“an observational study admission leukocytosis and …

A dissertation on

“AN OBSERVATIONAL STUDY ADMISSION

LEUKOCYTOSIS AND IT’S IMPLICATIONS ON INTRA-

CEREBRAL HEMORRHAGE”

Submitted in partial fulfilment of requirements for

M.D. DEGREE IN GENERAL MEDICINE

BRANCH-I

OF

THE TAMILNADU M.G.R.MEDICAL UNIVERSITY

CHENNAI.

INSTITUTE OF INTERNAL MEDICINE

MADRAS MEDICAL COLLEGE

CHENNAI – 600 003

MAY 2020

CERTIFICATE

This is to certify that the dissertation entitled “AN

OBSERVATIONAL STUDY ON ADMISSION


CEREBRAL HEMORRHAGE” is a bonafide work done by

Dr.M.NIRUMAL KHUMAR, at Madras Medical College, Chennai in partial

fulfilment of the university rules and regulations for award of M.D., Degree in

General Medicine (Branch-I) under our guidance and supervision during the

academic year 2017-2020.

Prof. Dr. NALINI KUMARAVELU M.D.,

Guide & Research Supervisor,

Institute of Internal Medicine,

Madras Medical College &

Rajiv Gandhi Govt. General Hospital,

Chennai - 3.

Prof. Dr. S. RAGUNANTHAN, M.D.,

Director (I/c) and Professor,

Institute of Internal Medicine,

Madras Medical College &

Rajiv Gandhi Govt. General Hospital,

Chennai - 3.

Prof. Dr. JAYANTHI, M.D, FRCP (Glasg)

DEAN

MMC & RGGGH,

Chennai - 03.

DECLARATION

I, Dr.M.NIRUMAL KHUMAR, solemnly declare that this dissertation

entitled “AN OBSERVATIONAL STUDY ADMISSION


CEREBRAL HEMORRHAGE” was done by me at Madras Medical

College and Rajiv Gandhi Government General Hospital, Chennai during 2017-

2020 under the guidance and supervision of

Prof Dr NALINI KUMARAVELU, M.D. This dissertation is submitted to the

Tamil Nadu Dr.M.G.R. Medical University towards the partial fulfilment of

requirements for the award of M.D. Degree in General Medicine (Branch-I).

Place: Chennai-3 Signature of Candidate

Date:

ACKNOWLEDGEMENT

I would like to thank our beloved Dean, Madras Medical College,

Prof. Dr. R.JAYANTHI. M.D., FRCP (Glasg), for her kind permission to use

the hospital resources for this study.

I would like to express my sincere gratitude to my beloved Professor and

Director, Institute of Internal Medicine Prof. Dr. S.RAGUNANTHAN, M.D., for

his guidance and encouragement.

With extreme gratitude, I express my indebtedness to my beloved Chief and

Teacher, Prof Dr NALINI KUMARAVELU, M.D. for his motivation, advice and

valuable criticism, which enabled me to complete this work.

I am extremely thankful to Assistant Professors of Medicine

Dr. A. PRIYATHARCINI, M.D., and Dr JACINTH PREETHI, M.D., for their

co-operation and guidance.

I thank all Professors, Assistant Professors, and Postgraduates of Institutes

of biochemistry, pathology, microbiology and radiology for their valuable support

in the analysis.

I would always remember with gratefulness, the cooperation and criticism

shown by my Postgraduate colleagues.

I am immensely grateful to the generosity shown by the patients who

participated in this study.

Above all I thank God for his immense blessings and guidance.

LIST OF ABBREVIATIONS

ICH- INTRACEREBRAL HEMORRHAGE

PMN- POLYMORPHONUCLEAR NEUTROPHILS

NET- NEUTROPHIL EXTRACELLUAR TRAPS

TNF- TUMOUR NECROSIS FACTOR

TFPI-TISSUE FACTOR PATHWAY INHIBITOR

VWF- VON WILLEBRAND FACTOR.

PCC-PROTHROMBIN COMPLEX CONCENTRATES

FFP-FRESH FROZEN PLASMA.

CONTENTS

S.

NO. TITLE

PAGE

NO.

1 INTRODUCTION

2 AIMS AND OBJECTIVES

3 REVIEW OF LITERATURE

4 MATERIALS AND METHODS

5 OBSERVATION AND RESULTS

6 DISCUSSION

7 CONCLUSION

8 LIMITATION OF STUDY

9 BIBLIOGRAPHY

10 ANNEXURES

- PROFORMA

- ETHICAL COMMITTEE APPROVAL

- PLAGIARISM SCREENSHOT

- PLAGIARISM CERTIFICATE

- INFORMATION SHEET

- CONSENT FORM

- MASTER CHART

1

INTRODUCTION

Intracranial haemorrhage is life threatening emergency and is one of the bad Prognostic

variants of stroke. (1) It accounts for about 10-20% of all cerebrovascular accidents.(1)

There are 4 types of intra-cranial haemorrhage namely subdural haemorrhage, extra-

dural haemorrhage, sub-arachnoid haemorrhage and intra-cerebral haemorrhage with or

without intra-ventricular extension. Of all these types intra-cerebral haemorrhage

results mostly from medical causes. Hematoma expansion occurs early in intracerebral

haemorrhage, is usually determined by multiple factors. It is usually associated with

adverse outcomes. Hence it’s a modifiable determinant of intracerebral haemorrhage.(2)

Acute leucocytosis is a well-established response to intracerebral haemorrhage. The

relationship between acute inflammation and pathology of intra-cerebral haemorrhage

is complex Leukocytes via its interaction with platelets, endothelium may shift the

balance in favour of coagulation and may therefore play a role in arrest of bleeding after

an intracerebral haemorrhage. In order to test the hypothesis whether acute leucocytosis

limits extent of the bleeding following intra-cerebral haemorrhage, we aim to

investigate the relation between hematoma volume expansion and intra-cerebral

haemorrhage in this study.

2

AIMS AND OBJECTIVES

1) In this study we attempt to establish a relationship between intra-cerebral

haemorrhage and leucocytosis that occurs at the face of it. With due focus also

on leukocyte subtype and its influence on hematoma expansion.

2) To use this as an early tool for detecting hematoma expansion. This can be used

both in prognostication and to also in developing newer drugs using this as a

therapeutic target.

3

REVIEW OF LITERATURE

INTRACEREBRAL HEMORRHAGE

Intracranial haemorrhage is a type of stroke. Patients with intracranial haemorrhage tend

to present with headache than patients with ischemic strokes. However imaging of the

brain is required to distinguish them. CT brain is highly sensitive and specific for

intracranial haemorrhage and also to determine its location. Based on the location intra-

cranial haemorrhage can be broadly classified in to 4 types, namely extra-dural

haemorrhage, sub-dural haemorrhage, sub-dural haemorrhage and intra-cerebral

haemorrhage. Of these types extra-dural haemorrhage ,sub-dural haemorrhage and sub-

arachnoid haemorrhage mostly result from traumatic causes.(1) Which sub-arachnoid

haemorrhage can also result from rupture of intracranial aneurysm, its most common

causes remains trauma. Intra-cerebral haemorrhage accounts for about 10% of all

strokes , and 35-45% of the patients who die within the first month. Incidence being

particularly high in Asians and blacks. Hypertension, coagulopathy, drugs(anti-

coagulants) , cerebral amyloid angiopathy. Risk is also increased by binge alcohol and

advanced age. Intra-cerebral haemorrhage can be arterial or venous. Venous

haemorrhage result from dehydration, oral contraceptive use in females or

inherited/acquired thrombo-philias. It is mostly a disease of young people. Arterial

haemorrhage occurs most commonly secondary to hypertension, Aterio-venous

malformations(AVM). Hypertensive bleeds occur most commonly in putamen,

thalamus , cerebellum and the pons. Hemorrhage in other areas of the brain should

4

SUBDURAL HEMORRHAGE

EPIDURAL HEMORRAHAGE

5

SUBARACHNOID HEAMORRHAGE

INTRA-CEREBRAL HEMORRHAGE

6

Prompt consideration and investigation in to lesser common aetiologies like

haemorrhagic disorders, tumour bleeds, vascular malformations, vasculitis and cerebral

amyloid angiopathy. Most intra-cerebral haemorrhages develop over 30-90 minutes,

whereas those associated with coagulopathy and anti-coagulant therapy evolve over 1-

2 days. One third of patients even those without significant coagulopathy may have

significant volume expansion within the first day. In 48-72 hours the macrophages begin

to phagocytize the hemosiderin particles at its outer surface. It may take about 1-6

months for the haemorrhage to look slit like cavity lines with glial tissue and

hemosiderin-laden macrophages. Primary intra-ventricular haemorrhage is a rare

entity, should prompt evaluation of underlying vascular anomaly. Rarely bleeding

though it begins in the periventricular substance of the brain can dissect into the

ventricular system without leaving signs of intra-parenchymal haemorrhage. Rarer

causes of bleeding include haemorrhagic transformation of ischemic strokes which

usually occurs with large parenchymal bleeds, drugs like cocaine and amphetamines

especially in younger individuals. Head injury can rarely cause intra-cerebral

haemorrhage. Tumours like choriocarcinoma, renal cell carcinoma, bronchogenic

carcinoma and malignant melanoma can produce central nervous system metastasis

with intra-cerebral haemorrhage. Glioblastoma multiforme and medulloblastoma in

adults and children respectively can produce areas of Intra-cerebral haemorrhage.

Sepsis can cause multiple petechial bleeds in the cerebral white matter. Moya-Moya

disease can cause ischemic symptoms can present with intra-cerebral haemorrhage.

7

HEMATOMA EXPANSION

Hematoma expansion in Intra-cerebral haemorrhage is defined as absolute increase of

6ml or 30 % of initial bleed volume. Although the biochemical mechanism of hematoma

expansion remain unclear , cumulative evidence suggests it may be due to ongoing

bleeding from secondary sites adjacent to the initial site.(3) The predictors of hematoma

expansion, its causes and implications has long been a matter of debate and controversy.

Several risk factors for hematoma expansion has been identified including baseline

bleed volumes, anti-coagulation therapy, CT angiography spot sign.(4) Choice of

imaging to detect hematoma expansion remains non-contrast CT Brain . The formula

of assessment of hematoma volume measurement can be ABC/2, ABC/4 depending

on institute protocols.(4) CT Angiography can be used for both diagnosis and

prognostication of intra-cerebral haemorrhage. Though initially they were used to

visualise vascular abnormalities underlying ICH such as Arterio-venous malformations,

aneurysms or neoplasms. They serve a additional purpose of visualisation of contrast

extravasation in to brain parenchyma commonly termed as spot sign.(4) Spot sign

correlates with active hematoma expansion and correlates with poor outcomes.

Widespread availability of NCCT makes it the imaging of choice in detecting hematoma

expansion. MRI with Gradient echoes can be very accurate in detecting microbleeds

and can also predict occurrences of future lobar ICH.

8

A) NCCT SHOWING RIGHT GANGLIOCAPSULAR BLEED

B) CT ANGIOGRAM SHOWING POSITIVE ‘SPOT’ SIGN

C) SUBSEQUENT NCCT SHOWING HEMATOMA EXPANSION

PATHOPHYSIOLOGY OF HEMATOMA EXPANSION:

Hematoma expansion can be considered analogous to a bathtub with a persistently leaky

tap. This way its easier to visualise. But there is no direct histopathological support for

a single leaky vessel model. An alternate ‘avalanche’ model was proposed in early 70s.

This model describes a process of hematoma growth due to shearing of neighbouring

vessels caused by expansion of initial bleed. There is a bi-modal distribution of as either

‘macro-bleeds’ or ‘microbleeds’ consistent with the avalanche model. This model is

also indirectly supported by data showing association of (APOE) ε2 allele to be

associated with hematoma expansion especially in lobar ICH. Since this allele correlates

with breakdown of vessel walls affected by cerebral amyloid angiopathy.(4) Its easier to

9

imagine this way that walls of these vessels are prone to rupture. Avalanche model is

also consistent with CTA Spot sign as sites of active bleeding, since multiple bleeding

sites within a single hematoma are common, suggesting rupture from multiple sheared

vessels than a single bleeding vessel.

COMPUTATIONAL MODEL:

A recent trial tried to create a computational simulation of the avalanche model that

would identify the characteristics of haemorrhage generated by simulated rupture of

adjacent vessels surrounding an initial bleed site.(5) The results of simulation indicated

that under simulated rate of vessel rupture and haemorrhage decay, this model yielded

bimodal distribution of micro and macro-bleeds. Anti-coagulant usage led to much

higher rates of haemorrhagic decays and macro-bleeds.

10

RISK FACTORS:

Hematoma expansion in ICH has many risk factors. Few established risk factors like

uncontrolled BP, anti-coagulant use. Larger initial bleed volumes are more likely to

expand. As established earlier APOE allele also increases the risk of expansion in Lobar

ICH. Another important predictor is CTA spot sign but its suffers from abnormally low

sensitivity which is 51% as per PREDICT trial.(4)

11

HEMATOMA PREDICTION SCORE:

Hematoma prediction is latest entry in to already numerous list of scoring systems in

ICH.(6) It is a ordinal scale of 6 factors, only one of which is related to CT finding

(subarachnoid haemorrhage in CT brain). Other factors relate to timing of symptom

onset and imaging, anti-platelet use, smoking, Glasgow coma scale at presentation,

presence of underlying dementia. In a few studies this was equated to CTA spot sign

when HEP score more than or equal to 4

12

ICH SCORE:

ICH Score is an important scoring system used in ICH, though it does not take in to

account for factors relating to hematoma expansion. It is a risk stratification score and

used to calculate 30 days outcomes in terms of mortality

13

TIMING OF IMAGING:

Timing of repeat imaging is important as it is a window of frame between initial bleed

volumes and final stabilised bleed volumes. Historically various trials and studies

have used different time frames for repeat NCCT brain.

APPEARANCE OF ICH IN VARIOUS PHASES.

Phase of

Blood

NCCT T1-Weighted MR T2-Weighted MR

Hyperacute Smooth-hyperdense Hypointense or isointense Hypointense

Acute (12–48

h)

Hyperdense with

fluid levels

Isointensity or slight

hypointensity with thin

hyperintense rim in the

periphery

Hypointense with

hyperintense

perilesional rim

Early

subacute (72

h)

Hypodense region

of edema with mass

effect

Hyperintensity Hyperintensity

Late subacute

(3–20 d)

Less intense with

ring like profile

Hyperintensity Hyperintense

Chronic (9

wk)

Isodense or modest

confined

hypodensity

Hypointensity Hypointensity

e or isointense core

surrounded by

hypointense rim

14

General consensus based on evdiences suggests that repeat imaging be performed 48-

72 hours after the initial episode taking in to account availability and logistic factors in

to consideration.

STATEGIES IN MANAGEMENT OF ICH:

The treatment of ICH have been dominated by two considerations

1) Type and intensity of medical interventions required to improve functional

prognosis

2) The choice between medical and surgical therapies

INITIAL MANAGEMENT

Emergency management should focus on airway, breathing and circulation. Assessment

of Glasgow coma scales is important. Airway stabilisation necessary if GCS is less than

8. Ventilation should be adequate to prevent aspiration , adequate enough to maintain

PaO2 > 60mmHg and PCO2 <50mmHg.Next focus should be on reduction of

intracranial pressure especially in those with impending signs of herniation like unequal

pupils or patients with brain stem dysfunction.

REDCUING INTRA-CRANIAL PRESSURE

1) Head end elevation to 30 degrees helps to reduce intra-cranial pressure as well

as helping in preventing aspiration.

2) Hyperventilation to maintain PCO2 between 30-35mmHg.(7)

3) Hypertonic saline and Mannitol administration. 20%Mannitol started at doses of

1-1.5g/kg given as bolus followed by 100-150 ml every 6-8 hours until any

15

neurosurgical procedure if required can be done. The goal of this therapy should

be to maintain ICP <20 mmHg. Other agents that can used are sorbitol, glycerol.

They are metabolised by liver. They have shorter half-lives , glycerol has

maximum CNS penetration. Use of corticosteroids have no proven benefit in

reduction of intra-cranial pressure.

MANAGEMENT OF BLOOD PRESSURE:

Control of blood pressure have been a subject of controversy in strokes especially in

patients with ICH . Blood pressure control is necessary because persistent high blood

pressures can increase cerebral edema and can increase ICP. However, this potential

benefit of BP reduction must be balanced against the possible effects of drug-induced

hypotension, with resulting cerebral ischemia and worsening neurological defects.

.Pharmacological correction of severe hypertension is required in acute ICH with goal

to maintain cerebral perfusion pressure of 50-70 mm Hg, and aiming at a blood pressure

of 160/90. Maintenance of mean arterial pressure about 130 is adequate. If initial

presenting systolic BP is between 150-220 then reduction to 140 mm Hg may be safe

and improves clinical outcomes.

16

CHOICE OF AGENT:

The anti-hypertensive agent of choice in ICH is IV Beta and alpha blocking agent

Labetolol which is often used in combination with loop diuretics. The use of IV calcium

channel blocking drug nicardipine is also an equally effective choice since it’s not have

cerebral vasodilatory effects. These agents also act rapidly and are also easy to titrate.

17

EARLY HEMOSTATIC THERAPY:

Early neurological deterioration in ICH was attributed to edema and mass effects it

exerts around the hematoma. But recent pathological, CT , SPECT have suggested

continuous bleeding in to the hematoma, as suggested by the avalanche model. The

rebleeding is associated with poorer outcomes and is now a target of treatment. Initial

efforts should be directed at identifying drugs that can cause ICH including

thrombolytic therapy, antiplatelet therapy or anti-coagulant use and reversing their

effects. The half- life of recombinant plasminogen activators is limited to 45 minutes.(8)

Hence haemorrhagic complications due thrombolytic therapy is limited to initial few

hours of its use. Guidelines in management of thrombolytic therapy induced ICH

includes transfusion of 4u of packed red cells, 4-6 units of cryoprecipitate or fresh

frozen plasma, and 1 unit of single donor platelets. Bleeding related to heparin use can

be managed with administration of 1 unit protamine sulphate for every 100 IU of

heparin. FFP should be withheld when treating heparin related coagulopathy as it can

provide anti-thrombin III which may prolong anti-coagulation status. Warfarin inhibits

recycling of vitamin K and prevent Gamma carboxylation of vitamin k dependent

factors. So administration of vitamin k may help reversal of warfarin toxicity but effect

may be delayed for 24 hours. In case of emergency FFP can be used for rapid reversal

of anti-coagulation. But concerns over persistence of coagulopathy despite reversal of

INR have advocated towards use of prothrombin complex concentrates(PCC).(7) Use

of anti-platelet agents prior to ICH is a risk factor for continuous bleeding and poor

18

outcome so these patients can be treated with platelet infusions and desmopressin

administration.

Activated factor VII a has been extensively studied in randomized control placebo

studies. The hemostatic effect was more pronounced with incremental doses of rFVIIa

used within 4 hours of symptom onset compared with placebo. The studies have

suggested that they can be used even in patients without underlying coagulation

disorder.

Anti-convulsant therapy:

Seizures are a very common presentation of ICH, can also occur as a complication of

ICH. The 30 day risk of seizures is around 8%. The seizure occurrence may also be

dependent on location of seizure with it being more common with lobar hematomas

which is a independent predictor of early seizures. No randomized control trial have

been evaluated for prophylaxis of seizures following ICH. Stroke council of AHA have

recommended prophylactic anti-epileptic treatment for 1 month in patients with intra-

cerebral haemorrhage which may be discontinued if no seizures occurs in that 1 month.

AGENTS OF CHOICE:

If patient is having active seizures management with intravenous lorazepam (0.05-

0.10mg/kg) followed by phenytoin loading dose/ fosphenytoin(15-20mg/kg),

Valproate(15-45 mg/kg) or phenobarbital (15-20mg/kg).(9)

19

FEVER CONTROL:

Fever is very common after an ICH and should be managed aggressively as it is

independent predictor of poor outcome.(10) As fever increases core body and brain

temperature, the metabolic activity is increased which can cause increase in cerebral

edema which again leads to poor outcomes. Central fever of neurological origin is a

diagnosis of exclusion when blood extends in to subarachnoid and intra-ventricular

spaces after ruling out infections as the cause of fever. Fever can be managed with

external cooling and acetaminophen.(11) ICH patients who are refractory to paracetamol

and cooling may require additional antibiotics and external cooling devices. Adhesive

cooling systems and heat exchange systems have proved useful in maintaining

normothermia.

DVT PROPHYLAXIS

Prophylaxis of deep venous thrombosis becomes important aspect of managing any

immobilized patient especially patients with stroke due to limb paresis and longer

duration of immobilization. Intermittent pneumatic compression devices and elastic

stockings have been advocated. Few studies recommend use of low dose heparin

beginning from day 2 of admission provided there is no contra-indication. No evidence

of rebleeding was observed.(12)

20

PNEUMATIC COMPRESSION DEVICE:

SURGICAL MANAGEMENT:

Extensive discussion about surgical management is beyond the scope of this discussion.

STITCH trial randomized patients to early surgery versus conservative medical

management. The size, location and volume of haemorrhage were almost similar in both

groups. The patients randomized to surgery underwent surgery within 24 hours. 3/4th of

the patients underwent craniotomy, reminder underwent removal by burr hole

technique. Overall no benefit was observed for early surgery was observed in

supratentorial bleeds. Only few subgroups with bleed within a centi-meter of cortex

showed benefit of early surgery. Infratentorial hematomas achieved benefit from early

surgery especially cerebellar hematomas greater than 3cm due to higher risk of

brainstem compression and risk of hydrocephalus within 24 hours.(13)Ventricular drains

21

have been conventionally used for patients with or at risk of hydrocephalus. Since

volume of IVH strongly suggests bad prognosis at 30 days. Some preliminary studies

have suggested use of intraventricular thrombolysis with urokinase within 72 hours of

IVH may help drain the blood-filled ventricles and decrease 30 day mortality rate.

Presence of lesions with potential for recurrence like AVM, intracranial aneurysms or

cavernous angiomas is a separate indication for surgery.

SUMMARY OF MANAGEMENT

22

LEUKOCYTOSIS AND ITS IMPLICATIONS

LEUKOCYTES:

Leukocytes are an important component of the immune system. Immune system can be

broadly classified in to innate and adaptive immune system. Neutrophils, monocytes,

form a important part of innate immune response.

INNATE IMMUNITY:

In vertebrates, the skin and other epithelial surfaces, including those lining the lung and

gut, provide a physical barrier between the inside of the body and the outside

environment. Tight junctions between neighbouring cells prevent easy access by

potential pathogens. The interior epithelial surfaces are also covered with a mucus layer

that protects these surfaces against microbial, mechanical, and chemical insults; many

amphibians and fish also have a mucus layer covering their skin. The slimy mucus

coating is made primarily of secreted mucin and other glycoproteins, and it physically

helps prevent pathogens from adhering to the epithelium. It also facilitates their

clearance by beating cilia on the epithelial cells.

23

ROLE OF NEUTROPHILS IN INNATE IMMUNITY:

Neutrophils being the most abundant leukocytes in circulation form the first line of

innate immunity. They capture and destroy invading microorganisms, through

phagocytosis and intracellular degradation, release of granules, and formation of

neutrophil extracellular traps after detecting pathogens.(14) Neutrophils also has a role

as mediators of inflammation. The traditional view for these leukocytes is that

neutrophils constitute a homogenous population of terminally differentiated cells with

a unique function. However, cumulative evidence, has revealed that neutrophils present

a large phenotypic heterogeneity and functional versatility, which place neutrophils as

important mediators of both inflammation and immune responses.(14) Indeed, the roles

played by neutrophils in homeostatic conditions as well as in pathological inflammation

and immune processes are the focus of a renewed interest in neutrophil biology.

24

Neutrophils, also known as polymorphonuclear (PMN) leukocytes, are the most

abundant cell type in human blood. Bone marrow has a huge reserve of, ~1011 cell per

day. Under homeostatic conditions, neutrophils enter the circulation, home to

inflammatory sites and are destroyed, all in a span of a day. They constantly patrol in

the blood stream for signs of microbial infections, and when found, these cells promptly

respond to the trap and kill the colonising pathogens. Three main antimicrobial

functions are recognized for neutrophils: phagocytosis, degranulation, and the release

of nuclear material in the form of neutrophil extracellular traps (NETs)(14). Until

recently these functions were considered, the only purpose of neutrophils. However,

current evidence by investigators in neutrophil cell biology has revealed that neutrophils

have a much diverse repertoire in their arsenal of functional responses that go beyond

the killing of microorganisms. Neutrophils respond to various signals and respond by

producing various cytokines and other inflammatory factors that influence and

modulate inflammation and also the immune system. Nowadays it is recognized that

25

neutrophils are transcriptionally active complex cells that produce cytokines and other

mediators, modulate the activities of neighbouring cells and contribute to the resolution

of inflammation, modulate macrophages for long-term immune responses actively

participate in several diseases including cancer and also has a role in autoimmune

diseases, and even have a role in innate immune memory.

PHASES OF NEUTROPHIL MATURATION:

NEUTROPHIL EXTRACELLULAR TRAPS:

Neutrophil extra-cellular traps were initially thought to be first line of innate defence

against circulating pathogens. Even though NETs have a protective role against

circulating pathogens, recent investigations suggest that an uncontrolled and excessive

NET activation within the vasculature may contribute to pathogenesis of thrombotic

disorders.(15) In vitro studies have suggested NETs promote vascular occlusion by

providing a scaffold on which platelets, red blood cells, extracellular vesicles, and other

procoagulant molecules, such as von Willebrand factor and tissue factor initiate the

clotting process. In addition, NET components enhance coagulation by both activating

the intrinsic pathway and degrading an tissue factor pathway inhibitor. NET formation

26

has been proposed to contribute to thrombus formation and propagation of arterial,

venous, and cancer-associated thrombosis

LEUKOCYTOSIS:

Leucocytosis is a common lab finding most often due to relatively benign conditions

like infections and inflammation.(16) More sinister causes include haematological

malignancies. Natural reaction of bone marrow to infection and inflammation is to

increase number of leukocytes especially polymorph nuclear neutrophils (PMNs). This

is commonly referred to as ‘shift to left’. Physical stress can also elevate white blood

cell counts. Medications like corticosteroids, lithium and Beta agonist also do the same.

Eosinophil and basophil counts can be elevated due to causes like parasitic infections

and allergic reactions. Extremely high counts should raise concern for a primary bone

marrow pathology. The patient may present with co-existent symptoms like weight loss,

easy fatigability, bruising and fever with splenic and lymph node enlargement. They

27

can be a result of acute leukaemia’s or chronic myeloproliferative neoplasms. Counts

higher than 1 lakh/mm3 is itself an medical emergency due high risk of CNS

haemorrhage.

NEUTROPHILIC LEUKOCYTOSIS:

DEFINITION OF NEUTROPHILIC LEUKOCYTOSIS FOR DIFFERENT

AGE GROUPS.

28

MONOCYTOSIS:

Monocytes represent about 5% of circulating leukocytes. They can be present as

circulating form or extravasate to tissues and differentiate in to macrophages , dendritic

cells or microglia depending on their location.(17) As widely known monocytosis occurs

in chronic infections such as tuberculosis, endocarditis, and granulomatous diseases.

Monocytosis is associated with atherosclerosis and its consequences such as coronary

artery disease, cerebrovascular disease, or kidney artery stenosis, for example, as a

source of foam cells. Increased monocyte counts after acute myocardial infarction

(AMI) were associated with left ventricular dysfunction.(17) A few studies have

identified monocytosis as a poor prognostic marker in emergency setting with poor 30

days outcomes. Monocytosis was broadly defined as 0.8*109/L in most studies.(18)

29

COAGULATION CASCADE:

Conventionally there are 13 clotting factor in plasma with their function and serum

levels being listed above.

30

The clotting factors can be grouped as

1) The vitamin K-dependent zymogens(prothrombin, factor VII, factor IX, factor

X and protein C )

2) The procoagulant factors (factor V, factor VIII)

3) Soluble co-factors (protein S and von Willebrand factor)

4) The cell surface associated factors (tissue factor, thrombomodulin, endothelial

protein C receptor)

5) Factor XI and the contact system (Factor XII, pre-kallikerin, high molecular

weight kininogen)

6) The fibrin network (fibrinogen, factor XIII, thrombin activatable fibrinolysis

inhibitor)

7) Inhibitors of coagulation (anti-thrombin, tissue factor pathway inhibitor,

protein Z/Protein Z-dependent protease inhibitor).(19)

The coagulation process proceeds when enough thrombin is generated on or near the

tissue factor-bearing cell to trigger activation of platelets and co-factors. Indeed, a

low-level of coagulation factor activation probably occurs at all times. This is known

as basal coagulation. (20)

31

HEMOSTASIS:

Hemostasis is a process by which bleeding is arrested at the site of damaged vascular

endothelium. It represents a dynamic interplay between the sub-endothelium,

endothelium, circulating cells and plasma proteins. The process can be divided in to 3

phases: vascular , platelet and the plasma.(21) The vascular phase in mediated by release

of locally active mediators that result in vasoconstriction at the site of injury and

reduced blood flow. Vascular injury exposes the underlying endothelium and pro-

coagulant proteins, including von Willebrand factor (VWF), collagen and tissue factor

(TF), which then come in to contact with blood. During the platelet phase, platelets bind

to VWF form a layer across exposed sub-endothelium, a process called platelet

adhesion. And subsequently are activated via receptors such as the collagen receptors,

integrin a2b1, and glycoprotein (GPV1). Resulting in mobilization of calcium from

stores, granule release, activation of fibrinogen receptor and subsequent platelet

aggregation.The final phase is the plasma phase which is due to activation of

coagulation cascade which will be discussed below

32

PLATELET ACTIVATION

EXTRINIC PATHWAY:

It begins when vascular injury leads to exposure of tissue factor (TF) in sub-

endothelium and activated endothelial cells. TF binds to small amount of circulating

activated factor VII(activated factor V11a), results in formation of TF:F VIIa complex

also known as extrinsic tenase complex.(22)This complex binds to and activates factor X

to activated factor Xa. Factor Xa forms a complex with activated factor V, released

from collagen- bound platelets to convert prothrombin to thrombin.

33

INTRINSIC PATHWAY:

Intrinsic pathway was initially described by Davie and Ratnoff and Macfarlane , a

waterfall- based sequential activation of clotting factors.(23) It initially begins by

activation of factor XII which gets activated on contact with negatively charged surfaces

which then activates factor XI , then activation of factor IX. Factor IX in combination

with Factor VIII on platelet surface forms the tenase complex of the intrinsic pathway

which cleaves factor X to form activated Factor Xa. The activated factor Xa in

combination with factor Va forms the prothrombinase complex.

35

COMMON PATHWAY:

The common pathway consists of the cascade of events of activation leading from the

formation of activated factor X to the formation of active thrombin, the cleavage of

fibrinogen by thrombin, and the formation of cleaved fibrin into a stable multimeric,

cross-linked complex.(24) Thrombin efficiently catalyzes the activation of several factors

required earlier in the clotting cascade, thus acting in effect as a positive regulator in

the loop of coagulation. At the same time, thrombin activates protein C, which in turn

catalyzes the inactivation of several of these upstream factors especially factor V ,

thereby limiting the clotting process. Thrombin can be trapped in stable, inactive

complexes with: antithrombin-III (SERPINC1), a circulating blood protein; heparin

cofactor II (SERPIND1) which inhibits thrombin in a dermatan sulphate–dependent

manner in the arterial vasculature.(24) Protein C inhibitor (SERPINA5) that inhibits

thrombin in complex with thrombomodulin; and Protease nexin-1 (SERPINE2) that

inhibits thrombin at the vessel wall and platelet surface. The balance between these

positive and negative modulators is critical to the normal regulation of clotting,

facilitating the rapid formation of a protective clot at the site of injury, while limiting

and physically confining the process.

NEW MODEL OF COAGULATION:

The model of extrinsic and intrinsic pathway fails to effectively explain various aspect.

It has left many unanswered questions like why Factor XII deficiency despite factor XII

appearing to have an important role in clotting process does not cause bleeding. It also

fails to explain why haemophilia A and haemophilia B which is deficiency of Factor

36

VIII and IX respectively cause bleeding despite normal extrinsic pathways. The

contributions of intrinsic and extrinsic pathways to the cascade has not been clearly

defined. These questions led to search for new models of coagulation and the answers

have made the picture much more vivid.

The cascade is divided in to 3 phases.

1) Initiation

2) Amplification

3) Propagation.

Initiation begins when a vascular injury leads to exposure of sub-endothelial layers on

damaged cells.(25) TF binds to small amount of activated factor VII which is similar to

what has been described previously in extrinsic pathway.(26) Once small thrombin

amount of thrombin is generated via extrinsic pathway. It is able to initiate coagulation

and generate an amplification loop by cleaving factor VIII from Von Willebrand factor,

Factor XI and platelets.(27) so this constitutes the amplification process.In the

propagation phase the primed platelets with an exposed phospholipid surface with

bound co-factors (FVa and FVIIIa). During the propagation phase factor IX binds

Factor VIII a to from the tenase complex which in association with factor V forms the

prothrominase complex on activated platelet surface. Common pathway is same as that

described above.

37

FIBRINOLYTIC SYSTEM:

Fibrinolytic system is a parallel system which is also activated along with activation of

coagulation cascade. It serves to limit the size of clot formed by the cascade.

Fibrinolysis is an enzymatic process which dissolves the fibrin clot into fibrin

degradation products (FDPs) by plasmin originating from fibrin bound plasminogen in

liver.(28) This reaction is catalysed by tissue plasminogen activator or urokinase

plasminogen activator (u-PA) released from vascular endothelium. The release of t-PA

is stimulated by tissue occlusion, thrombin, epinephrine, vasopressin and exercise.

38

Plasmin activity is under tight regulation by its inhibitor (α-2 antiplasmin) thus

preventing disseminated fibrinolysis.(29) In vivo activity of the fibrinolytic system is

Measured clinically by measuring the FDP's. D dimers are produced by digestion of

Cross linked fibrin and are specific indicators of fibrinolysis used diagnosis of

Venous thromboembolism and DIC .

REGULATORS OF COAGULATION CASCADE:

The haemostatic pathway are regulated by inhibitors that limit coagulation at the site of

injury and extinguish the reactions thereby preventing systemic activation of and

uncontrolled pathologic propagation of coagulation. The regulatory pathway has 3 main

component: Anti-thrombin III, protein C pathway and tissue factor pathway inhibitor.

The fibrinolytic had already been discussed above. Anti- thrombin III- It’s a serine

protease that binds and inactivates factors IX, X, X, XII. The enzymatic activity is

enhanced in the presence of heparin, however not physiological concentrations of

heparin present in serum.

39

Tissue Factor Pathway inhibitor: it’s a polypeptide produced by endothelial cells.(28)

it’s a naturally occurring anti-coagulant that quenches the combination of TF-FVIIa

complex.

PROTEIN C SYSTEM:

Protein c is a serine protease with anti-coagulant, pro fibrinolytic and anti-inflammatory

properties. Its requires activation by thrombin to form activated protein C (APC) which

binds to factor Va and factor VIIIa and inactivates them (with protein S and

phospholipids as co-factors). Endothelial protein C receptor is a transmembrane

receptor which helps in activation of protein C.Thrombomodulin: is a transmembrane

receptor on undamaged endothelial cells. Under physiological conditions it binds to

thrombin and prevents clot formation.Protein S : Is a vitamin k dependent glycoprotein

which Is produced by endothelial cells and hepatocytes. It is present in serum in bound

and free forms. It acts as anti-coagulant by inhibiting compliment activation and is thus

consumed in inflammatory states thus leading to pro-coagulant state.(30) It also acts as a

co-factor to protein C. It can also act by inhibiting the prothrombinase complex.

40

ROLE OF LEUKOCYTES AND INFLAMMATION IN COAGULATION

As we have previously seen about inflammation and leucocytosis, these factors can

influence coagulating at various levels. Inflammation contributes to thrombotic

response via both cellular and humoral immunity. Inflammatory mediators like

endotoxin and TNF alpha increase expression of tissue factor on endothelial cells which

can interact with factor VII and initiate the coagulation cascade. Under physiological

conditions as endothelium is intact these responses are blunted by natural anti-

thrombotic mechanism.(31) In inflammatory states the anti- coagulant mechanism are

depressed like consumption of protein C and protein S . Upregulation of anti-

41

phospholipid antibodies also impair activation of protein C as in inflammatory states

associated with auto immunity. In addition to shifting the balance in favour of

coagulation, inflammation also upregulates plasminogen activator inhibitor thereby

decreasing fibrinolytic activity. Interleukin 6 (IL-6) levels in inflammation can increase

platelet levels and also increases its interaction with agonist like thrombin. Hence the

overall balance shifts in favour of coagulation during acute inflammation.(31) Role of

chronic inflammation and its impact on coagulation cascade is yet to be fully

understood.

42

Role of platelets in inflammation:

Thrombin generated at the injury site is sustained by recruitment of circulating

monocytes and neutrophils to the growing thrombus via interaction of PSGL-1 which

is constitutively expressed by leukocytes to the P-selectin which expressed by recruited

platelets.(32) Monocytes can provide appropriate membrane surface for all proteins in

the coagulation cascade and hence can amplify the response.

43

LEUKOCYTOSIS AND ITS ROLE IN INTRA-CEREBRAL HEMORRAHAGE

Various studies have attempted to elucidate the relationship between leucocytosis which

occurs at the face of intra-cerebral haemorrhage. Few studies and authors

attempted to compare morality at 30 days with leukocyte counts at admission.

Agnihothri et al(33) The study compared leukocyte count and outcomes in ICH.

Primary outcome was mortality, secondary outcomes were mortality at 1 year

44

and modified barhel index at 3 years which is a disability index . The study was

a retrospective study . Patienst with sub-arachnoid haemorrhage , haemorrhage

secondary to trauma were excluded from the study. The study had enrolled 423

cases , the in-hospital mortality was 30.4%.(33) The study showed significant

change in MBI at 3 months with increased leukocyte counts at admission but

same significance could not be demonstrated at 12 months in this study due to

loss of MBI and leukocyte count data. The change in leukocyte counts over the

first 72 hours remained significant predictor of poor discharge disposition

The various limitations to this study are its retrospective design, single centre study and

lot of missing data at months. Overall the study demonstrated that increasing

leukocyte count after admission correlated with morality and poor neurological

outcomes.

Behrouz R, Hafeez S and Miller CM did a retrospective study in ICH patients admitted

over 2 years. The data collected include ICH size , location, intra-ventricular

haemorrhage, age, Glasgow coma scale, peak leukocyte count and temperature

in the first 24 hours and outcomes at discharge.(2) The study had enrolled 128

ICH patients of whom 41.4% had acute leucocytosis at admission. The study

reported that leucocytosis showed strong associated with IVH but study failed to

show correlation between leucocytosis and poor outcome at discharge. There

was no evidence of infection in these patients with leukocytosis which

strengthens the fact that leucocytosis in ICH is reactive.

45

Dr morotti et al(34) attempted to study the relationship between leukocyte count and

hematoma expansion in ICH. The study reported a inverse relationship between

ICH and volume expansion especially in patients with neutrophilic leucocytosis.

46

MATERIALS AND METHODS

Study design:

Observational study

Setting:

Patients with Intra-cerebral haemorrhage admitted at institute of internal

medicine, Madras Medical College and Rajiv Gandhi Government General

hospital during study period from April 2018 to April 2019.

Sample Size determination.

χ² tests - Goodness-of-fit tests: Contingency tables

Analysis: A priori: Compute required sample size

Input: Effect size w = 0.3

α err prob = 0.05

Power (1-β err prob) =0.85

Df =1

47

Output: Non-centrality parameter λ =9.0000000

Critical χ² =3.8414588

Total sample size =100

Actual power =0.850838

SAMPLE SIZE:

100 patients admitted with diagnosis of Intra-cerebral haemorrhage were enrolled in

study at institute of internal medicine, Madras medical college and Rajiv Gandhi

Government General Hospital. Informed consent was obtained from patients.

INCLUSION CRITERIA:

1) Diagnosis of spontaneous ICH on non-contrast CT scan within 48 hours from

onset

2) Available follow up NCCT

3) Complete blood count performed within 48 hours of admission.

EXCLUSION CRITERIA:

1) History or evidence traumatic intracranial

2) Vascular or neoplastic cause of bleeds

3) Venous haemorrhages.

4) Haemorrhagic transformation of ischemic strokes.

5) Primary IVH due to difficulty in assessing expansion

48

METHODOLOGY

After obtaining clearance and approval from the institutional ethics committee, 100

patients were selected as per inclusion and exclusion criteria.

1) Leukocytosis as defined by WBC count more than 11,000 measured within 24-

48 hours of the event(ICH). Differential counts were also studied with respect to

influence of particular subtypes on hematoma expansion. Monocytosis defined

by monocytes >8% or absolute monocyte count of 0.8*109/ mm3. Neutrophilic

leucocytosis defined by neutrophils more than 70%.

2) Follow up NCCT done 48 hours from the event. Hematoma expansion defined

by absolute increase of 6ml or 30% of initial volume.

49

OBSERVATION AND RESULTS

Descriptive for all patients of Volume Expansion

Mean Median

Std.

Deviati

on

Minimu

m

Maximu

m

Rang

e

Interquarti

le Range

Age 56.470

0

55.000

0

9.82828 28.00 74.00 46.00 15.00

total

count(103/

ul)

12.73

65

12.35

00

5.0259

8 5.00 24.50

19.5

0 6.80

Neutrophil

count (%)

75.567

0

78.500

0

11.8945

8

51.20 90.00 38.80 20.75

Monocyte

(%)

5.9450 5.6500 2.42180 .70 12.00 11.30 2.00

plt count

*105/ul

2.2411 2.2000 .47137 1.00 3.50 2.50 .60

Inr 1.0900 1.1000 .08087 1.00 1.30 .30 .11

first

CT(ml)

11.773

0

11.000

0

7.76404 .60 29.00 28.40 13.70

rpt CT(ml) 13.623

0

12.750

0

10.2208

2

.80 38.00 37.20 19.38

volume

exp(ml)

2.0580 0.0000 5.63530 -8.00 16.00 24.00 4.80

50

Descriptive for two groups of Volume Expansion

Descriptives

Volume expansion_group

Mean Median

Std.

Deviation Minimum Maximum Range

Interquartile

Range

Age <6 55.69 55.00 9.66 28.00 73.00 45.00 13.25

>6 59.23 62.50 10.14 45.00 74.00 29.00 20.50

total_count(103/ul) <6 12.71 12.35 5.52 5.00 24.50 19.50 7.83

>6 12.84 12.35 2.75 8.75 17.20 8.45 5.25

Neutrophil(pmn)% <6 76.15 82.00 12.84 51.20 90.00 38.80 21.00

>6 73.50 74.50 7.56 62.00 85.00 23.00 15.18

Monocyte (%) <6 4.98 5.00 1.48 0.70 7.70 7.00 2.00

>6 9.36 10.00 1.99 5.00 12.00 7.00 1.25

platelet_count(105/ul) <6 2.24 2.20 0.50 1.00 3.50 2.50 0.60

>6 2.25 2.20 0.35 1.70 3.00 1.30 0.48

Inr <6 1.10 1.10 0.08 1.00 1.30 0.30 0.20

>6 1.06 1.05 0.07 1.00 1.20 0.20 0.10

first_CT(ml) <6 10.96 10.00 7.62 1.70 29.00 27.30 11.83

>6 14.64 15.00 7.76 0.60 29.00 28.40 7.25

rpt_CT(ml) <6 10.14 8.75 8.03 0.80 30.00 29.20 11.93

>6 25.95 26.00 7.21 11.00 38.00 27.00 6.00

volume_exp(ml) <6 -0.69 -0.25 2.58 -8.00 4.00 12.00 1.23

>6 11.27 10.50 3.26 6.00 16.00 10.00 5.88

51

Frequency Table

age group Frequency Percent

20-40 Years 3 3.0

41-50 Years 25 25.0

51-60 Years 36 36.0

61-70 Years 29 29.0

71-80 Years 7 7.0

Total 100 100.0

3%

25%

36%

29%

7%

Percentage Distribution of Age Group

20-40 Years

41-50 Years

51-60 Years

61-70 Years

71-80 Years

52

hypertension Frequency Percent

yes 88 88.0

yes/CKD 9 9.0

yes/old cva 3 3.0

Total 100 100.0

88%

9%3%

Percentage Distribution of Hypertensive Group

Yes

Yes/CKD

Yes/Old CVA

53

diabetes Frequency Percent

No 64 64.0

Yes 36 36.0

total 100 100.0

64%

36%

Percentage Distribution of Diabetes Group

No

Yes

54

Gender Frequency Percent

female 18 18.0

male 82 82.0

Total 100 100.0

18%

82%

Percentage Distribution of Gender Group

Female

Male

55

volume expansion group Frequency Percent

insignificant exp 6 6.0

no exp 72 72.0

significant expansion 22 22.0

Total 100 100.0

6%

72%

22%

Percentage Distribution of Volume Expansion Group

Insignificant Expansion

No Expansion

Signficant Expansion

56

pmn group(neutrophils) Frequency Percent

<70% 29 29.0

>70% 71 71.0

Total 100 100.0

29%

71%

Percentage Distribution of Pmn Group

<70

>70

57

monocytes group Frequency Percent

>8% 19 19.0

<8% 81 81.0

Total 100 100.0

19%

81%

Percentage Distribution of Monocytes Group

>8

<8

58

drug use Frequency Percent

aspirin 6 6.0

No 94 94.0

Total 100 100.0

6%

94%

Percentage Distribution of Drug Used

Aspirin

No

59

first CT group(ml) Frequency Percent

<10 42 42.0

>10 58 58.0

Total 100 100.0

42%

58%

Percentage Distribution of First CT Group

<10

>10

60

Rpt CT group(ml) Frequency Percent

<10 42 42.0

>10 58 58.0

Total 100 100.0

42%

58%

Percentage Distribution of Repeat CT Group

<10

>10

61

volume expansion

group(ml)

Frequency Percent

<6 78 78.0

>6 22 22.0

Total 100 100.0

78%

22%

volume expansion group

<6

>6

62

total leukocyte count new1

Frequency Percent

<5000 1 1.0

5001-10000 36 36.0

10001-15000 34 34.0

15000-20000 20 20.0

Above 20000 9 9.0

Total 100 100.0

1%

36%

34%

20%

9%

Total leukocyte count

<5000

5001-10000

10001-15000

15000-20000

Above 20000

63

crosstab

volume expansion group Total

<6 >6

age group

20-40 Years

Count 3 0 3

% 3.8% 0.0% 3.0%

41-50 Years

Count 18 7 25

% 23.1% 31.8% 25.0%

51-60 Years

Count 33 3 36

% 42.3% 13.6% 36.0%

61-70 Years

Count 21 8 29

% 26.9% 36.4% 29.0%

71-80 Years

Count 3 4 7

% 3.8% 18.2% 7.0%

Total

Count 78 22 100

% 100.0% 100.0% 100.0%

Pearson Chi-Square=10.854* p=0.028

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

<6 >6

4%

0%

23%

32%

42%

14%

27%

36%

4%

18%

Comparison of Age group Between Volume Expansion group

20-40 Years 41-50 Years 51-60 Years 61-70 Years 71-80 Years

64

Crosstab

volume expansion

group

Total

<6 >6

hypertensio

n

yes

Count 72 16 88

% 92.3% 72.7% 88.0%

yes/ckd

Count 6 3 9

% 7.7% 13.6% 9.0%

yes/oldcv

a

Count 0 3 3

% 0.0% 13.6% 3.0%

Total

Count 78 22 100

% 100.0% 100.0% 100.0%

Pearson Chi-Square=12.058** p=0.002

0%

20%

40%

60%

80%

100%

<6 >6

92%

73%

8%

14%

0%14%

Comparison of Hypertension of Volume Expansion group

Yes Yes/CKD Yes/Old CVA

65

Crosstab

volume expansion

group

Total

<6 >6

diabetes

no

Count 51 13 64

% 65.4% 59.1% 64.0%

yes

Count 27 9 36

% 34.6% 40.9% 36.0%

Total

Count 78 22 100

% 100.0% 100.0% 100.0%

Pearson Chi-Square=0.295 p=0.587

0%

20%

40%

60%

80%

100%

<6 >6

65% 59%

35% 41%

Comparison of Diabetes of Volume Expansion group

No Yes

66

Crosstab

volume expansion

group

Total

<6 >6

drug use

aspirin

Count 3 3 6

% 3.8% 13.6% 6.0%

no

Count 75 19 94

% 96.2% 86.4% 94.0%

Total

Count 78 22 100

% 100.0% 100.0% 100.0%


0%

20%

40%

60%

80%

100%

<6 >6

4%14%

96%86%

Comparison of Drug Use of Volume Expansion group

No Yes

67

Crosstab

volume expansion

group

Total

<6 >6

monocytes

group

>8

Count 0 19 19

% 0.0% 86.4% 19.0%

<8

Count 78 3 81

% 100.0% 13.6% 81.0%

Total

Count 78 22 100

% 100.0% 100.0% 100.0%

Pearson Chi-Square=83.165** p<0.0001

0%

20%

40%

60%

80%

100%

<6 >6

0%

86%100%

14%

Comparison of Monocytes of Volume Expansion group

>8 <8

68

Crosstab

volume expansion

group(ml)

Total

<6 >6

first CT

group(ml)

<10

Count 38 4 42

% 48.7% 18.2% 42.0%

>10

Count 40 18 58

% 51.3% 81.8% 58.0%

Total

Count 78 22 100

% 100.0% 100.0% 100.0%


0%

20%

40%

60%

80%

100%

<6 >6

49%

18%

51%

82%

Comparison of Initial CT of Volume Expansion group

<10 >10

69

Crosstab

volume expansion

group(ml)

Total

<6 >6

Rpt CT

group

(ml)

<10

Count 42 0 42

% 53.8% 0.0% 42.0%

>10

Count 36 22 58

% 46.2% 100.0% 58.0%

Total

Count 78 22 100

% 100.0% 100.0% 100.0%

Pearson Chi-Square=20.424* p<0.001

0%

20%

40%

60%

80%

100%

<6 >6

54%

0%

46%

100%

Comparison of Repeat CT of Volume Expansion group

<10 >10

70

Crosstab

volume expansion

group(ml)

Total

<6 >6

sex

female

Count 18 0 18

% 23.1% 0.0% 18.0%

male

Count 60 22 82

% 76.9% 100.0% 82.0%

Total

Count 78 22 100

% 100.0% 100.0% 100.0%


0%

20%

40%

60%

80%

100%

<6 >6

23%

0%

77%

100%

Comparison of Gender of Volume Expansion group

<10 >10

71

Crosstab

volume expansion group

Total <6 >6

total leukocyte count

new1

<5000 Count 1 0 1

% within volume

expansion group

1.3% .0% 1.0%

5001-10000 Count 31 5 36

% within volume

expansion group

39.7% 22.7% 36.0%

10001-15000 Count 23 11 34

% within volume

expansion group

29.5% 50.0% 34.0%

15000-20000 Count 14 6 20

% within volume

expansion group

17.9% 27.3% 20.0%

Above 20000 Count 9 0 9

% within volume

expansion group

11.5% .0% 9.0%

Total Count 78 22 100

% within volume

expansion group

100.0% 100.0% 100.0%


0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

<6 >6

1% 0%

39%

23%

30%

50%

30%27%

Comparison of total Count Between Volume Expansion group

<5000 5001-10000 15001-20000 Above 20000

72

first ct group * pmn group Crosstabulation

pmn group Total

<70 >70

first ct

group(ml)

<10

Count 20 22 42

% 69.0% 31.0% 42.0%

>10

Count 9 49 58

% 31.0% 69.0% 58.0%

Total

Count 29 71 100

% 100.0% 100.0% 100.0%

Pearson Chi-Square=12.192** p<0.001

0%

20%

40%

60%

80%

100%

<70 >70

69%

31%

31%

69%

Comparison of First CT of Neutrophilic leukocytosis group

<10 >10

73

pmn group * volume expansion group

Crosstabulation

volume

expansion group

Total

<6 >6

pmn

group

<70

Count 18 11 29

% 62.07% 37.93% 100.00%

>70

Count 60 11 71

% 84.51% 15.49% 100.00%

Total

Count 78 22 100

% 78.00% 22.00% 100.00%

Pearson Chi-Square=6.014 p=0.014*

0%

20%

40%

60%

80%

100%

<6 >6

62%

38%

84%

16%

Comparison of neutrophilic leukocytosis with Volume Expansion

group

<70 >70

74

RESULTS:

(1) 100 Patients admitted with ICH were studied. Mean age of the population was 56

years, 82% males. All the patients In the study were hypertensive.

(2) 36 patients had diabetes. 9 patients were CKD 5 on maintenance dialysis.3 patients

had previous H/O ischemic stroke. 6 patients were on aspirin prior to the episode.

(3) The mean and median leukocyte count of the population were 12.7*103 / ul and

12.3*103/ul respectively.

(4) 68 patients had leucocytosis on admission. 71 patients had neutrophilic leucocytosis

which by definition in our study is polymorphonuclear leukocytes >70%.

(5) 19 patients had monocytes defined by monocytes >8%.

(6) 22 patients (22%) experienced significant hematoma expansion defined by absolute

increase in hematoma volume by 6ml/ 30% of initial bleed volume.

(7) After adjustment for established predictors of hematoma expansion like

hypertension, it was found that higher WBC count on admission was associated with

reduced risk of hematoma expansion.

(8) On further analysis, it was found that neutrophilic leucocytosis (pmn>70%) was

associated with significantly less hematoma expansion independent of other risk factors

(p value 0.014). As out 71 patients with neutrophilic leucocytosis 60 patients did not

have hematoma expansion as opposed to 11 out of 29 patients who did not have

neutrophilic leucocytosis.

(9) It was also statistically proven (p value <0.001) that neutrophilic leucocytosis was

preferentially present in patients with higher initial bleed volumes (>10ml).

(10) Significant association was also found between monocytosis(>8%) and hematoma

expansion as 19 patients who had monocytosis had significant volume expansion (p

75

value <0.0001). No significant association was established between lymphocytes and

volume expansion.

(11) volume expansion was significantly higher in patients with higher bleed volumes.

81% of patients who had volume expansion had higher initial bleed volumes.(p value

0.01).

76

DISCUSSION

The role of leukocytes in coagulation Is an ongoing field of research. The contrasting

effect of neutrophils and monocytes is the significant outcome of the study. Higher

neutrophil count was associated with reduced risk of hematoma expansion as opposed

to monocyte counts. Neuroinflammation and leukocyte infiltration of hematoma have

been main targets of neuroprotective strategies in ICH.(35) Chronic inflammation is a

proven detriment of secondary change in ICH. Presence of neutrophilic leucocytosis in

patients with higher initial bleed volumes also adds evidence that neutrophilic

leucocytosis is almost always reactive. Acute inflammation though complex, through

contrasting effects of neutrophils and monocytes on hematoma expansion can present

itself as therapeutic target which can affect the modifiable determinant of ICH which is

hematoma expansion. These findings and results are in concordance with study of

morotti et al(1)

77

CONCLUSION

1) This study highlights the role of acute inflammation on hematoma expansion in

intra-cerebral haemorrhage. Patients with higher monocyte had higher risk of

hematoma expansion which higher neutrophil counts were protective against

hematoma expansion

2) This may help early risk stratification and prognostication of ICH patients and

also provide a tool for identification of new therapeutic targets for controlling

hematoma expansion.

78

LIMITATION OF STUDY

1) Limited sample size due to in hospital mortality and loss to follow up.

2) The observation and results are based on temporal observation of differential

count values and hematoma expansion. The actual sequence of events requires

more scientific approach before it can used as a therapeutic target.

79

BIBLIOGRAPHY

1. Leukocyte Count and Intracerebral Hemorrhage Expansion [Internet]. [cited 2019

Oct19]. vailable from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4879062/

2. Admission Leukocytosis in Intracerebral Hemorrhage: Associated Factors and

Prognostic Implications. - PubMed - NCBI [Internet]. [cited 2019 Oct 19].

Available from: https://www.ncbi.nlm.nih.gov/pubmed/25761426

3. Yu Z, Zheng J, Guo R, Ma L, You C, Li H. Prognostic impact of leukocytosis in

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PROFORMA:

AN OBSERVATIONAL STUDY ON ADMISSION LEUKOCYTOSIS

AND ITS IMPLICATIONS IN ICH.

NAME :

AGE/ SEX :

OP/IP NO:

OCCUPATION:

ADDRESS:

CONTACT NUMBER :

SYMPTOMS:

� Loss of consciousness

� Weakness of upper and lower limbs

� Projectile vomiting

� Seizures

� Inability to speak

� Intense headache

� History of trauma

PAST HISTORY :

History of similar complaints in the past

History of any other co morbid illness.

History of previous intracranial surgeries

PERSONAL HISTORY :

History of alcohol intake : type of alcohol, quantity and duration

History of other substance abuse.

Diet history

GENERAL EXAMINATION :

Consciousness,

orientation to time,

place and person

Pallor/ Icterus / Cyanosis / Clubbing / Pedal edema / lymphadenopathy

Blood pressure: Pulse rate: respiratory rate : Temperature:

SYSTEMIC EXAMINATION :

Cardiovascular system:

Respiratory system

Per abdomen:

Central nervous system:

INVESTIGATIONS :

� Complete blood count

� NCCT brain

� Follow up NCCT brain

INFORMATION TO PARTICIPANTS

INVESTIGATORS: Dr. M. Nirumal Khumar

Dr. nalini kumaravelu M.D.,

NAME OF THE PARTICIPANT :

You are invited to take part in this study. The information in this document is meant to

help you decide whether or not to take part. Please free to ask if you have any queries or

concerns

We are conducting “AN OBSERVATIONAL STUDY ON ADMISSION

LEUKOCYTOSIS AND ITS IMPLICATIONS IN ICH” among patients attending

Rajiv Gandhi Government General Hospital, Chennai. Your co-operation to undergo

relevant investigations as per need may be valuable to us.

The purpose of this study is to find the correlation between admission leukocyte counts

and its implications in ICH

We are selecting certain cases and if you are found eligible, we would like to

perform extra tests and you will be subjected to a blood investigation which in any way do

not affect your final report or management.

The privacy of the patients in the research will be maintained throughout the study.

In the event of any publication or presentation resulting from the research, no personally

identifiable information will be shared.

Taking part in this study is voluntary. You are free to decide whether to participate

in this study or to withdraw at any time; your decision will not result in any loss of benefits

to which you are otherwise entitled.

The results of the special study may be intimated to you at the end of the study

period or during the study if anything is found abnormal which may aid in the management

or treatment.

Signature of Investigator Signature/left thumb ,

impression of Participant/guardian

Date:

Place:

‘NrHf;if nts;isaDg;ngUf;fk; %is uj;j frptpy;

mjd; tpisTfs;”

: kU. K. epUky; FkhH

PATIENT CONSENT FORM

Study Detail : AN OBSERVATIONAL STUDY ON ADMISSION

LEUKOCYTOSIS AND ITS IMPLICATIONS IN ICH

Study Centre : Rajiv Gandhi Government General Hospital, Chennai.

Patient’s Name

:

Patient’s Age

:

Identification

Number

:

Documentation of the informed consent

1. I ___________________________ have read the information in this form (or it has

been read for me). I was free to ask any questions and they have been answered. I am

over 18 years of age and exercising my free power of choice, hereby give my consent

to be included as a participant in the study.

2. I have read and understood this consent form and the information provided to me.

3. I have had the consent document explained to me.

4. I have been explained about the nature of the study.

5. I have been explained about my rights and responsibilities by the Investigator.

6. I am aware of the fact that I can opt out of the study at any time without having to give

any reason and this will not affect my future treatment in this hospital

7. I hereby give permission to the investigators to release the information obtained from

me as result of participation in this study to the sponsors, regulatory authorities, govt.

agencies and IEC.I understand that they are publicly published

8. I have understood that my identity will be kept confidential if my data are publicly

presented.

9. I have had my questions answered to my satisfaction.

10. I have decided to be in the research study

11. I am aware that if I have any question during this study, I should contact at one of the

addresses listed above. By signing this consent form I attest that the information given

in this document has been clearly explained to me and apparently understood by me. I

will be given a copy of this consent document.

‘NrHf;if nts;isaDg;ngUf;fk; %is uj;j frptpy;

mjd; tpisTfs;”

Urkund Analysis Result Analysed Document: Dr nirumal khumar thesis plag.docx (D57544602)Submitted: 10/23/2019 9:14:00 PM Submitted By: [email protected] Significance: 7 %

Sources included in the report:

plagiarism.docx (D57251465) RENISH THESIS MID NEW.doc (D57413908) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743539/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4879062/

Instances where selected sources appear:

14

U R K N DU

CERTIFICATE-II

This is to certify that this dissertation work titled “AN

OBSERVATIONAL STUDY ADMISSION LEUKOCYTOSIS

AND IT’S IMPLICATIONS ON INTRA-CEREBRAL

HEMORRHAGE” of the candidate Dr. M.NIRUMAL KHUMAR with

registration number 201711011 for the award of M.D. Degree in the Branch of

GENERAL MEDICINE. I personally verified the urkund.com website for the purpose

of plagiarism check. I found that the uploaded thesis file contains from introduction to

conclusion pages and result shows 7% Percentage of plagiarism in the dissertation.

Guide and Supervisor sign with seal

age hypertension diabetes drug use total count(103/mm3) pmn% monocyte% plt count(lakhs) inr first CT(ml) rpt ct(ml) volume exp(ml) sex inference s.no

56 yes no no 5.9 53 6 2 1.02 9 12 3 male no exp 1

57 yes no no 5.8 53 5 1.9 1 9.3 11 1.7 male no exp 2

60 yes no no 5.5 55 6 1.8 1 10 4 2.7 male no exp 3

70 yes yes no 14.5 90 4 2 1.1 4 2.7 -1.3 male no exp 4

70 yes yes no 15 88 5 2.5 1 4.2 2.8 -1.4 male no exp 5

68 yes yes no 15.5 88 4 2.2 1.1 5 3.7 -1.3 male no exp 6

60 yes no no 7 77 7 1.9 1.2 2.6 2 -0.6 male no exp 7

64 yes no no 7.5 78 6 1.6 1.1 2.5 2 -0.5 male no exp 8

62 yes no no 7.4 76 5 1.8 1.2 2.7 1.9 -0.8 male no exp 9

47 yes yes no 12 80 10 1.7 1.1 18 27 9 male sig exp 10

48 yes yes no 12.2 78 11 1.8 1 17 26 9 male sig exp 11


45 yes no no 7.9 70 7 3 1.3 12 12 0 male no exp 13

47 yes no no 7.5 68 7 2.5 1.2 11 11 0 male no exp 14


55 yes yes no 16.5 85 5 3.5 1.2 13 13.3 0.3 male no exp 16

57 yes yes no 16.3 80 6 2.8 1.1 13.1 13.4 0.3 male no exp 17

53 yes yes no 16 83 5 2.5 1.2 12.8 13 0.2 male no exp 18

45 yes no no 12.8 85 6 2.6 1 15.9 15.5 -0.4 female no exp 19

46 yes no no 12.5 84 5 2.4 1 15.8 15.3 -0.5 female no exp 20

44 yes no no 12.4 85 6 2.4 1.1 15.5 15.3 -0.2 female no exp 21

68 yes yes aspirin use 24.3 85 7 1.7 1.2 2.8 3.2 0.4 female no exp 22



55 yes no no 9.2 54 6 2 1.1 22.5 21.5 -1 male no exp 25

54 yes no no 9.4 55 6 2 1.2 22.4 21.6 -0.8 male no exp 26

55 yes no no 9.4 56 5 2.1 1.1 22 21.7 -0.3 male no exp 27

63 yes yes no 17 85 9 2.5 1 28 37.5 9.5 male sig exp 28


64 yes yes no 17.2 82 10 2.5 1.1 29 38 9 male sig exp 30




42 yes/ckd yes no 5.2 65 5 1.o 1 1.8 1.5 -0.3 male no exp 34

45 yes/ckd yes no 5.5 66 6 1.1 1 1.7 1.5 -0.2 male no exp 35

47 yes/ckd yes no 5.4 67 6 1.o 1.1 1.7 1.5 -0.2 male no exp 36

60 yes no no 11.3 80 6 2 1.3 29 27 -2 female no exp 37

62 yes no no 11.4 82 5 2.2 1.2 28 25 -3 female no exp 38

63 yes no no 12 85 4 2.8 1.1 26 23 -3 female no exp 39

70 yes yes no 5.2 51.4 5 1.5 1.2 2.25 1.5 -0.7 male no exp 40

71 yes yes no 5.3 52 5 1.9 1 2.3 1.8 -o.5 male no exp 41

73 yes yes no 5 54 4 1.8 1.1 2.5 2 -0.5 male no exp 42

55 yes no no 9.9 76 6 1.9 1 18 13 -5 male no exp 43

54 yes no no 9.9 76 6 1.6 1 17 13 -4 male no exp 44

57 yes no no 9.7 77 5 1.9 1.1 18 13 -4 male no exp 45

60 yes/ckd no no 17 85 6.5 2 1.2 8.5 9.5 1 male no exp 46

62 yes/ckd no no 17 85 6.2 2.5 1.2 8.25 9.5 1.25 male no exp 47

65 yes/ckd no no 16 86 6.5 2.2 1.1 9 9.5 o.5 male no exp 48

50 yes yes no 13 82 6 1.8 1 1.9 1.1 -0.8 female no exp 49

52 yes yes no 12 86 3 2.5 1.1 2 1.4 -0.6 female no exp 50

52 yes yes no 13 86 3 2.25 1 1.9 1.2 -0.7 female no exp 51

62 yes yes no 24 85 6 2.1 1 8.25 1 -7.25 male no exp 52

65 yes yes no 24 86 6 2.2 1 9 1.5 -7.5 male no exp 53

66 yes yes no 25 86 5 2.1 1.2 8.8 0.8 -8 male no exp 54

62 yes no no 14 65 12 1.9 1.1 0.6 12.5 11.9 male sig exp 55

65 yes no no 13 62 11 3 1.2 1 12 11 male sig exp 56

64 yes no no 14 65 12 3 1.1 1 11 10 male sig exp 57

49 yes no no 9 70 4 2.19 1.12 10 14 4 male insig exp 58

50 YES no no 9 71 5 2.2 1.1 11 15 4 male insig exp 59


74 yes yes no 8.75 71.2 9 2.23 1.1 12.5 27 14.5 male sig exp 61

70 yes yes no 9 70 10 2.1 1 12 28 16 male sig exp 62

72 yes yes no 9 71 10 2.o 1 12 28 16 male sig exp 63

50 yes no no 15 60 6 1.8 1.25 3.75 3.6 -0.1 male no exp 64

52 yes no no 15 61 5 1.9 1.1 3.6 3.5 -0.1 male no exp 65

51 yes no no 16 62 5 1.7 1 3.6 3.6 0 male no exp 66




45 yes/ckd5 no no 13 63 9 2.03 1.19 15 30 15 male sig exp 70

46 yes/ckd5 no no 13 62 10 2.1 1.1 15 31 15 male sig exp 71

47 yes/ckd5 no no 12 62 10 2.2 1 15 30 15 male sig exp 72

58 yes no no 17 84 7.7 2.2 1.1 22.5 21 -1.5 male no exp 73

57 yes no no 17 85 7..6 2.1 1.1 21 23 2 male no exp 74

54 yes no no 17 86 7 2.2 1 22 22 0 male no exp 75

44 yes no no 13 88 5.3 2.5 1.1 18.5 19 0.5 male no exp 76

46 yes no no 13 88 5.2 2.4 1 19 19 0 male no exp 77

47 yes no no 13 87 5 2.5 1.1 20 19 -1 male no exp 78

53 yes no no 14 90 0.7 3.06 1.23 15 7.5 -7.5 female no exp 79

54 yes no no 14 90 1 3.1 1.1 14 8 6 female no exp 80

53 yes no no 14 90 1 3.1 1.1 15 7.5 -7.5 female no exp 81

58 yes yes no 9 51.2 2.4 2.75 1.04 5 5.2 0.2 female no exp 82

57 yes yes no 9 51.2 2.1 2.5 1 5 5 0 female no exp 83

52 yes yes no 9 52 1.8 2.5 1 6 5 -1 female no exp 84

70 yes yes no 19 90 4 2.35 1.08 4 3 -1 male no exp 85

71 yes yes no 19 89 4 2.35 1 4 3 -1 male no exp 86

70 yes yes no 18 90 3 2.5 1 4 4 0 male no exp 87

52 yes no no 6 65 4.8 3.15 1.07 5.5 4.5 -1 male no exp 88

54 yes no no 6 65 4.5 3 1.1 5.2 5 -0.2 male no exp 89

55 yes no no 6 65 4.2 3 1 5.2 5 -0.2 male no exp 90

70 yes/oldcva no aspirin use 16 80.7 5 2.5 1 9 23 14 male sig exp 91

71 yes/oldcva no aspirin use 16 81 5 2.5 1 10 24 14 male sig exp 92

72 yes/oldcva no aspirin use 16 82 5 2.4 1 11 24 13 male sig exp 93

47 yes no no 11 87 4 2.03 1.19 10 7.5 -2.5 mALE no exp 94

50 YES No no 10 87 3 2 1 11 8 -3 male no exp 95

51 yes no no 10 86 3 2.1 1.1 11 10 -1 male no exp 96

50 yes no no 10 75 9 2.2 1.1 18 25 7 male sig exp 97

55 yes no no 11 74 9 2.1 1.1 18 26 8 male sig exp 98

52 yes no no 11 75 10 2.2 1 18 25 7 male sig exp 99

51 yes no no 10 74 10 1.1 16 24 8 male sig exp 100

“an observational study admission leukocytosis and …

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