XVII. European Stroke Conference
Nice, France
XVII. European Stroke Conference
Nice, France
Poster Session: Intracerebral and subarachnoid bleedings/ Cerebral haemorrhage and SAH
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Cerebral microbleeds are associated with statin use and low cholesterol level
H. Wersching
C. Stehling
L. Eckardt
S.P.Kloska
W. Heindel
S. Knecht
University of Muenster
GERMANY
Background and Purpose: Recent studies indicate that statins and low cholesterol levels may increase the risk of intracerebral hemorrhage. Cerebral microbleeds, commonly seen as an indicator of advanced small vessel disease, are frequent in patients with ICH and are associated with an increased risk for future bleeding. However, the incidence of cerebral microbleeds (CMBs) in patients treated with statins has not been investigated. We assessed the hypothesis that the appearance of CMBs in individuals without prior cerebral ischemia or bleeding may be associated with statin treatment and low cholesterol levels. Methods: We investigated 254 individuals (mean age 63 +/- 7.6 years) from the SEARCH-Health study (Systematic evaluation and alteration of risk factors for cognitive health), an interdisciplinary population-based cohort study on the relation of age, cardiovascular risk factors, mental status, and cerebral findings on MRI. MRI was performed on a 3.0 T scanner with T2*MRI sequence. CMBs were defined as focal parenchymal areas of low signal intensity on T2*MRI of less than 10 mm in diameter and counted within the whole brain. Age, gender, cardiovascular risk factors (smoking pack years, alcohol use, BMI, oral anticoagulation, platelet inhibitors, serum levels of cholesterol and HBa1c) and statin treatment were assessed and correlated with CMBs using a dichotomous logistic regression model. Results: Total incidence of microbleeds in our cohort was 10%. CMBs were indepently associated with low cholesterol levels (p<0.1, B=-0.012) and statin therapy (p<0.05, B=1.041). Splitting the cohort in two subgroups according to the current use of statins, we found low cholesterol levels to be significantly associated with CMBs only in subjects with current statin therapy (p<0.1, B=-0.023). Discussion: In conclusion, we found a significant association of CMBs with statin therapy and with low cholesterol levels in patients receiving statins. Future prospective studies need to assess whether an increased CMB load and statin therapy increases the risk of intracerebral hemorrhage.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Transient neurological signs and symptoms consequent to localized subarachnoid hemorrhage as a possible presentation of Cerebral Amyloid Angiopathy
R.J.Felgueiras
P.S.Pinto
C.P.Vasconcelos
J.L.Reis
M.M.Correia
L.F.Maia
Neurology Department, Centro Hospitalar do Porto
PORTUGAL
Background and Purpose Five percent of all spontaneous subarachnoid hemorrhage (SAH) are non aneurysmatic and non perimesencephalic. Cerebral or spinal arteriovenous malformations and hematologic disorders have been reported, but some cases remain unexplained. Cerebral Amyloid Angiopathy (CAA) is a clinicopathological condition secondary to the deposition of amyloid in the wall of leptomeningeal and cortical vessels. Its prevalence at autopsy series (2,3 to 12,1% age related) largely outnumbers the incidence of symptomatic lobar brain hemorrhages (30 to 40/100.000). We present the semiotic and imaging of four patients with localized cortical SAH. Case description Four patients aged between 63 and 92 presented with stereotyped transient neurological symptoms (paresthesias in a hemi-body interpreted as partial sensitive focal seizures). Localized SAH was identified in CT scan of all patients (sulcal spontaneous hyperdensity) and extensive etiological investigation (hemogram, coagulation, immunology and digital subtraction angiography) did not disclose any abnormality. MRI revealed cortico-subcortical microhemorrhages in three patients, one of those with two asymptomatic macrohemorrhages and a contralateral SAH. White matter changes correlated with the hemorrhagic load. Retrospective cognitive and neurological evaluation did not reveal any abnormality at baseline. One patient further hypocoagulated for primary prophylaxis of atrial fibrillation had a fatal lobar brain hemorrhage 3 months later. Another patient became demented after 4 years. Discussion Localized SAH may be attributed to CAA due to its tropism for superficial cerebral vessels. Still this isn't recognized in the present CAA diagnostic criteria. Although not supported by pathology, our cases together with recent published data, illustrate the increasing importance of localized SAH as a potential presentation of CAA. It is essential to diagnose such subtle presentation for consequent better clinical management and patient outcome. Follow-up of these patients should illustrate our point.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Increased incidence of vasospasm in intracerebral haemorrhage with intraventricular haemorrhage
J.U.Regula
M. Sykora
J. Schill
R. Veltkamp
P.A.Ringleb
Th. Steiner
UniversityHospital Heidelberg
GERMANY
Background: Intracerebral haemorrhage (ICH) with intraventricular haemorrhage (IVH) might have a poorer prognosis than ICH without ventricular affection. Up to date the incidence of vasospasms in IVH is controversial. Our aim was to evaluate the incidence of vasospasm and the correlation between a delayed neurological deterioration (also known as delayed clinical impairment = DCI) and these vasospasms. Methods: 60 consecutive patients with IVH were treated on our neurological intensive care unit in the last two years. Patients with primary subarachnoidal haemorrhage were excluded. Vasospasm was classified based on the peak systolic velocity (PSV): with a PSV > 180cm/s for definition of severe vasospasm and a PSV between 120cm/s and 180cm/s for the definition of marginal vasospasm. Data analysis was done retrospectively. Results: 20 patients died within 4 days after admission due to the bleeding (early mortality 33 %) and were therefore excluded from further evaluation. Out of the 40 patients who survived at least 4 days, 13 (32.5%) had severe, 8 (20.0%) marginal, and 19 (47.5%) no vasospasm. Mortality in these groups was 53.8%, 0%, and 0% respectively (chi²-test; p<0.001). DCI was observed in 7 patients with severe, in 1 with marginal, and in 0 with no vasospasms (chi²-test; p<0.001). DCI was caused by ischemic stroke in 5 patients and by rebleeding in 3 patients. Patients with both vasospasm and DCI had a particular high mortality of 71.4%. Conclusion: Vasospasms are common in patients with IVH and are associated with an increased mortality. We assume that vasospasms, especially severe vasospasms, are at least partially responsible for a DCI, death and the poor prognosis. Whether treatment with nimodipine reduces this risk has to be examined.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Magnetic Resonance Imaging Reveals Ischemia of the Ipsilateral Midbrain Peduncle in the Course of Acute Putaminal Hemorrhage.
J.M.OLIVOT
C. VENKATASUBRAMANIAN
M. MLYNASH
A FINLEY-CAUFIELD
I EYNGORN
R BAMMER
C WIJMAN
Stanford Stroke Center
USA
Background and Purpose: Hematoma growth, perihematomal edema, and intraventricular hemorrhage are the main initial complications of spontaneous intracerebral hemorrhage (ICH). Whether associated cerebral ischemia plays an important additional role remains speculative. Methods and Patients: A cohort of 40 consecutive patients with an acute spontaneous and primary ICH underwent 2 brain MRIs during the first 10 days following symptom onset. These patients were prospectively enrolled in the Diagnostic Accuracy of magnetic resonance imaging (MRI) in Spontaneous intracerebral Hemorrhage (DASH) study. We systematically reviewed the baseline and follow up brain MRI for the occurrence of new ischemic lesions between the first and second MRI. Ischemic lesion was defined as a new lesion on Diffusion Weighted Imaging (DWI) with a decreased apparent diffusion coefficient (ADC) and the absence of hemorrhage on the corresponding FLAIR and Gradient Echo imaging sequences. We report the occurrence of a striking pattern of midbrain peduncular infarction in the course of putaminal ICH. Results: Among the 40 patients (14 with putaminal hemorrhage), follow up MRI revealed a new isolated acute ischemic lesion limited to the ipsilateral midbrain peduncle in 5 patients. All patients had a putaminal hemorrhage. Their median age was 59 years (Range 22-75), the initial median NIHSS was 21 (Range:18-26) and median ICH volume 38 cc (Range 22-99). Follow-up MRI showed a median increase in lesion volume (hematoma plus edema) of 20cc (Range: 6-41) all caused by the development of peri-hematomal edema. After 3 months, median modified Rankin Scale was 4 (Range 3-6), one patient died from uncal herniation. The midbrain peduncle is supplied by the peduncular perforating artery (PPA) originating from the P2 portion of the posterior cerebral artery (PCA). We attribute the peduncular infarction to compression of the PPA by displacement of the temporal lobe. Conclusion: Isolated ischemia of the ipsilateral midbrain peduncle is not uncommon in the course of a spontaneous putaminal ICH.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Factors associated with the initial severity in patients with supra-tentorial intra-cerebral haemorrhages.
M. Pasquini
C. Cordonnier
F. Dumont
M. Rutgers
H. Hénon
D. Leys
Lille University Hospital
FRANCE
Background: In patients with intra-cerebral hemorrhage (ICH), initial ICH volume and clinical severity are the most powerful predictors of outcome. The identification of modifiable factors already present before ICH and related to initial severity may lead to preventive measures that could improve final outcome. The objective of our study was to identify predictors of initial severity in patients with supra-tentorial ICH. Method: this study was conducted among the 373 consecutive patients admitted in the Lille University Hospital for a non-traumatic ICH. We did not include patients referred from other hospitals, or with an intracranial vascular malformation. At admission, we recorded demographic data, risk factors for ICH, National Institute of Health stroke scale (NIHSS) score, and CT-scan characteristics, including ICH volume. Results: Among 373 patients, 318 had a single supra-tentorial haemorrhage (mean age 71 years, interquartile range 56-79). Oral anticoagulation (OAC) (OR: 5; 95% CI: 1.1-8.8), and previous stroke (OR: 3.9; 95% CI: 0.5-7.4) independently predicted NIHSS score at admission. OAC (OR: 32.6; 95% CI: 17.1-48.2), association aspirin-clopidogrel (OR: 48.1; 95% CI: 1.2-80.1), and previous stroke (OR: 17; 95% CI: 2.7-31.3) were independent predictors of ICH volumes at admission. Conclusion: OAC and association aspirin plus clopidogrel are associated with an increased severity of ICH at admission. Further studies are needed to explore the role of other variables potentially related to ICH risk, such as brain microbleeds or leukoaroaiosis, especially in patients receiving antithrombotics.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Cerebral Interleukin 6 in intracranial hypertension following aneurysmal subarachnoid hemorrhage
D. Graetz
A. Nagel
F. Schlenk
O. Sakowitz
P. Vajkoczy
A. Sarrafzadeh
Charité Campus Virchow Medical Center, Berlin
GERMANY
Background: Despite considerable advances in the diagnosis and treatment of patients with aneurysmal subarachnoid hemorrhage (SAH), the outcome remains poor, especially in SAH patients developing intracranial hypertension (intracranial pressure, ICP>20 mmHg). This study was to evaluate cerebral Interleukin-6 (IL-6) levels in SAH patients with high ICP compared to SAH patients with normal ICP values because IL-6 obviously plays a role in the pathogenesis of complications after SAH. Methods: 17 SAH patients were studied, classified into two groups: ICP>20 mmHg (n=7) and ICP≤20 mmHg (n=10). A microdialysis (MD) catheter was placed into the vascular territory of interest after aneurysm clipping. Samples were analyzed hourly for lactate-pyruvate ratio (LPR) and glutamate. MD and cerebrospinal fluid (CSF) samples for IL-6 were collected every 12 hours. For calculating between-group differences, the 24-hr median values of days 1-7 after SAH were used. Results: The presence of intracranial hypertension was associated with an inflammatory response with highest MD IL-6 concentrations on days 5 and 6 after SAH. These high IL-6 levels were measured in metabolically compromised brain tissue with higher LPR indicating anaerobic metabolism. Levels and time course of IL-6 differed between CSF and brain tissue, with CSF levels not reflecting the presence of intracranial hypertension. Discussion: Because MD IL-6 levels differed from CSF levels with lower CSF values in the subacute phase, a different origin of IL-6 production is possible. More detailed studies of the immunoreactive cascade are necessary to understand the role of IL-6 in aneurysmal SAH to improve the analysis of inflammatory and metabolic changes which may lead to new therapeutic options and a better outcome.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Prevalence and possible risk factors for anosmia after aneurysmal subarachnoid hemorrhage treated with coiling: an observational cohort study
A.S.E. Bor
S.L.Niemansburg
M.H.M. Wermer
G.J.E. Rinkel
Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht
THE NETHERLANDS
Background: Anosmia has an important impact on daily life, yet usually receives little attention from physicians. Anosmia has frequently been reported in patients after aneurysmal subarachnoid hemorrhage (SAH) treated with clipping. Recently it was found that patients with SAH treated with coiling may experience anosmia as well. The pathogenesis of anosmia after coiling is unknown. In an observational cohort study we analyzed prevalence and possible risk factors for anosmia after coiling for SAH. Methods: We interviewed all patients with SAH treated with coiling between 1997 and 2007 who had resumed independent living on loss of smell. Data on localization of the ruptured aneurysm, neurological condition on admission, hydrocephalus and treatment for hydrocephalus were retrieved from medical records. CT-scans on admission were analyzed for bicaudate index, amount of blood in the fissura interhemispherica and total amount of subarachnoidal blood. Risk factors were assessed by logistic regression analysis. Results: Overall, 197 patients were included, of whom 35 experienced anosmia (17.8%, 95%CI 12.4-23.1). Anosmia improved in 23 of the 35 (66%) patients; in 20 of them the recovery was complete. For 161 of the 197 patients the CT-scan on admission was available for assessment. None of the possible risk factors was statistically significant related to the occurrence of anosmia. Discussion: One in six SAH patients in whom the ruptured aneurysm is treated with coiling experiences anosmia. Anosmia after coiling has a good prognosis. The exact pathogenesis of anosmia after coiling remains unknown. There seems to be no relation with the amount or localization of subarachnoid blood or with the presence of hydrocephalus.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Single versus dual external ventricular drainage for intraventricular fibrinolysis in intraventricular hemorrhage
D. Staykov
H.B.Huttner
J. Lunkenheimer
F. Seifert
I.C.Kanter
M.J.Hilz
S. Schwab
J. Bardutzky
University of Erlangen
GERMANY
Background and purpose Intraventricular fibrinolysis (IVF) through an external ventricular drainage (EVD) has been shown to be an effective treatment method for clot lysis and evacuation in primary or secondary intraventricular hemorrhage. The effectiveness of IVF through a single versus dual bifrontal EVD in IVH with severe involvement of the lateral ventricles (LV) has not been studied sufficiently to date. Dual EVDs are usually placed at the discretion of the treating neurologist or neurosurgeon in cases with more severe involvement of the LV with the intention to provide a better access of the fibrinolytic agent. We investigated the efficacy of clot lysis and resolution in patients with secondary IVH treated with IVF through a single versus a dual EVD. Patients and methods A total of 17 patients aged 44-75 years with secondary IVH and obstructive hydrocephalus requiring EVD were treated with a single (n=7) or a dual (n=10) EVD and IVF with rtPA. Dual EVDs were placed if LV-involvement measured at least 3 Graeb score points for at least one LV on admission CT scan. Daily CT scans were performed. IVH-volumes were calculated through tracing of the ventricular clot and multiplication of surface and slice thickness. Results There was no significant difference in the resolution of the intraventricular clot during IVF in both groups, neither using IVH-volume, nor Graeb scores. Separate analyses of the third and fourth ventricle clearance, essential for treatment of obstructive hydrocephalus, showed similar results. There was a slight nonsignificant trend of better resolution of the clots in the LV in the dual EVD group. Conclusion There is probably no benefit of dual EVDs for IVF in patients with IVH considering clot lysis and resolution.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
The ER-alpha PvuII Polymorphism Contributes to the Pathogenesis of Intracranial Aneurysm
S. Abboud
B. Lubicz
J.G. Ribeiro Vaz
C. Raftopoulos
M. Pandolfo
U.L.B. Erasme hospital
BELGIUM
Background. Despite the catastrophic consequence of ruptured intracranial aneurysms (IA), very little is understood regarding their pathogenesis. Familial predisposition is the most important risk factor for IA. Hormones are suggested to play a role in the pathogenesis of IA as increased incidence of IA is seen in postmenopausal women, and the use of hormone replacement therapy is associated with a reduced risk. Furthermore in rat model, estrogen limits the formation and progression of IA. We hypothesize that estrogen receptor gene variation might influence sensitivity to estrogen and IA occurrence. We investigated the association of PvuII polymorphism of the estrogen receptor alpha (ER-alpha) gene with IA Material and method. The PvuII polymorphism of the estrogen receptor alpha (ER-alpha) gene was genotyped in a case-control study of 100 IA patients and 168 ethnicity and gender matched controls. Standard cardiovascular risk factors were reported. Results Smoking status was significantly more frequent in patients than controls (61.4% vs 18.6%, p<0.001), whereas hyperlipemia was less frequent in IA patients as compared to controls (23.2% vs 37.1%, p = 0.018). The risk of IA was associated with the TT genotype of PvuII ER-alpha polymorphism after adjustment for significant risk factors (OR = 2.04 95%CI: 1.01-4.13, p = 0.047). Conclusion. These finding suggest that genetic variation in ER-alpha gene contributes to the pathogenesis of IA. Further work is needed to confirm this finding in an independent set of samples.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Lumbar drainage for communicating hydrocephalus after intraventricular thrombolysis in secondary intraventricular hemorrhage. A feasibility and safety study.
D. Staykov
H.B.Huttner
F. Seifert
I.C.Kanter
J. Lunkenheimer
M.J.Hilz
S. Schwab
J. Bardutzky
University of Erlangen
GERMANY
Background and purpose Intracerebral hemorrhage (ICH) with severe ventricular involvement can cause life-threatening acute hydrocephalus (HC) through obstruction of the third and fourth ventricle. Treatment with external ventricular drainage (EVD) and intraventricular fibrinolysis (IVF) can restore the circulation of cerebrospinal fluid (CSF) and markedly lower short-term mortality. Beyond acute obstructive HC, CSF-circulation may remain impaired due to CSF-malresorption caused by blood degradation products after intraventricular hemorrhage (IVH), and prolonged external CSF-drainage may be necessary. At this point of treatment, lumbar drainage (LD) represents an alternative and less invasive method of external CSF-drainage with a lower complication profile than the EVD. We investigated the feasibility and safety of LD after IVF for treatment of communicating HC after secondary IVH. Patients and methods 16 patients aged 44-77 with hypertensive basal ganglia ICH with severe ventricular involvement and acute obstructive HC were treated with EVD, IVF with rtPA, and LD after communication of internal and external CSF-space was restored. Outcome was recorded after 6 months. Results IVF led to rapid resolution of IVH, all patients survived. External CSF-drainage for communicating HC was continued through the LD and EVD-duration was shortened. Thus no EVD-exchange was necessary. Clinical long-term outcome was variable. No patient required a CSF-shunt. No LD-associated complications were observed. Conclusions LD for communicating HC after IVF in patients with secondary IVH is feasible and safe. LD is less invasive and allows shorter EVD-duration and avoidance of EVD-exchange. IVF combined with LD possibly helps avoiding permanent impairment of CSF-circulation after IVH.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
OUTCOME DIFFERENCES BETWEEN INTRACEREBRAL HEMORRHAGE IN PATIENTS ADMITTED TO ACUTE STROKE UNIT (ASU) OR CONVENTIONAL UNIT (CU)
A. Rodriguez-Campello
A. Ois
M. Gomis
J. Jimenez-Conde
E. Cuadrado-Godia
R.M.Vivanco
E. Giralt
M. Sepulveda
J. Roquer
Hospital del Mar.
SPAIN
BACKGROUND: Clinical studies have shown that ASU care is effective in reducing morbidity and mortality compared to CU in ischemic and hemorrhagic stroke patients. Some factors such as the continuous monitoring system, early rehabilitation and multidisciplinary care are related to better outcome. Control of clinical complications leading a better outcome in patients monitored, probably due to an early detection and an early treatment. Only few studies about outcome in ASU in intracerebral hemorrhage (ICH) patients have been described. The aim of our study is to compare complications, functional outcome and mortality between patients with spontaneous ICH admitted to a ASU and those admitted to a CU. METHODS: Prospective review of 120 spontaneous ICH patients admitted in our hospital and allocated, to the ASU or CU in a 28-month period. We recorded demographic data, vascular risk factors, Glasgow coma scale (GCS), volume, ICH Score, severity (NIHSS) and outcome (mRS). Statistical analysis compared complications, mortality and outcome at three months in the 2 care settings. RESULTS: 120 patients were evaluated. 56 admitted in ASU (46.7%%) and 64 in CU (53.3%). Mean age was 72.62+/-12.85 years-old. 56.7% were men. Median initial NIHSS was 12 (q1,q3:4,20), initial GCS was 11.7+/-4.2. No differences between ASU-CU groups were seen in age, sex, vascular risk factors, volume, ICH score, glucose levels, cholesterol or length of stay. GCS was lower in CU patients (10.7 vs 13, p<0.003). Patients admitted in ASU presented more medical complications (58.9 vs 29.7%, p<0.001), essentially respiratory infection tract (28.6 vs 12.5, p<0.03), but mortality was lower in ASU (25% versus 46.9%; OR 0.38,p<0.01), and independence was greater (37.5 vs 21.95, ns). Multivariate analysis showed that ASU was an independent protective factor for disability (OR 0.27(0.09-0.86);p<0.02). CONCLUSIONS: Admission of ICH patients to a monitoring ASU is an independent factor of good outcome. Early detection and treatment of complications is essential to achieve more independence at three months.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Neurogenic Pulmonary Edema in Patients with Subarachnoid Hemorrhage
C. Muroi
M. Keller
S. Mink
A. Pangalu
E. Keller
Neurosurgical Intensive Care Unit, Department of Neurosurgery, University Hospital Zurich
SWITZERLAND
Neurogenic pulmonary edema (NPE), leading to cardiopulmonary dysfunction, is a potentially lifethreatening complication in patients with aneurysmal subarachnoid hemorrhage (SAH). We aimed to assess the clinical presentation and risk factors for the development of NPE after SAH. The database contained prospectively collected information on 477 patients with SAH. Baseline characteristics, clinical and radiological severity of the bleeding, localization of the ruptured aneurysm and clinical outcome of patients with NPE were compared to those of patients without NPE. Further, in patients with NPE, intracranial pressure (ICP), serum cardiac biomarkers and hemodynamic parameters during the acute phase were evaluated retrospectively. The incidence of NPE was 8% (39 of 477 patients). Most patients with NPE presented clinically severe and all of them radiologically severe hemorrhage. The incidence of NPE was significantly higher in patients with ruptured aneurysm in the posterior circulation. Elevated ICP was found in 67%, pathologically high cardiac biomarkers in 60% of patients with NPE. However no patient suffered from persistent cardiac dysfunction. Compared to patients without NPE, patients with NPE showed poor neurological outcome (Glasgow Outcome Scale 1 to 3 in 25% vs.77% of patients). Nevertheless, in none of these patients the poor outcome could be attributed to direct consequences of NPE. In conclusion, morbidity and mortality by cardiopulmonary failure due to NPE can be reduced by appropriate recognition and treatment. Therefore awareness of and knowledge about occurrence, clinical presentation and treatment of NPE, lined out in the present work, are essential for all those potentially confronted with patients with SAH in the acute phase.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Does age influence haematoma and oedema volumes?
M.Ö.McCarron
F. McVerry
M.J.Alberts
P. McCarron
Altnagelvin Hospital
UNITED KINGDOM
Background: Animal studies suggest that intracerebral haemorrhage (ICH) may affect aging and young brains in different ways. This study sought to determine whether haematoma and perihaematomal oedema volumes differed by age in a cohort of ICH patients. Methods: Haematoma and oedema volumes were recorded from admission computerised tomographic brain scans and compared between ICH patients below 60 years of age and ICH patients aged 60 years and older. The student's t test was used to compare volumes in each group. Results: There were 94 patients, 60 of whom were 60 years or older (37 men, 23 women, mean age 70.4 +/- 7.3 years SD). There were 34 patients under 60 years of age (21 men, 13 women, mean age 50.1+/-11.5 years). Mean haematoma volume was 44.9ml in patients 60 years and older compared to 31.4ml in patients less than 60 years, p=0.056. Perihaematomal oedema volumes were also larger in the older group, 26.3ml versus 16.0 ml, p=0.037. After excluding patients with intraventricular ICH (n=48), there was no evidence that haematoma volume (22.0ml versus 19.1ml, p=0.7) or oedema volumes (18.0ml versus 11.9ml, p=0.28) differed in younger patients compared to older patients. Discussion: In this group of ICH patients, age did not influence parenchymal haematoma or perihaematomal oedema volumes.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Cerebrovascular reactivity evaluated with TCD after acute subarachnoid hemorrhage.
E. Carrera
P. Kurtz
N. Badjatia
J.M.Schmidt
K. Lee
R.S.Marshall
S.A.Mayer
Division of Critical Care, Department of Neurology, Columbia University Medical Center, New York
USA
Background: Transcranial Doppler (TCD) is of limited value for predicting symptomatic vasospasm after subarachnoid hemorrhage (SAH) when measuring cerebral blood flow velocities (BFV) alone. Evaluation of cerebrovascular reactivity (CVR) dysfunction with TCD and CO2 challenge may improve the prognostic utility of TCD. We sought to describe the natural history of CO2 CVR after SAH Methods : We assessed CVR in 22 consecutive SAH patients. CVR was assessed by measuring changes in middle cerebral artery mean BFV after CO2 challenge, an increase of mean BFV < 2% per increase of 1 mm of CO2 was considered abnormal. CVR was performed, whenever possible, during the following time intervals: Period 1 (P1): SAH day 0-3 , P2: SAH day 4-7, P3: SAH days 8-10. Results: Among the 22 patients, 5 were men (23%), and mean age was 54 +/- 18 years. Symptomatic vasospasm occurred in 4 patients (18%). 52 CO2 challenge studies were performed (22 during P1, 20 during P2, and 10 during P3). Poor grade patients on admission (Hunt-Hess III-IV) presented a significantly lower CVR compared with good grade patients (Hunt-Hess I-II) during P1 (1.4 vs 2.3 %/mmCO2), P=0.048). During P2, CVR was significantly reduced in patients who developed symptomatic vasospasm compared with both good (0.6 vs1.9 %/mmCO2, P=0.004) and poor grade patients (0.6 vs 1.8 %/mmCO2, P=0.040) who did not develop symptomatic vasospasm. Conclusion: In the early stage after SAH (days 0-3), CO2 CVR is reduced in poor grade compared to good grade patients. Between days 3-7, CO2 CVR may be useful for identifying patients at increased risk for symptomatic vasospasm.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Intracranial hypertension in aneurysmal subarachnoid hemorrhage
Relation to metabolism, decompressive surgery and outcome
A. Nagel
D. Graetz
T. Schink
O. Sakowitz
P. Vajkoczy
A. Sarrafzadeh
Charité Campus Virchow Medical Center, Berlin
GERMANY
Background: Intracranial hypertension (intracranial pressure, ICP >20 mmHg) is a complication typically associated to head injury. Its impact on cerebral metabolism and ICP therapy including decompressive surgery (DS) and outcome has barely been studied in patients with aneurysmal subarachnoid hemorrhage (SAH) and is to be evaluated in this study. Methods: A database on cerebral metabolism in 182 SAH patients was analyzed retrospectively. Patients were classified into low- (<20 mmHg, n=164) and high- (>20 mmHg >6 hrs/day, n=18) ICP groups. For seven days cerebral microdialysis parameters of energy metabolism, glycerol and glutamate were analyzed hourly from brain parenchyma of interest. Seven patients underwent decompressive surgery. Twelve-month outcome (Glasgow Outcome Scale) was evaluated. Results: On days 1-7 after SAH glycerol concentrations, lactate/pyruvate ratio (p<0.005) and glutamate levels (p<0.05) were increased significantly in the high-ICP group. In 5 patients who underwent DS, cerebral metabolism was severely deranged 40 (25-48) hrs before onset of refractory intracranial hypertension which occurred 15 (4-28) hrs before surgery. Glycerol levels exceeding >80µM were the best markers of metabolic crisis. ICP was a predictor of mortality and poor outcome, independent of age, Fisher- and WFNS grade (p<0.001). Discussion: The relevance of intracranial hypertension as a severe complication in SAH patients was confirmed. Since high ICP is associated with severely deranged cerebral metabolism and unfavourable outcome, future studies might focus on optimized ICP therapy in these patients. A deterioration of markers of cerebral crisis might be a supporting clue to select a SAH-subpopulation and timing for decompressive surgery.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
The effects of hematoma volume reduction on clinical outcomes of patients with spontaneous deepseated intracerebral hematoma treated by stereotactic aspiration
C.T.Hsieh
Y.H.Chen
C.F.Chang
Tri-Service General Hospital
TAIWAN
Objective: Computed-tomography guided stereotactic hematoma evacuation has been reported to improve functional outcome in patients with spontaneous deep-seated intracerebral hemorrhages. Early and radically removal of hematoma has been considered as the best policy in management of this kind of patients. However, the optimal reduction volume of hematoma bringing the best outcome remains unclear. The aim of this study was to examine whether the moderate decompression volume of hematoma in the deep-seated location by computed-tomography guided stereotactic surgery without thrombolytic agents is essential to improve the clinical outcome. Methods: Ninety-nine patients were enrolled in this study. Forty-one patients were treated by computed-tomography guided stereotactic evacuation of the hematoma. The clinical features and outcome such as Glasgow Outcome Scale, level of consciousness, motor function and speech function were compared with the retrospective data of fifty-eight patients treated purely medically. Results: The level of consciousness, motor function, speech and Glasgow Outcome Scale and hospital stay improved markedly after stereotactic surgery than those after conservative treatment(71% vs 53%, 57% vs 21%, 40% vs 18%, 64% vs 16%, 28.35 days vs 37.7 days, respectively; p<0.05). After multivariable analysis, operation plays an important role in the improvement of Glasgow Outcome Scale and motor function. The reduction volume of hematoma ranged from 35% to 83%. The removal of about 67% volume could provide the improvement of Glasgow Outcome Scale. The rebleeding rate was approximately 7%. Conclusion: Computed-tomography guided stereotactic aspiration surgery is a minimal invasive and much effective surgery in management of patients with spontaneous deep-seated hemorrhages. Moderate reduction volume of hematoma about 67% is essential to provide the better clinical outcome.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Impact of Intraventricular t-PA for Intraventricular Hemorrhage
N.R.Gonzales
H. Hartman
H. Hallevi
M.M.Morales
A.M.Khaja
A.D.Barreto
S. Martin-Schild
A.T.Abraham
S.I.Savitz
J.C.Grotta
University of Texas Medical School-Houston
USA
Background:Intraventricular extension (IVH) of intracerebral hemorrhage (ICH) is an independent predictor of poor outcome. Small clinical studies suggest a radiographic and clinical benefit of intraventricular tPA (IVT). In 2006, we began an IVT protocol for patients with IVH. We evaluated the impact of IVT compared with a retrospective cohort of patients with IVH. Methods:From our prospective stroke registry, we identified patients with spontaneous hypertensive ICH with IVH who had placement of ventriculostomy (EVD). CT scans were reviewed to determine ICH and IVH volumes. Beginning in 2006, patients received IVT if: >12 hours after IVH, stable hematoma, GCS >5 and <14, CTA excluded vascular abnormality. Primary outcome measures: in-hospital mortality, discharge modified Rankin Scale (mRS), and IVH resolution by 10d after admission. Secondary outcome measures: ICU length of stay (LOS), length of EVD duration, and need for VP shunt. Poor outcome was defined as mRS of >3. Relationship of IVT with primary and secondary outcome measures was evaluated with Fisher's Exact, Mann-Whitney, or t-Test where appropriate. Results:Sixty-one patients were identified: 29 received IVT, 22 no IVT. There was no significant difference in age, gender, or ethnicity. There was no significant difference in baseline GCS (9 IVT, 9 no IVT), IVH volume (32cc IVT, 26cc no IVT, p=0.09), or ICH volume (18cc IVT, 26cc no IVT, p=0.18) between groups. There was a significant difference in mortality in the IVT group (38% vs 9%, p=0.025). There was no difference between poor outcome (86% IVT, 73% no IVT), ICU LOS (15d IVT, 11d no IVT, p=0.06), IVH resolution (75% IVT, 77% no IVT), or need for VP shunt (17% IVT, 14% no IVT). There was a significant increase in duration of EVD in the IVT group (12d vs 8d, p=0.01). These results were similar when only patients with primarily IVH (small ICH) were considered. Conclusion:In our retrospective cohort, we were not able to demonstrate a clinical or radiographic benefit of IVT. Routine use of IVT should await the results of a randomized, controlled trial.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Microalbuminuria: a modifiable risk for intracerebral haemorrhage?
A. Rocco
J. Diedler
M. Sykora
T. Steiner
W. Hacke
Kopfklink-Universitaet Heidelberg
GERMANY
Introduction Stroke is potentially preventable through risk factor modification. In recent years, the role of microalbuminuria (MA) as a risk factor for chronic diseases has become apparent. MA is independently associated with cardiovascular morbidity and mortality, and has been proposed as a possible risk factor for cerebrovascular disease. This pilot study was performed to assess the prognostic relevance of MA in patients with (ICH) and its correlation with the volume of the bleeding. Methods We prospectively studied all patients with ICH admitted to our Intensive Care Unit. Clinical history, neurological examination and CT scan were performed at admission. Severity of stroke was assessed by NIHSS and outcome by the modified Ranking Scale. The urinary albumin excretion was measured in 24-h collection of urine. The volume of the lesion was calculated by using the abc/2 index. Results Of the 41 patients (25M/16F; mean age 62yrs), 7 died; 35 had hypertension and 10 diabetes; the mean NIHSS and mRS at discharge were 21,1 ± 13,9 SD and 4.5 ± 1,2. MA was found in about 50% of ICH patients. Statistical analysis revealed MA significantly associated with a poor outcome (p=0,015). The volume of the bleeding did not correlated with the presence of MA. Conclusion This study suggests that MA is frequently associated with ICH. The presence of MA is associated with a poor outcome but apparently it is not associated with the volume of the lesion that is well known to influence the outcome. This suggests that MA is an independent risk factor for bad outcome. Hypertension has is claimed as potential risk factor for MA, and the majority of our patients had hypertension. Further studies are needed to clarify the actual impact of MA in ICH.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Incidence and risk factors for ventriculitis after intraventricular lysis in patients with obstructive hydrocephalus caused by intraventricular haemorrhage
S. Poli
M. Rein
P. Gruschka
Th. Steiner
University of Heidelberg
GERMANY
Objective Temporary external ventricular drainage (EVD) as a therapy for acute obstructive hydrocephalus caused by intraventricular haemorrhage has been considered as a relevant risk factor for ventriculostomy-related ventriculitis (VRV). Intraventricular lysis with rtPA (recombinant tissue plaminogen activator) as an accompanying treatment has been discussed controversially up to now. Neither benefits nor risks are sufficiently proven. The aim of this study is to illuminate the relation between intraventricular application of rtPA and the incidence of ventricular infections. Methods The study is based on the retrospective analysis of 2159 patients with intracerebral and subarachnoidal hemorrhage treated in our department over the last 10 years. 350 cases with a temporary external ventricular drainage were included in the study and analysed for the incidence of ventriculitis due to intraventricular lysis. Results Preliminary data identified 83 patients of our collective treated with intraventricular lysis; 45 of all 350 included patients suffered from ventriculitis. A trend towards an elevated risk for ventricular infection could be shown for cases where intraventricular application of rtPA was performed. Age at onset, subtype of haemorrhage, number of rtPA applications as well as the duration of treatment and number of EVDs and additional neurosurgical interventions were statistically analysed as covariates. Final results will be presented at the meeting. Conclusion Up to now no definitive evidence regarding effectiveness of intraventricular lysis of acute obstructive hydrocephalus caused by intraventricular haemorrhage could be demonstrated. Taking into account the results of this study showing a trend towards elevated infections, a restrictive indication for intraventricular lysis should be considered.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
FATAL HYPERACUTE CEREBRAL HEMORRHAGE AFTER CAROTID STENTING: A CASE WITH MULTIFACTORIAL EXPLANATION
C. de la Cruz Cosme
M. Márquez Martínez
M. Romero Acebal
M.A. García Alcántara
A. Martín Palanca
Virgen de la Victoria Hospital
SPAIN
BACKGROUND. The hyperperfusion syndrome (HPS) was described by Sundt in 1981 as complications following carotid endarterectomy due to dysregulation in the brain blood flow, but a second origin for intracerebral hemorrhage (ICH), with different pathophysiology and semiology, has been defended: High blood pressure (HBP). We present a case with a probably mixed ethiology. METHODS. A 49-years-old woman suffered two transitory ischemic attacks, with the findings of a left occipito-parietal punctiform acute ischemic lesion in the Magnetic Resonance Imaging (MRI) and a suboclussive segmentary stenosis of the left internal carotid arthery with bad intracranial collateralization in the angio-MRI. She underwent carotid angioplasty with stenting (CAS). The neurological examination and the cranial computerised tomography (cCT) after it were normal. Hours later she began with headache, blurred vision, distal paresthesias, cervical stiffness, and finally impairment of conciousness; blood pressure (BP) was 190/138 mmHg. A new cCT was performed. RESULTS . The cCT showed a massive subarachnoid hemorrhage (SAH). HBP was quickly controlled with intravenous drugs and the SAH was medically treated, but a subdural hematoma and a left frontal parenchymal hemorrhage appeared in the following days, with clinical worsening and death in spite of intensive medical and surgical management. DISCUSSION. Several risk factors for the hemorrhages after CAS can be admitted here: presence of an acute infarct, severe stenosis of the left ICA with bad collateralization, HBP after the procedure and use of heparinization plus antiplatelet agents. This is a case of mixed pathophysiological mechanism between the classic HPS and the hypertensive intracerebral hemorrhage, and we propose the active BP control as the main aim to avoid it.
