Trigger Factors for Spontaneous Intracerebral Hemorrhage: A Case-Crossover Study

Background and Purpose: Whether certain activities can trigger spontaneous intracerebral hemorrhage (ICH) remains unknown. Insights into factors that trigger vessel rupture resulting in ICH improves knowledge on the pathophysiology of ICH. We assessed potential trigger factors and their risk for ICH onset. Methods: We included consecutive patients diagnosed with ICH between July 1, 2013, and December 31, 2019. We interviewed patients on their exposure to 12 potential trigger factors (eg, Valsalva maneuvers) in the (hazard) period soon before onset of ICH and their normal exposure to these trigger factors in the year before the ICH. We used the case-crossover design to calculate relative risks (RR) for potential trigger factors. Results: We interviewed 149 patients (mean age 64, 66% male) with ICH. Sixty-seven (45%) had a lobar hemorrhage, 60 (40%) had a deep hemorrhage, 19 (13%) had a cerebellar hemorrhage, and 3 (2%) had an intraventricular hemorrhage. For ICH in general, there was an increased risk within an hour after caffeine consumption (RR=2.5 [95% CI=1.8–3.6]), within an hour after coffee consumption alone (RR=4.8 [95% CI=3.3–6.9]), within an hour after lifting >25 kg (RR=6.6 [95% CI=2.2–19.9]), within an hour after minor head trauma (RR=10.1 [95% CI=1.7–60.2]), within an hour after sexual activity (RR=30.4 [95% CI=16.8–55.0]), within an hour after straining for defecation (RR=37.6 [95% CI=22.4–63.4]), and within an hour after vigorous exercise (RR=21.8 [95% CI=12.6–37.8]). Within 24 hours after flu-like disease or fever, the risk for ICH was also increased (RR=50.7 [95% CI=27.1–95.1]). Within an hour after Valsalva maneuvers, the RR for deep ICH was 3.5 (95% CI=1.7–6.9) and for lobar ICH the RR was 2.0 (95% CI=0.9–4.2). Conclusions: We identified one infection and several blood pressure related trigger factors for ICH onset, providing new insights into the pathophysiology of vessel rupture resulting in ICH.

Zone III REBOA and the COBRA-OS™: Safety of Inadvertent Iliac Artery Device Deployment

Background: REBOA is an emerging technique in trauma. However, inadvertent iliac artery balloon inflation can lead to complications. This study aims to investigate the safety characteristics of the COBRA-OS™ compared to a 7 Fr commercially available device during purposeful iliac artery balloon overinflation. Methods: In vitro: the COBRA-OS™ was inflated in explanted porcine iliac arteries and intentionally overinflated until balloon or vessel rupture occurred. In vivo: the COBRA-OS™ and 7 Fr device were deployed in the iliac arteries and intentionally overinflated until rupture of the balloon or blood vessel. Results: In vitro: an average volume of 1mL was required for occlusion using the COBRA-OS™ and the mean balloon rupture volume was 32.5mL. The COBRA-OS™ partially migrated into the aorta in all cases. In vivo: the COBRA-OS™ and 7 Fr device occluded the iliac arteries with a mean volume of 3.5 mL. Overinflation resulted in no iliac ruptures with the COBRA-OS™ (mean balloon rupture volume = 10mL). Overinflation with the 7 Fr device resulted in 1 iliac rupture at 5mL. The other two 7 Fr devices had a mean balloon rupture volume of 5 mL. All COBRA-OS™ devices moved partially up into the aorta during inflation while all 7 Fr devices remained in the iliac artery. Conclusions: The COBRA-OS™ allows for significant overinflation when deployed in the common iliac artery of a porcine model due to its unique design. This ultimately may help to prevent balloon and blood vessel rupture during clinical use, however further studies are required.

Charcot–Bouchard aneurysms revisited: clinicopathologic correlations

Intracerebral hemorrhage (ICH) is a significant cause of morbidity and mortality worldwide. Hypertension and cerebral amyloid angiopathy (CAA) are the most common causes of primary ICH, but the mechanism of hemorrhage in both conditions is unclear. Although fibrinoid necrosis and Charcot–Bouchard aneurysms (CBAs) have been postulated to underlie vessel rupture in ICH, the role and significance of CBAs in ICH has been controversial. First described as the source of bleeding in hypertensive hemorrhage, they are also one of the CAA-associated microangiopathies along with fibrinoid necrosis, fibrosis and “lumen within a lumen appearance.” We describe clinicopathologic findings of CBAs found in 12 patients out of over 2700 routine autopsies at a tertiary academic medical center. CBAs were rare and predominantly seen in elderly individuals, many of whom had multiple systemic and cerebrovascular comorbidities including hypertension, myocardial and cerebral infarcts, and CAA. Only one of the 12 subjects with CBAs had a large ICH, and the etiology underlying the hemorrhage was likely multifactorial. Two CBAs in the basal ganglia demonstrated associated microhemorrhages, while three demonstrated infarcts in the vicinity. CBAs may not be a significant cause of ICH but are a manifestation of severe cerebral small vessel disease including both hypertensive arteriopathy and CAA.

Telomere-telomerase system status in patients with acute myocardial infarction with ST-segment elevation (STEMI) -relationship with oxidative stress

IntroductionWe aimed to find association of telomere length and telomerase activity in circulating leukocytes and thromboaspirates of patients with acute myocardial infarction (AMI). Furthermore, association of telomere-telomerase system with oxidative stress markers was tested.Material and methodsLeukocyte telomere length, telomerase activity and scores related to oxidative-stress status (Protective, Damage and OXY) were evaluated.ResultsPatients were divided into: stabile angina pectoris (AP) (n=22), AMI with: ST-segment elevation (STEMI) (n=93), non-obstructive coronary arteries (MINOCA) (n=7), blood vessel rupture (n=6) in three time points, and compared to with 84 healthy subjects. Telomerase activity was significantly higher in all CAD sub-groups compared to the control group [AP=0.373 (0.355-0.386), STEMI=0.375 (0.349-0.395), MINOCA=0.391 (0.366-0.401), blood vessel rupture=0.360 (0.352-0.385) vs CG=0.069 (0.061-0.081), p=0.000], while telomeres were significantly shorter in STEMI, MINOCA and blood vessel rupture compared to the control group [STEMI=1.179 (0.931-1.376), MINOCA=1.026 (0.951-1.070), blood vessel rupture=1.089 (0.842-1.173) vs CG=1.329 (1.096-1.624), p=0.030]. Values of OXY score were significantly higher in STEMI and MINOCA patients compared to control group and AP patients [5.83 (4.55-7.54) and 10.28 (9.19-10.72) vs 4.94 (3.29-6.18) and 4.18 (2.58-4.86), p=0.000]. Longer telomeres and higher telomerase activity were found in thromboaspirates, compared to peripheral blood leukocytes in the same patients [1.25 (1.01 - 1.84) vs 1.18 (0.909 - 1.516), p=0.036; and 0.366 (0.367 - 0.379) vs 0.366 (0.367 - 0.379), p=0.000, respectively]. Telomere length and telomerase activity had good diagnostic ability to separate STEMI patients from controls.ConclusionsLeukocyte telomere length and telomerase activity can differentiate CAD patients from healthy persons, and relate CAD to oxidative stress.

Influence of High-Intensity Focused Ultrasound (HIFU) Ablation on Arteries: Ex Vivo Studies

High-intensity focused ultrasound (HIFU) has been used to ablate solid tumors and cancers. Because of the hypervascular structure of the tumor and circulating blood inside it, the interaction between the HIFU burst and vessel is a critical issue in the clinical environment. Influences on lesion production and the potential of vessel rupture were investigated in this study for the efficiency and safety of clinical ablation. An extracted porcine artery was embedded in a transparent polyacrylamide gel phantom, with bovine serum albumin (BSA) as an indicator of the thermal lesion, and degassed water was driven through the artery sample. The HIFU focus was aligned to the anterior wall, middle of the artery, and posterior wall. After HIFU ablation, the produced lesion was photographically recorded, and then its size was quantified and compared with that in the gel phantom without artery. In addition, the bubble dynamics (i.e., generation, expansion, motion, and shrinkage of bubbles and their interaction with the artery) were captured using high-speed imaging. It was found that the presence of the artery resulted in a decrease in lesion size in both the axial and lateral directions. The characteristics of the lesion are dependent on the focus alignment. Acoustic and hydrodynamic cavitation play important roles in lesion production and interaction with the artery. Both thermal and mechanical effects were found on the surface of the artery wall after HIFU ablation. However, no vessel rupture was found in this ex vivo study.

Management of Multiple Head and Neck Paragangliomas With Assistance of a 3-D Model

Introduction: Extirpation of multiple head and neck paragangliomas carries challenge due to close anatomic relationships with critical neurovascular bundles. Objectives: This study aims to assess whether the application of 3-D models can assist with surgical planning and treatment of these paragangliomas, decrease surgically related morbidity and mortality. Methods: Fourteen patients undergoing surgical resection of multiple head and neck paragangliomas were enrolled in this study. A preoperative 3-D model was created based on radiologic data, and relevant critical anatomic relationships were preoperatively assessed and intraoperatively validated. Results: All 14 patients presented with multiple head and neck paragangliomas, including bilateral carotid body tumors (CBT, n = 9), concurrent CBT with glomus jugulare tumors (GJT, n = 4), and multiple vagal paragangliomas (n = 1). Ten patients underwent genomic analysis and all harbored succinate dehydrogenase complex subunit D (SDHD) mutations. Under guidance of the 3-D model, the internal carotid artery (ICA) was circumferentially encased by tumor on 5 of the operated sides, in 4 (80%) of which the tumor was successfully dissected out from the ICA, whereas ICA reconstruction was required on one side (20%). Following removal of CBT, anterior rerouting of the facial nerve was avoided in 3 (75%) of 4 patients during the extirpation of GJT with assistance of a 3-D model. Two patients developed permanent postoperative vocal cord paralysis. There was no vessel rupture or mortality in this study cohort. Conclusion: The 3-D model is beneficial for establishment of a preoperative strategy, as well as planning and guiding the intraoperative procedure for resection of multiple head and neck paragangliomas.

Craniofacial Trauma and Vascular Injury

Cerebrovascular injury is a potentially devastating outcome following craniofacial trauma. Interventional radiologists play an important role in detecting, grading, and treating the different types of vascular injury. Computed tomography angiography plays a significant role in the detection of these injuries. Carotid-cavernous fistulas, extra-axial hematomas, pseudoaneurysms, and arterial lacerations are rare vessel injuries resulting from craniofacial trauma. If left untreated, these injuries can lead to vessel rupture and hemorrhage into surrounding areas. Acute management of these vessel injuries includes early identification with angiography and treatment with endovascular embolization. Endovascular therapy resolves vessel abnormalities and reduces the risk of vessel rupture and associated complications.