[Network Meta-analysis of Chinese medicine injections in treatment of hypertensive intracerebral hemorrhage].

To systematically evaluate the efficacy and safety of Chinese medicine injections in the treatment of hypertensive intracerebral hemorrhage, we collected the relevant randomized controlled trials(RCTs) by computer retrieval from PubMed, EMbase, Cochrane Library, Web of Science, Wanfang, CNKI, VIP, and CBM within the timespan from inception to December 30, 2021. The obtained index data were analyzed by RevMan 5.3 and Stata 15.0. Finally, 63 RCTs were selected for analysis, involving 5 953 patients. The experimental groups involved 9 Chinese medicine injections, including Danshen Injection, Danhong Injection, Sodium Aescinate Injection, Qingkailing Injection, Compound Shexiang Injection, Shuxuening Injection, Yinxing Damo Injection, Ginkgolide Injection, and Xingnaojing Injection. The network Meta-analysis showcased the following trends.(1)The surface under the cumulative ranking curve(SUCRA) in improving neurological function ranked in the order of surgical operation+conventional treatment of western medicine combined with Danhong Injection>combined with Xingnaojing Injection>combined with Ginkgolide Injection>combined with Compound Shexiang Injection>combined with Danshen Injection>combined with Sodium Aescinate Injection>combined with Qingkailing Injection>combined with Shuxuening Injection>combined with Yinxing Damo Injection.(2)In terms of National Institutes of Health stroke scale(NIHSS) score, the SUCRA ranked in the order of surgical operation+conventional treatment of western medicine combined with Xingnaojing Injection>combined with Compound Shexiang Injection>combined with Yinxing Damo Injection>combined with Ginkgolide Injection>combined with Danhong Injection>combined with Sodium Aescinate Injection.(3)In terms of Glasgow coma scale(GCS) score, the ranking of SUCRA was surgical operation+conventional treatment of western medicine combined with Yinxing Damo Injection>combined with Qingkailing Injection>combined with Sodium Aescinate Injection>combined with Danhong Injection>combined with Ginkgolide Injection>combined with Xingnaojing Injection.(4)The SUCRA in volume of residual cerebral hematoma ranked in the order of surgical operation+conventional treatment of western medicine combined with Sodium Aescinate Injection>combined with Xingnaojing Injection>combined with Danhong Injection>combined with Ginkgolide Injection>combined with Shuxuening Injection>combined with Compound Shexiang Injection. The experimental group had lower incidence of adverse reactions than the control group. The results of network Meta-analysis suggest that on the basis of surgical operation+conventional treatment of western medicine, the application of Chinese medicine injections can improve the efficacy of treating hypertensive intracerebral hemorrhage. However, in view of the great differences in the quality and number of studies included for different therapies, the SUCRA of Chinese medicine injections need to be further verified with high-quality multi-center, large-sample, randomized double-blind trials.

Overexpression of LH3 reduces the incidence of hypertensive intracerebral hemorrhage in mice.

Hypertensive intracerebral hemorrhage (ICH) is a devastating cerebrovascular disease with no effective treatment. Lysyl hydroxylase 3 (LH3) is essential for collagen IV intermolecular crosslinking and stabilization. Deficiency in LH3 affects the assembly and secretion of collagen IV and basement membrane (BM) integrity of vessels. Here, we investigated whether LH3 has significant implications for disease progression and therapeutic intervention. Spontaneous hypertensive ICH of mice was induced by angiotensin II and L-NAME treatment. The adeno-associated virus was delivered into brain by stereotactic injection to knockdown or overexpress LH3. We found LH3 levels were reduced in human patients with ICH and gradually decreased in mice before ICH. LH3 knockdown increased the incidence of hypertensive ICH in mice. The incidence, number, and size of ICHs in mice were markedly reduced by LH3 overexpression. RNA-seq revealed that LH3 overexpression significantly reversed the profound alterations in gene transcriptional profiles of cerebral vessels. LH3 overexpression was sufficient to enhance BM integrity, inhibit matrix metalloproteinase activity, attenuate microglial activation and leukocyte infiltration, and reduce VSMC apoptosis before ICH. These results indicate that LH3 overexpression attenuates susceptibility to hypertensive ICH. We emphasize that LH3 modulation may serve as a viable approach for future investigations of ICH prevention.

Intraparenchymal haemorrhage and uncal herniation resulting from dobutamine stress echocardiography.

Intracranial haemorrhage (ICH) resulting from dobutamine stress echocardiography (DSE) is a rare complication in an otherwise relatively safe procedure. There has been one previously reported case of ICH associated with DSE in a patient who was fully anticoagulated. The authors report a second case of ICH associated with DSE leading to a poor outcome. Unlike the previous report, this patient was not fully anticoagulated and bleeding resulted from uncontrolled hypertension. Clinicians should be attentive to the risk of ICH associated with DSE in the setting of uncontrolled hypertension.

Delayed intracerebral hemorrhage after uneventful embolization of brain arteriovenous malformations is related to volume of embolic agent administered: multivariate analysis of 13 predictive factors.

BACKGROUND: The mechanisms and management of delayed intracerebral hemorrhage (dICH) after treatment of brain arteriovenous malformations (AVMs) are poorly understood and widely debated. Many clinical predictive factors have been theorized for dICH after an otherwise uneventful AVM embolization, but there is an absence of data to discern their significance. OBJECTIVE: To analyze 13 proposed predictive factors and to assess their potential in guiding prevention strategies. METHODS: One hundred sixty-eight embolization procedures were performed on 67 patients with brain AVMs by a single surgeon. Patients were divided into 2 groups: those with symptomatic dICH and control subjects. Thirteen factors were analyzed: age, sex, race, previous ICH, Spetzler-Martin grade, AVM size, eloquence, embolic volume, embolic agent, percent obliteration, and timing, number, and stage of embolizations. Univariate and multivariate analyses were performed on these factors to determine significance. RESULTS: Six procedures were complicated by dICH; 5 (83%) occurred after the final planned procedure. The volume of embolic agent was significantly higher in the dICH group (4.5 ± 1.0 mL) compared with control subjects (1.7 ± 0.2 mL) in both univariate and multivariate analyses (P < .01), even after controlling for AVM size. AVM size was significant in univariate analysis but not multivariate analysis. There were no statistically significant differences between the groups for any of the other possible predictive factors. CONCLUSION: High volume of embolic agent administered per procedure is an independent predictive factor for dICH. Limiting the injected volume for each procedure may reduce this poorly understood complication.

Intracranial hemorrhage after prehospital administration of intramuscular epinephrine.

BACKGROUND: The administration of epinephrine by the intramuscular route can be life-saving in cases of anaphylaxis or severe allergic reactions. However, the use of this drug can lead to a rapid rise in blood pressure, which theoretically could lead to deleterious effects in patients of any age, with elderly patients at greatest risk. OBJECTIVES: To present a rare case of intracranial hemorrhage potentially resulting from the administration of intramuscular epinephrine in an elderly patient with an allergic reaction. CASE REPORT: We present a case report of a 65-year-old woman who developed an intracranial hemorrhage after a single, therapeutic, intramuscular dose of epinephrine for a wasp sting to the tongue. The patient underwent successful craniotomy with evacuation of the intracranial hematoma. CONCLUSIONS: In circumstances where the severity of the allergic reaction remains unclear (lack of airway compromise, cardiovascular collapse, or true anaphylaxis), careful consideration of the potential risks of intramuscular epinephrine, such as a rapid rise in blood pressure leading to intracranial hemorrhage, should be undertaken when using this medication in elderly patients.

Role of antiplatelet agents in hematoma expansion during the acute period of intracerebral hemorrhage.

BACKGROUND: Oral anticoagulants have been associated with greater hematoma expansion in patients with intracerebral hemorrhage (ICH). The purpose of this study was to determine whether the reported use of antiplatelet agents also results in greater hematoma expansion. METHODS: Retrospective review of patients with spontaneous supratentorial ICH diagnosed within 6 h of onset, who underwent follow-up head CT approximately 48 h later. Digital imaging analysis of initial and second CT scans was performed for comparison of hematoma volume changes between patients reporting and those not reporting antecedent antiplatelet use. Statistical analyses to determine predictors of ICH volume change and in-hospital mortality were also performed via multivariate regression models. RESULTS: Of the 70 patients included, 17 were documented as taking antiplatelet agents. Groups were comparable regarding baseline demographic, clinical and laboratory characteristics, and the timing of CT scans was similar. Patients reporting antiplatelet use experienced greater absolute increase (7.7 ml vs. 5.5 ml) and proportional increase (110% vs. 21%) in ICH volume than those not reporting antiplatelet use, but these differences were not statistically significant (P = 0.94 and 0.61 respectively; Wilcoxon test). Baseline hematoma volume tended to correlate with percentage volume increase (P < 0.1), whereas IVH was inversely associated with percent volume increase (P < 0.05). Age (P < 0.05), absolute volume increase (P < 0.005), and final volume (P < 0.001) were associated with in-hospital mortality, the rates of which were similar between the two study groups (18% vs. 17%). CONCLUSIONS: Patients reporting antiplatelet use experienced similar degrees of hematoma expansion compared to patients not reporting antiplatelet use.

Intracerebral haemorrhage after thrombolysis for acute ischaemic stroke: an update.

Intracerebral haemorrhage (ICH) still represents the most feared complication of thrombolysis. Our aim was to review the literature regarding clinical, biological and imaging predictors of ICH following thrombolysis for acute ischaemic stroke. Relevant studies were identified through a search in Pubmed, using the following key words: "intracerebral", "haemorrhage", "stroke" and "thrombolytic". The query was limited to studies published in the English literature. The reference lists of all relevant articles were reviewed to identify additional studies. The main predictors of clinically significant ICH were age, clinical stroke severity, as assessed by the National Institute of Health Stroke Scale score on admission, high blood pressure, hyperglycaemia, early CT changes, large baseline diffusion lesion volume and leukoaraiosis on MRI. The contribution of biomarkers in the prediction of the ICH risk is currently under evaluation. Available data on patients with limited number of microbleeds on pretreatment gradient echo MRI sequences suggest safe use of thrombolysis. ICH after stroke thrombolysis is a complex and heterogeneous phenomenon, which involves numerous parameters whose knowledge remains partial. To minimise the risk of tissue plasminogen activator (tPA) related symptomatic ICH, careful attention must be given to the pre-therapeutic glycaemia value, and a strict protocol for the control of elevated blood pressure is needed during the first 24 h. Future research should focus on predictors of severe intracerebral haemorrhagic complications (parenchymal haematomas type 2 according to the European Cooperative Acute Stroke Study (ECASS) classification). The input of multimodal MRI and biological predictors of ICH deserves further investigation.

Pseudoephedrine-induced hemorrhage associated with a cerebral vascular malformation.

BACKGROUND: Sympathomimetic-related intracerebral hemorrhage is well-documented. Most cases are associated with phenylpropanolamine use. CASE REPORT: We report a case of intracerebral hemorrhage occurring in a middle-aged man who suffered from chronic sinusitis and had been ingesting pseudoephedrine daily for one year. This patient was previously well with no known cardiovascular risk factors. Clinical examination revealed no evidence of vasculitis nor coagulopathy and initial neuroimaging (i.e., computed tomography, angiography, magnetic resonance imaging) demonstrated no features consistent with aneurysm, arteriovenous malformation (AVM), cavernoma, nor cerebral metastases. A follow-up cerebral angiogram demonstrated a small AVM arising off a branch of the pericallosal artery and a small arteriovenous fistula arising off the costal marginal branch. The AVM was embolized without incident, however, the AVF was not accessible. CONCLUSIONS: Sympathomimetics have long been associated with intracerebral hemorrhage. Since 1979, over 30 published case reports have documented the relationship between phenylpropanolamine and stroke. Only one report links phenylpropanolamine consumption to an intracerebral hemorrhage in a patient with an AVM. There is a paucity of literature etiologically inculpating other ephedra alkaloids in the causation of intracerebral hemorrhage. This is a case of pseudoephedrine-induced intracerebral hemorrhage in a patient with an underlying vascular malformation.

The role of hypertension in bromocriptine-related puerperal intracranial hemorrhage.

The spate of medicolegal inquiries following the disqualification of Parlodel (bromocriptine mesylate) by the Food and Drug Administration for postpartum ablactation, uncovered previously unreported side effects associated with its postpartum administration. In 1994, bromocriptine mesylate was withdrawn from the market as a milk suppressant. Since this time, over a dozen cases of postpartum intracranial hemorrhages associated with its use have been reported. We describe three additional cases of postpartum intracranial hemorrhage related to bromocriptine usage. One patient, previously normotensive, developed hypertension and a headache; initial CT was normal, but CT 24 h later demonstrated intracranial hemorrhage. This suggests that the blood-pressure elevation was drug-induced and was the cause, rather than the consequence, of bromocriptine-related intracranial hemorrhage.