Study Of The Prognostic Factors Intracerebral Hemorrhage

Background: Acute intracerebral hemorrhage is the highest mortality and morbidity in the cerebrovascular diseases, involving more than one million people a year in the worldwide, but now there are few effective treatments. The outcome of intracerebral hemorrhage is depends on the primary injury(e.g., mechanical damage, hematoma and cerebral hernia, etc.) and the secondary injury(such as cell apoptosis, inflammation, necrosis, erythrocyte lysis and the formation of brain edema). In recent years, related animal experimental results have confirmed that the red blood cells split products(particularly iron) are toxic, which may be vital causes of intracerebral hemorrhagic injury. The red blood cells began to degradation about 24 hours after the ictus of intracerebral hemorrhage, lasted for many days, and the decompositions of hemoglobin also have cytotoxicity. The degradated products of hemoglobin have cytotoxicity, especially iron, through free radicals and oxidative stress production, which caused the death of brain cells. Now most studies focus on the brain iron metabolism, but the regulation of serum iron biomarker are still unclear. And the iron content is sharply increase after hemorrhagic brain injury, which aggravated the secondary damage and cerebral edema, the time of consciousness also prolonged, the opportunity of pulmonary infection obviously increase, and the outcome will be changed. Therefore, pulmonary infection is a common and serious complication of intracerebral hemorrhage, and also is one of the important reasons in severely intracerebral hemorrhage patients with death and multiple organ dysfunction syndromes. This is a huge problem to be solved in clinical treatment.Objective:1、To study the regulation of serum iron biomarker after intracerebral hemorrhage and to scree out the biomarker to judge the prognosis and severity of intracerebral hemorrhage.2、To study the recent characteristics of pathogen distribution and drug resistance in hemorrhagic brain injury patients with pulmonary infection in our hospital neurosurgical intensive care unit(NICU), and to improve the level of prevention and treatment, in order to improve the prognosis of patients.Methods:1、A total of 100 cases of intracerebral hemorrhage were included in the southwest hospital from May 2013 to August 2014. The patients were divided into better prognosis group(n = 41) and the prognosis is poorer groups(n = 59) according to 3-month following outcome. 75 normal patients as control group at the same time were collected. The information were observed and recorded in 1day,3day,7day,14 day,21day, about gender, age, hypertension, diabetes, coronary heart disease(CHD), the history of stroke, smoking, drinking, body temperature, systolic pressure, diastolic pressure and imaging data( the sites, breaking into the ventricle, the hematoma volume), laboratory data(white blood cells, red blood cells, platelets, hemoglobin, blood glucose, fibrinogen). And we also calculate the GCS, NIHSS, ICH score and the serum iron, serum ferritin and serum transferrin, serum ceruloplasmin were calculated and detected. Statistical software is SPSS 13.0. Count data were used by chi-square or Fisher’s exact test. Continuous variables are expressed as mean(SD) or the median and quartiles t or the Mann-Whitney test was carried on. Each time point biomarkers level compared with the control group use the nonparametric tes t.2、A retrospective analysis on the incidence of pulmonary infection,drug resistance and distribution of pathogens in hemorrhagic brain injury patients with pulmonary infection in our department from March 2013 to September 2014 in NICU, and the results were statistically analyzed. The information were observed and recorded about gender, age, GCS score, hematoma, smoking, coma time, breathing machine using time, the time in NICU, treatment, etc. Results:1、A total of 100 cases were included from May 2013 to August 2014. Poor outcome at 3 months was observed in 59 of 100(59.0%) patients. Fourteen patients died during the study period. The serum iron, serum transferrin in the poor outcome group were lower than that of good outcome group at admission(p < 0.05); The serum ferritin in the poor outcome group were higher than that of good outcome group at admission(p < 0.05). In terms of complications, the rate of pulmonary infection was high both in the poor and good outcome groups(94.9% vs.75.6%), but the rate was higher in the poor outcome group(P = 0.012). The serum iron in the pulmonary infection group were lower than that of pulmonary infection group at admission(p < 0.05); The serum ferritin in the pulmonary infection were higher than that of pulmonary infection group at admission(p < 0.05).2、Poor outcome, good outcome vs. control group: the serum iron, serum transferrin in the poor outcome and good outcome group were lower than that of control group(p < 0.05) at 1 day, 3 days, 7 days, 14 days, 21 days(p < 0.05); The serum ferritin in the poor outcome and good outcome group were higher than that of control group(p <0.05) a t 1 day, 3 days, 7 days, 14 days, 21 days(p < 0.05). However, the serum ceruloplasmin in the poor outcome and good outcome group compared with control group has no significant(p > 0.05).3、IVH, Non-IVH vs. control group: the serum iron, serum transferrin in the IVH and Non-IVH group were lower than that of control group(p < 0.05) at 1 day, 3 days, 7 days, 14 days, 21 days(p < 0.05); The serum ferritin in the IVH and Non-IVH group were higher than that of control group(p <0.05) at 1 day, 3 days, 7 days, 14 days, 21 days(p < 0.05). However, the serum ceruloplasm in the IVH and Non-IVH group compared with control group has no significant(p > 0.05).4、The hematoma volume more than 30 ml, the hematoma volume less than 30 ml vs. control group: the serum iron, serum transferrin in the hematoma volume more than 30 ml and the hematoma volume less than 30 ml were lower than that of control group(p < 0.05) at 1 day, 3 days, 7 days, 14 days, 21 days(p < 0.05); The serum ferritin in the hematoma volume more than 30 ml and the hematoma volume less than 30 ml were higher than that of control group(p <0.05) at 1 day, 3 days, 7 days, 14 days, 21 days(p < 0.05). However, the serum ceruloplasmin in the hematoma volume more than 30 ml and the hematoma volume less than 30 ml compared with control group has no significant(p > 0.05).5、Surgery, conservative vs. control group:the serum iron, serum transferrin in the Surgery and conservative were lower than that of control group(p < 0.05) at 1 day, 3 days, 7 days, 14 days, 21 days(p < 0.05); The serum ferritin in the Surgery and conservative were higher than that of control group(p <0.05) at 1 day, 3 days, 7 days, 14 days, 21 days(p < 0.05). However, the serum ceruloplasmin in the Surgery and conservative compared w ith control group has no significant(p > 0.05).6、During the study period, a total of 234 cases of hemorrhagic brain injury patients were included, among them 158 cases with pulmonary infection, the infection rate was 67.5%. 76 patients did not have pulmonary infection.7、Of the 158 cases, 61 cases were found with multiple infections, accounting 38.6 % of the infection patients. 26 cases combined two pathogen infection, accounted for 16.5%; 19 cases merged three kinds of pathogen, accounted for 12.0%; 16 c ase merged more than 3 kinds of pathogen, accounting for 10.1% of the infected patients.8、The outcome of non- pulmonary infection is better than that of pulmonary infection. Smoking and age increased the chances of pulmonary infection(p<0.05). The time of coma,breathing machine using, staying in NICU is prolonged(p<0.05).9、219 strains of pathogens were isolated from 158 cases of hemorrhagic brain injury patients with pulmonary infection. Among the 193 strains of gram negative bacteria, accounting for 88.2%; 13 strains of gram positive bacteria, accounting for 5.9% and 13 strains of fungi accounted for 5.9%.10、Gram negative bacteria were sensitive to amikacin,cefoperazone /sulbactam and ciprofloxacin imipenem, and gram positive bacteria were sensitive to vancomycin and teicoplanin. Fungi were no resistance to voriconazole, itraconazole, ketoconazole, amphotericin B.Conclusion:1、Patients of intracerebral hemorrhage have critical condition and high mortality. The outcome was related to the serum iron, serum ferritin and transferrin at admission. Pulmonary infection was high in intracerebral hemorrhage patients, and was related to the serum iron, serum ferritin at admission. The serum iron, serum transferrin in the experimental group were lower than that of control group at 1 day, 3 days, 7 days, 14 days, 21 days(p < 0.05); The serum ferritin in the experimental group were higher than that of control group. However, the serum ceruloplasmin in the experimental group compared with control group has no significant. So, the serum iron and serum ferritin can be used as a prognostic indicator of intracerebral hemorrhage.2、Pulmonary infection has closely related to the prognosis of patients with hemorrhagic brain damage. The hemorrhagic brain injury patients have the high incidence of pulmonary infection in NICU; the pathogens are diverse, dominated by Gram negative bacteria. Diagnosis should focus on the monitoring of multi-drug resistant strains. The choices of antibiotics should be based on the drug sensitivity test.