RESUMEN
INTRODUCTION: The apnea test (AT) is a crucial procedure in determining brain death (BD), with detection of spontaneous breathing efforts serving as a key criterion. Numerous national statutes mandate complete disconnection of the patient from the ventilator during the procedure to open the airway directly to the atmosphere. These regulations mandate visual observation as an exclusive option for detecting breathing efforts. However, reliance on visual observation alone can pose challenges in identifying subtle respiratory movements. CASE PRESENTATION: This case report presents a 55-year-old morbidly obese male patient with suspected BD due to cerebral hemorrhage undergoing an AT. The AT was performed with continuous electrical impedance tomography (EIT) monitoring. Upon detection of spontaneous breathing movements by both visual observation and EIT, the AT was aborted, and the patient was reconnected to the ventilator. EIT indicated a shift in ventilation distribution from the ventral to the dorsal regions, indicating the presence of spontaneous breathing efforts. EIT results also suggested the patient experienced a slow but transient initial recovery phase, likely due to atelectasis induced by morbid obesity, before returning to a steady state of ventilatory support. CONCLUSION: The findings suggest EIT could enhance the sensitivity and accuracy of detecting spontaneous breathing efforts, providing additional insights into the respiratory status of patients during the AT.
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Apnea , Muerte Encefálica , Impedancia Eléctrica , Obesidad Mórbida , Tomografía , Humanos , Masculino , Muerte Encefálica/diagnóstico , Muerte Encefálica/fisiopatología , Persona de Mediana Edad , Apnea/diagnóstico , Apnea/fisiopatología , Tomografía/métodos , Obesidad Mórbida/complicaciones , Obesidad Mórbida/fisiopatología , Respiración , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/complicaciones , Hemorragia Cerebral/fisiopatologíaRESUMEN
BACKGROUND: Hemorrhagic transformation (HT) and cerebral edema (CED) are both major complications following ischemic stroke, but few studies have evaluated their overlap. We evaluated the frequency and predictors of CED/HT overlap and whether their co-occurrence impacts functional outcome more than each in isolation. METHODS: 892 stroke patients enrolled in a prospective study had follow-up CT imaging evaluated for HT and CED; the latter was quantified using the ratio of hemispheric CSF volumes (with hemispheric CSF ratio < 0.90 used as the CED threshold). The interaction between HT and CED on functional outcome (using modified Rankin Scale at 3 months) was compared to that for each condition separately. RESULTS: Among the 275 (31%) who developed HT, 233 (85%) manifested hemispheric CSF ratio < 0.9 (CED/HT), with this overlap group representing half of the 475 with measurable CED. Higher baseline NIHSS scores and larger infarct volumes were observed in the CED/HT group compared with those with CED or HT alone. Functional outcome was worse in those with CED/HT [median mRS 3 (IQR 2-5)] than those with CED [median 2 (IQR 1-4)] or HT alone [median 1 (IQR 0-2), p < 0.0001]. Overlap of CED/HT independently predicted worse outcome [OR 1.89 (95% CI: 1.12-3.18), p = 0.02] while HT did not; however, CED/HT was no longer associated with worse outcome after adjusting for severity of CED [adjusted OR 0.35 (95% CI: 0.23, 0.51) per 0.21 lower hemispheric CSF ratio, p < 0.001]. CONCLUSIONS: Most stroke patients with HT also have measurable CED. The co-occurrence of CED and HT occurs in larger and more severe strokes and is associated with worse functional outcome, although this is driven by greater severity of stroke-related edema in those with HT.
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Edema Encefálico , Evaluación de la Discapacidad , Estado Funcional , Accidente Cerebrovascular Isquémico , Recuperación de la Función , Humanos , Masculino , Anciano , Femenino , Edema Encefálico/diagnóstico por imagen , Edema Encefálico/etiología , Edema Encefálico/fisiopatología , Edema Encefálico/líquido cefalorraquídeo , Accidente Cerebrovascular Isquémico/fisiopatología , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/líquido cefalorraquídeo , Accidente Cerebrovascular Isquémico/complicaciones , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Factores de Tiempo , Hemorragia Cerebral/fisiopatología , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/diagnóstico , Anciano de 80 o más Años , Pronóstico , Tomografía Computarizada por Rayos X , Hemorragias Intracraneales/fisiopatología , Hemorragias Intracraneales/etiologíaRESUMEN
OBJECTIVE: To describe the potential effects of Intracranial pressure monitoring on the outcome of patients with spontaneous intracerebral hemorrhage (ICH). METHODS: This study is a systematic review with meta-analysis. Patients with spontaneous ICH treated with intracranial pressure monitoring were included. The primary outcome was mortality at 6 months and in-hospital mortality. The secondary outcome was poor neurological function outcome at 6 months. RESULTS: This analysis compares in-hospital and 6-month mortality rates between patients with intracranial pressure monitoring (ICPm) and those without (no ICPm). Although the ICPm group had a lower in-hospital mortality rate, it was not statistically significant (24.9% vs. 34.1%; OR 0.51, 95% CI 0.20 to 1.31, P = 0.16). Excluding patients with intraventricular hemorrhage revealed a significant reduction in in-hospital mortality for the ICPm group (23.5% vs. 43%; OR 0.39, 95% CI 0.29 to 0.53, P < 0.00001). For 6-month mortality, the ICPm group showed a significant reduction (32% vs. 39.6%; OR 0.76, 95% CI 0.61 to 0.94, P = 0.01), with the effect being more pronounced after excluding intraventricular hemorrhage patients (29.1% vs. 47.2%; OR 0.45, 95% CI 0.34 to 0.60, P < 0.0001). However, there were no statistically significant differences in 6-month functional outcomes between the groups. Increased ICP was associated with higher 3-month mortality (OR 1.12, 95% CI 1.07 to 1.18, P < 0.00001) and lower likelihood of good functional outcomes (OR 1.11, 95% CI 1.04 to 1.18, P < 0.00001). CONCLUSIONS: Elevated ICP is associated with increased mortality and poor prognosis in ICH patients. Although continuous intracranial pressure monitoring may reduce short-term mortality rates in specific subgroups of ICH patients, it does not improve neurological functional outcomes. While potential patient populations may benefit from ICP monitoring, more research is needed to screen suitable populations for ICP monitoring.
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Hemorragia Cerebral , Mortalidad Hospitalaria , Presión Intracraneal , Humanos , Presión Intracraneal/fisiología , Hemorragia Cerebral/mortalidad , Hemorragia Cerebral/fisiopatología , Hemorragia Cerebral/diagnóstico , Monitoreo Fisiológico/métodos , Hipertensión Intracraneal/mortalidad , Hipertensión Intracraneal/fisiopatología , Hipertensión Intracraneal/diagnósticoRESUMEN
Segmentation and the subsequent quantitative assessment of the target object in computed tomography (CT) images provide valuable information for the analysis of intracerebral hemorrhage (ICH) pathology. However, most existing methods lack a reasonable strategy to explore the discriminative semantics of multi-scale ICH regions, making it difficult to address the challenge of complex morphology in clinical data. In this paper, we propose a novel multi-scale object equalization learning network (MOEL-Net) for accurate ICH region segmentation. Specifically, we first introduce a shallow feature extraction module (SFEM) for obtaining shallow semantic representations to maintain sufficient and effective detailed location information. Then, a deep feature extraction module (DFEM) is leveraged to extract the deep semantic information of the ICH region from the combination of SFEM and original image features. To further achieve equalization learning in different scales of ICH regions, we introduce a multi-level semantic feature equalization fusion module (MSFEFM), which explores the equalized fusion features of the described objects with the assistance of shallow and deep semantic information provided by SFEM and DFEM. Driven by the above three designs, MOEL-Net shows a solid capacity to capture more discriminative features in various ICH region segmentation. To promote the research of clinical automatic ICH region segmentation, we collect two datasets, VMICH and FRICH (divided into Test A and Test B) for evaluation. Experimental results show that the proposed model achieves the Dice scores of 88.28%, 90.92%, and 90.95% on the VMICH, FRICH Test A, and Test B, respectively, which outperform fourteen competing methods.
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Hemorragia Cerebral , Redes Neurales de la Computación , Tomografía Computarizada por Rayos X , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/fisiopatología , Humanos , Semántica , Procesamiento de Imagen Asistido por Computador/métodos , Aprendizaje Automático , Algoritmos , Aprendizaje ProfundoRESUMEN
Cerebral microhemorrhages (CMHs) are of paramount importance as they not only signify underlying vascular pathology but also have profound implications for cognitive function and neurological health, serving as a critical indicator for the early detection and management of vascular cognitive impairment (VCI). This study aimed to investigate the effects of hypertension-induced CMHs on gait dynamics in a mouse model, focusing on the utility of advanced gait metrics as sensitive indicators of subclinical neurological alterations associated with CMHs. To induce CMHs, we employed a hypertensive mouse model, using a combination of Angiotensin II and L-NAME to elevate blood pressure, further supplemented with phenylephrine to mimic transient blood pressure fluctuations. Gait dynamics were analyzed using the CatWalk system, with emphasis on symmetry indices for Stride Length (SL), Stride Time (ST), and paw print area, as well as measures of gait entropy and regularity. The study spanned a 30-day experimental period, capturing day-to-day variations in gait parameters to assess the impact of CMHs. Temporary surges in gait asymmetry, detected as deviations from median gait metrics, suggested the occurrence of subclinical neurological signs associated with approximately 50% of all histologically verified CMHs. Our findings also demonstrated that increases in gait entropy correlated with periods of increased gait asymmetry, providing insights into the complexity of gait dynamics in response to CMHs. Significant correlations were found between SL and ST symmetry indices and between these indices and the paw print area symmetry index post-hypertension induction, indicating the interdependence of spatial and temporal aspects of gait affected by CMHs. Collectively, advanced gait metrics revealed sensitive, dynamic alterations in gait regulation associated with CMHs, resembling the temporal characteristics of transient ischemic attacks (TIAs). This underscores their potential as non-invasive indicators of subclinical neurological impacts. This study supports the use of detailed gait analysis as a valuable tool for detecting subtle neurological changes, with implications for the early diagnosis and monitoring of cerebral small vessel disease (CSVD) in clinical settings.
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Modelos Animales de Enfermedad , Hipertensión , Animales , Hipertensión/fisiopatología , Hipertensión/complicaciones , Masculino , Ratones , Ratones Endogámicos C57BL , Marcha/fisiología , Hemorragia Cerebral/fisiopatología , Hemorragia Cerebral/complicaciones , Trastornos Neurológicos de la Marcha/etiología , Trastornos Neurológicos de la Marcha/fisiopatología , Entropía , Análisis de la Marcha/métodosRESUMEN
OBJECTIVES: Optic nerve sheath diameter (ONSD) may serve as an early marker of increasing intracranial pressure resulting from intracerebral hemorrhage (ICH). We investigated if changes in ONSD can predict 90-day functional outcomes in ICH patients. MATERIALS AND METHODS: We utilized ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage), a prospective, multi-center, case-control study of 3000 patients. We included patients with baseline and follow-up head CT with available outcomes. We measured change in ONSD from baseline and follow-up CT within a 6 (±1) hour window. Our primary outcome was the 90-day Modified Rankin (mRS) score. We compared patients with good (mRS 0-3) versus poor outcomes (mRS 4-6) to presence of significant change in ONSD using univariate analysis. We did an analysis of variance to assess for differences in ONSD. RESULTS: Of 93 ICH patients who fit the inclusion criteria, the mean age was 64.1 (SD +/- 14.6), with 36.6 % being females. Forty-nine patients (47.1 %) had significant ONSD change between baseline and follow-up CT. ONSD change in the poor outcome group was not significantly different than that of the good outcome group in both the right and left hemispheres (p = 0.21 and p = 0.63 respectively). CONCLUSIONS: We found that early change in the ONSD within the first 6 h of presentation in patients with ICH does not predict functional outcomes at three months.
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Hemorragia Cerebral , Nervio Óptico , Valor Predictivo de las Pruebas , Humanos , Femenino , Masculino , Persona de Mediana Edad , Anciano , Nervio Óptico/diagnóstico por imagen , Estudios Prospectivos , Estudios de Casos y Controles , Factores de Tiempo , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/fisiopatología , Tomografía Computarizada por Rayos X , Evaluación de la Discapacidad , Hipertensión Intracraneal/fisiopatología , Hipertensión Intracraneal/diagnóstico , Hipertensión Intracraneal/diagnóstico por imagen , Hipertensión Intracraneal/etiología , Estado Funcional , Recuperación de la Función , Pronóstico , Anciano de 80 o más Años , Presión Intracraneal , Estados UnidosRESUMEN
IMPORTANCE: Patients admitted with cerebral hemorrhage or cerebral edema often undergo external ventricular drain (EVD) placement to monitor and manage intracranial pressure (ICP). A strain gauge transducer accompanies the EVD to convert a pressure signal to an electrical waveform and assign a numeric value to the ICP. OBJECTIVES: This study explored ICP accuracy in the presence of blood and other viscous fluid contaminates in the transducer. DESIGN: Preclinical comparative design study. SETTING: Laboratory setting using two Natus EVDs, two strain gauge transducers, and a sealed pressure chamber. PARTICIPANTS: No human subjects or animal models were used. INTERVENTIONS: A control transducer primed with saline was compared with an investigational transducer primed with blood or with saline/glycerol mixtures in mass:mass ratios of 25%, 50%, 75%, and 100% glycerol. Volume in a sealed chamber was manipulated to reflect changes in ICP to explore the impact of contaminates on pressure measurement. MEASUREMENTS AND MAIN RESULTS: From 90 paired observations, ICP readings were statistically significantly different between the control (saline) and experimental (glycerol or blood) transducers. The time to a stable pressure reading was significantly different for saline vs. 25% glycerol (< 0.0005), 50% glycerol (< 0.005), 75% glycerol (< 0.0001), 100% glycerol (< 0.0005), and blood (< 0.0005). A difference in resting stable pressure was observed for saline vs. blood primed transducers (0.041). CONCLUSIONS AND RELEVANCE: There are statistically significant and clinically relevant differences in time to a stable pressure reading when contaminates are introduced into a closed drainage system. Changing a transducer based on the presence of blood contaminate should be considered to improve accuracy but must be weighed against the risk of introducing infection.
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Presión Intracraneal , Transductores de Presión , Presión Intracraneal/fisiología , Humanos , Sangre/metabolismo , Glicerol , Monitoreo Fisiológico/instrumentación , Monitoreo Fisiológico/métodos , Drenaje/instrumentación , Hemorragia Cerebral/fisiopatología , Hemorragia Cerebral/diagnósticoRESUMEN
BACKGROUND: Paroxysmal sympathetic hyperexcitability (PSH) is a group of complex syndromes with various etiologies. Previous studies were limited to the description of traumatic brain injury (TBI), and the description of PSH after other types of brain injury was rare. We explored the clinical features, treatment, and prognosis of PSH after various types of brain injuries. METHODS: Patients admitted to the neurosurgery intensive care unit with PSH after brain injury from July 2019 to December 2022 were included. Demographic data, clinical manifestations, drug therapy, and disease prognosis were retrospectively collected and analyzed. RESULTS: Fifteen male and 9 female patients with PSH after brain injury were selected. TBI was most likely to cause PSH (66.7%), followed by spontaneous intracerebral hemorrhage (25%). Glasgow coma scale scores of 19 patients (79.2%) were lower than 8 and 14 patients (58.3%) underwent tracheotomy. Electroencephalogram monitoring was performed in 12 individuals, none of which showed epileptic waves. Clinical symptom scale showed mild symptoms in 17 cases (70.8%). Almost all patients were administered a combination of drugs. After follow-up, most patients had a poor prognosis and 2 (8.3%) died after discharge. CONCLUSION: The etiology of PSH is complex. TBI may be the most common cause of PSH. Non-TBI may also be an important cause of PSH. Therefore, early identification, prevention and diagnosis are helpful for determining the prognosis and outcome of the disease.
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Electroencefalografía , Humanos , Masculino , Femenino , Persona de Mediana Edad , Adulto , Estudios Retrospectivos , Pronóstico , Electroencefalografía/métodos , Escala de Coma de Glasgow , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/fisiopatología , Anciano , Enfermedades del Sistema Nervioso Autónomo/etiología , Enfermedades del Sistema Nervioso Autónomo/diagnóstico , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/fisiopatología , Hemorragia Cerebral/complicaciones , Hemorragia Cerebral/fisiopatologíaRESUMEN
OBJECTIVE: Previous resting-state functional magnetic resonance imaging studies on intracerebral hemorrhage patients have focused more on the static characteristics of brain activity, while the time-varying effects during scanning have received less attention. Therefore, the current study aimed to explore the dynamic functional network connectivity changes of intracerebral hemorrhage patients. METHODS: Using independent component analysis, the sliding window approach, and the k-means clustering analysis method, different dynamic functional network connectivity states were detected from resting-state functional magnetic resonance imaging data of 37 intracerebral hemorrhage patients and 44 healthy controls. The inter-group differences in dynamic functional network connectivity patterns and temporal properties were investigated, followed by correlation analyses between clinical scales and abnormal functional indexes. RESULTS: Ten resting-state networks were identified, and the dynamic functional network connectivity matrices were clustered into four different states. The transition numbers were decreased in the intracerebral hemorrhage patients compared with healthy controls, which was associated with trail making test scores in patients. The cerebellar network and executive control network connectivity in State 1 was reduced in patients, and this abnormal dynamic functional connectivity was positively correlated with the animal fluency test scores of patients. INTERPRETATION: The current study demonstrated the characteristics of dynamic functional network connectivity in intracerebral hemorrhage patients and revealed that abnormal temporal properties and functional connectivity may be related to the performance of different cognitive domains after ictus. These results may provide new insights into exploring the neurocognitive mechanisms of intracerebral hemorrhage.
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Hemorragia Cerebral , Imagen por Resonancia Magnética , Red Nerviosa , Humanos , Hemorragia Cerebral/fisiopatología , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/complicaciones , Masculino , Femenino , Adulto , Red Nerviosa/fisiopatología , Red Nerviosa/diagnóstico por imagen , Conectoma , Persona de Mediana Edad , Función Ejecutiva/fisiología , Encéfalo/fisiopatología , Encéfalo/diagnóstico por imagenRESUMEN
PURPOSE OF REVIEW: When compared to ischaemic stroke, there have been limited advances in acute management of intracerebral haemorrhage. Blood pressure control in the acute period is an intervention commonly implemented and recommended in guidelines, as elevated systolic blood pressure is common and associated with haematoma expansion, poor functional outcomes, and mortality. This review addresses the uncertainty around the optimal blood pressure intervention, specifically timing and length of intervention, intensity of blood pressure reduction and agent used. RECENT FINDINGS: Recent pivotal trials have shown that acute blood pressure intervention, to a systolic target of 140mmHg, does appear to be beneficial in ICH, particularly when bundled with other therapies such as neurosurgery in selected cases, access to critical care units, blood glucose control, temperature management and reversal of coagulopathy. Systolic blood pressure should be lowered acutely in intracerebral haemorrhage to a target of approximately 140mmHg, and that this intervention is generally safe in the ICH population.
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Presión Sanguínea , Hemorragia Cerebral , Humanos , Hemorragia Cerebral/terapia , Hemorragia Cerebral/complicaciones , Hemorragia Cerebral/fisiopatología , Presión Sanguínea/fisiología , Antihipertensivos/uso terapéutico , Hipertensión/complicaciones , Hipertensión/terapia , Manejo de la EnfermedadRESUMEN
Cerebral microbleeds (CMBs) can be understood as a type of target organ damage caused by hypertension. We aimed to explore the association of the CMB burden with morning blood pressure (BP) variability in patients with hypertension. We divided patients with hypertension into two groups: a group with 1-10 CMBs and a group with more than 10 CMBs. The duration, grade, medication, and control of hypertension were recorded in all patients. Morning home BP measurements were performed every 3 days for a month. A total of 791 patients were recruited. Full factor model analysis showed that higher morning home diastolic BP variability (standard deviation [SD], OR = 1.080, 95% CI: 1.024-1.140, P = .005; coefficient of variation [CV], OR = 1.076, 95% CI: 1.028-1.128, P = .002) was associated with more than 10 CMBs. Morning home systolic and diastolic blood pressure variability (SD, CV, average real variability) in more than 10 non-lobar CMBs group was significantly higher than that in 1-10 non-lobar CMBs group (P < .05).The multivariate analysis showed higher morning home diastolic blood pressure variability (SD, OR = 1.124, 95% CI: 1.031-1.224, P = .008; CV, OR = 1.099, 95% CI: 1.019-1.186, P = .015; average real variability, OR = 1.055, 95% CI: 0.995-1.120, P = .075) was associated with more than 10 non-lobar CMBs. There was no significant relationship between morning home systolic blood pressure variability and more than 10 non-lobar CMBs (P > .05). Higher morning home diastolic blood pressure variability was associated with more than 10 CMBs and more than 10 non-lobar CMBs.
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Monitoreo Ambulatorio de la Presión Arterial , Presión Sanguínea , Hemorragia Cerebral , Ritmo Circadiano , Hipertensión , Humanos , Femenino , Masculino , Hipertensión/fisiopatología , Hipertensión/diagnóstico , Hipertensión/epidemiología , Presión Sanguínea/fisiología , Persona de Mediana Edad , Ritmo Circadiano/fisiología , Anciano , Hemorragia Cerebral/fisiopatología , Hemorragia Cerebral/epidemiología , Monitoreo Ambulatorio de la Presión Arterial/métodos , Monitoreo Ambulatorio de la Presión Arterial/estadística & datos numéricos , Antihipertensivos/uso terapéutico , Factores de RiesgoRESUMEN
Spontaneous intracerebral hemorrhage (ICH) is the most morbid of all stroke types with a high early mortality and significant early disability burden. Traditionally, outcome assessments after ICH have mirrored those of acute ischemic stroke, with 3 months post-ICH being considered a standard time point in most clinical trials, observational studies, and clinical practice. At this time point, the majority of ICH survivors remain with moderate to severe functional disability. However, emerging data suggest that recovery after ICH occurs over a more protracted course and requires longer periods of follow-up, with more than 40% of ICH survivors with initial severe disability improving to partial or complete functional independence over 1 year. Multiple other domains of recovery impact ICH survivors including cognition, mood, and health-related quality of life, all of which remain under studied in ICH. To further complicate the picture, the most important driver of mortality after ICH is early withdrawal of life-sustaining therapies, before initiation of treatment and evaluating effects of prolonged supportive care, influenced by early pessimistic prognostication based on baseline severity factors and prognostication biases. Thus, our understanding of the true natural history of ICH recovery remains limited. This review summarizes the existing literature on outcome trajectories in functional and nonfunctional domains, describes limitations in current prognostication practices, and highlights areas of uncertainty that warrant further research.
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Hemorragia Cerebral , Humanos , Hemorragia Cerebral/terapia , Hemorragia Cerebral/mortalidad , Hemorragia Cerebral/complicaciones , Hemorragia Cerebral/fisiopatología , Hemorragia Cerebral/diagnóstico , Recuperación de la Función/fisiología , Evaluación de Resultado en la Atención de Salud , Calidad de VidaRESUMEN
BACKGROUND: Hematoma volume is a major pathophysiological hallmark of acute intracerebral hemorrhage (ICH). We investigated how the variance in functional outcome induced by the ICH volume is explained by neurological deficits at admission using a mediation model. METHODS: Patients with acute ICH treated in three tertiary stroke centers between January 2010 and April 2019 were retrospectively analyzed. Mediation analysis was performed to investigate the effect of ICH volume (0.8 ml (5% quantile) versus 130.6 ml (95% quantile)) on the risk of unfavorable functional outcome at discharge defined as modified Rankin Score (mRS) ≥ 3 with mediation through National Institutes of Health Stroke Scale (NIHSS) at admission. Multivariable regression was conducted to identify factors related to neurological improvement and deterioration. RESULTS: Three hundred thirty-eight patients were analyzed. One hundred twenty-one patients (36%) achieved mRS ≤ 3 at discharge. Mediation analysis showed that NIHSS on admission explained 30% [13%; 58%] of the ICH volume-induced variance in functional outcome at smaller ICH volume levels, and 14% [4%; 46%] at larger ICH volume levels. Higher ICH volume at admission and brainstem or intraventricular location of ICH were associated with neurological deterioration, while younger age, normotension, lower ICH volumes, and lobar location of ICH were predictors for neurological improvement. CONCLUSION: NIHSS at admission reflects 14% of the functional outcome at discharge for larger hematoma volumes and 30% for smaller hematoma volumes. These results underscore the importance of effects not reflected in NIHSS admission for the outcome of ICH patients such as secondary brain injury and early rehabilitation.
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Hemorragia Cerebral , Humanos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Hemorragia Cerebral/fisiopatología , Hemorragia Cerebral/diagnóstico por imagen , Estudios Retrospectivos , Anciano de 80 o más Años , Recuperación de la Función/fisiología , Evaluación de Resultado en la Atención de Salud , Admisión del Paciente , Índice de Severidad de la EnfermedadRESUMEN
Cerebral microhemorrhages (CMHs, also known as cerebral microbleeds) are a critical but frequently underestimated aspect of cerebral small vessel disease (CSVD), bearing substantial clinical consequences. Detectable through sensitive neuroimaging techniques, CMHs reveal an extensive pathological landscape. They are prevalent in the aging population, with multiple CMHs often being observed in a given individual. CMHs are closely associated with accelerated cognitive decline and are increasingly recognized as key contributors to the pathogenesis of vascular cognitive impairment and dementia (VCID) and Alzheimer's disease (AD). This review paper delves into the hypothesis that atherosclerosis, a prevalent age-related large vessel disease, extends its pathological influence into the cerebral microcirculation, thereby contributing to the development and progression of CSVD, with a specific focus on CMHs. We explore the concept of vascular aging as a continuum, bridging macrovascular pathologies like atherosclerosis with microvascular abnormalities characteristic of CSVD. We posit that the same risk factors precipitating accelerated aging in large vessels (i.e., atherogenesis), primarily through oxidative stress and inflammatory pathways, similarly instigate accelerated microvascular aging. Accelerated microvascular aging leads to increased microvascular fragility, which in turn predisposes to the formation of CMHs. The presence of hypertension and amyloid pathology further intensifies this process. We comprehensively overview the current body of evidence supporting this interconnected vascular hypothesis. Our review includes an examination of epidemiological data, which provides insights into the prevalence and impact of CMHs in the context of atherosclerosis and CSVD. Furthermore, we explore the shared mechanisms between large vessel aging, atherogenesis, microvascular aging, and CSVD, particularly focusing on how these intertwined processes contribute to the genesis of CMHs. By highlighting the role of vascular aging in the pathophysiology of CMHs, this review seeks to enhance the understanding of CSVD and its links to systemic vascular disorders. Our aim is to provide insights that could inform future therapeutic approaches and research directions in the realm of neurovascular health.
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Envejecimiento , Enfermedades de los Pequeños Vasos Cerebrales , Humanos , Enfermedades de los Pequeños Vasos Cerebrales/fisiopatología , Enfermedades de los Pequeños Vasos Cerebrales/patología , Envejecimiento/fisiología , Aterosclerosis/fisiopatología , Hemorragia Cerebral/fisiopatología , Microcirculación/fisiología , Factores de Riesgo , Microvasos/patología , Microvasos/fisiopatología , AncianoRESUMEN
BACKGROUND AND OBJECTIVES: The prognosis of patients with spontaneous intracerebral hemorrhage (ICH) is often influenced by hematoma volume, a well-established predictor of poor outcome. However, the optimal intraventricular hemorrhage (IVH) volume cutoff for predicting poor outcome remains unknown. METHODS: We analyzed 313 patients with spontaneous ICH not undergoing evacuation, including 7 cases with external ventricular drainage (EVD). These patients underwent a baseline CT scan, followed by a 24-hour CT scan for measurement of both hematoma and IVH volume. We defined hematoma growth as hematoma growth > 33 % or 6 mL at follow-up CT, and poor outcome as modified Rankin Scale score≥3 at three months. Cutoffs with optimal sensitivity and specificity for predicting poor outcome were identified using receiver operating curves. RESULTS: The receiver operating characteristic analysis identified 6 mL as the optimal cutoff for predicting poor outcome. IVH volume> 6 mL was observed in 53 (16.9 %) of 313 patients. Patients with IVH volume>6 mL were more likely to be older and had higher NIHSS score and lower GCS score than those without. IVH volume>6 mL (adjusted OR 2.43, 95 % CI 1.13-5.30; P = 0.026) was found to be an independent predictor of poor clinical outcome at three months in multivariable regression analysis. CONCLUSIONS: Optimal IVH volume cutoff represents a powerful tool for improving the prediction of poor outcome in patients with ICH, particularly in the absence of clot evacuation or common use of EVD. Small amounts of intraventricular blood are not independently associated with poor outcome in patients with intracerebral hemorrhage. The utilization of optimal IVH volume cutoffs may improve the clinical trial design by targeting ICH patients that will obtain maximal benefit from therapies.
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Valor Predictivo de las Pruebas , Tomografía Computarizada por Rayos X , Humanos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Hemorragia Cerebral Intraventricular/diagnóstico por imagen , Hemorragia Cerebral Intraventricular/fisiopatología , Hemorragia Cerebral Intraventricular/terapia , Hemorragia Cerebral Intraventricular/diagnóstico , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/terapia , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/fisiopatología , Factores de Riesgo , Factores de Tiempo , Anciano de 80 o más Años , Evaluación de la Discapacidad , Hematoma/diagnóstico por imagen , Hematoma/diagnóstico , Curva ROCRESUMEN
BACKGROUND: Intraventricular haemorrhage (IVH) often arises as a cerebral complication directly related to preterm birth. The impaired autoregulation of cerebral blood flow is closely associated with IVH in preterm neonates. Three-dimensional pseudo-continuous arterial spin labelling (3D-pCASL) is a noninvasive magnetic resonance imaging (MRI) technique used for evaluating cerebral perfusion. OBJECTIVE: This study aimed to compare cerebral blood flow values among three distinct groups using 3D-pCASL: preterm neonates with and without IVH and preterm neonates at term-equivalent age. MATERIALS AND METHODS: A total of 101 preterm neonates who underwent conventional MRI and 3D-pCASL were included in this study. These neonates were categorised into three groups: 12 preterm neonates with IVH, 52 preterm neonates without IVH, and 37 healthy neonates at term-equivalent age. Cerebral blood flow measurements were obtained from six brain regions of interest (ROIs)-the frontal lobe, temporal lobe, parietal lobe, occipital lobe, basal ganglia, and thalamus-in the right and left hemispheres. RESULTS: The cerebral blood flow values measured in all ROIs of preterm neonates with IVH were significantly lower than those of neonates at term-equivalent age (all P<0.05). Additionally, the cerebral blood flow in the temporal lobe was lower in preterm neonates without IVH than in neonates at term-equivalent age (16.87±5.01 vs. 19.76±5.47 ml/100 g/min, P=0.012). Furthermore, a noteworthy positive correlation was observed between post-menstrual age and cerebral blood flow in the temporal lobe (P=0.037), basal ganglia (P=0.010), and thalamus (P=0.010). CONCLUSION: The quantitative cerebral blood flow values, as measured by 3D-pCASL, highlighted that preterm neonates with IVH had decreased cerebral perfusion. This finding underscores the potential of 3D-pCASL as a technique for evaluating the developmental aspects of the brain in preterm neonates.
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Circulación Cerebrovascular , Imagenología Tridimensional , Recien Nacido Prematuro , Marcadores de Spin , Humanos , Recién Nacido , Masculino , Femenino , Circulación Cerebrovascular/fisiología , Imagenología Tridimensional/métodos , Imagen por Resonancia Magnética/métodos , Enfermedades del Prematuro/diagnóstico por imagen , Enfermedades del Prematuro/fisiopatología , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/fisiopatologíaRESUMEN
BACKGROUND: Mortality and intraventricular hemorrhage (IVH) are common adverse outcomes in preterm infants and are challenging to predict clinically. Sample entropy (SE), a measure of heart rate variability (HRV), has shown predictive power for sepsis and other morbidities in neonates. We evaluated associations between SE and mortality and IVH in the first week of life. METHODS: Participants were 389 infants born before 32 weeks of gestation for whom bedside monitor data were available. A total of 29 infants had IVH grade 3 or 4 and 31 infants died within 2 weeks of life. SE was calculated with the PhysioNet open-source benchmark. Logistic regressions assessed associations between SE and IVH and/or mortality with and without common clinical covariates over various hour of life (HOL) censor points. RESULTS: Lower SE was associated with mortality by 4 HOL, but higher SE was very strongly associated with IVH and mortality at 24-96 HOL. Bootstrap testing confirmed SE significantly improved prediction using clinical variables at 96 HOL. CONCLUSION: SE is a significant predictor of IVH and mortality in premature infants. Given IVH typically occurs in the first 24-72 HOL, affected infants may initially have low SE followed by a sustained period of high SE. IMPACT: SE correlates with IVH and mortality in preterm infants early in life. SE combined with clinical factors yielded ROC AUCs well above 0.8 and significantly outperformed the clinical model at 96 h of life. Previous studies had not shown predictive power over clinical models. First study using the PhysioNet Cardiovascular Toolbox benchmark in young infants. Relative to the generally accepted timing of IVH in premature infants, we saw lower SE before or around the time of hemorrhage and a sustained period of higher SE after. Higher SE after acute events has not been reported previously.
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Entropía , Frecuencia Cardíaca , Recien Nacido Prematuro , Humanos , Recién Nacido , Masculino , Femenino , Hemorragia Cerebral/mortalidad , Hemorragia Cerebral/fisiopatología , Edad Gestacional , Hemorragia Cerebral Intraventricular/mortalidad , Enfermedades del Prematuro/mortalidad , Lactante , Modelos LogísticosRESUMEN
OBJECTIVES: A third of asymptomatic individuals with type 1 diabetes (T1D) show signs of cerebrovascular disease in brain MRI. These signs associate with advanced stages of diabetic retinal disease, but not in mild or moderate retinopathy. We aimed to evaluate a wider spectrum of retinal changes by exploring the relationship between quantitative measures of retinal vessel parameters (RVP) and cerebrovascular changes in T1D. METHODS: We included 146 neurologically asymptomatic individuals with T1D [51% women, median age 40 (33.0-45.1) years] and 24 healthy, sex-matched and age-matched controls. All individuals underwent a clinical and biochemical work-up and brain MRI, which was evaluated for cerebral microbleeds (CMBs), white matter hyperintensities, and lacunar infarcts. RVPs, including central retinal arteriole (CRAE) and central retinal vein (CRVE) equivalents and the ratio of the two variables (arteriovenous ratio, AVR) were assessed quantitatively by a computer-assisted method (IVAN software, version 3.2.6) from fundus images. RESULTS: Among T1D participants, those with CMBs had a lower arteriovenous ratio (AVR) compared with those without CMBs ( P â=â0.023). AVR was inversely associated with the amount of CMBs ( r â=â-0.063, P â=â0.035). CMB prevalence was higher in those with AVR below the median (31%) compared with above the median (16%, P â<â0.001), and this difference was significant also after individuals with only no-to-mild retinopathy were included (28 vs. 16%, P â=â0.005). A correlation between blood pressure and CRAE ( r â=â-0.19, P â=â0.025) appeared among those with T1D. CONCLUSION: Regardless of the severity of diabetic retinopathy, AVR is associated with the existence of CMBs in T1D.
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Hemorragia Cerebral , Diabetes Mellitus Tipo 1 , Imagen por Resonancia Magnética , Arteria Retiniana , Vena Retiniana , Humanos , Femenino , Masculino , Diabetes Mellitus Tipo 1/complicaciones , Adulto , Persona de Mediana Edad , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/fisiopatología , Vena Retiniana/diagnóstico por imagen , Vena Retiniana/patología , Arteria Retiniana/diagnóstico por imagen , Arteria Retiniana/patología , Imagen por Resonancia Magnética/métodos , Retinopatía Diabética/diagnóstico por imagen , Retinopatía Diabética/fisiopatología , Estudios de Casos y ControlesRESUMEN
BACKGROUND: Resting-state functional MRI (rs-fMRI) has identified static changes of local brain activity among patients with intracerebral hemorrhage (ICH). However, the dynamic and concordance-related characteristics of brain activity remain unclear. PURPOSE: To investigate static, dynamic, and concordance-related features of the regional brain activity of young non-disabled ICH patients. STUDY TYPE: Prospective. SUBJECTS: Thirty-three ICH patients (modified Rankin Scale score ≤2, 21% female, 46.36 ± 6.53) and 33 matched healthy controls (HCs) (21% female, 47.64 ± 6.16). FIELD STRENGTH/SEQUENCE: 3-T, rs-fMRI using gradient echo-planar imaging, T1-weighted imaging. ASSESSMENT: Neuropsychological and rs-fMRI data were acquired from all participants. Amplitude of low-frequency fluctuations (ALFF), fractional ALFF (fALFF), regional homogeneity (ReHo), voxel-mirrored homotopic connectivity, global signal correlation (GSCorr) and degree centrality (DC), and their dynamic and concordance-related changes with sliding window analysis were calculated based on rs-fMRI data at a whole-brain level. The burden of cerebral small vascular diseases (cSVD) was assessed by cSVD scores. All hemorrhage lesions were delineated on normalized T1 images. STATISTICAL TESTS: Multiple regression models, a voxel-level uncorrected P < 0.001, a cluster-level false discovery rate (FDR) corrected q < 0.05, a re-corrected qFDR <0.05 were considered significant. Pearson or Spearman correlation analyses between fMRI data and neurocognitive performance were performed. RESULTS: Compared to HCs, ICH patients showed significant abnormal changes of ALFF, dynamic ALFF, fALFF, ReHo, dynamic ReHo, GSCorr, DC, and voxel-wise concordance in multiple brain regions mainly including the bilateral cerebellar hemispheres, ipsilesional thalamus, and bilateral middle cingulum gyrus. The ALFF in the cerebellar posterior lobe and thalamus were significantly associated with attention (r = -0.481) and executive function (rho = -0.521) in ICH patients. DATA CONCLUSION: Young non-disabled ICH patients exhibit static, dynamic, and concordance-related alterations of local brain activity, part of which shows associations with cognitive functions. These findings may help comprehensively understand the mechanism of cognitive impairment after ICH. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: Stage 3.