高及糖尿病具有相关性。     

动脉瘤性蛛网膜下腔出血后脑血管痉挛的药物治疗

动脉瘤性蛛网膜下腔出血后脑血管痉挛( cerebral vasospasm,CVS)的发生是一个多因素参与的过程,其发生机制复杂,临床表现和影像学检查结果并不一致.理论上,通过阻断钙通道、抑制Rho激酶、清除氧自由基和拮抗内皮素受体等措施能防治CVS,但各类药物的实际临床效果却不尽如人意,尤其是在改善临床转归方面.3H治疗的临床应用因存在诸多潜在并发症而受到限制,而动脉内介入治疗则受到技术、设备、适应证等因素的影响.因此,CVS的防治仍然面临着许多挑战.     

Prospective study on alcohol intake and risk of subarachnoid hemorrhage among Japanese men and women

BACKGROUND: Few prospective data are available to evaluate potential risk factors of subarachnoid hemorrhage among the Japanese, although several prospective studies conducted in the United States and in Europe have shown a positive relationship between alcohol intake and the risk of subarachnoid hemorrhage. METHODS: A 9.4 year follow-up study was conducted on 12,372 men and women age 40 to 69 years who had no history of stroke, in six communities in Japan. The incident cases of subarachnoid hemorrhage were confirmed with computed tomography findings and/or clinical findings. Alcohol intake and other cerebrovascular risk factors were measured at the baseline examination. A Cox proportional hazard analysis was used to estimate the relative risks and 95% confidence intervals of the incidence of subarachnoid hemorrhage. RESULTS: During the follow-up assessment, 71 cases of subarachnoid hemorrhages occurred. For men, heavy drinking appeared to be an independent risk factor for subarachnoid hemorrhage; multivariate-adjusted relative risk was 4.3 (95% confidence interval [CI]: 1.1-16.8; p = 0.04). Among women, no excess risk was found for heavy drinking, probably due to the small number of heavy drinkers (n = 15). The combination of heavy drinking with smoking or hypertension increased the risk of subarachnoid hemorrhage substantially for men; the multivariate-adjusted relative risk was 6.0 (95% CI: 1.8-20.1;p = 0.004) for heavy drinking smokers and 13.0 (95% CI: 3.9-43.9; p < 0.001) for heavy drinking hypertensives. CONCLUSIONS: A reduction in alcohol intake, smoking cessation, and control of hypertension are important in preventing subarachnoid hemorrhage among Japanese men.     

三种量表预测自发性脑出血患者预后的研究

目的对比3种脑出血量表在预测自发性脑出血（intracerebral hemorrhage，ICH）患者预后中的作用。方法选择自发性脑出血患者61例。入院时采用Hemphill等的原始的ICH量表（original ICH score，OICH）及Chenug等的改良的ICH量表（modified ICH score，MICH）、新的ICH量表（new ICH score，NICH）进行评分。同时于入院时采用美国国立卫生研究院卒中量表（NIHSS）、Barthel指数评分。3个月时进行NIHSS、Barthel指数和改良的Rankin量表（MRS）评分。分析3种ICH量表与其他量表评分的相关性；以MRS为标准，对比3种ICH量表评价脑出血患者预后的准确性。结果①3种ICH量表评分与脑出血患者入院时NIHSS评分和3个月MRS、NIHSS评分均呈正相关，差异均有统计学意义（P〈0．01），而与入院时和3个月Barthel指数呈负相关，差异均有统计学意义（P〈0．01）。②与MRS量表比较，OICH、MICH、NICH量表判断ICH患者预后不良的敏感性分别为73．1％、84．6％、80．8％，特异性分别为80．0％、88．6％、60．0％，符合率分别为77．0％、86．9％、68．9％。结论OICH、MICH、NICH量表评分与脑出血患者神经功能缺损程度相关。3种量表相比，MICH量表对脑出血预后判断的敏感性、特异性及符合率最高。     

Association of blunted nocturnal blood pressure dip with intracerebral hemorrhage

OBJECTIVES: Nondipping pattern of nocturnal blood pressure is associated with silent ischemic cerebrovascular lesions and lacunar infarctions. In this case-control study, we aimed to evaluate the association of diurnal blood pressure variation with the occurrence of intracerebral hemorrhage. METHODS: Ambulatory blood pressure monitoring was performed at 21-28 days after ictus in 78 first-ever unselective consecutive patients with intracerebral hemorrhage and in 80 age-adjusted and sex-adjusted controls who were referred to the hypertension center of our institution. The degree of nocturnal blood pressure dip was calculated as [(mean daytime values-mean night-time values)/mean daytime values]x100. Nondippers were defined as patients who exhibited a <10% nocturnal dip in systolic blood pressure. Logistic regression models were constructed to assess the association of nondipping status with intracerebral hemorrhage after adjusting for potential confounders (cardiovascular risk factors, office and ambulatory blood pressure levels). RESULTS: Prevalence of nondipping was significantly greater among cases than among controls (74.4% vs. 43.8%, P<0.001). Nondipping status was independently (P=0.033) associated with intracerebral hemorrhage (OR: 2.326, 95% CI: 1.068-5.050) in a multiple variable logistic regression model that adjusted for baseline characteristics, cardiovascular risk factors, office and ambulatory blood pressure variables. The magnitude of the nocturnal systolic blood pressure dipping was inversely related to the risk of intracerebral bleeding; the odds ratio for intracerebral hemorrhage associated with every 1% decrease in nocturnal systolic blood pressure dip was 1.143 (95% CI: 1.058-1.235, P=0.001). CONCLUSIONS: Given the previous reports that nondipping contributes to the risk of cerebral infarction, our results indicate that blunted nocturnal blood pressure dip may be also associated with the occurrence of intracerebral hemorrhage.     

老年蛛网膜下腔出血患者脑血管痉挛的相关危险因素回顾性分析

目的探讨老年蛛网膜下腔出血(SAH)患者发生脑血管痉挛(CVS)的相关危险因素。方法选择SAH患者62例,以是否发生CVS,将患者分为CVS组(27例)和非CVS组(35例),比较2组基线资料,并对住院前和住院期间发生CVS的相关因素进行logistic分析和COX分析。结果与非CVS组比较,CVS组患者吸烟、糖尿病、高血压年限及发热时间更长(P0.05,P0.01)。WBC计数明显增高(OR=1.515,95% CI:1.045～1.247,P=0.028)是CVS预测因素;吸烟(RR=1.044,95% CI:1.010～1.078,P=0.010)和高血压(RR=1.092,95% CI:1.025～1.163,P=0.006)是住院期间CVS独立危险因素;适当延长住院时间可以降低CVS的发生(RR=0.931,95% CI:0.878～0.987,P=0.016)。由于样本量小,糖尿病是住院前和住院期间发生CVS的低概率危险因素。结论吸烟、高血压、入院时WBC计数增高的老年SAH患者CVS发生风险显著增加;适当延长住院时间,可以降低CVS风险。     

出血性脑卒中患者入院时血压与预后的关系

为研究急性出血性脑卒中患者入院时血压与预后之间的关系,对1361例脑出血患者入院时死亡组的平均血压与幸存组的平均血压作了比较。结果显示,死亡组入院时的平均血压壳核出血（17.95±4.5kPa）和丘脑出血（17.29±3.06kPa）明显高于幸存组（壳核出血16.36±2.79kPa、丘脑出血13.43±2.93kPa）,P＜0.01;而脑叶出血（死亡组15.43±2.93kPa、幸存组15.30±2.79kPa）、小脑出血（死亡组15.69±3.86kPa,幸存组16.49±2.93kPa）和桥脑出血（死亡组18.22±3.72kPa,幸存组17.16±3.19kPa）者平均血压与预后之间无相关性。提示壳核出血和丘脑出血患者死亡率升高与入院时血压升高有关,脑叶出血、小脑出血及桥脑出血患者的平均血压与预后无相关性。     

Relation of cardiac troponin I levels with in-hospital mortality in patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage

Troponin I levels were drawn within 24 hours of stroke in 161 of 175 patients (92%) with ischemic stroke, 94 of 107 patients (88%) with intracerebral hemorrhage, and 96 of 96 patients (100%) with subarachnoid hemorrhage. A troponin level >0.4 ng/ml was considered increased. In patients with ischemic stroke, in-hospital mortality occurred in 15 of 23 patients (65%) with increased troponin I compared with 6 of 138 patients (4%) with normal troponin I (p <0.001). In patients with intracerebral hemorrhage, in-hospital mortality occurred in 9 of 14 patients (64%) with increased troponin I compared with 22 of 80 patients (28%) with normal troponin I (p <0.005). In patients with subarachnoid hemorrhage, in-hospital mortality occurred in 8 of 20 patients (40%) with increased troponin I compared with 8 of 76 patients (11%) with normal troponin I (p <0.005). In conclusion, patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage with elevated troponin I levels have increased in-hospital mortality.     

非重症自发性脑出血急性期血压与近期预后的关系

目的探讨非重症自发性脑出血急性期血压与近期预后的关系。方法选择168例经头颅CT证实的非重症自发性脑出血患者起病后72 h内的血压情况,应用改良的Rankin量表(mRS)对患者第21天神经功能恢复情况进行评分并分组,mRS≥4分组(64例)和mRS4分组(104例),并进行回归分析。结果与mRS4分组比较,mRS≥4分组患者急性期收缩压、舒张压、平均动脉压(MAP)均明显升高,差异有统计学意义(P0.05)。与MAP≤120 mm Hg(1 mm Hg=0.1 33 kPa)患者比较,MAP120 mm Hg患者预后明显差(OR=2.593,95% CI:1.324～5.078,P=0.005)。MAP是近期预后差的独立危险因素(OR=1.025,95% CI:1.007～1.044,P=0.008)。结论非重症自发性脑出血急性期血压与近期预后密切相关,MAP升高是近期预后差的独立危险因素之一。     

Soy products and risk of an aneurysmal rupture subarachnoid hemorrhage in Japan.

BACKGROUND: The aim of this study was to explore the relationship between soy products and the risk of subarachnoid hemorrhage in a case-control study. DESIGN: A case-control study was conducted. METHODS: Incident subarachnoid hemorrhage cases (n = 201) were identified and individually matched on age (+/- 2 years) and sex to community (n = 201) controls from April 1992 to March 1997. A factor analysis was conducted to identify dietary patterns in relation to subarachnoid hemorrhage risk. RESULTS: Soy-rich products were significantly associated with a decreased risk of subarachnoid hemorrhage (lowest versus highest quartile, adjusted odds ratio 0.46; 95% confidence interval 0.18-0.88). CONCLUSION: The findings suggest that a diet high in soy products may be protective against the development of subarachnoid hemorrhage.     

氙-CT动态观察动脉瘤性蛛网膜下腔出血患者脑血流量变化的初步研究

目的探讨应用氙（Xe）-CT评价动脉瘤性蛛网膜下腔出血（SAH）患者的脑血流量变化以及与经颅多普勒超声（TCD）检测脑血流速度的关系。方法对7例在SAH后1～4d和7～14d的颅内动脉瘤患者进行2次Xe—CT检查。用自动皮质6分区模式和手工画法测量大脑中动脉（MCA）等血管分布区（每例患者双侧大脑半球10个感兴趣区，7例患者共70个）的脑血流量。在Xe—CT检查后1h内，采用TCD检测MCA血流速度，比较MCA供血区脑血流量与TCD检测的血流速度的相关性。结果Xe—CT检测7例患者SAH后1～4d双侧MCA供血区平均脑血流量为（48±12）ml·100g^-1·min^-1，7～14d为（43±15）ml·100g^-1·min^-1。TCD检测SAH后1～4d双侧MCA平均流速为（165±73）cm／s，7～14d为（151±70）cm／s。Xe—CT检测的MCA供血区局部脑血流量与TCD检测的MCA血流速度比较，SAH后1～4d的左侧MCA的脑血流量与血流速度呈显著正相关（r=0．869，P〈0．05），SAH后1～4d的右侧MCA和7～14d的双侧MCA的脑血流量和血流速度均呈负相关，但差异均无统计学意义（P〉0．05）。结论Xe—CT能获得脑血流量绝对值，可用于动脉瘤性SAH患者的脑血流量评价。TCD检测的MCA流速与Xe—CT测得的局部脑血流量可能无明显相关性，有待于扩大样本，继续深入研究。