磁敏感加权成像在脑出血中的应用价值

目的 探讨MRI磁敏感加权成像(SWI)在脑出血中的应用价值.方法 对12例经CT确诊的脑出血患者于发病2 d内及2周后分别进行MRI常规序列及SWI扫描,并进行血肿分期及对各序列的病灶显示率、微出血灶的分布和出血量评估.结果 在12例脑出血患者中,共发现33处出血灶.SWI、T,WI、T<,2>WI、Flair序列对...     

Absence of Microbleeds Reduces the Risk for Recurrent Intracerebral Hemorrhage

Background: Many known risk factors, including hypertension and hyperlipidemia cause intracerebral hemorrhage (ICH). Recently, microbleeds have been identified as one of the factors leading to ICH. While some patients have been found to have recurrent ICH, risk factors for recurrent ICH are scarcely reported. We conducted an observational study on the risk-factors of recurrent ICH, comparing stroke patients with a single hemorrhagic episode and those with recurrent ICH. Methods: A retrospective analysis of a single-center database was performed to analyze the clinical presentation and characteristics of patients with a single and recurrent ICH. From January 2016 to December 2017, a total of 317 patients were analyzed based on suspected factors including patients’ sex, age, medical history, antiplatelet therapy use, and presence of microbleeds on images. Results: Of the 317 patients, 36 patients (11.4%) developed a second episode of cerebral hemorrhage. Brain magnetic resonance imaging (MRI) of the patients without microbleeds, predicted reduced risk of recurrence. This is the first report strongly associating the presence of microbleeds with the possibility of a recurrent ICH. Other factors under study did not show an apparent association with recurrent ICH probably because of the high statistical significance obtained with the presence of microbleeds. Conclusion: Our findings revealed that the absence of microbleeds on images is a factor that strongly predicts a reduced risk for recurrent ICH and that the detection of microbleeds on MRI performed in patients with a single hemorrhagic episode, is useful in defining further therapeutic management. These findings may benefit physicians treating stroke patients.     

磁共振成像脑微出血与抗栓治疗脑出血相关

目的 观察脑微出血是否与抗栓治疗颅内出血(ICH)相关。方法 选择本院从2005年6月至2010年6月共43例抗栓治疗的脑出血患者,选择同期年龄、性别、高血压史相匹配的非抗栓治疗的脑出血患者及无脑出血史的抗栓药物使用患者作对照。结果 抗栓治疗脑出血组较无脑出血史的抗栓药物组更易发生脑微出血[31/43(72.1％)与12/57(21.1％),x2=6.731,P=0.011],抗栓治疗脑出血组较非抗栓治疗脑出血组更易发生脑微出血[31/43 (72.1％)与17/48 (35.4％),x2 =4.971,P=0.030]。脑叶微出血在抗栓治疗脑出血组为27/43(62.8％),而在非抗栓治疗脑出血组为19/48 (39.6％),两组比较差异有统计学意义(x2=4.019,P=0.042)。脑微出血数目是抗栓治疗脑出血的危险因素（OR=1.38,95％CI 1.07～1.71,t=0.806,P=0.021）。结论 脑微出血与抗栓治疗脑出血相关。     

Treatment and prevention of primary intracerebral hemorrhage

Intracerebral hemorrhage (ICH), which constitutes 10 to 15% of all strokes and affects approximately 65,000 people each year in the United States, has the highest mortality rate of all stroke subtypes. Hypertension, cerebral amyloid angiopathy, and anticoagulation underlie the majority of cases of ICH. Warfarin not only increases the risk but also increases the severity of ICH by causing hematoma expansion. With the advent of gradient-echo magnetic resonance imaging, patients with underlying cerebral amyloid angiopathy or hypertensive vasculopathy can be identified, and measures can be taken to prevent ICH. Initiating an antihypertensive regimen in a patient with nonlobar microbleeds suggestive of hypertensive vasculopathy, and withholding warfarin in patients with lobar microbleeds suggestive of cerebral amyloid angiopathy, are emerging prevention strategies. Although a treatment for cerebral amyloid angiopathy does not exist, agents targeting beta-amyloid metabolism and bioactivity are promising candidates. Strategies for preventing warfarin-associated hemorrhage include strict monitoring of anticoagulation levels and using agents such as direct thrombin inhibitors. The future of ICH management lies in therapies targeted at the pathophysiological steps in ICH. Potential treatments include glutamate receptor antagonists for preventing glutamate excitotoxicity, matrix metalloproteinase and thrombin inhibitors for preventing perihematomal edema, and recombinant activated factor VII for preventing hematomal expansion.     

Intracerebral hemorrhage in CADASIL

BackgroundIntracerebral hemorrhage (ICH) has been reported in few cases of Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), mostly in hypertensive patients. We aimed to assess the clinical and radiological characteristics of patients with CADASIL who presented with ICH.MethodsA retrospective analysis of all neuroimaging exams of CADASIL patients hospitalized in our academic neurology department for acute cerebrovascular events was performed to find ICH. A systematic review of the literature was performed on this topic.ResultsIncluding our five patients, a total number of 52 subjects with CADASIL and ICH (mean age: 56 years, SD 11, 36–69%- male) were reported. Intracerebral hemorrhages were mainly deep (34 subjects), followed by lobar (8 subjects), infratentorial (6 subjects) and mixed locations (4 subjects). Three ICHs were asymptomatic. Fourteen patients were taking antithrombotic medication, 18 had no regular antiplatelet or anticoagulant treatment while in 20 patients medical treatment was not detailed. Arterial hypertension was present in 37 out of 51 patients with available information. Neuroimaging showed extensive FLAIR hyperintensities in all CADASIL subjects with ICH, cerebral microbleeds in all but three patients, and lacunar infarction in 19 out of 25 subjects with available information.ConclusionsIntracerebral hemorrhage represents a possible yet uncommon manifestation of CADASIL and should be considered as a possibility in patients with ICH associated with leukoencephalopathy and microbleeds, even in the absence of other clinical symptoms.     

Periventricular and deep white matter leukoaraiosis have a closer association with cerebral microbleeds than age

Background: Taking an advantage of the high sensitivity of 3D T2*‐weighted gradient‐recalled‐echo (GRE) imaging to cerebral microbleeds, we investigated the relationship between cerebral microbleeds and leukoaraiosis. Methods: Participants aged 40 years or more have been evaluated for the presence of cerebral microbleeds using 3D T2*‐GRE sequence since 2006. The severity of periventricular hyperintensity (PVH) and deep white matter hyperintensity (DWMH) on fluid attenuated inversion recovery images was assessed using Fazekas rating scales. Multivariate logistic regression analyses were conducted after adjustment for stroke subtype, age, PVH, DWMH, hypertension, dementia, and use of platelet aggregation inhibitors. Additionally, we examined the association between cerebral microbleeds and other covariates using a Pearson’s correlation analysis. Results: Amongst 389 patients, 67 patients had a single microbleed and 93 had multiple microbleeds. The prevalence of microbleeds was 83% amongst 53 patients with intracerebral hemorrhage (ICH), 49% amongst 173 with infarction, and 20% amongst 163 without any type of stroke. In the multivariate analyses, the odds ratio (95% CIs) of microbleed detection was 10.1, (4.12–24.8) for ICH, 2.33 (1.12–4.85) for atherosclerotic infarction, 1.66 (1.10–2.48) for PVH, and 1.49 (1.02–2.19) for DWMH. In the Pearson’s correlation analysis, cerebral microbleeds were closely related to PVH (Pearson’s correlation coefficient; 0.48) and DWMH (0.37), compared with age (0.16). Conclusions: High‐grade PVH, high‐grade DWMH, ICH, and atherosclerotic infarction were significantly independent predictors for cerebral microbleeds. In addition, we found that the grades of PVH and DWMH have a closer association with the number of cerebral microbleeds than age.     

Cerebral microbleeds in CADASIL

BACKGROUND: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary arteriopathy leading to recurrent cerebral infarcts and dementia. Intracerebral hemorrhage (ICH) has been described sporadically in patients with CADASIL, suggesting that the affected arteries in CADASIL are not bleed-prone. However, the presence of cerebral microbleeds, which often remain undetected on conventional MRI, has not been determined in CADASIL. OBJECTIVE: To determine whether cerebral vessels in patients with CADASIL are prone to microbleeding. METHODS: T2*-weighted gradient echo MRI, which is highly sensitive for visualizing microbleeds, was performed in patients with CADASIL and their family members (n = 63). Known risk factors for ICH were determined for all individuals. On an exploratory basis, the presence of cerebral microbleeds was correlated with demographic variables, vascular risk factors, disease progression, ischemic MR lesions, and genotype. RESULTS: Cerebral microbleeds were present in 31% of symptomatic CADASIL mutation carriers, predominantly in the thalamus. Vascular risk factors such as hypertension did not account for the microbleeds in these patients. Factors associated with microbleeds were age (p = 0.008), Rankin disability score (p = 0.017), antiplatelet use (p = 0.025), number of lacunae on MRI (p = 0.009), and the Arg153Cys Notch3 mutation (p = 0.017). After correction for age, only the Arg153Cys mutation remained significantly associated with the presence of microbleeds. CONCLUSION: Patients with CADASIL have an age-related increased risk of intracerebral microbleeds. This implies that they may have an increased risk for ICH, which should be taken into account in CADASIL diagnosis and patient management.     

Intracerebral hemorrhages in CADASIL

Intracerebral hemorrhage (ICH) has been described only sporadically for patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). However, cerebral microbleeds (CMBs) were found in 31% to 69% of the patients with CADASIL, and this predicted an increased risk of ICH. In this study, the authors found that 25% of the symptomatic patients with CADASIL had ICHs, and their development was closely related to the number of CMBs.     

Hematoma Size in Deep Intracerebral Hemorrhage and its Correlation with Dot-Like Hemosiderin Spots on Gradient Echo T2*-Weighted MRI

BACKGROUND AND PURPOSE: Dot-like low intensity spots (dot-like hemosiderin spots: dotHSs) on gradient echo T2*-weighted MRI have been histologically diagnosed to represent old cerebral microbleeds associated with microangiopathies. They have also been correlated to the fragility of small vessels and the tendency to bleed. Therefore, a substantial number of dotHSs might be associated with a large-sized, deep intracerebral hematoma (ICH). On the other hand, dotHSs may reflect old microbleeds that did not enlarge to symptomatic size. METHODS: To investigate how dotHSs are related to the size (maximal diameter) of primary deep ICH, we analyzed the diameter and the number of dotHSs in 151 patients with deep ICH not associated with subarachnoid hemorrhage or intraventricular hemorrhage (75 males and 76 females, age ranged from 37 to 90 [65.7 +/- 11.3 years old] who were consecutively admitted to Hakodate Municipal Hospital. The hazard ratio (HR) for a maximal diameter of deep ICH < or =2 cm was estimated, using the number of dotHSs and risk factors for stroke. RESULTS: The number of dotHSs associated with the diameter < or =2 cm was 9.2 +/- 11.5, significantly larger than that with the diameter > or =2 cm (4.7 +/- 7.0, P= .012). Multivariate analysis revealed that a maximal diameter of deep ICH of < or =2 cm was found in patients with dotHS (HR, 3.7; 95% confidence interval [CI], 1.4-10.1; P= .009). CONCLUSION: Though small sample size limited the power of our analyses, these findings suggest that the number of dotHSs may be associated with a small diameter of deep ICH.     

脑出血与脑小血管病亚型及总负荷的关系研究

目的 探讨自发性脑出血的严重程度与脑小血管病（cerebral small vessel disease,CSVD）各亚型及总 负荷之间的关系。 方法 回顾性分析2013年8月-2017年8月于河南科技大学第一附属医院就诊的发病24 h内住院的 脑出血患者的临床资料。根据患者入院24 h内、3～5 d、10～14 d头颅CT检查结果及头颅MRI检查结 果,计算不同时间段血肿及水肿体积,评估腔隙（lacune,LA）、白质高信号（white matter hyperintensity, WMH）、扩大的血管周围间隙（enlarged perivascular space,ePVS）、脑微出血（cerebral microbleed,CMB） 的严重程度并计算总CSVD评分,分析脑出血的严重程度与CSVD各亚型及总负荷的关系。 结果 最终共纳入85例脑出血患者,其中脑叶出血33例（38.82%）,深部出血52例（61.18%）。校正 年龄、平均动脉压、入院GCS评分、入院NIHSS评分后,在血肿体积的多元线性回归模型中,CMB数目与 不同时期血肿体积均正相关,WMH的Fazekas评分与不同时期血肿体积均负相关;校正年龄、平均动 脉压、入院GCS评分、入院NIHSS评分、血肿体积后,在水肿体积的多元线性回归模型中,ePVS与不同 时期水肿体积均呈负相关。CSVD总负荷与不同时期血肿体积均不相关,与入院24 h内水肿体积不相 关,与3～5 d、10～14 d水肿体积负相关。 结论 CMB数目越多,WMH的Fazekas评分越低,血肿体积越大。ePVS的存在可能是脑出血后水肿程 度较轻的标志;CSVD总负荷可以预测3～14 d脑水肿的严重程度。     

Intracerebral haemorrhage and cognitive decline

Relationships between intracerebral hemorrhage (ICH) and dementia might be of interest since some causes of ICH such as cerebral amyloid angiopathy are strongly linked with dementia, especially Alzheimer's disease. The aim of this narrative review was to highlight the interesting relationship of ICH lesions and cognitive decline leading to dementia. We considered the whole spectrum of hemorrhagic lesions in the brain parenchyma, namely spontaneous ICH and brain microbleeds.     

Association between cerebral microbleeds and prior primary intracerebral hemorrhage in ischemic stroke patients

OBJECTIVE: To investigate association between cerebral microbleeds (CMB) and prior intracerebral hemorrhage (ICH) on MRI and topographic correlation of the two types of lesions. PATIENTS AND METHODS: Two hundred and sixty consecutive patients (67.0+/-11.1 years) with ischemic stroke were included. CMB and prior ICH were assessed on T2-gradient-echo MRI. The presence and number of CMB as predictors for prior ICH were examined. Topographic correlations between CMB and ICH lesions in patients with prior ICH in the infratentorial, basal ganglionic/thalamic and cortico-subcortical regions were tested. RESULTS: CMB were observed in 113 (43.5%) patients and a total of 50 prior primary ICH lesions were observed in 39 (15.0%) patients. Among the ICH lesions, 39 (78%) were asymptomatic. Presence of CMB (odds ratio 2.53, p=0.015) and number of CMB (odds ratio 1.11, p<0.001) were independent determinants for prior ICH. Topographic correlation between CMB and ICH was significant in the basal ganglionic/thalamic region (p=0.017), but not in the infratentorial (p=0.548) or cortico-subcortical regions (p=0.389). CONCLUSION: CMB were associated with prior ICH on MRI of patients with ischemic stroke. CMB in the basal ganglion or thalamus was associated with prior ICH in the same region.     

Lack of association of lobar intracerebral hemorrhage with apolipoprotein E genotype in an unselected population

BACKGROUND: Both the upsilon2 and upsilon4 alleles of the apolipoprotein E gene (APOE) have been reported to be overrepresented in lobar intracerebral hemorrhage and to be associated with cerebral amyloid angiopathy (CAA). These studies were performed primarily on the North American population and investigated in partly selected patient cohorts. METHODS: 193 consecutive patients suffering from primary intracerebral hemorrhage (ICH) were included in our study. The localization of the ICH, i.e. cortico-subcortical, deep white matter, basal ganglia, brainstem and cerebellum, was put in relation to the APOE genotype and vascular risk factors. In 101 of these patients, the APOE genotype was also correlated to the presence and distribution of microbleeds and other microangiopathy-related damage, as shown by magnetic resonance imaging (MRI). RESULTS: We found neither an association of a specific APOE genotype with ICH localization nor with microangiopathy-related MRI findings. CONCLUSIONS: In our study of an unselected Central European population, the APOE genotype was not confirmed as a candidate for providing additional diagnostic and potentially prognostic information in patients with ICH.     

Intracranial hemorrhage

The initial and exclusive use of MRI in patients with a stroke syndrome is feasible, probably cost-effective, and even time saving when considering its potential wealth of information. MRI may be the diagnostic tool of choice in patients with all stages of stroke, especially in the hyperacute assessment of ICH, and could be equivalent to CT and CTA in SAH diagnosis. The authors’ aim is to provide a comprehensive review about the potential role of MRI in evaluating ICH and SAH. Emerging applications, such as the assessment of microbleeds as a risk factor for secondary hemorrhage after thrombolysis and perihemorrhagic ischemic changes as a potential marker for patients likely to benefit from hematoma evacuation, are reviewed.     

脑内微出血对预测高血压脑出血血肿扩大的意义

目的研究脑内微出血(cerebral microbleeds,CMBs)在高血压脑出血血肿扩大中的意义。方法选择140例发病6h内的高血压脑出血患者,入院后立即行颅脑CT和梯度回波T2加权像(gradient echo pulse sequence-T2WI,GRE-T2WI)检查,测量血肿大小,发病后24h和72h复查颅脑CT,依据CT及MRI检查结果将血肿有无扩大患者分为微出血组和无微出血组。对比2组出现血肿扩大的比率及血肿扩大的值。结果入院时GRE-T2WI检查提示72例存在数量不一的CMBs。24h复查CT发现脑内血肿体积扩大比率为12.9%(18/140),72h查CT示血肿体积扩大比率15%(21/140)。微出血组患者存在的CMBs比率明显高于无微出血组[71.4%(15/21)与47.9%(57/119),χ2=4.215,P0.01]。72h后微出血组血肿体积扩大比率显著高于无微出血组[18.1%(13/72)与11.4%(8/70),χ2=3.065,P0.05]。结论 CMBs在高血压脑出血血肿扩大中扮演重要作用。     

Thrombolysis for ischemic stroke in patients with old microbleeds on pretreatment MRI

BACKGROUND: Old asymptomatic microbleeds (MBs) visualized on T2-weighted MRI are indicative of microangiopathy. They may be a marker of increased risk of intracerebral hemorrhage (ICH) following thrombolysis. However, data regarding this potential risk are limited. METHODS: A retrospective analysis of pretreatment T2-weighted MRI was performed in consecutive stroke patients who received intravenous tissue plasminogen activator (tPA). We aimed to assess the impact of MBs on the risk of cerebral bleeding. The frequency and location of MBs were assessed and compared with the location of ICH after thrombolysis. RESULTS: Forty-four patients were studied. MBs were present on pretreatment MRI in 8 cases (18.2%). At day 1, symptomatic ICH occurred in none of 8 patients with MBs versus 1 of 36 patients without (NS). At day 1, ICH occurred in 3 of 8 patients with MBs versus 10 of 36 patients without (NS). At day 7, symptomatic ICH occurred in 1 of 8 patients with MBs versus 2 of 36 patients without (NS). At day 7, ICH occurred in 5 of 8 patients with MBs versus 12 of 36 patients without (NS). No ICH occurred at the site of an MB. ICH occurred within the ischemic area in all patients who bled. CONCLUSIONS: Our study suggests that stroke patients with a small number of MBs on pretreatment MRI could be treated safely with thrombolysis. Larger prospective studies are needed to address the predictive value of detection of MBs with regard to the risk of tPA-induced ICH.     

Antiplatelet therapy and future intracerebral hemorrhage in hemodialysis patients with cerebral microbleeds

The use of antiplatelet drugs is thought to increase the risk for intracerebral hemorrhage (ICH) in patients with cerebral microbleeds (CMBs). However, hemodialysis (HD) patients have a high prevalence of CMBs and diverse pathologies that require antiplatelet therapy. In this study, we investigated whether the use of antiplatelet drugs increases the risk for ICH in HD patients with CMBs. Brain magnetic resonance imaging (MRI), including T2*-weighted MRI, was performed in 179 HD patients with no history of cerebrovascular events. CMBs were detected and patients were followed prospectively with a median follow-up period of 5.2 [1.4–6.2] years. To investigate whether the influence of antiplatelet therapy on the development of ICH differs in cases with and without CMBs, the inverse probability of treatment weighting method was used, including an interaction term between the presence or absence of CMBs and use of antiplatelet drugs. As a result, CMBs were detected in 45 patients (25.1%), and antiplatelet drugs were used in 66 patients (36.9%). When the effect of antiplatelet therapy on the incidence of ICH was modified by the presence of CMBs at baseline (P for interaction <0.001), the use of antiplatelet drugs was a significant risk factor for ICH in HD patients without CMBs, but not in HD patients with CMBs. Furthermore, the burden of CMBs significantly increased the risk for ICH, but the increase in this risk was slower in antiplatelet drug users as compared to non-antiplatelet drug users (P for interaction = 0.02). The influence of antiplatelet drugs on the development of ICH differed depending on the presence or absence of CMBs. In fact, the use of antiplatelet drugs did not increase the risk for ICH in HD patients with CMBs.     

脑出血患者血清超敏C反应蛋白水平与出血量、病情及认知功能损害的关系

目的探讨脑出血患者血清超敏C反应蛋白(hs-CRP)水平与出血量、病情及认知功能损害的关系。方法 56例脑出血患者(脑出血组)根据血肿体积分为小血肿亚组(<15 ml,23例)、中血肿亚组(15～30 ml,18例)和大血肿亚组(>30 ml,15例);根据入院时美国国立卫生研究院卒中量表(NIHSS)评分分为轻度亚组(≤7分,19例)、中度亚组(8～14分,21例)和重度亚组(≥15分,16例);检测患者发病后第1、3、7 d及30名正常对照者(正常对照组)血清hs-CRP水平;脑出血患者血肿吸收后进行简易精神状态检查(MMSE)量表评分。结果脑出血组发病后1、3、7 d血清hs-CRP水平明显高于正常对照组(均P<0.001);并且在小、中、大血肿亚组间及病情轻、中、重亚组间依次显著升高(P<0.05～0.001);出现认知功能障碍患者血清hs-CRP水平显著高于无认知功能障碍患者(P<0.001)。结论血清hs-CRP水平升高越明显,提示患者脑出血量大、神经功能缺损程度重,并可能发生认知功能损害。     

脑微出血与卒中

脑微出血作为一种具有出血倾向的脑小血管病变,随着影像学技术的发展,其检出率越来越高.目前,大量研究表明,脑微出血与缺血性卒中、脑出血和溶栓或抗栓治疗后症状性脑出血关系密切.本文旨在探讨脑微出血与上述疾病的相关性,将有利于脑微出血患者卒中防治策略的制定.     

Asymptomatic Striatocapsular slit-like Hemorrhage as a Severity Marker in Patients with Hypertensive Angiopathy

BackgroundConcomitant asymptomatic striatocapsular slit-like hemorrhage (SSH) is occasionally found in patients of spontaneous intracerebral hemorrhage (ICH), but was seldomly described in the literature. In this study, we described the clinico-radiological features of asymptomatic SSH in ICH patients with hypertensive microangiopathy.Methods and Results246 patients with strictly deep or mixed deep and lobar ICH/microbleeds were included. SSH was defined as hypointense lesions involving the lateral aspect of lentiform nucleus or external capsule in slit shape (>1.5 cm) on susceptibility-weighted imaging without history of associated symptoms. Demographics and neuroimaging markers were compared between patients with SSH and those without. Patients with SSH (n=24, 10%) and without SSH had comparable age (62.0 ± 12.6 vs. 62.3 ± 13.5, p = 0.912) and vascular risk factor profiles including the diagnosis of chronic hypertension, diabetes, and dyslipidemia (all p>0.05). SSH was associated with more common lobar microbleeds (79.2% vs 48.2%, p = 0.005), lacunes (75% vs. 41.4%, p = 0.002) and higher white matter hyperintensity (WMH) volumes (24.1 [10.4–46.3] vs. 13.9 [7.0–24.8] mL, p = 0.012) on MRI, as well as more frequent left ventricular hypertrophy (LVH) (50.0% vs. 20.5%, p = 0.004) and albuminuria (41.7% vs. 19.4%, p = 0.018). In multivariable analyses, SSH remains independently associated with LVH (p = 0.017) and albuminuria (p = 0.032) after adjustment for age, sex, microbleed, lacune and WMH volume.ConclusionsAsymptomatic SSH is associated with more severe cerebral small vessel disease-related change on brain MRI, and hypertensive cardiac and renal injury, suggesting a more advanced stage of chronic hypertension.