[Systematic review and Meta-analysis of efficacy and safety of acupuncture therapy on hypertensive intracerebral hemorrhage].

To systematically review the efficacy and safety of acupuncture combined with minimally invasive surgery or basic the-rapy in treating hypertensive intracerebral hemorrhage(HICH) patients compared with minimally invasive surgery or basic treatment. In this study, the four Chinese databases, the four English databases, Chinese Clinical Trial Registry and ClinicalTrail.gov, all above were systematically and comprehensively retrieved from the time of database establishment to September 10, 2020. Rando-mized controlled trials(RCTs) were screened out according to inclusion criteria and exclusion criteria established in advanced. The methodological quality of included studies was evaluated by the tool named "Cochrane bias risk assessment 6.1". Meta-analysis of the included studies was performed using RevMan 5.4, and the quality of outcome indicators was evaluated by the GRADE system. Finally, 17 studies were included, involving 1 852 patients with HICH, and the overall quality of the included studies was not high. According to Meta-analysis,(1)CSS score of the group of acupuncture combined with minimally invasive surgery or basic therapy was superior to the group of minimally invasive surgery or basic therapy(MD=-3.50,95%CI[-4.39,-2.61],P<0.000 01);(2)NIHSS score of the group of acupuncture combined with minimally invasive surgery or basic therapy was superior to the group of minimally invasive surgery or basic therapy(MD=-4.78,95%CI[-5.55,-4.00],P<0.000 01);(3)the cerebral hematoma volume of the group of acupuncture combined with minimally invasive surgery or basic therapy was superior to the group of minimally invasive surgery or basic therapy(MD=-4.44,95%CI[-5.83,-3.04],P<0.000 01);(4)ADL score of the group of acupuncture combined with minimally invasive surgery or basic therapy was superior to the group of minimally invasive surgery or basic therapy(MD=20.81,95%CI[17.25,24.37],P<0.000 01);(5)the GCS score of the group of acupuncture combined with minimally invasive surgery or basic therapy was superior to the group of minimally invasive surgery or basic therapy(MD=2.41,95%CI[1.90,2.91],P<0.000 01). The GRADE system showed an extremely low level of evidence for the above outcome indicators. Adverse reactions were mentioned only in two literatures, with no adverse reactions reported. The available evidence showed that acupuncture combined with minimally invasive surgery or basic therapy had a certain efficacy in patients of HICH compared with minimally invasive surgery or basic therapy. However, due to the high risk of bias in the included studies, its true efficacy needs to be verified by more high-quality studies in the future.

Hypertension is a Leading Cause of Nontraumatic Intracerebral Hemorrhage in Young Adults.

OBJECTIVE: To evaluate the etiology and discharge outcome of nontraumatic intracerebral hemorrhage (ICH) in young adults admitted to a comprehensive stroke center. METHODS: A retrospective chart review was performed on patients with a discharge diagnosis of nontraumatic ICH admitted from 7/1/2011 to 6/30/2016. Data was collected on demographics, clinical history, ICH score, hemorrhage location, do-not-resuscitate (DNR) orders, likely etiology, and discharge disposition. Categorical data was reported as percentage. Chi-squared test was performed to evaluate association of location of ICH, etiology of ICH, and ICH score with the discharge outcome. RESULTS: Sixty-three patients met the study criteria, with mean age 35.4 ± 6.4 years including 26 (41%) women and 40 (64%) whites. Headache (65%) and change in mental status (48%) were the most common presenting symptoms. Hemorrhage was most commonly seen in the deep structures in 29 (46%) patients followed by lobar ICH in 14 (22%) patients. The most common etiology of ICH was hypertension in 23 (37%) patients, followed by vascular abnormalities in 18 (29%) patients. Forty-two (67%) had good outcome defined as discharge to home (n = 25) or acute inpatient rehabilitation (n = 17). Twenty-one (33%) patients had bad outcome with discharge to skilled nursing facility (n = 6), hospice (n = 1) or died in the hospital (n = 14). Hospital DNR orders were noted in 11 (18%) patients. Higher ICH score (P < .0001) and use of DNR orders (P < .0001) were associated with bad outcome. All 11 patients with DNR orders died in the hospital. Location or etiology of hemorrhage were not associated with discharge outcome. CONCLUSIONS: Hypertension, a modifiable risk factor, is a major cause of nontraumatic ICH in young adults. Aggressive management of hypertension is essential to halt the recent increased trends of ICH due to hypertension. Early DNR orders may need to be cautiously used in the hospital.

Clinical Research of Early Hyperbaric Oxygen Therapy on Patients with Hypertensive Cerebral Hemorrhage After Craniotomy.

AIM: To observe the effect of early hyperbaric oxygen (HBO) therapy on the improvement of consciousness and prognosis of patients with severe brain damages after craniocerebral craniotomy. MATERIAL AND METHODS: Eighty-one patients who had cerebral hemorrhage and underwent clearance of hematoma and decompressive craniectomy from August 2013 to August 2016 were retrospectively analyzed. The patients were divided into HBO and non-HBO therapy groups. The treatment effects were scored and subjected to corresponding statistical analysis. RESULTS: There were significant differences in the Glasgow coma scale (GCS) scores at 3 and 5 weeks (t=2.293 and t=3.014, respectively, p < 0.05), and in Glasgow outcome scale (GOS) scores at 5 weeks and 3 months between the two groups (p < 0.05). CONCLUSION: Early HBO therapy could improve the consciousness and prognosis of patients with cerebral hemorrhage after craniotomy.

Intracranial Hypertension and Cerebral Perfusion Pressure Insults in Adult Hypertensive Intraventricular Hemorrhage: Occurrence and Associations With Outcome.

OBJECTIVES: Elevated intracranial pressure and inadequate cerebral perfusion pressure may contribute to poor outcomes in hypertensive intraventricular hemorrhage. We characterized the occurrence of elevated intracranial pressure and low cerebral perfusion pressure in obstructive intraventricular hemorrhage requiring extraventricular drainage. DESIGN: Prospective observational cohort. SETTING: ICUs of 73 academic hospitals. PATIENTS: Four hundred ninety-nine patients enrolled in the CLEAR III trial, a multicenter, randomized study to determine if extraventricular drainage plus intraventricular alteplase improved outcome versus extraventricular drainage plus saline. INTERVENTIONS: Intracranial pressure and cerebral perfusion pressure were recorded every 4 hours, analyzed over a range of thresholds, as single readings or spans (≥ 2) of readings after adjustment for intracerebral hemorrhage severity. Impact on 30- and 180-days modified Rankin Scale scores was assessed, and receiver operating curves were analyzed to identify optimal thresholds. MEASUREMENTS AND MAIN RESULTS: Of 21,954 intracranial pressure readings, median interquartile range 12 mm Hg (8-16), 9.7% were greater than 20 mm Hg and 1.8% were greater than 30 mm Hg. Proportion of intracranial pressure readings from greater than 18 to greater than 30 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 70 mm Hg were associated with day-30 mortality and partially mitigated by intraventricular alteplase. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and intracranial pressure greater than 20 mm Hg in spans were associated with both 30-day mortality and 180-day mortality. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 60 mm Hg were associated with poor day-30 modified Rankin Scale, whereas cerebral perfusion pressure less than 65 and less than 75 mm Hg were associated with poor day-180 modified Rankin Scale. CONCLUSIONS: Elevated intracranial pressure and inadequate cerebral perfusion pressure are not infrequent during extraventricular drainage for severe intraventricular hemorrhage, and level and duration predict higher short-term mortality and long-term mortality. Burden of low cerebral perfusion pressure was also associated with poor short- and long-term outcomes and may be more significant than intracranial pressure. Adverse consequences of intracranial pressure-time burden and cerebral perfusion pressure-time burden should be tested prospectively as potential thresholds for therapeutic intervention.

What did Joseph Stalin really die of? A reappraisal of his illness, death, and autopsy findings.

Joseph Stalin was one of the most important world leaders during the first half of the 20th century. He died suddenly in early March 1953 after a short illness, which was described in a series of medical bulletins in the Soviet newspaper Pravda. Based on both the clinical history and autopsy findings, it was concluded that Stalin had died of a massive hemorrhagic stroke involving his left cerebral hemisphere. However, almost 50 years later, a counter-narrative developed suggesting a more nefarious explanation for his sudden death, namely, that a "poison," warfarin, a potent anticoagulant, had been administered surreptitiously by one or more of his close associates during the early morning hours prior to the onset of his stroke. In the present report, we will examine this counter-narrative and suggest that his death was not due to the administration of warfarin but rather to a hypertension-related cerebrovascular accident resulting in a massive hemorrhagic stroke involving his left cerebral hemisphere. The counter-narrative was based on the misunderstanding of certain specific autopsy findings, namely, the presence of focal myocardial and petechial hemorrhages in the gastric and intestinal mucosa, which could be attributed to the extracranial pathophysiologic changes that can occur as a consequence of a stroke rather than the highly speculative counter-narrative that Stalin was "poisoned" by the administration of warfarin.

Serum calcium levels at admission is associated with the outcomes in patients with hypertensive intracerebral hemorrhage.

BACKGROUND/OBJECTIVE: Hypertensive spontaneous intracerebral hemorrhages (ICH) cause significant morbidity and mortality. In this study, we aimed to investigate the association between calcium level at admission and outcome in hypertensive ICH patients. METHODS: 658 hypertensive ICH patients were enrolled from January 2012 to January 2016 in this retrospective study, and demographic, clinical, laboratory, radiographic, and outcome data were collected. The associations between serum calcium level and initial hematoma volume, hematoma enlargement and functional outcome were assessed. RESULTS: Lower calcium level at admission was associated with larger initial hematoma volumes, baseline NIHSS and mRSscore (p < .05), but not with platelet count, activated partial thromboplastin time and international normalized ratio on admission (p > .05). For outcome assessment, 30 days mortality and 6 months mRS were adjusted for age, gender and time from onset to admission, cigarette smoking, alcohol drinking, history of hypertension, baseline NIHSS score, Baseline mRS score and hematoma position, lower calcium level at admission was associated with worse outcomes. CONCLUSION: Low calcium level at admission is associated with worse outcome and might be a prognostic factor for acute ICH.

Current management of spontaneous intracerebral haemorrhage.

Intracerebral haemorrhage (ICH) is the most devastating and disabling type of stroke. Uncontrolled hypertension (HTN) is the most common cause of spontaneous ICH. Recent advances in neuroimaging, organised stroke care, dedicated Neuro-ICUs, medical and surgical management have improved the management of ICH. Early airway protection, control of malignant HTN, urgent reversal of coagulopathy and surgical intervention may increase the chance of survival for patients with severe ICH. Intensive lowering of systolic blood pressure to <140 mm Hg is proven safe by two recent randomised trials. Transfusion of platelets in patients on antiplatelet therapy is not indicated unless the patient is scheduled for surgical evacuation of haematoma. In patients with small haematoma without significant mass effect, there is no indication for routine use of mannitol or hypertonic saline (HTS). However, for patients with large ICH (volume > 30 cbic centmetre) or symptomatic perihaematoma oedema, it may be beneficial to keep serum sodium level at 140-150 mEq/L for 7-10 days to minimise oedema expansion and mass effect. Mannitol and HTS can be used emergently for worsening cerebral oedema, elevated intracranial pressure (ICP) or pending herniation. HTS should be administered via central line as continuous infusion (3%) or bolus (23.4%). Ventriculostomy is indicated for patients with severe intraventricular haemorrhage, hydrocephalus or elevated ICP. Patients with large cerebellar or temporal ICH may benefit from emergent haematoma evacuation. It is important to start intermittent pneumatic compression devices at the time of admission and subcutaneous unfractionated heparin in stable patients within 48 hours of admission for prophylaxis of venous thromboembolism. There is no benefit for seizure prophylaxis or aggressive management of fever or hyperglycaemia. Early aggressive comprehensive care may improve survival and functional recovery.

Comparison of endoscopic evacuation, stereotactic aspiration and craniotomy for the treatment of supratentorial hypertensive intracerebral haemorrhage: study protocol for a randomised controlled trial.

BACKGROUND: Hypertensive intracerebral haemorrhage (HICH) is the most common form of haemorrhagic stroke with the highest morbidity and mortality of all stroke types. The choice of surgical or conservative treatment for patients with HICH remains controversial. In recent years, minimally invasive surgeries, such as endoscopic evacuation and stereotactic aspiration, have been attempted for haematoma removal and offer promise. However, research evidence on the benefits of endoscopic evacuation or stereotactic aspiration is still insufficient. METHODS/DESIGN: A multicentre, randomised controlled trial will be conducted to compare the efficacy of endoscopic evacuation, stereotactic aspiration and craniotomy in the treatment of supratentorial HICH. About 1350 eligible patients from 10 neurosurgical centres will be randomly assigned to an endoscopic group, a stereotactic group and a craniotomy group at a 1:1:1 ratio. Randomisation is undertaken using a 24-h randomisation service accessed by telephone or the Internet. All patients will receive the corresponding surgery based on their grouping. They will be followed-up at 1, 3 and 6 months after surgery. The primary outcome is the modified Rankin Scale at 6-month follow-up. Secondary outcomes include: haematoma clearance rate; Glasgow Coma Scale 7 days after surgery; rebleeding rate; intracranial infection rate; hospitalisation time; mortality at 1 month and 3 months after surgery; the Barthel Index and the WHO quality of life at 3 months and 6 months after surgery. DISCUSSION: The trial aims to investigate whether endoscopic evacuation and stereotactic aspiration could improve the outcome of supratentorial HICH compared with craniotomy. The trial will help to determine the best surgical method for the treatment of supratentorial HICH. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02811614 . Registered on 20 June 2016.

Therapeutic Benefits of Mesenchymal Stromal Cells in a Rat Model of Hemoglobin-Induced Hypertensive Intracerebral Hemorrhage.

Previous studies have shown that bone marrow mesenchymal stromal cell (MSC) transplantation significantly improves the recovery of neurological function in a rat model of intracerebral hemorrhage. Potential repair mechanisms involve anti-inflammation, anti-apoptosis and angiogenesis. However, few studies have focused on the effects of MSCs on inducible nitric oxide synthase (iNOS) expression and subsequent peroxynitrite formation after hypertensive intracerebral hemorrhage (HICH). In this study, MSCs were transplanted intracerebrally into rats 6 hours after HICH. The modified neurological severity score and the modified limb placing test were used to measure behavioral outcomes. Blood-brain barrier disruption and neuronal loss were measured by zonula occludens-1 (ZO-1) and neuronal nucleus (NeuN) expression, respectively. Concomitant edema formation was evaluated by H&E staining and brain water content. The effect of MSCs treatment on neuroinflammation was analyzed by immunohistochemical analysis or polymerase chain reaction of CD68, Iba1, iNOS expression and subsequent peroxynitrite formation, and by an enzyme-linked immunosorbent assay of pro-inflammatory factors (IL-1ß and TNF-α). The MSCs-treated HICH group showed better performance on behavioral scores and lower brain water content compared to controls. Moreover, the MSC injection increased NeuN and ZO-1 expression measured by immunochemistry/immunofluorescence. Furthermore, MSCs reduced not only levels of CD68, Iba1 and pro-inflammatory factors, but it also inhibited iNOS expression and peroxynitrite formation in perihematomal regions. The results suggest that intracerebral administration of MSCs accelerates neurological function recovery in HICH rats. This may result from the ability of MSCs to suppress inflammation, at least in part, by inhibiting iNOS expression and subsequent peroxynitrite formation.

Efficacy of lumbar cistern drainage combined with intrathecal antibiotherapy for the treatment of ventriculo-subarachnoid infections following surgery for hypertensive intracerebral hemorrhage.

OBJECTIVE: The aim of this study was to investigate the efficacy of lumbar cistern drainage combined with intrathecal injection of antibiotics (LCD-ITI) in treating postoperative intracranial infections of hypertensive intracerebral hemorrhage (pHIH-ICI). METHODS: Sixty pHIH-ICI patients were randomly divided into the control group and the treatment group, with 30 patients in each group. Conventional treatment was performed in the control group, while LCD-ITI was performed in the treatment group. The clinical outcomes, Glasgow Outcome Score (GOS), activities of daily living (ADL) scores, incidence rates of hydrocephalus and other indicators were compared. RESULTS: The improvement time of clinical symptoms, infection control time and hydrocephalus incidence of the treatment group were significantly lower than the control group (P<0.05). Also the infection control rate, GOS score and ADL score of the treatment group were significantly higher or better than the control group (P<0.05). CONCLUSION: LCD-ITI could improve clinical treatment and prognosis of pHIH-ICI patients.

Effect of integrated traditional Chinese and Western medicine therapy for acute hypertensive intracerebral hemorrhage: a meta-analysis.

Intracerebral hemorrhage (ICH) is an important public health problem associated with high mortality and morbidity. The aim of this study was to evaluate the clinical efficacy of integrated traditional Chinese (TCM) and Western medicine (WM) therapy for acute hypertensive ICH. Randomized controlled trials were searched in PubMed, Medline, Embase, Wanfang and CNKI database published between January 2000 and June 2016. Our results showed that integrated TCM and WM therapy appeared to be able to improve the clinical effect for patients with acute hypertensive ICH.

Clinical analysis and treatment of symptomatic intracranial hemorrhage after deep brain stimulation surgery.

BACKGROUND: Symptomatic intracranial hemorrhage (ICH) may lead to permanent neurological disability of patients and has impeded the extensive clinical application of deep brain stimulation (DBS). The present study was conducted to discuss the incidence, prevention, and treatment of symptomatic ICH after DBS surgery. METHODS: From January 2009 to December 2014, 396 patients underwent DBS with a total of 691 implanted leads. In all, 10 patients had symptomatic ICH. We analyzed these cases' clinical characteristics, including comorbid diagnoses and coagulation profile. We described the onset of ICH, imaging features, clinical manifestations, treatment, neurological impairment, and outcome of DBS. RESULTS: Of the 10 patients with symptomatic ICH, 2 had hypertension. Three cases of ICH occurred within 12 h of the procedure; four cases within 24 h. Five experienced grand mal seizures concurrently with hemorrhage. Unilateral frontal lobe hemorrhage occurred in all cases. In seven cases, hematomas occurred around the electrodes. Some hematomas were not well-circumscribed and had perihematomal edema. Conservative therapy was administered to 8 patients, and 2 patients underwent craniotomy and hematoma evacuation. All electrodes were successfully preserved. Neurological dysfunction in all patients gradually improved. Nine patients ultimately experienced effective symptom relief of Parkinson's disease with DBS. CONCLUSIONS: Symptomatic ICH should be identified as soon as possible after implantation surgery and treated effectively to limit neurological deficit and preserve DBS leads.

Sequential therapy for non-thalamus supratentorial hypertensive intracerebral hemorrhages.

OBJECTIVE: We sought to assess the effectiveness of sequential therapy for non-thalamus supratentorial hypertensive intracerebral hemorrhage (NTS-HICH). PATIENTS AND METHODS: We retrospectively analyzed clinical data of 110 patients with HICH. The patients were admitted 72 hours after disease onset, and 43 patients received sequential therapy. The length of hospital stay, treatment costs, incidence of pulmonary infections, mortality rates and Modified Rankin Score (mRS) 1 and 3 months after NTS-HICH were compared between patients who received sequential or non-sequential therapies. RESULTS: The length of hospital stay, treatment costs, and 1-month mortality rates were not significantly different between both groups. However, mortality rates at 3 months, incidence of pulmonary infection, and mRS at both 1 and 3 months were significantly better in patients who received sequential therapy. CONCLUSIONS: Sequential therapy significantly improves the prognosis for patients with NTS-HICH.

The role of admission timing in the outcome of intracerebral hemorrhage patients at a specialized stroke center.

INTRODUCTION: Admission at 'off times' has been suggested to result in increased risk of poor outcome. The utilization of high volume centers may be a potential remedy to this variability in care. OBJECTIVE: To assess the ability of a high volume center to mitigate variability in care due to timing of admission in a post hoc analysis of an observational study. METHODS: The medical records of 200 hypertensive intracerebral hemorrhage (ICH) patients admitted to the Neurological Intensive Care Unit (NICU) from 12 January 2009 to 4 April 2013 were identified and examined for variable outcome based on admission timing using the modified Rankin Scale (mRS). Multiple logistic regression was used to assess predictors of poor outcome, correcting severity of admission. RESULTS: Seventy-five admissions were recorded to have occurred on the weekend. The 3-month follow-up mRS of surviving patients was 3·78 in weekend admissions and 3·63 in weekday admissions (P  =  0·62). One hundred and seven night admissions occurred. The average mRS at 3 months of surviving patients was 3·56 in night admissions and 3·84 in daytime admissions (P  =  0·36). Thirteen patients were admitted in July. The 3-month mRS of surviving patients was 3·71 for July admissions and 3·38 for non-July admissions (P  =  0·58). Only ICH score was found to be a predictor of outcome on multivariate analysis (P < 0·001). CONCLUSIONS: No significant difference in the outcome of patients was identified regardless of time of admission. High volume centers may be less prone to temporal variability in care, though the existence of temporal variability in care at low volume centers is controversial.

Recurrent hypertensive intracerebral haemorrhages: what should we do when a new hemispheric ischaemic event strikes?

Hypertensive intracerebral haemorrhage is usually a once in a lifetime event and recurrences are rare. Most recurrences usually develop within 2 years of the first event and the majority usually target the basal ganglia and thalami. Failure of blood pressure control is the most important, potentially preventable, culprit behind the development of primary intracerebral haemorrhages. However, the occurrence of a recurrent bleed in patients with optimally controlled hypertension should always prompt the physician to think of a new co-operating factor. We report on a 60-year-old hypertensive woman who developed right-sided thalamic haemorrhage 5 days after sustaining a lacunar infarct of the left thalamus for which she had been prescribed a dual antiplatelet therapy: aspirin and clopidrogrel. She had a history of two bilateral sequential hypertensive deep cerebellar haemorrhages which were developed 2 years ago.

Comparison on different strategies for treatments of hypertensive hemorrhage in the basal ganglia region with a volume of 25 to 35 ml.

PURPOSE: To compare curative effect of different treatments for hypertensive cerebral hemorrhage of 25 to 35 ml. METHODS: In this study, 595 cases were enrolled and grouped regarding treatments including conservative treatment, evacuation with microinvasive craniopuncture technique within 6h and 6-48 h after the attack. RESULTS: After follow up for three months after the attack, the assessment based on the Activity of Daily Living (ADL) indicated no significant difference among conservative treatment and surgical interventions (p>0.05). However, surgical interventions showed advantages of shorter hospitalization, quick removal of hematoma and obvious reduction of cost. CONCLUSION: The microinvasive craniopuncture technique to drain the hematoma within 6-48 h may be a good way in treating hypertensive hemorrhage of basal ganglia region.

Comparison on different strategies for treatments of hypertensive hemorrhage in the basal ganglia region with a volume of 25 to 35ml / Comparação de diferentes estratégias no tratamento da hemorragia hipertensiva da região dos gânglios da base com volume de 25 a 35ml

PURPOSE: To compare curative effect of different treatments for hypertensive cerebral hemorrhage of 25 to 35ml. METHODS: In this study, 595 cases were enrolled and grouped regarding treatments including conservative treatment, evacuation with microinvasive craniopuncture technique within 6h and 6-48h after the attack. RESULTS: After follow up for three months after the attack, the assessment based on the Activity of Daily Living (ADL) indicated no significant difference among conservative treatment and surgical interventions (p>0.05). However, surgical interventions showed advantages of shorter hospitalization, quick removal of hematoma and obvious reduction of cost. CONCLUSION: The microinvasive craniopuncture technique to drain the hematoma within 6-48h may be a good way in treating hypertensive hemorrhage of basal ganglia region.

OBJETIVO: Comparar o efeito curativo de diferentes tratamentos da hemorragia hipertensiva cerebral de 25 a 35ml. MÉTODOS: Foram analisados 595 casos agrupados segundo tratamento conservador e evacuação com técnica de punção transcraniana dentro de 6h ou de 6 às 48h do início do quadro clínico. RESULTADOS: O seguimento após três meses e avaliado pelo Escore de Atividade de Vida Diário, indicou que não houve diferenças significantes entre os tratamentos conservador e cirúrgico (p>0.05) O tratamento cirúrgico mostrou vantagem com hospitalização mais curta e redução de custos. CONCLUSÃO: A técnica de punção transcraniana para drenagem de hematoma dos núcleos da base pode ser uma boa alternativa de tratamento.

Emergency neurological life support: intracerebral hemorrhage.

Intracerebral hemorrhage (ICH) is a subset of stroke resulting from bleeding within the brain parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, reversal of coagulopathy, and proper diagnosis. ICH was chosen as an emergency neurological life support (ENLS) protocol because intervention within the first critical hour may improve outcome, and it is helpful to have a protocol to drive care quickly and efficiently.

Clinical syndromes and management of intracerebral hemorrhage.

Spontaneous intracerebral hemorrhage (ICH) is a devastating disease with high morbidity and mortality. Acutely, ICH is associated with a sudden surge in intracranial pressure (ICP), as the volume of hematoma increases the pressure in the closed head, leading to non-specific symptoms of ICP: headache, nausea, vomiting, and alterations in consciousness. In the early phase, damage to the brain tissues surrounding the hematoma causes progression of neurologic symptoms. Expansion of supratentorial ICHs may result in transtentorial herniation, causing mental status deterioration and loss of pupillary light reflex. Compared to ischemic stroke, seizure is more common in ICH.

[Hypertensive intracerebral hemorrhage in isolated islands in Nagasaki Prefecture: a remote teleradiology and helicopter transportation system].

Hypertensive intracerebral hemorrhage (HICH) causes significant morbidity and mortality. The time required to transport the patients to a specialized hospital can influence the prognosis. In the isolated islands in Nagasaki prefecture, there is no medical institution which can offer emergent neurosurgical intervention. We reviewed the cases of HICH in this region from January 2006 to September 2010, who were transferred to Nagasaki Medical Center by a helicopter after consultation via teleradiology. Eighty four cases (23%) were transferred via helicopter to our institution from isolated islands. In three of them (4%), re-hemorrhage was demonstrated on computed tomography after helicopter transportation, and one of three had been administered an anti-coagulant agent. Only one case (1%) has deteriorated during helicopter transportation because of acute obstructive hydrocephalus. The outcome at discharge was as follows: modified Rankin Scale (mRS) I: 3 cases (4%), II: 5 cases (6%), III: 3 cases (4%), IV: 30 cases (36%), V: 31 cases (37%), VI: 12 cases (14%), 43 cases (51%) showed poor outcome (mRS V, VI). For medical management in isolated islands, a remote teleradiology system is indispensable to decide a strategy of treatment rapidly, and a helicopter transportation system is very useful in cases requiring emergent neurosurgical intervention, particular in cases of impending cerebral herniation or acute hydrocephalus. However, we may need to expand logistical supporting hospitals or secure other transportation facilities because many of the patients with poor outcome can not return to their home islands.