Search Results (80)

Background: Intracerebral hemorrhage (ICH) is a severe form of stroke associated with high morbidity and mortality. While neurosurgical evacuation may offer theoretical benefits, its impact on survival and hospital course remains debated. We aimed to compare the outcomes of surgical versus conservative management in patients with lobar, capsulo-lenticular, and thalamic ICH and to identify factors influencing mortality and the surgical decision. Methods: This single-center, retrospective cohort study included adult patients admitted to the County Clinical Emergency Hospital of Sibiu (2017–2023) with spontaneous supratentorial ICH confirmed via CT (deepest affected structure determining lobar, capsulo-lenticular, or thalamic location). We collected data on demographics, clinical presentation (Glasgow Coma Scale [GCS], anticoagulant use), hematoma characteristics (volume, extension), treatment modality (surgical vs. conservative), and in-hospital outcomes (mortality, length of stay). Statistical analyses included t-tests, χ², correlation tests, and logistic regression to identify independent predictors of mortality and surgery. Results: A total of 445 patients were analyzed: 144 lobar, 150 capsulo-lenticular, and 151 thalamic. Surgical intervention was more common in patients with larger volumes and lower GCS. Overall, in-hospital mortality varied by location, reaching 13% in the lobar group, 20.7% in the capsulo-lenticular group, and 35.1% in the thalamic group. Within each location, surgical intervention did not significantly reduce overall in-hospital mortality despite the more severe baseline presentation in surgical patients. In lobar ICH specifically, no clear survival advantage emerged, although surgery may still benefit those most severely compromised. For capsulo-lenticular hematomas > 30 mL, surgery was associated with lower mortality (39.4% vs. 61.5%). In patients with large lobar ICH, surgical intervention was associated with mortality rates similar to those seen in less severe, conservatively managed cohorts. Multivariable adjustment confirmed GCS and hematoma volume as independent mortality predictors; age and volume predicted the likelihood of surgical intervention. Conclusions: Despite targeting more severe cases, neurosurgical evacuation did not uniformly lower in-hospital mortality. In lobar ICH, surgical patients with larger hematomas (~48 mL) and lower GCS (~11.6) had mortality rates (~13%) comparable to less severe, conservative cohorts, indicating that surgical intervention was associated with similar mortality rates despite higher baseline risk. However, these findings do not establish a causal survival benefit and should be interpreted in the context of non-randomized patient selection. For capsulo-lenticular hematomas > 30 mL, surgery was associated with lower observed mortality (39.4% vs. 61.5%). Thalamic ICH remained most lethal, highlighting the difficulty of deep-brain bleeds and frequent ventricular extension. Across locations, hematoma volume and GCS were the primary outcome predictors, indicating the need for timely intervention, better patient selection, and possibly minimally invasive approaches. Future prospective multicenter research is necessary to refine surgical indications and validate these findings. To our knowledge, this investigation represents the largest and most contemporary single-center cohort study of supratentorial intracerebral hemorrhage conducted in Romania. Full article

Background/Objectives: Spontaneous intraparenchymal hemorrhage (sIPH) accounts for a significant proportion of strokes and is associated with an estimated 30-day mortality between 35 and 52%. Subsequent hematoma progression (HP) occurs in up to 30% of patients and is associated with blood pressure variability, increasing poor outcomes. This study evaluates systolic blood pressure and heart rate variability in the emergency department (ED) and HP in the first 24 h of admission. Methods: This retrospective study analyzed patients with sIPH presenting to the ED and transferred to a resuscitation unit between 2017 and 2020. Outcomes included the occurrence of HP. Variables included blood pressure variability as measured by the standard deviation in systolic blood pressure (SBP-SD), successive variation of systolic blood pressure (SBP-SV), standard deviation of heart rate (HR-SD), and successive variation of heart rate (HR-SV). Bivariate analysis and machine learning algorithms were used to identify ED predictors for HP. Results: Of the 142 records analyzed, 41 (29%) patients experienced HP. The medians [interquartile (IQR)] for baseline characteristics were similar between groups. In the group with no HP (control), the median [IQR] for SBP-SD was 17.6 [11–26] compared with 20.5 [13.9–26.1, p = 0.25]. The median [IQR] for standard deviation in SBP-SV was 18 [11.4–25.4] for the control group and 19.8 [15.2–27.3, p = 0.19] for the HP group. While bivariate analysis did not show statistical difference for SBP-SD, SBP-SV, HR-SD, or HR-SV, machine learning algorithms identified SBP-SD, HR-SD, and HR-SV as clinically impactful on HP with good accuracy (92.59% and 79.31%). Conclusions: This study suggests that there are factors in hyperacute hemodynamic management in the ED associated with HP among patients with sIPH. Full article

Background: Neurosurgical interventions are often indicated for patients with subcortical, supratentorial intracerebral hemorrhage (ICH); however, the optimal treatment modality is controversial. Whether minimally invasive surgery (MIS) may be superior to conventional craniotomy (CC) or decompressive craniectomy (DC) in real-world clinical practice is unknown. Methods: This was a retrospective cohort study of hospitalization data from the 2016–22 Nationwide Readmissions Database. International Classification of Diseases—10th edition (ICD-10) codes were used to identify patients with primary supratentorial subcortical ICH who underwent neurosurgical treatment. Patients with ICH in other brain compartments (other than intraventricular hemorrhage) were excluded. Coprimary outcomes were routine discharge to home without rehabilitation needs (excellent outcome) and in-hospital mortality. Outcomes were compared between MIS versus CC and MIS versus DC, with multivariable adjustments for patient demographics and comorbidities. Results: A total of 3829 patients were identified; 418 underwent MIS (10.9%), 2167 (56.6%) underwent CC, and 1244 (32.5%) underwent DC. Compared to CC patients, MIS patients were less likely female (p = 0.004) but otherwise had similar patient characteristics; compared to DC patients, MIS patients were older, less likely female, more likely to have mental status abnormalities, more likely to have underlying dementia, less likely to undergo external ventricular drainage, more likely to have vascular risk factors (hypertension, hyperlipidemia, diabetes), and less likely to have underlying coagulopathy (all p < 0.05). After multivariable adjustments, MIS patients had higher odds of excellent outcomes compared to CC (OR 1.99 [95%CI 1.06–3.30], p = 0.039), and similar odds compared to DC (OR 1.10 [95%CI 0.66–1.86], p = 0.73). In terms of in-hospital mortality, MIS had lower odds compared to DC (OR 0.63 [95%CI 0.41–0.96], p = 0.032) and similar odds compared to CC (OR 0.81 [95%CI 0.56–1.18], p = 0.26). Conclusions: For patients with subcortical, supratentorial ICH requiring surgical evacuation, MIS was associated with higherhigher rates of excellent outcomes compared to CC and lower rates of in-hospital mortality compared to DC. However, since key variables such as hematoma size and symptom severity were not available, residual confounding could not be excluded, and results should be interpreted cautiously. Dedicated prospective or randomized studies are needed to confirm these findings. Full article

Background/Objectives: In recent years, stereotactic aspiration followed by fibrinolysis has been accepted as being a less invasive and more effective treatment for spontaneous intracerebral hemorrhage (ICH). The aim of this study was to evaluate the safety and clinical outcomes of frameless stereotactic aspiration and fibrinolysis using urokinase in a single medical center. Methods: This study included 123 patients with spontaneous supratentorial ICH who were treated with stereotactic aspiration and subsequent fibrinolysis using urokinase. Their clinical status, radiological images, and functional outcomes were assessed. Results: Unfavorable outcomes at discharge were associated with each patient’s preoperative Glascow Coma Score, as well as their initial and residual volumes of hematoma. Low mortality and minimal complications of rebleeding were also recorded. Conclusions: The results revealed that stereotactic aspiration and subsequent fibrinolysis with urokinase appeared to be a safe and feasible treatment modality for treating ICH. Further studies are still needed in order to better assess the optimal therapeutic window, thrombolytic dosage, long-term evaluation, and controlled comparisons of mortality, as well as disability outcomes in treated and untreated patients. Full article

Non-traumatic intracerebral hemorrhage (ICH) is one of the most devastating and disabling forms of stroke; however, there are no effective pharmacological therapies available following the insult. Angiogenesis appears as a key step to overcoming the damage and promoting functional recovery. In this context, endothelial progenitor cells (EPCs) mobilization improves oxidative stress and promotes neovascularization, which has been linked to beneficial outcomes following both ischemic and hemorrhagic stroke. The TNF-like weak inducer of apoptosis (TWEAK), binding to its receptor Fn14, has been suggested as an inducer of EPCs differentiation, viability and migration to the injury site in a model of myocardial infarction. Here, we have performed a proof-of-concept preclinical study in a rat model of ICH where we report that a 50 μg/kg dose of rat recombinant TWEAK (rTWEAK) promotes blood progenitor cells mobilization, mainly EPCs. As soon as 72 h post-injury, brain neovascularization, and, importantly, long-term hematoma reduction and improved functional recovery is reported. In contrast, a higher dose of 150 μg/kg blocked those beneficial outcomes. Therefore, a low dose of rTWEAK treatment promotes neovascularization and reduces brain damage in a rat model of ICH. Further clinical studies will be needed to demonstrate if rTWEAK could represent a new strategy to promote recovery following ICH. Full article

Background: Catheter insertion is the most commonly used method for treating intracerebral hemorrhage (ICH). Simultaneous hematoma aspiration allows for faster decompression than catheter insertion alone. Methods: Between March 2020 and Apri1 2024, 49 patients (25 men and 24 women) with ICH underwent ICH catheter insertion. Thirty-two patients (Group A) underwent intraoperative aspiration simultaneously with ICH catheter insertion. The other seventeen patients underwent catheter insertion alone (Group B). Four patients in Group A (12.5%) and two patients in Group B (11.8%) died within one month after surgery. Consequently, a total of 43 patients were included in the final analysis (Group A-1 vs. Group B-1). The Glasgow coma scale (GCS) score and muscle strength of the four extremities in both groups were compared 2 weeks later (first period) and on the date of discharge (second period). Patients in Group A-1 were discharged 5 days earlier than those in Group B-1. (average 49 ± 20 vs. 54 ± 31 days). Results: In Group A, the preoperative ICH volume was 66.2 ± 28.8 mL, and the median aspiration volume was 30 ± 19.6 mL. The preoperative ICH volume was 55.9 ± 22.2 mL in group B. Intraoperative ICH aspiration (Group A-1) significantly improved motor scores during the second period (p = 0.001). It also showed the trend toward improved GCS scores during the first period (p = 0.095) and the second period (p = 0.069). Conclusions: Compared to ICH catheter insertion alone, additional intraoperative ICH aspiration resulted in greater motor improvement at 7 weeks postoperatively (p = 0.004). It also showed a trend toward greater improvement in the GCS scores (p = 0.12). Full article

Background/Objectives: This study aimed to research the potential association between brain atrophy and hematoma expansion (HE) in intracerebral hemorrhage (ICH). Methods: A retrospective analysis was conducted using data from patients with primary ICH in our stroke database. ICH volumes from initial and follow-up CT scans were manually segmented. Total brain and intracranial volumes were quantified using an automated head CT segmentation method. Normalized brain volume (NBV) was calculated by dividing the total brain volume by the total intracranial volume to account for individual head size differences. The relationship between the NBV and hematoma expansion was assessed using linear regression, adjusting for other variables influencing hematoma expansion. Results: Our final analysis included 420 patients. Brain atrophy (lower NBV) was associated with hematoma growth (>0 mL) in patients not on oral anticoagulants (β = −0.159, p = 0.032). A strong association was observed in patients using vitamin K antagonists (β = −0.667, p = 0.006) but not in those on direct oral anticoagulants (DOACs; (β = −0.159, p = 0.436)). Results remained significant in patients not on oral anticoagulants and in those on VKAs when hematoma expansion was defined as a volume increase >6 mL or >33%. Conclusions: This research provides initial evidence that brain atrophy is a risk factor for hematoma expansion, depending on the patient’s coagulation status. These findings could enhance risk stratification for acute clinical management and deepen understanding of the biological mechanisms behind hematoma expansion. Full article

Background: Spontaneous intracerebral hemorrhage (ICH) accounts for approximately 20% of all strokes and is associated with high mortality and disability rates. Despite numerous trials, conventional surgical approaches have not demonstrated consistent improvements in functional outcomes. Minimally invasive surgery (MIS) for ICH evacuation has emerged as a promising alternative, with the potential to improve functional outcomes and reduce mortality. Objectives: This narrative review aims to provide a comprehensive overview of various MIS techniques and their reported impact on functional outcomes in patients with spontaneous ICH while discussing key limitations in the existing literature. Methods: We systematically searched PubMed to identify studies published from 1 January 2010 to 22 March 2024. The search strategy included the following terms: (“minimally*”[All Fields] AND “invasive*”[All Fields] AND “surgery*”[All Fields] AND “intracerebral*”[All Fields] AND “hemorrhage*”[All Fields]) AND (2010:2024[pdat]). This review focuses on randomized controlled trials (RCTs) that evaluate MIS techniques for ICH and their clinical outcomes. Results: Our search identified six RCTs conducted between January 2010 and March 2024, encompassing 2180 patients with a mean age of 58.03 ± 4.5 years. Four trials demonstrated significantly improved functional recovery (mRs ≤ 3), reduced mortality, and fewer adverse events compared with standard medical management or conventional craniotomy. All MIS techniques rely on stereotactic planning and the use of tools such as exoscopes, endoscopes, craniopuncture, or thrombolytic irrigation for precise hematoma evacuation. These approaches reduce brain tissue disruption and improve precision. However, the variability in techniques, costs, and lack of an external validation limit the generalizability of these findings. Conclusions: MIS shows potential as an alternative to conventional management strategies for ICH, offering encouraging evidence for improved functional outcomes and reduced mortality in selected studies. However, these findings remain limited by gaps in the literature, including the need for external validation, significant methodological heterogeneity, and economic challenges. Further rigorous trials are essential to confirm the generalizability and long-term impact of these approaches. Full article

Intracerebral hemorrhage (ICH) is a significant health problem with high mortality and morbidity rates, partly due to limited treatment options. Hematoma after ICH causes neurological deficits due to the mass effect. Hemorrhage catalyzes secondary damage, resulting in increased neurological damage, poor prognosis, and treatment problems. This review evaluates the role of immunotherapeutic approaches in ICH based on original full-text and review articles on the pathophysiology and immunotherapy of ICH, with emphasis on the modulation of microglia/macrophage polarization to the M2 subtype. In this review, we concluded that the pathophysiology of injury progression after ICH is complex and multifaceted. Inflammation plays a dominant role in secondary injuries. Furthermore, cells involved in the inflammatory process have dual roles in pro-inflammatory/destructive and anti-inflammatory/healing. While the role of inflammation in the pathophysiology makes the immune system a therapeutic target in ICH, the dual role of cells makes them a therapeutic target that can modulate anti-inflammatory/healing. Resident microglia (and even macrophages migrating from a peripheral source) are important therapeutic targets for modulation because of their role in the initiation phase and in shaping immunity. Although clinical results remain poor, experimental and clinical trial data seem promising for deciphering the pathophysiology of ICH and providing treatment options. Full article

Hematoma expansion (HE) is an independent predictor of poor outcomes and a modifiable treatment target in intracerebral hemorrhage (ICH). Evaluating HE in large datasets requires segmentation of hematomas on admission and follow-up CT scans, a process that is time-consuming and labor-intensive in large-scale studies. Automated segmentation of hematomas can expedite this process; however, cumulative errors from segmentation on admission and follow-up scans can hamper accurate HE classification. In this study, we combined a tandem deep-learning classification model with automated segmentation to generate probability measures for false HE classifications. With this strategy, we can limit expert review of automated hematoma segmentations to a subset of the dataset, tailored to the research team’s preferred sensitivity or specificity thresholds and their tolerance for false-positive versus false-negative results. We utilized three separate multicentric cohorts for cross-validation/training, internal testing, and external validation (n = 2261) to develop and test a pipeline for automated hematoma segmentation and to generate ground truth binary HE annotations (≥3, ≥6, ≥9, and ≥12.5 mL). Applying a 95% sensitivity threshold for HE classification showed a practical and efficient strategy for HE annotation in large ICH datasets. This threshold excluded 47–88% of test-negative predictions from expert review of automated segmentations for different HE definitions, with less than 2% false-negative misclassification in both internal and external validation cohorts. Our pipeline offers a time-efficient and optimizable method for generating ground truth HE classifications in large ICH datasets, reducing the burden of expert review of automated hematoma segmentations while minimizing misclassification rate. Full article

Background: Post-hemicraniectomy patients often need extended intensive care treatment. While computed tomography (CT) is considered the gold standard for regular imaging, its frequent use could be linked to adverse clinical outcomes. This study aimed to assess bedside transcranial ultrasound (TUS) to capture intracranial anatomical structures and pathologies. Methods: We analyzed 19 patients treated in our neurosurgical ICU from 1 January 2023 to 1 February 2024. Six physicians from our unit (three residents and three attending physicians) conducted a retrospective evaluation. A total of 158 sessions, including multiple freeze frames and video footage, were analyzed, including 7 imaging categories, using a Likert scale. Subsequently, correlation between CT and TUS was evaluated for midline (ML) shift, subdural space, lateral ventricular width (LVW), and extent of intracerebral hematoma using the Pearson’s correlation coefficient (r). Results: TUS was performed on average on 8.32/19.53 days (mean inpatient stay). It provided the lowest Likert scores for the imaging categories ventricular system, midline, subdural space, intraventricular catheter placement, and cortical gyration. Residents reported slightly inferior assessability, resulting in higher scores on the Likert scale (0.02–0.93 mean difference compared with attending physicians). A high correlation was shown in terms of ML shift, LVW, and intracerebral hematomas. No relevant correlation was shown in subdural space. Conclusions: TUS is a safe, cost-, and time-efficient method, potentially gaining relevance for imaging post-hemicraniectomy patients. In our setting, the method seemed effective in depicting intraventricular catheter placement, hydrocephalus, ML shift, and space-occupying lesions. Further improvement in image quality could potentially reduce the overall number of indicated CT scans. Full article

Background: Intracerebral hemorrhages (ICH) and perihematomal edema (PHE) are respective imaging markers of primary and secondary brain injury in hemorrhagic stroke. In this study, we explored the potential added value of PHE radiomic features for prognostication in ICH patients. Methods: Using a multicentric trial cohort of acute supratentorial ICH (n = 852) patients, we extracted radiomic features from ICH and PHE lesions on admission non-contrast head CTs. We trained and tested combinations of different machine learning classifiers and feature selection methods for prediction of poor outcome—defined by 4-to-6 modified Rankin Scale scores at 3-month follow-up—using five different input strategies: (a) ICH radiomics, (b) ICH and PHE radiomics, (c) admission clinical predictors of poor outcomes, (d) ICH radiomics and clinical variables, and (e) ICH and PHE radiomics with clinical variables. Models were trained on 500 patients, tested, and compared in 352 using the receiver operating characteristics Area Under the Curve (AUC), Integrated Discrimination Index (IDI), and Net Reclassification Index (NRI). Results: Comparing the best performing models in the independent test cohort, both IDI and NRI demonstrated better individual-level risk assessment by addition of PHE radiomics as input to ICH radiomics (both p < 0.001), but with insignificant improvement in outcome prediction (AUC of 0.74 versus 0.71, p = 0.157). The addition of ICH and PHE radiomics to clinical variables also improved IDI and NRI risk-classification (both p < 0.001), but with a insignificant increase in AUC of 0.85 versus 0.83 (p = 0.118), respectively. All machine learning models had greater or equal accuracy in outcome prediction compared to the widely used ICH score. Conclusions: The addition of PHE radiomics to hemorrhage lesion radiomics, as well as radiomics to clinical risk factors, can improve individual-level risk assessment, albeit with an insignificant increase in prognostic accuracy. Machine learning models offer quantitative and immediate risk stratification—on par with or more accurate than the ICH score—which can potentially guide patients’ selection for interventions such as hematoma evacuation. Full article

Patients on hemodialysis (HD) are at a very high risk of stroke, especially hemorrhagic stroke, with worse outcomes than the general population. We have determined the indications for urgent neurosurgery for intracerebral hemorrhage (ICH) based on the hematoma volume and neurological severity, regardless of HD status. This study aimed to evaluate the neurosurgical outcomes of ICH in patients undergoing HD. We retrospectively reviewed 38 cases of surgical removal of ICH performed in patients on HD. Patients were categorized into poor or better (0–4) and very poor (5 or 6) groups according to their modified Rankin Scale (mRS) score at discharge. Patient demographics, clinical characteristics, and operative records were retrospectively analyzed. The median Glasgow Coma Scale (GCS) score and hematoma volume were 6 and 99 mL, respectively. A total of 30 patients (78.9%) had very poor outcomes at discharge. Significant differences were observed in GCS score (13 vs. 6) and hematoma volume (53 vs. 114 mL) between the poor or better and very poor groups. The receiver operating characteristic curve analysis showed the cut-off values were 9 for GCS (AUC = 0.821) and 63.3 mL for hematoma volume (AUC = 0.812). The most common complication was rebleeding (10.5%), followed by seizures (7.9%), infection (7.9%), and cerebral edema (7.9%). In conclusion, neurosurgical outcomes of ICH in patients undergoing HD remain poor, but 21.1% of these patients achieved an mRS ≤ 4. ICH patients on HD with a GCS score > 9 or hematoma volume < 63 mL are more likely to demonstrate mRS ≤ 4 after surgical evacuation. The postoperative management of patients on HD should be performed considering specific risks, such as seizures and rebleeding. Full article

Background: Intracerebral hemorrhage (ICH) is a severe type of stroke with high mortality. Persistent hyperglycemia following ICH is linked to deteriorated neurological functions and death. However, the exacerbating effect of hyperglycemia on ICH injury at the molecular level is still unclear. Therefore, this study explores the impact of diabetes on ICH injury using a non-obese diabetic (NOD) mouse model of type I diabetes mellitus. Methods: NOD and non-diabetic (non-obese resistant) mice subjected to ICH by intrastriatal injection of collagenase were sacrificed three days following the ICH. Brains were collected for hematoma volume measurement and immunohistochemistry. Neurobehavioral assays were conducted 24 h before ICH and then repeated at 24, 48 and 72 h following ICH. Results: NOD mice showed increased hematoma volume and impairment in neurological function, as revealed by rotarod and grip strength analyses. Immunohistochemical staining showed reduced glial cell activation, as indicated by decreased GFAP and Iba1 staining. Furthermore, the expression of oxidative/nitrosative stress markers represented by 3-nitrotyrosine and inducible nitric oxide synthase was reduced in the diabetic group. Conclusions: Overall, our findings support the notion that hyperglycemia exacerbates ICH injury and worsens neurological function and that the mechanism of injury varies depending on the type of diabetes model used. Full article

Background: Intracerebral hemorrhages (ICHs) are prevalent, with high morbidity and mortality. We analyzed whether decompressive craniectomy (DC) without evacuation of the acute intraparenchymal hematoma could produce better functional outcomes than treatment with evacuation. Methods: Patients with acute ICH treated with DC without clot evacuation, or evacuation with or without associated craniectomy were included. Matched univariate analyses were performed, and a binary logistic regression model was constructed using the Glasgow Outcome Scale (GOS) and modified Rankin scale (mRS) as dependent variables. Results: 27 patients treated with DC without clot evacuation were compared to 36 patients with clot evacuation; eleven of the first group were matched with 18 patients with evacuation. A significantly better functional prognosis in the group treated with DC without clot evacuation was found. Patients aged < 55 years and treated with DC without clot evacuation had a significantly better functional prognosis (p = 0.008 and p = 0.039, respectively). In multivariate analysis, the intervention performed was the greatest predictor of functional status at the end of follow-up. Conclusions: DC without clot evacuation improves the functional prognosis of patients with acute intraparenchymal hematomas. Larger multicenter studies are warranted to determine whether a change in the management of acute ICH should be recommended. Full article