Podcasts about intracerebral

Intracerebral hemorrhage carries high morbidity and mortality, but growing evidence highlights meaningful opportunities for prevention, risk reduction, and long-term recovery. This episode covers key strategies, including blood pressure management, interpretation of neuroimaging markers, and individualized decisions around antithrombotic therapy. It also emphasizes the prolonged recovery timeline and the importance of a holistic, patient-centered approach to improving outcomes. In this episode, Casey S. Albin, MD, FAAN, speaks with Wendy C. Ziai, MD, and Vishank A. Shah, MD, coauthors of the article "Intracerebral Hemorrhage" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Ziai is a professor of neurology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland. Dr. Shah is an assistant professor of neurology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland. Additional Resources Read the article: Intracerebral Hemorrhage Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @caseyalbin Guest: @VishankShah3 Full episode transcript available here Dr Albin: A patient has suffered an intracerebral hemorrhage. They're taken to the neuro ICU, and they fortunately survive. But the journey does not end there. In fact, in some ways, the journey has just begun. Join us today as we unpack holistic care for ICH patients.  Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast.  Dr Albin: Hello to our audience. This is Dr. Casey Albin. Today, I'm interviewing Dr. Wendy Ziai and Dr. Vishank Shah about their article on intracerebral hemorrhage. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast. I am so delighted that both of you are joining. To begin, let's just do a brief introduction of who you are and, and a little bit of how you got interested in the topic.  Dr Ziai: Hi, I'm Wendy Ziai. Thank you for having me on this podcast. I am a professor of neurology at Johns Hopkins. I am a neurointensivist, and I think I got primarily interested in this topic through clinical trials that I have been a part of since my fellowship days.  Dr Shah: Hi, everyone. I'm, uh, Vishank Shah. I am also, uh, very thankful for being invited to be a part of this podcast. I'm also a neurointensivist at Hopkins and the fellowship program director here for neurocritical care, and I'm interested in recovery after ICH, and that's why I'm a part of this work.  Dr Albin: Welcome to you both. It is such a treat for me to get to interview fellow neurointensivist, particularly those who have such a wealth of experience. So, I am delighted to dive into this. All right. So, to set the stage for our audience, intracerebral hemorrhage has long been approached with pessimism. But your article really highlights that there are meaningful advantages in prevention and risk stratification and long-term recovery for these patients. Though you both are neurointensivist, this article really emphasizes primary prevention and the holistic long-term care for the survivors. And so, to begin, Dr. Shah, can you just lay out a little bit for our listeners the scope of intracerebral hemorrhage and its community impact?  Dr Shah: Yeah. So, you know, ICH is the second most common type of stroke. There are more than three million new cases of ICH globally each year, and it accounts for thirty percent of all stroke types, but it is the one that has the highest mortality, with more than forty to fifty percent of the patients dying in the first thirty days, and then continued long-term impact on both functional as well as outcomes, as well as survivorship after the early period. And it also disproportionately impacts lower socioeconomic, and then minority races like Blacks, Asians, as well as Hispanic ethnicity. And so, there's a lot of work that needs to be done to reduce the burden of this disease.  Dr Albin: Absolutely. I mean, these can really be devastating for families, and I really am appreciative of your highlighting that there's a lot of disparities, and there's a lot of work to be done to really increase equity to these patients. I think a lot of this goes into really the AAN's focus on brain health and trying to improve some of what we're doing to maintain brain health. And I really wanted to kind of drill down on this because for ICH, there's a lot that can be done upfront as we think about how do we counsel patients who may walk into the office about strategies to prevent ever becoming an intracerebral hemorrhage patient. So, Dr. Shah, can you walk us through a little bit about what neurologists in the community need to be doing to make sure that no one ends up with us in the neurointensive care unit?  Dr Shah: Yeah, sure. So, I think, you know, one of the most important risk factors is, of course, hypertension and long-standing uncontrolled hypertension. And so really recognizing the need for early onset screening with regular blood pressure monitoring at a very early age, particularly in the races that I discussed earlier. And then I think another big part, obesity, metabolic syndrome, and type two diabetes. And I think there's a lot of interesting new work that with the GLP-1 agonist, you know, in a large multicenter cohort studies showing that patients receiving these had a significantly lower reduction risk of ICH. And so, this might be a really important part that, you know, clinicians need to start increasingly recognizing and using in their practice. And then, of course, other risk factors that are common include smoking, diet high in sodium, exposure to air pollution, both indoor as well as outdoor. And so, mitigating all of these risk factors can also reduce the burden of ICH.  Dr Albin: Absolutely. And I really want to highlight that hypertension plays such an important role and that we as neurointensivist, as community neurologists, really need to be creative about ways that we can help people meet those blood pressure target and meeting people in the community where they are, making sure that they're not suffering from side effects from their medication that would prevent them from sticking with it long term. Dr. Ziai, anything else to add about what we can do in the community?  Dr Ziai: So, we really want to emphasize, even in the acute phase, that patients moving forward need to have targeted interventions to reduce blood pressure, smoking, enhance their physical activity, have a diet that is high in fruits and vegetables and low in alcohol and salt, and then promoting weight loss, of course.  Dr Albin: And Dr. Ziai, I'm gonna ask you a little bit about one of the things that maybe not all of our listeners have heard about is this APOE2, APOE4 genetic risk for intracerebral hemorrhage. What's going on there and, and should clinicians be testing for that? Dr Ziai: That's a great question, and it is not one that we currently test people for at least acute ICH presentation. APOE2 and A4- E4 alleles, these give patients a two to three times higher risk of ICH by increasing cerebral amyloid deposition. And if you happen to have APOE2 carrier ship status, then along with other risk factors like white matter disease and vascular risk factors, these predict the onset of new microbleeds even during very short follow-up periods of about two years. And as we know, having cerebral microbleeds are associated with an increased risk of all strokes, ischemic and ICH, but they are one of many MRI markers of small vessel disease, which along with cortical superficial siderosis, does significantly increase future ICH risk. And so even in people who've never had an ICH, if they happen to have an MRI, it may be reasonable to look at the MRI and incorporate this burden of small vessel disease, and especially these hemorrhagic markers into, uh, decision-making about interventions.  Dr Albin: That's a really excellent point. And so, I think that your article did a really beautiful job of thinking holistically about the patient, incorporating clinical markers of their risk for having ICH, but also those radiographic markers. I'm just gonna ask you to summarize those again one more time because not everyone will be familiar with these. So, when you're looking at an MRI, what are the things that you're particularly clued in on that would increase the patient's risk of future ICH?  Dr Ziai: In the past, what we're looking for really is markers of cerebral amyloid angiopathy, which significantly increase a person's risk for lobar hemorrhage in particular. And so, we have a set of criteria called the Boston Criteria, and there's a new version of these, version 2.0. And these, um, incorporate a number of imaging markers that provide a very high sensitivity and specificity to diagnose CAA after an ICH. But even if someone's never had an ICH, and they evaluate that risk-benefit ratio for different cardiovascular prevention strategies. And so, the markers that we're specifically interested in are, of course, microbleeds. But not just having microbleeds, but are they lobar or are they deep? Lobar having a higher risk for lobar ICH. How many microbleeds are there? Is it greater than five, or is it just one or two? Also, cortical superficial siderosis is a marker, a hemorrhagic marker, that does portend a significant increased risk of recurrent ICH, along with having a lobar ICH. And now we have these new markers, which are the white matter hyperintensity multi spot pattern, which requires these hyperintensities on flare imaging in the subcortical area, having greater than at least ten of these multi spots, and also having enlarged perivascular spaces in the centrum semiovale, and having at least twenty of those. And finally, white matter hyperintensities, which can be measured with the physica score or just by visualizing them. We can look at white matter hyperintensities as well as being a measure of small vessel disease.  Dr Albin: Got it. And so just to summarize, we're looking for small vessel disease markers because that puts our patients at higher risk of ongoing future bleeds. And then we're also looking for markers of particularly small vessel disease that's caused by cerebral amyloid angiopathy, which again, because it's having that protein deposition, that puts the patient at risk of those leptomeningeal very small vessels, putting the patient at risk of lobar ICH. Just confirming I've summarized this all correctly.  Dr Ziai: Yes. That was perfect.  Dr Albin: Amazing. Dr. Shah, I'm gonna go back to you. Let's say we have a patient. Let's say this is a sixty-five-year-old man who comes in and they want follow-up and they're... And you're trying to think about they've had an ICH in the past, and they are also at risk for ischemic disease. Let's say they, they have hypertension, they've had a smoking history. They have some risk for ischemic events. And you're trying to think about how do you balance those. Let's say the patient needs to be on aspirin but does have some of those high-risk features on their MRI. Is there any guidance on how we think through preventing them from having a recurrent bleed if they're a high-risk patient, also preventing them from having an ischemic event, which they might be at high risk for as well?  Dr Shah: Yes. So, I think, you know, the first step is of course trying to understand what was the type of bleed. I think that has a very important role, like you mentioned. If it's a lobar hemorrhage versus a deep hemorrhage, the risk of recurrent ICH and ischemic events is very variable. So lobar hemorrhages, there's obviously a higher risk of recurrent hemorrhage events, whereas deep hemorrhage is actually at or behaves sort of like small vessel ischemic strokes and have a higher risk of recurrent arterial ischemic events. So that distinction in itself can help you gauge which patients would be safe and would benefit from these therapies. To begin, and of course, looking for some of these markers on MRI that were mentioned by Dr. Ziai for recurrence of hemorrhage risk. In terms of antiplatelet, the, there is a lot more data now to guide treatment, and we have the RESTART as well as the ESTART trial that showed that starting an, a single antiplatelet after intracerebral hemorrhage did not increase the risk of hemorrhage recurrence. They were very variable in the timing when aspirin was started, and so that remains still a question about what is the safest time point to start aspirin. For example, in the ESTART trial, they started them very early, within the first three days, whereas in  the RESTART it was all the way up to two months after the hemorrhage. And so... But in general, the risk of recurrent ICH was very low with a single antiplatelet agent. And so, if it's needed for ischemic prevention, it's relatively safe broadly across all types of hemorrhages.  Dr Ziai: Yeah. I would just mention that there was also a subgroup analysis of the RESTART trial using MRI. And so, this more than likely included patients with CAA, since 40% of the hemorrhages were lobar in that study, and therefore seeing that there was no increased risk of recurrent ICH in RESTART, it is thought that putting patients back on their antiplatelet therapy is safe.  Dr Albin: That's a really huge takeaway pearl for our listeners, that regardless of whether it's a lobar bleed or a deep bleed, if there is a strong indication, you know, this is not just, oh, because someone gave them aspirin 81, but truly that there is a reason that they need to be on a single antiplatelet agent, it probably benefits them to be on that agent, and there's good data that there's not a huge increase in risk. Summarizing all of that?  Dr Ziai: Great.  Dr Albin: Now, things are gonna get a little bit tricky here, because what if the patient, what if they need to be on dual antiplatelet therapy? Or what if they need to be on anticoagulation? Dr. Ziai, I'll, I'll throw that to you. How do you tackle that patient population?  Dr Ziai: Yeah, the safety of dual antiplatelet therapy hasn't really been studied in patients who've had a prior ICH. Although, in people who've had previous strokes, putting them on dual antiplatelets doesn't seem to increase the risk of ICH, but it does increase extracranial hemorrhage. And so there may be other reasons not to put patients on dual antiplatelet agents. Patients who have cancer and also cardiovascular or cerebrovascular disease, putting them on dual antiplatelet therapy does seem to increase the risk for intracranial hemorrhage. So, I think there is enough of a bias against DAPT therapy in patients who have had an ICH that we would not recommend DAPT for patients with a prior ICH.  Dr Albin: Absolutely. And, and then what about, let's say they have atrial fibrillation, and you know that they have a high CHA2DS2-VASc score, and they are at very high risk of ischemic events, but they've also had a prior intracerebral hemorrhage. Walk us through a little bit, how should we approach that patient? Dr. Ziai, I'm gonna start with you again.  Dr Ziai: Sure. So again, looking at the MRI, which all patients with ICH should have nowadays. If patients do have these hemorrhagic findings, a lobar ICH, evidence of CSS, cortical superficial siderosis, especially if it's disseminated, and also lobar microbleeds, especially if there are greater than five, if they're multiple, then anticoagulation should really be avoided in those patients.  Dr Albin: Absolutely. So, I'm really hearing that when we have a patient with ICH, it is just critically important that we understand is this a hypertensive bleed or is this a lobar bleed that is probably related to cerebral amyloid angiopathy? And getting to that distinction is going to play a major role in our deciding whether or not the patient can be on DAPT or can be on anticoagulation. And then what are some of the strategies for patients that you're referring them to if they really cannot tolerate being on anticoagulation, but they have atrial fibrillation, and they do need some sort of ischemic stroke prevention?  Dr Shah: There's still a lot of controversy, even in non-lobar hemorrhages, about resuming anticoagulation and when that would be safe. HAF trial, there was a reduction in ischemic stroke recurrence, uh, but a significantly higher increase in hemorrhage recurrences. I think that trial included both deep and lobar hemorrhages. So, we still need more data, and I think the ASPIRE trial and maybe a meta-analysis would answer that eventually. But in the meantime, if a, specifically for lobar hemorrhages, which are, uh, thought to be CAA related, if they, uh, and the patient has AFib, you know, where anticoagulation would be contraindicated, a watchman device or, you know, AFib ablation may be some of the other strategies that can be looked into for those patients specifically.  Dr Albin: Right. I think that's a really important point to emphasize, that we don't just don't give up and say, "Oh, you're not a candidate for anticoagulation," but we really reach out to our cardiovascular friends and say, "Hey, what other procedures can you offer that will minimize the risk of recurrence?" You know, we don't want them to have an ischemic event, but we also know long-term that there would be a real risk of anticoagulation. Just reminder to our listeners that there are new procedures, and our cardiology colleagues are always doing new trials and new devices, and so we should really leverage their expertise here. I am in the final minutes gonna just switch gears a little bit from talking about sort of the nitty-gritty of secondary ischemic prevention and secondary hemorrhagic stroke prevention and thinking about there has been this degree of pessimism around ICH patients, and that, you know, they have a much more severe outcome than our patients with ischemic strokes. I think that that is probably a myth that we need to do some debunking around, and I think maybe we need to reframe in terms of thinking about just the trajectory. So, Dr. Shah, walk us through a little bit about what we can expect about the recovery trajectory in ICH compared to those patients who have an ischemic stroke. Dr Shah: Yes. From some newer data and studies, it is becoming clear that recovery after ICH is much slower than we expect. In general, for ischemic stroke, recovery is measured within the first few weeks to up to 90 days. But in ICH, we now know that patients can keep recovering all the way up to six months and even beyond. In general, from just a, a study of heart recovery that occurs after ischemic stroke, there's a steep recovery in the first seven days, and then sort of after that, patients still continue to recover, but it, it starts plateauing where up to 90 days. Whereas with ICH, there is not much recovery in the first 7 to 30 days, but after that, there is a recovery that occurs significantly between day 30 and day 180, and then some patients continue to recover all the way up to one year. The more severe the hemorrhage, the slower the recovery, but there's still some evidence to suggest that even severe hemorrhage patients can recover all the way up to one year out and beyond. This is, of course, in terms of functional recovery.  Dr Albin: I think that's a really important point for our audience. Many of the listeners are residents, they're fellows, they're seeing these patients in the hospital, and they may not see a whole lot of improvement over even 30 days. But to keep in mind that just because the patient has not had a dramatic recovery within that first month that they may be in the ICU and then on the floor does not mean that that patient will never have recovery, and that we reset our expectations that recovery is possible, it's just gonna be slower. And I think that that's not only important for the healthcare team to take in mind, but also for patients and their families to know there is hope here. It's just gonna be slower. Dr. Ziai, looking ahead, what developments in this are you most excited about that you think will move the needle for care for the long-term outcomes and the prevention for these patients? What's ahead in, in ICH?  Dr Ziai: Yeah, I think the research that's going on is very exciting at the moment. We just saw the presentation at the World Stroke Organization conference in the fall of the TRIDENT trial, Triple therapy prevention of Recurrent intracerebral Disease events, meaning strokes. And these investigators found that a single pill, a fixed dose of three blood pressure-lowering agents actually was successful in significantly reducing the risk of recurrent stroke in patients who have had a history of ICH and have just normal or low-grade hypertension. So rather than having patients on multiple antihypertensive agents, it may be possible to have them on a single pill, and may dramatically reduce their stroke risk. So that's exciting. There is also a trial ongoing, ASPIRING, testing whether antiplatelet monotherapy after 24 hours only can reduce the risk of all serious vascular events in ICH survivors. So very early antiplatelets. The SATURN trial, we didn't talk about statins yet, but it is comparing continuation versus discontinuation of statin therapy in ICH patients. And then we have ongoing epidemiological studies that are really needed to understand this interaction between the cardiovascular prevention strategies, the antithrombotic use, the blood pressure targets, and these high-risk neuroimaging markers for ICH. And I think that's gonna be key, personalizing the interventions for these patients.  Dr Albin: So, I love that. And what I'm hearing is that it's really important to think about the personalized approach as well as how do we simplify things. We know that blood pressure control is critically important to the primary and secondary prevention of ICH, but we have to make it easy for patients to do so. Dr. Shah, I want to end with kind of understanding, you know, this was an unusual topic for neurointensivists to talk about. This was really about prevention. It was about long-term survivorship. It was about not what's happening in the neuro ICU. How did you guys get interested in sort of that aspect of care?  Dr Shah: Yeah, so that's a great question. Dr. Ziai has been my mentor since I was in fellowship, so now about eight years that I've been working with her, and this was a project that I started in fellowship with under her mentorship, looking at long-term recovery in ICH patients, and specifically severe patients. Happy that work has received a lot of recognition. It was published in JAMA Neurology. We looked at patients with severe intracerebral and intraventricular hemorrhage, those that survived with an mRS of four and five at day 30, and what happened to them over the course of the year. There was really not much data on recovery after ICH. And we were very surprised to see that up to 40% of patients that were an mRS of four and five, so really, really severely disabled at day 30, recovered to an mRS of zero to three by one year. About one-third of that group that recovered actually achieved functional independence with an mRS of zero to two, which was very surprising, really breaking the myths around the pessimism with ICH. We found that a lot of the baseline comorbidities like diabetes, white matter disease, as well as what happens to them during the acute hospitalization, were adding all of that information to the severity of the hemorrhage significantly improved our ability to predict long-term recovery after ICH. And so that's kind of how we got interested in this work, looking at how factors in the care that we provide in the ICU, as well as what the patients come in with, how all of that could be modified to promote recovery in these patients that are often been forgotten.  Dr Albin: I think that there's one takeaway to our listeners is that this is really a place where there's a lot of hope for recovery, and that the nihilism that has really surrounded ICH is a thing of the past, and we have to move forward with thinking about how do we proactively impact the recovery and counsel the patients and give them hope. Because just as your research shows, there really is the ability that they can attain that functional independence, which is absolutely astounding. It's really amazing. Again, today I've been interviewing Dr. Wendy Ziai and Dr. Vishank Shah about their article on intracerebral hemorrhage. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Please be sure to check out Continuum Audio episodes from this and other issues. Please go and check out. They have a wonderful article with lots of tables and figures, so much data. And again, thank you to our listeners for joining us today. Thank you, Dr. Ziai and Dr. Shah.  Dr Ziai: Thanks very much.  Dr Shah: Thank you.   Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

In this episode of the NCS Podcast Hot Topics series, host Eric Lawson, MD, is joined by Adam Arthur, MD, neurosurgeon at the University of Tennessee and Semmes Murphey Clinic in Memphis, Tennessee, to discuss the article "Minimally Invasive Surgery Versus Medical Management Alone for Intracerebral Hemorrhage: The MIND Clinical Trial," published in JAMA Neurology. Their conversation explores the MIND trial's evaluation of minimally invasive hematoma evacuation compared with best medical management for patients with intracerebral hemorrhage. Dr. Arthur reviews the trial's design, primary outcomes and early termination, and explains how findings from the ENRICH trial influenced enrollment and feasibility considerations. He also explores key considerations such as the importance of hematoma location, evacuation thresholds and timing, while reflecting on what the trial's negative primary outcome may still reveal about the future of surgical intervention and more individualized approaches for ICH patients. The views expressed on the NCS Podcast are solely those of the hosts and guests and do not necessarily reflect the opinions or official positions of the Neurocritical Care Society. 

In this episode of the NCS Podcast Hot Topics series, host Richard Choi, DO, FNCS, is joined by Wendy Ziai, MD, professor of neurology and critical care medicine at Johns Hopkins University, to discuss the article "Prophylactic Anti-Seizure Medication in Patients with Lobar Intracerebral Hemorrhage", recently published in Neurocritical Care. Their conversation explores the ongoing debate surrounding prophylactic antiseizure medication use in patients with lobar intracerebral hemorrhage. They review current guideline recommendations, highlight limitations in the existing evidence and consider the challenge of balancing seizure prevention with the risk of adverse effects. Dr. Ziai reviews key findings from prior trials as well as the featured study, which demonstrated lower rates of early seizures among patients who received prophylaxis. She also addresses questions related to patient selection, nonconvulsive status epilepticus and long-term cognitive outcomes. The discussion further considers the role of continuous EEG monitoring in the first 48 hours and how future study designs may help clarify which patients, if any, are most likely to benefit. The views expressed on the NCS Podcast are solely those of the hosts and guests and do not necessarily reflect the opinions or official positions of the Neurocritical Care Society. 

This INSIGHTS episode revisits a core topic from Neurocritical Care ON CALL®, originally released in August 2023. Listen to the fifth episode of the NCS INSIGHTS series focused on intracerebral hemorrhage. The INSIGHTS series is hosted by Casey Albin, MD, and Salia Farrokh, PharmD, and covers topics from Neurocritical Care ON CALL®, the only up-to-date, comprehensive resource dedicated exclusively to the practice of neurocritical care. Learn more about ON CALL®. This episode is sponsored by Ceribell. Time is brain when it comes to seizures. Ceribell point-of-care EEG empowers the bedside team to detect or rule out seizure activity in minutes. To learn more, visit ceribell.com. The views expressed on the NCS Podcast are solely those of the hosts and guests and do not necessarily reflect the opinions or official positions of the Neurocritical Care Society.

In this episode of the Neurocritical Care Society Podcast Hot Topics series, host Richard Choi, DO, FNCS, speaks with Wendy Ziai, MD, MPH, professor of neurology and critical care medicine at Johns Hopkins University, about the article The Association Between Hourly Systolic Blood Pressure Variability and Outcomes in Patients With Intracerebral Hemorrhage Is Time-Dependent: A Post Hoc Analysis of the ATACH-2 Trial, recently published in Neurocritical Care. Their discussion explores why blood pressure variability — not just absolute blood pressure targets — may play a critical role in outcomes following acute intracerebral hemorrhage. Dr. Ziai reviews key findings from ATACH-2 and INTERACT trials, the physiologic mechanisms that may link variability to hematoma expansion and neurologic deterioration and why the timing of variability within the first 8 to 12 hours appears especially important. They also examine the unresolved question of causation versus association, implications for antihypertensive management in the ICU and how emerging trials focused on variability may shape future practice. The views expressed on the NCS Podcast are solely those of the hosts and guests and do not necessarily reflect the opinions or official positions of the Neurocritical Care Society.

Moderator: Benedetta Storti (San Donà di Piave, Italy) Guest: Charlotte Cordonnier (Lille, France) Join Benedetta Storti and Charlotte Cordonnier for a discussion on the acute management of intracerebral hemorrhage. Discover the latest European Stroke Organization guidelines, the importance of timely intervention, and the evolving role of reversal agents and surgical approaches in stroke care.

ReferencesNeuroscience, 2023-11-21, V.533, Pages 22-35Pharmacological Research 2025.Volume 214, April 107685Front Neurol. 2022 Apr.11;13:804851.Rossini, G. 1829. William Tell Overture.https://music.youtube.com/watch?v=sHQ1Date2v0&si=AXQgrbUq-eOj3529Winwood/Capaldi. 1970. Freedom Rider https://music.youtube.com/watch?v=Qsm1j_dDNtE&si=wd9r8LyeNJY5NGI5

References Peer J. 2018 Nov 23;6:e6021Front Neurol.2022 Apr11;13:804851.Davis, G.Rev. 1960 Death Don't Have no Mercy. Grateful Dead . Live Dead. lp.https://music.youtube.com/watch?v=-9IVP8pCN5U&si=J6Do1-FhfxD8ZzZ-Biber, HI. 1676 The Rosary Sonatas.https://music.youtube.com/watch?v=Z0ypvC5LN6s&si=lBp9iqqe3iEqJlNo

Dr. Nadia Khalil and Dr. Jean Bouchart discuss the diagnostic approach to intracerebral hemorrhage, the causes of cerebral small vessel disease, and the interpretation of biomolecular tests.  Show reference: https://www.neurology.org/doi/10.1212/WNL.0000000000209796 

Dr. Nadia Khalil talks with Dr. Jean Bouchart about the diagnostic approach to intracerebral hemorrhage, the causes of cerebral small vessel disease, and the interpretation of biomolecular tests.  Read the related article in Neurology® Resident & Fellow Section.  Disclosures can be found at Neurology.org. 

For this episode we are joined by EBM guru, Dr. Brian Locke, who deftly breaks down all of our statistics questions. Is half dose DOAC as good as full dose DOAC for preventing VTE, and does it reduce bleeding risk? Can procalcitonin reduce duration of antibiotics for infections without compromising mortality rates? Can LLMs like GPT-4 help physicians manage patients better? Can reinforcement learning models predict when to start vasopressin in patients with septic shock? What is the risk of resuming anticoagulation in patients with atrial fibrillation and prior intracerebral hemorrhage? Is high flow nasal cannula as good as non-invasive ventilation for different types of respiratory failure? We answer all these questions and more!Half Dose DOAC for Long Term VTE Prevention (RENOVE)Biomarker-Guided Antibiotic Duration (ADAPT-Sepsis)GPT-4 Assistance for Physician PerformanceOptimal Vasopressin Initiation for Septic Shock (OVISS)DOACs for A fib after ICH (PRESTIGE-AF)High Flow Nasal Cannula vs NIV for Respiratory Failure (RENOVATE)Music from Uppbeat (free for Creators!): https://uppbeat.io/t/soundroll/dope License code: NP8HLP5WKGKXFW2R

Interview with David J. Seiffge, MD, author of Location and Timing of Recurrent, Nontraumatic Intracerebral Hemorrhage. Hosted by Cynthia E. Armand, MD. Related Content: Location and Timing of Recurrent, Nontraumatic Intracerebral Hemorrhage

Interview with David J. Seiffge, MD, author of Location and Timing of Recurrent, Nontraumatic Intracerebral Hemorrhage. Hosted by Cynthia E. Armand, MD. Related Content: Location and Timing of Recurrent, Nontraumatic Intracerebral Hemorrhage

Date: July 29, 2024 Reference: Connolly SJ et al (ANNEXA-I investigators) Andexanet for Factor Xa Inhibitor–Associated Acute Intracerebral Hemorrhage. NEJM May 2024 Guest Skeptic: Dr. Vasisht Srinivasan is an Emergency Medicine physician and neurointensivist at the University of Washington and Harborview Medical Center in Seattle, WA. He is an assistant professor in Emergency Medicine, Neurology, […] The post SGEM#450: Try Again – Andexanet for Factor Xa Inhibitor–Associated Acute Intracerebral Hemorrhage first appeared on The Skeptics Guide to Emergency Medicine.

There has been tremendous progress in recent decades in the management of ischemic strokes. Meanwhile, hemorrhagic strokes have stubbornly resisted this progress. Interventions for these types of strokes have failed again and again to show a benefit over standard medical management, until this year. The recently published ENRICH trial is the first to show that minimally invasive neurosurgery may improve functional outcomes for patients with hemorrhagic stroke. Study lead author, Dr. Gustavo Pradilla joins us today to talk about the differences between ENRICH and previous negative trials, and future neurosurgical approaches for spontaneous intracerebral hemorrhage. Dr. Pradilla is a Professor of Neurosurgery, Otolaryngology, and Head and Neck Surgery at Emory University School of Medicine and Chief of Neurosurgery at Grady Memorial Hospital. He spoke to Dr. Masoom J. Desai, neurointensivist and Assistant Professor of Neurology at the University of New Mexico. Series 5, Episode 9 Featuring: Guest: Dr. Gustavo Pradilla, Emory University School of Medicine & Grady Memorial Hospital Interviewer: Dr. Masoom Desai, University of New Mexico

What is the Human Brain Project and how might it advance epilepsy research? Dr. Maryam Nouri speaks with Dr. Philippe Ryvlin about the project in terms of the Human Intracerebral EEG Platform and how compiling these unique data from around the world could lead to new breakthroughs and understanding of epilepsy.The Human Intracerebral EEG Platform is an open-source platform designed for collecting, managing, analyzing, and sharing iEEG data at an international level. Its primary mission is to promote the development of large-scale iEEG research projects by facilitating international collaborations in the field.Links:Human Brain ProjectHuman Intracerebral EEG PlatformThe Virtual Brain Registration is now open for the 15th European Epilepsy Congress, held September 7th through 11th in Rome, Italy. Join your colleagues for five days of teaching courses, symposia, platform sessions, career development sessions, and more! To receive a discount on registration fees, register by May 10. Visit the ILAE website for more information, or register directly at bit.ly/ilaerome. That's

CME credits: 1.50 Valid until: 27-02-2025 Claim your CME credit at https://reachmd.com/programs/cme/implementation-of-the-2022-ahaasa-guideline-for-the-management-of-patients-with-spontaneous-intracerebral-hemorrhageare-you-doing-enough/18126/ Join experts and explore an exciting new frontier of care for patients on direct oral anticoagulants who present with an intracranial hemorrhage. Three factors can be used to optimize treatment: emerging data on anticoagulation reversal, artificial intelligence utilization, and evidence-based ABC care bundling. Learn how these developments transform clinical practice, deepen institutional expertise, and ultimately improve patient outcomes.

We've spent countless hours (rightfully so) discussing ischemic stroke management over the past several years. Sometimes, the other 20% of strokes, the hemorrhagic version, can get neglected. No, we don't have stroke-mobiles at MCHD to diagnose an ICH in the field, but there are some patient care keys to emphasize for EMS when we suspect non-traumatic, acute intracranial bleeding. REFERENCES 1. Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Steiner T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016 Sep 15;375(11):1033-43. 2. Zeiler FA, Sader N, West M, Gillman LM. Sodium Bicarbonate for Control of ICP: A Systematic Review. J Neurosurg Anesthesiol. 2018 Jan;30(1):2-9.

From the Institute for Stroke and Cerebrovascular Diseases at UTHealth Houston, today, we delve into a fascinating study exploring the intriguing concept known as the "obesity paradox" in patients with spontaneous intracerebral hemorrhage (ICH). Joining us are two esteemed guests, Dr. Jared Chen and Dr. Andrea Gaitan, who played integral roles in this research.  You are in for a treat as we unpack the study's background, objectives, and compelling results. The study, aiming to understand the association between body mass index (BMI) and functional outcomes in patients with ICH, also explores the role of race/ethnicity in this relationship. Their research article can be found at https://www.neurology.org/doi/10.1212/WNL.0000000000208014

Allie Curran, PharmD reviews blood pressure management strategies in intracerebral hemorrhage. For more pharmacy content, follow Mayo Clinic Pharmacy Residency Programs @MayoPharmRes. You can also connect with the Mayo Clinic's School of Continuous Professional Development online at https://ce.mayo.edu/ or on Twitter @MayoMedEd. 

Neurology Today Editor-in-chief Joseph E. Safdieh, MD, FAAN, discusses new research on the risk of spontaneous intracerebral hemorrhages after blood transfusions; the burden of long distance travel to see neurologists; and two promising biomarkers for early diagnosis of Parkinson's disease.

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: July 18, 2017 Trauma and hypertension account for the overwhelming majority of cases of intracerebral hemorrhage. Today, we address the minority. In this week's episode, Dr. Steven Messe discusses the atypical causes of intracerebral hemorrhage and how they are managed. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision-making in routine clinical practice. REFERENCES Biffi A, Greenberg SM. Cerebral amyloid angiopathy: a systematic review. J Clin Neurol 2011;7(1):1-9. PMID 21519520Gilden D, Cohrs RJ, Mahalingam R, Nagel MA. Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment. Lancet Neurol 2009;8(8):731-40. PMID 19608099Mast H, Young WL, Koennecke HC, et al. Risk of spontaneous haemorrhage after diagnosis of cerebral arteriovenous malformation. Lancet 1997;350(9084):1065-8. PMID 10213548Ruíz-Sandoval JL, Cantú C, Barinagarrementeria F. Intracerebral hemorrhage in young people: analysis of risk factors, location, causes, and prognosis. Stroke 1999;30(3):537-41. PMID 10066848Siegler JE, Ichord RN. Teaching neuroimages: multicompartmental intracranial hemorrhage in a pediatric patient. Neurology 2016;87(23):e284. PMID 27920292  We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date.

Welcome back Rounds Table Listeners! In this throwback episode, Mike and John discuss two papers exploring pharmacotherapy-based interventions for agitation experienced by individuals with dementia and when to start or restart antiplatelet therapy after stroke caused by intracerebral hemorrhage. Check it out below! Effects of Antiplatelet Therapy After Stroke Caused by Intracerebral Hemorrhage (0:00 – 7:14). ...The post TBT – Agitation in Dementia and Antiplatelet Therapy after Intracerebral Hemorrhage appeared first on Healthy Debate.

Welcome back Rounds Table Listeners! In this throwback episode, Mike and John discuss two papers exploring pharmacotherapy-based interventions for agitation experienced by individuals with dementia and when to start or restart antiplatelet therapy after stroke caused by intracerebral hemorrhage. Check it out below! Effects of Antiplatelet Therapy After Stroke Caused by Intracerebral Hemorrhage (0:00 – 7:14). ... The post TBT – Agitation in Dementia and Antiplatelet Therapy after Intracerebral Hemorrhage first appeared on Healthy Debate. The post TBT – Agitation in Dementia and Antiplatelet Therapy after Intracerebral Hemorrhage appeared first on Healthy Debate.

Dr. David Roh is an Assistant Professor of Neurology at Columbia University where he is an attending neurointensivist. In this lecture, Dr. Roh reviews the currently implemented diagnostic and treatment approaches for hemorrhage control in intracerebral hemorrhage and discusses novel approaches being investigated.

The ENRICH trial compared the outcomes between early surgical intervention using the BrainPath® Approach (i.e., MIPS) and a medically managed cohort. The integrated surgical approach included a combination of available technologies, including the FDA-cleared NICO BrainPath® for non-disruptive access and NICO Myriad® to achieve the goal of maximum clot evacuation. Alex Reynolds is joined by the ENRICH trial PIs, Gustavo Pradilla, Jonathan Ratcliff, and Alex Hall plus guests Chris Kellner and Kara Melmed to discuss the findings of the ENRICH clinical trial.  

Listen to the fifth episode of NCS' INSIGHTS series, this time on Intracerebral Hemorrhage. The INSIGHTS series is hosted by Casey Albin, MD and Salia Farrokh, PharmD, and covers different topics from Neurocritical Care ON CALL®, the only up-to-date, comprehensive resource to offer content exclusively dedicated to the practice of neurocritical care. Learn more about ON CALL®. This episode is sponsored by ceribell. Time is brain when it comes to seizures. Ceribell Point of Care EEG empowers the bedside team to detect or rule out seizure activity in minutes. To learn more, visit ceribell.com. The NCS Podcast is the official podcast of the Neurocritical Care Society.

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.08.01.551291v1?rss=1 Authors: Hamilton, L. K., Mbra, P. E. H., Mailloux, S., Galoppin, M., Aumont, A., Fernandes, K. J. L. Abstract: Evidence from genetic and epidemiological studies point to lipid metabolism defects in both the brain and periphery being at the core of Alzheimer's disease (AD) pathogenesis. Previously, we reported that central inhibition of the rate-limiting enzyme in monounsaturated fatty acid synthesis, Stearoyl-CoA Desaturase (SCD), improves brain structure and function in the 3xTg mouse model of AD. Here, we tested whether these beneficial central effects involve recovery of peripheral metabolic defects, such as fat accumulation and glucose and insulin handling. As early as 3 months of age, 3xTg-AD mice exhibited obesity-like phenotypes including increased body weight and visceral and subcutaneous white adipose tissue deposition, as well as diabetic-like peripheral gluco-regulatory abnormalities. Intracerebral infusion of an SCD inhibitor that normalizes brain fatty acid metabolism, synapse loss and learning and memory deficits in middle-aged symptomatic 3xTg-AD mice did not affect peripheral phenotypes. This suggests that the beneficial effects of central SCD inhibition on cognitive function are not mediated by recovery of peripheral metabolic abnormalities. Given the widespread side-effects of systemically administered SCD inhibitors, these data suggest that selective inhibition of SCD in the brain may represent a clinically safer and more effective strategy for AD. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

Welcome to the Master Class Series where we will learn from the masters in Neurocritical Care. On this episode, learn from Stephan Mayer, MD, FCCM, FNCS Director of Neurocritical Care and Emergency Neurology Services for Westchester Medical Center Health System and Professor of Neurology and Neurosurgery at New York Medical College as he discusses Hyperacute Management of Intracerebral Hemorrhage. NCS offers free CE credits for the NCS Podcast Series episodes. Listen to any of the posted episodes, complete a five-question survey, and claim your credits here! Credits are available for physicians, pharmacists, nurses, and non-physicians. The NCS Podcast is the official podcast of the Neurocritical Care Society. 

Dr. Seemant Chaturvedi discusses two trials in the field of intracerebral hemorrhage: INTERACT-3 trial and the ENRICH trial. This podcast is sponsored by argenx. Visit www.vyvgarthcp.com for more information.  

"...stroke is characterized by having poor blood flow to part of the brain leading to cell death they are grossly divided into ischemic and hemorrhagic with around 15 to 20 percent of Strokes being hemorrhagic a hemorrhagic stroke results from the rupture of a blood vessel leading to bleeding compared ischemic stroke that have a sudden occlusion of a blood vessel within hemorrhagic Strokes there are two main types intracerebral meaning bleeding within the brain itself which can be intraparenchymal Hemorrhage weather is bleeding within the brain tissue or an intraventricular Hemorrhage where there is bleeding within the ventricular system of the brain around one intracerebral hemorrhage into the ventricles intracerebral Hemorrhage is most commonly caused by hypertension and age-related cerebral amyloid angiopathy which is where deposition of Lloyd Peter peptide in the vessels leads to a weaker vessel structure which is then therefore more likely to bleed the other main type is a subarachnoid with the bleed occurs between the arachnoid Mater and the Pia Mater subarachnoid hemorrhages can be due to trauma or can be spontaneous in 85% of cases in taneous subarachnoid hemorrhage is caused by rupture of a cerebral aneurysm with the most common locations being the anterior communicating artery in 35 percent of cases internal carotid artery in 30% and middle cerebral artery in 22% in 30% of cases there are multiple aneurysms the remaining maybe caused by rupture of an arteriovenous malformation coagulopathy or extension of an intraparenchymal bleed note that both of these types of hemorrhagic I considered intracranial bleeds however other types of intracranial bleeds such as epidural and subdural hemorrhages are not considered hemorrhagic stroke we take this few seconds off to inform you are valued loyal listener about the best health and fitness podcast shows from the Nez pod Studios join us as we give you the best of the best health and wellness updates you can rely on for the treatment of chronic classic functional medicine Back to Basics health tips and special updates from the best doctors in the United States of America check out this health and wellness podcast shows explore Health talk healthy lifestyle matters excellent Health digest healthy and free daily and last but not least weekly health and fitness Corner also check out nasty Boise see the truest story never told Fiction podcast for that real life on the go experience with the 27 year old Golden boy..." Learn more about your ad choices. Visit megaphone.fm/adchoices

"...stroke is characterized by having poor blood flow to part of the brain leading to cell death they are grossly divided into ischemic and hemorrhagic with around 15 to 20 percent of Strokes being hemorrhagic a hemorrhagic stroke results from the rupture of a blood vessel leading to bleeding compared ischemic stroke that have a sudden occlusion of a blood vessel within hemorrhagic Strokes there are two main types intracerebral meaning bleeding within the brain itself which can be intraparenchymal Hemorrhage weather is bleeding within the brain tissue or an intraventricular Hemorrhage where there is bleeding within the ventricular system of the brain around one intracerebral hemorrhage into the ventricles intracerebral Hemorrhage is most commonly caused by hypertension and age-related cerebral amyloid angiopathy which is where deposition of Lloyd Peter peptide in the vessels leads to a weaker vessel structure which is then therefore more likely to bleed the other main type is a subarachnoid with the bleed occurs between the arachnoid Mater and the Pia Mater subarachnoid hemorrhages can be due to trauma or can be spontaneous in 85% of cases in taneous subarachnoid hemorrhage is caused by rupture of a cerebral aneurysm with the most common locations being the anterior communicating artery in 35 percent of cases internal carotid artery in 30% and middle cerebral artery in 22% in 30% of cases there are multiple aneurysms the remaining maybe caused by rupture of an arteriovenous malformation coagulopathy or extension of an intraparenchymal bleed note that both of these types of hemorrhagic I considered intracranial bleeds however other types of intracranial bleeds such as epidural and subdural hemorrhages are not considered hemorrhagic stroke we take this few seconds off to inform you are valued loyal listener about the best health and fitness podcast shows from the Nez pod Studios join us as we give you the best of the best health and wellness updates you can rely on for the treatment of chronic classic functional medicine Back to Basics health tips and special updates from the best doctors in the United States of America check out this health and wellness podcast shows explore Health talk healthy lifestyle matters excellent Health digest healthy and free daily and last but not least weekly health and fitness Corner also check out nasty Boise see the truest story never told Fiction podcast for that real life on the go experience with the 27 year old Golden boy..." Learn more about your ad choices. Visit megaphone.fm/adchoices

"...stroke is characterized by having poor blood flow to part of the brain leading to cell death they are grossly divided into ischemic and hemorrhagic with around 15 to 20 percent of Strokes being hemorrhagic a hemorrhagic stroke results from the rupture of a blood vessel leading to bleeding compared ischemic stroke that have a sudden occlusion of a blood vessel within hemorrhagic Strokes there are two main types intracerebral meaning bleeding within the brain itself which can be intraparenchymal Hemorrhage weather is bleeding within the brain tissue or an intraventricular Hemorrhage where there is bleeding within the ventricular system of the brain around one intracerebral hemorrhage into the ventricles intracerebral Hemorrhage is most commonly caused by hypertension and age-related cerebral amyloid angiopathy which is where deposition of Lloyd Peter peptide in the vessels leads to a weaker vessel structure which is then therefore more likely to bleed the other main type is a subarachnoid with the bleed occurs between the arachnoid Mater and the Pia Mater subarachnoid hemorrhages can be due to trauma or can be spontaneous in 85% of cases in taneous subarachnoid hemorrhage is caused by rupture of a cerebral aneurysm with the most common locations being the anterior communicating artery in 35 percent of cases internal carotid artery in 30% and middle cerebral artery in 22% in 30% of cases there are multiple aneurysms the remaining maybe caused by rupture of an arteriovenous malformation coagulopathy or extension of an intraparenchymal bleed note that both of these types of hemorrhagic I considered intracranial bleeds however other types of intracranial bleeds such as epidural and subdural hemorrhages are not considered hemorrhagic stroke we take this few seconds off to inform you are valued loyal listener about the best health and fitness podcast shows from the Nez pod Studios join us as we give you the best of the best health and wellness updates you can rely on for the treatment of chronic classic functional medicine Back to Basics health tips and special updates from the best doctors in the United States of America check out this health and wellness podcast shows explore Health talk healthy lifestyle matters excellent Health digest healthy and free daily and last but not least weekly health and fitness Corner also check out nasty Boise see the truest story never told Fiction podcast for that real life on the go experience with the 27 year old Golden boy..." Learn more about your ad choices. Visit megaphone.fm/adchoices

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.02.13.528249v1?rss=1 Authors: Jing, J., Chen, S., Wu, X., Yang, J., Liu, X., Wang, J., Wang, J., Li, Y., Zhang, P., Tang, Z. Abstract: Intracerebral hemorrhage (ICH) is an acute cerebrovascular disease with high disability and mortality rates. Recombinant tissue plasminogen activator (rtPA) is commonly applied for hematoma evacuation in minimally invasive surgery (MIS) after ICH. However, rtPA may contact directly with brain tissue during MIS procedure, which makes it necessary to discuss the safety of rtPA. We found that, in the in vivo ICH model induced by VII-type collagenase, rtPA treatment improved the neurological function of ICH mice, alleviated the pathological damage and decreased the apoptosis and autophagy level of the peri-hematoma tissue. In the in-vitro model of ICH induced by hemin, the administration of rtPA down-regulated neuronal apoptosis, autophagy, and endoplasmic reticulum stress of neurons. Transcriptome sequencing analysis showed that rtPA treatment upregulated the PI3K/AKT/mTOR pathway in neurons, and PI3K inhibitor (LY294002) can reverse the protective effects of rtPA in inhibiting excessive apoptosis, autophagy and ER-stress. Epidermal growth factor receptor inhibitor (AG-1487) reversed the effect of rtPA on PI3K/AKT/mTOR pathway, which might indicate that the EGF domain played an important role in the activation of PI3K/AKT/mTOR pathway. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.01.13.523921v1?rss=1 Authors: Alonso, F., Mercadal, B., Salvador, R., Ruffini, G., Bartolomei, F., Wendling, F., Modolo, J. Abstract: Intracranial electrodes are used clinically for diagnostic or therapeutic purposes, notably in drug-refractory epilepsy (DRE) among others. Visualization and quantification of the energy delivered through such electrodes is key to understanding how the resulting electric fields modulate neuronal excitability, i.e. the ratio between excitation and inhibition. Quantifying the electric field induced by electrical stimulation in a patient-specific manner is challenging, because these electric fields depend on a number of factors: electrode trajectory with respect to folded brain anatomy, biophysical (electrical conductivity / permittivity) properties of brain tissue and stimulation parameters such as electrode contacts position and intensity. Here, we aimed to evaluate various biophysical models for characterizing the electric fields induced by electrical stimulation in DRE patients undergoing stereoelectroencephalography (SEEG) recordings in the context of pre-surgical evaluation. This stimulation was performed with multiple-contact intracranial electrodes used in routine clinical practice. We introduced realistic 3D models of electrode geometry and trajectory in the neocortex. For the electrodes, we compared point (0D) and line (1D) sources approximations. For brain tissue, we considered three configurations of increasing complexity: a 6-layer spherical model, a toy model with a sulcus representation, replicating results from previous approaches; and went beyond the state-of-the-art by using a realistic head model geometry. Electrode geometry influenced the electric field distribution at close distances (~3 mm) from the electrode axis. For larger distances, the volume conductor geometry and electrical conductivity dominated electric field distribution. These results are the first step towards accurate and computationally tractable patient-specific models of electric fields induced by neuromodulation and neurostimulation procedures. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

We have another Grand Rounds follow up interview for you today, and a special one at that! Dr. Jared Chen has joined the Stroke Institute here at UTHealth Houston and we were so thankful not only for his time spent on his Grand Rounds presentation, but for sticking around for an in-depth look into his research and new faculty position. One of this year's Stroke Institute fellows, Mohammad Rauf, discussed Intracerebral Hemorrhage Therapies with Dr. Chen, past, present, and future, and we hope you enjoy, and share with colleagues. ____________________________________ Twitter: @UTHealthStroke Instagram: @UTHealthStroke Facebook: facebook.com/uthealthstroke Ideas and opinions are our own and this podcast is not a substitute for expert medical advice. About StrokeBusters is a podcast series of recorded conversations on the topic of stroke and cerebrovascular disease. Based in the Texas Medical Center, the largest medical center in the world, we tap into our local network of astonishing leaders in healthcare and medicine to discuss the latest and most exciting news on stroke. Throughout this ten-episode series, we connect with UTHealth physicians and researchers, many of who are experts in their field, to discuss their practice, cutting-edge research, and medical care. Who We Are The Institute for Stroke and Cerebrovascular Disease, better known as the Stroke Institute, serves as a multi-disciplinary hub for research and best practices in stroke recovery, stroke prevention, services, population health, and vascular dementia. We are one of the most active research and clinical programs in the country, the first Comprehensive Stroke Center in the state, and launched the first Mobile Stroke Unit in the nation. Our stroke program, founded by Dr. James Grotta in 1979, specializes in stroke epidemiology, clinical trial design, and basic science. We train the next generation of revolutionary academics and leaders in cerebrovascular disease through our NINDS-funded fellowship programs. Contact For more information or if you have any questions, please contact us at info.uthiscd@gmail.com

The post Episode 88. Review of the AHA 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage appeared first on The Pharm So Hard Podcast.

In this week's podcast, Neurology Today's editor-in-chief discusses new findings on chronic kidney disease and risk for intracerebral hemorrhage, the potential of  gonadotropic replacement for improving cognition in Down syndrome, and distinguishing polio from acute flaccid myelitis and other viruses.

On Episode 18 of the Stroke Alert Podcast, host Dr. Negar Asdaghi highlights two articles from the July 2022 issue of Stroke: “Impact of Shunting Practice Patterns During Carotid Endarterectomy for Symptomatic Carotid Stenosis” and “Socioeconomic Inequalities in Reperfusion Therapy for Acute Ischemic Stroke.” She also interviews Dr. Magdy Selim about his article “Effect of Deferoxamine on Trajectory of Recovery After Intracerebral Hemorrhage: A Post Hoc Analysis of the i-DEF Trial.” Dr. Negar Asdaghi:         Let's start with some questions. 1) Is deferoxamine mesylate yet another failed agent for treatment of patients with intracerebral hemorrhage, or is deferoxamine getting us closer than ever to an approved therapy for this deadly form of stroke? 2) Are different strokes happening to different folks due to their disadvantaged socioeconomic status? 3) And finally, how does a surgeon's personal practice preference to either routinely or selectively use carotid shunting during carotid endarterectomy impact the recurrent risk of stroke or death in patients with symptomatic carotid disease? We'll tackle these questions and a lot more in today's podcast as we continue to cover the cerebrovascular world's latest and greatest because, without a doubt, this is the best in Stroke. Dr. Negar Asdaghi:         Welcome back to the July issue of the Stroke Alert Podcast. My name is Negar Asdaghi. I'm an Associate Professor of Neurology at the University of Miami Miller School of Medicine and your host for the monthly Stroke Alert Podcast. The July 2022 issue of Stroke contains a range of really interesting papers that I'd like to highlight here. As part of our Cochrane Corner articles, giving us short summaries of the long systematic review of a given topic, we have two short articles, one on the issue of local versus general anesthesia for carotid endarterectomy, where we learn that based on the current evidence, there's no convincing difference between local versus general anesthesia in the risk of stroke and death within 30 days after the procedure. In the second Cochrane Corner article, titled "Information Provision for Stroke Survivors and Their Carers," we learn that stroke survivors and their caregivers routinely report dissatisfaction with information provided to them by their clinicians about their condition and how active approaches to information provision is superior to its passive forms in improving patients' involvement in their care, their satisfaction, and, ultimately and not surprisingly, their stroke outcome. Dr. Negar Asdaghi:         As part of our original contributions in this issue of the journal, we have an important paper titled "The Risk of Early Versus Later Rebleeding From Dural AV Fistulas With Cortical Venous Drainage." We are reminded in this paper that cranial dural arteriovenous fistulas are classified based on their venous drainage into those with or those without cortical venous drainage, or CVD. Dural AV fistulas without CVD rarely cause intracranial bleeding, while those with CVD may cause hemorrhage. In this study, the authors show that the risk of rebleeding of dural AV fistulas with CVD presenting with hemorrhage is increased in the first two weeks after ICH, emphasizing the importance of early detection of these malformations by vascular imaging and early treatment of AV fistulas with cortical drainage. This paper is another analysis from the CONDOR registry. Our devoted Stroke Alert listeners recall that we covered this registry in more detail when we interviewed Dr. Amin-Hanjani last October on the outcomes of intracerebral hemorrhage patients found to have dural AV fistulas. I encourage you to review these articles in addition to listening to our podcast today. Dr. Negar Asdaghi:         Later in the podcast, I have the distinct honor of interviewing Dr. Magdy Selim from Harvard Medical School on a critical analysis from i-DEF trial to examine the long-term outcome of patients with ICH who were randomized to receive deferoxamine versus placebo. As an expert in the field of intracerebral hemorrhage and a member of the recently published American Heart Association Guidelines Committee, Dr. Selim was not fazed at all about the neutral results of the trial. "The future of ICH is bright," he says, and in the interview, he tells us why. But first, with these two articles. Dr. Negar Asdaghi:         Since its first reported successful surgery in 1953, carotid endarterectomy, or CEA, has become a common surgical procedure to prevent ischemic stroke in patients with carotid disease. CEA requires a temporary clamping of the carotid artery that is being worked on. During this time, the ipsilateral hemisphere is, of course, dependent on collateral flow from the posterior circulation or from the contralateral anterior circulation to maintain its perfusion pressure. Intraoperatively, various methods are used to monitor cerebral perfusion, and the risk of clamping-induced hypoperfusion is obviously variable for each patient depending on the patient's specific anatomy, their collateral status, and other risk factors. One way to protect the brain against possible clamp-induced ischemia is to do carotid shunting. The problem is that carotid shunting also comes with its own set of risks and problems. There's the risk of causing carotid dissection, embolization of pieces of the plaque during shunt insertion, or the risk of causing air embolism. Dr. Negar Asdaghi:         There are also other shunt-related local complications that should be noted, such as possibility of causing injuries to the cranial nerves or development of neck hematoma related to the more extensive surgical exposure required for shunting. So, it's not surprising that the practice patterns with regards to shunting is quite variable amongst different surgeons. There are surgeons that are considered routine shunters, and those who are considered selective shunters, meaning that the shunt is inserted only in cases with a particular indication. The question is whether the surgeon's preference for shunting can impact the CEA outcomes. In the current issue of the journal, we have an interesting study led by Dr. Randall DeMartino from the Division of Vascular and Endovascular Surgery at Mayo Clinic, Rochester, where the authors look at the impact of shunting practice patterns during carotid endarterectomy on the following post-CEA outcomes: number one, in-hospital stroke and in-hospital death rates, and number two, combined stroke and death in patients with a recent symptomatic carotid disease, that is, carotid stenosis associated with a history of either ipsilateral stroke or TIA within the past 14 days of endarterectomy. Dr. Negar Asdaghi:         So, the data for the study came from the ongoing Vascular Quality Initiative database, which comprises a network of more than 600 North American academic and community hospitals, and collects data on 12 different vascular procedures, one of which is CEA. The study included over 13,000 carotid endarterectomies performed from 2010 to 2019 for symptomatic carotid patients. This number came after they applied their exclusion criteria to all CEAs performed in the database during this timeframe, importantly excluding any asymptomatic carotid surgeries or those in whom surgery was performed after the two-week mark post qualifying TIA or stroke. Now, before we go over the results, let's go over some definitions used in the study. They had to classify surgeons to be able to do the study into two categories of routine versus selective shunters. So, what they did was to analyze all consecutive CEAs, whether they were done on symptomatic or asymptomatic carotids, in this database, aggregated at the surgeon level. Surgeons routinely shunting in over 95% of their procedures were gauged as routine shunters. Otherwise, they were classified as selective shunters. Dr. Negar Asdaghi:         Now, coming to each case included in this study, each surgical case was, in turn, classified into four categories based on whether or not a shunt was actually used for that particular case: category one, no shunt used; category two, shunt used as a routine procedure; number three, shunt used for a preoperative, mostly anatomical indication; number four, shunt was used for an intraoperative indication, which, as we mentioned before, these are mostly intraoperative hemodynamic compromised situations. And here are the results: In total, 3,186 of surgeries, that is 24% of surgeries, were performed by routine shunters versus 76% by selective shunters. So, most surgeons were selective shunters in this study. The demographic of patients operated by the routine versus selective shunters were more or less similar with regards to the age of the patients, most of their vascular risk factors, and the degree of ipsilateral or contralateral carotid stenosis or occlusion, with a few notable exceptions, in that patients undergoing surgery by routine shunters were more likely White, more likely to have had a prior CABG, more likely to undergo the operation while taking a P2Y12 inhibitor antiplatelet agent, and these patients were more likely to have had a TIA rather than a stroke as their qualifying event, which probably explains why they were more likely to be operated on within 48 hours of symptom onset as well. So, the authors accounted for these differences when they did their multivariate analysis. Dr. Negar Asdaghi:         The other thing to note was that overall, routine shunters used a shunt in 98.1% of their cases, whereas selective shunters used them in 46% of their cases. Now, in terms of their study outcomes, the shunting practice pattern did not impact the primary outcomes of in-hospital stroke or death, or a combination of these two outcomes, or even the odds of development of cranial nerve injuries or hemorrhage in the adjusted model, which is really good news here. But interestingly, in the final adjusted model, whether or not an actual shunt was placed during surgery did significantly increase the risk of postoperative stroke, with the odds ratio of 1.29, an effect that was entirely driven by the use of shunt by a surgeon classified as a selective shunter in this study. Dr. Negar Asdaghi:         So, in simple terms, if a shunt was placed during CEA, it did increase the risk of stroke only if that surgeon was a selective shunter. Another interesting association was that amongst selective shunters, placing a shunt for a patient with a very recent ischemic event, that is, TIA or stroke within the past 48 hours prior to surgery, and placing a shunt for an intraoperative indication, meaning shunt placement was not pre-surgically planned, also significantly increased the risk of postoperative stroke. So, what we learned from the study is that, though a surgeon's shunting practice pattern did not have an impact on the overall postoperative risk of stroke or death, the placement of a shunt did indeed increase the risk of postoperative stroke only if it was placed by a surgeon who is a selective shunter, especially for an intraoperative indication in a patient with a recent ischemic event. Dr. Negar Asdaghi:         So, shunts can be tricky, especially if they're done by a surgeon who doesn't place them routinely. So, my take-home message is that ultimately, like every other procedure in medicine, clinical outcomes are as much operator dependent as they are patient dependent, and for every procedure, it's fair to say that practice makes perfect. Dr. Negar Asdaghi:         It is now more than 25 years since intravenous thrombolytic therapy has been approved for treatment of patients with acute ischemic stroke and more than seven years since randomized control trials demonstrated the efficacy of mechanical thrombectomy to improve clinical outcome in ischemic stroke patients with large vessel occlusions. To date, reperfusion therapies are the only available acute treatments for select patients with ischemic stroke. What do we mean by "select"? "Select" meaning that not all patients will benefit from these therapies, making it absolutely necessary for clinicians to be up to date with various indications and contraindications to use these therapies. Needless to say that the criteria for reperfusion therapies do not and should not consider the socioeconomic status of patients, but sadly, socioeconomic inequalities seem to impact the use of reperfusion therapies. Dr. Negar Asdaghi:         In this issue of the journal, in the study titled "Socioeconomic Inequalities in Reperfusion Therapy for Acute Ischemic Stroke," Dr. Øgendahl Buus from Aarhus University Hospital in Denmark and colleagues studied the impact of the socioeconomic status of stroke patients on the odds of receiving reperfusion therapies in the large nationwide Danish Stroke Registry, or DSR. Now a bit about the registry: DSR contains prospectively collected nationwide data on all stroke patients admitted to Danish hospitals. It's interesting to note that in Denmark, stroke patients are exclusively admitted to public hospitals, and all departments treating stroke patients are obligated to report data to DSR. Now, for this study, they included over 63,000 stroke patients from 2013 to 2018. After excluding hemorrhagic stroke, TIAs, and other exclusion criteria of the study, they arrived at their sample size of 37,187 patients that were included in this study. Dr. Negar Asdaghi:         Now, a few definitions. The socioeconomic status of each patient was determined based on three parameters. Parameter number one, their educational level. It was categorized into three levels of low, medium, or high levels of education. Category number two, income level. This was calculated based on the average family equivalent disposable income, or FED income, during five years prior to stroke onset, again classified into three categories of high, medium, or low income. And the third factor was the employment status of the patient during the calendar year prior to the stroke onset, also categorized into three categories of employed, unemployed, and retired. And, of course, the authors used various definitions to be able to fit special situations into these categories. For instance, a person who is temporarily unemployed due to illness or other special situation was still categorized under the employed category. So, that gave them, in total, nine groups to analyze across these three categories. Dr. Negar Asdaghi:         And here are their findings. The median age of total stroke patients in the cohort was 73.2 years, 44.1% were women, 41% categorized under low educational level, 68% retired, and 33.3% had low income levels. Not surprisingly, patients and hospital characteristics varied tremendously across these nine groups of education, employment, and income, and a univariate analysis in general, low socioeconomic status was associated with more severe strokes, living alone, living at an assisted living residency, having had prior stroke, high comorbidity index score, hypertension, and late hospital arrival. So, they accounted for these differences in their multivariate analysis. Dr. Negar Asdaghi:         Now, overall, the treatment rates of IV thrombolysis was 17.6%, which is actually considered a very high percentage as compared to other registry-based studies, but the percentage of IV thrombolytic use dramatically varied based on the different socioeconomic designation. So, let's look at this. In the univariate analysis, for education, intravenous thrombolysis rates were 19.3% among patients with high educational level compared to 16.2% among patients with low educational level. Let's look at income. For income, IV thrombolytic treatment rates reach 20.7% for high-income patients compared to 14.8% for low-income patients. For employment status, thrombolytic rates were 23.7% among employed patients compared to 15.7% for unemployed patients. In their fully adjusted models, unemployed patients were less likely to receive IV lytics as compared to their employed counterparts. Dr. Negar Asdaghi:         Now, for thrombectomy, socioeconomic gradients were also noted for these three categories. For education, thrombectomy rates were 4.5% among patients with high education level compared to 3.6% among patients with low educational level. For income, treatment rates were 3.2% among low-income patients compared to 4.7% among high-income patients. But arguably, the most robust differences were noted again across the category of employment. Employed patients were nearly twice more likely to receive thrombectomy as compared to unemployed patients, rates being 5.1% versus 2.8%, respectively. Now, when they adjusted their analysis to only those patients presenting within the reperfusion time windows in the fully adjusted models, unemployment and low income remain significant negative predictors of receiving both of these reperfusion therapies. So, what we learned from this study is that stroke patients who were unemployed, earned a relatively low income, or had fewer years of formal education were less likely to receive life-saving reperfusion therapies despite potentially being eligible for these treatments. Dr. Negar Asdaghi:         Now, let's take a moment to really understand that data presented here are in the context of a tax-funded, universal healthcare offered across Denmark, where we can at least make the assumption that financial constraints potentially preventing access to therapies are likely minimized. There are many countries around the globe where patients or family members have to pay for these therapies before even receiving them. So, these findings from the current study from Denmark are alarming in that they point to possibly more robust inequalities across the globe in other healthcare systems. Dr. Negar Asdaghi:         Intracerebral hemorrhage, or ICH, is an aggressive form of stroke, typically carrying a higher morbidity and mortality than its ischemic counterpart. Yet much of the research in the field of intracerebral hemorrhage has followed the ischemic stroke footsteps, including defining the optimal primary outcome for the randomized trials of ICH. For ischemic stroke, the 90-day functional outcome, as measured by the modified Rankin Scale, is commonly used as a primary outcome in clinical trials. There are many reasons for this selection, including the ease of use and the fact that the majority of functional recovery post-ischemic stroke occurs during the first 90-day time period. But time to maximum recovery and, importantly, the trajectory of recovery may be different in hemorrhagic as compared to ischemic stroke. Defining the long-term outcomes and longitudinal trajectory of recovery in ICH is, therefore, important to better understand its prognosis and, of course, selecting the appropriate primary outcome measure for future randomized trials of ICH. Dr. Negar Asdaghi:         In the recent years, the safety and efficacy of various agents to improve ICH outcomes have been tested. Deferoxamine mesylate, an iron-chelating agent, is one such agent that was recently studied as part of the i-DEF multicenter randomized trial, and the main results of the study were published in Lancet Neurology in 2019. In the current issue of the journal, in the study titled "Effect of Deferoxamine on Trajectory of Recovery After Intracerebral Hemorrhage," we learn about the results of a post hoc analysis of i-DEF that looks at the trajectory of functional outcome in patients enrolled in the trial with a special attention on their continued recovery after the 90-day post-ICH mark. Dr. Negar Asdaghi:         Joining me now is the senior author of this paper, Dr. Magdy Selim, who's also one of the primary investigators of i-DEF trial. Dr. Selim is a Professor of Neurology at Harvard Medical School and Chief of Stroke Division at Beth Israel Deaconess Medical Center in Boston. He's a world renowned researcher in the field of cerebrovascular disorders with special focus on treatment of patients with intracerebral hemorrhage. Dr. Selim has led and currently leads multiple National Institutes of Health-funded clinical trials of intracerebral hemorrhage, including the ongoing SATURN trial. I'm delighted to welcome him to our podcast today. Good afternoon, Magdy. Thank you for joining us today. Dr. Magdy Selim:             Thank you, Dr. Asdaghi. It's really my pleasure to be here with you, and I'm certainly honored to do this today. Dr. Negar Asdaghi:         That's great. Thank you. So, let's start with some background on deferoxamine and the literature supporting the use of deferoxamine before i-DEF. Dr. Magdy Selim:             So, as you mentioned, deferoxamine is an iron chelator; it binds to iron and removes excess iron from the body. The unique thing about it is that it has other neuroprotective properties, which are good for hemorrhagic stroke and ischemic stroke. It also has anti-inflammatory and anti-apoptotic effects. It even lowers the blood pressure, which we know sometimes is helpful in intracerebral hemorrhage. The rationale behind this or why this would be effective really comes from animal studies. After you have a hemorrhage, there is hemolysis of the red blood cells, there is a release of hemoglobin degradation products, in particular, iron, and the accumulation of iron in the hematoma and the surrounding tissue triggers a cascade of molecular and cellular events that lead to what we call secondary injury, characterized by inflammation, hydroxyl radical formation, and cell death. And many animal studies, animal models of intracerebral hemorrhage, whether in pigs or in rats, young or aged rats, have shown that treatment with deferoxamine can reduce iron in the brain after intracerebral hemorrhage and also results in improved performance on behavioral tests. And that was the reason why we moved into clinical testing. Dr. Negar Asdaghi:         So, a lot of encouraging data before the trial. Can we hear a little bit about the trial, its design, and inclusion criteria, please? Dr. Magdy Selim:             Sure. So i-DEF was a phase 2 study, and actually it started as Hi-DEF, which was high dose deferoxamine, and then became i-DEF, which intermediate dose deferoxamine. So, it's a randomized, double blind, placebo control trial. We used something called futility design, which is actually sort of new in the stroke field. And we had 294 patients who had supratentorial hemorrhage that were randomized within 24 hours to either get placebo or deferoxamine. And deferoxamine initially was given at 62 mg per day for three days, but then we ran into some safety issues with this high dose, and that's why we lowered it to 32, and that became the intermediate dose, or the i-DEF. So, the only kind of thing unique about inclusion/exclusion criteria was that there was an age cutoff, patients had to be 80 or younger. They needed to have some deficit on the exam, so their NIH Stroke Scale had to be 6 or greater, and their GCS had to be greater than 6, and their modified Rankin before the onset of the hemorrhage had to be less than 1. Dr. Negar Asdaghi:         And so, what were the primary and secondary outcomes in i-DEF? Dr. Magdy Selim:             The primary outcome was twofold actually. One of them was safety. One of the issues we ran into with the high dose is that the drug is associated with increased risk for adult respiratory distress syndrome, ARDS. So, we wanted to make sure that this lower dose was safe, and it does not increase the instance of ARDS. The second thing was, as I said, we used something called the futility design, and we wanted to compare the outcome of patients treated with deferoxamine versus placebo to determine whether it's futile to move to a large phase 3 trial or not. And what we were looking at is a difference in outcome and modified Rankin 0 to 2 at 90 days, and the difference would be at least 12% in favor of deferoxamine in order for us to move forward. You asked about the secondary outcomes as well? Dr. Negar Asdaghi:         Yes. Dr. Magdy Selim:             So, actually, the secondary outcomes, they're relevant because they're relevant to the study that we just published. So, the secondary outcomes was also to look at modified Rankin 0 to 3, instead of 0 to 2, at 90 days and the difference between the two treatment groups. We wanted to look at the ordinal distribution of the Rankin at the same time point. And we also wanted to look at all the outcomes at six months, 180 days. And that came a little bit later in the course of the study because there was some evidence emerging at that time that maybe assessment of outcome later in intracerebral hemorrhage would be more accurate than assessing it early on. Dr. Negar Asdaghi:         So, I want to come back to the secondary outcome, of course, that's sort of the topic of your current paper in this issue of the journal, but can you just briefly tell us, please, the primary outcome and the sort of results of what was published in 2019 with i-DEF before we move on to the current paper? Dr. Magdy Selim:             Yeah. So, as I said, the primary outcome was the difference in the proportion of patients that achieved modified Rankin 0 to 2 at 90 days, and what we wanted to see is a difference of around 12%. Unfortunately, the primary outcome was neutral, we did not see that. But what we saw actually, almost all the secondary outcomes were positive, except for the primary outcome. So, when we looked at the secondary outcome using modified Rankin 0 to 3, instead of 0 to 2, the difference was 12.1%. When we looked at the difference in the modified Rankin 0 to 2 at six months, the difference was 15.6% in favor of deferoxamine, but these were secondary outcomes and not the primary outcomes. Dr. Negar Asdaghi:         So, the trial is almost positive. It just depends on how you define the primary outcome, which is really a nice segue to your current study. In the current study, you looked at this secondary outcome in a longitudinal way and looked at the mRS of 0 to 2 at six months from ICH. Can you please tell us about this current paper? Dr. Magdy Selim:             Yeah. So, one of the things that we did with i-DEF is that we were checking the modified Rankin at different time points for all the patients. So, we had it after one week, after one month, after two months, after three months, and after six months. And what we wanted really was a couple of things, just in patients with intracerebral hemorrhage without any treatment, what's the natural course of recovery? And the interesting thing we found out is that patients actually continue to improve over time, and that's what you expect, but what we didn't expect is that they even continue to improve after 90 days. Dr. Magdy Selim:             We always used to think that maximum recovery is around 90 days from ischemic stroke literature, but we saw a lot of patients getting better after 90 days. And this turns out to be also the case with deferoxamine, but the interesting thing is that the percentage of patients that had a good outcome, modified Rankin 0 to 2, was higher with deferoxamine at day seven, at day 30, at day 60, not at 90 days, but again at six months. So, actually, it was higher at all time points except our primary endpoint. Dr. Negar Asdaghi:         So, Magdy, you've already answered my next question, which is exactly what you alluded to, deferoxamine seemed to have improved the outcomes at all of those time points, except for the 90 day, which was the primary outcome of your trial. Why do you think the magic was lost at 90 days? Dr. Magdy Selim:             This is really the million-dollar question. I think we obviously struggled over this. And we went back, we thought maybe there was misrating of the modified Rankin in some of the patients. We tried to correct for this. The difference was bigger, but still not significant. So, we don't really have a good reason to tell you why, at this particular time point, we didn't see the difference except bad luck, I think. But I mean, there are reasons, I think, the question that people actually ask me is the opposite, is why do you think a drug that you give for three days early on is going to make a difference after six months? And I think there are biological reasons to explain this. Dr. Magdy Selim:             So, what happened is that those hemorrhage patients have a lot of other problems. They have increased ICP, they have hydrocephalus, they have intraventricular hemorrhage, and actually iron has been implicated in the development of hydrocephalus in chronic white matter injury. So, my explanation is that you start early on with the treatment, it does help, but it takes a while for it to kick in and for this kind of medical complication to resolve until actually you see the true effect of the drug. And maybe that's why you see the unmasking at the end between the two groups. Dr. Negar Asdaghi:         Yeah, I think I want to recap this for our listeners. Very important to, again, think about those things that some of the acute therapies that we offer the patients may not have a measurable improvement outcome difference early on, certainly with intravenous thrombolysis, we saw that, whereas we saw measurable outcome difference at 90 days, or maybe in this case at six months, but not quite early on. So, it doesn't mean that they don't work. We just are unable to measure that difference and improvement early on. So, what do you think the future holds for deferoxamine? Are we going to see another trial? Dr. Magdy Selim:             Well, I certainly hope so. We're working on some few ideas for that. A lot of people think that maybe we should just do the same thing, but look at six months as the primary outcome. But I think we're actually, that's probably not our primary thinking at this point in time. So, we have published other papers, other analysis, to show that the effect of deferoxamine actually relates to the volume of the hemorrhage. So, if the hemorrhage is very small, there is very minimal benefit. If the hemorrhage is very large, also there is very minimal benefit. And that's really to get kind of the big bang for your buck. You really want people who have mild-to-moderate size hemorrhages. So, we're thinking of a couple of ways to go about deferoxamine with this, whether alone or in combination with other interventions. So, hopefully, we'll have some stuff to share with you in the coming few years, two or three. Dr. Negar Asdaghi:         We'll definitely look forward to reading about those or being involved in the trials as a site, but there's a great way of just actually talking about my next question. It's just completely different than the current paper. I wanted to digress a bit and talk about the recently published intracerebral hemorrhage guidelines, which just published a few months ago. You were part of the guidelines committee. Can you give us a little bit of your point of view of what are the top two most important updates from the guidelines in ICH treatment? Dr. Magdy Selim:             Actually, the guidelines, for the first time this year, in the first page, they have the top 10 take-home messages or top 10 new ones. So, in my opinion, the most important ones, we usually tell you what to do, but here we tell you what not to do because we think it's not good for the patients. So, for example, using steroids just as a prophylactic therapy is actually not recommended. The same thing, we see a lot of people put patients with hemorrhage on hypertonic saline, hyperosmolar therapy, just prophylactically. I don't think there's any benefit that this helps as well, and the same thing for antiepileptic drugs. So, that was one important point. The second one was blood pressure lowering, and there is emphasis now that whatever you use to lower the blood pressure, you want to make sure that the blood pressure variability is very minimal and that there is a smooth kind of control over blood pressure that has been shown to be actually important in terms of help. I'm going to make them three, not two, because I think the third one is important. Dr. Negar Asdaghi:         Okay. I'll give you one more then. Dr. Magdy Selim:             Which is the first time we include this in the guideline, and with emphasis on the role of the home caregiver for hemorrhage patients and the psychological support, the education that they need, and the training that they need to actually care for these patients and how to improve their quality of life. So, I think that's an important aspect that we didn't touch upon before, and obviously very important. Dr. Negar Asdaghi:         Very important points. Let me just review them again for our listeners. So, don't do steroids, hypertonics, and preemptive antiepileptic therapies. They don't work. The second point that you raise is reduction of blood pressure, important to keep that in mind, but paying attention to blood pressure variability. And the third one, the importance of social aspect of care of patients with intracerebral hemorrhage. That's great for us. Let me just end with one last question. Magdy, thank you so much for all of this wonderful take-home messages from the current study from i-DEF and also the guidelines. There's been a lot of excitement in the field of ischemic stroke with the success of reperfusion therapies, and yet not much for intracerebral hemorrhage. What is your hope in terms of future therapies for ICH? Dr. Magdy Selim:             So, I happen to be one of the people who is very optimistic about the future of ICH. I think it's just a matter of time. But I think we need to make some changes. We need to really treat ICH as an emergency, so time is really important. And I think right now, you see a hemorrhage patient, they just put them on the side because they think that there's nothing to do. But the way I see the future evolving, and probably the breaking point to be, is that we can diagnose ICH in the field. You immediately lower the blood pressure, reverse coagulopathy if you can, and even kind of use hemostatic agents, if the FASTEST trial shows evidence to support that, and then you take them to the hospital where there might be some role for hematoma reduction using minimally invasive therapy and some other treatments like deferoxamine, or there are a lot of other agents to target the secondary injury at the same time. So, I think it's going to be a combination of things, and they need to happen in tandem and continuously, but we need to start quickly on these patients. Dr. Negar Asdaghi:         Dr. Magdy Selim, it's been a pleasure interviewing you on the podcast. We look forward to having you back and covering more of your work. Thank you for joining us. Dr. Magdy Selim:             Thank you very much for having me. Dr. Negar Asdaghi:         And this concludes our podcast for the July 2022 issue of Stroke. Please be sure to check out this month's table of contents for a full list of publications, including a series of Focus Updates on the very topic of, you guessed it, intracerebral hemorrhage. These updates are great complements to the newly published American Heart Association guidelines for the management of patients with spontaneous intracerebral hemorrhage in May 2022. Dr. Negar Asdaghi:         And with this, we end our July podcast and draw inspiration from one particular July story, which unfolded on July 20. In 1969, on this day, Commander Neil Armstrong and lunar module pilot Buzz Aldrin landed on the moon, and Armstrong became the first person to walk on the moon. The crew of Apollo 11 changed the course of history, landing humanity on another celestial body for the first time and later safely returning everyone back to earth. Armstrong, an experienced naval aviator, a test pilot, a decorated veteran, astronaut, and university professor, passed away in 2012 from complications of coronary artery disease, reminding us that every step we take in understanding, diagnosing, and treating vascular disorders is truly part of that giant leap to save the mankind. And what better way to do this than to stay alert with Stroke Alert. Dr. Negar Asdaghi:         This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, visit AHAjournals.org.

Welcome back Rounds Table Listeners! We are back today with our Classic Rapid Fire Podcast! This week, Mike and John do a Rapid Fire session to discuss two recent papers exploring pharmacotherapy-based interventions for agitation experienced by individuals with dementia and when to start/restart antiplatelet therapy after stroke caused by intracerebral hemorrhage. Two papers, here ...The post Episode 32 – Agitation in Dementia and Antiplatelet Therapy after Intracerebral Hemorrhage appeared first on Healthy Debate.

Welcome back Rounds Table Listeners! We are back today with our Classic Rapid Fire Podcast! This week, Mike and John do a Rapid Fire session to discuss two recent papers exploring pharmacotherapy-based interventions for agitation experienced by individuals with dementia and when to start/restart antiplatelet therapy after stroke caused by intracerebral hemorrhage. Two papers, here ... The post Episode 32 – Agitation in Dementia and Antiplatelet Therapy after Intracerebral Hemorrhage appeared first on Healthy Debate.

Intracerebral hemorrhages are challenging to manage and patients need immediate interventions to preserve life and limit morbidity. Lessons learned from the ICU and ED shed light on how to best care for these patients.

In this episode we are joined by Associate Professor Nawaf Yassi to discuss his approach to the investigation and management of a patient presenting with intracerebral haemorrhage. We discuss boht common and rarer causes for the presentation alongside the evidence base behind treatment decisions. Music: Good Starts - Jingle Punks https://youtu.be/NstTz8iyl-c

Freddy Frost, research fellow in cystic fibrosis in Liverpool, hosts this week's episode of The Rounds Table with Alex Pickard, trainee in acute and emergency medicine in South London.  Together they cover new research on draining malignant pleural effusions and tranexamic acid in intracerebral haemorrhage. To start, Freddy walks listeners through a multicenter study looking ...The post REPLAY: Cut & Dried – Malignant Pleural Effusions and Tranexamic Acid in Intracerebral Haemorrhage appeared first on Healthy Debate.

Freddy Frost, research fellow in cystic fibrosis in Liverpool, hosts this week's episode of The Rounds Table with Alex Pickard, trainee in acute and emergency medicine in South London.  Together they cover new research on draining malignant pleural effusions and tranexamic acid in intracerebral haemorrhage. To start, Freddy walks listeners through a multicenter study looking ... The post REPLAY: Cut & Dried – Malignant Pleural Effusions and Tranexamic Acid in Intracerebral Haemorrhage appeared first on Healthy Debate.

Freddy Frost, research fellow in cystic fibrosis in Liverpool, hosts this week's episode of The Rounds Table with Alex Pickard, trainee in acute and emergency medicine in South London.  Together they cover new research on draining malignant pleural effusions and tranexamic acid in intracerebral haemorrhage. To start, Freddy walks listeners through a multicenter study looking ...The post Cut & Dried: Malignant Pleural Effusions and Tranexamic Acid in Intracerebral Haemorrhage appeared first on Healthy Debate.

Freddy Frost, research fellow in cystic fibrosis in Liverpool, hosts this week's episode of The Rounds Table with Alex Pickard, trainee in acute and emergency medicine in South London.  Together they cover new research on draining malignant pleural effusions and tranexamic acid in intracerebral haemorrhage. To start, Freddy walks listeners through a multicenter study looking ... The post Cut & Dried: Malignant Pleural Effusions and Tranexamic Acid in Intracerebral Haemorrhage appeared first on Healthy Debate.

Review Your brain is held inside your skull by a tri-layer membrane called the meninges.  These membranes and all the other structures in your brain are nourished by blood vessels, and different circumstances will make these vessels at risk of rupturing. *ALL BRAIN BLEEDS REQUIRE MEDICAL ATTENTION!*  Brain bleeds are classified based on the membrane they are closest to.  They can be caused by physiological malformations, stroke or aneurism from age or disease, or trauma. From the outside in Extracranial bleed: (extra = external; cranial = cranium = skull bones), between your skin and your skull.  Doesn't affect your brain, there is more room for it to stretch. Intracranial bleed: (intra = internal); bleeds inside the skull increase the intracranial pressure and requires medical intervention.  Main goal is to reduce intracranial pressure so brain cells aren't pressed on and damaged. Epidural (yep, that place they put the anesthesia for women having babies, except it's in the spinal cord): Epi = above, Dural = Dura mater, that topmost, durable layer of the meninges.  Between the skull and the dura mater. Subdural: Sub = under; blood leaks in between the dura mater and the arachnoid mater, which are normally in close contact, so the separation causes pain. Subarachnoid: under the arachnoid mater. Normally, under the arachnoid layer is the subarachnoid space which contain cerebral spinal fluid (CSF).  People who have had a subarachnoid bleed and survived, describe hearing a “thunderclap”.  Officially called a “thunderclap headache”.  It's like they can hear the blood vessel pop and experience extreme pain all over their head all at once.  Described as “the worst headache of my entire life”.  Because the pia mater under the subarachnoid space lays directly on top of the brain cells and follows all the grooves and wrinkles of the brain, this type of bleed will require emergent attention and possible surgery. Intracerebral: cerebral = cerebrum, the main part of your brain Intraparenchymal: Parenchyma = organ tissue, means it's right up against the brain cells Intraventricular: Ventricles = pockets inside the brain that make, hold, and reabsorb CSF.  The deepest part of the brain. *ALL BRAIN BLEEDS REQUIRE MEDICAL ATTENTION!*  Connect with me Support us on Patreon *NEW* Join the Pharmacist Answers Podcast Community on Facebook Subscribe: iTunes, Stitcher, GooglePlay, TuneIn Radio Like the Facebook page Music Credits:  “Radio Martini” Kevin MacLeod (incompetech.com)  Licensed under Creative Commons: By Attribution 3.0  http://creativecommons.org/licenses/by/3.0/

This week we dive into the PATCH trial investigating the role of platelet transfusions in patients with spontaneous ICH on antiplatelet meds https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_55_0_Final_Cut.m4a Download Leave a Comment Tags: Intracerebral Hemorrhage, PATCH Trial, Platelets Show Notes Read More REBEL EM: The PATCH Trial: Hold the Platelets in Spontaneous Intracerebral Hemorrhage? St. Emlyn's: JC – Platelets for Intracranial Haemorrhage EM Lit of Note: Put the Platelets Away in ICH References

This week we dive into the PATCH trial investigating the role of platelet transfusions in patients with spontaneous ICH on antiplatelet meds https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_55_0_Final_Cut.m4a Download Leave a Comment Tags: Intracerebral Hemorrhage, PATCH Trial, Platelets Show Notes Read More REBEL EM: The PATCH Trial: Hold the Platelets in Spontaneous Intracerebral Hemorrhage? St. Emlyn's: JC – Platelets for Intracranial Haemorrhage EM Lit of Note: Put the Platelets Away in ICH References