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【Abstract】Objective: To present our experience in using decompressive craniectomy (DC) among severe trau-matic brain injury (TBI) patients during operation and to discuss its indication. Methods: From October 2008 to May 2009, 41 patients aged between 18 and 75 years with severe TBI were in-cluded in this study. They underwent DC or non-DC (NDC) according to their intraoperative findings. Postoperative intracranial pressure (ICP), complications, requiring second operation or not and outcomes were observed. Results: Fifteen patients underwent DC and 26 pa-tients did not. The average postoperative ICP of each pa-tient was lower than 20 mm Hg. For patients received DC, 2 had seizures after operation and 1 developed cerebrocele in the follow-up period; only 1 NDC patient had post-trau-matic seizures, but none of them had delayed haematoma, cerebrospinal fluid fistula, cerebrocele or infections. At the end of follow-up, 10 patients died, 6 had the GOS of 2, 2 of 3, 9 of 4 and 14 of 5. Conclusions: DC is necessary to manage fulminant intracranial hypertension or intraoperative brain swelling. If there was not brain swelling after removal of the haematoma and necrotized neural tissues, it is safe to replace skull flap. The intraoperative finding is an important factor to decide whether to perform DC or not. Key words: Decompressive craniectomy; Brain injury; Intracranial pressure

Background: Pneumonia is one of the most common complications after spontaneous intracerebral hemorrhage (sICH), i.e., stroke-associated pneumonia (SAP). Timely identification of targeted patients is beneficial to reduce poor prognosis. So far, there is no consensus on SAP prediction, and application of existing predictors is limited. The aim of this study was to develop a machine learning model to predict SAP after sICH., Methods: We retrospectively reviewed 748 patients diagnosed with sICH and collected data from 4 dimensions-demographic features, clinical features, medical history, and laboratory tests. Five machine learning algorithms-logistic regression, gradient boosting decision tree, random forest, extreme gradient boosting, and category boosting-were used to build and validate the predictive model. We also applied recursive feature elimination with cross-validation to obtain the best feature combination for each model. Predictive performance was evaluated by area under the receiver operating characteristic curve., Results: SAP was diagnosed in 237 patients. The model developed by category boosting yielded the most satisfactory outcomes overall with area under the receiver operating characteristic curves in the training set and test set of 0.8307 and 0.8178, respectively., Conclusions: The incidence of SAP after sICH in our center was 31.68%. Machine learning could potentially provide assistance in the prediction of SAP after sICH., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: An elevated preoperative red cell distribution width (RDW) is associated with adverse prognostic outcomes in various diseases. However, the correlation between changes in RDW (ΔRDW) and the prognosis following brain tumor craniotomy remains unclear. Accordingly, this study aimed to investigate the prognostic significance of perioperative changes in RDW in patients undergoing brain tumor craniotomy., Methods: This retrospective cohort study included patients undergoing craniotomy for brain tumors at West China Hospital, Sichuan University, from January 2011 to March 2021. We defined perioperative changes in RDW: group A (non-significant RDW changes, ΔRDW ≤0.4%), group B (drop in RDW, ΔRDW < -0.4%), and group C (rise in RDW, ΔRDW >0.4%). The relationship between the changes in RDW and all-cause mortality was analyzed by categorizing the patients according to perioperative ΔRDW (RDW at postoperative one week - RDW at admission)., Results: The present study included a total of 9589 patients who underwent craniotomy for the treatment of brain tumors. A rise in RDW was significantly associated with increased mortality, with an adjusted OR of 3.56 (95% CI: 2.56-4.95) for 30-day mortality and 1.57 (95% CI: 1.33-1.85) for one-year mortality compared to those with non-significant RDW changes (ΔRDW ≤0.4%). Conversely, a decrease in RDW showed no significant association with 30-day mortality (adjusted OR: 1.04, 95% CI: 0.53-2.04) and one-year mortality (adjusted OR: 1.18, 95% CI: 0.92-1.53). These findings were also supported by restricted cubic spline, which shows that increases in RDW were significantly associated with lower survival rates compared to stable RDW levels during the follow-up period., Conclusions: Among patients undergoing craniotomy for a brain tumor, a rise in RDW was associated with 30-day mortality and higher long-term mortality risks, even if patients' admissions for RDW values were within the normal range. It was worth noting that maintaining stable RDW levels during this period was associated with better survival., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests.ZCX., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Study Objective: Hypernatremia is a treatable biochemical disorder associated with significant morbidity and mortality in patients undergoing surgery. However, its impact on patients who undergo elective craniotomy is not well understood. This study aimed to investigate the prognostic implications of postoperative hypernatremia on the 30-day mortality of patients undergoing elective craniotomy., Design: Retrospective cohort study., Setting: The Department of Neurosurgery of a high-volume center., Patients: Adult patients undergoing elective craniotomy except those with pituitary tumors, intracerebral hemorrhage, subarachnoid hemorrhage, or traumatic brain injury., Interventions: None., Measurements: Perioperative laboratory data were collected for all study participants, including sodium levels, neutrophil count, serum albumin, lymphocyte count, and blood glucose. These measurements were obtained as part of routine clinical care and provided valuable information for data analysis., Main Results: Of the 10,223 identified elective craniotomy patients who met our inclusion and exclusion criteria, 14.9% (1519) developed postoperative hypernatremia. This population's overall postoperative 30-day mortality rate was 1.7% (175). After performing an adjusted logistic regression analysis, we found that the odds of 30-day mortality increased gradually with increasing severity of hypernatremia: 2.9 deaths (OR, 3.79; 95% CI, 2.46-5.85) in patients with mild hypernatremia, 13.9 deaths (OR, 17.73; 95% CI, 11.17-28.12) in those with moderate hypernatremia, and 38.3 deaths (OR, 67.00; 95% CI, 40.44-111.00) in those with severe hypernatremia., Conclusions: Hypernatremia is common after elective craniotomy, and its presence is associated with increased mortality and complications, particularly in cases of severe hypernatremia. These results emphasize the significance of risk evaluation in neurosurgical patients and propose the advantages of closely monitoring serum sodium levels in high-risk individuals. Future randomized controlled trials could provide more insight into the effect of treating postoperative hypernatremia in these patients., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest related to this work. This research was not funded by any external agency, institution, or corporation. The authors have full control of all primary data, and they agree to allow the journal to review such data if required. All authors have read and approved the final version of the manuscript and are responsible for its content., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Climate change and biological invasions pose significant threats to the conservation of biodiversity and the provision of ecosystem services. With the rapid development of international trade and economy, China has become one of the countries most seriously affected by invasive alien plants (IAPs), especially the Asteraceae IAPs. For this end, we selected occurrence data of 31 Asteraceae IAPs and 33 predictor variables to explore the distribution pattern under current climate using MaxEnt model. Based on future climate data, the changes in distribution dynamics of Asteraceae IAPs were predicted under two time periods (2041-2060 and 2081-2100) and three climate change scenarios (SSP126, SSP245 and SSP585). The results indicated that the potential distribution of IAPs was mainly in the southeast of China under current climate. Climatic variables, including precipitation of coldest quarter (BIO19), temperature annual range (BIO07) and annual precipitation (BIO12) were the main factors affecting the potential distribution. Besides, human footprint (HFP), population (POP) and soil moisture (SM) also had a great contribution for shaping the distribution pattern. With climate change, the potential distribution of IAPs would shift to the northwest and expand. It would also accelerate the expansion of most Asteraceae IAPs in China. The results of our study can help to understand the dynamics change of distributions of Asteraceae IAPs under climate change in advance so that early strategies can be developed to reduce the risk and influence of biological invasions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Early control of elevated blood pressure is the most promising treatment for acute intracerebral haemorrhage. We aimed to establish whether implementing a goal-directed care bundle incorporating protocols for early intensive blood pressure lowering and management algorithms for hyperglycaemia, pyrexia, and abnormal anticoagulation, implemented in a hospital setting, could improve outcomes for patients with acute spontaneous intracerebral haemorrhage., Methods: We performed a pragmatic, international, multicentre, blinded endpoint, stepped wedge cluster randomised controlled trial at hospitals in nine low-income and middle-income countries (Brazil, China, India, Mexico, Nigeria, Pakistan, Peru, Sri Lanka, and Viet Nam) and one high-income country (Chile). Hospitals were eligible if they had no or inconsistent relevant, disease-specific protocols, and were willing to implement the care bundle to consecutive patients (aged ≥18 years) with imaging-confirmed spontaneous intracerebral haemorrhage presenting within 6 h of the onset of symptoms, had a local champion, and could provide the required study data. Hospitals were centrally randomly allocated using permuted blocks to three sequences of implementation, stratified by country and the projected number of patients to be recruited over the 12 months of the study period. These sequences had four periods that dictated the order in which the hospitals were to switch from the control usual care procedure to the intervention implementation of the care bundle procedure to different clusters of patients in a stepped manner. To avoid contamination, details of the intervention, sequence, and allocation periods were concealed from sites until they had completed the usual care control periods. The care bundle protocol included the early intensive lowering of systolic blood pressure (target <140 mm Hg), strict glucose control (target 6·1-7·8 mmol/L in those without diabetes and 7·8-10·0 mmol/L in those with diabetes), antipyrexia treatment (target body temperature ≤37·5°C), and rapid reversal of warfarin-related anticoagulation (target international normalised ratio <1·5) within 1 h of treatment, in patients where these variables were abnormal. Analyses were performed according to a modified intention-to-treat population with available outcome data (ie, excluding sites that withdrew during the study). The primary outcome was functional recovery, measured with the modified Rankin scale (mRS; range 0 [no symptoms] to 6 [death]) at 6 months by masked research staff, analysed using proportional ordinal logistic regression to assess the distribution in scores on the mRS, with adjustments for cluster (hospital site), group assignment of cluster per period, and time (6-month periods from Dec 12, 2017). This trial is registered at Clinicaltrials.gov (NCT03209258) and the Chinese Clinical Trial Registry (ChiCTR-IOC-17011787) and is completed., Findings: Between May 27, 2017, and July 8, 2021, 206 hospitals were assessed for eligibility, of which 144 hospitals in ten countries agreed to join and were randomly assigned in the trial, but 22 hospitals withdrew before starting to enrol patients and another hospital was withdrawn and their data on enrolled patients was deleted because regulatory approval was not obtained. Between Dec 12, 2017, and Dec 31, 2021, 10 857 patients were screened but 3821 were excluded. Overall, the modified intention-to-treat population included 7036 patients enrolled at 121 hospitals, with 3221 assigned to the care bundle group and 3815 to the usual care group, with primary outcome data available in 2892 patients in the care bundle group and 3363 patients in the usual care group. The likelihood of a poor functional outcome was lower in the care bundle group (common odds ratio 0·86; 95% CI 0·76-0·97; p=0·015). The favourable shift in mRS scores in the care bundle group was generally consistent across a range of sensitivity analyses that included additional adjustments for country and patient variables (0·84; 0·73-0·97; p=0·017), and with different approaches to the use of multiple imputations for missing data. Patients in the care bundle group had fewer serious adverse events than those in the usual care group (16·0% vs 20·1%; p=0·0098)., Interpretation: Implementation of a care bundle protocol for intensive blood pressure lowering and other management algorithms for physiological control within several hours of the onset of symptoms resulted in improved functional outcome for patients with acute intracerebral haemorrhage. Hospitals should incorporate this approach into clinical practice as part of active management for this serious condition., Funding: Joint Global Health Trials scheme from the Department of Health and Social Care, the Foreign, Commonwealth & Development Office, and the Medical Research Council and Wellcome Trust; West China Hospital; the National Health and Medical Research Council of Australia; Sichuan Credit Pharmaceutic and Takeda China., Competing Interests: Declaration of interests LS reports funding from the Medical Research Council of the UK, Sichuan Credit Pharmaceutic, and Takeda China; and speaker fees from Takeda China. CSA has received grants from the National Health and Medical Research Council and Medical Research Futures Fund of Australia, the Medical Research Council of the UK, Penumbra, and Takeda China; is also the chair of the data and safety monitoring boards for several trials; is a board member of WHO; and is the Editor-in-Chief of Cerebrovascular Disease. CY has received funding from West China Hospital. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objective: We aimed to evaluate the risk factors for patients, who had hypertensive intracerebral hemorrhage (ICH)-specific location hemorrhage without hypertensive history, to elucidate a novel and detailed understanding., Methods: We conducted a retrospective review to identify patients diagnosed with hemorrhage in hypertensive ICH-specific locations without hypertensive history between January 2011 and December 2019 from West China Hospital. A least absolute shrinkage and selector operation (LASSO) algorithm was used to select the optimal prognostic factors, and then we performed a multivariable logistic analysis. To verify the accuracy of the nomogram in predicting patient outcome, we used Harrell's statistics, area under the curve, and a calibration as well as decision curves., Results: The LASSO method, at a tenfold cross-validation for 7-day mortality, 90-day mortality, and 90-day morbidity, was applied to construct the prognosis-predicting models. Both a higher Glasgow Coma Scale (GCS) score at admission and larger hematoma volume ≥13.64 mL were independently associated with better survival at 7 days and 90 days in multivariate analysis. Lactic dehydrogenase >250 IU/L and neutrophilic granulocyte/lymphocyte ratio in 1 increase were significantly associated with poor outcome at 90 days. Only one factor (GCS score at 7 days) influencing 90-day morbidity remained in a LASSO model., Conclusions: In this study, the GCS score, hematoma volume, and other laboratory factors (Lactic dehydrogenase and neutrophilic granulocyte/lymphocyte ratio) were related to survival. Our current findings of the specific location ICH need to be proven by a large randomized controlled trial study., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The adverse health effects of household air pollution have been widely explored, but few studies have evaluated the effects of household air pollution on the risk of cardiometabolic multimorbidity (CMM), a pressing public health concern worldwide. Thus, we aimed to investigate whether exposure to household use of polluting fuels is associated with morbid CMM and, if so, whether a healthy lifestyle could mitigate this association., Methods: In this prospective, nationwide representative cohort of the China Health and Retirement Longitudinal Study (CHARLS), participants free of CMM (defined as the coexistence of 2 or more of the following: heart disease, stroke, and diabetes or high blood sugar) were included in 2011-2012 and followed for CMM incidence until 2018. Household air pollution was measured as the use of solid fuels for cooking and heating. The healthy lifestyle score was determined by six factors, physical activity, smoking, body mass index, total cholesterol, blood glucose, and blood pressure, and categorized into three groups (unhealthy, 0-1 factors; intermediate, 2-4; and healthy, 5-6). Cox proportional hazards models investigated associations between household air pollution and incident CMM. The potential modifier effect of a healthy lifestyle score was tested through stratified analyses., Results: Among 7125 eligible participants, 239 incident cases of CMM were identified over a median follow-up of 7.0 years. After adjustment for potential confounders, the use of solid household fuels for heating was associated with more significant hazards of CMM (adjusted hazard ratio [HR] 1.71, 95 % confidence interval [CI] 1.28 to 2.28), while use for cooking (HR, 1.14; 95 % CI, 0.85 to 1.52) was not. Compared with participants in the unhealthy group, those in the healthy and intermediate groups had considerably lower CMM risk, with adjusted HRs (95 % CI) of 0.17 (0.09 to 0.31) and 0.39 (0.29 to 0.53), respectively, regardless of the household air pollution category. Importantly, when participants adhered to a healthy lifestyle, exposure to household air pollution was no longer significantly associated with a higher risk of CMM (adjusted HR 1.77, 95 % CI 0.51 to 6.12; P = 0.369)., Conclusions: Household usage of polluting fuels was significantly associated with a higher risk of CMM, and adherence to a healthy lifestyle may mitigate this adverse effect. From a broader perspective, our findings underscore the importance of public health policies and interventions targeting multiple exposures (air pollution, physical activity, smoking, etc.) in enhancing the prevention of detrimental cardiometabolic health effect., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Objectives: We sought to perform a network meta-analysis to compare the safety and efficacy of the systemic administration of corticosteroids for the treatment of COVID-19., Methods: A Bayesian network meta-analysis was performed to combine the direct and indirect evidence. The surface under the cumulative ranking curve was obtained to estimate the ranking probability of the treatment agents for each outcome. The efficacy outcome was 28-day all-cause mortality. The safety outcome was serious adverse events., Results: A total of 16 trials with 2992 patients comparing four treatments (dexamethasone, hydrocortisone, methylprednisolone, and placebo) were identified. Direct analysis showed that corticosteroids were associated with a reduced risk of 28-day mortality compared with usual care (risk ratio [RR] 0.83; 95% confidence interval [CrI] 0.70-0.99). Network analysis showed that the pooled RR was 0.63 (95% CrI 0.39-0.93) for all-cause mortality at 28 days comparing methylprednisolone with usual care or placebo (surface under the cumulative ranking curve: 91%). Our analysis demonstrated that patients who received a low dose of corticosteroids (RR 0.80; 95% CrI 0.70-0.91) and a long course of treatment (RR 0.81; 95% CrI 0.71-0.91) had higher survival rates than patients in the placebo group., Conclusion: Administration of corticosteroids was associated with a reduced all-cause mortality at 28 days compared with placebo or usual care. Our analysis also confirmed the mortality benefit associated with low-dose and long-term treatment with corticosteroids., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Until now, it has remained difficult for doctors to make an informative decision as to which concentration of hypertonic saline (HTS) is more beneficial for patients with traumatic brain injury (TBI). We therefore investigate the effect of different concentrations of hypertonic saline on mortality and ICP lowering efficacy in this group of patients., Methods: Several databases including Ovid MEDLINE, Ovid EMBASE, PubMed, and Cochrane Central Register of Controlled Trials were searched comprehensively from inception to February 28, 2022. We only included RCTs that compared HTS with different concentrations and mannitol in adult patients with TBI. The main outcome was mortality from any cause. We reported relative risks (RR) and 95% confidence intervals (CIs) from direct meta-analysis and 95% credible intervals (CrIs) from network meta-analysis., Results: Overall, 13 trials containing 593 patients were included in this study. Direct analysis revealed that HTS was associated with decreased risk of all-cause mortality (RR, 1.29; 95% CI: 1.08 to 1.54). In the network meta-analysis, 5% HTS was associated with a significant decrease in all-cause mortality compared with mannitol (RR 0.34, 95% CrI: 0.14 to 0.72). We also found 7.5% HTS was associated with a significant increase in all-cause mortality compared with 5% HTS (RR, 2.87; 95% CrI: 1.00 to 8.99)., Conclusions: Among patients with TBI, the application of 5% HTS was associated with decreased all-cause mortality compared with mannitol and other concentration. Treatments with 10% and 15% HTS was more likely to decrease ICP compared with other fluids. More trials are needed to verify the current findings., Competing Interests: Declarations of Competing Interest None., (Copyright © 2022. Published by Elsevier Ltd.)

Objective: Intracranial aneurysms (IAs) are occasionally associated with moyamoya disease (MMD). The purpose of this study was to elucidate differences between patients with MMD with and without IAs and differences between patients with IAs at different locations., Methods: Between May 2012 and December 2017, consecutive patients with MMD were enrolled in a retrospective single-center study. IAs were classified as circle of Willis (CoW) or peripheral aneurysms according to the anatomic location. Clinical characteristics and hemodynamic parameters were collected and analyzed. A hemispheric analysis was performed for Suzuki stage and computed tomography perfusion parameters., Results: The study included 31 patients with MMD with IAs and 279 patients with MMD without IAs. The patients with IAs had more severe neurological dysfunction, more advanced Suzuki stage, and less hemodynamic dysfunction than the patients without IAs (P < 0.05). Of patients with MMD with IAs, 17 had CoW aneurysms, and 13 had peripheral aneurysms. Patients with CoW aneurysms were older and had more advanced Suzuki stage than patients with peripheral aneurysms (P < 0.05)., Conclusions: Patients with MMD with IAs had different clinical and hemodynamic features compared with patients with MMD without IAs. CoW aneurysms and peripheral aneurysms may occur at different stages of MMD, which may explain their differences in anatomical location, type of hemorrhage, and treatment strategy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate whether the postoperative neutrophil-to-lymphocyte ratio (NLR) is a prognostic marker for patients with intracerebral hemorrhage (ICH) undergoing surgical hematoma evacuation., Methods: This retrospective cohort study was conducted to identify patients with ICH who underwent hematoma evacuation between January 2013 and December 2018. Data on demographics, clinical features, laboratory tests (admission and postoperative), and imaging information were collected. The associations between variables and 30-day mortality were assessed by multivariable logistic regression analysis. The predictive power of independent predictors was evaluated by receiver operating characteristic (ROC) curve analysis., Results: A total of 380 patients were included. Multivariable analysis identified admission Glasgow Coma Scale score (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.53-0.70; P < 0.001) and initial hematoma volume (OR, 1.01; 95% CI, 1.01-1.02; P = 0.022) were independently associated with 30-day mortality. With regard to laboratory biomarkers, postoperative NLR (OR, 1.04; 95% CI, 1.01-1.08; P = 0.014) was independently correlated with 30-day death, but admission NLR (OR, 1.00; 95% CI, 0.97-1.03; P = 0.944) was not. The best predictive cutoff point of 12.97 for postoperative NLR (area under the ROC curve, 0.606; P = 0.006) for predicting 30-day mortality was determined by ROC analysis., Conclusions: In patients with ICH undergoing hematoma evacuation, admission Glasgow Coma Scale score, initial hematoma volume, and postoperative NLR were independently associated with 30-day mortality. Postoperative NLR may be a prognostic marker in surgical ICH patients, and future studies are needed to confirm this finding., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Seizures are common complications following intracranial aneurysms and present a greater risk to pediatric patients than adults. Though the risk factors of seizures in adults with intracranial aneurysms have been well documented, the risk factors in pediatric patients remain unknown. The aim of this study was to evaluate the risk factors for preoperative seizures and the effect of the treatment approach on postoperative seizures in pediatric patients with intracranial aneurysms., Patients and Methods: The data of 64 pediatric patients (mean age 11.4 ± 5.7 years; 68.8 % of males) with intracranial aneurysms were retrospectively analyzed from January 2012 to April 2017. Comparisons were made between patients with preoperative seizures (case group) and those without (control group)., Results: Twenty-four patients (37.5 %) had preoperative seizures, and 15 patients (23.4 %) had postoperative seizures. Multiple logistic regression analysis revealed that younger age (0-5 years), head trauma history, ruptured aneurysms, lobe hematomas, modified Fisher grade 3-4, giant aneurysms, pseudoaneurysms and distal arterial aneurysms were independently associated with the increased risk of preoperative seizures. Patients in the surgical and endovascular groups did not differ significantly in the rates of preoperative seizures or early postoperative seizures (within 1 month) (P > 0.05). However, a significantly lower incidence of late postoperative seizures (1-3 months and 3-6 months) was observed in the surgical group compared with the endovascular group (P < 0.05)., Conclusion: Pediatric patients with intracranial aneurysms are at high risk for seizures. Risk factors for preoperative seizures included younger age (0-5 years), head trauma history, lobe hematomas, modified Fisher grade 3-4, giant aneurysms, pseudoaneurysms and distal arterial aneurysms. Compared with the endovascular treatment, surgical intervention provided more benefits with regard to reducing the risk of late postoperative seizures., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019. Published by Elsevier B.V.)

Background: Primary intraventricular hemorrhage (PIVH) is rare, and causes, characteristics, and outcomes remain unknown in children., Methods: We retrospectively analyzed the clinical characteristics of patients 1 month to 21 years of age who were admitted to the hospital with PIVH over a 7-year period. PIVH was defined as bleeding confined to the ventricular system without parenchymal or subarachnoid hemorrhage involvement., Results: Of 18 included patients, 55.6% were female, and mean age was 13.8 ± 6.0 years. The most common presenting symptoms were headache (77.8%) and vomiting (33.3%). In 15 patients (83.3%), known etiologies were diagnosed, including arteriovenous malformations (66.7%), moyamoya disease (11.1%), and aneurysms (5.6%). Idiopathic PIVH was the diagnosis in 3 patients (16.7%). Surgery was performed in 15 patients (83.3%), and 3 patients (16.7%) received conservative treatment. Four patients (28.6%) had an unfavorable outcome at discharge, and 3 patients (16.7%) had an unfavorable outcome at the 3-month follow-up. Higher Graeb score was associated with an unfavorable outcome in both short-term and long-term follow-up., Conclusions: Arteriovenous malformations were diagnosed in most pediatric patients with PIVH. Specific surgical treatment of underlying etiologies should be required to increase clinical improvement. Children with a higher Graeb score at admission tended to have poor early and late outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: In the present study, we sought to evaluate the timing and outcomes in patients with hemorrhagic stroke who received tracheostomy., Methods: A retrospective database search was undertaken to identify patients with hemorrhagic stroke between January 2010 and December 2018. Clinical data on basic demographics, clinical features, and outcomes were extracted. The primary outcome was in-hospital mortality and secondary outcomes were hospital stays and hospital costs. Univariate and multivariate analyses were used to compare the characteristics and outcomes between patients with hemorrhagic stroke who underwent tracheostomy early (days 1-6) and late (days 7 or later)., Results: A total of 425 patients were identified, 74.4% (n = 316) received an early tracheostomy during the hospitalization. Patients with hemorrhagic stroke who received early tracheostomy had a higher rate of neurosurgical operation (odds ratio, 2.77; 95% confidence interval, 1.54-4.99; P = 0.001) and different types of hemorrhagic stroke (P = 0.001) in comparison with the late tracheostomy patients. In addition, early tracheostomy was associated with shorter hospital stays (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P = 0.003) and reduced hospital costs (P < 0.001) than with late tracheostomy. However, no significant difference was observed with regard to in-hospital mortality between early and late tracheostomy groups (P = 0.744)., Conclusions: In our cohort, early tracheostomy in patients with hemorrhagic stroke may help reduce hospital stays and hospital costs, but not in-hospital mortality. Future prospective multicenter studies are warranted to validate these findings., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Hemorrhagic moyamoya disease (MMD) is one common subtype in adult patients. However, the study about outcome of hemorrhagic MMD patients in the acute stage is still lacking. This study is aimed to explore the short-term prognostic factors for adult patients with hemorrhagic MMD in the acute stage., Patients and Methods: Adult hemorrhagic MMD patients in the acute stage awere retrospectively analyzed. Both clinical and imaging data were collected. Unfavorable functional outcome at discharge was considered when modified Rankin Scale score ≥3. Multivariate logistic regression was used to investigate the prognostic factors in patients with hemorrhagic MMD in the acute stage., Results: A total of 107 patients were included in this study. Among these patients, 17 died and 59 had unfavorable functional outcome at 9.6 ± 7.8 days. In multivariate logistic regression, admission blood glucose (odds ratio (OR) = 1.457, 95% confidence interval (CI) 1.156-1.836, P = 0.001), midline shift >5 mm (OR = 24.268, 95%CI 4.324-136.191, P < 0.001), and subarachnoid hemorrhage (OR = 13.067, 95%CI 2.020-84.512, P = 0.007) were independently associated with death at discharge. Moreover, admission Glasgow Coma Scale (GCS) score (OR = 0.420, 95%CI 0.296-0.598, P < 0.001), midline shift >5 mm (OR = 6.685, 95%CI 1.226-36.455, P = 0.028), and intraparenchymal hemorrhage (OR = 4.790, 95%CI 1.184-19.381, P = 0.028) were independently associated with unfavorable functional outcome at discharge., Conclusion: This study shows that admission blood glucose, midline shift >5 mm, and subarachnoid hemorrhage are independent predictors of short-term mortality in hemorrhagic MMD in the acute stage. In addition, admission GCS score, midline shift >5 mm, and intraparenchymal hemorrhage are independent predictors of short-term unfavorable functional outcome in hemorrhagic MMD in the acute stage., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Brainstem hemorrhage (BSH) is the most dangerous and devastating subtype of intracerebral hemorrhage and is associated with high morbidity and mortality. However, to date, no effective prevention methods or specific therapies have been available to improve its clinical outcomes. We preliminarily explored the efficacy of deferoxamine (DFO), a clinical chelator known for its iron-scavenging activities, in a rat model of BSH induced with collagenase infusion., Methods: DFO or saline was administrated 6 hours after BSH induction and then every 12 hours for ≤7 days. The survival curve of the rats was created, and the neurological scores were examined on days 1, 3, and 7 after BSH. The rats were sacrificed after 1, 3, and 7 days of DFO treatment for histological examination and immunohistochemistry., Results: The results showed that administration of DFO delayed erythrocytes lysis, reduced iron deposition, reduced reactive oxygen species generation, reduced heme oxygenase-1 expression, and alleviated brain injury such as neuron degeneration and myelin sheath injury. However, DFO did not improve the survival rate and neurobehavioral outcomes in this model., Conclusions: Administration of DFO had limited therapeutic effects on collagenase-induced brainstem hemorrhage in rats. Some potential explanations were proposed, and more preclinical work is required to clarify the controversial curative effect of DFO in ICH., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To investigate the risk factors in the development of pneumonia and its impact on outcome after primary intraventricular hemorrhage (PIVH)., Methods: This is a single-center retrospective study including consecutive patients with PIVH admitted to West China Hospital from 2010 to 2016. Pneumonia was defined according to the modified Centers for Disease Control and Prevention criteria within 7 days after PIVH onset. Poor outcome (modified Rankin score ≥3) and mortality at discharge and at 90 days were analyzed., Results: Among the included 174 patients, pneumonia occurred in 13 (7.5%) patients. Patients with pneumonia had lower Glasgow Coma Scale (GCS) score (P = 0.001) and greater Graeb score (P = 0.001) at admission, presented more often with acute hydrocephalus (P = 0.04) and greater rates with stroke history (P = 0.002), and harbored greater admission blood glucose (P = 0.01) and absolute neutrophil counts (P = 0.02). In a multivariable analysis, only GCS score and stroke history were independent predictors of pneumonia after PIVH. The patients with pneumonia had longer duration of hospital stay (P = 0.002) and poorer outcome (P = 0.02) at 90 days. However, after adjustment for confounders, pneumonia after PIVH was not an independent predictor of poor outcome at 90 days., Conclusions: GCS score and stroke history were independent predictors of pneumonia development after PIVH. Pneumonia after PIVH was associated with longer duration of hospital stay and poorer outcome at 90 days., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: The neutrophil-to-lymphocyte ratio (NLR) reflects the balance between innate and adaptive inflammatory responses. This study intended to evaluate parameters associated with admission high NLR and its impact on clinical outcome in patients with primary intraventricular hemorrhage (PIVH)., Methods: This study retrospectively analyzed consecutive patients with PIVH without a history of head trauma or parenchymal/subarachnoid hemorrhage on computed tomography scan between 2010 and 2016 in a single center. Clinical outcomes at discharge and 90 days were assessed with the modified Rankin Score (mRS) and dichotomized as good (mRS 0-2) and poor (mRS 3-6) outcomes. Associations were estimated using multivariable logistic regression., Results: We had 171 patients with PIVH included in the present study. There were 94 male (55.0%) and 77 female (45.0%) patients, with an average age of 46.1 ± 17.2 years. Multivariable logistic analyses revealed independent associations of high NLR (≥8.25) with higher Graeb score, Moyamoya disease, higher admission blood glucose level, and lower platelet count. The patients with high NLR had poorer outcome at discharge and 90 days. After adjustment, the patients with high NLR tended to be associated with poor outcome both at discharge and 90 days. In addition, NLR exhibited a superior predictive power of pneumonia in PIVH than absolute neutrophil count and white blood cell count., Conclusions: NLR tended to be associated with 90-day clinical outcomes of patients with PIVH and exhibited independent predictive power for pneumonia in PIVH., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Delayed cerebral ischemia (DCI) happens in about 30% of patients with aneurysmal subarachnoid hemorrhage (SAH) and is related to higher mortality and disability. Some studies have shown cerebral autoregulation impairment can be a predictor of DCI in aneurysmal SAH. We conducted this meta-analysis to evaluate the predictive value of cerebral autoregulation impairment for DCI based on the current literature., Methods: A systematic literature search was performed in PubMed and Embase. According to inclusion and exclusion criteria, 2 authors screened the records and extracted data from the included studies. Pooled sensitivity, specificity, and their 95% confidence intervals (CIs) were obtained. To investigate the overall accuracy, a summary receiver operating characteristic (SROC) curve was built and the area under SROC curve was calculated. Deeks' linear regression was used to assess the publication bias. All statistical analyses were performed with Stata 14.0., Results: A total of 7 studies were finally included in this meta-analysis. The pooled sensitivity and specificity values of impaired cerebral autoregulation for DCI prediction were 0.79 (95% CI, 0.65-0.88) and 0.85 (95% CI, 0.615-0.96). Moreover, the area under the SROC curve of cerebral autoregulation impairment for DCI prediction was 0.87 (95% CI, 0.835-0.89). No obvious publication bias was found in Deeks' linear regression (P = 0.99)., Conclusions: Cerebral autoregulation impairment can be a helpful predictor of DCI in aneurysmal SAH. Its accuracy for DCI prediction should be verified by more studies in the future., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: We investigated the outcomes of patients with an unruptured intracranial aneurysm (UIA) and >2 risk factors concerning complications, obliteration rate, and other factors after surgical or endovascular treatment., Methods: Coiling and clipping were compared in patients with UIAs treated in West China Hospital from January 2015 to May 2017. Patient survival, dependency, retreatment, complications, and other clinical outcome indexes were compared between the 2 groups., Results: A total of 82 patients (92 aneurysms) had undergone treatment for UIAs with multiple risk factors. Of these 82 patients, 45 (54.9%) had undergone clipping and 37 (45.1%) had undergone coiling. No deaths were related to either treatment. Morbidity (modified Rankin scale score >2) at 1 year had developed in 1 of 45 and 1 of 37 patients in the clipping and coiling groups, without a statistically significant difference. Hospitalization >5 days (30 of 45 vs. 12 of 37; P < 0.05) was less frequent after coiling. The number of aneurysms with complete occlusion (48 of 51 vs. 33 of 41; P < 0.05) was greater in the surgical group. No differences in peritreatment complications were found in the surgical and endovascular groups (8 of 45 vs. 6 of 37; P > 0.05)., Conclusions: In our study, clipping and coiling showed advantages for the treatment of UIAs with multiple risk factors. Surgical clipping of UIAs is achievable with a low rate of unfavorable outcomes and a high rate of complete obliteration for patients with multiple risk factors. However, endovascular treatment was also successful, with a shorter length of stay and low procedure-related morbidity. Additional randomized evidence are required to support the superior efficacy of clipping., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Delayed cerebral ischemia (DCI) is significantly related to death and unfavorable functional outcome in patients with aneurysmal subarachnoid hemorrhage (SAH). The association between alpha-delta ratio (ADR) on quantitative electroencephalography (EEG) and DCI has been reported in several previous studies, but their results are conflicting. This meta-analysis was conducted to assess the accuracy of ADR for DCI prediction in patients with aneurysmal SAH., Methods: PubMed and Embase were systematically searched for related records. Study selection and data collection were completed by 2 investigators. Sensitivity, specificity, and their 95% confidence intervals (CIs) were pooled. A summary receiver operating characteristic curve was plotted to show the pooled accuracy. Deeks funnel plot was used to evaluate publication bias., Results: Five studies were included in this meta-analysis. The pooled sensitivity and specificity of worsening ADR for DCI prediction in patients with aneurysmal SAH were 0.83 (95% CI 0.44-0.97) and 0.74 (95% CI 0.50-0.89), respectively. In addition, the area under the summary receiver operating characteristic curve was 0.84 (95% CI 0.81-0.87). No obvious publication bias was found using Deeks funnel plot (P = 0.29)., Conclusions: Worsening ADR on quantitative EEG is a reliable predictor of DCI in patients with aneurysmal SAH. Further studies are still needed to confirm the role of quantitative EEG in DCI prediction., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Spinal dural arteriovenous fistula (DAVF) occurs at any spinal level; however, a sacral location of fistula is extremely rare, and the clinical characteristics of sacral DAVF have not been well described. This study aimed to document the clinical features of sacral DAVF and review the existing literature., Case Description: The first patient was a 55-year-old man who had progressive weakness and numbness in his lower extremities, along with mild urinary incontinence. The second case was a 32-year-old man who had a 1-year history of progressively worsening bilateral lower extremity weakness associated with diminished sensation. The third patient was a 43-year-old woman with 6-month history of progressive motor weakness of her lower limbs. On spinal angiography, a sacral DAVF with perimedullary vein drainage in all cases was observed. The sacral fistulas were completely obliterated with surgical intervention, and the symptoms of these patients have been gradually resolved. Follow-up magnetic resonance imaging showed complete or partial resolution of the edema within the spinal cord and disappearance of the abnormal vascular flow voids., Conclusions: Sacral DAVFs are extremely rare and are easily missed by spinal angiography. Clinicians should be aware of the possibility of the occurrence of sacral DAVFs, and spinal angiography for the complete assessment of spinal vasculature should be carried out., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The BAT score is a novel prediction score of hematoma expansion based on noncontrast computed tomography (CT) and consists of the blend sign, hypodensities, and time interval from onset to CT. This study aimed to compare the BAT score and the spot sign on CT angiography in a cohort of patients with spontaneous intracerebral hemorrhage., Methods: Eligible patients with spontaneous intracerebral hemorrhage were analyzed retrospectively. The BAT score and the spot sign were assessed according to the criteria described in previous studies. Receiver operating curve analysis was used to assess the performance of the BAT score and the spot sign in hematoma expansion prediction., Results: In 225 included patients, 34 (15.1%) had a BAT score ≥3. The spot sign was shown in 68 (30.2%) patients. Hematoma expansion was identified in 56 (24.9%) patients. In multivariate analysis, both BAT score ≥3 and presence of spot sign were independently correlated with hematoma expansion. BAT score ≥3 had 0.41 sensitivity and 0.93 specificity, and spot sign had 0.64 sensitivity and 0.81 specificity. The area under the curve of BAT score ≥3 and area under the curve of spot sign were 0.673 and 0.727, respectively (P = 0.386)., Conclusions: The BAT score based on noncontrast CT is a good predictor of hematoma expansion. When CT angiography spot sign is unobtainable, the BAT score can be used to predict hematoma expansion., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: It is well established that inflammation plays a critical role in the progression of intracerebral hemorrhage (ICH). Recently the neutrophil-to-lymphocyte ratio (NLR) was identified as a predictor for the short-term outcome in ICH patients. However, the association of NLR with the long-term outcome in patients with ICH remains unknown. Here, we aimed to assess the relationship between NLR and the long-term prognosis in ICH patients., Methods: All patients with spontaneous ICH who were hospitalized at West China Hospital of Sichuan University from October 2013 to May 2017 were retrospectively enrolled. White blood count, absolute count of neutrophils, and lymphocytes were extracted from electronic medical records, and NLR was calculated according to admission neutrophil count (ANC) and lymphocyte count (ALC). The associations between long-term outcomes and laboratory biomarkers were estimated by multivariable logistic regression analysis. Receiver operating characteristic (ROC) curves were also determined to compare the predictive powers between each inflammatory factor., Results: A total of 481 ICH patients were included in the study. Of those, 204 presented with unfavorable outcomes, and 142 were dead within 6 months. Age, Glasgow Coma Scale (GCS) scores, WBC, ANC, NLR, hematoma size, and hydrocephalus were independently associated with poor prognosis of ICH. Multiple linear analysis showed GCS, hematoma volume, WBC, ANC, and ALC to be correlated with NLR. Moreover, in comparison with other single laboratory determinations, NLR also showed better predictive capacity for long-term mortality and morbidity, for which the best predictive cutoff values were 9.07 and 8.69, respectively., Conclusions: NLR independently predicts 180-day morbidity and 180-day mortality in patients with spontaneous ICH., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Primary intraventricular hemorrhage (PIVH) is a rare condition in adult patients. PIVH occurs frequently in adult hemorrhagic Moyamoya disease (MMD). Idiopathic PIVH is defined as PIVH without cerebrovascular abnormalities. This study is aimed to compare the baseline characteristics and outcomes of acute MMD-related and idiopathic PIVH., Methods: Adult patients with acute MMD-related or idiopathic PIVH were retrospectively included. Baseline characteristics and outcomes at discharge were obtained and compared. Chi-square test, Student's t-test, or rank-sum test were used in statistical analyses., Results: This study finally included 32 patients with acute MMD-related PIVH and 112 with acute idiopathic PIVH. Patients with acute MMD-related PIVH were significantly younger (53.3 ± 15.8 vs. 42.8 ± 12.2 years, P < 0.001). The admission systolic blood pressure in patients with acute idiopathic PIVH was significantly higher (161.7 ± 30.9 vs. 134.6 ± 24.6 mm Hg, P < 0.001). Patients with acute idiopathic PIVH had significantly higher admission serum urea (5.68 ± 2.66 vs. 4.34 ± 1.62 mmol/L, P = 0.008), cystatin C (0.97 ± 0.72 vs. 0.68 ± 0.16 mg/L, P = 0.023), and uric acid (309.01 ± 105.97 vs. 242.24 ± 77.65 μmol/L, P = 0.001). In patients with acute MMD-related PIVH, only one (3.1%) patient was dead at discharge. In contrast, a total of 22 (19.6%) patients with acute idiopathic patients died at discharge (P = 0.027)., Conclusions: Compared with patients with acute idiopathic PIVH, patients with acute MMD-related PIVH have younger age, lower blood pressure, and better renal function. Moreover, patients with acute MMD-related PIVH have lower short-term mortality., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Hematoma enlargement happens in about 30% patients with intracerebral hemorrhage, which is reported to be closely correlated with poor prognosis. Swirl sign has been reported to have correlation with hematoma enlargement. This meta-analysis analyzed the accuracy of swirl sign for predicting hematoma enlargement in intracerebral hemorrhage., Methods: Five databases were searched for potentially eligible literature. Studies were included if they were about the predictive properties of swirl sign for hematoma enlargement in intracerebral hemorrhage. Sensitivity and specificity of swirl sign for hematoma enlargement prediction were pooled. Pooled positive and negative likelihood ratios were also calculated., Results: Six studies with 2647 patients were finally included in meta-analysis. The pooled sensitivity and specificity of swirl sign were 0.45 (95%CI 0.32-0.59) and 0.79 (95%CI 0.73-0.84), respectively. The pooled positive likelihood ratio of swirl sign was 2.2 (95%CI 1.8-2.5). In contrast, the pooled negative likelihood ratio of swirl sign was 0.69 (95%CI 0.57-0.84)., Conclusions: This meta-analysis suggests that swirl sign has the relatively high specificity for hematoma enlargement prediction in patients with intracerebral hemorrhage., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: Primary intraventricular hemorrhage (PIVH) is rare in the aging population and remains a challenge for cerebrovascular surgeons. In the present study, the authors reviewed the patient characteristics, angiographic results, and treatments and determined clinical outcomes in 34 patients older than 60 years of age who were treated at West China Hospital between 2010 and 2014., Methods: The medical records of elderly patients were queried. The parameters regarding patient demographics, presenting symptoms, treatment modalities, angiographic results, and clinical outcomes were assessed and analyzed., Results: There were 19 male (55.9%) and 15 female (44.1%) patients, with an average age (±SD) of 67.9 ± 7.7 years in our study. The most common symptoms on presentation were headache (50%), followed by disturbance of consciousness (26.5%). Only 5 patients (14.3%) were diagnosed with underlying cerebrovascular etiologies including Moyamoya disease (5.9%), arteriovenous malformations (2.9%), and aneurysms (5.9%). Idiopathic PIVH was diagnosed in 29 patients (85.7%). Thirteen patients (38.2%) underwent surgical intervention, while 21 patients (61.8%) received conservative treatment. Twelve patients (35.3%) had an unfavorable outcome at discharge, and an unfavorable outcome was observed in 14 patients (41.2%) at the 3-month follow-up. Patients with higher Graeb score might be associated with an unfavorable outcome both in short-term and long-term follow-up., Conclusions: Most PIVH patients were diagnosed with idiopathic PIVH in the elderly. Surgical treatment of aging patients should be optimized to improve clinical outcomes. The admission Graeb scores were considered to be the independent prognostic factors for both short-term and long-term outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Oligochitosan (OCHI) is known to have some specific biological activities. However, its interactions with blood components and related correlation with molecular structures remains to be clarified due to its growing use in biomedical areas. Herein, a series of OCHI were prepared by hydrogen peroxide induced degradation combined fractionation in ethanol solutions and their molecular structures were characterized by GPC, FTIR, 1 H and 13 C NMR, and then the interactions of the prepared OCHI with blood components, including red blood cells (hemolysis, deformability, and aggregation), coagulation system, complement (C3a, and C5a activation), and platelet (activation, and aggregation), were investigated. For red blood cells, OCHI has a quite low risk of hemolysis in a dose- and MW-dependent manner and the deformability and aggregation were observed in its high MW fraction. The coagulation tests revealed that OCHI is capable of a mild anticoagulation through blocking the intrinsic pathway and the anticoagulation corresponding MW was identified. In terms of complement, OCHI could inhibit C3a in a dose-dependent manner and activate C5a with its high MW fraction. In addition, there is no significant effect of OCHI on platelet activation and aggregation. Based on above results, the interactions related mechanism was discussed and proposed., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: Intracerebral hemorrhage (ICH) is a type of stroke that leads to high mortality. Hematoma growth (HG) happens in about one third of all patients with ICH and is independently related to poor outcome. Previous studies have shown that an indicator on noncontrast computed tomography, called hypodensities, can predict HG in patients with ICH. Thus, this study was done to assess the predictive validity of this marker., Methods: Bibliographic databases were searched, without language restriction, for original investigation on hypodensities and HG in ICH. Data were extracted, and study quality was assessed by 2 reviewers independently. Pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio, and their 95% confidence intervals (CIs) were obtained. A summary receiver operating characteristic curve was depicted., Results: Five cohorts with 2157 patients in 4 studies were included in the present meta-analysis. The pooled sensitivity was 0.58 (95% CI 0.46-0.68) and the pooled specificity was 0.71 (95% CI 0.62-0.79). In addition, the pooled positive LR was 2.0 (95% CI 1.6-2.5) and the pooled negative LR was 0.60 (95% CI 0.49-0.73). The pooled diagnostic odds ratio was 3 (95% CI 2-5) and the area under summary receiver operating characteristic curve was 0.69 (95% CI 0.65-0.73)., Conclusions: This study suggests that hypodensities on noncontrast computed tomography can be helpful in HG prediction, although its pooled predictive values are not very satisfying in the current study. The role of hypodensities in predicting HG should be confirmed by further studies., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Patients with intracerebral hemorrhage (ICH) have high disability and mortality. Leukoaraiosis refers to the diffuse abnormalities of white matter on neuroimaging, which has been suggested to be with poor outcome in patients with ICH. This meta-analysis was performed to summarize the current evidence on the prognostic significance of leukoaraiosis in ICH patients., Methods: Databases were searched for published studies about leukoaraiosis and prognosis in patients with ICH. Data from eligible studies were extracted. Odds ratios (ORs) and their 95% confidence intervals (CIs) from each study were combined with DerSimonian-Laird method and random effect model for quantitative analysis. Begg's funnel plot was adopted to assess the publication bias., Results: A total of nine studies with 4948 patients were finally included in this meta-analysis. Six studies reported functional outcome, two studies reported mortality, and another study reported both functional outcome and mortality. The meta-analysis showed that leukoaraiosis was significantly associated with worse functional outcome in patients with ICH (OR = 1.40, 95%CI 1.17-1.68, P < .001). In addition, leukoaraiosis was also significantly associated with higher mortality in patients with ICH (OR = 1.59, 95%CI 1.21-2.08, P = .001)., Conclusions: Leukoaraiosis is significantly associated with both worse functional outcome and higher mortality in patients with ICH. Leukoaraiosis can be a useful imaging marker for predicting outcome in patients with ICH., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: It is well known that early hematoma expansion is associated with short-term prognosis of patients with intracranial hemorrhage (ICH). And spot sign is recognized as a reliable computed tomography angiography (CTA) predictor for early hematoma expansion. Recently, island sign is also reported as a novel computed tomography (CT) predictor for early hematoma growth. Here, we compared the predictive abilities of these two signs for short-term outcomes of ICH patients., Patients and Methods: All the ICH patients were retrospectively identified. Clinical characteristics and radiological parameters were obtained from electronic medical records. Hematoma expansion, spot sign and island sign were assessed by two senior neurologists according to the initial and follow-up CT scans. 3-months prognoses were estimated according to Glasgow outcome scale (GOS). Multivariate logistic regression analyses were employed to explore the associations of short-term prognosis on island sign, spot sign and other clinical variables., Results: There were 283 ICH patients included. 113 of them presented with early hematoma expansions. 66 of them exhibited island sign, while spot sign occurred in 85 patients. Univariate analyses demonstrated that GCS score at admission (OR: 0.464, 95%CI: 0.395-0.547), hematoma volume (OR:1.062, 95%CI: 1.041-1.083), interventricular extension(OR:9.528, 95%CI: 3.915-23.187), island sign (OR: 4.595, 95%CI: 2.404-8.784) and spot sign (OR: 4.052, 95%CI: 2.297-7.147) were correlated with 3-months morbidity. Moreover, multivariate logistic regression analyses further revealed that both spot sign (OR: 3.413, 95%CI: 1.570-7.422) and island sign (OR: 7.564, 95%CI: 2.969-19.273) were strongly associated with 3-months poor outcome and have comparable predictive values (AUC: 0.636 vs. 0.622, P = .58). However, spot sign exhibited a superior predictive ability for 3-months mortality compared to island sign (OR: 2.713, 95%CI: 1.570-4.217 vs. OR: 2.362, 95%CI: 1.238-3.899, AUC: 0.700 vs. 0.603, P < .01)., Conclusions: Island sign is not just a convenient and reliable predictor for short-term prognosis of ICH patients, but also could be used as an indicator for accurate diagnosis and aggressive treatment., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: Among several novel predictors on noncontrast computed tomography (CT) for hematoma expansion in spontaneous intracerebral hemorrhage (sICH), shape irregularity grade, satellite sign, and island sign are all related to irregular shape of hematoma. This study is aimed to compare the accuracy of these imaging markers for predicting hematoma expansion in the same cohort of sICH patients., Methods: This retrospective study enrolled sICH patients who underwent diagnostic computed tomography (CT) scans within 6 hours after onset and another follow-up CT scan within 24 hours after initial CT scan. Shape irregularity grade, satellite sign, and island sign were assessed according to the definitions in previous studies. The accuracy of these imaging indicators for predicting hematoma expansion was analyzed using receiver operator analysis., Results: Finally, a total of 196 patients were included. Shape irregularity grade ≥3 was found in 87 (44.39%) patients, satellite sign was identified in 76 (38.78%) patients, and island sign was shown in only 41 (20.92%) patients. Only island sign remained an independent predictor for hematoma expansion in multivariate logistic regression. The sensitivity values of shape irregularity grade ≥3, satellite sign, and island sign were 0.52, 0.63, and 0.48, respectively. By contrast, the specificity values of these 3 predictors were 0.58, 0.69, and 0.85, respectively. Shape irregularity grade ≥3 had the smallest area under the curve (0.597), and island sign had the largest (0.676)., Conclusions: Island sign seems to be the optimal shape-related predictor for hematoma expansion in sICH patients and could be included in the future predictive model for hematoma expansion., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The island sign is a novel imaging predictor for early hematoma growth, implying multifocal active bleeding. The prognostic value of the island sign for long-term outcome in patients with intracranial hemorrhage (ICH) remains unrevealed. The aim of this study is to investigate associations between the island land and long-term prognosis in patients with ICH., Methods: Both clinical characteristics and radiologic parameters were retrospectively obtained from electronic medical records. According to the initial and follow-up computed tomography scans of patients, hematoma expansion and the island sign were determined independently with 2 experienced physicians. Multivariate logistic regression analyses were used to explore the associations of hematoma expansion, 1-year poor outcome, and 1-year death on other clinical variables., Results: A total of 322 patients were included, and 126 of them presented with early hematoma expansion, with 81 exhibiting the island sign. There were 116 patients who died, and 157 patients with ICH had poor outcome at the first year after onset. The multivariate logistic regression analyses revealed that initial Glasgow Coma Scale score, hematoma size, and presence of intraventricular hemorrhage and island sign were strongly associated with long-term poor outcomes., Conclusions: The island sign is an easy-to-use and novel imaging marker which predicts both early hematoma expansion and long-term poor prognosis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: The prognostic value of admission serum glucose for early hematoma growth in patients with intracranial hemorrhage remains controversial. Island sign is a novel imaging predictor for early hematoma growth, implying multifocal active bleeding. The aim of this study is to investigate the potential associations between hyperglycemia and early hematoma expansion in patients with intracranial hemorrhage with or without island sign., Patients and Methods: Clinical characteristics and radiologic parameters were retrospectively obtained from the electronic medical record. Admission blood glucose was measured within 24 hours from disease onset. Hematoma expansion and island sign were estimated by 2 experienced reviewers from initial and follow-up computed tomography scans. Multivariate logistic regression analyses were used to explore the associations of hematoma expansion and island sign on other clinical variables., Results: In total, 187 patients were enrolled in current study; 61 patients were presented to have early hematoma expansion, whereas 32 exhibited island sign. The average blood glucose level was 7.64 mmol/L among all patients. The multivariate logistic regression analyses revealed that the time from ictus to initial computed tomography scan, Glasgow Coma Scale score on admission, hematoma volume, island sign, and hyperglycemia were associated with hematoma expansion, whereas only admission serum glucose and hematoma size were associated with island sign., Conclusions: Admission serum glucose is associated with hematoma growth and prevalence of island sign, respectively. These results indicated that elevated blood glucose level plays a pathological role in active bleeding. Further studies concerning exact molecular signal pathway are urgently required., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The inflammatory response plays a vital role in the pathologic mechanism of intracerebral hemorrhage. It recently has been reported that neutrophil to lymphocyte ratio (NLR) could represent a novel composite inflammatory marker for predicting the prognosis of intracranial hemorrhage (ICH). However, in considering the effects of surgical evacuation on the initiation of inflammatory responses, the relationship between NLR and functional outcome of patients with ICH after surgical treatment is still controversial. Here, we aimed to assess the predictive value of admission NLR and other available laboratory parameters for 90-day outcome of patients with ICH undergoing neurosurgical treatment., Methods: In total, 104 patients with acute ICH admitted to West China Hospital from October 2016 to January 2018 were retrospectively enrolled. Admission absolute neutrophil count, lymphocyte count, and white blood count were extracted from electronic medical records of patents with ICH. The associations between outcome and laboratory biomarkers were assessed by multivariable logistic regression analysis. The comparison of predictive power of independent predictors was evaluated by receiver operating characteristic curves., Results: In total, 59 patients with ICH who underwent surgical treatment exhibited unfavorable outcomes, which was associated with greater admission NLR (odds ratio [OR] 0.692, 95% confidence interval [CI] 0.518-0.925, P = 0.01; OR 1.148, 95% CI 1.078-1.222, P < 0.01; OR 1.215, 95% CI 1.015-1.454, P = 0.03), lower Glasgow Coma Scale score, and larger hematoma. NLR showed the best predictive power by comparing with other laboratorial variables (area under the curve 0.668, 95% CI 0.569-0.757, P < 0.01) and also was found to linearly correlate with Glasgow Coma Scale score at admission, hematoma volume, absolute neutrophil count, absolute lymphocyte count, and hydrocephalus. Meanwhile, the best predictive cutoff point of 6.46 for NLR also was identified., Conclusions: Other than the association of prognosis of patients with ICH, NLR exhibited potential independent predictive ability for 90-day functional outcomes of patients with ICH after surgery., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To evaluate the parameters related to the high risk of preoperative seizures in infants (1 year or younger) with ruptured intracranial aneurysms., Methods: Infants with ruptured intracranial aneurysms treated at our institution from January 2012 to January 2018 were retrospectively analyzed. Seventeen similar cases of infant patients with seizures reported in published studies were reviewed., Results: The mean age of the 7 infant patients treated at our institution was 4.1 ± 3.3 months (range, 28 days to 11 months), with 2 male and 5 female subjects. One patient (14.3%) had an internal carotid artery aneurysm with subarachnoid hemorrhage, and the remaining 6 patients (85.7%) had middle cerebral artery (MCA) aneurysms in the distal arterial region with lobe hemorrhage. Five of the 7 infants (71.4%) had seizures, 4 of whom (4/5, 80.0%) had MCA distal arterial aneurysms with lobe hemorrhage. Management was successful for all patients with aneurysm clipping or resection surgery, and one patient experienced postoperative seizures. Of the 17 reviewed cases of infant patients with seizures, 10 patients (58.8%) exhibited the typical distal arterial aneurysm with lobe hemorrhaging, and 6 (60%) of them had aneurysms in MCA., Conclusions: Infant patients with ruptured intracranial aneurysms have a high risk of preoperative seizures. The typical radiologic finding of distal arterial aneurysm with lobe hemorrhage was frequently observed in the MCA, and it might be related to the high risk of preoperative seizures in this population. Microsurgical techniques effectively control postoperative seizures in infants with ruptured intracranial aneurysms., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease. Emerging evidence has indicated that the apolipoprotein E (ApoE) genotype might be associated with the risk of aSAH as well as complications and outcomes after aSAH, although the results remain controversial., Methods: We searched published literature on PubMed, Embase, China National Knowledge Infrastructure, and Wanfang database to identify studies involving the ApoE genotype and aSAH. A meta-analysis was performed to summarize the relationship between ApoE genotype and aSAH, including susceptibility, complications, and prognosis., Results: Eighteen studies were considered eligible for inclusion. Generally, ε4 carriers had increased risk of aSAH (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.01-1.49). White patients with the ε2/ε2 genotype had a greater risk of aSAH (OR 3.38, 95% CI 1.13-10.11). The patients with aSAH carrying the ε4 allele had an increased risk of poor outcome (OR 2.21, 95% CI 1.21-4.05) compared with non-ε4 carriers, especially in Asian patients (OR 4.99, 95% CI 1.73-14.40). ApoE ε4 carriers have increased risk of delayed ischemic neurologic deficit compared with non-ε4 carriers in the overall population. No significant difference was detected regarding the effect of certain ApoE genotypes on aSAH admission severity, rebleeding, or cerebral vasospasm after aSAH., Conclusions: We found that the ApoE genotype was significantly associated with aSAH risk, whereas its effect on certain ethnic populations differs. Patient carrying the ε4 allele might have a worse outcome, whereas current evidence was insufficient to prove the association between ApoE genotypes and post-SAH complications., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: A successful animal brainstem hemorrhage model can be used to study pathophysiology and molecular mechanisms of neurologic deterioration or recovery and therapeutic interventions after the brainstem hemorrhage. Herein, we provide a reproducible and reliable model for rat brainstem hemorrhage and summarize our key points to success in modeling., Methods: Twenty-four adult male Sprague-Dawley rats were divided into 3 groups and were injected with 30, 40, and 60 μL autologous blood into the right pontine basal tegmentum after being sedated. The initial model was evaluated with neurobehavior testing, autopsy, and histopathology. The modeling conditions were modified in Group IV rats, and 20 more rats were used to check the reproducibility and reliability of the modified model. Finally, magnetic resonance imaging (MRI) was used to confirm the brainstem hemorrhage., Results: Only 6 rats had significant pontine hemorrhage in initial 3 groups on autopsy. Whereas after the modification, all Group IV rats had serious pontine hemorrhage, and modified conditions model had a 90% success rate. MRI confirmed a stable hematoma in the right basal tegmental pons with oval shape 24 hours after of blood injection. Histopathologically, there was significant perihematomal swelling, migration of inflammatory cells and structural changes in neuronal shape and contents., Conclusions: An ideal and repeatable rat brainstem hemorrhage model by injecting autologous blood stereotactically was created, and it mimics the natural onset of brainstem hemorrhage. This brainstem hemorrhage model shows promise that providing a better way for neurology researchers to investigate pathophysiologic procedure of brainstem intracranial hemorrhage and further explore the treatment., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Hematoma expansion (HE) is closely related to poor outcome in spontaneous intracerebral hemorrhage (sICH). Island sign (IS) is a novel HE predictor based on noncontrast computed tomography (NCCT). This study is aimed to confirm the accuracy of IS for predicting HE and compare it to the spot sign (SS) on computed tomography angiography (CTA)., Methods: Patients with sICH and initial CTA within 6 hours after onset and follow-up NCCT within 24 hours after initial CTA were included. IS and SS were screened by 2 independent readers. The sensitivity and specificity were evaluated for both signs. Receiver-operator analysis was conducted to assess the accuracy of both signs for predicting HE., Results: This study included 165 patients. IS was found in 33 (20.0%) patients, and SS was identified in 42 (25.5%) patients. In the 41 patients with HE, 19 (46.3%) had IS and 26 (63.4%) had SS. The sensitivity and specificity of IS were 46.3% and 88.7%, respectively. In contrast, the sensitivity and specificity of SS were 63.4% and 87.1%, respectively. The areas under the curve of IS and SS were 0.675 and 0.753, respectively (P = 0.275)., Conclusions: IS is independently associated with HE. Although the accuracy of IS for predicting HE is lower than SS, it can be an alternative predictor if CTA cannot be performed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To summarize the characteristics of intracranial pseudoaneurysms (IPAs) in pediatric patients., Methods: Pediatric IPAs treated at our center between January 2012 and April 2017 were analyzed retrospectively. Related literature was reviewed, and the results of those studies were compared with our present findings., Results: A total of 15 pediatric IPAs from 64 pediatric intracranial aneurysms (23.4%) were included in our study. Eleven of the 15 patients (73.3%) were male, and 9 (60%) had a history of head trauma. Seven patients (46.6%) presented with seizures, 9 of 11 patients (81.8%) with ruptured aneurysms with presented intracerebral hematoma, and 9 IPAs (60%) were large or giant in size. The internal carotid artery (ICA) and middle cerebral artery (MCA) were the most common aneurysm sites (n = 6; 40.0%). Eight IPAs (53.3%) were distal arterial aneurysms. Seven patients (46.7%) underwent craniotomy surgery, and 8 (53.3%) underwent endovascular treatment. During a mean follow-up of 2.0 ± 1.3 years, 12 patients (80.0%) had favorable outcomes, with a modified Rankin Scale (mRS) score of 0-2. One patient in the endovascular group died due to postoperative rebleeding., Conclusions: IPAs are prevalent among all pediatric intracranial aneurysms, and head trauma is the most important risk factor. IPAs present with more intracerebral hematomas, tend to be larger, and are commonly observed in the ICA, MCA, and distal arterial location; they also carry a high risk of seizures. Both surgical and endovascular treatment could achieve favorable clinical outcomes, but more studies are needed to reveal which treatment approaches are best suited for pediatric IPAs., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To reveal the characteristics of spontaneous intracerebral hemorrhage (sICH) in a plateau area based on the Tibetan population., Methods: Data of Tibetan and Han patients (control group) with sICH treated at our center from January 2013 to April 2017 were retrospectively reviewed., Results: A total of 122 Tibetan and 927 Han patients were included. Compared with Han patients, Tibetan patients were older (54.7 ± 11.2 vs. 50.9 ± 18.3 years, P = 0.027), exhibited higher male-to-female ratios (73.8% vs. 55.0%, P < 0.001), were more overweight (22.1% vs. 13.1%, P = 0.007) had more smokers (36.9% vs. 20.5%, P < 0.001), had a higher concentration of hemoglobin (163.7 ± 17.6 vs. 134.8 ± 20.2 g/L, P < 0.001), and included a higher number of patients with hypertension (83.6% vs. 60.5%, P < 0.001), diabetes mellitus (19.2% vs. 9.3%, P = 0.002), and prior hemorrhagic stroke (9.0% vs. 2.0%, P < 0.001). Tibetan patients also experienced more brainstem hemorrhage (11.5% vs. 5.1%, P = 0.039) in the infratentorial region and had a higher risk of in-hospital complications resulting from hematoma enlargement (20.5% vs. 10.4%, P = 0.002) and cerebral infarction (59.0% vs. 9.7%, P < 0.001). During a 6-month follow-up period, they had higher rates of unfavorable outcomes and case mortality (P < 0.05). A multivariable analysis adjusted for confounding factors revealed that the Tibetan race was positively associated with unfavorable clinical outcomes in sICH patients (P < 0.05)., Conclusions: Tibetan sICH patients from the plateau area presented unique characteristics in their baseline measurements, incidence of comorbidities, hematoma location, risk of in-hospital complications, and clinical outcomes compared with Han patients. The Tibetan race was positively associated with unfavorable 6-month outcomes in ICH patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Hematoma expansion is related to unfavorable prognosis in intracerebral hemorrhage (ICH). The black hole sign is a novel marker on non-contrast computed tomography for predicting hematoma expansion. However, its predictive values are different in previous studies. Thus, this meta-analysis was conducted to evaluate the predictive significance of the black hole sign for hematoma expansion in ICH., Methods: A systematic literature search was performed. Original researches on the association between the black hole sign and hematoma expansion in ICH were included. Sensitivity and specificity were pooled to assess the predictive accuracy. Summary receiver operating characteristics curve (SROC) was developed. Deeks' funnel plot asymmetry test was used to assess the publication bias., Results: Five studies with a total of 1495 patients were included in this study. The pooled sensitivity and specificity of the black hole sign for predicting hematoma expansion were 0.30 and 0.91, respectively. The area under the curve was 0.78 in SROC curve. There was no significant publication bias., Conclusions: This meta-analysis shows that the black hole sign is a helpful imaging marker for predicting hematoma expansion in ICH. Although the black hole sign has a relatively low sensitivity, its specificity is relatively high., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: It remains unknown if ultra-early (within 24 hours after onset) treatment can improve the prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). We aimed to evaluate the effect of ultra-early treatment on functional outcomes and mortality in patients with poor-grade aSAH via a systematic review and meta-analysis., Methods: We performed a literature search in the PubMed, MEDLINE, and Web of Science databases. Primary outcomes were death and functional outcome assessed at any time period. Secondary outcomes were the rebleeding rate before an aneurysm occlusion procedure and the incidence of intraoperative technique difficulty (ITD). The results are reported as odds ratio (OR) with 95% confidence interval (CI)., Results: A total of 14 articles containing 1111 patients met our inclusion criteria and were included in our analysis. The pooled incidence was 47% (95% CI, 40%-54%) for favorable outcome across 13 studies, 26% (95% CI, 19%-32%) for mortality in 11 studies, 10% (95% CI, 3%-16%) for rebleeding in 5 studies, and 20% (95% CI, 10%-31%) for ITD in 5 studies after ultra-early treatment of poor-grade aSAH. Compared with delayed treatment (>24 hours), the ultra-early treatment failed to improve outcomes (OR, 1.23; 95% CI, 0.75-2.01; P = 0.40) or reduce mortality (OR, 0.84; 95% CI, 0.58-1.22; P = 0.45), but tended to prevent preoperative rebleeding (OR, 0.59; 95% CI, 0.32 to 1.07; P = 0.08) in 6, 4, and 4 case-control studies, respectively., Conclusions: Our findings show no significant change both in functional outcome and mortality between ultra-early and delayed treatment although ultra-early treatment may be associated with lower rebleeding rate., (Copyright © 2018 Elsevier Inc. All rights reserved.)