Influence of Intracerebral Hemorrhage Location on Outcomes in Patients With Severe Intraventricular Hemorrhage.

Background and Purpose- We investigated the prognostic significance of spontaneous intracerebral hemorrhage location in presence of severe intraventricular hemorrhage. Methods- We analyzed diagnostic computed tomography scans from 467/500 (excluding primary intraventricular hemorrhage) subjects from the CLEAR (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) III trial. We measured intracerebral hemorrhage engagement with specific anatomic regions, and estimated association of each region with blinded assessment of dichotomized poor stroke outcomes: mortality, modified Rankin Scale score of 4 to 6, National Institutes of Health Stroke Scale score of >4, stroke impact scale score of <60, Barthel Index <86, and EuroQol visual analogue scale score of <50 and <70 at days 30 and 180, respectively, using logistic regression models. Results- Frequency of anatomic region involvement consisted of thalamus (332 lesions, 71.1% of subjects), caudate (219, 46.9%), posterior limb internal capsule (188, 40.3%), globus pallidus/putamen (127, 27.2%), anterior limb internal capsule (108, 23.1%), and lobar (29, 6.2%). Thalamic location was independently associated with mortality (days 30 and 180) and with poor outcomes on most stroke scales at day 180 on adjusted analysis. Posterior limb internal capsule and globus pallidus/putamen involvement was associated with increased odds of worse disability at days 30 and 180. Anterior limb internal capsule and caudate locations were associated with decreased mortality on days 30 and 180. Anterior limb internal capsule lesions were associated with decreased long-term morbidity. Conclusions- Acute intracerebral hemorrhage lesion topography provides important insights into anatomic correlates of mortality and functional outcomes even in severe intraventricular hemorrhage causing obstructive hydrocephalus. Models accounting for intracerebral hemorrhage location in addition to volumes may improve outcome prediction and permit stratification of benefit from aggressive acute interventions. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00784134.

Safety and efficacy of herbal medicine for acute intracerebral hemorrhage (CRRICH): a multicentre randomised controlled trial.

OBJECTIVE: To evaluate the safety and efficacy of removing blood stasis (RBS) herbal medicine for the treatment of acute intracerebral haemorrhage (AICH) within a 6-hour time window. STUDY DESIGN: A randomised, multicentre, double-blind, placebo-controlled study performed in 14 hospitals in China. PARTICIPANTS AND INTERVENTIONS: Patients with AICH were randomly assigned to receive a placebo, the ICH-1 (Intracerebral Haemorrhage) formula (eight herbs, including the RBS herbs hirudo and tabanus) or the ICH-2 formula (six herbs without the RBS herbs hirudo and tabanus) within 6 hours of ICH onset. OUTCOMES: The primary safety outcome was the incidence of haematoma enlargement at 24 hours and at 10 days after treatment. The secondary outcome was the incidence of poor prognosis (mortality or modified Rankin Scale score ≥5) assessed at 90 days after symptom onset. RESULTS: A total of 324 subjects were randomised between October 2013 and May 2016: 105 patients received placebo; 108 patients received the ICH-1 formula; and 111 patients received the ICH-2 formula. The incidence of haematoma enlargement at 24 hours was 7.8% in the placebo group, 12.3% in the ICH-1 group and 7.5% in the ICH-2 group; the incidence of haematoma enlargement on day 10 was 1.1% in the placebo group, 1.1% in the ICH-1 group, and 3.1% in the ICH-2 group, with no significant differences among the groups (P>0.05). The mortality rates were 3.8% in the placebo group, 2.8% in the ICH-1 group, and 0.9% in the ICH-2 group; the incidences of poor prognosis were 7.1% in the placebo group, 6.0% in the ICH-1 group and 4.8% in the ICH-2 group at 3 months, with no significant differences among the groups (p>0.05). However, the overall frequency of treatment-emergent adverse events in the ICH-1 group (12.1%) was higher among the three groups (5.8% and 2.8%, respectively, p<0.05). All three cases of serious adverse events were in the ICH-1 group. CONCLUSIONS: Ultra-early administration of ICH-1 formula for AICH patients did not exert significant beneficial effects on clinical outcomes but increased the risk of bleeding, which probably resulted from the inclusion of RBS herbal medicines in ICH-1. TRIALREGISTRATION NUMBER: NCT01918722.

Location of Thalamic Hemorrhage Impacts Prognosis.

OBJECTIVE: Approximately 12% of intracerebral hemorrhages (ICHs) occur in the thalamus. Understanding the anatomic regions involved with thalamic hemorrhages is potentially useful, offering the physician a more accurate prognosis for patient outcomes. This study was performed to determine if thalamic hemorrhage location observed on a computed tomography (CT) scan was predictive of neurologic outcomes. METHODS: A sample of 168 thalamic hemorrhage patients admitted to a tertiary care center were analyzed. Axial CT scans of thalamic hemorrhages were classified into 1 of 6 possible categories based on thalamic nuclei anatomy: anterior, posterior, medial, lateral, central, or global. For each classification, patient clinical characteristics were collected to identify variables indicative of clinical outcome. Outcome measures used in this study included mortality, hospital length of stay, readmission within 30 days, ICH score, Glasgow Coma Scale score, neurologic deterioration (calculated as a change in modified Rankin scale score from admission to discharge), and discharge disposition. RESULTS: On multivariable analysis, patients with posterior and lateral thalamic hemorrhages demonstrated a decreased likelihood of mortality; patients with posterior hemorrhages were less likely to have neurologic deterioration relative to global thalamic hemorrhages when controlling for hemorrhage volume and ventriculomegaly. Ventriculomegaly and hemorrhage volume were also predictive of both mortality and neurologic deterioration. CONCLUSIONS: In thalamic hemorrhages, patient prognosis may be influenced by hemorrhage location, with posterior and lateral hemorrhages demonstrating better clinical outcome versus hemorrhages in other locations. This is potentially valuable because hemorrhage location affords the treating physician a readily available prognostic factor when assessing intracranial hemorrhages.

Development and validation of a score for evaluating comprehensive stroke care capabilities: J-ASPECT Study.

BACKGROUND: Although the Brain Attack Coalition recommended establishing centers of comprehensive care for stroke and cerebrovascular disease patients, a scoring system for such centers was lacking. We created and validated a comprehensive stroke center (CSC) score, adapted to Japanese circumstances. METHODS: Of the selected 1369 certified training institutions in Japan, 749 completed an acute stroke care capabilities survey. Hospital performance was determined using a 25-item score, evaluating 5 subcategories: personnel, diagnostic techniques, specific expertise, infrastructure, and education. Consistency and validity were examined using correlation coefficients and factorial analysis. RESULTS: The CSC score (median, 14; interquartile range, 11-18) varied according to hospital volume. The five subcategories showed moderate consistency (Cronbach's α = 0.765). A strong correlation existed between types of available personnel and specific expertise. Using the 2011 Japanese Diagnosis Procedure Combination database for patients hospitalized with stroke, four constructs were identified by factorial analysis (neurovascular surgery and intervention, vascular neurology, diagnostic neuroradiology, and neurocritical care and rehabilitation) that affected in-hospital mortality from ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The total CSC score was related to in-hospital mortality from ischemic stroke (odds ratio [OR], 0.973; 95% confidence interval [CI], 0.958-0.989), intracerebral hemorrhage (OR, 0.970; 95% CI, 0.950-0.990), and subarachnoid hemorrhage (OR, 0.951; 95% CI, 0.925-0.977), with varying contributions from the four constructs. CONCLUSIONS: The CSC score is a valid measure for assessing CSC capabilities, based on the availability of neurovascular surgery and intervention, vascular neurology, diagnostic neuroradiology, and critical care and rehabilitation services.

In Models of Intracerebral Hemorrhage, Rivaroxaban is Superior to Warfarin to Limit Blood Brain Barrier Disruption and Hematoma Expansion.

BACKGROUND: Intracerebral hemorrhage (ICH) during oral anticoagulation therapy with an oral vitamin K epoxidase reductase such as warfarin is a life-threatening complication. However, whether direct oral anticoagulants (DOACs) are associated with larger hematoma volume and higher mortality rates remains controversial. We evaluated the hematoma volume and pathophysiology of ICH during anticoagulation with warfarin or rivaroxaban, an orally active direct factor Xa inhibitor. METHOD: Mice were orally pretreated with rivaroxaban (10 or 30 mg/kg), warfarin (4 mg/kg), or vehicle. ICH was induced by intrastriatal collagenase-injection. Hematoma volume and neurological deficits 24 h after ICH induction were significantly decreased in the rivaroxaban-pretreated group in comparison with the warfarin-pretreated group. Rivaroxaban did not increase the hematoma volume relative to that observed for vehicle, and improved survival rate 7 days after ICH induction compared with warfarin. RESULT: We evaluated blood-brain barrier (BBB) permeability 6 h after ICH induction using Evans blue spectrophotometry. Evans blue extravasation was significantly reduced in the rivaroxaban group compared with the warfarin group. To investigate the mechanism underlying hematoma expansion and BBB permeability, we focused on thrombin, a clot-derived factor and one of the major contributors to ICH-induced brain injury. To investigate the effects of anticoagulant agents on thrombin-induced injuries, human brain endothelial cells were used in membrane permeability assays. Rivaroxaban, but not warfarin, significantly mitigated the thrombin-induced increase in membrane permeability. CONCLUSION: These findings indicate that rivaroxaban decreases BBB disruption after ICH, and limits early hematoma expansion in these experimental models compared with warfarin. Our study suggests that rivaroxaban has advantages over warfarin with respect to ICH, an important complication during long-term anticoagulation therapy.

Hyperbaric-Oxygen Therapy Improves Survival and Functional Outcome of Acute Severe Intracerebral Hemorrhage.

BACKGROUND: Prognosis of spontaneous intracerebral hemorrhage (ICH) remains poor worldwide. AIMS OF THE STUDY: To investigate the effect and optimal protocol for hyperbaric-oxygen therapy (HBOT), and reduce incidence of upper gastrointestinal bleeding (UGIB) in ICH. METHODS: This prospective, randomized, controlled trial included 565 patients with acute severe ICH. Participants were randomly assigned to a sham-control group (Group A) and four intervention groups: Groups B and C with 2.0 atmospheres absolute (ATA) pressure and HBOT exposure for 60 or 90 sessions, respectively; and Groups D and E with 1.5 ATA for 60 or 90 sessions, respectively. All patients received emergency craniotomy with hematoma evacuation. Outcome measures were modified Barthel Index (MBI) and modified Rankin Scale (mRS) scores, mortality rates at follow-up six months. UGIB rates were assessed as potential side effect. RESULTS: In four intervention groups, MBI and mRS scores were all significantly improved, and mortality rates were all significantly decreased compared with Group A (all p < 0.005). UGIB rates were 39.25, 60.00, 64.49, 36.79, and 34.26% in Groups A, B, C, D, and E, respectively. UGIB rates in Groups B and C were significantly increased compared with Groups A, D and E (all p < 0.005). None of UGIB were clinically significant. CONCLUSIONS: HBOT significantly improves survival and functional outcomes of ICH. HBOT at 1.5 and 2.0 ATA had the same beneficial effect. A pressure of 1.5 ATA and 60 HBOT exposures represents an optimal protocol for HBOT. Further studies are needed to optimize the protocol per specific patient.

Palliative Care Utilization in Nontraumatic Intracerebral Hemorrhage in the United States.

OBJECTIVES: Palliative care is now recognized as an essential component of comprehensive care in serious illness that interferes with quality of life. We explored utilization of palliative care in spontaneous intracerebral hemorrhage at a population level using a large national database. DESIGN: Population based cross-sectional study. SETTING: Inpatient hospital admissions from the Nationwide Inpatient Sample. PATIENTS: A total of 311,217 patients with intracerebral hemorrhage. INTERVENTIONS: Palliative care use. MEASUREMENTS AND MAIN RESULTS: Intracerebral hemorrhage patients with and without palliative care were identified from the 2007-2011 Nationwide Inpatient Sample using International Classification of Diseases, 9th Revision, codes. Demographics, comorbidities, surgical procedures, and hospital characteristics were compared between patients receiving and not receiving palliative care (code V66.7). Resource utilization measures were inflation-adjusted cost of care and length of stay. Pearson chi square and Wilcoxon-Mann-Whitney tests were used for categorical and continuous variables respectively. Logistic regression was used to construct a predictive model of palliative care. Of the 311,217 intracerebral hemorrhage patients, 32,159 (10.3%) received palliative care. Utilization of palliative care increased from 4.3% in 2007 to 16.2% in 2011 (trend p < 0.001). Patients receiving palliative care had higher Charlson comorbidity scores (p < 0.001), higher all-patient refined diagnosis-related group mortality risk (p < 0.001), and lower resource utilization measures compared with those without palliative care. Independent predictors of palliative care use were older age (odds ratio, 4.06; 95% CI, 3.87-4.23; p < 0.001), female sex (odds ratio, 1.17; 95% CI, 1.14-1.20; p < 0.001), Caucasian race (p < 0.001), Medicare insurance (p < 0.001), hospitals in the west and mid-west (p < 0.001), hospital transfer (odds ratio, 1.23; 95% CI, 1.18-1.30; p < 0.001), high intracerebral hemorrhage case volume (p < 0.001), anticoagulant use (odds ratio, 1.24; 95% CI, 1.19-1.31; p < 0.001), higher Charlson comorbidity score, ventriculostomy placement (odds ratio, 1.18; 95% CI, 1.13-1.29; p < 0.001), and mechanical ventilation (odds ratio, 1.44; 95% CI, 1.39-1.49; p < 0.001). Cerebral angiogram, craniotomy, and gastrostomy were independently associated with absence of palliative care use. CONCLUSIONS: An apparent increasing trend of palliative care utilization in intracerebral hemorrhage has occurred over the last decade. After clinical severity adjustment, gender and racial differences and hospital characteristics appear to influence palliative care use among intracerebral hemorrhage patients in the United States.

Promoting blood circulation for removing blood stasis therapy for acute intracerebral hemorrhage: a systematic review and meta-analysis.

AIM: To conduct a systematic review and meta-analysis to assess the current evidence available regarding the promoting blood circulation and removing blood stasis (PBCRBS) therapy for Chinese patients with acute intracerebral hemorrhage (ICH). METHODS: Six databases were searched from their inception to November 2013. The studies assessed in ≥ 4 domains with 'yes' were selected for detailed assessment and meta-analysis. The herbal compositions for PBCRBS therapy for acute ICH patients were also assessed. RESULTS: From the 6 databases, 292 studies claimed randomized-controlled clinical trials (RCTs). Nine studies with 798 individuals were assessed in ≥ 4 domains with 'yes' by using the Cochrane RoB tool. Meta-analysis showed that PBCRBS monotherapy and adjuvant therapy for acute ICH could improve the neurological function deficit, reduce the volume of hematoma and perihematomal edema, and lower the mortality rate and dependency. Moreover, there were fewer adverse effects when compared with Western conventional medication controls. Xueshuantong Injection and Fufang Danshen Injection, Buyang Huanwu Decoction and Liangxue Tongyu formula, and three herbs (danshen root, sanqi and leech) were the most commonly used Chinese herbal patent injections, herbal prescriptions and single herbs, respectively. CONCLUSION: Despite the apparently positive findings, it is premature to conclude that there is sufficient efficacy and safety of PBCRBS for ICH because of the high clinical heterogeneity of the included studies and small number of trials in the meta-analysis. Further large sample-sizes and rigorously designed RCTs are needed.

Effect of statin use during hospitalization for intracerebral hemorrhage on mortality and discharge disposition.

IMPORTANCE: Statin use during hospitalization is associated with improved survival and a better discharge disposition among patients with ischemic stroke. It is unclear whether inpatient statin use has a similar effect among patients with intracerebral hemorrhage (ICH). OBJECTIVE: To determine whether inpatient statin use in ICH is associated with improved outcomes and whether the cessation of statin use is associated with worsened outcomes. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 3481 patients with ICH admitted to any of 20 hospitals in a large integrated health care delivery system over a 10-year period. Detailed electronic medical and pharmacy records were analyzed to explore the association between inpatient statin use and outcomes. MAIN OUTCOMES AND MEASURES: The primary outcome measures were survival to 30 days after ICH and discharge to home or inpatient rehabilitation facility. We used multivariable logistic regression, controlling for demographics, comorbidities, initial severity, and code status. In addition, we used instrumental variable modeling to control for confounding by unmeasured covariates at the individual patient level. RESULTS: Among patients hospitalized for ICH, inpatient statin users were more likely than nonusers to be alive 30 days after ICH (odds ratio [OR], 4.25 [95% CI, 3.46-5.23]; P < .001) and were more likely than nonusers to be discharged to their home or an acute rehabilitation facility (OR, 2.57 [95% CI, 2.16-3.06]; P < .001). Patients whose statin therapy was discontinued were less likely than statin users to survive to 30 days (OR, 0.16 [95% CI, 0.12-0.21]; P < .001) and were less likely than statin users to be discharged to their home or an acute rehabilitation facility (OR, 0.26 [95% CI, 0.20-0.35]; P < .001). Instrumental variable models of local treatment environment (to control for confounding by unmeasured covariates) confirmed that a higher probability of statin therapy was associated with a higher probability of 30-day survival (with an increase in probability of 0.15 [95% CI, 0.04-0.25]; P = .01) and a better chance of being discharged to home or an acute rehabilitation facility (with an increase in probability of 0.13 [95% CI, 0.02-0.24]; P = .02). CONCLUSIONS AND RELEVANCE: Inpatient statin use is associated with improved outcomes after ICH, and the cessation of statin use is associated with worsened outcomes after ICH. Given the association between statin cessation and substantially worsened outcomes, the risk-benefit balance of discontinuing statin therapy in the acute setting of ICH should be carefully considered.

Predictors of hematoma volume in deep and lobar supratentorial intracerebral hemorrhage.

IMPORTANCE: Hematoma volume is the strongest predictor of outcome in intracerebral hemorrhage (ICH). Despite known differences in the underlying biology between deep and lobar ICHs, limited data are available on location specificity of factors reported to affect hematoma volume. OBJECTIVE: To evaluate whether determinants of ICH volume differ by topography, we sought to estimate location-specific effects for potential predictors of this radiological outcome. DESIGN: Prospective cohort study. SETTING: Academic medical center. PARTICIPANTS: A total of 744 supratentorial primary ICH patients (388 deep and 356 lobar) aged older than 18 years admitted between January 1, 2000, and December 31, 2010. MAIN OUTCOMES AND MEASURES: Intracerebral hemorrhage volume measured from the computed tomography scan obtained on presentation to the emergency department. Linear regression analysis, stratified by ICH location, was implemented to identify determinants of log-transformed ICH volume. RESULTS: Median ICH volume was larger in lobar hemorrhages (39 mL; interquartile range, 16-75 mL) than in deep hemorrhages (13 mL; interquartile range, 5-40 mL; P < .001). In multivariable linear regression, independent predictors of deep ICH volume were intensity of anticoagulation (ß = 0.32; standard error [SE] = 0.08; P < .001; test for trend across 4 categories of the international normalized ratio), history of coronary artery disease (ß = 0.33; SE = 0.17; P = .05), male sex (ß = 0.28; SE = 0.14; P = .05), and age (ß = -0.02; SE = 0.01; P = .001). Independent predictors of lobar ICH volume were intensity of anticoagulation (ß = 0.14; SE = 0.06; P = .02) and antiplatelet treatment (ß = 0.27; SE = 0.13; P = .03). CONCLUSIONS AND RELEVANCE: Predictors of hematoma volume only partially overlap between deep and lobar ICHs. These findings suggest that the mechanisms that determine the extent of bleeding differ for deep and lobar ICHs. Further studies are needed to characterize the specific biological pathways that underlie the observed associations.

[Novel oral anticoagulants and atrial fibrillation in the elderly]. / Les nouveaux anticoagulants oraux et la fibrillation atriale du sujet âgé

Atrial fibrillation treatment relies on anticoagulation therapy that reduces the risk of stroke. Vitamin K antagonists (VKA) were the only oral anticoagulant drugs for more than 50 years, but they are difficult to manage especially in the elderly. In France, VKA are the main cause of iatrogenic hospitalizations with about 17,000 hospitalizations per year and around 4,000 to 5,000 deaths per year. Pharmacologic properties of VKA, especially the narrow therapeutic margin explain the complexity of their management. Several studies have shown that patients treated with VKA were on average only 50% of the time with an INR in the therapeutic range. In other words, patients are, half of the time, either-under treated or over-treated. Within this framework, development of new oral anticoagulant drugs appeared necessary, in order to obtain drugs with larger therapeutic margin and a better risk/benefit profile than VKA. Three large randomized clinical trials including almost 50,000 patients with 20,000 subjects over 75 years old and 8,000 over 80 years old, show a better risk/benefit profile of the new oral anticoagulants (NOAC) than VKA, characterized by a 50% reduction of cerebral hemorrhages, 22% reduction of stroke and 12% reduction of total mortality. Meanwhile, their renal elimination and the lack of control of the biological efficacy need to be taken into account for their prescription. Renal failure (estimated glomerular filtration rate according to Cockcroft formula < 30 mL/min) contraindicates their use. Their half-life is shorter than that of VKA and the biological monitoring is not available, thus a good adherence to the treatment is important. Studies specifically conducted among geriatric older population with poly-pathologies and frail are therefore needed to evaluate tolerance of NOAC in real life conditions.

A randomized controlled study comparing omeprazole and cimetidine for the prophylaxis of stress-related upper gastrointestinal bleeding in patients with intracerebral hemorrhage.

OBJECT: Patients with intracerebral hemorrhage (ICH) are at high risk for severe stress-related upper gastrointestinal (UGI) bleeding, which is predictive of higher mortality. The aim of this study was to evaluate the effectiveness of omeprazole and cimetidine compared with a placebo in the prevention and management of stress-related UGI bleeding in patients with ICH. METHODS: In a single-center, randomized, placebo-controlled study, 184 surgically treated patients with CT-proven ICH within 72 hours of ictus and negative results for gastric occult blood testing were included. Of these patients, 165 who were qualified upon further evaluation were randomized into 3 groups: 58 patients received 40 mg intravenous omeprazole every 12 hours, 54 patients received 300 mg intravenous cimetidine every 6 hours, and 53 patients received a placebo. Patients whose gastric occult blood tests were positive at admission (n = 70) and during/after the prophylaxis procedure (n = 48) were treated with high-dose omeprazole at 80 mg bolus plus 8 mg/hr infusion for 3 days, followed by 40 mg intravenous omeprazole every 12 hours for 7 days. RESULTS: Of the 165 assessable patients, stress-related UGI bleeding occurred in 9 (15.5%) in the omeprazole group compared with 15 patients (27.8%) in the cimetidine group and 24 patients (45.3%) in the placebo group (p = 0.003). The occurrence of UGI bleeding was significantly related to death (p = 0.022). Nosocomial pneumonia occurred in 14 patients (24.1%) receiving omeprazole, 12 (22.2%) receiving cimetidine, and 8 (15.1%) receiving placebo (p > 0.05). In patients with UGI bleeding in which high-dose omeprazole was initiated, UGI bleeding arrested within the first 3 days in 103 patients (87.3%). CONCLUSIONS: Omeprazole significantly reduced the morbidity of stress-related UGI bleeding in patients with ICH due to its effective prophylactic effect without increasing the risk of nosocomial pneumonia, but it did not reduce the 1-month mortality or ICU stay. Further evaluation of high-dose omeprazole as the drug of choice for patients presenting with UGI bleeding is warranted. Clinical trial registration no.: ChiCTR-TRC-12001871, registered at the Chinese clinical trial registry (http://www.chictr.org/en/proj/show.aspx?proj=2384).

Wound complications following rivaroxaban administration: a multicenter comparison with low-molecular-weight heparins for thromboprophylaxis in lower limb arthroplasty.

BACKGROUND: The oral anticoagulant rivaroxaban is recommended for venous thromboembolic prophylaxis following lower limb arthroplasty. Concerns regarding high rates of wound complications following its use have prompted this multicenter comparison with low-molecular-weight heparins. METHODS: English hospital trusts that replaced a low-molecular-weight heparin with rivaroxaban for thromboprophylaxis in lower limb arthroplasty during 2009 were identified. Prospectively collected national data for these units were analyzed to determine the thirty-day rates of wound complications and major bleeding (cerebrovascular event or gastrointestinal hemorrhage) and the ninety-day rates of symptomatic deep venous thrombosis (proximal or distal), symptomatic pulmonary embolism, and all-cause inpatient mortality before and after the change to rivaroxaban. A total of 2762 patients prescribed rivaroxaban following knee or hip arthroplasty were compared with 10,361 patients prescribed a low- molecular weight heparin. Data were analyzed with use of odds ratios (ORs). RESULTS: There were significantly fewer wound complications in the low-molecular-weight heparin group (2.81% compared with 3.85%; OR = 0.72, 95% confidence interval [CI] = 0.58 to 0.90; p = 0.005). There were no significant differences between the low-molecular-weight heparin and rivaroxaban groups in the rates of pulmonary embolism (0.55% compared with 0.36%; OR = 1.52, 95% CI = 0.78 to 2.98), major bleeding (OR = 0.73, 95% CI = 0.48 to 1.12), or all-cause mortality (OR = 0.93, 95% CI = 0.46 to 1.89). There were significantly more symptomatic deep venous thromboses in the low-molecular-weight heparin group (0.91% compared with 0.36%; OR = 2.51, 95% CI = 1.31 to 4.84; p = 0.004). CONCLUSIONS: The rivaroxaban group had a higher wound complication rate and a lower deep venous thrombosis rate; there were no differences in symptomatic pulmonary embolism or all-cause mortality. Longer follow-up is needed to assess any potential relationship between wound complications and joint stiffness, latent infection, and limb consequences of deep venous thrombosis.

Liver cirrhosis and risk of intracerebral hemorrhage: a 9-year follow-up study.

BACKGROUND AND PURPOSE: The purpose of this study was to investigate the risk of future intracerebral hemorrhage development in patients with liver cirrhosis. METHODS: Data were collected from the National Health Insurance Research Database of Taiwan. The study cohort included 948 patients with liver cirrhosis diagnosed in 1999 and 9480 age- and sex-matched patients of the same year. All patients were tracked from their index visits for 9 years. RESULTS: Intracerebral hemorrhage developed in 1.3% of patients with liver cirrhosis and 1.0% of patients in the comparison cohort during the follow-up period. Log-rank test analysis showed no significant difference between the 2 cohorts (P=0.39). A stratified Cox proportional regression model showed an adjusted hazard ratio of 1.62 (95% CI, 0.85 to 3.10) for patients with liver cirrhosis to develop intracerebral hemorrhage compared with patients without liver cirrhosis. CONCLUSIONS: Patients with liver cirrhosis had a similar intracerebral hemorrhage incidence rate but a trend of increased risk for intracerebral hemorrhage compared with the comparison cohort during the 9-year follow-up period.

Endoscopic surgery for intraventricular hemorrhage (IVH) caused by thalamic hemorrhage: comparisons of endoscopic surgery and external ventricular drainage (EVD) surgery.

BACKGROUND: Intraventricular hemorrhage (IVH) caused by thalamic hemorrhage has high mortality and morbidity. The aim of this study was to investigate the efficacy and the results of endoscopic surgery for the evacuation of IVH caused by thalamic hemorrhage compared with that of external ventricular drainage (EVD) surgery. METHODS: From January 2006 to December 2008, 48 patients with IVH caused by thalamic hemorrhage were enrolled and treated in our department. Patients with IVH caused by thalamic hemorrhage who also resulted in acute hydrocephalus were indicated for surgery; the patients who were included were randomly divided into an EVD group and an endoscopic surgery group. The clinical evaluation data included the Glasgow Coma Scale, length of intensive care unit (ICU) stay, age, intracerebral hemorrhage volume, and severity of IVH. Outcome was measured using the 30-day and 90-day mortality rate, ventriculoperitoneal (VP) shunt dependent rate, and Glasgow Outcome Scale after three months. RESULTS: The clinical features of the 24 patients in each group showed no significant differences in age or Glasgow Coma Scale assessment on admission. There was also no significant difference in intracerebral hemorrhage volume or Graeb score between the endoscopic group and the EVD group. The length of ICU stay was 11 ± 5 days in the endoscopic surgery group and 18 ± 7 days in the EVD group. The endoscopic surgery group had a shorter ICU stay (P = 0.04) compared with the EVD group. The 30-day and 90-day mortality rates were 12.5% and 20.8% in the endoscopic surgery group and 12.5% and 16.6% in the EVD group, respectively. The mean Glasgow Outcome Scale score was 3.08 ± 1.38 in the endoscopic surgery group and 3.33 ± 1.40 in the EVD group. Outcome significantly correlated with initial consciousness level; the severity of IVH did not influence the outcome in all of the cases. There was no significant difference in mortality rate or outcome between the endoscopic group and the EVD group. The VP shunt rates were 47.62% in the endoscopic surgery group and 90.48% in the EVD group. Endoscopic surgery group had a significant lower VP shunt rate (P = 0.002; odds rate = 9.8) compared with the EVD group. CONCLUSIONS: Endoscopic surgery was found to have significantly lower shunt-dependent hydrocephalus, and the ICU stay was shorter compared with EVD surgery. This can decrease the need for permanent VP shunts in patients with IVH caused by thalamic hemorrhage.

Metabolic and clinical effects of the supplementation of a functional mixture of amino acids in cerebral hemorrhage.

BACKGROUND: Oral supplementation of a specific mixture of essential and non-essential amino acids has been shown to modulate hypercatabolism in patients with chronic heart failure, leading to improved clinical outcome. The aim of this study was to test whether such effects could be replicated in an acute clinical model of hypercatabolism. METHODS: After approval by the Ethics Committee, patients with acute brain hemorrhage admitted to the Neurosurgical ICU were randomly assigned to receive enterally for 14 days 20% of their estimated nitrogen requirements as a standard protein supplement (control group; n = 9) or as a functional amino acid mixture (Aminotrofic®, Errekappa Euroterapici; study group; n = 10). Metabolic and clinical outcome measures were monitored. RESULTS: In the study group, insulin sensitivity and total lymphocyte count appeared to improve when compared with control patients. Less positive blood cultures were found in the study group against control patients (4 vs. 7, respectively; P = 0.05). Also, mortality in the study group was reduced than in control patients (60 vs. 77%; P = n.s.). CONCLUSIONS: Supplementation with specific amino acids in critically ill patients may modulate metabolic response and improve clinical outcome.

The TRACH score: clinical and radiological predictors of tracheostomy in supratentorial spontaneous intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Spontaneous intracerebral hemorrhage (sICH) continues to have high morbidity and mortality. Patients with sICH and poor mental status are at high risk of airway compromise and frequently require intubation. The traditional ventilatory weaning parameters are not reliable in patients with brain pathology. The objective of this study is to identify clinical and radiological predictors for tracheostomy in mechanically ventilated patients with sICH and to develop a scale that will accurately predict the need for tracheostomy in these patients. METHODS: Only patients with supratentorial sICH intubated on the field or on admission who survived the first 3 days were included. Univariate and multivariate logistic regression analysis of clinical and radiological variables was performed, and independent predictors were identified. A risk stratification scale (TRACH Score) was developed using these independent predictors. RESULTS: Several independent factors were associated with early tracheostomy. The significant clinical predictor was Glasgow Coma Scale (GCS) score (P < 0.003). Radio-logical predictors were presence of hydrocephalus (OR: 12.5; P < 0.002), septum pellucidum shift (OR: 9; P < 0.025), and location of sICH in the thalamus (OR: 9; P < 0.025). The TRACH score was defined by two variables radiological scale (RScale) and Glasgow Outcome Score (GOS). TRACH score = 3 + (1 x RScale) -(0.5 x GCS). The RScale (L + H + S) was obtained by adding individual points assigned according presence of: sICH location in the thalamus (L) 2 points, hydrocephalus (H) 1.5 points, septum pellucidum shift (S) 3 points. The scale was very predictive of tracheostomy needs (OR: 2.57, P < 0.0001) with an ROC = 0.92, sensitivity of 94%, positive predictive value of 83%, and negative predictive value of 95%. CONCLUSIONS: The TRACH Score is a practical clinical grading scale that will allow physicians to identify patients who will be needing tracheostomy. Application of this scale could have significant impact on length of stay and cost of hospitalization.

Minimally invasive craniopuncture therapy vs. conservative treatment for spontaneous intracerebral hemorrhage: results from a randomized clinical trial in China.

BACKGROUND AND PURPOSES: To evaluate the effects of minimally invasive craniopuncture therapy compared with conservative treatment in treating intracerebral hemorrhage (25-40 ml) in the basal ganglion. METHODS: A multicenter, randomized control clinical trial comprised 465 cases of hemorrhage in the basal ganglion from 42 hospitals in China. Three hundred and seventy-seven patients with hemorrhage were randomly assigned to receive minimally invasive craniopuncture therapy (n=195) or conservative control treatment (n=182). The main indices of evaluation were the degree of neurological impairment at the 14th day after treatment, activities of daily living at the end of the 3rd month and the case fatality within 3 months. RESULTS: Improvement of neurological function in the minimally invasive craniopuncture group was significantly better than that in the control group at the 14th day (chi(2)=7.93, P=0.02). At the end of the 3rd month, there was a significant difference between the two groups in activities of daily living score (chi(2)=23.13, P<0.001). The proportion of dependent survival patients (modified Rankin scale >2) in the craniopuncture group (40.9%) was significantly lower than that in the conservative group (63.0%) at the end of the 3rd month (chi(2)=16.95, P<0.01). There was no significant difference in the cumulative fatality rates within three months between the two groups [6.7% (13/195) in the craniopuncture group and 8.8% (16/182) in the conservative group]. CONCLUSIONS: This minimally invasive craniopuncture technique can improve the independent survival of patients with small basal ganglion hemorrhage. It is a safe and practical technique in treating cerebral hemorrhage.

Prognostic significance of third ventricle dilation in spontaneous intracerebral hemorrhage: a preliminary clinical study.

OBJECTIVE: Although numerous factors have been described that predict outcome after spontaneous intracerebral hemorrhage (ICH), very little is know about the role of hemorrhagic dilation of the third ventricle in development of hydrocephalus and prognosis. The objective of this study was to investigate whether the presence of hemorrhagic third ventricle dilation after ICH would predict development of hydrocephalus and outcome. METHODS: We identified the patients with spontaneous ICH treated with external ventricular drainage (EVD) in this retrospective study. Computerized tomography (CT) was performed at admission within 24 hours of onset and retrospectively analysed to determine lesion size and location, status of third and fourth ventricle and frontal horn index (FHI). Glasgow coma scale (GCS) score, mean arterial pressure (MAP), etiology and demographic data were obtained from medical records. Outcome was determined using modified Rankin score at month 3. Patients with and without third ventricle dilation were compared in terms of hydrocephalus (FHI > 0.38), initial GCS score, age and MAP, and analyses were performed to determine whether third ventricle dilation was a predictor of poor outcome. RESULTS: Of the 22 patients studied, all had thalamic or basal ganglia hemorrhage with intraventricular hemorrhage (IVH) and all are treated with external ventricular drainage (EVD). Of the 22 patients, 12 had third ventricle dilation (width > or = 10 mm) and ten patients had non-dilated third ventricle (width < 10 mm). Patients with third ventricle dilation had lower GCS scores (7.4 +/- 1.8 versus 9.7 +/- 2.1, p < 0.005) and had higher FHI (0.46 +/- 0.06 versus 0.38 +/- 0.02, p < 0.005) as compared to patients with non-dilated third ventricle. The differences in age (59.5 +/- 9.4 versus 59.2 +/- 11.2) and MAP (128.3 +/- 16.0 versus 130.5 +/- 13.6) of the patients were not significant statistically. Sixty-six percent of patients (8/12) with third ventricle dilation and 60% of patients (6/10) with normal third ventricle were dead 6 months post-operation and mortality rate did not differ significantly. DISCUSSION: Although the roles of various factors are well described in the prognosis of spontaneous ICH, little is known about the role of third ventricle dilation. Based on our results, we concluded that third ventricle dilation is a poor prognostic factor.