Background and Purpose-Cerebral microbleeds (MB) are potential risk factors for intracerebral hemorrhage (ICH), but it is unclear if they are a contraindication to using antithrombotic drugs.

Objectives: Antiplatelet therapy (APT) promotes bleeding; therefore, APT might worsen outcome in patients with intracerebral hemorrhage (ICH). We performed a systematic review and metaanalysis to address the hypothesis that pre-ICH APT use is associated with mortality and poor functional outcome following ICH. Methods:The Medline and Embase databases were searched in February 2008 using relevant key words, limited to human studies in the English language. Cohort studies of consecutive patients with ICH reporting mortality or functional outcome according to pre-ICH APT use were identified. Of 2,873 studies screened, 10 were judged to meet inclusion criteria by consensus of 2 authors. Additionally, we solicited unpublished data from all authors of cohort studies with Ͼ100 patients published within the last 10 years, and received data from 15 more studies. Univariate and multivariable-adjusted odds ratios (ORs) for mortality and poor functional outcome were abstracted as available and pooled using a random effects model. Results:We obtained mortality data from 25 cohorts (15 unpublished) and functional outcome data from 21 cohorts (14 unpublished). Pre-ICH APT users had increased mortality in both univariate (OR 1.41, 95% confidence interval [CI] 1.21 to 1.64) and multivariable-adjusted (OR 1.27, 95% CI 1.10 to 1.47) pooled analyses. By contrast, the pooled OR for poor functional outcome was no longer significant when using multivariable-adjusted estimates (univariate OR 1.29, 95% CI 1.09 to 1.53; multivariable-adjusted OR 1.10, 95% CI 0.93 to 1.29). Conclusions:In cohort studies, APT use at the time of ICH compared to no APT use was independently associated with increased mortality but not with poor functional outcome. Neurology GLOSSARYAPT ϭ antiplatelet therapy; CI ϭ confidence interval; GOS ϭ Glasgow Outcome Scale; ICH ϭ intracerebral hemorrhage; mRS ϭ modified Rankin Scale; OR ϭ odds ratio.Aspirin or other antiplatelet therapy (APT) could worsen outcome from intracerebral hemorrhage (ICH) by promoting bleeding. Published observational studies of outcomes in pre-ICH APT users have yielded conflicting results, however. Some suggest an increased risk of poor outcome 1-3 while others suggest no increased risk. 4,5 If prior APT worsens outcome, then restoration of normal platelet function could be a therapeutic target.We hypothesized that pre-ICH APT use would be associated with increased mortality and functional impairment following ICH, and tested this hypothesis by performing a systematic review of the literature. To reduce the likelihood of publication bias, we additionally requested information from established cohort studies that had not previously published on the association between pre-ICH APT and clinical outcomes.METHODS Search strategy, selection criteria, and data abstraction. Using the Meta-analysis of Observational Studies in Epidemiology (MOOSE) criteria as a guide, 6 we searched for studies describing mortality or functional outcome of consecutive adults with spontaneous ICH by APT use, ex...

Cerebrospinal fluid (CSF) plays an essential role in maintaining the homeostasis of the central nervous system. The functions of CSF include: (1) buoyancy of the brain, spinal cord, and nerves; (2) volume adjustment in the cranial cavity; (3) nutrient transport; (4) protein or peptide transport; (5) brain volume regulation through osmoregulation; (6) buffering effect against external forces; (7) signal transduction; (8) drug transport; (9) immune system control; (10) elimination of metabolites and unnecessary substances; and finally (11) cooling of heat generated by neural activity. For CSF to fully mediate these functions, fluid-like movement in the ventricles and subarachnoid space is necessary. Furthermore, the relationship between the behaviors of CSF and interstitial fluid in the brain and spinal cord is important. In this review, we will present classical studies on CSF circulation from its discovery over 2,000 years ago, and will subsequently introduce functions that were recently discovered such as CSF production and absorption, water molecule movement in the interstitial space, exchange between interstitial fluid and CSF, and drainage of CSF and interstitial fluid into both the venous and the lymphatic systems. Finally, we will summarize future challenges in research. This review includes articles published up to February 2016.

The “cerebrospinal fluid (CSF) circulation theory” of CSF flowing unidirectionally and circulating through the ventricles and subarachnoid space in a downward or upward fashion has been widely recognized. In this review, observations of CSF motion using different magnetic resonance imaging (MRI) techniques are described, findings that are shared among these techniques are extracted, and CSF motion, as we currently understand it based on the results from the quantitative analysis of CSF motion, is discussed, along with a discussion of slower water molecule motion in the perivascular, paravascular, and brain parenchyma. Today, a shared consensus regarding CSF motion is being formed, as follows: CSF motion is not a circulatory flow, but a combination of various directions of flow in the ventricles and subarachnoid space, and the acceleration of CSF motion differs depending on the CSF space. It is now necessary to revise the currently held concept that CSF flows unidirectionally. Currently, water molecule motion in the order of centimeters per second can be detected with various MRI techniques. Thus, we need new MRI techniques with high-velocity sensitivity, such as in the order of 10 μm/s, to determine water molecule movement in the vessel wall, paravascular space, and brain parenchyma. In this paper, the authors review the previous and current concepts of CSF motion in the central nervous system using various MRI techniques.

Background and Purpose Hematoma expansion following acute intracerebral hemorrhage (ICH) is common and is associated with early deterioration and poor clinical outcome. The CT angiography (CTA) spot sign is a promising predictor of expansion, however frequency and predictive values are variable across studies, possibly due to differences in onset-to-CTA time. We performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and frequency and predictive ability of the spot sign. Methods We completed a systematic review for studies of CTA spot sign and hematoma expansion. We subsequently pooled patient-level data on the frequency and predictive values for significant hematoma expansion according to five pre-defined categorized onset-to-CTA times. We calculated spot sign frequency both as raw and frequency-adjusted rates. Results Among 2051 studies identified, 12 met our inclusion criteria. Baseline hematoma volume, spot sign status and time-to-CTA were available for 1176 patients, and 1039 patients had follow-up CTs for hematoma expansion analysis. The overall spot sign frequency was 26%, decreasing from 39% within two hours of onset to 13% beyond eight hours (p<0.001). There was a significant decrease in hematoma expansion in spot positive patients as onset-to-CTA time increased (p=0.004), with positive predictive values decreasing from 53% to 33%. Conclusions The frequency of the CTA spot sign is inversely related to ICH onset-to-CTA time. Furthermore, the positive predictive value of the spot sign for significant hematoma expansion decreases as time-to-CTA increases. Our results offer more precise risk-stratification for patients with acute ICH, and will help refine clinical prediction rules for ICH expansion.

Rapid administration of antifibrinolytic agents consisted of intravenous administration of 2 g tranexamic acid over 10 minutes. Systolic BP was strictly maintained below 150 mm Hg using intravenous nicardipine. Immediately after diagnosis of ICH on computed tomography (CT), 188 patients who were admitted within 24 hours of symptom onset were treated with a combination of rapid administration of antifibrinolytic agents and BP control. Hematoma enlargement was determined on the basis of a second CT scan performed the day after admission. Several factors, including those that have been reported to affect hematoma enlargement, were compared between patients with and without hematoma enlargement. Hematoma enlargement (> or =20% volume increase) was observed in eight (4.3%) of 188 patients. Previous use of antiplatelet agents was significantly more frequent in patients with hematoma enlargement (p < 0.05). No significant between-group difference was found for any other factors Conclusions. Previous use of antiplatelet agents was a predictor of hematoma enlargement in patients with ICH treated with rapid administration of antifibrinolytic agents and BP control.

obJective The middle meningeal artery (MMA) is suspected to play an important role in the development of chronic subdural hematoma (CSDH). The aim of this study was to clarify whether the MMA was enlarged in patients with CSDHs. Methods The authors retrospectively assessed 55 patients in whom CSDH was diagnosed between 2010 and 2014 and who underwent MR angiography (MRA) after the onset of CSDH. The authors compared MMA diameters between hemispheres with and without CSDHs on MR angiograms. A case-control study was also performed with 55 sex- and age-matched patients with incidental unruptured aneurysms as controls. results In 55 patients with CSDHs, the diameters of the 79 MMAs on the CSDH side were significantly larger than the diameters of the 31 MMAs on the non-CSDH side (p < 0.05). In 24 patients with bilateral CSDHs, no significant difference was found between the MMA diameters on the larger hematoma side and those on the smaller hematoma side. In 13 patients who underwent MRA before the onset of the CSDH, the MMAs on MR angiograms acquired after onset of the CSDH were significantly larger than those on MR angiograms acquired before the CSDH onset (p < 0.05). The diameters of the MMAs in 55 patients with CSDHs were significantly larger than those of the MMAs in the 55 control patients (p < 0.05). coNclusioNs The MMA is enlarged with development of a CSDH. Information about the MMA observed on MRA in patients with CSDHs may be useful in developing a strategy for future treatment of CSDHs.

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