Prediction of Shunt Dependency After Intracerebral Hemorrhage and Intraventricular Hemorrhage

Background

Spontaneous intracerebral hemorrhage is a disease with high morbidity and mortality. Extension of the hemorrhage into the ventricles is associated with the development of acute hydrocephalus and a poor outcome. Although it can be managed by external ventricular drainage (EVD), a subset of these patients require placement of permanent ventricular shunts. This study aimed to examine the factors on admission that can predict shunt dependency after EVD management.

Methods

Seventy-two patients who underwent EVD were included in this study. Seventeen of these patients underwent placement of a ventriculoperitoneal shunt. Variables analyzed included age, intraventricular hemorrhage (IVH) score, bicaudate index, acute hydrocephalus, initial Glasgow Coma Scale scores, and blood volume in each ventricle.

Results

In univariate analysis, IVH score (p?=?0.020), bicaudate index (p?<?0.001), blood volume in lateral ventricles (p?=?0.025), blood volume in the fourth ventricle (p?=?0.038), and the ratio of blood volume in lateral ventricles to that in third and fourth ventricles (p?=?0.003) were significantly associated with persistent hydrocephalus. The best multiple logistic regression model included blood volume parameters and bicaudate index as predictors with the area under a receiver operating characteristic curve of 0.849. The variance inflation factor (VIF) showed that collinearity was not found among predictors. Patients diagnosed with acute hydrocephalus had less blood volume in the lateral ventricles (OR?=?0.910) and had more blood volume in the third ventricle (OR?=?3.174) and fourth ventricle (OR?=?2.126).

Conclusions

These findings may promote more aggressive monitoring and earlier interventions for persistent hydrocephalus after intraventricular hemorrhage in patients at risk.

     

Development and Validation of a Nomogram for Predicting Death within 2 days After Intracerebral Hemorrhage

Objective: This study aimed to establish and verify a model for predicting death within 2 days after spontaneous cerebral hemorrhage based on the patient's characteristics at the time of admission.Methods: During 2015–2017, the records of a cohort of 397 patients with clinically diagnosed cerebral hemorrhage were collected for model development. Minimum absolute contraction and the selection operator (lasso) regression model were used to determine factors that most consistently and correctly predicted death after cerebral hemorrhage. Discrimination and calibration were used to evaluate the performance of the resulting nomogram. After internal validation, the nomogram was further assessed during 2017–2018 using a different cohort of 200 consecutive subjects. Results: The nomogram included four predictors from the lasso regression analysis: Glasgow Coma Scale, hematoma location, hematoma volume, and primary intraventricular hemorrhage. The nomogram showed good discrimination and good calibration for both training and verification cohorts. Decision curve analysis showed that the prediction nomogram was clinically useful. Conclusion: This prediction model can be used for early, simple, and accurate prediction of early death following cerebral hemorrhage.     

Educational Placement After Pediatric Intracerebral Hemorrhage

BackgroundThis study describes educational placement of school-aged children after spontaneous intracerebral hemorrhage and examines whether educational placement is associated with severity of neurological deficits.MethodsChildren with spontaneous intracerebral hemorrhage presenting from 2007 to 2013 were prospectively enrolled at three tertiary children's hospitals. The Pediatric Stroke Outcome Measure and parental interview gathered information about neurological outcome, school attendance, and educational placement.ResultsThe cohort of 92 enrolled children included 42 school-aged children (6 to 17 years) with intracerebral hemorrhage. Four children died; one was excluded because of preexisting cognitive deficits. Thirty-seven children completed three-month follow-up, and 30 completed 12-month follow-up. At 12 months, 14 children (46.7%) received regular age-appropriate programming, 12 (40%) attended school with in-class services, three (10%) were in special education programs, and one child (3.3%) received home-based services because of intracerebral hemorrhage–related deficits. Of 30 children with three- and 12-month follow-up, 14 (46.7%) improved their education status, 13 (43.3%) remained at the same education level, and three (10%) began to receive in-class services. An increasing Pediatric Stroke Outcome Measure score predicted the need for educational modifications at three months (odds ratio, 3.3; 95% confidence interval, 1.4 to 7.9; P = 0.007) and at 12 months (odds ratio, 2.1; 95% confidence interval, 1.1 to 3.9; P = 0.025).ConclusionsMost children returned to school within a year after intracerebral hemorrhage, and many had a reduction in the intensity of educational support. However, a great need for educational services persisted at 12 months after intracerebral hemorrhage with fewer than half enrolled in regular age-appropriate classes. Worse deficits on the Pediatric Stroke Outcome Measure were associated with remedial educational placement.     

Prevalence and Characterization of ECG Abnormalities After Intracerebral Hemorrhage

Background  

Although electrocardiographic (ECG) abnormalities are well known in ischemic stroke and subarachnoid hemorrhage, these changes have only rarely been investigated systematically in patients with intracerebral hemorrhage (ICH). The purpose of this study is to investigate the prevalence and type of ECG abnormalities in a consecutive series of ICH patients, and their possible association with pre-defined neurological and radiological parameters.     

Risk of Thromboembolism Following Acute Intracerebral Hemorrhage

Introduction  Intracerebral hemorrhage (ICH) is the most feared complication of oral anticoagulant therapy (OAT). While anticoagulated patients have increased severity of bleeding following ICH, they may also be at increased risk for thromboembolic events (TEs) given that they had been prescribed OAT prior to their ICH. We hypothesized that TEs are relatively common following ICH, and that anticoagulated patients are at higher risk for these complications. Methods  Consecutive patients with primary ICH presenting to a tertiary care hospital from 1994 to 2006 were prospectively characterized and followed. Hospital records were retrospectively reviewed for clinically relevant in-hospital TEs and patients were prospectively followed for 90 day mortality. Results  For 988 patients of whom 218 (22%) were on OAT at presentation, median hospital length of stay was 7 (IQR 4–13) days and 90-day mortality was 36%. TEs were diagnosed in 71 patients (7.2%) including pulmonary embolism (1.8%), deep venous thrombosis (1.1%), myocardial ischemia (1.6%), and cerebrovascular ischemia (3.0%). Mean time to event was 8.4 ± 7.0 days. Rates of TE were 5% among those with OAT-related ICH and 8% among those with non-OAT ICH (P = 0.2). After multivariable Cox regression, the only independent risk factor for developing a TE was external ventricular drain placement (HR 2.1, 95% CI 1.1–4.1, P = 0.03). TEs had no effect on 90-day mortality (HR 0.7, 95% CI 0.5–1.1, P = 0.1). Conclusions  The incidence of TEs in an unselected ICH population was 7.2%. Patients with OAT-related ICH were not at increased risk of TEs.     

Intracerebral Monitoring of Silent Infarcts After Subarachnoid Hemorrhage

Background

Silent infarction is common in poor-grade subarachnoid hemorrhage (SAH) patients and associated with poor outcome. Invasive neuromonitoring devices may detect changes in cerebral metabolism and oxygenation.

Methods

From a consecutive series of 32 poor-grade SAH patients we identified all CT-scans obtained during multimodal neuromonitoring and analyzed microdialysis parameters and brain tissue oxygen tension (PbtO2) preceding CT-scanning.

Results

Eighteen percent of the reviewed head-CTs (12/67) revealed new infarcts. Of the eight infarcts in the vascular territory of the neuromonitoring, seven were clinically silent. Neuromonitoring changes preceding radiological evidence of infarction included lactate-pyruvate-ratio elevation and brain glucose decreases when compared to those with distant or no ischemia (P ≤ 0.03, respectively). PbtO2 was lower, but this did not reach statistical significance.

Conclusions

These data suggest that there may be distinct changes in brain metabolism and oxygenation associated with the development of silent infarction within the monitored vascular territory in poor-grade SAH patients. Larger prospective studies are needed to determine whether treatment triggered by neuromonitoring data has an impact on outcome.     

基于机器学习算法的脑出血相关肺炎预测模型研究

目的 建立基于机器学习的脑出血相关肺炎预测模型。 方法 选择中国国家卒中登记Ⅱ（China National Stoke Registry Ⅱ,CNSRⅡ）数据库中发病7 d内的急 性脑出血住院患者为研究对象,登记时间为2012年5月-2013年1月,研究覆盖我国219家医院。研究对 象按照8∶2比例随机分为训练集和测试集。采用多因素Logistic回归分析,筛选出候选预测因子。应用 基于机器学习的Logistic回归、CatBoost、XGBoost和LightGBM算法构建诊断预测模型,比较4种方法构建 的模型对脑出血相关肺炎的预测诊断价值。 结果 本研究共筛选2303例患者,平均年龄62.1±12.7岁,其中男性占62.1%。患者随机分为训 练集（n =1841）和测试集（n =462）,两组脑出血相关肺炎发生率分别为15.6%和15.8%（χ 2=0.007, P =0.934）。根据多因素Logistic回归分析,候选预测因子为年龄（OR 1.03,95%CI 1.02～1.04）、NIHSS 评分（OR 1.02,95%CI 1.00～1.04）、白细胞计数（OR 1.11,95%CI 1.07～1.16）和吞咽功能障碍（OR 6.85,95%CI 5.01～9.39）。Logistic回归、CatBoost、XGBoost和LightGBM四种模型灵敏度分别为75.34%、 50.68%、80.82%和80.82%;特异度分别为68.64%、86.12%、52.96%和57.33%;ROC曲线下面积分别 为0.776、0.692、0.736和0.767。Logistic回归和LightGBM模型诊断效果显著高于CatBoost和XGBoost模型 （DeLong test,P <0.05）。 结论 基于机器学习建立的脑出血相关肺炎风险预测模型有较高的诊断价值,年龄、NIHSS评分、白 细胞计数和吞咽功能障碍为模型的候选预测因子,可将模型纳入脑出血相关肺炎诊断决策。本研究 结果的临床应用价值有待于更大样本的外部队列进行验证。     

Therapeutic Temperature Modulation for Fever After Intracerebral Hemorrhage

Background

We sought to determine whether therapeutic temperature modulation (TTM) to treat fever after intracerebral hemorrhage (ICH) is associated with improved hospital complications and discharge outcomes.

Methods

We performed a retrospective case–control study of patients admitted with spontaneous ICH having two consecutive fevers ≥38.3 °C despite acetaminophen administration. Cases were enrolled from a prospective database of patients receiving TTM from 2006 to 2010. All cases received TTM for fever control with goal temperature of 37 °C with a shiver-control protocol. Controls were matched in severity by ICH score and retrospectively obtained from 2001 to 2004, before routine use of TTM for ICH. Primary outcome was discharge-modified Rankin score.

Results

Forty patients were enrolled in each group. Median admission ICH Score, ICH volume, and GCS were similar. TTM was initiated with a median of 3 days after ICH onset and for a median duration of 7 days. Mean daily T _max was significantly higher in the control group over the first 12 days (38.1 vs. 38.7 °C, p ≤ 0.001). The TTM group had more days of IV sedation (median 8 vs. 1, p < 0.001) and mechanical ventilation (18 vs. 9, p = 0.003), and more frequently underwent tracheostomy (55 vs. 23 %, p = 0.005). Mean NICU length of stay was longer for TTM patients (15 vs. 11 days, p = 0.007). There was no difference in discharge outcomes between the two groups (overall mortality 33 %, moderate or severe disability 67 %).

Conclusions

Therapeutic normothermia is associated with increased duration of sedation, mechanical ventilation, and NICU stay, but is not clearly associated with improved discharge outcome.     

Hematoma Locations Predicting Delirium Symptoms After Intracerebral Hemorrhage

Background

Delirium symptoms are associated with later worse functional outcomes and long-term cognitive impairments, but the neuroanatomical basis for delirium symptoms in patients with acute brain injury is currently uncertain. We tested the hypothesis that hematoma location is predictive of delirium symptoms in patients with intracerebral hemorrhage, a model disease where patients are typically not sedated or bacteremic.

Methods

We prospectively identified 90 patients with intracerebral hemorrhage who underwent routine twice-daily screening for delirium symptoms with a validated examination. Voxel-based lesion–symptom mapping with acute computed tomography was used to identify hematoma locations associated with delirium symptoms (N = 89).

Results

Acute delirium symptoms were predicted by hematoma of right-hemisphere subcortical white matter (superior longitudinal fasciculus) and parahippocampal gyrus. Hematoma including these locations had an odds ratio for delirium of 13 (95 % CI 3.9–43.3, P < 0.001). Disruption of large-scale brain networks that normally support attention and conscious awareness was thus associated with acute delirium symptoms.

Conclusions

Higher odds ratio for delirium was increased due to hematoma location. The location of neurological injury could be of high prognostic value for predicting delirium symptoms.

     

Fever Burden and Health-Related Quality of Life After Intracerebral Hemorrhage

Background

Fever is associated with worse functional outcomes after intracerebral hemorrhage (ICH); however, there are few prospective data to quantify the relationship with health-related quality of life (HRQoL). We tested the hypothesis that increased burden of fever is independently associated with decreased HRQoL at follow-up.

Methods

In this prospective observational cohort study of 106 ICH patients admitted to a tertiary care hospital between 2011 and 2015, we recorded the highest core temperature each calendar day for 14 days after ICH onset. Fever burden was defined as the number of days with a fever?≥?100.4 °F (38 °C). HRQoL outcomes were measured with Neuro-QoL domains of Cognitive Function and Mobility at 28 days, 3 months, and 1 year. Results were analyzed using mixed effects regression analysis.

Results

Each additional day with a fever was independently associated with lower Mobility HRQoL (T-score ? 0.9, [? 1.6 to ? 0.2]; p?=?0.01) and Cognitive Function HRQoL (T-score ? 1.3 [? 2.0 to ? 0.6]; p?=?0.001) after correction for National Institutes of Health Stroke Scale score on admission, age, and time to follow-up.

Conclusions

Each additional day with a fever was predictive of worse HRQoL domains of Cognitive Function and Mobility after ICH up to 1 year. These data extend previous evidence on the negative association of fever and functional outcomes to the domains of Cognitive Function and Mobility HRQoL. HRQoL outcomes may be a sensitive and powerful way to measure the efficacy of fever control in future research.

     

Predictors of Late Neurological Deterioration After Spontaneous Intracerebral Hemorrhage

Background

Although intracerebral hemorrhage (ICH) is a common form of cerebrovascular disease, little is known about factors leading to neurological deterioration occurring beyond 48 h after hematoma formation. The purpose of this study was to characterize the incidence, consequences, and associative factors of late neurological deterioration (LND) in patients with spontaneous ICH.

Methods

Using the Duke University Hospital Neuroscience Intensive Care Unit database from July 2007 to June 2012, a cohort of 149 consecutive patients with spontaneous supratentorial ICH met criteria for analysis. LND was defined as a decrease of two or more points in Glasgow Coma Scale score or death during the period from 48 h to 1 week after ICH symptom onset. Unfavorable outcome was defined as a modified Rankin Scale score of >2 at discharge.

Results

Forty-three subjects (28.9 %) developed LND. Logistic regression models revealed hematoma volume (OR = 1.017, 95 % CI 1.003–1.032, p = 0.019), intraventricular hemorrhage (OR = 2.519, 95 % CI 1.142–5.554, p = 0.022) and serum glucose on admission (OR = 2.614, 95 % CI 1.146–5.965, p = 0.022) as independent predictors of LND. After adjusting for ICH score, LND was independently associated with unfavorable outcome (OR = 4.000, 95 % CI 1.280–12.500, p = 0.017). In 65 subjects with follow-up computed tomography images, an increase in midline shift, as a surrogate for cerebral edema, was independently associated with LND (OR = 3.822, 95 % CI 1.157–12.622, p = 0.028).

Conclusions

LND is a common phenomenon in patients with ICH; further, LND appears to affect outcome. Independent predictors of LND include hematoma volume, intraventricular hemorrhage, and blood glucose on admission. Progression of perihematomal edema may be one mechanism for LND.     

脑出血后迟发性脑水肿的磁共振波谱分析

目的：了解脑出血后迟发性脑水肿的磁共振波谱特点，探讨其可能的发生机制。方法：对12例脑出血14d后发生迟发性脑水肿患者的MRS检查，观察血肿周围迟发性脑水肿组织的MRS谱线，与脑出血后1周水肿的谱线进行对照研究，定量分析相关代谢物峰值的变化。结果：9例患者获得满意谱线，14d时血肿周围水肿区N-乙酰天门冬氨酸／肌酸（NAA／Cr）较7d时显著降低[（13．7±3．2）％对（18．34-4．4）％，P〈0．05]。7例检测到乳酸峰，8例患者检测到甘露醇峰。结论：脑出血后迟发性水肿区MRS的NAA／Cr降低和乳酸峰的出现表明水肿区神经元受损或缺血，迟发性水肿区甘露醇峰的存在在迟发性脑水肿中起着重要作用，提示局部血脑屏障破坏。     

Impact of Perihemorrhagic Edema on Short-Term Outcome After Intracerebral Hemorrhage

Background

Intracerebral hemorrhage (ICH) is a devastating disease with ICH volume being the main predictor of poor outcome. The prognostic role of perihemorrhagic edema (PHE) is still unclear; however, available data are mainly derived from analyses during the first days after symptom onset. As PHE growth may continue up to 14 days after ICH, we evaluated PHE over a longer period of time and investigated its impact on short-term clinical outcome.

Methods

In this monocentric retrospective cohort study, patients with spontaneous supratentorial ICH were identified from our institutional data base. Different time points of CT scans were merged to time clusters for better comparison (day 1, 2–3, 4–6, 7–9, 10–12). Absolute volumes of ICH and PHE were obtained using a validated semiautomatic volumetric algorithm. Clinical outcome at discharge was assessed using the modified Rankin Scale (0–3 = favorable, 4–6 = poor).

Results

220 patients (83 with favorable, 137 with poor outcome) were included in the final analysis. Mean ICH volume on admission was 22.8 [standard deviation (SD) 24.6] cm³. Mean absolute PHE volume on admission was 22.5 (SD 20.8) cm³ and increased to a mean peak volume of 38.1 (SD 31.4) cm³ during 6.7 (SD 4.1) days on average. Besides GCS on admission, functional status before ICH, peak hematoma volume, lobar localization and fever burden, and high peak PHE volume predicted poor outcome at discharge [OR 0.977 (95 % CI 0.957–0.998)] in the multivariable analysis.

Conclusions

PHE may have a negative impact on short-term functional outcome after ICH and therefore represent a possible treatment target.

     

脑出血后脑水肿形成机制的研究进展

脑出血后脑水肿的形成机制及病理过程十分复杂,本文对近年来备受关注的与脑水肿形成有关的诸因素作一综述。     

Risk Factors of Intracerebral Hemorrhage: A Case-Control Study

Background: Hypertension is a well-known risk factor for intracerebral hemorrhage (ICH). On many of the other potential risk factors, such as smoking, diabetes, and alcohol intake, results are conflicting. We assessed risk factors of ICH, taking also into account prior depression and fatigue. Methods: This is a population-based case-control study of 250 primary ICH patients, conducted in Helsinki University Hospital, Finland. The controls (n = 750) were participants of the FINRISK study, a large Finnish population survey on risk factors of chronic noncommunicable diseases, matched with cases by sex and age. Ages were matched in 5-year age bands. However, as the oldest FINRISK participants were 74-year-olds, controls for the age group 75-84 were selected from the age group of 70-74 years. Patients aged greater than or equal to 85 years were excluded. Patients and controls were compared in univariate analyses. The age categories less than 70, and greater than or equal to 70 years were also analyzed separately. Binary logistic regression analysis was performed for variables with P less than .1 in univariate analysis. Results: Analyzing all cases and controls, the cases had more hypertension, history of heart attack, lipid-lowering medication, and reported more frequently fatigue prior to ICH. In persons aged less than 70 years, hypertension and fatigue were more common among cases. In persons aged greater than or equal to 70 years, factors associated with risk of ICH were fatigue prior to ICH, use of lipid-lowering medication, and overweight. Conclusions: Hypertension was associated with risk of ICH among all patients and in the group of patients under 70 years. Fatigue prior to ICH was more common among all ICH cases.     

儿童脑出血患者住院期间脑积水危险因素研究

目的 探讨儿童脑出血患者发生脑积水的相关危险因素,为早期识别儿童脑出血患者发生脑积水的风险提供循证依据.方法 本研究为多中心回顾性分析,纳入北京市4家医院2018年度诊治的脑出血或非创伤颅内出血的儿童患者资料.从病案资料中收集患儿年龄、性别、医疗保险类型、影像检查结果、住院期间并发症(脑积水、癫痫和肺部感染)、住院时长...     

Associations of Diffusion-Tensor Fractional Anisotropy and FIM Outcome Assessments After Intracerebral Hemorrhage

Aim

This study aimed to clarify the associations between fiber tract degeneration evaluated by diffusion-tensor imaging (DTI) and outcomes following intracerebral hemorrhage (ICH).