Intracerebral Hemorrhage

Intracranial pressure variability predicts short-term outcome after intracerebral hemorrhage: A retrospective study

Authors: Tian Y, Wang Z, Jia Y, Li S, Wang B, Wang S, Sun L, Zhang J, Chen J, Jiang R.

INTRODUCTION: Elevated intracranial pressure (ICP) is generally observed in brain injury and intracerebral hemorrhage (ICH) patients and is consistently associated with poor neurological outcome. Intracranial pressure variability (IPV) is a better predictor of long-term neurological outcome than mean ICP in traumatic brain injury patients. However, whether IPV regulates functional outcome in ICH patients has not been investigated. In the present study, we investigated the relationship between IPV and functional outcome in ICH patients and determined whether IPV is a valid predictor of neurological outcome in ICH patients.

Pediatric Intracerebral Hemorrhage: Acute Symptomatic Seizures and Epilepsy

Authors: Beslow LA, Abend NS, Gindville MC, Bastian RA, Licht DJ, Smith SE, Hillis AE, Ichord RN, Jordan LC.

IMPORTANCE Seizures are believed to be common presenting symptoms in neonates and children with spontaneous intracerebral hemorrhage (ICH). However, few data are available on the epidemiology of acute symptomatic seizures or the risk for later epilepsy. OBJECTIVE To define the incidence of and explore risk factors for seizures and epilepsy in children with spontaneous ICH. Our a priori hypotheses were that younger age at presentation, cortical involvement of ICH, acute symptomatic seizures after presentation, ICH due to vascular malformation, and elevated intracranial pressure requiring urgent intervention would predict remote symptomatic seizures and epilepsy. DESIGN Prospective cohort study conducted between March 1, 2007, and January 1, 2012. SETTING Three tertiary care pediatric hospitals. PARTICIPANTS Seventy-three pediatric subjects with spontaneous ICH including 20 perinatal (≥37 weeks' gestation to 28 days) and 53 childhood subjects (>28 days to <18 years at presentation). MAIN OUTCOME MEASURES Acute symptomatic seizures (clinically evident and electrographic-only seizures within 7 days), remote symptomatic seizures, and epilepsy. RESULTS Acute symptomatic seizures occurred in 35 subjects (48%). Acute symptomatic seizures as a presenting symptom of ICH occurred in 12 perinatal (60%) and 19 childhood (36%) subjects (P = .07). Acute symptomatic seizures after presentation occurred in 7 children. Electrographic-only seizures were present in 9 of 32 subjects (28%) with continuous electroencephalogram monitoring. One-year and 2-year remote symptomatic seizure-free survival rates were 82% (95% CI, 68-90) and 67% (95% CI, 46-82), respectively. One-year and 2-year epilepsy-free survival rates were 96% (95% CI, 83-99) and 87% (95% CI, 65-95), respectively. Elevated intracranial pressure requiring acute intervention was a risk factor for seizures after presentation (P = .01; Fisher exact test), remote symptomatic seizures, and epilepsy (P = .03, and P = .04, respectively; log-rank test). CONCLUSIONS AND RELEVANCE Presenting seizures are common in perinatal and childhood ICH. Continuous electroencephalography may detect electrographic seizures in some subjects. Single remote symptomatic seizures occur in many, and development of epilepsy is estimated to occur in 13% of patients at 2 years. Elevated intracranial pressure requiring acute intervention is a risk factor for acute seizures after presentation, remote symptomatic seizures, and epilepsy.

Involvement of GMRP1, a novel mediator of Akt pathway, in brain damage after intracerebral hemorrhage

Authors: Zheng M, Zhu H, Gong Y, Wang D, Xie Q, Tang H, Yang Z, Lu B, Chen X, Wang X.

GMRP1, also known as BTBD10, has been reported to inhibit apoptosis of neuronal and islet beta cells via Akt pathway. The present study attempted to investigate whether GMRP1 and its mediated Akt pathway were involved in brain injury of rats after intracerebral hemorrhage (ICH). Rat models of ICH had been established successfully. Western blotting was used to investigate the levels of GMRP1 protein in caudate nuclei tissues of hemorrhagic and contralateral sides at 6 h, day 1, day 3, day 5, day 7 after ICH. Phosphorylation of Akt was determined in caudate nuclei mentioned above. TUNEL assay was used to measure the cell apoptosis. GMRP1 protein levels, as well as phosphorylations of Akt, significantly decreased in caudate nuclei of hemorrhagic side, compared with those of contralateral side at day 1, day 3 after ICH. Enhanced cell apoptosis was observed in hemorrhagic side by TUNEL assay. We presented here evidence that decreased GMRP1-mediated Akt pathway contributed to cell apoptosis in hemorrhagic side, suggesting that GMRP1 played an important role in brain damage after ICH.

Burden of Blood Pressure-Related Alleles Is Associated With Larger Hematoma Volume and Worse Outcome in Intracerebral Hemorrhage

Authors: Falcone GJ, Biffi A, Devan WJ, Brouwers HB, Anderson CD, Valant V, Ayres AM, Schwab K, Rost NS, Goldstein JN, Viswanathan A, Greenberg SM, Selim M, Meschia JF, Brown DL, Worrall BB, Silliman SL, Tirschwell DL, Rosand J; on behalf of the GOCHA Investigators.

BACKGROUND AND PURPOSE: Intracerebral hemorrhage (ICH) is the acute manifestation of a progressive disease of the cerebral small vessels. The severity of this disease seems to influence not only risk of ICH but also the size of the hematoma. As the burden of high blood pressure-related alleles is associated with both hypertension-related end-organ damage and risk of ICH, we sought to determine whether this burden influences ICH baseline hematoma volume.
METHODS: Prospective study in subjects of European descent with supratentorial ICH who underwent genome-wide genotyping. Forty-two single nucleotide polymorphisms associated with high blood pressure were identified from a publicly available database. A genetic risk score was constructed based on these single nucleotide polymorphisms. The score was used as the independent variable in univariate and multivariate regression models for admission ICH volume and poor clinical outcome (modified Rankin Scale, 3-6).
RESULTS: A total of 323 ICH cases were enrolled in the study (135 deep and 188 lobar intracranial hematomas). The blood pressure-based genetic risk score was associated with both baseline hematoma volume and poor clinical outcome specifically in deep ICH. In multivariate regression analyses, each additional SD of the score increased mean deep ICH volume by 28% (or 2.7 mL increase; β=0.28; SE=0.11; P=0.009) and risk of poor clinical outcome by 71% (odds ratio, 1.71; 95% confidence interval, 1.05-2.80; P=0.03).
CONCLUSIONS: Increasing numbers of high blood pressure-related alleles are associated with mean baseline hematoma volume and poor clinical outcome in ICH. These findings suggest that the small vessel vasculopathy responsible for the occurrence of the hemorrhage also influences its volume.

Experimental high-altitude intracerebral hemorrhage in minipigs: histology, behavior, and intracranial pressure in a double-injection model

Authors: Zhu H, Li F, Zou M, Xue X, Yuan J, Feng H, Lin J.

BACKGROUND: Specific pathophysiological mechanism in intracerebral hemorrhage (ICH) at high altitude is unclear, and at present, there is no relevant and suitable animal model.
METHODS: A hypobaric chamber was used to simulate an altitude of 4,000 m. Autologous arterial blood (3 ml) was slowly infused into the right basal ganglia of minipigs by a double-injection method for producing ICH.
RESULTS: The intracranial pressure and neurological score of the high-altitude group were significantly higher than those of the low-altitude (plain) group. The brain water contents and pathological lesions of perihematoma tissue were more severe in the high-altitude group.
CONCLUSIONS: The injury resulting from ICH at high altitude was more severe than that in the plain group. This model was able to produce controllable and reproducible hematomas and visible neurological deficits, which may be useful for future studies of the pathophysiology and functional rehabilitation of high-altitude ICH disease.

Postpartum Trifecta: Simultaneous Eclamptic Intracerebral Hemorrhage, PRES, and Herniation Due to Intracranial Hypotension

Authors: Orehek EK, Burns JD, Koyfman F, Azocar RJ, Holsapple JW, Green DM.

BACKGROUND: In the postpartum patient, sudden depression of consciousness may be caused by a number of etiologies and can result in serious consequences. Rapid, accurate diagnosis allows for specific treatments that optimize outcome, but diagnosis can be challenging in this population. We present a case of postpartum herniation due to intracranial hypotension in a patient with eclampsia, posterior reversible encephalopathy syndrome (PRES), and intracerebral hemorrhage (ICH).

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