High haemoglobin levels and mortality in males with intracerebral haemorrhage: a retrospective cohort study

ObjectivesTo examine the association between high haemoglobin levels and outcomes in intracerebral haemorrhage (ICH) in a multicentre cohort study.DesignProspective multicentre cohort study.Settings21 tertiary hospitals across mainland China.ParticipantsA total of 5318 consecutive in-hospital spontaneous ICH patients were recruited between January 2012 and June 2016.Primary and secondary outcome measuresHaemoglobin levels were measured on admission. Binary or ordinary logistic regression was used to evaluate the independent relationship of haemoglobin level with clinical outcomes at 3 months, measured as death or disability. Restricted cubic spline regression was fitted to examine the potential non-linear shape of the dose–response curve between the whole haemoglobin levels and 3-month poor outcomes.ResultsA total of 5031 patients with ICH were analysed (64.3% male; mean age (SD), 57.8 (15.2) years). We found that the highest haemoglobin quintile was associated with poor outcomes 3 months in males (adjusted OR (aOR) 1.65, 95% CI 1.21 to 2.25) but not in females, which was also observed in the pooled analysis of three subcohorts in male patients (average aOR 1.70, 95% CI 1.23 to 2.33). The spline regression suggested a non-linear association between haemoglobin levels and outcomes and a linear relationship was observed between an elevated haemoglobin level and 3-month disability/death in males (haemoglobin level per 10 g/L: aOR 1.24, 95% CI 1.10 to 1.40, p<0.001), which was mediated by larger haematoma volume (effect size: 0.115, 95% CI 0.012 to 0.231).ConclusionsThis study found a sex-specific association between an elevated haemoglobin level and poor 3-month outcomes, which might be mediated by larger haematoma volume.

Atorvastatin combined with dexamethasone in chronic subdural haematoma (ATOCH II): study protocol for a randomized controlled trial

Background Chronic subdural haematoma (CSDH) is a common condition in the elderly that often requires neurosurgical management. For small CSDH, evidence has emerged that statins may reduce haematoma volume and improve outcomes, presumably by reducing local inflammation and promoting vascular repair. We wish to extend this evidence in a study that aims to determine the efficacy and safety of atorvastatin combined with low-dose dexamethasone in patients with CSDH. Methods The second ATorvastatin On Chronic subdural Hematoma (ATOCH-II) study is a multi-centre, randomized, placebo-controlled, double-blind trial which aims to enrol 240 adult patients with a conservative therapeutic indication for CSDH, randomly allocated to standard treatment with atorvastatin 20 mg combined with low-dose dexamethasone (or matching placebos) daily for 28 days, and with 152 days of follow-up. The primary outcome is a composite good outcome defined by any reduction from baseline in haematoma volume and survival free of surgery at 28 days. Secondary outcomes include functional outcome on the modified Rankin scale (mRS) and modified Barthel Index at 28 days, surgical transition and reduction in haematoma volumes at 14, 28 and 90 days. Discussion This multi-centre clinical trial aims to provide high-quality evidence on the efficacy and safety of the combined treatment of atorvastatin and low-dose dexamethasone to reduce inflammation and enhance angiogenesis in CSDH. Trial registration ChiCTR, ChiCTR1900021659. Registered on 3 March 2019, http://www.chictr.org.cn/showproj.aspx?proj=36157.

Biocompatible Iron Sulphide Nanoparticles Against Neuroinflammation for Intracerebral Haemorrhage and Long-term Neurological Functional Recovery

BackgroundMass effects of haematoma, neuroinflammation, oxidative stress, and neuronal apoptosis are the major causes of poor prognosis of intracerebral haemorrhage (ICH). Our previous study suggests that biocompatible iron sulphide nanoparticles possess peroxidase-like activity and can release hydrogen polysulfanes, which may inhibit brain injury. The purpose of this study was to investigate the neuroprotective efficacy of diallyl disulfide (DADS)-nFeS in mice after ICH and preliminarily illustrate the potential mechanism. MethodsAdult male C57BL/6 mice (n = 176) were injected with bacterial collagenase in the striatum. In the first part, DADS-nFeS at different doses (25, 50, or 100 mg/kg) was intragastrically administered 2 h, 26 h, and 50 h before ICH. In the second and third parts, DADS-nFeS (50 mg/kg) was administered 2 h, 26 h, and 50 h before and after the induction of ICH in the pre-treatment group and post-treatment group, respectively. H&E staining was performed to detect drug toxicity. Haematoma volume measurement, Fluoro-Jade C (F-JC) staining, Nissl staining, immunofluorescence staining, western blotting, terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) staining, malondialdehyde (MDA) and superoxide dismutase (SOD) assays, and neurobehavioural tests were performed. ResultsAll three doses of DADS-nFeS had neuroprotective effects, and 50 mg/kg resulted in the best outcome. DADS-nFeS reduced the haematoma volume and MDA content, inhibited the activation of microglia and astrocytes, progressive neuronal degeneration, and apoptosis, increased SOD activity and neuronal survival, and improved both short-term and long-term neurological functions in perihaematomal areas after ICH. Moreover, DADS-nFeS was associated with the downregulation of Iba-1, GFAP, TNF-α, IL-1β, 4-hydroxynonenal (4-HNE), and Bax/Bcl-2 levels in perihaematomal areas after ICH. Finally, post-treatment with DADS-nFeS had a better effect than pre-treatment with DADS-nFeS. ConclusionsOur study indicated that gavage administration of DADS-nFeS decreased the haematoma volume, suppressed neuroinflammation, oxidative stress, and neuronal apoptosis, and improved short- and long-term neurological functions, which was, at least in part, realized by inhibiting the activation of microglia and astrocytes, enhancing local SOD activity, and decreasing the recruitment of reactive oxygen species. Therefore, DADS-nFeS may serve as a potential therapeutic strategy via the diet against central nervous system diseases.

Comparison of the curative effect and prognosis of stereotactic drainage and conservative treatment for moderate and small basal ganglia haemorrhage

Background Minimally invasive surgery has achieved good results in the treatment of cerebral haemorrhage.However, no large-scale clinical study has demonstrated that surgical treatment of cerebral haemorrhages less than 30 ml can improve the curative effect. Our study explored the efficacy and complication of stereotactic drainage based on the amount of cerebral hemorrhage (15-30 ml) in hypertensive basal ganglia. Method Sixty patients with hypertensive basal ganglia haemorrhages were divided into a control group and an experimental group with 30 patients in each group. Patients in the control group were treated conservatively. In contrast, those in the experimental group received stereotactic drainage, and urokinase was injected into the haematoma cavity after the operation. The haematoma volume at admission and 1, 3, 7 and 30 days after treatment and National Institute of Health stroke scale(NIHSS) score data were recorded. Complications after treatment in the two groups of data were compared and analysed. Result No significant differences in age, sex, time of treatment after onset, admission blood pressure, admission haematoma volume or admission NIHSS score were noted between these two groups (P > 0.05). After treatment, significant differences in haematoma volume were noted between the two groups on the 1st, 3rd, 7th and 30th days after treatment (P < 0.05). The amount of hematoma of patients in the experimental group was significantly reduced compared with that in the control group, and the NIHSS scores were significantly different on the 3rd, 7th and 30th days after treatment. The neurological deficit scores of patients in the experimental group were significantly reduced compared with those in the control group, and the incidence of pulmonary infection and venous thrombosis in the lower limbs of patients in the experimental group were significantly reduced (P < 0.05). ROC curve analysis showed that stereotactic drainage affected the early neurological function of patients with small and medium basal ganglia haemorrhages. Conclusion For patients with small and medium basal ganglia haemorrhages, stereotactic drainage can be used due to the faster drainage speed of haematomas after operation, which is beneficial to the recovery of neurological function and reduce complications.

Correlation of Haematoma Volume with Early Outcome in Surgically Treated Spontaneous Primary Supratentorial Intra-Cerebral Haematomas

Introduction: Spontaneous intracerebral hemorrhage (ICH) comprises 10-15% of all strokes. Aim: To assess the relationship between the haematoma volume and early surgical outcome of patients with spontaneous primary supratentorial intracerebral hemorrhage by Glasgow Outcome Scale at the 30th post ictus day. Methods: This prospective study was done from April 2014 to March 2016 in Department of Neurosurgery, Combined Military Hospital (CMH), Dhaka. Forty seven cases were selected by set down criteria. Glasgow Coma Scale (GCS) score was recorded on admission, haematoma volume was calculated from the CT scan immediately after admission by Modified Ellipsoid Method and the surgical outcome of ICH patients was determined by Glasgow Outcome Scale (GOS) by face to face interview or by structured interview over phone at their 30th post ictus day. Correlation between the haematoma volume and the surgical outcome of ICH was done by Chi-square test. Again the correlations of three variables (haematoma volume, admission GCS and ICH score) with GOS was compared by Spearman’s correlation coefficient test. Results: Patients with haematoma volume of 30cc or more were found to have worst outcome. Conclusion: Relationship between haematoma volume and surgical outcome was found statistically very significant. Risk stratification of the patients with spontaneous primary supratentorial intracerebral hematomas basing on hematoma volume may be used to improve standardization of treatment protocols and clinical research studies. JAFMC Bangladesh. Vol 15, No 1 (June) 2020: 46-49

Deep learning for automatically predicting early haematoma expansion in Chinese patients

Background and purposeEarly haematoma expansion is determinative in predicting outcome of intracerebral haemorrhage (ICH) patients. The aims of this study are to develop a novel prediction model for haematoma expansion by applying deep learning model and validate its prediction accuracy.MethodsData of this study were obtained from a prospectively enrolled cohort of patients with primary supratentorial ICH from our centre. We developed a deep learning model to predict haematoma expansion and compared its performance with conventional non-contrast CT (NCCT) markers. To evaluate the predictability of this model, it was also compared with a logistic regression model based on haematoma volume or the BAT score.ResultsA total of 266 patients were finally included for analysis, and 74 (27.8%) of them experienced early haematoma expansion. The deep learning model exhibited highest C statistic as 0.80, compared with 0.64, 0.65, 0.51, 0.58 and 0.55 for hypodensities, black hole sign, blend sign, fluid level and irregular shape, respectively. While the C statistics for swirl sign (0.70; p=0.211) and heterogenous density (0.70; p=0.141) were not significantly higher than that of the deep learning model. Moreover, the predictive value for the deep learning model was significantly superior to that of the logistic model of haematoma volume (0.62; p=0.042) and the BAT score (0.65; p=0.042).ConclusionsCompared with the conventional NCCT markers and BAT predictive model, the deep learning algorithm showed superiority for predicting early haematoma expansion in ICH patients.

Atorvastatin combined with dexamethasone in chronic subdural haematoma (ATOCH II): study protocol for a randomised controlled trial

Background Chronic subdural haematoma (CSDH) is a common condition in the elderly that often requires neurosurgical management. For small CSDH, evidence has emerged that statins may reduce haematoma volume and improve outcomes, presumably by reducing local inflammation and promoting vascular repair. We wish to extend this evidence in a study that aims to determine the efficacy and safety of atorvastatin combined with low-dose dexamethasone in patients with CSDH. Methods The second ATorvastatin On Chronic subdural Hematoma (ATOCH-II) study is a multi-center, randomized, placebo-controlled, double blind trial which aims to enroll 240 adult patients with a conservative therapeutic indication for CSDH, randomly allocated to standard treatment with atorvastatin 20 mg combined with low-dose dexamethasone (or matching placebos) daily for 28 days, and with 152 days of follow-up. The primary outcome is a composite good outcome defined by any reduction from baseline in haematoma volume and survival free of surgery at 28 days. Secondary outcomes include functional outcome on the modified Rankin scale (mRS) and modified Barthel Index at 28 days, surgical transition, and reduction in haematoma volumes at 14, 28 and 90 days. Discussion This multi-centre clinical trial aims to provide high-quality evidence on the efficacy and safety of the combined treatment of atorvastatin and low-dose dexamethasone to reduce inflammation and enhance angiogenesis in CSDH. Trial registration: ChiCTR, ChiCTR1900021659. Registered 3 March 2019, http://www.chictr.org.cn/showproj.aspx?proj=36157

Prior antiplatelet therapy and haematoma expansion after primary intracerebral haemorrhage: an individual patient-level analysis of CLEAR III, MISTIE III and VISTA-ICH

ObjectiveTo evaluate the relationship between prior antiplatelet therapy (APT) and outcomes after primary intracerebral haemorrhage (ICH), and assess if it varies by haematoma location.MethodsWe pooled individual patient data from the Virtual International Stroke Trials Archive-ICH trials dataset, Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase III trial. The exposure was APT preceding ICH diagnosis. The primary outcome was haematoma expansion at 72 hours. Secondary outcomes were admission haematoma volume, all-cause mortality, death or major disability (modified Rankin Scale (mRS) score ≥4) and shift in mRS distribution. Mixed-effects models were used to assess the relationship between APT and outcomes. Secondary analyses were stratified by ICH location and study cohort.ResultsAmong 1420 patients with ICH, there were 782 (55.1%) lobar and 596 (42.0%) deep haemorrhages. APT was reported in 284 (20.0%) patients. In adjusted regression models, prior APT was not associated with haematoma expansion (OR, 0.97; 95% CI 0.60 to 1.57), major disability or death (OR, 1.05; 95% CI 0.61 to 1.63), all-cause mortality (OR, 0.89; 95% CI 0.47 to 1.85), admission haematoma volume (beta, −0.17; SE, 0.09; p=0.07) and shift in mRS (p=0.43). In secondary analyses, APT was associated with admission haematoma volume in lobar ICH (beta, 0.25; SE, 0.12; p=0.03), but there was no relationship with other ICH outcomes when stratified by haematoma location or study cohort.ConclusionsIn a large heterogeneous cohort of patients with ICH, prior APT was not associated with haematoma expansion or functional outcomes after ICH, regardless of haematoma location. APT was associated with admission haematoma volumes in lobar ICH.

Correlation of Glasgow outcome scale (GOS) and Haematoma Volume during Surgical and Conservative Management of Spontaneous Supratentorial Intracerebral Hemorrhage Patients

Background: Haematoma volume is an important issue for the management of spontaneous supratentorial intracerebral hemorrhage patients. Objective: The purpose of the present study was to correlate the Glasgow outcome scale (GOS) and haematoma volume during surgical and conservative management of spontaneous supratentorial intracerebral hemorrhage patients. Methodology: This randomized control trial which was conducted in the Department of Neurosurgery at Dhaka Medical College and Hospital from January 2010 to October 2011 for a period of one year and ten months. All hypertensive patients with spontaneous supratentorial intracerebral hemorrhage who were admitted within 48 hours of stroke in Neurosurgery Department during the study period were considered as a study population. Patients underwent surgery was considered as group I and patients those who did not give the consent for operation were treated conservatively was considered as group II. Surgery and conservative groups were matched in age, GCS, GOS, hematoma location and volume of hematoma. Result: A total of 31 patients were enrolled in this study of which 14 patients underwent surgical evacuation and 17 cases were selected for conservative therapy. Significant negative correlation was found between GCS on admission with hematoma volume in surgery group (r=-0.631; P=0.016) and conservative group (r=- 0.854; p=0.001). A negative but not significant correlation (r=-0.426; P=0.129) between GOS with hematoma volume in group I, where negative significant correlation (r=-0.503; P=0.039) in conservative group II. Conclusion: In conclusion Glasgow outcome scale (GOS) is positively correlated with the haematoma volume during surgical and conservative management of spontaneous supratentorial intracerebral hemorrhage patients Journal of Science Foundation 2019;17(1):9-14