Effect of different operation time on surgical effect and quality of life in patients with severe hypertensive intracerebral hemorrhage
American journal of translational research. 2021;13(8):9538-9545
OBJECTIVE To investigate the effect of different operation time on the surgery effect and quality of life of patients with severe hypertensive cerebral hemorrhage. METHODS A total of 98 patients with severe hypertensive cerebral hemorrhage were selected in this prospective study. According to the random number table, 98 patients were divided into group A and group B. About 47 patients in group A received surgical treatment within 6 hours after onset of a cerebral hemorrhage and 51 patients in group B received surgical treatment within 6-24 hours after onset of a cerebral hemorrhage. The effect of the operation, quality of life (the World Health Organization Quality of Life Scale Brief Version, WHOQOL-BREF) score, neuro function (National Institute of Health stroke scale, NIHSS), the ability of daily living (Barthel index), athletic ability (Fugl-Meyer motor function score), complications and prognosis (GOS) were compared between the two groups. RESULTS The total effective rate of operation in group A (91.49%) was higher than that in group B (76.47%), and the incidence of complications (8.70%) was lower than that in group B (27.08%; all P<0.05). NIHSS score of group A was lower than that of group B, and the WHOQOL-BREF score was higher than that of group B three months after the operation (all P<0.05). Barthel Index and Fugl-Meyer motor function scores of group A were higher than those of group B three months after the operation (all P<0.05). The prognosis of group A was better than group B three months after the operation (P<0.05). CONCLUSION Operation performed within 6 hours after the onset of cerebral hemorrhage is useful in the treatment of severe hypertensive intracerebral hemorrhage. It can effectively improve patients' neurological function, the ability of daily living and motor function without increasing complications and, the quality of life, as well as the prognosis of patients.
Intracranial Pressure and Cerebral Perfusion Pressure in Large Spontaneous Intracranial Hemorrhage and Impact of Minimally Invasive Surgery
Frontiers in neurology. 2021;12:729831
Introduction: We investigated the effect of hematoma volume reduction with minimally invasive surgery (MIS) on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with large spontaneous intracerebral hemorrhage (ICH). Methods: Post-hoc analysis of the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE III) study, a clinical trial with blinded outcome assessments. The primary outcome was the proportion of ICP readings ≥20 and 30 mmHg, and CPP readings <70 and 60 mm Hg. Secondary outcomes included major disability (modified Rankin scale >3) and mortality at 30 and 365 days. We assessed the relationship between proportion of high ICP and low CPP events and MIS using binomial generalized linear models, and outcomes using multiple logistic regression. Results: Of 499 patients enrolled in MISTIE III, 72 patients had guideline based ICP monitors placed, 34 in the MIS group and 38 in control (no surgery) group. Threshold ICP and CPP events ≥20/ <70 mmHg occurred in 31 (43.1%) and 52 (72.2%) patients respectively. On adjusted analyses, proportion of ICP readings ≥20 and 30 mmHg were significantly lower in the MIS group vs. control group [Odds Ratio (OR) 0.27, 95% Confidence Interval [CI] 0.11-0.63 (p = 0.002); OR = 0.18, 0.04-0.75, p = 0.02], respectively. Proportion of CPP readings <70 and 60 mm Hg were also significantly lower in MIS patients [OR 0.31, 95% CI 0.15-0.63 (p = 0.001); OR 0.30, 95% CI 0.11-0.83 (p = 0.02)], respectively. Higher proportions of CPP readings <70 and 60 mm were significantly associated with short term mortality (p = 0.04), and (p = 0.006), respectively. Long term mortality was significantly associated with higher proportion of time with ICP ≥ 20 (p = 0.04), ICP ≥ 30 (p = 0.04), and CPP <70 mmHg (p = 0.01). Conclusion: Our results are consistent with the hypothesis that surgical reduction of ICH volume decreases proportion of high ICP and low CPP events and that these variables are associated with short- and long-term mortality.
Hypertension management in elderly with severe intracerebral hemorrhage
Annals of clinical and translational neurology. 2021
OBJECTIVE To explore the effect of individualized blood pressure (BP)-lowering treatment on the outcomes of elderly patients with severe intracerebral hemorrhage (ICH). METHODS We performed an exploratory analysis of Controlling Hypertension After Severe Cerebrovascular Event (CHASE) trial, which was a multicenter, randomized, controlled clinical trial. Patients with severe ischemic or hemorrhagic stroke (defined as GCS ≤ 12 or NIHSS ≥ 11) were randomized into individualized versus standard BP-lowering treatment in CHASE trial. In this exploratory analysis, patients with severe ICH were included. The primary outcome was the percentage of patients with 90-day functional independence defined as modified Rankin Scale (mRS) ≤2. RESULTS We included 242 patients with severe ICH in the present analysis, consisting of 142 patients aged <65 years and 100 patients aged ≥65 years. There were significant differences between patients aged ≥65 years and <65 years in the proportion of functional independence (47.9% vs. 15.0%, P < 0.001) and good outcome (73.9% vs. 50.0%, P < 0.001) at day 90. In patients aged ≥65 years, the adjusted individualized BP-lowering treatment had an unequivocal effect on the functional independence at day 90 (21.6% vs. 8.2%, odds ratio [OR]: 4.309, 95% confidence interval [CI]: 1.040-17.859, P = 0.044) and improved the neurological deficits at discharge (∆ NIHSS ≥ 4: 64.7% vs. 34.7%, OR: 4.300, 95% CI: 1.599-11.563, P = 0.004). INTERPRETATION Compared with the younger counterparts, the elderly patients (≥65 years) with acute severe ICH might benefit more from individualized BP-lowering treatment.
Targeting Pro-Oxidant Iron with Deferoxamine as a Treatment for Ischemic Stroke: Safety and Optimal Dose Selection in a Randomized Clinical Trial
Antioxidants (Basel, Switzerland). 2021;10(8)
A role of iron as a target to prevent stroke-induced neurodegeneration has been recently revisited due to new evidence showing that ferroptosis inhibitors are protective in experimental ischemic stroke and might be therapeutic in other neurodegenerative brain pathologies. Ferroptosis is a new form of programmed cell death attributed to an overwhelming lipidic peroxidation due to excessive free iron and reactive oxygen species (ROS). This study aims to evaluate the safety and tolerability and to explore the therapeutic efficacy of the iron chelator and antioxidant deferoxamine mesylate (DFO) in ischemic stroke patients. Administration of placebo or a single DFO bolus followed by a 72 h continuous infusion of three escalating doses was initiated during the tPA infusion, and the impact on blood transferrin iron was determined. Primary endpoint was safety and tolerability, and secondary endpoint was good clinical outcome (clinicalTrials.gov NCT00777140). DFO was found safe as adverse effects were not different between placebo and DFO arms. DFO (40-60 mg/Kg/day) reduced the iron saturation of blood transferrin. A trend to efficacy was observed in patients with moderate-severe ischemic stroke (NIHSS > 7) treated with DFO 40-60 mg/Kg/day. A good outcome was observed at day 90 in 31% of placebo vs. 50-58% of the 40-60 mg/Kg/day DFO-treated patients.
Reactive Oxygen Species Scavenger in Acute Intracerebral Hemorrhage Patients: A Multicenter, Randomized Controlled Trial
BACKGROUND AND PURPOSE Patients with intracerebral hemorrhage (ICH) have oxidative stress. Oxidative stress contributes to the development and progression of perihematomal edema (PHE) in brain hemorrhage patients. We hypothesized that reactive oxygen species (ROS) scavengers might have a neuroprotective role in the acute period of patients with ICH. METHODS This prospective, multicenter, single-blind, randomized study was conducted between June 2017 and October 2019. Intracranial bleeding, including spontaneous ICH, secondary ICH due to vascular anomalies, venous thrombosis, neoplasms, or hemorrhagic infarction, were included in our study. These ROS scavengers were given for 14 days with a dose of N-acetylcysteine 2000 mg/d and selenium 1600 µg/d intravenously. Other patients received a placebo. The primary outcome was hemorrhage and PHE volume changes in 2-week follow-up computed tomography between ROS scavenger versus placebo groups. RESULTS In total, 448 patients were enrolled with 123 patients remaining after applying the inclusion and exclusion criteria. There were no significant differences in baseline characteristics between the ROS scavenger (n=57) and placebo (n=66) groups. No significant differences in baseline hematoma and PHE volumes were observed but 2 weeks follow-up computed tomography showed significant differences in PHE volume (21.90±17.63 versus 30.66±32.35, P<0.01) and PHE ratio (1.19±0.73 versus 2.05±1.27, P<0.01). Among clinical factors, time to reach target Richmond Agitation Sedation Scale (5.98 hours [95% CI, 4.82-7.241 versus 8.42 hours], [95% CI, 6.57-10.77], P<0.01) and the length of intensive care unit stays (6.46 days [95% CI, 2.38-10.55 versus 12.66 days], [95% CI, 8.47-16.85], P<0.01) were significantly shortened among patients who received ROS scavengers than among patients who did not receive ROS scavenger. CONCLUSIONS ROS scavenger showed a significantly reduced PHE volume, time to reach target Richmond Agitation Sedation Scale, and shortened length of intensive care unit stay in patients with acute ICH. Early and high doses of ROS scavengers in a combination regimen may have played a key role in obtaining a favorable outcome in our study.
Postsurgical functional outcome prediction model using deep learning framework (Prediction One, Sony Network Communications Inc.) for hypertensive intracerebral hemorrhage
Surgical neurology international. 2021;12:203
BACKGROUND Reliable prediction models of intracerebral hemorrhage (ICH) outcomes are needed for decision-making of the treatment. Statistically making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on DL-based functional outcome prediction models for ICH outcomes after surgery. We herein made a functional outcome prediction model using DLframework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to original ICH score, ICH Grading Scale, and FUNC score. METHODS We used 140 consecutive hypertensive ICH patients' data in our hospital between 2012 and 2019. All patients were surgically treated. Modified Rankin Scale 0-3 at 6 months was defined as a favorable outcome. We randomly divided them into 100 patients training dataset and 40 patients validation dataset. Prediction One made the prediction model using the training dataset with 5-fold cross-validation. We calculated area under the curves (AUCs) regarding the outcome using the DL-based model, ICH score, ICH Grading Scale, and FUNC score. The AUCs were compared. RESULTS The model made by Prediction One using 64 variables had AUC of 0.997 in the training dataset and that of 0.884 in the validation dataset. These AUCs were superior to those derived from ICH score, ICH Grading Scale, and FUNC score. CONCLUSION We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the DL-based model was superior to those of previous statistically calculated models.
Effects of mild hypothermia therapy combined with minimally invasive debridement in patients with hypertensive intracranial hemorrhage: a randomized controlled study
American journal of translational research. 2021;13(7):7997-8003
OBJECTIVE To investigate the clinical effect of mild hypothermia therapy (MHT) combined with minimally invasive debridement (MID) in patients with severe hypertensive intracranial hemorrhage (HICH). METHODS A total of 120 patients with severe HICH who received clinical intervention in our hospital were enrolled as study subjects. In this randomized, controlled, double-blind trial, they were divided into a study group (SG, n=70) and a control group (CNG, n=50). The CNG was treated with MID, and the SG was treated with MID combined with MHT. The general surgical indices, short-term postoperative outcomes, postoperative neurological and recovery in activities of daily living, and complications were compared between the two groups. Patients' Glasgow prognosis (Glasgow Outcome Scale, GOS) scores at 1 year after surgery were analyzed. RESULTS The operative time, intraoperative blood loss and intensive care unit (ICU) admission were shorter/lower in the SG than in the CNG (P<0.05). The SG had higher hematoma clearance rate at 1 d and 3 d postoperatively, and lower residual hematoma volume at 3 d and 7 d postoperatively than the CNG (P<0.05). Patients in the SG had higher Barthel scores and lower National Institutes of Health Stroke Scale (NIHSS) scores than the CNG at 1-12 months after intervention (P<0.05). The incidence of complications in the SG was lower than that in the CNG (P<0.05). The percentage of GOS grade IV and V was significantly higher in the SG than in the CNG 1 year after surgery (P<0.05). CONCLUSION The combination of MID and MHT in patients with severe HICH has better clinical results in the short and long term, and improves the postoperative outcomes and quality of life. It can also reduce the incidence of perioperative complications.
Clinical efficacy of comprehensive nursing in patients with cerebral hemorrhagic hemiplegia
American journal of translational research. 2021;13(5):5526-5532
OBJECTIVE To explore the clinical efficacy of comprehensive rehabilitation nursing (CRN) intervention in patients with cerebral hemorrhagic hemiplegia (CHH). METHODS A total of 102 patients with CHH admitted to our hospital were selected for the prospective study. The patients were randomly divided into the control group (n=51) and the observation group (n=51) according to the random number table method. Routine nursing was performed in the control group, while CRN was conducted in the observation group. Fugl-Meyer motor function assessment scale, activity of daily living scale (Barthel index), self-rating anxiety scale (SAS), complications and muscle strength improvement (Brunnstrom assessment) were compared between the two groups. RESULTS Compared with those before nursing, Fugl-Meyer score, Barthel index and SAS score in the two groups after nursing were significantly improved (P<0.01). Fugl-Meyer score and Barthel index of the observation group were significantly higher than those of the control group after nursing, while SAS score showed the opposite change (P<0.001). The incidence of complications in the control group was 49.02%, and that in the observation group was 29.41% (P<0.05). The rate of muscle strength improvement in the observation group was 80.39% after nursing, which was significantly higher than that in the control group (60.78%; P<0.05). CONCLUSION CRN intervention has a positive clinical efficacy in patients with CHH. It can enhance motor ability, improve the ability of daily life, amend psychological mood and reduce the incidence of complications.
The effect of butylphthalide injection on the cognitive function and the TLRs/NF-κB pathway in hypertensive intracerebral hemorrhage
American journal of translational research. 2021;13(8):9578-9585
OBJECTIVE This study explored and analyzed the effects of butylphthalide injection on the cognitive function and on the TLRs/NF-κB pathway in hypertensive intracerebral hemorrhage patients. METHODS A total of 115 patients admitted to our hospital with hypertensive intracerebral hemorrhages were recruited as the study cohort and randomly placed in the observation group (n=60) or the control group (n=55). In addition to the routine treatment administered in both groups, the control group was additionally administered oral nimodipine tablets, and the observation group was administered intravenous butylphthalide injections. Both groups were treated continuously for 14 days. Subsequently, the changes in the clinical efficacy, the NIHSS scores, the extremity motor function, the Fugl-Meyer scores, the blood-brain barrier (BBB) and the peripheral blood mononuclear cells (PBMCs), the TLR2, TLR9, and the NF-κB mRNA levels in the two groups before and after the treatment were compared, and any adverse reactions were observed. RESULTS The total effective rate in the observation group was significantly superior to the total effective rate in the control group (P<0.05). The post-treatment NIHSS scores in the two groups were dramatically lower (P<0.05), and the post-treatment scores in the observation group were significantly lower than they were in the control group (P<0.05). The post-treatment cerebral spinal fluid (CSF) albumin and BBB indexes in the two groups were decreased significantly compared to their pre-treatment levels (P<0.05), and the post-treatment indexes in the observation group were significantly lower than the post-treatment indexes in the control group (P<0.05). The post-treatment relative TLR2, TLR9, and NF-κB mRNA expressions in the two groups were apparently lower than their in pre-treatment levels (P<0.05), and the relative expressions in the observation group after the treatment were clearly lower than they were in the control group (P<0.05). CONCLUSION Butylphthalide injection has a high clinical efficacy in treating hypertensive intracerebral hemorrhages. The drug can effectively improve patients' cognitive functions, extremity motor functions, and BBB indexes, and its mechanism may connect with the expressive suppression of the TLRs/NF-κB signaling pathway. The treatment is safe and effective, so it is worthy of clinical promotion.
Effects of early mobilization on short-term blood pressure variability in acute intracerebral hemorrhage patients: A protocol for randomized controlled non-inferiority trial
BACKGROUND Early out-of-bed mobilization may improve acute post-intracerebral hemorrhage (ICH) outcomes, but hemodynamic instability may be a concern. Some recent studies have showed that an increase in mean systolic blood pressure (SBP) and high blood pressure variability (BPV), high standard deviation of SBP, may lead to negative ICH outcomes. Therefore, we investigated the impact of an early mobilization (EM) protocol on mean SBP and BPV during the acute phase. METHODS The study was an assessor-blinded, randomized controlled non-inferiority study. The participants were in An Early Mobilization for Acute Cerebral Hemorrhage trial and were randomly assigned to undergo EM or a standard early rehabilitation (SER) protocol within 24 to 72 hour after ICH onset at the stroke center. The EM and SER groups each had 30 patients. 24-measurement SBP were recorded on days 2 and 3 after onset, and SBP were recorded three times daily and during rehabilitation on days 4 through 7. The two groups' mean SBP and BPV under three different time frames (days 2 and 3 during the acute phase, and days 4 through 7 during the late acute phase) were calculated and compared. RESULTS At baseline, the two groups' results were similar, with the exception being that the mean time to first out-of-bed mobilization after symptom onset was 51.60 hours (SD 14.15) and 135.02 hours (SD 33.05) for the EM group and SER group, respectively (P < .001). There were no significant differences in mean SBP and BPV during the acute and late acute phase between the two groups for the three analyses (days 2, 3, and 4 through 7) (P > .05). CONCLUSIONS It is safe to implement the EM protocol within 24 to 72 hour of onset for mild-moderate ICH patients during the acute phase.