Ruozhen Yuan

Low free triiodothyronine levels are related to symptomatic intracranial hemorrhage and poor functional outcomes after intravenous thrombolysis in acute ischemic stroke patients.

Background and Objective: Low free triiodothyronine (fT3) levels have been associated with increased mortality and poor functional outcomes in patients with stroke. However, the research of relationship between fT3 levels and acute ischemic stroke (AIS) patients with intravenous thrombolysis (IVT) is scarce. We aimed to investigate the association of fT3 levels with symptomatic intracranial hemorrhage (sICH) and functional outcomes at discharge in AIS patients with IVT. Methods: Patients with AIS admitted to West China hospital, Sichuan University, who had underwent IVT treatment, were consecutively and retrospectively included. Demographic and clinical information were collected and analyzed according to the levels of fT3. We used logistic regression analysis to estimate the multivariable adjusted association of fT3 levels and post-IVT sICH, and functional outcomes at discharge. Results: Among the 46 patients (26 males; mean age, 63.6 years) in the final analysis, 17 patients (37.0%) had fT3 levels lower than the reference range. After adjustment for age, gender, and statistically important variables (NIHSS on admission, urea levels and creatinine levels), low fT3 levels were significantly associated with post-IVT sICH (p = 0.01, OR = 0.27, 95% CI 0.10–0.77) and poor functional outcomes at discharge (p = 0.04 OR = 2.58, 95% CI 1.05–6.35). Conclusion: We found that lower free T3 levels are independently related to post-IVT sICH and poor functional outcomes at discharge in AIS patients with IVT, which should be verified and extended in large cohorts in the future.

Etiology, clinical characteristics and prognosis of spontaneous intracerebral hemorrhage in children: A prospective cohort study in China.

BACKGROUND AND OBJECTIVE Much is known about spontaneous intracerebral hemorrhage (SICH) in adults, but few studies have examined pediatric SICH, especially in China. The aim of the present study was to describe the etiology, clinical characteristics and prognosis of SICH in children from southwest China. METHOD Consecutive patients aged 1-18 years with SICH at our medical center were prospectively enrolled from January 2012 to June 2014. SICH was defined by WHO criteria and confirmed by CT or MRI findings. Demographic and clinical information was collected at baseline, and follow-up assessments were conducted at 3 and 6 months after SICH, when patients were scored on the modified Rankin Scale (mRS) and events of deaths and recurrent hemorrhagic stroke were recorded. RESULTS Among the 70 children (43 males; median age, 12.0 years) in the final analysis, 44 patients (62.9%) had SICH due to arteriovenous malformation, and less frequent etiologies were cavernous malformation (n=4), aneurysm (n=2), tumors (n=2), moyamoya (n=2), hemophilia (n=1), hypertension (n=1), while 14 (20.0%) had SICH of unknown etiology. The mortality rate at 3 months and 6 months was equal, which was both 3%. The rate of disability was 12.1% at 3 months and 9.1% at 6 months. CONCLUSION The most frequent etiology of pediatric SICH in this Chinese cohort was arteriovenous malformation. SICH of unknown etiology occurred much more often in our cohort than in previously published Caucasian patients in the US and Europe.

Prognosis of 908 patients with intracerebral hemorrhage in Chengdu, Southwest of China

Background and purpose: Intracerebral hemorrhage (ICH) is the deadliest, most disable and least treatable form of acute cerebral accident. Prognostic risk factors of ICH are not yet fully identified. This study investigated the possible clinical factors leading to poor outcomes in patients with ICH, which can be used to guide clinical treatment and predict prognosis. Methods: We prospectively enrolled patients with ICH who were admitted within 7 d of stroke onset from January 2012 to April 2014. The prognostic factors of patients with ICH were analyzed in univariate analyses and logistic regression analyses. Results: A total of 908 consecutive patients with ICH (mean age, 57.87 ± 13.92 years) were finally included, of which 616 patients (67.8%) were male. 59.5%, 54.5% and 52.2% patients with ICH had poor outcomes (death/disability) at 3, 6 and 12 months, respectively. Stroke severity and stroke-related complications during hospitalization were independently associated with poor outcomes both at 3 and 12 months. In addition, hyperglycemia, hematocrit and blood urea nitrogen on admission were independently associated with poor outcomes at three months. Conclusion: This study found that severity of ICH and stroke-related complications were independent predictors of poor outcomes at three months and one year after ICH. Thereby, it highlights the importance of understanding the role of clinical features in ICH prognostic evaluation.

Liver function may play an uneven role in haemorrhagic transformation for stroke subtypes after acute ischaemic stroke.

Haemorrhagic transformation (HT) is common after acute ischaemic stroke. Whether liver function plays a role in HT remains an open question.

A cohort study of relationship between serum calcium levels and cerebral microbleeds (CMBs) in ischemic stroke patients with AF and/or RHD

AbstractCalcium is an essential element for life and has cerebroprotective property in stroke patients. Low serum calcium levels were found to be related to large hematoma volumes in intracerebral hemorrhagic patients and hemorrhagic transformation in ischemic stroke patients after thrombolysis. However, their impact on hemorrhage-prone small vessel disease represented by cerebral microbleeds (CMBs) is uncertain. We aim to investigate whether low serum calcium levels are associated with presence and location of CMBs.Ischemic stroke patients with atrial fibrillation (AF) and/or rheumatic heart disease admitted to our hospital were consecutively and prospectively enrolled. Demographic and clinical information were collected and analyzed according to the occurrence and location of CMBs, and levels of serum calcium. We used logistic regression analysis to estimate the multivariable adjusted relationship between serum calcium levels and the presence or location of CMBs.Among the 67 patients (28 males; mean age, 67.3 years) in the final analysis, 39 (58.2%) were found to have CMBs. After adjustment for age, sex, smoking habits, drinking habits, and renal impairment, the presence of CMBs and deep CMBs was, respectively, 4.96- and 4.83-fold higher in patients with lower serum calcium levels (⩽2.15 mmol/L) than in patients with higher serum calcium levels.Lower serum calcium levels (⩽2.15 mmol/L) are independently associated with the presence of CMBs and deep CMBs in ischemic stroke patients with AF and/or rheumatic heart disease, which should be verified and extended in large cohorts, with other types of stroke patients and the general population.

Association between leukoaraiosis and hemorrhagic transformation after cardioembolic stroke due to atrial fibrillation and/or rheumatic heart disease

Cardioembolic stroke due to atrial fibrillation (AF) and/or rheumatic heart disease (RHD) often involves hemorrhagic transformation (HT), and we examined whether leukoaraiosis (LA) was associated with HT in these cases. We prospectively enrolled 251 patients who were admitted to two hospitals within one month of experiencing cardioembolic stroke due to AF/RHD. LA severity was assessed using three visual rating scales. HT was identified in 99 patients (39.4%) based on baseline computed tomography (CT) and post-admission magnetic resonance imaging or second CT. Univariate analysis identified risk of HT as higher in the presence of frontal LA based on the age-related white matter changes scale and in the presence of anterior LA based on the VSS scale. Multivariate analysis confirmed that moderate to severe LA was independently associated with higher HT risk. Of the various sites affected in LA, frontal LA correlated with highest risk of HT (OR 3.199, 95%CI 1.555-6.580). These results suggest that moderate to severe LA, especially at periventricular and anterior sites, is associated with HT after cardioembolic stroke due to AF/RHD. These findings suggest the need to take LA into account as a HT risk factor when considering the use of anticoagulation and thrombolysis in these patients.

Cerebral Amyloid Angiopathy-related Intracerebral Hemorrhage Score For Predicting Outcome.

The existing intracerebral hemorrhage (ICH) scores were based on the clinical and anatomical parameters of all primary ICH. We aimed to study whether the original ICH Score can predict cerebral amyloid angiopathy (CAA)-related ICH mortality and functional outcome and whether modified score can improve the predictions. The patients with ICH were consecutively recruited from 21 tertiary and secondary hospitals across Mainland China from January 2012 to December 2014. CAA-related ICH was defined as Boston Criteria. Logistic regression was performed in the derivation cohort of patients with CAA-related ICH to identify predictors of 3-month mortality and good outcome [modified Rankin score (mRS) of 0-2 at 3 months]. The areas under the receiver operating characteristic curves (AUCs) were used to assess model discrimination. A total of 360 CAA-related ICH patients were included. According to AUCs, the original ICH Score was less reliable predictor for mortality (AUCs=0.69) and good outcome (AUCs=0.67) in CAA- related patients. The range of CAA-related ICH score values is 0 to 7. The scale consist of four clinical items and the score points were assigned based on the Glasgow Coma Scale score on admission, age, presence of intraventricular hemorrhage, and presence of midline shift. CAA-related ICH score showed good discrimination in the derivation cohort (AUCs: 0.87 for mortality; 0.80 for good clinical outcome) and validation cohort (AUCs: 0.89 for mortality; 0.81 for good clinical outcome). The original ICH Score may be less reliable in predicting mortality and good clinical outcome at 3 months for CAA-related ICH patients. The modified scores improve its ability to predict clinical outcome at 3 months for CAA-related ICH.

Predictive value of plasma matrix metalloproteinase-9 concentrations for spontaneous haemorrhagic transformation in patients with acute ischaemic stroke: A cohort study in Chinese patients

Whether matrix metalloproteinase 9 (MMP-9) concentrations in plasma predict risk of spontaneous haemorrhagic transformation (sHT) in acute ischaemic stroke is unclear. From 1 March 2003 to 27 February 2006, patients with acute ischaemic stroke admitted to West China Hospital within 24 h of onset and healthy controls were enrolled and blood samples obtained. Plasma MMP-9 concentrations were determined using enzyme-linked immunosorbent assay, and sHT was diagnosed based on brain computed tomography or magnetic resonance performed 3-14 d after stroke onset. MMP-9 concentrations were compared for sHT patients, non-sHT patients and healthy controls. The threshold concentration for predicting sHT was determined using receiver operating characteristic analysis and the association between MMP-9 concentration and sHT was tested. One hundred and sixty-eight stroke patients and 40 healthy controls were included. Spontaneous HT occurred in 17.3% (29/168) of stroke patients and median plasma MMP-9 concentration in the sHT subgroup [244.3 ng/mL; interquartile range (IQR), 190.6-431.4] was significantly higher than in the non-sHT subgroup (110.0 ng/mL; IQR, 54.4-172.2) as well as in healthy controls (63.3 ng/mL; IQR 37.9-84.9) (both P < 0.001). We identified 181.7 ng/mL as the threshold MMP-9 concentration, for which the positive predictive value was 48% and the negative predictive value was 96%. After controlling for potential confounding factors, MMP-9 concentration >181.7 ng/mL was an independent predictor of sHT (odds ratio 18.8, 95% confidence interval 6.0-58.5, P < 0.001). Plasma MMP-9 concentration >181.7 ng/mL within 24 h after stroke onset independently predicts sHT in patients with ischaemic stroke.

The Burden of Non-symptomatic Cerebral Ischemia on MRI and Its Effect on Clinical Outcomes in Patients with First-ever Intracerebral Hemorrhage

ABSTRACT Purpose: To compare the burden of non-symptomatic cerebral ischemia (NSCI) detected on magnetic resonance imaging (MRI) and computed tomography (CT), and assess the association of MRI-NSCI with clinical outcomes among patients with first-ever intracerebral hemorrhage (ICH). Methods: Two thousand three hundred and five consecutive ICH patients admitted to our institution from May 2012 to October 2015 were retrospectively reviewed. Data on clinical characteristics and MRI/CT scans were collected during hospitalization. Information on clinical outcomes at three-month were also obtained. Results: Three hundred and seventy-seven patients performed MRIs and 1966 had CTs during hospitalization. NSCI was detected in 152 (40.3%) patients with MRIs and in 638 (32.5%) with CTs. Comparing with CT, NSCI detected by MRI was more common (40.3% vs. 32.5%; P = 0.011), more likely to be multiple loci (93.4% vs. 79.6%; P < 0.001) and bilateral hemispheres (84.9% vs. 73.2%; P = 0.003). Furthermore, the presence of NSCI, multiple NSCI, bilateral NSCI and bilateral hematoma combined with bilateral NSCI were associated with poor outcomes (P < 0.001, P < 0.001, P < 0.001, P = 0.041, respectively) in univariate analysis. In multivariable logistic regression, bilateral hematoma combined with bilateral NSCI was still associated with poor outcomes (OR 3.983, 95% CI 1.172–13.539; P = 0.027). Conclusions: Compared with CT, NSCI on MRI tends to be multiple loci and located in bilateral hemispheres. The results of NSCI in ICH may be underestimated based on CT. In addition, the increased poor outcomes at three-month suggest that NSCI may play an important role in reducing clinical outcomes.

Prognostic Significance of Intraventricular Hemorrhage in Vascular Structural Abnormality-Related Intracerebral Hemorrhage

BACKGROUND The prognostic significance of intraventricular hemorrhage (IVH) in patients with vascular structural abnormality-related intracerebral hemorrhage (VSARICH) is poorly understood. METHOD We prospectively included consecutive patients diagnosed with VSARICH. Imaging of initial brain computed tomography (CT) scans within 48 hours of symptom onset was analyzed. The presence and severity of IVH were recorded. Severity of IVH was measured using the modified Graeb (mGraeb) score. Baseline characteristics and 3-month outcomes were compared between the IVH and non-IVH groups. Multivariate logistic regression was used to examine the independent association between IVH and 3-month outcomes. RESULTS A total of 132 VSARICH patients were included for analysis, and 71 (53.8%) of them had IVH on initial CT imaging. IVH patients had a median mGraeb score of 15 (6-21), and compared to non-IVH patients, they had shorter delay to first CT scan and higher stroke severity on admission (all P ≤ .005). At 3 months, IVH patients had higher death rates (30.3% versus 7.0%; P = .001) and poor outcome rates (48.5% versus 21.1%; P = .002) than non-IVH patients. After multivariate analysis, IVH severity was associated with 3-month death (Model 1 OR 1.112, 95% CI [1.027-1.204], P = .009; Model 2 OR 1.110, 95% CI [1.027-1.200], P = .009) and poor outcome (Model 2 OR 1.053, 95% CI [1.001-1.108], P = .047), although no independent association between IVH presence and outcomes was observed. CONCLUSION IVH severity measured by mGraeb score independently predicts death and poor functional outcome in patients with VSARICH.