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Karamian A, Seifi A, Karamian A, Lucke-Wold B. Incidence of intracranial bleeding in mild traumatic brain injury patients taking oral anticoagulants: a systematic review and meta-analysis. J Neurol 2024:10.1007/s00415-024-12424-y. [PMID: 38755424 DOI: 10.1007/s00415-024-12424-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is one of the leading causes of disability and death worldwide. Most TBI cases occur in older people, because they are at a higher risk of accidental falling. As the population ages, the use of anticoagulants is increasing. Some serious complications of TBI, such as intracranial hemorrhage (ICH), may occur even in mild cases. According to the current guidelines regarding managing mild TBI patients, a CT head scan is recommended for all patients receiving anticoagulation. We aim to assess the incidence of ICH in patients with mild TBI taking oral anticoagulants. METHODS Our systematic review and meta-analysis were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The protocol was registered in PROSPERO (CRD42024503086). Twenty-eight studies evaluating patients with a mild TBI from ten countries with a total sample size of 11,172, 5671 on DOACs, and 5501 on VKAs were included in our meta-analysis. RESULTS The random-effects overall incidence of ICH among oral anticoagulated patients with mild TBI was calculated to be 9.4% [95% CI 7.2-12.1%, I2 = 89%]. The rates of immediate ICH for patients taking DOACs and VKAs were 6.4% and 10.5%, respectively. The overall rate of immediate ICH in anticoagulated mild TBI patients was 8.5% [95% CI 6.6-10.9%], with a high heterogeneity between studies (I2 = 88%). Furthermore, the rates of delayed ICH in patients with mild TBI taking DOACs and VKAs were 1.6% and 1.9%, respectively. The overall incidence of delayed ICH among oral anticoagulated mild TBI patients was 1.7% [95% CI 1-2.8%, I2 = 79%]. The overall rate of ICH among mild TBI patients taking DOAC was calculated to be 7.3% [95% CI 5.2-10.3%], with significant heterogeneity between studies (I2 = 79%). However, the overall ICH rate is higher in patients who take only VKAs 11.3% [95% CI 8.6-14.7%, I2 = 83%]. Patients on DOACs were at lower risk of ICH after mild TBI compared to patients on VKAs (OR = 0.64, 95% CI 0.48-0.86, p < 0.01, I2 = 28%). CONCLUSION Our meta-analysis confirms the need for performing brain CT scan in patients with mild TBI patients who receive oral anticoagulants before injury. Due to limited data, further multi-center, prospective studies are warranted to confirm the true incidence of traumatic ICH in patients on anticoagulants.
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Affiliation(s)
- Armin Karamian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Seifi
- Department of Neurosurgery, University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Amin Karamian
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA.
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2
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Kirchhof P, Bakhai A, de Asmundis C, de Groot JR, Deharo JC, Kelly P, Lopez-de-Sa E, Monteiro P, Fronk EM, Lamparter M, Laeis P, Smolnik R, Steffel J, Waltenberger J, Weiss TW, De Caterina R. Long-term effectiveness and safety of edoxaban in patients with atrial fibrillation: 4-year data from the ETNA-AF-Europe study. Int J Cardiol 2024; 408:132118. [PMID: 38697397 DOI: 10.1016/j.ijcard.2024.132118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/28/2024] [Accepted: 04/29/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND To assess long-term effectiveness and safety of edoxaban in Europe. METHODS AND RESULTS ETNA-AF-Europe, a prospective, multinational, multi-centre, post-authorisation, observational study was conducted in agreement with the European Medicines Agency. The primary and secondary objectives assessed real-world safety (including bleeding and deaths) and effectiveness (including stroke, systemic embolic events and clinical edoxaban use), respectively. Median (interquartile range) age of the 13,164 patients was 75.0 (68.0-80.0) years; CHA2DS2-VASc and HAS-BLED scores were 3.0 (2.0-4.0) and 2.0 (1.0-2.0), respectively. Follow-up duration was 3.98 (3.21-4.05) years. Patients on edoxaban 30 mg (n = 3042) at baseline were older (80.0 vs 73.0 years), more likely assessed as frail by investigators (27.0% vs 6.6%) and had more comorbidities than those on edoxaban 60 mg (n = 9617; missing dosing information for n = 505). Annualised event rates of all-cause and cardiovascular death in the overall population, edoxaban 60 mg and edoxaban 30 mg groups were 4.1%, 2.8% and 8.4%, and 1.0%, 0.7% and 2.0%, respectively. Annualised rates of stroke were relatively constant throughout the follow-up, transient ischaemic attack and systemic embolism were < 1% in the overall population. Rates of any major and major gastrointestinal bleeding were low, with slightly higher rates for edoxaban 30 vs 60 mg group. Intracranial haemorrhage was uncommon (0.2%). CONCLUSIONS In European patients with AF, long-term therapy with edoxaban is associated with low and relatively constant annualised rates of stroke and major bleeding. Differences in outcomes between the two approved doses are attributable to differences in clinical characteristics.
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Affiliation(s)
- Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, IBR 136, Wolfson Drive, Birmingham B15 2TT, UK; Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg Eppendorf, Martinistraße 52, Hamburg 20246, Germany; German Center for Cardiovascular Sciences (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Ameet Bakhai
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels, Belgium
| | - Joris R de Groot
- Amsterdam UMC location University of Amsterdam, Cardiology, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam 1105 AZ, the Netherlands
| | - Jean Claude Deharo
- AP-HM, Aix Marseille University, Hospital Timone, Cardiologie, Rythmologie, 264 rue Saint-Pierre, Marseille 13005, France
| | - Peter Kelly
- Department of Neurology, HRB Stroke Clinical Trials Network Ireland, University College Dublin/Mater Misericordiae University Hospital, Eccles St, Northside, Dublin, Ireland
| | - Esteban Lopez-de-Sa
- Cardiology Department, Hospital Universitario La Paz, IDIPAZ, Madrid 28046, Spain
| | - Pedro Monteiro
- Department of Cardiology, Centro Hospitalar e Universitario de Coimbra, Praceta Mota Pinto 3000-075, Coimbra, Portugal
| | - Eva-Maria Fronk
- Daiichi Sankyo Europe GmbH, Zielstattstr. 48, Munich 81379, Germany
| | | | - Petra Laeis
- Daiichi Sankyo Europe GmbH, Zielstattstr. 48, Munich 81379, Germany
| | - Rüdiger Smolnik
- Daiichi Sankyo Europe GmbH, Zielstattstr. 48, Munich 81379, Germany
| | | | - Johannes Waltenberger
- Chair of Cardiology and Vascular Medicine, University of Münster, Schlossplatz 2, Münster 48149, Germany; Diagnostic and Therapeutic Heart Center, Kappelistr. 35, Zurich 8002, Switzerland
| | - Thomas W Weiss
- Institute for Cardiometabolic Diseases, Karl Landsteiner Society, St. Polten, Austria
| | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa, and Cardiology Division, Pisa University Hospital, 56124 Pisa, Italy; and Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy.
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3
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Pozzi A, Lucà F, Gelsomino S, Abrignani MG, Giubilato S, Di Fusco SA, Rao CM, Cornara S, Caretta G, Ceravolo R, Parrini I, Geraci G, Riccio C, Grimaldi M, Colivicchi F, Oliva F, Gulizia MM. Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures. J Clin Med 2024; 13:2451. [PMID: 38730979 PMCID: PMC11084691 DOI: 10.3390/jcm13092451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/22/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024] Open
Abstract
In clinical practice, the number of patients treated with direct oral anticoagulants (DOACs) has consistently increased over the years. Since anticoagulant therapy has been associated with an annual incidence of major bleeding (MB) events of approximately 2% to 3.5%, it is of paramount importance to understand how to manage anticoagulated patients with major or life-threatening bleeding. A considerable number of these patients' conditions necessitate hospitalization, and the administration of reversal agents may be imperative to manage and control bleeding episodes effectively. Importantly, effective strategies for reversing the anticoagulant effects of DOACs have been well recognized. Specifically, idarucizumab has obtained regulatory approval for the reversal of dabigatran, and andexanet alfa has recently been approved for reversing the effects of apixaban or rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding events. Moreover, continuous endeavors are being made to develop supplementary reversal agents. In emergency scenarios where specific reversal agents might not be accessible, non-specific hemostatic agents such as prothrombin complex concentrate can be utilized to neutralize the anticoagulant effects of DOACs. However, it is paramount to emphasize that specific reversal agents, characterized by their efficacy and safety, should be the preferred choice when suitable. Moreover, it is worth noting that adherence to the guidelines for the reversal agents is poor, and there is a notable gap between international recommendations and actual clinical practices in this regard. This narrative review aims to provide physicians with a practical approach to managing specific reversal agents.
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Affiliation(s)
- Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6229 HX Maastricht, The Netherlands
| | | | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy;
| | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy;
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy;
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy;
| | - Giovanna Geraci
- Cardiology Unit, S. Antonio Abate Hospital, ASP Trapani, 91016 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy;
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Grainger BT, McFadyen JD, Tran H. Between a rock and a hard place: resumption of oral anticoagulant therapy after intracranial hemorrhage. J Thromb Haemost 2024; 22:594-603. [PMID: 37913910 DOI: 10.1016/j.jtha.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023]
Abstract
Intracranial hemorrhage (ICH) is the most feared and lethal complication of oral anticoagulant (OAC) therapy. Resumption of OAC after ICH has long posed a challenge for clinicians, complicated by the expanding range of anticoagulant agents available in modern clinical practice, including direct OACs and, more recently, factor XI and XII inhibitors. A review of the current literature found support for resuming OAC in the majority of patients after ICH based on pooled retrospective data showing that resumption is associated with a lower risk of mortality and thromboembolism without a significantly increased risk of recurrent hemorrhage. The optimal time to resume OAC is less clear; however, the available evidence suggests that the composite risk of both recurrent hemorrhage and thromboembolism is likely minimized, somewhere between 4 and 6 weeks, after ICH in most patients. Specific considerations to guide the optimal resumption time in the individual patient include ICH location, mechanism, and anticoagulant class. Patients with mechanical heart valves and intracerebral malignancy represent high-risk groups who require more nuanced decision making. Here, we appraise the literature with the aim of providing a practical guide for clinicians while also discussing priorities for future investigation.
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Affiliation(s)
- Brian T Grainger
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia.
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Huyen Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Khan MZ, Shatla I, Darden D, Neely J, Mir T, Abideen Asad ZU, Agarwal S, Raina S, Balla S, Singh GD, Srivatsa U, Munir MB. Intracranial bleeding and associated outcomes in atrial fibrillation patients undergoing percutaneous left atrial appendage occlusion: Insights from National Inpatient Sample 2016-2020. Heart Rhythm O2 2023; 4:433-439. [PMID: 37520018 PMCID: PMC10373143 DOI: 10.1016/j.hroo.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Abstract
Background Percutaneous left atrial appendage occlusion (LAAO) has proved to be a safer alternative for long-term anticoagulation; however, patients with a history of intracranial bleeding were excluded from large randomized clinical trials. Objective The purpose of this study was to determine outcomes in atrial fibrillation (AF) patients with a history of intracranial bleeding undergoing percutaneous LAAO. Methods National Inpatient Sample and International Classification of Diseases, Tenth Revision, codes were used to identify patients with AF who underwent LAAO during the years 2016-2020. Patients were stratified based on a history of intracranial bleeding vs not. The outcomes assessed in our study included complications, in-hospital mortality, and resource utilization. Result A total of 89,300 LAAO device implantations were studied. Approximately 565 implantations (0.6%) occurred in patients with a history of intracranial bleed. History of intracranial bleeding was associated with a higher prevalence of overall complications and in-patient mortality in crude analysis. In the multivariate model adjusted for potential confounders, intracranial bleeding was found to be independently associated with in-patient mortality (adjusted odds ratio [aOR] 4.27; 95% confidence interval [CI] 1.68-10.82); overall complications (aOR 1.74; 95% CI 1.36-2.24); prolonged length of stay (aOR 2.38; 95% CI 1.95-2.92); and increased cost of hospitalization (aOR 1.28; 95% CI 1.08-1.52) after percutaneous LAAO device implantation. Conclusion A history of intracranial bleeding was associated with adverse outcomes after percutaneous LAAO. These data, if proven in a large randomized study, can have important clinical consequences in terms of patient selection for LAAO devices.
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Affiliation(s)
- Muhammad Zia Khan
- Division of Cardiology, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia
| | - Islam Shatla
- Department of Internal Medicine, Kansas University Medical Center, Kansas City, Kansas
| | - Douglas Darden
- Division of Cardiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | - Joseph Neely
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, California
| | - Tanveer Mir
- Department of Medicine, Wayne State University, Detroit, Michigan
| | - Zain Ul Abideen Asad
- Department of Internal Medicine, University of Oklahoma, Oklahoma City, Oklahoma
| | - Siddharth Agarwal
- Department of Internal Medicine, University of Oklahoma, Oklahoma City, Oklahoma
| | - Sameer Raina
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Sudarshan Balla
- Division of Cardiology, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia
| | - Gagan D. Singh
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, California
| | - Uma Srivatsa
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, California
| | - Muhammad Bilal Munir
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, California
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Cao H, Morotti A, Mazzacane F, Desser D, Schlunk F, Güttler C, Kniep H, Penzkofer T, Fiehler J, Hanning U, Dell'Orco A, Nawabi J. External Validation and Retraining of DeepBleed: The First Open-Source 3D Deep Learning Network for the Segmentation of Spontaneous Intracerebral and Intraventricular Hemorrhage. J Clin Med 2023; 12:4005. [PMID: 37373699 DOI: 10.3390/jcm12124005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/03/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The objective of this study was to assess the performance of the first publicly available automated 3D segmentation for spontaneous intracerebral hemorrhage (ICH) based on a 3D neural network before and after retraining. METHODS We performed an independent validation of this model using a multicenter retrospective cohort. Performance metrics were evaluated using the dice score (DSC), sensitivity, and positive predictive values (PPV). We retrained the original model (OM) and assessed the performance via an external validation design. A multivariate linear regression model was used to identify independent variables associated with the model's performance. Agreements in volumetric measurements and segmentation were evaluated using Pearson's correlation coefficients (r) and intraclass correlation coefficients (ICC), respectively. With 1040 patients, the OM had a median DSC, sensitivity, and PPV of 0.84, 0.79, and 0.93, compared to thoseo f 0.83, 0.80, and 0.91 in the retrained model (RM). However, the median DSC for infratentorial ICH was relatively low and improved significantly after retraining, at p < 0.001. ICH volume and location were significantly associated with the DSC, at p < 0.05. The agreement between volumetric measurements (r > 0.90, p > 0.05) and segmentations (ICC ≥ 0.9, p < 0.001) was excellent. CONCLUSION The model demonstrated good generalization in an external validation cohort. Location-specific variances improved significantly after retraining. External validation and retraining are important steps to consider before applying deep learning models in new clinical settings.
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Affiliation(s)
- Haoyin Cao
- Department of Radiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Andrea Morotti
- Neurology Unit, Department of Neurological Sciences and Vision, ASST-Spedali Civili, 25123 Brescia, Italy
| | - Federico Mazzacane
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
- U.C. Malattie Cerebrovascolari e Stroke Unit, IRCCS Fondazione Mondino, 27100 Pavia, Italy
| | - Dmitriy Desser
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Frieder Schlunk
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Christopher Güttler
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Tobias Penzkofer
- Department of Radiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), BIH Biomedical Innovation Academy, 10178 Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Andrea Dell'Orco
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), BIH Biomedical Innovation Academy, 10178 Berlin, Germany
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de Mendiola JMFP, Arboix A, García-Eroles L, Sánchez-López MJ. Acute Spontaneous Lobar Cerebral Hemorrhages Present a Different Clinical Profile and a More Severe Early Prognosis than Deep Subcortical Intracerebral Hemorrhages-A Hospital-Based Stroke Registry Study. Biomedicines 2023; 11:biomedicines11010223. [PMID: 36672731 PMCID: PMC9856131 DOI: 10.3390/biomedicines11010223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/09/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
Acute spontaneous intracerebral hemorrhage (ICH) is the most severe stroke subtype, with a high risk of death, dependence, and dementia. Knowledge about the clinical profile and early outcomes of ICH patients with lobar versus deep subcortical brain topography remains limited. In this study, we investigated the effects of ICH topography on demographics, cerebrovascular risk factors, clinical characteristics, and early outcomes in a sample of 298 consecutive acute ICH patients (165 with lobar and 133 with subcortical hemorrhagic stroke) available in a single-center-based stroke registry over 24 years. The multiple logistic regression analysis shows that variables independently associated with lobar ICH were early seizures (OR 6.81, CI 95% 1.27−5.15), chronic liver disease (OR 4.55, 95% CI 1.03−20.15), hemianopia (OR 2.55, 95% CI 1.26−5.15), headaches (OR 1.90, 95% CI 1.90, 95% IC 1.06−3.41), alcohol abuse (>80 gr/day) (OR 0−10, 95% CI 0.02−0,53), hypertension (OR 0,41, 95% CI 0.23−0−70), sensory deficit (OR 0.43, 95% CI 0.25−0.75), and limb weakness (OR: 0.47, 95% CI 0.24−0.93). The in-hospital mortality was 26.7% for lobar and 16.5% for subcortical ICH. The study confirmed that the clinical spectrum, prognosis, and early mortality of patients with ICH depend on the site of bleeding, with a more severe early prognosis in lobar intracerebral hemorrhage.
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Affiliation(s)
| | - Adrià Arboix
- Department of Neurology, Hospital Universitari Sagrat Cor, Universitat de Barcelona, 08029 Barcelona, Spain
- Correspondence: ; Tel.: +34-93-4948940
| | - Luís García-Eroles
- Department of Neurology, Hospital Universitari Sagrat Cor, Universitat de Barcelona, 08029 Barcelona, Spain
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Muacevic A, Adler JR. Submassive Pulmonary Embolism in the Setting of Intracerebral Hemorrhage: A Case of Suction Thrombectomy. Cureus 2022; 14:e32432. [PMID: 36644103 PMCID: PMC9833621 DOI: 10.7759/cureus.32432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 12/14/2022] Open
Abstract
Pulmonary embolism (PE) in the setting of intracerebral hemorrhage (ICH) is an unfortunate, challenging, and highly morbid clinical problem. Interventional strategies have lower associated bleeding risks than the standby for PE treatment: systemic anticoagulation. Despite this benefit, there are few examples in the literature of its utilization in the management of PE in the setting of ICH. This present case provides an example of the successful utilization of suction thrombectomy to manage PE in the setting of ICH. An 80-year-old female presented to an outside hospital with complaints of dizziness, headache, nausea, and vomiting of abrupt onset one hour before arrival. Computed tomography (CT) of the head with CT Angiography (CTA) of the head and neck was performed and demonstrated hemorrhage in all ventricles; most prominently within the left lateral ventricle. Magnetic Resonance Imaging (MRI) of the brain suggested that the cause of her hemorrhage was reperfusion injury after a small acute infarction in the left internal capsule in the setting of anticoagulant use. Ten days after her diagnosis of ICH, a submassive PE was diagnosed with a class IV pulmonary embolism severity index (PESI). An interdisciplinary evaluation was conducted between hospitalist medicine, neurology, neurosurgery, and interventional radiology. A successful suction thrombectomy was performed on hospital day 11. No new neurologic deficits were appreciated post-procedure. The patient's heart rate remained elevated but improved. Blood pressure remained controlled. The patient was weaned off oxygen to room air. Neurosurgery assessed the patient to be of acceptable risk for discharge with the further deferment of anticoagulation until repeat CT head six weeks after discharge. The patient was discharged on hospital day 14. Treating PE in the setting of ICH is without clear guidelines. The appropriate treatment modality is reliant upon the clinical judgment and the individual details of each case. In this case, a high PESI with imaging demonstrating a stable hematoma without evidence of new blood resulted in the decision to use a suction thrombectomy. More research is needed to develop consistent evidence-based guidelines for this clinical challenge.
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Jelinek M, Duris K. Inflammatory Response in Sepsis and Hemorrhagic Stroke. BRAIN HEMORRHAGES 2022. [DOI: 10.1016/j.hest.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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10
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Qu Y, Zhuo Y, Lee J, Huang X, Yang Z, Yu H, Zhang J, Yuan W, Wu J, Owens D, Zee B. Ischemic and haemorrhagic stroke risk estimation using a machine-learning-based retinal image analysis. Front Neurol 2022; 13:916966. [PMID: 36071896 PMCID: PMC9441897 DOI: 10.3389/fneur.2022.916966] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background Stroke is the second leading cause of death worldwide, causing a considerable disease burden. Ischemic stroke is more frequent, but haemorrhagic stroke is responsible for more deaths. The clinical management and treatment are different, and it is advantageous to classify their risk as early as possible for disease prevention. Furthermore, retinal characteristics have been associated with stroke and can be used for stroke risk estimation. This study investigated machine learning approaches to retinal images for risk estimation and classification of ischemic and haemorrhagic stroke. Study design A case-control study was conducted in the Shenzhen Traditional Chinese Medicine Hospital. According to the computerized tomography scan (CT) or magnetic resonance imaging (MRI) results, stroke patients were classified as either ischemic or hemorrhage stroke. In addition, a control group was formed using non-stroke patients from the hospital and healthy individuals from the community. Baseline demographic and medical information was collected from participants' hospital medical records. Retinal images of both eyes of each participant were taken within 2 weeks of admission. Classification models using a machine-learning approach were developed. A 10-fold cross-validation method was used to validate the results. Results 711 patients were included, with 145 ischemic stroke patients, 86 haemorrhagic stroke patients, and 480 controls. Based on 10-fold cross-validation, the ischemic stroke risk estimation has a sensitivity and a specificity of 91.0% and 94.8%, respectively. The area under the ROC curve for ischemic stroke is 0.929 (95% CI 0.900 to 0.958). The haemorrhagic stroke risk estimation has a sensitivity and a specificity of 93.0% and 97.1%, respectively. The area under the ROC curve is 0.951 (95% CI 0.918 to 0.983). Conclusion A fast and fully automatic method can be used for stroke subtype risk assessment and classification based on fundus photographs alone.
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Affiliation(s)
- Yimin Qu
- Centre for Clinical Research and Biostatistics, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
- Centre for Clinical Trials and Biostatistics Lab, CUHK Shenzhen Research Institute, Shenzhen, China
- School of Population Medicine and Public Health, Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Yuanyuan Zhuo
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Jack Lee
- Centre for Clinical Research and Biostatistics, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
- Centre for Clinical Trials and Biostatistics Lab, CUHK Shenzhen Research Institute, Shenzhen, China
| | - Xingxian Huang
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Zhuoxin Yang
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Haibo Yu
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Jinwen Zhang
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Weiqu Yuan
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Jiaman Wu
- Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, China
| | | | - Benny Zee
- Centre for Clinical Research and Biostatistics, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
- Centre for Clinical Trials and Biostatistics Lab, CUHK Shenzhen Research Institute, Shenzhen, China
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11
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Badescu MC, Ciocoiu M, Badulescu OV, Vladeanu MC, Bojan IB, Vlad CE, Rezus C. Prediction of bleeding events using the VTE-BLEED risk score in patients with venous thromboembolism receiving anticoagulant therapy (Review). Exp Ther Med 2021; 22:1344. [PMID: 34630698 DOI: 10.3892/etm.2021.10779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/03/2021] [Indexed: 12/15/2022] Open
Abstract
Venous thromboembolism (VTE) is a major healthcare problem due to its high incidence, significant mortality rate from pulmonary embolism, high recurrence rate and morbidity from long-term complications. After a first episode of VTE all patients must receive anticoagulant treatment for 3 months. Further anticoagulation is recommended in patients without transient risk factors for VTE or patients with active cancer, if they are not at a high risk for bleeding. The VTE-BLEED risk score was created with the purpose of enabling a better stratification of the bleeding risk during stable anticoagulation after a first VTE. Currently, it is the most validated risk score in VTE settings (selected and non-selected cohorts). It has a good prediction power for major bleeding events in patients receiving any of the currently available classes of oral anticoagulants, and it can identify patients at risk of intracranial and fatal bleeding events. The aim of our review was to highlight the strengths of the VTE-BLEED risk score, to acknowledge its weak points and to properly position its use in current medical practice.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Manuela Ciocoiu
- Department of Pathophysiology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Oana Viola Badulescu
- Department of Pathophysiology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Maria-Cristina Vladeanu
- Department of Pathophysiology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Iris Bararu Bojan
- Department of Pathophysiology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cristiana Elena Vlad
- Department of Nephrology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
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Abstract
ABSTRACT While acute blood pressure elevations are commonly seen in the ED, not all require emergency treatment. True hypertensive emergencies are characterized by a rapid elevation in blood pressure to a level above 180/120 mmHg and are associated with acute target organ damage, which requires immediate hospitalization for close hemodynamic monitoring and IV pharmacotherapy. Recognizing the clinical signs and symptoms of hypertensive emergency, which may vary widely depending on the target organ involved, is critical. High blood pressure levels that produce no signs or symptoms of target organ damage may be treated without hospitalization through an increase in or reestablishment of previously prescribed oral antihypertensive medication. However, all patients presenting with blood pressure this high should undergo evaluation to confirm or rule out impending target organ damage, which differentiates hypertensive emergency from other hypertensive crises and is vital in facilitating appropriate emergency treatment. Drug therapy for hypertensive emergency is influenced by end-organ involvement, pharmacokinetics, potential adverse drug effects, and patient comorbidities. Frequent nursing intervention and close monitoring are crucial to recuperation. Here, the authors define the spectrum of uncontrolled hypertension; discuss the importance of distinguishing hypertensive emergencies from hypertensive urgencies; and describe the pathophysiology, clinical manifestations, and management of hypertensive emergencies.
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Affiliation(s)
- Essie P Mathews
- Kartavya Sharma is an assistant professor in the Departments of Neurology and Neurological Surgery at the University of Texas Southwestern Medical Center, Dallas, where Essie P. Mathews is an advanced practice RN in the Department of Neurology and Faith Newton is an adult-gerontology acute care NP in the Department of Neurology. Contact author: Kartavya Sharma, . The authors and planners have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the authors is available at www.ajnonline.com
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13
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Platte S, Korff M, Imberg L, Balicioglu I, Erbacher C, Will JM, Daniliuc CG, Karst U, Kalinin DV. Microscale Parallel Synthesis of Acylated Aminotriazoles Enabling the Development of Factor XIIa and Thrombin Inhibitors. ChemMedChem 2021; 16:3672-3690. [PMID: 34278727 PMCID: PMC9292294 DOI: 10.1002/cmdc.202100431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Indexed: 01/12/2023]
Abstract
Herein we report a microscale parallel synthetic approach allowing for rapid access to libraries of N‐acylated aminotriazoles and screening of their inhibitory activity against factor XIIa (FXIIa) and thrombin, which are targets for antithrombotic drugs. This approach, in combination with post‐screening structure optimization, yielded a potent 7 nM inhibitor of FXIIa and a 25 nM thrombin inhibitor; both compounds showed no inhibition of the other tested serine proteases. Selected N‐acylated aminotriazoles exhibited anticoagulant properties in
vitro influencing the intrinsic blood coagulation pathway, but not extrinsic coagulation. Mechanistic studies of FXIIa inhibition suggested that synthesized N‐acylated aminotriazoles are covalent inhibitors of FXIIa. These synthesized compounds may serve as a promising starting point for the development of novel antithrombotic drugs.
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Affiliation(s)
- Simon Platte
- Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Corrensstr. 48, 48149, Münster, Germany
| | - Marvin Korff
- Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Corrensstr. 48, 48149, Münster, Germany
| | - Lukas Imberg
- Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Corrensstr. 48, 48149, Münster, Germany
| | - Ilker Balicioglu
- Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Corrensstr. 48, 48149, Münster, Germany
| | - Catharina Erbacher
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstr. 30, 48149, Münster, Germany
| | - Jonas M Will
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstr. 30, 48149, Münster, Germany
| | - Constantin G Daniliuc
- Institute for Organic Chemistry, University of Münster, Corrensstr. 40, 48149, Münster, Germany
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstr. 30, 48149, Münster, Germany
| | - Dmitrii V Kalinin
- Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Corrensstr. 48, 48149, Münster, Germany
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Nawabi J, Elsayed S, Morotti A, Speth A, Liu M, Kniep H, McDonough R, Broocks G, Faizy T, Can E, Sporns PB, Fiehler J, Hamm B, Penzkofer T, Bohner G, Schlunk F, Hanning U. Perihematomal Edema and Clinical Outcome in Intracerebral Hemorrhage Related to Different Oral Anticoagulants. J Clin Med 2021; 10:2234. [PMID: 34063991 PMCID: PMC8196746 DOI: 10.3390/jcm10112234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/05/2021] [Accepted: 05/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is a need to examine the effects of different types of oral anticoagulant-associated intracerebral hemorrhage (OAC-ICH) on perihematomal edema (PHE), which is gaining considerable appeal as a biomarker for secondary brain injury and clinical outcome. METHODS In a large multicenter approach, computed tomography-derived imaging markers for PHE (absolute PHE, relative PHE (rPHE), edema expansion distance (EED)) were calculated for patients with OAC-ICH and NON-OAC-ICH. Exploratory analysis for non-vitamin-K-antagonist OAC (NOAC) and vitamin-K-antagonists (VKA) was performed. The predictive performance of logistic regression models, employing predictors of poor functional outcome (modified Rankin scale 4-6), was explored. RESULTS Of 811 retrospectively enrolled patients, 212 (26.14%) had an OAC-ICH. Mean rPHE and mean EED were significantly lower in patients with OAC-ICH compared to NON-OAC-ICH, p-value 0.001 and 0.007; whereas, mean absolute PHE did not differ, p-value 0.091. Mean EED was also significantly lower in NOAC compared to NON-OAC-ICH, p-value 0.05. Absolute PHE was an independent predictor of poor clinical outcome in NON-OAC-ICH (OR 1.02; 95%CI 1.002-1.028; p-value 0.027), but not in OAC-ICH (p-value 0.45). CONCLUSION Quantitative markers of early PHE (rPHE and EED) were lower in patients with OAC-ICH compared to those with NON-OAC-ICH, with significantly lower levels of EED in NOAC compared to NON-OAC-ICH. Increase of early PHE volume did not increase the likelihood of poor outcome in OAC-ICH, but was independently associated with poor outcome in NON-OAC-ICH. The results underline the importance of etiology-specific treatment strategies. Further prospective studies are needed.
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Affiliation(s)
- Jawed Nawabi
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (E.C.); (B.H.); (T.P.)
- BIH Biomedical Innovation Academy, Berlin Institute of Health (BIH), 10178 Berlin, Germany;
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy;
| | - Anna Speth
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Berlin Institute of Health, Freie Universität Berlin, 10117 Berlin, Germany; (A.S.); (M.L.); (G.B.)
| | - Melanie Liu
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Berlin Institute of Health, Freie Universität Berlin, 10117 Berlin, Germany; (A.S.); (M.L.); (G.B.)
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Tobias Faizy
- Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Elif Can
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (E.C.); (B.H.); (T.P.)
| | - Peter B. Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
- Department of Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Bernd Hamm
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (E.C.); (B.H.); (T.P.)
| | - Tobias Penzkofer
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (E.C.); (B.H.); (T.P.)
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Georg Bohner
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Berlin Institute of Health, Freie Universität Berlin, 10117 Berlin, Germany; (A.S.); (M.L.); (G.B.)
| | - Frieder Schlunk
- BIH Biomedical Innovation Academy, Berlin Institute of Health (BIH), 10178 Berlin, Germany;
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Berlin Institute of Health, Freie Universität Berlin, 10117 Berlin, Germany; (A.S.); (M.L.); (G.B.)
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
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Intracerebral hemorrhage in COVID-19: A narrative review. J Clin Neurosci 2021; 89:271-278. [PMID: 34119280 PMCID: PMC8096173 DOI: 10.1016/j.jocn.2021.05.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 05/03/2021] [Indexed: 12/23/2022]
Abstract
Coronavirus Disease 19 (COVID-19) pandemic affects the worldwide healthcare system and our understanding of this disease grows rapidly. Although COVID-19 is a mainly respiratory disease, neurological manifestations are not uncommon. The aim of this review is to report on the etiology, clinical profile, location, and outcome of patients with intracerebral hemorrhage (ICH) and COVID-19. This review includes 36 studies examining ICH in the clinical presentation of COVID-19. Overall, 217 cases with intracranial hemorrhage, of which 188 ICHs, were reported. Generally, a low incidence of both primary and secondary ICH was found in 8 studies [106 (0.25%) out of 43,137 hospitalized patients with COVID-19]. Available data showed a median age of 58 years (range: 52–68) and male sex 64%, regarding 36 and 102 patients respectively. Furthermore, 75% of the patients were on prior anticoagulation treatment, 52% had a history of arterial hypertension, and 61% were admitted in intensive care unit. Location of ICH in deep structures/basal ganglia was ascertained in only 7 cases making arterial hypertension an improbable etiopathogenetic mechanism. Mortality was calculated at 52.7%. Disease related pathophysiologic mechanisms support the hypothesis that SARS-CoV2 can cause ICH, however typical ICH risk factors such as anticoagulation treatment, or admission to ICU should also be considered as probable causes. Physicians should strongly suspect the possibility of ICH in individuals with severe COVID-19 admitted to ICU and treated with anticoagulants. It is not clear whether ICH is related directly to COVID-19 or reflects expected comorbidity and/or complications observed in severely ill patients.
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Abstract
Intracerebral hemorrhage is a stroke subtype with high mortality and poor functional outcome in survivors. Its main causes are hypertension, cerebral amyloid angiopathy, and anticoagulant treatment. Hematomas have a high frequency of expansion in the first hours after symptom onset, a process associated with neurologic deterioration and poor outcome. Control of severe hypertension, reversal of anticoagulant effect, and management of increased intracranial pressure are the mainstays of management of intracerebral hemorrhage in the acute phase. Surgical evacuation of the hematoma by conventional craniotomy does not improve outcomes, but minimally invasive techniques may be a valuable approach that deserves further evaluation.
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Affiliation(s)
- Carlos S Kase
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
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The efficacy and safety of direct oral anticoagulants plus aspirin in symptomatic lower extremity peripheral arterial disease: a systematic review and meta-analysis of randomized controlled trials. J Thromb Thrombolysis 2021; 52:904-913. [PMID: 33704652 DOI: 10.1007/s11239-021-02417-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Abstract
Patients with lower extremity peripheral artery disease (PAD) are at increased risk of major adverse limb events (MALE). The efficacy and safety of direct oral anticoagulants (DOACs) in this context is evolving. To assess the efficacy and safety of DOAC combined with aspirin compared to the use of antiplatelet agents in patients with symptomatic lower extremity (LE) PAD. We systematically searched PubMed, Embase and Cochrane databases, in September 2020, for randomized controlled trials (RCTs) that were designed to investigate the effect of DOACs in the treatment of PAD. A random-effects meta-analysis was performed targeting ischemic and bleeding events. Three randomized clinical trials were included, providing a total of 9533 patients, and 744 pooled MALE events (316 in DOAC plus aspirin and 428 in control). Only data on rivaroxaban and edoxaban were available. The use of DOAC plus aspirin in PAD patients significantly decreased the rate of MALE (pooled OR 0.70 [0.61-0.83], P < 0.001; I2 = 0%). In terms of safety, there was a significantly higher rate of major bleeding events (pooled OR 1.46 [1.16-1.84], P = 0.001; I2 = 52%). In rivaroxaban-RCTs, the addition of low-dose rivaroxaban to aspirin was still associated with a lower MALE compared to aspirin alone (pooled OR 0.68 [0.53-0.88], P = 0.003; I2 = 28%), but also conferred higher major bleeding rate (pooled OR 1.48 [1.18-1.86], P < 0.001; I2 = 0%). In conclusion, our pooled data suggests that for patients with symptomatic LE-PAD, the use of DOAC combined with aspirin reduced the risk of major ischemic limb events at the expense of an increased risk of major bleeding.
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Imaging-Based Outcome Prediction of Acute Intracerebral Hemorrhage. Transl Stroke Res 2021; 12:958-967. [PMID: 33547592 PMCID: PMC8557152 DOI: 10.1007/s12975-021-00891-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/03/2021] [Accepted: 01/12/2021] [Indexed: 02/08/2023]
Abstract
We hypothesized that imaging-only-based machine learning algorithms can analyze non-enhanced CT scans of patients with acute intracerebral hemorrhage (ICH). This retrospective multicenter cohort study analyzed 520 non-enhanced CT scans and clinical data of patients with acute spontaneous ICH. Clinical outcome at hospital discharge was dichotomized into good outcome and poor outcome using different modified Rankin Scale (mRS) cut-off values. Predictive performance of a random forest machine learning approach based on filter- and texture-derived high-end image features was evaluated for differentiation of functional outcome at mRS 2, 3, and 4. Prediction of survival (mRS ≤ 5) was compared to results of the ICH Score. All models were tuned, validated, and tested in a nested 5-fold cross-validation approach. Receiver-operating-characteristic area under the curve (ROC AUC) of the machine learning classifier using image features only was 0.80 (95% CI [0.77; 0.82]) for predicting mRS ≤ 2, 0.80 (95% CI [0.78; 0.81]) for mRS ≤ 3, and 0.79 (95% CI [0.77; 0.80]) for mRS ≤ 4. Trained on survival prediction (mRS ≤ 5), the classifier reached an AUC of 0.80 (95% CI [0.78; 0.82]) which was equivalent to results of the ICH Score. If combined, the integrated model showed a significantly higher AUC of 0.84 (95% CI [0.83; 0.86], P value <0.05). Accordingly, sensitivities were significantly higher at Youden Index maximum cut-offs (77% vs. 74% sensitivity at 76% specificity, P value <0.05). Machine learning–based evaluation of quantitative high-end image features provided the same discriminatory power in predicting functional outcome as multidimensional clinical scoring systems. The integration of conventional scores and image features had synergistic effects with a statistically significant increase in AUC.
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